Editors at The New England Journal of Medicine (NEJM) invited presidential candidates Hillary Clinton and Donald Trump to respond to this question: "What specific changes in policy do you support to improve access to care, improve quality of care, and control health care costs for our nation?"

Clinton laid out her plan in the NEJM issue published online September 28.

Trump did not respond, the journal stated, but a RAND survey, funded by the nonpartisan Commonwealth Fund, recently reported in Medscape Medical News compared the two plans.

The RAND report said Clinton's plan, which modifies the Affordable Care Act (ACA), would increase numbers of insured by 400,000 to 9.6 million, and decrease consumers' health spending compared to current law. "However, the policies with the largest coverage gains also increase the federal deficit, with impacts ranging from –$0.7 billion to $90 billion."

Trump's plan, which would repeal the ACA, "would increase the number of uninsured individuals by 16 million to 25 million relative to the ACA. … Enrollees with individual market insurance would face higher out-of-pocket spending than under current law. Because the proposed reforms do not replace the ACA's financing mechanisms, they would increase the federal deficit by $0.5 billion to $41 billion," according to the RAND report.

Nancy Nielsen, MD, PhD, senior associate dean for Health Policy at Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo in New York, and a past president of the American Medical Association, told Medscape Medical News she cautions against assigning too much power to either candidate to change healthcare because the reforms must get approval from a divided Congress and the challenges are formidable.

"I think it's naive to believe that everything a candidate says is something they can accomplish by virtue of their own will," she said.

Clinton's Four-Point Plan

Clinton outlined four major goals in the journal.

First is to improve the ACA, which she calls "an essential step toward universal health care."

She would improve it, she explains, by first urging expansion of Medicaid coverage in the 19 states that did not expand coverage.

"[W]e need to ensure the availability of a public option choice in every state, and let Americans over 55 buy in to Medicare," she writes.

The public option is controversial, and while it was originally part of the ACA draft, it was scrapped because conservatives feared it would have undue advantages and would bankrupt private insurers.

Dr Nielsen said she believes that ultimately in either a Trump or a Clinton presidency, the ACA will remain.

"I think most believe that scrapping the ACA is not going to happen," Dr Nielsen said. "Although it's hard to comment on Trump's plan because it's hard to figure out what it is."

Clinton's second goal is "to extend a refundable [applied in advance of tax payments] tax credit of up to $5,000 per family for excessive out-of-pocket health costs." It would be applied against the sum of an individual's or family's premium contributions, deductibles, and copayments.

She adds: "I will impose a requirement on all insurers to limit out-of-pocket prescription drug costs to $250 a month on covered medications."

She plans to address barriers that keep drug prices high by streamlining approval of biosimilar and generic drugs and allowing Medicare to directly negotiate for better prices. She plans to create a federal consumer response team to track excessive price hikes in long-standing, life-saving treatments and give the team the tools to respond to the hikes.

A third priority is integration of mental and physical health. Her plan includes an infusion of support to community and mental health centers, as well as the National Health Service Corps, to promote faster response to health disasters, such as the Flint, Michigan, water crisis and the Zika spread.

Clinton also outlined her stance on reproductive rights.

"We must ensure that women's personal health decisions are made by a woman, her family, and her faith, with the counsel of her doctor. That's why I will fight back against attempts to restrict access to quality, affordable reproductive health care, and defend access to affordable contraception, preventive care, and safe and legal abortion — not just in principle, but in practice," she writes.

Lastly, Clinton said she will bump up the funding for biomedical research for all diseases, but especially Alzheimer's disease and HIV/AIDS.

"And we must maintain a continued commitment to the cancer moon shot so we can provide health care providers with new tools and treatments for their patients," she writes.

Dr Nielsen notes that a president controlling the budget "is a nice piece of fiction, because it is Congress who passes a budget. She's going to have to sell a lot of this," she said.

Dr Nielsen says healthcare won't be what decides this election and said it is not the biggest topic on voters' minds when compared with issues such as homeland security and the economy.

"I don't think you're going to see big divisions over what the health plans are," she said.

Dr Nielsen notes that candidates publishing health plans in a medical journal is not unprecedented and pointed to the plan put forth by Barack Obama in JAMA and commentary on plans by Obama and John McCain in NEJM in 2008.

Dr Nielsen has disclosed no relevant financial relationships.

N Engl J Med. Published online September 28, 2016. Full text

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