Ariel Cohen and Sandhya Raman | (TNS) CQ-Roll Call

WASHINGTON — Republican vice presidential nominee JD Vance’s plan to rework President Barack Obama’s signature health care law is vague on details, but many conservative health care experts say it would take the Republican Party back to a place it doesn’t want to go.

Vance’s comments, made over the last week, have added some details to Republican presidential nominee Donald Trump’s assertion during the Sept. 10 presidential debate that he had a “concept of a plan” to reform the Obama-era health exchanges.

“We’re going to actually implement some regulatory reform in the health care system that allows people to choose a health care plan that works for them,” Vance said at a campaign rally last week in Raleigh, N.C., adding that people who use the health care system frequently would be on a different plan from those who are healthy and don’t go to the doctor as often.

“Now, what that will also do is allow people with similar health situations to be in the same risk pools,” the Ohio senator added.

Republican health policy experts say Vance’s comments could allude to one of several policy changes: restructuring insurance risk pools, expanding the transitional reinsurance programs or reinstating Trump-era changes to short-term limited duration plans.

Or it’s possible he’s just improvising.

“I’m not sure he knows what he means,” said Chris Pope, senior fellow at the Manhattan Institute, a conservative-leaning think tank. But, Pope conceded, politicians don’t often go into extreme policy detail on the campaign trail.

Sen. Bill Cassidy, R-La., the ranking Republican on the Senate Health, Education, Labor and Pensions Committee, was very involved in the repeal and replace effort in 2017, and said he’d need to see more details on Vance’s plan before making a judgment.

But he suggested going back to risk pools could be challenging.

“The actuarial case would be difficult,” Cassidy said of separating the sick and healthy into different insurance risk pools.

“Historically there have been some adverse selection issues,” he added.

The Trump-Vance campaign did not return a request for comment.

The focus on health care policy, specifically changes to the 2010 health law, is unusual for this 2024 campaign. In April Trump emphasized he was not interested in changing or overturning the law.

That statement marked a shift from Trump’s presidency, when he fought to deregulate or even overturn the law. After several failed attempts to do so, Trump — and the Republican Party — moved on.

But this election cycle it’s Vance, not Trump, taking the lead on policy on the campaign trail. Vance was not a member of Congress during the Trump administration, when Republicans spent considerable effort trying to repeal and replace the health care law.

Policy experts who support changes to the health care law are skeptical that overhauling the law would be a priority or even tenable for a Trump-Vance administration.

“Do I think this is something that Trump and Vance care about or will push themselves?” said Michael Cannon, director of health policy studies at the libertarian Cato Institute. “I’m not holding my breath.”

Risk pools

Vance first pitched changes to health insurance risk pools during a Sept. 15 appearance on “Meet the Press.”

“Think about it: A young American doesn’t have the same health care needs as a 65-year-old American. A 65-year-old American in good health has much different health care needs than a 65-year-old American with a chronic condition,” said Vance, while critiquing the “one-size-fits-all approach that puts a lot of people into the same insurance pools.”

High-risk pools, which spread out health care costs only among those with certain preexisting conditions, have mostly become obsolete after the implementation of the 2010 health care law, which required that insurers cover people with preexisting conditions the same as healthy individuals. As a result, everyone’s in one risk pool, and everyone pays the same insurance premiums regardless of their health status.

The required coverage of high-risk pools quickly became one of the most popular parts of Obama’s health care law.

But some Republicans have held on to the idea of separating out risk in the insurance markets, despite the widespread popularity of covering individuals with preexisting conditions. Proponents of using both high- and low-risk pools argue that this method can allow insurers to provide cheaper plans for individuals with fewer expected needs.

“The preexisting conditions provisions in Obamacare are undermining universality,” said Cannon.

Cannon argues that preventing insurers from discriminating against people with preexisting conditions at enrollment doesn’t change the economic reality of covering those more expensive conditions.

“You’ve only made it impossible for insurers to be transparent about how they deal with them, and so they will deal with them in less transparent and more harmful ways,” he said, pointing to the exchanges.

Republicans tried to change the risk pools in 2017. Trump and then-House Speaker Paul D. Ryan, R-Wis., promoted a $15 billion federal high-risk pool to provide insurance coverage for Americans with preexisting conditions in an effort to lower costs for healthy people. The legislation failed in the Senate with Arizona Republican Sen. John McCain’s infamous thumbs-down vote.

It’s possible Vance’s plan may not involve two separate risk pools on the exchanges, Pope hypothesized.

Instead, those who are currently on the health care exchange who like their plans could remain on their plans and continue to have all the protections of the law, including coverage for preexisting conditions along with the 10 essential health care benefits, which include preventive care, laboratory services and mental health.

But healthy individuals who do not need coverage for preexisting conditions and who may want to pay less could opt out into another government-sponsored insurance plan that would cost less, Pope explained.

Still, most Republican policy experts say that this is not a smart policy and could lead to more federal spending, a greater deficit and increased government involvement in the health care markets.

“From a rational standpoint, this doesn’t make any sense,” Joe Antos, senior fellow emeritus at the conservative American Enterprise Institute, said.

“You can’t do it that way. You need some healthy people in there with some sick people. Otherwise you’re going to have a financially unsustainable system,” Antos added.

Reinsurance

Ed Haislmaier, senior research fellow at the Center for Health and Welfare Policy at the Heritage Foundation, said campaign remarks tend to be high-level and conceptual, compared with the nitty-gritty of actual regulations and legislation.

“The problem here is people are reading into a general observation details that may not be there,” he said.

But the general proposal, as he interprets it, is more likely to refer to a back-end restructuring of risk pools among insurers.

“In other words, it would all be the same to the enrollees. They wouldn’t see a difference,” said Haislmaier. “What you’re doing is you’re moving the dollars around.”

Haislmaier said if it is this policy, it’s something that has been successful under both Republican and Democratic administrations and could work more broadly.

For example, states can currently apply for Section 1332 state innovation reinsurance waivers that allow marketplace subsidies to be paid directly to the state to reallocate rather than straight to the insurer.

“It’s worked to bring down premiums in states, and this has been in red states and blue states as well,” he said, adding that it could also be a discussion for the next Congress on how to streamline the expansion of this process.

Other options

Republicans on Capitol Hill have been pushing for other changes to lower costs on the federal health care exchanges that don’t involve separating the risk pools, such as codifying the Trump rule on short-term plans or expanding association health plans.

The Trump administration expanded short-term health plans to 12 months. The plans were traditionally meant to be a low-cost, skimpier coverage option for people in times of transitional coverage. The Biden administration reversed this rule because many Americans were purchasing the cheaper plans without realizing they had few consumer protections, and once again limited the plans to four months.

Republicans on Capitol Hill criticized the move. Cassidy and Mike Braun, R-Ind., said the move forced “individuals and families into plans that are more expensive and less tailored to their needs.”

House Republicans are also in favor of expanding association health plans, which are offered by groups of employers that join forces and are not required to meet the 2010 health care law’s parameters.

The Trump administration’s 2018 rule was vacated by a federal judge in 2019 before it could go into effect, though the Trump administration tried to appeal that ruling. The Biden administration proposed to rescind the 2018 rule.

Earlier this month, Republicans on the House Education and the Workforce Committee voted in support of a Congressional Review Act resolution to block the Biden administration’s rule limiting access to association health plans. Republicans argued that the plans help small businesses lower health costs for their employees.

A messaging problem

Right-leaning policy experts largely agree that the Trump-Vance campaign is facing a messaging problem on health insurance policy. Lowering costs is popular. Relitigating the 2010 health care law is not.

Antos encouraged the Trump-Vance campaign to take a page out of Democratic presidential nominee Kamala Harris’ campaign playbook and speak in more broad terms about the health costs while talking to voters. Republicans spent years trying to repeal and replace the 2010 health care law and failed to do so. Voters, they say, have largely moved on and lost interest.

“Health insurance clearly is not a very relevant issue for the election,” Antos said. “I’m not saying that the insurance problems have been solved. It’s just that they’ve been truly minimized. Basically, the ACA [the 2010 health care law] did work.”

___

James Rainey and Hailey Branson-Potts | (TNS) Los Angeles Times

Is he rambling? Indifferent to his audience? Exhibiting symptoms of cognitive decline? Or, instead, could former President Donald Trump’s extended discourses demonstrate his genius — an ability, as he says, to “weave” disparate stories into a beautiful tapestry?

The 78-year-old Republican nominee’s meandering speaking style — and what it might say about his mental state — has become a new fixation in a race already upended when President Joe Biden, 81, dropped out this summer amid questions about his own age and mental acuity.

In recent weeks, Trump has said he would deport Haitian immigrants in Springfield, Ohio, “back to Venezuela.” He said he was being supported by “the vice president’s family” — meaning relatives of Minnesota Gov. Tim Walz, who is running for the office but is not vice president.

He insisted — incorrectly — he had been in a helicopter crash with former San Francisco Mayor Willie Brown. Trump has repeatedly hurled critiques at former President Obama, when his real target seemed to be President Biden, misstatements he insisted were “sarcasm.”

In August, the science-and-health-focused website Stat News published a detailed analysis of Trump’s speech patterns in recent months, comparing them with public speeches in 2017. Several researchers noted “more short sentences, confused word order, and repetition, alongside extended digressions.”

Those changes “could be attributed to a variety of possible causes,” the experts told Stat, “some benign and others more worrisome. They include mood changes, a desire to appeal to certain audiences, natural aging, or the beginnings of a cognitive condition like Alzheimer’s disease.”

James Pennebaker, a social psychologist at the University of Texas at Austin, performed a more formal analysis for Stat based on complete transcripts of 35 Trump interviews from 2015 through this year. Using statistical software, he found a roughly 60% increase in use of absolute terms like “always,” “never” and “completely.”

Trump’s recent dialogue also contained fewer positive words. Increased all-or-nothing thinking can also be linked to changes in cognitive ability, Pennebaker wrote, adding: “Another person whose all-or-nothing thinking has gone up is Biden.”

Last week, critics on the left picketed the New York Times’ headquarters, demanding that the media stop “sane-washing” Trump’s disjointed statements.

Kathleen Hall Jamieson, a co-founder of FactCheck.org and director of the Annenberg Public Policy Center at the University of Pennsylvania, said in an interview that “there’s always been the question: Is Donald Trump in touch with a knowable reality?”

Trump’s speaking style, she said, has always been defined by braggadocio and exaggeration, but, these days, he is making more comments that are outright bizarre. “He’s doing it more now than he was in the past,” she said. “He’s more tangential.”

Jamieson said Americans need to be asking two questions about his ability to communicate: “Does this tell you something important about his capacity as president? And should it factor into our votes or not?”

Trump has made clear he’s aware of the criticism, defending his speaking style repeatedly in recent weeks. He assured a Pennsylvania rally that even English professors marvel at the intricate “weave” of his storytelling. He blamed the “fake news media” for intentionally misrepresenting his sarcastic flourishes to claim he suffered a cognitive impairment.

Speaking in Savannah, Georgia, on Tuesday, Trump sounded off on Biden’s mental state and questioned the competency of Vice President Kamala Harris.

“You talk about cognitive problems? She’s got bigger cognitive problems than [Biden] has,” he said.

Trump campaign spokesperson Karoline Leavitt told The Times that reporting on mental acuity would create “a garbage article based upon a bunch of ‘sources’ who have no idea what they’re talking about and are trying to deflect from the fact that our sitting president, Joe Biden, was ousted off the Democrat ticket due to his clear cognitive decline.”

“President Trump is sharp as a tack,” Leavitt added, “and executes a rigorous campaign schedule every single day.”

Trump suggested at a Tucson rally this month that it wasn’t just his enemies questioning his onstage behavior. He said he called former First Lady Melania Trump, who had watched a recent speech on television, and asked whether she “saw how great my speech was tonight, darling.” People loved it, he said he told her.

“Well, yeah, they might, but you look really bad,” Trump said she replied. “You couldn’t find the stairs off the stage.”

Feigning exasperation, he said he had to explain to his wife that he had been joking — that he was imitating Biden but that “the fake news” was distorting his sarcasm.

Trump’s supporters plead for a more generous interpretation when it comes to Trump on the stump: They say they go to the former reality TV star’s rallies knowing that he will entertain — including with convention-defying remarks and flights of fancy, as when he has mused about whether it would be preferable to die by shark attack or electrocution. (“I’ll take electrocution every single time.”)

To MAGA adherents, those moments offer more proof that their hero is blunt. Real. Unlike Harris and other politicians glued to their teleprompters.

Amid questions about his speaking style, media analyst Jamieson urged journalists to let Trump be Trump, but in a different sense. She said reporters should throw off the traditional journalistic imperative of brevity and simplicity and quote Trump in full, revealing how he actually expresses himself.

As good a place to start in that regard might be Trump’s defense of his verbal walkabouts during a town hall meeting last week in Michigan with Arkansas Gov. Sarah Huckabee Sanders:

“I do have to say, so I give these long, sometimes very complex sentences and paragraphs, but they all come together. I do it a lot. I do it with Raising Caine, that story. I do it with the story on the catapults on the aircraft carriers. I do it with a lot of different stories. When I mentioned Dr. Hannibal Lecter, I’m using that as an example of people that are coming in, from ‘Silence of the Lambs.’ I use it. They say, ‘It’s terrible.’ So they say — so I’ll give this long, complex area, for instance, that I talked about, a lot of different territory.”

He went on, bringing up automobiles:

“The bottom line is, I said, the most important thing: We’re gonna bring more plants into your state and this country to make automobiles. We’re gonna be bigger than before. But the fake news — and there’s a lot of them back there, you know, for a town hall; this is a lot of people. But the fake news likes to say, the fake news likes to say, ‘Oh, he was rambling.’ No, no, that’s not rambling. That’s genius. When you can connect the dots.

“Now, now, Sarah, if you couldn’t connect the dots, you got a problem, but every dot was connected, and many stories were told in that little paragraph.”

The Harris campaign, on X, quoted Trump’s remarks with no comment.

Concerns about mental fitness and age have long been a feature of presidential politics. The media questioned whether Bob Dole and Ronald Reagan were too old to serve as chief executive.

The subject became most prominent in 2020, when Trump and Biden ran as two of the oldest candidates ever to seek the presidency. Trump famously challenged Biden to take a cognitive exam, boasting that he had passed such a test himself, in part by remembering a string of words: “Person. Woman. Man. Camera. TV.”

(Experts said the exam sounded like the Montreal Cognitive Assessment, or MoCA, which is used for early detection of mild cognitive impairment.)

In 2024, Biden’s stiff walking gait and sometimes distracted affect again raised the issue of geriatric cognition. The topic became unavoidable when he and Trump debated in June, with Biden’s incomplete thoughts and vacant stare setting off alarm bells among Democrats. Biden soon abandoned his reelection campaign.

Since then, Democrats have demanded to know why Trump’s public behavior hadn’t gotten as much scrutiny, noting that he would be 82 by the end of another term in the White House. Critics point to his “word salad” diatribes and his misidentification of key players — for instance, saying it was former U.N. Ambassador Nikki Haley who had not done enough to defend the U.S. Capitol during the Jan. 6, 2021, insurrection when he meant then-House Speaker Nancy Pelosi.

Trump’s camp has made clear that it will not exempt his current opponent, the 59-year-old Harris, from cognitive critiques.

Video of Harris’ sometimes meandering sound bites have become a staple of GOP critics. That includes the time Harris made an obscure reference to falling out of a coconut tree and her oft-repeated line about being “unburdened by what has been.” Previously fodder for detractors, those same moments have been remixed by Harris fans into laudatory TikTok videos, Instagram memes and Etsy merch.

Before Biden and Trump, the media tended to treat the mental fitness of would-be presidents gingerly. Part of that caution showed a desire for objectivity, but part also reflected the fear of duplicating what happened to Barry Goldwater, the Republican senator from Arizona, when he ran for president in 1964.

An article in the now-defunct Fact magazine — headlined: “1,189 Psychiatrists say Goldwater is Psychologically Unfit to be President!” — quoted an informal poll of U.S. psychiatrists, none of whom had actually met Goldwater.

After losing in a landslide to Lyndon B. Johnson, Goldwater successfully sued the magazine for libel. The American Psychiatric Assn. then produced the “Goldwater Rule,” which states that it is “unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

As a result, psychiatrists today generally hesitate to issue armchair diagnoses.

Dr. Zaldy Tan, director of the Memory and Healthy Aging Program at Cedars-Sinai Medical Center in Los Angeles, noted that partners in law firms are sometimes required to get neurological evaluations. There is no such requirement in politics. And what would the standards be?

“I think the difficulty there would be drawing the line between what is ageist and what is really fair,” Tan said. “And the evaluation would depend on the tasks that are deemed important,” which, he said, would also be hard to agree upon.

Jamieson recommended that voters study the candidates closely and try to separate behavior of real concern from trivial incidents. In the latter category, Jamieson included misnaming individuals and bragging about crowd sizes. Many people slip in identifying people, she said. And Trump has a long history of boasting.

Other comments, she said, merit more scrutiny, including Trump’s claim that the size of Harris’ audiences has been faked by the use of images generated by artificial intelligence.

“If he really believes that,” Jamieson said, “then he’s delusional.”

____

Trump’s speaking style

Trump’s recent answer to a question about how to make childcare more affordable:

“It’s a very important issue. But I think when you talk about the kind of numbers that I’m talking about that — because the child care is, child care, it’s, couldn’t, you know, there’s something, you have to have it. In this country, you have to have it.

“But when you talk about those numbers compared to the kind of numbers that I’m talking about, by taxing foreign nations at levels that they’re not used to, but they’ll get used to it very quickly — and it’s not going to stop them from doing business with us, but they’ll have a very substantial tax when they send product into our country. Those numbers are so much bigger than any numbers that we’re talking about, including child care, that it’s going to take care.”

____