Hospital Impact: A deep dive into Clinton, Trump healthcare positions

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The presidential candidates’ positions on health reform could not be farther apart. Hillary Clinton has made it clear she supports the Affordable Care Act. She has stated publicly that she considers “affordable healthcare a basic human right” and wants to “build on the progress we’ve made.” Donald Trump, on the other hand, wants to repeal and replace the ACA.

Here’s a closer look at their respective policy positions:

Affordable Care Act. If elected, Clinton plans to prop it up the ACA with more taxpayer subsidies. Trump’s idea to repeal it entirely includes rolling back Medicaid expansion, insurance regulations and the coverage mandates.

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Health coverage provisions. Under the ACA, the government subsidizes all premiums in excess of 2 percent to 9.5 percent of income, based on a sliding scale. Clinton would lower the premium cap from 9.5 percent to 8.5 percent, providing more subsidies to moderate-income families. She also favors creation of $2,500 (individual) /$5,000 (family) tax credit to help many families pay out-of-pocket costs (and exchange plan premiums) that exceed 5 percent of income for those not eligible for public programs. Many states lack the authority to approve or deny premium hikes. Clinton would grant that authority to the Secretary of Health and Human Services in states that do not regulate premiums.

Both Clinton and Trump want to require greater transparency so consumers can compare prices for medical care. But the devil is in the details: Advocating for meaningless transparency laws is unlikely to force providers or insurers to reveal actual prices. Clinton also would forbid insurers from charging higher out-of-network co-pays when patients are at an in-network hospital. Again, it’s difficult to see how this could work. Both Clinton and Trump would jettison the so-called Cadillac Tax.

Most worrisome is Clinton’s proposal to require health plans to provide three free office visits for illnesses before deductibles are met. This would effectively do away with Health Savings Accounts (HSAs), since health plans that provide benefits below the statutory limit ($1,300 per individual, $2,600 family in 2016) do not qualify for HSAs. Trump would allow people to use HSAs to pay out-of-pocket costs. As many other analysts have noted, it is not clear how this differs from current law. Presumably, Trump favors expanding eligibility.

Trump would allow the sales of insurance across state lines and allow individuals to deduct the cost of individual coverage from their taxes.

The Clinton campaign supports allowing undocumented immigrants to purchase coverage through the public exchanges, but it is unclear whether this includes subsidies. Clinton also supports spending more federal dollars on outreach to enroll people in both the federal marketplace and Medicaid.

Medicaid. Under Clinton’s proposal, states that have not expanded Medicaid could do so at any time and receive three years with 100 percent federal matching funds, just as the early adopters did. Clinton would not change the structure of Medicaid otherwise. States that want to experiment would have to apply through the same process allowed under the ACA and prior laws. By contrast, Trump would repeal Medicaid expansion along with the ACA and convert Medicaid federal matching funds into a block grant. Trump would allow states to experiment, design their own Medicaid programs and make most of their own coverage decisions.  

Medicare. This is where Clinton departs from the conventional wisdom. She would also allow individuals ages 55 to 64 to buy into Medicare. The provisions have not been specified, but this is presumably in response to unaffordable exchange premiums that many upper-middle-age individuals face. The Clinton campaign also wants Medicare to expand the use of value-based purchasing, and hopes Medicare will serve as a model for employers and insurers to do the same.

Prescription drugs. Clinton also supports allowing the U.S. Department of Health and Human Services to negotiate the prices for drugs for the Medicare program--especially specialty drugs and other high-cost medications. Trump originally favored government negotiation of Medicare drugs but has backed away from this point in recent months. Clinton would also require drug makers to provide rebates to all federal programs similar to what Medicaid receives.

Clinton would allow Americans to import drugs from abroad for personal use, but only from countries with safeguards as strong as U.S. standards. It’s not clear how this would work. Although currently illegal, personal importation already occurs on a relatively small scale but is quietly ignored most of the time by the U.S. Customs Service. This policy is similar to one advocated by Trump early in his campaign.  

Clinton would cap the co-pay on prescription drugs at $250 per month. A few states already do this, and only about 1-2 percent of drugs would be affected. Clinton also opposes “pay-for-delay” agreements by drug companies that fend off generic competition. In addition, she woulds eliminate tax deductions for direct-to-consumer advertising. It is arguably little more than campaign rhetoric, but Clinton would make drug makers justify their price increases. Finally, Clinton favors reducing the exclusivity period for biologics from 12 years to seven in an attempt to bring down costs and spur new innovation.  

The presidential candidates have a hodgepodge of health proposals that are rather diverse. As you would expect, Trump relies on the free market and specifies fewer policy details. Clinton has a veritable plethora of government interventions, many of which may be campaign rhetoric or merely wishful thinking.

Devon M. Herrick, Ph.D.., is a health economist and senior fellow at the National Center for Policy Analysis.

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