As Election Day 2016 approaches, it is time to take a look at the candidate’s health care proposals.  Although this issue has not played an especially prominent role recently in either Hillary Clinton’s or Donald Trump’s campaigns–although it was briefly discussed the October 9 debate–it is certainly an issue of importance to many Americans, and will continue to be so well after the election is over.

The Commonwealth Fund recently released a report comparing the two candidate’s health care proposals and not surprisingly, there are stark differences between their two approaches.  In short, Clinton wants to keep the Affordable Care Act (ACA) but make needed changes; her proposals would increase the number of people with health insurance by 400,000 to 9.6 million.  Trump would repeal and replace the ACA with a proposal entitled “Healthcare Reform to Make America Great Again;” it would decrease the number of people with health insurance by 15.6 million to 25.1 million.  Both Clinton’s and Trump’s proposals have an impact on the deficit of course; the Commonwealth Fund has estimated that the impact of Clinton’s proposals could range from a $0.7 billion reduction in the deficit to a $90 billion increase.  They estimate that the Trump proposals would increase the deficit by $0.5 billion to $41 billion.

The Commonwealth Fund’s report focuses on four aspects of Clinton’s plan that focus on affordability of coverage and on increasing the number of people with insurance.   Perhaps the most well-known – and possibly the most controversial — of her proposals would create a so-called “public-option” in the ACA marketplaces that would compete with private plans.

Her plan would also create a cost-sharing refundable tax credit of up to $2,500 per individual and $5,000 per family to offset the cost of out-of-pocket spending on health care – including premiums, co-pays and coinsurance —  that exceeds 5 percent of income; this would be available to anyone enrolled in private coverage.  Clinton would also reduce the maximum premium contribution that individuals must make to purchase insurance in the marketplace.  Today, the maximum is 9.66 percent of income; her plan would reduce that to 8.5 percent for people at 400 percent of poverty, with lower limits at lower income levels.  Finally, her plan would fix the “family glitch” by giving families access to ACA premium tax credits if the contribution for family coverage exceeds 8.5 percent (currently “affordability” is tied to cheaper individual coverage, not family coverage).

Trump’s proposals with regard to insurance coverage and out-of-pocket costs would, in addition to repealing and replacing the ACA, allow individuals to fully deduct insurance premium payments on their federal tax returns.  In other words, it would allow people to purchase health insurance with pre-tax dollars, which is currently only available for employer-sponsored insurance.  This proposal would ameliorate the impact of repealing the ACA on the number of uninsured to some extent.   His plan would also block grant Medicaid; the Commonwealth Fund assumes his plan would also block grant CHIP.  The block grant would likely be based on pre-ACA (i.e., pre-expansion) spending.  Finally, Trump would promote the sale of health insurance plans across state lines.  In other words, health insurers could sell plans in a state without complying with that state’s insurance regulations and requirements.

As the fourth open enrollment period approaches with attendant higher premiums for 2017, it is certainly possible that health care will play a bigger role in the upcoming Presidential election.  But even if it does not become a central theme in the debate, it is certain that health care, and ever growing health care costs, will remain a primary issue for many Americans.  And we hope for Congress and the next President.