At the federal level, the nation’s two major political parties have vastly different visions for the future of healthcare. The election will help to determine which course the nation follows for the foreseeable future. What are the likely outcomes depending on who wins the presidency?
A Republican in the White House could spell the end for the ACA
For some time now, the Republican mantra when it comes to the Affordable Care Act has been “repeal and replace.” While this phrase is oft-repeated, it is not so obvious what the GOP to actually replace the law with. “Republicans – and Trump – are fervently united by what they oppose: ObamaCare,” John McDonough, a professor at the Harvard T.H. Chan School of Public Health, told Healthcare Dive. “They are far less certain about what they support as a replacement.”
Republican legislators widely support repeal of the ACA, interstate health insurance sales, tax deductions for health insurance premium costs, expansion of health savings accounts, and Medicaid block grants for states. However, if Republicans win control of Congress and the presidency, it is not clear which items they will prioritize.
It does seem likely Republicans will target the ACA if they win control of Congress and the presidency. However, they won’t necessarily succeed, McDonough said. Democrats will likely maintain enough influence to filibuster attempts at full repeal. Even if Republicans use the budget reconciliation process to avoid filibuster and reverse key elements of the ACA, enough Republicans might resist legislation to eliminate coverage for millions of previously uninsured Americans.
On the other hand, a Republican-controlled House has already passed a bill to repeal the ACA, but President Barack Obama vetoed the reconciliation bill in January. “Should the impediment of the presidential veto be removed, survival of the ACA in the face of a Republican-controlled Congress and White House seems unlikely,” Alexander Mainor, a fellow at the Dartmouth Institute, told Healthcare Dive.
In a March article that Mainor co-authored for The Hill, he and his colleagues encouraged Republican-leaning voters with a stake in healthcare to push for policies that preserve successful elements of the ACA. “Should a Republican be elected, careful legislation rather than repeal could preserve the architecture of the Affordable Care Act that supports value-based healthcare,” they wrote. “In this scenario, acceleration of value-based reforms would be slowed, but not lost altogether.”
Republican opposition would stymie a Democratic president’s efforts to improve the ACA
As Republicans are united in their opposition to the ACA, Democrats are united in their desire to improve the ACA. However, while there is agreement around certain policy ideas, there isn’t nearly as much around others. For instance, Democratic presidential candidate Hillary Clinton supports a public option. However, even with strong numbers in Congress, a public option is unlikely because too few Democrats support it, according to McDonough.
There are areas where Democrats widely agree, but are unlikely to make progress. For instance, most Democrats support legislation that would expand Medicaid in all 50 states. However, even if Democrats maintain control of the White House and gain a majority in the Senate, it is likely they will still have the filibuster and a Republican-controlled House of Representatives to contend with, according to Mainor.
There are some reforms, including some enhancements to the ACA, that could be enacted with bipartisan support under a Democratic president, Mainor said. These include small maintenance changes to the ACA, such as repeal of the “Cadillac Tax” and a fix for the “family glitch,” which prevents families from receiving ACA subsidies when an individual family member has access to employer-based coverage considered affordable by the law.
However, given the current political climate, the potential for bipartisan support is limited. “Any such proposal requires a willingness to negotiate from both parties that simply may not exist,” Mainor said.
The presidential candidates’ healthcare platforms do share one feature in common. Both would target rising drug costs by pushing for legislation to allow Medicare to negotiate drug prices and to remove market barriers to entry for drug manufacturers. However, there isn’t much of an appetite for either of these proposals among congressional Republicans, according to McDonough.
There seems to be more disagreement than agreement both between and within in the two parties. While there is potential for significant legislative change, both candidates would face an uphill battle when it comes to implementing their plans for healthcare. Although results the election will provide a clearer picture for where healthcare is headed, the only thing that seems truly certain is that political gridlock will make health reform difficult.