In March, prior to becoming the presumptive Republican nominee, Donald Trump released a seven-point health care plan (read it in full at www.donaldjtrump.com).
Clif Cleaveland* A full repeal of the Affordable Care Act (ACA) from Congress on its first day in session following his inauguration. No mention is made of the fate of 30 million Americans who have gained coverage under the ACA. Broader coverage is due to allowing dependents to remain on health plans of their parents until age 26, removing barriers to health insurance for people with pre-existing medical problems, extending Medicaid in many states that supported coverage for more poor people, and subsidizing premiums for people with incomes inadequate to afford health insurance.
* Allow purchase of health insurance across state lines so residents of states with higher premiums could select coverage from states with lower costs. This overlooks the fact that health plans establish contractual networks with preferred providers - hospitals, clinics, and physicians - within each state. Who would provide care for a resident of New York who chose to purchase coverage from a company in Nevada? Which state would be responsible for oversight of the insurer?
* Individuals can fully deduct health insurance payments from income taxes. This would not help people with marginal incomes who would be hard-pressed to buy insurance. Nor would this provide benefit to the many people who are included in group health insurance plans at their place of employment. Under this heading is a vague pledge to work with states to assure that anyone who wants health care coverage can have it. But what about people who decline coverage? What happens to them when they become ill or injured?
* Individuals and families may make tax-free contributions to high-deductible health savings accounts (HSAs). The money may accumulate tax-free and be passed to heirs. HSAs, however, are beyond the financial reach of many Americans.
' Price transparency among all providers will allow patients to shop among providers for the best price. Cheaper service does not assure quality. Will patients have sufficient information to determine qualifications and measures of performance for providers in their communities?
* Change Medicaid to block grants to each state. Medicaid programs currently vary widely among states. Some states offer more extensive coverage such as dental care and comprehensive mental health programs. Income eligibility among states varies from 25 to 138 percent of the Federal Poverty Level. Design and implementation of the program would be up to each state. Some states would likely design comprehensive programs; others would fail. There would be no universal standard to assure compassionate, high-quality care.
* Allow purchase of pharmaceuticals across national boundaries. This free-market approach is touted to offer safe, reliable, cheaper products to patients. But who would monitor imported drugs for quality and purity?
Trump also has made pledges to assure that illegal immigrants receive no health care and to reform mental health programs, though no specifics are offered.
A health care proposal must be assessed in terms of improving access, controlling costs and insuring quality. The ACA is a work in progress, consisting of a step-by-step approach to attaining the three goals.
Increased costs associated with the ACA are in part due to insuring 30 million people who previously had no health insurance. The rate of increase in health care costs has been slower since ACA.
Cost control and quality improvement are being addressed under terms of the ACA in a series of demonstration projects which seek better coordination of care for people with complex, chronic illnesses, for elderly people and for Medicaid recipients.
Additional quality improvements include provision of many preventive health services, such as recommended vaccinations, with no co-payment under ACA plans.
Perhaps the Trump plan will be revised or fleshed out during the Republican convention. The current proposals do little to contain costs and would deprive many Americans of health care coverage which they currently enjoy. It would be helpful to know who advises Trump in health care issues. The current proposals show limited insight into the complexities of health care in the U.S.
Disclaimer: I am a longtime member of the American College of Physicians, whose 100,000-plus members include specialists and sub-specialists in adult medical care. The organization, along with a variety of other professional organizations, has supported the ACA from its inception.
Contact Clif Cleaveland at ccleaveland@timesfreepress.com.