Trump’s Health Policy Karaoke

Republican presidential front-runner Donald Trump must have had a few minutes to spare this week, so he decided on Tuesday to release from captivity his plan for “Healthcare Reform to Make America Great Again.”  To borrow the older words of Dr. Samuel Johnson, Trump addressing health policy reform is “like a dog's walking on his hind legs. It is not done well; but you are surprised to find it done at all.” 

The Trump plan resembles the efforts of a foreign student trying to learn quickly health policy as a second language. Or perhaps a co-worker getting up on the late-night stage to lip synch some standard tunes in the karaoke bar. 

Nevertheless, it is always important to encourage the sudden interest of a lagging pupil in achieving measurable progress, even if it is not that hard to pull a few paragraphs of orthodox Republican policy stances off the shelves and shoot for the 50th percentile, if not a gentleman’s C.

One of the Trump plan’s opening critiques of Obamacare is how it raised economic uncertainty for everyone. His solution: repeal the entire law right away once he is president, and then let Congress figure out how it might replace it. Transition problems and timing issues are not addressed. In fact, Trump appears to be more prone to defer to Capitol Hill on this issue than his usual posture of a dominant executive suggests. 

Nevertheless, Trump manages to check off several of the usual items on the health policy checklist of most conservative members of Congress and other Republican candidates. Individual mandate – gone. (No more “I like the mandate.”). His plan includes facilitating the sale of health insurance across state lines, and, unlike The Donald’s previous stumbles on this issue, it provides a somewhat more competent, though thumbnail, summary of that policy proposal. Trump also waves affirmatively at the generic Republican support for block granting Medicaid to the states. He claims that states will have incentives to seek out and eliminate fraud (perhaps because defrauding federal taxpayers in other states will become less lucrative?). 

The rest of the plan reveals the weaknesses in trying to start studying for an exam the night before taking it. Trump’s proposal for changing the tax treatment of health insurance confuses the business deduction for employer-paid premium (as ordinary and necessary expenses) with the tax exclusion from income and payroll taxes, whose benefits pass through predominantly to a firm’s employees. His endorsement of extending tax deductibility for health care expenses to individuals would work far better for the high-income residents of Trump Tower than for the workers (whether unionized or undocumented) who built it, due to the perversities of deductions within a progressive income tax rate structure. Hence, the support of many other Republicans for various forms of tax credits that are more generous to lower-income Americans. 

Another bullet point in the Trump plan favors Health Savings Accounts, but describes them as a new proposal rather than established in law more than 12 years ago. It is not quite as bold as the Columbus discovery of the New World, but similarly lacking in navigational familiarity. 

Trump’s one partial deviation from mainstream Republican health policy involves his support for imported drugs. At least he is pro-trade for some products, even if they are most likely to come from Mexico than Canada. Unlike imported cars, no 35 percent tariffs on imported drugs. And Republicans even have nominated presidential candidates in the past who once supported drug importation (see McCain, version 1.0).      

The Trump plan admits that its limited proposals are just a start. They do not really deal with very much of what would be needed to replace Obamacare in other important aspects (e.g., pre-ex condition protection, Medicare reimbursement, safety net subsidies, health care deregulation, and how to unwind current Affordable Care Act subsidies). But there is sufficient time to decry the cost burden of health care for illegal immigrants. (Do not let them die in the streets here, but rather back in their country of origin…)

So, there may not be much here, or has been said of more than one past presidential aspirant – “Deep down, he’s shallow.” Nor is the language of the Trump plan always well-stated, let alone understood. But as de La Rochefoucauld once wrote, “Hypocrisy is the homage vice pays to virtue.”