Although he rarely talks about it, the most significant gift President Donald Trump bequeathed to economic prosperity was deregulation. And the one sector that was deregulated more than any other was health care.
Since Joe Biden has been re-regulating the economy, it’s hard to think of a starker contrast between the two leading presidential candidates this year—and it affects all aspects of health care.
Trump might have won the 2020 election if he had campaigned on his health care accomplishments. Below are some of them.
Insurance Tailored to Individuals, Families
Imagine combining the average premium with the average deductible for health insurance purchased by a family of four in the Obamacare exchanges. In 2020, that totaled more than $25,000. In other words, a family not getting a subsidy had to spend more than $25,000 before getting any benefit from their health insurance plan! And they had to do that every year!
Not surprisingly, the unsubsidized part of the market was in a free fall. Democrats in Congress responded by creating “enhanced subsidies”—even for people who are wealthy. The government is now virtually giving away free health insurance to average-income families.
If you are sick, things are far less rosy, however. The annual out-of-pocket maximum exposure for a family this year is $18,900. That’s the amount you may have to pay in the form of deductibles and coinsurance—over and above any premium payment. Families with ongoing, chronic conditions have to pay as much as that amount—every year!
Self-Management of Chronic Illnesses
There is mounting evidence patients suffering from diabetes, heart disease, and other chronic illnesses can (with training and the right support) manage a lot of their own care as well as—or better than—traditional doctor therapy can. They can do an even better job if they are also managing the money that pays for that care.
Health Savings Accounts (HSAs) are a natural vehicle. However, current law’s requirement of an across-the-board deductible makes HSAs incompatible with smart insurance design for chronic care. For example, a wise employer might want to make insulin available for free to diabetic employees to encourage its use. The same employer might ask noncompliant employees who show up in emergency rooms to pay for that care out of their own account.
Under guidance issued by the Trump administration, employers and insurers can now provide first-dollar coverage for the purchase of maintenance drugs for 13 chronic conditions without running afoul of HSA regulations.
More needs to be done. HSAs ought to be completely divorced from the high-deductible requirement. Let the market, rather than government, make decisions about the optimum role of cost-sharing.
Personal and Portable Health Insurance
Before Obamacare, some employers gave their employees pre-tax dollars to purchase individually owned-insurance. This was insurance the employees could take with them from job to job and in and out of the labor market.
President Obama completely shut down this practice with a threat to fine any employer caught doing it as much as $100 per employee per day. This was countermanded by a Trump rule that has allowed (and even encouraged) employers to fund employee-owned health insurance since January 2020.
It is striking to observe how many significant health policy changes have been effected by presidential action alone—without any act of Congress. Yet congressional action is needed to take full advantage of the opportunities.
Under the Trump executive order, employees can only use their employer’s funds to buy “Obamacare compliant” insurance, which mainly means insurance sold in the exchanges. Moreover, they cannot get the subsidies other buyers get in the exchanges. Since the exchange plans are otherwise very unattractive, the take-up rate for this opportunity has been well below initial expectations. What is needed is congressional action to allow the employees to buy any kind of insurance.
Round-the-Clock Primary Care
Concierge doctors used to be available only to the rich. Today “direct primary care” (DPC) is much more affordable. Atlas MD, in Wichita, Kan., for example, provides all primary care along with 24/7 phone and email access. They offer discounts on lab tests and generic drugs for less than what Medicaid pays. The cost: $50 a month for a middle-aged adult; $10 a month for a child.
An unfulfilled goal of the first Trump administration was to allow employers to put money into individual accounts from which the employees could make monthly payments to DPC doctors of their choosing.
This should be a high priority in a second Trump term.
Focused Factories in Medicare
Another important development in the first Trump administration was encouraging “focused factories” in Medicare. In contrast to the rest of the health-care system, Medicare Advantage “special needs” plans can specialize in 15 chronic conditions.
The Obamacare exchanges would be enormously improved if they allowed the same sort of specialization and the same type of risk adjustment that we now find only in the Medicare Advantage program.
Back to the Future Agenda
Space does not permit a discussion of other reforms, including liberating Association Health Plans, renewable short term plans (see related articles here and here), requiring hospital price transparency, and expanding options under Medicare Advantage.
But I hope I have made clear that Donald Trump does not need a new health policy agenda. He merely needs to complete the agenda of the first Trump administration.
John C. Goodman, Ph.D. (johngoodman@goodmaninstitute.org) is co-publisher of Health Care News and president and founder of the Goodman Institute for Public Policy Research. An earlier version of this article was published at goodmaninstitute.org. Reprinted with permission.
