Did Healthcare Policy Issues Play a Role in the Iowa Presidential Caucus Results?

By Harris Meyer for Modern Healthcare

After attacking Donald Trump over the weekend for his previous favorable remarks about single-payer healthcare, Texas Sen. Ted Cruz squeaked out a victory over the billionaire New York developer in the Iowa presidential caucuses Monday night, with Florida Sen. Marco Rubio trailing close behind.

Meanwhile, the Iowa Democratic Party declared Hillary Clinton the narrow winner over Vermont Sen. Bernie Sanders in their unexpectedly tough contest for the Democratic nomination, though Sanders had not conceded early Tuesday morning. Former Maryland Gov. Martin O’Malley dropped out of the race after winning only a tiny proportion of the caucus votes. Unlike Sanders’ support for single-payer national health insurance, O’Malley’s advocacy for a system like Maryland’s featuring a global budget for hospital spending gained little traction with Iowa Democrats.

Rubio’s strong third-place finish positions him well for the Nov. 9 presidential primary in New Hampshire, where GOP voters tend to favor more mainstream conservatives, though Trump has led the polls there for months. Cruz is expected to do better in the Feb. 20 primary in South Carolina, where a high percentage of Republican voters are evangelical Christians, as in Iowa.

Republican presidential hopefuls Jeb Bush, Chris Christie, and John Kasich won small shares of the Iowa caucus votes, and will have to do well in New Hampshire to save their candidacies.

It’s unclear whether healthcare policy issues played a role in the GOP caucus results, but some observers believe Sanders’ support for single-payer helped him energize his supporters in the Democratic race.

Most of the Republican candidates have said little about healthcare during the campaign so far other than denouncing the Affordable Care Act and calling for its repeal.

Cruz offered slightly more detail last week, saying he wants to “delink health insurance from employment, so if you lose your job, your health insurance goes with you, and it is personal, portable and affordable.” He cited three pet conservative reforms he favors–allowing insurers to sell plans across state lines, expanding health savings accounts, and severing the link between coverage and employment. The problem is that he offers no way to maintain the ACA’s coverage expansion if he abolishes the law.

Indeed, on Saturday an Iowa voter challenged Cruz with a story about how his brother-in-law was only able to afford health insurance after the ACA took effect. He twice asked Cruz what he would replace the law with. Cruz replied with his standard proposal for expanding health savings accounts and allowing insurers to sell plans across state lines.

Over the weekend, Trump said he strongly opposes Obamacare and rejects a single-payer system. But when asked how his healthcare proposal differs from the ACA, Trump said “I want people taken care of” and that he would “work something out” after abolishing the ACA. “We’re going to work with our hospitals. We’re going to work with our doctors. We’ve got to do something … I have a heart.”

Rubio last summer laid out a brief healthcare proposal centered on offering a refundable tax credit to help people buy health insurance, with a gradual reduction in the tax exclusion for employer health plans. In addition, he would establish federally funded high-risk pools to cover people with preexisting conditions, let insurers sell plans across state lines, and expand health savings accounts. Plus, he promised to shift Medicare into a defined-contribution, “premium-support” system and convert Medicaid into a capped state block grant program.

On the Democratic side, there has been a spirited healthcare policy debate between Clinton and Sanders, with Clinton favoring fixes to the ACA to reduce consumers’ out-of-pocket and drug costs and Sanders advocating a tax-supported single-payer system with no premiums, deductibles, or cost-sharing.

Sanders seemed to win substantial liberal support in Iowa with his single-payer stand, though some liberal analysts questioned the political and economic viability of his proposal. It remains to be seen how much appeal his single-payer stance will have in New Hampshire and South Carolina, where Democrats may be less enthusiastic about a plan that would require significant new taxes on middle-income households.