Trump Triumphs, or Biden Better?
As Best We Can Assess, a Healthcare Voter Guide
In President Trump’s view and that of his supporters, his administration has orchestrated a massive redevelopment project, much like tearing down a blighted neighborhood and erecting gleaming new residential areas and commercial structures, hallmarks of his pre-presidency livelihood.
His actions relating to health care and thus health insurance, flow from the same mindset that replaced trade agreements, withdrew from a climate accord, ended the Iran nuclear deal, and otherwise executed vast policy makeovers of most that preceded him.
There’s been little legislation but more than a dozen executive orders.[i] One of the few Trump initiatives to impact employer plans directly came by executive order in October 2017.[ii] It paved the way for association employers to group together for more competitive rates. It extended short-term, limited-duration insurance from three months of coverage to three years (albeit without protecting pre-existing conditions).[iii] It also provided employers greater flexibility in structuring Health Reimbursement Accounts (HRA).
Trump for Transparency
More recently the administration has enacted an executive order that will oblige hospitals to post prices for hundreds of common medical services come January 1. About a month ago, there was an order providing “most-favored-nation pricing” on prescription drugs and biological products purchased through Medicare. The Trump administration capped Medicare’s price for insulin at $35, and issued a rule allowing states to import drugs from Canada where they are cheaper due to government price controls.
Legislatively, the Trump Administration gained passage of “right to try” in May 2018 giving patients with life-threatening diseases access to medications in clinical trial but not yet approved by the FDA.[iv]
Its other legislative accomplishment now rests in the center of a political storm. The Tax Cuts and Jobs Act passed in December 2017 included repealing the penalty of the ACA individual mandate effective January 1, 2019. More on this later.
Goodman Good With It
John C. Goodman, Ph.D., President/CEO of the Goodman Institute, is an economist and whose writings appear frequently in national publications such as Forbes magazine. In a September briefing posted on Youtube,[v] Dr. Goodman lauded Trump’s healthcare initiatives and a post on his website carried a headline that read in part:
“An Alternative to Obamacare is Already Halfway There.”[vi]
Less complimentary are many other esteemed organizations.
“When it comes to health care,” a post last month at Kaiser Health News read, “President Donald Trump has promised far more than he has delivered.”
Criticism of the President’s policies related to healthcare center upon his changes to the ACA while failing to repeal and replace it fully, a Republican party promise in the 2016 election. Understandably, since he was second in command at enactment of the Affordable Care Act, former Vice President Joe Biden promises “to do everything in my power to protect it (the ACA) and build on it”[vii] if elected.
“He has a plan to build on the Affordable Care Act by giving Americans more choice, reducing health care costs and making our healthcare system less complex to navigate.”
So it says in bold lettering on the Biden campaign website. There were no examples given of how he’d make the healthcare system something less than a navigational nightmare. It’s also reported, at least by Forbes magazine, that Biden would work with Congress to re-institute the individual mandate.[viii]
Of course, the ACA may be out of existence by inauguration day.
The case scheduled for hearing November 10 by the Supreme Court sounds almost like a college football game: California v. Texas.[ix] This is a battle of numerous state attorneys general and a few governors representing 35 states, 17 supporting California and 18 aligned with Texas. The Trump administration sides with the Texas-led group but is not a plaintiff in the case. You’ll recall that SCOTUS upheld the ACA in 2012 but removing the mandate for private individuals to purchase health insurance prompted this particular court challenge.
The current status of the ACA is that has been ruled unconstitutional by a lower court and the overturn upheld in the 5th Circuit Court of Appeals; hence: it’s back again before the Supreme Court.
Will there be an ACA (aka: Obamacare) with employer penalties come the new year?
“If we win, we will have a better and less expensive plan that will always protect individuals with pre-existing conditions,” President Trump said about a month ago. “If we lose, what we have is better than the original version of Obamacare, by far. Much better. Much better.”[x]
Critics won’t accept hyperbolic statements in the absence of a point-by-point comprehensive healthcare plan, yet to be unveiled by either the Trump administration or his campaign.
As a counterpoint, Dr. Goodman, who claims to be in regular contact with the White House, holds the ACA in low esteem.
“In most places, the individual market is a mess. Thanks to Obamacare, premiums have doubled, deductibles have tripled, and provider networks look like Medicaid managed care with a high deductible,” he wrote.[xi]
If the overturn of the law is upheld, Congress can always pass a new version, presumably.
Biden’s Plan Beyond Obamacare
While most of Biden’s stated proposal involves individual plans, what could effect employers is a cap on premiums and tax credits. According to his website:
- Biden will help middle class families by eliminating the income cap set at 400% of the poverty level on tax credit eligibility and lowering the limit on the cost of coverage from 9.86% of income to 8.5%
- Biden will increase the size of tax credits by calculating them based on the cost of a more generous gold plan, rather than a silver plan.
“If a family is covered by their employer but can get a better deal with the 8.5 percent premium cap, they can switch to a plan on the individual marketplace,” it stated.
Of greater impact to employers, eventually if not immediately, would be Biden’s proposal of a public option “like Medicare,” according to his campaign, but not Medicare for All.
“As in Medicare, the Biden public option will reduce costs for patients by negotiating lower prices from hospitals and other health care providers,” JoeBiden-dotcom states. “It also will better coordinate among all of a patient’s doctors to improve the efficacy and quality of their care, and cover primary care without any co-payments. And it will bring relief to small businesses struggling to afford coverage for their employees.”
Sources other than the campaign website characterize this public option as lowering Medicare eligibility to age 60 instead of 65. A writer at Forbes rolled together Biden’s public option with his running mate’s co-sponsorship in the Senate of Medicare for All into what the writer termed “Medicare for More.”[xii]
The Biden plan also calls for extending Medicaid to individuals living in states that did not accept Medicaid expansion under the ACA. His plan would even automatically enroll those at 138% of the federal poverty into the public option “when they interact with certain institutions (such as public schools) or other programs for low-income populations (such as SNAP),” according to his website.
If you’re keeping score, Vice President Biden’s plan involves:
- The ACA with a reinstituted individual mandate and preserved employer penalties, presumably.
- Tax credits for purchases on the exchange.
- A cap on premiums at 8.5% of income.
- Eliminate the 400 percent of the federal poverty level to qualify for financial assistance.
- A public option “like Medicare,” perhaps restricted to low-income individuals or maybe not and maybe including an employer buy-in.
- Medicaid for those in states that bypassed the program’s expansion under the ACA.
- Automatic enrollment into the public option for those at or near the federal poverty level.
In 19 days, America elects a President, an entire House of Representatives, and about a third of the United States Senate. A week later, the United States Supreme Court may decide whether the Affordable Care Act stands in whole or in part.
Forthcoming legislative action would likely require the party of whomever is elected president controlling both the House and a filibuster-free Senate. Existing executive orders can be removed at the stroke of a pen, and new ones constructed just as easily.
Most of what’s discussed here effects healthcare generally, impacting cost, with ramifications for private health insurance both individually and through employers.
Bringing a realistic picture into focus of what the future holds for health care and thus health insurance – given today’s political hysteria – is about like trying to referee an out-of-control food fight. We’ve attempted a bias-free assessment of the realistic possibilities with tempered political passion.