By ROBERT PEAR and MAGGIE HABERMAN
WASHINGTON — Donald J. Trump calls for “a full repeal of Obamacare” but says that “everybody’s got to be covered.” Initially, he liked “the mandate,” a central feature of the Affordable Care Act that requires most Americans to have insurance or pay a penalty, but he backed off that position under fire from conservatives.
He would allow people who purchase insurance on the individual market to take tax deductions for their premium payments. But aides acknowledge that this tax break would not be worth much to people whose income is so low they pay little or nothing in federal income taxes. For them, Trump aides say, there would be Medicaid, which the billionaire businessman says he would not cut but would turn into a block grant to state governments.
This whipsaw of ideas is exasperating Republican experts on health care, who call his proposals an incoherent mishmash that could jeopardize coverage for millions of newly insured people. But for Mr. Trump’s campaign, such criticism appears only to bolster the candidate’s outsider status. His chief policy adviser, Sam Clovis, said Mr. Trump was running against the political establishment in Washington and was therefore not relying on advice from “traditional establishment Republican people.”
Instead, Mr. Clovis said in an interview, Mr. Trump is receiving advice on health care policy from at least half a dozen “very prominent people,” but he declined to name them. “They are not ready to have their support of the Trump campaign known,” Mr. Clovis said.
Some experts outside Mr. Trump’s campaign have been unsparing.
“If you repeal the Affordable Care Act, you’ve got to have a serious way to expand coverage to replace what you have taken away,” said Gail R. Wilensky, who was the administrator of Medicare and Medicaid under President George Bush from 1990 to 1992. “There’s nothing I see in Trump’s plan that would do anything more than cover a couple million people.”
Robert Laszewski, a former insurance executive and frequent critic of the health law, called Mr. Trump’s health care proposals “a jumbled hodgepodge of old Republican ideas, randomly selected, that don’t fit together.”
Mr. Clovis, the national co-chairman of the Trump campaign, acknowledged that the ideas Mr. Trump has offered to replace the health law were just “a starting point,” a framework. He said Mr. Trump would have a detailed, comprehensive plan to replace the law if Congress repealed it, and added that any replacement “must be bipartisan.”
Asked if Mr. Trump’s plan would insure all those who have gained coverage under the health law, Mr. Clovis said: “That might be correct, but we really don’t know that. A lot of it depends on what initiatives we can get through Congress.”
Mr. Trump’s health policy can be pieced together from speeches, television interviews, Twitter posts and a seven-point plan, titled “Health Care Reform to Make America Great Again.” He says Congress should encourage the sale of health insurance across state lines and allow individuals to take tax deductions for insurance premium payments. His Medicaid proposal would send lump sums of federal money to each state to provide health care to low-income people, although unlike other Republicans, he has vowed not to cut overall Medicaid spending.
That Mr. Trump’s ideas confound Democrats is no surprise. More interesting are the acerbic comments of serious students of health policy often aligned with Republicans.
Mr. Trump’s health care platform “resembles the efforts of a foreign student trying to learn health policy as a second language,” said Thomas P. Miller, a health economist at the American Enterprise Institute and a harsh critic of President Obama’s health law.
Millions of low-income people have gained coverage under the Affordable Care Act and could lose it if Congress repealed the law. Mr. Trump’s proposal for a tax deduction for premium payments would not help them much, Mr. Miller said, because they do not pay much in income taxes.
Sam Clovis, Mr. Trump’s chief policy adviser, has acknowledged that Mr. Trump’s ideas to replace the Affordable Care Act are a framework. Credit Charlie Neibergall/Associated Press
Mr. Clovis called that “an excellent point,” and he suggested that low-income people could obtain coverage through Medicaid — even as Mr. Trump seeks to slow the growth of Medicaid spending with a block grant. At the same time, Mr. Clovis said, some workers with employer-sponsored coverage might prefer to take the tax deduction and buy health insurance on their own.
“The trend will eventually be that employers will provide income to buy insurance on your own, and the employers will get out of the group policy business,” Mr. Clovis said. This trend, he said, could help workers who are now “held captive by their benefits in a business or company they work for.”
James C. Capretta, a senior fellow at the Ethics and Public Policy Center, a conservative nonprofit group, said Mr. Trump underestimated how difficult it would be to uproot a law that was now embedded in the nation’s health care system.
“It took a herculean political effort to put in place the Affordable Care Act,” said Mr. Capretta, who worked at the White House Office of Management and Budget from 2001 to 2004. “To move in a different direction, even incrementally, would take an equally herculean effort, with clear direction and a clear vision of what would come next. I just don’t see that in Trump’s vague plans to repeal the law and replace it with something beautiful and great.”
Many of the proposals Mr. Trump has embraced have been Republican standards for years, such as allowing insurers to sell their products across state lines. In a debate in Houston in late February, Mr. Trump said repeatedly that he wanted to “get rid of the lines around the states,” and he explained: “Instead of having one insurance company taking care of New York, or Texas, you’ll have many. They’ll compete, and it’ll be a beautiful thing.”
But Mr. Laszewski, the former insurance executive, said this was no panacea. Before a Texas company could, for example, sell insurance in New York, he said, it would need to establish or “rent” a network of doctors and hospitals to meet the needs of consumers.
Moreover, state insurance officials have resisted such legislation, saying it could undermine their power to regulate insurance and their ability to protect consumers.
Grace-Marie Turner, the president of the Galen Institute, a champion of free-market health policy, said Mr. Trump’s proposals were sketchy and inadequate.
“He has to discard some of his ideas, like the importation of prescription drugs, because they would be damaging and unworkable,” Ms. Turner said. “And he has to flesh out his other proposals with much more detail if he hopes to persuade voters that he has a credible plan to replace Obamacare.”
Mr. Trump has called for removing barriers to imported drugs from other countries, such as Canada, saying it will lower drug prices and offer consumers more options. Democrats have long embraced the idea but have been blocked by pharmaceutical industry opposition as well as concerns over drug safety.
Mr. Trump’s views have evolved. Writing about health care in his 2000 book, “The America We Deserve,” he said, “I’m a conservative on most issues but a liberal on this one,” and he expressed interest in the idea of a “single-payer plan,” with consumers free to choose from competing private options. He backed away from that idea in an interview with The New York Times in 2011, when he was flirting with a White House bid and his conservative credentials were under scrutiny.
A populist theme still runs through many of Mr. Trump’s statements. “The insurance companies are making a fortune because they have control of the politicians,” he said in a debate last year. For a similar reason, he says, drug companies get away with overcharging consumers.
Mr. Trump says Medicare should be able to negotiate prices with pharmaceutical companies — a proposal embraced by Democrats and blocked by Republicans in Congress for more than a decade — and he promises that if elected he would “negotiate like crazy.”