WASHINGTON — President Donald Trump is not known for plunging into the details of complex policy issues, and health care is no exception. Since his campaign days, Trump has addressed health care in broad, aspirational strokes. Nonetheless he made some clear promises along the way.
Those promises come under two big headings. First, what Trump would do about the Affordable Care Act, his predecessor’s health care law, often called “Obamacare.” Second, the kind of health care system that Trump envisions for Americans.
On repealing Obama’s law, Trump seems to have a realistic chance to deliver. But he’s nowhere close to fulfilling his generous promises of affordable health care for all.
A look at some of the president’s major health care promises, and how the Republican legislation advancing in Congress lines up with them:
Repealing President Barack Obama’s signature domestic achievement has been a clear and consistent promise from Trump. Under the Obama law, some 20 million people gained coverage through a combination of subsidized private insurance and a state option to expand Medicaid for low-income people. Costs have been a problem, as are shaky insurance markets for people buying their own policies. But the nation’s uninsured rate is at a historic low, about 9 percent.
Both the House and Senate GOP bills would largely fulfill Trump’s promise to repeal Obama’s law.
Both bills end Obama’s unpopular requirement for individuals to carry health insurance or risk fines. The legislation also phases down the Medicaid expansion and repeals hundreds of billions of dollars in taxes on upper-income people and health care industries, used under Obama to finance coverage. And it opens the way for states to seek waivers of federal health insurance requirements.
Some Republican critics on the right say the congressional bills leave other major parts of “Obamacare” in place, such as subsidies for people buying private insurance, and too many rules. While the subsidy structure would remain, much less taxpayer money is invested in it.
“INSURANCE FOR EVERYBODY”
In a Washington Post interview before his inauguration, Trump distilled his vision for health care into a few visionary goals.
“We’re going to have insurance for everybody,” he said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”
Trump said he was close to finishing a plan of his own that would have “lower numbers, much lower deductibles.”
But the White House never delivered a health care plan from the president.
And the congressional plans are likely to increase the number of uninsured people, because even if all Americans have access to coverage, some may no longer be able to afford it.
Deductibles are likely to rise for many people with individual coverage because the congressional plans would end subsidies under Obama’s law that reduced out-of-pocket costs for those with modest incomes.
The Congressional Budget Office has projected that, on average, premiums for individual policies would be lower over the long run than under current law. But there would be winners and losers. Younger adults and those in good health are likely to find better deals. Older people and those requiring comprehensive coverage could well end up paying more.
TAKING AWAY THE LINES
During the presidential campaign, Trump called for a system in which insurance plans would compete nationally, offering Americans choice and lower premiums.
“What I’d like to see is a private system without the artificial lines around every state,” he said at one of the presidential debates.
Many experts say Trump’s vision of interstate competition is unrealistic because health insurance, like real estate, reflects local prices. In any case, it remains unfulfilled in the GOP legislation.
Some congressional leaders have promised that cross-state insurance will be addressed in follow-on legislation. Such a bill, however, would likely have to meet a 60-vote test in the Senate.
PRESCRIPTION DRUG PRICES
During the presidential campaign, and since becoming president, Trump called for action to bring down the cost of prescription drugs.
The GOP bills in Congress basically sidestep that.
At one point in the campaign, Trump called for giving Medicare the authority to directly negotiate prices with drug makers, an approach favored to some extent by Obama and Democratic presidential candidate Hillary Clinton.
Trump also proposed letting Americans import prescription drugs from other countries, where prices are usually lower because of government regulation.
But Medicare negotiations are a nonstarter for most congressional Republicans, and Trump’s call for allowing drug importation has faded.
In a 2015 interview with The Daily Signal, Trump said: “I’m not going to cut Social Security like every other Republican and I’m not going to cut Medicare or Medicaid.”
But last year, his campaign started backtracking on the Medicaid promise, endorsing the idea of limited federal financing for the federal-state program that covers some 70 million low-income people, from newborns to elderly nursing home residents, from special-needs kids to part-time workers lacking job-based health insurance.
The Republican bills in Congress would phase out Obama’s financing for Medicaid expansion and limit future federal payments for the entire program as well. The Congressional Budget Office said the House bill would reduce federal Medicaid spending by $834 billion over 10 years, and the program would cover about 14 million fewer people by 2026, a 17 percent reduction.
Several Republican governors have joined their Democratic counterparts calling that a massive cost-shift to the states.
The Trump White House says it’s serious about confronting the nation’s opioid epidemic, which shows no sign of letup.
“The president is all in,” health secretary Tom Price said on a recent visit to New Hampshire. “He has such passion for this issue because he knows the misery and the suffering that has occurred across this land.”
But state officials say rolling back Obama’s Medicaid expansion would deal a heavy blow to their efforts to treat addiction and get its victims back to jobs and family. Among the group of low-income adults made eligible for Medicaid under Obama are many younger people struggling with drug problems. They’ve been able to get treatment and support services through Medicaid.
The Senate bill would set up a $2 billion fund to help states fight the epidemic; some GOP senators had sought $45 billion. The House bill does not address it.
Associated Press researcher Jennifer Farrar contributed to this report.
An occasional look at the promises public officials make _ and how well they keep them
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