How the Primary Candidates Would Reform Healthcare

Neil Chesanow


May 25, 2016

In This Article

Hillary Clinton's Healthcare Proposals

Of the three candidates' proposals, Clinton's are the most factually detailed.[6] For supporters of Bernie Sanders, however, this is a criticism, not a compliment. Her proposals, in their view, fail to address the nation's healthcare problems, starting with the 33 million people—10.4% of the population—who remain uninsured.[9]

"She's really proposing more or less a continuation of current policies, with very minor tweaks as far as things that would really affect doctors," contends internist David Himmelstein, MD, professor at the CUNY School of Public Health at Hunter College in New York, lecturer at Harvard Medical School, and cofounder of Physicians for a National Health Program. "What you see is what you get."

"What you get" is, in the view of many doctors and patients, a significant improvement over health policy before the ACA was enacted, but it has left many others, regardless of their political orientation, deeply disappointed.

Internist Marc K. Siegel, professor of medicine at New York University School of Medicine and a Fox News medical correspondent, is one of them. Dr Siegel describes himself as "a practicing physician who has studied and been victimized by the damaging effects of Obamacare." On the right-wing, he writes, "I am on the lookout for any plan that aims to undo the worst of Obamacare: spiraling premiums, limited access to providers, high deductibles that hamstring poor and middle-class patients, and heavy federal subsidies and related tax hikes."[10]

Such criticisms are echoed in many liberal media outlets as well. A New York Times op-ed, "Sorry, We Don't Take Obamacare," notes that "some early studies of the impact of the Affordable Care Act plans are proving patients' grumbling justified: Compared with the insurance that companies offer their employees, plans provide less coverage away from patients' home states, require higher patient outlays for medicines and include a more limited number of doctors and hospitals, referred to as a narrow network policy."[11]

Affordable Care Act

Clinton is the only candidate who supports the ACA. As her website declares, "Hillary will defend the Affordable Care Act and build on it to slow the growth of out-of-pocket costs."[6]

Healthcare Costs

Clinton says she would lower out-of-pocket costs like copays and deductibles—which, in employer-sponsored health plans, rose from $1240 in 2002 to about $2500 in 2013.[6] One way she would do this is by offering a tax credit of up to $5000 per family that buys its health insurance on an ACA exchange, to offset out-of-pocket and premium costs above 5% of their income.

She would require all health plans, including employer-provided plans, to give individuals three sick visits per year without needing to meet the deductible first.[6] According to a study by the Commonwealth Fund, 31 million Americans with health coverage were nevertheless underinsured in 2014, with high deductibles or out-of-pocket costs relative to their income.[12] As a result, many skip needed care. A tax credit, it is hoped, would help address this gap.

Clinton would enhance the tax credits for health insurance premiums currently available through the ACA exchanges.[6] Families purchasing insurance on an exchange would not spend more than 8.5% of their income for premiums—less than under current law.

She would eliminate a glitch in the ACA that makes whole families ineligible for premium subsidies if even one member of the family is eligible for employer-paid insurance, even if that plan is too expensive to cover everyone in the family.[6]

Clinton would increase price transparency so that people understand how much their healthcare costs and can more easily comparison-shop for the best deals.[6]

She would protect consumers against surprise medical bills.[6] For example, patients may use a health plan's in-network hospital, thinking that they only owe the deductible specified in their policies, yet end up receiving unexpected multi-thousand-dollar bills from anesthesiologists, surgeons, radiologists, emergency physicians, and other doctors who, unbeknownst to them, were not in the network. Clinton would absolve consumers from having to pay those extra charges.

She would enforce antitrust laws and investigate mergers, consolidations, and business practices of providers and insurers that could harm consumers.[6]

She would strengthen state authority to block excessive insurer rate increases.[6]

Drug Prices

Reducing the cost of prescription drugs—for which spending leaped from 2.5% in 2013 to 12.6% in 2014—is a Clinton priority.[6] She would require insurers to cap out-of-pocket drug spending for health plan members at $250 per month, fully fund the US Food and Drug Administration's (FDA's) Office of Generic Drugs to speed low-cost generic drug approvals, and reduce the amount of time that brand-name biologic drug makers are protected from price-cutting competition from 12 to 7 years.[6,13]

All three primary candidates have proposed allowing Americans to import less-expensive medications from abroad, provided that safety standards are equivalent to those here.[6,7,8]

This is easier said than done. "How is the FDA to monitor all the possible international vendors that want to sell Americans drugs?" wonders economist Merrill Matthews, resident scholar at the Institute for Policy Innovation, a nonpartisan think tank.[14] "There are huge profits to be made—that are already being made—selling US consumers fake, outdated, diluted, and compromised drugs at a fraction of the US pharmacy price. Both organized crime and terrorists have become involved, and they would love easier access to the US market."

Importation of lower-priced drugs is not the only market intervention that Clinton has proposed. She would eliminate tax breaks for drug companies whose advertising is aimed at consumers.[6,12] And she would put pressure on pharmaceutical companies to spend more of their revenue on research and development.

All three primary candidates would rescind the 2003 federal law that forbids the federal government from negotiating Medicare drug prices directly with drug companies to get better deals for Medicare beneficiaries.[6,7,8] For Clinton and Sanders this is no surprise; repealing the law has long been a Democratic goal. For Trump, it subverts the small-government, free-market ideals of the GOP.

Clinton would require pharmaceutical manufacturers to provide rebates to low-income Medicare enrollees equal to those offered under the Medicaid program.[6]

She would move the healthcare system away from fee-for-service toward bundled payments to reduce doctors' incentives to order excessive tests and procedures, a shift that is already underway.[6] The proposed rule on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), announced on April 27, would incentivize doctors to participate in alternative payment models—including bundled payments and accountable care organizations—which are intended to reimburse doctors for quality of performance, not quantity of procedures.[15]

Clinton would broaden the use of telehealth, particularly in underserved rural areas.[6]


Clinton opposes any plan to privatize Medicare, although Trump, paradoxically for a conservative, would leave the Medicare program untouched.[6,8] It's paradoxical because, with large numbers of people becoming eligible for Medicare with each passing year, the program is a prime reason why healthcare costs are rising unsustainably. Privatizing Medicare by block-granting it to the states would help control these costs, conservative leaders maintain.[15,16,17] Leaving the program intact, to their way of thinking, would be fiscally irresponsible, something that only a liberal would be expected to advocate.


Clinton supports state expansion of Medicaid under the ACA.[6] To make this palatable to the 16 holdout states—all under the control of anti-ACA Republican governors or legislators—the federal government would pick up 100% of the expansion's cost for the first 3 years of implementation.[18] The government's current offer to fund the full Medicaid expansion cost for 3 years ends this year.

"Her hope is that the prospect of more free money will goad these states to climb down from their ideological resistance, even if the prospect of providing decent health coverage to hundreds of thousands of their lowest-income residents hasn't done the trick," explains Los Angeles Times business columnist Michael Hiltzik.[18]

As many as 16 million people—about half of those who remain uninsured even after the implementation of the ACA—are eligible for virtually free Medicaid or ACA exchange coverage for as little as $100 per month.[6] Yet they are not enrolled, presumably due to lack of awareness or inability to navigate the enrollment process. Clinton would invest $500 million per year in navigators, advertising, and other outreach efforts to spread awareness and make enrollment easier.

The Public Option

The enthusiasm of Millennials and many other Democrats for Sanders's Medicare-for-all plan prompted Clinton to revive support among "interested governors" for a "public option," which she had proposed in 2008 when competing against Obama in the Democratic primaries.[6,9,18] This would bring competition to the commercial insurance industry via a federal government–run alternative that would let Americans between 55 and 65 years of age buy into the Medicare system as an alternative to purchasing commercial insurance.

Clinton would not try to push a public option through Congress (as Sanders would attempt to do with his single-payer plan). This would be futile as the Senate and House are currently constituted, reports Politico, a website for Washington insiders. Instead, Clinton "will work with governors using existing flexibility under Obamacare 'to empower states to establish a public option choice.'"[19]

"Doctors and hospitals would be very likely to oppose the idea, because they prefer the higher reimbursement rates of private insurance companies," the New York Times notes in a May 12 editorial.[9] "Insurers would also fight it because they don't want to compete with the government program for customers."

Both advocates and opponents view a public option as a step toward universal coverage.[19,20,21] If it proved a popular alternative to costlier commercial insurance, there would be a mandate to expand eligibility; expanded eligibility moves us closer to Medicare-for-all, which would vastly increase healthcare costs, conservatives fear.

Women's Health

Finally, Clinton would protect women's access to reproductive health, including contraception and safe, legal abortion.[6]


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