Much speculation has already been written on what a Trump administration may look like, but comparatively little has been said about the potential impact of that administration on physicians, hospitals, and patients. While details will obviously not be available for some time, some early generalizations are possible, based on the position paper President-elect Donald Trump issued in March and the statements he has made since then.
One of Mr. Trump’s earliest and most repeated pledges was the one to repeal the Affordable Care Act and replace it with “something fantastic.” A repeal would be welcome news to many physicians, even without any idea of what its “fantastic” replacement might be; but Trump has hedged already. In mid-November, he told the Wall Street Journal that Obamacare would be “amended, or repealed and replaced,” which introduces considerable wiggle room.
He also told the Journal that he wanted to keep the provision that allows young adults to stay on their parents’ coverage through age 26 years, as well as the provision that prohibits health insurance companies from denying coverage because of preexisting conditions. While the former would pose few difficulties, it would probably be impossible to retain the preexisting condition ban without also keeping the mandate to buy insurance and the subsidies to low- and middle-income families; in short, most of the ACA’s essential components.
In an interview with CNN, Mr. Trump indicated he would keep the individual mandate; but the next day, he tweeted – and then reiterated in his position paper – that he would remove the mandate and install a “backstop for preexisting conditions.” In the 1990s, when a few states tried to prohibit discrimination based on preexisting conditions without a corresponding mandate, premiums increased precipitously, driving away healthy customers, forcing insurers to stop selling policies in those states, and demonstrating that one cannot work without the other. Perhaps a more-informed Mr. Trump will come to see this.
Other proposals have been more enlightened. Mr. Trump has said that he favors portability of health insurance from state to state. In theory, this will introduce more competition into the system and drive premiums down. He has also proposed making health insurance premiums fully tax deductible for individuals, as they are now for businesses, further lowering premium costs.
He has proposed expanding the health savings account program, making contributions tax free, cumulative, and part of a patient’s estate. I have been a fan of HSAs since their inception because they eliminate the insurance “middleman,” which is good for physicians as well as for patients, who are more aware of what services they are receiving and what they are paying for them. Along the same lines, he has called for price transparency, so that patients can shop for the best prices for procedures and examinations, which now vary widely from one hospital or clinic to another.
Another good idea, in my opinion, is the removal of barriers to the sale of cheaper foreign-manufactured drugs in this country. Such barriers have kept drug prices higher here than anywhere else; consumers should be able to import their medications, from Canada, India, and elsewhere, as long as they are similarly safe and effective. Mr. Trump has also said that Medicare should be able to negotiate drug prices, which should have been true from the outset. The savings, particularly where biologics and other expensive new drugs are concerned, could be significant, since Medicare frequently sets the standard for prices in the industry. He also would raise the Medicare eligibility age, which I believe is a good idea as well.
Less inspired is his proposal to turn over administration of Medicaid to the states, supported by federal block grants. This plan does not take into account that Medicaid, an expensive and inefficient program with a narrow network of doctors, desperately needs an overhaul. Simply expanding it, and handing over full responsibility to the states, is not a viable solution, in my opinion.
Mr. Trump’s position paper also contains the dubious assumption that enforcing immigration laws will significantly decrease health care costs. Sealing the Southern border, he reasons, will help hospitals overburdened by the costs of services they provide to illegal immigrants who can’t pay for them and curtail the burgeoning heroin trade and its associated medical costs. There is little evidence to support either assumption – or even that the border can be effectively sealed in the first place.
So Mr. Trump has a health care plan, of sorts. How it will look by Inauguration Day, and what portion will be implemented, remains to be seen.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com .
