Clinton lays out healthcare plan in NEJM; Trump opts out

In recent elections there has been a trend for candidates to outline their plans for healthcare, as well as other components of their platform, and this election is no different.

The New England Journal of Medicine (NEJM) invited presidential hopefuls Hillary Clinton and Donald Trump to respond to this question: “What specific changes in policy do you support to improve access to care, improve quality of care, and control healthcare costs for our nation?”

Brill

“Healthcare executives would benefit from reviewing Secretary Clinton’s plan in the NEJM, as well as the RAND survey, funded by the nonpartisan Commonwealth Fund, which compared the two plans and offers insights on Mr. Trump’s plans,” says Managed Healthcare Executive editorial advisor Joel Brill, MD, chief medical officer at Predictive Health. “The more information that is made available, the more that the public and business can make informed decisions.”

Clinton offered her plan in the September 28 issue of NEJM. Her four goals included: (1) improve, not repeal, the Affordable Care Act (ACA); (2) ensure greater affordability for all Americans; (3) achieve improved health and healthcare in an integrated fashion; and (4) secure true innovations in diagnosing, treating, and curing disease.

Two new Commonwealth Fund reports find that some of Clinton’s proposals would increase the number of people with insurance by between 400,000 and 9.6 million in 2018, while some of Trump’s proposals would decrease the number of people with insurance by between 15.6 million and 25.1 million.

Hoagland

“On the basis of the RAND analysis, I felt it was a fair assessment of what they could model of any Trump health plan,” says G. William Hoagland, former staff director U.S. Senate; former vice president of government affairs at Cigna; and current senior vice president at Bipartisan Policy Center, Washington, D.C. “However, what could be modeled indicated a reduction in health insurance coverage. The study did not address the impact on healthcare costs under either plan.”

According to Hoagland, Clinton’s proposals build upon the current ACA, which means healthcare executives should expect marginal changes in their activities. “As an example, Clinton’s proposals to double down on current programs to shift toward value-based reimbursement systems either via bundling or accountable care organizations would continue unaltered. For some executives, Clinton’s proposal to expand investments in basic research to diagnose, treat and cure diseases will be welcome,” he says.

Healthcare and all business executives that provide employer healthcare plans will have mixed feelings about allowing employees aged 55 to 65 years to enroll in Medicare, according to Hoagland. “Dropping them off their employer rolls might reduce employer costs, at the same time it would increase Medicare costs and potentially drive up Medicare payroll withholdings for all other employees,” he says.

Next: Incorporating a public option

Proposals to incorporate a public option into the exchanges will be an anathema that will be perceived as the “nose of the camel” toward government-run healthcare for all, according to Hoagland.

“Further, proposals to increase subsidies on the exchange to encourage participation along with capping out-of-pocket expenditures will be assessed as not addressing the underlying cost drivers of healthcare but actually resulting in increased premium costs in the long-run,” he says. “[Clinton] is having to bend to the progressive wing of her party by proposing to bring back the public option into the ACA and to allow for early enrollment in Medicare coverage-essentially [Bernie] Sanders’ effort to convert to a Medicare-for-all healthcare system.” 

There is a real risk of adverse selection in regard to the Medicare buy-in option, according to Hoagland. “Employers might want to encourage those in that age group with high medical costs to drop their employer coverage, I would think an issue of discrimination, or to retire early that would create additional problems later on for their own retirement security, not having saved for retirement sufficiently,” he says. “Further if those with high medical costs were the ones to take the option, it would increase the costs of Medicare and drive up premiums for all Medicare recipients.”

These proposals may help firm up Clinton’s base for the general election, “but if elected they would only serve as a potential going-in negotiating position going,” Hoagland says. “Many moderate Democratic Senate and House members would be opposed to both the public option and early Medicare enrollment.”

What about Trump? According to Hoagland, Trump “will argue that he has already laid out his plan-repeal ACA, 100% deductibility of health insurance premiums, allow sale across state borders, block grant Medicaid, and require ‘transparency’ of all healthcare providers,” he says. “Why his campaign staff was not willing to respond to the NEJM when he has made these proposals, seems ill-informed on the staff’s part, or at worst a snub to one of the more important and respected health journals in the country.”