UPDATE: I Watched the Sanders/Cruz Obamacare Debate So You Don't Have To.

Last night, CNN held a full, 90-minute debate between Bernie Sanders and Ted Cruz which was billed as "The Future of Obamacare". It was a clever idea for a couple of reasons: Not only was each of them the "runner up" for the 2016 Presidential nomination of their party, but each of them made healthcare a core part of their campaign (Bernie, of course, is a die-hard Single Payer guy, while Cruz literally shut down the federal government to stop the bulk of the ACA from being implemented).

I didn't actually watch it live last night; I watched it on YouTube this morning (no idea whether this version will stay up or not).

I don't have time to get into a detailed analysis of the whole thing, but here's some general observations:

  • Cruz stuck to the usual "Obamacare Sux" talking points:
    • Attacking President Obama re. "failed promises": "You can keep your plan! You can keep your doctor! Premiums lowered by $2,500!"
    • Pushing for GOP Healthcare Pixie Dust: "Health Savings Accounts! Sell Across State Lines!"
  • Bernie, meanwhile, tried to stay on script (remember, he was supposed to be defending the Affordable Care Act), and did a pretty good job of it at times, but only spent about half of the debate actually doing so. He spent the other half either pushing his Single Payer/Medicare for All plan or simply wandering off into his usual "Income Inequality! Oligarchy! One Percent!" stump speech from the campaign, much of which had little to do with the topic at hand.
  • Bernie gave a pretty crappy response to one of the questions from the audience. A small business owner from Texas with just under 50 employees was griping about not being able to expand her business due to the 50-and-up employer coverage mandate. Under the ACA, once you hit 50+ employees, you have to provide coverage for all of them. Bernie's response, while candid, didn't exactly go over too well:

SANDERS: And what kind of health insurance do you provide for them?

QUESTION: I don't -- none.

SANDERS: You provide no health insurance to them?

QUESTION: Correct.

SANDERS: Let me be -- let me give you an answer you will not be happy with, and that is I think that for businesses that employ 50 people or more, given the nature of our dysfunctional health care system right now, where most people do get their health insurance through the places that they work, I'm sorry, I think that in America today, everybody should have health care. And 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.

QUESTION: So my question is, how do I do that without raising my prices to my customers or lowering wages to my employees?

SANDERS: ...But my guess is, one of the problems that we have is there may be somebody else in Fort Worth who is providing decent health insurance to their employees, and they are in an unfair competitive situation regarding you. You can compete and maybe charge lower prices, get business, while they on the other hand may be providing decent health insurance. I don't think that's that...

SANDERS: ... do believe, to be honest with you, that if you have more than 50 people, yes, you should be providing health insurance.

Here's the thing: The employer mandate was established mainly because nearly half the country already has coverage through their employer to begin with. Since the ACA was trying to be as non-disruptive as possible, it tried playing to this trend by requiring that large and medium-sized employers provide coverage.

The problem is that not only does this indeed create a lot of extra paperwork for the employers to keep track of who's covered, who isn't and so forth, but it also runs directly against another positive feature of the ACA: Getting rid of "job lock".

In any event, whether you agree or disagree with the employer mandate, I guarantee you that Bernie's response did not sit well with this woman. He was basically scolding her for being a crappy boss.

To his credit, Bernie did point out later on that there's a good chance that the real reason this woman's employees don't have healthcare coverage is because Texas never expanded Medicaid under the ACA, which means that her employees may very well fall into the Medicaid Gap. Unfortunately, that still doesn't address the "50 employee cut-off" issue.

On the other hand, Cruz didn't do himself any favors with the next questioner either:

TAPPER: ...since Obamacare was enacted, governors of 31 states, plus the District of Columbia, have opted to expand Medicaid through federal funding, providing insurance to 11 million low income people. One of the Americans who benefited from the Obamacare Medicaid expansion is Carol Hardaway of Salisbury, Maryland. Carol?

QUESTION: Thank you. I have multiple sclerosis, but could not afford insurance. Without the treatment or medications I need, I had problems with walking, with my speech, and my vision. When the Affordable Care Act was passed, I moved from our home state of Texas -- because they refused to expand Medicaid -- to Maryland, and within two weeks, I started receiving treatments through Medicaid and am now well enough to work as a substitute teach.

Senator Cruz, can you promise me that you and the Republican leaders in Congress will have -- actually have a replacement plan in place for people like me who depend on their Medicaid? In other words, I like my coverage. Can I keep it?

CRUZ: Well, Carol, thank you for sharing your story. And congratulations on dealing with MS. It's a terrible disease. And congratulations on your struggles dealing with it.

WTF??? Who "congratulates" someone for "dealing with" Multiple Sclerosis? Who "congratulates" them for their "struggles" dealing with MS? Good heavens.

You know, if you look at Medicaid, more than half of the people who have been covered under Obamacare have been under Medicaid. And the problem is: Medicaid is a profoundly troubled program. And so it may be working well with you, but I'll tell you nationally, the health outcomes under Medicaid are really poor.

Nationally, 54 percent of doctors won't take new Medicaid patients. Nationally, dental care appointments for moms are denied at a 63 percent rate on Medicaid. The denial rate for private insurance is 4 percent. And Medicaid patients are almost twice as likely to die from medical treatment as those with private health insurance.

Aside from the fact that he never actually answers her question (Tapper actually asked Ms. Hardaway whether he had done so and she confirmed that no, he definitely hadn't), Cruz starts ripping on Medicaid because a lot of doctors refuse to take new Medicaid patients. Of course, the reason some doctors don't take them is because Medicaid's reimbursement rate is too low for them to do so. There's an obvious solution to this: Increase the reimbursement rate, and suddenly doctors will be perfectly fine taking them as patients...except that would require raising taxes, of course, and the GOP line is to never do THAT, so the problem must be with the (underfunded) program itself.

I should also note that even if every one of Cruz's claims is accurate (and I have no idea whether they are or not), he's failing to point out that being "twice as likely to die from medical treatment" under Medicaid than under private coverage is still infinitely better than being 100% more likely to die without any treatment whatsoever.

Cruz is seriously trying to argue that you're better off not having any sort of coverage at all (and presumably crawling into an Emergency Room in the final stages of Hodgkin's Disease or whatever) than by being covered by Medicaid, which is simply nuts.

And what's happened also -- it's really quite striking -- because Obamacare dramatically expanded Medicaid, many of the people who had been on Medicaid, many of the people who are really suffering and needy, have found their wait times increasing. In fact in Illinois, on Medicaid, over 700 people have died on the waiting list for care for Medicaid.

Think about what he's saying here: "There's a lot of sick people waiting to be treated, and then Obamacare added more sick people to be treated!" I hate to tell you, Ted, but those additional sick people were already sick and suffering before Medicaid expanded. Cruz is acting as though adding these people to Medicaid magically caused them to become ill.

Later on, a visibly pregnant nursing student hit Cruz on the whole "pregnancy as an essential benefit" issue. You know the line: "I'm a man, why should I have to pay for maternity converge?" or "I'm a woman past menopause who'll never get pregnant again, why should I have to pay for it?"

Cruz's response was, of course, to say that it's a silly requirement...and then to go off on his obsession with "selling across state lines" bla bla bla, which, again, had nothing to do with the woman's actual question.

However, Sanders, in my opinion, also completely blew his response:

BASH: Senator, we're going to get to the question of fines and so forth in a minute. But I want to circle back to women's health and ask you, Senator Sanders, why should a 60-year-old male or women beyond childbearing years be required to have health insurance plans that have maternity care?

SANDERS: I don't think they should.

BASH: That's what Obama --

SANDERS: That's one of the things we might want to look at.

NO. You shouldn't be ceding this point, Bernie! The reason why maternity/prenatal care is required across every QHP is because it's fucking expensive and you need to spread the risk. That's the whole point of insurance in the first place.

Men can't become pregnant, and neither can older women, but by the same token, women can't get testicular or prostate cancer (well, technically speaking they could get prostate cancer but it's absurdly rare). Yet those are also covered as an essential benefit across all QHPs because that's the function of insurance.

If you strip out maternity/prenatal care from most policies, guess what happens? The same thing as segregating people with cancer, diabetes, etc. into high risk pools: The premiums might go down somewhat for everyone else, but the cost would skyrocket for the pregnant woman and her family. In addition, as Sanders himself notes, becoming pregnant isn't always an intended thing. Aside from cases of rape/incest, there are plenty of women who simply become pregnant when they didn't intend for it to happen (missed a pill, partner didn't wear a condom, what have you). Unless she chooses to have an abortion at that point (which, of course, is a whole other kettle of fish), it's gonna cost a ton of money to have that kid, and that's assuming it's a healthy pregnancy/delivery. If you get into neonatal care, forget about it; you could be talking $10,000/day or higher (my own son was a preemie, and the "official" full NICU price tag for the 10 days he was in the neonatal unit hit 6 figures easily).

The thing is, it's true that half the population can't get pregnant...but it's also true that 100% of the population was BORN at some point. To a mother. Who required, you know, maternity and prenatal care.

There are certainly some conditions, ailments, medications etc which you can debate whether they should be covered as standard or not, but maternity/prenatal care is not one of them in my book, and I'm rather stunned that Bernie conceded this point.

In fact, it's even more surreal because under Bernie's own "Medicare for All" single payer plan, maternity/prenatal care would be covered for everyone and paid for by taxes anyway...which means that yes, men and post-menopausal women would indeed be helping pay for it then as well.

UPDATE: Oh, I almost forgot the "Lamborghini" metaphor:

CRUZ: Every mandate, people will say, gosh, I like the -- imagine if the federal government mandated that everyone in America must drive a Lamborghini. I've never driven a Lamborghini. I mean, they look kind of fun. 

But you know what? I'm willing to bet most of us, if that was the mandate -- and it would be cool, you sit in a leather seat, you could go 200 miles an hour, what it would mean for most people is you couldn't afford a car? If they said, but, you know, gosh, the VW Bug is not fancy enough. You need everything. For most people who can't afford it, it doesn't work. 

That's what Obamacare is doing. I would love for everyone to have maximum coverage on everything, but there's no magic fairy with pixie dust that gives it away for free. These mandates are hurting people because it's putting people in a situation like Rolanda (ph) where they get nothing, they don't get healthcare of any kind. Her employees don't get healthcare because Obamacare has driven the cost up. That's why people are hurting so much under it. 

Actually, that's not what the ACA is doing at all. It's not saying you have to buy a Lamborghini (that would be a top of the line Platinum plan). What the ACA says is that you can sell a wide variety of cars, ranging from a Nissan Versa (Bronze) up to a Cadillac Escalade (Platinum), but that every model has to include 4 wheels, an engine, a steering wheel, seat belts, a windshield and so forth. You know, just like the NHTSA does for real. What you can't do is sell a golf cart and claim that it's a street legal automobile fit for the freeway.

Anyway, it went back and forth on that note quite a bit. They wrapped things up with the issue of PHARMA, re-importing drugs from Canada and Medicare negotiating drug costs, but really, I'm not sure that much good came out of the whole event. Cruz just kept spouting tired talking points (dude, enough with the "Sell Across State Lines" thing...even the carriers aren't interested in doing it the way you guys want) while Bernie gave a half-hearted defense of the ACA but kept shifting over to "Medicare for All" which kind of undercut his argument. I suspect the audience members who asked questions either didn't get an answer to their question at all or hated the response if they got one.

Bottom line: Healthcare is messy.