It is important for you to realize that this posting is not an effort to convince you to cast your vote for any candidate, up or down the ticket. It is probably clear where I stand before the election. If you have not decided for whom you will vote, you may find the website https://www.isidewith.com to be useful. On this site you can answer questions about all the issues with your own preferences. The tool then matches up your answers with the candidates.
Prior to the second debate, I was delighted to see that the October 6 issue of the New England Journal of Medicine contained a group of three papers in its “Perspectives” section:
From Obamacare to Hillarycare — Democrats’ Health Care Reform Agenda by
Jonathan Oberlander, Ph.D.
What Would a Republican Win Mean for Health Policy?
Gail R. Wilensky, Ph.D.
and finally from David Blumenthal and James Morone, the authors of The Heart of Power: Health and Politics in the Oval Office
Past as Prologue — Presidential Politics and Health Policy
The articles are short and taken together are only about 4,000 words. Whether or not you have the time or interest to read them I do give you bits and pieces of all three woven within this posting.
The article by Blumenthal and Morone from the October 6 NEJM offers perspective as we try to look beyond the election.
They remind us of the long story that they outlined in The Heart of Power:
…Since Harry Truman first advocated universal national health insurance during his 1948 campaign, Democratic presidential contestants have generally endorsed expanding coverage for the uninsured through governmental financing and regulation. This position has reflected the interests of their political base: lower-income, more heavily minority, and more likely to be uninsured.
Republican candidates have often opposed these coverage extensions. When pressed to set out alternatives, they’ve proposed more modest programs that rely on private-sector solutions. These positions have reflected the interests of Republicans’ political base: more affluent, less likely to be minorities, more likely to be insured, and mistrustful of government.
These dynamics are playing out once again. Hillary Clinton supports the Affordable Care Act (ACA) and proposes to augment its coverage provisions. According to a recent RAND Corporation analysis, her plans would increase the number of insured Americans by up to 9.6 million individuals. Donald Trump promises to repeal the ACA and replace it with programs that will, according to the RAND analysis, cover as many as 15.6 million fewer individuals and rely more heavily on market mechanisms…
The core concepts of the ACA are Republican ideas that really can be traced as far back as Eisenhower’s administration. Bernie Sander’s attraction to single payer and “entitlement” was first articulated by Truman in the late forties. The core Democratic proposal shifted from Truman’s idea of entitlement to the Republican concept of a mandate as far back the first Clinton proposal in 1993. The core questions remain:
- How do we cover more people?
- How do we pay for the program?
Following the discussion of “locker room” humor, the second Presidential Debate finally did have a discussion of healthcare and the ACA. Anderson Cooper introduced Ken Karpowitz, one of the undecided voters participating in the “town hall” format, and he asked about healthcare.
“Affordable Care Act, known as Obama care. It is not affordable. Premiums have gone up. Deductibles have gone up. Co-pays have gone up. Prescriptions have gone up. And the coverage has gone down. What will you do to bring the costs down and make coverage better?”
Hilary and Donald seemed unsure who should initially answer Mr. Karpowitz’s question. Trump deferred to Clinton who said:
Well, I think Donald was about to say. And getting rid of the Affordable Care Act. And I’m going to fix it because I agree with you. Premiums have gotten too high, co-pays, deductibles, prescription drug costs. And I have laid out a series of actions that we can take to try and get those costs down. But here’s what I don’t want people to forget when we’re talking about reigning in the costs, which has to be the highest priority of the next president. When the Affordable Care Act passed, it wasn’t just that twenty million people got insurance that did not have it before. But that in and of itself was a good thing. I meet these people all the time and they tell me what a difference having the insurance meant to them and their families. But everybody else, the one hundred and seventy million of us, who get health insurance through our employers, got big benefits. Number one, insurance companies can’t deny you coverage because of a pre-existing condition. Number two, no lifetime limits, which is a big deal if you have serious health problems. Number three, women cannot be charged more than men for our health insurance, which is the way it used to be before the Affordable Care Act. Number four, if you are under 26 and your parents have a policy, you can be on that policy until the age of 26.
Something that didn’t happen before. So I want to very much to save what works and what is good about the Affordable Care act. But we have got to get costs down, we have to provide some additional help to small businesses so that they can afford to provide health insurance. But if we repeal it, as Donald has proposed, and start over again. All of those benefits I just mentioned are lost to everybody. Not just people who get their health insurance on the exchange, and then we would have to start all over again. Right now, we are at ninety percent health insurance coverage. That is the highest we have ever been in our country.
After Secretary Clinton finished her presentation, Mr. Trump spoke:
It is such a great question, and it’s maybe the question I get almost more than anything else. Outside of defense.Obamacare is a disaster. You know it, we all know it. It is going up at numbers that nobody has ever seen worldwide. Nobody has ever seen numbers like this for health care. It is only getting worse. In seventeen, it implodes by itself. Their method of fixing it is to go back and ask Congress for more money. More and more money. We have right now have almost twenty trillion dollars in debt. Obamacare will never work. It is very bad, very bad health insurance. Far too expensive, and not only expensive for the person that has it, unbelievably expensive for our country. It’s going to be one of the biggest line items, very shortly.
We have to repeal it, and replace it with something absolutely much less expensive. And something that works. Where your plan can actually be tailored. We have to get rid of the lines around the state, artificial lines. Where we stop insurance companies from coming in and competing because they wanted President Obama and whoever was working on it. They want to leave those lines because that gives the insurance companies, essentially, monopolies. We want competition. You will have the finest health care plan there is. She wants to go to a single-payer plan, which would be a disaster. Somewhat similar to Canada. And if you haven’t noticed the Canadians, when they need a big operation, they come into the United States, in many cases. Because their system is so slow, it is catastrophic in certain ways. But she wants to go to single-payer.
The discussion went back and forth several times and fact checkers have refuted much of what was said. You can review transcript of the debate annotated with “fact checking” by NPR commentators. The section is brief and runs from 9:34 PM to 9:43 PM. Considering how critical the questions of healthcare access and expense are to so many Americans, you may want to read this section of the debate.
What the candidates said verifies the presentations in the NEJM. In What Would a Republican Win Mean for Health Policy? Gail Wilensky, who was the Administrator of CMS from 1990 to 1992 under President George HW Bush, reviewed most of the ideas that Mr. Trump presented in the debate. In her article she begins by saying that the President alone, despite the power of executive orders, can’t do away with the ACA. She goes on to say:
…Donald Trump has supported several policy changes commonly proposed by Republicans. These include repealing the Affordable Care Act (ACA), though with little indication of what would replace it; expanding the availability of health savings accounts (HSAs, nontaxable money that can be used to cover medical expenses not covered by insurance and that can be rolled over from one year to the next, unlike flexible spending accounts); permitting insurance to be sold across state lines; turning Medicaid into a block-grant program; protecting people from large increases in insurance premiums or exclusions because of preexisting conditions, as long as they maintain continuous coverage; and allowing people without employer-sponsored insurance to deduct their premiums from their taxes. Unlike other Republicans, Trump has also proposed allowing drug importation and permitting Medicare to negotiate drug prices (though he hasn’t provided any details about what that would mean).
Wilensky is reassured by the fact that the most likely outcome of the election is that neither party will control both houses of congress and the presidency which may create an environment for bipartisan change.
In From Obamacare to Hillarycare — Democrats’ Health Care Reform Agenda Jonathan Oberlander, Ph.D asks a question and then sees a possibility:
What happens to Obamacare after its namesake leaves the White House? …
If Hillary Clinton wins the presidency…Democrats can advance the ACA. For decades, reformers sought to enact universal health insurance. Now that they’ve taken a major step toward that goal, what happens next? Victory in the 2016 elections could allow Democrats to shift their focus from preserving the reforms to strengthening and improving them. The ACA’s record reflects both substantial accomplishments and significant shortcomings. One priority should be to make health plans more affordable and thereby achieve further gains in coverage.
He adds information that Hillary Clinton did not emphasize in her debate answers:
Clinton has proposed extending provision of 100% federal funding for the first 3 years to any state expanding Medicaid. Making that funding level permanent — it’s scheduled to phase down to 90% by 2020 — could further entice states. There are also about 9 million uninsured Americans who are eligible for but not enrolled in Medicaid or the Children’s Health Insurance Program. Vigorous outreach and enrollment efforts are needed to reach these people and those eligible for subsidized marketplace coverage — together, they account for nearly half the remaining uninsured population.
He contradicts Trumps thesis that the ACA is breaking the bank and makes a huge point about the future being dependent upon establishing a bipartisan approach:
Growth in health care spending has been remarkably moderate since 2008, and the ACA has cost much less than initially forecast. Obamacare has produced considerable Medicare savings, though its precise contribution to the spending slowdown outside that program is unclear...
The biggest obstacle to building on the ACA’s achievements and addressing its flaws is hyper-partisanship…If Clinton is elected, her chances of strengthening the ACA will depend on whether Democrats have congressional majorities — and on her ability to advance reform in this extraordinarily polarized time.
I hope that when the election is over we will be able to share a common objective of bringing better healthcare to every person:
Care better than we’ve seen, health better than we’ve ever known, cost we can afford…for every person, every time.
The Triple Aim is the “what” we want. The “how” will confound us until we can set aside partisan concerns to share the objectives of the Triple Aim.
