health care policy

good morning, hank. it's tuesday. let’s talk about the healthcare proposalsof donald trump and hillary clinton, but first i should say that if you’re interestedin healthcare or health in general, you should check out health care triage, hosted by dr.aaron carroll. it’s an amazing show. okay, to understand the candidates’ proposals,we need to look at the current healthcare system and its problems, so journey back withme to 2008. at the time, most americans got insurancethrough private companies. there was a publicly funded program for theelderly to get insurance called medicare.

many low-income families got coverage througha publicly funded program called medicaid, and about 15% of americans had no health insuranceat all. so, broadly speaking, back in 2008, our healthcaresystem had three huge problems. the first was those 15% of people withoutinsurance. many people who didn't work for big companies,including me, literally could not get health insurance for any price because private insurerscould deny you based on pre-existing conditions. and for many other people, private insuranceplans were just too expensive to afford. and that brings me to our second big problemback in 2008, which was that our health care just cost too much.

we were spending 16% of our nation's totaleconomic output on healthcare. most other rich nations spent under 10%. like, our healthcare costs were so stupefyinglyhigh that in the united states, more tax dollars per capita went to healthcare spending thangermany, japan, the united kingdom, or canada. all those countries spending fewer tax dollarsper person on healthcare had universal, publicly funded healthcare. the united states had nothing close to that. also, lastly, for all this money we were spendingnot to insure everyone, we weren’t getting particularly good healthcare outcomes, like,by almost any measure.

from life expectancy to medical errors tohospital admissions for preventable diseases, the united states was not near the top. so then comes the affordable care act of 2010,which was designed to address some of these problems, with the emphasis on the “some.” the aca was primarily designed to get morepeople health insurance. about half of the newly insured were supposedto get medicaid, which was expanded to include everyone making up to 138% of the povertyline, and the other half were supposed to get insurance through exchanges, these marketplaceswhere everyone can get health insurance regardless of pre-existing conditions.

and the insurance would be affordable becausehouseholds making up to 400% of the poverty line would have their insurance costs subsidizedby the government on these exchanges. the aca also sought to reduce spending bylowering costs within medicare, and it raised some new taxes, including one on medical devices. but it left the rest of the u.s. healthcaresystem largely unchanged. so that was the basic idea. now, the aca has never been fully implementedbecause a 2012 supreme court decision made the medicaid expansion optional for states,and nineteen states have so far declined to do it, which means that millions of pooreramericans remain uninsured.

that said, the aca has been successful atreducing the number of uninsured people. today, it’s around 9.1%. and it may have played a role, although expertsdisagree about this, in the slowing growth of healthcare costs in the united states. for the twenty years before 2008, healthcarecosts in the united states rose by an average of 8%. in the last five years, they’ve risen byan average of 5.5%. but, to be clear, costs are still rising fasterthan inflation and median weekly earnings. healthcare outcomes continue to lag behind,and our healthcare system is still far, far more expensive than any other nation on earth,although the gap with europe has closed a bit.

the aca wasn’t really designed to addressthose problems, and it hasn’t. and there are other problems, too. in the employer market, premiums and deductiblesare rising as employers cover on average a smaller percentage of healthcare expensesthan they did ten years ago. on the exchanges, some insurance companiesare offering fewer plans. and because companies are insurers are nowrequired to offer comprehensive coverage with no lifetime benefit limits, many people whopreviously had bare bones insurance plans have seen their insurance costs go way up. these are all real problems, but it’s veryimportant to understand that the structural

shortcomings of the united states healthcaresystem are much, much older than obamacare. the aca is not the reason our healthcare costsare so high, and we know that because they were very high before the aca. so with all that in mind, let’s look atboth candidates’ healthcare reform proposals, using analysis from the rand corporation,which is nonpartisan and widely considered centrist. let’s start with trump’s plan. first, he would repeal the aca. now, trump has said he’ll find ways to makesure that private insurers continue offering plans to people with pre-existing conditions,but he hasn’t said how this would be possible.

trump would also change the way medicaid isfunded, to block grants. this would basically mean that states wouldget to administer their own medicaid programs, but most analyses see these block grants over timeinvolving lots of cuts. and lastly, trump would allow insurance companiesto sell plans across state lines, and he would also make all health insurance premiums taxdeductible. but remember, these are deductions, not tax credits,so they would mostly benefit people with high incomes for reasons explained in this video. altogether, the rand analysis concludes, i’mjust gonna quote here: “the trump proposals decrease the number of insured, increase out-of-pocketspending for consumers enrolled in individual

market plans, and raise the federal deficitcompared to the aca.” so, here’s how: around 19.7 million peoplewould lose their insurance if the aca were repealed, and medicaid block grants wouldprobably increase the number of uninsured further. sales of plans across state lines and taxdeductible premiums would get some people insured, but all in all, rand concludes thatabout 20.3 million fewer americans would have health insurance under trump’s plan. out-of-pocket expenses would go up, accordingto rand, for two reasons. first, because the tax deductions offeredby the trump plan are less generous than the tax credits offered by the aca.

and secondly, they estimate that sales ofplans across state lines would raise out-of-pocket expenses because there would be an increasein the so-called bare bones plans. these are plans with high co-pays or deductibles,or limits to annual or lifetime benefits. rand estimates that the average annual out-of-pocketexpenses per person, including deductibles and co-pays and insurance premiums and everything,would go from about $3200 per person to $5700 per person. and the deficit would go up, because withthe repeal of the aca, the taxes it raised would also be repealed, as would the changesin medicare reimbursement. this would lower some taxes, but most of thesavings were in changes to medicare, so all in all, under trump’s plan, according torand, the deficit would go up by about 5.8 billion dollars.

and i should add that all the nonpartisananalyses i could find agreed on all three fronts: that trump’s plan would reduce thenumber of insured people, increase out-of-pocket costs, and increase the deficit. okay, let’s move on to hillary clinton’sproposals. clinton would amend the aca in three big ways. first she would introduce a $2500 tax credit,or $5000 for married couples filing jointly, that could be applied to healthcare expensesover 5% of income. so if you’re a single person making $50,000a year and you pay $5000 a year in health insurance premiums, you would get a $2500tax credit.

because this is a tax credit and not a deduction,it would be available to everyone, not just high-income households, but that also meansit would be more expensive. secondly, clinton would reduce the marketplacepremium maximum. i know this is a little confusing. healthcare policy makes tax policy look likea pleasant walk in the park. but basically, right now the cost of healthinsurance premiums on the marketplace exchanges is effectively capped at 9.6% of income. to not benefit from the cap, a family of fourhas to make $96,000 a year or more. basically, clinton’s plan would lower thecap from 9.6% to 8.5% for most households.

but of course, that program would also costmoney. and then lastly, and maybe most interestingly,clinton would offer a public insurance option on the exchanges. this would allow anyone, not just seniorsand low-income people to get their insurance from the government. rand hasn’t yet updates its analysis ofthe public option, but basically, it would probably be cheaper than private insurancebecause it would share administrative costs with medicare, and so it would slightly reducethe deficit by reducing healthcare subsidies. so all in all, according to rand, i’m justgonna quote again: “all of the policies

considered increase the number of insuredpeople and reduce consumers’ out-of-pocket spending on health care.” rand estimates that the clinton tax creditalone would lead to 9.6 million more people getting health insurance, and that householdsof all income levels would see their out-of-pocket healthcare expenses go down. the biggest reduction in healthcare costswould be for families making between thirty and sixty thousand dollars a year, but theywould go down for everyone. but of course these problems would also increasethe federal deficit by what rand estimates to be ninety billion dollars.

so that is rand’s summary. trump’s plan would lead to significantlyhigher out-of-pocket costs, fewer insured people, and a modestly higher budget deficit. clinton’s plan would insure more people,lower out-of-pocket costs, but raise the deficit more. but of course you have to consider those deficitsin the broader context of the candidates’ budget and tax proposals. and to be clear, overall, under trump’sproposals, the budget deficit would be trillions of dollars more than under clinton’s proposals. the other question, of course, is will eitherof these proposals significantly reduce the

overall cost of u.s. healthcare? and the answer is probably not. the trump campaign will argue that sellingpolicies across state lines will increase competition, but that is deeply contested. and also, even in the rosiest projections,it wouldn’t decrease spending much. the clinton campaign, meanwhile, will saythat a public option would put real price pressure on private insurers. and it might, but i’ll put a link in thedooblydoo explaining why a single-payer healthcare system would not magically fix the u.s.’sproblems.

the truth is, this is a complicated, multifacetedproblem, and anyone trying to sell you simple solutions probably isn’t telling you thewhole story. and that includes me, by the way. this is definitely only an introduction. if you want to learn much more about healthcarepolicy and health insurance and different strategies for dealing with it, check outhealth care triage. they’ve got a great video out now aboutmedicaid’s return on investment, and next week, they’re have a much more comprehensiveanalysis of the candidates’ healthcare plans, so subscribe to them.

you can find sources, as well as informationabout how to vote in the dooblydoo below. hank, i will see you on friday, unless youhave a child in the interim. end screen, hank always says i need an endscreen. so i put some videos here about health insurance,why you need it, what the healthcare system in the united states is like, why it’s soincredibly complicated. also, if you’re looking for a hot sliceof tax policy, that video is just one click away, and rosianna drew you a bunny to cheeryou up. thanks, rosianna.