With just a handful of primary contests remaining and less than 200 days until the 2016 election, presidential politics remain in flux. Donald Trump and Sen. Ted Cruz (R-Texas) have gained momentum on the Republican side, while Gov. John Kasich (R-Ohio) trails by a number of delegates. On the Democratic side, Sen. Bernie Sanders (D-Vermont) and Hillary Clinton, a former U.S. Senator as well as Secretary of State, continue to battle for the nomination, with Sen. Clinton leading in the delegate count. The Republican National Convention, to be held in Cleveland, Ohio, July 18–21, and the Democratic Convention, to be held in Philadelphia, July 25–28, will cement the party nominees. In the meantime, the candidates continue to discuss where they stand on important issues, including those related to health care.

Like the rest of the Republican nominees, Mr. Trump has promised to ask Congress to immediately deliver a full repeal of the Affordable Care Act (ACA). According to his campaign plan, any reform effort must begin with Congress; a series of reforms should "follow free market principles" and "restore economic freedom and certainty to everyone in this country." Specifically, Mr. Trump advocates modifying existing law that inhibits the sale of health insurance across state lines. Mr. Trump's plan states that "as long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state." The plan further outlines changes that would allow individuals to fully deduct health insurance premium payments from their tax returns, and would remove barriers to entry into free markets for drug providers that offer safe, reliable, and cheaper products.

Additionally, Mr. Trump highlights a plan to require price transparency from all healthcare providers, "especially doctors and healthcare organizations like clinics and hospitals," stating that individuals should be able to find the best prices for procedures, exams, or any other medical-related procedure.

According to the plan, the reforms would lower healthcare costs. "There are other reforms that might be considered if they serve to lower costs, remove uncertainty, and provide financial security for all Americans," states the Trump plan. "And we must also take actions in other policy areas to lower healthcare costs and burdens. Enforcing immigration laws, eliminating fraud and waste and energizing our economy will relieve the economic pressures felt by every American. It is the moral responsibility of a nation's government to do what is best for the people and what is in the interest of securing the future of the nation."

Although he has not detailed a healthcare plan online, Sen. Cruz has discussed reform ideas at various debates. In addition to vowing to repeal the ACA, he has stated he plans to allow individuals to purchase insurance plans across state lines, expand health savings accounts, and break the ties between insurance and employment. He has also suggested that to save Medicare, we must gradually increase the eligibility age and move to a "premium support system that expands choices for seniors, opens up innovation, and utilizes market forces to rein in healthcare costs."

"If I am elected President, I will repeal Obamacare and propose commonsense reform that makes health care personal, portable, and affordable," Sen. Cruz stated in January. "I will expand competition in the marketplace, empower consumers and patients to make healthcare decisions with their doctors, and disempower the government from getting in between doctors and their patients."

Another Republican who promises to repeal and replace the ACA is Gov. Kasich, who states online that access to affordable health insurance is an important priority, but "Obamacare has failed to achieve this because it has driven up the cost of health insurance approximately 80 percent in Ohio's individual and small group market and raised taxes to help subsidize health insurance coverage for families making up to $94,000 annually." Gov. Kasich proposes replacing the ACA with a primary care system that helps promote long-term good health "instead of just reacting when someone gets sick." He suggests the Ohio model provides a path forward for the nation through "patient-centered care, choices, market competition, decentralized decision-making, higher quality, respect for individuals, and an end to Obamacare's big government interference."

Further, Gov. Kasich emphasizes rewarding value instead of volume as a way to control costs and maximize quality. He highlighted work done in Ohio starting in March 2015 with the state's four largest commercial insurers and five Medicaid managed care plans "to set this model in motion for certain high-cost episodes."

"In a joint replacement, for example, surgeons, anesthesiologists, hospitals, device manufacturers, rehabilitation therapists, and drug makers all have separate roles and little incentive to worry about each other's costs," Gov. Kasich's plan states. "Instead, what if the surgeon earned more for meeting high quality standards while also better managing the entire procedure in order to produce lower costs? Many providers are actually doing this today but the savings only accrue to the health insurance plan, not the high-value provider who generates it."

In contrast to all the Republican contenders as well as Sanders, former Sen. Clinton wants to defend the ACA and build on it "to slow the growth of out-of-pocket costs" and expand coverage while making it "possible for providers to deliver the very best care to patients." For example, to reduce the cost of purchasing health insurance on the ACA exchanges, Sen. Clinton's plan would provide a tax credit of up to $5,000 per family to offset a portion of excessive out-of-pocket and premium costs above five percent of their income. She would also enhance the current premium tax credits and fix the "family glitch" so families can access coverage when an employer's family plan premium is too expensive. Clinton's plan also outlines a commitment to building on delivery system reforms in the ACA that reward value and quality.

Sen. Clinton's campaign also focuses on investing in outreach activities, like navigators and advertising, to ensure individuals understand their options and to make enrollment easier. This could include $500 million per year for an "aggressive enrollment campaign to ensure more people enroll in these extremely affordable options." Additionally, she would support new incentives to encourage all states to expand Medicaid, and would work with interested governors and others to support a "public option" choice for states. Sen. Clinton included the public option in her 2008 campaign health plan. While it was discussed during the drafting of the ACA, the provision was ultimately excluded from the legislation.

To further expand coverage, Sen. Clinton would also address rural health care by broadening the scope of healthcare providers eligible for telehealth reimbursement under Medicare and other programs, "including federally qualified health centers and rural health clinics." Her plan further stipulates that "she will also call for states to support efforts to streamline licensing for telemedicine and examine ways to expand the types of services that qualify for reimbursement." In addition, Sen. Clinton would expand access to affordable health care to families regardless of immigration status.

Finally, Sen. Clinton has also suggested cracking down on prescription drug prices and holding drug companies accountable "so they get ahead by investing in research, not jacking up costs."

Sen. Sanders, on the other hand, is advocating for a plan that provides "Medicare for all" by creating a federally administered single-payer healthcare program covering the entire continuum of care, "from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing, and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics, and treatments."

"We outspend all other countries on the planet and our medical spending continues to grow faster than the rate of inflation," statesSen. Sanders' plan. "By moving to an integrated system, the government will finally have the ability to stand up to drug companies and negotiate fair prices for the American people collectively. It will also ensure the federal government can track access to various providers and make smart investments to avoid provider shortages and ensure communities can access the providers they need."

The plan, which would cost an estimated $1.38 trillion per year according to Sanders' website, would be fully funded by income-based healthcare premiums paid by employers, income-based premiums paid by households, progressive income tax rates, and other measures.

Elizabeth Fassbender is the communications manager in the AAOS office of government relations. She can be reached at fassbender@aaos.org

Remaining 2016 Presidential Election Dates
May 10: Primaries: Nebraska (Republican), West Virginia
May 17: Primaries: Kentucky (Democrat), Oregon
May 24: Primary: Washington State (Republican)
June 3: Primary: Indiana
June 7: Primaries: California, Montana, New Jersey, New Mexico, South Dakota; Caucus: North Dakota (Democratic)
June 14: Primary: Washington, D.C.
June 28: Primary: Utah
July 18-21: Republican National Convention (Cleveland, Ohio)
July 25-28: Democratic National Convention (Philadelphia, Penn.)
Sept. 26: First presidential debate
Oct. 4: Vice presidential debate
Oct. 9: Second presidential debate
Oct. 19: Third presidential debate