Donald Trump on Health Care

How Trump Can Destroy Obamacare Without Repeal

Trump and Mitch McConnell
U.S. President Donald Trump (C) arrives at the East Room of the White House as Senate Majority Leader Sen. Mitch McConnell (R-KY) (L) and Sen. Pat Roberts (R-KS) (R) wait for the beginning of a meeting June 27, 2017 in Washington, DC. President Trump invited all GOP Senate members to the White House to discuss the Health Care bill. Photo by Alex Wong/Getty Images

On July 29, 2017, President Trump threatened to stop reimbursing insurers who waive deductibles and copayments for low-income customers.  Insurance companies will raise premiums by 20 percent if Trump stops the payments. Many more will leave the exchanges. They must decide on their 2018 plans by September 2017. (Source: "How to Repair the Health Care Law," The New York Times, July 29, 2017.)

Trump was warning Congress that it still needs to reform the Affordable Care Act of 2010.

His warning followed the July 28, 2017 Senate vote against a new "skinny bill." Senator John McCain, R-Ariz.,cast the deciding vote. He disapproved of the process and urged a return to bipartisan lawmaking. Congress announced it would move on. It must pass tax reform legislation, a budget and raise the debt ceiling after it returns from recess in September. (Source: "The Night John McCain Killed the GOP's Health Care Fight," The Washington Post, July 28, 2017.)

After Trump's warning, Senator Lamar Alexander, R-Tenn., said the Senate Health, Education, Labor and Pensions Committee will create legislation to fix Obamacare. He urged the president to continued funding long enough for the committee to develop a bipartisan solution.  (Source: "Senators Launch Bipartisan Effort to Shore Up Obamacare," The New York Times, August 1, 2017.)

How Trump Is Weakening the ACA Without Replacing It

Trump has directed the Internal Revenue Service to allow people to slide by if they don't get insurance.

Taxpayers are supposed to indicate on their tax returns whether they have insurance or not. If they don't fill in anything, the IRS will not investigate further. That is reducing the number of healthy people who buy policies. Insurance companies will lose revenue. They can't afford to offer plans on the exchanges.

 

The head of the Department of Health and Human Services is former Representative Tom Price, R-Ga. HHS manages Medicare, Medicaid and Obamacare. Price wrote the Empowering Patients First Act which Obama vetoed. (Source: "By Picking Tom Price to Lead HHS, Trumps Shows He Is Serious About Dismantling Obamacare," Vox, November 28, 2016.) 

Price can weaken ACA requirements. He vowed to weaken the rule that health insurance companies must provide all of the 10 essential benefits. Price can also relax requirements that insurers cover some preventive services such as contraception. 

Price can require that Medicaid recipients must get a job. He has already assured states that HHS would support them if they started requiring that. He might allow states to establish premiums, lifetime caps on benefits or other cost-sharing rules for Medicaid recipients. But HHS must have public hearings to do so. (Source: "With GOP Plan Dead, Trump Eyes Other Ways to Reshape Health Care," The Wall Street Journal, March 25, 2017.)

Trump nominated Seema Verma to lead the Centers for Medicare and Medicaid Services. Verma had helped Mike Pence create a Medicaid expansion plan in Indiana. She advocates that Medicaid recipients pay a small monthly fee to receive Medicaid.

(Sources: "If Trump's Medicare Chief Is Approved, You'll Need to Be on Your Best Behavior," Time, March 6, 2017. "Why the Health Insurance Industry Is Calm Despite Trump's Obamacare Threats," Fortune, November 30, 2016.)

With Verma’s policy, Medicare recipients would not be able to afford preventive care or treatment for chronic diseases. They would likely wait until the diseases created a crisis. They could then go to emergency rooms that must treat everyone. This more expensive care is billed to Medicaid. Substituting expensive hospital emergency rooms for primary care physicians increases health care costs for everyone. (Source: "House GOP Releases Plan to Repeal, Replace Obamacare," CNBC, March 7, 2017.)

How the Senate Plan Failed 

Had it passed the "skinny" bill would have gone to the House.

Senators were hoping they could add or remove features in a conference. But the House could have approved the bill and send it to the president for signature. McCain opposed that possibility. (Source: "Senate Republicans Vote to Open Debate on a Health Care Bill," Vox, July 25, 2017.  "GOP Leaders Close to Getting 50 Required Votes," Washington Post, July 25, 2017.)

The "skinny bill" would have repealed ACA's mandate that individuals must buy insurance. It didn't require companies with 50 or more employees to provide insurance benefits. It would have repealed the tax on medical device manufacturers. It would have defunded Planned Parenthood, the Prevention and Public Health Fund and the Community Health Center Fund. The Congressional Budget Office found it would leave 16 million people without insurance. (Source: "CBO: 16 Million People Could Lose Health Insurance," The Business Insider, July 27, 2017.)

The CBO warned that the bill would have increased premiums by 20 percent per year. That's because health insurance companies would lose revenue. People who lost their insurance would no longer pay premiums. That would undermine their ability to provide health coverage for those with pre-existing conditions.  They would be forced to raise premiums on existing policies to cover their costs. (Source: "Senate GOP Leaders Work to Round Up Votes for Modest Health Care Overhaul," PowerPost, July 27, 2017.)

In the week before the vote, the Senate had voted on several other bills to replace Obamacare. None of them passed.  None of these bills would have actually repealed the ACA. Republicans never had the 60-vote majority needed to do this. Democrats would not repeal an Act they created.  Instead, Senate Republicans used a budget reconciliation bill to dismantle the spending and revenue portions of the ACA. They could only use this if the bills did not add to the debt over the next 10 years.  (Source: “Senate Health Care Bill: How the ‘Secret’ Draft Process Endangers Obamacare Repeal Plan,” Newsweek, June 22, 2017.)

The Senate Plan Could Have Affected These 10 Key Obamacare Benefits

The following 10 changes were in the Senate plans. The negotiations would have determined how many would remain in the final bill. Here's what would have happened if the Senate had its way.

1. Reduce federal payments for Medicaid expansion beginning in 2021. End expansion by 2023. That means states could no longer sign up new adults to the expanded Medicaid program. Many conservative Republicans want to eliminate the expanded Medicaid program in 2018. 

2. Cut Medicaid spending starting in 2024. Calculate Medicaid payments to the states based on enrollment numbers. Under the ACA, the federal government paid 90 percent of state costs. The House plan would have given states a fixed block grant. The Senate bill ties spending growth to inflation, not the growth in health care costs. This flies against Trump’s campaign promise to protect Medicaid funding. (Source: “Trump Hasn’t Spoken With Sanders About Medicaid Cuts,” Axios, June 22, 2017.)

3. Reduce Obamacare tax credits. Provide subsidies to those earning up to 350 percent of the poverty level. The ACA provided subsidies to those earning up to 400 percent of the poverty level. Calculate subsidies so the average person pays for 42 percent of health care costs. Under the ACA, the average person paid for 30 percent of health care costs. (Source: "Premiums and Tax Credits Under the ACA vs. the Senate Better Care Reconciliation Act," Kaiser Family Foundation, June 23, 2017.)

For example, the Kaiser Family Foundation estimated what would happen to deductibles for someone making $18,090 or less. Under Obamacare, that person's deductible would be $255 on average. Under the Senate bill, it would skyrocket to $6,105. (Source: "Don't Blame Trump for the Republican Health Care Disaster," The Washington Post, July 20, 2017.)

The revised bill provides an additional $70 billion to states to subsidize premium costs. That's in addition to $100 billion already included. (Source: "Senate Republicans Unveil New Health Bill but Divisions Remain," The New York Times, July 13, 2017.)

The cost of individual plans will increase for most people. A study by the Commonwealth Fund and Rand Corporation found that an individual policy would cost $4,700 by 2018 if Obamacare were repealed. If Trump pushes through his tax deduction on premiums, the cost would be $3,500. That compares to the average cost of an exchange policy of $3,200. (Source: "What Trump's Win Means for Your Wallet," Money, November 9, 2016.)

The Congressional Budget Office estimated that the cuts to the subsidies and to Medicaid would prevent 22 million people from getting insurance. That would reduce the debt by $321 billion over 10 years. (Source: "Senate Republican Health Bill: What’s Next After Delay?" The Wall Street Journal, June 27, 2017.)

4. Keep the mandate to cover those with pre-existing conditions. But remove the ACA mandate to provide 10 essential health benefits. The Republican bills allow states to decide what counts as an essential health benefit. The ACA requires insurers to cover pregnancy, mental health and equipment for chronic diseases. This mandate increased most people's premiums because their plans provided more services. 

Changing essential health benefits could jeopardize coverage of those with pre-existing conditions. Their condition should be under one of the essential benefits. If it wasn't, then the insurance company could deny coverage. That would lower the cost of plans for those without those conditions.  (Source: “Comparing the Senate Health Care Bill to Obamacare and the House Proposal,” CNN Politics, June 22, 2017.)

Senator Ted Cruz proposes that the revised bill allow insurers to sell a bare-bones policy to healthy people. In return, they must also provide a full-coverage policy to those with pre-existing conditions. That allows insurance companies to charge different prices for different policies. That means that those with pre-existing conditions will pay much more than they did under the ACA. Those who are healthy will pay less. (Source: “GOP Senate Leader Charts Plan for Moving on New Health Bill,” The Washington Post, July 11, 2017.)

The Senate bill also increases “1332” state waivers. That means it no longer restricts subsidies to plans bought on the health care exchanges. Instead, states could allow subsidies for other private individual plans. (Source: “Senate Health Care Draft Repeals Obamacare Taxes,” The Washington Post, June 21, 2017.)

5. Allow insurance companies to charge seniors higher premiums. The Senate and House plans allow companies to charge seniors five times as much as younger Americans. Under the ACA, premiums for older people can't be more than three times the cost for younger people.

6. Strip federal funds from Planned Parenthood. The Senate bill strips Medicaid and Title X reimbursement for Planned Parenthood health care services for a year. These federal funds are never used for abortions. But Republicans are concerned that the organization uses the funds for research they oppose.

This action would increase Medicaid costs since most Planned Parenthood Medicaid recipients use the agency for routine health care, including family planning and contraceptives. If those services are cut, the Act could actually increase the number of women seeking abortions. Two Republican Senators oppose Planned Parenthood defunding. (Source: "The GOP Obamacare Replacement Plan Defunds Planned Parenthood and Restricts Abortion Coverage," Vox, March 7, 2017.)

7. Eliminate the tax on those who don't buy insurance. Both the Senate and House plans make that change. That means people who don't have insurance in 2017 won't have to pay the penalty. The CBO estimates that 14 million people will drop their insurance coverage once they no longer had to pay the penalty.  In 2015, 6.5 million taxpayers owed a tax penalty. (Sources: "Senate Health Care Bill: Here's How It Would Affect You," USA Today, June 22, 2017. "CBO Cost Estimate American Health Care Act," CBO, March 13, 2017.)

Removing the mandate will increase health insurance costs overall. The CBO estimated that premiums will be 15 to 20 percent higher in 2018 and 2019. That's because insurance companies will raise them to make up for the premiums they lose when healthy people drop coverage. The mandate kept prices low because there were enough healthy people in the risk pool to pay for the sick ones. Without the mandate, many people will wait until they are sick before buying insurance. If only the sick bought insurance, insurance companies would not be profitable.

8. Remove the tax on companies that don't provide health insurance. Many employees will lose coverage once employers aren’t forced to provide it. They'll find that individual insurance costs much more than company-sponsored plans. The Senate plan retains the tax on "Cadillac" insurance plans. But it repeals taxes on drug and other medical supply companies. (Source: "Assessing the Impact of the House GOP Health Bill," The Wall Street Journal, April 5, 2017.)

9. Expand Health Savings Accounts to everyone. The revised Senate plan also allows people to use HSAs to pay for premiums. Currently, HSAs are only available for those with high-deductible insurance plans. The accounts help pay for care until the deductible is reached. It doesn't help people who can't afford to set aside income in the HSA. (Source: "Senate's Obamacare Replacement Bill to Boost Health Savings Accounts," CNBC, June 22, 2017.)

10. Three million young adults up to age 26 could stay on their parents' plan. This ACA provision was very popular with families and with the insurance companies. The plan retains Trump’s promise to keep the most popular Obamacare benefits

How It Would Have Affected You

If all 10 elements remained in the revised Senate bill, it would have reduced your costs if:

  • You don't have insurance. You no longer have to pay a penalty.
  • You earn more than $200,000 a year. You no longer have to pay Obamacare taxes on your income. You would still pay taxes on investment income under the revised Senate bill.
  • You own a small business. You no longer have to pay a penalty if you don’t provide insurance.
  • You own a medical devices company or a tanning salon. You no longer have to pay Obamacare taxes.

You would have been adversely affected if you are in one of the states that reduce the essential benefits. Only those with individual or small group plans would be affected immediately. Eventually all health care plans would default to conform with the states with the least coverage.

Reduced coverage would have lowered your costs if you fall into one of these categories:

  • You are healthy.
  • You are young.

Similarly, you would have had higher costs if you fall into one of the following categories:

  • You have a chronic disease. These are the most expensive diseases to treat. Insurance plans would pressure states to drop coverage for these areas first.
  • You are older. That’s when chronic diseases take their toll. The Senate bill allows insurance companies to charge seniors five times what they charge younger people. Obamacare limited that to three times. Your costs would skyrocket if you are a senior who loses Medicaid coverage under the plan. Many seniors need Medicaid to cover the out-of-pocket Medicare costs.
  • You become pregnant. Many states would drop this from the essential benefits.
  • You need an abortion. The plan prohibits insurance companies sold on the exchanges from covering abortion services.
  • Your company only provided coverage because the ACA forced them to.
  • You are one of the 22 million people who received subsidies or the Medicaid expansion.
  • You use mental and behavioral health services, including drug rehab. These are also very expensive for insurance companies. The plan includes $2 billion to pay states for drug treatment. That's not enough to offset the cuts to Medicaid and insurance companies who drop coverage for these services.
  • You decide to reapply for health insurance after a lapse of 61 days. You'll have to pay a 30 percent premium increase.

Regardless of what passes, Trump’s health plan wouldn't affect individuals until November 1, 2017, at the earliest. That's because plans bought on the exchanges are a legally binding contract between the person and the health insurance company. (Source: "Trump and the GOP Can Absolutely Repeal Obamacare," Vox, November 9, 2016.) 

Some people who get plans from their employers may also be affected. That's because the ACA allows employers to choose a coverage plan from any state in the union. That didn't matter when the ACA mandated all plans to have the same benefits. But if some states have fewer benefits, then employers may legally select those states' benefits to cut costs. (Source: "GOP Health Bill Jeopardizes Out-of-Pocket Caps in Employer Plans," The Wall Street Journal, May 4, 2017.)

Once an illness is removed from the list of 10 essential benefits, insurance companies can reinstate annual and lifetime limits. Only essential health benefits are protected by Obamacare’s ban on annual and lifetime limits, and caps enrollees' out-of-pocket spending. (Source: "A New G.O.P Health Proposal Evokes the Old Days," The New York Times, April 20, 2017. "White House Officials Push Revised Health Bill," The New York Times," April 20, 2017.)

That could potentially affect people outside of the state. That's because employer health plans can choose the benefits from any state. It's possible that every company insurance plan will default to the state with the least coverage. (Source: "Little-noted Provision of GOP Health Bill Could Alter Employer Plans," The Wall Street Journal, May 4, 2017.)

Health care costs would have risen at a faster rate than under Obamacare. Keeping the ACA means that health care costs will continue to rise at around 5 percent. Costs rose 5.3 percent in 2014 and 5.8 percent in 2015. Right before the recession, they rose 6.5 percent or more. From 2000 to 2004, health care costs rose 7 percent or more.  For annual cost increases since 1960, see The Rising Cost of Health Care by Year. 

This is because Obamacare helped more people receive lower-cost preventive care before they needed high-cost emergency room care. (Source: "Trump Promised to Repeal Obamacare. Now What?" Reuters, November 9, 2016.)

The new plan could add to the debt. That’s because Obamacare taxes were necessary to pay for the benefits. The Congressional Joint Committee on Taxation estimated that the tax cuts in the House plan would add $460 billion to the debt over 10 years.

  • $270 billion from high-income and investment taxes.
  • $145 billion from insurers.
  • $25 billion from drugmakers.
  • $20 billion from manufacturers of medical devices.

The plan’s backers never explain how their plan won't add to the debt. That was one reason many conservatives were opposed to it. (Source: "Health Groups Denounce G.O.P. Bill as Its Backers Scramble," New York Times, March 9, 2017.)

Senate Versus House Bill

The Senate had to reconcile its bill with the House of Representatives' American Health Care Act. That would have occurred in a conference committee with the Senate and House leadership. There are five major differences between the House bill and McConnell's health care replacement.

First, McConnell wanted to make deeper cuts to Medicaid. He would delay those cuts until later. Senator Susan Collins, R-Maine., opposed the bill because the cuts were still too deep. Senator Shelley Moore Capito, R-W.Va, "expressed serious concerns" about the cuts. (Source: "Senate Republicans Unveil New Health Bill but Divisions Remain," The New York Times, July 13, 2017.)

Second, the Senate bill would have calculated insurance subsidies based on income instead of age. Third, it would have retained some protection for those with pre-existing conditions. The House allowed states to completely opt out. Fourth, it would have cut federal funding to Planned Parenthood for one year. The House cut funding permanently. (Source: "Here's What's in the Senate Health Care Bill," The Washington Post, June 22, 2017.)

Fifth, it kept the taxes on high-income earners. The House plan eliminated Obamacare taxes

Both plans allowed states to decide whether to keep all 10 essential health benefits.  But they imposed a penalty on those who dropped their insurance then reapplied for coverage within 63 days. It allowed insurance companies to add 30 percent to premiums for a year when someone re-enrolls. That's to discourage people from dropping their insurance to apply only when they become sick. The House added the 30 percent premium increase to help insurers pay for these added costs.

But the penalty wouldn't solve the problem. A healthy person who lets their insurance lapse will avoid the increase. Only a very sick person would feel the increase was worth it if it meant getting insured. (Source: Sarah Kliff, "The American Health Care Act: The Republicans' Bill to Replace Obamacare, Explained," Vox, March 6, 2017.)

These votes occurred just one week after Senate Republican leaders abandoned all efforts. On July 18, 2017, they realized they couldn't get enough Republican votes to pass the Better Care Act.  But President Trump put pressure on Republican holdouts. They subsequently agreed to at least allow the bill to move forward for discussion. (Source: "GOP Senate Leader Mitch McConnell Abandons Health Care Bill," July 18, 2017.)

House Plan Details That Are No Longer in the Senate Plan

On May 3, 2017, the House passed the American Health Care Act. Here are some elements of the plan that are no longer part of the Senate bill. They could reappear as the House and Senate bills undergo reconciliation.

Give states a block grant for Medicaid. The block grant means the federal government will stop sharing a percentage cost of Medicaid. Instead, it will give each state a fixed amount. In return, states can design their own Medicaid benefits. The fixed block grants won't pay for as many people as the ACA's percentage federal coverage.

Insurance companies would then only have to comply with state, not federal, regulations. Trump believes that would make the states more efficient in their use of funds. It also means that Medicaid would compete with other state priorities for the funds. That's what led to the failure of community mental health centers under deinstitutionalization

Provide a flat tax credit based on age, not income. The breakout is as follows:

Age

Tax Credit

Younger than 30

$2,000

30-39

$2,500

40-49

$3,000

50-59

$3,500

60 and older

$4,000

A family can receive up to $14,000 a year. The credits start to phase out for individuals who earn $75,000 or more and households that earn $150,000 or more. The subsidy is not based on the cost of plans. As insurance costs rise, the subsidy remains the same. That means it does not take into account the higher cost of living in states such as Hawaii and Alaska. (Source: "What’s in the AHCA: The Major Provisions of the Republican Health Bill," The New York Times, May 4, 2017. "Analysis: GOP Plan to Cost Obamacare Enrollees $1,542 More a Year," Vox, March 7, 2017.)

Under the House bill, the federal government would have paid $100 billion over 10 years to a Patient and State Stability Fund. States can use the fund to increase tax credits. Some states might send the money to insurance companies who have a lot of very sick patients. The CBO estimates that the fund would help lower premiums by 20 percent after 2026. (Source: "The Congressional Budget Office Cost Estimate American Health Care Act," CBO , March 13, 2017.)

States could also use the fund to create high-risk pools for those with pre-existing conditions. That would raise the costs for those in the high-risk pools. People with chronic illnesses would face higher premiums and larger deductibles. This would also affect those with pre-existing conditions if they had more than a 63-day gap in coverage. Many companies already offer high-risk pools called "Cadillac" plans to their employees. Insurance companies like this option. (Source: Sarah Kliff, "The American Health Care Act: The Republicans' Bill to Replace Obamacare, Explained," Vox, March 6, 2017.)

The House bill would have allowed states to waive several rules of the ACA for individual and small-group insurance plans. States could only do so if the waiver either 1) lowered rates, 2) increased the number of insured people or 3) advanced "the public interest of the state."

States could then waive the rule that insurance firms must charge the same price to every person of the same age, regardless of health. That rule protected people with pre-existing conditions. The ACA made insurance companies charge the same rate for those with pre-existing conditions as they did for healthy people. In states that waive the rule, chronic disease sufferers would pay much higher rates.

States could set up a high-risk pool to cover them. That will make insurance more expensive for those with pre-existing conditions. To offset some of this cost, the AHCA would appropriate $138 billion over 10 years for the states to subsidize those in the high-risk pool. (Source: "I Read Seven Obamacare Replacement Plans. Here's What I Learned," Vox, November 17, 2016.)

The CBO estimated the House bill would reduce the federal budget deficit by $170 billion from 2017 to 2026. The revenue loss from tax cuts was offset by spending cuts in Medicaid and subsidies. That's because many of Obamacare's cost-cutting measures remained in place. (Source: "H.R. 1628. American Health Care Act of 2017," CBO, May 24, 2017.)

Background

Major hospital groups opposed Trump's plan. They know their emergency room costs will increase if preventive care under expanded Medicaid is withdrawn. (Source: "Health Groups Denounce G.O.P. Bill as Its Backers Scramble," New York Times, March 9, 2017.)

Lobbyists for health insurance companies and pharmaceutical companies don't want to see many of the changes proposed. For example, the health insurance lobby, America's Health Insurance Plans, opposes any reductions to Medicaid financing. The ACA's expansion brought them many new customers paid for by the federal government. (Source: "Health Groups Denounce G.O.P. Bill as Its Backers Scramble," New York Times, March 9, 2017.)

The health insurance industry will file lawsuits against any plan they don't support. The industry played a significant role in forming Obamacare. For example, it was responsible for the individual mandate. The insurance companies wouldn't insure those who are sick unless the government mandated that the healthy are also covered.

President Trump had backed a bill to replace Obamacare in his first 100 days. The Freedom Caucus opposed the first version of the House Bill because it didn't cut costs enough. House Republicans pulled the bill on March 24, 2017. Congressional Republicans had negotiated amendments on April 20, 2017. (Source: "Budget Reconciliation Explained," Vox, November 23, 2017.)

Trump needed to submit his proposal to the states by April or May 2017 for any changes to occur in 2018. Each state set up its health insurance exchange or signed onto the federal government's site. The states have the final approval since they are responsible for implementation. (Source: "Trump Stands By Universal Health Care," STAT, February 5, 2016.)

Head of HHS Price and Speaker of the House Ryan never received enough support from other Republicans. Some conservatives thought the plan didn't do enough to repeal Obamacare. Others didn't like that the bill was being put to a vote without hearings. Two Senators oppose defunding Planned Parenthood. (Source: "Health Groups Denounce G.O.P. Bill as Its Backers Scramble," New York Times, March 9, 2017.)

Ryan first outlined his health reform ideas in the "Better Way" in 2016 and the "Patient's Choice Act" in 2009. He supported using block grants to fund Medicaid. That would cut Medicaid spending by $160 billion by 2022. He suggested replacing Medicare with vouchers to purchase private health insurance. (Source: "Why the Health Insurance Industry Is Calm Despite Trump's Obamacare Threats," Fortune, November 30, 2016. "Analyzing the House GOP Replacement for Obamacare," Citizens Against Government Waste, July 2016.)

Trump's plan would have forced companies to take the high proportion of sick people who would sign up. That's like asking auto insurance companies to insure only those who have been in car accidents. If forced to do so, insurance companies would go out of business because they couldn't make a profit. It wouldn't work, and they wouldn't agree to it.

Other Trumpcare Possibilities

On his first day in office, President Trump signed an executive order to "ease the burden" of Obamacare. It directs agencies to do what they can within the existing law to lift the ACA regulations. They can create more exemptions for people. This is a way to weaken Obamacare's requirement that everyone must have insurance or pay a tax. (Source: "Trump Signs Obamacare Executive Order," TheHill.com, January 20, 2017.)

Trump announced on March 7 and 8 that these two proposals will be forthcoming. It's unclear if that will happen now.

1. Allow health insurance companies to operate across states lines. Each state has specific regulations. That makes it expensive for a national company to operate in different states. As a result, five companies serviced half the insured population. Trump maintains that the increased competition would drive insurance costs down. But it could increase these five companies' monopoly power instead. This would raise costs. The Supreme Court would have to change the law. That's because it has ruled that insurance is not subject to federal oversight. Another way to modify the law is to amend the Constitution itself. (Source: Susan Randall, “Insurance Regulation in the United States: Regulatory Federalism and the National Association of Insurance Commissioners,” Florida State University Law Review, 2014.)

2. Allow Medicare to negotiate lower prescription drug prices with pharmaceutical companies. Trump had backed away from that idea in a meeting with pharmaceutical companies on January 31, 2017. Obama, Clinton and Sanders had also proposed this idea. But Congress would have had to amend the act that established Medicare Part D. It explicitly prohibited Medicare from negotiating. Drug companies said they needed that protection to provide funds for research and development of new cures. Also, the CBO found that Medicare wouldn't save much more by negotiating. That's because health insurance companies already do a lot of negotiation. (Sources: "After Meeting With Pharma Lobbyists, Trump Drops Promise to Negotiate Drug Prices," Vox, January 31, 2017. "Not Up for Negotiation," USNews, February 26, 2016.) 

Trump has mentioned the following four ideas, but they are not in any current congressional plans.

1. Keep existing Medicare and Social Security benefits intact. These benefits were created by prior Acts of Congress and cannot be changed by a president. These two programs cost $1.565 trillion or 38 percent of total spending. Social Security is self-funded until 2035. Medicare is only 53 percent self-funded. Keeping benefits intact does not solve the problem of rising health care costs. For more, see Mandatory Budget

2. Offer a universal “market-based” plan. Trump originally wanted to provide a range of choices similar to the Federal Employees Health Benefits Program. He proposed this in his 2000 book, The America We Deserve. In 2016, he suggested expanding Medicare. Ironically, that's what was in Obama's original health care reform plan. Congress rejected it for a plan that relied on health insurance companies. Trump might find that Congress still doesn't want universal coverage. Neither do those Americans who are worried that it's a sign of socialism. That was one reason for the failure of Hillarycare. (Source: "Donald Trump on Health Care," OnTheIssues.org, 2016.)

3. Require health care providers to post prices for their services. That allows people to shop for the best value. The competition should drive prices down. 

4. Allow consumers to purchase drugs overseas. That will drive down drug prices. (Sources: "Healthcare Reform," DonaldJTrump.com. "Donald Trump Hates Obamacare," Forbes, July 31, 2015.)

Other Trump Policies

To understand the ACA better, see my book, The Ultimate Obamacare Handbook (2015 - 2016).