By AnneMarie Schieber
In the November 2020 election, voters will decide between candidates with widely different visions of American health care, especially in the context of the COVID-19 pandemic.
The Democratic candidate for president, former vice president Joe Biden, says he favors a larger government role in the delivery of health care, such as with a public health insurance option. Biden favors expanding the Affordable Care Act, lowering the eligibility age for Medicare, and regulating drug prices.
President Donald Trump unveiled his health plan in December 2018, a 124-page health document entitled, “Reforming America’s Healthcare System Through Choice and Competition.” The Trump Administration implemented a number of reforms through executive authority, many of them expedited under the emergency declaration in response to the COVID-19 pandemic. Congress will need to act to make a number of reforms permanent.
The election will be a vote for competing visions of health care, says Chad Savage, M.D., physician and policy advisor to The Heartland Institute, which co-publishes Health Care News.
“Vice President Biden envisions a top-down health care system where bureaucrats make life and death decisions through a governmentally controlled health system,” Savage said. “He would move us toward a single choice system where patients will have no options but the ones chosen for them by their ‘betters.’”
Choice is the primary feature of the Trump plan, Savage says. “Americans will have a plethora of quality choices,” Savage said. “Health care choices will be as dynamic and customizable as those that exist in all other industries subject to the consumer-friendly influence of the free market. Additionally, by putting the patient in charge of health care, instead of bureaucrats, President Trump will keep the decision making in the most ethical location: with the patient.”
This is a “health care make-or-break” election, says Merrill Matthews, a resident scholar with the Institute for Policy Innovation. “If Joe Biden wins, he will make every effort to expand the government’s role in health care. And if he has a Democratic Senate and House, he will be able to go as far as he (or Bernie Sanders) wants,” said Matthews. “President Trump, by contrast, wants to expand flexibility and consumer choice in most areas of health care. And with a Republican House and Senate, he might be able to set the country back on the right path. It would not necessarily be a free market in health care, but it would be much freer than a Biden health care system.”
A Health Care Revolution
Many of the reforms under the Trump health plan have already amounted to a dramatic shift in health care, says John Goodman, president of The Goodman Institute and co-publisher of Health Care News.
“Vice President Biden wants to expand existing programs, like Obamacare, that are highly regulated and offer doctors and patients little flexibility in delivering care,” said Goodman. “Trump wants to deregulate health care programs because he realizes by putting health care more in the hands of the private sector, we will get more innovation.”
In an upcoming Health Affairs article, Goodman and Marie Fishpaw, director of domestic policy studies at The Heritage Foundation, describe seven areas where deregulation has been most pronounced. The reforms include changes made in virtual medicine, round the clock medical care, patient power, and chronic care centers for excellence for chronic care, price transparency, and customized, personal and portable health insurance.
Virtual Health Care
During the pandemic, the Trump Administration, with the help of Congress, removed reimbursement obstacles to a visit to the doctor by phone or online. “Legalizing telemedicine was not a simple act,” Goodman and Fishpaw write. “There are roughly 7,500 procedures Medicare pays doctors to do.”
The Trump Administration had been sorting through these for three years prior to the pandemic, deciding which were appropriate for virtual medicine and how much Medicare should pay. This laid the groundwork for rapid execution when Covid-19 struck, Goodman and Fishpaw write.
Additionally, the Trump Administration, prompted by the coronavirus pandemic, temporarily stopped enforcing privacy rules so doctors could communicate with their patients using Facetime, Skype, Zoom, and other similar platforms.
The insurance market is where the Trump Administration made significant progress, with the potential for even more radical change.
Short-term, limited-duration health insurance plans (STLD) have been one solution advanced by the Trump Administration. The plans are more affordable than those offered on the Obamacare exchanges because they are not subject to the same regulations. STLD plans are temporary plans to “bridge a gap,” mostly for healthy individuals, as they move from in and out of the workforce.
The plans, which cost up to one-haft the price of Obamacare plans, are often criticized as “junk insurance.” “Remember, people with a chronic condition can always enroll in an Obamacare plan,” write Goodman and Fishpaw.
Personal and portable insurance is another significant reform under the Trump Administration, write Goodman and Fishpaw. The idea behind health reimbursement accounts (HRAs) is to give employees the opportunity to own their own health insurance. Beginning January 1, 2020, employers can provide pre-tax dollars to employees to buy their own insurance. The insurance can travel with the employee in from job to job and in and out of the labor market.
Under a new executive order, employers will soon be able to put money into HRAs to buy direct primary care. DPCs are membership-based and can provide round the clock access to care, face to face, by phone, or virtually.
Patient-Managed Chronic Care
Another reform has been to give patients more control to manage chronic conditions. Goodman and Fishpaw write studies show that with minimal training, patients can manage their own care as well or better than traditional doctors. The Trump Administration has liberalized the use of health savings accounts to allow patients to do that.
Similarly, insurance could be tailored to address specifically the needs of patients with chronic conditions, write Goodman and Fishpaw. “Insurance doesn’t need to be all things to all people,” said Goodman in reference to the article. “Health plans should be able to specialize and become focused factories in the treatment of chronic care.”
The Trump Administration has already demonstrated this with Medicare Advantage. “Medicare Advantage Chronic Condition Special Needs Plans specialize in 15 chronic conditions,” said Goodman. “Congress needs to apply the same type of reforms to the Obamacare exchanges.”
Patients could also make better health care decisions with more price information, says Goodman. President Trump signed an executive order in 2019 that requires hospitals to post prices for common procedures. Additionally, hospitals must also release payment details on the payment arrangements they have with insurers.
“The next step is for Congress to act. Every executive order can be rescinded by a future president and every act of Congress that facilitates these reforms is tied to Covid-19,” says Goodman, (see related article).
Some of the executive orders were made and supported by the pandemic. “When the virus goes away these new freedoms will also go away unless there is legislation,” Goodman and Fishpaw write.