What Donald Trump would do with the US healthcare systemBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2996 (Published 26 May 2016) Cite this as: BMJ 2016;353:i2996
- Leigh Page, freelance healthcare writer, Chicago, Illinois, USA
Donald J Trump, the presumptive Republican nominee for president of the United States, would follow many of his party’s established healthcare policies, such as seeking to repeal the US health reform law, but he also breaks with Republicans on several key healthcare issues.
The Affordable Care Act, passed by Democrats in 2010, aims for universal coverage but stops short of creating a centralized system covering every American. Instead, it provides subsidies to buy private insurance and it expands Medicaid, a government program that covers people with low incomes.
Trump would replace the reform law with new policies—“We’re going to have something better,” he said in February1—but he has said very little about what that system would be. “If somebody has no money and they’re lying in the middle of the street and they’re dying, I’m going to take care of that person.”
Don Berwick, who implemented the Affordable Care Act as the head of the US government's Center for Medicare and Medicaid Services (CMS), says he is not sure what that statement means. He thinks it might mean that Trump believes every American has a right to healthcare. But he says it’s also possible that Trump is simply supporting “the kind of episodic care that emergency rooms already offered” before reform, without providing any preventive care.
Jeff Anderson, a senior fellow at the conservative Hudson Institute, in Washington, DC, is also unclear what the Republican candidate’s healthcare pronouncements actually mean. He fears Trump wants to make government bigger, which conservatives like Anderson oppose. For example, “Trump seems to want to expand Medicaid even beyond Obamacare’s already bloated levels,” he says, using a common term for the reform law.
For his part, Trump says he would turn Medicaid over to the states, which is what Anderson and other conservatives want. The federal government currently sets the rules for the program, but Trump's website explains: “The state governments know their people best and can manage the administration of Medicaid far better.”2
Trump adheres closely to Republican doctrine when promoting Health Savings Accounts (HSAs). People can pay into HSAs without being taxed and then use the money to pay for their healthcare. However, HSA tax breaks “don't help most people, except for the rich,” Berwick says. “When the funds in the accounts run out, people would have no place to go.”
Plans for Medicare
On the other hand, Trump defies party doctrine on Medicare, the government insurance program for Americans aged 65 and older. Many conservatives want to replace the program with vouchers to buy private insurance. “Medicare reform is crucial for getting our fiscal house in order,” Anderson says. But Trump wants to leave Medicare alone. “It’s actually a program that’s worked,” Trump said in October.3
Instead, Trump wants to save Medicare money by allowing the government to negotiate prices with drug companies. “Though the pharmaceutical industry is in the private sector, drug companies provide a public service,” Trump’s website states.
Trump would also allow Americans to buy drugs in Canada at much lower prices. This proposal “makes a lot of sense,” Berwick says. “Pharmaceutical costs are insanely expensive in this country.”
Lack of coherence
Despite Trump’s non-doctrinaire approach to healthcare, both Anderson and Berwick agree that the Republican candidate doesn’t understand the nuances of this complex field. “Trump is weak on healthcare,” Anderson says. “His policies on immigration and free trade made him popular, and healthcare has been something of a side issue for him.”
Berwick adds: “The lack of coherence and comprehensiveness in Trump's policies is among the most striking characteristics of his health proposals.” For example, he says that while Trump would repeal the reform law, he plans to keep its requirement that insurers sell policies to everyone—even those with pre-existing health conditions, such as diabetes or cancer.
However, insurers argue that the pre-existing conditions requirements can function only if the law’s requirement for everyone to buy insurance is allowed to stand. Without the coverage mandate, insurers say, people would only need to buy coverage when they were seriously ill, in which case the insurer wouldn’t earn enough money from the policyholder to cover the illness.
Asked in February if he agreed with the insurers’ argument, Trump said, “I think they are wrong 100%. The insurance companies take care of the politicians. The insurance companies get what they want.”1
Perhaps Trump's most well known healthcare proposal is to allow insurers to sell policies in other states. The argument, embraced by many conservatives, goes like this: when a state allows insurers to provide less robust coverage at lower prices, those insurers should be allowed to sell the same low cost policies in other states that require more robust coverage at higher prices.
Trump has repeated his proposal to eliminate “the lines between the states” countless times on the campaign trail. However, a statement on his website says selling across state lines should only be allowed if the policy “complies with state requirements.” In that case, an insurer entering another state would have to offer the robust coverage required in that state, which would cancel the cost saving benefit of selling across state lines.
One of the biggest concerns for Berwick, however, is Trump's plan to repeal the reform law. “Millions of Americans would lose coverage, causing a great deal of pain,” he says. Furthermore, it’s a complex law, involving many changes in the way healthcare is regulated. “It would be very hard to unwind important pieces of the law that have already taken root,” he says.
“Trump’s election would be disastrous for the country in many ways, and healthcare is no exception,” Berwick says.
Anderson has a different perspective. “Trump hasn't wanted to make the hard choices,” he says. “He tells people that you can continue to get everything from the government, and the money to pay for it will apparently fall from the skies.”
Hillary Clinton: Trump's opposite
Whereas Trump has little healthcare background, Hillary Clinton, his presumptive Democratic challenger, has been involved in healthcare for decades. She was in charge of her husband Bill Clinton's unsuccessful attempt at health reform when he was president.
Clinton wants to improve President Obama's health reform rather than repeal it. She proposes to give a tax credit to Americans whose health costs exceed 5% of their income and to require insurers to completely cover three visits to the doctor each year.
But she matches Trump's proposals on prescription drugs. She would legalize the importation of prescription drugs from Canada and wants Medicare to be able to negotiate drug prices.
Clinton disagrees with the proposal of her Democratic challenger, Bernie Sanders, to scrap the reform law and create a government run, single payer, healthcare system like Canada’s.
Recently, however, she proposed expanding government run healthcare. She wants to allow people aged 50 or 55 to buy into Medicare, which is currently only for people age 65 and older.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.