President-elect Donald Trump, in between obnoxious, deeply insecure tweets in which he attacked both John Lewis and Saturday Night Live, gave an interview to The Washington Post over the weekend, despite labeling it and other publications as "the dishonest media."
Trump told reporters Robert Costa and Amy Goldstein, “We’re going to have insurance for everybody." Trump continued, "There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us."
Some observers like writer Dave Weigel speculated that perhaps Trump's plan is Medicare-For-All, which would ostensibly eliminate the "65 years or older" requirement to enroll in the popular and embattled seniors-only government-run healthcare program. I assume Weigel and others were being facetious because there's literally no way Trump would propose such a socialist-leaning program.
Pulling a Nixon-to-China move on healthcare, however, Trump would be uniquely positioned to steal Bernie Sanders's thunder and push for such a thing. But, again, it'll never happen. There's simply no way the congressional GOP would go along with anything resembling a single-payer program, even though it'd be the ultimate fuck you to the Democrats. The Republicans would sooner fully fund Planned Parenthood as well as a gun confiscation program before they'd agree to a European-style healthcare system.
Instead, the Trump replacement for the Affordable Care Act will likely be a hodge-podge of weak, ineffectual, free market health insurance gibberish. Specifically, if we look at incoming HHS secretary Tom Price's plan, combined with Paul Ryan's recent remarks, along with something Kellyanne Conway said over the weekend about health savings accounts, the replacement scenario becomes a little more clear. And it's not single-payer.
UPDATE: Trump spokesperson Sean Spicer clarified the Trump plan on Monday:
Trump’s goal is “to get insurance for everybody through marketplace solutions, through bringing costs down, through negotiating with pharmaceutical companies, allowing competition over state lines," Sean Spicer, the incoming White House press secretary, said during an interview on NBC’s “Today” show.
Basically, we're looking at a combination of several replacement solutions. Cutting to the chase, Trumpcare is a chimera of terrible ideas.
1) High-risk pools. Trumpcare (or Ryancare or Whatevercare) would retain the ACA's language about pre-existing conditions, but instead of allowing customers with existing health issues to buy into the regular insurance market, Trump would shove sick and injured people into state-run, federally-financed high-risk pools. We're very likely talking about horrendous catastrophic plans with high premiums (covered by the government?) and punitively large deductibles (covered by customers). To repeat: these pools would be filled with sick people and therefore the plans would be hugely expensive, both for the government and for customers. According healthcare experts, the cost to the government would be in the range of $15 to 20 billion annually, capped at four million enrollees. Worse, the cost of premiums in existing high-risk pools are as much as 25 percent of the annual income for customers. By comparison, the ACA capped expenses at 10 percent or less of our annual income.
34 states have experimented with high-risk pools. Most have failed.
2) Health Savings Accounts. The insanely high deductibles that typically accompany high-risk pools and catastrophic plans won't prevent customers from lapsing into severe medical debt, given the massive out-of-pocket expenses. To cover such expenses, the Bush administration, back in 2003, began to pitch the idea of "health savings accounts" as a possible solution to making insurance more affordable. With HSAs, customers can contribute payments to their accounts every month, tax-free, in order to help pay high deductibles. The accounts roll over year-to-year and mitigate the financial risk of getting sick or injured. On the surface, it sounds like a promising stop-gap for medical expenses, but not for lower income Americans who can barely make ends meet, much less sock away thousands of dollars into an HSA. Consequently, most people who use HSAs tend to be Americans with more disposable income -- the one-percent and the like. Meanwhile, even if you can pay, you're still locked into a crappy catastrophic plan that may or may not be adequately funded. Oh, and last but not least, HSA's are tied to the stock market. In an unstable Trump era, good luck with anything market-dependent.
3) Tax credits. Tom Price's plan involves tax credits to help pay for premiums. If this sounds like the ACA subsidies to you, you're correct, with one big difference. Under Price's plan, government aide would ostensibly come once-a-year at tax time rather than the ACA's system of covering premium expenses every month through the ACA's state marketplaces and Healthcare.gov -- both of which will be eliminated when Congress uses reconciliation to de-fund the ACA. Furthermore, how would Congress pay for the credits? The ACA was set up to be deficit neutral. There's no scoring available for the Price/Trump/Ryan plans because none of the plans really exist in detail enough to evaluate. Will the GOP authorize a plan that adds billions to the deficit? Maybe, maybe not.
And finally, Price's plan allows anyone who's already been covered for at least 18 continuous months to continue to buy insurance in the individual market, regardless of pre-existing conditions. On the surface, this would allow anyone who's been enrolled within a year-and-a-half of the end of the ACA to continue buying coverage -- including me. But what will this continued coverage look like? If the Republicans repeal the consumer protections in the ACA, we could be charged ridiculously high premiums, punitive deductibles and co-pays, and the services covered could be severely limited. We just don't know, but the "known knowns" are really bad.
The Trump plan (that we know of) is in no way better than the ACA. It's far worse, and if it actually passes, customers will long for the glory days of Obamacare. Just imagine -- the guy responsible for Trump University is on the job. It's reasonable to expect something equally as shoddy, only this time it'll impact the lives and health of 20-plus million Americans.