How the Primary Candidates Would Reform Healthcare

Neil Chesanow

Disclosures

May 25, 2016

In This Article

Donald Trump's Healthcare Proposals

Donald Trump's healthcare proposals are far less detailed than those of Hillary Clinton, and according to numerous GOP health policy experts, they are philosophically inconsistent. For example, Robert Laszewski, president of Health Policy and Strategy Associates and a former insurance company executive, calls them "a jumbled hodgepodge of old Republican ideas, randomly selected, that don't fit together."[30]

"Donald Trump has released his health care plan after being pressured into doing so," economist Merrill Matthews noted in Forbes in March.[14] "He should have taken a little more time. Though six of his seven points—they aren't developed enough to be called proposals—are standard Republican fare, they are too vague and superficial to determine what Trumpcare would be like."

Here, in any event, is what Trump is advocating.

Affordable Care Act

Trump calls for "a full repeal of Obamacare." But he still says that "everybody's got to be covered."[8,31] Assuming that he truly means "everybody," between 2010, when the ACA was passed, and 2014, 10 million uninsured Americans gained coverage. If the ACA were repealed, they would lose it.[9] In addition, 33 million Americans continue to lack health insurance coverage.[9]

If "repeal and replace" would help all of those people keep or gain coverage, the question arises: Replace with what? Trump has not yet supplied that information.

To be fair, the Republican-controlled House of Representatives has tried to repeal the ACA over 60 times, Matthews points out, and they have yet to propose a replacement plan either.

"One of the most frequently asked questions I get out there, if I'm giving speeches, is, 'What's the Republican plan?'" Matthews told Medscape. "You can't really give an answer to that. There are several potential elements for a Republican plan. But the leadership has never rallied around four, five, or six points that they could say are the basic elements of our plan."

Healthcare Costs

Trump would leave the Medicare program untouched.[8]

He says he would let the cost of insurance premiums be deducted from federal income tax so that "no one slips through the cracks simply because they cannot afford insurance."[8]

Trump would let individuals use health savings accounts (HSAs) to pay for out-of-pocket expenses,[8] although "HSAs have been in law since 2003 and in practice maybe a year after that," American Enterprise Institute (AEI) economist and health policy expert Tom Miller told Medscape. "There's not really any proposal there, other than recognizing what already exists and saying, 'Yeah, I think it's a good idea.' It shows a lack of familiarity with well-established health policy."

Trump would, as his website says, "modify existing law that inhibits the sale of health insurance across state lines.[8] As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up."

But it's not so simple, Matthews points out.

"Health insurance is tied to a local network of providers—doctors, hospitals, clinics, and sometimes pharmacies," he observes. "If you're in one state, find an affordable policy in a state across the country, and want to buy that policy, even if you could, how does the insurance company get its contracted provider network in the other state back to the state you are in?"

"If you're in New York and are buying a policy from a state that's much less expensive, your premiums would be higher anyway because of the higher cost of living and other costs," Matthews elaborates. For example, lower premiums in a state like Wyoming would also reflect state-mandated benefits and coverage, local competition, and provider treatment patterns that don't apply to New York.

However, the assumption that open borders would allow insurers in low-regulation, low-cost states to sell their less-expensive products in costlier high-regulation states at a competitive advantage over insurers already serving those markets is also questionable, Matthews maintains.[14] Since the passage of the ACA, which mandates what health insurance coverage must include, low-regulation, low-cost states are a thing of the past, he says, even if the problem of contracting with far-flung provider networks could somehow be overcome.

Drug Prices/Medicare

Trump says he would let Medicare negotiate with drug makers to lower drug prices.[8] In 2003, the pharmaceutical industry convinced Republican legislators to forbid Medicare from negotiating drug prices when Congress enacted the law creating Part D drug plans.[32,33] Changing the law is strongly opposed by drug makers and the GOP. Republican thought leaders support market competition to drive down drug prices and seek to shrink the role of government, not greatly expand it.

In addition, Trump would lower barriers to purchasing cheaper medications from other countries (proposed by Clinton and Sanders as well), drawing flak from the Right that he is not a true conservative, only masquerading as one.[8]

"Trump has deviated from most Republican orthodoxy on prescription drug pricing on both ends," AEI's Tom Miller observes, "first by directly taking a hands-on approach to suggest that the President be very active in directly negotiating the prices of brand-name drugs as a large purchaser to lower rates; and then by proposing the reimportation of drugs, which is not a new idea—but for a Republican presidential candidate to be aggressively embracing that, that's new."

Republicans are in favor of increased price transparency, one of the least controversial of Donald Trump's proposals.[8] One way to contain healthcare costs, GOP leaders maintain, is for consumers to be less insulated from the cost of their care and have "more skin in the game" (ie, pay more for their care out of pocket).[14] This would incentivize them to make cost-conscious decisions regarding their care, for which price transparency would be a necessary precondition.

Medicaid

In a move long advocated by conservatives but fiercely opposed on the Left, Trump proposes (as Ted Cruz did before him) to award federal funding to administer the Medicaid program via block grants to the states.[8]

"Nearly every state already offers benefits beyond what is required in the current Medicaid structure," Trump's website says.[8] "The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources."

This would cut federal funding for the Medicaid program by $913 billion over the next decade, according to the Patient Choice, Affordability, Responsibility, and Empowerment Act (the Patient CARE Act), introduced by Republicans in 2015 and awaiting a GOP president to sign it into law. This, GOP leaders maintain, would help stem the unsustainable rise in healthcare costs.[34]

"Block-granting Medicaid is a very common Republican proposal," counters Dr Himmelstein. "What it does is give states license to cut Medicaid, which I think has quite severe repercussions."

"Such a law would be bad news for beneficiaries and for providers, especially those that serve low-income communities, since under such financing terms few, if any, states could maintain existing coverage for affected populations," write Sara Rosenbaum and Timothy Westmoreland in the New England Journal of Medicine.[34] The reduced budgets "would force most states to put eligibility, benefit, and cost-sharing protections on the line as they attempted to cope with the brunt of future cost growth."

Women's Health

In the healthcare proposals posted on his website, Trump doesn't mention women's health. But he has gone on record elsewhere as saying that Planned Parenthood should be defunded.[35]

On abortion, Trump has changed his position so often that it's hard to know what he actually believes.[36] At various times, he has said that he is pro-choice and pro-life.[36] He recently said that women who have abortions should be punished; an hour later, his campaign issued a statement of clarification to the effect that doctors who perform abortions should be punished, not women who have abortions.[36] Most recently he has said that he "will change the law through his judicial appointments and allow the states to protect the unborn."[36]

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