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.
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Caitlin Owens is a health care reporter at National Journal. Her work has previously appeared in the Los Angeles Times, The News & Observer and The Charlotte Observer. She is a graduate of the University of North Carolina at Chapel Hill.