The magnitude and pace of Mr Trump’s changes to healthcare may be smaller and slower than supporters demand or opponents fear.
Dr Lockwood, editor in chief, is Senior Vice President, USF Health, and Dean, Morsani College of Medicine, University of South Florida, Tampa. He can be reached at DrLockwood@ubm.com.
How will the recent election of Donald J Trump affect your practice? What will be the fate of the Affordable Care Act (ACA), the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and Medicare value-based payments? Will we see radical change or will intramural Republican conflicts and obdurate Senate Democrats conspire to sustain the gridlock that has paralyzed our federal government for the past 6 years?
Before answering these questions perhaps we need a bit of detached perspective. To start with, while the recent US general election was by all criteria divisive, inflammatory and, at times, vile, by historical standards it paled in comparison to the vitriol hurled when Andrew Jackson challenged John Quincy Adams, or when Reagan stunned Carter; and in each case our nation emerged none the worse for wear.
Polls and pundits simply failed to account for the American habit of cyclical rejection of ruling parties, a legacy of Thomas Jefferson, who himself had 2 extraordinarily vituperative campaigns against another founding father, John Adams. The polls also missed long-simmering frustrations among rural and exurban white working-class voters over the perception that both parties-but especially the Clinton wing of the Democratic Party-had consistently focused on urban poor and minorities but paradoxically also on Wall Street and the professional classes, all at their expense (eg, why Sanders voters turned to Trump).1 Moreover, such class resentments were exacerbated by disparate regional economic growth.
Then there is the unique American tendency to elect the opposite persona of the last president. But mostly, the pollsters missed the far greater enthusiasm for Trump compared with Clinton voters fed by Mr Trump’s pitch-perfect channeling of their fears over economic consequences of globalization, immigration, and multiculturalism.
I suspect those terrified and those elated by the prospect of a Trump presidency will be both pleasantly surprised and decidedly frustrated by the next few years. Our federal system of checks and balances, bureaucratic inertia, and all-too-frequent elections promotes incrementalism, while the equipoise of red and blue states, unrestrained bipartisan PAC dollars, and the relentless scrutiny of social media and partisan cable news outlets conspire to sustain deadlock.
Having lived in New York for 12 years and observed President-elect Trump in action, I also suspect he is far more pragmatic than ideological and an astute-enough student of public opinion not to stray far from the mainstream.
We already see signs of that pragmatism in his statement that he will try to sustain popular components of the ACA such as its prohibition against health insurers denying coverage for pre-existing medical conditions, allowing children to stay on their parents’ coverage until age 26, and closing the “doughnut hole” for Medicare Part D prescriptions. On the other hand, he opposes the federal mandate requiring health insurance, which funds these popular programs by virtue of insurance companies receiving premiums from relatively healthy younger subscribers.
Suddenly eliminating health insurance for the more than 20 million Americans now insured through various ACA programs would be political madness. It would also create acute financial harm to both hospitals and many physicians. Thus, while the GOP is likely to move expeditiously to eliminate federally run or supported public exchanges, tax credits and expanded health savings accounts are likely to be simultaneously enacted to allow purchase of private health insurance and cover deductibles.
We can also expect elimination of federal support for state Medicaid expansion and affording states far greater autonomy in running their Medicaid programs (witness Mr Trump’s support of state Medicaid block grants). Thus, expect states to experiment with capitation, privatization, and their own versions of accountable care.
Vice President-elect Pence can be expected to push novel federal/state partnerships as he has done in Indiana. Trump promises to eliminate prohibitions against the sale of interstate health insurance products. This would likely lead to a few dominant national health insurers whose size would reduce risks of adverse selection and thus enable them to offer lower premiums and bend the healthcare cost curve. On the other hand, they would also be able to suppress local provider-based insurance products and could acquire unprecedented leverage to drive down physician and hospital reimbursement.
Do not expect MACRA to go away-sorry. It was passed by enormous bipartisan margins and is viewed by both parties as the only effective way to maintain Medicare solvency. This strong bipartisan support to pay for evidence-based, value-enhanced outcomes and capitated care rather than the mere production of services will also add to downward pressure on provider reimbursement.
Moreover, President-elect Trump has vowed to permit Medicare to negotiate drug costs and permit consumers to purchase international pharmaceuticals. This would almost certainly result in lower medication costs but could stifle development of new treatments and reduce provider infusion revenue.
Perhaps nowhere is the threat of radical change greater than financing of graduate medical education (GME). It is unclear precisely where President-elect Trump stands on the issue of Medicare support for hospital-based resident and fellowship training. Stopping such support could result in catastrophic reductions in training slots with many US medical student graduates unable to match. Organized medicine is likely to put up a strong fight over such reduced funding but, as a medical school dean, this is one of my greatest fears, particularly since many medical schools are already facing competition for GME slots from Caribbean-based programs that offer to pay for residency opportunities.
Early casualties of Mr Trump’s election may include the Center for Medicare and Medicaid Innovation, the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, and the many grants and pilot projects they now support. National Institutes of Health (NIH) funding could also be at risk.
Mr Trump plans to slash corporate and personal income tax rates while funding large-scale infrastructure improvements and increased military spending. While that may act as a potent fiscal stimulant to the economy, it may also trigger either inflation or draconian cuts in non-entitlement/non-defense components of the federal budget to avoid massive deficits. In any event, NIH funding could be on the chopping block. Since 2003, the NIH has lost 22% of its funding when adjusted for biomedical inflation.2 With many NIH institute paylines now below 10%, we are already at risk of losing a generation of young scientists and ob/gyn departments are at particular risk. Further cuts would be unsustainable.
President-elect Trump has made clear his opposition to abortion except in cases of rape, incest, and risk of maternal mortality. It is likely that this would serve as a litmus test for his Supreme Court nominees. However, the Supreme Court now has a 5-3 majority supporting Roe v. Wade. President Trump would need to appoint at least 2 new justices to affect federally protected access to abortion.
Moreover, overturning Roe v. Wade would not end abortion access nationwide but rather would result in a patchwork of states either permitting or prohibiting pregnancy termination. The results could be state boycotts by pro-life and pro-choice groups, exacerbating the already substantial red state-blue state cultural divide. On the other side of maternal/family issues, Mr. Trump favors 6 weeks of guaranteed paid maternity leave.3
The election of Mr Trump and retention of Republican majorities in the House and Senate will result in significant changes to healthcare financing and women’s healthcare. However, the magnitude and pace of these changes may be smaller and slower than supporters demand or opponents fear.
Look for the largest impact in the first 100 days after which Mr Trump’s honeymoon, such as it is likely to be, may dissipate and legislators’ eyes will instinctively return to, God forbid, the next election cycle.
Finally, a closing thought. I live in Hillsborough County, Florida-a crucial battleground county in a crucial battleground state. Thus, for the past 4 months I have been deluged by the most censorious, malicious, and painful political ads imaginable. Our local newspaper-the multiple Pulitzer Prize-winning Tampa Bay Times “Politifact” service recorded many, many “Pants on Fire” (patently false) statements by virtually all candidates running for local, state, and federal offices in both parties.4
Thus, I would propose that, if physicians are expected to dutifully practice evidence-based medicine, it’s time for our politicians to practice evidence-based politics!
1. Williams JC. What so many people don’t get about the U.S. working class. Harvard Business Review. https://hbr.org/2016/11/what-so-many-people-dont-get-about-the-u-s-working-class
2. Federation of American Societies for Experimental Biology. Restore NIH funding factsheet. http://www.faseb.org/Portals/2/PDFs/opa/2016/Factsheet_Restore_NIH_Funding.pdf
3. Harrington R, Sheth S. Here’s where Trump stands on abortion and other women’s health issues. Business Insider. http://www.businessinsider.com/donald-trump-abortion-womens-health-platforms-positions-2016-11