Red state, blue state: What the election may mean for kids

One candidate favors reducing the government’s role in healthcare, the other increasing it. One candidate offers broad-brush proposals, the other detailed policy briefs. One candidate has spent years working on children’s welfare, the other has no public track record on it.

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All in all, it’s hard to imagine a more polarizing choice than the one that Donald Trump and Hillary Rodham Clinton will offer voters interested in children’s health in this year’s presidential election.

“Elections, particularly presidential elections, are often characterized as historic and important,” says Irwin Redlener, MD, president and co-founder, Children's Health Fund, New York. “This one transcends what normally happens.”

In combination with the results of the congressional elections, the outcome could significantly change the number of children with health insurance and the way pediatricians are reimbursed.

Neither campaign responded to a request from Contemporary Pediatrics to discuss the candidates’ healthcare positions. However, on their respective campaign websites, Clinton has issued a series of healthcare policy briefs and Trump has posted a concise outline of his healthcare proposals.

The candidates differ sharply on matters of insurance. The percentage of children without healthcare coverage has steadily declined in recent decades, reaching a historic low of 4.8% in the most recent census, down from 13.9% in 1997.

Most of the gain in coverage results from the expansion of Medicaid and the Children’s Health Insurance Program (CHIP), which together cover more than a third of US children aged 0 to 18 years. Depending on what voters decide in November, these programs could continue expanding or begin to contract.

Both programs pay for healthcare costs for children whose families are in poverty, and together they have improved children’s health, says Joan Alker, MPhil, executive director of the Georgetown University Health Policy Institute, Washington, DC. “There’s a lot of research coming out showing the health benefits for kids,” she says, “and the benefits continue to accrue even when they’re adults.” She cites lower blood pressure, less use of emergency departments, better high school graduation rates, and better economic outcomes.

Medicaid

Medicaid covers about 36.8 million children. The Affordable Care Act (ACA) of 2010 expanded eligibility for Medicaid to 138% of the federal poverty level in states that choose to participate. That level is $20,160 for a family of 3.

Prior to the passage of the ACA, states set their own eligibility cutoff levels, and eligibility still varies in the 19 states that have declined to participate in the expansion.

Clinton says on her website that she would work to expand Medicaid in these states by making the federal government pick up 100% of the program’s costs. That won’t affect children directly, says Alker, because CHIP already picks up where Medicaid leaves off, insuring children up to at least 200% of the federal poverty line.

However, the expansion of Medicaid has indirectly brought healthcare coverage to some children because not all of those eligible for CHIP are enrolled. Sometimes, when parents gain coverage they sign up their children as well, Alker says.

Trump, on the other hand, proposes to fund Medicaid through block grants. “The state governments know their people best and can manage the administration of Medicaid far better without federal overhead,” his website says. “States will have the incentives to seek out and eliminate fraud, waste, and abuse to preserve our precious resources.”

In practice, Alker and other analysts interpret this to mean that overall Medicaid funding would be reduced. “[Trump’s] proposal doesn’t have a lot of detail, but there really has never been a block grant proposal that doesn’t include substantial cuts,” she says “and reimbursement for providers would probably be one of the first things on the chopping blocks for states.”

In an analysis by the nonpartisan Rand Corporation, switching to block grants for Medicaid and repealing the ACA would reduce the number of people with health insurance by 25.1 million. Rand arrived at this figure by assuming that federal funding for the program would drop back to levels from before the ACA passed into law. The Rand report does not say how many of those losing coverage would be children.

NEXT: CHIP

CHIP

Children’s Health Insurance Program covers 8.4 million children. Clinton has been a staunch supporter of the program. Although her exact role in its genesis is somewhat in dispute, Clinton has energetically worked to reauthorize it. She has shown a keen interest in children’s issues in general, beginning early in her career when she served as a staff attorney at the Children’s Defense Fund.

The CHIP’s current funding expires September 30, 2017, and given her record on the program, Clinton could be expected to make reauthorization a priority if she were president.

Trump has said little on the topic, nor does he have a track record of showing interest in public policy specifically related to children. However, on his website he implies that Medicaid and CHIP would become less necessary if he is elected.

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“To reduce the number of individuals needing access to programs like Medicaid and Children’s Health Insurance Program we will need to install programs that grow the economy and bring capital and jobs back to America,” his website says. “The best social program has always been a job-and taking care of our economy will go a long way toward reducing our dependence on public health programs.”

Affordable Care Act

The 2 candidates have taken opposite positions on the ACA, with Trump promising to repeal it and Clinton promising to defend it.

Simply repealing the ACA would reduce the number of insured Americans by 19.7 million, according to the Rand Corporation analysis. The analysis did not break down the effects by age group, but Alker estimates that about 1 million children are currently insured through the insurance exchanges set up by the ACA. Children are underrepresented in the exchanges compared with the general population because so many are covered by Medicaid and CHIP, she says.

Repealing the ACA could also affect children by eliminating a couple of provisions aimed specifically at children:

·      It requires states to maintain their current eligibility levels of children’s coverage in Medicaid and CHIP through September 2019.

·      It requires states to keep children aged 6 to 18 years with family incomes between 100% and 138% of the federal poverty level in Medicaid rather than CHIP. This eliminates insurance premiums for these families.

Charging premiums reduces enrollment by low-income families, Alker says.

Other proposals

Trump has proposed to “replace” the ACA with a set of other initiatives. Apart from the broad package of economic reforms that he claims would reduce the number of people needing government assistance, he would expand tax deductions for healthcare costs, allow insurance companies to offer plans across state lines, allow the import of drugs from overseas, broaden the use of tax-deductible health savings accounts, and require more transparency in healthcare costs.

Would these policies compensate for the loss of coverage through ACA and Medicaid? According to the Rand analysis, the combined effects of repealing the ACA, expanding tax deductions, paying for Medicaid through block grants, and allowing insurers to sell across state lines would result in a net reduction of 20.3 million persons (adults and children) losing healthcare coverage.

Rand does not attempt to analyze Trump’s other proposals. A 2005 analysis by a researcher at Columbia University, New York, found that health savings accounts were unlikely to expand health insurance coverage because most uninsured people are not paying high enough taxes to benefit from the deductions.

NEXT: Divided government

Clinton, meanwhile, offers programs aimed at expanding government healthcare coverage. The one that might most directly affect children is elimination of the so-called “family glitch.” Currently, the ACA provides tax credits for employees with low incomes if their employer charges them a health insurance premium exceeding 9.66% of their income. However, the ACA considers only the cost of the premium for insurance provided to the employee. Clinton would amend the law to include the cost of premiums for insurance provided to the employee’s family. This would extend insurance to 1.1 million persons, according to Rand, and, presumably, many of them would be children.

Clinton also proposes to institute a new “public-option” insurance plan, a new tax credit of $5000 per family to offset the cost of out-of-pocket spending above 5% of income, and a reduction in the maximum premium individuals must pay in the ACA’s insurance marketplace.

Whereas Rand estimates that these policies could extend coverage to millions more adults and children, it doesn’t offer a combined total and notes that Clinton also has put out multiple other proposals. Among these proposals are new negotiation strategies with drug companies, limits on out-of-pocket costs for drugs, and increased funding for community health centers.

Divided government

Clinton’s proposals fit much more closely than Trump’s with the policy agenda of the American Academy of Pediatrics (AAP), the nation’s largest organization of pediatricians. In its Blueprint for Children, released in September 2016, the organization supports CHIP reauthorization and repair of the family glitch. It lays out a wish list for children’s provisions it would like to add to the ACA. In addition, it opposes block grants for Medicaid.

The document goes far beyond such programs aimed directly at children’s health insurance to call for changes in policies around childcare, immigration, emergency preparedness, juvenile justice, food security, and a host of other issues.

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Although the organization refrains from endorsing candidates, this document and the AAP’s other public statements come down on one side in the philosophical debate that divides most Republicans from most Democrats: whether the federal government should do more or less.

“Right now, if we look out across the landscape, children have very different experiences based on their zip codes,” explains the AAP’s chief public affairs officer, Mark Del Monte, JD. “And we don’t believe that’s just. It’s a national priority to have healthy children and to have children that are growing up well and developing as they should. That’s a collective priority for all of us across the country. So it’s the role of the federal government to ensure there is a basic minimum for all kids."

The presidential election won’t necessarily tip the balance of power either for or against the expansion of the federal government, however. Most projections show the Republicans retaining a majority in the House of Representatives, where they could block many of Clinton’s initiatives. Prognostications about the Senate have oscillated, but no one expects either party to gain the two-thirds majority necessary to pass sweeping reforms.

If Trump is elected but Republicans don’t have the necessary numbers to rescind the ACA, Redlener says, Trump could still undermine the program, perhaps by pushing through legislation to eliminate a crucial provision such as the individual mandate. “There are pivot points in the ACA that, if they were voted down or retracted, you would see the collapse of the house of cards,” he says.

A Clinton supporter, Redlener says Clinton might work more effectively across the aisle, relying on contacts and experience she accumulated through years in the Senate and the White House.

Joseph Antos, PhD, a healthcare expert at the conservative American Enterprise Institute, Washington, DC, doesn’t think Trump can destroy the ACA. “Congress is not going to take away insurance subsidies from people after they have been receiving them for years,” he says.

Yet Antos agrees that Clinton would be more effective than President Barack Obama in reaching compromises. “I think she knows more members of Congress on a personal basis than Barack Obama does now and probably ever will,” he says.

Given the possibility of divided government, it may be enlightening to look at recent bipartisan healthcare legislation. Without much fanfare last year, for example, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) by a vote of 92 to 8 in the Senate and 392 to 37 in the House of Representatives.

Besides reauthorizing CHIP, the legislation moved Medicare in the direction of new payment models in which physicians are reimbursed less through fees for their services and more for achieving measurements of “value” such as reducing hospitalizations or infections.

Pediatricians don’t get paid through Medicare, but the agency wields huge influence that is likely to shape the way private insurers set up payment models, Antos says, so more and more pediatricians may be asked to accept value-based payments. That won’t happen overnight because what constitutes value in the context of pediatric care is likely to be the subject of protracted debate, he points out.

Meanwhile, Antos envisions pressure on pediatricians to group together in larger practices that might be asked to accept lump-sum payments per patient or per “episode of care.”

“The idea of encouraging physicians to get together in some business arrangement so that there could be some bundled payment or something other than fee-for-service is where we’re headed,” he says.

Might new cost-cutting initiatives work in the favor of primary care physicians such as pediatricians, who labor so hard to prevent their patients from getting sick?

“Primary care, for all of the lip service that Congress gives to it, has always been reimbursed at lower rates by Medicare and Medicaid and private insurance,” says Antos. “There is no light at the end of the tunnel.”

Mr Harrison is a writer based in Oakland, California. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.