(Editor's Note: This article was originally published before the failure of a bill to repeal the Affordable Care Act. It has been edited to reflect that action.)
President Trump has mostly stayed on the sidelines of the messy policy debates regarding health care reform. But amid the war on Capitol Hill among Republican factions, he could seize the opportunity to provide leadership consistent with his campaign message to disrupt existing health policy.
Instead of trying to satisfy the free-market wing of his party, Trump could push for a solution that delivers on his populist promises by proposing universal catastrophic coverage, ending the specter of medical bankruptcy for many Americans.
There is little question that the recently pulled Affordable Care Act replacement legislation proposed by House Speaker Paul Ryan has disappointed many on Capitol Hill, leaving moderates and conservatives alike unhappy and drawing opposition from groups as diverse as the Heritage Foundation and AARP. And even if Ryan could have won passage of this legislation, the Senate probably would have rewritten it during the reconciliation process.
During the campaign, Trump promised that his replacement for President Barack Obama’s signature domestic policy would retain some of the most popular aspects of Obamacare, but do so in a less-expensive way that provides better care. He repeatedly promised that his plan would cover everybody.
The House Republican bill, the American Health Care Act, would not have delivered on Trump’s promises. It represented a real attempt by Ryan to overhaul entitlements and send authority for Medicaid to the states. What it didn’t do is try to deliver health insurance to all Americans, as Trump pledged: Even with hundreds of billions of dollars of refundable tax credits under the initial plan, 52 million Americans were projected to be uninsured in 2026, according to the Congressional Budget Office.
Trump won the presidency in part because of some big promises, including a vow to break from conservative orthodoxy on entitlements. If Congress fails to deliver on that promise, Trump could correct it by going boldly in a direction anathema to many on the right but potentially acceptable to some Democrats: universal coverage for catastrophic care.
Many Americans’ greatest fear is that their health care costs will bankrupt them. The quality of care we receive is high — I experienced this myself this month after a cardiac incident left me reading the Republican plan in an emergency room — but the expense is opaque, and Americans are not wrong to worry about these costs.
By providing catastrophic care for all, Trump could ensure that everyone has an ultimate backstop against medical bankruptcy, while freeing the states to experiment with options for reform. It would also enable the private sector to offer new insurance products to supplement the basic catastrophic care coverage.
This idea has some support among conservatives. In 2012 Kip Hagopian and Dana Goldman estimated in National Affairs that to insure all 209 million Americans not already covered by public insurance programs would cost about $2,000 per person, or $7,200 per family per year — about half the projected $1.7 trillion cost of Obamacare over the coming decade. Individuals and families could then purchase additional coverage given their particular health needs, but would not be bankrupted by severe illness or accident.
Some on the right may not be comfortable with this plan, given that it would represent a permanent redistributive entitlement. But the House Republican bill also included a hugely expensive tax credit. This plan would be a straightforward approach to providing insurance against devastating loss that would also render an incredibly complex system of mandates and rules moot, Hagopian and Goldman argue. That would include ending the requirement that all plans cover pre-existing conditions; the mandate that all individuals buy health insurance; one-size-fits-all “community rating” pricing; and the requirement that insurance companies sell insurance for the same price to everyone regardless of health status.
“Almost all of the costs of these regulations, as well as the negative cost effects of the intrusions into the market that accompany them, would disappear if this plan were in place,” they wrote.
Some on the left may find this kind of plan unacceptable, since universal catastrophic care falls far short of Medicare for all. But Hagopian and Goldman point out that even catastrophic plans of this sort could cover prenatal care, statin drugs that lower cholesterol and other treatments for chronic illnesses without raising costs for patients.
“If otherwise unaffordable health expenses were covered by insurance and routine health expenses were treated like normal household expenditures, the entire population would be shielded from devastating losses while an efficient consumer market in health care could emerge,” they said.
Given the choice between something similar to the failed House Republican plan or one where all Americans are covered, moderate Democrats would be wise to go along with this solution.
It is obviously not a solution that will satisfy true limited-government conservatives. Any universal benefit along these lines comes with costs that would have to be funded via taxes or debt. But it would be a step consistent with Trump’s bold message and it could resolve the debate on Capitol Hill.
Trump has never shied away from thinking big, and now he has the potential to turn the politics of health care upside down with a populist solution that might go a long way toward solving one of the nation’s biggest problems.
By Benjamin Domenech © 2017 The New York Times. Benjamin Domenech is the publisher of The Federalist.