The 2016 presidential campaign, which culminates today, offers two starkly different paths into the future. The healthcare policies that would be pursued depending on who wins the election is no exception.
In a recent conversation, Gerald Kominski, director of the Center for Health Policy Research at the University of California at Los Angeles, told me that Hillary Clinton proposes to “maintain and expand the Affordable Care Act,” which has been beset with issues such as dramatically rising premiums and market withdrawals from major insurers.
In contrast, Donald Trump proposes scrapping the ACA entirely in favor of a variety of loosely connected free market-oriented approaches.
The Clinton plan includes a variety of relatively minor tweaks to the ACA that, taken as a whole, Kominski said would “address a number of shortcomings that have come up since the implementation of this law.” They include:
- Lowering maximum individual premium contributions to 8.5 percent of income from the current 9.66 percent
- Establishing tax credits for anyone with private insurance coverage whose out-of-pocket spending exceeds 5 percent of their income
- Repealing the 40 percent Cadillac tax on health plans valued at more than $10,200 for individual coverage and $27,500 for a family (it does not go into effect until 2018)
- Creating a public option health plan for the state insurance exchanges to encourage greater price competition among the private payers
In addition to those changes, the 19 states that have so far declined to expand Medicaid eligibility under the ACA would be offered an extension. They would still be allowed to claim a 100 percent funding subsidy from the federal government during the first three years of a future expansion (the subsidy for states that have already opted in expires in 2017).
Clinton also proposes additional funding for exchange outreach, primarily to get younger, healthier Americans to sign up for coverage. That is intended to curb some of the adverse selection that resulted as a large proportion of older, less healthy individuals obtained coverage.
She has also made some bolder proposals that would likely encounter significant political and business opposition, such as allowing Americans between the ages of 55 and 64 to buy into Medicare coverage, and allowing Medicare to negotiate drug prices on behalf of the Part D program.
Trump's proposals include the following:
- The complete repeal of the ACA
- Allowing health insurance to be sold across state lines
- Making health insurance premiums fully tax-deductible
- Increasing promotion of health savings accounts
- Requiring price transparency from all healthcare providers
- Block-granting of Medicaid funding to states
Kominski raised a number of concerns regarding Trump's proposals. He noted that repealing the ACA would likely mean the bar against pre-existing conditions and lifetime policy dollar limits would be eliminated. Allowing health insurance to be sold across state lines would lead to what he called a “race to the bottom” among health insurers in terms of offering coverage with skimpy benefits. Making all health benefits fully tax-deductible would also be a bigger help to wealthier individuals than those of middle and lower incomes.
Kominski was particularly concerned about the block-granting of Medicaid funding to the states. “Block grants can have nefarious consequences,” he said, adding that it would almost certainly lead to significant reductions in enrollment.
Kominski did praise the proposal for price transparency, observing that most consumers have little bargaining power in the absence of knowing exactly what their care costs. He said it “was the one aspect of healthcare reform from the Trump campaign that makes a lot of sense.”
What is the net effect of the separate proposals?
A recently released study by the Commonwealth Fund and the RAND Corp. projects that Clinton's plan would increase the number of Americans with healthcare coverage by as much as 14.3 million. The biggest jump would come from the changes to the tax credits, adding as many as 9.6 million to the ranks of the insured. The public option, considered to be among the most controversial of the proposals, would only insure an additional 400,000.
By contrast, Trump's plan could cause as many as 19.7 million people to lose their insurance--pretty much the entirety of the coverage gains made under the ACA. If block granting of Medicaid is included, coverage could decrease by as much as 25.1 million. The study did note that Trump's deductibility and state line easements could increase insurance coverage among families earning more than $60,750 annually by as much as 4.1 million, but that would be far eclipsed by the overall decline in coverage.
The study concluded that Clinton's plan would add $103 billion a year to the federal deficit. Trump's plan would add $108.3 billion.
“It’s clear that there are two widely disparate approaches to ensuring Americans’ healthcare coverage, access to the care they need and protection from burdensome healthcare costs,” wrote Commonwealth Fund President David Blumenthal, M.D.
Jonathan H. Burroughs, MD, MBA, FACHE, FAAPL is a certified physician executive and a fellow of the American College of Healthcare Executives and the American Association for Physician Leadership. He is president and CEO of The Burroughs Healthcare Consulting Network and works with some of the nation's top healthcare consulting organizations to provide "best practice" solutions and training to healthcare organizations.