Discussions about healthcare policy have played a central role throughout the presidential primaries. It is incredibly important for healthcare providers to have an understanding of healthcare’s current state and the manner in which each of the presidential candidates intends to reform it. This work will describe the public positions espoused by the presidential candidates in both the Republican and Democratic primaries. Where specifics are available, we will provide them. Where they are not, we will attempt to highlight those gaps in knowledge.
Donald Trump: Trump is still the national leader in the Republican Primary polls [1-3]. His healthcare positions are briefly described on his campaign website . We will consciously avoid references to statements made earlier in his campaign unless he has re-emphasized those points on his website, as many are contradictory. Trump’s proposals include:
- Repeal and Replace the Affordable Care Act (ACA): Trump has repeatedly stated that Obamacare must be repealed and replaced [5-6], with the rough outline of a replacement described on his website . Key provisions of his plan are noted in following bullet points.
- Interstate Purchasing: Trump intends to allow healthcare coverage to be purchased across state lines, which he believes would lead to a significant reduction in healthcare costs.
- Healthcare Savings Accounts (HSAs): HSAs are broadly defined as a tax-preferred savings and investment accounts in which those with high-deductible insurance plans could save money to be used on medical needs . Trump has publicly endorsed HSAs without providing details on how they would be established . His website elaborates that these accounts would involve tax-free investments, be usable by any member of a family, and be inheritable free from estate taxation .
- Medicaid Block Grants: Trump would change Medicaid disbursement from a federal program to a block grant system, whereby funds are given without instructions on how they should be spent. If his proposal conforms to prior Republican block grant proposals, this would also include steep budget cuts for Medicaid at the federal level .
- Imported Medications: Trump is the only Republican candidate to incorporate a plan for the importation of cheap medication as a mechanism to decrease healthcare prices.
- Universal Coverage: Though Trump has previously made campaign statements that supported healthcare coverage for those with pre-existing conditions (for example, he once stated he wants to prevent people from “dying in the streets”) , the plan described on his website does not mention coverage for this population, or for those who would inevitably be in a high-risk pool.
Ted Cruz: Cruz’s positions mirror that of Trump in that he would also like to repeal the ACA  and implement interstate purchasing and HSAs. However, unlike Trump, he specifically avoids references to medication pricing or Medicaid. Other portions of his plan include:
- Interstate Insurance: Cruz focuses specifically on the idea that a nationwide marketplace would drive down the cost of catastrophic health insurance, a variety of low premium, high deductible plans that cover only minimal services and are designed for largely healthy populations [12-13].
- Healthcare Savings Accounts: As above, Cruz supports HSAs for all other healthcare purposes [14-15]. Given his statements regarding catastrophic coverage, it is reasonable to assume that Cruz would offer coverage for high-risk pools or those with pre-existing conditions through HSAs, as catastrophic coverage would not be adequate for these populations’ persistent healthcare requirements.
- Non-employer Insurance: Finally, Cruz would dissociate healthcare coverage from employment, allowing people to carry healthcare with them between jobs and when out of work.
John Kasich: Kasich’s plan has a very different focus compared to the other candidates, however his public statements  and his political website  offer few specifics. Kasich’s outlined proposals include:
- Repeal the ACA: Kasich, like others in his party, calls for a complete repeal of the ACA, though his replacement plan lacks specific suggestions.
- Expanded Medicaid: Kasich has publicly and repeatedly endorsed the ACA expansion of Medicaid , which he defended during his first debate performance . As the majority of the ACA’s coverage expansion came through Medicaid, it would appear that Kasich would continue this aspect of the program.
- Eliminate Mandatory Coverage: Kasich would eliminate the individual mandate to receive health coverage, the employer mandate to provide coverage, and the insurance mandate to offer coverage to people with pre-existing or high-risk conditions. As his plan currently stands, it is unclear how these individuals would actually be covered.
- Emphasis on Primary Care: Unlike any of the other candidates on the trail, Kasich points to specialty medicine and procedure overuse as key drivers of cost. Kasich’s plan emphasizes a move towards preventative screening and primary care via changes in reimbursement incentives, though he does not explicitly offer details for this plan.
- Value-Based Coverage: Kasich heavily endorses the bulk-payment system for each patient, in which hospitals are reimbursed through a lump sum for diagnoses instead of being paid for each procedure a patient undergoes. Without explicitly stating how, his plan aims to shift such cost-saving incentives to the healthcare provider rather than to insurance companies.
Hillary Clinton: Compared to their Republican counterparts, both Democratic candidates offer very specific healthcare policy proposals. Clinton, in particular, is vocal about her desire to maintain the ACA while drafting legislation to limit out-of-pocket expenses in the case of significant medical costs. Her proposed plan includes:
- Defend the ACA: Though no specifics are provided on her own website , Clinton states that she would defend the ACA against Republicans’ repeal attempts.
- Reduce Prescription Drug Costs: Clinton provides a bevy of specific proposals which would alter the subsidy and funding structure currently in place . Specifically, she would end tax credits for direct-to-consumer advertising, with the goal of redirecting those funds to research and development. While some of these goals could be accomplished through executive action, much of it would require Congressional cooperation, which is unlikely in the current political climate.
- Tax Credits: Clinton would add a new credit of up to $5000/year to cover “excessive” out-of-pocket medical costs . The plan does not specify the funding source of this credit, nor does it suggest a threshold value for “excessive” costs.
- Reproductive Access: Unlike her Republican counterparts, Clinton explicitly mentions reproductive health in her platform . Specifically, she states that she would repeal the Hyde amendment , which restricts the use of federal funds on abortion except in cases of rape, incest, or risk to the health of the mother. Additionally, Clinton would expand the availability of reproductive care to women of low socioeconomic status, but she does not offer specifics on how this would be implemented.
Bernie Sanders: Sanders’ proposals differ significantly from those of any other presidential contender. Specifically, he proposes expanding the ACA into a single-payer system . His platform emphasizes the following points:
- End Employer-Sponsored Insurance: As with Cruz, Sanders would end employer-sponsored insurance and convert to an exclusively individual or family insurance market.
- Price Pressure on Drug Companies: Per Sanders, using a single-payer system would allow the government significant negotiation power in setting prices for the most commonly used medications. This has been true in Medicare , which has successfully lowered the costs of many medications commonly used by the elderly.
- Explicit Funding Sources: Sanders describes both the cost of his plan (approximately $1.38 trillion) and the potential funding sources. These include an employer healthcare premium, individual healthcare premium, changes to the existing income tax, and increasing capital gains and estate taxes. His site references approximate values for these funding sources, but it does not cite who provided these estimates, which suggests they might be internal estimates.
Several themes arise from a brief analysis of the candidates’ positions. First, the Republican leaders are unified in their desire to repeal the ACA and, in theory, lower the cost of healthcare through interstate insurance purchasing. Trump’s plan also addresses a longtime concern for international drug purchasing, which has also been espoused by leaders of each party at different times over the past several years. Kasich’s plan is unique in framing the problem as a provider-sided cost issue associated with the current reimbursement model; however, he has surprisingly few solutions to this problem.
Each of the Democratic candidates dedicate multiple public posts to their respective positions, highlighting the relative importance of healthcare in their agendas. Their plans also address fundamentally restructuring healthcare provision and coverage, though each candidate identifies and addresses a different set of problems. Irrespective of which candidate reaches the White House, it is imperative that we understand healthcare policy positions and how they impact physicians and patients. Ultimately, being politically involved can allow us to convert patient advocacy into permanent positive change.
Dr. Ajay Prakash is a 1st year resident at NYU Langone Medical Center
Peer Reviewed by Neil Shapiro, Editor-In-Chief, Clinical Correlations, Emily Milam, Copy Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
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