President Trump’s impossible health care dream

Lesley Becker/Globe Staff; Adobe; Globe file photo/Globe Staff; Adobe; Globe file photo

President Trump wants the GOP to become the party of health care — read: to try again to replace the Affordable Care Act with a Republican scheme — but his usually compliant enablers in Congress have no interest in that. At least not now.

Why? Well, for starters, some learned from the shellacking they took in the 2018 midterms. But other congressional Republicans probably also comprehend a reality the president chooses to ignore. That is, despite Trump’s repeated promises to provide health care that covered everyone and was “far less expensive and far better” than Obamacare, the chances of that are next to nil.


“It is total nonsense,” says Phil Johnston, New England administrator of the US Department of Health and Human Services under Bill Clinton and former Massachusetts secretary of human services. “You can do one or the other, but not both.” Not, that is, without adding billions of dollars in government subsidies or dropping lots of people from the insurance rolls.

Here’s why: Health insurance premiums reflect a complex calculation based on the cost of various medical services and procedures and the best estimate of the number of times those will be performed across the group of people that make up an insurance risk pool. (In Massachusetts, that determination accounts for 90 cents of every premium dollar, with the rest going for plan administration, taxes, and assessments.)

You can’t simply alter that math by decree. So how can you lower premiums? One way is by narrowing the list of medical procedures insurance carriers must cover. That’s the approach the Trump administration has taken in pushing high-deductible limited-coverage short-term plans, notes John McDonough, professor of public health practice at Harvard’s T.H. Chan School of Public Health.


Certainly if insurers no longer must cover, say, treatment for recurrent cancer or chronic kidney problems, the cost of a health insurance plan would be comparatively less. Oh, but they would never do that, you say. OK, then let’s use a different example. Assume insurers weren’t required to cover obstetrics or knee replacements; if so, the price of health insurance would be relatively lower. But if you are or plan to become pregnant or need to have a knee replaced, your coverage couldn’t be called “far better” than ACA plans.

But let’s return for a moment to treatment for recurrent cancer or chronic kidney problems. Not so very long ago — that is, pre-ACA — coverage for either might well have been excluded if an insurer could argue the cancer or the kidney problems were preexisting conditions – that is, that they predated a person’s coverage by that insurer. Anyone willing to argue that was better coverage?

Another way to make health insurance cheaper for the average reasonably healthy purchaser is by limiting an insurer’s financial responsibility for sicker, higher-cost patients. With those expenses reduced, premiums for everyone else would decline. But some sort of public subsidy would then be required to provide those high-cost patients with coverage they could afford. So while the full cost of caring for those patients would no longer be factored into insurance premiums, they wouldn’t disappear. They would simply be shifted onto taxpayers.

One favorite GOP proposal is to transform Medicaid into block grants for the states and then leave it to them to devise health care solutions for low-income citizens. That would save the federal government money over time, but would probably force states to (1) come up with more money of their own or (2) reduce the quality of their Medicaid programs or (3) limit the number of people they cover.


There just isn’t, then, any way to bring about the much better, much less expensive health care Trump has promised. That was made abundantly clear during the GOP’s unsuccessful 2017 effort to repeal and replace Obamacare. Congressional Republican aren’t going to take the matter up again before the 2020 elections. But make no mistake: Given the right opportunity, they’ll be right back at it in 2021.

Caveat emptor.

Scot Lehigh can be reached at lehigh@globe.com. Follow him on Twitter @GlobeScotLehigh.