Affordable Care Act

The Democratic Candidates on Obamacare and Health Care Reform

Published on April 27, 2016


For each candidate, we examined the health care reform plans they have on their web sites. We then took their plans and created a grid that highlights areas where candidates agree and disagree or have differences.
After the grid we look at each issue, and pose one (hopefully) fair and thoughtful question we’d like the candidates who support it to answer.
Here are the Democrats:

Candidate/Reform Plan
Hillary Clinton
Bernie Sanders
Single-Payer Healthcare System
Expansion of ACA Health Insurance Tax Credits
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New Incentives to Expand Medicaid
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Increase funding to promote Navigators and Exchanges
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Expand Access to Health Care for Non-Citizens
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Create a “Public Option” to compete with private insurance companies
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Lower Rx Drugs Prices
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Value-Based Insurance
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So, let’s start with the first item on the list that is supported by the remaining candidates:
Single-Payer Healthcare SystemConceptually, the single-payer healthcare system provides universal healthcare to everyone in the country.  Essentially, the government would collect $1.38 trillion in new taxes each year to provide healthcare for everyone in the US.
Bernie Sanders is the champion of this idea, which essentially undoes the Affordable Care Act (ACA/Obamacare) and replaces it with “Medicare for all.” Hillary Clinton on the other hand wants to maintain and expand on the ACA. Sanders’ website has a bullet-pointed list of new taxes he would raise, and spending that would be reduced in other places, in order to pay for this system.
Since Sanders idea is so large and complex, we thought of two fair questions to ask:
Q: How would you get this idea through a Republican Congress? When President Obama became president in January of 2009, he had a “Super Majority” of Democrats in Congress, which means he did not need a single Republican vote to pass legislation. The idea of a single-payer system was discussed at that time as well, but Democrats passed on it in favor of the Affordable Care Act (ACA/Obamacare). Now Republicans control Congress; wouldn’t that make it harder to implement a single-payer system?
Q: Would your “Medicare for all” approach, totally eliminate private insurance? Today, people on Medicare can enroll in one of two types private insurance plans called Medicare Supplements and Medicare Advantage plans. Each protects people from Medicare’s out-of-pocket costs. Some provide other benefits that Medicare doesn’t, like drug coverage and dental insurance. Would Sander’s single-payer model keep these private insurance options or eliminate them altogether?
Expansion of ACA Health Insurance Tax CreditsThe Affordable Care Act (Obamacare / ACA) providers “premium tax credits” (also referred to as Obamacare subsidies) to families who buy their own health insurance, if their income is below a specific threshold. Secretary Clinton would increase access to these tax credits to lower the cost of insurance for more families.
This is Secretary Clinton’s top issue. A fair question to ask people who support this position would be:
Q: What do more tax credits do to lower the true cost of care? In 2013, the average cost of an individual health insurance policy bought at was $197. In 2014, the cost was $271 (link). That is a 38% increase in one year, due primarily to the changes created by the ACA. But, tax credits kept many lower-income people from experiencing those price increases. If we simply expand tax credits are we just hiding higher prices from more people and what does that do to actually lower health care costs?
New Incentives to Expand Medicaid Medicaid is health insurance for very low-income individuals and families. To qualify for Medicaid, a person’s income can’t be over an amount set by the government.
The ACA/Obamacare offered to pay more of every state’s Medicaid costs for three years, if the states agreed to offer Medicaid to people with slightly higher incomes. But, in exchange, the states had to agree to eventually pay to cover the cost to insure more people. All-in-all, 32 states expanded Medicaid and 19 states did not.
Without a Medicaid expansion, people who earn too little qualify for Obamacare’s subsidies and earn too much to qualify for Medicaid have few insurance options, other than short-term medical.
This is another important issue for Secretary Clinton. A fair question to ask people who support this position would be:
Q: How would you pay to expand Medicaid, if more people than expected continue to enroll? Medicaid enrollments have exceeded initial estimates, (link), which could put extreme pressure on state budgets to pay for Medicaid once Federal dollars go away.
Increase funding to promote Navigators and ExchangesThe ACA/Obamacare created Navigators and Exchanges to be the focal point of the Obamacare enrollment effort. Secretary Clinton has committed to invest more in Navigators and Exchanges to boost enrollment further.
This is another important issue for Secretary Clinton. A fair question to ask those who support this position would be:
Q: What would you change in the Navigator and Exchange programs to boost their success? In January, the Congressional Budget Office (CBO) estimated that 13 million people would sign up for insurance through Exchanges, with the help of Navigators. That 13 million is 40% below initial projections (link). Is it wise to continue to invest in an enrollment system that has consistently under-delivered?
Expand Access to Health Care for Non-CitizensSecretary Clinton sponsored legislation that allows immigrant children and pregnant women to obtain Medicaid and CHIP. As president she wants to allow families to buy health insurance on exchanges, regardless of their immigration status.
A fair question to ask those who support this position would be:
Q: Would you allow non-citizens to use Affordable Care Act Tax Credits (Obamacare Subsidies) to pay for their health insurance? Today, you can legally buy health insurance in the private market, even if you’re an undocumented immigrant. However, current law does not allow an “illegal immigrant” or “undocumented immigrant” to use taxpayer-funded tax credits to help pay for their health insurance. Secretary Clinton’s web site does not make it clear as to how immigrants, regardless of their immigration status, would pay for the health insurance they would buy on an Exchange.
Create a “Public Option” to Compete with Private Insurance CompaniesSecretary Clinton would like to create a “public option” – essentially a government-run insurance company – that competes with private insurers on the Exchanges.
A fair question to ask those who support this position would be:
Q: How would the public option differ from the health insurance co-ops created under the Affordable Care Act, which have largely failed to gain enrollment? Non-profit co-ops were created under Obamacare as a way to increase competition with established, for-profit insurers. Today, 12 of the original 23 co-ops are no longer operating (link). It would be interesting to hear how these co-ops would differ from the proposed public option, and what would change to make them a success?
Lower Rx Drugs PricesAccording to the Centers for Medicare & Medicaid Services (CMS), prescription drug spending increased 12.2% to $297.7 billion in 2014, faster than the 2.4% growth in 2013 (link). eHealth research from 2015 found that, on average, people enrolled in “Obamacare” health plans who face unexpected drug costs spend over $800 annually on prescription drugs.
A fair question to ask supporters of Secretary Clinton on this issue would be:
Q: How would you lower prescription drug spending? Secretary Clinton’s web site makes it clear that this is a priority for her, but it does not provide any detail into how she would go about doing it.
Value-Based Insurance This is a concept that aims to move away from a fee-for-service model in health care, where doctors and hospitals get paid for every test and/or service they provide. Instead, this is a “pay for performance” model, where doctors get paid more when their customers get healthy and/or stay healthy after a visit.
This is an important initiative for Secretary Clinton. A fair question to those who support this position is:
Q: How will this differ from “Accountable Care Organizations” (ACOs) created under the Affordable Care Act? How would the Clinton version of value-based insurance differ from ACOs and what changes need to made to improve performance in suburban and rural areas? (link)
Now, let’s look at the Republicans.

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