Lost in all the coverage of the firing of FBI Director James Comey last week were a pair of in-depth interviews President Donald Trump gave that included lengthy comments on health care – one with Time Magazine and the other with The Economist.
He acknowledged to Time interviewers that health care was not an area of expertise in his previous job. “It was just not high on my list,” he said. But he added that “in a short period of time I understood everything there was to know about health care.”
Among the president’s more questionable claims was his description of the House-passed health bill as “You’re going to have absolute coverage.”
The last full estimate from the Congressional Budget Office predicted that a previous version of the bill would result in 24 million fewer people with insurance after 10 years.
Trump also told The Economist that “we’re getting rid of the state lines,” a reference to allowing health insurers to sell across state lines. Not only is that not in the GOP bill, many experts agree such a policy would not work to increase competition.
Possibly the most curious comment was this one, also in The Economist interview: “[T]his was not supposed to be the way insurance works. Insurance is, you’re 20 years old, you just graduated from college, and you start paying $15 a month for the rest of your life and by the time you’re 70, and you really need it, you’re still paying the same amount and that’s really insurance.”
“He seems to think it’s like a life insurance policy, which you can buy at a certain age and it keeps you at a fixed premium dollar forever,” said Gail Wilensky, a health economist who ran the Medicare and Medicaid programs under President George H.W. Bush. Except “you can’t buy health insurance that way,” Wilensky said. “Even if you stay continuously insured, that’s just not how it works.”
On the other hand, Wilensky said, it might not matter all that much how well a president understands the intricacies of health policy. “It matters whether he thinks it’s important,” she said. The president she worked for was much more comfortable on issues of foreign relations and defense. “It wasn’t that he didn’t care” about health, she said. “He just didn’t know that area the way he knew other areas.”
Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill, points out that a deep understanding of a subject by itself is not enough to produce policy change.
“Bill Clinton thought he knew health policy, and look at how that turned out,” he said, referring to the collapse of his health reform plan in Congress in 1994. Still, “ignorance surely doesn’t help,” he added.
David Blumenthal, president of the Commonwealth Fund and co-author of a book on presidents and health care, agreed with both Wilensky and Oberlander.
“A president has to know enough to sell the plan” to Congress and the public, he said. “But presidents can make mistakes by getting too deep in the details.” He pointed to not only Clinton but also President Jimmy Carter as chief executives who got mired in the small print of health policy.
At the same time, however, Blumenthal said that a president has “to lay out principles and parameters that the Congress knows if they meet he will sign the bill.” And while Trump has done that, “I don’t think he’s been entirely consistent with what he’s said, so it’s not clear how much the Congress is being guided by his principles,” he said.
One health issue Trump is clearly not ignorant about is his power to stop paying insurance companies who are providing help to some low-income policyholders in the health insurance exchanges. The “cost-sharing reductions” are the subject of a lawsuit that was appealed by the Obama administration, and Trump could, in fact, stop the payments by dropping the appeal.
Insurers say uncertainty about whether they will get that money is a key reason they are asking for higher rates or dropping out of markets.
Trump did not help allay that uncertainty. He told The Economist that “we don’t have to subsidize it. You know if I ever stop wanting to pay the subsidies, which I will.”