Stark Differences In Clinton, Trump Health Proposals
Whether or not Hillary Clinton or Donald Trump is elected President next month could have an enormous impact on the U.S. healthcare system and how many Americans are insured in the coming years, according to a prominent health policy expert in California.
“This (presidential) campaign is unlike anything we've seen in our lifetimes,” said Gerald Kominski, director of the UCLA Center for Health Policy Research, during a presentation he made at the university last week.
Kominski meant that not only in the sense that it was the first time a major political party put forth a female candidate in Clinton and the populist, sometimes surreal tone struck by Trump, but the stark differences in how each one would approach healthcare delivery.
According to Kominski, Clinton plans to expand on the existing Affordable Care Act, which was signed into law in 2010 although mostly enacted over the past three years. While the ACA has had a significant impact on lowering the nation's uninsured rate from 18.2% in 2009 to 10.5% in late last year, according to data from the Kaiser Family Foundation, premiums have been on the upswing in recent months, raising concerns about the ongoing affordability for millions of Americans.
Among Clinton's expansions would be the creation of a public option in the state health insurance exchanges; offering of tax credits of $2,500 per individual and $5,000 per household to offset out-o-fpocket spending; lowering the cap on the maximum premium contribution to 8.5% of income from the current 9.66%; allowing any family that spends more than 8.5% of their income on health insurance to receive premium subsidies, no matter how much they earn; and an extension of the full three-year subsidy for Medicaid expansion to the 19 states that have continued to opt out. There would also be a move to eliminate “surprise bills” to consumers who unwittingly use an out-of-network provider when being treated at an in-network hospital.
There are also some bolder – and likely more quixotic – proposals that have little chance of becoming law anytime soon, such as individuals being able to buy into Medicare at the age of 55 (Kominski noted that the original intent of Medicare was to expand coverage to Americans who are younger than the age of 65); and empowering the Part D program to negotiate with pharmaceutical firms to purchase drugs in bulk. Undocumented residents would also be able to purchase subsidy-free coverage in any of the state exchanges (undocumented Californians may currently do so, but most other states bar the practice under federal law).
Clinton's plan would also try to address both the opioid addiction epidemic and the rising costs of pharmaceuticals. It would include a $250 monthly cap on out-of-pocket costs for drugs, a change that Kominski said “would be really important for someone using one of the new high-cost drugs,”;
allow the importation of drugs from international manufacturers that meet U.S. safety standards; narrow the timeframe for biologic exclusivity from 12 to seven years, thereby encouraging the market for generic equivalents; eliminate the tax deduction for advertising drugs and require the approval of the Food and Drug Administration for all ads; and expand prevention and treatment programs for those struggling with opioid addiction.
If all of Clinton's proposals were enacted, Kominski said it would reduce the number of uninsured in the U.S. by as much as 14.5 million, cutting it by slight more than half overall.
But Kominski observed that given the polarizing effect of the law on many Americans, getting even a small proportion of Clinton's proposals through Congress could be challenging.
A Stark Divide
Trump's proposals have little in common with Clinton's, reflecting the stark ideological divide in the U.S. regarding health insurance.
It would include the wholesale repeal of the ACA; permit the selling of health insurance plans across state lines (which Kominski said might lower premiums but would almost certainly dilute coverage for policyholders, what he referred to as a “race to the bottom”); greater promotion of health savings accounts; requiring price transparency from all providers in a non-specific fashion; and removing market barriers for pharmaceutical manufacturers in order to make cheaper products available.
Of those proposals, Kominski only supported a greater push for price transparency, which he said “was the one aspect of healthcare reform from the Trump campaign that makes a lot of sense.”
Kominski said the end result of Trump's proposals would cause the ranks of the uninsured to swell by about 20 million, pretty much undoing the work of the ACA to date. A similar prediction was included in a recent study by the Commonwealth Fund on both Clinton and Trump's health plans. He noted that Trump has also promised a replacement for the ACA, but that nothing concrete has been proposed, suggesting that the other policies put forward would serve as the replacement.
The difference between the number of insured between the Clinton and Trump proposals is as high as 34.5 million, or roughly 10% of the entire U.S. population.
In addition to repealing the ACA, Trump has also proposed converting the Medicaid program to block grants to individual states so they can experiment with how to provide coverage. Kominski said it would only result in reduced services and coverage.
“Block grants can have nefarious consequences,” Kominski said, adding that those currently enrolled in Medicaid should be “shaking in their boots” at such a prospect.
