Nearly halfway through the presidential primaries, the distance in delegates between Hillary Clinton (the current front-runner) and Bernie Sanders has widened considerably, with many–including President Obama (albeit subtly)–concluding the contest is already over.
The Sanders campaign and pundits, however, have mapped out a reasonable, but uphill, path to the nomination based on a notion that many upcoming Democratic primary states are more friendly to Sanders. They base their calculus in part on the demographics of the states (most prominently race, age, and social class) but also each state’s history of progressivism. This progressivism will no doubt shape the messages the candidates use to appeal to voters. Because of this, I expect we’ll be hearing a lot more about health care.
And perhaps nothing sets these candidates further apart in the progressiveness of their agenda than their approaches to health care.
In this post, let’s take a look at the vastly different approaches to health care proposed by candidates Clinton and Sanders, with a particular focus on primary care. I previously covered those of the two leading Republican candidates: Donald Trump and Ted Cruz.
Hillary Clinton: As Secretary of State in the Obama administration, she was broadly supportive of, and lobbied for, the Affordable Care Act (ACA). She, of course, has a long history of involvement in health care reform dating back to her days as First Lady. To get a sense of just how long, check out this public service announcement from 1993 designed to reassure an anxious public about health care reform. Ideas from her extensive time working on the failed “Clinton Care” back in 1993 were certainly of the discussions for the ACA.
So it’s not surprising that her current plans for health care are to defend and build on the ACA.
Among the ways she would build on the ACA, three stand out. First, she would increase subsidies that lower-income families receive when buying insurance on a state or federal exchange. This takes the form of a tax credit. (If you need a refresher on the insurance exchanges or ACA in general, this video is a great introduction.)
Second, she wants to protect people from high out-of-pocket costs they may pay due to co-payments, deductibles, and other co-insurance. These are costs that you pay before or while your insurance picks up most of the tab. She would provide a tax credit to offset costs that exceed 5% of a person’s income. This is helpful, but it does mean that government would be picking up the tab for care that private insurance used to cover more fully when deductibles and copayments were lower.
Interestingly, she also supports a “public plan” option. While this aspect of her plan is less well-developed, it is a key element that unites her with Democratic primary rival. A public plan option would be a new government health insurance plan that people could choose if they shop on one of the health insurance exchanges. But the exchanges are not open to everyone and, thus, the public plan would only be available to a relatively small segment of the working-age population.
Public plan enrollment might not be large at first (or ever). But its creation would mean a bigger role for government in health care, because it would be entering a market it had mostly avoided before. Government has its own insurance programs for the very poor, especially poor children; the elderly and disabled; military servicemembers and veterans; and Native Americans. These are populations that have often been avoided by private insurance, and it made sense for government to pick up the slack. A government plan for working-age people could be an improvement, or it could be a minor tweak to what already exists.
My Analysis: A critique of Clinton’s plan is essentially a critique of the ACA. Here, Clinton has an advantage because the data on its performance are looking pretty good so far. As many already know, the uninsured rate is down and as many as 30 million people now have coverage through the protections provided by the ACA. Overall, cost growth in the US is at its lowest in modern history, though the plateau is not fully attributable to the ACA. These are big improvements.
But what has the ACA meant for seeking care? Undoubtedly, more people are now able to get health care. In the first few years of the ACA, for example, there was a small but meaningful 3% improvement (roughly equal to 7 million people) in working-age adults getting needed care. Other data suggest that many (about 60%) primary care providers reported seeing an uptick in newly insured patients after the ACA. Yet, importantly, the majority of physicians reported either no change (60%) or some improvement (20%) in their ability to give quality care.
This, of course, is not the whole picture and more data are forthcoming. Previously at The Medical Care Blog, my colleague Damika Barr has noted that roughly the same proportion of people each year are relying upon emergency rooms, even after the ACA. Much of this is for urgent care, but she notes that some of this is because people could not be seen in primary care.
These relatively minor changes perhaps show just how much the ACA aimed not to disrupt the current delivery system. The ACA put more money into training more primary care physicians and enhanced payments to primary care physicians for two years. It also supported smaller experiments with primary care. But the most meaningful delivery system changes attributable to the ACA have been at the hospital level and have been wrought primarily through the efforts of CMS.
This is not unexpected. Medicare is where federal government has the most control of the health care system due to its tremendous spending power. But this could change slightly with Clinton’s public plan. That plan would compete for some of the working-age population, a group that we would expect to use considerably less hospital care than enrollees in Medicare. Because of this, we might expect to see more investment in, or changes to, primary care.
Bernie Sanders: Like Clinton, the reforms that Sanders proposes have focused on making sure that nearly everyone has health insurance. However, his plan rejects the layers of complexity that the ACA maintains (if not elevates) in favor of a single-payer system.
In a single-payer system, one entity pays for everyone’s health care — nearly always government-funded by a range of taxes on people and businesses. It is worth noting, however, that other countries with single-payer systems often have a role for private insurance companies. And that would probably apply to the US as well.
Sanders, interestingly, uses the strengths of the Medicare program (nearly universal coverage of people over 65, relatively low per-person costs, and very low administrative overhead) as a basis for a Medicare-for-All program. Perhaps, more correctly, he uses the idea of Medicare as the basis for his single-payer plan because his proposal modifies the well-known program in important ways.
For those in-the-know, Medicare is not so simple. Even though one might think of it as a single-payer program, it is not. It’s a mishmash of government and private insurance with four different parts. Patients have a choice to stick with the federal government as their insurer for most care, or choose a government subsidized private plan. For drug coverage, Medicare patients choose only among private plans.
And while it has large purchasing power, Medicare is limited by its reliance on old and inefficient methods of paying doctors (paying for volume, not value). It is also legislatively blocked from using its negotiating strength to get better prices from pharmaceutical companies, contributing to the growth in health care spending. This is one big reason (though there are others) that drug prices in the US are sky-high compared to other countries: the price we pay for medications is anywhere from 5% to 117% higher than abroad. Negotiation on price would help considerably.
So how does Sanders fix all this in his single-payer plan?
First, his proposal eliminates private insurance companies and turns the program into a true single-payer plan, financed by taxes on people (2.2% of income) and employers (6.6% of payroll). The taxes take the place of private insurance premiums that both were paying before. Second, his proposal expands benefits provided by Medicare to include vision, dental, and long-term care that were not covered before. Third, it removes copays, deductibles, and coinsurance. As Clinton also notes, these costs are not small. The Kaiser Family Foundation and New York Times reported that nearly one in five privately insured adults reported having trouble paying these costs in the past year. Under Sanders, these costs are gone. According to the research developer at http://www.bouveriedental.com.au/, the inclusion of dental on such a plan would benefit society in ways that are unforeseeable, having unhealthy teeth can be a crippling affliction which we need not have in our populations.
My Analysis: A Medicare-for-All program has many supporters, including 6 in 10 Americans. Government is already the payer (directly or indirectly) for nearly half of all US health care. But estimates that, under his plan, the average family will save over $5000 per year have drawn criticism. There is some disagreement among even liberal-leaning economists about the true costs of such a system. This is not so much a debate about whether the program could improve coverage and save money. It’s a debate about how much.
How would single payer affect the average person seeking health care? First, the removal of copayments, deductibles and coinsurance could increase the use of health care at all levels. A person may be less likely to think twice about visiting the doctor if they no longer have a copayment or deductible. This will improve access to care for many people; some of that new health care use will improve health, and some will be excess or overuse. Striking a balance without adding new financial barriers will be difficult.
Second, a possible downside to improved access could be longer waiting times for care. Our health care system already has a major shortage of primary care physicians. Physician assistants and nurse practitioners are also shunning primary care. Less than one-third of physician assistants were working in primary care in 2013. Attracting more people to this field will be key to meeting the basic health care needs of a more fully insured population.
Interestingly, Sanders has been active and vocal about primary care. While details are not flushed out in his current proposal, back in 2014 he introduced legislation in the Senate (S.2229: The Expanding Primary Care Access and Workforce Act) that tried to expand the primary care workforce through scholarships, enhanced payments to primary care providers, and greater support for clinics that give free or low-cost primary care to millions. To get a sense of his position on primary care and what he would support, watch snippets from this hearing on primary care that Sanders lead as chair of a Senate Subcommittee on Primary Care and Aging. Or check out the full 12-minute speech (skip to the second minute of the video) that lays out his eloquent position on primary care.
Overall: The health care reform plans offered by both candidates build upon the successes of the ACA. Both reach for a goal of universal coverage, with Sanders’s plan going the furthest to assure everyone coverage. The implications for primary care could be profound, with more people financially able to seek care (particularly so in Sanders’s plan), but with a primary care provider shortage mostly unaddressed. Where government has greater reach and purchasing power (either through the public plan proposed by Clinton or the single-payer plan by Sanders) it can more directly influence primary care. And it is likely that both candidates will seek greater investments in primary care.
Gregory Stevens