Analyses Find Stark Differences Between Effects of Clinton, Trump Healthcare Plans

Up to 25 million Americans would lose health coverage under a Donald Trump presidency in 2018, while Hillary Clinton’s proposals would add up to 9.6 million to the rolls, according to analyses of the presidential nominees’ healthcare plans by the RAND Corporation.

Democrat Clinton and Republican Trump have starkly different visions of how—or whether—to move forward with President Barack Obama’s signature law, the 2010 Affordable Care Act (ACA). Clinton wants to expand it, adding a public option to the marketplaces, while Trump wants to get rid of it completely.

Trump’s earliest and most distinct healthcare idea would let large, multi-state employers buy coverage “across state lines,” but it doesn’t appear that would expand availability. From the consumer’s perspective, the report finds, repealing the ACA would negate the effect of letting employers leverage market power; while the boss might save money, those with serious illnesses could once again be denied coverage for pre-existing conditions. Where cost-sharing is involved, older and sicker workers would pay substantially more. RAND estimates that coupled with repeal of the ACA, 17 million people would still be without coverage.

By far, Trump's most far-reaching proposal would be repealing the ACA itself, which the analysis says would eliminate coverage for 19.7 million people in 2018. Almost all of them would be low- and moderate-income.

Clinton’s most meaningful idea, according to the report, would be to extend a tax credit to anyone with private insurance whose premium and out-of-pocket healthcare costs exceed 5% of income; the analysis finds this would result in coverage for another 9.6 million people.

The simulation, led by RAND’s Christine Eibner and sponsored by The Commonwealth Fund, used modeling to estimate how each candidate’s proposals would affect health insurance coverage, the federal deficit, and consumers’ out-of-pocket spending on healthcare, according to a statement released today by the Commonwealth Fund.

When Trump released his healthcare ideas, he did not attach estimates of what they would cost or their effect on their deficit, which is significant, because any plan would have to pass the US House of Representatives and Speaker Paul Ryan, a known opponent of programs that increase the deficit. The RAND analysis estimates that each of Trump’s proposals would increase the deficit:

• Repealing the ACA would increase the deficit by $33.1 billion.
• Repealing the law and replacing it with a tax deduction for premiums would increase it by $41 billion.
• Medicaid block grants would increase it by $500 million.
• Sales of insurance policies across state lines would increase the deficit by $33.7 billion.

When it comes to the deficit, Clinton’s policies offer a mixed bag: the tax credit, which would be easiest to swallow, politically, would balloon the deficit the most. But the element Republicans are most likely to resist—the public option—would actually reduce the deficit:

• The tax credit would raise the deficit by $90.4 billion.
• Reducing the maximum premium contribution to 8.5% would raise the deficit $3.5 billion.
• Correcting the so-called “family glitch” and reducing the maximum premium contribution would increase the deficit $10 billion. This provision would make marketplace premium tax credits available to those with employer insurance if their contribution to a family plan would exceed 8.5% of income.
• Adding a public option would trim the deficit by $700 million.

The RAND analysis finds that Trump’s call for tax deductions would still result in at least 15.6 million people losing coverage, because it would be less generous than the tax subsidies that currently help people buy coverage through the marketplace, or the funds that have extended Medicaid to individuals earning up to 138% of the federal poverty level.

A practice of Medicaid block grants could require states to cap the number of enrollees, which could limit the number of families who could be helped in an economic downturn. A recent report from the Government Accountability Office warned about the unforeseen downsides of a block grant or per capita Medicaid program.