Apples and Oranges: How Should We Look at Republican, Democratic Health Care Plans?

Former Secretary of State Hillary Clinton supports the Affordable Care Act but says that there is room for improvement. Sen. Bernie Sanders (I-Vt.) wants a single payer health care system.
On the Republican side, Gov. Scott Walker (R-Wis.) wants to replace the ACA and use high-risk pools to provide coverage to people with pre-existing conditions. Sen. Marco Rubio (Fla.) would allow individuals to purchase coverage across state lines. And Donald Trump wants to “work out some kind of very, very smart deal with hospitals.”
Comparing the heath care proposals of the 2016 presidential hopefuls is a little like comparing apples to oranges. And it can be difficult to gauge the effects of plans that differ so greatly in their priorities, experts say.
So how should we be looking at the candidates’ plans? We talked with a couple of experts to get some insight. Here’s what they suggest.

Recognize Differences in Agendas

According to Sara Collins, vice president of health care coverage and access at the Commonwealth Fund, the first step is to “get a good sense of what the overall philosophy and goal” of the plan is, while also recognizing that the U.S. is “in a really different environment in terms of reform issues,” compared with eight or even just four years ago. Collins has authored several reports analyzing health reform plans during past election cycles.
Larry Levitt, senior vice president of special initiatives at the Kaiser Family Foundation, agrees: “One really important consideration in looking at these proposals … is to recognize that they may have different aims.”
Unsurprisingly, Republicans and Democrats this election cycle have starkly different agendas. Unlike in the 2008 and 2012 presidential elections, health reform is not as much of a top-tier issue among Democrats.
“In many ways, they have succeeded on health [reform] — in passing and implementing the ACA — so it’s a very different set of health issues Democrats are talking about,” Levitt says.
Instead, “the tables are turned,” and it’s Republicans who are pushing for health reform and trying to “upend the status quo,” just as President Obama did in implementing the ACA, Levitt says.
Democratic candidates largely want to maintain that status quo, which means extending the coverage gains under the ACA and continuing the push for Medicaid expansion.
Aims for Republicans, who want to decrease regulation and reduce federal spending, include repealing and replacing the ACA.
These plans are vastly different and are going to have a “whole set of effects on coverage, cost and the budget,” Levitt says. He notes that Republican proposals, for example, are “unlikely to cover as many people or provide as comprehensive coverage as the ACA does,” simply because of a difference in ideology.

Use Existing Benchmarks To Make Comparisons

Instead of comparing two hypotheticals — or comparing the proposals directly to one another — Collins says a more effective method is to “evaluate them against current law.”
In this case, current law is the ACA. The law has been in place long enough that it can serve as a baseline, Collins says.
Next, Collins suggests determining whether candidates have proposed “a marginal change to existing law or to repeal the law and replace it with something entirely different.” And if they are, “what is the replacement plan and its effects?”
Collins recommends establishing criteria to measure potential changes if the ACA were swapped with something new. Criteria setting might sound simple, but it isn’t necessarily straightforward. Levitt points out, “Assessing a policy proposal inevitably involves value judgements in setting the criteria that you’re using to judge the plan.”
The ACA was so sweeping that there are myriad measurements to choose from. But there are some obvious metrics to monitor in 2016, according to Levitt and Collins.
There are the hot-button issues like Medicaid, which the law expanded but Republicans want to roll back. And then there’s ensuring access to care for individuals with pre-existing conditions, “an idea everyone wants to get behind,” Levitt says.
The list goes on, but Collins and Levitt both say the Republican and Democrat proposals will inevitably have overlaps in terms of what they affect, such as whether they will:

  • Decrease the uninsured rate;
  • Increase costs to consumers;
  • Improve quality of care;
  • Maintain the individual and employer mandates; and/or
  • Reduce the federal deficit.

Use the Past To Make Predictions

Most of the candidates’ ideas aren’t necessarily new, Collins and Levitt say. Several plans aim to address existing issues by reconsidering past reform efforts.
“A lot of proposals that we’re hearing have been proposed in the past,” Collins says. That can help observers “look at what we know about them so far” and draw comparisons, she notes.
In a recent Los Angeles Times opinion piece, Levitt looks to the past to predict the future effects of some Republican proposals, including:

  • Allowing consumers to buy insurance across state lines; and
  • Using high-risk pools to provide affordable coverage to people with pre-existing conditions.

In the opinion piece, Levitt demonstrates that the past can be used to support, or in this case debunk, current proposals.
He writes, “Historically, … high-risk pools haven’t been effective,” and selling coverage across state lines “is unlikely to increase the availability of insurance much because major insurers typically operate in many states already.”

Some Final Words

As they stand, many proposals from both Democratic and Republican presidential candidates lack enough detail to make conclusions, Levitt and Collins say.
That will change as the race narrows, at which point it will be easier to identify implications, Levitt notes.
And once the candidates elaborate, that’s when the “hard numbers of what this means to [people] and what it means to their families” can be determined, Collins says.
Around the nation
Here’s a look at other stories making the news on the road to reform.
The Go Ahead. Alaska Gov. Bill Walker’s (I) administration can start implementing its Medicaid expansion plan after the state Supreme Court rejected lawmakers’ requests to block the expansion, the Washington Times reports.
Double Digits. Some state insurance commissioners have approved premium hikes as high as 36% for their states’ largest health plans in 2016, the Wall Street Journal reports.