No Deal: How Does Trump Plan to Reform America's Healthcare System?

Donald Trump doesn't know what he thinks about health care. He has been a periodic advocate of a United Kingdomâ€“style monopoly system and a periodic critic of such monopolies. He says that we should repeal the so-called Affordable Care Act and replace it with . . . something. Something "terrific."

When asked by New Hampshire debate moderator Mary Katharine Ham whether his flirtations with single-payer leave him closer to Vermont socialist Bernie Sanders than to mainstream Republicans, Trump gave a hilariously incoherent answer based in one part on banalities and one part on lies -- which is the Trump magic formula. He said that he was the only candidate on stage free to explore all the policy options because he is self-funded and therefore not beholden to special interests. Trump is in fact mainly funded by donors, like the other candidates, but he persists in this lie, brazenly. He also claimed that the insurance companies are "getting rich on Obamacare," which would be news to United, Cigna, Aetna, and others who have taken a bath on their ACA offerings. (They might have thought they were going to get rich -- it's nice to have a federal law mandating the purchase of your product -- but, having gone to bed with the devil, they are waking up with a burning sensation.) Trump also promises a system that would not leave Americans "dying on the street."

Trump likes to talk about "deals," and to tout his purported expertise as a dealmaker. To the extent that he has communicated anything that deserves to be called an idea on the issue of health care, it is in joining in with Barack Obama, Bernie Sanders, Hillary Rodham Clinton, et al., in calling for government negotiation with pharmaceutical companies over prescription-drug prices. Trump promises to apply the business acumen he has brought to the casino racket and his reality-television enterprise to negotiate better deals on pharmaceuticals.

It is a superficially appealing position: About two-thirds of Republicans tell pollsters they believe the government should engage in such negotiations. As things stand, the Department of Health and Human Services is prohibited from engaging in direct price negotiations with pharmaceutical companies, a rule that was adopted in the creation of Medicare Part D, the competitive prescription-drug benefit program. There were three reasons for that: One, it was a sop to the pharmaceutical companies; two, Congress and the George W. Bush administration had quite reasonable concerns that transferring the price-negotiating function from private insurers to the Centers for Medicare and Medicaid Services would create something like a price-fixing monopsony; three, the experience of Medicaid suggests that such negotiations might backfire, with pharmaceutical companies raising their prices in the private market to create the illusion of steeper discounts for government buyers.

Barack Obama had campaigned on undertaking such negotiations, but, in a rare concession to reality, he quietly dropped from the ACA a provision that permitted them. The idea that a team from the Centers for Medicare and Medicaid Services is going to sit around a table with the top brass from Merck and Purdue and hammer out standing deals covering the thousands of permutations of pharmaceuticals American medical patients receive is impractical, to say the least. The Obama administration and Mrs. Clinton have since changed their approach, suggesting that the government become involved in direct negotiations over the prices of a small number of very expensive drugs, such as biologics, especially those that do not have very many competitors.

The belief that a single federal health soviet is going to come to a better settlement than a large number of insurance companies negotiating a large number of different deals to serve a large number of different interests is a classic example of monopolistic progressive thinking, something for which Trump, who currently styles himself a conservative of some sort, has a weakness. In reality, one of the reasons private-sector negotiation has failed to produce large savings is that the private insurance companies face prohibitions of their own, thanks to federal regulation.

There are six classes of care that are "protected" by federal regulation, meaning that private insurance plans doing business with Medicare are obliged by law to cover "all or substantially all" prescription drugs related to them. Which is to say, the law ensures that insurance companies are in a weak negotiating position, because they cannot walk away from the transaction -- in the end, they are required by federal law to buy the drugs. There's a little poetic justice in that: Under the ACA, insurance premiums are going up, because consumers are required by law to carry certain insurance; the insurance companies are in the same position (an unwieldy federal mandate) vis-Ã -vis certain pharmaceuticals.

The Congressional Budget Office studied the question a few years back and concluded that direct negotiations probably would not have much effect on overall prices. In a report for the National Bureau of Economic Research, professors Mark Duggan and Fiona M. Scott Morton found that a larger Medicaid footprint in the market for particular drugs was associated with higher prices, not lower prices: A 10 percent increase in Medicaid's share of the buyers' market for a prescription was associated with a 7 to 10 percent increase in the average price of that prescription.

Trump goes astray in the same way that Obama, Sanders, and Clinton do: in the assumption that what ails American health care is profit. What actually ails American health care is demographics, with an aging society undermining the finances of Medicare and the Social Security disability program; defective markets in which state-by-state insurance licensing prevents the emergence of a national market, and hence national competition, for insurance services; preexisting regulatory burdens that all but ensure high prices for health-care consumers; special-interest concessions written into every program from Medicaid to Obamacare, paid out as the price of industry support for various federal interventions. If Trump's confused answer about "lines around the states" was a reference to the fractured U.S. insurance market, then he is correct to identify that as a problem. Beyond that, his strategy seems to consist mainly of adjectives: wonderful, terrific, etc.

Trump's error is useful to consider inasmuch as he is not the only one who imagines the federal government in the role of master dealmaker in the health-care market. In reality, the main problem isn't a lack of deals but a lack of competitive markets, consumer choice, and transparent prices. Two-party deals between Big Government and Big Pharma are one way to make that situation even worse than it is.

Be sure to see where Cruz is praising Laurence Tribe near the end along with Clinton’s counselor! Ted never met a lawyer he didn’t love....they give him plenty of $$....him, Rubio, Clinton and Bush! ...look it up. lol

TED CRUZ is the reason we are stuck with Obamacare.

http://www.nationalreview.com/node/214989/print
http://www.nationalreview.com/node/214989/print

The Right Stuff
John Roberts should be a quick confirm.
By Ted Cruz — July 20, 2005
In 1995, while clerking for Chief Justice William Rehnquist, I and my two fellow law clerks asked the chief whom he thought was the best Supreme Court lawyer currently practicing. The chief replied, with a twinkle in his eye, that he thought he could probably get a majority of his colleagues to agree that John Roberts was the best Supreme Court advocate in the nation.
This week, the president announced his intention to nominate John Roberts to be a Supreme Court justice.
His nomination has been met with widespread praise, from left and right. Nevertheless, there are some who have raised complaints that his two years on the bench provide insufficient record for them to assess (and attack) his jurisprudence.
That complaint misses the mark for three reasons. First, his judicial record would have stretched 14 years, had Senate Democrats not delayed its consideration twice, in 1991 and again in 2001. When his nomination did finally make it to the Senate floor, in 2003, he was confirmed by unanimous consent.
Second, many distinguished jurists, such as Chief Justices William Rehnquist and Earl Warren and Justices O’Connor, Souter, and Thomas, similarly had very limited experience on the federal bench prior to ascending to the Court.
And third, although two years on the bench provides a limited number of opinions, he has a far longer record that is relevant: his professional career as a Supreme Court litigator.
At the outset, Judge Roberts is brilliant. A summa cum laude Harvard graduate, Roberts began by clerking for two giants of the bench, Judge Henry Friendly, and Chief Justice Rehnquist.
He then argued 39 cases before the Court, more than all but a handful of lawyers ever. And he has earned a reputation as a balanced, scholarly advocate.
When he stood at the podium, he was never oratorical or flashy, not given to waxing rhetorical. Instead, he was unflappable. His preparation was so extensive that-unlike many lawyers, who try to dodge tough questions from justices-he would simply stand and answer the hard questions one after the other, calmly and coolly addressing the most difficult obstacles to his case.
He didn’t always prevail; but, even in loss, his quick wit remained. As he observed to one unsuccessful client, aghast and asking why they had lost their case 9-0, he replied, “well, there are only nine justices.”
In November of 2000, I had spent the past year and half as domestic-policy adviser on the Bush campaign, and was part of the team assembling the lawyers to help litigate Bush v. Gore. We needed the very best lawyers in the country, and I called John and asked him to help. Within hours, he was on a plane to Florida.
Humble and soft-spoken, he was happy to be behind the scenes, writing and editing the president’s Supreme Court briefs. Midway through the recount, on November 28, John started heading out to return to D.C. Distraught, I asked where he was going-we were in the middle of enormous legal battle. Quickly, he replied, “I know, but I’ve got a Supreme Court argument tomorrow morning.”
He flew back to D.C. Tuesday night, argued a complicated trademark case Wednesday morning, and returned immediately to Florida to continue helping us represent the president.
Few, if any, other lawyers could have accomplished such a feat.
Judge Roberts is a lawyers’ lawyer. And that matters immensely, especially for the U.S. Supreme Court.
Some of the most storied justices in history, including William Howard Taft, Charles Evans Hughes, Thurgood Marshall, and Robert Jackson, came from similar experiences as experienced advocates at the highest Court.
The mainstay of Supreme Court justices’ work consists of complex, non-ideological cases, where rigorous analysis of precedent is at a premium.
With judicial nominees, the charge of “judicial activism” is much bandied about. Depending upon one’s perspective, what precisely constitutes activism is subject to debate. The simplest definition is whether a judge will substitute his own personal policy views for the clear dictates of the law.
But, figuring out the dictates of law requires diligent study of legal precedent-no easy task. And for that enterprise, decades of litigating experience, at the highest levels, is invaluable-because it trains the judge to read precedent exactingly, and because it engenders an approach that looks to law and not to personal predilection.
For that reason, Roberts’s particular personal views, which will no doubt be subject to extensive hermeneutic effort, matter far less than his judicial methodology.
Those trying to divine his personal views will likely look to his judicial service on the D.C. Circuit, often referred to as “the second-highest Court in the nation.” Three current Supreme Court Justices, Scalia, Thomas and Ginsburg, previously served on the D.C. Circuit.
One notable opinion was in Rancho Viejo v. Norton, where he would have granted rehearing to reconsider whether a panel decision was consistent with the Supreme Court’s federalism cases. In that case, a panel concluded that Congress had the constitutional authority to regulate California “arroyo toads,” deeming them within “interstate commerce.”
As Judge Roberts wrote in dissent, “[t]he panel’s approach in this case leads to the result that regulating the taking of a hapless toad that, for reasons of its own, lives its entire life in California constitutes regulating ‘Commerce . . . among the several States.’”
“[T]o be fair,” he added, “the panel [had] faithfully applied” D.C. Circuit precedent, but not Supreme Court precedent, which is why he felt en banc review appropriate.
Another opinion is Hedgepeth v. WMATA, a unanimous decision rejecting a constitutional challenge to the unfortunate arrest of a 12-year-old girl for eating a French fry in a Washington Metro station:
No one is very happy about the events that led to this litigation. . . . The district court described the policies that led to her arrest as “foolish,” and indeed the policies were changed after those responsible endured the sort of publicity reserved for adults who make young girls cry. The question before us, however, is not whether these policies were a bad idea, but whether they violated the Fourth and Fifth Amendments to the Constitution.

What is most notable about the opinion is not the result-all four judges who considered the case agreed on that-but rather the methodology whereby he arrived at that result.
As he did as a litigator, his opinion eschews his own policy preferences and instead rigorously reviews and applies the relevant legal precedents.
That’s exactly what judges should do.
Nevertheless, some activists have chosen to vilify Judge Roberts. The principal reed upon which they rely consists of fifteen words in a 1991 brief for the United States in Rust v. Sullivan: “[W]e continue to believe that Roe v. Wade was wrongly decided and should be overruled.”
Of course, Roberts was writing that brief for the administration of former President Bush, and, as deputy solicitor general he was obliged to faithfully represent the position of his client. And, he won the case, 5-4, at the Supreme Court.
As his opposing counsel, Harvard Law Professor Larry Tribe, observed, “I like [John Roberts] a lot. I even liked him when he defeated me in [Rust], 5-4.”
As an individual, John Roberts is undoubtedly a principled conservative, as is the president who appointed him. He clerked for Chief Justice Rehnquist, worked in the Reagan White House, and served as the principal deputy solicitor general in President George H.W. Bush’s Justice Department.
But, as a jurist, Judge Roberts’s approach will be that of his entire career: carefully, faithfully applying the Constitution and legal precedent.
He is a mainstream judge, respected across the ideological spectrum. Thus, he’s earned praise from liberal icons such as Harvard Law Professor Larry Tribe, and Chicago Law Professor Cass Sunstein, as well as from Clinton Solicitors General Walter Dellinger and Seth Waxman, and Carter and Clinton Counsel Lloyd Cutler, the latter two of whom both described Roberts as a man of “unquestioned integrity and fair-mindedness.”
As Professor Tribe observed Tuesday night, “[i]t is clear that in the absence of some serious objection that is not now visible . . . he is very likely to be confirmed.”
The Senate should confirm him swiftly.
-Ted Cruz is the solicitor general of Texas.

I said this right here a year ago: you aren’t getting rid of Obamaacare. It’s too late. Cruz can say he’ll come in and repeal every world. Great. Now what?

Cruz and Trump have similar talking points on this:

*”portability.” Well, no. It’s not like YOU own your policy. Your employer owns your policy. Portability is possible if you move from one state to another with the SAME EMPLOYER, but utterly impossible if you switch employers. Even if their plans are similar, the pools of insured people are different, and change the coverage. There is no way around that. So it’s disingenuous for anyone to pretend we can mandate “portability.”

*Cruz, and even Trump to some degree, talk “Health Savings Accounts.” Really? In an age where most Americans don’t have much savings at all (last I saw, a majority don’t even have $1000 in the bank), you are going to set up a system where they have to save MORE? Oh, and by the way, the main benefit they get from this is a tax benefit . . . when a majority of Americans don’t pay income taxes? No. I personally spoke with Sen. Cruz about this a year ago, and said at the very least it was a losing political issue, but I also think it just won’t work where America is now. In the 1960s? Yes. We aren’t that economy now.

*Simply repealing everything won’t put back the tens of thousands of policies now destroyed. There is no mandate that can force insurance companies to re-establish those policies, and even if you did do that, the people have CHANGED in the five years since they lost their policies. They are certainly older, many are likely sicker.

*That brings me to “pre-existing conditions.” As Heritage and many others have shown, this is akin to forcing an insurance company to cover your house after it burned down. I understand horrible diseases. I have first hand knowledge of MS. But there is no government on earth that can force an insurance company to post hoc cover someone with such a disease.

*It’s NOT so much even the medical treatment as it is the drugs. This is where someone like Trump could be a genius. Our drug policies subsidize Europe. MS meds are hundreds of dollars there, $80,000 (!!!!) for the same drug here, annually. Why? Because we pay for their socialized systems, and because they ration.

*All Rubio’s “fix” in closing the “risk corredors” did was move responsibility FURTHER to the government (i.e., further toward single payer).

Without addressing the drug issue, even “repealing” Obamacare (which now can’t happen for reasons I showed above) would itself still be meaningless-—you can get to see a doctor, but still can’t get the meds you need. Unless someone can show me how you go back to the system we had before, re-insure all the people who lost coverage, and somehow re-create the insurance companies who failed, went out of business, got out of the industry, or mergged-—which is impossible, I don’t see a plan out there. And to single out Trump is just stupid. NO ONE has an answer, including Cruz.

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