Political criticism is rarely kind. After last month's unveiling of GOP presidential frontrunner Donald Trump's "Healthcare Reform to Make America Great Again," (www.donaldjtrump.com/positions/healthcare-reform), vitriolic commentary was in no short supply.
"Donald Trump's healthcare plan shows his complete disregard for expertise," wrote Peter Suderman at Reason.com. "It is a bunch of words somewhat related to health policy that his campaign is calling a 'plan.' Those words demonstrate not only that Trump does not understand healthcare policy, but that he cannot be bothered to hire anyone who does to work with him."
Politico's Paul Demko wrote that the plan was actually "Trump's healthcare surrender. While the billionaire businessman has repeatedly said that poor people shouldn't be 'dying in the street,' for instance, now he wants to turn the country's biggest health program for the poor into a block grant and give tax breaks to people who buy their own insurance."
Putting politics aside, how does the plan resonate with others who consider health policies from multiple perspectives? ADVANCE offers the following points of view for readers' consideration.
An Academic Perspective
Len M. Nichols, PhD, professor, and director of the Center for Health Policy Research and Ethics, College of Health and Human Services at George Mason University, was quick to weigh in with the following point-by-point insights on Trumps seven-point plan (shown in italics):
Point 1 - "Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to."
Nichols noted, "Over 20 million people would lose coverage the day that repeal becomes effective, causing tremendous disruption in every state. Complete repeal of cost-saving provisions means all the Medicare payment reforms which have held cost growth below historical norms since 2010 will go away. This means less coverage, and higher cost from the outset."
Point 2 - "Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up."
"'Across state lines' sounds great, but no serious actuary or economist ever supported this, unless there are federal minimum standards like those in the ACA for guaranteed issue (GI) and modified community rating (MCR)," explained Nichols. "But Trump's Point 1 repeals ACA in toto, so we're back to the historical version of this proposal. I admit it sounds great, and it appeals to the ideological wing of the Republican Party. But in reality, it is not designed to improve consumer options in the insurance market, but rather to enable insurers to select their preferred set of regulations. In a world of ACA repeal - one with no GI or MCR in all states - insurers will find states that have no rules about selling to all or restrictions on how much they can charge those who have health conditions. They will officially domicile there, and use the rules of that state to cherry-pick the healthy in states that try to have rules. This is what proponents of this policy have always wanted (this long pre-dates Trump and I doubt he is aware). They want no restrictions on medical underwriting, which would lead to lower premiums for the healthy, and much higher premiums - and lack of insurance - for those with pre-existing conditions. They would be left in the cold."
SEE ALSO: The Future of Obamacare
Point 3 - "Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn't Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, 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."
"This is a simple matter of tax fairness, and it would help encourage more people who do not have group coverage at work to buy coverage. So this is a good 'fairness' idea," said Nichols.
Point 4 - "Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate."
Nichols clarified, "This is a liberalization of current rules on HSAs, which are somewhat restrictive at the moment. HSAs are seen as ways to make high-deductible plans more palatable to people who generally prefer more generous plans. But note, high deductibles are touted because they force consumers to bear cost, put 'skin in the game,' etc. HSAs defer the pinch of that skin, i.e., they negate the avowed purpose of the high deductible in the first place. This point basically enables high-income healthy individuals to avoid out-of-pocket payments for care, which will not help hold down healthcare costs."
Point 5 - "Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure."
"Transparency is generally good, but be careful what you wish for," cautioned Nichols. "There are 9000 CPT codes. medical prices are complicated, and the rates vary by payer. The biggest problems consumers have are: (1) the same set of doctor/hospital charges will cost consumers different amounts, depending on which insurer they have, and (2) it's pretty hard to anticipate all services you will need in a hospitalization before you are admitted. Without insurer-specific transparent tools, this plank will not help consumers much."
Point 6 - "Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources."
"Both God and the devil live in these details," said Nichols. "If the block-grant approach is reasonable (risk adjusted per capita caps), this could be humane and wise. But if the block-grant proposal is a fixed pie/global budget mostly designed just to shift costs to the states, then this is actually a bait-and-switch attempt to reduce our society's commitment to the most vulnerable among us. It's hard to determine the true objective from the language released so far."
Point 7 - "Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers."
"Re-importation sounds good, but would in fact be counterproductive in the extreme," said Nichols. "The U.S. does pay the highest prices for drugs, because our government is prohibited by Congress (which is apparently sufficiently controlled by pharma) from negotiating with drug companies. That can be fixed without re-importation. But if we were allowed re-importation from Canada, there simply would not be enough drugs sold to Canada to flood back in to satisfy our much larger demand. Furthermore, drug companies would likely raise prices overseas and not lower them here, so U.S. consumers would not gain much and consumers overseas would lose. Ultimately, everyone would lose, because less revenue means less research and development, and less future innovation."
A Nursing Perspective
Sunny Hallowell, PhD, PPCNP-BC, IBCLC, is assistant professor of nursing at Villanova College of Nursing in Villanova, Pa., and president of the Pennsylvania-Delaware Valley Chapter of the National Association of Pediatric Nurse Practitioners.
Hallowell offered her thoughts on Trump's plan from her self-described, multitasking perspective of a "woman, mother, nurse practitioner, researcher, professor and clinician with more than 15 years of experience in pediatrics and perinatal medicine."
The biggest problem with Trump's plan, she said, is an apparent lack of detail and innovation. "The seven points do not describe a healthcare plan; they are talking points, the same talking points made by every Republican candidate in the current presidential race, " she remarked. Of great concern, she said, is the extremely limited discourse ". with America's three million nurses who comprise the largest proportion of the healthcare workforce." She further reminded that RNs are predominantly female (92%) and are a powerful voting sector with whom all candidates should consult.
"Any successful implementation of Trump's ideas would require the elimination of unnecessary barriers that prevent advanced practice nurses from practicing to the fullest extent of their practice and training," suggested Hallowell. "To date, only 21 states and the District of Columbia allow NPs to practice to the full-scope of practice and authority."
She also noted that any new healthcare reform policies should consider evidence related to the nursing workforce and improved patient outcomes, and provide direct reimbursement to NPs at a rate comparable to others providing comparable primary care - such as doctors. "Any new proposal for healthcare reform should center on. nursing and the nursing healthcare workforce," said Hallowell about a sector Trump has so far seemingly overlooked.
A Cost Perspective
An analysis published in early March from the Committee for Responsible Federal Budget (CRFB) examined the seven-point Trump plan to determine its budgetary impact vs. its human potential. The resulting report contributed some reason for rejection of the plan, while at the same time not necessarily endorsing the ACA.
"We found that. the plan would result in about 21 million people losing health insurance. Now we don't necessarily think government should have to pay for everyone's health insurance," said Mark Goldwein, senior vice president and senior policy director for CRFB, speaking by phone from his Washington, DC, office. "But the problem we see is that at the same time 21 million people lose coverage, Trump's plan would actually add to the deficit, at a cost of about $270 billion over 10 years."
Goldwein also pointed out that Trump's plan doesn't necessarily align with his assertion that "poor people shouldn't be dying in the streets." "His plan would remove coverage from 21 million people, and then add coverage for only one million." In short, it's a quid pro quo that doesn't make sense, because it would seem that everyone loses.
A Think Tank Perspective
Sally Pipes is president, CEO and Thomas W. Smith Fellow in Healthcare Policy at the Pacific Research Institute, a California-based free-market think tank that promotes "the principles of individual freedom and personal responsibility" through policies that emphasize a free economy, private initiative, and limited government.
Pipes finds some good in the Trump plan, and is vocal about her support of an ACA repeal. "I support 'repeal-and-replace' and believe poll numbers remain steady in showing that American people disapprove of the law," said Pipes. "High deductibles, high premiums, and small networks of hospitals and doctors have been surprising to people. But repeal will take a president who can work with Congress and who has a real backbone. This is not a job for the faint of heart."
Pipes recalled an annual check-up at her doctor's office shortly after the passage of the ACA. "When I took out my wallet to pay, the receptionist said, 'Oh, there's no charge. This is all free now under Obamacare. And I whispered under my breath, 'It's not free; now I pay for it with higher taxes.'"
Pipes suggested that the ACA is not really all that affordable for participants. "A Kaiser tracking poll released March 22 shows that nearly half of those polled who remain uninsured did not buy coverage because it is too expensive," she commented.
On the tax deduction for healthcare premiums that Trump has suggested for individuals, Pipes believes a more equitable approach would be an age-based deduction. She recently wrote an Opinion piece for Forbes in which she asserted, "Trump should instead embrace age-based refundable health insurance tax credits, which every American would be able to claim and use to purchase coverage, regardless of income or tax liability. Since healthcare costs often increase with age, these credits should do the same: $1,200 for those aged 18 to 35, $2,100 for those 35 to 50, and $3,000 for anyone over 50. Families should also receive $900 for each child covered."
A strong supporter of HSAs, Pipes told ADVANCE the amount people can sock away should be raised to match the level allowable in Individual Retirement Accounts (IRAs) - $5,500 per person, $6,500 per person over age 50. "This would also help with Trump's goal of transparency. Consumers will be spending their own money, so they'll have a strong incentive to demand clear rate quotes from healthcare providers."
Pipes is in favor of Trump's plan to switch to federal block-grants to states for Medicaid. She noted in her opinion piece for Forbes, "By switching to block grants, the government can challenge states to spend their Medicaid dollars wisely. States could tailor their programs to meet the specific needs of their state's low-income population. As Trump correctly notes, 'The state governments know their people best and can manage the administration of Medicaid far better without federal overhead.'"
However she breaks with Trump on the issue of drug re-importation, calling his last point "not great." Her concern is the effect it would have on research and development. "Drugs in other nations are cheaper because their governments cap their prices. Importing foreign price controls would gut medical research and innovation."
A Legal Perspective
Doug Levy is a New York City-based healthcare lawyer and consultant who believes Trump's plan lacks specifics needed to understand how it would actually reduce costs or increase access. "Much of what he says is symbolic, and some of it likely would increase overall healthcare costs, not reduce them," he told ADVANCE. "Without specifics on his replacement for Obamacare, it's impossible to properly judge his overall intentions, other than to say the system is much more complex than Trump's comments seem to reflect."
Levy offered this bulleted list of his opinions on the plan:
Relatively few people would benefit from interstate insurance sales or making insurance premiums tax-deductible.
Expanding HSAs is probably a good idea, but this and the tax deduction for premiums would reduce federal revenue without defined spending reductions to compensate for it.
Price transparency sounds good, but it would require a ton of work, since much of our current crazy-quilt of billing codes stems from Medicaid and Medicare rules and decades of layered regulations. And our experience with "transparent" insurance plans shows that consumers are not very good at price-shopping for healthcare.
Import barriers concern me, since the current system assures people are actually getting the medicine that is on the label, and we currently do import a huge number of pharmaceuticals that are made in less expensive factories in India and other places. Bringing drug prices down is important, but opening up safety regulations gives me pause.
Levy concluded, "Fundamentally, the elements that Trump lays out require legislation and massive overhaul of regulations in multiple areas. Even if this were a brilliant plan, it would not happen quickly."
Valerie Newitt is on staff at ADVANCE. Contact: firstname.lastname@example.org.