President Trump’s disgraceful performance at the first presidential debate needs little comment. He showed himself to be a malicious bully, a habitual liar, and a power-hungry authoritarian. When asked to denounce racist xenophobes, he declined to do so. I doubt many lukewarm Republican or uncertain voters were impressed. But Trump, once again, successfully prevented discussion of the basic problems confronting the nation.

The inadequacy of our national health care system has been an issue for decades. Candidate Trump acknowledged this reality and pledged to forge a system that lowered costs and increased services. Such a plan has never materialized. Instead, drug prices have risen annually and there a 10% rise in drug plan fees is scheduled for 2021. This comes at a time when the inflation rate is 1% and drug companies have outsized profit margins. And yes, Canadians are still paying far less for the very same drugs. At recent House hearings on price gouging, freshman Democrat Katie Porter (CA) revealed Mark Alles, a pharma CEO, has an annual salary of $13 million that is directly tied to his raising drug prices.

A new election ploy by Trump concerning drugs is his proposal to send $200 checks to the 33 million seniors on Medicare. The checks would happen to arrive a few weeks before the election. The money comes from a Medicare Trust Fund that is designed to finance pilot programs testing ways to make Medicare more efficient. Whether this is a legal use of such funds is unclear, and Trump, as usual, offers no details on his proposal.

Where the funds to replace those taken from the trust will come from has not been addressed. Presently, the trust gets considerable annual income from the payroll tax. That’s the tax that Trump insists should be lowered. So, in order to win favor with senior voters, Trump proposes to raid a valuable research program while simultaneously lowering its future stability.

Trump’s most vigorous action to take on healthcare is directing the Justice Department to actively support the effort to have the Supreme Court rule on the Obama era’ Affordable Care Act. That Supreme Court decision is expected shortly after the November third election. Two of Trump’s appointees would have to join the Court’s three liberals to keep ACA intact. Not probable.

The Republican party has vowed to undo the modest reforms of ACA since it came into existence in 2010. A decade later they still offer no alternative agenda. Republican spokespeople state that months will be needed to implement any Supreme Court decision. That supposedly gives them time to formulate a replacement plan. Just how thoughtful and effective such hurried legislation could be is anybody’s guess.

Should the Court rule as expected, some twenty million Americans will lose their health care coverage. Guaranteed equal coverage for people with pre-existing conditions will end. Trump has vowed he would take an action regarding that immediately, but he offers no details and it is unclear how pre-existing conditions would be defined. Will the tens of thousands of Americans who had recovered from COVID-19 but still experience symptoms be protected?

Biden wishes to expand ACA to make it more effective and to open it to all Americans who chose to use it. Individuals and trade unions that want to maintain their present coverage would be free to do so. Trump’s rhetorical flimflam did not allow Biden to get into details, but they are available on Biden’s web site.

The disarray in our health care system is reflected in the fact that America spends twice as much per person on healthcare as any other nation. We do not, however, get superior results. In UN charts showing the average life span in different nations, the United States is thirty-sixth while the World Health Organization ranks us forty-sixth.  In both calculations, Cyprus and Greece do far better than we, although we do remain ahead of Turkey.

Our life expectancy rates are reflective of other rankings of health outcomes. Even in something as basic as the infant mortality rate, we lag behind all nations in the EU. The COVID-19 disaster in America is a more obvious example of public health mismanagement. We have 4% of the world’s population but 20% of its COVID-19 dead. As of October, twenty states still have historically high daily increases in their rates of infections and deaths. Epidemiologists predict a total of 300,000 dead Americans by the end of the year. In an incredible grade inflation, Trump gives himself A++ on how he has handled the crisis and offers no plan to stem the rising tide. Biden does, but Trump’s debate tirade made it impossible to discuss the topic rationally.

Americans have been complaining about health care for decades. The upcoming election will determine if we opt for more of the same or for change.