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

    The outcome of this year’s presidential election could significantly change the federal government’s role in addressing children’s health.

     

    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.

    Next: Why the jump in SSI benefits for kids?

    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.”


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