Last year all spending in the U.S. on prescription drugs rose by 11.7 percent over 2014, according to a report published in the current American Journal of Health-System Pharmacy. The authors attribute the spending growth to sharp price hikes driven by new specialty medications and price gouging on older drugs that face few or no competitors. They also forecast an 11 to 13 percent increase in total drug expenditures this year.

At the same time, a study appearing last week found private insurers increased the portion of their total drug spending on specialty drugs from 11 percent of all prescriptions filled in 2003 to 43 percent in 2014. During this period, "patients' out-of-pocket costs for pricey drugs climbed 46 percent."

The obvious question during this presidential election year is what the two main candidates and their parties are doing to address this national issue.

Obama's Affordable Care Act, with its emphasis on access to care, has had hardly any impact on controlling costs.

The plan to expand access while leaving private insurers in charge was inspired by some European nations. But those countries tariff premiums, control drug prices and limit physician-hospital charges, while Obamacare leaves it to profit-seeking businesses to set their prices.  So, as was the case even before Obamacare, U.S. health care is the world's most expensive while outcomes here rank below those of other advanced nations.

Obamacare did reduce the number of uninsured Americans from 50.7 million in 2010 to 28.6 million in 2015. But a large and growing percentage of people with formal coverage find that their plans still leave them with such high, out-of-pocket costs that they decline to seek treatment.

So what are the candidates proposing to set matters right?

Presumptive Republican nominee Donald Trump has made vague references to universal health care without specifying what he means by the term or how he plans to achieve it. He has neglected to mention whether his concept of universal care would require tax increases and whether it would raise or lower out-of-pocket costs for individuals.

He also has tried cozying up to Republican Party leaders by giving lip service to House Speaker Paul Ryan's health care proposal, which would limit access by creating even higher costs for individuals through the following steps.

1. Repeal the Affordable Care Act's (ACA) requirement that all Americans buy health insurance if they are not covered through their work or by a government program;

2. Do away with the ACA's insurance exchanges in the states;

3. Set up "high risk" insurance pools to help sick people obtain coverage;

4. Provide a tax credit refund for people who buy private health insurance.

The problem with the Ryan plan, according to political scientist Anthony Dimaggio, is that it "will do nothing to help uninsured Americans afford skyrocketing health care premiums, growing out-of-pocket costs, and escalating deductibles. It does nothing to help those who are not poor enough to qualify for Medicaid, but who cannot afford the growing costs of private market insurance plans."

Its only benefit will consist of a modest tax subsidy for people with enough money to buy their own insurance. At the same time it would increase the number of uninsured by denying access to state insurance exchanges that provide federal subsidies.

Although the high-risk pools proposed by the Republicans can, in theory, provide sufficient subsidies to make premiums affordable, doing so is costly and the Republican plan doesn't offer adequate funding for the pools to accomplish that.

Just as importantly, the Ryan Republican plan leaves profit-making insurers at the health system's control center where they can continue to gouge the public. It also maintains the government's hands-off approach to prices for prescription drugs and health care services.

So we are left to conclude that an ill informed and detached Trump would concern himself mainly with symbolic gestures while leaving the details of governing to Paul Ryan and the Republican Congress.

Now to Hillary Clinton, who has said she wants to "build on Obamacare," an idea as sensible as trying to build a skyscraper on quicksand.

Yet late last week, to win an endorsement from Bernie Sanders, Clinton publicized the topline elements of a health care policy that at least makes some constructive first steps:

1. Letting states install a public option system in which residents could elect coverage in state-managed plans;

2. Permitting individuals to enroll in Medicare at age 55;

3. Increasing funding for community health care centers in rural areas;

4. Granting the Secretary of Health and Human Services authority to limit excessive premium increases;

5. Capping out-of-pocket costs paid by consumers for drugs, premiums, deductibles and co-pays, though  details remain sketchy;

6. Allowing Medicare to negotiate prices with pharma companies;

7. Allowing drugs to be imported from abroad.

Yet Clinton's surrogates voted down platform amendments supporting single-payer healthcare, the only systematic means of maintaining affordability, access and quality.

This fact stokes strong suspicion that she would revert to form after winning the election by allowing her pharma donors to keep enriching themselves.

The hope that political action will make health care more affordable comes down to whether Donald Trump will defy his party and otherwise act out of character or whether Hillary Clinton will go against her donors to act with principle rather than expediency.

What are the odds that either of those might happen?


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