Perspective from the 19^th Hole is the title I chose for my personal blog, which is meant to give me an outlet for one of my favorite crafts – writing – plus to use an image from my favorite sport, golf.  Out of college, my first job was as a reporter for the Daily Astorian in Astoria, Oregon, and I went on from there to practice writing in all my professional positions, including as press secretary in Washington, D.C. for a Democrat Congressman from Oregon (Les AuCoin), as an Oregon state government manager in Salem and Portland, as press secretary for Oregon’s last Republican governor (Vic Atiyeh), and as a private sector lobbyist.  This blog also allows me to link another favorite pastime – politics and the art of developing public policy – to what I write.  I could have called this blog “Middle Ground,” for that is what I long for in both politics and golf.  The middle ground is often where the best public policy decisions lie.  And it is where you want to be on a golf course.

Donald Trump and J.D. Vance have no idea what they are talking about when it comes to national health care policy.

So, health care stands much like almost every other public policy topic for those running on the Republican presidential ticket.

They don’t care about policy, including for health care.  Or they don’t even want to know about it.

Doing so would just distract them from criticizing everyone and everything.

Consider two recent developments:

• In the debate against Kamala Harris, when Trump was asked whether he had a plan for health care coverage that would either replace or improve upon the Affordable Care Act, he said only this:  “I have concepts of a plan.”

• Then, to compound this incomprehensible statement, Vance, in the vice-presidential debate against Democrat Tim Walz, claimed that, as president, Trump worked hard to save the Affordable Health Care Act, which had been developed by President Barack Obama.  Of course, Trump tried to do just the reverse.  He wanted to send it to the dust bin.

New York Times opinion columnist Paul Krugman wrote about some of this in a recent post.  It started this way:

“Donald Trump has been ridiculed, rightly, for his answer, during his debate with Kamala Harris, about whether he had a plan for health care coverage that would either replace or improve upon the Affordable Care Act:  ‘I have concepts of a plan.’

“He has been running for president or sitting in the White House for nine years, and that’s all he has?

“But the other day, J.D. Vance, his running mate, gave us a bit more insight into those concepts — concepts that, if implemented, would have the effect of denying health care to millions of Americans, particularly those who need it most.”

Krugman continued:

“On September 15 on ‘Meet the Press,’ Vance — after noting that people in good health have very different needs from those with chronic conditions — called for de-regulation, saying that we should ‘promote some more choice in our health care system and not have a one-size-fits-all approach that puts a lot of people into the same insurance pools, into the same risk pools.’

“It’s not clear whether Vance was laying out a real vision for health policy or just floating his own concepts of a plan.  These remarks by Vance — who is closely associated with the Heritage Foundation’s president, Kevin Roberts, one of the architects of Project 2025 — sounded similar to this airy statement in the Project 2025 manifesto:

“The federal government should focus reform on reducing burdens of regulatory compliance, unleashing innovation in health care delivery, ceasing interference in the daily lives of patients and providers, allowing alternative insurance coverage options and returning control of health care dollars to patients making decisions with their providers about their health care treatments and services.”

Why, Krugman asks, would Vance stake out such an unpopular position, conveying the impression that he was speaking for Trump as well?

“I don’t know whether he was blurting out in public what Project 2025 proponents say to one another in private or whether he was just winging it on an issue he really hasn’t thought through.  Of course, these explanations aren’t mutually exclusive.

“In any case, while Trump doesn’t have a health care plan, Vance’s remarks offer a pretty good preview of what he’ll propose if he wins.  It might be summed up as:  ‘Trump to Sick Americans:  Drop Dead.’”

Back in the day, just after I retired as a health care lobbyist in Oregon, I wrote this:  “It’s time for something different, a middle-of-the-road plan that takes into account perspectives from reasonable folks on both sides of the aisle in Congress.”

I outlined what I called “four legs of the health care stool.”

1.  It won’t be popular in some quarters, especially with some Republicans, but, first, a critical component of reform is to require all citizens to have health insurance, either by buying it if they can afford it, or by having it provided, at least partially, by government if they cannot.

Without everyone in the to-be-insured pool, any system will collapse.  The very rationale for insurance is that the largest pool possible should be covered to spread the risk.

Think of it this way.  All of us who drive cars are required to have automobile insurance.  If we don’t, we pay a price.  The same policy should exist for health insurance.

2.  Second, a catastrophic health insurance plan should be provided so that those who cannot afford regular insurance have an option for a lower-cost plan, such as has occurred to a degree with what has come to be called ObamaCare.

3.  Third, just as is now the case with ObamaCare, any new middle-of-the-road health coverage approach should accommodate people with pre-existing health conditions.

I have mixed emotions about this because, inevitably, the price of insurance has gone up and will go up further with the added risk of covering pre-existing conditions.  Yet, there is a reasonable social consensus that people should not be penalized financially for health problems largely outside of their control.

And, I firmly believe in the concept that human beings should take care of other human beings (if they are willing to accept help) rather than send the differently-abled to the scrap heap.

4.  Fourth, any new plan should allow broad access to health-savings accounts (HSA).  ObamaCare pushed millions of Americans into high-deductible insurance without giving them the opportunity to save and pay for care before insurance kicks in.  

There should be a one-time federal tax credit to encourage all Americans to open an HSA and begin using it to pay for routine medical bills. And HSAs, combined with high-deductible insurance, could be incorporated directly into the Medicare and Medicaid programs.

Now, the reality is that, given the achievements of ObamaCare, health care policy is not necessarily top-of-mind as it used to be, nor has it been a major issue in the current presidential campaign.

Trump and Vance should be thankful for that, because if health care policy rises in the public consciousness, the two of them have nothing good to say about health care – or perhaps even nothing at all.

Which is what they have to say about almost anything these days.