Af­ter nod to San­ders, Clin­ton may go her own way on health pol­icy

Modern Healthcare - - NEWS - By Har­ris Meyer

Hil­lary Clin­ton, Bernie San­ders and Barack Obama haven’t al­ways sung “Kum­baya” when it comes to health­care pol­icy. But their solo tunes mostly har­mo­nized by the time San­ders fi­nally en­dorsed Clin­ton for the Demo­cratic pres­i­den­tial nom­i­na­tion last week.

To win the Ver­mont sen­a­tor’s back­ing, Clin­ton tweaked her health­care plat­form to more strongly em­brace a public plan op­tion in the Af­ford­able Care Act in­sur­ance ex­changes, sharply boost fund­ing for fed­er­ally qual­i­fied com­mu­nity health cen­ters and the Na­tional Health Ser­vice Corps, and al­low peo­ple to vol­un­tar­ily buy in to Medi­care at age 55. Those pro­pos­als helped ease the sting for San­ders and his sup­port­ers re­sult­ing from the Demo­cratic Plat­form Com­mit­tee’s de­ci­sion not to ad­vo­cate a govern­ment sin­gle-payer sys­tem, the emo­tional heart of the San­ders cam­paign.

Fol­low­ing re­lease of Clin­ton’s up­dated health plat­form, Pres­i­dent Obama pub­lished a health­care re­form progress re­port in JAMA on July 11 rec­om­mend­ing estab­lish­ment of a “Medi­care-like public plan … to com­pete along­side pri­vate in­sur­ers in ar­eas of the coun­try where com­pe­ti­tion is lim­ited.” Adding a public plan, he ar­gued, would strengthen the ACA mar­kets, give con­sumers more af­ford­able plan choices and save the govern­ment money.

San­ders quickly praised Clin­ton’s health­care agenda. “These steps will get us closer to the day where ev­ery­one in this coun­try has ac­cess to qual­ity, af­ford­able health­care,” he said. About her plan to dou­ble fund­ing for com­mu­nity health cen­ters to $40 bil­lion over 10 years, San­ders, who long has cham­pi­oned these fed­er­ally sup­ported clin­ics for poor and unin­sured peo­ple, gushed that “it will save lives. It will ease suf­fer­ing. … And it will cut health­care costs.”

The Democrats’ rel­a­tive unity on health­care go­ing into their na­tional con­ven­tion, which opens July 25, con­trasts with lin­ger­ing un­cer­tainty on the Repub­li­can side about whether pre­sump­tive nom­i­nee Don­ald Trump will fully align him­self with the re­cent House Repub­li­can lead­er­ship pro­posal to re­peal and re­place Oba­macare, tax em­ployer health plans, and cap and cut Medi­care and Med­i­caid spend­ing. Adding to the dis­ar­ray, some Repub­li­cans fa­vor keep­ing key parts of the ACA, in­clud­ing the law’s Med­i­caid ex­pan­sion and var­i­ous rev­enue sources, to help mil­lions of Amer­i­cans stay in­sured.

Clin­ton and the Demo­cratic Na­tional Com­mit­tee say their fo­cus is im­prov­ing the func­tion­ing of the ACA mar­kets to

The Democrats’ rel­a­tive unity on health­care go­ing into their na­tional con­ven­tion con­trasts with lin­ger­ing un­cer­tainty on the Repub­li­can side.

make pre­mi­ums, out-of-pocket costs and pre­scrip­tion drugs more af­ford­able. Clin­ton’s pro­posal would re­quire health plans to cover three sick vis­its to a doc­tor a year with­out ap­ply­ing the de­ductible; give in­sured peo­ple a $5,000 per fam­ily re­fund­able tax credit for out-of-pocket costs ex­ceed­ing 5% of in­come; bar providers and in­sur­ers from charg­ing pa­tients outof-net­work bills for ser­vices re­ceived in an in-net­work hos­pi­tal; and strengthen state au­thor­ity to block ex­ces­sive in­sur­ance pre­mium in­creases.

In ad­di­tion, she wants to cap Amer­i­cans’ out-of-pocket costs for pre­scrip­tion drugs, let Medi­care ne­go­ti­ate drug prices, and al­low con­sumers to buy lower-cost drugs from for­eign coun­tries with ap­proved safety stan­dards. Clin­ton and Obama touted the public plan op­tion as a way to boost com­pe­ti­tion and make the ex­changes more vi­able. Their pro­pos­als come as 16 of the 23 not-for-profit coop plans cre­ated by the ACA have col­lapsed and a num­ber of pri­vate in­sur­ers have ex­ited the ex­changes, com­plain­ing that the cus­tomers tend to be sicker and more costly to cover than non-ex­change mem­bers. These plan clo­sures and de­par­tures have left hun­dreds of coun­ties and three en­tire states with only one in­surer sell­ing prod­ucts on the ex­change.

But some ob­servers won­der whether Clin­ton stepped up her sup­port for the public op­tion and Medi­care buy-in more to pla­cate the siz­able sin­gle-payer wing of her party rather than be­cause she se­ri­ously in­tends to pur­sue those con­tro­ver­sial poli­cies if she’s elected. She surely has not for­got­ten that in 2009, the public op­tion was so po­lit­i­cally toxic that Democrats re­moved it from the ACA leg­is­la­tion to win pas­sage of the law.

There’s no rea­son to think it’s less volatile now. “I’m not sure (the public op­tion) would be in her 100-day agenda, or in her two-year agenda,” said Jim Manley, a for­mer top aide

to Sens. Harry Reid and Ted Kennedy who worked on draft­ing the ACA. “It will take some time to round up the nec­es­sary sup­port.” He added that even if the Democrats win con­trol of the Se­nate in Novem­ber, it would take 60 votes to pass a public op­tion mea­sure and other ACA changes, and that would be a very tough hur­dle.

The Clin­ton cam­paign pre­vi­ously said that rather than seek­ing to es­tab­lish a public op­tion plan through fed­eral leg­is­la­tion, she would work with in­ter­ested gover­nors on a state-by-state level, us­ing cur­rent flex­i­bil­ity un­der the ACA. In her up­dated pol­icy state­ment, how­ever, she promised to try to im­ple­ment a public plan op­tion in ev­ery state.

The pre­sump­tive Demo­cratic nom­i­nee is more likely to pur­sue her big pro­posed ex­pan­sion of fund­ing for the na­tion’s 1,300 com­mu­nity health cen­ters, which cur­rently pro­vide care for an es­ti­mated 23 mil­lion peo­ple at 9,000 sites across all states and en­joy bi­par­ti­san sup­port, pre­dicted Leighton Ku, a health pol­icy pro­fes­sor at Ge­orge Wash­ing­ton Univer­sity. Manda­tory fund­ing for the cen­ters is set to ex­pire next year. “That’s def­i­nitely more doable than the public op­tion or the Medi­care buy-in, which con­ser­va­tives are more likely to dig in on,” he said.

But Chris Jen­nings, an out­side health pol­icy ad­viser to the Clin­ton cam­paign, said the public op­tion could be an ef­fec­tive tool along with a wide range of other mea­sures for strength­en­ing the ex­change mar­kets. He noted that Clin­ton’s health­care agenda also in­cludes in­creas­ing ex­change en­roll­ment through ag­gres­sive out­reach, ad­di­tional subsidies to con­sumers, tougher cost con­trols, and con­tin­ued de­liv­ery sys­tem re­forms. “The com­bi­na­tion of these steps should in­crease en­roll­ment, sta­bi­lize the mar­ket­place, re­duce pre­mi­ums, and con­vince more plans to en­ter the mar­ket be­cause there will be more and health­ier cus­tomers,” he said.

Given the un­cer­tainty about who will con­trol Congress next year, a Pres­i­dent Clin­ton would look at ad­min­is­tra­tive as well as leg­isla­tive op­tions, Jen­nings added. “She’ll work very ag­gres­sively to go as far as she can to en­sure Amer­i­cans in the ex­changes have a vi­able choice of health plans.”

Hos­pi­tal and in­sur­ance in­dus­try groups strongly fa­vor ef­forts to ex­pand in­sur­ance cov­er­age and make the ACA mar­kets work bet­ter, which is con­sis­tent with Clin­ton’s ap­proach. More than two-thirds of the health­care CEOs re­cently sur­veyed by Mod­ern Health­care said they op­posed the GOP push to re­peal and re­place the ACA.

“I would like to see get­ting to uni­ver­sal cov­er­age faster be­cause there are a lot of unin­sured and un­der­in­sured peo­ple utiliz­ing health­care ser­vices,” said Dr. Wil­liam Con­way, CEO of the Henry Ford Med­i­cal Group, which is part of Henry Ford Health Sys­tem in Michi­gan. “Sin­gle-payer is not go­ing to hap­pen. I think Hil­lary’s pro­posal on out-of­pocket costs would help.”

But many providers and in­sur­ers dis­like the idea of a public plan op­tion or Medi­care buy-in be­cause they fear the govern­ment would set in­ad­e­quate rates. In the Mod­ern Health­care survey, most health­care CEOs were op­posed to or skep­ti­cal about the Medi­care ex­pan­sion con­cept. “We op­posed (the public op­tion) in 2009, and hospitals would take the same po­si­tion (now),” said Chip Kahn, CEO of the Fed­er­a­tion of Amer­i­can Hospitals.

John Rother, a vet­eran health­care lob­by­ist who heads the Cam­paign for Sus­tain­able Rx Pric­ing, pre­dicted that soar­ing pre­scrip­tion drug costs will be a prom­i­nent cam­paign is­sue that will help Clin­ton. But he said her pro­posal to have Medi­care ne­go­ti­ate drug prices is not po­lit­i­cally vi­able and that it would be bet­ter to fo­cus on achiev­able goals like in­creas­ing price trans­parency and com­pe­ti­tion. Medi­care ne­go­ti­at­ing drug prices “is not go­ing to hap­pen in Congress as I know it, and I don’t ex­pect her to em­pha­size that,” he said.

While many Democrats are pleased that Clin­ton and San­ders seem­ingly have rec­on­ciled on health­care, there still could be a con­ven­tion fight over sin­gle-payer, a lodestar is­sue for many pro­gres­sives who have lit­tle pa­tience with Clin­ton­style in­cre­men­tal ad­vances. Na­tional Nurses United has promised that its del­e­gates at the con­ven­tion will push for lan­guage sup­port­ing Medi­care-for-all.

The Plat­form Com­mit­tee drafted “ex­tremely vague lan­guage that we all think uni­ver­sal health­care is a good thing, with no plan to ac­tu­ally get there,” com­plained Dr. St­effie Wool­han­dler, a pro­fes­sor at City Univer­sity of New York School of Public Health who is a long-time ad­vo­cate of a sin­gle-payer sys­tem. “Peo­ple are say­ing they want a plat­form fight at the con­ven­tion. I can’t say if that will hap­pen.”

Jen­nings said that while a lot of Democrats still want sin­gle­payer, Clin­ton and San­ders have come to­gether on a pol­icy that builds on and im­proves the ACA rather than re­struc­tur­ing and dis­rupt­ing the health­care mar­ket. And even though health pol­icy so far hasn’t be­come a cen­tral is­sue in the cam­paign, un­like in the past few elec­tions, the choices for vot­ers will be­come clearer as the elec­tion nears.

“This elec­tion prob­a­bly has more im­pli­ca­tions for the fu­ture of health­care in this coun­try than for any other do­mes­tic pol­icy,” he said. “The dif­fer­ences be­tween us and the other side could not be more stark.”

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