President-elect Donald Trump gave an interview to the Washington Post Sunday in which he described an alternative to Obamacare that sounds pretty terrific. That — or it’s a huge con that Trump isn’t going to be able to keep covered up for much longer.
Trump vowed that his plan would provide “insurance for everybody” — unlike the Affordable Care Act, which still leaves about 25 million people without coverage. Insurance plans, he promised, would have “much lower deductibles.” And price, he said, won’t be an issue. “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.”
The only thing missing from Trump’s amazing health proposal was his actual health care plan.
The Washington Post’s Robert Costa writes that “Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished.” This made it somewhat odd that there was no inkling of how Trumpcare works — how it would get the entire American population coverage, for example, or what type of health plans we’d get — if the plan was supposedly just about done.
Costa’s article leaves out some important context: We’ve seen this game from Trump before, during the campaign. He promised a plan that covered everybody, that left no one behind. But the campaign proposal he ultimately rolled out was far from that — instead of covering everybody, it would have caused 21 million Americans to lose coverage.
Trump’s promise’s are far from his previous health care proposals. They’re also far from current Republican doctrine on health policy, which emphasizes more out-of-pocket spending (including higher deductibles) to make consumers more price-sensitive when they seek medical care. Having more “skin in the game,” the argument goes, will lower health costs for everyone, as consumers only go to the doctor when they really need it.
Trump is nowhere in the ballpark of those type of plans with these new promises, which sound a lot more like a liberal ideal in health care: a single-payer system.
Trump spent the campaign promising coverage for everyone — but introduced a plan that would cause millions to lose their insurance
During the 2016 campaign, Trump promised a health plan that would cover everyone. He staked out a position that was decidedly different from those of his Republican rivals during the primaries.
"I am going to take care of everybody," Trump told 60 Minutes in an interview in the fall of 2015. "I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now."
Trump staked out a similar position in the Republican primary debates, getting into a heated exchange with Sen. Ted Cruz (R-TX) over government funding of health coverage. “We’re going to take care of people who are dying on the street,” Trump said at that debate, seemingly tacking far to the left of his opponents.
Trumpcare repeals Obamacare’s coverage expansion (the subsidies for private coverage as well as the Medicaid expansion), and allows insurers to go back to refusing to sell coverage to those with preexisting conditions.
Repealing Obamacare would leave an additional 22 million people uninsured, the Committee for a Responsible Federal Budget analysis estimates using Congressional Budget Office projections. These people would mostly be losing coverage they get through the health law's marketplaces and its Medicaid expansion.
Obamacare doesn't offer universal coverage; CBO estimates that in 2018, it will still leave 27 million people uncovered. Still, it outperforms Trumpcare by a lot, because Trumpcare would add 21 million to that group, for a grand total of 48 million uninsured Americans.
About a million of those who lost Obamacare would gain insurance through Trump's proposal to allow insurance plans to sell across state lines. That would, theoretically, allow shoppers in highly regulated markets to gain access to less expensive coverage. (The Upshot's Margot Sanger-Katz has a good summary of this part of the Trump plan.)
But even with the sale of insurance across state lines, Trump's plan would leave 21 million Americans without coverage.
Trump says in his plan that America "must also make sure that no one slips through the cracks simply because they cannot afford 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.
The plan Trump is describing? It sounds a lot like single-payer health care.
Trump’s promises aren’t impossible — the health care systems we see in Canada, England, and across Europe meet his goals. A plan with low deductibles and universal coverage, as conservative health policy writer Philip Klein points out, sounds a lot like a single-payer system.
Trump's quotes in this interview are consistent with single-payer, but not with any GOP alternative ever. https://t.co/MFDwC2mgLm— Philip Klein (@philipaklein) January 16, 2017
The reason single-payer systems can achieve Trump’s goals is that they cut costs by cracking down on providers — they negotiate much, much lower prices with hospitals, doctors, pharmaceutical companies, and medical device manufacturers. The low prices they pay for medical services help them keep deductibles and copays down. And the reason everyone can be covered is those countries are willing to raise the taxes necessary to fund a truly universal system.
As Klein notes, this is far, far from what Republicans on Capitol Hill have proposed. And let’s be clear: Trump’s promises are very, very far from his own health policy proposal. What we’ve seen before is Trump talk about something that sounds like single-payer as he campaigns, but deliver something very different when he writes his ideas down on paper. Trump’s plan actually offers less coverage than those that have come out of congressional Republican leadership.
Maybe Trump has made a 180 on health policy and will produce something that delivers on his promises. But given what we’ve seen from him on the subject so far, there is good reason to reserve some skepticism until we actually see his plans written out on paper.