Ed Dolan's Econ Blog

CNN’s Sanders-Cruz Healthcare Debate: A Scorecard

CNN, Senator Sanders, and Senator Cruz deserve congratulations for a great town hall. Real focus, real exchange of views, even real agreement now and then on some important ideas. Worth viewing, or if you missed it, worth reading the transcript.

Still, articulate and well prepared though the participants were, there were things they should have said that they didn’t say. I often had the feeling that Cruz was changing the subject when he didn’t have answers and glossing over some key points that needed closer examination. At the same time, I think Sanders missed some chances to hold him to account. Here is my scorecard, organized by topic.

Pre-existing conditions

The ACA (or Obamacare) has many detractors, and it has flaws that Sanders himself admits, but some parts are popular. None is more popular than the mandate that insurance companies must cover people regardless of pre-existing conditions. Probably fewer than one in ten Americans falls into that category, but almost everyone has a parent or child or spouse or friend who is in the ten percent. Together that ten percent of patients account for about two-thirds of all personal healthcare spending. Even if you are healthy, your biggest fear is that you might develop cancer, or diabetes, or have a bad auto accident, and end up in the ten percent without adequate healthcare coverage.

The pre-existing conditions mandate was, appropriately, the subject of the very first question from the audience.

AUDIENCE MEMBER NEOSHO PONDER (A breast cancer patient): “Senator Cruz, what can you do to protect people like me who are alive because of Obamacare?”

Cruz gave several versions of his response:

CRUZ: All of [the GOP proposals] prohibit insurance companies from canceling someone because they got sick. They prohibit insurance companies from jacking up the insurance rates because they got sick or injured.

CRUZ: [a] proposal that is consistent in virtually every one of the pieces of Republican legislation that’s been filed is a prohibition on insurance companies canceling people because they got sick.

CRUZ: all of the Republican legislation that has been filed that the Democrats have opposed maintains a continuity of coverage so that insurance companies can’t cancel policies.

Sanders tried to press him:

SANDERS: What you just said is “cancel your insurance.” “Cancel your insurance,” OK? That’s good. But what happens if tomorrow you wake up and you go to the doctor and you discover that you have cancer? All right? You just discovered it. And the insurance companies say, hey, you’re not a good deal for us, we can’t make money off of you, you will not get that health insurance.

Unfortunately, Sanders didn’t quite drive home the key point that the Republic plans only protect people with pre-existing conditions if they maintain continuity of coverage. Continuity of coverage is a proviso in several GOP proposals. It forbids insurance companies to cancel coverage or raise rates for people who were already insured before they got sick and have been continuously covered since. They are not required to cover, or are allowed to charge higher rates, if people develop their cancer or diabetes or whatever during a period when they are uninsured. Even if they were insured when they were first diagnosed, if they have had a gap in their coverage after they develop their condition, neither their former insurer or a new one has to take them on.

Sanders should have made it crystal-clear that continuity of coverage is not enough. There are lots of reasons people might not meet the continuity of coverage requirement. One reason is that young people might not get coverage in the first place. They might not have parents with a plan they can stay on until they are 26. Under GOP plans, they would not have the spur of an ACA-type fine for not having coverage. Or they might just think they are immortal, like most normal young people do. Then, at age 27, they might crash their car or wake up one morning with a scary lump and suddenly want insurance for the first time. Under a system that requires continuity of coverage, they would be out of luck.

Another other big problem comes if your coverage is linked to your job. What if you lose your job? Will you have COBRA coverage (the main continuity mechanism before the ACA) or something similar? Can you afford it during the interval of financial stress while you are looking for a new job? Will your new employer even offer insurance? Under GOP plans, not necessarily.

In practice, then, loss of job, not to mention death of a covered spouse, divorce, and other events, carry considerable risk of losing continuity of coverage. Under some GOP plans, even a brief loss of coverage could turn into a virtual death sentence for a person with a pre-existing condition.

For this segment, I give Cruz a C- for obfuscation when he tries to pass off continuity of coverage as being an adequate solution to the problem of pre-existing conditions. I give a B to Sanders for not driving home the point as effectively as he might have. 


More than once, Sanders brought up the fact that the US spends more on healthcare than any other advanced country, even though they have universal coverage and we don’t. Each time Cruz blamed this on rationing. For example:

CRUZ: [Sanders] often points to Canada, the United Kingdom. He says why do we pay more?

Well, there’s a reason we pay more than those countries. We get a lot more and a lot better health care.

Let me give you some basic facts. As I noticed in all the Democratic primary debates, there was no discussion of the facts on the other side. The United States, population controlled, delivers three times as many mammograms as Europe, two-and-a-half times the number of MRI scans, and 31 percent more C sections. We provide more health care.

Not only that, in the United Kingdom, for example, wait times, in 2013, you waited 72 days for cataract surgery, you waited 89 days for hip replacement, 95 days for knee replacement. There are 3.7 million people in the United Kingdom right now on a waiting list, waiting for health care.

Whenever you put government in charge of health care, what it means is they ration.

Sanders replies that the US rations too, but rations by price rather and gaps in coverage rather than by waiting periods:

SANDERS: We have enormous rationing in this country. When you have 28 million people who have no health insurance, that’s rationing. When you have people who can’t afford to go to the doctor or can’t afford to buy prescription drugs, one out of five Americans can’t afford the prescription drugs their doctors prescribe, that’s called rationing. Except there’s no rule on that; there’s no law on that. It’s just people don’t have the money to buy what they need in terms of health care.

True enough, but if Sanders had really been on his toes, he would have challenged Cruz’s assertion that waits for care are longer in other countries. Cruz had a notebook full of useful data. Sanders should have had one too. Among other things, his notebook should have included data from a widely-cited study of healthcare in eleven wealthy countries from the Commonwealth Fund. Key findings of the study:

  •  Far from offering “a lot more and a lot better health care” than other advanced countries, the US ranked 11th out of 11 overall, 5th on quality of care, 9th on access, and 11th on efficiency.
  • On timeliness, the US ranked 5th overall, 7th on waiting for emergency care, and 8th on evening and weekend access.
  • The US scored better, but still not the very best, on waits to see a specialist (3rd) and waits for treatment after diagnosis (2nd).
  • Cruz was off-base to cite UK as inferior to the US in terms of timeliness of care. In the Commonwealth survey, the UK scored 3rd vs. 5th for the US on overall timeliness. Cruz should have stuck to Canada, the one country that does make the US look good. Canada is dead last on timeliness of care.

Sanders also could have challenged Cruz’s assertion that more C-sections, more MRI’s, and more mammograms mean more and better care. More is not always better. Complaints that US doctors perform too many C-Sections and too many MRIs are common.

I’ll give Cruz a C- on this one; he didn’t have his facts right despite his notebook. Sanders gets a B- for not having  a better rebuttal.

Bernie’s big fumble

Sanders’ biggest fumble came in answer to a question by LaRonda Hunter, an audience member from Texas. Hunter owns a string of hair salons and is afraid to expand or hire more people because doing so would take her over the fifty employee limit, beyond which the ACA would require her to provide health care. She said she couldn’t afford to do so without cutting wages or raising prices. In fact, she said she can’t even afford health insurance for herself. Here is how Sanders answered:

SANDERS: [L] me give you an answer you will not be happy with . . . if you have more than 50 people, you know what, I think—I’m afraid to tell you—I think you will have to provide health insurance.  . .  If you have more than 50 people, yes, you should be providing health insurance.

I don’t know what he was thinking. Sanders own healthcare plan, Medicare for all, completely eliminates employer-provided care. His answer  to Hunter’s question should have been, simply, that employer provided health care is not a good idea for any business, large or small.

Later, Sanders seemed to remember that and tried to backtrack, but it was too late. I give him a D for this episode. Cruz gets an A for being smart enough to stand aside and let his opponent twist in the wind.

Promises, promises

Cruz repeatedly hammered away at “broken promises of Obamacare.” We all know the litany. The ACA did not let everyone who liked their doctor keep their doctor—instead it steered many of them into narrow networks with limited choices. It did not let everyone who liked their plan keep their plan—some plans that people liked were canceled because they didn’t meet ACA standards or because companies withdrew from the marketplace. Premiums and out-of-pocket costs went up, not down, at least for many people.

Fair enough. It is hard to deny that the early rhetoric of ACA supporters overpromised and under delivered. But what about the promises Cruz and other GOP reformers are now making? Here is a sample from Cruz’s closing statement:

CRUZ: We can do better. I believe we are going to honor the promises we made to the American people and we are going to repeal what Bill Clinton called Obamacare—the craziest law in the world. Instead, we’re going to give you choice, let you buy insurance across state lines, expand health savings accounts, make insurance portable, block grant Medicaid to the states so you can have experimentation, health savings accounts so we can meet your need, put you in charge of your health care with your doctor, not government.

What is missing here is any actual mechanism by which the GOP plan can maintain coverage at least as broad as the ACA, and cut premiums, and increase choice, and cut the cost of healthcare to the federal budget. You can’t get all that by just waving a magic wand and repeating “market, market.”

Ideas like buying insurance across state lines are just tweaks. They might help, but they address just a little piece of the problem. Ditto for shopping overseas for drugs (a suggestion Cruz made earlier in the debate).  Medical savings accounts are a good idea for people who are relatively healthy and just need a way to manage deductibles and co-pays, but they are little help for people who have serious chronic conditions. For the top 5 percent of healthcare users, who account for half percent of all spending, yearly costs average $40,000. Anyone with expenses like that would quicly exhaust a medical savings account.

Medicaid block grants are primarily a way to reduce aid to poor patients, not a way to improve their coverage. Their whole purpose is to cut the federal budget by capping the federal contribution to healthcare spending. They would stick states with the hard choices of how to ration care for the poor. Longer waits? Harder to qualify? Fewer choices of doctors or drugs? Not our problem, says Congress, call your governor.

Sanders, on the other hand, actually has a plan. His Medicare for all—that would establish a single payer system similar to the ones that are already up and running in other advanced countries. Sanders plan is not perfect (read my detailed critique here) but does touches all the bases. The Republicans don’t have any detailed plan at all. There is no real way even to debate them until they put something specific on the table.

On promises, I’ll give an A- to Sanders for being smart enough not to defend the ACA’s obvious flaws and for actually having a complete, if imperfect, alternative. Cruz gets a C- for carping about the ACA without offering more than jam-tomorrow promises as an alternative.

The bottom line

I found the debate as a whole to be refreshing. It was so much better than any debate or town hall during the campaign. On the whole, I thought Sanders had more passion, and secondarily because he did bring a compete plan to the table. Cruz, however, is a very skilled debater. He had facts and figures at his fingertips, and took advantage of Sanders’ inability to refute them in the same detail. Most of all, he was frightening successful at covering up the fact that the GOP really does not know what to do with the healthcare system over which it now has so much power.

6 Responses to “CNN’s Sanders-Cruz Healthcare Debate: A Scorecard”

BryanWillmanFebruary 10th, 2017 at 4:01 pm

That is all well and good, but misses 3 elephants in the room.
1. So long as most people get health insurance from their employers, and that health insurance is platinum plated, the system will be very difficult to repair. This particular elephant, bound up as it is with platinum plated benefits and union involvement, will be very difficult to chase away.
2. The US already runs very very large single payer systems, one of which nobody is very happy with (medicaide) and the other is widely viewed as freeriding as the "marginal customer" (medicare.) There's no particular reason to think that any new plan will be better.
3. The US income tax system is about as progressive as it can actually get, which means that paying for "universal coverage" (er medicare for all) will be net very costly at basically all levels of the income scale – and the blowback will be incredible. (See the attempts at state level universal coverage that have failed so far…) In other words, faced with the actual cost, the majority of citizens are likely to refuse to pay for it. ("tax the rich" is not a scheme that works forever.)

Given that the majority of citizens are riding elephant #1 (employer health insurance) or elephant #2 (medicare) the rest are badly outnumbered.

All of that ignores the question of whether the actual healthcare resources of the US actually have the capacity to offer adequate care to all citizens.

[I'm not happy with any of this, but yes Ed, you can accuse me of a council of dispair.]

Ed Dolan EdDolanFebruary 12th, 2017 at 11:03 am

Sorry for long delay in approving this comment. You make good points. US does run big single-payer systems (you didn't even mention VA) already and they do not work as well as single-payer systems in other advanced countries. They produce inferior outputs at greater costs. However, one way or another, the US is going to have to figure out how to get a single-payer system that works, because of two other "elephants": (1) 5% of individuals account for 50% of healthcare costs; most of those have conditions that are uninsurable outside a single payer system. Even the GOP is talking about things like assigned risk pools for this part of the population. They are not true insurance and require subsidies to exist. (2) Employer based insurance is gradually dying (see e.g.…. In addition to fewer people covered, union-type platinum plated systems with first-dollar coverage, no caps, broad networks, etc. are becoming a thing of the past except for top execs. There is no way the GOP can stop this trend.

windrivenFebruary 13th, 2017 at 9:50 pm

"There is no way the GOP can stop this trend."

Nor should they try.

But the larger issue is that the Republicans had a good many years to fix the US healthcare system – and they did nothing. The Democrats came up with ACA – a crappy plan that amounts to little more than modest insurance reform – and the Republicans are splitting a gut without any coherent, unified offering of what they'd do differently.

The fact is that both Parties are bereft of new and interesting ideas and neither is fit to lead.

Ed Dolan EdDolanFebruary 14th, 2017 at 7:29 pm

If the two parties would work together (Ha, Ha!) they could get something reasonable out of the best ideas in their plans. But even when they agree, they put different names on things and fight over them.

Ed Dolan EdDolanFebruary 16th, 2017 at 3:16 pm

BryanWillman submits the following further comment, in two parts, which did not post directly, due to a technical problem.

Part 1:

The original post makes the perfectly sensible observation that discussions about healthcare can be much better than they have been. The exchange in comments between Ed and I point out (correctly) that there are cross subsidies (hidden or not) and general poor arrangements in the current system.

(Skepticism warning) I now think that the opaque nature of the system is required for it to carry out as much redistribution as does, and while a clear and transparent explanation of who is getting a subsidy, who is or is not paying for some part of the social burden, who is getting a raw deal, and so forth is possible, it may not produce the sort of result that any of us would hope for.

I think the reason is for this is two fold:

1. The current arrangement, in spite of its opaque cost shifting, provides subsidies or ducking of costs of one kind to another to very large and important groups. Changing the arrangement to be what the Left might call "more fair" would involve serious redistribution of wealth, and the people it would be redistributed away from would fight it long and hard, and probably win, as they hold an electoral majority.

I think the current system in effect over time favors large organizations (both companies and government) and unions, disfavors smaller organizations (be they companies or branches of government.)

It disfavors those who do not have some kind of attachment to favored entities (membership, a spouse with coverage, etc.)


Ed Dolan EdDolanFebruary 16th, 2017 at 3:21 pm

(continuation of BW comment)

Part 2

It also hides costs and creates a system where A is spending what feels like somebody else's money with B (who happily takes it) while C struggles to pay this bill.

But even without that aspect of the system, the entrenchment of interests is very strong. And many citizens probably don't grasp how large the effects are – they don't actually see health insurance on their paycheck or tax bill (and companies and unions fight any change to this), they do not actually see that by defining the risk pool along org membership lines, the high premium pools exclude a fair number of the sickest patients. They may not be aware of the degree to which cost shifting and part of their income tax bill partially offset this.

In short, they really don't know what deal they are getting, but they can be (rightly) sure it's a good deal, and pretty confident that any system that addresses the issues the Left wishes to fix, will cost them something – more out of pocket, more taxes, less coverage, something.

On the converse, trying to make a relatively small number of young healthy people pay for insurance they think they do not need and perhaps do not want, is a fool's errand. People figure out quickly that it's a losing proposition and drop. More aggressive mandate or income tax enforcement will have no effect on a pool of people who don't have any money anyway.

OK, "tax the rich" to pay for it – nice try, except we already have the world's most progressive income tax system, and the sums of money are larger than you could reliably get.

This means paying for this coverage for those who don't have it, coverage that some number of them need very badly, but a large fraction of them do not actually want at all, will have to come out of the pockets of the large pool of relatively well off relatively healthy people covered by employer/government/union arrangements.

2. Unlike the (comparatively small population) countries whose systems some wish to emulate, the United States is explicitly NOT ethnically or regionally integrated. We can imagine Denmark being full of Danes who have some degree of sympathy for almost all other Danes. Americans have that to *some* much smaller extent. Nobody really seems to think that Swedes or Germans should be higher taxes to cover healthcare for southern Italians. But somehow people in Montana and Washington states should pay to offer healthcare coverage for people in Alabama?

In short, there is less support for redistribution in the US than elsewhere (something documented in various places.)

ANY conversation about "fixing healthcare" is really talking about "fixing" something that is not broken for a huge swath of the currently entrenched beneficiaries, by taking something from them and giving it to some other people (for whom the system is clearly broken.) Given the numbers, this depends on people (a) wanting to help "their fellow americans" and (b) not paying too much attention to what it will cost them.

I am deeply skeptical this can happen. Especially since any such undertaking will be large and slow, and people will therefore figure out what it is going to cost them before its finished.

The ACA (obamacare) may well have poisoned any hope of such reform for some time, since "if you like your policy you can keep it" proved to be a lie that made people angry, and as widely predicted some variant of the "death spiral" is coming home to roost as well.

What does this have to do with Ed's sensible post? It helps explain why I am skeptical that clarity of what is really going on will actually enable fixing the broken parts of the system.

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