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Tuesday Oct 11, 2016

Donald or Hillary? How Choice Affects Health Care

In less than 30 days, the United States will elect its 45th president. The upcoming elections also will determine who represents your state and community in the U.S. House of Representative and Senate -- not to mention thousands of state and local offices.  

Nov. 8 will bring to a close one of the more memorable presidential campaigns in modern history. If you watch television or read a newspaper you have likely heard that this is the "most important election of our lifetime." Pundits and political operatives tend to say this every four years, so the idea has a bit of a "boy who cried wolf" feel to it. I find such statements a little amusing.  

Electing a single individual to lead the most economically and militarily powerful country on earth is a process that should be taken seriously, by each of us, every time. To this end, whether you are "with her," want to "make America great again," or even if you can't stand either of the major parties' candidates,  I urge you to participate in our electoral process and cast your ballot on Nov. 8 or through your state's early voting opportunities. To quote the incomparable Winston Churchill, "Democracy is the worst form of government, except for all the others."

Our next president will be responsible for overseeing the federal government for the next four years, including major health insurance programs such as Medicare, Medicaid, and the Veterans Health Administration. To date, the two leading candidates have not featured health care as priority issues for their campaigns. I will note that a former President has made some headlines for his views on health care lately, but the two candidates themselves have stayed focused on other issues -- mainly each other.  

While health care hasn't emerged as a top-tier issue for the campaigns in the 2016 elections, the economics of health care continues to be important to voters. The September Kaiser Health Tracking Poll includes some interesting insights into voters attitudes towards health care coverage and cost. Sixty percent of respondents said the cost of health insurance premiums is "very important" to their vote for president in 2016.  Additionally, 55 percent stated that the cost of health insurance deductibles is "very important" to their vote for president in 2016. Fifty-one percent said that the cost of prescription drugs is "very important" to their vote.

Despite a daily focus on large-scale health care reforms, both candidates have expressed their commitment to addressing the opioid epidemic and their support for greater access to mental health services. The campaigns also have expressed a desire to improve access to care for our nation's veterans. Another interesting area where the candidates have expressed shared concern is the cost of prescription drugs. Interest in this area makes good political sense - it's a kitchen table issue for millions of Americans who are facing escalating bills due to the cost of their prescription drugs. The Kaiser Health Poll mentioned above showed that 77 percent of Americans view the cost of prescription drugs as "unreasonable." More than 35 percent of individuals who take four or more drugs state that it is difficult for them to afford their prescription drugs.

The health policy agenda of the two candidates are difficult to compare due to a lack of comprehensive proposals on the part of the Trump campaign. Kaiser Family Foundation has a side-by-side comparison of the candidates' positions on seven key health care issues. I have found this to be the most comprehensive resource other than the candidates' websites. The following are the top-line policies each candidate is advancing as their "health care agenda."

Donald Trump's health care agenda is outlined in a five-point plan:

  • Repeal and replace the Patient Protection and Affordable Care Act with health savings accounts.
  • Work with Congress to create a patient-centered health care system that promotes choice, quality and affordability.
  • Work with states to establish high-risk pools to ensure access to coverage for individuals who have not maintained continuous coverage. 
  • Allow people to purchase insurance across state lines, in all 50 states, creating a dynamic market.
  • Maximize flexibility for states via block grants so that local leaders can design innovative Medicaid programs that will more appropriately serve their low-income citizens.

Hillary Clinton has published several position papers on a variety of health care issues. In addition, she has a nine-point health care plan:

  • Defend and expand the Affordable Care Act, which covers 20 million people.
  • Bring down out-of-pocket costs like copays and deductibles.
  • Reduce the cost of prescription drugs.
  • Protect consumers from unjustified prescription drug price increases from companies that market long-standing, life-saving treatments and face little or no competition.
  • Fight for health insurance for the lowest-income Americans in every state by incentivizing states to expand Medicaid.
  • Expand access to affordable health care to families regardless of immigration status.
  • Expand access to rural Americans, who often have difficulty finding quality, affordable health care.
  • Defend access to reproductive health care.
  • Double funding for community health centers, and support the health care workforce.

The most notable difference is the respective positions on the Affordable Care Act. Secretary Clinton supports the law but seeks to improve it. Trump opposes the ACA and pledges to repeal it. The two also split on Medicaid. Trump is promoting the well-established Republican policy of providing states block-grants to operate their Medicaid program. Clinton would expand access to the traditional federal-state partnership model for the Medicaid program.

Regardless of the outcome on Nov. 8, the AAFP will be prepared and positioned to advance policies aimed at improving our health care system for you and your patients.  We also will provide information and insight through this blog and AAFP News.

 Go vote!


Embarrassed that my professional society would present the question as though there are only two candidates. Each of whom carry significant baggage, and have won the suspicion of much of the American public. Fewer than 20% of American voters voted for both of them TOGETHER in the primaries...

We will have an adversarial, partisan, politicized system for as long as we keep pretending there are just two parties. Can we hear about Johnson and Stein's plans, please?

Posted by Bruce Kinzinger on October 11, 2016 at 11:41 AM CDT #

My problem with this article and everything from the AAFP on this issue is the fact my leaders at AAFP really don't care what the membership thinks.(or at least they consciously choose to go against it)
This was demonstrated when the AAFP supported the ACA in the first place even though the majority of family docs did not.
I previously quit the AMA because of similar behavior on their part and came close to doing the same with my AAFP membership.
I seriously question whom the AAFP represents if it is not the majority voice of Family Physicians?

Posted by Charles Bess on October 11, 2016 at 11:47 AM CDT #

I find life is divided into three categories. Those things I can control, those that I can influence, and those I can do neither. Regardless of the outcome of the election, this country needs family doctors to be advocates of quality care while being good resource stewards for our patients. My definition of waste is "not helpful". Let's look at all aspects of our work in this light. Thank you AAFP for your patient-centered focus.

Posted by Bill Wright on October 11, 2016 at 11:52 AM CDT #

The ACA was designed to fail. No other insurance sector allows for unlimited benefits with no risk underwriting. Imagine the effect on the cost of auto insurance if, instead of "totalling" out your car, and only being paid out the Blue Book value of your car, you could go out and buy any new car you wanted and your insurance company was forced to pay for it. Or the effect on home owners premiums if your $250000 home burned down and you wanted to rebuild a home at a cost of $750000, or a million dollars, and your homeowners insurance was forced to pay for that? Auto and homeowners premiums would skyrocket!
So, with the ACA, with no risk underwriting ("pre-existing conditions") and no lifetime cap on benefits, insurance premiums necessarily skyrocketed. Congress and the president knew this. It is no surprise then that insurance companies are bailing on the exchanges--it is a business model that is doomed to fail.

Trump's five points as listed in Mr. Martin's blog, have as their common theme increased choice for consumers, and increased flexibility/choice closer to home in the individual states.

Clinton's nine points cluster around the following themes:

Expand an already imploding ACA system (somehow; probably by increasing federal spending to subsidize it further leading to greater taxation or deficit spending, while further driving up premiums)

Price controls--an anti-free market solution that will invite the worst kind of croneyism and lobbying by those industries affected to try to curry special deals. We have seen this for years with Medicare--AAFP and others trying to talk congress/CMS into raising the paltry amount paid to primary care doctors. Due to limited profit motives this also will stifle innovation and PREVENT companies from developing generic drugs or alternatives to expensive options currently available.

Increase Federal Spending--every time you read "Access", Medicaid, or Community Health Center, simply add to the end of the line "by raising taxes" or "by increasing federal deficit spending". In a country with $20 Trillion dollars of operating debt and over $200 Trillion in unfunded liabilities, increasing spending is like taking out a consumer loan to pay off a credit card.

By exiting the third party payor world and providing a free-market direct-pay, fee-for-service and employer-sponsored direct primary care, our organization has been able to bend the cost curve for thousands of patients plus several employers locally. One of our clients has held employee's health insurance premiums stable for 3 years and this year will DECREASE premiums!

Neither of these candidates has mentioned a "free market" solution by name, though Trump clearly leans more that direction than Hillary Clinton. Market forces are a law of nature, however, and whether you regulate more, or de-regulate, the law of supply and demand will not go away.
With less federal regulation, prices and processes can become more transparent and costs can come down with decisions made across the dinner table, or at the state government level.
With more regulation, the system become more complex, incomprehensible, and expensive, spawning less transparency, more backroom deals and centralizing power over our health decisions in Washington D.C.

I prefer the dinner table. So do our patients.

Posted by David Usher, MD on October 11, 2016 at 12:30 PM CDT #

Dr. Kinzinger makes a valid point. There are two additional candidates running for President who will appear on a number of state ballots. Those candidates are Jill Stein from the Green Party and Governor Gary Johnson from the Libertarian Party.

For more information on Gary Johnson's policy agenda, please visit www.johnsonweld.com/issues. For information on Jill Stein's policy positions please visit www.jill2016.com/plan.

Posted by Shawn Martin on October 11, 2016 at 01:05 PM CDT #

Dr. Kinzinger makes a valid point. There are two additional candidates running for President who will appear on a number of state ballots. Those candidates are Jill Stein from the Green Party and Governor Gary Johnson from the Libertarian Party.

For more information on Gary Johnson's policy agenda, please visit www.johnsonweld.com/issues. For information on Jill Stein's policy positions please visit www.jill2016.com/plan.

Posted by Shawn Martin on October 11, 2016 at 02:03 PM CDT #

This article has opened up a Pandora's Box.
We all know the issues.
We all know that we will have to deal with our agenda with the next administration
no matter who wins.
I think with regard to this election the AAFP should "mix out"

Posted by Daniel Orr on October 12, 2016 at 05:55 AM CDT #

Mr. Martin, thank you for including links to the candidates positions at least in these footnotes. To clarify your point about ballot access: Governor Johnson will receive votes in all 50 states plus DC. Dr. Stein can receive votes in all but OK, SD and NV.

Our media has not informed us much of these candidates, reneging on their higher role on our Free Press country, often referring to "both" candidates, etc. It is a real disservice, since many patients in the trenches are very anxious about this election cycle, often believing that they only have two choices, and they are having a real hard time voting their conscience. Many physicians feel the same way.

For the record, I do vote routinely, but do not endorse a candidate, engage in partisanship, nor belong to a party. I simply hope to raise awareness of options in a time like this, irrespective of the motivations of our general media (news?) sources.

I do have high expectations of headlines in professional sources with the highly educated audience served, and the influence that audience collectively has. Thank you.

Posted by Bruce Kinzinger on October 12, 2016 at 10:26 AM CDT #

I agree with many of the above posters that a national healthcare discussion is not so simple as "Donald or Hillary." We do too often see the mainstream media push aside ideas not coming directly from the DNC/RNC. Hearing from candidates of additional major parties like the Greens and Libertarians can elevate and broaden the discussion, which I find is always in the best interest of the people.

Jill Stein supports an expanded and improved http://www.jill2016.com/dr_jill_stein_applauds_national_health_program">Medicare for all. I don't find any direct references to healthcare on https://www.johnsonweld.com/">Gary Johnson's page.

Many media outlets are now hosting town hall and other events for both parties because they are barred from the private debates. The links above should let you find any upcoming events.

Posted by Scott Nass on October 13, 2016 at 05:42 PM CDT #

As professionals, we are held to the highest ethical, even moral particularly for healthcare, standards. It helps to have a father who'd practiced in the "Golden Age" of medicine to know what this means. Upon graduating medical school, I remembered sending my father an article to what is the definition of "professional" in medicine.

That was an opinion editorial, in JAMA, dated in the 1960's. You can look it up.

That was 55 years ago. There has always been a threat to this definition, and how it is practiced. Nowadays, I sense that our profession is being remapped to be a major part, if not the biggest domestic labor market, of the common working class.

Here we are 55 years later. My father has since retired. On a daily basis, I find myself doing this a lot in my practice:

To be a part of the solutions, that is obvious, that has always been the assumption in our profession.

I also find myself working twice as hard to do this:

To NOT be a part of the problem. This was something I had to learn "how to" nowadays, what to avoid, the operational booby traps that detract and deter from patient care. I also find myself being more realistic in what I can bring to the table, and as a doctor, it's not easy to have to look at this in the mirror everyday. We are not that type of people. The end goal here is to be a part of the solutions.

This is an over-simplification, but it is my template for any healthcare policy. An answer to why I have to work so hard not to be a part of the problem perhaps is because with any changes, there are experimentation, and with any new idea, there's always the "I don't know if it will work or not, but just try it, what do you have to loose?" mentality (I'm actually quoting a hospital CEO during a quarterly staff meeting five years ago), That hospital CEO has since moved on.

Posted by Michael N., MD on October 25, 2016 at 09:01 AM CDT #

terrorist attacks both domestic and foreign have been tied repeatedly to a failed mental health system that does not adequately identify, treat, or follow those with serious mental health problems. Neither of the candidates show a vision on how to correct the mental healthcare delivery system. When I see the isolated lives that these ill persons live, and speak to our local hospital psychiatrists on the long waiting list that exists for follow-up care, I can't help, as a normal caring person, but be moved by apathy that exists. I doubt Hillary or Donald have even thought about it but it is the elephant in the room.

Posted by Gary Arvary on October 26, 2016 at 10:33 AM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.