By Patricia Salber MD, MBA

This guest post is part of the Festschrift of the Blogosphere celebrating HealthBlawg’s Tenth Blogiversary. Festschrift posts are appearing throughout the month of June 2016.

As the grueling Republican primary is drawing to a close, it looks more and more like The Donald is going to be the Red candidate (unless, of course, there are some successful shenanigans at an open convention). So, it’s probably time to do a deep dive into Trump’s thinking about healthcare. And, what better place to start than his campaign website (accessed April 24, 2016) where he briefly outlines his seven proposals for reform.

1. Repeal Obamacare

No matter what some of our Republican friends say, The Donald is a Republican, at least when it comes to his first proposal: “Completely repeal Obamacare.” He goes on to say that “our elected representatives must eliminate the individual mandate” because “no person should be required to buy insurance unless he or she wants to.” There are so many problems with the last part of his statement that it is hard to know where to start.

First of all, except for people who are able to self-fund the treatment of serious conditions (say, advanced cancer, a heart attack, or injuries from a car crash), everyone wants health insurance when they actually need it. They just don’t want to pay for it when they are young, healthy, and, in their own minds, invincible.

Next, there are tons of people who want health insurance, but can’t afford it. Obamacare has made a dent in the number, but, in too many states, failure to expand Medicaid has left lots of lower income people in the lurch. The individual mandate means that the pool of people paying into the insurance pool is bigger and the premiums lower than if only sick people participate.

2. Sell health insurance across state lines

This is another Republican favorite, but with a twist. The Trump proposal adds that “as long as the plan purchased complies with state requirements,” any insurer should be able to sell their products in any state.

As far as I can tell, this is already the case. All of the large plans already sell plans in almost every state. The problem, according to proponents of this measure, is that they have to comply with state requirements, such as state mandates for coverage and rules and regulations of whatever state entity is overseeing health insurance. This, they say, drives up costs. What they want—the words that Trump’s proposal don’t suggest—is for plans to be able to sell across state lines and avoid those mandates and that regulation.

Trump goes on to say that “by allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up.” As anyone who watches TV during open enrollment season knows, there is already fierce competition between insurers within the states. Despite that (or perhaps, in part, because of that), health insurance premiums continue to rise in the face of shrinking coverage and rising out-of-pocket costs.

Finally, a number of states tried the “Sell Across State Lines” experiment, but none of them were able to meet their goals—in part because no out-of-state insurers wanted to participate. The heart of the issue is that health plans need to develop a provider network (you know, doctors and hospitals) to actually deliver the healthcare to their enrollees. Just because a plan has low premiums in one state does not mean they will be successful at developing a network of providers that can deliver care at the same low prices in another. As Merrill Matthews, a scholar at the Institute for Policy Innovation explained in an August 31, 2015 article in the New York Times:

Just because a good affordable policy is available in another state doesn’t mean that I would be able to get the network of physicians and the good prices that are available in that other state.

3.  Health insurance premium deductions

It’s unclear from Trump’s website if this deduction is separate from other medical expense deductions that don’t kick in until they exceed 10% of your adjusted gross income for the year. If the former, one might wonder why have first dollar deduction of health insurance premiums and not other health care costs. If the latter, it could benefit low-income individuals who pay a significant percentage of their income on premiums.

For some reason, Trump goes on to say in the paragraph on this proposal, “We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.” Love it! Does this mean he is in favor of expanding Medicaid? This will surely endear him to the Red State governors and their legislators who are vehemently opposed (Hah!).

4. HSAs

Trump says HSAs should be tax-free and should be allowed to accumulate and be inherited! They should also be able to be used by any member of a family without penalty. My main issue with this is that it probably won’t contribute much to the unaffordability of healthcare, particularly if people use the dollars to “buy” healthcare they might have foregone if they didn’t have the account.

5. Price transparency

The Donald thinks “individuals should be able to shop to find the best prices” for health services. Yeah, I agree. But it isn’t really the way healthcare actually works. There are so many important and costly decisions that are simply not going to be made by the average consumer. Here are some examples:

  • Which hospital the ambulance will take you to when you are unconscious after a major injury
  • Which drug to choose for chemotherapy when the choice is one very expensive branded targeted drug (e.g., Tarceva) vs. older, less expensive approaches (at least in the short run) such as chemotherapy
  • How long you stay in the hospital (at $10,000 a day)

I could go on and on, but I think you get the point. Price transparency will work for some things (i.e., which of several comparable drugs should I choose or which primary care doctor should I enroll with). But an important caveat is that price transparency must be combined with quality transparency so that consumers will know what they are getting for the cheapest price?

6. Block-grant Medicaid to the states

According to Trump, “states can manage the administration of Medicaid far better without federal overhead.” But an important part of the overhead is oversight. Although he infers that all states are good actors when it comes to Medicaid, that simply is not the case. According to a 2014 article in the Atlantic, Mississippi, a state consistently ranked as having one of the worst healthcare systems in the country,

Medicaid eligibility for non-disabled adults is limited to parents with incomes below 29 percent of poverty, or about $6,800 a year for a family of four, and adults without dependent children remain ineligible regardless of their income.

Need I say more?

7. Free markets for drug providers

Now, this one I like: “Remove barriers to entry into free markets for drug providers that offer safe, reliable, and cheaper products.” The one caveat is that he needs to ensure there is good oversight so that only drugs that are safe and reliable are a part of the prescription drug marketplace—that would probably mean beefing up and depoliticizing the FDA. Trump goes on to say, “Congress will need the courage to step away from the special interests and do what is right for America.” Hmmm, I say Amen to that.

So, can DonaldCare fix the problem?

I think not. These proposals are too narrow and too focused on the free market to lead to what Trump calls for in the introduction to his health platform:

…broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.

Our healthcare non-system is just too convoluted to fix it with these 7 proposals. For one thing, Trump doesn’t mention quality except in this opening statement. Only focusing on cost of care is unlikely to lead to a system that reliably delivers high-quality care—that actually takes requires a lot of work.

Further, his reliance on free market forces in an industry as lucrative as healthcare seems to ignore the powerful driver called greed. Think about it. Has any industrial sector in our country actually done the right thing without serious regulation and oversight (think banking, guys). Is that really the kind of healthcare system we want?

I believe if we are going to get a grip on healthcare we need to look outside our country to see what is actually working elsewhere, for example, the Canadian system or the UK’s NHS. OK, I know some of you are ready to go berserk on me for bringing up single payer, but that, my friends is the subject for another blog.

Patricia Salber, MD, MBA (@docweighsin) is the founder and host of The Doctor Weighs In. She is also the CEO of Health Tech Hatch, the sister site of TDWI that helps innovators tell their stories to the world. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare.

Image: Gage Skidmore via Flickr CC

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