He can barely bring himself to pretend he cares.
That’s the usual time period in which Donald Trump has, for the last 10 years, promised the arrival of a spectacular plan to reform the healthcare system, one that would solve every problem anyone could identify, whether individual or systemic.
Just you wait, he’d say — the plan is coming in
two weeks, and you’re gonna love it.
Well now the White House has indeed released what
it calls “The Great Healthcare Plan.” Is it great? No. Is it a plan? Not
really. It is, however, in its combination of stupidity, ideological
derangement, and unseriousness, a near-perfect expression of everything Trump
and his party believe about a policy challenge that has bedeviled the United
States for decades.
If the White House wanted to enact some kind of healthcare
reform, it would put out a document explaining a series of changes it would
like to make to the system, then work with Republicans on Capitol Hill to turn
those ideas into legislation. That is not happening. There are a few Republican
bills rolling around Congress, but no one takes them seriously.
What we have, then, is a bunch of vague statements of
principle, some outright nonsense, and a few absolutely terrible ideas.
The very bad healthcare non-plan
The plan (forgive us for using that word) is spread out over
a few short documents (here, here, and here).
It does contain a few things that look like big ideas, but are immediately
baffling.
The biggest is this one: “The government is going to pay the
money directly to you,” the plan quotes Trump saying. “It goes to you, and then
you take the money and buy your own healthcare.” How exactly is that going to
work? We’ll each get a check every month from the government? Is the entire
insurance system going to be replaced by health savings accounts?
Worry not: Trump insists that prices will come down, because
he says you’ll “go out and buy your own healthcare, and you’ll make a great
deal.”
Imagine the future that could be yours. You wake up in the
middle of the night with a crushing chest pain. Convinced you’re having a heart
attack, your first instinct is to call 911. But wait, you think — I’m an
empowered consumer in the free-wheeling healthcare market. As sweat pours down
your brow and you struggle for breath, you begin to shop around to decide where
you should seek care.
What’s the cost of a triple bypass at St. Joseph’s Hospital?
Can I make a deal with them? You check the Yelp reviews on Downtown General to
see how many five-star customer satisfaction scores that hospital gets. Then
you begin feeling dizzy, and as you slip into unconsciousness, you know that
healthcare has finally become great.
This is the ultimate expression of a foundational Republican
belief about healthcare, which is that if we could only inject more free-market
magic into the system, all the problems that bedevil it would disappear.
We’ll get more into that in a moment, but what else does the
Trump plan suggest?
It’s a little hard to understand on the question of
insurance. At times it seems to propose eliminating insurance altogether, while
at other times it wants to prop up the industry. For instance, Trump says the
plan “fully funds a long-neglected part of the law known as the Cost Sharing
Reduction program. This measure alone should cut premiums on the most popular
Obamacare plans — it’s hard to believe there are any because it’s a hated
program, it’s unaffordable — but it’s going to cut them by an average of 10 to
15 percent.”
If you aren’t a health policy wonk you’d have no idea what
he’s talking about, but briefly: The Affordable Care Act requires insurers to
cover basic care like checkups at no cost, and provided “cost sharing”
subsidies to insurers to pay for it without raising premiums. But in the first
Trump term, his administration eliminated those insurer subsidies, which led to
premium increases. So now he’s reversing himself and restoring this part of the
original ACA structure. What an amazing reform! (There’s a helpful explainer
here.)
The plan also says Americans should benefit from “the same
low prices for prescription drugs that people in other countries pay.” Terrific
— and how will that happen? Government price controls, perhaps? It doesn’t say.
It also would require providers to post prices for their procedures “in their
place of business.” Imagine a kind of McDonald’s menu, but with all the
thousands of different treatments one might receive in a hospital.
In fairness, there are some specific and not completely
insane ideas included here and there; for instance, it suggests making “more
verified safe pharmaceutical drugs available for over-the-counter purchase.”
Which might be fine, depending on how that
process is streamlined. But it isn’t exactly transformative. Likewise,
the plan suggests requiring insurers “to publish the percentage of their
revenues that are paid out to claims versus overhead costs and profits on their
websites. Again, perfectly fine — that’s called the “medical loss ratio,” and
the information is already public.
But nothing in the plan tackles any of the biggest problems
in the healthcare system, especially the millions of Americans who lack
insurance (a number that will increase
dramatically because of the Republicans’ Big Beautiful Bill) and the
overall cost of the system.
Trump versus the GOP
It’s quite clear that if someone asked Trump to name two
things his “plan” does, he would not be able to.
This has been one of the defining features of healthcare
policymaking in both Trump terms: He not only knows almost nothing about the
issue, he has no evident beliefs about healthcare; in fact, he couldn’t care
less about it.
Shortly after taking office in 2017, confronted with what it
would take to follow through on his promise to repeal the ACA, he lamented that
“nobody knew that healthcare could be so complicated,” though he seemed to be
the only person in America who didn’t know. From time to time
the issue bubbles back up to the top of the public’s agenda and he’s forced to
answer questions and pretend he has a “plan,” but he’d be much happier if it
just went away.
Trump, does, however, have a simplistic but basically
accurate understanding of what the public wants, so when speaking off the cuff
he’ll say things that make him sound almost liberal. For instance, he repeatedly
said he was going to deliver “insurance for everybody,” which would
certainly be nice.
“You’ll have healthcare the likes of which you’ve never
seen,” he
would say, and promised repeatedly to preserve Medicaid and Medicare.
Even if his policies have attacked those programs
(especially Medicaid), he gets that what people want from the insurance system
is pretty simple. They don’t want to be empowered consumers or healthcare
comparison shoppers. They just want to know that when they’re sick they can get
treated. They don’t want to be crushed by healthcare costs. If a private
insurer can give them that, they’re fine with it, and if a government program
gives them that, they’re fine with that, too. Nobody actually says “I like Medicare,
but I wish this was a private plan, because I believe so firmly in the free
market.”
But that is what many Republican lawmakers believe, no
matter how clear the evidence that markets in healthcare produce terrible
outcomes. They continue to insist that once we get government out of the way
and unleash the invisible hand in all its wisdom, costs will plunge, quality
will improve, maddening bureaucracy will melt away, and we’ll finally achieve
the kind of security and satisfaction we have longed for.
What they won’t admit, however, is that you don’t have to
look far to find populations that have just that kind of security and
satisfaction — just go to pretty much any other industrialized country in the
world.
While they use a variety of systems, the main difference in
structure between us and other developed nations is that they have more government
involvement in healthcare. They acknowledge that getting your gall bladder
removed is not like buying a car; healthcare is a place where markets simply
don’t work, and management by regulation is a necessity. Because they
appreciate that, those countries also cover everyone, usually produce better
health outcomes, and spend
much less than we do.
Trump certainly isn’t going to approve more regulation,
unless it’s in the context of a “deal” wherein someone (like drug companies)
genuflects before him and gives him a policy concession. But when it comes time
to produce something that vaguely resembles a policy blueprint, Trump steps
aside and the right-wing ideologues who surround him take over. His only job is
to record a brief video, try to stay awake through a White House event on the
subject, and then go back to not talking about it for the next year.
Even Trump’s aides know, however, that if all the changes
they proposed were actually turned into law, the result would be a political
disaster. Which is how we get what we got last week: A plan that is not a plan,
released so they can say they have a plan but not actually do anything. And
that’s just fine with Trump.
