Dan Gorenstein: Dumpster fire is one way to sum up the first presidential debate. About a third of the 90-minute free-for-all ended up being about health care.

We heard some wildly untrue one liners…

Trump (debate clip): Insulin, I’m getting it for so cheap, it’s like water.

DG: We heard another dead-end debate over the ACA…

Biden (debate): There are 20 million people getting health care through Obamacare now and he wants to take it away.

Trump (debate): Obamacare is no good.

DG: And we heard coronavirus accusations fly…

Trump (debate): I don’t wear masks like him. Every time you see him, he’s got a mask. He shows up with the biggest mask I’ve ever seen.

Biden (debate): He knew all the way back in February how serious this crisis was.

DG: What we didn’t hear: a substantive debate over the real, hard health policy questions facing America. Today, from the Annenberg Studio at the University Pennsylvania…the conversations these candidates could be having.

I’m Dan Gorenstein and this is Tradeoffs. 

To help us have the conversation lots of us health policy wonks longed for…we’ve invited on Harvard health economist Amitabh Chandra.

Amitabh, let’s first start with Vice President Biden’s proposal around a public option, which would be a government run health plan that competes with plans offered by Aetna, Cigna and United — private insurers.

Hit us with the upside that comes with a public option.

Amitabh Chandra: So a public option makes a ton of sense in markets where we have insufficient competition between private insurers. So, if you have a market with a single private insurer, that private insurer can charge exceedingly high prices. So in that market, if we introduced a public option, an option that paid Medicare rates, then the private plan has to compete with those Medicare prices and premiums would come down.

DG: And what about the downside?

AC: The problem is what happens if we roll the public option out nationally. It essentially becomes a way to kill off the private insurance market. And while I don’t really care about private health insurance companies, I do care about the fact that in the absence of competition, you don’t get innovation. Think about a world, Dan, where we only have a public option and people are actually willing to spend more for a better cancer treatment for a better hospital stay and the public option refuses to pay for that kind of improved quality. Well, if it’s not willing to pay for that kind of improve quality, we’ll never get that improved quality.

DG: This really gets to almost philosophical question, Amitabh, which is what’s the purpose of health insurance?

AC: Dan, that is such a good question. It’s a question I think we don’t spend enough time talking about right now in America. Health insurance is a bit like fire insurance. Fire insurance helps me if my house burns down. It doesn’t actually prevent my house from burning. And so health insurance today in America looks a lot like a financial product that allows me to pay for expensive drugs, expensive doctors, expensive hospital care if I fall sick. But it’s not preventing me from falling sick. And if it becomes a product that keeps me healthy, it’s going to have to think a lot more about long-term prevention, like making sure that I’m not hungry or that I’m not cold. If we want health insurance to be something different than fire insurance we’re going to have to spend more.

DG: Biden said one in 1,000 Black Americans have died from COVID. As you know, racial disparities persist in lots of other health care outcomes as well. Amitabh, how should our health system address these gaps? 

AC: First of all, let’s just make sure that everyone in America, regardless of their race or socioeconomic circumstance, is covered. But I think we’re going to have to do much more than just insure people. So we’re going to have to do a lot more taking on of the social determinants of health. But I think at some point we also have to realize that the structural racism that exists in American society cannot be solely the responsibility of the health care industry to fix at some point, we have to be willing to take on the criminal justice system, the schooling system and the particularly regressive manner in which we fund schooling. If you want to change American society for the better, fundamentally, we’re going to have to have a very robust conversation on tax policy.

Chris Wallace (debate clip): The second subject is covid-19, which is an awfully serious subject, so. Let’s try to be serious about it.

DG: Moderator Chris Wallace did his best. 

Since that didn’t happen during the debate…we asked University of Michigan professor and chief health officer Preeti Malani to walk us through a couple of the key questions.

Preeti, obviously, everyone is desperate for a vaccine to get us out of this situation. But what else do you think the American people need to hear about this vaccine process besides that it’s moving fast?

Preeti Malani: Really, vaccine development has been one of the success stories out of the pandemic with Operation Warp Speed helping to coordinate and speed up the approval process, which normally takes many years. But I’d like some precision about it, not just that they’re going to be vaccines very soon, but what does a vaccine actually mean? That is a separate conversation that I have not heard, at least from elected leaders, yet. The ability to get a vaccine doesn’t mean that the current situation is going to end in an instant, but it is an important way forward.

DG: There’s a lot of skepticism among people, right, about this vaccine’s safety. In a recent NBC poll, less than half of Americans said they’d get a vaccine if it were available right now. What should be done to increase that trust?

PM: So what I want to hear is really that the approval process — and I think all Americans really want to hear this — that the approval process will be rigorous based on scientific data and that all that information will be shared fully even if it takes longer. Safety has to be front and center, especially when this is a new vaccine that feels like it might be experimental. One of the biggest tragedies that I can imagine is that we have a safe and highly effective vaccine that no one wants to get. 

DG: And that’s why safety has to come first, even though there’s clearly a need for speed here. 

PM: One of the things that I’ve had to think about and that some of my colleagues have had to think about is whether to enroll in clinical trials ourselves and we have had conversations offline saying, you know, this is safer than getting COVID, even if there are some unknowns. And you need that safety data up front and you need scientists to lead in the space.

DG: Would you be willing to take the vaccine early in an effort to, as you say, lead as as as a scientist?

PM: I did volunteer to enroll in one of the trials that’s being done at my institution, but that vaccine trial is currently on hold. So I haven’t been called, but I would feel comfortable to enroll in the clinical trial. And then when a vaccine eventually becomes available, I plan to get vaccinated and I plan to encourage my family to do the same.  

DG: Preethi, what else would you really like to hear candidates discuss in a debate around this pandemic and its policy implications?

PM: One thing that I don’t hear enough about is just the fact that families are in distress, kids are home, parents are worried about their jobs. People cannot visit with their older relatives. I think this is all unsustainable. And we’re not really capturing the full human toll of the pandemic. I just want to really hear a more comprehensive view, like what do we need to do to move forward, not just we’re going to have a vaccine, but how are we going to put everything back together.

DG: And if COVID is really a chance for the US to put things back together, that includes our health care system…which could be facing some real existential questions soon whether the Supreme Court overturns the ACA or the Democrats take back the White House and the Senate.

So I asked Amitabh one final question about how we should do that. I wanted to close on his response because I think it’s good food for thought…health food, not the meal full of empty carbs we got Tuesday night.

DG: You and Kate Baicker, who is currently a dean at the University of Chicago, wrote in the new wrote in the New England Journal of Medicine about the slogans our politicians use. And you and Kate urged the country to have more serious conversations to understand the difficult challenges that come with improving our health. How do you think we can begin to have this conversation?

AC: It’s certainly true that these slogans allow listeners to fill in their own notions and mask varying beliefs. You know, Medicare for All appeals to our preferences for universal coverage, but it sidesteps all these difficult discussions about the tradeoffs from a public option. On the other side of the political aisle, you know, repeal and replace absolutely appeals to people’s skepticism about government’s role in health care, but leaves voters to imagine what a replacement might be like.

The single biggest question in health care or the single biggest tradeoff in health care that we have never confronted as a nation is, you know, whom to cover versus what to cover. So in other words, the more exotic treatments that we cover, the more expensive hospitals we cover, the less money there is to insure other people. If we figured out a way to actually say health care may be a right, but that doesn’t mean that infinite health care is a right we would actually be able to make coverage available to all Americans, but as long as people think that you can get something for nothing like, “Oh, I’m going to insure people and save money doing that,” we’re not dealing with this fundamental tradeoff. We never dealt with it in 1965 when we created Medicare, we never dealt with it in 2010 when we passed the ACA. So I think, you know, to answer your question, Dan, I think a kind of some willingness to kind of get past the slogans and get into understanding what it is that people actually want would help us arrive at a far more sustainable solution.

DG: If your craving for substance still isn’t satisfied, we’ve put together a handy guide to both candidates’ policy positions on our website: tradeoffs.org/trumpbiden

There you’ll find breakdowns of each candidates’ positions … plus analysis from top health policy experts.

I’m Dan Gorenstein, and this is Tradeoffs.