Donald Trump released a major policy proposal Wednesday night. It's a seven-point plan to overhaul American health care — or, as Trump puts it, "healthcare reform to make America great again."
In broad terms, Trump's plan looks a lot like the dozen or so other Republican Obamacare repeal plans that have come out over the past few years. Trumpcare allows insurance companies to go back to refusing coverage for preexisting conditions, a key barrier to coverage before Obamacare's coverage expansion.
Trump says in his plan that America "must also make sure that no one slips through the cracks simply because they cannot afford insurance." In a recent Republican debate, Trump promised that, if elected, he would "not allow people to die on the sidewalks and the streets of our country" for lack of access to health insurance.
But there's nothing in his health overhaul that prevents people from dying in the streets; there's no guaranteed access to insurance at all. Trumpcare, like other Republican replacement plans, has plenty of cracks to slip through.
Trumpcare has seven main policy points. Many of them are Republican orthodoxy, like allowing insurance sales across state lines (part of the Republicans' 2010 Pledge to America) and fostering a greater reliance on health savings accounts (a favorite policy proposal of Mitt Romney during the last campaign cycle). And, of course, Trump repeals Obamacare.
The key insurance reform that Trumpcare settles on is allowing individuals to deduct their premiums from their tax returns. This would give preferential tax treatment to the policies that individuals purchase, much like employer-sponsored plans (which the government does not tax). And it might help lower the premiums of people who buy health insurance coverage.
This part strays in a nuanced but important way from recent Obamacare repeal plans — and makes Trump's proposal much less favorable to low-income people than other Republican alternatives to the Affordable Care Act.
Harvard's John McDonough's analysis of eight recent replacement proposals shows that most follow Obamacare in relying on tax credits rather than deductions. Credits deliver an equal dollar value to all households, whether rich or poor. Deductions are much more valuable to high-income families who pay in high tax brackets, and often do nothing to help low-income families who likely don't itemize their deductions at all.
Putting all that aside, Trumpcare erects a massive barrier to coverage: It allows insurers to deny coverage to sick people. This is pretty typical of Republican Obamacare replacement plans; only one of eight plans that McDonough analyzed required insurers to offer coverage to all individuals, even if they were especially sick.
Trumpcare would also allow the return of underwriting, where insurers can charge some subscribers more because they're especially sick. Under Trumpcare, a cancer patient could, theoretically, deduct his or her premium, which could make coverage more affordable — but that cancer patient might not be able to get coverage or have the cash to pay for it in the first place.
There are at least 60 million Americans with preexisting conditions. Some of them have coverage under Obamacare. If Trumpcare became law, there's no guarantee they'd get to keep it. It's a pretty big crack to slip through.
What Trump and Sanders's health care plans have in common
My colleagues Ezra Klein and Dylan Matthews have written extensively on Bernie Sanders's single-payer proposal. One of their biggest critiques has been that lofty, big promises (free health care, without a deductible, for all!) aren't backed up with actual policies to make those plans realistic.
"Sanders promises his health care system will cover pretty much everything while costing the average American almost nothing," Ezra wrote last month. "He's raised real concerns about the plausibility of his own ideas."
There's a similar thing going on in Trump's new proposal. He says, "We must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it."
There's a hint of a promise there that under Trumpcare, everything will be fine. Everyone will have access to health insurance, should they desire it. But there's nothing in Trump's proposal that takes him from point A to point B. There's no explanation of whether the government will pay for this care and how they'll deliver it, the point that Sen. Ted Cruz was trying to press on when Trump made his "die in the streets" comments:
CRUZ: So does the government pay for everyone’s health care?
TRUMP: … I’m not fine with it. We are going to take those people…
CRUZ: Yes or no. Just answer the question.
TRUMP: Excuse me. We are going to take those people and those people are going to be serviced by doctors and hospitals. We’re going to make great deals on it, but we’re not going to let them die in the streets.
CRUZ: Who pays for it?
Campaign proposals do not have to be fully fleshed-out legislative text. There is certainly space for ideas to develop in the course of an election and an administration.
But as it's written, Trump's proposal doesn't fulfill his promises, and it doesn't set him apart from the rest of the Republican field. Trump has suggested, in debate after debate, that he will break with the Republican field and make sure every American can afford coverage. As of now, that's a lie. His plan would leave millions uninsured, and it suggests Trump's platform is much more conventionally Republican than the candidate lets on.