Democrats and Republicans agree on very little when it comes to the future of the U.S. health system. But what both sides have in common is the prioritization of health as a campaign issue in the 2016 presidential race. Numerous reports have found that Americans pay more for their health care than any other developed country but see some of the worst health outcomes.
Democrats Bernie Sanders and Hillary Clinton and Republican Donald Trump have all provided a set of proposals to address how they’d change health care. Clinton has taken a relatively cautious approach by seeking to bolster Obamacare, while Sanders is pushing for universal health care. Meanwhile, Trump believes he can save the health care system $11 billion by deporting illegal immigrants.
I asked a panel of seven experts ranging from entrepreneurs to health policy experts to weigh in some of the proposals put forward by the candidates: Are they viable? Crazy? Practical? Too vague to be understood?
Here’s what they had to say.
Her platform: Of all the candidates, Clinton has most firmly hitched her wagon to Obamacare. To assuage various criticisms of the law, she recommends a series of tweaks that aim to reduce out-of-pocket costs for individuals and families. This approach might seem fairly conservative, but she has taken a step to the left with a proposal to bring back the “public option.” That would give more people the opportunity to buy into Medicare.
The proposal: Make it more affordable for individuals and families to buy health care via the Obamacare exchanges by offering tax credits to offset out-of-pocket costs for those who are eligible. Fix the “family glitch,” an error that doesn’t take an employee’s family into account when determining subsidies. So if an employer offers affordable insurance but doesn’t offer it to the family, they won’t be able to get subsidies through the exchanges.
What our experts say: Thumbs up, but it won’t be easy.
Bari: “Let’s not focus on a complicated tax credit; let’s just close the ‘family glitch’ loophole. Get Congress on board. Just fix it.”
Diamond: “The ‘family glitch’ is one of the peskiest problems with Obamacare–and one that hasn’t been fixed for six years and counting, so Clinton would have her work cut out for her.”
Ostrovsky: “This is a good proposal and would likely lead to better experience of care for low-income families.”
The proposal: “Crack down on rising prescription drug prices and hold drug companies accountable so they get ahead by investing in research, not jacking up costs,” Clinton stipulates in her health care plan.
What our experts say: A bit vague, and might serve to obfuscate the bigger issues.
Chase: “That seems like a Band-aid. The bigger issue is making sure that we don’t give drug makers the ability to jack up prices.”
Ostrovsky: “Pharma drug pricing is part of a larger systemic problem, and fixing that problem requires a thoughtful approach that takes into account all stakeholders’ perspectives, including pharma. Just cracking down on pharma will likely not be a fix.”
Harlow: “That’s a significant issue with extreme examples, like the Martin Shkreli case taking over news reports. But of course, there are counter examples. A Hepatitis C drug might cost $100,000 for a course of treatment, but that’s a lot cheaper than scheduling a kidney transplant.”
The proposal: Give more people the option to buy into Medicare. “Hillary supports a ‘public option’ to reduce costs and broaden the choices of insurance coverage for every American,” her health plan reads.
What our experts say: Yes, in some–but not all–contexts.
Bari: “It’s a good idea in some contexts. In counties and states where there aren’t players on the exchanges, bringing in the public option might be a good way to increase competition and drive down prices.”
Kraus: “She’s throwing a bone to Bernie’s supporters. Medicare is very popular. This seems reasonable to me.”
Diamond: “Intriguing idea. It would address several of the biggest challenges with Obamacare–like private payers’ lackluster support for the insurance exchanges–and while expanding a government entitlement program can sometimes seem like a political nonstarter, it’s worth noting that the White House already did that, with Medicaid.”
The proposal: Continue President Obama’s Medicaid expansion effort by allowing any state that signs up to receive a 100% match for the first three years, her campaign website suggests.
What our experts say: A great idea; unclear what costs will be incurred in the short and long term.
Bari: “It should be permanent. The people eligible for Medicaid expansion don’t cost a ton of money to the system. Generally speaking, they are low-income but they aren’t elderly or disabled. It will really help states commit to Medicaid expansion, which is really important to further health coverage to people who need it and prevent costs down the road.”
Harlow: “Great. A real opportunity to help people. But how would it address the ‘woodwork effect,’ where previously eligible individuals appear to come out of the woodwork to sign up for Medicaid as a side effect of Obamacare?”
Kraus: “I’m a believer in Medicaid. In the short term, this will likely lead to massive government deficits and cost increases. But in the long term, I think it’s a good thing for population health. We’ll have to look back 30 or 40 years to find out if it was a good investment.”
His platform: “I would end Obamacare and replace it with something terrific, for far less money for the country and for the people,” Trump proclaimed to reporters last July. But thus far, Trump has been fairly vague about what that “terrific” plan might be. Many of his critics say that repealing the Affordable Care Act would be a political disaster at this point, especially without a solid plan to replace it. Trump’s plan hinges on deregulation and opening up the free market (with the exception of Medicare). One proposal he has put forth to reduce health care costs is to deport illegal immigrants.
The proposal: Increase competition by modifying an “existing law that inhibits the sale of health insurance across state lines,” Trump’s campaign website suggests.
What our experts say: Nonsensical.
Fifield: “Health insurance plans aren’t magically priced. They are based on market rates of health services in that state. I’d love to buy in Texas, but all health services will cost more, which would break the actuarial model. This plan is cuckoo.”
Diamond: “A Republican hobby horse that probably wouldn’t amount to much. Insurers can sell across state lines right now, and there are clear reasons for why they don’t–it’s not financially remunerative, for starters.”
Ostrovsky: “Abolishing Obamacare would likely be harmful to patients and politically nearly impossible. Sales of health insurance across state lines may bolster competition and lower prices, and I would support a systematic testing of that hypothesis through rigorous quality improvement.”
The proposal: Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Trump says on his website, “Businesses are allowed to take these deductions, so why wouldn’t Congress allow individuals the same exemptions?”
What our experts say: I guess so . . .
Bari: “Totally fine, but it doesn’t address the main problem with the Affordable Care Act: Affordability. If you can’t pay a premium, it won’t help that you can deduct it from your taxes.”
Fifield: “57% of Americans get health insurance through their employer. They deduct [it] already.”
Chase: “Excellent idea. I agree that it’s not fair to individuals.”
The proposal: Save money by reducing access to health care by illegal immigrants. This costs the U.S. “some $11 billion annually,” Trump’s official health care reform plan reads. “If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve health care cost pressures on state and local governments.”
What our experts say: Not ethical, and unclear whether it would lower costs
Bari: “I don’t think it would serve to reduce costs in a meaningful way. A lot of people use emergency services now, including those who are undocumented, but it’s not the biggest part of our cost.”
Ostrovsky: “This, like most other Trump policies, is unethical, financially imprudent, and would likely not get enough political support to be operationalized.”
Fifield: “Hospitals won’t deny people that don’t have coverage. They find ways to write off these costs. We’d be better off if we acknowledged and accounted for this, whether it’s illegal immigrants or people who don’t have insurance.”
The proposal: “Remove barriers to entry into free markets for drug providers that offer safe, reliable, and cheaper products,” his campaign website reads. Trump’s campaign doesn’t offer many further details, except “allowing consumers access to imported, safe, and dependable drugs from overseas will bring more options to consumers.”
What our experts say: Not a totally crazy idea with a few caveats
Bari: “Interesting because he is addressing the affordability issue around pharmaceuticals, but from a health economics standpoint, I don’t think that pharma companies in the U.S. would be happy with that. It might also raise the price of those drugs in other countries.”
Kraus: “That might be one of the least crazy ideas as it applies to generics and branded pharmaceuticals that are in pill form.”
Ostrovsky: “In the short term, this would likely be a benefit to patients because they would have lower cost drug options. This would also create a large disruption to the U.S. pharma industry that could be good and bad for patients. Notably, if revenues for pharma went down, their R&D budgets could be impaired, leading to less development of less profitable drugs.”
The proposal: “Require price transparency from all health care providers, including doctors,” Trump’s campaign website recommends.
What our experts say: Sure, but how?
Fifield: “A workable concept, but the mechanics make it difficult. Would patients be much helped by seeing each provider’s fee schedule?”
Harlow: “Transparency is a good thing. But we also need quality transparency. Price doesn’t mean much without quality.”
Chase: “This is a bit vague, but I have no problem with it. You know the price ahead of time when you buy food or a car, why not health care?”
His platform: Bernie Sanders is the only candidate to mention other countries’ health systems in his health care proposal. Sanders wants to move to universal health care in the U.S. by separating health coverage from employment. He’d start by creating a federally administered health care program akin to “Medicare for all.” Sanders says this would take a “huge bite” out of the financial distress felt by low-income people. But critics say the cost of such a transition would vastly exceed the benefits.
The proposal: Via Sanders’ campaign website: Let’s create a single-payer system to get health care spending under control. Rather than leaving it up to private insurers, the government will reimburse doctors and hospitals for treatments. Let’s pay for it with progressive tax rates, a 2.2% income-based premium, and a 6.2% income-based health care premium paid by employers.
What our experts say: Wonderful in theory, but It could prove more costly than you might think
Bari: Every credible estimate has shown that it’s at least twice or three times more expensive than he’s estimated. Nothing wrong with the idea, but it requires a massive shift across the country.
Kraus: My biggest issue with the shift to single payer, besides the costs around it, is that it might create even more “haves and have nots” in health care. It might lead to an increase in concierge medicine, and doctors and patients who operate outside of the single payer system. I worry that it will lead to a more fractured health care system.
Harlow: It’s a wonderful idea in the abstract, but it’s a little pie in the sky. Some analysis has shown that it would very expensive.
Diamond: This is slightly more improbable than Sanders winning the Democratic nomination–an idea that, like single-payer, has fervent supporters but seems politically impossible.
It’s fairly typical at this stage for the candidates’ health plans to be rather vague. But many of the experts saw some noticeable gaps that none of the candidates even mentioned, let alone addressed. “Interoperability is a big one,” says Harlow, speaking to the lack of data sharing among the various electronic medical record vendors, which has led to medical errors and patients carrying around their records in paper bags.
Another gap? Precision medicine. None of the candidates have shared plans on whether they would support the $215 million initiative that aims to uncover the genetic roots of disease and tailor treatments to individual patients. Without support from the candidates, it’s possible that the initiative won’t meet its goal of gathering data from at least 1 million volunteers by 2019.
What do you think about these proposals? And where do you see gaps in the candidates’ plans? Let me know on Twitter @chrissyfarr