The presidential primaries are in full swing and health care is an issue for both parties. The candidates have left themselves plenty of wiggle room, but there is enough information in the public domain to make some predictions about what the different approaches (and they are different) would mean for the health care system.
This time, I’ll take a look at the basic elements of the health care proposals of the two leading Republican contenders: Donald Trump and Ted Cruz. 
Next time, I’ll tackle the Democratic side. We’ll look at what their plans will likely mean for health care generally and primary care specifically. Why primary care? That’s where most people use health care in any given year and where many of us could be affected.
Because both candidates have proposed dismantling the Affordable Care Act (ACA), it’s worth brushing up on the details. Check out these two short videos from the Kaiser Family Foundation about reform and how you might be affected if you need a refresher.
Donald Trump: Trump has released a plan that has sweeping changes. Like most Republican legislators, he would fully dismantle the ACA. This includes the rule, widely disliked by the public, that everyone have insurance or pay a penalty. But it also includes the widely liked protections against the worst behaviors of health insurance plans and the financial help for people to buy coverage.
He designed his plan to encourage, but not force, people to buy insurance if they don’t get it from an employer. He would make health insurance that you buy on your own (without help from an employer) tax-exempt. It currently is not. He would also expand the use of health savings accounts. What are health savings accounts? Simply, tax-exempt ways to put money aside to pay for your health care. Not your health insurance; the costs of your doctors visits, labs, etc.
His plan does nothing to protect millions of people who have health conditions that made getting insurance nearly impossible without the ACA.
My Analysis: The most fair assessments of Trump’s plan, including this one by Drew Altman of the Kaiser Family Foundation and this one by the Committee for a Responsible Federal Budget, suggest it does a couple of things right. Tax deductions would make insurance more affordable for some people who buy insurance on their own. But they would do nothing for the millions of “working poor” who are among the least likely to have health insurance, yet already pay very little (or nothing) in taxes. And by dismantling the ACA, an estimated 19-25 million people would lose their insurance through 2025.
On balance, this is a problem.
The millions who lose coverage will again find their primary care options limited. Government funded free or low-cost primary care clinics, called Federally Qualified Health Centers (FQHCs), would likely see an uptick in use. These clinics are known for providing very good primary care, but the number of uninsured clients will cause them financial stress.
Trump’s plan to nudge people to buy health insurance also nudges people to sign-up for lower-cost “high deductible health plans.” And most experts think it will further urge employers to offer these types of plans to their employees, a trend which was underway before the ACA. Without the ACA setting a minimum coverage level called the “essential health benefits,” it is possible that these low-cost plans will also cut the services they cover and how thoroughly they cover them.
Low-cost sounds good, except when we realize the term “high deductible” in the title means that people will have to pay directly when they visit a doctor. With common deductibles ranging into several thousands, many people will have to pay the full cost of the health care they use each year, making people think twice about making a trip to their primary care doctor. On the other hand, there is good evidence that if you make people pay more out-of-pocket for their own care, they use less care that does not improve health. This is probably not the case for millions of people with chronic conditions, like diabetes, or people in lower-income households, who will also forgo necessary and important health care.
Finally, although this is not in his current plan, it is worth noting that he did once have a brief soft spot for how single-payer health care has worked in Scotland and other countries. Whether this might ease his view of the ACA in the long run, or affect his choices to limit the negative impact of any plan on the uninsured, is unknown.
Ted Cruz: Cruz goes further than Trump in his health care proposal. His campaign website, surprisingly, does not list health care as a key issue in his campaign, but his opposition to the ACA has been loud and clear. He famously used a reading of Green Eggs and Ham during a filibuster to explain that the American people did not like Obama Care after trying it for several years (“Not in a box, with a fox, in a house or with a mouse”). Fans of Dr. Seuss will remember a different end to the story.
Cruz has cosponsored legislation in the Senate (the Health Care Choice Act of 2015) that would repeal most, but not all, of the ACA. The bill would let health insurers sell plans across state lines (a popular free-market approach touted to increase competition, but one that also lessens state power to regulate health plans), and extend Health Savings Accounts, both also proposed by Trump. The bill, however, did leave in place subsidies to buy health insurance plans, but made them less generous.
Since that bill, Cruz has gone further, by proposing to de-link health insurance from employment, with a goal of everyone buying insurance on their own. The hassle of changing insurance when you change jobs is undoubtedly problematic, and can discourage those unhappy with their employment to stay anyway to keep coverage. But a shift away from employer-sponsored coverage does sacrifice the negotiating strength of large employers and the employer’s help in paying for the insurance. It would be nice, of course, if employers then raised salaries to replace that lost benefit, but there is no sign this would happen in the short-term. Over the long-term, employers still have to compete for talent and wages will certainly rise. But will the wages rise quickly enough to replace the lost benefits and keep up with premiums?
Interestingly, Cruz would keep elements of the ACA. To keep some degree of coverage for people with pre-existing conditions, he proposed returning them to “high-risk pools,” which were used before the ACA with mixed success. And Cruz has, at least once, proposed a national insurance exchange that was part of the original plans for the ACA that would take the place of state exchanges.
My Analysis: Because of the similarities between plans, the impact on the number of uninsured and their ability to get primary care is also similar. How a movement away from employer-based insurance will impact health care is harder to predict. People tend not to switch plans when they get them through an employer, even if they have choices. But the allure of having people shop for coverage, is the presumed comparisons they could (and would be expected) to do each year to make the most of competing plans. How effective this shopping around is will depend greatly on how many choices people have. In some geographic areas, choices can be pretty limited.
The degree of switching has potential implications for primary care. Because health plans often have different networks of providers, there is no guarantee of being able to keep a primary care doctor when changing plans. And the lack of continuity with a primary care doctor often means losing some medical history, increasing the risk of duplicative testing, and creating gaps in preventive and acute care. This is not a risk solely from Cruz’s plan, as the current state health insurance exchanges used in the ACA by many people also rely on the savvy of people to shop for better plans. The most recent rate of switching plans through HealthCare.gov, the federally run exchange for states that did not create their own, was about 29%.
Overall: The health plans proposed by Trump and Cruz make some fairly drastic moves away from the ACA. The expected increases in the number of uninsured, the emphasis on paying out-of-pocket for most primary care (and other care), and the reliance upon frequent and skillful comparison shopping among private plans, all risk some turbulence in getting good primary care.
The ACA also has key supports for increasing the primary care workforce and for experimenting with new models of care. The models, such as the patient-centered medical home and Accountable Care Organizations, emphasize and assign greater value to primary care. I’ve touched on these in an earlier post, and it is worth noting that dismantling the ACA also would cut these important experiments short.
Next time, I’ll take a look at the vastly different proposals on the democratic side.
Gregory Stevens
Pingback: The Health Plans of the Democratic Presidential Candidates and How They May Affect Primary Care | The Medical Care Blog