The plan includes some items that are on most Republican wish lists when it comes to health care reform, including the repeal of Obamacare and removing restrictions on how Medicaid money is spent. But it also features some proposals guaranteed to piss big pharma companies off, like the recommendation that rules against importing prescription drugs be loosened.But when you add it all up, what do you get? To go into more detail about Trump's plan, we called up Gerald F. Kominski, a professor who is the director of the UCLA Center for Health Policy Research*. He said that there were some good points, but in the end, "we'll be much worse off because of this proposal."VICE: Let's start with the basics: Why this demand at the top that Obamacare be repealed?
Gerald F. Kominski: The simplest thing is that he's running as a Republican. Republicans made Obamacare the lightning rod for everything that's wrong with the United States. Like, It's responsible for global warming, air pollution. It's just a blanket hatred of this law. In order for him to appeal to a Republican base, he's gotta say that this is a horrible law. He's just being consistent with what Republicans have been saying for the past six years.If he wanted to, couldn't he make alterations to Obamacare instead of repealing it?
He absolutely could do that. I think the reason he's not doing it is because he's strategically decided that will cost him votes. So, like he does on a lot of things, he's just going all in. That's his style.What about the second point, which calls for allowing companies to sell insurance across state lines? That's another talking point for Republicans, right?
Right now, insurance companies have difficulties marketing a product across the country. Health insurance is largely regulated at the state level. And there's federal law that protects the states' right to regulate health insurance. What he's saying—and Republicans have proposed this over the years—is, "Let's get rid of the state regulation of health insurance. Let's just let insurance companies do business in any state that they want to."So it's in line with his free-enterprise rhetoric.
Exactly. This way, you guarantee that the minimal possible regulations rule nationally.His third point would allow people to deduct health insurance premiums from their taxes, and the plan points out, "Businesses are allowed to take these deductions so why wouldn't Congress allow individuals the same exemptions?" That doesn't sound too bad to me, actually.
It's not an unreasonable proposal. I think the biggest shortcoming of this is that it will increase the federal deficit. Basically, it means that people won't be paying taxes [on health insurance]. Individuals who get their insurance through work already are exempt from taxes. The health insurance premiums that you pay at work for many people are exempt from taxes right now.Tell me about "price transparency," which is one of the other things Trump proposes.
Of all the things he proposes, this is the one I agree with the most. I really don't like most of the aspects of this [plan], but what he's saying is, right now, when people pay for health care services, it's hard to get any good information about what it's gonna cost. If you try to look on the internet and do some comparison shopping, it's hard to find the information, and it's not always very reliable.One of the problems with hospitals and health care is that they will bill you a certain amount for their services, but then end of up accepting much less than the bill amount as their final payment. What he's saying—and what a lot of people in our field have been saying for years now—is that what really matters is what doctors and hospitals except as their final payment, not what they bill or charge for their service. Think about buying a car: You get a sticker price, but then there's what you actually pay, and hopefully you're a good enough negotiator that you pay less than that price.How have companies been getting away with being secretive?
I think it's a long story, but the short answer is they can, but they don't have to provide the information. So they don't.Trump also wants "block-grant Medicaid to the states." That would mean removing the restrictions the federal government places on how Medicaid money is spent by the states, right?
Creating block grants is something Republicans have wanted to do for a long time. [The idea is], Look, the federal government is just going to give you money so you could run the program any way you want. We're not going to give you a lot requirements; we're just going to give you the freedom to spend that money in lots of different ways. Republicans think that this is the way to fix Medicaid because it gives states more flexibility. The concern is that if the federal government doesn't hold the states to some standard, they could spend that money in a way that really wouldn't necessarily serve low-income people very well—which is the purpose of the Medicaid program.The final point is a call to "remove barriers to entry into free markets for drug providers that offer safe, reliable, and cheaper products." What's at stake here?
I think what he's signaling here is that he wants to say, Look, we ought to be able to import drugs from other countries where they're cheaper. There are currently barriers to do that because the companies manufacturing pharmaceuticals around the world are not necessarily subject to the FDA regulations. There's possible safety concerns—however, what he's saying is that if we could figure out a way to guarantee that something made in India is safe, then we ought to be able to import those drugs, because that will drive prices down. The same drug in India is much less expensive than the drug being sold here.If you can guarantee safety, it's not a bad idea at all. It's just an issue of guaranteeing.So what would happen if all these proposals became reality?
Repealing Obamacare and the other aspects that he's proposing will basically rewind the clock to where we were in the early part of the 2000s. More people are going to be struggling to get coverage, and we're potentially going to unravel the progress that we've made. The people with the lowest incomes, who now have expanded access to Medicaid—switching to a block grant program is likely to allow states to push more people off of their Medicaid program. I think overall, we'll be much worse off because of this proposal.Follow Brian Josephs on Twitter.Correction 3/4: An earlier version of this article misstated Kominski's title at the UCLA Center for Health Policy Research
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Gerald F. Kominski: The simplest thing is that he's running as a Republican. Republicans made Obamacare the lightning rod for everything that's wrong with the United States. Like, It's responsible for global warming, air pollution. It's just a blanket hatred of this law. In order for him to appeal to a Republican base, he's gotta say that this is a horrible law. He's just being consistent with what Republicans have been saying for the past six years.If he wanted to, couldn't he make alterations to Obamacare instead of repealing it?
He absolutely could do that. I think the reason he's not doing it is because he's strategically decided that will cost him votes. So, like he does on a lot of things, he's just going all in. That's his style.What about the second point, which calls for allowing companies to sell insurance across state lines? That's another talking point for Republicans, right?
Right now, insurance companies have difficulties marketing a product across the country. Health insurance is largely regulated at the state level. And there's federal law that protects the states' right to regulate health insurance. What he's saying—and Republicans have proposed this over the years—is, "Let's get rid of the state regulation of health insurance. Let's just let insurance companies do business in any state that they want to."
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Exactly. This way, you guarantee that the minimal possible regulations rule nationally.His third point would allow people to deduct health insurance premiums from their taxes, and the plan points out, "Businesses are allowed to take these deductions so why wouldn't Congress allow individuals the same exemptions?" That doesn't sound too bad to me, actually.
It's not an unreasonable proposal. I think the biggest shortcoming of this is that it will increase the federal deficit. Basically, it means that people won't be paying taxes [on health insurance]. Individuals who get their insurance through work already are exempt from taxes. The health insurance premiums that you pay at work for many people are exempt from taxes right now.Tell me about "price transparency," which is one of the other things Trump proposes.
Of all the things he proposes, this is the one I agree with the most. I really don't like most of the aspects of this [plan], but what he's saying is, right now, when people pay for health care services, it's hard to get any good information about what it's gonna cost. If you try to look on the internet and do some comparison shopping, it's hard to find the information, and it's not always very reliable.One of the problems with hospitals and health care is that they will bill you a certain amount for their services, but then end of up accepting much less than the bill amount as their final payment. What he's saying—and what a lot of people in our field have been saying for years now—is that what really matters is what doctors and hospitals except as their final payment, not what they bill or charge for their service. Think about buying a car: You get a sticker price, but then there's what you actually pay, and hopefully you're a good enough negotiator that you pay less than that price.
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I think it's a long story, but the short answer is they can, but they don't have to provide the information. So they don't.Trump also wants "block-grant Medicaid to the states." That would mean removing the restrictions the federal government places on how Medicaid money is spent by the states, right?
Creating block grants is something Republicans have wanted to do for a long time. [The idea is], Look, the federal government is just going to give you money so you could run the program any way you want. We're not going to give you a lot requirements; we're just going to give you the freedom to spend that money in lots of different ways. Republicans think that this is the way to fix Medicaid because it gives states more flexibility. The concern is that if the federal government doesn't hold the states to some standard, they could spend that money in a way that really wouldn't necessarily serve low-income people very well—which is the purpose of the Medicaid program.The final point is a call to "remove barriers to entry into free markets for drug providers that offer safe, reliable, and cheaper products." What's at stake here?
I think what he's signaling here is that he wants to say, Look, we ought to be able to import drugs from other countries where they're cheaper. There are currently barriers to do that because the companies manufacturing pharmaceuticals around the world are not necessarily subject to the FDA regulations. There's possible safety concerns—however, what he's saying is that if we could figure out a way to guarantee that something made in India is safe, then we ought to be able to import those drugs, because that will drive prices down. The same drug in India is much less expensive than the drug being sold here.If you can guarantee safety, it's not a bad idea at all. It's just an issue of guaranteeing.So what would happen if all these proposals became reality?
Repealing Obamacare and the other aspects that he's proposing will basically rewind the clock to where we were in the early part of the 2000s. More people are going to be struggling to get coverage, and we're potentially going to unravel the progress that we've made. The people with the lowest incomes, who now have expanded access to Medicaid—switching to a block grant program is likely to allow states to push more people off of their Medicaid program. I think overall, we'll be much worse off because of this proposal.Follow Brian Josephs on Twitter.Correction 3/4: An earlier version of this article misstated Kominski's title at the UCLA Center for Health Policy Research