President Donald Trump used his first congressional address to deliver a five-point outline of some policies he supports in an Obamacare repeal-and-replace plan.
Hill Republicans badly need to get on the same page to craft and pass a bill. Trump basically told party leaders they are on the right track, but he did not provide any further direction or a pitch for unity. Quite the opposite — he even decided to take sides on one specific issue diving Republicans: whether the replacement plan ought to include tax credits.
Here's a guide to the specific policies Trump mentioned, what they mean, and how they fit into the current political debate over the fate of the Affordable Care Act.
1) "First, we should ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges."
Obamacare barred health insurers from discriminating against customers with preexisting conditions. Under the health law, sicker patients cannot be denied coverage or charged higher premiums.
Trump has repeatedly spoken very positively about keeping this part of Obamacare. He likes the idea that insurers have to offer coverage to everybody. Trump's word choice here, however, is notable in thinking about how far he'll go to protect this provision. Trump doesn't say he wants to ensure that health plans can't discriminate against Americans with preexisting conditions. Instead, he says he wants to make sure that those people have "access to coverage."
This seems like a nod toward the leading plans on Capitol Hill, which require insurers to offer coverage to everybody — but also let health plans charge higher prices to people with preexisting conditions who have a break in coverage. That is a lot of people: One report from the Commonwealth Fund in the mid-2000s estimated that about 36 percent of Americans have a gap of coverage at least one month long in an average year. (That number has likely declined, however, since Obamacare took effect.)
All indications are that Trump does favor more protections for those with preexisting conditions than existed before Obamacare. But his statement here also suggests the protections would be weaker than what exists for patients right now.
2) "Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts — but it must be the plan they want, not the plan forced on them by the government."
The Affordable Care Act included tax credits to help make coverage more affordable for low- and middle-income Americans. The tax credits are on a sliding scale, giving more financial help to the Americans who earn the least.
Its notable that Trump decided to endorse tax credits in his congressional address. Republicans on Capitol Hill are currently split over whether they should continue any version of this Obamacare program.
More centrist congressional leadership, in line with Trump, favors continuing the tax credits (although they would reform the program quite significantly, basing the size of tax credits on age rather than income). More conservative legislators, however, have come out staunchly opposed to any version of a tax credit, describing it as Obamacare Lite.
"The tax credits included in Ryan's plan will create an entirely new entitlement program," Freedom Caucus Chair Mark Meadows (R-NC) told Breitbart News. "We are concerned about a new federal plan that will only increase premiums and lead to higher prices. We are not going to fix healthcare by replacing Obamacare with another plan that won't work."
The tax credits are arguably one of the biggest fights currently happening in the Republican Party over what a replacement should look like, and in this speech, President Trump is taking a side.
3) "Thirdly, we should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out."
This particular point is a bit difficult to decode. The idea of "resources and flexibility" seems to hint at the idea of a block grant, where the federal government would give states a lump sum of money and let them run the entitlement program as they see fit, with less federal oversight. Block grants (including the one proposed in the recently leaked GOP plan) are typically used as a way to cut federal Medicaid spending.
The second part of the sentence is interesting here, too, as Trump promises to "make sure no one is left out." This sure feels like a nod toward the Republican governors (and some senators) who have pushed to maintain the Medicaid expansion. This would include Ohio Gov. John Kasich, whom Trump met with on Saturday and who has been a vociferous advocate for continuing the Medicaid expansion. The governors are still figuring out their exact position on what they want from Trump on Medicaid, and this seems like a space still subject to significant change in coming weeks and months.
4) "Fourthly, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance — and work to bring down the artificially high price of drugs, and bring them down immediately."
The first part of this point appears to be a reference to medical malpractice reform — which, perhaps somewhat surprisingly, hasn't been a huge subject of discussion among Republicans as they craft replacement plans. The Congressional Budget Office does not score medical malpractice reforms, such as capping payouts to patients, as producing significant savings or lowering premiums in a meaningful way.
The second part of this sentence is pretty interesting, though. It is yet another attack on the high price of American drugs, something that Trump has been unusually focused on for a Republican president. Calling out the "artificially high price of drugs" harks back to his previous comments about how Medicare should start to negotiate for lower drug prices.
"There's very little bidding on drugs," Trump said in one speech last month. "We're the largest buyer of drugs in the world. And yet we don't bid properly. We're going to start bidding."
5) "Finally, the time has come to give Americans the freedom to purchase health insurance across state lines — creating a truly competitive national marketplace that will bring cost way down and provide far better care."
This is, as far as I can tell, the one health policy position that Trump has held since his very first campaign proposal. He wants to allow health insurers based in one state to sell somewhere else, without having to comply with the other states mandates and regulations.
For example: New York tends to have more mandated benefits than Mississippi. Under Trump's proposal, a health insurer from Mississippi could set up shop in New York and sell its skimpier benefit package at a lower price. In theory, this would give New Yorkers more choice — and those who want cheaper premiums could purchase a plan from this new Mississippi health plan.
But there are two big hurdles to this type of policy. One is that insurers just don't seem that eager to sell across state lines. Setting up a health insurance plan means building a network with doctors and hospitals. And it turns out that can be awfully hard to do when you're an insurer based half way across the country.
Georgetown University's Sabrina Corlette recently looked at what happened when six states opened their borders for cross-state sales. Not one of them had a new insurer come in from out of state:
Across state lines laws did not result in a single insurer entering the market or the sale of a single new insurance product. Further, there was no evidence that these initiatives actually bring down costs or increase consumer options. In fact, such proposals could put consumers at risk by limiting state officials' ability to respond to the needs of their residents and eliminating important state-based protections.
Second, a lot of state level officials really don't like this idea, which they think tramples on their right to regulate their own insurance market. Why should a Mississippi insurer, the argument goes, get to come in and sell plans that don't include the benefits that New York has determined to be important?
The two points Trump left out of his speech matter a lot
Trump used his congressional address to cover the things people typically like about health reform, like protections for preexisting conditions and tax credits to help make coverage affordable.
But there are two less popular policies that will need to become part of any Republican replacement plan at some point in the near future that went conspicuously unmentioned.
How do you pay for the plan? The tax credits that Trump endorsed will, obviously, cost money. And Trump didn't get into his preferred vehicle for paying those financial subsidies. Many Republican plans propose capping the tax exclusion for employer-sponsored coverage, which would generate significant revenue. This would significantly increase the cost of insurance for the 156 million Americans who receive insurance at work. Obamacare included a slew of new taxes to pay for the insurance subsidies, but Republicans want to repeal those — leaving them looking for another revenue source.
What replaces the individual mandate? It is clear that the individual mandate is not popular. So the Republican plans have an alternative: They require Americans to maintain continuous coverage or else face higher costs for preexisting conditions when they do return to the market.
Trump didn't talk about it this way; he just talked about how people with preexisting conditions would have "access" to a plan. He didn't mention that nearly every Republican proposal would let insurers charge sicker patients a higher rate if they ever had a break in coverage.
This "continuous coverage" provision will likely be unpopular for the same reason that the individual mandate is unpopular: It penalizes people for not carrying health insurance. As I reported yesterday, I've been working with the research firm PerryUndem to run focus groups with Obamacare enrollees. We found that when we explained this provision, it got a very negative reaction.
Obamacare had the individual mandate because it needed a policy to encourage people to buy insurance even when they were healthy, not just when they were sick. Whatever replacement plan Trump comes up with will need a policy like that too, even if the president isn't keen to talk about it.