UH Clinical Update - October/November 2016
Cliff A. Megerian, MD, FACS, President, University Hospitals Physician Services
The presidential election is days away, and its outcome will have profound effects on the health care industry and its future.
True, the debates did not offer much evidence of the candidates’ positions on health care policy, colored as they were by rhetoric and animosity. But in other venues and online, both candidates have laid out their visions for health care in America, with varying degrees of specificity. Of course, how much either of those visions would become policy will be greatly affected by the outcomes of the elections to the U.S. House and the U.S. Senate.
There are several scenarios that could unfold, and in its October 6, 2016 issue, the New England Journal of Medicine offers some predictions about what might happen in 2017 and beyond, through analyses by three health care economists. Each is definitely worth reading in its entirety. Here are summaries, followed by my conclusions about what this might mean for our health system.
In the article “Past as Prologue: Presidential Politics and Health Policy,” David Blumenthal, MD, MPP and James Morone, PhD, point out that there’s a good deal of continuity when it comes to health care positions held by Democratic and Republican candidates, respectively. President Harry Truman first advocated universal national health care insurance in 1948, and since then Democratic candidates for president have generally endorsed expanding coverage for the uninsured, paid for and regulated at least in part by government.
Republican candidates have often opposed the expansion of health coverage. Instead, they’ve proposed more modest programs that rely on solutions provided by the private sector.
The analysis describes Hillary Clinton’s support of the Affordable Care Act (ACA), and her desire to augment its coverage. A RAND corporation analysis said that her plan would increase the number of insured Americans by up to 9.6 million.
Donald Trump, on the other hand, has promised to repeal the ACA and replace it with his program, one that the RAND analysts say will cover about 15. 6 million fewer people and rely more on market mechanisms.
If Hillary Clinton wins…
In “From Obamacare to Hillarycare – Democrats’ Health Care Reform Agenda,” Jonathan Oberlander, PhD, reminds us of all that the Affordable Care Act has survived: opposition from Congressional Republicans and GOP-led state governments, several legal challenges and the technologically disastrous rollout of healthcare.gov.
Now, he posits that a Clinton victory will preserve the ACA and assure supporters time for reforms that address what is the most significant short-coming – the affordability of coverage.
Though the ACA has reduced the uninsured population from 48.6 million in 2010 to 27.3 million in early 2016, many Americans with modest incomes still have not signed up for coverage. Oberlander writes that the next administration may have to consider stabilization measures – and making market place health plans more affordable would help.
The high price of the insurance is one problem, but Americans are also paying higher out-of- pocket costs for medical care, and face higher deductibles. So Clinton has proposed a refundable tax credit (up to $2,500 for an individual and $5,000 for a family) for Americans who are facing high out-of-pocket costs. She also wants to cap prescription drug costs for people with serious or chronic health conditions.
Another way of boosting coverage, Oberlander notes, would be to persuade more states to expand Medicaid. Clinton has proposed extending provisions of 100% federal funding for the first three years to any state that would do that.
There are also 9 million uninsured Americans who are eligible for coverage by Medicaid or the Children’s Health Insurance Program, and Oberlander says that vigorous outreach efforts are needed to get these people enrolled.
If Clinton is elected, Oberlander concludes, her chances of actually strengthening the ACA will depend on whether Democrats have congressional majorities.
If Donald Trump wins…
Gail R. Wilensky, PhD, In “What Would a Republican Win Mean for Health Policy?” writes that Donald Trump has supported several policy changes that are in line with those commonly proposed by Republicans. These include repealing the Affordable Care Act (ACA), though he offered little information about what would take its place; expanding the availability of Health Savings Accounts (also known as HSAs, nontaxable money that can be rolled over from year to year and used for medical expenses), permitting insurance to be sold across state lines; turning Medicaid into a block-grant program and allowing people without employer-offered insurance to deduct premiums from their taxes.
Trump stands apart from other Republicans in that he also has proposed allowing drug importation (to achieve lower prices) and permitting Medicare to negotiate drug prices, though few details have been given on this option.
Another proposal, one offered via Speaker of the House Paul Ryan, calls for gradually raising the Medicare eligibility age to 67. He, too, has proposed selling insurance across state lines and expanding the use of HSAs. And he and Trump share the belief that exclusion for pre-existing conditions, or higher-than-normal premiums, should be prohibited for people who have had continuous coverage.
Wilensky predicts that this year’s election will likely lead to split government – which means any changes to the ACA will have to be reached with bipartisan support. She adds that the biggest question is whether, if Republicans lose the presidency, the Senate, or both, they will be willing to work to “fix” the ACA” rather than to repeal it.
On the larger stage, this country still faces at least two profound health care challenges:
- Total health care spending is approximately 19 to 20 percent of the Gross Domestic Product (GDP). In countries comparable to the U.S., that number is about 11 percent. So we are spending almost twice as much per capita on health care, which is unsustainable for the long term.
- The national debt is approaching $20 trillion. It’s clear that Medicare is vulnerable to cuts in an aim to right-size the deficit.
So where does this leave us here at UH?
Regardless of who wins the Presidential election, the one thing we know is that health care costs will continue to rise, and that the reimbursements we receive from the government will be reduced. That is why, as a hospital system, we are constantly trying to be more efficient. We will double down on these efforts.
Being a lean and efficient system – one that nevertheless provides the highest-quality care to patients – has never been more critical.