While health care has not been central to the 2016 Presidential campaign, the election’s outcome will be a major determining factor in the country’s future health care policy. A number of issues have garnered media attention, including the future of the Affordable Care Act (ACA), rising prescription drug costs, and the opioid epidemic.
Hillary Clinton and Donald Trump have laid out different approaches to addressing these and other health care issues. Central among these is their position on the future of the ACA. Hillary Clinton would maintain the ACA, and many of her policy proposals would build on provisions already in place. Donald Trump, in contrast, would fully repeal the ACA, and although his policy proposals and positions do not offer a full replacement plan, they do reflect an approach based on free market principles.
The Affordable Care Act (ACA) set new standards for virtually all private health plans, including a prohibition on pre-existing condition exclusions and a requirement for private plans to extend dependent coverage to the age of 26. The law also established new marketplaces for the sale of nongroup insurance to all individuals except undocumented immigrants, and created new subsidies for nongroup coverage. New fees, taxes, and offsetting budget savings were adopted to finance ACA subsidies and reduce the deficit, including a so-called “Cadillac tax” on high-cost employer-sponsored plans. The Congressional Budget Office (CBO) estimated repeal of the ACA would increase the federal deficit by $137 – $353 billion over 10 years (2016-2025). Since enactment, the uninsured rate has fallen to 8.6% and an estimated 20 million Americans have gained coverage, while 27 million remain uninsured. Public opinion about the ACA remains divided, largely on partisan lines. Several issues have emerged in the 2016 campaign.
Affordability of premiums and cost sharing. Under ACA, refundable premium tax credits (APTCs) subsidize the cost of marketplace policies for people ineligible for affordable group coverage at work or public programs and who have income between 100% and 400% of the federal poverty level (FPL). These APTCs protect individuals from the full cost of coverage in the marketplaces; however, bigger premium increases proposed for 2017 are a concern. An estimated 6.1 million people are ineligible for APTCs because of the so-called “family glitch,” in which the definition of affordable group coverage takes into account the cost of self-only coverage even if adding dependents to the job-based plan is not affordable.
The ACA also offers cost sharing subsidies for marketplace participants with income between 100% and 250% FPL, and requires all new private plans to limit cost sharing for covered benefits to more than $7,150 for self-only coverage in 2017. Affordability of cost sharing pre-dates the ACA and continues to be a challenge. Under job-based group plans since 2010, annual deductibles have risen almost three time as fast as premiums and about seven times as fast as wages and inflation. One in five insured Americans struggle to pay medical bills. Health plan cost sharing is the leading factor contributing to medical debt among the insured. Out-of-network medical bills also contribute significantly; and 7 in 10 people who could not afford bills from out-of-network providers were unaware the provider was not in their plan network when they received care. Such bills are sometimes called surprise medical bills.
Enrollment in high-deductible plans continues to grow, a trend that predates the ACA. Enrollees in such plans can often open health savings accounts (HSAs) to defray cost sharing and could deduct HSA contributions. HSAs can transfer tax free to heirs who are spouses, but are otherwise subject to income tax upon the account holder’s death.
Marketplace enrollment. In March 2016, 11.1 million individuals were enrolled in marketplace plans representing 40% of the population estimated eligible to enroll in marketplace plans, though enrollment varies by state. If all states enrolled at the average rate of the top ten highest performing states (that together have enrolled 59% of eligible consumers) marketplace enrollment could be nearly 50% higher. Affordability continues to be the major reason that the uninsured lack coverage, but lack of awareness about the ACA is also a factor. Although Marketplaces are required to provide in-person consumer assistance, as the third open enrollment period ended, two-thirds of uninsured consumers polled were unaware the deadline was approaching and 80% said they had not been contacted by anyone about signing up for coverage.
Health plan choice and competition. The ACA requires all plans to provide standardized summaries of coverage to facilitate plan comparisons. Also to help consumers and regulators compare plan performance, the ACA requires all new private plans to disclose transparency data indicating how promptly claims are paid, how often they are denied, the availability and cost of in-network providers, and other measures. These transparency provisions have not yet been implemented.
Marketplaces were designed to encourage competition between health insurers. However, for 2017, some insurers have announced they will no longer offer plans on the marketplace, raising concerns about consumer access to a choice of plans and a reduction in competition, particularly in rural counties. Two-thirds of marketplace participants in urban counties will likely continue to have a choice of 3 or more insurance companies in 2017; by comparison, 41% of enrollees in rural counties will likely have a single insurer, up from 7% in 2016.
Where the Candidates Stand
Hillary Clinton. Hillary Clinton supports policies to maintain and build upon the ACA. She would increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage. She would also fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status. Hillary Clinton would make a public plan option available in every state and give people the option of buying into Medicare starting at age 55. She would invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions. She would authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, and she would repeal the Cadillac tax. Hillary Clinton has also proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network. She has also proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
Donald Trump supports complete repeal of the ACA, including the individual mandate to have coverage. In lieu of requiring insurers to provide coverage to everyone regardless of health status, he would work with states to create high risk pools for individuals who have not maintained continuous coverage. In place of refundable premium tax credits, Donald Trump would provide a tax deduction for the purchase of individual health insurance. Donald Trump would promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply. Donald Trump would promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs. Donald Trump would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.
Medicaid is the nation’s main public health insurance program for people with low incomes covering about 70 million Americans. Medicaid provides coverage for low income individuals and families with low or no out-of-pocket costs for care; assistance to low-income Medicare beneficiaries; coverage for long-term services and supports, and financing for safety-net hospitals, clinics and states. The two key Medicaid issues in the campaign focus around financing and the ACA Medicaid expansion.
ACA Medicaid Expansion. Effective January 1, 2014, ACA expanded Medicaid eligibility millions of non-elderly adults with income at or below 138% of the federal poverty level (FPL) – about $16,394 for an individual in 2016. The law also provided for 100% federal funding of the expansion through 2016, declining gradually to 90% in 2020 and future years. The Supreme Court ruling on the ACA in June 2012 effectively made the Medicaid expansion optional for states. As of September 2016, 32 states (including the District of Columbia) have implemented the ACA Medicaid expansion.
Financing. States administer their own Medicaid programs within federal requirements, and states and the federal government jointly finance the program. Under current law, federal Medicaid payments are guaranteed with no pre-set limit based on a formula set in statute that pays a larger share of program costs in poorer states. The financing structure allows states and the federal government to increase spending when there is increased demand or need (to respond to recessions, epidemics, emergencies or increases in medical or drug costs); however, it also makes federal financing more unpredictable and harder to control.
Where the Candidates Stand
Hillary Clinton. Hillary Clinton supports policies to maintain and strengthen the current Medicaid program and financing structure. Hillary Clinton would encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand. Clinton would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
Donald Trump. Donald Trump supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion). He has said he would cover the low-income uninsured through Medicaid after repealing the ACA. The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.
Medicare is the nation’s health insurance program that provides coverage to 57 million seniors and younger adults with permanent disabilities. Four issues related to Medicare have emerged during the 2016 presidential campaign.
Premium support. Some have proposed changing the structure of Medicare to a system of premium supports under which Medicare would make a payment on behalf of each beneficiary which would be used toward the purchase of health insurance coverage — either traditional Medicare or a private plan. This proposal was frequently debated in the 2012 election, supported by Speaker Paul Ryan and included in the House Republican Plan.
Prescription drug costs.Rising drug costs, especially high-priced specialty drugs, have emerged as a significant issue for consumers, Medicare and other payers, leading to a number of proposals to slow cost increases.
The future of the Affordable Care Act (ACA), including its Medicare provisions. A major issue in this election is whether the ACA should be repealed. The ACA included a number of changes to Medicare, such as reduced costs for Medicare-covered preventive services and prescription drugs, and several reforms to how Medicare pays for and delivers care to beneficiaries. If repealed, Medicare spending would increase by more than $800 billion over 10 years, according to the Congressional Budget Office.
Medicare buy-in for adults between the ages of 55 and 64. Allowing older adults to buy in to Medicare would provide another option for health insurance coverage, in addition to individual policies available to them in (or outside) the ACA Marketplaces.
Where the Candidates Stand
Hillary Clinton. Hillary Clinton supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs, Clinton supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid. Hillary Clinton does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms. On the issue of Medicare eligibility, Clinton has proposed to allow people ages 55 to 64 to buy into Medicare.
Donald Trump. Donald Trump has not stated his position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare. Trump supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions. On the issue of prescription drug costs, Trump supports allowing safe re-importation of prescription drugs from other countries.
Prescription drugs are the third largest area of U.S. health spending, and a main driver of growth. New drugs, which require significant research and development (R&D) investments, receive a period of patent protection and market exclusivity. Following this period, the Food and Drug Administration (FDA) may approve generic drugs, which perform the same as the brand name product, often at much lower costs. The Affordable Care Act (ACA) includes a provision to fast-track approval of “biosimilars,” which are drugs that perform similarly to an existing biologic drug (one derived from living organisms). Since 2010, more new specialty drugs have been approved than traditional drugs. Unlike traditional drugs, specialty drugs (which are often biologics) require special administration (such as injection) or close observation by a physician.
Prescription drug spending and prices. Spending on prescriptions had grown slowly, even dropping at times in recent years, due to a number of drugs losing patent protection and substitution by more affordable generics. In 2014 and 2015, drug costs rose rapidly, driven by the introduction of high-cost specialty drugs as well as fewer drugs coming off patent. On average, generic drug prices have declined while brand name prices have increased, though there are several notable examples of generic price increases. The prices of many prescription drugs are higher in the U.S. than in similar countries, and the U.S. is one of only two developed nations that allow direct-to-consumer advertising.
Out-of-pocket drug costs. Though most of the increase in drug spending was covered by insurance in 2014, out-of-pocket (OOP) spending on prescriptions also increased. In 2015, most people taking prescription drugs said they could afford their treatment, but about 1 in 4 people taking drugs have difficulty affording their medication.
Where the Candidates Stand
Hillary Clinton. To address drug prices, Hillary Clinton proposes to increase generic competition by prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry; increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog; reducing the market exclusivity period for biologics; and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs, she proposes to establish consumer oversight in federal agencies; penalize drug companies for unjustified price increases; and allow importation of lower-cost drugs from countries with similar safety standards. She also supports eliminating tax deductions for direct-to-consumer advertising; requiring FDA approval of advertisements; tying federal support for drug companies to their investment in R&D; increasing transparency of the additional value new drugs have over existing treatments; and allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions, Hillary Clinton proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
Donald Trump. Donald Trump supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S. He also supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.
In recent years, the use of prescription painkillers for nonmedical purposes, as well as drugs derived from opium (such as heroin), has emerged as a major public health issue. In 2013, 1 in 20 nonelderly adults used opioids for nonmedical purposes. For one in five users (almost 2 million nonelderly adults), the nonmedical use of opioids increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction. Overdose deaths involving opioids have quadrupled since 1999, with over 14,000 individuals dying from opioid overdoses in 2014, leading to what many refer to as an “opioid epidemic.” The opioid epidemic creates an estimated $55 billion annually in societal costs, such as health care expenditures, workplace costs due to lost wages and utilization of sick days, and criminal justice costs. Proposed policy actions to address the opioid epidemic include efforts to change prescribing practices to curb utilization of opioids, improve access to treatment for individuals with opioid use disorder, and enforcing drug laws to combat access, sale and use of illicit drugs.
Where the Candidates Stand
Hillary Clinton. Hillary Clinton has released a $10 billion (over ten years) plan to fight drug addiction. The plan includes a federal-state partnership to support education and mentoring programs, development of treatment facilities and programs, efforts to change prescribing practices, funding to increase first responders’ access to naloxone, and criminal justice reform. Clinton’s plan also includes direct federal action to increase funding for inpatient and outpatient treatment options, change federal rules that prevent nurse practitioners and physician assistants from prescribing recovery medications, enforce federal parity standards, remove obstacles to Medicare and Medicaid payment for addiction services, and issue guidance on prioritizing treatment over incarceration for nonviolent and low-level federal drug offenders.
Donald Trump. Donald Trump has said he will stop of the flow of illegal drugs into the country by building a wall on the U.S.-Mexican border and closing shipping loopholes that allow dangerous drugs to be mailed into the U.S. Donald Trump would also enhance access to addiction services, end Medicaid policies that obstruct inpatient treatment, increase first responders’ access to naloxone, lift the cap on the number of patients that providers can treat with recovery medicines, and expand incentives for state and local governments to use drug courts and mandated treatment to respond to the addiction crisis.
Reproductive health is an essential element of women’s healthcare. The Affordable Care Act (ACA) greatly expanded coverage for these services for millions of women. Access and availability of abortion services and federal payments for contraceptive providers, however, have emerged as key issues in this year’s presidential election.
Preventive services. For women, a key provision of the ACA requires that all new private insurance plans and Medicaid expansion programs cover no-cost preventive services. The majority of these services are exclusively or primarily used by women, such as prescription contraception, STI counseling and testing, cancer screenings, a broad range of pregnancy-related screenings, and well-woman visits.
Publicly funded family planning. The Federal government has a long record of support for publicly funded family planning services through Medicaid and the Title X program. Planned Parenthood is a key participant in both of these programs. Recently, some states have attempted to remove Planned Parenthood from their Medicaid provider network. However, they have been blocked because the current federal law requires states to allow Medicaid beneficiaries to access family planning services from any participating provider of their choice.
Abortion. Starting with Roe v. Wade, the Supreme Court has defined a woman’s constitutional right to abortion. In 1980 the Court upheld the Hyde Amendment, which greatly restricts federal funding for abortion for millions of women enrolled in Medicaid as well as others covered by federal programs such as the military and Indian Health Service. In addition, many states have regulations that restrict access to abortion services. Most recently, the Supreme Court’s decision in Whole Women’s Health limited the state legislature’s ability to impose regulations on abortion clinics.
Where the Candidates Stand
Hillary Clinton. Hillary Clinton supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion. She defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. She has promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. She has also called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care. She would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
Donald Trump. Donald Trump has called for defunding Planned Parenthood if they continue to provide abortion and would redirect their funding to community health centers. He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment. Trump has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade. He would also work to make the Hyde Amendment permanent law and sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions. He would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.
Zika is a virus transmitted primarily by mosquitos; it can also be spread through sexual contact, from mother to child, and via blood transfusion. In 2015, Zika was reported for the first time in the Western Hemisphere. Zika infection during pregnancy has been linked to microcephaly and other serious birth defects. This link prompted the World Health Organization to declare a “public health emergency of international concern” earlier this year and the Centers for Disease Control and Prevention (CDC) to issue travel warnings to pregnant women and those seeking to become pregnant to avoid Zika-affected areas. The first cases of locally-transmitted Zika (from mosquito to human) in the U.S. were reported in Puerto Rico in December 2015. In July 2016, local transmission was reported in Miami, Florida.
Zika is the latest in a growing list of infectious disease outbreaks, joining HIV, SARS, H1N1, and Ebola, which have taken the world largely by surprise, raising challenging questions about how the U.S. and other countries can best anticipate and respond to these threats. With Zika, such questions have become political, particularly concerning funding as well as access to family planning and reproductive health services for women.
Funding for emerging disease threats. The U.S. currently has limited funding mechanisms available to respond to emerging disease threats and new Congressional appropriations are often needed or funding must be reallocated from other areas. Because of this, in February of this year, President Obama sent an emergency funding request to Congress for almost $1.9 billion to address Zika internationally and domestically (as it did with the Ebola outbreak in 2014). Congress has considered several bills to fund Zika, each of which provides significantly less funding than the President requested and includes other program and policy differences. To date, Congress has yet to approve any Zika funding, and the Administration is using funds from other areas, including Ebola, to address Zika.
Access to family planning and reproductive health services. Because the main public health concern related to Zika is the link between infection during pregnancy and birth defects, women’s access to family planning and reproductive health services is critically important and has become a contested issue in the Zika response. The Conference Agreement passed by the House placed a restriction on some of the funding for HHS, which some have argued would prevent funds from going to organizations that provide family planning and reproductive health services, and as a result, it has been opposed by Democrats in Congress.
Where the Candidates Stand
Hillary Clinton. Hillary Clinton supports emergency funding for Zika, and in March, called upon Congress to appropriate $1.8 billion in emergency funding. She supports the bipartisan Senate bill which passed in May and includes $1.1 billion in funding. She has stated that Congress should pass a bill “free of politics”. More broadly, Clinton has called for investment in public health preparedness including the creation of a Public Health Rapid Response Fund to address emerging disease threats like Zika.
Donald Trump. Donald Trump does not have a position on funding for Zika or on public health preparedness.
Election 2016: Side-by-Side