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January 23, 2017

The Trump effect: Experts predict how the president will change health care

Daily Briefing

Last week, the Daily Briefing's Josh Zeitlin asked several health care experts, "How do you expect President Trump will change health care? At least, what's your best guess?"

Below are their responses, which have been edited and condensed for clarity. The same experts also shared their perspectives with the Daily Briefing on how former President Obama changed health care. Read their takes on Obama and health care.

Ashish Jha

Internal medicine physician, VA Boston Healthcare System; health policy professor, Harvard T.H. Chan School of Public Health; director, Harvard Global Health Institute

President Trump has had some level of inconsistency about his vision, but I actually think there's a lot of consistency in the vision of health care of the people he is picking to run things, like Tom Price and Seema Verma. At the end of the day, while the president sets the tone, it's really the secretary of HHS and the head of CMS who are setting the day-to-day agenda of health care.

In general, I think you are going to see less direct involvement by Medicare about how care is delivered on the front lines. A bunch of the mandatory programs that we saw come out of the Obama administration—like bundled payments and other kinds of delivery reform—are likely to become a lot more voluntary.

“I think the push toward alternative payment models I think will happen much more slowly under President Trump than it would have under a third Obama term or under a President Clinton.”

Harvard professor Ashish Jha

I think the push toward alternative payment models will happen much more slowly under President Trump than it would have under a third Obama term or under a President Clinton. At the same time, I think there will continue to be pressure on the private sector to experiment with new models, driven both by CMS and by the market realities around the cost of care.

The interesting issue in my mind is what happens to MACRA. That of course has been a very bipartisan effort to date. But my sense is, there's a lot in MACRA—in how we're going to start evaluating and paying individual physicians on the ambulatory side—that people like Tom Price oppose.

When I talk to my colleagues, most of them say, "They're not going to touch MACRA, it's bipartisan, they'll leave it alone." I'm actually not so sure about that. Whether there's some interest in reforming MACRA, making some of the payment stuff a little bit weaker, less onerous, however you want to see it, that I think is actually a question on the table.

On the issue of insurance and access, it's much less clear in my mind what could happen. Trump just came out and said everyone has to have insurance. At the same time, they're all committed to repealing the ACA. So it's very hard for me to have a crystal ball about that.

I don't see any major reforms happening to either Medicare or Medicaid. I think a lot of Republican governors would not be happy about Medicaid block grants, and there's going to be a lot of concern in Congress about whether this is politically worth doing. And when it comes to Medicare premium support, I think you'd get a lot of pushback from senior groups. I don't see why President Trump would want to expend a ton of political capital to do a substantial reform of the way Medicare is paid for.

Rodney Whitlock

VP, health policy, ML Strategies; former health policy advisor and acting health policy director, Senate Finance Committee Chair Chuck Grassley (R-Iowa)

Given President Trump's penchant for salesmanship, he has the biggest opportunity to rebrand whatever the [ACA replacement] policy is in a way that might move it beyond the Obamacare tag.

That policy is still to be determined, but if he can marry his ability to market with actual progress on the affordability issues that have vexed the Affordable Care Act's popularity, there is real potential. How he gets there is the difficult question that we are all following and trying to affect.

Uwe Reinhardt

Professor of political economy, economics, and public affairs, Woodrow Wilson School, Princeton University; member, National Academy of Medicine

It is not clear what President Trump actually thinks about health care—what he believes should happen to, say, a low income American stricken by a serious illness. On occasion he has talked as if he was center-left. 

Republicans in general seem to me to have dreamt of a system in which every American has access to a basic, relatively barebones set of health care benefits, but that beyond that health care is just another basic consumer good, like food, housing, and clothing. That view means that rationing health care by price and ability to pay (by income/class) is OK.

My hunch is that the "replace" in what is coming will reflect that conservative vision. It is bound to spell more hardship for the poor, the old, and the sick. I may be wrong, of course, and hope I am; but that is what I think at the moment, an impression extracted from decades of past health reform proposals coming from the conservative side.

I thought that from a political perspective, Speaker Paul Ryan (R-Wis.) was very effective last week in trashing Obamacare and offering a "replace." But that "replace" was a pig in the poke, so to speak. One would need much more information on, say, the high risk pools [he discussed] before being able to comment meaningfully on them.

Thomas Miller

Resident Fellow, American Enterprise Institute; former senior health economist, United States Joint Economic Committee

How will President Trump change health care? I would use the words erratically, episodically, occasionally, and unpredictably. I really think we are way too far in the beginning to make good predictions. On one hand, the election has opened the door that others have been ready to run through. Now they're looking to see where the exit signs may be.

“We haven't really gotten any glimpse yet, in any consistent way from tweet to tweet, as to what the Trump administration most prefers of all. ”

AEI Fellow Thomas Miller

We know what the Congressional game plan is, but we haven't really gotten any glimpse yet, in any consistent way from tweet to tweet, as to what the Trump administration most prefers of all, which would set some foundation and some boundary lines to work around. Aside from qualitative adjectives and just a couple of characters, we don't have real policy indicators that tell us what it's going to be.

The early indication is that the ACA repeal and replace effort will be led by Congress. People fill vacuums and sputter along until they run into roadblocks. Ultimately, what this reflects more broadly is not just dysfunction in Republican ranks or "Congress versus the White House." We all want good things without the bad things, and we don't know how to balance them out and make a little more long-lasting decisions. So there's a lot more zig-zagging and veering from one ditch to another ditch. We might find out that there's another ditch to go in for a while.

At the end of this process, whether it's in one year or two years, or in the extreme four years, something will be different about our health care and our health policy. That's unquestionably the case. I never promise it'll be better, I just promise it'll be different. There's not yet clarity as to what that's going to look like. You can see some indicators on the margins, but there are a lot more rewrites and revisions to come.

Nicholas Bagley

Professor of law, University of Michigan Law School; former attorney with the appellate staff in the Civil Division, U.S. Department of Justice

I worry less about what President Trump will do to health reform than what congressional Republicans will do.

“Trump has to answer to the American public, and I don't think the public will be happy if the ACA's gains are rolled back. He may end up being a moderating force.”

University of Michigan law professor Nicholas Bagley

Trump has to answer to the American public, and I don't think the public will be happy if the ACA's gains are rolled back. He may end up being a moderating force. Most Republican members of Congress, however, come from deep red districts and worry less about being beaten by a Democrat than by a future primary challenger.

That helps explain why the Republican majority in Congress is so committed to complete repeal, even though that's not a position that polls well.

Martin Gaynor

Professor of economics and health policy, Carnegie Mellon University; governing board chair, Health Care Cost Institute

The question of how Trump will change health care is a real tough one. I think if you'd asked the question at the beginning of the Obama administration it would have been equally difficult. I'm not sure if people would have envisioned something quite like the ACA.

At this point it's just a lot of ferment, a lot of ideas popping around. A couple of days ago, Trump mentioned something about covering everybody, and having it cost less and have lower deductibles. That doesn't appear to be consistent with the vision that House Speaker Paul Ryan (R-Wis.) has. And to get an ACA replacement plan through the Senate the GOP will need to attract some Democratic votes, and that is another thing that makes this harder to predict.

My best guess would be that some parts of the Affordable Care Act are removed or changed and there are some new features put in. Part of what makes it difficult is that to keep some of the popular parts of the ACA like guaranteed issue, you need something to get people to enroll in insurance so you have a reasonable risk pool. The individual mandate was an approach to that. There are some GOP plans that would take different approaches, such as automatic enrollment or continuous coverage.

“Part of what makes it difficult is that to keep some of the popular parts of the ACA like guaranteed issue, you need something to get people to enroll in insurance so you have a reasonable risk pool.”

Carnegie Mellon professor Martin Gaynor

What will emerge is very hard to predict, but if I had to guess right now, I'd say the Trump plan will have something that maintains guaranteed issue, that has finer-grain rating bands than the ACA does, maybe a penalty for not having continuous coverage, and a repeal of some kinds of mandates for certain kinds of benefits. I think there's a reasonable chance that the Medicaid program is changed, that it could go to block grants. I don't expect that we'll see any major Medicare changes, because Medicare is pretty hard to touch.

I do think it would be very feasible for the Trump administration to take steps to strengthen markets and increase competition in the health care industry, because I think that's consistent with both Democratic and Republican priorities for a healthy health care system. While health insurance markets are super important, I think it would be a mistake if we allowed all our policy focus on health care to be devoted solely to that.

12 things CEOs need to know in 2017

12 things CEOs need to know in 2017

The continued growth of the consumer-driven health care market threatens the durability of patient-provider relationships—and, at the same time, the push toward population health management and risk-based payment is greater than ever.

Hospitals and health systems must adopt a two-pronged strategy to respond to these pressures and serve both public payers and the private sector.

At the core of that strategy? A formula of accessible, reliable, and affordable care that wins consumer preferences and drives loyalty over time. Below, we share 12 key insights for senior executives working to create a consumer-focused health system.

Download the research brief

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