Trump’s ‘Concepts of a Plan’ for Health Care Really Means He Has No Plan

Kamala Harris exceeded my expectations in her debate with Donald Trump on Tuesday. I knew that she was smart, but for whatever reason, many insiders have questioned her political talent. I assume that her remarkable skill at baiting Trump into one trap after another has ended those questions.

Trump, by contrast, was who he has always been. He essentially sounded the same as he does at his rallies – except that this time TV viewers experienced his ranting raw, not sanewashed by summaries that make him sound more coherent than he is.

True, I thought even Trump would have enough sense to steer clear of the Haitians-eating-pets stuff and wouldn’t get into a fight over who has bigger rallies. On the other hand, many people get worse as they grow older because they become more like themselves. And the bizarro exchanges on these subjects will probably define the debate in many voters’ eyes.

For policy wonks like me, however, the most remarkable moment in the debate probably came when Trump was asked whether he had a plan for health care reform, and his answer was: “I have concepts of a plan.”

Bear in mind that health care coverage is a crucial (in some cases life-or-death) issue for many Americans. Furthermore, health care – unlike, say, grocery or gas prices – is an issue on which public policy can make a big difference. In particular, the coming of the Affordable Care Act, aka Obamacare, led to a large decline in the percentage of Americans without health insurance and made an especially big difference for people with preexisting conditions that might otherwise have made them uninsurable.

Trump, however, has repeatedly insisted that Obamacare is “lousy” and that he can come up with something much better. And to be fair, claiming that they can improve on existing policies is something almost all politicians do.

But Trump began running for president nine years ago and has been denouncing Obamacare and promising a superior alternative the whole time. Yet the only policy alternative he has ever proposed was 2017 legislation that would have more or less dismantled the ACA without a viable replacement – and which the Congressional Budget Office estimated would have increased the number of Americans without health insurance by 32 million within a few years.

That legislation failed to pass the Senate – thanks in part to John McCain’s bravery in breaking with his party – and helped Democrats gain the House of Representatives in 2018. Surely, then, Trump has had a strong incentive to come up with a real alternative to Obamacare that won’t alienate so many voters. So how can he possibly still have only “concepts” of a plan?

I do think he has shown clearly that he’s generally unwilling to roll up his sleeves and get into the nuts and bolts of policy, but I don’t think that’s why his promised alternative to Obamacare has never appeared. The truth, I’d argue, is that he’s blowing smoke when he claims to have even “concepts.” That is, neither he nor anyone around him has any real clue about how to do better than the ACA, which is a much smarter piece of legislation than many people ever gave it credit for.

Bear in mind that the primary goal of the ACA wasn’t to magically make health care coverage super cheap. It was to make health care coverage available to all Americans, including those with pre-existing conditions. How can you do that?

One way is simply to have the government pay medical bills, as it does under Medicare and Medicaid. These programs, by the way, cover about one-third of us. And there’s a good argument in principle for having the government cover everyone – you know, “Medicare for All.”

As a practical matter, however, Medicare for All is out of reach. Insurance companies would, of course, fight against being put out of business. But special-interest politics aside, many Americans have what they consider decent coverage from their employers; replacing that with a government program might improve their lives, but good luck convincing enough people of that.

The alternative is to enhance private insurance rather than replace it – to regulate insurers so that they can’t discriminate based on medical history, and to subsidize premiums so that everyone can afford insurance. Which is basically how Obamacare works.

The ACA is a bit of a Rube Goldberg machine, a complicated solution to what could be a simple problem. But it works, and it got better under the Biden-Harris administration, thanks to improved premium subsidies.

Which brings us back to Trump. Does he have “concepts” about health care that are fundamentally different from the principles of our current system, and has he spent all these years working out the details to turn these concepts into a superior plan? If you believe that, I have a degree from Trump University you might want to buy.

No, very likely, the reason Trump has never produced a health care plan that wouldn’t deny coverage to millions of Americans is that he and those around him don’t know how to do that. If they’ve thought seriously about it at all, they might have realized that they’d probably just end up reinventing the ACA.

So, am I saying that Trump has probably been faking it all along, that he has never had an idea about how to improve on Obamacare? Why, yes.

This article originally appeared in The New York Times.