Regardless of whether the presidential debate changed any minds, it provided an opportunity -- sometimes entertaining, sometimes cringe-worthy -- to see the presidential candidates literally side-by-side and facing off on the issues. 

A number of key issues were left out of the debate, most notably healthcare and voting rights. But issues such as race, crime, and the economy all figured prominently, and the 400 pound hackers of America (purportedly capable of the DNC hack) got a shout-out. 

One of the most memorable moments of the debate was when Trump's comment that not paying taxes makes him "smart." Apart from the obvious tax evasion issues of someone of his financial standing not paying his taxes, there are a number of political and moral issues that must be confronted. 

Trump's well-known slogan is "Make America Great Again." Well-meaning people can debate over whether America is already great, and how to build on its progress and its pitfalls. But regardless of where one stands on this issue, it is important to note that policy change requires investment. 

Here are a few things our taxes go toward: 

* Social Security -- retirement benefits for millions of Americans
* Medicare, Medicaid, CHIP, ACA subsidies -- healthcare benefits to seniors, the poor, and those with disabilities
* Defense and security-related international assistance
* Food stamps, school meals, and other such assistance addressing food insecurity
* Low-income housing assistance
* Transportation and infrastructure
* K-12 education
* Veterans' benefits

Good people disagree over the extent to which we should be investing in federal programs versus garnering program support from tax revenues. But investing to some degree in these programs is essential to protecting children, families, seniors, the poor, veterans, and in truth every American citizen given the diffuse benefits that people reap from infrastructure, security, and economic investments. America will never be great for those who can no longer afford health benefits, who are no longer protected if they lose their job, who rely on the VA, who cannot afford lunch at school, if these programs are not funded by our government. Indeed, in 2015, over 59 million Americans received Social Security benefits. 16% of Americans receive Medicare benefits and 16% receive Medicaid benefits. These are far from fringe issues.  

If you want to make America great again, that's your prerogative. But if Trump wants to make America great again, he needs to invest in America. Trump has his opportunity to do so every April 15 and instead called it "smart" to opt out. 

Some questions I'm hoping the moderators will touch on in the first presidential debate...

1. In the absence of the Affordable Care Act, how specifically would you work to prevent health insurance denials for pre-existing conditions?

2. A number of healthcare advances have been made in states that opted for Medicaid expansion under the Affordable Care Act, providing lifesaving primary care. How will you ensure that a move toward doing block grants for state Medicaid coverage won’t result in a rollback in care?

3. Your stated preferences on abortion have wavered over the course of the campaign. Under what exact conditions would you allow versus prohibit abortion, and to what extent will abortion positions be a litmus test for the appointment of federal judges?

4. What do you anticipate as the main effects of your proposed rollbacks on food safety and other regulations?

5. Despite the consensus among scientists regarding climate change, your campaign has at times characterized it as a hoax. On whom would your administration rely for scientific expertise regarding the environment, health, and other matters of science and technology?

6. What major newspapers have been particularly critical of you on the campaign, you have revoked press credentials or threatened to do so. Part of being president involves making decisions that may be important but politically unpopular, or unpopular with a large subset of the population. How would you plan to manage the challenges of governance while also ensuring a free and independent media, which is essential to a democratic society? 

7. What ​do you plan to look for your cabinet leadership appointments, and to what extent would you plan to promote diversity in your appointments?

If Donald Trump's healthcare "plan" is to be nicknamed "Trumpcare," it seems to have forgotten about the "care" part. ​

The New York Times rightly noted recently in an editorial that healthcare deserves a more prominent place in the 2016 presidential election than it thus far has earned. Donald Trump’s main argument has been the repeal of the Affordable Care Act (“Obamacare”), though precious little attention has been paid to determining with what it might be replaced. Even more strikingly, the Gary Johnson/Bill Weld website’s “issues” section, while taking time to discuss internet freedom and the war on drugs, has literally no mention of healthcare.
 
The centerpiece of course is the repeal of the ACA, whereas Hillary Clinton seeks further expansion of the ACA and the reduction of premiums by providing families a tax credit to pay for insurance. The Washington Post recently evaluated that while 9.6 million could gain insurance under Clinton, over 20 million could lose insurance under Trump. Moreover, among those not losing health insurance, premiums were projected to go up from $3,200 to $4,700 a year.

Trump’s stated position holds that they stand for the repeal of the ACA, allowing the selling of health insurance across state lines, allowing individuals to fully deduct health insurance premium payments from their tax returns, allowing individuals to use Health Savings Accounts, requiring price transparency from healthcare providers, giving states more autonomy over Medicaid provision, and removing barriers to entry into free markets for drug providers for reliable and cheaper alternatives.
 
A few points. A number of health insurance plans already offer the option of Health Savings Accounts and whether people opt in or out of them is consumers’ prerogative. Thus, this would not be a change from the status quo. Researchers have already shown in a number of contexts that Medicaid expansion produces a number of health benefits such that those states opting out of expansion are left out with more adverse health consequences. Moreover, the block grant allocation may not be sufficient to continue to support the healthcare benefits that they have gained under the ACA’s Medicaid expansion for the poor. Price transparency is all well and good, though few details are specified as to how it would be provided for. Some tools have already been in place, with Fair Health Consumer’s medical cost directory allowing one to search for the price of a procedure or office visit by zip code, though price comparing across hospitals within a region is not necessarily an easy task for the average consumer, particularly if sick and in need of care. And while allowing for international prescription drug importation may help to curb prescription drug prices, there are the additional regulatory barrier which is that they presumably must still meet FDA standards.

At least as crucially is the fact that Trump's plan does not include provisions to protect people from being denied health insurance due to preexisting conditions. While the New England Journal of Medicine recently published a discussion of the importance of addressing high-need high-cost patients -- with 5% of patients accounting for 50% of the nation's healthcare spending -- having multiple chronic conditions is indeed quite prevalent, with higher rates among the poor and elderly. Indeed, in 2014 at the national level, 30.1% of Americans identified by CMS had 2 or 3 chronic conditions, 20.9% had 4 or 5 chronic conditions, and 14.5% had 6 or more conditions. (Not too surprisingly, the rates of multiple chronic conditions is higher among those who are lower income, such that the challenges in obtaining care due to preexisting condition status only exacerbates the already marked health disparities that persist in the United States). These high rates would constitute grounds for insurance denials of millions of Americans in need of coverage for basic primary care as well as specialty care, with access to good preventive care being valuable to avoiding more costly hospitalizations and procedures. It pays to invest in good healthcare, but giving people the opportunity access coverage is an essential first step (whether through the ACA or not) that Trump's plan unfortunately does not ensure. 
 
There is little question that the implementation of the ACA has not gone according to plan and has not been a dream scenario for its more vociferous advocates, particularly amid news of continued insurer withdrawals from markets due to financial losses, the projections of increasing premium rates in 2017, and the limited choice of marketplace providers for consumers in many parts of the country (with 17% of consumers having only one insurance carrier in their region). Yet the rate of uninsured Americans hit a historic low of 9.1% (declining from 10.4% in 2014), with reductions in uninsured rates seen across nearly all age, race, and income groups. While millions of Americans continue to struggle with underinsurance – that is, facing high deductibles and other large out-of-pocket costs that absorb far too much of their income – there is little doubt that having some coverage is preferable to no coverage, and that people are newly getting access to life-saving primary care and thus diagnoses for conditions with which they may have already have been struggling. Indeed, diabetes diagnoses went up in those states that opted for Medicaid expansion under the Affordable Care Act, confirming other findings that those benefiting from Medicaid expansions were more likely to see a physician or go to the hospital for medical care. And investments in good primary care and having healthier patient pools, thus obviating the need for more advanced and expensive medical treatments, can help to control premiums.
 
This is not to say that there are not problems with the ACA’s implementation. To be sure, premium increases adversely affect millions, vastly outpacing increases in income, as do the sometimes exorbitant prescription drug prices (highlighted most notoriously recently in the case of EpiPens). But these problems call attention to the need for things to be fixed, not done away with.  While a single-payer program would address many of the challenges that we face currently with the business model of healthcare provision in the states – a business model that allows healthcare profit motives to trump the human aspects of health – it is not politically feasible in the current climate of divided government and polarization. Addressing the challenges healthcare pricing and access must be within the confines of the contemporary healthcare apparatus that is the Affordable Care Act.
 
“Trumpcare” would too quickly downplay the operative word of “care,” at least for lower and middle class Americans.
 
The ACA needs salvaging and expansion, not repeal. (RAND provided an economic analysis of the Clinton and Trump plans, analyzed here at The Commonwealth Fun). 

​For the dedicated Springsteen follower, it comes as little surprise that Gillette Stadium’s (admittedly stingy) curfew would be treated as more of a guideline than a mandate, especially in a line of concerts consistently clocking in around four hours in length and in many cases recently breaking his own record for longest concerts (a feat at any age let alone nearly 67). And true to form, still playing “Dancing in the Dark” at 11:30, the audience knew that more songs would remain in store for this night that ultimately clocked in at four hours, ending a couple of minutes before midnight.
 
When the lights go down at a Springsteen concert, immediately yielding the eruption of Bruuuuce’ing from the audience, there permeates the stadium a feeling that anything is possible for the next few hours, in the company of fellow fans and the music of faith and redemption for America’s working class. As the final show on this tour, the energy of Gillette Stadium was buzzing with particular excitement that any songs were virtually fair game. And indeed, while not setting a record in concert length this time, Bruce and the band more than delivered with a setlist full of older favorites and some rarer treats. Following the now customary “NYC Serenade” opening song was “Prove It All Night” with the 1978 intro, a long, searing guitar solo leading into the fist pumping favorite that the song always delivers as. From there, he took the band on a long journey through his debut album Greetings from Asbury Park, NJ, omitting only “Mary Queen of Arkansas,” “The Angel,” and “For You” (the last of which is likely the only one that was at all missed). Leading into “Does This Bus Stop at 82nd Street?” Bruce mentioned his upcoming birthday (“a big one”) and that he wrote this song when he “was a baby child.”
 
Perhaps enhanced by the upcoming release of his autobiography, though true over the course of his entire career, Bruce is first and foremost a storyteller, both in his lyrics and in the tales behind them that many fans recount fondly in the 1986 live album (e.g., “The River” and “Growin’ Up”). He is a songwriter who lays bare his vulnerabilities and doubts, his struggle for redemption, his strife with his father, his search for faith, a deeply personal record of music that allows for a closeness and intimacy between artist and fan that is not true of many of Bruce’s contemporaries. Reflecting in Foxborough on his teenage years (“My friends didn’t like me, my town didn’t like me, my family liked me okay…”) and his narrow aptitudes as a fourteen year-old (“I was really only good at one thing,” which he couldn’t do for four hours without seeking “medical attention”) until saving up $18 for his first guitar, which he earned through what he characterized as the only honest work he’s done. “Blinded By the Light” was a wonderful rocker that many fans are lucky to hear at all given its scarcity in his setlists, though to be sure its wordiness is not the most conducive to singing along.
 
Bruce then reflected on his development as a musician, first not realizing that he needed to tune his guitar, then practicing religiously but sounding terrible, and finally being asked in New York City to play a song, which led in to this fateful audition song that was “It’s Hard to Be a Saint in the City,” followed by “Growin’ Up.” For all the electricity and clapping and fist pumping passion that is a Springsteen performance, it is his stories that manage to make his 55,000 person concerts intimate, that allow Bruce to forge a bond with so many devoted enough to cross oceans or continents to experience (at least) one more time the feeling of a Springsteen concert in full force.
 
Following the ever-beloved “Spirit in the Night” and “Lost in the Flood,” the Wild and Innocent rarities were next, with “Kitty’s Back” leading into “Incident on 57th Street,” straight into “Rosalita,” a rocking crowd-pleaser that invariably has every audience member with a pulse dancing but which historically has tended to appear toward the end of his concerts rather than the middle.
 
A signature aspect of Bruce’s last few tours has been his collection of signs from the audience, with all eyes on to what extent the night’s “last show status” might trigger more unexpected selections from the crowd. Following the far from rare but nevertheless well-liked “No Surrender” (written across a fan that Bruce carried in his mouth while holding the numerous signs), he launched into a cover of “Boom Boom,” a fun rocker that came out of left field but that seemed as much a treat for Bruce as for the audience and almost akin to his performance of “Jailhouse Rock” in night two of the old Giants stadium shows of 2009. “Detroit Medley” and “Light of Day” were also unexpected rockers that brought everyone in the stadium to their feet. After all, no matter how tired the audience may be from hours of standing, no one is giving more than Bruce himself, nearly 67 and in better shape than most of his fans as he continues to put in marathon concerts across the globe. Bruce is, with reason, not a performer to go through the motions on stage. He gives 100% each night and expects 100% from his audience.
 
“Fourth of July, Asbury Park (Sandy)” was a largely acoustic highlight as Bruce waved the band off until the conclusion of the final verse, at which point Charlie and the others joined in to play the familiar notes with which the audience is accustomed. The stripped-down version was unusual and to be sure lowered the energy level of the audience, but had the sweetness and softness of a walk down memory lane, which no doubt it was for him, and fitting given the tenor of the concert.  
 
The encore lead off with the requested “Long Walk Home,” prefaced with a comment on the ugliness of the present election cycle, along with his typical public service announcement, a reminder of the social conscience in which his music and his work continues to be rooted. Jake was masterful as ever in his “Jungleland” solo for so long identified exclusively with Clarence, and the frequency of it in the setlists never makes it less of a treat to hear. He has truly come into his own with the E-Street Band and is one of them now. “Rocking All Over the World,” was the final surprise of the night, with the exception of the disappointing absence of “Thunder Road” from the final show of the tour.
 
It is hardly common for a band to seemingly improve with age, especially past a certain age, but Bruce and his legendary E-Street Band seem in their marathon shows to defy the odds. And they may continue to do so, as Bruce uttered before leaving the stage the always coveted words, “We’ll be seeing you!”

The American Medical Association (AMA) and several consumer groups are calling upon New York regulators to reject the proposed $53 billion merger of Anthem and Cigna, two of America's leading insurers. The issue was raised at the recent New York Department of Financial Services hearings. 

To be sure, this is not the first time that major insurance companies have proposed and/or succeeded in making such reductions in competition, with Aetna and Humana being the most noteworthy recent development, made controversial by the revelation of information by Aetna suggesting a retrenchment from the Affordable Care Act marketplaces in the event that the merger should be blocked. (Aetna recently withdrew from 11 of the 15 states in which it was in an ACA market). 

And further, this issue is hardly unique to the American healthcare system. Over the years, we have seen reductions in the number of cable companies (hence the number of people for whom the word "Comcast" induces panic and/or rage), airline companies (replace "Comcast" with "United Airlines"), telephone companies, and the like. Perhaps it is not surprising that antitrust has been a dominant subject on the Supreme Court's agenda under John Roberts. 

What is unique to the American healthcare system is the deeply personal nature of the effects of mergers, which generally tend to reduce competition and thus drive up prices (potentially driving down quality of care given the reduction in the number of competitors). When we have to take a different airline because it garners us better savings (though probably not better than a few years ago), we might utter an expletive, shrug our shoulders, and click "complete purchase." When we have only one cable company in a given region, we do the same thing, because we and they know, our stubbornness rarely is such that we will forego cable and internet (most of all, internet). Most of us can begrudgingly deal with the extra $30 in our cable/internet package (in that terrain, we're often a captive audience without a viable alternative), or shop around for travel discounts. But in the terrain of healthcare, it can be literally life and death. 

The real-world consequence of cable mergers is a reduction in consumer choice, potentially slower service, and a modest markup in the price of services we might have already had in the first place. The real-world consequence of health insurance mergers is that people cannot obtain reasonable healthcare plans, thus interfering with the ability to obtain needed services, whether preventive care or interventions in serious medical problems that might bankrupt a lower-income family if their income level doesn't quite meet criteria for Medicaid but that doesn't allow for the purchasing of a lower-deductible plan. (As in all cases including healthcare, the middle class often gets squeezed the worst). 

At the New York Department of Financial Services hearing, Dr. Malcolm Reid, the president of the Medical Society of the State of New York, said, "If Anthem gets its way, it will have even less incentive than it does now to take care of people, and the merger would ultimately compromise the ability of physicians to advocate for their patients... In practice, market power allows big insurers to exercise control over clinical decisions, which undermines the patient-physician relationship and eliminates key safeguards of patient care," and went on to note that the lack of insurer competition has negatively impacted patients as well as physicians, who are left often to join larger networks rather than struggle to negotiate reimbursement rates with the insurance giants that are spawned by way of consolidation. 

When we place physicians in a weaker position relative to the companies helping to cover the cost of their patients' care, the quality of care inevitably gets undermined. Reimbursement rates are more difficult to negotiate. Claims denials become more difficult to appeal, and there are fewer alternative insurers to which to turn. When we place patients in the position of having even fewer options from which to choose health insurers, they are potentially less likely to be able to obtain a plan that best suits their or their family's needs. Indeed, the AMA's antitrust attorney Henry Allen held that "[t]he diminished competition leading to higher prices will also lead to lower plan quality."

Competition is essential in general, and all the more so when discussing the human issue of American healthcare, which too often is reduced to the less-than-human business models. We do not have the votes in Congress for a single-payer program, and the mixed response to the Affordable Care Act does not suggest that we are anywhere close to deleting the words "over 65" from Medicare. But if we do not reduce the role that corporate anti-competitive practices play in providing essential medical services to the American public, too many (and not just the poor) will suffer the consequences.