Republican health care policy proposals appear to fall into two categories: scalpels and sledgehammers. There are more modest ideas like promoting health savings accounts or greater price transparency that can be debated on the merits, but they generally sound good to voters and don’t represent major goals for Democrats. Then there are the extremely controversial ideas such as Medicare premium support or a blanket subsidy under the Medicaid/Affordable Care Act (ACA) or weakening pre-insurance guarantees. They work in exactly the opposite way, giving the Democrats goals for the election campaign and scaring voters.
The Republican Study Committee went there to sledgehammer the ideas. It’s not surprising that they made the suggestions they did; Most are well known and have been done before, and the study committee regularly proposes very conservative ideas. I cannot comment on the merits of the proposals here. The question for political analysis is why these ideas are being raised now, at the start of an overheated election season. And how will former President Donald Trump react and what political impact will this have?
Here are some of the third cornerstones that the study committee’s plan touches on:
- The plan would provide premium support or a voucher-like system for Medicare, again exposing Republicans to accusations that they would destroy the traditional Medicare program.
- The plan would weaken protections for people with pre-existing conditions and replace many provisions of the ACA with a pool of funds that states can use for that purpose. There are arguments for how effective state pools can be, but politically the plan is vulnerable to accusations that it undermines protections for people with pre-existing conditions.
- While the plan does not repeal the ACA, it combines ACA subsidies with a complicated five-block grant system to cap and cut Medicaid. This is a policy double whammy: replacing current ACA coverage (at its peak with over 20 million on the marketplaces) and eliminating the coverage guarantee for 85 million people with Medicaid, while simultaneously handing the program over to states with far less federal funding.
- And the plan would end popular Medicare drug price negotiations. And the upper limit on monthly insulin costs. And on the costs of Medicare medications that must be paid out of pocket.
There are familiar arguments for and against each of these proposals, as well as underlying philosophical debates about the role of government and markets in health care. Many very liberal ideas are also controversial, such as Medicare for All. However, they are currently neither represented in Congress nor in the election campaign. We have analyzed all of these plans at KFF as they have changed over the years.
What’s surprising is the release of a list of the most unstable health policy ideas in the middle of an election season (see “Americans Really Don’t Like Trump’s Health Care Plans”). It is the Republican equivalent of a Democratic study committee, announcing a plan to federalize Medicaid, cover all undocumented people, eliminate Medicare Advantage and regulate hospital rates. On the other hand, if Republican candidates don’t champion the ideas and Trump ignores them and Democratic candidates don’t attack them, it won’t matter in the election.
Conservative Republicans have always believed in the goal of reducing federal health care spending and the federal government’s role in health care, and may simply want to continue to advance those goals, regardless of political timing or possible political consequences. They think ACA subsidies are inefficient — and that’s a fundamental difference from liberals — and have always viewed Medicaid as part of the welfare state they want to shrink, rather than a government insurance program for lower-income Americans that plays a crucial role plays in the fragmented continuum of coverage that we have in our country.
Former President Trump could ignore, accept or reject these proposals. He has stated that he is not interested in another attempt to repeal the ACA (with additional language but no details on how to make the law stricter and less expensive), acknowledging the unpopularity of the idea. He has also said he will not touch Medicare or Social Security. Trump is not bound by political orthodoxy and conventional conservative health policy goals. His comments on the ACA signal that he will keep his distance from any proposal that he believes is unpopular or will force him to fight on ground favorable to his opponent.
While progressive Democrats have shelved Medicare for All and, for now, embraced President Biden’s general approach of gradually building on existing programs like the ACA and Medicaid, conservative Republicans in the House of Representatives, on the other hand, have put forward a far-reaching and controversial health care agenda that their candidate is unlikely to support in the election campaign. That may be partly their reasoning. Since Trump is largely policy-agnostic, they may want to set markers for a health policy agenda in the House if they retain control. (In fact, Trump’s budgets have included some of these ideas in the past, but in the unique political jiu-jitsu he practices, he doesn’t talk about them and sometimes distances himself from them.)
In campaigns, there is often a divide between the experts, activists and job seekers who craft political plans and the political people who set messaging and strategy. In this way, Democratic campaigns, for example, often create extensive policy plans on almost every health issue, aimed primarily at pleasing constituencies while positioning candidates for administration. The plans are too long and too dense for any candidate to implement. However, they represent a time-honored way to appeal to constituencies and contributors and allow the authors of their components to stand out to higher-ups in the event of a candidate’s victory.
Almost uniquely, the Trump campaign has produced no policy plans, making the study group’s proposals the only formal Republican health care plans in existence. They are responding to the Republican right, particularly political activists, who have long advocated these and similar proposals. The group’s members largely come from safe red congressional districts; It is Trump and other Republicans running for office, not themselves, who could be threatened by their proposals. In this one case, Trump and his campaign appear to have given conservatives in the House room to propose what he said he wouldn’t do: tackling Medicare and repealing at least part of the ACA.
There’s a chance that these controversial proposals could cause a stir at the polls, with Republicans campaigning for them or Democrats campaigning against them. Whether they will do so remains to be seen. It also needs to be clarified whether the press can tell former President Trump whether he supports or rejects these proposals.
Check out all of Drew’s Beyond the Data columns.