When it comes to health care, the choice between Hillary Clinton and Donald Trump comes down to whether to keep, or trash, the Affordable Care Act.
Trump says he wants to repeal and replace the health care law that is responsible for insuring about 20 million people, while Clinton has vowed to retain it and even expand its reach.
Here are the candidates' plans:
- Keep and build on Obamacare
- Offer a tax credit of up to $5,000 to offset out-of-pocket costs over 5 percent of income
- Create a "public option" for health insurance
- Increase funding for community health centers
- Establish federal oversight of drug price increases
- Allow people to "buy in" to Medicare starting at age 55
Clinton's plan maintains the basic structure of Obamacare, with its expansion of Medicaid to more people with higher incomes and the ability to buy insurance through government-run exchanges. But she acknowledges problems with the program in its current form and offers changes to cut consumer costs, rein in drug prices, and ensure more uninsured people get covered.
The so-called public option would allow consumers to buy health insurance directly from the federal government. It's proposed in most cases to ensure there are choices for buyers in places where only one insurance company offers policies through the Obamacare exchanges.
An analysis of Clinton's plan by the Commonwealth Fund, a private foundation that supports independent health care research, concludes it would boost the number of people with health insurance by about 400,000. But the impact on the federal deficit is unclear: The report says it could range from a small decline to an increase of as much as $90 billion.
The Commonwealth analysis doesn't account for Clinton's proposal to allow people to "buy in" to Medicare at 55 rather than waiting until 65. That could reduce premiums for younger people who buy insurance through the ACA exchanges but would increase the cost of Medicare, says Joe Antos, a scholar at the American Enterprise Institute.
"She says 'buy in' because that disguises the fact that there has to be more taxpayer money in the subsidy to work," Antos says.
If the House remains under Republican control, there's little to no chance the public option or Medicare buy-in will become law.
- Repeal and replace Obamacare
- Promote tax-free health savings accounts
- Make insurance premiums tax-deductible
- Allow insurers to sell policies across state lines
- Turn Medicaid into a state block grant program
- Allow consumers to import drugs from other developed countries
Trump, like most Republicans, says he wants to repeal Obamacare, but he hasn't offered many details about what will happen to the 20 million people who will lose their insurance if that happens. In a speech this week, his running mate, Mike Pence, said Obamacare subsidies would be phased out so consumers could have a smoother transition to new insurance.
To buy that insurance, Trump wants to expand the use of health savings accounts, which allow people to save money tax-free to pay for health care costs. He also says allowing insurance companies to sell policies across state lines will cut costs, a notion economists question.
The Commonwealth Fund analysis says Trump's proposal would increase the number of people without insurance by as many as 25 million.
As with Clinton's plan, the estimates of this plan's impact on the budget is a big range, from no impact to an increase of as much as $41 billion. That's because much of his plan involves tax breaks to encourage people to buy insurance, while taking away the requirement to buy that's embedded in the Affordable Care Act.
AUDIE CORNISH, HOST:
Now let's look at where the presidential candidates stand on the issues. It's time for Platform Check.
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HILLARY CLINTON: Raise the national minimum wage so people have...
DONALD TRUMP: We're going to have the biggest tax cut since Ronald Reagan and...
CLINTON: We have to reform our criminal justice system so...
TRUMP: A very, very strong border.
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CORNISH: We're going to be talking about the Affordable Care Act, or Obamacare as it's known. Open enrollment began this week. That means people are logging onto their computers to buy health plans for next year. About 20 million people now have health insurance because of the law.
Hillary Clinton and Donald Trump have very different opinions of it, and joining us now to explain them is NPR's health policy correspondent Alison Kodjak. Welcome to the studio.
ALISON KODJAK, BYLINE: Thanks for having me.
CORNISH: So first we should mention that this is actually a pivotal moment for Obamacare right now, right? What's going on?
KODJAK: Yeah, we're going into the fourth year of Obamacare in terms of the insurance policies being sold on the exchanges. And what's happened is several insurance companies have pulled out of the program in many markets.
So there's less choice for consumers, and prices are going up. People see this as a make-or-break year in some ways because if more people don't enroll, we may have more insurance companies pull out.
CORNISH: And of course Hillary Clinton has defended Obamacare as part of the Obama White House legacy, but she says she would change it. And at the second presidential debate, she said this.
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CLINTON: You may not be able to have insurance because you can't afford it. So let's fix what's broken about it, but let's not throw it away.
CORNISH: All right, Alison, give us some details. What would Hillary Clinton do?
KODJAK: She wants to reduce the amount of money people have to pay out of pocket either by limiting that number overall or by offering tax credits that let people get money back at the end of the year if more - if a certain amount of their income is spent on health care costs.
In addition, broadly, she wants to reduce the amount of money spent on health care overall, and the first big proposal she made has to do with making sure that drug companies don't increase drug prices too much. And she would have federal authorities watch what they're doing and make sure that there's a reason for their drug price increases.
CORNISH: So is she talking about kind of tweaking what's there, or does she have bigger changes in mind?
KODJAK: Well, those are mostly the tweaks. She does have some bigger changes in mind, though. One would allow people 55 and older to buy into Medicare. Right now it's limited to people 65 and older. And that would bring many more people into the Medicare program but also ensure that younger, healthier people are the ones buying insurance on the individual market, which could lower premiums there.
In addition, she's proposed bringing back the idea of the public option, which is having the federal government directly sell insurance in the Obamacare exchanges. And that would theoretically increase competition in places where there may be only one insurance company offering plans there.
CORNISH: All right, Alison, so let's turn to Donald Trump. What has he had to say so far?
KODJAK: Well, Trump, like most Republicans, says he wants to repeal and replace Obamacare. He hasn't really completely defined what he's going to replace it with, but we can hear what he has to say about it this week.
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TRUMP: Our replacement plan includes health savings accounts, a nationwide insurance market where you can purchase across state lines and letting states manage Medicaid dollars so much better.
KODJAK: So he's proposing here health savings accounts which allows people to save tax-free to pay for what their health care costs, including premiums and any other costs that they come up with after their insurance doesn't cover it.
He's also proposing allowing insurers to sell policies across state lines, which would, he says, increase competition by having more insurance companies selling insurance in different markets, and therefore it would lower premiums across the country. And he wants to make premiums tax-deductible. That means most of his policies really are done through the tax code.
CORNISH: But you - it sounds like what you were saying is he does leave it up to the individual to get their own insurance.
KODJAK: Yeah, he'll get rid of the Obamacare mandate which says you have to buy insurance or pay a tax penalty and instead allow people tools to save money in order to buy their own plan. But a lot of critics say that that wouldn't be enough for lower-income people who don't have a lot of excess cash in order to buy insurance.
CORNISH: Have people looked at these plans? Do we know what the effect of this proposal would be if it became policy?
KODJAK: Yeah, there's been one major examination of both the plans by the RAND Corporation, and what they found is essentially both plans probably will increase the deficit to some degree. They have a big range from no increase to billions of dollars up to, like, $90 billion for Trump's plan and $40 billion to Hillary's.
And then separately, there's says that Hillary Clinton's plan would reduce the number of people who don't have insurance while Donald Trump's plan would increase it by millions of people.
CORNISH: That's NPR's Alison Kodjak. Alison, thanks so much.
KODJAK: Thanks for having me. Transcript provided by NPR, Copyright NPR.