Robert Farley, Lori Robertson and D'Angelo Gore

FactCheck.org

EDITOR'S NOTE: With the Nov. 6 midterms just weeks away, President Donald Trump has hammered on a campaign trail theme in which he has painted Democrats' health care policies as "socialist" and has suggested their plans could put health coverage for senior citizens at risk.

Many of Trump’s arguments relitigate the visceral debate that played out for months before Congress approved Obamacare in 2010. But in a USA TODAY op-ed published on Wednesday, Trump also focused heavily on a proposal to broaden health care coverage through a "Medicare for All" program.

An examination of the president's claims by FactCheck.org, a partner of USA TODAY, showed several instances where he misrepresented the facts and made misleading statements about Medicare and health insurance in general.

Op-ed from President Trump:Democrats 'Medicare for All' plan will demolish promises to seniors

Here are the findings from FactCheck.org:

The president claimed that the Medicare for All Act, one of several Democratic-sponsored health insurance bills, would “cost an astonishing $32.6 trillion during its first 10 years.” That’s an estimate of the cost to the federal government, but that ignores the offsetting savings in health care costs for individuals, employers and state governments.

federal government, but that ignores the offsetting savings in health care costs for individuals, Trump wrote that the Medicare for All Act would “take away benefits” from seniors. The plan calls for adding new benefits to Medicare coverage, including dental, vision and hearing aids, and eliminating deductibles.

The president overstates the consensus when he says “we have seen Democrats across the country uniting around” the Medicare for All Act. There are competing bills that would expand insurance coverage by increasing access to Medicare or Medicaid.

Trump claimed he kept his campaign promise to “protect coverage for patients with pre-existing conditions.” But the administration supports a lawsuit that it says would lead to the elimination of the Affordable Care Act’s pre-existing condition protections.

The president also said he has kept his promise to “create new health insurance options” to lower premiums, “and we are now seeing health insurance premiums coming down.” But not all premiums are “coming down.”

Trump wrote his op-ed under the headline “Democrats ‘Medicare for All’ plan will demolish promises to seniors.” And, as the headline implies, the piece is largely about the Medicare for All Act, introduced by Sen. Bernie Sanders on Sept. 13, 2017.

But it also makes sweeping, unsupported attacks on the “radical socialist plans of the Democrats.” The president falsely claims, for example, that Democrats support “open borders” and says, without evidence, that the Democrats “will seek to slash budgets” for Medicare and Social Security.

The cost of Medicare for All

Trump starts his op-ed with the claim that Medicare for All would “cost an astonishing $32.6 trillion during its first 10 years.” That’s one estimate of the cost to the federal government. But that doesn’t take into account the offsetting savings in health care costs for others.

Under the plan, as the expense of health care shifts entirely to the federal government, people, employers and state governments would pay less for health care. So the cost to the federal government might be $32 trillion, but the overall health expenditures would not increase by that amount. And supporters maintain it would result in overall net savings.

Trump, Oct. 10: Dishonestly called “Medicare for All,” the Democratic proposal would establish a government-run, single-payer health care system that eliminates all private and employer-based health care plans and would cost an astonishing $32.6 trillion during its first 10 years.

Trump is referencing an analysis by the Mercatus Center at George Mason University of the Medicare for All Act, as introduced by Sanders. The paper concluded the bill would cost the federal government an additional $32.6 trillion over its first 10 years of full implementation.

That the federal government would pay more under Medicare for All is a given. The government would absorb all of the cost of health care. But that also would mean people would no longer have to pay for private health insurance, or foot the bill for co-pays, deductibles and other costs from employer plans.

So proponents of Medicare for All argue that the increase or decrease in overall health care expenditures is the true “cost” of the plan.

What the Mercatus paper says about the bill’s effect on overall health expenditures has been the center of intense political debate. Sanders claimed the study from the Mercatus Center – which gets some of its funding from the libertarian Koch brothers – showed that his bill would reduce overall health expenditures by $2 trillion. But as we wrote in August, that calculation is based on assumptions in Sanders’ bill about reduced administrative and drug costs, as well as deeply reduced reimbursement rates to health care providers under a universal health care system. The author of the Mercatus paper contends those savings are unrealistic.

The Mercatus report considered another alternative scenario, one that assumed instead that payments to health care providers would “remain equal on average to the current-law blend of higher private and lower public reimbursement rates.” Under that scenario, the numbers showed a $3.3 trillion netincrease in health care spending. Still, not $32 trillion.

An Urban Institute analysis of the Medicare for All plan proposed by Sanders during the 2016 presidential campaign (which differs a bit from the bill Sanders introduced in the Senate) also concluded the federal government would spend about $32 trillion more over 10 years. (Though the estimates from Mercatus and Urban “seem remarkably similar,” the Urban Institute noted that its analysis is different. For example, the analyses looked at different 10-year windows and made different assumptions about how much the government would pay to health care providers.)

“The increase in federal spending is so large because the federal government would absorb a substantial amount of current spending by state and local governments, employers, and households,” the report states.

In other words, lead author John Holahan told us in a phone interview, yes, there would be an increase in federal government spending and an increase in taxes to pay for that. But, he said, private spending on health care would be nearly eliminated.

The Urban Institute analysis concluded national health expenditures would increase by $6.6 trillion (16.6 percent) between 2017 and 2026. Part of that increase is tied to an expansion of long-term care benefits that was part of Sanders’ plan during the campaign but is not in the bill he ultimately introduced.

Sanders’ office argues Medicare for All would save money on health care expenditures overall, due to savings such as administrative cost-sharing and reduced prescription drug costs.

There are lots of assumptions and speculation involved in analyzing such a massive health care overhaul, and we take no position on whether Sanders’ plan would reduce national health care expenditures or increase them by several trillion dollars. The point is that Trump’s claim that it would cost $32.6 trillion is an estimate of what it would cost the federal government. It is not an estimate of the impact on national health expenditures.

'Take away benefits'?

An op-ed is an opinion piece, and the president offers his opinion that a “Medicare for All” plan would mean fewer benefits for seniors. The legislation as written, however, includes an increase in Medicare benefits.

Trump wrote that the proposal would “take away benefits that seniors have paid for their entire lives.” And he goes on to say: “[T]he Democratic plan would inevitably lead to the massive rationing of health care. Doctors and hospitals would be put out of business. Seniors would lose access to their favorite doctors. There would be long wait lines for appointments and procedures. Previously covered care would effectively be denied.”

In terms of benefits, the Sanders plan calls for adding new benefits to Medicare coverage, including dental, vision and hearing aids, and eliminating deductibles. That would be giving more benefits to seniors, not taking any away.

The president offers his opinion that it wouldn’t work out that way. A White House spokesperson pointed to longer wait times in the United Kingdom, as detailed in a January New York Times story, and “rationed care”in Canada, as a column in the conservativeNational Reviewsaid in 2017. And, the spokesperson said, once people leave private plans, they would “undoubtedly” lose “access to certain coverage and doctors.”

An article by Linda J. Blumberg and Holahan at the Urban Institute warns that if payment rates under a Medicare for All plan are reduced below the level of provider costs then the problems that Trump suggested in his op-ed could be a concern. Holahan says the Sanders bill, as written, would reimburse health care providers for patients at Medicare payment rates, which are currently below hospital costs.

Urban Institute, October 2018: A health reform that provides such a large increase in coverage with very broad benefits and essentially no cost-sharing requirements will lead to higher levels of national expenditures, even when private sector provider payment rates are reduced to the level of provider costs. Reducing provider payment rates further risks creating provider supply shortages and impeding access to necessary medical care.

Are Democrats 'uniting around' Medicare for all?

In his editorial, Trump also claimed: “As a candidate, I promised that we would protect coverage for patients with pre-existing conditions and create new health care insurance options that would lower premiums. I have kept that promise, and we are now seeing health insurance premiums coming down.”

But the administration supports a lawsuit that it says would lead to the elimination of the Affordable Care Act’s pre-existing condition protections. And not all premiums are “coming down.”

In the op-ed, there’s a link on “pre-existing conditions” to a Washington Post Fact Checker story that actually says Trump flip-flopped on his “promise.” Indeed, we also found that the president has misleadingly claimed in recent weeks that “preexisting conditions are safe” with him as president and that he “will always fight for … patients with preexisting conditions.”

The fact is, the Department of Justice, “[a]fter careful consideration, and with the approval of the President of the United States” decided not to defend the U.S. government in a lawsuit seeking to overturn the Affordable Care Act, as a June 7 letter from Attorney General Jeff Sessions explains.

Sessions said that the administration sided with the plaintiffs but didn’t agree that the entire ACA would have to be eliminated, as the suit argues. The administration said two ACA provisions would need to be eliminated: those guaranteeing that people can’t be denied coverage by insurers or charged more based on certain factors.

Those provisions protect those on the individual market with pre-existing conditions from being denied a policy or charged higher premiums.

As we said when we addressed this claim last week, it’s disingenuous for the president to claim he kept a promise to “protect coverage for patients with pre-existing conditions,” given the administration’s stance in the lawsuit.

Also, the president says he promised to “create new health care insurance options that would lower premiums.” He has kept that promise. But one of the new options wouldn’t have to meet ACA prohibitions against denying or pricing coverage based on health status – in other words, it wouldn’t protect those with pre-existing conditions.

The administration issued a final rule, which took effect Oct. 2, to expand short-term, limited-duration health insurance plans. An Obama-era rule had limited such plans to less than three months in duration; the Trump administration rule said the plans could be up to 12 months in duration and insurers could renew such policies for up to 36 months.

Short-term plans don’t have to meet ACA requirements. As the journal Health Affairs explains, “Short-term insurers can charge higher premiums based on health status, exclude coverage for preexisting conditions, impose annual or lifetime limits, opt not to cover entire categories of benefits (such as substance use disorder treatment or prescription drugs), rescind coverage, and require higher out-of-pocket cost-sharing than under the ACA.”

The administration’s rule acknowledges that the plans could cause “reduced access to some services and providers for some consumers who switch from available individual market plans” and a “potential increase in out-of-pocket costs for some consumers, possibly leading to financial hardship.” But less-expensive, less-comprehensive coverage would be welcomed by others, it said. “This rule empowers consumers to purchase the benefits they want and reduce overinsurance.”

Trump’s administration also expanded association health plans, through a rule that took effect in August, allowing associations to form to offer insurance for those in the same trade or industry, or for businesses in the same state or metropolitan area. These plans couldn’t deny coverage or charge more based on health status, but they wouldn’t have to cover the10 essential health benefits the Affordable Care Act requires of plans on the small-group market or individual market. They also could price plans based on age, gender or occupation.

So, those plans, too, would likely be less expensive than other options available on the individual market, but that could be because they offer more limited benefits.

And more spin on premiums

The president claimed that he “kept that promise” on new health insurance options and pre-existing condition protections – even though he hasn’t on the latter point – “and we are now seeing health insurance premiums coming down.” The op-ed links to a news article on Health and Human Services Secretary Alex Azar announcing that average premiums for benchmark plans in the states using HealthCare.gov are expected to decrease by 2 percent for the 2019 plans. But experts told us most administration actions in the past two years have driven premiums up.

The actions the administration has taken – such as a repeal-and-replace effort and the elimination of cost-sharing subsidies on the ACA exchanges – “by and large have destabilized the market,” saidCynthia Cox, the director of the program for the study of health reform and private insurance at the Kaiser Family Foundation.

And while the new insurance options Trump cites would likely have lower price tags themselves, they would actually drive up premiums on HealthCare.gov. The nonpartisan Congressional Budget Office said in a May report that it expects healthier individuals to join association and short-term plans, which would then increase premiums for those remaining in the individual and small-group markets by an estimated 2 to 3 percent “in most years.”

When we looked at premiums for the individual market recently, health care experts told us lower growth was expected for 2019 for several reasons: less political uncertainty this year compared with 2017, slower growth in medical expenses, an overpricing of plans last year and insurers’ growing familiarity with the market.

Kelley Turek, executive director of employer and commercial policy at the insurer trade group America’s Health Insurance Plans, told us that after several years under the ACA, “we are getting to a point where issuers are getting a better sense of this market,” she said, such as the population, their health costs and how to price plans.

Meanwhile, premiums for employer-sponsored plans, where nearly half of Americans get their coverage, have continued to grow. Family premiums went up by 5 percent from 2017 to 2018, according to the Kaiser Family Foundation’s annual employer health benefits survey.

No cuts to Medicare under Obamacare

The president also repeated some claims on border enforcement, the Affordable Care Act and Medicare’s finances.

Trump: Indeed, the Democrats’ commitment to government-run health care is all the more menacing to our seniors and our economy when paired with some Democrats’ absolute commitment to end enforcement of our immigration laws by abolishing Immigration and Customs Enforcement. That means millions more would cross our borders illegally and take advantage of health care paid for by American taxpayers. Today’s Democratic Party is for open-borders socialism.

As we’ve written before, Democrats are not advocating open borders. Some rank-and-file Democrats in Congress have called for ending Immigration and Customs Enforcement, but they have also said many of ICE’s functions should be redistributed to other government agencies. Only one member of theSenate orHouse Democratic leadership – Sen. Elizabeth Warren – is among those calling for ICE to be abolished.

No Democrat has called for abandoning border enforcement, as Trump suggests.

Trump: Democrats have already harmed seniors by slashing Medicare by more than $800 billion over 10 years to pay for Obamacare.

Republicans have been using a version of this misleading attack for years. The fact is, there were no cuts to Medicare benefits under the Affordable Care Act. Instead, the health care law reduces the future growth of spending over a decade, primarily by slowing the growth of payments to hospitals. One benefit of the law was the closing of the so-called “doughnut hole” in Medicare Part D prescription drug coverage for seniors.

Even though he claims these Medicare changes in the ACA “have already harmed seniors,” Trump supported legislation that would have kept them in place. The GOP repeal bills in 2017 – including the House-passed American Health Care Act and the Senate’s Graham-Cassidy-Heller-Johnson bill – would have retained the ACA’s reductions to Medicare Advantage and provider payment growth, according to analyses by the nonpartisan Kaiser Family Foundation.

The president also repeated some spin about his “promise” to “protect Medicare.”

Trump:I also made a solemn promise to our great seniors to protect Medicare. That is why I am fighting so hard against the Democrats’ plan that would eviscerate Medicare.

As wewrote before, Medicare’s finances have actually gotten worse since Trump took office. The Medicare Part A trust fund, which covers payments to hospitals, will run out of money by 2026, three years earlier than the Medicare trustees projected just last year, according tothe latest trustees report. The tax cut law Trump signed in 2017 is partly to blame, for reducing Medicare revenues and increasing expenses.

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