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When it comes to health care reform law changes that the major presidential contenders advocate, the differences are striking.
Of the five leading candidates, only Democratic Party front-runner Hillary Clinton backs the Patient Protection and Affordable Care Act.
In her five-page health care position paper, Ms. Clinton says she would “defend the Affordable Care Act and build on it.”
“One of the most striking differences is that it is pretty obvious what Hillary Clinton would do as president with respect to health care: She would reinforce the Affordable Care Act and perhaps try to extend its reach,” said Gretchen Young, senior vice president of health policy at the ERISA Industry Committee in Washington.
“It is clear she wants to keep the ACA. She views it as a great starting point,” said Allison Klausner, a principal with Xerox HR Services in Washington.
Still, while Ms. Clinton is clear in her support, she hasn't provided much detail on some of the changes she would make to the ACA.
For example, Ms. Klausner noted, while Ms. Clinton advocates repeal of the upcoming 40% excise tax on health insurance premiums that exceed certain amounts, she has yet to detail what she would propose to offset the loss of tens of billions of dollars in federal revenue government researchers say the tax would generate.
Sen. Bernie Sanders, I-Vt., Ms. Clinton's chief opponent, would scrap the ACA and replace it with a single-payer national health insurance system, which he describes as “Medicare for all,” a reference to the 50-year-old federal program that provides health care coverage to more than 50 million Americans, mostly age 65 and older.
The frontrunners for the Republican presidential nomination — businessman Donald Trump, Sen. Ted Cruz, R-Texas, and Ohio Gov. John Kasich — are united on one key position: “On repealing the ACA, the Republican candidates are all on the same page,” said Geoff Manville, a principal with Mercer L.L.C. in Washington.
“Obamacare is causing millions to lose their jobs, be forced into part-time work, lose their doctors and health insurance, and pay skyrocketing premiums. This law isn't working,” according to a position paper by Sen. Cruz.
Gov. Kasich supports repeal of the health care reform law, which his position paper says “has driven up the cost of health insurance approximately 80% in Ohio's individual and small-group market.”
Mr. Trump makes three in his opposition to the ACA.
“On day one of the Trump administration, we will ask Congress to immediately deliver a full repeal of Obamacare,” Mr. Trump said in a health care position paper he released this month.
Repeal and replace
But that's where the similarity among the Republicans ends. All have different ideas about changing the nation's $2 trillion health care system.
Sen. Cruz says he backs expanding health savings accounts and allowing individuals to purchase health care coverage across state lines, giving them a greater number of insurers from which to choose.
Mr. Trump backs tax deductions to help individuals pay for premiums, would require greater price transparency from health care providers and make it easier for drug manufacturers outside the United States to export their products here.
“Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers,” Mr. Trump says in his position paper.
Observers say they understand the driving force behind Mr. Trump's position: double-digit increases in prescription drug costs.
“Perhaps prices would come down somewhat” if more imports were allowed, said Steve Wojcik, vice president of public policy at the National Business Group on Health in Washington.
Position paper to ACA
Candidate position papers have, in the past, been a first step on the path to significant changes in health care law.
The most recent example of that came in 2008, when Barack Obama, then a Democratic senator representing Illinois, was running for president. Then-Sen. Obama proposed in his health care reform position plan a mandate that employers — except the smallest firms — offer health coverage to their employees or face financial penalties.
He also proposed requiring employers to extend coverage to employees' young adult children, as well as federal health insurance premium subsidies to make coverage more affordable for the lower-income uninsured.
Those positions ultimately were included in the health care reform legislation that President Obama signed into law in March 2010. The result: The nation's uninsured rate fell to just over 10% in 2014, from 13.3% in 2013, the year before many ACA-mandated coverage provisions took effect.
Similar proposals by the 1992 Democratic Party presidential nominee, then-Arkansas Gov. Bill Clinton, didn't fare so well.
His campaign health care reform promises, which included coverage requirements for employers and creation of a national board to set health care spending limits, an initiative overseen by Ms. Clinton when she was first lady, didn't receive much support, even from congressional Democrats, and died in the second year of the Clinton presidency.
Still, while the fate of the 2016 presidential candidates and their health care positions are likely to evolve, they give voters something to scrutinize.
For example, in her position paper, Ms. Clinton says she would expand a health care reform law requirement under which employers can be hit with a stiff financial penalty if the premiums employees pay for single coverage exceed 9.5% of their income, with affected employees eligible for federally subsidized coverage in public insurance exchanges.
Ms. Clinton says the employee health plan premium contribution limit, which, if topped, makes employees eligible for federal premium subsidies used to buy coverage in ACA-authorized public exchanges, should also apply to family coverage, contending that the current omission was a congressional “glitch.”
She also wants to place new limits on employees' annual out-of-pocket health costs, which she says are “squeezing” American families.
“She has not said how she would change the out-of-pocket limits,” Ms. Klausner said. In 2016, those limits are $6,850 for single coverage and $13,700 for family coverage.
Picking up the tab
By contrast, Sen. Sanders has provided more details on certain aspects of his proposal to create a single-payer health care system.
For example, employers would pay an assessment equal to 6.2% of their income to help fund coverage, while employees would pay a premium up to 2.2% of income.
Of the Republican candidates, Sen. Cruz has provided the most detailed proposals.
He says he would expand HSAs and allow insurers to sell policies across state lines.
“That will create a true 50-state national marketplace, which will drive down the cost of catastrophic health insurance,” Sen. Cruz said during a Republican candidates' debate in late January in Des Moines, Iowa.
Sen. Cruz also said health insurance should be portable for employees.
“We should work to de-link health insurance from employment so if you lose your job, your health insurance goes with you and it is personal, portable and affordable,” he said during the Des Moines debate.
Quality over quantity
Gov. Kasich focuses specifically on cost control, calling for an overhaul of the medical payment system to tie provider reimbursement more closely to keeping patients healthy.
“The first step is having a primary care system that helps promote long-term health instead of just reacting when someone gets sick,” Gov. Kasich says in his position paper.
In addition, he says he would link providers' compensation to their ability to coordinate with other medical professionals on procedures.
According to the position paper: “In a joint replacement, for example, surgeons, anesthesiologists, hospitals, device manufacturers, rehabilitation therapists and drugmakers all have separate roles and little incentive to worry about each other's costs. Instead, what if the surgeon earned more for meeting high quality standards, while also better managing the entire procedure in order to produce lower costs?”
In response to a request for comment, Mr. Trump's campaign offered the candidate's position paper. The other campaigns did not respond.
The United States and Canada share a several thousand-mile border, and the differences in the two countries' health care systems are just as vast.