Clinton's Health Plan Gets Mostly Passing Grades From Policy Experts (Mostly passing, say I, but lukewarm at best)
By Joyce Frieden
Democratic presidential candidate Hillary Clinton's ideas for improving the Affordable Care Act (ACA) drew cautious praise from health policy scholars, but they said they had no chance of enactment without a major change in Congressional attitudes.
"If we're really serious about getting to the general uninsured and getting costs down, and it's a choice between scratching everything and starting over [or] building on the Affordable Care Act ... I would build on what Clinton's talking about," Ken Thorpe, PhD, of Emory University in Atlanta, said in a phone interview.
Clinton's plan is "Very much a small adjustment to ACA, and in the climate we have, getting anything through [Congress] is a real challenge," said Paul Hughes-Cromwick, MA, of the Center for Sustainable Health Spending at the Altarum Institute, in Ann Arbor, Mich. "Most of what she's talking about is very small, and some things are already happening."
On her website, Clinton lists the following planks among those in her healthcare proposal:
* Make premiums more affordable and lessen out-of-pocket expenses for consumers purchasing health insurance on the ACA exchanges. This would include a tax credit of up to $5,000 per family to offset a portion of out-of-pocket and premium costs above 5% of income.
* Support new incentives to encourage all states to expand Medicaid. Clinton proposes allowing any state that signs up for the Medicaid expansion to receive a 100% match for the first 3 years.
* Invest in navigators, advertising, and other outreach activities to make exchange enrollment easier. Today, as many as 16 million people or half of all those uninsured are eligible but not enrolled in Medicaid or an exchange plan. Clinton plans to invest $500 million per year in an aggressive enrollment campaign.
* Expand access to affordable healthcare to families regardless of immigration status. Clinton "believes we should let families -- regardless of immigration status -- buy into the Affordable Care Act exchanges," according to her website.
* Continue to support a "public option." Clinton wants states to be able to establish a public option under which people could buy into a publicly funded health insurance plan.
* Defend the ACA. "Hillary will continue to defend the ACA against Republican efforts to repeal it," the website said. "She'll build on it to expand affordable coverage, slow the growth of overall health care costs (including prescription drugs), and make it possible for providers to deliver the very best care to patients."
* Lower out-of-pocket costs like co-pays and deductibles. "Hillary believes that workers should share in slower growth of national healthcare spending through lower costs," according to the website.
* Reduce the cost of prescription drugs. "Hillary believes we need to demand lower drug costs for hardworking families and seniors."
* Transform our healthcare system to reward value and quality. "Hillary is committed to building on delivery system reforms in the Affordable Care Act that improve value and quality care for Americans."
Compared with the plan offered by Clinton's Democratic primary opponent, Sen. Bernie Sanders (I-Vt.), who wants to institute a single-payer "Medicare-for-all" program, hers is "definitely more realistic," said Michael Sparer, PhD, JD, of Columbia University in New York City, in an interview. However, "a lot depends on what happens to Congress as well [if she becomes President]. If something would change in Congressional makeup, I think she has a pretty clear fix-it agenda."
Even without such a change in Congress, "she will try to use whatever authority under ACA to encourage states to experiment," he added.
Similarly, Elbert Huang, MD, MPH, at the University of Chicago, said he was impressed by the level of specificity in Clinton's plan, especially compared with those of Sanders and Republican presidential candidate Donald Trump.
Jon Oberlander, PhD, of the University of North Carolina-Chapel Hill, agreed in an email that, overall, Clinton's plan is "more than realistic" -- "if we are to continue to make progress in reducing the uninsured population, making Obamacare more affordable for Americans with modest incomes is imperative. Politically, however, even these incremental measures are not so easy."
However, Oberlander continued, "As for [Clinton's] public option ... its chances of enactment in the current Congressional environment are zero. Even if Democrats retake majorities in Congress in 2016, it would face an uphill path to enactment."
A federally run public option, he said, "is symbolic politics, something that liberal Democrats like that allows Clinton to counter Sanders' single-payer proposal."
Clinton's Medicaid expansion proposal "will be incredibly tricky to pull off politically," said David Becker, PhD, of the University of Alabama at Birmingham School of Public Health, in an email to MedPage Today.
"Even in a state like Louisiana where Medicaid expansion will take effect on July 1, it is somewhat unlikely that Republican senators and representatives would support expanding federal support. This proposal also assumes that states that have already expanded their programs will be happy to support the extension of funding without asking for something in return."
As to spending more money on navigators, "I'm not entirely sure this is money well spent," Becker said. "People that are eligible but not enrolled for public health insurance programs tend to be low-utilizers who re-enroll when they need care. Although marketing and outreach efforts have varied across the states, the benefits of increased spending on these efforts are not clear."
Clinton's proposal to lower out-of-pocket costs might work with plans on the insurance exchanges, said Alan Sager, PhD, at Boston University, but is incompatible with the economics of private insurance.
"For private employers it's very tough today, since employers and their benefits advisors think that higher out-of-pocket costs are the one tool they can wield to contain their healthcare costs," Sager said in an email. "Many economists fantasize that higher out-of-pocket costs will somehow shoehorn size 10 healthcare into size 5 free-market competition. And some reporters and 'consumer advocates' fantasize that better information about price and quality will make us healthcare super-shoppers."
Sager added, "Without real cost controls -- not widely supported politically by Americans -- out-of-pocket costs will continue to look to many people like the only game in town" for restraining overall costs.
He also dismissed the "reward value and quality" part of Clinton's plan, calling it "tough to do without torturing hospitals and doctors to make them give us still more data. And they control the data so they can game the measures of value/quality if they want."
David Howard, PhD, another Emory University scholar, told MedPage Today that he was troubled by Clinton's proposing of new spending without suggesting how the costs would be offset.
"Clinton promises new subsidies for people who buy insurance on the exchanges, new subsidies to help offset out-of-pocket costs, and additional funds to subsidize state Medicaid expansions," he wrote in an email. "At a time when the federal government is struggling to afford entitlements, it is irresponsible to promise new spending without offsetting spending reductions elsewhere."
Jan Carney, MD, MPH, at the University of Vermont in Burlington, said she is concerned about what's missing from all the candidates' proposals, including Clinton's.
"Public health issues such as infant mortality, obesity, HIV, injuries, homicides, and drug-related deaths all represent preventable contributors to health care costs," she said in an email. "These specific areas (where we do much worse than other countries) and other areas of public health, would make a strong addition to this national healthcare discussion."
Christopher Jones, PhD, of the Vermont Center for Clinical and Translational Science, in Burlington, named another topic of concern: biocybersecurity. “Health information has a longer shelf life than financial information and when both are sold on the black market, it is health information that commands a higher price,” he said in an email. “This will most assuredly be a concern for the Democratic candidate when s/he gets elected.”
Not a very exciting article. And that’s the point. When you read Hillary Clinton’s proposals, they all fall under the category of mere tweaks to our current dysfunctional system.
Tens of millions will remain uninsured; underinsurance will not be eliminated; Medicaid would be expanded without addressing its deficiencies in access; administrative excesses, including waste in marketing would increase; the undocumented would be allowed in without a way to pay for it; an ineffectual public option would continue to be offered through Section 1332 waivers; and so forth. Lower co-pays and deductibles along with a higher tax credit would be helpful, but to be effective, it would require significantly higher taxes when we have a Congress that continues to resist, on a bipartisan basis, any tax increases.
Although the title of this article indicates that the health policy experts cited give her efforts a “passing grade,” they basically do not see much more than fine tuning of the status quo. There is no suggestion that we could achieve reform goals of universality, affordability, increased provider choice, greater access, greater administrative efficiency, and optimal equity in the financing of health care.
Many of the Clinton measures proposed would further increase health care spending while falling short on goals. That would be a shame when instead we could place effective controls on spending through a single payer national health program - an improved Medicare for all - while achieving all of the listed goals of reform.
Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.
People, you really ought to look at Hillary's foreign policy as secretary of state before you vote for her. There is a pile of destructive actions (to be polite). The most recent reported on is in Haiti. Before that there is Libya -- I'm not talking about Ben Ghazi -- as reported in two NY Times articles here and here and a video here. Googling Hillary Libya will get you many more critical articles. Then there is Honduras here: https://www.washingtonpost.com/blogs/post-partisan/wp/2016/03/10/hillary-clinton-needs-to-answer-for-her-actions-in-honduras-and-haiti/. there are plenty of other articles if you google Hillary Honduras. Then there's Mexico. Mexico's narcoquagmire owes at least some of its mess to Clinton's stands and actions. Here . is one article: http://fpif.org/hillary-clintons-dark-drug-war-legacy-mexico/ I know more about this because I live in Mexico and read about it and talk about it all the time. But this article is a good start, and again, googling will get you a lot more. Then there's her push for a no-fly zone over Syria, which was criticized for being unfeasible and was something Obama himself didn't want. Then of course there's her vote for war in Iraq.
When I watch her in debates and town hall meetings, she seems too confident, not introspective, deaf to cultural and local political issues, unaware that she is involved in decisions to take human lives. I just don't trust her to be president.
In their editorial in the Sunday Review, the Times said that Revolutions are bottom up, not top down. This is silliness. Revolutions have LEADERS who often are the ones who give form to the inchoate yearnings of the people. In the US, I don´t think Sanders means a Cuban-style revolution, but rather movements that give voice to the very legitimate claims people have about the dominance of corporate wealth in our economy, about climate change, about unequal chances. I don´t trust Hillary to help these voices make changes.
Sometimes on holidays or special days, often, actually, Jim and I go on excursions instead of going out to eat or buying each other gifts. We were, this Valentine's Day, in need of an excursion. They've become altogether too few and far between. So we got into the RAV 4 which is now seventeen years old and headed out with three of the dogs:Jocko the Afghano, Happy, the Mexican Brown Dog and Little Guy the salsiccia. We didn't quite know where we were headed at first, but by the time we got to the Crucero, the crossroads of the highway between Coatepec and Xico and the road that goes from our Colonia in one direction toTeocelo in the other we had settled on Barranca Grande which is down an escarpment about halfway between Teocelo and Cozautlan. Our whole area is lush with plant life pouring down steep slopes into narrow valleys and along rivers. Small (for the most part) towns climb hillsides, hug escarpments, roll over hillsides and nestle in basins.
This trip we followed the road to from Teocelo to Cosautlán to the Barranca Grande turn-off. The people of the area demonstrated to have it properly paved, but it still is only partly completed with sectionns (smallish) being fine, others still filled with deep potholes and still others in a rough state of incompletion so the trip which is about eighteen miles from our house takes over an hour.
On the map below, you can see our colonia as a weird red squiqqle above San Marcos de León.
The road from Teocelo (A) to Cosautlan (B) as you can see is extremely (to put it mildly) twisting.
The road to Barranca Grande splits off probably half way from Teocelo to Cosautlan. It hugs the side of a precipice and is marked with sharper, steeper turns than the road it leaves.
On the left, a view across the barranca from the top of the road next to the bus stop. On the right, capilla which stands at a sharp curve's bend.
And a cross on a rock on another curve.
El Río Pescados which flows through Barranca Grande seen on the right at a bit of a distance. This is a view of the river from the road down the escarpment.
On 9 September 2008 heavy rains caused a devastating rock and mud slide that severely damaged a large part of Barranca Grande in the state of Veracruz. Two people, including a three year old child, were killed and three were wounded. Below you can see the church, now abandoned and a school damaged by rocks and also abandoned. Five and a half years later, the town is still desolate since the government's aid entailed relocating the inhabitants to a nearby location they say is not susceptible to slides.
This house on the left is literally the only bright spot we saw. Most of the houses are small and unpainted
This is what's left of the village's health services. It's a sign urging men to use condoms not just to prevent unwanted pregnancies but to protect women's health.
You can just about see Jim on the other side of this foot bridge which crosses the river at the north end of the town. It connects with a trail in one direction and a pantheon or cemetery in another. After Jim explored a bit, we drove a bit further along the road which ended a bit further on the river and turned back. On our way back we came across a large crowd of people coming over the bridge following a celebration in the pantheon. A pickup and a station wagon were waiting to take some of them home. They were going to Barranca Nueva, the place higher up the escarpment where the government had resettled some of the victims of the landslide.
The government wanted to relocate everyone to Barranca Nueva in the community of Xixitla. It transferred 732 people, providing 203 houses for them. 149 people remained in Barranca Grande in 42 homes. There are currently no services in Barranca Grande and the town no longer exists in the minds and maps of officialdom.
The houses provided in Barranca Nueva are made of pressed cardboard, and indeed this type of construction has been used elsewhere with some success. But here people have not been happy. The cardboard gets mushy and soft in the often humid weather. Many of the people have worked with brick and mortar and are reconstructing their houses out of this sturdier material. In addition, large families were squeezed into tiny rooms. Fifteen of the relocated families ironically and unfortunately find themselves in possible danger from slides from a nearby quarry.
I don't know the status of the promised school, health clinic and Opportunidades (Progreso)buildings, but as of 2012 they didn't exist. There were some mobile classrooms.
The reason the people of Barranca Grande were encouraged to resettle seems at least as much because the previous governor contracted with the giant Brazilian dam-building company Odebrecht to build dams for electricity to be sold away from the area, including one which would flood Barranca Grande out of existence. One of the dams was to be in Jalcomulco, but as of today, the protests there led to it (hopefully) being cancelled with the company having to restore the areas it had damaged. This whole project is a probably destructive tangle which I may write about in the future.
Consulta Mitovsky does many surveys of life and attitudes in Mexico. Below I´ve translated the recent survey of attudes towards gays and lesbians. Here is the link to the PDF file of the survey. . As usual, I would like to remind you that there are various places in the country more liberal than others, but that there haven´t been any of the angry demonstrations nor angry rhetoric that you find in the US, especially now, where in the US gay marriage has once again turned into a campaign issue accompanied by the usual vitriol. I´ve translated "homosexual" as "gay or lesbian" because they are the more common terms in the US.
Do you have any gay or lesbian family members (man or woman)?
Don´t know/No opinion 2.8%
2. Are gays and lesbians born being gays and lesbians?
Strongly agree: 55%
Agree a little or not at all: 32.2%
Don´t know/no opinion
3. A gay/lesbian couple ought to have the same rights as a heterosexual copy.
Strongly/somewhat in agreement: 51.1%
A little/not at all in agreement: 39.7%
Don't know/no opinion 9.2%
Strongly or somewhat agree by age group:
18 to 29 years old: 62.0%
30 to 45 years old: 47.7%
46 and more years old: 46.1%
4. A lesbian couple should be permitted to adopt.
Strongly/somehwat in agreement: 47.6%
A little/not at all in agreement: 43.3%
Don't know/no opinion: 9.1%
5. A gay couple should be permitted to adopt,
Strongly or somewhat agree; 41.8
A little/not at all in agreement: 48.1
Don't know/no opinion: 10.1%
6. A gay couple should be permitted to get married.
Strongly or somewhat agree: 47.6%
A little or not at all in agreement: 43.3%
Don´t know/know opinion: 9.1%
Attitude by sex: Men
Very/somewhat in agreement: 42.3%
Little/not at all in agreement: 47.7%
Don´t know/no opinion: 10.0%
Attitude by sex: women
Very/somewhat in agreement: 52.3%
Little/not at all in agreement: 39.6%
Don't know/no opinion: 8.1%
Attitude by age
Very/somewhat in agreement:
18 to 29 years: 50.8%
30 to 45 years: 47.3%
46 years and over: 45.5%
7. Would you be willing to meet the partner of a gay or lesbian son or daughter?
Prefer not to meet the partner: 26.7%
Do not want to meet the partner: 16.7%
Here is a link to an article in Patheos discussing opposition to Girl Scout Cookies by the St. Louis Archdiocese and Franklin Graham because of the Girl Scout positions on gays.