It's unclear whether healthcare policy issues played a role in the GOP caucus results, but some observers believe Sanders' support for single-payer helped him energize his supporters in the Democratic race.
Most of the Republican candidates have said little about healthcare during the campaign so far other than denouncing the Affordable Care Act and calling for its repeal.
Douglas Gross, a Republican attorney in Des Moines who headed Mitt Romney's Iowa presidential campaign in 2008, predicted that his state's caucus outcomes would leave the healthcare policy discussion unchanged in the 2016 campaign. “Rubio and Cruz would like to repeal Obamacare, but they haven't accomplished it and they don't have a specific alternative that's likely to pass,” Gross said. “And the Democrats are resolved to defend Obamacare. That means there won't be much change. And I don't see the policy discussion becoming any more detailed.”
Cruz offered slightly more detail last week, saying he wants to “delink health insurance from employment, so if you lose your job, your health insurance goes with you, and it is personal, portable and affordable.” He cited three pet conservative reforms he favors—allowing insurers to sell plans across state lines, expanding health savings accounts, and severing the link between coverage and employment. The problem is that he offers no way to maintain the ACA's coverage expansion if he abolishes the law.
Indeed, on Saturday an Iowa voter challenged Cruz with a story about how his brother-in-law was only able to afford health insurance after the ACA took effect. He twice asked Cruz what he would replace the law with. Cruz replied with his standard proposal for expanding health savings accounts and allowing insurers to sell plans across state lines.
Over the weekend, Trump said he strongly opposes Obamacare and rejects a single-payer system. But when asked how his healthcare proposal differs from the ACA, Trump said, “I want people taken care of” and that he would “work something out” after abolishing the ACA. “We're going to work with our hospitals. We're going to work with our doctors. We've got to do something … I have a heart.”
Rubio last summer laid out a brief healthcare proposal centered on offering a refundable tax credit to help people buy health insurance, with a gradual reduction in the tax exclusion for employer health plans. In addition, he would establish federally funded high-risk pools to cover people with pre-existing conditions, let insurers sell plans across state lines, and expand health savings accounts. Plus, he promised to shift Medicare into a defined-contribution, “premium-support” system and convert Medicaid into a capped state block grant program.
On the Democratic side, there has been a spirited healthcare policy debate between Clinton and Sanders, with Clinton favoring fixes to the ACA to reduce consumers' out-of-pocket and drug costs and Sanders advocating a tax-supported single-payer system with no premiums, deductibles or cost-sharing.
Sanders seemed to win substantial liberal support in Iowa with his single-payer stand, though some liberal analysts questioned the political and economic viability of his proposal. It remains to be seen how much appeal his single-payer stance will have in New Hampshire and South Carolina, where Democrats may be less enthusiastic about a plan that would require significant new taxes on middle-income households.
Democratic state Sen. Rob Hogg of Cedar Rapids said Iowa Democratic voters, like Clinton and Sanders, have “differing visions” of how to proceed on healthcare, though he doesn't think that was the dominant reason causing people to vote the way they did. “But what I do see from Democrats is a strong desire to move forward on a healthcare system that covers more people and not to go backward,” he said.