In seemingly every presidential election, we are told by pundits and politicos that this particular contest represents the starkest choice between two vastly opposed ideologies that we’ve seen in decades. The future, your kid’s future and your grandchildren’s future, depends on its outcome.
Some may argue that such hyperbole is an understatement this year, and, whether that’s true or not, one thing is clear—this election gives voters the choice between the known and the unknown. If Secretary Hillary Clinton wins, the nation will likely stay on its current path—a pursuit of incremental change shaded by Democratic ideologies. If Donald Trump wins, no one is quite sure what will happen, although a look at his proposals and the GOP’s 2016 platform provides some insight.
Clinton has made it clear she believes in upholding and improving the Affordable Care Act (ACA). Her website lists several other health care policies including:
• Expanding Medicare by lowering eligibility age from 65 to 55
• Lower prescription drug costs by requiring drug companies to invest in research and development in order to receive taxpayer support
• Incentivize states to expand Medicaid (no specifics given)
• Allow families to buy insurance on the health exchanges regardless of immigration status
• Identify ways to make providers eligible for telehealth reimbursement under Medicare
• Expand federally qualified health centers and rural health clinics
• Double funding for primary-care community health centers
All this amounts to what would be a hefty expansion of the ACA and would likely face stiff resistance from the GOP-controlled Congress.
On Trump’s website, the candidate lists seven policy points regarding health care, with the first being repealing the ACA. The other positions consist of:
• Eliminating laws limiting the sale of insurance across state lines
• Make health insurance premium payments tax deductible for individuals
• Use health savings accounts (HSAs) as the primary program to replace the ACA
• Mandate price transparency from all providers so consumers can compare by price
• Block-grant Medicaid to the states
• Increase competition in the pharmaceutical industry by allowing consumers to purchase drugs from overseas
The last point is one of the few areas where the two candidates agree, as Clinton has also called for allowing foreign drug providers to sell to American consumers.
Probing the Plans
A recent analysis done by the RAND Corporation, a non-partisan policy think tank, highlights the differences between the two candidates’ health care plans. The study used RAND’s computer microsimulation to analyze the portions of each candidate’s plans with enough detail to model. The analysis found that Clinton’s proposals would increase the amount of people with insurance by between 400,000 and 9.6 million in 2018, while Trump’s proposals would decrease the number of insured by between 15.6 million and 25.1 million.
Digging into each candidate’s specifics, the report found that Clinton’s tax credit proposals would cost approximately $94 billion. Her plan calls for offering refundable tax credits to individuals with private insurance whose premium out-of-pocket costs exceed 5% of income as well as lowering the maximum premium contribution on the marketplace to 8.5% of income. These would cost $90.4 billion and $3.5 billion respectively. Her call to fix the “family glitch,” offering marketplace premium tax credits to families with employer insurance if their contribution to a family plan would exceed 8.5% of income, would add another $10 billion to the deficit. Her proposal to add a public option, however, was projected to lower the deficit by $700 million.
Analyzing Trump’s plans, the study concluded that repealing the ACA would add $33.1 billion to the deficit. Further, implementing tax-deductible premiums would increase the deficit by $41 billion, allowing interstate insurance sales would add $33.7 billion and block-granting Medicaid would add another $500 million.
As for out-of-pocket costs, the RAND study projected Trump’s plan to increase them for ACA enrollees anywhere from $300 to $2,500 per year while Clinton’s tax credits would decrease costs for low- and moderate-income individuals (those making $16,243 to $29,425 for an individual, $33,465 to $60,625 for a family of four) by an average of 33%. For example, under current law an individual with an income of $41,580 would be required to pay $4,017, whereas under Clinton’s plan that individual’s contribution would be reduced to $3,534. It should be noted that there were elements of Trump’s plans which could not be modeled due to lack of detail. The authors stated that if either candidate was to release further details that would alter the figures, they would run a new simulation and release new numbers.
The Future of Obamacare
Once again, the ACA is approaching a defining moment. After surviving a presidential election and two U.S. Supreme Court decisions, Obamacare is again in the political crosshairs. If Trump wins, some sort of dismantling will at the very least be attempted. Of course, taking insurance away from 20 million people, even if you have a plan to get it back to them in a different form, won’t be easy. If Democrats take control of the Senate, it will be very difficult if not impossible for a President Trump to pass anything that harms Obama’s signature achievement. If Trump wins and Republicans keep the Senate, Democrats will still have the power of the filibuster at their disposal.
Likewise, if Clinton wins, regardless of what party controls the Senate, Republicans will likely remain fiercely opposed to the ACA and could use the filibuster to prevent most of her major proposals, such as instituting a public option. What might be possible under a President Clinton, according to reporting from Modern Healthcare, is an effort to increase exchange enrollment through system reforms and aggressive outreach, as well as increase subsidies for low-income patients. If Trump wins, most expect him to pass the issue to Speaker Paul Ryan, who would likely be unable to actually repeal the ACA but would try to chip away at it by attacking the individual and employer mandates, the Center for Medicaid and Medicare Services (CMS) Innovation Center, and the Medicare Independent Payment Advisory Board.
Of course, for the optimist, there is always a chance that the combination of a new president and national fatigue over fighting the ACA for seven years would inspire a compromise, regardless of who wins. A possible bargain might consist of using Section 1332 of the ACA, which allows the federal government to grant waivers to states to leave the ACA exchanges and use their own methods to reach coverage and cost control goals. This would please conservatives as it takes power away from the federal government and gives it to states. In exchange, Democrats would likely ask for more cost-sharing subsidies for low-income enrollees.
Affordable multifamily housing issues rarely surface during general election campaigns and this year is no different. There is no mention of housing on Trump’s website. The Republican platform for 2016 stops short of calling for the abolition of Fannie Mae and Freddie Mac, but it does describe both as “corrupt business models” whose usefulness should be reconsidered. The platform calls for the end of government mandates that required Fannie, Freddie and federally-insured banks to satisfy lending quotas to specific groups, calling such practices discriminatory. It opposes the Obama Administration’s Affirmatively Further Fair Housing (AFFH) rule which it says undermines local zoning laws and gives too much control to the federal government. The goal of AFFH is to “address significant disparities in access to community assets, to overcome segregated living patterns and support and promote integrated communities” which it aims to do by requiring a new assessment of fair housing by HUD program participants.
Clinton has a housing section on her website that promotes increasing incentives for new development and strengthening programs that give low-income renters more options outside of high-poverty areas. Although she doesn’t mention the U.S. Supreme Court disparate impact decision last summer that makes it easier for developers to build low-income housing in high-income neighborhoods, it’s clear she supports it. Further, she recently penned an op-ed in the New York Times on poverty that advocates for the expansion of the low-income housing tax credit (LIHTC).
Clearly, the outcome of this contentious presidential election will have substantial ramifications on the health care and housing industries. The good news is, after almost two years of discussion and campaigning, the finish line is in sight.