Over the next two months, I’m going to be analyzing what everyone—from health policy experts to advocates—is saying about how Trump will affect health. But before I do that, I need to make sure we all understand what Trump himself is saying, before we start ripping his words apart.
On his website, Trump says he plans to:
- Completely repeal the Affordable Care Act (the ACA/Obamacare)
- Allow the sale of insurance across state lines
- Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system.
- Allow individuals to use Health Savings Accounts (HSAs).
- Block-grant Medicaid to the states.
- Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals.
- Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products.
- Some other odds and ends that are all AMAZING and I’m going to end with these to try to instill some ~ hope ~
Now I’m going to break these eight down for you…. And at the end of each one, I’ll let you know my opinion.
1) “Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to.”
My third post is entirely dedicated to Trump’s plan to repeal Obamacare. So I’m not going to say a lot here.
Many of you may be hearing the classic lines of, “Trump is going to repeal the ACA, but he will keep the “pre-existing conditions and under-26 aspects.” You’ll find out in my third post that that’s not entirely true.
But I will say this: There are two possible methods available to the Trump administration to remove the ACA. The first is simply to stop funding it. By removing money intended to go to regulating the law, it would become difficult and maybe impossible to enforce it. The second process available is via the “reconciliation” process that in 2010 Democrats originally established to pass the ACA. The reconciliation process is a legislative procedure whereby Congress can review a budget bill with 20 hours of debate time without the other procedural hurdles like the required super majority seen above. According to Ben Conley, the most likely outcome is a combination of the two (Corporate Wellness Magazine).
“Since enactment of the ACA, the GOP-controlled House has voted sixty-two times for its repeal, only to be blocked by the Senate. With this election, the House Republican majority is stronger and Trump supporters were elected to the Republican Senate majority. It seems reasonable to predict the ACA will be voted out of existence (Council on Foreign Relations).”
Senate Majority Leader Mitch McConnell (Ky.), one of the ACA’s loudest critics, declined Wednesday to spell out details of the procedures Republicans would use to abolish the law. But in a media briefing to celebrate the Senate preserving its majority, he said, “All of that is underway.”
I’ll talk about alllllllll the possible effects of repealing the ACA in my third post, but here’s an idea of what we know about the effects on the repeal, which, in a word, is contradictory:
The Center for Health and Economy, which is nonpartisan and includes both liberal and conservative experts, estimates that 18 million people — mostly low-income adults — would become uninsured in the first year and that Trump’s changes would decrease the deficit by $583 billion between 2017 and 2026. Previously, the Committee for a Responsible Federal Budget, which promotes fiscal constraint and is anti-deficit, calculated that repealing the ACA would double the number of uninsured, leading to more than 21 million people losing coverage, and would cost $550 billion over a decade. The Congressional Budget Office in 2015 estimated 22 million fewer people would have coverage in 2017 if a repeal bill were enacted. So…. Who really knows?!?!?
Given all of this, Post #3 will be especially important for your understanding of the changing landscape of the ACA going forward… It’s massively complicated, there are a lot of actors and more than 30 proposed plans out there…. But don’t worry, I’ll break it down for you J
My opinion: Republicans AND Democrats know that Obamacare needs to be reformed. It was a great idea, but the implementation was terrible. That’s something we can all agree on (And if you don’t, just read any article on the ACA…). My opinion gets into the nitty gritty of the reform, though, so you’ll hear about it in post 3.
2) Modify existing law that inhibits the sale of health insurance across state lines. 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.
The Kaiser Health Foundation released this video discussing the implications of selling insurance across state lines.
It’s only 2 minutes long. That’s like shorter than the time it takes to brush your teeth. Click on the link and watch the video. It’s really good. And while you’re at it, get lost in the amazingness that is Kaiser Health Foundation. #mydreamjob
Did you watch the video???? Watch. It.
I love the idea of selling insurance across state lines. The idea that someone could buy an insurance plan without the fancy benefits of, to use the video’s example, infertility treatment sounds genius. It helps get rid of the major problem with Obamacare: that many people choose not to enroll because being charged the fine of not enrolling is cheaper than enrolling. Cheaper coverage by going across state lines sounds perfect! It’s a great idea, but the implementation is the problem. This video highlights that in practice insurance companies have a hard time selling across state lines and this could result in people flocking to where the insurance is cheaper. These negative consequences are quite a bummer because the intentions behind selling insurance across state-lines are great….
3) Allow individuals to deduct fully insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.
According to Forbes tax writer Ryan Ellis, this wouldn’t have as much of an impact as you might think. First, almost half of tax filers have no income tax liability, so an additional deduction is pretty worthless for them. This includes most Americans receiving Medicare coverage and paying part of their Parts B and D premiums. Second, virtually all Americans who get their health insurance from work already get a tax deduction for their share of the premiums on the paycheck level. Third, many Americans now receive health insurance for free from Medicaid, the Veterans Administration, Tricare, or CHIP. Nothing to deduct there. Finally, self-employed people can already deduct premiums individually. This is true of sole proprietors, partners, and S-corporation owners.
So who does that leave? People who are buying individual market health insurance AND are not self-employed AND have a tax liability. While that’s a target population we should be looking to help, it’s a pretty discrete group of people. I think it’s great that Trump’s trying to help this group of people, but in the grand scheme of his giant health care policies and changes, this one is pretty miniscule.
It’s important to note that Trump wants to work with states to establish high-risk pools to ensure access to coverage for individuals who have not maintained continuous coverage. According to Rand, this is another GOP favorite. High-risk pools were at the core of the health care plan of Sen. John McCain (R-Ariz.) when he ran for president in 2008. Before the ACA, these high-risk pools were state-based insurance just for people who had ailments that needed a lot of medical care (and who also had trouble finding coverage before the ACA made it illegal for insurers to refuse to cover people with pre-existing medical problems). With McCain possibly in Trump’s cabinet—potentially as Secretary of State, but still— this could really come to fruition.
4) Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate.
From Sally Pipe, President of the Pacific Research Institute, covers Health Policy for Forbes:
“Trump wants to promote tax-advantaged Health Savings Accounts, which have been available since 2003… He’s right about this one… HSAs allow consumers with high-deductible health plans to set aside money tax-free for healthcare expenses. They can also withdraw the funds without paying tax, provided they go toward a qualified medical expense.”
Trump also calls for HSAs to be part of an individual’s estate. An account could therefore be passed on to next of kin without fear of being faced with federal taxes.
HSAs will help increase price transparency, another of Trump’s healthcare goals. Because consumers will be spending their own money, they’ll have a strong incentive to demand clear rate quotes from healthcare providers. This means providers would compete with each other to offer the best prices for clients.
5) Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. 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.
Medicaid was created in the 60s, and it’s an entitlement program. This means that the government will cover everyone who qualifies, but in return states must cover certain people—for example, women and children (states do have some freedom to set eligibility rules and exclude some benefits). This means that each year the money spent on Medicaid varies based on who enrolls in the program and how much they utilize it.
If Trump succeeds in moving Medicaid to a block grant system, the government would instead give states a certain amount of money for the people in their state needing Medicaid. If more people utilize the program than the federal money covers, the state would have to pay their own money.
Trump has not said exactly how the block grants would work, but, based on previous GOP plans, the Center for Health and Economy predicts that the change would save $488 billion in federal spending over a decade. An Emory University health policy professor, Kenneth E. Thorpe, predicts a savings of about $370 billion over a decade (The Washington Post).
This isn’t a new idea. Reagan proposed this in 1981. House Speaker Newt Gingrich called for this in 1995 (the year I was born!), and so did Bush in 2003. Gingrich actually almost succeeded in making Medicaid block grants; the bill passed in Congress, but President Clinton only approved of making welfare become block grants (What we now know as TANF—Temporary Assistance for Needy Families) (Lena H. Sun and Lenny Bernstein, The Lancet).
Critics say that, over time, a lot of money would be cut from Medicaid if the federal grants fail to keep pace with the program’s costs, inevitably eroding eligibility and benefits. I personally worry that states would create ridiculous and unattainable eligibility requirements to ensure that they have don’t to pay out of their own state dollars, meaning that less people would qualify for Medicaid and get the care they need. This could be an unfounded worry, but it’s what comes to the top of my head when I hear this idea.
Yet supporters say block grants would encourage states to reduce waste, save the federal government billions of dollars and give states more freedom to choose how to implement the program. They also say that the program would not be so rigid, allowing states to apply for additional federal funding in times of recession or population growth. Which sounds great to me!
Oren Cass, a senior fellow at the Manhattan Institute (conservative think tank), spoke to Politico and said that with block grants states could use the money saved for other anti-poverty programs. It’s always nice to have a little extra cash…
One uncertainty here is the part of the ACA intended to expand Medicaid eligibility to people with slightly higher incomes — up to 138% of the federal poverty level, which this year is about $16,000 for an individual and $33,000 for a family of four. This applies to 31 states and DC. It is unclear whether, in making other changes to Medicaid, Trump would let them keep the extra federal money they received for enrolling newly eligible people…..
6) Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure.
Hey that’s a super good thing!!! Unfortunately, he has not detailed how he plans to make prices more transparent. HSAs (from #4) would help, though. This one seems like a lot of talk and not a lot of do.
7) Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.
He concludes by saying, “providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments.
Here, Trump is basically alluding to the FDA process. It’s rumored that Trump will heavily look into getting rid of Phase III clinical trials…. Trump hasn’t taken as hard of a stance as Clinton or Sanders on the absurd price of certain medications, but he has said publicly that medicines should be more affordable. We’ll have to wait and see what happens in this area. More and more is coming out every day on how Trump will affect access to medications, so I may add a post or throw some info in on that somewhere. Stay tuned!
8) Some Other Odds and Ends—LOOKING ON THE BRIGHT SIDE OF THINGS!!!
Well, the first 7 goals were a mixed bag. I tried to add in where I think some of his policies are a good idea, but for the most part, we can see that there are some massive issues with all of them. Overall, I’d say most are good ideas but would end up failing in implementation. Classic.
I thought I’d end with three policy proposals—mentioned specifically on Trump’s website—that are overwhelmingly good news.
To reduce the number of individuals needing access to programs like Medicaid and Children’s Health Insurance Program we will need to install programs that grow the economy and bring capital and jobs back to America. The best social program has always been a job – and taking care of our economy will go a long way towards reducing our dependence on public health programs.
This is super super super super super huge. The Republican party often fails to support—or sometimes understand—the idea that public health and the economy, social factors, culture, dietary practices, etc are all interconnected. Whether you agree that the best social program is a job, it’s amazing that he endorses the idea that the economy and public health are interrelated. Plus, who can argue with programs aimed at increasing jobs? It’s at least a positive statement.
Reform mental health programs:
Trump says on his website: “We need to reform our mental health programs and institutions in this country… Families, without the ability to get the information needed to help those who are ailing, are too often not given the tools to help their loved ones.”
This is AWESOME. Mental health is often entirely left out of campaigns, and for Trump to mention this it shows that he has some sort of idea of the kinds of crises our nation is experiencing. Rejoice in the small victories, people.
Offer paid maternity leave: Trump is calling for paid maternity leave, $300 a week. That’s 1/3 of the median income of an American worker. It’s long overdue, but it’s a great step!!!!!