Hillary Clinton put forward two major health care proposals across her political career: the Health Security Act of 1993, which sought to guarantee universal coverage through a new system of employer mandates and regional purchasing groups, and her 2016 presidential campaign platform, which aimed to expand the Affordable Care Act with a public insurance option, lower drug costs, and a Medicare buy-in for people 55 and older. The two plans reflected very different strategies, but both centered on the same goal of making health coverage more affordable and accessible.
The 1993 Health Security Act
In 1993, President Bill Clinton tasked First Lady Hillary Clinton with leading a task force to overhaul the American health care system. The result was the Health Security Act, an ambitious proposal to achieve universal health insurance coverage. At the time, roughly 37 million Americans had no insurance at all.
The plan’s central mechanism was an employer mandate. Employers would be required to pay 80 percent of the average cost of their employees’ health plans, with workers covering the remaining share. Small businesses and low-income individuals would receive government subsidies to offset costs. Every American would receive a health security card guaranteeing a standard benefits package that included doctor visits, hospital care, prescription drugs, and preventive services.
Coverage would be organized through regional health alliances, essentially large purchasing cooperatives that would negotiate with insurers and health plans on behalf of consumers. The idea was that pooling millions of people together would give these alliances bargaining power to drive down premiums, similar to how large corporations negotiate group rates for their employees. People could choose among competing private plans within their alliance, but the government would set a ceiling on how much premiums could rise each year.
The plan drew fierce opposition from insurance companies, small business groups, and Republicans who saw it as government overreach. Critics argued the structure was too complex and bureaucratic, and that price controls would reduce the quality of care. The “Harry and Louise” television ads, funded by the insurance industry, became a symbol of the campaign against the plan. By September 1994, the Health Security Act was dead in Congress without ever receiving a full vote in either chamber. It remains one of the most prominent legislative failures in modern American health policy.
The 2016 Campaign: Building on the ACA
By 2016, the health care landscape had changed dramatically. The Affordable Care Act, signed into law in 2010, had created insurance marketplaces, expanded Medicaid, and extended coverage to roughly 20 million previously uninsured Americans. Clinton’s 2016 platform took a fundamentally different approach from her 1993 effort. Rather than replacing the existing system, she proposed expanding and strengthening the ACA to close its remaining gaps.
The centerpiece was a public option: a government-run insurance plan that would compete directly with private insurers on the ACA’s health insurance exchanges. The public option had originally been part of the ACA’s design but was dropped during negotiations in 2009. Clinton proposed bringing it back, structured similarly to Medicare, where the government sets payment rates and administers the plan directly. The primary goal was to act as a backstop in markets where few private insurers participated. In areas where only one or two companies sold exchange plans, prices had climbed steeply because of the lack of competition. A public option would give consumers an alternative and put downward pressure on premiums.
A more limited version was also floated: deploying the public option only in areas where private competition was inadequate or costs were unusually high, rather than rolling it out nationwide. The specific details of how providers would be paid and what level of subsidies enrollees would receive were never fully fleshed out during the campaign.
Medicare Buy-In at Age 55
Clinton also proposed allowing people ages 55 and older to buy into Medicare before reaching the standard eligibility age of 65. This addressed a specific pain point: older Americans who aren’t yet eligible for Medicare often face the highest premiums on the individual insurance market because insurers can charge older enrollees more. A Medicare buy-in would give this age group access to a large, established insurance program with lower administrative costs than most private plans. The proposal effectively would have lowered Medicare’s entry age by a decade for those willing to pay a premium to join.
Prescription Drug Costs
Drug pricing was a major focus of Clinton’s 2016 health platform. She proposed a $250 per month cap on out-of-pocket prescription drug costs for patients with chronic or serious health conditions. At the time, patients with diseases like multiple sclerosis, hepatitis C, or cancer could face thousands of dollars a month in medication costs even with insurance, because many plans required high copays or coinsurance on specialty drugs.
Beyond the spending cap, Clinton called for allowing Medicare to directly negotiate drug prices with pharmaceutical companies. Federal law had prohibited Medicare from negotiating since 2003, forcing the program to accept whatever prices manufacturers set. Clinton argued that Medicare’s massive purchasing power, covering tens of millions of enrollees, could be leveraged to bring prices down significantly. She also proposed allowing Americans to import certain prescription drugs from countries like Canada and European nations, where governments regulate drug prices and the same medications often cost a fraction of what they do in the United States.
Medicaid Expansion and Subsidies
When the Supreme Court ruled in 2012 that states could opt out of the ACA’s Medicaid expansion, 19 states chose not to expand, leaving millions of low-income adults in a coverage gap. Clinton proposed extending 100 percent federal matching rates to encourage the remaining holdout states to expand Medicaid. Under the original ACA, the federal government covered 100 percent of expansion costs initially but that rate was scheduled to gradually decrease to 90 percent. By promising to cover the full cost indefinitely, Clinton aimed to remove the financial argument state legislators used against expansion.
She also proposed increasing premium subsidies on the ACA exchanges so that families would spend a smaller share of their income on health insurance. The goal was to reduce the burden on middle-income households that earned too much to qualify for generous subsidies but still struggled with premium costs.
Public Health Investments
Clinton’s 2016 platform extended beyond insurance coverage into broader public health priorities. She proposed increased funding for community health centers, which serve as the primary source of care for millions of low-income and rural Americans. The plan also included investments in Alzheimer’s disease research and development, public health initiatives to reduce exposure to lead and other environmental toxins, and expanded access to primary care services in underserved areas.
How the Two Plans Compared
The 1993 and 2016 proposals reflected two very different theories of how to reform health care. The Health Security Act was a top-down restructuring: it created entirely new institutions, imposed mandates on employers, and set government price controls on premiums. It tried to solve the problem all at once, and its complexity became a political liability.
The 2016 platform was incremental by design. It accepted the ACA as the foundation and proposed targeted fixes for its weaknesses: not enough competition in some markets, drug costs too high, Medicaid expansion incomplete, older adults falling through the gap before Medicare eligibility. Each proposal could theoretically be passed as a standalone bill rather than requiring a single massive piece of legislation. The lesson Clinton and her advisors appeared to draw from 1993 was that sweeping overhauls are politically fragile, and that building on existing structures, even imperfect ones, was a more viable path forward.