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Election Preview: Where the Candidates Stand on Health Care

Independent analysts examine Clinton and Trump proposals

Health care issues may not have made many headlines of late in the presidential campaign, but plans put forth by the two major party candidates could alter the landscape for physicians and patients alike, and in strikingly different ways.

trump and clintonFor instance, Democratic nominee Hillary Clinton wants to keep the Affordable Care Act alive, making what she sees as needed fixes. Republican nominee Donald Trump wants to kill the ACA and start over with something he says would work better and cost less.

To determine what effect their stances would have on health care in general, the RAND Corp., a nonprofit public policy research institute, drilled deep into the candidates' proposals, offering insight into how the American health care system would fare under their administrations. Backed by the Commonwealth Fund, a private foundation that supports health care policy research, the RAND report was issued in September.

Here's a closer look at each candidate's health care plan along with perspective from other independent reports and experts.

A Look at Clinton's Proposals

"She will try to fix problems that are in the ACA and not go back to the drawing board in the direction of repeal," said John Holahan, a fellow and former director of the Urban Institute's Health Policy Center in Washington, D.C.

As Clinton declared about the ACA during the second presidential debate: "I'm going to fix it. Premiums have gotten too high -- copays, deductibles, prescription drug costs. I've laid out a series of actions that we can take to try to get those costs down."

In its analysis, RAND looked at four of Clinton's proposed policies: cost-sharing tax credits to help certain consumers who pay more than 5 percent of their income on health care expenses, a reduction in maximum premiums on the marketplace, a fix for the ACA's so-called "family glitch" and a new "public option" to offer an alternative to consumers using the ACA marketplace to find insurance coverage.

RAND found that the four policies "increase the number of insured people and reduce consumers' out-of-pocket spending on health care." Specifically, the report estimates that the polices would boost the number of people insured by more than 10 million and would lower average spending by moderately poor consumers by as much as a third. However, those changes could boost the federal deficit by $88.5 billion, according to the RAND report.

Under Clinton's cost-sharing tax credit proposal, consumers with private insurance who pay more than 5 percent of their income on out-of-pocket health care expenses (including premiums) could get tax credits up to $2,500 per individual or $5,000 per family. RAND estimates that this policy could affect 9.6 million people, noting that the credits could "reduce consumer out-of-pocket spending for all groups; people with incomes above 400 percent of poverty will see a 7 percent reduction in spending."

As for lowering premiums, Clinton's proposal would shrink maximum premiums for benchmark plans available through the marketplaces. RAND estimates this policy change could bring insurance to 1.7 million more people.

"To really fix the Affordable Care Act and make it affordable for more people and create markets that are attractive to many of the insurers who've dropped out, we have to put more money into subsidies so people can afford more than lowest-cost options," Holahan said. "When more people can choose higher-cost options, it's more attractive to insurers and providers."

A recent Urban Institute report, co-written by Holahan, found that premium "benchmark" plans on the marketplaces are actually cheaper, by 10 percent, than average employer plans in most states and metro areas.

The third plank of Clinton's proposals that RAND analyzed would fix the "family glitch" -- a situation that can develop when the family breadwinner has employer-provided insurance that the government considers affordable, essentially blocking family members from getting subsidized coverage via the marketplace. Clinton's plan aims to make it possible for some with high family insurance costs to get premium assistance.

RAND estimates that fixing the glitch -- assuming that maximum premiums have been lowered, too -- would affect 2.8 million people.

The Kaiser Family Foundation reported in September that employer-sponsored health premiums for families had grown modestly, by 3 percent, in 2016. However, costs rose on another front, with deductibles increasing by 12 percent, on average, but more at smaller firms.

"We're seeing premiums rising at historically slow rates, which helps workers and employers alike, but it's made possible in part by the more rapid rise in the deductibles workers must pay," Drew Altman, the foundation's president and chief executive, said when releasing the report.

The fourth Clinton proposal analyzed by RAND was one that would introduce a "public option" -- similar to Medicare and Medicaid -- as an extra choice for people using the marketplaces. RAND estimated that this would boost the number of insured people by just 400,000.

"It is possible people could prefer the public plan if, for example, it has larger networks or fewer restrictions on service use," the RAND authors noted. "However, we have limited basis to assume that the public plan would be preferred to the private option." Using Medicare as an example, they wrote that "prior research has found that doctors are less likely to accept new Medicare patients than patients with private insurance."

Holahan described the public option as a "good idea" but cautioned that it might not be cheaper in all markets. Also, "you need a provider network," he said. "What kind of structure would be in place to negotiate with hospitals and doctors?"

RAND did not analyze several other health care proposals Clinton has put forth, including new protections for prescription drug users, perks for states that expand Medicaid, a Medicare "buy-in" for people 55 to 64 years old and marketplace access, without subsidies, for undocumented immigrants.

If Clinton were elected, her health care proposals could face immediate roadblocks in Congress if Republicans maintain control.

"If Republicans keep the House, which seems likely right now, what will Clinton do?" asked Merrill Matthews, a resident scholar with the Institute for Policy Innovation, a nonprofit public policy institute based in Texas that has a personal responsibility/limited government focus. "She wants to 'fix' Obamacare, but most Republicans want to repeal it. I've said for some time that it's unlikely they will repeal it -- even if they could -- but they do not support Clinton's price control proposals or providing more funding. So the question isn't really what would Hillary do to fix the ACA, but what would Hillary do to fix the ACA given a Republican House and possibly a Republican Senate?"

A Look at Trump's Proposals

In contrast to Clinton's list of health care proposals, Trump has offered more general ideas without details. "He has never provided many specifics about his plan, and most of what he has provided isn't much more than Republican boilerplate," Matthews said.

"Obamacare is a disaster -- you know it, we all know it," Trump told the audience tuned in to the second presidential debate. "We have to repeal it and replace it with something absolutely much less expensive and something that works, where your plan can actually be tailored."

As it did with Clinton, the RAND report analyzed four proposals from Trump: repeal of the ACA; allowing consumers more deductions for individual insurance premiums; the establishment of block grants for state Medicaid programs; and the elimination of current rules that prevent the sale of insurance across state lines.

"The policies would increase the number of uninsured individuals by 16 million to 25 million relative to the ACA," the RAND report found. "Coverage losses disproportionately affect low-income individuals and those in poor health. Enrollees with individual market insurance would face higher out-of-pocket spending than under current law."

RAND estimated that the four Trump reforms would boost the deficit by $5.8 billion.

Trump's plan to repeal the ACA would eliminate insurance for 20 million people, according to the RAND analysis. "All the coverage would be lost," Holahan said.

Sara Collins, an economist and Commonwealth Fund vice president for health care coverage and access, told the Associated Press that Trump's replacement plan isn't robust enough to make up for the insurance losses from repealing the ACA. "Certainly it doesn't fully offset the effects of repeal," she said.

Trump's proposal related to new deductions for health insurance premiums would eliminate federal subsidies for insurance coverage but allow consumers to purchase coverage on the open market with pre-tax dollars.

RAND estimated that this would add $40 billion to the deficit, compared with the cost of the existing ACA.

The third Trump proposal examined by RAND was his idea to convert Medicaid to a block grant program. He would give fixed amounts to states to fund Medicaid and, possibly, the Children's Health Insurance Program.

"We assume that states would eliminate eligibility for the ACA's Medicaid expansion population if offered block grants based on pre-ACA funding levels," the RAND report authors wrote. "But more than half of those who newly enrolled in Medicaid in 2014 were eligible under previous rules. Unless the block grants covered this woodwork population, states would have to find alternative means to finance this group or would need to reduce enrollment to break even."

Holahan said such a plan probably would produce intense political infighting over exactly what those fixed amounts would be.

"States have very different levels of spending," he said. "On day one, you would be giving State A four to five times as much as State B. As soon as senators and congressmen from places like State B see how much less they're getting, they'll oppose it. If you try to make it equal, you get a different set of losers."

The fourth Trump proposal analyzed by RAND was one that would affect the buying and selling of insurance policies. Individual states have traditionally controlled insurance coverage through regulations, but Trump wants to overhaul that system.

"Although details have not been fully specified," according to the RAND report, "this policy would allow insurers in one state to sell plans in another state without complying with the other state's regulations."

Analysts have raised a variety of concerns about this particular proposal. For one, states would lose their ability to force insurance companies to protect their consumers.

"You're moving back to a pre-ACA world," Collins said. "You'd likely see a race to the bottom in insurance carriers going to states with the least regulations in place. Those loosely regulated markets tend to benefit healthy people."

Matthews, who lives in Texas, voiced another concern: How out-of-state insurance companies would handle the challenge of offering local networks of providers.

Trump "has never explained how, if I buy a plan available in Utah, I'll have access to the Utah-based provider network tied to that plan," he said. "Many large health insurers sell in many, some in nearly all, of the states. I can buy a UnitedHealthcare plan for Texas, but that's based on cost of living and the provider network in Texas. So how does buying a UnitedHealthcare policy based in Utah, with Utah providers, help me in Texas?"

The Bottom Line for ACP Members

With the election just over two weeks away, it's time for American College of Physician members -- regardless of party preference -- to get schooled on health care issues that matter to physicians, determine where their preferred candidate stands and check whether those stances are consistent with ACP policy, said Dr. Nitin S. Damle, president of the American College of Physicians and an internist in Wakefield, R.I.

"Visit the ACP's election tool on our website for the College's perspectives on the top priority issues and ask your candidate and yourself who will best serve our patients," Damle said.

More Information

The ACP website's Presidential Election 2016 section includes a rundown of the College's stand on issues of importance in the current campaign.

The RAND Corporation offers a Q&A on its report, Estimating the Impacts of the Trump and Clinton Health Plans on its website.

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