How Democratic presidential nominee Clinton might expand upon Obama's health policy legacy

Topics: Politics and Policy, Elections, 2016, Health Care Reform

By Josh Zeitlin, contributing editor

Hillary Clinton on Thursday officially accepted the Democratic nomination for president.

The former senator and secretary of state has repeatedly defended President Obama's record on health care, and it shows in her proposals, which for the most part don't represent a major shift from the current president's stances on health care.

But while a potential Clinton presidency might not represent a major change in the executive branch's approach to the industry, it could still have significant implications for providers, ranging from changes to patients' financial burdens to big differences in health care payment and delivery.

Coverage and out-of-pocket costs

In a recent JAMA piece, President Obama said that the uninsured rate has declined by 43 percent since the Affordable Care Act (ACA) became law and that research has shown "accompanying improvements in access to care ... financial security ... and health" of patients.

During her campaign, Clinton has pledged if elected president to "build on" President Obama's health care record and "do more to bring down health care costs for families, ease burdens on small businesses, and make sure consumers have the choices they deserve."

She has put forward several proposals to reduce patients' out-of-pocket costs, which could, if enacted, help further reduce providers' bad debt. For instance, she has proposed creating a new refundable tax credit of up to $2,500 for individuals or up to $5,000 for families to combat out-of-pocket costs and placing a $250 monthly limit on consumers' out-of-pocket spending for drugs covered by their health plans.

Clinton has also called for expanding coverage options, including allowing undocumented immigrants to purchase coverage through the ACA's exchanges, allowing U.S. residents 55 years and older to buy into Medicare, and pursing Medicaid expansion in more states.

In addition, she has proposed implementing a "public option" on the exchanges to compete against traditional insurance plans. That's an idea some hospital groups have pushed back against if the public option reimbursement rates would be similar to Medicare's rates. The American Hospital Association and the Federation of American Hospitals wrote recently that "adding millions more enrollees whose health care would be reimbursed at Medicare rates would likely threaten access to needed health care services."

Delivery system reform

The chances that Clinton's proposals to reduce patients' out-of-pocket costs and expand coverage would become law if she becomes president would depend largely on the results of congressional elections.

However, because of the power of the HHS secretary under the ACA, a potential Clinton administration could make big changes to care delivery no matter the composition of Congress.

For instance, the Center for Medicare & Medicaid Innovation (CMMI), established under the ACA, tests voluntary and mandatory payment and delivery system models for Medicare, Medicaid, and CHIP, which the HHS secretary has the authority to expand nationwide.

Clinton during her campaign has specifically called for implementing new value-based payment systems and expanding alternative payment models, so it's possible that a Clinton administration could expand alternative payment models, even mandatory ones, across the United States.

By contrast, Trump has said he wants to repeal the ACA and has not indicated whether he supports alternative payment models, so it is less certain whether his potential administration would continue to push providers to shift away from the traditional fee-for-service payment system.

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Meanwhile, the health care reform plan released in June by House Speaker Paul Ryan (R-Wis.) calls for repealing CMMI beginning in 2020. It also states that the center is "operating beyond its intended

authority, with a complete lack of transparency and disregard for the input of stakeholders most affected by their proposals."

At the same time, the reform plan notes that "there is a growing consensus that we should tie reimbursement to quality," indicating that Ryan and other leading Republican lawmakers may support some initiatives to further promote value-based payments.

While it remains an open question how big a difference a Clinton and Trump presidency would be when it comes to the shift away from fee-for-service, both potential commanders-in-chief would likely have a big effect on health care.