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

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 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 out-of-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 co-op 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-of-pocket 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 Clinton-style 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 single-payer, 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.”