“It was the best of times, it was the worst of times. It was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way” – Charles Dickens, A Tale of Two Cities

The words of Charles Dickens can perfectly describe our current Presidential election as well as the state of Healthcare reform in this country. Last night’s second Presidential debate finally broached the subject of healthcare. Twenty-four minutes into the debate, the candidates received their first healthcare question. Secretary Clinton and Mr. Trump were able to discuss the merits of their healthcare policies for the next 7 minutes and forty-five seconds.

“Affordable Care Act, known as Obamacare, it is not affordable. Premiums have gone up, deductibles have gone up, copays have gone up, prescriptions have gone up, and the coverage has gone down. What will you do to bring the cost down and make coverage better?” – Question from the audience.

Clinton

Secretary Clinton agreed with many of the sentiments expressed in the question but reminded America about all the positive aspects of the law. She explained when the law passed in 2010, it was not just focused on the 45 million Americans that lacked insurance at the time, but also improved the coverage of the roughly 170 million Americans that already received healthcare coverage from their employer.

She outlined the following key provisions of the Affordable Care Act that helped those Americans already insured:

Elimination of lifetime limits: Health plans can no longer stop covering a consumer when their health costs reach a certain dollar amount.
Elimination of Pre-existing conditions: Health plans can no longer deny coverage to consumers who enroll already diagnosed with a sickness or disease.
Expanded Coverage up to Age 26: Health plans now cover children up to age 26 regardless of educational status. This was expanded from the old limits of age 19 or up to 23 for fulltime students.

Many of these provisions extended coverage to those Americans who cost more to the Healthcare system. As such, these features indirectly correlated to the premium, deductible, and copay increases Americans have faced since 2014. Many healthcare policy experts warned us of this issue asserting that the Affordable Care Act would increase costs early on as more people got expanded benefits. Healthcare costs would only begin to stabilize and decline over time.

Lastly, the Department of Health & Humans Services released a report on September 29th outlining the “historic, widespread increase in Health insurance coverage”. Specifically, 20 million Americans have gained health coverage as a result of the Affordable Care Act. That is close to a 50% decrease in the amount of people that lacked health coverage in 2014; the 1st year of the Health Insurance Marketplaces. In 2010 , 16% of the country lacked coverage, it has lowered to 8.6% through March 2016. The gains in health coverage were seen across all demographics including race, income, age, and geography.

Secretary Clinton is leery on repealing the entire law and starting from scratch. She wishes defend and extend the law: continue the provisions that work and improve the ones that do not. However, she did not provide specifics on how she would get that done.

“Right now we [have] 90% Health insurance coverage. That’s the highest we’ve ever been in our country. So I want us to get to 100% but get costs down and keep quality up.” – Secretary Hillary Clinton

Trump

Donald Trump started his comments laser focused on the premium increases certain Americans will be facing in 2017. The McKinsey Center for U.S. Healthcare Reform reports that next year will be the highest increase of monthly prices for health care coverage through the Health Insurance Marketplaces since its inception. In 2014, the median increase ranged from 2.7% for Bronze plans to 6.6% for Platinum plans. In 2017, the median price increases will range from 7.6% for Platinum plans up to 17.1% for Catastrophic plans. Ironically, Catastrophic plans were specifically designed to attract young and healthy people. Those plans have the highest deductibles and are specifically sold Americans under the age of 30 that lack insurance coverage due to the costs.

Without using specifics, Donald Trump alluded to states like Tennessee that will see 25% rate increases for their Health Insurance Marketplace plans in 2017. This is the second year in a row consumers in Tennessee will see increases over 20%. Even large national health care plans will average 27% rate increases in 2017. Competition appears to be dwindling as well. Many health plans have started to exit certain states.

2017 Health Insurance Marketplaces – Average Health Plan Rate Increase

42% will receive single digit increases up to 10%
30% will receive double digit premium increases over 10%
20% will receive premium decreases of 10% or less
Only 8% will receive premium decreases more than 10%

Donald Trump also focused on costs, properly mentioning that healthcare is one of the most expensive line items in the Federal budget. He believes costs are on the rise because of the lack of competition. His remedy is to increase competition by eliminating the current barriers health companies face selling coverage over state lines.

However, he failed to mention that medical cost trends have declined from a 11.9% annual increase to a projected 6.5% in 2017. That would be the lowest cost trend increase we have seen in years. The declines have been seen in physician costs, which have been offset by increases in prescription drug costs and utilization.

While Trump strongly calls for the repeal and replacement of the Affordable Care Act, he failed to provide any details or specifics on his alternative approach. He also did not specify which portions of the Affordable Care Act would also be in his replacement plan. It is hard to ascertain whether Trump is for or against mandated coverage for all Americans, health insurance market places, the elimination of pre-existing conditions, or the elimination of lifetime limits. He did however hint at agreeing with Paul Ryan’s budget plan which calls for block grants to states to administer the Medicaid program. Health policy analysts and Democrat Governors are leery on this idea since it would inevitably lead to spending cuts to Medicaid. Since 2014, Medicaid growth has been exponential.

“Not only are your rates going up by numbers that nobody believes, but your deductibles are going up. So that unless you get hit by a truck, you’re not going to be able to use it. It is a disastrous plan and it has to be repealed and replaced.” – Donald Trump