Trump’s historic opportunity to make Americans healthy again

After years of crushing inflation, “woke” priorities and bureaucratic overregulation, Donald Trump and the Republican Party achieved a resounding victory in November. Part of that victory was built upon his promise to challenge the status quo in our healthcare system and to “make America healthy again.” The first step? Ending patient-last policies in Medicare, Medicaid, drug pricing and health insurance that prioritize the health of the healthcare system over the health of patients, driving up the cost of care at the expense of patients and taxpayers. 

Healthcare is the only market where customers discover the price after consuming a good or service, and these surprising costs are contributing to crushing medical debt. It doesn’t have to be this way. The first Trump administration instituted sweeping changes for patients to protect their right to know their healthcare prices, but the Biden administration caved to big DC interests and hasn’t properly enforced them. This has allowed patient-last practices to flourish; for example, the price of a routine colonoscopy in Wisconsin varies from $88 to $1,940, but a patient doesn’t find out what they’re paying until after the procedure is done and is unable to find the right provider at the right price. It’s not just patients who don’t know the price ahead of time — the employers and unions writing the check for the care are often blocked from getting an itemized receipt of the drugs and treatments that they paid for, which keeps them from being able to negotiate down the costs. Policymakers should ensure that these price transparency rules are enforced and made permanent, making it easier and cheaper to get healthy. 

It’s not just the lack of price transparency that hurts patients. Legal loopholes require seniors to pay more than twice as much at outpatient clinics owned by hospital systems than independently owned physician offices for the same services. There is no good reason for this policy; just armies of DC lobbyists advocating for big hospital systems to get paid more than small doctors’ offices. In 2020, Trump called for equalizing these payments between independent and hospital-owned outpatient facilities, as it could save seniors $94 billion in lower cost-sharing and premiums and taxpayers $141 billion from the Medicare trust fund. Even worse, without a change, this continues an enormous incentive for large hospital chains to absorb outpatient practices to generate higher payments from Medicare. These higher costs prevent seniors, often on fixed incomes, from getting healthier — making it harder to afford medicine, healthy groceries and other critical goods.  

Even if patients realize they could pay less at a small doctor’s practice, the Biden administration’s patient-last policies force seniors to get certain common procedures, like hip replacements, at a hospital rather than an outpatient clinic, like an ambulatory surgical center, or ASC. These clinics can do the same treatments, at the same quality, at 58 percent of the cost as hospital-based facilities — and have to operate under significant safety standards. In his first term, President Trump recognized how these clinics could save seniors money and improve their health, and changed the “inpatient only list” to allow seniors to get care for more than 1,700 surgical procedures at ASCs, as well as hospitals. Reforming this list, as the Trump administration tried to do, will allow seniors to benefit from ASCs delivering more affordable, high-quality care. 

Seniors should be able to trust that the Medicare program, including Medicare Advantage, or MA, is making them healthier. Policymakers can consider changes to ensure that MA can do what it promised seniors it would do — improve the health of the seniors in their plan while reducing the costs. Instituting changes in how these plans are designed, like requirements for these plans to compete on premium costs and quality, could focus these plans on what they were supposed to do while driving down costs for patients, taxpayers, and the federal government.  

 It’s not just seniors — it’s also the disabled and the truly needy in the Medicaid program. The Democrats created a patients-last loophole in the Patient Protection and Affordable Care Act, or ACA, where the federal government pays 90 percent of the states’ cost of care for able-bodied adults but only 50–78 percent for poor children, their pregnant mothers and disabled people. This means that the state has less incentive to care about the most vulnerable in the system, letting them get sicker or languishing on waiting lists for care. Instead, Democrat states enroll able-bodied adults and use other legal patient-last policies for political gain but ignore the health of the most needy in the program. With the help of the Biden administration, these states ignore the rules and enroll illegal immigrants, those with health insurance through work, and others who shouldn’t be in the program. These fraudulent and erroneous payments are estimated to cost taxpayers roughly $404 billion between 2019 and 2024 — a huge amount of money that could be used to improve the healthcare of the most complex, vulnerable patients in America. On top of that, just by simply removing the incentive to ignore the pregnant mother, poor child or the disabled, policymakers could save $631 billion over the next decade and shift it to the needs of the most complex, vulnerable patients, like giving each one of these patients a subscription to an on-call, primary care doctor. 

A symptom of this patient-last policy is that, despite massive injections of cash, the truly needy and disabled have to wait for care because the system is overcrowded. The first step to ensure that Medicaid is protected for those whose health is most at risk could be requiring that non-disabled adults can only get Medicaid if they’re volunteering, working, looking for work or enrolled in workforce training programs and can’t get Medicaid through work — protecting the promise to prioritize the nation’s most vulnerable. Another way is through block granting parts or all of Medicaid, which would end the budget gimmicks that incentivize states such as California to enroll illegal immigrants. States should be incentivized to focus on maximizing health and reducing costly chronic conditions, not gaming the system, maximizing federal revenues, and following onerous top-down processes.  
 
These patient-last policies exist in our drug pricing system, too, giving Americans access to life-saving treatments but at exorbitant costs. Americans pay to develop the drug but then pay 4.22 times higher prices than other rich countries for the same brand-name drugs. Similar to how other countries underinvest in military spending and rely on the United States to pay for global security, these countries also underpay for drug development and refuse to pay market price for the drug. This dynamic weakens the negotiating power of drug companies because other countries know that they can charge high prices in the United States. As a result, up to 78 percent of global pharmaceutical profits were generated from American patients in 2016. We can end America’s global giveaway by incentivizing pharmaceutical companies to negotiate higher prices in other countries, requiring that whatever price they negotiate abroad will be the same price that seniors on Medicare will use to purchase the same brand-name drug, giving our drug companies the leverage needed abroad while protecting patients’ health in the United States.  

These high drug costs contributed to 6 million seniors not buying their medicine in 2022 because the costs were too high. If a patient can’t get their medication, they often become sicker and can end up in the hospital. The consequences stack up: poorer health, increasing costs for seniors, worse quality of life and higher costs to the Medicare program. Policymakers could consider patient-first reforms, which allow plans to target the elimination of copays for certain critical drugs, which defray these higher costs and prevent worsening health.  

Patient-last policies contribute to why Medicare Part D plans can cover some drugs and not others, keeping things more expensive for patients for the benefit of others. Medicare’s outpatient care program, Part B, pays facilities that administer drugs to patients by calculating the average sales price plus 6 percent of the cost of the drug, incentivizing bad actors to administer more expensive medications to patients and for drug makers to make drugs for Part B and not Part D. Drug costs in Part B increased for each senior, on average, by 9.2 percent each year between 2008 and 2021, compared to the 2.6 percent increase in Part D. Simply letting seniors use their Part D plan to pay for these drugs could allow them to get the same drugs at a lower cost, in expanded locations, with greater benefit to their health.  

Generics account for 90 percent of all prescriptions and are a great option for lowering prices while increasing health outcomes. However, these generics are often blocked by patient-last policies, which allow drug companies to inappropriately block competition from generics and engage in costly patent litigation. Ending these practices will bring more competition for better products, lower prices, and improve patient outcomes.

Policymakers should also close patient-last loopholes in drug pricing, which lets middlemen make money by pushing patients to more expensive drugs. One solution could be to require pharmacy benefit managers, or PBMs, to abide by the same fiduciary duty as the health plan they work for. In a recent lawsuit, patients who worked for Johnson & Johnson found out their PBM negotiated the cost of their drugs so poorly that the employees paid over $10,000 for a ninety-day supply of a drug that cost $28 if they paid cash at a local pharmacy. Under a fiduciary duty, the PBM would be accountable for the costs they negotiate for patients instead of making themselves more money at the expense of the health of the patient.  

The ACA is full of patient-last policies that do nothing other than protect health in name only. Subsidies, which are given to insurance companies, have to be used by patients to purchase ACA plans that might not work for them. Policymakers should allow patients to use the subsidies on any insurance plan authorized by their state’s insurance commissioner, depositing the subsidy in a portable account like a health savings account. This can be done with safeguards, protecting the funds from being used fraudulently or using taxpayer dollars on abortion. Patients could purchase plans like Farm Bureau plans, which can cost 50 percent less than ACA plans, or short-term plans that cost up to 60 percent less than ACA plans — all of which improve health and allow patients to get the care they need at the cost they can afford.  

Lastly, policymakers should end patient-last policies that drive up costs and hurt children’s health by instituting a ban on federal funding for gender transition services for children and blocking doctors and hospitals who participate in Medicare from providing gender transition treatments to children.  
 
Voters gave Trump and Congress a historic mandate to make Americans healthy again. They can uphold this responsibility by instituting changes through regulations, new laws, or a reconciliation bill to put patients first and empower them with more control over their health and healthcare coverage.