Trump’s health plan has no goal of preserving or expanding insurance coverage

The Trump administration’s recent move to abandon its legal defense of protections for people with pre-existing conditions has launched the latest battle in the health-care war. The decision, which is already a 2018 midterm topic, signifies that the fight over the direction of the health system will undoubtedly continue into the 2020 presidential election.

The latest action concerns a lawsuit claiming that, by lowering the tax for being uninsured to zero last December, Republicans in Congress have somehow taken away the choice to be uninsured. Doing so is unconstitutional, the argument goes, and so the entire Affordable Care Act (ACA) should be struck down. Shockingly, Trump’s Department of Justice has agreed with this claim about the so-called individual mandate, asserting that pre-existing condition protections are illegal as well.

{mosads}The case will wend its way through the legal system, potentially reaching the Supreme Court in 2020. Should the Supreme Court side with the plaintiffs, President Trump will have achieved the “ObamaCare explosion” that he predicted would force Congress to act.

Short of that, the President’s rejection of the DOJ-recommended defense of the ACA is the strongest signal yet of his undiminished antipathy toward the ACA. Barring a midterm surprise, the next Congress is unlikely to succeed where the last one failed. As such, “repeal and replace” would be a repeat promise in Trump’s reelection campaign.

We are already seeing what the 2020 campaign plans may look like. Candidate Trump will likely adopt President Trump’s 2019 budget proposal: the Graham-Cassidy-Heller-Johnson amendment.

The most radical plan proposed by Congressional Republicans in 2018 was rebranded last week by conservative think tanks and endorsed by the White House. The proposal would basically eliminate the ACA’s private insurance marketplaces and Medicaid expansion, replacing them with lower funding through state block grants with few strings attached.   

The Trump proposal’s deregulation, devolution, and capped federal funding echo past GOP platforms. Republicans have consistently rejected a government-run health system in favor of loosely regulated private insurance since the 1940s.

In the 60s, GOP candidates supported a state-based program instead of Medicare for seniors, partly reflecting the (resurgent) regional divide over social issues. And during the 80s, President Reagan proposed replacing Medicaid with a block grant.

But President Trump’s assumed campaign plan parts from those of recent Republican candidates in an important way: it does not aspire to expand private insurance through employers or tax incentives.

President Nixon supported an employer requirement to offer coverage; this President wants to repeal it. Both Bushes, Bob Dole, and Sen. John McCain (R-Ariz.) proposed expanding the individual market through tax policy; such policies are absent from the current plan. Simply put, Trump’s plan has no goal of preserving or expanding health insurance coverage.

Conservatives’ far-reaching approach has sparked an equal and opposite reaction among liberals. It is telling that Bernie Sanders’ version of “Medicare for All” was introduced on the same day as the Graham-Cassidy amendment. His plan would largely replace privately sold insurance with Medicare, reflecting low public opinion of health insurance companies.

Elsewhere, Democrats have introduced “Medicare for More” proposals, which offer public plans alongside private insurance for some or all Americans. Government-backed plans are hardly new to Democratic presidential platforms, although fell out of favor in some elections.

Why do these potential campaign plans deserve our attention now, more than two years before the 2020 presidential election?

Because, contrary to conventional wisdom, campaign platforms matter — especially in health care. They signal to voters the direction of each party; they impact elections and are used to hold elected officials accountable; and, perhaps most importantly, they set the agenda for a president and influence future policy outcomes. Studies suggest that roughly two-thirds of campaign promises have been kept by presidents in the last five decades.

To be sure, the emerging 2020 health reform plans may look different than those of the past or present, especially given growing support for the ACA. Favorable opinion of the ACA hit an all-time high in 2018. Stakeholders across the board came to the ACA’s defense in 2017 and 2018. And, to date, the health insurance marketplaces and coverage gains have been largely resilient to actions that undermine them.  

Short-term stabilization of the current system may trim the interest in or boldness of health reform plans. But it won’t diminish the partisan clash over health care, which will reach the presidential election stage shortly after the midterms.

As such, policymakers, experts, and concerned citizens alike should look beyond the daily health policy drama, and start caring about the big plans. Now is when they are being developed, modified, and solidified. Now is when they deserve our scrutiny. Because if past is prologue, they’ll matter.

Jeanne Lambrew, PhD is a former deputy assistant to President Obama for health policy and currently is a Senior Fellow at The Century Foundation. She is author of the new Commonwealth Fund report, “Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us.”