Stay the course, Mr. President, stay the course!
Donald Trump has just declared that he’ll unveil a health care proposal in the near future, and let’s hope he does, for that would be a highly instructive enterprise.
Earlier this spring, Senate majority leader Mitch McConnell tried to talk Trump off his renewed repeal-the-Affordable Care Act obsession. He obviously knows the issue isn’t a winner for Republicans. Better, then, to rely on those traditional McConnell tactics: Attack the Democrats on their plans, but dissemble, deflect, and duck about your own. Not that McConnell puts it quite that way, of course.
The majority leader’s basic instinct is right here: This is not a winning issue for the GOP. After all, the last Republican vote to repeal and replace the ACA — a plan torpedoed by the late, lamented John McCain — would have resulted in many millions more without health care coverage,
But in an ABC News interview that aired Sunday, Trump declared that “Obamacare has been a disaster” and that within a month or two, he’ll put out a health plan of his own — one that will lower costs while providing “phenomenal health care.” This is not a new blandishment, mind you; in 2016, Trump promised health care that would be “much less expensive and much better” than Obamacare. Alas, that elusive unicorn never emerged.
Here’s where an understanding of public policy possibilities comes in handy. Possessed of that, one can say with near certainty that nothing Trump proposes will: (1) keep comparable levels of the population insured while (2) making health care coverage much better and (3) much cheaper.
“It is sort of the equivalent of a perpetual motion machine,” said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation “It is not physically possible.”
Trump could make the ACA better by increasing individual subsidies, thereby rendering plans more affordable for those buying them on the exchanges. That, however, wouldn’t be cheaper. Or he could limit the health services and procedures covered. That would be cheaper — but it wouldn’t be better. He could reduce plan costs by saying insurers needn’t cover preexisting conditions. That would make health care cheaper for those without long-term maladies, but far worse for those who suffer from them. In fact, it would be disastrous for many of those patients.
One favorite Republican nostrum is to transform Medicaid from a federal program that covers anyone who meets the income guidelines to a block health care grant to be administered by the states. But unless those grants keep pace with need — and if that were the intention, why do block grants at all? — that just passes the buck (or the need to provide more bucks) to the states. They would then face the choice of coming up with more dollars on their own, or limiting participants in their Medicaid programs, or shrinking coverage.
The one place where Trump might find a way to make significant savings is by empowering the federal government to negotiate drug prices with the pharmaceutical companies. However, he’d be endorsing and pushing beyond a proposal by House Speaker Nancy Pelosi, who wants to allow Medicare to negotiate drug prices. Anyone think that will happen?
Given those realities, rather than offering a detailed proposal, Trump will probably take refuge in a set of principles that will guide his approach. Still, even that will be helpful, because failing to come up with a real plan will speak volumes. As will the experts, as they point out the likely devil in the missing details.
This, then, should be a clarifying exercise indeed. And one teed up just in time for the 2020 election. So thank you, Mr. President. And please, don’t let Mitch McConnell dissuade you. Follow through. Put out your plan!