President Trump certainly made a very good presentation last week to members of Congress. Regarding his comments on healthcare, here are some thoughts:
His opening remarks regarding expanding coverage and access while reducing costs are certainly goals and objectives everyone can embrace. Also, his statements about reducing pharmaceutical costs would certainly benefit consumers, providers, and the overall healthcare delivery system.
His remaining remarks mirrored House Speaker Paul Ryan’s policy paper announced on June 22, 2016 entitled “A Better Way: Our Vision for a Confident America.” This policy paper called for repealing the Affordable Care Act including the health insurance market exchanges. Trump even used the market places as an example of failure under ACA. However, we know the marketplace exchanges need revisions and modifications, but they only represent 7 percent of the insurance coverage for the entire population. Employer-based health insurance still represents 49 percent of the population. And then we have Medicare, Medicaid, and other sources of insurance.
Health Saving Accounts are not insurance: They are savings accounts designed for appropriate wage earners that have the additional funds to put into them. Additionally, they are designed with high deductibles and tax advantages for income producing people. They are not necessarily a good vehicle for people at or near the federal poverty level.
The initial tax credit models tie the credits to age so younger people plus older participants receive less than the subsidies under ACA. While these are good for the higher income people, one size does not fit all. Again, this is not beneficial to lower income people.
The high risk pools in Texas in the pre-ACA days helped but covered few people (out of the ones needed the high risk pool) and incurred high costs.
Is the true goal of Medicaid block grants or Medicaid per-capita plans to cut funding or reduce federal guarantees? If so, the states will bear an added financial responsibility because block grants really disconnect the level of funding on the number of beneficiaries and the cost of care. Even per-capita plans would be limited to certain individuals with no way for the states to add or expand coverage to different groups. What would be the contingency plans for disasters like a major hurricane?
Trump advocated for selling insurance across state lines which was also included in Ryan’s plan. I have researched and found no credible evidence that selling insurance across state lines would reduce healthcare costs. To my knowledge, no insurance companies, providers or consumers have demanded this action. Several states already have that ability and have not had any takers. Each state has an insurance commissioner who needs to be consulted, asked for advice and guidance regarding this discussion . We have a prompt pay provision in Texas so selling across state lines could actually negatively impact providers cash flow.
Trump did not expand any on Ryan’s plan regarding Medicare and he might not adopt those positions. However Ryan’s plan did raise the age of Medicare to 67, redesign Medicare’s benefits and cost sharing, and convert Medicare to a premium support system.
Trump was certainly on target when he said we need a bi-partisan, collaborative effort to develop effective health care. However, the Congressional Budget Office must score all of these changes and many conservatives have already said publicly–they will not support some of these changes like tax credits.
Hopefully, we can strive for public health policy which should not be political policy as we are all stakeholders who must work together for the health of not only Texas (the highest uninsured rate), but also our nation.