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MedPage Today
March 15, 2016
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.”
Comment by Don McCanne
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.
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