GOP preview: major differences on Medicare

Presumptive GOP presidential nominee Donald Trump is nothing like the party's previous nominees, so it isn't surprising that the GOP health policy platform only days ahead of the convention remains largely unknown—very unlike 2012 or 2008.

Health policy experts say there is even considerable uncertainty about who will drive the health platform at the Republican National Convention in Cleveland starting July 18. Normally, the nominee's campaign staffers work with congressional committee staff, conservative policy experts and key lobbying groups to draft the health and other policy planks on which the nominee and congressional candidates will run.

But this time around, experts at conservative think tanks and lobbying groups say they have not been asked to participate by either the Trump campaign or the Republican National Committee. They've been kept in the dark about how the platform will be written.

That's at least partly because those traditionally Republican-aligned players are not necessarily in sync with Trump and his stated views, including his repeated rejection of cuts in Medicare and Medicaid. Some business groups and lobbyists are opting out of the convention entirely.

“Given that it's Trump, the professionals probably don't line up very well with where Trump comes out,” said Joe Antos, a health policy expert at the conservative-leaning American Enterprise Institute. “It's really a mystery this year.”

“I don't know who will have influence,” said Chip Kahn, CEO of the Federation of American Hospitals, which canceled a planned health policy seminar at the Republican convention for lack of news media interest. “Like everything with Trump, it's all new and different.”

The big question is whether the presumptive nominee and his campaign will embrace, as the basis for the platform, all or part of the comprehensive health policy white paper released last month by House Speaker Paul Ryan and other top House Republican leaders to repeal and replace the Affordable Care Act. That 35-page document includes controversial proposals to cap and cut spending on Medicare and Medicaid and tax employer health benefits.

The Trump campaign's vague seven-point health policy agenda released in March contains concepts similar to the House GOP proposal. It backs turning Medicaid into a state block grant program, but does not address Medicare or taxing employer plans.

Conservative health policy experts hope the GOP platform will include the House Republican ideas as its centerpiece, though probably with less specific language. The House plan articulates long-standing conservative policy principles and formed the heart of the 2012 Republican health platform. That year's document proposed without detail to “save Medicare by modernizing it, by empowering its participants, and by putting it on a secure financial footing.”

“It's pretty clear that (the House GOP) plan will become the primary plan for conservatives and Republicans going forward because it deals with the health reform challenge in a way that's realistic and practical,” said James Capretta, a conservative health policy expert at the Ethics & Public Policy Center who has been sharply critical of Trump.

But unlike in 2012, when Republican nominee Mitt Romney openly advocated turning the politically popular Medicare program into a defined-contribution or “pre-mium support” benefit, many observers expect Trump to keep any reference to that proposal out of the party platform and to avoid discussing the issue. It's expected, however, that Democrats will launch their traditional attacks accusing Republicans of promoting “vouchers” and wanting to “end Medicare as we know it.”

During the primaries, Trump repeatedly criticized Ryan's past efforts to restructure and cut Medicare and Medicaid, and blamed Ryan's proposals for Romney's 2012 election loss. “That was the end of that campaign, by the way, when they chose Ryan,” Trump said in February. “I said, 'You've got to be kidding because he represented cutting entitlements, etc., etc.' The only one that's not going to cut is me.”

Kahn said there may be a GOP platform battle over Medicare. “If you look at what Trump has on his website and at the Ryan proposal, there's a lot of common ground and they can probably work something out,” said Kahn, who served for many years as a senior Republican congressional staffer. “The big difference is Medicare, where there's a different vision between House leadership and Trump.”

Kahn added that the final shape of the platform statement about Medicare could signal what to expect in a Trump presidency. “Whether the platform reflects more the current Trump position or the House leadership plan could be an important sign regarding Medicare,” he said.

But another veteran political observer predicted Trump will strenuously distance himself from Ryan's Medicare premium support plan during the campaign. “It's incredibly controversial among people who could vote Republican,” said Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. And it would be “very difficult for Trump to change his mind given that he made such an issue of opposing Ryan's proposal.”

“They couldn't possibly talk about Medicare premium support at the convention, which is a solid middle-class benefit that everyone's mother has,” Antos said. “It's much easier to talk about Medicaid, which they think is for people who won't vote for them anyway.”

The Trump campaign, the RNC, and the office of Sen. John Barrasso (R-Wyo.), who heads the platform committee, did not respond to requests for comment for this article.

Still, it's not clear whether health policy will receive much attention at the convention or as a Republican campaign issue, unlike in 2012, when Romney and congressional Republicans campaigned hard on repealing Obamacare. That was before the ACA's coverage expansions took effect in 2014. Now, there is greater caution about angering the estimated 20 million Americans who have gained coverage under the law. Indeed, Sen. Lamar Alexander (R-Tenn.), chairman of the Senate Health, Education, Labor and Pensions Committee, recently told Politico he was open to a deal with Democrats to fix Obamacare's problems.

“Healthcare may or may not be an issue at the convention,” said Kevin Kuhlman, legislative affairs director at the National Federation of Independent Business, an influential Republican-leaning lobbying group that plans to offer input on the GOP health platform. “But healthcare affordability will certainly by an issue by November, as open enrollment begins and folks see the headlines and premium requests.”

Like other employer groups, the NFIB has reservations about the House leadership proposal to limit the tax exclusion for employer health plans. While the GOP white paper says that “most Americans' plans would not be affected,” some experts question that. That's because Republicans, after repealing all Obamacare taxes, would need a large new revenue source to finance their proposed refundable tax credits to help people without employer coverage buy insurance. “We definitely want more details on the limits to the tax exclusion they propose,” Kuhlman said.

In 2012, the GOP platform finessed the tax exclusion issue by proposing without detail to “equalize the tax treatment of group and individual health insurance plans.”

Any GOP plan to tax health benefits “will be a little tough to sell” given congressional Republicans' harsh criticism of the ACA's Cadillac plan tax on higher-value employer health plans, which led to a two-year delay in the levy, said Norm Ornstein, a veteran political analyst at the American Enterprise Institute for Public Policy Research. “It will not be well-received by a lot of employers or employees.”

Healthcare industry leaders overwhelmingly back the Affordable Care Act and support its goal of pushing providers away from fee-for-service medicine and toward delivering value-based care, according to a recent Modern Healthcare survey of healthcare CEOs. More than two-thirds of the CEOs surveyed said they opposed repealing and replacing the ACA.

In line with that, Kahn said he and his investor-owned hospital members will be talking to the Trump campaign and Republican leaders about preserving the ACA's insurance expansions and moving toward universal coverage. But if Republicans are determined to roll back coverage, his group's priority will be making sure the ACA's Medicare and Medicaid payment cuts, which were premised on a reduction in uncompensated care, are repealed as well.

“If Republicans do something that gets us to that kind of coverage, that's fine,” he said. “If not, you have to roll back the (payment) reductions.”

Antos doesn't expect much detailed health policy discussion at the convention because the Republicans will have their hands full with broader political problems, though that may change by August. In Cleveland, he said, “someone on Trump's team will have to negotiate some kind of compromise” between what Trump wants and the House Republican proposal. “Whatever they work out might be the shortest platform statement ever written.”