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The critical issue the first debate missed

Story highlights
  • Lynn O'Connor Vos: First presidential debate left one key domestic issue out: the state of American health care
  • Moderators in the forthcoming debates must push the candidates to define and defend their health care platforms

Editor's Note: (Lynn O'Connor Vos is chief executive officer of Greyhealth Group. She is a registered nurse and a board member of the Jed Foundation, a national mental health advocacy organization. She is also a donor to the Clinton campaign. The views expressed in this commentary are her own.)

(CNN) As America decides on its next president, two critical domestic issues are at stake -- the economy and health care. In their first debate, Hillary Clinton and Donald Trump spoke at length on one: the economy. But how much time was devoted to the other? Absolutely none. Unless you consider Donald Trump's possible symptoms -- sniffling, fatigue, dehydration -- which suggest that his own health may have been partially compromised.

Lynn O'Connor Vos

And though a candidate's health is important, the health of more than 300 million Americans is even more significant and worthy of discussion in the remaining presidential debates. In mid-summer, the Pew Research Center reported that 74% of Americans consider health care a critical issue in this election cycle. (Only the economy, terrorism and foreign policy scored higher.) Because it is an issue that affects every American, concern over health care is notably also bipartisan and steady across age groups.

Though Obamacare reforms have slowed the rise of health care costs, added 20 million people to the ranks of the insured and created a revolution in health care information, there are still glitches in the system. The next president will be expected to guide the repair process -- and at the first debate we did not get to hear about that process. We need to going forward.

Where do the candidates stand?

No one is happier with Obamacare than Clinton is. She says she will build on the Democrats' success and implement steps to improve on what we have, making the good even better. She has proposed several concrete steps to improve on Obamacare. Among them are tax credits to help with out-of-pocket medical expenses, offering more people the option of choosing the lower-cost Medicare system, stricter government oversight of prescription drug pricing and improved reimbursement and delivery of mental health care, including suicide prevention and mental health training for police.

So far, the main thing we know about Trump's approach to health care is that he intends to immediately scrap Obamacare. Over and over again he has promised to "end Obamacare and replace it with something terrific," but he has said almost nothing about how this would be accomplished.

There is no way to simply roll back all of Obamacare without creating complete chaos. Indeed, so many people -- so many voters -- benefit from its provisions, including 20 million Americans who have been added to the insurance rolls under Obamacare and millions of others who have enjoyed benefits under provisions that expand coverage for families and individuals. Given those numbers, Republicans in Congress will hesitate to act as rashly as Trump would like.

When he does offer a bit more detail on his health care policy, Trump recycles points made in a debate that ended long ago. He says efficiencies can be realized if health plans are sold across state lines, but insurance companies are already permitted to sell in whatever state they choose. He wants Medicaid block grants to give states spending flexibility, but the states already enjoy lots of power to tailor Medicaid to local needs and reduce regulations on drug companies.

Trump's misdirection and distractions

Clinton has invested substantial time and energy into health care issues. Her website credits her work in health care as beginning in 1979, when she became chair of the Arkansas Rural Health Advisory Committee, a team working to expand health care access within the state. She was the driving force behind the attempted health care reform in her husband's administration and when it failed helped push the Child Health Care Program through Congress.

As senator, she also made it possible for 9/11 responders to receive the health care they needed, and in 2009, she helped the Obama administration push through its sweeping reforms. In the current campaign, she has devoted considerable time on the campaign trail to explaining her health care platform.

Besides his opposition to Obamacare, Trump has addressed health only as it pertains to his opponent. During the first debate, he said, "She doesn't have the stamina. I said she doesn't have the stamina. And I don't believe she has the stamina to be president of this country you need tremendous stamina." This sexist statement echoes the Trump campaign's ongoing effort to substitute innuendo for a discussion of health care issues that impact millions of Americans.

Instead of saying how he will help more Americans access affordable quality care, he has dispatched Rudy Giuliani, former mayor of New York, to say Clinton looks "tired" and "sick" and urged voters to search the internet for information about her condition.

In fact, following a few days of rest after a bout with pneumonia, Clinton appeared vibrant and alert both before and during the debate, which notably required her to stand in the camera's glare for more than the expected 90 minutes. In contrast, Trump sniffled, gulped water and peered at moderator Lester Holt with eyes that looked puffy and exhausted.

Although viewers may have been distracted by Trump's references to Clinton's "stamina" and by his own possible sickly symptoms, they are genuinely concerned about access, cost and quality of health care.

They consider it vital to the well-being of their families and communities. Americans also understand that the country faces serious public health problems, including growing rates of obesity, diabetes and high blood pressure. As such, they want answers -- and they want them now -- about how the next president will improve a still broken health care system.

How a president's health can matter

Ever since Franklin D. Roosevelt showed that a determined and vigorous disabled man could be chief executive, presidents have served as health role models for the nation. With the exception of Lyndon Johnson and Richard Nixon, who considered politics their sport, most have been eager to demonstrate their fitness. Jimmy Carter took to the tennis court. George W. Bush biked. Bill Clinton (now a vegan) balanced his Big Macs with running. Barack Obama badgers his aides about exercise.

Clinton is a woman of normal weight for her height. She works out three to four times per week, practices yoga and, unlike Trump, isn't a big fan of fast food. In addition to the bottle of hot sauce she always keeps in her purse (to boost her immune system), Clinton eats mainly fish and vegetables.

As secretary of state and as a presidential candidate, Clinton has demonstrated remarkable stamina. Nothing in her records supports Trump's insinuations. And while conspiracy-minded bloggers like to speculate about her condition, there's no evidence that she is any less fit, physically speaking, than Trump.

In contrast, Trump's health habits should cause concern. At age 70, he is the son of a man who developed Alzheimer's and died with it. As the Alzheimer's Association reports, exercise of the sort Trump avoids and a diet far healthier than Trump's -- which he says is heavy on junk food -- can help forestall dementia. More importantly, good health habits preserve and improve the brain's functions. Trump, who has said his IQ is "very high, one of the highest," should take note.

America's health must be top priority

More important than the president's physical health will be his or her leadership. The United States spends more on health care as a percentage of its economy than any other industrialized nation. A study published in June in Lancet estimated that poor health habits cost the U.S. $28 billion in expenses and lost productivity. Worldwide, the figure was set at $68 billion, with $10 billion paid directly by individuals.

What does that money buy? Not much. According to a study published by the Commonwealth Fund, a dozen comparable countries enjoy a higher life expectancy. (Australians live, on average, three years longer than Americans.) America is bested by the same dozen in measure of infant mortality, obesity and chronic conditions.

The data suggest that with the right policies we can make improvements so that we live longer and better. For instance, the mortality rate in Massachusetts declined substantially in the four years after the state enacted a law mandating universal health care coverage, providing the model for the Affordable Care Act.

But we need to know if the candidates are up to the job. The Pew report that found high voter interest in health care also noted that it is more important to voters than issues like guns, trade, Supreme Court appointments or abortion. So far, we haven't heard enough, especially from Trump, to determine whether the next president will be up to the challenge of health care reform.

In the two remaining debates, we need to hear specific plans for improving health care, especially from the candidate who hasn't offered any. Are you listening, moderators?

Lynn O'Connor Vos is chief executive officer of Greyhealth Group. She is a registered nurse and a board member of the Jed Foundation, a national mental health advocacy organization. She is also a donor to the Clinton campaign. The views expressed in this commentary are her own.
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