ASHINGTON — The rise of Donald Trump has been disappointing for establishment Republicans — and downright excruciating for conservatives involved in health care policy.
Even after the release of his health care plan Wednesday, Trump strikes many of them as barely familiar with the most basic conservative health care ideas in their life’s work. In interviews, some of the most influential Republican experts on the issue told STAT they’re dismayed by what they consider the GOP front-runner’s lack of understanding of health care, his inconsistent statements about what he really believes, and his embrace of populist ideas for lowering drug prices that are straight out of the Democratic playbook.
It’s not in most policy experts’ nature to lash out or lob colorful insults at a presidential candidate, the way politicians and operatives do. But thanks to Trump, these are not ordinary times.
Take Pete Wehner, one of the leading authors of conservative “reform” ideas for 2016. If Trump becomes the nominee, Wehner won’t lift a finger to help him. Wehner said he hates Trump and thinks his command of policy is “less than a centimeter deep.”
He hopes that Republican health care policy experts who know the issues, and can get Trump up to speed, will offer their help. Specifically, he hopes that someone like James Capretta, one of his colleagues at the Ethics and Public Policy Center, a conservative think tank, will help Trump if he gets the nomination.
But Capretta, one of the main authors of a detailed Republican plan for replacing Obamacare, is already shooting down the idea of helping Trump in any way.
“Under no circumstances. Will not happen,” he said. Trump, he said, is a “buffoon” who shows no understanding of health care and is “totally unfit to be running, much less winning.”
For Republican health care policy experts who have spent the last four years preparing for a change in administration — drawing up detailed plans to replace Obamacare, encourage medical innovation, and lower drug prices through greater competition — Trump’s rise has been agonizing to watch.
The entire Republican Party establishment is going through a crisis over Trump, but the party’s leading health care experts have their own reasons for despair, as they see a crucial opportunity to challenge Democrats on health care slip out of reach.
“Sometimes if you just close your eyes and you hear a quote, you might wonder which party you were talking to,” said Paul Howard, director of health policy at the Manhattan Institute, noting that Trump mixes standard Republican ideas on Obamacare repeal with more traditionally Democratic ideas on drug prices. “I think it really makes you want to scratch your head and possibly bounce it off a table once or twice.”
The Trump campaign did not respond to requests for comment.
Trump’s release of a health care plan Wednesday was supposed to allay at least some Republican fears by explaining how he would replace Obamacare — since he has promised to repeal it — and how he would tackle other pressing issues, like rising drug prices and the cost of other health care services.
Instead, it has opened him up to more criticisms — especially since his plan included a new proposal to import cheaper drugs from other countries, an idea ripped from the pages of the Hillary Clinton and Bernie Sanders plans to reduce drug prices. Trump has previously endorsed another Democratic idea — letting Medicare negotiate drug prices — though his plan this week made no mention of it.
Capretta said Trump’s plan is “basically without substance,” and that the drug reimportation idea seemed to be little more than “his nod to do something on drug pricing without including the Medicare negotiations, for some reason.”
Dr. Scott Gottlieb of the American Enterprise Institute, who worked at the Food and Drug Administration and the Centers for Medicare and Medicaid Services under President George W. Bush, said the drug reimportation idea “really wouldn’t save money.”
Gottlieb said he worked on a regulatory plan for the FDA in 2004, when it looked like the proposal might pass Congress, and found that after adding in the costs of inspecting for counterfeit drugs and repackaging them in English, “they wouldn’t be much cheaper than drugs sold inside our closed American system.”
And Avik Roy, a Republican health care expert who also has worked on Obamacare replacement plans, wrote in Forbes that Trump’s health care plan “has the look and feel of something that a 22-year-old congressional staffer would write for a backbencher based on a cursory review of Wikipedia.”
Not all of the feedback on Trump’s health care plan was bad. Jeffrey Anderson of the Hudson Institute, who developed an Obamacare alternative for a group called the 2017 Project, said Trump and his advisers should get credit for putting out a plan — and that it puts him ahead of rivals Marco Rubio and Ted Cruz, who have been vague in their own ways.
He just doesn’t like what they put out.
“I think it’s a bunch of goodies, and it’s a bad plan,” he said, because it includes an expensive tax break for individuals’ health insurance costs and likely would end up with more people in Medicaid.
Before the release of the plan, Trump’s lack of detail on health care was becoming a liability in the campaign. At last week’s CNN/Telemundo debate, Rubio heckled Trump as he tried to explain how his plan would let health insurers sell coverage across state lines. It’s a standard GOP idea that’s widely used in Obamacare alternatives, but when Trump talked about it, it came out as “get rid of the lines around the states.”
“So, your only thing is to get rid of the lines around the states. What else is part of your health care plan? … That’s your only plan?” Rubio asked.
Others cringed as they heard Trump talk on the campaign trail about how Medicare could save $300 billion a year if it negotiated drug prices.
“It’s more than the entire government pays” for Medicare prescription drug coverage, said the Manhattan Institute’s Howard. Gail Wilensky, who ran the Medicare program under the first President George Bush, said Trump’s estimate was “just silly.”
The drug reimportation plan, at least, doesn’t come with questionable savings estimates. But Howard said the FDA could never guarantee the safety of the drugs. Worse yet, he said, it could discourage medical innovation because “you’re effectively trying to break the innovators’ patents” that guarantee a certain price in the United States.
It would only be good for one thing, in Howard’s view: allowing Trump to “neutralize” Clinton on drug prices in the fall if she’s the Democratic nominee. “Hillary Clinton will say, ‘Drug prices are too high.’ And he’ll say, ‘I agree. Let’s have drug reimportation,'” Howard said.
Some of these experts are nervous about what Trump’s inconsistent policy chops could mean for health care if he actually wins the White House. They’re worried that he might approach it like he would any business transaction: just get a bunch of people in a room and cut a deal.
“Who knows? Maybe he’ll just sit down with Harry Reid and Nancy Pelosi and try to cut some kind of deal without any particular orientation to it,” said Ramesh Ponnuru, another prominent “reform conservative” who worked on the Republican health agenda released in December.
If Trump wins the presidency, Capretta worries that he won’t put enough thought into health care to make good on Republican promises to replace Obamacare: “He would talk big, find out that it’s all more complicated than he thought, and then he’d make some marginal changes and claim victory.”
Other Republican health care experts predict that Trump will build out his health care plans if he’s the nominee, because he’ll bring in more advisers to help with a fall campaign. But the ones who have spent the most time on detailed policies, like Obamacare replacement plans, say they’re concerned because they don’t know anyone in mainstream GOP health policy circles who has actually been working with Trump.
Trump’s chief policy adviser is Sam Clovis, a former economics professor and radio talk show host from Iowa who ran for the US Senate in 2014. By contrast, Rubio has brought in one of the leading GOP health care policy experts, Lanhee Chen of Stanford University, who served as Mitt Romney’s policy director during the 2012 presidential campaign.
And Clinton has surrounded herself with well-known policy advisers, including Ann O’Leary, an early childhood education expert and former Senate aide who leads her health care work.
Still, Howard said it’s clear that Trump is trying to run as a populist, not a free-market conservative — so Republicans shouldn’t be surprised if his health care plan doesn’t satisfy all of their concerns.
“I don’t think he’s trying to be that candidate. I think he’s trying to be the populist candidate,” Howard said.