Back when Donald Trump was a renegade, populist insurgent in the Republican primaries, he promised that he could save the nation's social safety net — programs like Medicare and Medicaid — "without cutting it to the bone." But now he's president elect, and he's assembling a dream team for GOP orthodoxy, threatening the very notion that access to health care is anything resembling a basic right.
Mr. Trump's choice to head the department of Health and Human Services, Rep. Tom Price of Georgia, is not just a leading critic of the Affordable Care Act. He also is somewhere to the right of House Speaker Paul Ryan when it comes to gutting the federal commitment to provide health care for the elderly and the poor. That selection and Mr. Trump's choice of health care consultant Seema Verna to run the Woodlawn-based Centers for Medicare and Medicaid Services suggests a future in which costs and risks are increasingly passed on to the states and individuals — a shift that will mean more uninsured, more lives ruined by medical debts and no appreciable effort to transform the health care system to make it more affordable and effective.
Long-time Republican efforts to transform Medicaid, the health insurance program for the poor, from an open-ended partnership between the federal and state governments into a limited, and ever-shrinking federal commitment are now front and center. Dr. Price, an orthopedic surgeon, is a long-time advocate of plans to make Medicaid a block grant in which the federal government provides a fixed amount of money to each state, with the growth rate pegged at a level lower than medical cost inflation, while providing governors with increased flexibility to cover fewer people and to offer them fewer benefits. And unlike many Republicans who have offered proposals to replace Obamacare, Dr. Price's plan would ditch the Medicaid expansion the legislation provided altogether. That's 13 million people who would lose care right off the bat.
Ms. Verna's record suggests the program could change in other ways, too. She worked closely with officials in Indiana (including Vice President-elect Mike Pence) on that state's ACA Medicaid expansion. Unlike other states, Indiana got permission from CMS to require that beneficiaries — even those with extremely low incomes — pay premiums if they want full benefits. If they don't, they can be frozen out of coverage for up to six months. The program is a complex blending of insurance choices, health savings accounts and co-pays, and though it has led to increased coverage, it has not made Indiana appreciably healthier — the state ranked 33rd healthiest in 2006, before the expansion, and 41st in 2015, according to America's Health Rankings, a long-established annual report produced by United Health Foundation and the American Public Health Association. Those who worked with Ms. Verna in Indiana and other states that sought to replicate its model said she was extremely well versed in the details of federal policy so that she could fit this square peg into Medicaid's round hole. Now she will be in charge of setting that policy.
As for Medicare, the health insurance program for the elderly, Dr. Price said after Mr. Trump's election that he planned to fast-track privatization, a long-held Republican idea in which seniors would be provided vouchers to buy whatever insurance they choose. But those subsidies would also grow more slowly than medical inflation, leaving seniors to pick up more of the cost or to forego adequate care. Mr. Ryan's latest iteration works a lot like the Obamacare exchanges — private insurers and the government would offer plans from which seniors could choose, and if they pick one that costs more than their subsidy, they pick up the tab. Mr. Price has also supported raising the eligibility age from 65 to 67.
All this would cut costs for the federal government — the Congressional Budget Office estimated that Dr. Price's Medicaid proposal would reduce federal spending by $1 trillion over a decade, effectively reducing the program's budget by a third in the final year of that period. The savings from the latest privatization program for Medicare aren't clear, but Mr. Ryan has couched his proposals in terms of reducing the entitlement's long-term costs — which is ironic in that Obamacare actually extended the solvency of the program by 11 years.
But it wouldn't necessarily cut costs for the health care system, and in fact, Dr. Price has been hostile to the federal government's efforts to shift away from fee-for-service models of payment toward ones that focus on quality and outcomes — perhaps the most far reaching of which is Maryland's Medicare waiver. That experiment has held hospital spending growth in Maryland to a cumulative 4.2 percent since January of 2014, saving Medicare nearly $420 million. Meanwhile, the hospital readmission rate for Medicare patients here during that time dropped nearly 6 percent compared to the national average, and the rate at which patients acquire infections in the hospital has dropped by a third.
In all, Dr. Price and Ms. Verna offer the prospect of a health care system transformed far more radically than President Barack Obama ever attempted. That's not what Mr. Trump campaigned on, but it may be what the American people are about to get.