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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.

 

 

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Remember back in the 1990s? Clintons were in the White House. Bushes wanted to be in the White House. Health care reform was fresh on everyone’s mind. As the French say, plus ça change, plus c’est la même chose, I guess.

The care delivery reform vehicle of the 1990s was to be Health Maintenance Organizations. Not particularly liked by physicians, these were groups of physicians and non-physician providers (hospitals and other health care entities)  who were tied by a common goal of delivering quality care at low cost. The problem is the definition of quality on the part of the HMO (low use of services that were not proven to be effective) was not the same as that of the patient (immediate access to services felt to be necessary by a prudent lay person).

In 1998, 3200 graduates of US medical schools went into Family Medicine.

The HMO movement eventually receded, as a consequence of consumer and physician revolt, although some remained (Kaiser and Group Health Puget Sound are the most well known from that era). For most Americans in the ensuing years, health care consumption was considered a matter of personal choice and, as Americans, we opted for convenience and technology. Insurance companies obliged us by limiting out-of-pocket cost. One could eat at the health care buffet and it only cost a couple of dollars.

As  physicians, we opted to provide these services in as efficient a manner as possible, with this efficiency being manifest as immediate access for folks with insurance. What happened was fairly predictable. Physician salaries skyrocketed. Health care inflation soared. Consumption was increased in areas of surgical procedures and high cost medications. Use of opiates such as Lortab dramatically increased.  If the analogy was one of restaurant dining, it is as if everyone with insurance in America got a free dining card with unlimited dessert.

For those without insurance (about 15% of adults under 65), care was not readily accessible unless they had significant cash to spend. Their dining card allowed them to stand by the dumpsters and wait for table scraps.

In 2004, only 1100 US grads went into Family Medicine.

Medical students in this country started talking about the ROAD to success, getting a position in a Radiology, Ophthalmology, Anesthesia, or Dermatology residency. Relatively easy work, really high pay. The pastry chefs of medicine.

American medical school in 2006 stood ready to respond to this new market reality, as encapsulated in this report from the era. They recommended a strategy of increasing enrollment in medical schools by 30%, supporting it with evidence of an aging workforce and the fact that physicians were not located where they needed to be (areas of shortage). In addition, they pointed to increased demand for more convenient access by an aging population.

If you fill the bucket to overflowing, they figured, student physicians could not help but go to places of need and select specialties of need. The market would sort things out. The aging population would get the doctors they needed, more Americans could catch the brass ring of “my son/daughter the doctor,” and we could continue to allow the market to set the tone. Or, to use the restaurant analogy, everyone who wants to be a pastry chef can be, and certainly someone will want to clean the dishes.

Did it work? We have increased the number of medical students from 14,000 in 2006 (the year the AAMC decided that the answer was to increase the number of doctors) to 22,500, an increase of 66%. The number of positions offered for training after medical school has increased from 24,000 to 27,000. Of those new US grads, the number electing to do radiology is up 200% and anesthesia is up 300%, Physical medicine and rehabilitation (one of the “new road” specialties) is up 300%. Family medicine, the specialty that goes to rural areas, the most rapidly aging specialty—how are we doing? Up 20%. The rest of the Family Medicine training slots? Filled by folks who went to medical school  in other countries

American students, it seems, are betting that we as a country are going to continue to allow people to eat unlimited dessert and they all want to be the pastry chef. So much for allowing our country’s workforce policy to be set by 25 year-olds. Heck of a way to run a restaurant.

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