President Donald Trump was at it again on Thursday night, promising to protect health care for many millions of Americans while he’s actually trying to take it away.
The vow came during the second and final 2020 presidential debate, which was held in Nashville, Tennessee. Moderator Kristen Welker, from MSNBC, asked Trump how he would respond if the Supreme Court strikes down the Affordable Care Act, taking coverage away from an estimated 21 million people and throwing the health care system into chaos.
It’s a real possibility because the court is hearing a new challenge to the law one week after the election. And by that time, Trump appointee Amy Coney Barrett is likely to be on the bench.
“It is in court because Obamacare is no good,” Trump said. And if the court does throw it out, he said, he had a plan to give the American people “brand new, beautiful health care” while “always protecting people with preexisting conditions.”
The lawsuit against the ACA originally came from 20 Republican state officials, but it has Trump’s support. He instructed the Justice Department to file briefs supporting it, even though sitting administrations typically defend all federal statutes in court.
And that was just one instance of Trump trying to get rid of “Obamacare.”
He spent the first year of his presidency trying furiously to push repeal legislation through Congress and, when that failed, he tried to use his executive authority to undermine the law ― by, for example, slashing outreach funds or promoting work requirements in Medicaid that would limit enrollment in the Affordable Care Act’s expansion of the program.
Trump has throughout these efforts made claims like he did on Thursday night ― that he would make sure there was “insurance for everybody” and that coverage would be cheaper and more secure than it was already.
He’s also made very specific promises to protect people with preexisting conditions, and last month he actually issued an executive order that would supposedly make that promise a policy reality.
But the executive order was meaningless, as experts pointed out quickly, and that’s pretty typical for what he’s tried to do. Pretty much every piece of legislation he supported during the repeal fight would have dramatically reduced the number of Americans with insurance and undermined existing protections for people with preexisting conditions.
The only question was how many would lose coverage and how weak those protections would get.
Since then, Trump has repeatedly promised he’d come up with an alternative like the one he described in his presidential campaign and again on Thursday ― one that would provide better coverage than the Affordable Care Act has made available, at a lower price. But he never has.
There’s a reason for all of that. Health care (as Trump famously acknowledged after taking office) really is complicated. And protecting people with preexisting conditions isn’t simply a matter of issuing some kind of executive edict.
It requires, instead, some combination of government regulation and government spending ― whether it’s the complex subsidies and rules of the Affordable Care Act or something that looks more like “Medicare for All,” the proposal to displace private insurance with a new, government-run insurance plan.
Trump actually brought up Medicare for All, by implication, when he said that former Vice President Joe Biden wanted to get rid of private insurance and introduce socialized medicine. As Biden rightly pointed out, he explicitly rejected Medicare for All during the primaries ― drawing a clear distinction between him and more progressive candidates, most notably Sen. Bernie Sanders (I-Vt.).
For better or worse, Biden has instead proposed to bolster the ACA by making its financial assistance more generous, by making subsidized insurance available to more people and by creating a “public option” into which enrollment would be voluntary.
In the discussion of the public option, Biden made a false statement of his own: He said that nobody would lose their private coverage under his plan, just like nobody had lost their plans under Obamacare, except when they wanted to switch coverage.
Virtually any change in insurance rules could lead to some cancellation of plans and, in at least some cases, people who lose those plans might be upset about it. This was memorably a major source of controversy during the first year of the Affordable Care Act’s implementation, when cancellation notices showed up in mailboxes and people who thought they’d get to keep their old plans couldn’t.
But most employers are likely to keep offering insurance, at least for the time being, because they will still have plenty of incentive to do so. Although it’s entirely possible millions would move from employer plans into the public option ― or subsidized private insurance, like the kind available through HealthCare.gov ― it’d predominantly be people who switched because it allowed them to save money.
Instead, the biggest tradeoff in Biden’s plan is likely to be the sheer cost. His proposal would make insurance more affordable primarily by having the government spend a lot more to subsidize people who don’t get enough help now.
The price to the federal government is likely to be $750 to $850 billion over 10 years, according to the latest (and still very rough) projections. But Biden came right out and said that on Thursday night ― and pointed out, accurately, that the money would make it possible for people to get “better plans, cheaper plans.”
The savings for lower- and middle-class workers could be substantial, as a recent report from the Henry J. Kaiser Family Foundation demonstrated. In addition, between 12 and 15 million previously uninsured Americans would get coverage, according to the Committee for a Responsible Federal Budget.
Afterward, Biden summed up the goal of his agenda.
“I don’t think health care is a privilege,” he said. “It is a right. Everybody should have the right to affordable health care.”
It’s not so different from what Trump always promises, except that Biden’s policies would bring the U.S. closer to that goal and Trump’s would push it farther away.
This article originally appeared on HuffPost and has been updated.