The Trump Victory and Its Implications for Patients and Physicians

November 20, 2016

What does a new Trump healthcare system look like? Patient Journeys’ Stanton Mehr takes a look in a recent article.

The stunning upset victory by Donald Trump in his run for the US Presidency can mean big changes for patients and the health care system in general. These changes may come in several areas, and from different directions.

An avid opponent of the Affordable Care Act, many believe that President-Elect Trump will attempt to repeal and replace the Act. No plan was described during the election campaign, but he did indicate that he favored allowing health insurance companies to sell their plans across state lines, as a way of increasing competition. More competition is desperately needed in many state exchanges today, as plan price increases, eroding insurance coverage with cost shifting, and insurer withdrawals from the marketplace have left the existing system teetering dangerously. Without subsidies, consumers cannot afford skyrocketing premiums, and with subsidies, increasing tax dollars are needed to pay far greater shares. However, insurers who want to sell policies across state lines will have to design and create new provider networks and be able to meet the insurance regulations in their new state of operation. This may not be easy to incorporate into their existing operations.

For patients with chronic diseases, a principal benefit of the federal law is the removal of an exclusion for pre-existing conditions. If this is retracted, insurance may be unattainable for this population, at even today’s extremely high prices. Another aspect of the ACA that may be attacked is the essential benefits package, the mandatory set of preventive and primary care benefits that all qualified plans must provide. On the one hand, this could create a pathway for selling new catastrophic care plans to large populations, which may be a more affordable way of obtaining some limited insurance protection for healthy individuals. However, this will be of no use to patients with chronic disease. In fact, this can further persuade healthy Americans to leave the exchanges, which will create more adverse risk for their insurers (and thus significant rate hikes the following year).

One idea that is likely to be revived by the new chief executive is a Medicaid financing system that employs block grants to the individual states, which was proposed by Republican leaders more than a decade ago. This type of approach was introduced to limit the federal government’s payments to the Medicaid program. This approach may well roll back Medicaid expansion and even lead to fewer benefits for all Medicaid recipients.

One change that will almost certainly happen pertains to the Supreme Court. The nomination of Merrick Garland, President Obama’s choice to replace the late Justice Antonin Scalia, has been frozen because of Republican Senators’ refusal to hold confirmation hearings. Now that a Republican President has been elected, the Senate will presumably be eager to confirm a new conservative justice. In fact, President-Elect Trump may have the opportunity to make at least 1 other nomination during the next 4 years, based on the composition of the Supreme Court today. This could result in a long-term, pronounced conservative majority who may want to revisit the ACA, Roe v Wade, or other important health care–related issues that could affect the patient journey.

It is unlikely that a new presidential administration will focus on Medicare’s value-based payment pilots and demonstrations. Several of these, like accountable care organizations (ACOs), have not been opposed by Republican lawmakers. However, it is possible that other initiatives to change the way physicians are paid, like Medicare’s part B payment proposal and MACRA, may be reconsidered, based on a general trend towards smaller government and opposition from physician and hospital groups.

It does sound as if the weeks and months ahead for patients will be rocky, indeed. Beyond the challenges to patients imposed by the present exchange marketplace, one hopes that the number of uninsured will not begin to reverse course, increasing dramatically and swiftly.

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