HEALTH CARE/Joan Retsinas

Convergence in Health Care: Trump Meets Sen. Sanders

“Repeal and replace”: the mantra of many Republicans. The “repeal” part sounds easy. “Replace” is harder.

Senators Cruz and Rubio, along with Republican colleagues, had the chance to offer feasible alternatives to Obamacare during its gestation. And former Florida Gov. Bush and Ohio Gov. Kasich are leaning to “reform,” not wholesale repeal, if only because their stints as state executives made them pragmatic. They know the difficulties of “replace.”

So we are left with Donald Trump, alone among the candidates whom anybody trusts to “replace.” Mr. Trump’s supporters credit this “great” deal-maker with the savvy to create a new system – one that lets you keep the doctor you like, get the care you need, the drugs you want, without burdening you with impossibly high premiums. His supporters believe he can lead us into the healthcare Valhalla.

Let’s glimpse Act One of Mr. Trump’s reign: the repeal part.

“Repeal” promises a surge in the uninsured. With no “mandate” for individuals to enroll in a plan, and no penalties for not enrolling, millions will bow out. Why not? The “individual market” costs too much, especially for those healthy young people who are gambling on their vigor to carry them through the next decade. Without federal subsidies, moreover, a swathe of people cannot afford even low premiums. Indeed, without Obamacare, insurers won’t need to offer “individual market” policies. Why should they? Those policies are not likely to be profitable. Donald Trump, the billionaire business mogul, would understand.

Furthermore, the number of workers lucky enough to get insurance through their workplaces has waned, as the economy has shifted. Millennials are more likely to drive for Uber, post blogs, make videos, or start up Internet offerings that might, or might not, morph into the next Facebook, than their parents. Add the contract, part-time, “independent entrepreneurs.” Cash-strapped cities and states offer unionized workers insurance, but those cash-strapped employers can “privatize” services to cut costs (translation: bow out of health insurance).

As for the poor, more of them will be uninsured. Obamacare offered states the chance, at minimal cost, to expand Medicaid. The 30 states that took up the offer can dump their new enrollees. Without the hefty federal incentive, can they prudently keep them on? As for the 20 states that said “no” to expanding Medicaid, the repeal will make no difference.

Without federal reins, for-profit insurers will revert to their no-longer outlawed techniques of bolstering profits: exclusions for pre-existing conditions, caps on expenditures for rehabilitation (or overall yearly caps), waiting periods. For prescription drugs under Medicare, Obamacare shrunk the “doughnut hole.” The hole will re-open.

Insurers will lose the expanded market that Obamacare created though mandates and subsidies; but presumably the megaliths will find a way to maintain profits.

Hospitals will face “unpaid collectibles” from patients who show up, uninsured, at their emergency rooms. Administrators will need to search their archives for mission statements, to see how many of these patients they must accept. The non-profit hospitals, some built with Hill-Burton federal dollars that mandated service to the poor, have turned into multi-million dollar entities, headed by multi-million dollar executives.

A President Trump will face a nation with more than 40 million people uninsured, at least that many underinsured (inadequate policies, high cost-sharing), and hospitals beset with debt — the world before Obamacare.

What to do?

Subsidies to individuals to buy insurance on the private market? “Vouchers” sound fine, but do you regulate the policies that people can buy with those subsidies – as we regulate the housing that people can buy with government housing vouchers, the nursing homes that people can go to with government dollars, the groceries they can buy with food stamps? Probably. The “individual” subsidies now evoke the Affordable Care Act.

How much do you micro-manage the insurers? They depend on limited formularies, limited networks, prior authorizations – all the money-saving techniques that insurers use, and that patients abhor.

Do you mandate participation? If not, insurers lose the “healthy non-users” that spread the costs of care throughout a pool. Again, we resemble what we have.

What do you do about the poor, those who can’t afford premiums? Obamacare tried to get states to expand Medicaid, but twenty said “no.”

Do you scrap subsidies and give money to the states, let the “laboratories of democracy” figure out their own solutions. Maybe it would work in Massachusetts (Romneycare was an exemplar), Minnesota, Pennsylvania. But would Donald Trump the deal-maker trust Alabama, Mississippi or Arkansas to design a system that was universal, comprehensive?

Maybe Donald Trump, the compleat deal-maker, would look back to the future, to 1965, to “replace” Obamacare with a federally-financed system that covers every citizen, supported by a mixture of taxes and premiums (geared to income), that gets states out of the business of healthcare, that frees employers from embracing part-time and contract workers, that lets millennials make money however they can without worrying about health costs, that takes the battlefield of private insurers competing for healthy enrollees out of the marketplace. In short, maybe Donald Trump would look at the figures: “government” in some form insures a majority of Americans (Medicare, Medicaid, Veterans Administration, government employers). The money that employers spend on insurance constitutes part of wages: freeing employers from that burden would raise workers’ pay. Why not expand Medicare?

“Replace” might propel convergence for Donald Trump and Bernie Sanders. Bizarre, but maybe not improbable in the topsy-turvy politics of today.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, March 15, 2016

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