The New York Times rightly noted recently in an editorial that healthcare deserves a more prominent place in the 2016 presidential election than it thus far has earned. Donald Trump’s main argument has been the repeal of the Affordable Care Act (“Obamacare”), though precious little attention has been paid to determining with what it might be replaced. Even more strikingly, the Gary Johnson/Bill Weld website’s “issues” section, while taking time to discuss internet freedom and the war on drugs, has literally no mention of healthcare.
The centerpiece of course is the repeal of the ACA, whereas Hillary Clinton seeks further expansion of the ACA and the reduction of premiums by providing families a tax credit to pay for insurance. The Washington Post recently evaluated that while 9.6 million could gain insurance under Clinton, over 20 million could lose insurance under Trump. Moreover, among those not losing health insurance, premiums were projected to go up from $3,200 to $4,700 a year.
Trump’s stated position holds that they stand for the repeal of the ACA, allowing the selling of health insurance across state lines, allowing individuals to fully deduct health insurance premium payments from their tax returns, allowing individuals to use Health Savings Accounts, requiring price transparency from healthcare providers, giving states more autonomy over Medicaid provision, and removing barriers to entry into free markets for drug providers for reliable and cheaper alternatives.
A few points. A number of health insurance plans already offer the option of Health Savings Accounts and whether people opt in or out of them is consumers’ prerogative. Thus, this would not be a change from the status quo. Researchers have already shown in a number of contexts that Medicaid expansion produces a number of health benefits such that those states opting out of expansion are left out with more adverse health consequences. Moreover, the block grant allocation may not be sufficient to continue to support the healthcare benefits that they have gained under the ACA’s Medicaid expansion for the poor. Price transparency is all well and good, though few details are specified as to how it would be provided for. Some tools have already been in place, with Fair Health Consumer’s medical cost directory allowing one to search for the price of a procedure or office visit by zip code, though price comparing across hospitals within a region is not necessarily an easy task for the average consumer, particularly if sick and in need of care. And while allowing for international prescription drug importation may help to curb prescription drug prices, there are the additional regulatory barrier which is that they presumably must still meet FDA standards.
At least as crucially is the fact that Trump's plan does not include provisions to protect people from being denied health insurance due to preexisting conditions. While the New England Journal of Medicine recently published a discussion of the importance of addressing high-need high-cost patients -- with 5% of patients accounting for 50% of the nation's healthcare spending -- having multiple chronic conditions is indeed quite prevalent, with higher rates among the poor and elderly. Indeed, in 2014 at the national level, 30.1% of Americans identified by CMS had 2 or 3 chronic conditions, 20.9% had 4 or 5 chronic conditions, and 14.5% had 6 or more conditions. (Not too surprisingly, the rates of multiple chronic conditions is higher among those who are lower income, such that the challenges in obtaining care due to preexisting condition status only exacerbates the already marked health disparities that persist in the United States). These high rates would constitute grounds for insurance denials of millions of Americans in need of coverage for basic primary care as well as specialty care, with access to good preventive care being valuable to avoiding more costly hospitalizations and procedures. It pays to invest in good healthcare, but giving people the opportunity access coverage is an essential first step (whether through the ACA or not) that Trump's plan unfortunately does not ensure.
There is little question that the implementation of the ACA has not gone according to plan and has not been a dream scenario for its more vociferous advocates, particularly amid news of continued insurer withdrawals from markets due to financial losses, the projections of increasing premium rates in 2017, and the limited choice of marketplace providers for consumers in many parts of the country (with 17% of consumers having only one insurance carrier in their region). Yet the rate of uninsured Americans hit a historic low of 9.1% (declining from 10.4% in 2014), with reductions in uninsured rates seen across nearly all age, race, and income groups. While millions of Americans continue to struggle with underinsurance – that is, facing high deductibles and other large out-of-pocket costs that absorb far too much of their income – there is little doubt that having some coverage is preferable to no coverage, and that people are newly getting access to life-saving primary care and thus diagnoses for conditions with which they may have already have been struggling. Indeed, diabetes diagnoses went up in those states that opted for Medicaid expansion under the Affordable Care Act, confirming other findings that those benefiting from Medicaid expansions were more likely to see a physician or go to the hospital for medical care. And investments in good primary care and having healthier patient pools, thus obviating the need for more advanced and expensive medical treatments, can help to control premiums.
This is not to say that there are not problems with the ACA’s implementation. To be sure, premium increases adversely affect millions, vastly outpacing increases in income, as do the sometimes exorbitant prescription drug prices (highlighted most notoriously recently in the case of EpiPens). But these problems call attention to the need for things to be fixed, not done away with. While a single-payer program would address many of the challenges that we face currently with the business model of healthcare provision in the states – a business model that allows healthcare profit motives to trump the human aspects of health – it is not politically feasible in the current climate of divided government and polarization. Addressing the challenges healthcare pricing and access must be within the confines of the contemporary healthcare apparatus that is the Affordable Care Act.
“Trumpcare” would too quickly downplay the operative word of “care,” at least for lower and middle class Americans.
The ACA needs salvaging and expansion, not repeal. (RAND provided an economic analysis of the Clinton and Trump plans, analyzed here at The Commonwealth Fun).