The ACA: Where Do the Candidates Stand? 

This week, all eyes are on the presidential hopefuls as the primary election season kicks into high gear. With health care on the docket as one of the key domestic policy issues of this election, it’s important for voters to know where each candidate stands, relative to the ACA and Medicare.

Our blog team put together the following summary that we share with a caveat -- these are our impressions of the candidate’s views based on what we have read in the news and seen on TV.

On the Democratic Side:

Hillary Clinton

• Hillary Clinton is a proponent of the Affordable Care Act, albeit with a few tweaks that she says would reduce consumers’ out-of-pocket and prescription drug costs. For instance, she proposes having Medicare administrators negotiate with drug companies for lower prices for beneficiaries, requiring health insurers to cap out-of-pocket drug spending at $250 per month, and mandating that all plans (including employer-sponsored) provide individuals with three sick visits per year before needing to meet their deductible. She opposes any plans to privatize Medicare and she supports the state expansion of Medicaid under the ACA.

Bernie Sanders

• A supporter of universal health care, Bernie Sanders thinks the ACA didn’t go far enough, creating an interesting rift in the Democratic Party. Sanders wants to expand Medicare to create a “Medicare-for-all” single-payer national health insurance. This tax-supported single-payer system would entail no premiums, deductibles or cost-sharing, and private health insurance would only exist to provide supplemental coverage. Until then, he supports the expansion and improvement of Medicaid for low-income families.

On the Republican Side:

Ted Cruz

• Ted Cruz wants to repeal the ACA (as do most of the Republican candidates) and cut the link between health insurance and employment. He also wants to expand health savings accounts and allow insurers to sell plans across state lines. But he has kept mum on what he would do to maintain the ACA’s coverage expansion, if he were to abolish the law. As for Medicare, he would raise the eligibility age and move to a premium-support system in which beneficiaries are given a fixed government contribution to buy a Medicare insurance plan; if the plan exceeds this amount, individuals would be accountable for the difference. Cruz also opposes Medicaid expansion under Obamacare.

Donald Trump

• Donald Trump opposes both the ACA and the idea of a single-payer system. He says he would repeal the ACA and allow consumers to buy plans from insurers in any state, no matter where they live, and he supports the use of HSAs to pay for medical expenses not covered by insurance. He has said that he would preserve Medicare by strengthening the economy enough to support the program.

Marco Rubio

• Marco Rubio would like to repeal the ACA and replace it with a refundable tax credit to help people purchase health insurance, which would increase each year with a gradual reduction in the tax exclusion for employer health plans. He would also establish high-risk pools funded by the federal government to cover those with pre-existing conditions, allow insurers to sell plans across state lines, and expand HSAs to pay for medical expenses not covered by insurance. He says he would preserve traditional Medicare for current beneficiaries, but future generations would be transitioned into a defined-contribution, premium-support system. He also says he’d convert Medicaid into a capped state block grant program.

Ben Carson

• The M.D. of the presidential hopefuls, Ben Carson advocates repealing the ACA and replacing it with health empowerment accounts (HEAs) to be given to all US citizens along with their social security numbers. Citizens would contribute to their HEAs tax-free and would be able to use the accounts to pay for medical expenses for themselves and their family members. The money is theirs, whether they change jobs or move across state lines, and would be paired with high-deductible health plans for catastrophic medical costs. In terms of Medicare, he’d give beneficiaries a fixed contribution with which to buy private health insurance, and if their plan of choice costs less than the government contribution, the remaining dollars would go straight into their HEAs (and if it costs more, the difference could come out of their HEAs). He’d also increase the Medicare eligibility age from 65 to 70, with beneficiaries able to use their HEAs for out-of-pocket expenses, deductibles, and co-pays.

Jeb Bush

• Like his Republican counterparts, Jeb Bush wants to repeal the ACA, but his plan seems to rely on the employer-based system more than the others. He says he’d offer a tax break for workers on health benefits they receive through their employers and let small businesses make tax-free contributions toward their employees’ plans. In addition, he’d provide a tax credit for catastrophic insurance plans and increase contribution limits for HSAs from $3,350 to $6,550. He’d also cap the employer tax exclusion so that employer-sponsored plans costing more than $12,000 for individuals or $30,000 for families would be taxed. He wants to privatize Medicare and provide lower government subsidies to wealthier people.

John Kasich

• John Kasich wants to repeal the ACA, though he expanded Medicaid in Ohio under the law as governor, and he has said that he supports coverage for pre-existing conditions. He thinks there needs to be more of an emphasis on patient-centered primary care, and he criticizes the fee-for-service system, wanting to reward value instead of volume.

We offer a few general observations about any possible changes being discussed:

• First thing to keep in mind is that more people have health insurance today than before the law was passed -- 12.7 million are enrolled in the public exchange with most getting a subsidy and an additional 7 million are covered by expanded Medicaid or CHIP. Those who favor ACA repeal need to keep in mind the challenge to make sudden any changes that would adversely impact 18 million new beneficiaries.
• From an employer perspective, over the past five years we have made benefit changes, taken on more administrative responsibilities and communication requirements, and paid significant fees to support the ACA. Several of the ACA requirements were very popular with employees -- expanded dependent eligibility to age 26 and the elimination of lifetime maximum benefits to name just two. While we might be happy to see all the ACA requirements go away, we realize some features may be hard to roll back. On the other hand, some of the candidates favor approaches that would rely even more on employer support.
• Finally, the excise tax on high-cost plans has long been the number one ACA concern for employers. The two-year delay is a step in the right direction and we are hopeful that step is actually a step closer to repeal of the excise tax provision. Stay tuned for a separate post on the lack of meaningful impact of the proposed changes in the 2017 budget.

Fasten your seat belts, it will be an interesting ride!