A Suggestion for TrumpCare Using Past GOP Plans

Suggestions For What TrumpCare Could Look Like

Here is a suggestion for what TrumpCare should look like. We explain how to synthesis all current GOP plans with the ACA to create something awesome. I would suggest Rand Paul, Paul Ryan, Tom Price, Trump, a House Committee, or anyone else working on a plan consider these ideas… especially given Trump’s promise of “insurance for everybody” which will be expected to be upheld.

There are some great ideas in past GOP health plans, but there are also some big sticking points that would needlessly make things worse for many (like the preexisting conditions exclusion and the fact that no plan seeks 100% coverage).

Our plan seeks to bridge the gap between the public option progressives want, the market-based system the GOP wants, and the choices and coverage healthcare providers and Americans need.

TIP: This plan seeks to synthesize HIP 2.0, the House “Better Way” plan, the Price plan, and Trump’s plan… and the ACA… and Bernie Sander’s Plan… and  Rand Paul’s ideas… and the JAMA articles to create something that finds a center between the left and right, libertarian and progressive, Democrat and Republican ideologies. The goal is to create a plan that finds wide support and works for the people, not just one that starts up another battle over healthcare. Can we deregulate and increase coverage?

TIP: This page assumes that compromise will need to be made. However, in the meantime, there is still time to fight to save ObamaCare as it stands and make the conversation more about reforming than replacing. Those who get too wishful about a replacement should note the CBO’s projections of what repeal and replace could mean if we simply defer to a stock Republican health plan. One thing for everyone to keep in mind is that even a staunch supporter of the ACA tends to support further health care reform, and that most Americans support general provisions of banning preexisting conditions, and as such there is room for compromise despite differing politics.

TIP: The simplified plan below should be compared to our “fix” for the GOP’s Pre-Existing Conditions exclusion, an alternative plan for fixing ObamaCare (another similar plan that could work with a few different ideas), our page on an HSA-Eligible Public Option, and our non-profit public network “fix”.

1. Take the ACA and remove as little as possible to satisfy the Republican repeal promise. We all know, most of this is fine, mundane, and workable. We should not repeal stuff that is working due to politics. We only need to replace key coverage and revenue provisions for practical purposes.
2. Take Pence’s Healthy Indiana Plan 2.0 and turn it into a national public option executed at the state level. This can block-grant Medicaid, expand state-based solutions, and is market-driven. DETAILS: More specifically, let states keep sec. 1115 and sec. 1332 waiver programs, but require an HSA eligible buy-in available for all income levels in exchange; states can still design their own version. Those in the Medicaid Gap get a POWER account, those over the gap can buy in and use an HSA. With only a 60 day exclusion period (this is what HIP 2.0 uses), this plan removes the need to mandate private insurers to cover preexisting conditions and provides an avenue for 100% coverage (major promise 1 and 2, check and check).
3. Expand HSAs, the tax benefits of HSAs should help attract young and healthy customers to a simple public option from the time they turn 18 on. This is even more true if you allow for an opt-in via taxes and follow the other guidance on this page (such as letting employer’s fund this). What if everyone had the option to be covered under the public option and fund an HSA every year when they filed taxes. Would probably just become custom for young people to do.
4. Include drug reform, litigation reform, and selling across state lines contained in past GOP plans. Whatever.
5. Age based tax credits are fine… but some will need an extra form of assistance (which can be provided via the public option). TIP: By keeping subsidies for private coverage fixed by age, but offering a fallback with the public plan, it fixes the need for income based subsidies by allowing people to choose a public plan that has premiums that scale based on income.
6. Remove the employer mandate, but let employer’s fund an employee’s Public Option and fund their POWER/HSA (even just in part). NOTE: This allows a worker to choose the public option or private insurance and still allows the employer to contribute.
7. Make premiums tax deductible. Now everyone in America, rich or poor, employer or employed, gets more equal assistance (either through subsidization or tax breaks).
8. Generally keep as many taxes as possible at first. Prove the program is working before you cut funding and revenue. Let the perks of the new market-driven plan offset upsets over taxes.
9. Keep and expand the exchanges. They are a smart way to shop for plans and get help. All plans should have to be sold on an exchange, even if only some plans qualify for certain benefits. This will help keep things transparent and force the limited number of entities to compete side-by-side. The free-market only works if people understand their choices and there is transparency.
10. To whatever extent one can without bringing back junk insurance, deregulate insurance. We can keep the current standards as a baseline, but some people really only want a basic catastrophic plan. Let insurers sell what they want (as long as it isn’t junk), lets just focus on our public programs and create better plans through competition.

The general goal is to simplify, expand coverage, and create incentive for low-income and young to participate in a market-based healthcare system and investing (via an HSA). Insurers lose a bunch of regulations, but the public option provides constant competition. The market either reacts by competing or it doesn’t… not really the Government’s problem.

I would also:

1. Go over the ACA, all related bills (including all Medicaid, Medicare, etc), and any upcoming plan with a fine tooth comb and debate provisions that aren’t earnestly trying to fix things or working, without being political. Some provisions look good on paper, but actually just punish poor people indirectly. An age-based tax credit alone, that punishes poor people, but an age-based credit with a public option, that provides extra assistance, creates a fall-back, and a path for success. The worst of our assistance programs create glass ceilings that trap the power at an income level, let us avoid this too.
2. Combine all public insurances into one program and then manage groups as needed. This would make the Medicaid, Medicare, VA, Indian Health, Public Option, etc plan. One entity that can be managed and accounted for more easily. Also it ensures that everyone has a stake in getting the pubic option right.
3. The above plan could include supplemental and drug plans, as described here. Private insurers could also sell supplemental like they do with Part C and D. If everyone has access to a basic market-based plan, it frees up public and private entities to build off that system without being forced to assume some of the risks they do today.
4. Ideally, citizens should be able to opt-in and out of the public option via their taxes. If it is going to be a thing of tax breaks and tax credits, why not let a tax-paying citizen take care of their yearly coverage in one fell swoop. This would work like the 8965 and 8962 forms do now, you take the coverage in advance, and square up at the end of the year. If you had coverage, you are set, if you didn’t have MEC of any type (private, public option, or whatever), then you pay a tax. Yes, I’m suggesting we don’t remove the individual mandate and instead framing it as an “opt-out” choice. People don’t like “being forced”, but everyone accepts some degree of taxation. Thus, an opt-out fixes this. Unlike the ACA which taxes those without MEC, but doesn’t provide you coverage. This suggestion is to simply cover anyone who doesn’t “opt-out” by having another form of insurance because they will owe the tax.
5. I strongly suggest having separate drug plans. It’ll be easier to negotiate if we don’t have all coverage hung up by drugs and can tally drug costs on a separate plan.
6. I think a preexisting conditions / chronic health plan is smart under the right conditions. It shouldn’t be some separate side-ways thing, but it does make sense to have different plans and tiers within a public option. If people need constant managed care, lets account for them and coordinate using a body constructed for this purpose. If it doesn’t exclude people due to price or network, and just seeks to optimize a network for specific needs, I don’t see the problem.
7. A focus should remain on wellness, mental health, addiction, dental health, and vision. If we pretend like health starts at the neck down and we don’t incentivize healthy life styles we do a disservice to the public and ignore vast fields of healthcare. All we need to do is count this care toward maximums on public plans and let private insurers follow suit.
8. We should probably keep protections like bans on lifetime limits. There are some rules that are hard to remove without creating crazy loopholes. I struggle to find a way that lifting a ban on lifetime limits for private insurers doesn’t come back to haunt a public plan that kept lifetime limits. Generally, one can’t provide 100% coverage if one doesn’t have an option that includes this ban.
9. Please, fix ObamaCare’s family glitch and other sticking points. Also, allow people the liberty to buy annual contracts. Having to pay month-to-month is… rather despotic. Statistically this is going to result in people getting dropped. Insurers are using non-payments to drop people and exclude them for a year, Congress wouldn’t know first hand, but out here in the real world it is a battlefield. It is a real problem, but difficult to detect. See: Health Insurance Cancellation Reform for Non-Payment for our suggestions.
10. The above plan could reduce tons of costs for all insurers by building the public network Bernie Sanders’ describes in his American Health Security Act, S. 1782.

TIP: I’m trying to convey all these ideas quickly (so it is readable), thus there are key details left out. If this makes it into the hands of anyone who takes it seriously or cares, I’m happy to provide feedback. Just comment below.

Conclusion

The above plan pairs a public option with deregulation and a focus on a market-based system. Instead of trying to make America conform to Republican ideas or Democratic Party ideas, we just kind of give them both choices (like original Medicare a bit, which people love).

I think Pence’s HIP 2.0 [while not perfect] is on a really solid foundation, and it just so happens to pair well with Bernie and Obama’s public option… and Trump’s promises for “insurance for everybody”…. and even Ryan and Price’s plan. All without turning the preexisting conditions exclusion period or less generous tax credits into a divisive voter issue. People just want access to insurance that they can afford and voters know that the US as a whole is spending far too much for far too little.

If an upcoming plan does not heed the advice about a public option, or doesn’t try to soften the aforementioned exclusions or trimmed down assistance, it’ll only be making a small fraction of the ideological middle class happy (who will quickly realize that ObamaCare itself wasn’t the primary problem with healthcare if a lackluster TrumpCare replaces it).

Do this plan, or something like this, and I think we have the basis for a compromise position that both parties can be happy about (again, like Pence’s HIP 2.0). The keys here, aside providing coverage and keeping cost curbing measures, are providing an opt-out for all and an opt-in for all; AKA choice.

TIP: HIP 2.0 is Indiana’s Medicaid plan. It was difficult to get passed, but finally the GOP got a GOP plan that Democrats in power approved of for ObamaCare. That is the type of result we want for national healthcare. I and tens of millions of others, don’t want “to repeal the ACA”, we just want a great bipartisan health plan we can all be proud of. We have Pence and Trump now, lets keep our fingers crossed they lead us in this direction.