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Donald Trump vs. Hillary Clinton? Many physicians are having a hard time picking either and healthcare isn't the reason why.
After of being of primary importance in 2012, healthcare is almost an afterthought in the 2016 election.
In a poll of Gallup voters from April 2, 2012, healthcare was rated the single most important issue in that year’s general election between President Barack Obama and former Massachusetts Governor Mitt Romney. This year, Gallup polled members of both parties; for Republicans, healthcare the fourth most important issue and for Democrats, it was third.
Sure, both candidates - former Secretary of State Hillary Clinton for the Democrats and Donald Trump for Republicans - have their healthcare talking points. But while the Affordable Care Act and healthcare may have led the stump speeches in 2012, those issues are way down the list in 2016. Moreover, the positions aren't as clear as they may have been just four years ago.
"I don't think healthcare has been discussed much; there has been some talk on what could be done with the Affordable Care Act," says Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association. "Most physicians and practices are philosophically conservative, not in their political beliefs but more in the approach to the intervention of government in the practice of medicine. They want limited intervention. Irrespective of who wins, it's hard to tell in this election which candidate would provide that."
For Trump, his healthcare plans boil down to repealing the Affordable Care Act (ACA) and attempting to build a system based on free-market principles. In addition, the real estate developer says he wants to increase access to imported, safe, reliable drugs to increase competition and lower prices of prescription medication. Clinton plans to fix what's broken about the ACA, such as repealing the "Cadillac tax" on premium health plans, and keep what's working about it, such as the expansion of Medicaid. She also says she'd like to lower out-of-pocket and prescription drug costs through the offer of a tax credit of up to $5,000 to cover costs exceeding 5 percent of a household income, and expand Medicare to make it available for people at the age of 55.
Like most Americans, physicians are divided and not really factoring healthcare into the decision. In this year's Great American Physician Survey, which charted the responses of more than 1,300 physicians on their professional and personal state of mind. Of the respondents, 45.6 percent said they'd vote Republican, 40.2 percent said they'd vote for Democrat, and 14.1 were unsure. While this was conducted as the primaries were wrapping up, before the general election really began to take shape, the answers were similar when it came to party registration. Nearly 37 percent were registered Republicans, 26.6 percent were registered Democrats, and 28.4 percent registered Independent.
A few months into the general election, Physicians Practice spoke to a panel of frontline physicians across different areas, some in battleground states, to get their thoughts on the candidates and how they were voting.
Who and Why
The only thing that seemed to unite those interviewed was a relative distaste for both options. "I cannot make a choice between these two candidates and my choice would have nothing to do with healthcare. My choice will have to do with national security and the economy," says Joseph Zebley, a Baltimore-based family medicine physician at a concierge practice. He says Clinton is untrustworthy but at least has some experience, while Trump doesn't have any experience in healthcare and constantly makes a fool of himself.
Arvin Nanda, a family medicine physician at a three-doc practice in Dayton, Ohio, says he too cannot make a choice between Trump and Hillary. He says neither candidate gives Americans a great selection. Since he doesn't see a need to repeal the ACA and start over, he admitted he is leaning Democrat if he had to choose.
Like Zebley, Brenda Fortunate, a retired family medicine physician who works as a part-time faculty member for Genesys Health System in Grand Blanc, Mich., hasn't made a clear cut decision and it will have nothing to do with healthcare. However, she says on medical matters, she doesn't have much faith in either.
"When Hillary was in charge of healthcare reform under her husband's administration, I have it from a source of someone involved in the planning that she did not even allow on the table a discussion on limiting healthcare in any way. I don't think we can afford a Hillary Clinton healthcare [plan]. I don't think Donald Trump understands it [either],”she says.
Paul Norwood, an endocrinologist out of Fresno, Calif., has made his choice. While he says both candidates are "terribly flawed," Trump is the lesser of two evils. "As far as healthcare, I do think Trump will try to find a market solution, compared to Hillary Clinton, who will find a socialist solution to the problem, which is not workable," he says.
Not unlike the general electorate, physicians have put healthcare on the backburner comparatively to other important issues on how they are picking a candidate. Stacey Blyth, a Greensboro, N.C.-based family physician for multispecialty medical group LaBauer HealthCare, says she is a lifelong progressive and has generally made up her mind. However if she were to change her mind, it wouldn't be because of healthcare.
Of course this doesn't mean physicians don't have strong opinions on what actions the next president should take with regards to healthcare. For instance, Blyth would like to see a public option be put back on the table. She sees this as the main way towards salvaging the ACA.
Nanda says he hopes to see more insurance reform in the future. "…One of the ACA's tenants was to cap profitability of the insurance companies at 20 percent and make 80 percent of premiums to be payable as benefits. [Insurance companies] were very upset with that. A 20 percent profit for a business is incredible. That they'd be upset is ridiculous. We constantly see denial by insurance of care for patients on a daily basis. That still needs to be addressed," he says.
The Dayton-based doctor adds that proposed mergers between health insurers (Aetna and Humana; Anthem and Cigna) are concerning because less competition is needed in that industry, not more.
Zebley says he'd like to see a policy where states purchased and made vaccines more available to practicing physicians. He'd also like to see government funds put into prenatal and early well child care as well as other pediatric public health issues.
In the Great American Physician Survey, 48.4 percent of respondents said they'd like to see the next president rein in prescription drug costs; 45.9 percent, similarly to Nanda, would like to see stronger regulations on health insurers; 44.6 percent would like to see a full repeal of the ACA; and 43 percent would like to see physician income disparity addressed between primary-care and specialty physicians.
Does it Even Matter?
Policy experts, such as Robert Berenson, a physician and institute fellow at the Urban Institute, a Washington D.C.-based think tank, say it may not matter. He says, there isn't going to be a lot of difference whether it's a Republican or Democrat in office. "It's not as if one party is on their side, mostly [the politicians are all] oblivious to the problem," he says.
Another reason it may not matter who is living at 1600 Pennsylvania Avenue come next January is the system of checks and balances. Unless, as Gilberg points out, Congress and the new administration are controlled by the same party (such as when President Obama passed the ACA), there isn't likely be significant legislative progress.
Many physicians on the frontline seem to agree. "I don't think it matters. We, as Americans, make a bigger deal out of it than it actually is ," says Nanda. Fortunate agrees and says it doesn't seem to matter who is in office, as the cost of care continues to rise without the outcomes to show for that increase.
Even though she leans Democratic, Blyth says that either way her practice will "stay sound."
Norwood says he too won't be affected by who will be in office, but for different reasons than his peers. In the world of endocrinology, because it's not a high-income field, he says he won't have as much taken from him if a Democrat were to be in office. "We wouldn't be affected as much. It's the higher price specialties - cardiologists, oncologists - who are more at risk," he says, before adding, "I think a Republican would be better off in office, giving us more of a market solution."
It's important for practices to realize they have a lot on their plate over the next four years regardless of who will be living in the White House. The implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) starting next year and continuing into the 2020s will be a significant challenge for small practice physicians. Inability to comply with the measures could mean up to an 8 percent cut in Medicare reimbursement, which could surely sink some physicians.
Moreover, MACRA isn't getting appealed and in this respect, the next president doesn't really matter. "CMS [and] HHS [drive] a large part of the regulatory framework that really touches physicians [on a day-to-day basis] and affect physician practices," says Gilberg. "So if you have a political change, you still will have a large bureaucracy that's working on these regulations and that bureaucracy will remain regardless of who is president, The regulatory framework for MACRA has been created, it was a bipartisan law, [and because of all this], I fully expect it to be implemented "