More On Health and Politics: The Peculiar Timing of Republican Health Policy Plans
Republican health policy proposals seem 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 present big targets to Democrats. Then there are the hugely controversial ideas like Medicare premium support or a Medicaid/Affordable Care Act (ACA) block grant or weakening pre-x coverage guarantees. They work just the other way around, giving Democrats targets to campaign on and scare voters about.
The Republican Study Committee has gone there, to the sledgehammer ideas. It’s not surprising that they have made the proposals they have made; most are familiar and have been made before, and the Study Committee regularly proposes very conservative ideas. I have no comment here on the merits of the proposals. The question for political analysis is why raise these ideas now, at the beginning of a super-heated election season? And how will former President Donald Trump respond and what will the political impact be?
Here are some of the third rails the Study Committee’s plan touches:
- The plan includes a premium support or voucher-like system for Medicare, opening Republicans up, again, to the charge that they will destroy the traditional Medicare program.
- The plan would weaken protections for people with pre-existing conditions, replacing many of the ACA’s provisions with a pool of funds states can use for that purpose. There are arguments to be made about how effective state pools can be, but politically, the plan is vulnerable to the charge 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 scheme to cap and cut Medicaid. That’s a political double whammy: Replacing current ACA coverage (at its high point with over 20 million in the marketplaces) and ending the guarantee of coverage for 85 million people on Medicaid while also handing the program to the states with much less federal funding.
- And the plan would end popular Medicare drug price negotiation. And the cap on monthly insulin costs. And on out-of-pocket Medicare drug costs.
There are well known 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, like Medicare for All. They, however, are not being advanced in Congress or the campaign trail right now. We have analyzed all of these plans at KFF as they have morphed over the years.
What is surprising is putting out a slate of the most volatile health policy ideas in the middle of an election season (see “Americans Really Don’t Like Trump’s Health-Care Plans”). It’s 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, it won’t matter in the election if Republican candidates don’t campaign on the ideas and Trump ignores them, and Democratic candidates don’t attack them.
Conservative Republicans have always believed in the goal of reducing federal health spending and the role of the federal government in health and may simply want to continue to advance these objectives irrespective of political timing or potential political consequences. They consider ACA subsidies inefficient—and this is a fundamental difference with liberals—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 vital role in the fragmented continuum of coverage we have in our country.
Former President Trump could ignore, embrace, or repudiate these proposals. He has said he is not interested in another run at repealing the ACA (adding language but no details about making the law stronger and less expensive), an acknowledgement of the unpopularity of the idea. He has also said he won’t touch Medicare or Social Security. Trump is not wedded to policy orthodoxy and conventional conservative health policy goals. His comment on the ACA is a signal that he will keep his distance from any proposal he senses is unpopular or will force him to fight on ground favorable to his opponent.
While progressive Democrats have put Medicare for All on hold and have fallen in line for now with President Biden’s general approach of building incrementally on existing programs like the ACA and Medicaid, by contrast, conservative Republicans in the House have laid out a far-reaching and controversial agenda on health that their candidate is unlikely to endorse during the campaign. That may be partly their rationale. Since Trump is largely policy agnostic, they may want to lay down markers for a health policy agenda in the House if they maintain control. (In fact, Trump’s budgets in the past have included some of these ideas, but in the unique policy jiu-jitsu he practices, he does not talk about, and sometimes distances himself, from them.)
Often in campaigns, there’s a disconnect between the experts, activists, and job seekers who put together policy plans and the political people who determine message and strategy. That’s how, for example, Democratic campaigns often produce voluminous policy plans on virtually every health issue aimed mainly at satisfying constituencies while positioning job candidates for the administration. The plans are too long and too dense for any candidate to run on. They are, however, a time-honored way to be responsive to constituencies and contributors, and for authors of their component parts to distinguish themselves with higher ups for jobs if the candidate wins.
The Trump campaign, almost uniquely, does not produce policy plans, making the study group’s proposals the only formal Republican health plans out there. They are responsive to the Republican right, especially policy activists who have long advanced these and similar proposals. The group’s members are largely from safe red Congressional districts; it’s Trump and other Republicans running for office that their proposals might threaten, not them. In this one instance, Trump and his campaign seems to have given House conservatives space to propose what he has said he would not do: go after Medicare and at least partially repeal the ACA.
The potential is there for these controversial proposals to make waves in the election if Republicans campaign on them or Democrats campaign against them. Whether they will do that remains to be seen. Also to be determined, whether or not the press can put former president Trump on the record about whether he endorses or repudiates these proposals.