No one honestly knows what presumptive Republican presidential nominee Donald Trump will say about healthcare policy—or anything else—during the general election campaign, and no one can confidently predict what health policies he would pursue as president. It's likely that Trump himself doesn't know, given his frequent reversals on issues such as taxes, abortion, and the minimum wage.
But there's mounting speculation about how he will handle the issue of strengthening Medicare during the general election campaign and what he would do about it if elected president.
A lot of the uncertainty arises from Trump's seemingly ad hoc policy statements. During the primary campaign, the New York real estate and casino tycoon said things that led many observers to think he favored government-provided healthcare for people who are sick and needy.
But last month he released a brief seven-point health policy agenda that consisted entirely of standard GOP talking points with no bold new government initiative to take care of people without money. Moves like that have led some pundits to say Trump doesn't really care about policy and has no particular agenda except for a few key promises like building a wall along the Mexican border.
Still, Trump has been emphatic on the campaign trail that he opposes proposals by House Speaker Paul Ryan and the conservative establishment to significantly restructure Medicare, Medicaid and Social Security to sharply reduce future federal spending on those programs. “I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid,” he tweeted last May.
He has promised to make those social insurance programs financially solvent for the long term by cutting out the “tremendous waste, fraud and abuse.” Experts say that would do little to solve the problems.
Trump has assailed the proposals of Ryan, the Wisconsin Republican who has pushed through House budgets that would convert Medicare into a defined-contribution, voucher-style program and change Medicaid into a capped state block grant program. Some experts say the plan would impose significantly higher costs on seniors.
“He's so anti-Medicare, Medicaid, Social Security,” Trump said of Ryan last fall.
On Thursday, Trump announced that “I am not ready to support Speaker Ryan's agenda.”
Based on such Trump statements, many conservatives are distraught over the ascension of a Republican presidential nominee who has repeatedly rejected one of their party's top domestic policy priorities. An op-ed column in the Wall Street Journal in February carried the mournful headline “A farewell to entitlement reform.”
But there is sharp debate over whether a President Trump would remain faithful to his campaign statements up to now and reject Ryan-style restructuring and spending cuts in those programs, especially with Ryan and his like-minded fellow Republicans in control of Congress.
Observers agree that the politically savvy Trump almost surely won't say anything during the campaign about entitlement reform, which likely Democratic nominee Hillary Clinton would use as powerful ammunition against him with older voters. That's very different from other GOP presidential candidates such as Sen. Marco Rubio, former Gov. Jeb Bush, and Gov. Chris Christie, who explicitly favored big Medicare changes.
“Trump needs a very large portion of the over-60 vote, and he's not going to go near any change in Social Security or Medicare,” said Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “He has said one of the reasons Mitt Romney lost in 2012 is because he took up Ryan's proposal. He'll say flat out that the Ryan plan isn't where he's going.”
The main disagreement among political observers is over what Trump would do after moving into the White House. The next president will face a growing federal budget deficit, which could be worsened by a recession, said Chris Edwards, an economist and budget expert at the libertarian Cato Institute, which favors Ryan-style changes in Medicare and Social Security. That will create great pressure to reform entitlements, he added.
“Trump is a dealmaker,” Edwards said. “He might have promised not to cut benefits. But he's clearly the type of person whose opinions change all the time. I don't think what he has said so far would have much bearing on what he would do as president. I think he would agree to what Ryan shepherds through Congress.”
A President Trump wouldn't say he's cutting Medicare, Edwards predicted. Instead, he'd say he's changing the structure of the benefits, and that people could stay in the current system or voluntarily move to the new program.
Adding to the pressure to cut spending on Medicare, Medicaid, and Social Security would be Trump's proposed tax cuts. His tax package released last year would cost a whopping $9.5 trillion over the first decade and $15 trillion over the second decade, according to the nonpartisan Tax Policy Center.
If Trump followed through on his tax plan, he would have to slash spending enormously on the social insurance programs, since they account for nearly half of all federal spending. “He's not going to get a tax cut anywhere near that big,” Edwards said. “But I think he would still have a tax cut, and that would increase pressure on Congress to control entitlement spending growth.”
Blendon disagrees. At most, he thinks a President Trump would agree to a more limited compromise plan to reduce Medicare spending, along the lines of budget deals during the Obama administration. On the other hand, he would devote substantial effort to replacing the Affordable Care Act, which has weaker popular support than Medicare, Blendon predicted.
“It's so clear in every statement he makes that he's not going to do anything to the future of Medicare and Social Security,” Blendon said. “The Ryan plan was never popular with anyone except House conservatives.” But, he cautions, “nobody's been accurate at predicting what Trump would do or say.”
Jonathan Oberlander, a health policy and management professor at the University of North Carolina who studies Medicare and healthcare reform policy, isn't sure what Republicans would do about Medicare if they controlled the White House and Congress. “After the election all bets are off,” he said in an interview several months ago. “Conservatives see entitlement reform as essential to deficit reduction, while others would worry and say, 'We just got in. Do we want to set the Democrats up to accuse us of killing off seniors?' ”
Whether Trump raises the issue of entitlement reform or not during the coming campaign, Democrats, particularly congressional candidates, are sure to issue dire warnings to seniors about the threat to their beloved Medicare and Social Security. And Republicans are likely to push back and accuse their opponents of running a “Mediscare” campaign, which is what has occurred in many elections over the past 20 years.
“If I were a Democrat running for Congress, I would try to make the election about the Ryan plan,” Blendon said. "That's why Trump will say nothing will change."