Comparison of National Health Reform Proposals
First a little background. Medicare is the primary program for seniors and the disabled. It is paid for by taxes on employers and employees and administered by the federal government.
Medicaid is the primary program for the poor. It is paid for by the federal and state governments with taxes. Each state runs its own program and decides who and what to cover within federal floors and ceilings; 20 states (primarily in the South) have not yet expanded their Medicaid programs to cover all the poor with the funding available under the ACA.
About half of all Californians under 65 have employment-based coverage. The federal and state governments pay for about a third of the costs with a little understood mechanism known as pre-tax purchasing.
Individual coverage is partially paid for by the federal government with refundable tax credits and for the self employed with tax deductibility. The numbers of people with individual coverage have doubled due to the ACA.
The uninsured are people with none of the above coverage and no VA (Veterans Affairs) coverage. In California the numbers of uninsured have fallen very dramatically (more than half) due to the ACA. Undocumented Californians make up at least half of the remaining uninsured; they are not for the most part eligible for full scope Medicaid or for refundable tax credits.
This is a program by program analysis of what is being proposed during the Presidential campaigns as compared to current law:
Medicare federal program for seniors and the disabled
· Senator Sanders: Expands to all Americans
· Secretary Clinton: Expands as public option to individuals over 55 through the Exchanges; expands payment reforms; negotiates drug prices
· PresidentObama: Expands as public option in regions without adequate competition; expands payment reforms; negotiates drug prices
· ACA (Affordable Care Act): Closes prescription donut hole and adds coverage for preventive services; reforms provider and plans’ payments; caps growth in per capita spending
· Speaker Ryan: Changes eligibility to age 67; moves to vouchers for younger Americans; repeals provider and plan payment reforms
· Donald Trump: Repeals ACA benefit expansions and payment reforms
Medicaid: state-federal program for the poor
· Sanders: Replaced by Medicare for all
· Clinton: Three years of 100% FFP for the expansion population in 20 non-participating states
· Obama: Three years of 100% FFP for the expansion population in 20 non-participating states
· ACA (Affordable Care Act): Expands coverage to all low income persons under 138% of FPL, except the undocumented.
· Ryan: Gives states a choice of a Medicaid block grant or a per capita cap
· Trump: Repeals ACA expansion and block grants the program to the states
Employment-based coverage (large and medium sized employers)
· Sanders: Replaced by Medicare
· Clinton: Repeals Cadillac benefit tax
· Obama: Revises Cadillac benefits tax
· ACA: Employer mandate to offer basic coverage; Cadillac benefits tax on excessively costly plans
· Ryan: Repeals employer mandate; revises Cadillac benefits tax
· Trump: Repeals employer mandate and Cadillac benefits tax
Employment-based coverage (small businesses)
· Sanders: Replaced by Medicare
· Clinton: No change from ACA
· Obama: No change from ACA
· ACA: Tax credits for low wage small employers who offer coverage; SHOP purchasing pools and underwriting reforms to assure availability and continuity of basic coverage
· Ryan: Repeals tax credits, SHOP exchanges and underwriting reforms
· Trump: Repeals all ACA improvements for small employers
Individual coverage
· Sanders: Replaced by Medicare
· Clinton: Improved tax credits to increase affordability
· Obama: Improved tax credits to increase affordability
· ACA: Individual responsibility, exchanges to pool purchasing power, refundable tax credits to assure affordability, and underwriting reforms to assure availability and continuity of basic coverage
· Ryan: Repeals individual mandate; replaces refundable tax credits: repeals under-writing reforms; enacts high risk pools for those with pre-existing conditions
· Trump: Repeals all ACA improvements; expands tax deductibility and tax advantaged HSAs and allows interstate purchase of coverage
Financing
· Sanders: Taxes on employers and individuals
· Clinton: No change from ACA, other than repeal of Cadillac benefits tax
· Obama: No change from ACA
· ACA: Financed ½ by cuts in program reimbursements and ½ by increased taxes on the wealthy, the plans, the drug and device industries
· Ryan: Repeals all financing, but retains modified Cadillac benefits tax
· Trump: Repeals all financing
Prepared by: Lucien Wulsin
Dated: 7/25/16
Sources: Summaries of the Clinton, Sanders, House Republican and Trump Plans at www.luciensblog.com derived from their respective web sites.