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Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:

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So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims.  The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

  • Clinton
    • supports policies to maintain and build upon the ACA.
    • increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
    • fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.
    • make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
    • invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
    • authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
    • proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
    • proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
  • Trump
    • complete repeal of the ACA, including the individual mandate to have coverage.
    • create high risk pools for individuals who have not maintained continuous coverage.
    • provide a tax deduction for the purchase of individual health insurance.
    • promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
    • promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
    • would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

  • Clinton
    • encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
    • would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
  • Trump
    • supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
    • would cover the low-income uninsured through Medicaid after repealing the ACA.
      • The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

  • Clinton
    • supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
    • supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
    • does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.
    • proposed to allow people ages 55 to 64 to buy into Medicare.
  • Trump
    • No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
    • supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.
    • supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

  • Clinton
    • proposes prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry
    • increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
    • reducing the market exclusivity period for biologics
    • and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
    • proposes to establish consumer oversight in federal agencies
    • penalize drug companies for unjustified price increases
    • allow importation of lower-cost drugs from countries with similar safety standards.
    • She also supports eliminating tax deductions for direct-to-consumer advertising
    • requiring FDA approval of advertisements
    • tying federal support for drug companies to their investment in R&D
    • increasing transparency of the additional value new drugs have over existing treatments
    • allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
    • proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
  • Trump
    • supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
    • supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

  • Clinton
    • released a $10 billion (over ten years) plan to fight drug addiction.
      • includes a federal-state partnership to support education and mentoring programs
      • development of treatment facilities and programs
      • efforts to change prescribing practices, and criminal justice reform.
      • direct federal action to increase funding for treatment programs
      • change federal rules regarding prescribing practices
      • enforce federal parity standards
      • promote best practices for insurance coverage of substance use disorder services
      • issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
  • Trump
    • Will build a wall on the U.S.-Mexican border
      • will help stop the flow of drugs and thus address the opioid epidemic.

Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services

  • Clinton
    • supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.
    • defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.
    • would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
  • Trump
    • called for defunding Planned Parenthood if they continue to provide abortion
    • He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
      • has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
    • would also work to make the Hyde Amendment permanent law
    • would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
    • would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.

 

 

139263_600Ben Carson on setting up health savings accounts in a post Obamacare world:

“You also give people flexibility to transfer money within a family. So if you were $500 short, your wife could give it to you, your daughter could give it to you, your uncle, your cousin.”

Me in conversation with a fellow who is homeless and suffers from a terminal illness last week:

“Can you give me a ride? I sleep in a cot in the shelter down the way. I worked all my life until I got sick. Just got discharged a week ago from the hospital. Can walk about a half a block before I have to rest. I spend my morning walking to the this place for food.”

Me: “How long does it take you?”

“Oh, all morning. It’s about 3/4 of a mile. I spend the afternoon walking back. The give me a lot of medicines but when I run out I end up back in the hospital”

From a blog on population health

…..success (in lowering healthcare costs and increasing quality of healthcare/better outcomes for patients) …will require the ability to embrace the messiness of disease and the complexity of patients, rather than providing idealized solutions that impress in the boardroom but flop in the examination.

It is refreshing not to have a wonkish campaign for the Republican nomination. Both 8 years ago and 4 years ago terms like “bending the cost curve” and “medical loss ratio” were being used by the actual candidates. Voters don’t want to hear that. They want common sense solutions for common sense problems. For healthcare, the answers are simple—after all, we’ve all been to the doctor, right? Make the sick folks make choices. Get ’em out and working. Since Dr Carson is, well, a doctor, his common sense answers are just the prescription for our sore ears.

As found here, he feels that Health Savings Accounts for almost all are just what the doctor ordered:

ObamaCare, he opines, is way too restricting. Why should people need to have the details of what they purchase?

A major problem is that many people in our entitlement society see nothing wrong with forcing others to provide for their desires. In a free and open society, anyone should be able to purchase anything they want that is legal.

Given enough freedom, the invisible hand will sort things out:

Most people will want to get the biggest bang for the buck and will independently seek out both value and quality. That, in turn, will bring all aspects of medicine into the free-market economic model, thus automatically having an ameliorating effect on pricing transparency and quality of outcomes.

In addition, the miracle of compound interest will overcome the human predisposition to become sicker as we get older:

If accounts are established at the time of birth, they will be even more potent because the vast majority of people will not experience catastrophic or even major medical events until well into adulthood. By that time, a great deal of money will have accumulated.

Lastly, Americans are generous to a fault and will contribute to a fund if it goes to those who are deserving:

The 5 percent of patients with complex pre-existing or acquired maladies would need to be taken care of through a different system, similar to Medicare and Medicaid, but informed by the many mistakes in those programs from which we can learn. Even this kind of system should have elements of personal responsibility woven into it.

Problem is, facts really get in the way of an attractive market-based narrative:

  1. Healthcare in this country costs about $8,000 annually for each man, woman, and child, of which the government currently pays around $5,000.- President Carson would put $2,000 into everyone’s account. Already he’s saved us money!
  2. Five percent of the population accounts for almost half (49 percent) of total health care expenses with most of those people being on Medicare or Medicaid.- Um, does that mean we bonus everyone $2,000 and then have to pay the same amount for folks on Medicare anyway? Or does their account magically grow? 
  3. The lower 50 percent of spenders accounted for 3 percent of the total national health care dollar.- Uh, oh, here’s a problem. We have taken this money out of health care and moved it into a savings account for healthy people.
  4. High spending persists over multiple years for many patients, while others return to more normal spending levels after an expensive episode. There is also evidence that high spending occurs near the end of life for many patients, particularly within the Medicare population- Well, this is a problem…what happens when the savings account runs out? I guess they are walking to the homeless food site.

Interestingly, Dr Carson performed operations that cost the patient’s insurance $3,000,000 on a routine basis. He never published his results, but the operation he became famous for (separation of twins joined at the head) apparently has a mortality of 50%, and an unknown but high rate of severe disability. It is clear that informed consent remains a real problem regarding outcomes without surgery. Since these operations occur in the first year of life, the twins could kick in the first $4,000 from their HSA. Wonder if having to collect $2,996,000 from the health savings accounts of 1498 of the parent’s closest friends and family would make a difference?

Me, I’m now into the Donald’s plan:

Trump said that the Affordable Care Act has “gotta go” and that he would repeal the law and replace it with “something terrific.”

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