Democratic Debate Dives Deep into Health Care Topics

Posted onAuthorCedric Dark, MD, MPH, FACEP

We don’t have a literature review for this week so instead I wanted to provide some insights on the recent Democratic Debate held last night. Two main healthcare themes came up for discussion – the future of health reform and gun control – by the three candidates Hillary Clinton, Bernie Sanders, and Martin O’Malley.

The Future of Health Reform

On the democratic side, the differing platforms can be described as defending the status quo i.e. the Affordable Care Act (Clinton), adopting Medicare for All (Sanders), or implementing All-Payer for Some (O’Malley). Obviously, Clinton’s plan is to solidify and expand on the structure of the ACA if she becomes president. In all practicality, this is what any of the three democratic candidates would do if actually elected. Sanders, attacking from the left, advocates for a single-payer (Canada-style) system. While likely the democratic ideal, I maintain that this is still politically not feasible anytime soon. Of course, some people think that the failure of the ACA will result in the American populace ultimately demanding single payer. I personally disagree with that assessment.

O’Malley made a mention of as a cost-saving panacea. Unfortunately, O’Malley’s all-payer approach only applies to hospitals and not to the remaining two-thirds of healthcare system costs.

The discussion on Twitter was as interesting as on television, as parties debated the “heart of the ACA.” Some view it as trying to expand health insurance coverage as much as possible. Others, like me, think the heart the ACA was really the insurance reforms (guaranteed issue, modified community rating, and the individual mandate).

Source: Disney | ABC Television (Flickr/CC)

Source: Disney | ABC Television (Flickr/CC)

The wonky among us conversed (or maybe opined) about expanding Medicare to younger Americans, folding CHIP into Medicaid, and essentially consolidating various healthcare programs while incrementally eliminating private coverage for public coverage. This is the discussion that we need to have — should the administration of health insurance be done through government or through private parties? While many European nations have different viewpoints on this (France and Switzerland for example) they all agree than every one of their citizens needs to be covered. It seems that the United States is approaching this consensus.

My current philosophy suggests that we should build on the ACA Marketplaces and use the existing private system (because the majority of Americans would more likely approve of that) as opposed to expanding Medicare for all. Either way, if everyone had coverage, I wouldn’t really care the mechanism (i.e. Canadian-, French-, or Swiss-style).

Gun Control

The philosophy of most democrats on gun control is that “more is better.” The candidates all call for universal background checks,  assault weapons bans, etc. During the debate, Martin O’Malley (aka The Urban Candidate) promoted his successes in passing gun safety legislation while taking jabs at Sanders (aka The Rural Candidate) who recently changed his position on immunity for gun manufacturers. Clinton similarly took swings at Sanders’ record and enumerated nearly a dozen votes that her opponent made that were pro-gun. Despite O’Malley and Clinton having the inside track on gun control, Sanders suggested that he was in the best position to get both sides to compromise.

Gun safety, gun control, and gun crime represent a complex, intertwined series of issues which is overly politicized due to the 2nd amendment. In researching the issue lately, I’ve spoken to several gun owners in an attempt to reach consensus on potential solutions to the problem of gun violence.

The gun owners I spoke with all seemed okay with the concept of who wish to buy firearms. The right to bear arms is akin to the right to vote. Voting requires you to register in order to exercise that right. Gun owners do not seem opposed to registering the individual in order to exercise the right to bear arms.

Secondly, each of the gun owners I spoke with described that when they bought or sold a gun in a private transaction  (which doesn’t necessarily require record keeping) they obtained a bill of sale anyway to track the transfer of each particular firearm. It’s a liability issue. If the gun you buy or sell is used in a crime somewhere, you really want to be able to say who you sold it to or from whom you bought it. And since all guns used in crimes initially start as legally obtained guns from a wholesaler or retailer, it certainly seems prudent to know the chain of ownership.

Gun owners seemed okay with requiring record-keeping for all private party firearm transactions. Where they draw the line is having a government database saying who owns which type and how many guns.

In sum

Last night’s debate offered some good material for health care voters. The differences in the candidates ultimately is not that different on gun control. But as for health care reform, Clinton and Sanders make this a higher priority than O’Malley. The main difference between to top two candidates is their stance on coverage expansion – through private insurers as expansion of the ACA versus through a single public payer.