1. The Sanders-Cruz Debate
When I first heard Sen. Cruz and Sen. Sanders were going to be debating healthcare on CNN, my specific thought was, "Wow, that will be useful, a debate on healthcare, one between two men who are neither clinicians, nor administrators nor even healthcare lawyers nor health economists. That should add a lot to the debate!"
My general observation over the years about healthcare reform is that when people on the Left don't really understand the issue, they talk about "single payer" and that when people on the Right don't understand the issue, they talk about "buying insurance across state lines."
After listening to the debate, as to both points (as we used to say at FT Sill): "Check."
2. Why Don't the Exchanges Work as Pres. Obama Promised?
To be brief, policies in the individual health insurance markets, that were offered in "guaranteed issue," states, were often unaffordable (like the individual market in New York State after 1993 reforms). On the other hand, health insurance on the individual market, in states where insurance coverage could be denied due to pre-existing conditions, were much less expensive, but were also much harder to get.
Functionally, PPACA made the individual health insurance market in the entire country "guaranteed issue." Predictably, this made insurance in the individual market easier to get but much harder to afford.
On the other hand, the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") did away with exclusion for pre-existing conditions in group insurance, requiring a 12 month waiting period that could be waived in the case of continuous coverage.
While this is less favorable to people with pre-existing conditions than PPACA it is both favorable and sustainable. And, if there were mechanisms that favored continuous coverage (Sen. Cruz's point about "portability"), then waiting periods would become a fairly moot point.
3. What Might Work Better?
At this point, it is worth looking at what other nations do about paying for healthcare. A good reference is T.R. Reid's 2010 book, The Healing of America,
In general, per Reid (and contrary to Sanders), the lowest costs and the best clinical outcomes tend to be, not is "socialized medicine countries" (like Great Britain, with the National Health Service, a government-owned delivery system, or Canada with Medicare, a government [Federal and Provincial]-run insurance program), but in countries with "Bismarck Systems" (like France, the FRG and Japan).
Bismarck Systems are systems of government regulated and mandated universal private insurance. To an extent, the employer-based health insurance that covers a declining majority of Americans is a sort of a Bismarck system.
Introduced during World War II as a way around wartime wage & price controls, unions fought for its expansion during the 1950s and 1960s, but it never became universal. This was probably due to the fact that even in the "Organization Man" 1950s, most Americans were employed by small businesses or were self-employed.
Because of the general movement towards self-employment (the "Gig Economy"), those trends are getting even stronger than they were. One way to cope with te trend is with PPACA which, either is the form of the Exchanges or in the form of Expanded Medicaid, is not employment-based. However, as described above, an individual market for health insurace does not really favor the consumer.
The Fundamental Questions, then, seem be to be: 1) how do you build a Bismarck System for the "Gig Economy;" and 2) how do you structure non-employment (perhaps more accurately stated, "non-employer")-based groups?
To Be Continued . . . .