The health care segment of Wednesday night’s Democratic presidential debate was a baffling morass. The conversation mostly consisted of a showdown between Sen. Kamala Harris and former Vice President Joe Biden, in which the two sniped at one another and “muddled through key details” of their proposals, as the Washington Post put it. There were lucid interludes from minor candidates like Michael Bennet, but on the whole, it felt like noise. Even those of us who cover health policy for a living had trouble with it.
This is very unfortunate: Health care is arguably the Democratic Party’s top issue, and voters deserve an illuminating discussion. So I’d like to offer a solution to make sure that future debates are clearer for the audience. From this day forward, whenever Democrats discuss health care on TV, they should be broken up into three teams. And they should be forced to wear hats.
Presidential debate stages are pretty much the absolute worst places in the world to try to have a detailed public policy conversation. The time-limited, sound-bitey format does not lend itself to the nuance or granularity, and when you have 10 politicians appearing at a time, the action can become chaotic. Instead, debates are meant to contrast candidates based on their broad philosophical principles and set up dramatic confrontations. If an entire topic can be boiled down to a simple, clear-cut question, all the better.
Conveniently, most of the conversation about health care this season has centered on just such a question: Should Democrats try to ban private insurance and replace it entirely with a single, national health care plan? Single-payer advocates like Bernie Sanders and Elizabeth Warren say yes. Everyone else says no (though there are many shades of gray within the opposition). It’s a straightforward and very important query about vision that you can poll with a show of hands, which is how NBC handled it during the first two debates.
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But as the campaign has worn on and more canidates have introduced their own health care proposals, things have gotten complicated. Some candidates, like Joe Biden, want to keep Obamacare but beef it up. Others, like Kamala Harris and Beto O’Rourke, want compromise approaches where the U.S. would offer pretty much everybody the option of a national health care plan but leave room for private coverage.
Unlike single payer, which is simple to explain—everybody gets the same government health care plan, paid for with higher taxes—laying out these alternative approaches requires a bit of effort from the politicians and concentration from the audience. Not all of the candidates are up to the task. Biden, for instance, accidentally said that copays on his plan would reach $1,000 (he meant deductibles) and later suggested his proposal would cover everybody (his campaign admits it wouldn’t). Watching Harris explain her plan, I badly wished she had a PowerPoint.
The upshot of all this is that it’s a bit hard to figure out where the candidates actually stand in relation to one another. Did you know that John Delaney, perhaps the most aggressive single-payer critic of this whole motley crew, is actually far to Biden’s left on health care? Did you know that during its 10-year transition period, Kamala Harris’ plan basically looks like a version of Beto O’Rourke’s? My guess is not.
This is where the teams, and the hats come into play. Right now, each of the presidential candidates falls into three main buckets:
• The single-payer diehards, led by Sanders and Warren, who want to pass “Medicare for All” and be legends.
• The Obamacare lifers—led by Biden, Bennet, and Amy Klobuchar—who want to improve the Affordable Care Act in part by adding a public option of some sort.
• The in-betweeners—led by Harris, O’Rourke, and possibly Pete Buttigieg (his plan is a bit light on detail, so it’s hard to tell for sure)—who want to move more aggressively toward a true Medicare-style national health program that everybody can sign up for but don’t want to annihilate the private insurance industry. You could go on forever about the different flavors of their plans, but that’s really the important part.
Come the next debate, each candidate should be roped into one of these three groups, and forced to argue as a team, defending the broad contours of their health care approach. If it were up to me, I would require them to wear hats with their team name, because it’d be vaguely funny, would probably help people remember the battle lines, and would even the hair playing field. As well as being an entertaining break from the typical debate slog, this setup would keep the discussion from devolving into obscure and inscrutable specifics, and instead draw clear distinctions about broad philosophical themes. Why should we get rid of private insurance or keep it? Is there a value to building fast but incrementally on the health care system that’s already in place? Do we think we can really sell radically higher taxes to the American people in return for lower health spending? How much should we try to squeeze out of hospitals? When it comes to health care, this is frankly the stuff that matters most right now, since Congress is inevitably going to end up handling the specifics if and when it comes time to legislate.
This approach will also force everyone to actually pick a team, preventing the candidates who’ve intentionally kept things vague so far—here’s looking at you, Cory Booker—from obscuring where they stand. Because we’ll literally be able to see where they’re standing. And their hats.
There are downsides to the company softball game approach to public policy debate. First off, the in-betweeners don’t agree with each other on everything, which might lead to some internal squabbling that could bring down the whole team. Second, they’d probably need a better name. Buttigieg calls his proposal “Medicare for All Who Want It,” which is pretty simple and clever. It also more or less describes O’Rourke’s policy and the first 10 years of what Harris has proposed. But after a decade, hers turns into something more like “Medicare (with the option of buying a Medicare Advantage–style private plan) for All.” If you force all of them into a room, though, I’m sure they can come up with a compromise. I mean, if they can’t negotiate that, there’s no way they’re ever going to hash out a health care bill with Capitol Hill.