Off the Couch, Onto the Stage: My First, Only and Not-So-Great Presidential Debate

DETROIT, MICHIGAN – JULY 31: Democratic presidential candidate former Vice President Joe Biden (C) speaks while Sen. Kamala Harris (D-CA) (R) and Sen. Cory Booker (D-NJ) listen during the Democratic Presidential Debate at the Fox Theatre July 31,


I could’ve been Kamala Harris, Joe Biden and Marianne Williamson all rolled into one. That’s how I might have handled my first, only, and not-so-great presidential debate. 

No, I wasn’t actually running for president. But I was involved in the campaign of someone who was: Barack Obama. In September, 2008, the campaign asked me to serve as a surrogate in a debate with John McCain’s health care adviser when one of Obama’s close advisers – as opposed to me, who’d met the candidate once at a campaign event – couldn’t make it. 

As a policy wonk and politics junkie, I was ecstatic. Entering the debate, I was confident. Afterwards, metaphorically dusting the dirt off my clothing and checking for cuts and bruises, I was chastened. 

Getting off the couch and onto the stage, even a small one, is tougher than it looks. Watching the cluster of Democratic presidential candidates go at it on health care, I scoffed and sneered along with other experts at their obfuscations and oversimplifications. (More on that in a moment.)  But I also sympathized. 

As the fictional Mr. Dooley character opined in oft-quoted wisdom, “Politics ain’t bean-bag.” That’s an old-fashioned way of saying that politics is a rough game.

The Obama campaign turned to me because they knew me, the event was close by, and it involved senior corporate human resources (HR) executives. I’d been a health care consultant for an HR consulting firm. 

McCain’s adviser had been hurriedly brought onto the campaign when health care became a high-profile issue. Having pored over the differences between Obama’s thoughtful plan and McCain’s sketchy one, I almost felt sorry for someone having to defend it.

Republican presidential nominee John McCain (L) and Democratic presidential nominee Barack Obama (R) during the 2008 debates

I’ve dug up my brief opening statement. Similar to California Sen. Harris, I touted a plan whose goal was “affordable, comprehensive and portable health coverage for every American.” In the mold of former Vice President Biden, I praised a plan that would “contain spiraling health care costs.” And let’s not forget wellness guru Williamson. The Obama plan, I told the group, would help “prevent disease and protect against natural and man-made disasters.”

Wait. Did I actually imply that Obama would eliminate floods and earthquakes?

Perhaps I was a tad overenthusiastic. But as the debate began, and I prepared to dazzle the group with detail, a couple of things became obvious. First, the HR exec moderator wasn’t going to strictly hold my opponent to the time limits on opening statements and responses. Second, and more worrisome, was that my opponent could tell bald untruths and nobody seemed to realize it.

Sound familiar?

For instance, nonpartisan analysts concluded that McCain’s plan would do almost nothing to cover the uninsured. Indeed, a conservative intellectual who’d helped craft it suggested that as long as there were hospital emergency rooms, there was no such group as the “uninsured.”

Moreover, the McCain plan would blow up the employer-based system – and remember, this was an employer audience – in favor of individual tax credits, a marketplace experiment that makes today’s Medicare for All proposals look meek.

None of this, however, was getting across. If this was a boxing match, I was being repeatedly hit below the belt while the ref just smiled.

So I changed tactics. Became more aggressive. Didn’t worry as much about time. Emphasized key, simple points no matter what the question. The momentum turned. At the bell, it was at worst a draw, as the massive media coverage (one reporter for a trade publication) showed.

Up on the Big Stage, as we’ve repeatedly seen, it’s often not all that different. When former Maryland Congressman John Delaney challenged Massachusetts Sen. Elizabeth Warren on Medicare for All, she responded with a scorching soundbite that had a lawyerly relationship with the truth.

“We are the Democrats. We are not about trying to take away health care from anyone,” Warren declared. “That’s what the Republicans are trying to do.”

great applause line for the faithful. But while it’s true Republicans pay mostly lip service to covering the uninsured, the Medicare for All proposal of Warren and Sen. Bernie Sanders (I-Vt.) would, in fact, take away private health insurance, exactly as she was accused of doing. And while Sanders was correct that saying hospitals would suffer widespread bankruptcy if all of them were paid Medicare rates ignored the administrative savings from eliminating private insurer paperwork, the skeptics are also assuredly correct about the bad politics.

As I wrote in a recent health journal article:

“A health reform that upends the lives of the 67 percent of the American public that has private health insurance, however inadequate or unaffordable it may be for some, in order to move the total number of the insured from 90 percent to 100 percent, consistently fails to garner popular support once trade-offs become clear. A political promise that, after an unspecified period, people’s health care costs will drop and their paychecks will rise has little to no credibility.”

Not to mention the problem of throwing out of work everyone whose job in any way touches on the health insurance industry.

Interestingly, while the candidates spewed calculated sound bites either demonizing insurers or defending “employer” and “union” health insurance (and carefully avoided mentioning sky-high hospital prices), none pointed out that those evil “high deductible, high co-pay” plans were not the insurers’ idea. Instead they were originally the brainchild of conservative ideologues who assured us that having “skin in the game” would drive down costs by making Americans smarter consumers.

That mantra was embraced by employers, who could tell their workers they were encouraging eagle-eyed shopping. In fact, since few of us can distinguish necessary from unnecessary medical services, so-called “consumer-driven health plans” just shifted costs from companies and insurers to individuals, who promptly started putting off “I’ll-get-to-it-when-I-can” services like cancer screening.

But when you’ve got a minute to talk and 30 seconds to respond, nuance gets neutered, and no one dares acknowledge that complex problems like health care costs, access and quality or immigration or the spread of nuclear weapons don’t have simple solutions. 

These are not so much debates as a chance to make a sales pitch, and who cares if the morning-after critics moan. As I learned in even my very brief appearance on a minor presidential debate side stage, the only goal is to win.

Michael L. Millenson is president of Health Quality Advisors LLC and adjunct associate professor of medicine at Northwestern University Feinberg School of Medicine. This article originally appeared on Forbes here

1 reply »

  1. Americans say they want “change” but are afraid to vote for a candidate who advocates change, so end up voting for platitudes and false promises – then feel betrayed. Not sure how employer plans exert co-pays and deductibles but I’ve not heard anyone happy with their employer plans either.

    I’m for Medicare for All as that’s the only way to lower prices. The employer plans can stay, but as employers see how economical Medicare is they’ll soon dump employees on to it. Remember when employers were dumping people onto the ACA.

    Right now rural hospitals are going bankrupt. How happy would rural residents be if Medicare saved their local hospital.