When he introduced the 2020 federal budget President Trump re-emphasized his intention to repeal the Affordable Care Act, known more popularly to most of us as ‘Obamacare’.

Perhaps that is the issue! Trump and Obamacare!

The Affordable Care Act is irrevocably associated with the Democratic Party and ex-President Obama in particular.  Most citizens benefit from it one way or another.

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Since the swing to the Democratic Party at the Mid-Term elections in 2018 President Trump has been remarkably quiet on his plans for replacing Obamacare if he is granted a second term by the American public.  Indeed, he has made it clear that there will be no new legislation until at least 2021.

In the meantime, he will be watching the polls and judging the voters’ intentions as the Democrat candidates put their healthcare policies ‘on display’.

Nobody claims the Affordable Care Act is perfect.  All agree it can be improved.  At the 2018 mid-term elections more than half the voters claimed that healthcare was the major factor in their voting decision.  That is why it stays at the top of the political agenda. After all, our spending on healthcare accounts for nearly 20% of the way in which we spend the country’s income (Gross Domestic Product).

Donald Trump intends to repeal the ACA, though not all republicans in either Congress or the Senate agree. Given the age spectrum of the party, this is hardly surprising, but there remains a hard core on the right wing of the Republican Party which vehemently opposes Medicaid and its potentially unlimited call on federal funding.

By repealing the Act and by replacing it with a ‘block grant’, whereby individual states will run their own healthcare programs, President Trump hopes to reduce the overall cost of the nation’s healthcare.  In effect, Trump will put a cap on federal spending and put the onus on each state to meet the cost of Medicaid from state taxes.  It is proposed that the ‘block grant’ will rise annually in line with inflation.  Historically, medical and care costs rise faster than inflation so the value of the ‘block grant’ will decrease over time.  Proponents of the ‘block grant’ approach claim that the states can make savings by running the programs more efficiently.

This may be true but there are limits to savings from increased efficiency and inflation is inevitable.  The outcome is, necessarily, reduction in benefits or in enrollment.

The Affordable Care Act mandates that insurers must cover a specified range of essential health benefits (many of them preventative) including maternity care.  Another key element of the Act is the requirement for insurers to accept consumers with pre-existing conditions at no extra cost.  There are proposals (largely driven by the right-wing of the party) to remove these conditions to enable insurers to offer lower-cost health plans.

The projected saving over the next ten years is $774 million. This includes reducing access to Medicaid and eliminating the subsidies for low-income groups, which enable them to self-insure (Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana. Report Fall 2017).

There is no indication as to how this ‘saving’ will be allocated (tax reductions – for whom? Alternative federal projects?) nor how those who cannot afford insurance now will be able to do so in the future.

There are signs that Trump might be prepared to keep the subsidies (generally associated with medication and prescription drugs) and allow income-related tax relief.

Trump has, in the past, been critical of pharmaceutical companies making excessive profits but this a relatively straightforward way of reducing the nation’s healthcare bill. Whether this bill is federal, state or individual it faces huge corporate resistance and no longer seems to figure in his rhetoric.

Healthcare was a key factor in the 2018 mid -term elections and, judging by the polls, it will be again in the 2020 presidential campaigns. 

Of his rivals Bernie Sanders occupies the most extreme position. ‘Medicare for all’, an easy slogan for a program which it is hard to cost, and taken to extremes impossible (for a single payer, the federal government) to pay for.  It would be an easy target for Republicans of all shades!

Read more: Bernie Sander Medicare for all explained

Emerging as the front running idea is the Democrats’ plan to introduce a federally/publicly run Health Insurance option to compete with the privately-run health insurers.  It is a concept finding favor with a growing number of voters both left and right of center.

We can wait till later in the year for Trump to run his flag up the mast!

It will need majorities in both houses for one party or the other to progress their ambitions for the health of the nation.