Raised voices and sharp words marked Wednesday night’s fourth Republican presidential primary debate as four candidates argued about everything from their own electability to the continued front-runner status of former President Donald Trump. Abortion was never mentioned.

Florida Gov. Ron DeSantis, former South Carolina Gov. Nikki Haley, entrepreneur Vivek Ramaswamy, and former New Jersey Gov. Chris Christie faced off in Tuscaloosa, Alabama, just 40 days before the Iowa caucuses. They sparred over antisemitism and the war between Israel and Hamas as well as the conflict in Ukraine. There were references to cryptocurrency and TikTok. Candidates also attempted to tackle inflation, corruption, border issues, and the inner workings of the Department of Justice, among other things.

As he did in the previous three meetings, Trump opted not to participate, this time attending a fundraiser in Florida. The event was moderated by NewsNation’s Elizabeth Vargas; Megyn Kelly, host of “The Megyn Kelly Show” on SiriusXM; and Eliana Johnson, editor-in-chief of The Washington Free Beacon.

Our PolitiFact partners fact-checked the candidates in real time. You can read the full coverage here.

Health care — in the form of the Affordable Care Act — took center stage during the debate’s last minutes. Until recently, it seemed that the Republican Party had all but abandoned its years-long effort to repeal and replace Obamacare. But Trump resurrected the campaign with a social media post over Thanksgiving weekend describing the GOP’s failure to achieve this goal during his first term as “a low point for the Republican Party.”

DeSantis, who seemed to pick up on some of Trump’s ACA criticisms, has since promised that he will have a health plan that is “different and better.” He was challenged by debate moderators with the question: “Why should Americans trust you more than any other Republicans who have disappointed them on this issue?” In his response, he offered key buzzwords but few specifics. “You need price transparency. You need to hold the pharmaceuticals accountable. You need to hold big insurance and big government accountable, and we’re gonna get that done.”

Ramaswamy followed with his own take, involving similar concepts but different words. “We need to start having diverse insurance options in a competitive marketplace that cover actual health, preventative medicine, diet, exercise, lifestyle, and otherwise.”

Throughout the evening, some of the most heated clashes came as candidates sparred over transgender issues and gender-affirming care. PolitiFact examined some of these claims:

DeSantis: “I did a bill in Florida to stop the gender mutilation of minors. It’s child abuse and it’s wrong. [Nikki Haley] opposes that bill. She thinks it’s fine and the law shouldn’t get involved with it.”

This claim has two parts, and each needs more context.

In May 2023, the Florida Legislature passed a bill that banned gender-affirming surgeries for minors. Experts told PolitiFact that gender-affirming surgeries are not the same as genital mutilation. And the law didn’t ban just surgeries — it banned all gender-affirming medical care, including puberty blockers and cross-sex hormones, which are supported by most major U.S. medical organizations.

Surgeries are rarely provided as part of gender-affirming care for minors.

In a June CBS interview, Haley said that when it comes to determining what care should be available for transgender youth, the “law should stay out of it, and I think parents should handle it.” She followed up by saying, “When that child becomes 18, if they want to make more of a permanent change, they can do that.”

Haley’s campaign pointed to a May ABC appearance in which she said that a minor shouldn’t have a “gender-changing procedure” and opposed “taxpayer dollars” funding one.

Haley: “I said that if you have to be 18 to get a tattoo, you should have to be 18 to have anything done to change your gender.”

During the debate, Haley likened her position on gender-affirming care for minors — that it should be up to parents until the child is 18 — to age requirements for getting a tattoo: “I said that if you have to be 18 to get a tattoo, you should have to be 18 to have anything done to change your gender.”

We’ve heard that comparison before. For what it’s worth, two-thirds of U.S. states allow minors to get tattoos if their parents consent. And medical experts have told us gender-affirming care is in many cases considered medically necessary, while tattoos are cosmetic.

Ramaswamy: “I think the North Star here is transgenderism is a mental health disorder.”

PolitiFact rated Ramaswamy’s claim False after he introduced it at the second primary debate.

In the past, the medical community viewed the experience of being transgender as a “disorder,” but they no longer agree on that categorization. In the past decade, diagnostic manuals published by the World Health Organization and the American Psychiatric Association contained updated language to clarify that being transgender is not a mental illness. Experts told us that persistent gender dysphoria can cause other mental health issues, but it is not itself a mental health disorder.

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By KFF Health News and PolitiFact staffs
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.