The 90 minute presidential debate between Hillary Clinton and Donald Trump ended last night without a single word about healthcare. Yet two-thirds of voters said “the future of Medicare and access and affordability of healthcare are top priorities for the candidates to be talking about during the 2016 presidential campaign.” 
Clinton, a Democrat, and Trump, a Republican, have both said they support “universal” healthcare and both rely on market forces and private insurers to provide coverage for healthcare. What follows is a summary of what is—and isn’t—known about the candidates’ positions on various healthcare issues, followed by comments from critics right and left.
On health insurance and “universal care”
Clinton says she will “defend and expand” the Affordable Care Act, which has reduced the number of individuals without health insurance from 47 million before the Act to approximately 30 million still uninsured as of the beginning of this year. She would allocate $500 million to help enroll those still unenrolled into a plan. [2,3]
Trump says he will ask Congress to “deliver a full repeal of Obamacare.” He doesn’t give specifics about how he will achieve universal coverage but says he will support a plan that “follows free market principles.”  This contradicts his earlier statements that he would cover everyone under a plan paid for by “government”  and he no longer supports mandatory insurance coverage. 
Both Clinton and Trump express their support for Medicare. However, Trump’s support appears qualified and at times contradictory. He makes no mention of Medicare in his 7-point plan.  At times he has said he would make cuts to Medicare and at others he says it must be preserved. 
Clinton says she supports a plan to allow individuals age “55 years or older to opt in while protecting the traditional Medicare program.” 
Clinton says “19 states…have left 3 million Americans without health insurance because their states have refused to expand Medicaid.”  She says she will “incentivize” states to expand Medicaid.
Trump says he supports taking Medicaid out of the hands of the federal government and turning it over to individual states using block grants.
On care for immigrants
Clinton supports expanding healthcare to everyone “regardless of immigration status.” 
Trump claims that “Providing healthcare to illegal immigrants costs us some $11 billion annually,” and says he will enforce laws so there are no illegal immigrants in the country.
On reining in healthcare costs
Clinton says she would work with interested governors to establish a “public option” that would be a government-run alternative to private insurance. [2,8] She says she would lower out-of-pocket expenses for individuals and families by placing unspecified caps on those expenses.
Trump wants to allow the sale of health insurance across state lines, which he says will allow “full competition” and force costs to go down. He also supports Health Savings Accounts, long-favored by Republicans. The accounts, which can only be used with high-deductible insurance plans, allow individuals or families to use a tax-free savings account to pay for out-of-pocket expenses. [6,8]
Prescription drug costs
Both Clinton and Trump support allowing drug importation with quality controls to lower prescription drug costs. Both say they support allowing Medicare to negotiate drug prices, which is currently prohibited. 
Clinton wants to “ensure that all women have access to preventive care, affordable contraception, and safe and legal abortion.” 
Trump says he opposes late-term abortion except when the life of the mother is threatened or in cases of rape or incest. He would defund Planned Parenthood as long as it provides abortions, and ban any government payments for abortion by making the Hyde Amendment permanent.
Who gets the money?
Clinton outstripped every candidate by very wide margins in receiving money from almost every sector, from banking to gambling and casinos, according to the Center for Responsive Politics. During the 2016 cycle, Clinton has received more than $17.1 million from the healthcare sector.
Trump came in behind 7 other candidates to receive $1.3 million in donations from the healthcare sector.
What the critics say
Adam Gaffney, a critical care doctor and advisor to the board of Physicians for a National Health Program told The BMJ that Clinton’s “public option” is “coming from the right place but won’t solve the fundamental problems of the healthcare system.” He said it won’t fix the problems of the 29 million who are still uninsured, as “the public option would—just like the private plans it competes with—impose premiums and cost sharing that are unaffordable for many.” Nor would it address the 31 million non-elderly adults who are underinsured, he said citing a Commonwealth Fund study, which found that among the underinsured, 47% were forced to empty their savings accounts; 34% to take on credit card debt, and 7% to declare bankruptcy. 
Gaffney says neither candidate is supporting the one plan most favored by the public; a federally funded, universal health program, which is supported by 58% of Americans, according to a Gallup poll.  He said a Canadian-style plan could dramatically cut administrative costs, shaving off more than $350 billion or 15% of healthcare expenditures. 
Yevgeniy Feyman, adjunct fellow in health policy at the Manhattan Institute, a “leading free-market think tank,” told The BMJ that “Donald Trump doesn’t really know what Donald Trump wants on healthcare; he’s taking bits and pieces from this grab bag of vaguely sounding conservative ideas and some more liberal ideas.” Feyman says he has “a lot of reservations” about Hillary Clinton, and that the cost of her proposals has not been accurately assessed. However, he said, “She has a much more concrete plan that you can negotiate with.” Feyman takes issue with both Clinton and Trump regarding their support for drug importation, saying “It would have a lot of negative effects…including an impact on R&D spending.”
Wendell Potter, former public relations executive for health insurers, told The BMJ that Trump’s plan to reduce costs by allowing insurers to cross state lines “sounds swell,” but he said, “anyone who knows something about the insurance industry knows it won’t create competition and lower costs.” 
Potter, who has been outspoken about “insurance industry greed” said, “Neither candidate is suggesting anything “radical or transformational; both are working with a system that is largely controlled by the health insurance industry. Our political system has become so corrupted that we have to address the problem of money in Congress or [truly] ambitious proposals will never make it.”
Jeanne Lenzer is a medical investigative journalist who sadly has to leave fascinating tidbits about various stories on the cutting room floor. The Backstory is an attempt to archive some of those bits and to provide a bit of insight for the public about the “behind-the-scenes” aspect of investigative journalism.
Competing interests: None declared.
- Kaiser Health Tracking Poll 2016: Kaiser Family Foundation.
- Clinton H. Hillary Clinton’s Commitment: Universal, Quality, Affordable Health Care for Everyone in America 2016.
- Clinton H. Healthcare: Universal, quality, affordable health care for everyone in America. 2016.
- Donald Trump on Healthcare: OntheIssues.org; 2016.
- 60 Minutes interviews Donald Trump on healthcare.
- Gurnon E. Where Trump And Clinton Stand On Health Care And Medicare. Forbes 2016.
- Trump D. Healthcare Reform to Make America Great Again. 2016.
- Snapshot of Where Hillary Clinton and Donald Trump Stand on Seven Health Care Issues.
- 31 Million People Were Underinsured in 2014; Many Skipped Needed Health Care and Depleted Savings to Pay Medical Bills: The Commonwealth Fund; 2015.
- Majority in U.S. Support Idea of Fed-Funded Healthcare System: Gallup Poll.
- Jiwani A, Himmelstein D, Woolhandler S, Kahn JG. Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14:556.
- What Trump Doesn’t Get About Those “Artificial Lines” Around States. 2016. Accessed 8/10/2016.