Our current slate of likely presidential candidates offer differing views on the future of the Affordable Care Act (ACA) and the future of healthcare, but their ideas do not split perfectly into a Democratic view and a Republican view. Based on their written and public statements, here’s how each candidate might affect healthcare and the ACA:
Repeal and Replace with Universal Healthcare
Sen. Bernie SandersBernie SandersSanders aide: 'Someone needs to be held accountable' for DNC emails Democrats vote to overhaul superdelegate system Green candidate: Sanders should leave party that 'betrayed' him MORE (I-Vt.) and Donald TrumpDonald TrumpSanders aide: 'Someone needs to be held accountable' for DNC emails Democrats vote to overhaul superdelegate system Trump: Cruz is 'lucky' that I walked in on his speech MORE are the most radical and, surprisingly, almost completely aligned:
Sanders advocates a universal, single-payer system, “Medicare for all”: his plan covers everything, including nursing home care. He would finance it through a variety of new and existing revenue streams, and employers would still contribute their share.
In his first public statement on the issue, Trump said he would make healthcare cheaper and better by making deals with hospitals and using those savings to finance universal coverage. More recently, in a South Carolina town hall, he vaguely referred to Medicare expansion and perhaps making commercial insurance national.
The Effect: Almost everything would change.
- Much more care would move to less costly ambulatory and digital health settings.
- More emphasis would be placed on “hub” hospitals that provide higher levels of acute care.
- Many traditional community hospitals that care for low-acuity patients would evolve into ambulatory centers for advanced care. Inpatient beds would occupy less space to keep capital and operating costs low.
- Population health and its social determinants would receive greater emphasis. Organizations of all types would have greater freedom to develop healthy initiatives.
Partially Repeal and Replace with Market-Based Healthcare
The more traditional Republican candidates offer a range of replacement options:
Sen. Ted Cruz (R-Texas) advocates opening insurance markets across state lines, expanding health savings accounts and delinking health insurance from employment. His reforms are aimed at the commercial insurance market.
The Effect: National consolidation of healthcare providers and payers.
- National provider and insurance systems would develop, creating hub-and-spoke healthcare systems with distinct characteristics, some seeking the broad middle market, others the upper echelon.
- Many systems will have multiple offerings, and their hospitals and ambulatory settings will reflect this in look and experience.
Sen. Marco Rubio (R-Fla.) would reform commercial insurance with a market-driven alternative that would expand coverage and lower costs. But he would still keep it state-based. He claims he would improve Medicare and Medicaid without saying how. He would also end aspects of the ACA, cutting Medicare Advantage, the medical device tax and taxes on health savings accounts.
The Effect: Regional consolidation of providers.
- We’ll see further regional consolidation of healthcare providers and more hospital closures, but “hub” hospitals will thrive as inpatient volume is funneled to them.
- Cheaper forms of care like urgent care and digital health will develop further, as consumers become actual buyers of healthcare; negatively, consumers may defer needed care.
Keep and Improve
Secretary Clinton is in the “keep and improve” camp. She would expand affordable coverage, slow the growth of overall healthcare costs (including prescription drugs) and help providers deliver the best care to patients. How? As far as we can tell, by ending fee-for-service reimbursement. She also emphasizes digital health, especially for rural areas, as an affordable and accessible care option.
The Effect: Consolidation and closures will continue at a faster pace.
- As under Cruz and Rubio, “hub” hospitals will thrive and expand.
- Digital health will thrive.
- New non-traditional providers will enter the market to leverage the incentives Clinton’s improvements will create.
What Can Hospitals Do Now?
Regardless of who gets elected this November, hospitals can do certain things immediately to improve the health of their communities and boost their bottom lines:
- Form more partnerships with community organizations and others who have deep interests in improving community health.
- Accelerate the development of lower-cost ambulatory and digital healthcare offerings; we are moving inexorably toward a future where healthcare is highly distributed in the community, the home and the person.
- Seek greater operational efficiency. Efficiency and quality go together, and we must raise the bar on both. Technologies and systems now exist in healthcare that can do this, and they should be applied to hospital and ambulatory care alike.
There is no greater patient experience than receiving highly reliable care at the lowest cost possible. That should continue to be care providers’ top priority, regardless of who occupies the Oval Office in 2017.
Bellefeuille, MS, and Oelrich, BSN, MBA, are leaders in NBBJ’s healthcare practice, an architecture firm that designs hospitals and clinics for 11 of the 15 U.S. News & World Report Honor Roll Hospitals, including Massachusetts General Hospital, NYU Langone Medical Center, and Brigham and Women’s.