As president, Donald J. Trump took firm steps to deregulate health care.
Although he rarely talks about it, Donald Trump's most important gift to economic prosperity was deregulation. And it was the medical field that was more deregulated than any other field.
It's hard to imagine such a stark contrast between this year's two leading presidential candidates, as Joe Biden reregulates the economy, which affects every aspect of health care.
I'm not alone in thinking that Trump could have won the 2020 election if he had touted his medical achievements. Let's see if this year's election turns out differently.
COVID vaccine. Deregulation of vaccine production was an early success of the Trump administration, even before the world had heard the words “new coronavirus.” Thanks to these early steps, we were much better prepared when the coronavirus actually arrived. Economists at the University of Chicago estimate that their project, WARP Speed, produced a COVID-19 vaccine at least six months earlier than anyone expected. This saved an estimated 183,000 lives.
Insurance tailored to the needs of individuals and families. Imagine combining the average premium and average deductible for health insurance for a family of four on the Obamacare exchanges. in 2020, That totaled over $25,000. In other words, an unsubsidized family would have had to pay more than $25,000 before he could benefit from his health insurance plan. And they had to do it every year!
Not surprisingly, the unsubsidized portion of the market fell into free fall. Congressional Democrats responded by creating “enhanced subsidies” for the wealthy as well. The government currently provides health insurance virtually free to average-income households.
However, when it comes to illness, things are not so easy. This year, his family's annual out-of-pocket maximum is $18,900. This is the amount you may have to pay in the form of deductibles and coinsurance in addition to your premium payments. Families with ongoing chronic illnesses must pay that amount each year.
As an alternative, President Trump used an executive order that expands people's access to “short-term” insurance. These plans are very similar to the insurance that was popular before Obamacare. They often sell for about half the price of Obamacare insurance. Deductibles are typically lower and provider networks are broader. And it provides greater protection for those who experience costly medical problems.
Congressional Democrats are generally very hostile to these plans, with clear support from big insurance companies. President Obama limited that period to three months. President Biden recently made the renewal period one month and capped it at three months. Under the Trump administration, it was available for one year and could be renewed for another two years. The second type of insurance can bridge the three-year term gap and allow you to continue your relationship with the insurance company indefinitely.
Under Trump's approach, the short-term market could easily evolve into the closest thing yet to a free market in health insurance, including free market solutions to the pre-existing condition problem.
Note that (despite much Republican rhetoric) Trump did not repeal Obamacare or even limit it. Mr. Trump's approach was to expand people's choices. The Biden/Obama approach eliminates options.
Personal and portable health insurance. Before Obamacare, some employers gave pre-tax dollars to their employees to buy privately owned insurance. This was insurance that employees could carry from job to job and in and out of the labor market.
President Obama shut down the practice completely, threatening to impose fines of $100 per employee per day on employers caught engaging in this practice. This was reversed by President Trump's rule allowing (and even encouraging) employers to fund employee-owned health insurance starting in January 2020.
It is amazing to observe how many important health policy changes have been influenced by presidential action alone, without any act of Congress. But Congressional action is needed to make the most of this opportunity.
Under Trump's executive order, employees can only use employer funds to purchase “Obamacare-compliant” insurance, which primarily means insurance sold on exchanges. Additionally, employees cannot receive subsidies that other buyers are getting on the exchange. The take-up of this opportunity is much lower than initially expected, as the exchange plan is very unattractive. What is needed is Congressional action to allow employees to purchase all types of insurance, including the short-term plans mentioned above.
virtual medicine. When Donald Trump became president, In most cases, it was illegal (by Congressional law) for doctors to bill Medicare for visits by phone, email, Skype, Zoom, Facebook, etc. One of the few positive aspects of the coronavirus was the liberation of telemedicine.
Given the coronavirus crisis, telemedicine would likely have been unleashed even if Hillary Clinton had been president. But it may have taken another year to achieve that change. The reason is that she has 10,000 jobs that Medicare pays for doctors. Because Medicare insists on setting a price for all care in all facility settings and in all regions, it is important to understand what telemedicine can and cannot do and what the appropriate price should be. Understanding it is a huge challenge.
The reason telemedicine has risen so quickly under President Trump is because his administration believed in deregulating barriers to telemedicine and was preparing to do so long before COVID-19.
Chronic disease. There is growing evidence that patients suffering from diabetes, heart disease, and other chronic conditions can manage their own care as well or better than traditional physician care (with training and the right support). . If you manage your own care, you'll do a better job if you also manage the money that goes into that care.
HSA is nature's vehicle. However, current law's flat deductible requirements make HSAs incompatible with smart insurance design for chronic care. For example, a smart employer may want to provide free insulin to employees with diabetes to encourage insulin use. The same employer may require a noncompliant employee who shows up at the emergency room to pay for that treatment out of his or her account.
Under guidance issued by the Trump administration, employers and insurance companies can now provide $1 coverage for the purchase of maintenance medications for 13 chronic conditions without running afoul of HSA regulations.
More needs to be done. HSAs should be completely separated from high deductible requirements. Let the market, not the government, decide the optimal role for cost sharing.
Another important development during the first Trump administration was the move to encourage “concentration factories” in Medicare. In contrast to other health plans, Medicare Advantage's “special needs” plans can specialize in 15 chronic conditions. These plans allow you to exclude applicants who do not meet the criteria. You can also ask health questions and request medical records.
The Obamacare exchanges would be vastly improved if they allowed the same kind of specialization and the same kind of risk adjustment that we currently see only in the Medicare Advantage program.
24-hour primary care. Concierge doctors used to be available only to the wealthy. Today, “direct primary care” (DPC) is much more affordable. For example, Atlas MD in Wichita, Kansas, offers a full range of primary care services in addition to 24/7 phone and email access. They offer discounts on tests and generic drugs at prices lower than what Medicaid pays. Prices are $50 per month for middle-aged adults and $10 per month for children.
A goal that the first Trump administration failed to achieve was to allow employers to deposit funds into personal accounts and allow employees to make monthly payments to the DPC physician of their choice.
This should be a top priority for President Trump in his second term.
Future challenges. Space does not allow us to discuss other reforms, such as opening up association health plans, requiring transparency in hospital prices, and expanding options under Medicare Advantage.
But I think we've made it clear that Donald Trump doesn't need a new health policy agenda. He simply needs to complete the agenda of the first Trump administration.
The vision behind President Trump's policies is: Reforming the American healthcare system through choice and competition. The 124-page health and welfare document, created in 2018, argues that the most serious problems in health care are caused by government failures, not market failures.
It's time to dust off your documents and reread them.
