Letting the states decide how to insure residents might lead to a cobweb of unwieldy regulations
By Daniel C. Bryant, M.D.
Portland (Maine) Press Herald, Dec. 5, 2016
Will Donald Trump make our country’s health care system great again? Of course, for many it was never that great in the first place, but it is important to consider what changes may lie ahead during a Trump presidency. For this, we can turn to his website, where he promises to:
• Repeal the Affordable Care Act. Though Mr. Trump has suggested he may keep some features of the ACA, this may mean that 20 million people will lose their health insurance and millions more will find it increasingly hard to find affordable policies with reasonable coverage.
• Replace the ACA with health savings accounts. In the HSA scheme, individuals with high-deductible plans can set aside thousands of dollars of income a year, tax free, to pay future health care costs.
This, of course, limits HSAs to those with extra money to set aside, who will then be faced with the recurring quandary of whether a medical problem “deserves” their depleting their account or should be ignored because something worse might come along.
• Return health insurance regulation to the states. Dealing with 50 different sets of insurance regulations will be a challenge both to businesses with employees living in multiple states and to the companies that provide insurance to those businesses.
And people with costly medical problems will be tempted to move to states that require insurers to offer good coverage, thus burdening those well-intentioned states; while businesses will be tempted to move to states with low coverage requirements and premiums, thus forcing poorer policies on their employees.
• Maximize flexibility for states in administering Medicaid. Like the above, this “states’ rights” emphasis would give states so inclined a tool for modifying their demographics to their economic advantage: namely, by keeping out the poor and the sick.
• Enable people to purchase insurance across state lines. The resulting competition might well reduce premiums, but in order to maintain their bottom lines, for-profit insurers would have to compensate by reducing coverage or provider reimbursement. And it will be tricky, indeed, for insurers to sell group and individual policies across state lines if every state has a different set of regulations.
• Re-establish high-risk pools. By segregating the sick or likely-to-get-sick into “pools,” we shift some of the extra cost of their care to them, and away from the already more fortunate. The balance of the cost must then be paid by the government, which may or may not be willing to do so.
This all flies in the face of the basic idea of insurance, which is to spread cost over the fortunate as well as the unfortunate, not concentrate it. And what is even worse, it perpetuates a two-class system – normal people, and the sick and poor.
• “Modernize” Medicare. This is too vague a prescription to try to interpret at this point; it could mean anything from lowering the age limit and increasing coverage, to phasing out the program altogether.
Reviewing Mr. Trump’s likely health care policies, we can note two themes, both of concern – complexity and inequity.
Complexity, and its associated financial costs, would come from the co-existence of millions of HSAs, millions of individual and employer-sponsored insurance plans and a variety of Medicaid and other governmental programs, all operating within the competing regulations of the 50 different states among which people and businesses are constantly moving.
Inequity, and its associated social costs, would come from the vastly different access to health care that people of different means and locales would have.
The Affordable Care Act, too, is complex, and, though much more equitable than Mr. Trump’s policies, may well not survive. As for the system that the president-elect’s policies would lead to, it will be unlikely to survive either because of its own complexities, and should not because of its inequities.
In the aftermath of both Barack Obama’s and Mr. Trump’s efforts at health care reform, we will be left then to design a new system, preferably the one we should have had all along – a simple and equitable system of the single-payer, Medicare-for-All type, similar to those that every other industrialized country has adopted.
No, Donald Trump will probably not make our health care system great again, but he may, if inadvertently, help to make it great at last.
Daniel C. Bryant, M.D., of Cape Elizabeth is leader of the Portland chapter of Maine AllCare (maineallcare.org), an organization devoted to getting universal health care in Maine.