On Health Reform, Presidential Candidates Propose Divergent Paths

With Republican Presidential candidate Donald Trump proposing to repeal the Affordable Care Act (ACA) and Democratic candidate Hillary Clinton promising to strengthen and expand it, this year’s presidential race offers stark choices on health care reform.

Health care reform has played a prominent role since the start of the 2016 presidential campaign season, with candidates and even Speaker of the House Paul Ryan (R-WI) proposing everything from a repeal of the Affordable Care Act to Medicare for all. As voters prepare to head to the polls, health policy experts say there are still many unanswered questions about how the health system would be affected by the 2 remaining major party candidates’ proposals or Speaker Ryan’s proposal.

“These issues are necessarily complex, because the American system of delivering and paying for health care is extraordinarily complex,” wrote Brookings Institution Senior Fellow Alice M. Rivlin, PhD, and Urban Institute Distinguished Fellow Robert D. Reischauer, PhD, in a report the pair issued at the outset of the presidential campaign in November 2015 (http://brook.gs/2b4hJDX). “Hence, proposed policy changes are inevitably complicated and hard to make clear to most voters.”

The report cited 3 key challenges the candidates must address, including resolving the future of the ACA, slowing unsustainable health spending growth, and reforming Medicare to ensure its long-term viability. Rivlin and Reischauer urged the candidates to rise above the current hyperpartisanship surrounding health reform to tackle these enormous challenges.

“Health care has to be a bipartisan program. It is too important not to be,” Rivlin said in an interview. “Unfortunately, we’ve gotten ourselves in this very polarized situation where the parties have very different approaches and there is gridlock.”

So far, however, the candidates’ and Ryan’s proposals have broken down along party lines.

Expanding ACA

Hillary Clinton’s health care proposals focus on expanding and strengthening the ACA.

“I want to build on the progress we’ve made,” states Clinton on her website. “I’ll do more to bring down health costs for families, ease burdens on small businesses, and make sure consumers have the choices they deserve.”

Clinton proposes making health care premiums more affordable, providing more generous federal subsidies, reducing out-of-pocket expenses, and capping prescription drug costs. As a compromise with her former rival Sen. Bernie Sanders (D-VT), Clinton also proposes adding a public option to the existing ACA health insurance exchanges. All of these proposals would require legislation and Clinton would have to negotiate with Congress, Rivlin noted.

Adding the public option is intended to increase options in markets where so far there has been less competition among insurers and fewer choices for consumers, explained Stephen Parente, MPH, PhD, Endowed Chair of Health Finance and Director of the Medical Industry Leadership Institute at the University of Minnesota.

But its effects on costs and competition depend on how it is structured.

We don’t know what a public option would look like or whether it would save money,” Rivlin said.

Prior to the enactment of the ACA, proponents of the public option worried that premiums in the insurance exchanges would be too high and argued a public option would bring premiums down, Rivlin explained. But 3 years into the exchanges, those assumptions have proven to be incorrect.

“Premiums came down in the individual insurance market quite dramatically, though they have crept up since,” Rivlin said. “[Insurance company] profits have been variable, but it hasn’t been a bonanza for insurance companies and many are losing money. It is not clear a public option would be a money saver.”

Clinton also proposes allowing those over age 55 to buy into Medicare. Again, Rivlin said a lot depends on how this plan would be enacted.

“If they set the premium at a level that would cover the cost, it wouldn’t affect the Medicare Trust Fund,” said Rivlin.

Boosting Medicaid access is another goal of the Clinton plan, including passing legislation that would extend the ACA’s Medicaid expansion to the 19 hold-out states. If they are successful, about 10 million people would gain coverage through Medicaid, said Parente, “but it’s a major cost.”

Those who are still not covered by insurance could receive care at a community health center, noted Parente. Clinton proposed doubling the funding for federally qualified community health centers. Again, however, there are costs associated with such increased access, he noted.

While some of the proposals are associated with increased costs, Rivlin said that Clinton’s plan stresses the continuation of health spending reforms created as part of the ACA. For example, Rivlin noted that Clinton has talked about moving alternative payment models and bundled payments from demonstration programs into wider use.

“I think she is very conscious of the problem of rising costs,” Rivlin said.

While none of Clinton’s proposals are specific to patients with chronic disease, if she succeeds in expanding coverage it might result in more insurance coverage for individuals with CKD.

“Anything that improves access is helpful,” said nephrologist John R. Sedor, MD, chair of the American Society of Nephrology’s Public Policy Board.

Sedor, who works at MetroHealth in Cleveland, Ohio, said it might be particularly helpful for the population of low-income patients with CKD at his hospital.

Scrapping ACA

On the other side of the aisle, Donald Trump promises to fully repeal the ACA, including the mandate that individuals buy insurance, and replace it.

“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 in the country,” he states on his website.

The Trump plan would allow sale of health insurance across state lines, allow more individuals to deduct the cost of insurance purchased on the individual market, boost use of health savings accounts, and require price transparency from health care providers.

Trump’s plan would change Medicaid into a block grant program, where states receive a set amount from the federal government to do with as they wish. Currently, the federal government has certain base requirements for state Medicaid programs and shares the costs with the states. States may offer more generous benefits.

An analysis of the Trump health reform plan by Parente and his colleagues at the Center for Health and the Economy found that the proposal would lead to an estimated 18 million fewer insured individuals, but is also projected to reduce premiums and health care spending (http://bit.ly/2b8MV59).

“It’s considerably cheaper than the status quo with the ACA,” Parente noted.

But there are trade-offs to the reduced costs associated with repealing the ACA.

“I think we’d go back to where we were with people having poor access to care,” said Sedor. “They would appear on our doorstep extremely ill and often require emergent care.”

Patients covered by Medicaid would be hardest hit.

“It’s mostly the Medicaid population who is losing their coverage,” explained Parente.

This loss of Medicaid coverage may be particularly detrimental to patients with CKD at the public hospital where Sedor works. He explained many of his patients have part-time jobs or jobs without benefits.

“Our patient population tends to be less highly employed; a lot of them don’t necessarily get coverage through work,” said Sedor. “Without Medicaid, they may not have an option.”

Patients with end stage renal disease (ESRD) wouldn’t be affected, noted Parente, because Medicare covers them regardless of age. But for those with less severe kidney disease, coverage would be contingent on whether they have access to employer-sponsored health coverage, are eligible for their state’s Medicaid program, and what they can afford, he noted.

“It really depends on disease severity, what state they are in, and how they want to try get their coverage,” he said.

Parente and his colleagues projected that premiums would decrease under the plan because it would roll back the ACA insurance requirements, such as that plans cover certain essential benefits or that companies issue insurance regardless of an individual’s health, explained Parente. Guaranteeing access to coverage regardless of health alone drives up premiums by 20%–25%, he noted.

“It reverts you back to what state regulations were in 2010,” said Parente.

Lower premiums and the return of “catastrophic plans” that provide very limited coverage at low cost might somewhat counteract the increase in the number of uninsured, Parente said. But, “it by no means compensates for the loss of coverage you get from eliminating ACA’s Medicaid expansion.”

Some patients with CKD, however, may prefer high-deductible, consumer-driven plans because they often place fewer restrictions on which clinicians are covered, Parente said. He explained that lower deductible plans might contain costs by excluding physicians who appear to be providing expensive care. Clinicians who specialize in providing care for those with severe disease may fall into this category.

“I’ve known a few people who are on dialysis or on kidney care and they are some of the most astute shoppers I know, whether they are clerical workers or academics,” Parente said. “They are not just shopping for a cheaper price but for more effective care.”

But Rivlin said the effect of the Trump plan on premiums really depends on whether it would repeal all the insurance market reforms implemented as part of the ACA. If it does, the individual insurance market would revert to the “chaotic” pre- ACA state, where individuals with chronic diseases, like CKD, pay more—if they can get insurance at all, she said.

“Premiums would go down for healthy people and up for the unhealthy,” Rivlin said. “We’ve been there.”

“People forget what a huge advance the insurance reforms were,” she said. “They’ve created a market in which insurance plans are competing on price and coverage rather than just competing to insure the lowest cost group of people.”

The Trump plan might also increase health spending, if it eliminates the cost-containment experiments like alternative payment models in the ACA, Rivlin noted.

The Ryan alternative

The Ryan proposal (http://bit.ly/28MOcdF) also draws on some Republican mainstays, including making Medicaid a block grant program. However, Parente and his colleagues at press time hadn’t yet analyzed the plan’s effects and were still gathering details about it.

“The Trump plan has ideas [Republicans] have talked about for 10 years, but is not stitched together very well,” Parente said. “As a consequence, it leaves a lot of people without insurance. The Ryan plan tries to get some of the efficiency that is in the Trump plan but still covers as many as possible.”

For example, the Ryan plan preserves a modified version of the ACA’s prohibition on insurance denials based solely on pre-existing conditions, Parente noted. Individuals would at least receive a quote, he said. The Ryan plan also preserves a modified version of the ACA’s community rating system. Under the ACA, companies are not allowed to set premiums based on health status, only age, geographic area, and smoking. The ACA also limits how much more insurers can charge based on these factors. Under the ACA, insurers can charge older customers up to 3 times more than younger ones for an identical insurance plan. Ryan’s plan would allow them to charge older customers up to 5 times more than younger ones.

The Ryan plan proposes making high-risk pools available for patients who can’t access coverage elsewhere.

The effects of Ryan’s Medicaid block grant plan on coverage are uncertain.

“It would depend on how it would be structured,” Rivlin said. “The fear is that ungenerous states would cut back.”

The official Republic National Committee platform also proposes shifting Medicare toward a premium support program rather than a defined benefit and increasing the eligibility age (http://bit.ly/24W6Ipw). Under such a plan, seniors would purchase competing commercial insurance plans using a federal subsidy, similar to the way ACA works, Rivlin noted.

“I’m on the record as thinking a gradual shift to premium support, if well designed, is a good thing,” said Rivlin. “The federal government can define the subsidy and not increase it any faster than Congress wants to.”

But it has to be done carefully and gradually, she emphasized. She noted earlier health reform proposals suggested by Ryan would be very gradual, but the subsidies over time would become much less generous than Medicare in its current form.

“It doesn’t have to be that way,” Rivlin said. “In fact, Ryan himself moved to a more moderate plan.”

One possible scenario if Trump wins and Ryan remains Speaker of the House is that the Ryan plan will move forward, said Parente.

“The Ryan plan has probably greater traction to move,” said Parente.

The chances that either parties’ plans will be enacted as is, is “zero,” said Rivlin. She predicts that most likely ACA and Medicare will be preserved and improved upon. Medicare might move in the direction of premium support, building on Medicare Advantage plans, which already cover about one-third of Medicare beneficiaries.

Regardless of who is elected, the health reform changes that are made during their presidency could well be a mash-up of the two parties’ proposals. Parente, who advised Sen. John McCain (R-AZ) during the 2008 presidential campaign, noted that the ACA has ideas from both Hillary Clinton’s and Sen. McCain’s 2008 campaign health proposals.

“It more or less became a fusion of McCain’s and Clinton’s plans,” he said. “That could happen here, too.”