Bill Frist, MD
(Forbes, November 2016)
Yesterday Americans woke up to news of a new president-elect: Donald J. Trump. The immediate question for those whose lives focus around lifting the health of individual Americans is, “What does this mean for health care in America?”
At the heart of the answer is uncertainty. Trump is an “unknown unknown” when it comes to deep, thoughtful health policy. He has excelled in many fields, but at best he personally has only dabbled in the field of health care, which accounts for a fifth of our overall economy and affects literally every American. So, to begin to answer the question, we can only start with what he has said on the campaign trail and the bare-boned, seven-point “plan” on his website and conjecture from there.
In the big picture, we can logically assume his full life in business and competition will translate into moderating health costs, not with more and more regulation but rather with open markets and enabling consumers to be smarter and more impactful in making their choices. That means greater transparency in pricing and continued evolution of outcome and quality metrics to allow consumers and purchasers of health services (and payors) to make wise decisions. The center of gravity of reform shifts away from the federal government and toward state government, private enterprise, and consumers. The driving themes will be more choice and more affordability.
After mending fences with individuals in Congress stirred up during the campaign, he will in all likelihood quickly turn to those Congressional leaders who have specialized in health policy, most notably House Speaker Paul Ryan whose comprehensive white paper will serve as the foundation for discussion of Republican health care reforms.
What can we expect?
Affordable Care Act
First, Trump has pledged to call for repeal of the Affordable Care Act (ACA), or Obamacare, on his first day in office. Even if the words “repeal of Obamacare” remain the mantra for a while, the law is now sufficiently entrenched with six years of investment by the private and public sectors that a total unwinding is unlikely. Expect Congressional efforts to greatly diminish (though not abolish) President Obama’s signature health care law by eliminating the individual and employer mandates and reducing both the minimum essential benefit packages and the subsidies paid to individuals on the new state exchanges.
Because his campaign did not flesh out a comprehensive health care approach, Trump will rely heavily on the Ryan blueprint to provide refundable tax credits and expanded tax-advantaged Health Savings Accounts to address some of the 20 million previously uninsured people who gained coverage under Obamacare but would lose it with even partial repeal. With a new president who has never served in government in any capacity and has no legislative negotiating experience, Vice President-elect Mike Pence, who previously served in the House Republican leadership, may well become the critical bridge between both branches of Congress and the Administration.
Since President Obama extensively used executive orders to implement aspects of Obamacare, it is likely that President Trump will similarly use this bypass of the legislative process to quickly undo some of these same orders even in the first week of his term. Moreover, the administration will have at its disposal such vehicles as Section 1332 of the ACA, which lets the federal government grant innovation waivers to states to take a different approach to care (e.g., opting out of the exchanges) as long as it ensures high quality, affordable health insurance.
Republicans in the Senate are far short of the 60 votes necessary to legislatively unwind aspects of the Affordable Care Act. With only a slim Republican majority of 51 (or 52 depending on the outcome of Louisiana runoff), any purely partisan Congressionally-developed changes to the ACA could be achieved either via budget reconciliation (the Senate procedure the Democrats previously used to pass the ACA) or by defunding through the Appropriations Process.
On the campaign trail, Donald Trump said he would “save” Medicare without cuts, but this differs from the House Republican platform. He has not provided details on his Medicare plan. The business approach to delivery would suggest continued support of Medicare Advantage.
Trump has also argued Medicare could “save $300 billion” annually by directly negotiating drug prices with major pharmaceutical companies, although this has not been listed as a formal part of his health care plan.
In line with Speaker Ryan’s healthcare plan, President-elect Trump has called for block granting Medicaid to avoid inefficient regulatory restraints and increase flexibility for states to tailor programs to their individual needs. Instead of a federal matching program, Medicaid would be transitioned to a lump-sum payment to states with fewer strings attached. We will almost certainly see rapid elimination of the additional federal financial incentive for a state to expand Medicaid under the ACA.
For insight into what Medicaid provisions Trump might be supportive of, look to Mike Pence’s plan to expand Medicaid in Indiana through a waiver that reflects GOP-leaning principles, and puts individuals on the hook for some level of personal accountability with required contributions to Health Savings Accounts.
Americans want quick action to bring down the cost of drugs. In addition to calling for Medicare to negotiate drug prices, Trump advocates for the re-importation of drugs from abroad. A Canada-specific initiative is the most likely (and safest) approach. He backs removing barriers to competition from lower-price, equally effective medications, and will encourage Congress to advance legislation to achieve this.
Perhaps most definitively, President Trump will likely use market solutions to address access issues and improve affordability as his go-to anchor in health reform . He hopes to empower consumers—who are facing increased personal payment responsibility—by requiring price transparency from all health care providers, including doctors, clinics, and hospitals. He would allow individuals to fully deduct health insurance premiums payments from their tax returns, encourage tax-free Health Savings Accounts, and promote the Republican-standby of cross-state insurance sales.
While not quite a blank canvas, the portrait of TrumpCare is yet to be seriously painted. His campaign left more questions than answers. Our first indications of what to expect over the next four years begins today with the actions of his transition team and the appointments he will make over the coming three months. Indeed health care reform is facing much greater uncertainty today than it did just three days ago, but amid this democracy-induced upheaval, a fresh look just may bring some unanticipated, constructive innovation and change.