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March 2, 2016
Quarterly Article
Gail R. Wilensky
December 2024
Dec 19, 2024
Back to The Milbank Quarterly
Although the country remains in the run-up period to the political conventions, it is already clear that health care is going to play a very different and smaller role in the primaries and in the presidential election than it has in previous years. Final decisions about both the platforms and the candidates for each party will not occur until July—when Republicans hold their convention, immediately followed by the Democrats and theirs.
While those decisions will have some effect on the role of health care in the months after the conventions leading to the election, some directions are already apparent.
Health care will be an issue in the final election, but it will not have the prominence it had in the past 2 presidential elections. Both party’s candidates will need to talk about the future of the Affordable Care Act (ACA)—including changes both major (such as “repeal and replace” proposals) and minor that are needed or that should be made—and perhaps also about the sustainability of Medicare. That said, health care will not be a dominant issue.
The answer as to why this is so is evident from opinion polling data. The Kaiser Health Tracking Poll, which provides ongoing data about the public’s views on issues related to health care, shows that while health care remains “an issue,” especially its rising costs, it does not register either as “extremely important” to one’s vote for president in 2016 or as the “most important” factor in one’s vote. The areas of most concern for the 2016 election cycle are (1) the economy and jobs, and (2) terrorism—in that order. When asked about which issues are “extremely important,” respondents cite the same two but in reverse order of importance. The ACA per se is much less significant, ranking 8th in issues.1
The Gallup polling data shows that both Republicans and Democrats prioritize first the economy followed by terrorism, jobs, and health care as the 4 most critical issues, but then Republicans put more importance on fixing government and the deficit while Democrats rate climate change and inequality as more significant.2
Where the Candidates and Their Parties Stand
Hillary Clinton is a strong defender of the ACA. Her position has been to “defend and improve the ACA”—including getting insurance to the remaining uninsured. She has been sharply critical about the amounts individuals have to spend on prescription drugs under Medicare and has recommended limiting out-of-pocket spending to $250 per month per senior. Along with most Democrats, she also supports granting Medicare the right to “negotiate” drug prices although she has not specified what exactly that means or how it would occur—an actual negotiation, a process with which CMS has no experience, or the use of administered pricing as exists elsewhere in Medicare. She has also advocated an end to direct-to-consumer drug advertising.
The surprising debate in the Democratic party primaries, this past winter, was Bernie Sanders’s push to move the United States to a single-payer system—something not even discussed in the run-up to the 2008 election, except by Dennis Kucinich who was never regarded as a serious candidate. Although Sanders has described his plan as “Medicare for all,” it is radically different from Medicare with its lack of deductibles and copayments for hospital and physician services and prescription drugs, its expansion of covered benefits, and its elimination of private insurance. His campaign has predicted massive savings over a 10-year period, but health policy analysts from both parties have estimated that if his plan were enacted, spending would probably increase by trillions of dollars rather than decrease.3
Republican candidates have been unified on some health policies—most notably the desire to repeal and replace the ACA. Most Republican candidates have not released detailed health policy proposals (other than Jeb Bush who dropped out of the race in February), but some common elements have been mentioned. These include (1) using health savings accounts (HSAs)—nontaxable money that can be used to cover deductibles, copayments, and uncovered services and that can be rolled forward to the next year (unlike flexible spending accounts that must be used in their entirety in any given year); (2) being able to buy insurance across state lines; and (3) banning preexisting condition exclusions for people who maintain continuous insurance coverage. Marco Rubio has recommended using refundable taxable credits as subsidies and converting Medicare to a premium-support program.
Donald Trump is the most nontraditional Republican in terms of health policy on some elements, but like the others, he favors repealing the ACA, protecting against preexisting conditions, increasing the use of HSAs, and being able to buy insurance across state lines. Although his campaign has released few policy details during the primary season, he has previously supported mandating insurance coverage, providing universal coverage, and allowing Medicare to negotiate drug prices. No specifics have been made available by his campaign as to how he would accomplish these policies. His estimate of saving $300 billion on prescription drug spending by negotiating drug prices makes no sense since it is 4 times the cost of the Medicare prescription drug program and has been given a “four Pinocchio” rating by the Washington Post Fact Checker columnist.4
That the Republicans have been lacking both in focus on health care and in detail about what they would use to replace the ACA during the primary season should not be regarded as surprising. Republicans traditionally have focused less on health care than Democrats and thus the Republican candidates’ proposals on health care changes and reforms are unlikely to be important reasons for Republican primary voters to use to choose among various candidates. That tends to change somewhat once the candidates move to the general election and need to appeal beyond their own party members.
According to the Kaiser Health Tracking Poll, the all-important voting bloc of independents, who usually determine the outcome of presidential and other national elections, tend to fall somewhere between where Democrats and Republicans lie on various health care issues. This fact, alone, guarantees that health care will become more of an issue in the closing months of the campaign.
As of early 2016, more Americans continue to register unfavorable views of the ACA than favorable opinions: 44% against versus 41% for the ACA.1 Despite these numbers, there is no historical precedent for repealing a benefit that has been in place for what will have been more than 3 years by the time the next president is sworn in, and it is hard for me to imagine it happening in 2017. Furthermore, approval ratings for many of the components of the ACA remain higher than overall approval, which means even if the law were replaced, many ACA elements would probably appear in the new legislation.
Whether a reformed or “improved” ACA, which would reflect changes from follow-on legislation, as has occurred after all major pieces of social legislation, should be labeled as an ACA replacement or an improved version of the ACA can be left for the linguists to decide. Changes to the ACA will occur no matter who is elected president. How extensive these changes will depend on the outcome of the presidential election and the makeup of the Congress.
References
Gail R. Wilensky, PhD, was an economist and senior fellow at Project HOPE, an international health foundation. She directed the Medicare and Medicaid programs and served in the White House as a senior adviser on health and welfare issues to President George H.W. Bush. She was also the first chair of the Medicare Payment Advisory Commission. She had expertise on strategies to reform health care, with particular emphasis on Medicare, comparative effectiveness research, and military health care. Wilensky served as a trustee of the Combined Benefits Fund of the United Mine Workers of America and the National Opinion Research Center, on the Board of Regents of the Uniformed Services University of the Health Sciences (USUHS), and the Board of Directors of the Geisinger Health System Foundation, United Health Group, Quest Diagnostics, and Brainscope. She was an elected member of the Institute of Medicine, served two terms on its governing council, and chaired the Healthcare Services Board. She was a former chair of the board of directors of Academy Health, a former trustee of the American Heart Association, and a director of numerous other non-profit organizations. She received a bachelor’s degree in psychology and a PhD in economics at the University of Michigan and had several honorary degrees. July 2024
