On the campaign trail, Donald Trump has repeatedly promised to repeal and replace Obamacare with something "terrific." But the details he has generally provided have been vague and contradictory.
Last week, however, Trump finally released his health care replacement plan. It is not terrific. It is not really a plan at all. Instead, it is a bunch of words somewhat related to health policy that his campaign is calling a plan. Those words demonstrate not only that Trump does not understand health care policy, but that he cannot be bothered to hire anyone who does to work with him. Even more than that, Trump's willful ignorance on this issue and others on suggests that his entire campaign is rooted in near-total disregard for expertise.
Let's start with the plan. It has a number of provisions, including: allowing for the full deduction of individual health plans on tax returns, block granting Medicaid, requiring price transparency from all health care organizations, legalizing the re-importation of prescription drugs from other countries, allowing for tax-free contributions to Health Savings Accounts (HSAs), and allowing individuals to purchase health care across state lines.
Not all of these provisions are objectionable. In particular, there is a good case to be made for block-granting Medicaid, which is currently split between states and the federal government in a way that encourages overspending. But in no way does this grab bag of provisions constitute a coherent plan or system. There is no unifying theory behind these ideas, no policy framework to connect them. Calling this a "plan" is like finding a pantry cabinet that happens to have some yeast and flower in it and calling it bread.
Even that may be too generous, however, for the plan also demonstrates that Trump does not understand the ingredients he is working with.
His call to allow for the purchase of health insurance across state lines, for example, was predictable enough, given that removing the "lines around the states" was the only idea he could remember when asked at debate last month how he would replace Obamacare.
During the debate, it wasn't clear that Trump understood what he was proposing: He repeated his promise to eliminate "lines around the states" several times, but never offered any clear rationale for why you would want to remove legal barriers to purchasing state. It was as if that catch phrase was the only part of the talking point he could remember.
His plan confirms that he does not understand the purpose of the idea. The reason why you would want to allow interstate purchase of health insurance is that it would allow people in states where large numbers of insurance mandates have driven up the cost of coverage to purchase care from states where insurance is less subject to fewer mandates, and thus less expensive. So it is more than a little bit odd that his plan says that "as long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state." Trump's plan manages to specifically negate the intended benefit of the provision he is proposing.
TrumpCare's HSA provision is also worth singling out. The plan would "allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate," and would be able to be passed on tax-free as part of an estate, and used by any family member.
What makes this provision so strange is that HSAs that work exactly like this already exist. As Ryan Ellis notes at Forbes, they have existed since 2003, and more than 20 million Americans already use them.
Trump's plan makes no mention of this, and seems unaware that this provision has been law for more than a decade. It is less a health care plan than an admission of ignorance on the topic of health care policy.
At this point however, it is not really news that Trump is clueless when it comes to health policy. Trump has never demonstrated even the smallest iota of interest in in the underlying details of policy on this or any other issue. To the extent that he has provided any, they have been incoherent or contradictory: In interviews and speeches, he has praised single-payer health care and promised universal coverage paid for by the government, but also said that his Obamacare replacement will rely on competition and private plans. It is nonsense policy.
What this plan really demonstrates, then, is that his disdain for details extends beyond his personal ignorance and encompasses his entire campaign organization.
Trump apparently could not even be bothered to consult with someone who had a modicum of knowledge about health care policy. As Michael Cannon, a health policy scholar at the Cato Institute, wrote recently at Forbes, Trump's plan looks like it was put together by "a campaign operative copying and pasting a bunch of stuff from the around the web, without knowing what it means or even realizing that he's describing current law." No one seems to know who is advising Trump on health policy, and his campaign has refused to name any advisors—which, in combination with his plan and his statements on the trail, strongly suggests that no one is advising him. Trump is totally winging it.
And in the process, Trump is strongly signaling that he would govern the same way. When pressed for details about the vagueness of his plans, Trump often likes to say that he would rely on the advice of experts, putting them in a room and forcing them to come up with something that works. Conservative health wonks think his plan is absurd. Trump's half-baked health care plan makes it clear that he couldn't even be bothered to do that. No experts were locked in a room to create this plan. There is no evidence that any expertise was involved at all.
This utter disregard for expertise has visible throughout Trump's entire presidential run. His campaign has been promising for months to release the names of his foreign policy advisers in short order. The release is always said to be just a few days or weeks away. Sometimes Trump suggests that a team is already in place. But so far, the names of the advisers have not been released. Indeed, 117 Republican foreign policy experts just signed a harshly critical letter denouncing Trump as wildly inconsistent, fundamentally dishonest, and a danger to the Constitution. This is unusual even amongst populist outsider candidates. Ben Carson, whose grasp on policy detail was decidedly weak, made a token effort to seek out some policy expertise, though it didn't necessarily take.
Trump, then, is not just ignorant on policy details. He is willfully ignorant. It's not just that he doesn't know what he's talking about. It's that he's avoided finding out.
He has cut off himself and his entire campaign from any basic facts or understanding of what governance involves or how it works. And the consequences of this decision are evident throughout his campaign, whether in his ludicrous promises to make Mexico pay for the construction of a southern border wall or in his insistence can cut $300 billion from $78 billion in government spending. He has not just cut himself off from the particulars of policy, but from reality itself.