Sounds of health-care silence in GOP debate

Lack of Obamacare talk speaks volumes

I HAD ONE mission last night watching the Republican debate among the party’s top 10 presidential contenders: What, if anything, could we learn about the state of play regarding the Affordable Care Act and US health policy?

What I observed: The impassioned debate about the Affordable Care Act/ACA/Obamacare is over, even among Republicans.

Here is what I noted from the debate that referenced the ACA:

First, Ohio Gov. John Kasich restated his strong support for his decision to expand his state’s Medicaid program as enabled and financed by the ACA, invoking President Ronald Reagan as someone who “expanded Medicaid three or four times.” He emphasized how the expansion helps both Ohio’s working poor as well as the mentally ill in prisons. No apology, no retreat, and no damage or attacks from any of his rivals.

Second, asked about his prior public support for a Canadian-style single payer health care system, Donald Trump commented that “single payer works well in Canada and incredibly well in Scotland.” He said he wants a “private system without artificial lines around states” (so much for states’ rights). He said he opposes “insurance companies that make a fortune because they have total control of the politicians. Get rid of the artificial lines,” said Trump. “Take care of the people who can’t take care of themselves.” Oddly, at the end of his closing statement, he added, apropos of nothing: “We have to end Obamacare and make our country great again.”

Former Florida governor Jeb Bush said he wants to “get rid of Obamacare and replace it with something that doesn’t suppress wages.”  No indication of what the “something” might be.

Wisconsin Gov. Scott Walker simply said he wants to “repeal Obamacare.”

That’s it. Except for Trump, none of the others mentioned the issue in their closing statements. Even Texas Sen. Ted Cruz, in his lengthy litany of first-day-as-president actions, left executive action on the ACA off his list. Cruz, as many will recall, was the key instigator of the 2013 federal government shutdown as a final gasp to prevent implementation of the ACA’s insurance coverage expansions on January 1, 2014.

The only question from the panel of three Fox news journalists relating to health reform was the one to Trump regarding his past support for single payer health insurance – more of a Fox gotcha moment than a thrust into health policy.

I looked at dozens of news accounts of the program from journalists across the political spectrum. Obamacare/ACA merited no mention anywhere in the their accounts and analyses.

This is the sound of silence as the ACA disappears from the nation’s political radar screen.

Why is this happening now? It’s because Republicans are almost out of real ammunition to fight the law. More than 16 million previously uninsured now have coverage through the private insurance and Medicaid expansions. The other parts of the law are well into implementation. We have been through more than five years of historically low growth rates in health care spending. And the sky has not fallen.  Right now, the reverse is true — repeal the law and the sky collapses for millions of Americans now appreciating the benefits of the law.

Yes, US health policy is becoming boring again, still a never-ending feast for the policy wonks, still a continuous hand-wringing exercise for patients and medical providers dealing with their daily challenges, and now a big nothing-burger for most Americans focused on other concerns.

On two other health related issues, we heard repeated statements of opposition to public funding for Planned Parenthood and, of course, strident statements of opposition to abortion, where the focus put candidates on the defensive who were willing to allow abortion in cases of rape, incest, and to save the life of the mother.

And nothing about Ebola!

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I am sure in future debates the ACA will return and receive a higher profile. But temperatures are cooling and last night’s debate was important affirmation.

John E McDonough teaches at the Harvard TH Chan School of Public Health and blogs at