I wrote this column before Monday night's first presidential debate between Hillary Clinton and Donald Trump. But no matter who is considered the winner and loser, it is clear that healthcare will have its share of winners and losers depending on who is elected president.
First, Clinton wants to keep the Affordable Care Act in place, and focus on its areas of weakness, of which there are many. The most glaring one is the lack of cost controls. This was primarily due to the tortured process of getting the ACA passed through Congress with a narrow Democratic majority in 2010, and the vigorous lobbying of virtually every business and special interest group to get their cut before any Americans got their health coverage.
The Clinton proposals primarily work around the margins, but they would work nonetheless. The most important is the introduction of the “public option”--a government-operated health plan--in the state exchanges. The analysis describes it as a public plan that “would reimburse hospitals and physicians at Medicare rates and could achieve administrative savings relative to private plans.”
But Clinton's proposals do not stop there. They include tax credits to offset out-of-pocket spending, caps on maximum premium contributions and greater flexibility that would allow families offered employer-based coverage they cannot afford an option to purchase a plan on the exchange without a penalty.
The analysis estimates that this would add 12.6 million Americans to the insurance rolls by as early as 2018, cutting the uninsured rate by 39 percent. The biggest boost would come from the expanded premium tax credit, which would add 9.6 million to the ranks of the insured. Surprisingly, the public option would only provide insurance for another 400,000, likely because many mainstream consumers would be put off by their network options.
But if all of Secretary Clinton's proposals were enacted, it would cut the existing uninsured rate by about half, and by about 75 percent from before the passage of the ACA.
Whatever your views of Donald Trump, his policy proposals have been vague at best. As discussed before, his primary intention is a full repeal of the ACA, with few replacements. Essentially, health insurance would become fully tax-deductible, health savings accounts would be encouraged, and health insurers would be able to sell coverage across state lines. Medicaid funding would also come in the form of block grants as opposed to per-person payments. Trump's campaign website also mentions price transparency, which is sorely needed, but absolutely no details as to how this would be achieved.
The net result? The RAND/Commonwealth analysis concluded it would lead to 19.7 million Americans losing their health insurance by 2018--pretty much a complete unraveling of the achievements of the ACA. It's an even higher estimate than the 18 million Americans who would lose coverage calculated earlier this year by The Center for Health and Economy.
A Trump win presupposes the Republicans maintaining control of the Senate (even if tied, Vice President Mike Pence would cast the deciding vote). It would therefore make the repeal of the ACA a highly likely scenario seven years after it was signed into law.
Hospitals would simply get clobbered if the ACA is repealed. Their uncompensated care costs have been plummeting since the passage of the ACA (even in states that did not expand Medicaid eligibility; most of those savings would vanish quickly.
No matter your politics, a Trump victory would be financially catastrophic for hospitals after years of gains. And while a Clinton victory would not guarantee that the government would implement all of her proposals, at the very least what has been a financially stable status quo would remain in place.
The winners and losers of the debate may or may not be clear-cut by the time you read this. But the winners and losers of each candidate's healthcare policy proposals are crystal clear. – Ron (@FierceHealth)