Steven Senne/AP

Clinton’s Health Care Plans Might Be Headed Nowhere

To make major changes, a Democratic president probably needs Democrats in control of both chambers of Congress, which isn’t likely in 2017.

The last time Hil­lary Clin­ton was in the White House, she pitched Amer­ic­ans on a plan to change the Amer­ic­an health care sys­tem—only to see Con­gress suc­cess­fully stand in her way. If Clin­ton gets her way in 2016 and earns a re­turn trip to the White House (this time as pres­id­ent rather than first lady), she may have the same ex­per­i­ence all over again.

Clin­ton re­cently rolled out a health care policy agenda, say­ing she would work to bring out-of-pock­et costs down for con­sumers at the ex­pense of phar­ma­ceut­ic­al com­pan­ies and in­surers. Many of those pro­pos­als, however, could be en­acted only with Con­gress’ con­sent, and that’s where even a Pres­id­ent Hil­lary Clin­ton would have a prob­lem. Demo­crats are com­pet­ing for con­trol of the Sen­ate, but bar­ring an elec­tion res­ult that even ar­dent Demo­crats con­cede is far-fetched, Re­pub­lic­ans will keep con­trol of the House next Novem­ber.

All of which leads to the ques­tion: If Clin­ton wins, could she move any of her health care agenda for­ward?

In short, it’s com­plic­ated. Some of Clin­ton’s policy pro­pos­als, par­tic­u­larly those ex­pand­ing and en­for­cing the Af­ford­able Care Act, could be ac­com­plished through ex­ec­ut­ive ac­tion. But many of her more am­bi­tious plans, in­clud­ing those aimed at bring­ing down drug costs, would re­quire le­gis­la­tion, which would be un­likely to pass through Con­gress without Demo­crat­ic con­trol in both cham­bers.

“I think the pres­id­ent has con­sid­er­able lever­age with one house,” said Robert Blendon, an as­so­ci­ate dean at Har­vard’s schools of pub­lic health. “You can’t have a dra­mat­ic ma­jor change, but you can tilt it one way or the oth­er if you had a pres­id­ent and the Sen­ate or the pres­id­ent and the House.”

Sev­er­al ex­perts—though nu­anced in their re­sponses—gen­er­ally agreed upon the fol­low­ing paths for­ward for her policy pro­pos­als.

What Clin­ton could do through ex­ec­ut­ive ac­tion:

To put it simply, the policies Clin­ton could most likely en­act through ex­ec­ut­ive ac­tion are the ones that bore voters and ex­cite health care wonks.

They’re also the ones that build off of the Af­ford­able Care Act, par­tic­u­larly the pieces of it de­signed to lower over­all health care costs and pro­tect con­sumers.

Clin­ton pro­posed strength­en­ing the law in sev­er­al areas, in­clud­ing pay­ment re­form that moves away from the cur­rent fee-for-ser­vice mod­el and in­stead re­wards value-driv­en care. Spe­cific­ally, the plan calls for im­ple­ment­ing new and ex­pand­ing ex­ist­ing sys­tems that pay pro­viders for bundles of care. In oth­er words, rather than be­ing paid for every test or pro­ced­ure, pro­viders would be giv­en a lump sum of money to pay for an en­tire epis­ode of care. Do­ing so would ideally give doc­tors and hos­pit­als in­cent­ive to co­ordin­ate care in an Ac­count­able Care Or­gan­iz­a­tion.

“Clin­ton is com­mit­ted to build­ing on the Af­ford­able Care Act and the Obama Ad­min­is­tra­tion’s re­forms that ex­pand value-based de­liv­ery sys­tem re­form in Medi­care and Medi­caid,” the pro­pos­al stated, adding that she will pro­pose “pub­lic-private ef­forts that in­centiv­ize em­ploy­ers and in­surers to work to ex­pand these proven pay­ment mod­els to oth­er sources of cov­er­age.”

Her plan also builds on the ACA’s trans­par­ency pro­vi­sions, ex­pands dis­clos­ure re­quire­ments, and makes new cost-shar­ing pro­tec­tions, with the goal of giv­ing con­sumers more in­form­a­tion while se­lect­ing plans and doc­tors and pro­tect­ing people from un­ex­pec­ted med­ic­al bills.

Out­side of Obama­care, Clin­ton ad­dressed grow­ing con­cern about in­dustry con­sol­id­a­tion fol­low­ing news about in­surer and pro­vider mer­gers, say­ing that “care­ful stud­ies have shown that mer­gers lead­ing to high­er mar­ket con­cen­tra­tion can raise premi­ums for con­sumers.” Her plan would cre­ate a fall­back pro­cess for states that do not have the au­thor­ity to modi­fy or block premi­um in­creases pro­posed by in­surers. It would also more strongly en­force an­ti­trust laws, mak­ing sure reg­u­lat­ors have the re­sources to mon­it­or health in­dustry con­sol­id­a­tion and in­vest­ig­ate mer­gers that could po­ten­tially raise premi­ums.

In one of her vaguer pro­pos­als, she also prom­ises to lever­age re­sources to en­cour­age en­tre­pren­eur­ship in health care, an­oth­er task she might be able to ac­com­plish through ad­min­is­trat­ive ac­tion.

What Clin­ton would need Con­gress to ac­com­plish:

Most of Clin­ton’s more ex­cit­ing policy pro­pos­als—in­clud­ing those aimed at lower­ing pre­scrip­tion drug costs—fall in­to this cat­egory.

“With­in her drug plan, it doesn’t ap­pear there’s a single piece that could be done without con­gres­sion­al ac­tion,” said Loren Adler, re­search dir­ect­or at the Com­mit­tee for a Re­spons­ible Fed­er­al Budget.

On Tues­day, Clin­ton re­leased a pre­scrip­tion-drug policy agenda that has already drawn the ire of phar­ma­ceut­ic­al com­pan­ies. In it, she pro­poses di­vert­ing drug-com­pany funds from mar­ket­ing to re­search, in­creas­ing com­pet­i­tion for pre­scrip­tion drugs by en­cour­aging the de­vel­op­ment of gen­er­ics, al­low­ing drugs to be im­por­ted from abroad, de­mand­ing high­er re­bates for pre­scrip­tion drugs in Medi­care, and al­low­ing Medi­care to ne­go­ti­ate drug prices. She would also cap monthly and an­nu­al out-of-pock­et costs for pre­scrip­tion drugs, a policy that does not lower the ac­tu­al cost of the drugs but lowers how much con­sumers pay for them, mean­ing in­surers pick up the dif­fer­ence.

These pro­pos­als build off of gen­er­al pub­lic opin­ion that pre­scrip­tion drugs are too ex­pens­ive and something should be done to lower the cost. To date, however, Wash­ing­ton has done next-to-noth­ing to at­tempt to con­trol price in­creases.

Part of that is due to Re­pub­lic­an op­pos­i­tion, which could be a prob­lem if Clin­ton be­comes pres­id­ent and wants to ac­tu­ally lower prices through policy.

“Re­pub­lic­ans are not go­ing to like price con­trols on phar­ma­ceut­ic­als; that’s al­ways made them very, very nervous,” Blendon said. “But there are some changes in how the fed­er­al gov­ern­ment would pur­chase drugs, in­form­a­tion, lessen times on pat­ents—there’s things that they might find that they could agree on with one house that would move something on that agenda for­ward.”

There is the chance that Re­pub­lic­ans could even­tu­ally suc­cumb to voter pres­sure to act on some of the more pro­gress­ive policies as well.  

Clin­ton also pro­posed build­ing on the ACA by re­quir­ing in­surers and em­ploy­ers to provide up to three sick vis­its to a doc­tor an­nu­ally without need­ing to meet a de­duct­ible first. She would ad­di­tion­ally provide a pro­gress­ive, re­fund­able tax cred­it of up to $5,000 per fam­ily to help cov­er ex­pens­ive out-of-pock­et costs. Both of these pro­vi­sions, ex­perts say, would need to be im­ple­men­ted through stat­utes.

The sil­ver lin­ing for Clin­ton is that her primary com­pet­i­tion is in the same boat. She and Sen. Bernie Sanders have very sim­il­ar drug-policy le­gis­la­tion, mean­ing he too would have to work with Con­gress to tackle drug prices.

“While man­dat­ing min­im­um drug re­bates in Medi­care or al­low­ing drug im­port­a­tion may be un­likely, it’s very pos­sible that high and rising drug prices cause enough of an up­roar to cause some ac­tion on that front,” Adler said. “To that end, it’s nice to see her—and Sanders—work­ing to add new ideas to help con­trol drug spend­ing bey­ond just the stal­warts that have been around for a long time.”

At the end of the day, however, it might not mat­ter what Clin­ton can and can’t do; voters gen­er­ally don’t want to hear can­did­ates wade in­to messy le­gis­lat­ive scen­ari­os on a de­bate stage.

“I think the de­bates will be around what your vis­ion is for the fu­ture rather than what it is that can get through Con­gress,” Blendon said.