In chaotic debate, Trump, Biden clash on future of ACA, COVID-19 handling

President Donald Trump and former Vice President Joe Biden square off in the first Presidential Debate of 2020. (Photo by Scott Olson/Getty Images)

Fittingly enough for a debate held at Case Western's health education campus and overseen by experts from the Cleveland Clinic, healthcare and related topics dominated the first half of last night's presidential debate, which could be charitably described as "chaotic." Moderator Chris Wallace attempted to moderate an exchange between sitting President Donald Trump and former Vice President Joe Biden that regularly devolved into contradictions of facts, personal attacks and outright name-calling.

The long discussion of healthcare boiled down to a few fundamentals: Trump repeatedly failed to present any plan for replacing the Affordable Care Act, which has a greater chance of being struck down by the Supreme Court if his nominee, Amy Cohen Barrett, is confirmed. Trump's healthcare accomplishments consist of allowing drug importation from Canada and other countries and an executive order protecting individuals who have preexisting conditions, an order that has little legal force.

Biden deflected attempts to tie his healthcare plan to that of his primary opponents (Medicare for All). In the second segment Trump and Biden clashed on a number of issues around the COVID-19 pandemic, including travel bans, vaccine timelines and mask effectiveness.

The future of the Affordable Care Act

The candidates pivoted to healthcare almost immediately on the first question, about whether Trump ought to be confirming a new Supreme Court justice to the vacancy left by the passing of Justice Ruth Bader Ginsburg. Biden framed the issue as a referendum on Trump's efforts to dismantle the Affordable Care Act, the landmark health legislation Biden helped pass during his term as President Barack Obama's number two.

"Now, what's at stake here is the President's made it clear, he wants to get rid of the Affordable Care Act. He's been running on that. He ran on that and he's been governing on that. He's in the Supreme Court right now trying to get rid of the Affordable Care Act, which will strip 20 million people from having health insurance now, if it goes into court. And the justice, I'm not opposed to the justice, she seems like a very fine person.

"But she's written, before she went in the bench, which is her right, that she thinks that the Affordable Care Act is not constitutional," Biden said, "... and there's a hundred million people who have pre-existing conditions. And they'll be taken away as well, those pre-existing conditions. Insurance companies are going to love this. And so it's just not appropriate to do this before this election. If he wins the election and the Senate is Republican, then he goes forward. If not, we should wait until February."

In the fragmented discussion that followed, Trump contested the point that 100 million people have pre-existing conditions. (The Biden camp has pointed to a report from healthcare consulting firm Avalere as their source.) He briefly attacked Biden on his administration's handling of military healthcare. When Wallace pointed out to Trump that he had never presented a plan to replace the ACA, Trump pointed to his plan to eliminate the individual mandate, "the most unpopular aspect of Obamacare," to which Wallace replied, "That's not a comprehensive plan."

"Obamacare is no good," Trump said. "We made it better and I had a choice to make very early on. We took away the individual mandate. We guaranteed pre-existing conditions, but took away the individual mandate. Listen, this is the way it is. And that destroyed … they shouldn't even call it Obamacare. Then I had a choice to make: Do I let my people run it really well or badly? If I run it badly, they'll probably blame him, but they'll blame me.

"But more importantly, I want to help people. Okay, I said, 'You've got to run it so well.' And I just had a meeting with them. They said the problem is, no matter how well you run Obamacare, it's a disaster. It's too expensive. Premiums are too high that it doesn't work. So we do want to get rid of it. Chris, we want to get rid of that and give something that's cheaper and better."

In another attempt to answer the question, Trump pivoted to his efforts to reduce drug prices. Then he pivoted to Medicare for All, accusing Biden of supporting socialist medicine. Biden forcefully deflected Trump's attempts to tie him to his primary competitors, saying, "The party is me. Right now, I am the Democratic Party. [...] The platform of the Democratic Party is what I, in fact, approved of."

A referendum on COVID-19 handling

Wallace's next question brought the candidates into a second healthcare topic, around Trump's handling of the COVID-19 pandemic. Biden went on the attack immediately, alluding to recent revelations from Bob Woodward's reporting that proved the President was aware of the seriousness of COVID-19 very early in the pandemic.

"We, in fact, have 4% of the world's population, [but] 20% of the deaths," Biden said. "Forty thousand people a day are contracting COVID. In addition to that, about between 750 and 1000 people a day are dying. When he was presented with that number, he said, 'It is what it is.' Well, it is what it is because you are who you are. That's why it is.

"The President has no plan. He hasn't laid out anything. He knew all the way back in February how serious this crisis was. He knew it was a deadly disease. What did he do? He's on tape as acknowledging he knew it. He said he didn't tell us or give people a warning of it because he didn't want to panic the American people."

Trump responded with a litany of established talking points, blaming China for the virus, dubiously claiming positive reviews of his handling of the crisis, and blaming the media for skewed coverage.

"You didn't think we should have closed our country because you thought it was terrible," Trump said. "You wouldn't have closed it for another two months. By my doing it early, in fact, Dr. Fauci said, 'President Trump saved thousands of lives.' Many of your Democrat Governors said, 'President Trump did a phenomenal job.' We worked with the Governor. Oh really, go take a look.

"The Governors said I did a phenomenal job. Most of them said that. In fact, people that would not be necessarily on my side said that President Trump did a phenomenal job. We did. We got the gowns. We got the masks. We made the ventilators. You wouldn't have made ventilators. And now we're weeks away from a vaccine. We're doing therapeutics already. Fewer people are dying when they get sick. Far fewer people are dying. We've done a great job."

According to NPR's fact check of the debate, experts disagree about the role the early travel ban played in slowing or not slowing the spread of the disease. Dr. Anthony Fauci has praised the decision and suggested that it likely lowered the number of cases early on.

The two also clashed on vaccines and masks. In response to a question about disagreeing with his own experts, Trump claimed that a vaccine was "weeks away" and that reports to the contrary were "a political thing." Biden countered that a vaccine is likely months, if not a year away, and that even when one is ready distribution will be complicated. 

On masks, Trump suggested that experts including Fauci have actually decried masks, to which Biden replied "No serious person has said the opposite." Some experts were slow to recommend masking early in the pandemic, partially out of fear that individuals would deplete supplies of PPE needed by hospitals. But at this point consensus about the benefits of masks is nearly universal."