None of the remaining Republican presidential candidates has a detailed health-care plan. The one who has done the most to outline an agenda, Florida Sen. Marco Rubio, is still a bit lighter on those details even than Barack Obama was when he ran in 2008. But Rubio is at least on the right track, while the other candidates are wandering aimlessly, refusing to say where they would go, or headed in the wrong direction.
In the recent past, billionaire Donald Trump has said that he would repeal President Obama's health-care law and put in place a new system where the government would pay to make sure that everyone had health care. Costs would come down as a Trump-led government drove a hard bargain with providers. It sounded like Obamacare with even more micromanagement by the federal government.
In Thursday night's debate, Trump sounded different. He would still repeal Obamacare, and still faulted other Republicans for supposedly being willing to see sick people "die in the street." But it was unclear how his version of a world without Obamacare would avoid this horror.
He offered three clues. He would get rid of Obamacare's "individual mandate." He would keep Obamacare's protections for people with pre-existing conditions. And he would make it possible for people to buy health insurance across state lines.
Trump's first two points contradict each other. Obamacare includes an individual mandate to make its protection for people with pre-existing conditions work. If people can buy insurance on the same terms whether they're sick or well, and they're free to choose whether to buy it, they have an incentive to go without insurance when they're well and buy it when they sick. If enough people act on that incentive, insurance markets can't work. What Trump described is a formula for unraveling health insurance. It's possible to protect people with pre-existing conditions without a mandate -- but only if you protect them in a different way than Obamacare does.
Rubio said that he agreed with Trump's third point, but that by itself it would not do much. Trump harrumphed that he had nothing else to add to his plan. The Congressional Budget Office backs Rubio, not Trump. It found in 2009 that a health plan featuring interstate purchase would cover only three million more people than the pre-Obamacare health system.
Ohio Gov. John Kasich talked about managing government health-care spending better, rewarding the better providers and penalizing the worse ones in a way that he suggests will make the whole system more efficient. While the Ohio governor has presented this idea as an alternative to Obamacare, it is more accurate to say that it's an attempt to build on it. The government's enormous role as a purchaser of health services gives this idea some plausibility. The fact that it is barnacled by special interests and bureaucracy, and limited in what it can know about how health care should evolve, takes it all back.
Rubio's idea, which has support from an increasing number of Republicans, would replace Obamacare with a health-care market in which the government plays an enabling rather than a managerial role. The tax break for employer-provided insurance, which existed before Obamacare, would be changed: It would no longer reward the most expensive employer plans for being expensive, and people without access to employer plans would get a tax credit that they could use to purchase at least catastrophic coverage for themselves.
While Rubio has not specified how he would make sure that people with pre-existing conditions could afford care, we can guess from what he has said and from plans that are similar to what he has said. Insurers would have to provide coverage to them at the same rates as everyone else, so long as they had bought coverage when they were healthy. So people would have the incentive to buy when healthy and, thanks to the tax credit, they would have the ability too.
The health-care ideas Rubio has endorsed would repeal Obamacare, and let markets flourish, without people dying in the streets. Trump might even find that he likes these ideas, if he ever thought about them.