Where Clinton and Trump stand on healthcare policy
By Harris Meyer
November 7, 2016 - Modern Healthcare
Tens of millions of Americans will have voted for
president, members of the U.S. House and Senate, governors and state legislators
by the end of Tuesday in an election that will have a major impact on the future
direction of U.S. healthcare.
The closely contested Senate races in a
number of states will determine control of the Senate, which could make it
easier or harder for the new president to carry out her or his
agenda.
The elections surely won't end the nonstop political war over the
shape of the U.S. healthcare system that's lasted eight years so far. But the
ballot results likely will determine whether the changes driven by the
Affordable Care Act continue in the same
direction or the system returns to its less-regulated, pre-ACA
contours.
Here is a breakdown of where the candidates stand on the health
reform law, Medicare, Medicaid and the rising pressure for the White House and
Congress to rein in drug prices. A version of this story was originally
published in July. Little in their healthcare policy proposals has changed since
then.
Hillary
Clinton has promised to preserve and expand the ACA's coverage expansions
and delivery system reforms.
Donald Trump
says he wants to repeal them, without offering much detail about what he would
put in their place. The fate of the victor's proposals, however, will depend
heavily on the partisan makeup of Congress.
The clearest scenario is if
Trump wins and his party retains control of both the House and the Senate, which
would enable conservatives to repeal or roll back the ACA and implement at least
some of the proposals outlined in the GOP party platform and the House
Republican leadership white paper on healthcare. But there are divisions even
among conservatives over issues such as Medicare restructuring and how to help
Americans afford health insurance. And Senate Democrats almost certainly would
use their filibuster power to block major ACA changes.
If Clinton wins
and Democrats take control of both the Senate and the House—which is considered
unlikely—she might be able to push through proposals such as increasing funding
for federally qualified community health centers. But Senate Republicans also
could use the filibuster to foil her. In the more likely scenario of a
Democratic-controlled Senate and a GOP-controlled House, it's not clear how much
Clinton could achieve through the legislative process.
That's why some
observers predict that a President Trump or a President Clinton would have to
use executive powers to put their healthcare policies in place. One possible
tool is Section 1332 of the ACA, which lets the federal government grant waivers
to states to opt out of the ACA's exchanges and achieve coverage and cost
control goals via innovative models.
But the administrative approach
carries political and legal risks. The Obama administration has faced a number
of court setbacks and infuriated congressional Republicans with its
administrative end runs.
Here are some questions and speculations about
how the election could affect key health policies:
What would happen to the Affordable Care Act under President Clinton?
The law will survive and undergo repairs if Clinton
wins, becoming more firmly entrenched by the end of her term.
She has
promised to improve the functioning of the ACA markets by offering additional
subsidies to consumers to make premiums, out-of-pocket costs and prescription
drug costs more affordable. She also wants to boost exchange enrollment through
aggressive outreach, tougher cost controls and continued delivery system
reforms. gThe combination of these steps should increase enrollment, stabilize
the marketplace, reduce premiums, and convince more plans to enter the market
because there will be more and healthier customers,h said Chris Jennings, an
outside health policy adviser to the Clinton campaign.
In July she
updated her healthcare platform to more strongly embrace a public plan option in
the exchanges. But there are doubts about whether she seriously intends to
pursue the controversial public option approach if she's elected.
gI'm
not sure (the public option) would be in her 100-day agenda or in her two-year
agenda,h said Jim Manley, a former top aide to Sens. Harry Reid and Ted Kennedy
who worked on drafting the ACA. Even if the Democrats win control of the Senate,
he noted, it would take 60 votes to pass a public option measure and other ACA
changes, and that's a high hurdle.
Douglas Holtz-Eakin, an adviser to
John McCain's presidential campaign in 2008 and former director of the
Congressional Budget Office, said Clinton's agenda for improving and expanding
the ACA would be dead on arrival in Congress because there's no money to fund it
and because Republicans are fiercely against it.
So how could Clinton
implement any of her ACA fixes? She would look at administrative as well as
legislative options, Jennings said. gShe'll work very aggressively to go as far
as she can to ensure Americans in the exchanges have a viable choice of health
plans.h
How would the ACA fare under President Trump?
Under Trump, the ACA probably would be shrunk rather
than abolished and would receive a new name. It's widely expected that Trump
would hand off the health policy portfolio to House Speaker Paul Ryan, whose
recent House leadership white paper is seen by conservative wonks as the
blueprint for a Republican administration's policy. Republicans likely won't
completely repeal the law despite their long-standing promise to do so. The
political backlash from suddenly ending ACA coverage for an estimated 20 million
Americans would be too great. Perhaps even more important, they won't be able to
get 60 votes in the Senate for repeal.
Still, Trump and congressional
Republicans would try to end the individual and employer mandates, eliminate ACA
insurance reforms such as minimum essential benefit packages, pare back and
restructure the premium subsidies, and junk the CMS Innovation Center and the
Medicare Independent Payment Advisory Board, Holtz-Eakin said.
Experts
say those measures would largely unravel the ACA system and could lead to
millions of people losing coverage.
It's not clear whether or how a Trump
administration would provide subsidies to help people buy or keep coverage. The
House Republican leaders' plan proposed refundable tax credits for individuals
without access to employer-based or public coverage. But the Trump campaign's
seven-point healthcare proposal and the GOP health policy agenda don't mention
any subsidy mechanism. Another issue is that if they moved to repeal the ACA and
its hundreds of billions in revenue, Republicans would have no way to fund
subsidies for the uninsured, noted John Goodman, a veteran Republican health
policy expert.
House GOP leaders have proposed taxing employer health
benefits to provide revenue for subsidies and help control overall healthcare
spending. But it's not clear whether Trump would embrace such a widely unpopular
measure. The bottom line, many observers predict, is that Trump would whittle
away at the ACA but wouldn't chop it down.
Will Medicare face major restructuring?
It won't if Clinton wins. But she will push for a
continued shift to value-based reimbursement models such as bundled payment and
accountable care. And to address affordability, she might try to pass her
proposal to let people 55 and older voluntarily buy into Medicare, though
Republicans would strongly oppose it.
On the other hand, there is the
potential for changes to improve Medicare benefits and care coordination and
reduce costs for patients with chronic conditions, which have bipartisan
support. There's also an outside chance for a deal on GOP-backed reforms merging
Medicare Parts A and B, capping out-of-pocket costs for seniors and potentially
saving the program money by requiring deductible payments.
If Trump wins,
Ryan and congressional Republicans will press hard to transform Medicare into a
so-called premium-support program, in which the government makes fixed
per-capita contributions and beneficiaries use those payments to get their care
from either traditional Medicare or private plans. A move away from defined
benefits would potentially expose seniors to higher out-of-pocket costs. The GOP
platform includes that proposal, even though Trump repeatedly promised in the
primaries to leave Medicare unchanged.
Holtz-Eakin suggested that a Trump
administration might try to nudge Medicare toward a premium-support model by
making the privatized Medicare Advantage program more of a competitive bidding
system. gThey could do it in a sequential way and (eventually) get rid of CMS
price-fixing entirely,h he said. To win Democratic support for this, he added,
the Republicans might agree to expand the bundled-payment model within
traditional Medicare.
Will the Medicaid expansion continue or will Medicaid be converted into a
state block grant program?
Clinton says she will ask Congress to extend the ACA's
enhanced, 100% federal matching rate for covering low-income adults to states
that have not yet expanded Medicaid. That would give incentives to the 19
non-expansion states to extend coverage. But she would need a
Democratic-controlled Congress to pass it.
Even so, it's expected that
more Republican-led states would accept the expansion to help their hospitals
and their budget pictures once it's clear that the ACA is here to stay under a
Democratic president. Florida, Oklahoma, Tennessee, Utah and Wyoming are among
the states where key GOP state leaders have backed expansion.
In
contrast, Trump and GOP congressional leaders want to convert Medicaid into a
system of capped federal contributions to the states and give state leaders
enormous freedom to set eligibility, benefits and program structure. Democrats,
healthcare providers, and even many state officials oppose such a change,
fearing it would slash funding, reduce provider payments, and leave lots of
low-income people without healthcare.
The House Republican leadership
plan, which calls for repealing the ACA and its Medicaid expansion, would let
states roll back their coverage extensions to gable-bodiedh adults. At the same
time, conservative experts argue that giving states more flexibility under the
block-grant approach, such as letting them set work requirements and trim
benefits, would enable them to cover this population more
cost-effectively.
Holtz-Eakin said there could be a bipartisan Medicaid
deal between a President Clinton and a GOP-controlled Congress, with Clinton
getting expansion in all 50 states in return for giving state officials greater
leeway in program design. It might even involve giving each state a single pot
of money to cover both the Medicaid and exchange populations. gThere's a trade
in there somewhere,h he said.
Will there be any action to control rapidly rising prescription drug
costs?
Clinton wants to cap Americans' out-of-pocket costs for
prescription drugs, let Medicare negotiate drug prices, and allow consumers to
buy lower-cost drugs from foreign countries with approved safety standards. But
those measures would face all-out resistance from the powerful pharmaceutical
industry.
Trump also has called for letting Medicare negotiate prices.
But GOP congressional leaders reject that, preferring to focus on reforms to
speed Food and Drug Administration approvals for new drugs and devices that they
say will reduce costs. Despite that stance, some conservative health policy
experts have said a Trump administration would face mounting public pressure to
address the drug cost issue.
John Rother, a veteran healthcare lobbyist
who heads the Campaign for Sustainable Rx Pricing, said the proposals by Clinton
and Trump to have Medicare negotiate drug prices are not politically viable and
that it would be better to focus on achievable goals such as increasing price
transparency and competition. Medicare negotiating drug prices gis not going to
happen in Congress as I know it,h he said.