Clinton's and Trump's Positions on Major Healthcare Issues

As the presidential election nears, the positions of the two major candidates on healthcare have received more attention. Both Clinton and Trump have their healthcare positions listed on their websites (1,2). Below is a table listing their positions from their websites and occasionally other sources followed by a brief discussion of each of the issues. 

Table 1. Presidential candidate positions on healthcare issues. A questions mark denotes an unclear position.

Affordable Care Act (ACA, Obamacare)

This is a major difference between Clinton and Trump. Clinton favors its retention (1). Trump favors its repeal (2).

Access to reproductive health

Clinton supports reproductive preventive care, affordable contraception, and safe and legal abortion (1). Trump's position is unclear. He currently is pro-life but would not use Federal funds for abortion (2). Federal funding for abortions us is prohibited by law (3).

Allow importing drugs to reduce costs

Both candidates favor importation of prescription drugs to reduce prices (1,2).

Block-grant Medicaid to the states

Trump block-grants asserting that "the state governments know their people best and can manage the administration of Medicaid far better without federal overhead" (2). This idea is not new with Congressional Republicans pushing for block-granting Medicaid at least since the 1990s (4) Clinton's position is unclear (1).

Coverage of poor

Both candidates favor universal healthcare including the poor (1,2).

Healthcare for illegal immigrants

Clinton favors extending healthcare to families regardless of immigration status by allowing families to buy health insurance on the health exchanges (1). Trump's website notes that providing healthcare to illegal immigrants costs us some $11 billion annually and he favors strict enforcement of the current immigration laws (2).

Healthcare savings accounts

Trump favors savings accounts which are permitted under the ACA but with restrictions (2,5). Clinton's position is unclear.

Increase access to healthcare

Both candidates favor increased access to healthcare (1,2).

Increase income tax deductions for healthcare costs

Both candidates favor increasing income tax deductions for healthcare costs but their plans are different (1,2). Trump favors full deduction of health insurance premium payments from tax returns. Clinton favors a refundable tax credit of up to $5,000 per family for excessive out-of-pocket costs.

Price transparency

Both candidates favor increased healthcare price transparency (1,2).

Public option

Clinton favors a public option (1). Trump's position is unclear.

Reduce copays and deductibles

Clinton favors reducing copays and deductibles (1). Trump's position is unclear.

Sell insurance across state lines

Trump favors insurance companies selling healthcare insurance across state lines (2). This has been a part of the platform of every Republican presidential nominee and is permitted in 5 states but insurance companies have been reluctant to sell these policies (6). Clinton's position is unclear.

References

1. Hillary Clinton for America. Available at: https://www.hillaryclinton.com/issues/health-care/ (accessed 9/6/16).
2. Donald J. Trump for President. Available at: https://www.donaldjtrump.com/positions/healthcare-reform (accessed 9/6/16).
3. Salganicoff A, Beamesderfer A, Kurani N, Sobel L. Coverage for abortion services and the ACA. Kaiser Family Foundation. September 19, 2014. Available at: http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/ (accessed 9/6/16).
4. Dickson V. GOP's Medicaid block-grant plan won't happen while Obama's in office. Medscape. March 19, 2015. Available at: http://www.modernhealthcare.com/article/20150319/NEWS/150319877 (accessed 9/6/16).
5. Norris L. Under the ACA, can I still have an individual HDHP and an HSA? Healthinsurance.org. May 16, 2016. Available at: https://www.healthinsurance.org/faqs/i-have-an-individual-hdhp-and-an-hsa-will-i-still-be-able-to-have-them-under-the-aca/ (accessed 9/6/16).
6. Cauchi R. Out-of-state health insurance - allowing purchases (state implementation report). National Conference of State Legislators. December, 2015. Available at: http://www.ncsl.org/research/health/out-of-state-health-insurance-purchases.aspx (accessed 9/6/16).

Cite as: Robbins RA. Clinton's and Trump's positions on major healthcare issues. Southwst J Pulm Crit Care. 2016;13(3):126-8. doi: http://dx.doi.org/10.13175/swjpcc091-16 PDF

IDSA Releases Updated Coccidioidomycosis Guidelines

The Infectious Diseases Society of America (IDSA) has released updated Guidelines for the Treatment of Coccidioidomycosis, also known as cocci or Valley Fever (1). Coccidioidomycosis is a fungal infection endemic to the southwestern United States and a common cause of pneumonia and pulmonary nodules in this area. However, the infection can disseminate systemically especially in immunocompromised hosts and certain ethnic populations resulting in a variety of pulmonary and extrapulmonary complications. In addition to recommendations for these complications, the new guidelines address management of special at-risk populations, preemptive management strategies in at-risk populations and after unintentional laboratory exposure. The guidelines also suggest shorter courses of antibiotics for hospitalized patients and more ambulatory treatment for most individuals who have contracted Valley Fever.

The panel was led by John N. Galgiani, MD, director of the Valley Fever Center for Excellence at the University of Arizona Health Sciences. Galgiani led a panel of 16 experts including faculty from the University of Arizona, Mayo Clinic Arizona, University of California San Diego, University of California Los Angeles, Utah, Barrows Neurological Institute and the University of Utah.  

A reference booklet, “Valley Fever (Coccidioidomycosis)—Tutorial for Primary Care Physicians,” from the UA Valley Fever Center for Excellence complements the guidelines and is available through the Southwest Journal of Pulmonary and Critical Care (2) and also available at the Valley Fever Center for Excellence website.

The guidelines begin with a disclaimer that it is "important to realize that guidelines cannot always account for individual variation among patients and ... not intended to supplant physician judgment". This is especially important because many of the guidelines are based on expert  opinion rather than strong scientific evidence.

References

1. Galgiani JN, Ampel NM, Blair JE, Catanzaro A, Geertsma F, Hoover SE, Johnson RH, Kusne S, Lisse J, MacDonald JD, Meyerson SL, Raksin PB, Siever J, Stevens DA, Sunenshine R, Theodore N. 2016 Infectious Diseases Society of America (IDSA) clinical practice guideline for the treatment of coccidioidomycosis. Clin Infect Dis. 2016 Sep 15;63(6):e112-46. [CrossRef] [PubMed]
2. Galgiani JN. Valley fever (coccidioidomycosis): tutorial for primary care physicians. Southwest J Pulm Crit Care. 2015;10(5):265-88. [CrossRef]

Cite as: Robbins RA. IDSA releases updated coccidioidomycosis guidelines. Southwest J Pulm Crit Care. 2016;13(3):125. doi: http://dx.doi.org/10.13175/swjpcc090-16 PDF

Withdraw of Insurers from ACA Markets Leaving Many Southwest Patients with Few or No Choices

Thirty-one percent of the nation’s counties are projected to have only one insurer offering health plans on the Affordable Care Act’s (ACA) exchanges next year, according to the nonpartisan Kaiser Family Foundation (1). Another 31% are projected to have only be only two. Most of the likely one-insurer counties are predominantly rural (Figure 1).

Figure 1. Estimated number of insurers participating in Affordable Care Act exchanges by county, 2017.

Particularly hard hit is Arizona where most of the rural portions of the state will have only one insurer and Pinal County will have none. Rural Nevada is similarly affected along with Utah, Wyoming, Oklahoma and much of the Southeast US.

That would give exchange customers in large areas of the U.S. far less choice than they had this year, when only 7% of counties had one insurer and 29% had two (Figure 2).

Figure 2. Net changes in number of insurers compared to 2016.

Many insurers are losing money on the health plans they sell through the exchanges. Insurance giants UnitedHealth, Humana, and Aetna have cited heavy losses as the reason for withdrawing from ACA marketplaces (2). The insurers that remain are in some cases seeking sharp premium increases for next year, trying to get back in the black amid higher-than-expected costs.

The marketplaces were supposed to hold down prices and expand choice by fostering competition among insurers. A concern when the exchanges were set up was that they might eventually reach the "tipping point". This is the point where too many sick patients with high health care costs are enrolled in the exchanges. Their high costs lead to higher insurance premiums driving the young and healthy enrollees out of the exchanges. According to the insurers the young and healthy enrollees low costs are necessary to balance out claims ledgers. President Obama has called for the creation of a public insurance option to compete alongside private plans in places where competition is limited.

References

1. Cox C, Semanskee A. Preliminary data on insurer exits and entrants in 2017 affordable care act marketplaces. Kaiser Health News. August 28, 2016. Avialble at: http://kff.org/health-reform/issue-brief/preliminary-data-on-insurer-exits-and-entrants-in-2017-affordable-care-act-marketplaces/ (accessed 8/29/16).
2. Mathews AW, Armour S. Health insurers’ pullback threatens to create monopolies. Wall Street Journal. August 28, 2016. Available at: http://www.wsj.com/articles/health-insurers-pullback-threatens-to-create-monopolies-1472408338 (accessed 8/29/16).

Cite as: Robbins RA. Withdraw of insurers from ACA markets leaving many southwest patients with few or no choices. Southwest J Pulm Crit Care. 2016;13(2):97-8. doi: http://dx.doi.org/10.13175/swjpcc085-16 PDF 

Another Phoenix VA Director Leaves

The Arizona Republic reports that the director at the Phoenix VA Medical Center, Deborah Amdur, will retire after only 9 months for health reasons (1).  Amdur will be replaced by Barbara Fallen, director of the VA Loma Linda Healthcare System. Fallen will be interim director until a permanent replacement for Amdur can be found. This is the fifth hospital director since former Director Sharon Helman was removed in mid-2014 amid the nationwide veterans health-care scandal that was first exposed at the Phoenix VA.

The Veterans Integrated Service Network (VISN) in Gilbert, which oversees the VA Medical Center in Arizona, New Mexico and West Texas has also been through a series of 4 directors since Susan Bowers retired under pressure in the wake of the VA scandal. Marie Weldon, current acting regional director, also oversees the Los Angeles-based VA Desert Pacific Healthcare System. Weldon described Fallen as “an experienced leader who will continue the tremendous effort being made to improve access to high quality health care for veterans in the Phoenix area.”

Amdur's retirement comes just one day after 12 News KPNX in Phoenix reported a taped conversation between a patient and employees at the Southeast VA Clinic in Gilbert (2). During the visit a nurse called the patient phone scheduling system “a nightmare", and a doctor employed by the VA for 3 months said he was “not a fan of the VA” and complained that assigning him 500 patients on May 23rd did not allow him sufficient time with patients. According to the tape the doctor expresses his desire to help but simply states, “It’s just I’m so lost in what to do.” Regarding the audio recording, Director Amdur said before her resignation that "the agency is looking into the matter" and threatened "actions with the providers involved”.

Congressman Matt Salmon, who represents Arizona's 5th District which includes the Southeast VA Clinic, told 12 News he was “disappointed” by what the audio recording revealed and does not consider it an anomaly. Salmon said while there are pressing matters facing the agency, he is optimistic new leadership can help turn it around. "I have nothing but praise for Director Amdur who is running the (Phoenix) VA. I think she is a breath of fresh air," Salmon said. "But the problem is so many people who still work there are the people that were there when the problem was created and getting rid of people that don’t do the job the way they are supposed to is almost impossible in the VA." Salmon said the VA's HR system needs to be revamped in order to recruit higher-quality employees. "It needs to be streamlined so that when they find good doctors they are able to hire them quickly," Salmon said.

Amdur's threats and Salmon's comments are in line with the last 2 and a half years of VA excuses for poor care by blaming bad employees rather than mismanagement and lack of oversight. Both the nurse and the doctor are new to the VA and will likely shortly be gone for telling the truth further worsening the shortage of providers. As predicted 2 and half years ago, no fundamental changes have been made at the VA and it is not surprising that problems with patient scheduling persist (3). The last 20 years demonstrate that if the VA wants to provide the best of care, it is time to stop putting VA bureaucrats in charge and replace them with professionals who know something about it, doctors and nurses. Those doctors and nurses need to be overseen by a local committee of professionals to ensure that Veterans get the best of care. Otherwise no real change occurs and VA bureaucrats and politicians will continue to blame bad employees rather than a bad system. If no fundamental change is made, it may be time to scrap the VA system and send patients to outside providers as suggested by both the patient who made the recording and implied by Salmon.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Wagner D. Phoenix VA hospital getting yet another boss. Arizona Republic. August 26, 2016. Available at: http://www.azcentral.com/story/news/local/phoenix/2016/08/26/phoenix-va-hospital-getting-yet-another-boss/89412700/ (accessed 8/27/16).
2. Dana J. VA cancer patient secretly records doctor visit. 12 News KPNX. August 25, 2016. Available at: http://www.12news.com/news/local/valley/va-cancer-patient-secretly-records-doctor-visit/307185216 (accessed 8/27/16).
3. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. doi: http://dx.doi.org/10.13175/swjpcc077-14.

*The views expressed are those of the author and do not necessarily reflect the views of the Arizona, New Mexico, Colorado, or California Thoracic Societies or the Mayo Clinic. Dr. Robbins does see VA patients under the Veterans Choice Act.

Cite as: Robbins RA. Another Phoenix VA director leaves. Southwest J Pulm Crit Care. 2016;13(2):95-6. doi: http://dx.doi.org/10.13175/swjpcc084-16 PDF

Hospital Executive Compensation Act Dropped from Ballot

The Hospital Executive Compensation Act did not qualify for the November 8, 2016 ballot in Arizona as a state statute (1). The Service Employees International Union (SEIU) dropped the initiative just before arguments were to begin in a lawsuit that challenged the legality of signature gatherers who failed to register with the state. The measure would have limited total pay for executives, administrators and managers of healthcare facilities and entities to the annual salary of the President of the United States. A similar measure in California was also dropped by the SEIU in 2014.

Supporters of the proposal said it would decrease escalating healthcare costs. Opponents of the measure, including the Arizona Chamber of Commerce who filed the suit challenging the proposition, alleged that it would lead to poorer healthcare. However, a survey conducted by the Southwest Journal of Pulmonary and Critical Care showed that most supported the measure and felt that it would not lead to poorer healthcare (2).

References

1. Ballotpedia. Arizona hospital executive compensation act (2016). Available at: https://ballotpedia.org/Arizona_Hospital_Executive_Compensation_Act_(2016) (accessed 8/22/16).
2. Robbins RA. Survey shows support for the hospital executive compensation act. Southwest J Pulm Crit Care. 2016;13:90. [CrossRef] 

Cite as: Robbins RA. Hospital executive compensation act dropped from ballot. Southwest J Pulm Crit Care. 2016;13:91. doi: http://dx.doi.org/10.13175/swjpcc081-16 PDF