By Michael R. Mancinelli
While the clock ticks down towards the Iowa caucuses early next year, a number of presidential hopefuls have already announced their intent to run against President Donald Trump. When Iowa voters gather to kick off the presidential primary season on February 3, 2020, healthcare will surely be a hot topic as costs continue to rise and insurance coverage and access issues linger. By looking at the policies proposed by the all candidates now, we can start to gauge what policies will define health law during the next decade.
So far, roughly one dozen Democrats have entered the 2020 race looking to unseat Trump. They are: Vermont Senator Bernie Sanders, Minnesota Senator Amy Klobuchar, New Jersey Senator Corey Booker, California Senator Kamala Harris, Massachusetts Senator Elizabeth Warren, Hawaii Representative Tulsi Gabbard, former HUD Secretary Julian Castro, former Maryland Representative John Delaney, entrepreneur Andrew Yang, Jay Inslee, former Colorado Governor John Hickenlooper, former Texas Representative Beto O’Rourke, New York Senator Kristen Gillibrand, and Miramar Mayor Wayne Messam. The field could grow even larger if former Vice President Joe Biden or South Bend, Indiana Mayor Pete Buttigieg declare their candidacies. For Republicans, only former Massachusetts Governor William Weld has expressed interest in challenging Trump. Meanwhile, Trump has pledged to dismantle former President Obama’s signature healthcare policy, the Affordable Care Act, and replace it with something else – but he has been unclear with the specifics of his proposal.
Here is a brief snapshot of some of the issues all the current candidates have discussed that will shape presidential campaign rhetoric about healthcare in 2020:
Single-Payer Healthcare
Progressives support single-payer healthcare – a system where the government would use tax revenues to pay essential healthcare costs for everyone. Sen. Bernie Sanders (I-VT) has proposed creating a single-payer health insurance system, dubbed “Medicare-for-All,” which would function like Canada’s healthcare system. The Sanders plan would automatically enroll every U.S. citizen in Medicare which would then pay for all healthcare services. Private practitioners and providers would still deliver care. Senators Kamala Harris (D-CA), Kirsten Gillibrand (D-NY), and Corey Booker (D-NJ) and Elizabeth Warren (D-MA) all co-sponsored Sanders’ Medicare-for-All bill. Congresswoman Tulsi Gabbard (D-HI) supports the bill. Former Obama administration Housing and Urban Development Secretary Julian Castro (TX) also supports Medicare-for-All and would consider raising taxes on corporations and the wealthiest Americans to pay for it.
While Sanders has said he would essentially eliminate private health insurance, other Democrats have been more equivocal on this issue. Analysis from the Washington Post found that Mayor Pete Buttigieg (South Bend, Ind.), entrepreneurs Marianne Williamson and Andrew Yang and Sen. Gillibrand support Medicare-for-All, but were open to keeping private health insurance for now. Other candidates, like Sen. Amy Klobuchar (D-MN) support allowing people to choose between public and private insurance options. Sen. Warren has voiced support for Bernie Sanders’ Medicare-for-All proposal, but according to the Washington Post she has recently dodged questions about the role of private insurance under that plan. Former Texas Congressman Beto O’Rourke has not yet clearly stated a position on this issue.
Generally, Republicans have opposed implementing a single-payer system or even a plan which would create a public health insurance option. In the past, President Trump supported single-payer healthcare – at least its use in other countries. During the 2016 election conservatives used these positions against Trump. His subsequent positions became less clear. More recently Trump has attacked the “Medicare-for-All” model claiming that it would hurt senior citizens and lead to massive rationing of healthcare.
Alternatives to Single-Payer Healthcare
Last year Sen. Warren and colleagues introduced the Consumer Health Insurance Protection Act to build on provisions of the Affordable Care Act (“ACA”), President Obama’s keystone legislation. According to a press release on Warren’s website, her proposal would guarantee that everyone who purchases health insurance through the ACA marketplaces would have access to a plan that covers 80% of out-of-pocket costs and premiums would be capped at 8.5% of income. The bill would also increase subsidies for those purchasing health insurance through the ACA marketplaces. Additionally, among other provisions, the bill would establish an ombudsman program to track consumer complaints about insurers. Senators Sanders and Gillibrand co-sponsored the bill.
To reduce costs under our current system, Sen. Klobuchar wants to make it easier for states to enact reinsurance programs. Klobuchar’s home state, Minnesota created a reinsurance program which sought to stabilize premiums in the state’s individual health insurance market by partially reimbursing insurers for high-cost claims. The idea here is that reinsurance shields the greater market against high premiums which are caused by small groups of patients with extreme healthcare costs.
Former Maryland Congressman and healthcare financier John Delaney (D-MD) has expressed concerns about universal healthcare plans that eliminate all private insurance. He argues that such plans, like Sanders’ Medicare-for-All will lead to less investment, less access, and less innovation. Instead his idea for universal healthcare would leave Medicare alone and fold Medicaid into a new program that everyone between birth and age 65 would fall under to cover basic essential medical services. This new program would include a marketplace for individual and group private insurance that would supplement the basic services provided to everyone.
Earlier this year in Washington state, Governor Jay Inslee (D-WA) proposed a public option plan for Washington citizens he called Cascade Care. Under the voluntary plan, patients would spend no more than 10 percent of their income on premiums. The state would put out bids for insurers to offer plans to the individual market and use its bargaining power to drive down prices, cap reimbursement rates and expand access to in the individual market. Plans would have to cover the entire state, not select counties.
Prescription Drug Costs
Analysts predict that the pharmaceutical industry will be a popular target of both Democrats and Republicans during the upcoming election as prescription drug costs continue to rise each year. For example, a recent study showed that insulin spending in Massachusetts increased 50 percent in the last three years. A more egregious example sure to be relayed by candidates on the campaign trail is the story of former Turing Pharmaceuticals CEO Martin Shkreli who was convicted of securities fraud. Shkreli acquired the rights to Daraprim, a drug long used by AIDS patients and increased the price from $13.50 per pill to $750.00 per pill. Both sides will use the narratives of people they meet during the campaign as individual examples of very sick people who can no longer afford their medication to bolster their policy proposals.
In a February hearing before the Senate Finance Committee notable for bipartisan attacks on the pharmaceutical industry, a number of drug executives insisted that they are not to blame for recent price hikes and argued that they are forced to set high prices because of a system that requires rebates to insurers and pharmacy benefit managers. They further argued that insurers are not passing these rebate discounts on to patients and that the rebates should be eliminated across the board. In response, President Trump who has publicly railed against the pharmaceutical industry and its increasing costs on Twitter and in other forums, has proposed eliminating these rebates from certain Medicare and Medicaid programs – but not private health insurance. According to Forbes, Trump’s proposal would raise Medicare Part D premiums for everyone.
For Democrats, Sen. Warren has proposed tackling high pharmaceutical costs by creating a new Office of Drug Manufacturing within the Department of Health & Human Services (“DHHS”) which would mass-produce generic drugs to increase supply and drive down prices.
Sen. Sanders has publicly accused the major drug companies of fraudulent practices and has advocated for fair drug prices. A bill he announced late last year along with California Congressman Ro Khanna, the Prescription Drug Price Relief Act, would allow the government to approve cheaper versions of generic medications to stop price gouging through competitive licensing. In effect it would allow DHHS to survey the cost of a drug in five other wealthy countries, determine the median cost, and set a maximum price that the manufacturer could charge in the U.S. If the manufacturer refused, the manufacturer would lose its monopoly and the government would license any manufacturer that wanted to make the drug, to do so at the median price. Sen. Sanders has also supported importing prescription medication through Canada, where it is significantly cheaper.
Sen. Klobuchar has introduced import legislation which would allow the import of drugs from Canada, and, in certain situations, from the European Union and Australia. Klobuchar has previously called on the Federal Trade Commission to investigate anticompetitive practices and price manipulation.
Congresswoman Tulsi Gabbard (D-HI) wants to empower the government to negotiate with pharmaceutical companies to bring down the cost of drugs.
Medicare/Medicaid Budget Cuts
Beyond Sen. Sanders’ Medicare-for-All plan, Democrats generally support expanding the current versions of Medicare and Medicaid. On the other hand, President Trump’s recent budget proposal would make cuts to both. The Washington Post predicts these opposing viewpoints will lead to a messaging battle: Medicare-for-All versus Medicare-for-Less. According to a report from the Kaiser Family Foundation, Trump’s budget proposal for the next fiscal year would cut at least $800 billion from Medicare and at least $200 billion from Medicaid spending over the next 10 years. Although another report from the Committee for a Responsible Federal Budget analyzing the same budget proposal said the Medicare cuts would be much less, between $515 billion and $575 billion.
Trump’s budget would also establish a block grant system for funding Medicaid. Block grants would convert Medicaid from an entitlement program to one with capped payments to the states. Critics say these block grants would not keep pace with rising healthcare costs. Democrats have attacked these proposed cuts and argued that they go against promises Trump made during his 2016 campaign. Joe Biden argued in a recent speech to the International Association of Fire Fighters that Trump has proposed these cuts to pay for his tax cuts for the wealthy.
Veterans’ Healthcare
There is bipartisan support in Congress for improving the VA health system for military veterans. President Trump has supported these efforts. He signed legislation in June 2018 intended to expand access to VA-funded care from private providers.
As a combat veteran, Congresswoman Gabbard has introduced several pieces of legislation to improve the VA system. Notably, her proposed Access to Care and Treatment Now for Veterans Act would direct the VA to reimburse non-VA medical providers to help eligible veterans receive faster care.
Mental Health
Sen. Kamala Harris has introduced legislation to expand mental health access in rural and underserved areas through telemedicine and student loan repayments for mental health professionals who agree to work in those areas.
Entrepreneur Andrew Yang, a proponent of universal basic income, wants to move towards a single-payer healthcare system but also argues that we need to treat patients with a more holistic approach. His ideas about holistic healthcare for all citizens would see primary care physicians investigate underlying mental health issues and, if necessary, provide referrals to treat those issues.
Sen. Sanders supports closing gaps in insurance coverage that prevent a number of people with mental health issues from seeking treatment.
What to Look for In 2020
Based on bipartisan support for lowering prescription drug prices, the biggest healthcare issue in this election will be how to reign in the pharmaceutical companies. This is a strong area for candidates to target undecided voters – nearly everyone takes at least one kind of prescription medication and has been or would be affected by price hikes of their prescriptions. Concrete policy proposals that go beyond the normal glittering generalities of the campaign trail should sway these voters to a particular candidate.
The idea that increased drug costs are driving up insurance premiums will surely resonate with voters who are paying increasingly more for drugs that have been on the market for years. A savvy candidate should equate these rising costs with how time affects the cost of other technologies. In most instances consumer products decline in price over time – the price of televisions and laptops over the last 20 years is a prime example. Voters who are suddenly paying hundreds of dollars more for medications that they have used for years want answers about why prices have jumped so high. Sen. Warren’s proposal to have the government mass produce its own generic drugs is intriguing, but would be subject to fierce opposition from the pharmaceutical lobby as a socialist takeover of their industry. A starting point to lowering pharmaceutical costs should be to require more transparency as to the decisions behind price hikes through more detailed public disclosures.
The other major issue of this election will be single-payer health insurance. One media outlet has said that support for Sen. Sanders’ Medicare-for-All plan is a sort of progressive litmus test for Democratic candidates. The cynical reality is that the plan would face an uphill battle in Congress without very strong progressive majorities in the House and Senate. Even then, Democrats from swing states or the so called purple states that split almost evenly between Democrats and Republicans may be reluctant to support such a broad-reaching proposal. It is also doubtful a plan that eliminates private insurance would survive a court challenge considering the current makeup of the Supreme Court. Additionally, because the health insurance industry and medical profession wields massive political influence and their pockets run deep, the framing of “death panels” that derailed President Obama’s push for a public health insurance option would pale in comparison to the lobbying efforts and battle for hearts and minds that would meet a full scale assault on private health insurance in this country. More realistically, ideas like Sen. Warren’s that cap premiums at a percentage of income, or Sen. Klobuchar’s plan to bolster reinsurance to drive down costs, have a better chance of success.
Michael Mancinelli is 2L day student at Suffolk University Law School and a Journal of Health & Biomedical Law staff member. Before law school, Michael worked as a paralegal for Conway Homer, PC, a Boston firm that specializes in vaccine adverse reaction litigation. As an undergraduate, Michael majored in broadcast journalism at Suffolk University and covered high school sports for the Boston Globe as a correspondent. Michael is interested in personal injury litigation, criminal law, municipal law and public policy.
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Disclaimer: The views expressed in this blog are the views of the author alone and do not represent the views of JHBL or Suffolk University Law School.