What's wrong with Trumpcare (so far)

 As a college student many years ago I had a summer internship at a top consulting firm, where I learned an important lesson from my boss: “Don’t come tell me about a problem without proposing a solution.” It went without saying that before speaking up I was expected to focus only on real problems, analyze the situation, and propose realistic, logically consistent solutions.I’m reminded of this lesson pretty much whenever I hear Donald Trump say something, on subjects ranging from immigration to the environment to foreign policy. If he were a summer intern he would have been fired, and We the People should have known better than to hire him for his current gig.Trump has no problem calling the Affordable Care Act (ACA) a “complete and total disaster” and saying everything should be thrown out the window and replaced with "something terrific." But if you listen in recent days it’s become clear to me that Trump doesn’t even know what the Affordable Care Act includes. I’m sure if a reporter asked him to name five key elements of Obamacare he couldn’t do it, not that he could be bothered to try.The things Trump says he wants to achieve are mainly in line with the objectives of the ACA itself. Furthermore, the ACA has achieved some or a lot of success in many of these areas. To the extent Trump has backed different approaches, they are either irrelevant, ineffectual, contradictory, or fiscally unsound.Trump said in his speech to Congress that he wants to replace the ACA “with reforms that expand choice, increase access, lower costs, and at the same time, provide better healthcare.” He continued with talking points that he and Congressional Republicans have used in the past:

• Allowing the sale of insurance across state lines –which unlike what Trump said, will not lead to a national market nor achieve the other goals. In any case, selling across state lines isn’t forbidden today but there’s little interest in it from health plans themselves because they would have to set up local networks and wouldn't have leverage to negotiate with local providers. It’s just policy ideologues and ignoramuses who think this will work. (It also requires contradicting typical Republican views about states rights.)
• Ensuring that people with pre-existing conditions have access to coverage is a cornerstone of Obamacare, and a successful one at that. So it isn’t something Trump or Republicans can take credit for and was never a GOP goal before the ACA. If we’re going to be pure about a full repeal of Obamacare, why leave this –and other popular provisions—in place?
• "Giving our state governors the resources and flexibility they need with Medicaid to make sure no one is left out." --Well if making sure no one is left out is the goal then the states should accept the Medicaid expansion. Shifting to block grants may provide flexibility but won't add resources
• The use of tax credits and Health Savings Accounts to allow individuals to buy plans of their choice (not ones "forced by the government") is just fancy words. Tax credits would have the same objectives as the current subsidies for premiums and out-of-pocket costs but they would probably be less efficient. If the credits aren't refundable and/or they are based on age but not income, it won't help poor people buy insurance. And if people can buy whatever plan they want it will help young, healthy people who want bare bones coverage but will make insurance more expensive for everyone else. Already, Trump's instructions to the IRS not to penalize people who don't buy insurance is undermining the Obamacare exchanges rather than helping them
• Malpractice reform. Sorry, that will have no meaningful impact
• "Bring down the artificially high price of drugs and bring them down immediately" --No word on how that would be done, certainly not immediately.

It's notable that none of these so-called principles actually deals with improving the delivery of healthcare. They're all about insurance and financing.He concluded "On this and so many other things, Democrats and Republicans should get together and unite for the good of our country and for the good of the American people."Amen to that. A good way to start would be for Trump and the rest of the GOP to apologize for demonizing and undermining the implementation of Obamacare and then work on improving it. With hardliners from the ironically named Freedom Caucus likely to oppose pragmatic policies, it's up to the GOP to persuade Democrats why they should go along.

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By healthcare business consultant David E. Williams, president of Health Business Group.