Serious candidates for office don’t normally shun golden opportunities to outline their policies for an attentive audience. So when the New England Journal of Medicine invited the two top presidential candidates to describe their goals and plans for American healthcare in their administrations, Hillary Clinton jumped at the chance.

Donald Trump didn’t respond at all.

Perhaps it’s unfair to suggest that the differing responses reflect the candidates’ relative interest in hard policy matters because what’s important is the content of those policies. So let’s examine those, to the extent we can.

We need to expand Medicaid in every state so that everyone has access to care, regardless of their income and where they reside. Hillary Clinton, New England Journal of Medicine


Clinton’s response to the journal appears online and in its current issue, dated Sept. 28. For the most part, it hews closely to the healthcare position paper on her campaign website, with the additional element of an implicit appeal to congressional Republicans to cease making healthcare “a partisan or divisive issue.”

Clinton is against repealing the Affordable Care Act, though she has several ideas on how to improve it. These include expanding Medicaid to the 19 states — all with Republican governors or legislatures or both — that continue to reject the program’s coverage of the poorest Americans. “We need to expand Medicaid in every state so that everyone has access to care, regardless of their income and where they reside,” she writes.

She advocates expanding the ACA’s tax credits to cover more of the deductibles and co-pays that consumers face after paying their health insurance premiums, and empowering federal authorities to set standards for drug pricing and address excessive price increases. She would allow undocumented immigrants to purchase insurance on the Obamacare exchanges, from which they’re currently barred even if they pay full price. She hasn’t offered to make them eligible for tax subsidies, however.

Trump’s silence in response to the journal’s offer of a soapbox forces us to refer to his website for a look at his plan. As we’ve observed in the past, it’s essentially a rehash of such Republican healthcare shibboleths as allowing the sale of policies across state lines, eliminating the individual mandate and expanding of health savings accounts, the tax benefits of which flow disproportionately to the rich.


Trump adds rhetoric and stirs: “Since March of 2010,” he says, “the American people have had to suffer under the incredible economic burden of the Affordable Care Act — Obamacare.” He says he’ll seek a full repeal on day one of his administration; never mind that that would deprive 20 million Americans of coverage they’ve gained via the law and drive up costs for millions of others.

Trump throws in a nod to his favorite target: “Providing healthcare to illegal immigrants costs us some $11 billion annually,” he says. He doesn’t provide a source for this figure, and we couldn’t find one. A 2006 Rand Corp. study pegged the cost at $1.1 billion at all government levels; perhaps he misplaced a decimal point.

Since March of 2010, the American people have had to suffer under the incredible economic burden of the Affordable Care Act — Obamacare. Donald Trump campaign website

As for the rest, Trump proposes allowing insurers to sell policies across state lines, a favorite GOP notion of longstanding even though it obviously would launch a race to the bottom in plan quality — just as allowing credit card companies to issue across state lines led to your becoming subject to the sky-high interest rates allowed by South Dakota and Delaware. Trump says this should be allowed as long as the policy “complies with state requirements,” but that effectively negates the proposal.


He argues for block-granting Medicaid — giving states a lump sum to spend as they choose. But that almost certainly would conceal a cutback in funding that would grow larger with every year, jeopardizing coverage for millions of people. The saving grace of the Affordable Care Act’s Medicaid expansion is that it sets standards for services and income eligibility, which would disappear under a block-grant system.

Another flaw in TrumpCare? Trump advocates building new hospitals, but the growth of outpatient care and decline of inpatient admissions means we have too many hospital beds already. (Modern Healthcare )

One other element of Trump’s healthcare policy was picked up by the eagle ears of Modern Healthcare’s Merrill Goozner during Monday’s debate, despite the supposed audio problems affecting Trump’s microphone. This was his call for more hospital construction, which he folded into a statement on infrastructure: “We have a country that needs new roads, new tunnels, new bridges, new airports, new schools, new hospitals,” he said.

As Goozner observes, the U.S. already has more hospital capacity than it needs. That’s one driver of excessive healthcare spending. Inpatient admissions have fallen by 7%, to 34.9 million in 2014 from 37.9 million in 2008. Shrinking lengths of stay have driven down the average daily inpatient census to 584,000 in 2014 from 710,000 two decades earlier.


Much of this results from advances in medical techniques and practices that allow more conditions to be treated on an outpatient basis, which is generally good. Having too many beds to accommodate a smaller patient load is the essence of inefficiency. Trump would know this if he devoted some attention to healthcare policy other than repeating GOP mantras.

In sum, according to the Rand Corp., which analyzed both plans with funding from the Commonwealth Fund, Clinton’s proposals would add as many as 9.1 million persons to the rolls of the insured; Trump’s would reduce the insured’ ranks by as many as 20.3 million. A head-to-head comparison by Rand’s Christine Eibner is on the Rand website here, with more detail at the Commonwealth Fund here.

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UPDATES:

2:21 p.m.: This post has been updated with details from Rand’s analysis of both candidates’ proposals.