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10/31/2016

Bioethics.net: The Presidential Election Edition

by Craig Klugman, Ph.D.

Every four years the United States chooses a new chief executive. Although encoded in the Constitution, the idea that a person with such power would willingly surrender it and walk away to allow another to lead is remarkable. It was even more remarkable in 1797 when George Washington began this tradition of a peaceful transition of power, an action that was nearly unthinkable in a world ruled by monarchs. As the character of King George says in the musical Hamilton, “I wasn’t aware that was something a person can do.” Of course that tradition may be ending as Republican candidate Donald Trump stated that he reserves the right not to honor the election results.

Many states are in the middle of early voting and all states (except Oregon in which everyone mails in a ballot) are nearing Election Day on November 8. Thus, I thought that it was appropriate to view both of the major party candidates’ positions on health issues. Specifically, I will look at the candidate’s positions on abortion, the Affordable Care Act, Family Life Issues, Supreme Court nominations and the curious case of medical diagnosis from afar.

Abortion

The candidate’s offer different perspectives on the issue of abortion, a contrast made clear in the third Presidential debate. Clinton has repeatedly stated that abortion is a woman’s decision and not one that the state should be making for her. She supports the work of Planned Parenthood, opposes any restrictions to abortion access, and supports repealing the Hyde Amendment (banning any federal dollars to be used for abortion).

Trump chose a pro-life running mate in Michael Pence and professes a belief that abortion “should be illegal except in cases of rape, incest, or when a pregnant woman’s life is endangered.” By “endangered” he means if the mother will die. He believes that there should be a ban on abortion after 20 weeks gestation (which seems redundant given a stance that abortion should be illegal) and that there should be no funding for Planned Parenthood. He has vowed to only appoint pro-life nominees for the Supreme Court, and that women who have an abortion and physicians who perform them should be punished. This is a position that Trump has come to since as recently as 1999, he came out in favor of pro-choice positions.

Affordable Care Act

The Affordable Care Act (ACA) or “Obamacare” is another point of contention between the candidates. Trump’s plan is to immediately repeal the ACA, especially the individual mandate (the segment of the law that requires everyone to carry health insurance, a step that is necessary to ensure that enough funding is in the system to cover costs).

The signature reform he would introduce is to remove the restriction that only permits the sale of insurance within state lines. By removing the restrictions, he feels competition would be opened and prices would come down. For example, Blue Cross/Blue Shield of Indiana could offer insurance policies in Illinois.

He would allow individuals to deduct health insurance costs the same way that businesses who purchase insurance plans for their employees can. Of course, this only benefits those who make enough money to pay taxes and take such deductions.

Encourage tax-free Health Savings Accounts—money set aside from a person’s paycheck that could be used by any family member to pay for health care and could be paid forward as part of one’s estate upon death.

Encourage patients to shop around for their health care. Trump would require hospitals and clinics to offer transparent pricing, allowing the market to reduce prices.

Make Medicaid a block grant program to the states. Instead of a partnership with federal requirements, the feds would simply give money to the states to administer, as they will.

And lastly, to encourage a free market for drugs, mostly by allowing “consumers” (not patients) to buy drugs from overseas. He feels that this expanded market will again lower prices.

The RAND corporation projects that Trumps plan would increase the number of uninsured by 20.3 million people who would instantly be thrown off of ACA exchange plans and young people who could no longer be on their parent’s insurance until age 26. His plan would increase the deficit by $5.8 million.

The challenge of course, is his reliance on the free market, a system that seems to work pretty well for supply and demand of goods, but has been a failure when it comes to non-tangibles like health and medical care. Such systems tend to benefit those with means but hurt those of lower socioeconomic status. Also, deregulation of industries has rarely resulted in lower prices and increased competition, simply look at airlines, telecoms, and banks as places where deregulation led to the creation of super companies gobbling up competition and focusing on increasing profits over serving the public. In general, Trump’s concept is that he will heat up the economy to make more profits, which will raise all boats.

In contrast, Clinton would expand the ACA by allowing people over 55 to buy into Medicare, reducing copays and deductibles and prescriptions drugs.

Clinton would use the government’s power to increase competition in pharmaceuticals and increase compassionate care access to drugs approved in other nations with rigorous testing.

Expand Medicaid in every state, even the ones that opted out of the ACA expansion

Expand the ACA health marketplace to immigrants who currently are excluded from the exchanges. Of the 20 million Americans who currently lack insurance coverage, more than half fall into this category.

Provide Medicare and insurance reimbursement for telehealth to expand access for rural areas

Ensure “that all women have access to preventive care, affordable contraception, and safe and legal abortion

Increase funding for primary care services and community health centers

Provide government subsidies to limit premiums for those who have employer-based insurance to be no more than 8.5% of their income

Adding a publicly run insurance plan option to the exchanges

Provide a tax credit for people whose individual insurance plan costs (premiums and out-of-pocket expenses) exceed 5% of their income

The RAND corporation projects that Clinton’s plan would decrease the number of uninsured by over 9 million people. However, Clinton doesn’t give details as to how she will be able to cover everyone and keep the system solvent by reducing patient costs. RAND estimates her plan would raise the deficit by $88.5 billion. The money has to come from somewhere and if it isn’t from patient fees then it has to be from federal subsidies and increased taxes.

Family Life Issues

Both candidates stress a strong interest in the family, specifically in leave to take care of one’s family and caps on the cost of childcare. How they go about doing this and what benefits they advocate for differ.

Clinton proposes guaranteeing 12 weeks of paid family and sick leave at 2/3 of full-time salary. She will use federal dollars and tax credits to limit the cost of childcare to no more than 10% of family income.

Trump would institute a tax credit for child care costs (the average cost of care in one’s state) and expand the earned income tax credit. He would give six months of paid maternity leave to new mothers (but not paternity leave nor did he say where businesses will find the money to offer this benefit).

Research

Clinton is a supporter of medical research and says she would make Alzheimer’s research a priority by committing $2 billion in funding to find a cure by 2025. She has also expressed an interest in funding more research into autism, has endorsed Obama’s cancer moonshot and has been in favor of more funding for Zika research and treatment. Trump on the other hand does not have a science advisor on his team and has said very little on this topic. He is a not a fan of the NIH. The one thing he did say, in response to a direct question, was Alzheimer’s would be a top priority.

Supreme Court

The current situation of an 8-member Supreme Court has led to many tied decisions since the Justices are roughly split 4-to-4 in conservative-progressive camps. In recent years the Court has ruled (or tied) on issues of abortion and the Affordable Care Act and plans to take up the issue of transgender bathroom rights in schools. Several Justices are advancing in age as well. Thus, whom each candidate might nominate for the Court has strong bearing on the direction of health in this country. Trump has come out with a list of judges he would consider for the courts, people that he claims are like the late Justice Scalia—strong Constitutional conservatives who support gun rights and oppose abortion.

Although not presenting a list of candidates, Clinton is likely to nominate justices who support her views, a move that would tilt the Court to the left for the first time in nearly 20 years.

In a curious move, the Republican Congressional leadership has announced that if Clinton should win, they may prevent any hearings on Supreme Court justices during her time in office, a move that could lead to fewer justices on the court and would continue the Senate neglecting its Constitutional duties.

Diagnosing From Afar

The health of both Donald Trump and Hillary Clinton has been an endless source of speculation. The letters from their doctors attesting to their health has been scrutinized. Trump’s coughing and sniffling during debates has raised questions. Clinton’s stumble while entering a car raised concerns. Their ages, Clinton at 69 and Trump at 70 have aroused debate over whether they can handle the rigor of office. Armchair physicians and psychologists have offered diagnoses and prognoses of each candidate’s psychological and physiological health.

The candidates themselves have also offered physical and psychological evaluations of each other’s health. Trump has claimed that Clinton is taking performance enhancing drugs, lacks the stamina for office, and doubted her strength after a bout with pneumonia. Trump wonders if Clinton is “crazy” and Clinton says that Trump says crazy things making him “unqualified” and “a threat to democracy.” Clinton’s camp has expressed concern about the short and non-traditional physician letter that Trump provided.

In an editorial, Arthur Caplan strongly cautioned against such backseat medicine, saying that one should not offer a diagnosis of any person without (a) having a license to do so and (b) having examined the patient in person. To do otherwise may be practicing without a license, violating professional standards, or operating outside one’s scope of practice.

Your Civic Duty

There you have it—the health-related stances of the candidates in the U.S. Presidential election. As I tell my students, voting is a duty of citizenship. Though voting rates tend to be low in the U.S>, it is important to cast a vote in this and all elections. Otherwise we are not a government of the people, for the people and by the people.

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