JAMA Forum: What is Trumpcare?

Many of the top Democratic presidential candidates have released plans for how they want to reform the health care system.

Sen Bernie Sanders (I, Vermont) is closely associated with “Medicare for all,” which would cover everyone automatically and virtually eliminate private insurance. As he said in a recent debate, “I wrote the damn bill.”

Sen Kamala Harris (D, California) has proposed her own version of Medicare for all, which would create a longer 10-year transition and preserve private insurance as an option as part of Medicare through Medicare Advantage plans (which cover about one-third of Medicare beneficiaries today).

Former Vice President Joe Biden has a plan that would build on the Affordable Care Act (ACA) by expanding subsidies to help people pay their premiums and give everyone the option of joining a Medicare-like plan.

South Bend, Indiana, Mayor Pete Buttigieg’s plan would also expand ACA subsidies and make Medicare available to “all who want it.”

Interestingly, Senator Elizabeth Warren—who has detailed plans for many issues—doesn’t really have a specific health reform plan of her own at this point. She supports Medicare for all and is a co-sponsor of the Sanders bill. She is a co-sponsor of public option bills as well, and she has her own bill to strengthen the ACA.

The debate among Democrats largely boils down to whether to build on the ACA and create an option for people to enroll in Medicare or create a Medicare-for-all plan that covers everyone.

On the other side of the partisan divide, President Trump has repeatedly promised a health care plan, but not yet delivered one. On ABC News in June, he said “we already have the concept of the plan,” and “we’ll be announcing that in about 2 months.” He also said it would be “less expensive than Obamacare by a lot” and that it would “produce phenomenal health care.”

On Twitter, the president has said in recent months that the “Republican Party will become the Party of Great HealthCare!” and that Republicans are “developing a really great HealthCare Plan with far lower premiums (cost) & deductibles than ObamaCare.”

The president has vowed to repeal the ACA if he is reelected and Republicans gain control the House in addition to the Senate.

Maybe more immediately, the Trump administration is arguing in court that the ACA should be overturned, including its preexisting condition protections, premium subsidies to make coverage more affordable, Medicaid expansion, and a host of other provisions. The case is currently before the 5th Circuit Court of Appeals, and it’s possible that a decision could come next spring from the Supreme Court, right in the middle of the campaign. A court decision to overturn the ACA would produce immediate chaos in the health care system.

Meanwhile, recent Census data show that the number of Americans who are uninsured increased by 1.9 million in 2018, after reaching an historic low following passage of the ACA. Still, 91.5% of people were covered by health insurance last year.

We may or may not see a health care plan from President Trump soon, but in the meantime there are lots of clues as to what Trumpcare represents based on previous actions and statements. For example,

  • In his budget proposal earlier this year, the president proposed converting the ACA into a block grant to states, scaling back insurance protections, and limiting federal Medicaid spending. All told, his budget would have reduced federal health spending by more than $1.3 trillion over a decade.
  • The administration has given states substantially greater flexibility in Medicaid, including permitting them to impose work requirements for Medicaid beneficiaries. President Trump’s budget also proposed requiring all states to impose work requirements on “able-bodied, working-age individuals.”
  • Short-term health plans—which can deny coverage for people with preexisting conditions and often exclude or limit ACA-required benefits like prescription drugs, maternity care, mental health, and substance use treatment—can now be sold for up to 364 days. The president has said,  “We will always protect patients with preexisting conditions, very importantly,” but has not put forward a plan to do so.
  • Congress and the president repealed the ACA’s individual mandate penalty, which was the most unpopular element of the ACA. That has led to higher premiums in the individual insurance market, with insurers expecting some healthy people to forego coverage.
  • Recently issued regulations modify “public charge” rules, making it harder for immigrants with health conditions or who are more likely to use a variety of public benefits (now including Medicaid) to obtain admission into the United States or a green card. The changes will also likely depress enrollment in coverage broadly among immigrant families due to fears and confusion.
  • New rules under the Title X family planning program prohibit health centers receiving funding from providing referrals for abortion and require complete financial and physical separation from abortion services. Many health centers have left the program as a result.
  • Proposed regulations would require hospitals to disclose the prices they negotiate with insurers, providing much greater transparency for patients.

We may never see Trumpcare in the form of a detailed plan or piece of legislation. Recent news reports suggest that a plan is less likely and that the White House is concentrating on health issues like vaping that steer clear of controversial broader reforms. But voters can get a pretty good sense of what President Trump might try to do in a second term by examining his record. The contrast between President Trump and all of the major Democratic candidates on health care is quite stark, but that contrast has so far been obscured as Democrats debate among themselves.

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About the author: Larry Levitt, MPP, is Executive Vice President for Health Policy at the Kaiser Family Foundation, overseeing the organization’s policy work on Medicare, Medicaid, the health care marketplace, the Affordable Care Act, women’s health, and global health. (Image: Ted Grudzinski/AMA).

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About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.



Categories: Caring for the Uninsured and Underinsured, Health Policy, The JAMA Forum, Uncategorized

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