Where are the hard questions about health care?

Published 9:14 am Thursday, September 1, 2016

Minneapolis Star Tribune

Distributed by Tribune Content Agency

Namechecks of a current and former speaker of the U.S. House cropped surprisingly often during a recent debate in Minnesota’s Third Congressional District.

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As DFL challenger Terri Bonoff tried to tie incumbent Erik Paulsen to GOP presidential nominee Donald Trump, the four-term Republican congressman responded with repeated references to Reps. Paul Ryan and Nancy Pelosi. Ryan, R-Wis., is the current speaker. Pelosi served in that role from 2007 to 2011. The dots Paulsen wanted the audience to connect: that he aligns himself with Ryan, known for his deficit-busting plans, and that Bonoff would ally herself with Pelosi, D-Calif.

The frequent references to the speakers, both of whom are bona fide health care policy wonks, were welcome in that they put a timely spotlight on health care, an issue lamentably neglected this election year, particularly at the presidential level.

Pelosi is unquestionably an Affordable Care Act (ACA) architect, for which she is both lionized and demonized. Less well understood is that Ryan is the leading proponent of another dramatic health care overhaul that, if passed, could bring significant changes to Medicare, the popular health insurance program relied on by those 65 and older.

No further debates between Paulsen and Bonoff, a state senator, have been scheduled. That’s a shame: More are needed. The Aug. 17 event raised more questions than answers. Health care is also a critical issue in the Third District, home to many medical device companies. Energetic exchanges between two knowledgeable candidates could spur voters to ask harder questions of other Minnesota office-seekers.

Bonoff’s time in the Minnesota Senate during the ACA’s bumpy rollout gave her an up-close view of the law’s implementation challenges at the state level. She was also one of the few DFL legislators to criticize the 2013 legislation enabling the creation of MNsure. Voters deserve to know more about how she’d fix ACA challenges, such as the dwindling number of health insurers competing for consumers in ACA marketplaces.

Paulsen’s invocation of Ryan begs follow-up, as well. How would the broad changes to Medicare that Ryan calls for impact the thousands of seniors in Paulsen’s district who rely on this popular program?

Ryan has long called for raising the Medicare eligibility age from 65 to 67 and for transitioning Medicare to a “premium support” system in which the federal government would offer seniors a certain level of assistance to buy a health insurance plan. In general, premium support plans differ from today’s Medicare in that they would shift the program from one that guarantees health care coverage to one that provides a contribution to help seniors buy a plan. If it sounds a lot like the shift from “defined benefit” retirement pensions to today’s “defined contribution” 401(k) savings account system, that’s because it is.

Questions about Medicare’s future, including how Democrats plan to sustain this expensive program, urgently need airing beyond Minnesota’s Third District. Many Republicans, including Ryan, have endorsed Donald Trump. They believe it would be easier to enact the Republican Congressional agenda with the New York businessman in the Oval Office. Raising the Medicare eligibility age and the premium-support plan is still very much part of that agenda.

Trump’s inflammatory rhetoric and Hillary Clinton’s e-mail mess have kept health care in the background this election year. That’s unacceptable. Democrats’ signature health reform — the ACA — needs improvement. Medicare changes called for in a hallmark Republican health policy aren’t well understood. It’s time for health care to be front and center in 2016.