4 reasons 'TrumpCare' won't put patients in charge
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The cornerstone in Team Trump’s case for the House’s hastily-birthed “American Healthcare Act” is the promise to put consumers “in charge.”  “The goal of all this is patient-centered health care, where patients and families and doctors are making medical decisions,” Health and Human Services Secretary Tom Price said last week.

For the more than 80 million Americans who get their health insurance through Medicaid or an ObamaCare exchange, this promise is medicine’s “Bowling Green Massacre” — pure fiction.

Consider some basics:

For starters, by slashing subsidies for lower-income Americans dependent on the individual market’s coverage offerings, the House bill forces a bitter “choice” between cheaper insurance and going bare.

For some, this choice will be “easy” — and bitter — picking between paying the rent and buying medical insurance is a no-brainer.  If you can’t pay a doctor, don’t count on being “in charge.”


But what about cheaper coverage — might that open new paths toward “patient-centered” care?  And won’t competing insurers have powerful incentives to keep their prices down?  They will, but consider how private insurers control their costs, and thus their prices.  They have, basically, four options.

First, they can try to avoid sick customers.  Rules against “pre-existing condition” exclusions and outright refusal to sell to sick people limit this approach.  But health plans can target their promotional messages (Washington, D.C., Metro stations were plastered some years back with HMO ads featuring fit women in tight jeans), and otherwise fashion benefits bundles and sales strategies to appeal selectively to the healthy.  

This zero-sum competition does nothing to put patients in charge.  It merely sorts the sick into “losing,” higher-cost plans or, worse, into the ranks of the uninsured.

Second, insurers can restrict doctors’ and patients’ therapeutic choices — the opposite of putting them “in charge.”  “Managed” health plans did so with a vengeance in the 1990s, refusing to authorize pricey tests, treatments, and referrals.  Consumer ire over this perceived intrusiveness forced the industry to back off.  

A new round of such intrusion, at odds with the promise of more “patient-centered” care, would likely draw harsher backlash, this time directed at President Trump and Congressional Republicans, not just insurers.

Third, health plans can coax doctors to stint on care through schemes of bonuses and penalties.  You can’t choose tests and treatments that your doctor doesn’t tell you about — or declines to provide.  The managed health plans of the 1990s tried this with some success — until public revelations of such arrangements sparked consumer outrage.  

Should such pressure on doctors to break faith with patients become a TrumpCare cornerstone, expect journalists, plaintiffs’ lawyers, and other entrepreneurs of revelation to spotlight the stunning disconnect between patient-centered promise and covert withholding of clinical options.

Fourth, insurers can hike co-payments and deductibles, giving the lie to Trump’s promise to slash out-of-pocket costs through “Repeal and Replace.”  It’s both widely expected that insurers would do this under TrumpCare and a sure thing that these higher costs would reduce millions of Americans’ therapeutic options.

For people dependent on Medicaid, prospects for “patient-centered” care are worse.  Not only would the bill’s rollback of Medicaid expansion render millions uninsured, it’s cruelly selective spending cap would mean a growing chasm, over time, between the therapeutic options available to Medicaid’s remaining beneficiaries and to other insured Americans.

That’s because the cap (a new, dollars-per-patient limit on federal support for states’ Medicaid programs) rises annually based on the medical CPI, a metric that increases more slowly than does actual clinical spending (since medical CPI neglects the costs of diagnostic and therapeutic advance).  Over several years, the percentage-point difference can grow to double digits, ensuring a health care freedom gap (and a quality gap).  This cap would thus transform Medicaid from a means for getting mainstream care into a cog in a clinical caste system.

So Team Trump’s claim to “put patients first” by giving them “more choice at a lower cost” appears to be false cover for a plan to strip choice — and access to care without fear of financial catastrophe — from tens of millions of Americans.

Perhaps President Trump will prove able to tweet Congressional Republicans into submission, given their alarm over the political price of failure to “Repeal and Replace.”  But in the dog’s breakfast of deceit that is the “American Health Care Act,” the false promise of patient freedom could be the Act’s undoing as the medical marketplace gives the lie to Team Trump’s “alternative” healthcare facts.  

M. Gregg Bloche, M.D., J.D., @greggbloche on Twitter, is professor of law at Georgetown University and author of “The Hippocratic Myth.”  He helped to develop President Obama’s 2008 campaign healthcare reform plan and advised the 2008-2009 presidential transition.

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