THCB

Measuring Hillary

Screen Shot 2016-05-02 at 8.18.04 AMHillary Clinton is now the presumptive Democratic nominee and the odds-on favorite to be our next president.    

For healthcare, that could be a very good thing, not just compared to a Trump (or Cruz) presidency but for the following reasons:    

(1) Hillary knows and cares deeply about healthcare.   

Even if you don’t support or like her, she’s been a tireless advocate for reform and coverage expansion for decades.  She worked, for example, in the 1980s with the Children’s Defense Fund and other groups to enhance coverage for children.    

As first lady, of course, Bill put her in charge, in 1991, of developing a health reform plan.  Though the process had its flaws, she was steeped in the subject for over a year and learned it inside and out.

Famously, the legislation failed in 1993-94 due to staunch Republican opposition (and, yes, a bungled legislative strategy by the White House).      A widespread impression still exists that Hillary slunk back from the issue after the Clinton reform failed.  Not true. 

 She worked with Republicans and Democrats to create and then pass the Children’s Health Insurance Program (CHIP) in 1997, which now covers about 8 million kids.  It was re-authorized in 2015 for two years.   (Ted Kennedy led the CHIP effort in Congress but cited Hillary’s leadership as key to securing sufficient funding for the program.) 

As a Senator from New York from 2001 to 2009, Clinton was a strong advocate for sustaining the CHIP program, expanding Medicaid, supporting experiments to make Medicare seniors more efficient, and for the adoption of HIT. 

On HIT, she actively sought common ground with Republicans and in 2005 joined arch-rival Newt Gingrich to put forward the 21st Century Health Information Act.  The bill, which promoted EHRs, helped put HIT on the map, along with George Bush’s establishment of the Office of the National Coordinator for HIT in 2004.   

And both set the stage for the passage of the HITECH Act in 2009, which formally established and funded ONCHIT and allotted tens of billions of dollars for HIT/EHR adoption.    

Clinton’s excellent analysis of health policy issues in The New York Times Magazine on April 18, 2004 contains observations that remain relevant today. 

Clinton dropped domestic healthcare issues when she was Secretary of State, 2009-2013.  There should be little doubt, however, that she has significant pent-up desire to finish what Obama started and make her mark, at last, in this area.   

(2) She has articulated a realistic short-term path in healthcare.

Hillary has been in the middle on healthcare during the campaign. The All the Republicans candidates have opposed her plan to “defend the Affordable Care Act and build on it.”  They would repeal it.  On the left, Sanders pushed a Medicare for All/single-payer plan, and a transition to that from Obamacare. 

She’s got the best approach, I think.   Even if Trump is elected, Obamacare won’t be repealed as long as the Republicans don’t have 60 votes in the Senate (highly unlikely this year). 

And, as almost every analyst agrees, the chances that a single payer system would be enacted in the U.S. in the foreseeable future are nil, zippo, nada. (See this concise analysis by Jonathan Oberlander, a long time single payer advocate. (New England Journal of Medicine, April 14, 2016) 

As an aside: 

Thank you, Bernie, for showing us that single payer is far from dead, and that it has the support of roughly 25% to 30% of the population, including a lot of young people.  After all, we are half way there: around 50% of the $3.4 trillion we’ll spend on healthcare in 2016 is publicly (tax) financed via Medicare, Medicaid, CHIP, the VA, government and military employee coverage, and subsidies to low income people in the exchanges.  Together these programs cover some 140 million Americans. 

If by 2024, we have failed to make progress and healthcare spending has risen to 23% or more of GDP (up from 18% now and greater than the 19.6% currently projected for that year) a single payer system may become start to become inevitable.  

So what is Hillary’s proposed path?  You can go on her campaign website to see the list and further details.  But for your convenience here are her top priorities:

* Build on the ACA and fix the parts of the law that are not working.   She has opposed the “Cadillac tax,” for example.

* Slow the growth of healthcare costs, and particularly out-of-pocket costs.  She would enhance the tax credits in the exchanges such that families eligible for a tax credit would not spend more than 8.5% of their income for premiums.

* Create new incentives to encourage states to expand Medicaid.

* Crack down on rising prescription drug prices and hold drug companies accountable so they get ahead by investing in research, not jacking up costs.

* Expand access to health care to families regardless of immigration status.  She would push for letting immigrant families buy into the exchanges.   

* Transform the system to reward value and quality, through delivery system reforms.

* Expand access for rural Americans.   She supports telehealth reimbursement under Medicare, for example. 

* Protect women’s access to reproductive health care, including contraception and safe, legal abortion.

(3) Clinton’s experience as Secretary of State matured her as a leader. 

With a few notable exceptions (Libya and email-gate), she exhibited good judgment, navigated tough international waters, and strengthened relationships with our allies.   

Such maturity and skills are going to be critical if, as expected, the House and Senate remain in Republican hands.

There’s at least a chance that a Paul Ryan-run House will back down on attempts to repeal the ACA if Hillary becomes president.  Ryan and the House Republicans are expected to release a policy platform for 2017-18 this summer, possibly including a new tack on healthcare. 

In that context, it’s worth noting that the House and Senate passed MACRA (the Medicare Access and CHIP Reauthorization Act) with overwhelming bipartisan support a year ago.  That law built on the ACA and the two laws (ACA and MACRA) are now tightly aligned in advancing payment reform and provider accountability.       

I didn’t want Hillary to run.  She was too polarizing; many Republicans hate her.  There was the dynasty thing—too many Clintons and Bushes.  And she was too old, in my view. 

But it looks like she’s who we are going to get.  All things considered, that may end up being very positive for progress in healthcare over the next four years.   

Steven Findlay is an independent journalist and editor who covers medicine and healthcare policy and technology. 

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Paul @ Pivot ConsultingLLCWanda CommanderSteven FindlayJohn V. PhelanWilliam Palmer MD Recent comment authors
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William Palmer MD
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William Palmer MD

There is no way you can be FOR Hillary if you read the NYTimes, Dec. 19, 1997 and the article by Robert Pear about Judge Royce Lamberth’s fine [$285,000] of the Clinton health care task force “Judge Rules Government Covered Up Lies on Panel.”

“This type of conduct is reprehensible, and the Government must be held accountable for it.”….Judge Lamberth.

Paul @ Pivot ConsultingLLC
Member

Here is the article Dr. Palmer referenced. No firewall…pretty amazing it is readily available.
http://www.nytimes.com/1997/12/19/us/judge-rules-government-covered-up-lies-on-panel.html

Steven Findlay
Member
Steven Findlay

The Committee for a Responsible Federal Budget is out today with an analysis of Hillary’s health proposals. They are nearly fully paid for but Rs will hate how.
http://fiscalfactcheck.crfb.org/adding-up-secretary-clintons-campaign-proposals-so-far/

BobbyGvegas
Member

The latest at 538 has Hillary over Trump with 374 Electoral College votes, a total bloodbath. But, we still have a long way to go to November. Lots could still happen. A well timed Benghazi indictment or large-scale stateside ISIS attack inuring to the benefit of Mr. “I Alone Can Solve” (http://tinyurl.com/zqe68h4) “Even if you don’t support or like her, she’s been a tireless advocate for reform and coverage expansion for decades.” Recall Smartest-Guy-In-The-Room Ira Magaziner and “Managed Competition”? (and “Harry and Louise”) Yeah, that was all really swell. AHIPcare 2.0 likely awaits. Whatever. I’m voting Democratic down the line… Read more »

William Palmer MD
Member
William Palmer MD

Would you rather have AHIP 2.0 or single payer, Bobby? Is the utility function of the entire US to provide health care? The Constitution can be found as a subset of the ICD-10 manual?

BobbyGvegas
Member

We’re gonna get AHIP 2.0 (or worse) irrespective of what I think. I will leave the rest to you Constitutional Experts.

Moreover, I’m no unalloyed Single Payer fan. I first took a run at it in graduate school, wherein I did a detailed analytical deconstruction of the 1994 JAMA Single Payer proffer. http://www.bgladd.com/PDF/JAMA1994SinglePayerProposalAssessment.pdf

William Palmer MD
Member
William Palmer MD

I like your horror of American Health Insurance Plans becoming god, Bobby. And the alternative ruler of the universe, the federal government, lurks in 180 degree opposition with Hillary at the helm.
I also worry about the hospitals recent spurt into oligopolies and attempts at market power (ability to affect prices.)