Health policy after the election

The 2016 elections on Nov. 8 will have huge consequences for health policy.

If President Clinton is elected, she would largely pursue a continuity agenda: continuing to expand coverage options under the Affordable Care Act (ACA), including offering a “public option” to compete with private plans on the marketplaces, and offering people ages 55 to 65 the option to buy into Medicare coverage. She also will propose changes to stabilize the health insurance marketplaces in each state for small group and individual insurance to address the challenges of rising premiums and insurers pulling out of some of the markets, such as increasing the premium and cost-sharing subsidies and reinvigorating an expired re-insurance program to help insurers who enroll a less healthy mix of patients. However, the proportion of her agenda that could be enacted will depend on whether Democrats take control of the Senate from the GOP, whether the House remains under Republican control, and by what margins in both cases.

If President Trump is elected, his agenda is less clear, although he has pledged to work with Congress to repeal the ACA. He could replace it by allowing the selling of insurance across state lines, making health insurance premiums in the individual market fully tax-deductible, eliminating requirements that people buy insurance, and striking mandates on the benefits that plans must offer. However, how far he could go in repealing the ACA depends on which party controls the Senate and the House. Even if the GOP were to control both chambers, it would have to gain a filibuster-proof majority in the Senate. As a practical matter, it would be politically challenging to enact legislation that would take coverage away from the 20 million people currently covered under the ACA.

State legislature and gubernatorial elections will also have a major impact. If Democrats gain control of more state legislatures and governorships, it is likely that most of those states will decide to accept the money authorized by the ACA to expand Medicaid. If the GOP retains or increases the number of states under its control, Medicaid expansion will likely continue, but much more slowly (unless, of course, Congress repeals the ACA and with it the money dedicated to Medicaid expansion).

But as important as the ACA is, I believe that there are 4 big issues that the next president and Congress will have to address, even though they will come at them from different ideological and political perspectives:

Rising and unsustainable prescription drug costs. Public opinion polls show that tackling the cost of prescription drugs is a top concern of voters, Republicans, Democrats, and independents alike. As more personalized medication therapies are developed, the enormous costs associated with them will challenge the ability of insurers, employers, public agencies, and individuals to pay for them without breaking the budget.

The pharmaceutical industry will not readily go along with legislation to increase transparency, increase competition, reduce market exclusivity, and consider the value of different therapies in terms of lengthening and improving the quality of life in payment, pricing, and coverage decisions, yet I believe such measures will get strong consideration.

The historical analogy is when the managed care industry faced a public backlash in the mid-1990s over gatekeepers and other barriers to patients getting the care they wanted from the physicians they chose, leading to laws being enacted throughout the country to rein in industry practices.

High-deductible health plans. For more than a decade now, the amount that insured persons have to pay out of pocket, in the form of deductibles and co-payments, for their health care has steadily increased, as employers and the public sector have tried to control their own costs by shifting them onto the people they insure. As people are forced to pay more, they will begin pushing back at their employers and at their elected officials.

ACP, in a recent position paper available online , has proposed innovative solutions to the problem, such as varying cost-sharing levels based on income, so that lower-income persons pay an appropriately smaller share of their health care expenses, and by the comparative effectiveness of different treatments, so that more effective treatments would have lower cost-sharing than less expensive ones.

Climate change. While Mr. Trump and most GOP members of Congress have questioned the existence of global warming and humans' contributions to it, the reality of rising seas threatening low-land areas, as is already happening in areas like Miami; Norfolk, Va.; and pretty much the entire state of Louisiana, will get politicians' and the public's attention, sooner rather than later, I believe.

Science shows us that global warming will also lead to more deaths and illnesses relating to heat waves, respiratory diseases, and infectious diseases, including many principally treated by internists, which is why ACP has played a leadership role in proposing solutions and practical steps that can be taken to the mitigate the crisis. What is now widely disputed will become widely accepted, I believe, and the politics will be on the side of those who put forward practical and realistic policies to slow global warming.

Value-based payment and delivery. The movement toward aligning payments with the “value” of care will continue, regardless of the outcome of the election. However, the next administration and Congress will have to show that they can make the payment changes resulting from the Medicare Access and CHIP Reauthorization Act (MACRA) work in practice for physicians and their patients, without imposing even more paperwork on them. In addition, look for a broad reexamination of how “value” is currently being measured and applied, as a growing number of stakeholders, ACP included, have concluded that the current approaches to measuring performance miss the boat.

That I believe these 4 issues will need to be addressed by the next president and Congress does not imply that achieving consensus on solutions will be easy. It won't, and if anything, in the short term, polarization and gridlock will continue to rule the day. Yet I believe that the public will demand that the politicians pay attention to them, and when the voters want something, sooner or later they get it.