WASHINGTON -- Republican front-runner Donald Trump, who has vowed to scrap the Affordable Care Act and replace it with "something terrific," finally provided a rough idea of what he thinks terrific looks like.
The bullet points published on the billionaire businessman's website Wednesday night don't amount to a detailed plan to overhaul the health care system, but they're about as specific as is typical for a presidential campaign and in line with the vague proposals touted by rivals Sen. Ted Cruz (R-Texas) and Sen. Marco Rubio (R-Fla.). It's certainly more than the Republican Congress has managed to produce in the six years since the ACA became law. And, yes, Trump calls it "Healthcare Reform to Make America Great Again."
It's notable that Trump unveiled his proposal the night after his Super Tuesday triumph over Cruz and Rubio and the night before another Republican debate. It also comes as he maneuvers toward a general election campaign against whoever wins the Democratic nomination, former Secretary of State Hillary Clinton or Sen. Bernie Sanders (I-Vt.).
So what does Trump want to do on health care? Of course, the first order of business is to entirely get rid of Obamacare and its individual mandate that nearly everyone get health coverage or face a fine (a subject that recently got Trump into some hot water). There's a bunch of stuff on his website complaining about Obamacare, which gives Trump something in common with the congressional Republican leaders he likes to insult.
Let's start with what's not in Trumpcare, apart from estimates of how much it would cost and how it would affect the health care system. He seems to have no notion about covering the uninsured -- there are no tax credits or new government programs to help the millions who, without the substantial financial assistance that Obamacare offers, could never afford decent coverage on their own.
As a result, Trump's plan would dramatically increase the number of people who would be uninsured by scrapping Obamacare and making cuts to Medicaid. That's despite Trump's repeated assurances that when he's president, nobody will "die in the streets" due to lack of health care. There's nothing about guaranteeing coverage to people with pre-existing conditions, either, even though he has expressed vague support for these protections in the past.
The Affordable Care Act, for sure, has its share of worrisome problems. But rather than calling for fixing them or rolling out a plan to achieve its goals of expanded coverage, cost-containment and quality-improvement, Trump dismisses Obamacare as a failure. Undoing the law would create major disruption after years in which it has transformed the health care system, provided coverage to more than 17 million previously uninsured people and trimmed the uninsured rate to historically low levels.
With that in mind, let's take a look at what the Trump campaign says it wants to do. Mostly, Trumpcare is based on proposals Republicans have touted for years, but never put much effort into enacting, even as they continue to claim an Obamacare replacement is just around the corner.
The most consequential item on Trump's wish list is to allow anyone to deduct the full cost of their health insurance premiums for their income taxes.
Today, anyone who gets health insurance from an employer already doesn't pay taxes on the value of that fringe benefit. This proposal would level the playing field for people who buy health coverage directly from an insurer, although they already can deduct the cost now under limited circumstances.
That may be a great deal for people who make a lot of money, giving them a big new tax break. But anyone with a low income or middle income may still find health insurance unaffordable -- and that's especially true for those who earn so little that the cost of insurance is higher than what they owe in taxes. And this would be enormously expensive for the government, because it would deprive the treasury of a tremendous amount of revenue.
Naturally, another of Trump's big ideas is to increase the use of health savings accounts paired with high-deductible health insurance policies, a go-to GOP policy proposal. The theory behind these -- other than the accounts serving as tax shelters for people who can afford to sock away money in them -- is that health care consumers with more "skin in the game" will become smarter shoppers, demand lower prices for health care and products and drive down national health care spending.
The problem with that -- as the proliferation of high-deductible plans in the last decade or so is showing -- is that patients sometimes just go without health care and don't do a very good job differentiating between care they need and care they could do without. And, again, health savings accounts aren't much use to people who don't have the spare income to deposit money into them.
And then there's what heretofore had been the only tangible element to Trump's health care agenda: allowing health insurance companies to sell policies across state lines. This, too, is a very old conservative reform idea.
The trouble is, it probably wouldn't accomplish anything. Health insurance companies aren't clamoring for this freedom -- and some even oppose it. That's because one of the primary functions of a modern health insurer is to create local networks of doctors, hospitals and other providers their customers can go see. An insurer based in Alabama, for example, would have to expend a lot of time, effort and money to sell coverage to customers in, say, Pennsylvania.
The supposed upside to this approach is that insurers based in lightly regulated states could sell barebones policies to people elsewhere. And while that might enable some people to get a better deal, it would be disastrous for the health insurance markets. If people who need insurance the least can buy the cheap, skimpy plan that wouldn't serve the needs of sicker people, that would leave only the latter group in the insurance pool in the state where they live. This eventually would drive up premiums to an unsustainable degree.
There's also some smaller things in the Trump plan, like allowing prescription drugs to be "reimported" to the United States from countries like Canada, where their cost is lower, and requiring medical providers to disclose their prices. Curiously, there's no mention of Trump's ballyhooed (and quite exaggerated) proposal to permit Medicare to directly negotiate drug prices.
Now we get to Medicaid, the joint federal-state health care program for low-income people, children, pregnant women, people with disabilities and elderly nursing home patients. Borrowing from House Speaker Paul Ryan (R-Wis.) and countless GOP leaders before him, Trump calls for "block granting" the program. That's another way of saying he wants to set a cap on how much the federal government will give states to run the programs in exchange for allowing states to modify it with less federal involvement. It's also another way of saying he wants to drastically shrink this program, which provides benefits to more than 70 million people.
So how does it all add up? Trumpcare would cover far fewer people than Obamacare, take away not only the consumer protections that law provides but undermine strong insurance regulations in states that have them, force an unknown number of people off Medicaid, and let wealthy people save money on health insurance and reduce their tax burdens.
It's hard to see how any of this would prevent anyone dying in the street.