Healthcare on the Line in Federal, State Elections

October 18, 2016

On November 8, healthcare may not be the foremost issue on the minds of voters, but whom they elect as the next president promises to either bolster President Barack Obama's signature healthcare reform legislation or trash it.

And after they vote for Republican Donald Trump or Democrat Hillary Clinton, millions of Americans will consider ballot issues in their states to lower drug prices, legalize medical marijuana and physician-assisted suicide, and enact other healthcare reforms. State medical societies that have taken a position will watch the results closely.

Several leading pollsters, such as the Pew Research Center, say that healthcare trails the economy and terrorism as the prime concern of voters in the presidential election. The Kaiser Family Foundation, however, found that the candidates' personal characteristics tied with terrorism and national security as worrying voters more than anything else, and that was in July, months before a recording of Trump's remarks about grabbing women's genitals went public. Or before WikiLeaks divulged excerpts of Hillary Clinton's private speeches to Wall Street banks, for that matter.

And since July, voters have faced another personal matter besides sexual mores or honesty: the candidates' health. Trump has made an issue of Clinton's stamina, citing a bout of Memorial Day dizziness that her physician attributed to dehydration and overheating (she also had a mild case of pneumonia at the time). Both candidates produced a physician's letter declaring them fit to serve. When it comes to an overall cholesterol number, Trump beats Clinton, 169 to 189.

The Next President's Healthcare Agenda

Judging from their physician letters, Clinton and Trump appear to be getting the best healthcare that money can buy, but how to achieve that for the rest of the nation is an issue that sharply divides the candidates.

Clinton says that she wants to build on the best parts of the Affordable Care Act (ACA) and further expand insurance coverage while lowering the costs of exchange-plan premiums and high deductibles, which she calls too high. Her healthcare Rx calls for a government-run health plan or "public option" in every state to compete with private plans in the exchanges. She would lower the maximum amount that a person has to contribute toward a premium and create a tax credit of up to $2500 per person or $5000 per family to offset out-of-pocket spending that exceeds 5% of income. Clinton also favors allowing Americans over 55 years of age to buy into Medicare, 10 years before the current eligibility age.

Following the lead of congressional Republicans, Trump promises to repeal the ACA if elected and replace it with free-market solutions for uninsured or underinsured Americans. Under his plan, health insurers could sell policies across state lines, promoting competition; people could use pretax dollars to purchase coverage; and individuals could open health savings accounts, another staple of Republican reform plans. Trump also wants to replace open-ended federal contributions to state Medicaid programs with block grants designed to give states more say-so in spending the money.

Clinton has warned that repealing the ACA would remove the law's prohibition of insurers denying coverage based on pre-existing conditions. In the second presidential debate, Trump countered that his plan would preserve this consumer protection, but he didn't explain how. However, he has supported the creation of state high-risk pool plans for people who have not maintained continuous coverage.

The RAND Corporation in conjunction with the Commonwealth Fund released a study last month assessing the likely impact of Clinton's and Trump's key healthcare proposals. According to RAND, Clinton's plan would extend coverage to an additional 10 million people and cost the government as much as $90 billion in 2018. Under Trump's plan, an estimated 25 million people would lose coverage while the federal government in 2018 would lose up to $40 billion.

Whether it's Clinton or Trump, the next president will need congressional cooperation to enact a healthcare agenda. That prospect for either candidate is dicey, given how this year's congressional races are shaping up. By all accounts, Trump's stumbling campaign and worsening poll numbers are hurting Republicans farther down on the ballot. Prognosticators expect the GOP to maintain its majority, albeit slimmer, in the House, but possibly lose the Senate, where it now occupies 54 seats. Democrats (and the two independents who caucus with them) need only a net gain of 5 seats to gain control. A net gain of 4 seats would put them even with the GOP at 50-50, and if Clinton is elected president, her vice presidential nominee, Sen. Tim Kaine (D-VA), would cast the deciding vote in the case of a tie.

However, Democrats seeking to pass healthcare reforms proposed by a triumphant Clinton would need 60 seats to override any Republican filibuster, and that supermajority doesn't look likely. Conversely, if Trump is elected, and the Senate stays in GOP hands, there probably will be at least 41 Democrats in the chamber to filibuster his pet bills. In other words, gridlock may continue and maintain the status quo for healthcare policy on a national level.

Another State Medical Society Goes Neutral on Physician-Assisted Suicide

Capitol Hill gridlock or not, states will take some healthcare matters into their own hands on November 8.

In Colorado, voters will decide whether to create a universal healthcare coverage system that would replace private insurance and Medicaid for individuals under 65 years of age, but not military programs such as TRICARE. A provision of the ACA allows states to enact their own healthcare reforms if they extend comprehensive and affordable healthcare coverage to as many people as the ACA would without increasing the federal deficit. States that win a waiver to opt out of the ACA this way receive all the federal funds they otherwise are entitled to, particularly for Medicaid.

Supporters of so-called ColoradoCare say that the new system would cover individuals left uninsured under the ACA and provide better care at a lower cost. Opponents object to the tax burden it would impose on Colorado employers and employees and predict that it would drive businesses out of the state.

One opponent is the Colorado Medical Society. Its president, Katie Lozano, MD, said in a news release that although the current health system isn't perfect, "our physician members believe the complexity, uncertainty and approach behind [ColoradoCare] may make things worse."

Colorado voters also will decide whether to become the sixth state to allow physician-assisted suicide, also called assisted death. The ballot measure, modeled after a landmark Oregon law, would permit a physician to prescribe a lethal drug to a terminally ill patient — defined as someone with less than 6 months to live — who requests it. The patient would self-administer the drug. However, certain prerequisites apply, such as counseling on palliative and hospice care and a determination that the patient is competent and making an independent decision.

Washington, Vermont, and most recently California have enacted their versions of the Oregon law. Physician-assisted suicide also is legal in Montana because its supreme court ruled that nothing in state law prohibits it.

Epitomized by the current stance of the American Medical Association, organized medicine traditionally has branded physician-assisted suicide as a violation of the Hippocratic injunction to do no harm. In Colorado, however, as in California, the state medical society has adopted a neutral position. Metropolitan medical societies in Denver, Boulder, and Pueblo have come out in support of legalizing the practice.

Marijuana: Treatment, Treat, or Public Health Threat?

2016 is a big year for state ballot issues that would legalize marijuana for medical or recreational purposes. Arkansas, Florida, Montana, and North Dakota will vote on medical marijuana, and Arizona, California, Maine, Massachusetts, and Nevada will look at recreational marijuana.

State medical societies have already taken their stand on the marijuana questions. The societies in all four states considering medical marijuana have urged residents to vote no. They contend that there's not enough scientific evidence — and vetting by the US Food and Drug Administration — to indicate that marijuana can safely and effectively treat pain, nausea from chemotherapy, seizures, and other conditions. Plus, medical marijuana could be diverted for nonmedical use, the argument goes.

In the five states voting on recreational marijuana, organized medicine is split. The Massachusetts Medical Society, for example, calls recreational marijuana a public health threat, especially for young people whose cognition and brain development would be at risk. However, the California Medical Association (CMA) has endorsed legalization for adults. The CMA argues that while it does not encourage anyone to use marijuana, it prefers strict control, regulation, and taxation of the psychoactive plant instead of prohibition.

There's another drug question on the November 8 ballot for Californians, this one about standardizing — and controlling — prices for prescription drugs. Proposition 61 would require California's Medicaid program, called Medi-Cal, and other state agencies to pay the same price for drugs that the Department of Veterans Affairs pays. Backers such as the California Nurses Association and the state chapter of AARP contend that such price parity would improve access to life-saving drugs and save billions of dollars in healthcare costs. Pharmaceutical companies predictably have rallied against the proposition, curiously citing some of the same arguments made by proponents.

The CMA and California chapters of several national specialty groups number among the opponents. For its part, the CMA fears that if passed, the proposition could invalidate existing discounts that the state has obtained from pharmaceutical companies and remove many drugs from Medi-Cal's formulary, which would create a "prior authorization hurdle" for physicians and patients, the society said in a position statement.

Follow Robert Lowes on Twitter @LowesRobert

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