While health care was not 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.
President-elect Donald Trump has laid out different approaches to addressing these and other health care issues. Central among these is his position to fully repeal the ACA.
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.
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, Trump would provide a tax deduction for the purchase of individual health insurance. He 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. He would promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs. 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.
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.
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. He 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.
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.
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. He 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.
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.