Monday, January 16, 2017

TrumpCare's coming! What kind of garbage in a gold box awaits us?

The Washington Post's Robert Costa published the gist of an interview with Trump last night in which Trump claimed that his administration is putting the finishing touches on a health reform plan that would provide universal access to affordable, low deductible coverage. This is so apparently out of keeping with existing Republican ACA replacement plans that it's hard to know what to make of it. Here are three possibilities:

1) Trump's plan will depend heavily on "mini-med" plans for low income people -- that is plans with low up-front costs but tight caps on how much the plan will pay (annual caps, lifetime caps or both).  An ACA replacement plan put forward by Senator Bill Cassidy (R-Louisiana) and Rep. Pete Sessions (R-Texas) features such plans for the poor.

2) Trump will offer a plan that proposes something very like Medicaid for people higher up the income chain than the ACA does with something very like Tom Price's plan for people with somewhat higher incomes -- that is, relatively small tax credits, unadjusted for income, to be spent in a deregulated insurance market. I've proposed this myself, and I think it's too good to be Trump.

3) Trump is talking complete nonsense,and has nothing approaching a viable ACA replacement anywhere near development.

Given Trump's lifelong habit of passing off garbage for gold, I'm going with the mini-meds. But who knows?

P.S. Trump says the plan is all but ready to go, but he's waiting for Tom Price to be confirmed before it's unveiled. Maybe among other things it's a ploy to speed Price's confirmation.

P.P.S. Trump also says, "I won't tell you how, but we will get approval." While that was a reference to the awesome power of his tweeting, perhaps Republicans are also planning to abolish the Senate filibuster.

P.P.P.S. See the comments for evidence that Price is interested in a combination of catastrophic coverage and very limited first-dollar coverage via "Direct Primary Care" practices.. Price's ACA replacement bill also touched on this, allowing use of Health Savings Accounts to pay for Direct Primary Care Service Arrangements


  1. I think you are near the mark on mini-meds. But there’s an interesting twist - a shiny new object - to be watching for.

    An Atlanta Journal and Constitution columnist, Kyle Wingfield, has long been a cheerleader for, confidante of, and conniver with Tom Price. A few weeks ago, with the help of a Georgia-based right-wing think tank, he trotted out this column flogging a revision of Medicaid comprising, for each beneficiary, a “true catastrophic” insurance plan coupled to membership in a “direct primary care” (DPC) practice. The total cost per beneficiary was pegged at $2500 per year, $1750 for the high deductible insurance premium and $750 for an annual membership in the DPC practice.

    DPC practices presumably assure easy to get , guaranteed, unlimited access to pre-paid primary care, and typically include labs and basic generic drugs at the cost to the practice. There are only a small number of such practices and no bona fide evidence that they adequately deliver even primary care. At a capitation of $750 per patient, success and unlimited access would seem unlikely.

    What seems clear, however, is that even if DPCs were a sound vehicle for delivering primary care, a scheme of “DPC + catastrophic” would leave a giant coverage cap between the point where primary care gives out and the deductibles of a catastrophic plan kick in. Even with discounting for a DPC patient, I estimate, a catastrophic plan with a premium of $1750 would have an individual deductible of well over $5000 (and even more if Trumpcare dispenses with minimum AV requirements).

    Shades of the Bush Medicare drug plan, a Republican’s dream: catastrophic coverage, the cash value of which increases with personal wealth; a regressive donut hole whose successful navigation depends heavily on personal wealth; and a basic benefit providing just enough value to just enough people to create a constituency and support a talking point.

    Just enough, in this case, for the brag: Trumpcare covers everyone with lower out-of-pocket costs that Obamacare. Universal access! Might even last a few years, until enough DPC members or first need to see a specialist or use a non-generic drug and realize they’ve been had.

    1. Thank you for this, Ratman - definitely relevant. I'll see if I can dig out the Wingfield piece.

  2. Even a broken clock is right twice a day, and there may be some merit in the DPC part of this proposal.....see the attached, from the John Locke Foundation that I suspect is up to no good...

    1. Under the ACA , DPC-based plans can be offered on the exchanges, provided that they met the same requirements (adequate package of benefits, maximum percentages of admin costs and profits). So, yes, there may be some merit to adequately funded insurance plans organized around DPCs.

      Working from the Georgia right-wing think tank article cited by Bob Hertz, the only actual data presented by its North Carolina right-wing think tank author suggests that tiny Union County, NC, spends at least $3750 a year for its presumably successful DPC+catastrophic plan. Also, Union County self-insures so need not pay insurance company profits. We are not told what additional payments amounts are required as employee (premium) contributions. We do know that the county leaves its employees with up to $2750 in out of pocket expenses.

      Yet, the Georgia Public Policy Foundation relies on the success of this exact DPC+catastrophic plan to support its pet idea of a $2500 per capita plan for persons below the poverty line. So, yes again, they and the John Locke Foundation are up to no good.

    2. Thanks for this, Bob. Price's ACA replacement also privileged direct contracting with physicians, allowing use of HSAs to pay for "direct primary care service arrangements"

    3. Oops. I meant to include the link.

    4. Update: my deep dive into the plan Bob identifies shows that, even for those within the DPC, Union County’s layouts per adult run OVER Medicaid expansion’s $6336 per year ( - and that the DPC enrollment has been cherry-picked (

    5. Problem with links! Try these:

      For cherry-picking, see

      For cost level comparison to Medicaid, see