The Choices on Health Reform in the US Presidential and Congressional Elections

The commentary below was published in JAMA Internal Medicine online on October 10 2016 and was written by me and David K. Jones from the Boston University School of Public Health:

Although the outcomes of the US Presidential and Congressional elections in November 2016 will not be determined by attitudes toward the Affordable Care Act (ACA), the results will likely determine its long-term fate. As was the case in 2008 and 2012, the electorate’s decisions on whether the Republicans or the Democrats control the White House, the Senate, and the House of Representatives will have fundamental consequences for the future of national health reform.

A Republican victory that includes that party’s control of the White House, Senate, and House of Representatives would likely augur huge shifts in national health policy. A Democratic victory that included the White House and a Senate majority would likely further embed the ACA into state and federal health policy, and perhaps lead to further expansion and reforms. More than 6 years after President Barack Obama signed the legislation into law in 2010, the ACA has yet to become settled policy.

The Republican Agenda

Over the past 4 years, Republican members of Congress and conservative think tanks such as the American Enterprise Institute and the Manhattan Institute have advanced numerous proposals to repeal and replace the ACA. As the final stages of the 2016 campaign approach, 2 plans stand out: Republican presidential candidate Donald Trump’s agenda as outlined on his campaign website,1 and the House Republican leadership plan released by Speaker Paul Ryan (R-WI) in June 2016.2

Trump’s agenda is far less detailed than the 37-page Ryan document. Of 7 items on the Trump agenda, 5 also are part of the Ryan plan: (1) complete repeal of the ACA; (2) permitting interstate sale of health insurance; (3) allowing individuals to deduct the cost of health insurance premiums on their federal tax returns; (4) expanding use of health savings accounts; and (5) reforming Medicaid by implementing state spending block grants (or per beneficiary enrollment caps as an alternative under Ryan’s plan). Trump’s plan also promotes price transparency for physicians and hospitals, and would permit the importation and domestic sale of drugs with regulatory approval in other countries.

Ryan’s plan includes more details on the proposals it shares with Trump’s approach, plus policy proposals not included in Trump’s plan. Most of Ryan’s proposals reflect recommendations that are also key elements of other Republican and conservative plans, such as: capping the tax deductibility of employer provided health insurance; nationwide limits on noneconomic damages in medical liability litigation; continuing the ACA’s guaranteed issue of health insurance though only for individuals who maintain “continuous coverage,” and reestablishing state high-risk pools for uninsured persons with preexisting conditions; not allowing expansion of Medicaid as permitted by the ACA in states that had not expanded Medicaid by January 1, 2016; raising the eligibility age for Medicare to 67 years; and moving Medicare toward a premium support financing structure to limit the federal government’s financial obligations.3

Many of Ryan’s proposals are ambiguous. Moreover, the plan has not been written in legislative language, preventing scoring by the Congressional Budget Office to determine the likely cost and the impact on health insurance coverage. Regarding the Trump proposals, an analysis by the Committee for a Responsible Federal Budget, a nonprofit, nonpartisan organization, concluded that it would increase the number of uninsured by 21 million by 2018, raising the number of uninsured Americans from nearly 30 million to about 50 million, and increase the federal budget debt over 10 years by between $330 and $550 billion.4

The Democratic Agenda

Proposals for a health reform agenda in 2017 have been advanced by Hillary Clinton, the Democratic presidential candidate,5 Families USA,6 the Urban Institute7 and the Century Foundation.8 All 4 proposals build on reforms in the last 6 years to strengthen core provisions of the ACA. All assume that a Democratic President would block Republican attempts to repeal the ACA. None call for establishing a single-payer system to finance health care.

The proposals fit 4 categories. First, they would expand the number of people who would benefit from the ACA’s insurance coverage provisions leading to a likely decrease in the number of uninsured. Clinton wants all 50 states to expand Medicaid and embraces the Obama administration’s proposal to give states 3 years of full federal funding whenever they expand their programs (under current law, 100% federal funding ends in 2016 and gradually reduces to 90% for each state by 2020). The Century Foundation suggests that the federal government pay 100% of the cost of Medicaid expansion indefinitely. Clinton wants to open Medicaid and the Children’s Health Insurance Program (CHIP) to immigrant pregnant women and immigrant children. All 4 proposals advocate eliminating, through legislation or regulatory change, the ACA’s “family glitch” that bars coverage for some working families for whom employer-based coverage is deemed affordable for an individual worker but not for a full family.

Second, the proposals would make insurance coverage more affordable by increasing the value of premium tax credits for households with an income that is less than 400% of the federal poverty level who buy insurance through an exchange. Clinton and the Urban Institute advocate protecting families with incomes more than 400% of the federal policy level from spending more than 8.5% of their income on health insurance. All 4 plans propose different methods to reduce consumer out-of-pocket cost sharing. Clinton’s proposal would provide a tax credit for families whose expenditures exceed 8.5% of their household income.

Third, all the proposals seek to increase the number of people who obtain coverage through the ACA by expanding enrollment efforts. Clinton proposes spending $500 million per year on outreach and enrollment. Families USA suggests funding to improve online applications; the Urban Institute calls for more people employed full-time to assist with enrollment.

Finally, all the proposals include additional reforms. Families USA would require that all public and private health plans include dental coverage. Clinton would eliminate the ACA’s “Cadillac Tax” on high-premium employer health insurance plans, direct Medicare to negotiate drug prices with manufacturers, and expand funding for federally qualified community health centers and the National Health Service Corps. In contrast to Republican proposals, Clinton’s proposals would allow people younger than 65 years to buy into Medicare and would encourage states to establish “public option” exchange plans reminiscent of what many Democrats unsuccessfully sought when the ACA legislation was being considered by Congress. An analysis of Clinton’s health policy proposals by the Committee for a Responsible Federal Budget (including her more recent proposal to expand Medicare eligibility) shows a net cost of $200 billion over 10 years.9 The impact of the proposals on insurance coverage was not analyzed.

Prospects for Policy Change

Whether Donald Trump, Hillary Clinton, or Paul Ryan will be able to implement their respective visions depends on whether the Republicans or the Democrats win the White House and control of Congress, and on the size of the respective majorities in the Senate and House of Representatives. If Trump wins, Republicans are likely to do better in battleground states hosting competitive Senate races, enabling Republicans to maintain Senate and House control. Less certain is whether the Republicans could maintain unity to dismantle key coverage portions of the ACA that would eliminate health insurance coverage for many of the 21 million low and lower-middle income people who have gained coverage in the last 6 years.

If Clinton wins and the Democrats win a Senate majority, they will struggle to enact ACA enhancements if there is still a Republican majority in the House. Unlike their campaign statements in the 2012 and 2014 federal election cycles, Democrats in 2016 are outspoken in defending the ACA and in proposing improvements and additional health care reforms. Regardless of the outcome, the federal elections in November 2016 matter, and are likely to have long-term consequences for the future of the ACA and related health reform proposals.


  1. “Healthcare Reform to Make America Great Again.” Donald Trump for President website: Accessed June 22, 2016.

  1. “A Better Way: Our Vision for a Confident America.” House Republican Conference website: Accessed June 22, 2016.

  1. McDonough J, Fletcher M. “What Would Republicans Do Instead of the Affordable Care Act?” Health Affairs Blog. September 18, 2015:

http: //    Accessed June 22, 2016.

  1. Committee for a Responsible Federal Budget. “Analysis of Donald Trump’s Health Care Plan.” May 9, 2016. Accessed June 22, 2016.

  1. Hillary Clinton for President; Health Issues Webpage. Accessed June 22, 2016.

  1. Families USA. Health Reform 2.0. Accessed June 22, 2016.
  1. Urban Institute. After King vs Burwell. Accessed June 22, 2016.

  1. The Century Foundation. Key Proposals to Strengthen the Affordable Care Act. Accessed June 22, 2016.

  1. Committee for a Responsible Federal Budget. “Analyzing Clinton’s Health and Education Expansions.” July 27 2016. Accessed June 22, 2016.

Author: John McDonough

I offer insights and opinions on how to improve health care systems for everyone

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