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Five key areas of healthcare, the candidates’ proposals for them, and analysis from experts.
While Hillary Clinton vows to forge ahead with Obamacare if she is elected president, Donald Trump would scrap it altogether. The end results would be two very different forms of healthcare, and industry leaders have much to consider.
Brill“Many different factors are weighing on managed care executives such as the costs of pharmaceuticals, diagnostics and devices; the impact of consolidation amongst hospitals, physicians, health plans; and the losses in the exchange marketplace,” says Managed Healthcare Executive editorial advisor Joel V. Brill, MD, chief medical officer, Predictive Health, LLC, which partners with stakeholders to improve coverage of value-driven care. “With each of these factors, plans can, at least at a high level, make some educated guesses about the relative risk of each factor and impact to the bottom line.”
The election results, however, are much less certain, which from a risk perspective, weighs heavily on the minds of healthcare executives, Brill says. “How can you plan for business knowing that whatever you are doing currently could be upended in the beginning of November?”
To help provide some clarity, Managed Healthcare Executive identified five of the top industry issues, reviewed the candidates’ platforms for each, and asked industry experts to weigh in.
If elected, Clinton has said she would build on Obamacare to bring affordable healthcare to more people-dubbed Obamacare 2.0-and make a public option possible. This government-run health insurance agency would compete with private insurers in the exchanges, according to her official campaign website.
Hacker“A public option modeled after Medicare would provide affordable, broad-network coverage and insurance competition in all parts of the country, including the quarter or so of U.S. counties where only a single private insurer now operates,” says Jacob Hacker, director of the Institution for Social and Policy Studies, and Stanley B. Resor Professor of Political Science at Yale University. “Medicare’s own history with Medicare Advantage plans shows that it is possible to create a viable private market alongside a stable public plan, even as that public plan achieves comparatively slow per capita spending growth,” he says.
Sally Pipes, president and CEO, Pacific Research Institute, an advocacy group dedicated to advancing free-market policy solutions, says that if Clinton expands upon Obamacare, the government would have increased control and healthcare would move more toward a single-payer system.
Clinton has also said she would increase the enforcement of existing Affordable Care Act (ACA) requirements, such as having health insurers disclose the costs of specific medical services, their claims payment policies and practices, and certain quality data, says Joseph M. Mack, MPA, president, Joseph Mack & Associates, a healthcare business advisory firm.
To enforce these requirements, Mack says Clinton would need to ensure that the HHS secretary can block or modify unreasonable health insurance premium rate increases so coverage is more affordable.
Trump has said that he plans to repeal Obamacare on his first day in office. “We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone,” his campaign website states. This would be accomplished, Trump says, by following free market principles and creating sound public policy that would broaden healthcare access, make healthcare more affordable and improve the quality of care.
PipesWhat’s more, the site states, “Conservative Republicans have been offering reforms that can be delivered individually or as part of more comprehensive reform efforts.”
Although Trump hasn’t provided further details regarding his reform proposals, he did state during a February 2016 CNN-Telemundo Republican debate that he supports maintaining the pre-existing conditions provision of Obamacare, Mack says.
Pipes believes that repealing Obamacare would reduce the burden on health insurers struggling with financial losses due to poor enrollment in the Obamacare exchanges. “The major problem is that not enough young, healthy individuals have enrolled to cover the cost of claims for those who are older and sicker,” she says.
MackNinety percent of Americans now have health insurance because of Obamacare, according to Clinton’s campaign website. “Under Clinton, health insurance accessibility would be equal to or greater than it is presently under Obamacare,” Mack says. “The challenge would be controlling premium costs, as well as healthcare expenditures.”
Pipes cautions that more healthcare coverage would not necessarily mean universal access, as it could be more difficult for patients to secure appointments, treatments, and procedures.
Clinton also supports allowing individuals aged 55 or older to join Medicare, and has pledged to defend access to reproductive healthcare, double the funding for primary care services at community health centers over the next decade, and supports President Obama’s call for a near tripling of the size of the National Health Service Corps.
Finally, Clinton has several proposals aimed at ensuring insurance parity for essential health benefits provided through expansion of the ACA, including mental health and substance use disorder services, Mack says.
Trump plans to eliminate the individual mandate. His website sites, “No person should be required to buy insurance unless he or she wants to.” How could this affect access?
PadudaJoseph Paduda, MS, principal of consulting firm Health Strategy Associates and president of CompPharma, LLC, a consortium of PBMs, says that Americans would lose access to care they obtained via the ACA, “as insurers faced with rampant adverse selection pull back from markets.” Moreover, he says, “by completely deregulating the health insurance industry-except for maintaining the pre-existing conditions waiver-consumers would face a bewildering array of choices and options that will likely overwhelm all but the most expert buyers. Therefore, many would likely purchase coverage without understanding what they just bought.”
Mack adds that Trump’s plan to repeal Obamacare might also decrease the number of states expanding Medicaid.
In an effort to increase accessibility, Trump says he would allow health insurance to be sold across state lines. Although Trump does not clearly set forth this position, one argument is that by enabling insurance to be sold across state lines, it would shift from federal to state control, Mack says. “Theoretically, states may begin to compete with each other to lessen regulatory restrictions and costs on services required, and be more responsive to consumers’ demand for specific health insurance coverage. This may be more plausible for higher demand services for patients who have the ability to pay, than for services which may also be in high demand but which cost more-sought by those with limited or no ability to pay.”
Pipes says that individuals who live in high-cost states would be able to buy coverage from lower-cost states. “A national market would reduce restrictions on insurers as to where they could sell and would allow them to expand their consumer base, she says.
In an effort to make health insurance more affordable, Clinton’s plan bars insurers and providers from charging patients for out-of-network services received at in-network hospitals. It would also strengthen states’ authority to block insurance premium increases deemed unreasonable.
Pipes cautions that this could negatively affect insurers. “Many more insurers that are already dealing with major financial losses would likely be forced to leave the exchanges as a result of provisions such as these,” she says.
Clinton is also proposing to require health plans to provide three sick visits per year without counting toward deductibles, and to provide a new, progressive refundable tax credit of up to $2,500 per individual and $5,000 per family for excessive out-of-pocket costs. This would be funded by demanding rebates from drug manufacturers and asking “the most fortunate,” to pay their fair share, according to her website.
“The credit will be available to insured Americans with qualifying out-of-pocket health expenses in excess of 5% of their income, and who are not eligible for Medicare or claiming existing deductions for medical costs,” Mack says.
Clinton has also proposed limiting monthly out-of-pocket costs to $250 per month for individuals, and requiring pharmaceutical companies to pay higher rebates to Medicare in exchange for the federal program insuring prescriptions drugs, a measure her campaign says would save the program $100 billion.
“One of Clinton’s major focuses is on how to reduce out-of-pocket costs for consumers,” says Richard Sorian, who leads the Washington, D.C. healthcare team at FleishmanHillard, a public relations and marketing agency. “Those costs have been rising as more insurance policies come with very high annual deductibles and apply copayments to more services than before.”
Paduda believes Clinton’s stances related to the public option and Medicare for younger individuals would reduce the cost of insurance. “In particular, by removing older and more expensive individuals from the health insurance risk pool, premiums would cost less for people under age 55,” he says.
To make healthcare more affordable, Trump has said he would promote tax-advantaged health savings accounts (HSAs), and allow HSA holders to pass these funds on to their next of kin, tax-free, following their death.
“This will help not only consumers, but also employers reduce costs because HSAs allow individuals with high-deductible health plans to set aside money tax-free for healthcare expenses,” Pipes says.
Trump has also called for eliminating Obamacare's essential health benefit mandates, which Pipes says would make healthcare more affordable. “People would be free to purchase low-cost plans with high deductibles that don't cover procedures they don't want or need,” she says.
Trump also plans to lower healthcare costs by excluding all health insurance premiums from taxation and requiring all healthcare providers to provide price transparency, Sorian says.
Keeping the ACA in place, as Clinton has pledged to do, would ensure that many of its provisions to improve quality would continue, Sorian says. These include linking payments under Medicare to performance, and testing a variety of delivery system reforms, including accountable care organizations and patient-centered medical homes.
“We need to implement new and expand existing systems that pay for an entire episode of care or ‘bundle,’ or those that incentivize doctors and hospitals to coordinate care in an accountable care organization, so that providers are responsible for offering the best possible care at the highest value to patients-rather than letting costs rise higher and higher without more effective care,” her website states.
Pipes says Trump's vision for a private insurance market would protect those with pre-existing conditions by barring insurers from raising premiums because of health status or history, as long as that person has maintained continuous coverage. “This encourages people to buy and keep insurance, and not game the system under the special enrollment program,” she says. “Staying on insurance encourages people to get regular checkups and other preventive care, instead of only going to doctors when they're sick. A private market would also provide people with more power to choose healthcare providers, ensuring quality healthcare for everyone.”
Mack has a less positive view. “Under his proposals, healthcare consumers do not have access to free market information and the knowledge required to interpret such data to enable them to evaluate quality providers, mechanisms to report subpar healthcare services, or regulatory bodies to require standardized quality outcomes,” he says.
In addition to allowing individuals aged 55 or older to buy into Medicare, Clinton has pledged to work with governors to expand Medicaid in every state. “It is a disgrace that 19 states have left 3 million Americans without health insurance because their states have refused to expand Medicaid,” her campaign website states.
Clinton also plans to expand access to rural Americans by “making more healthcare providers eligible for telehealth reimbursement under Medicare and other programs, including federally qualified health centers and rural health clinics,” according to her website, which notes that funding for these centers would expand by $40 billion over the next 10 years.
Trump would convert Medicaid into a block grant program that states would run, according to his website, which notes that state governments “know their people best” and can manage the administration of Medicaid better without federal overhead. The site also states, “We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it.”
By switching to block grants, the government would be able to challenge states to spend their Medicaid dollars wisely, Pipes says. “States could tailor their programs to meet the specific needs of their state’s low-income population.”
Regarding Medicare and Social Security benefits, Trump has said that he does not want to cut them because most Americans want to keep these benefits as they currently stand, Mack says.
Regardless of which candidate is elected, the success of their proposals depends on which party controls Congress. “If Congress is split or controlled by Republicans, and if exchange premiums continue to increase, it will be difficult for Clinton to achieve Obamacare expansion,” Mack says.
He adds that the ability of the next president to potentially nominate several members of the Supreme Court will also affect the future of healthcare. Clinton would likely nominate justices who support women’s reproductive rights and Obamacare, while Trump might nominate justices that would overturn Roe v. Wade and healthcare reform.
November 8 will surely be a day to remember as Americans make their presidential choice.
Karen Appold is a medical writer in Lehigh Valley, Pennsylvania.
Editor’s note: The information contained in this article reflects the candidates' platforms as of September 1, 2016.