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    Outlook for healthcare under a President Trump

     

    Implications for healthcare from a Trump incumbency

    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.

    NEXT: Impact on graduate medical education and research >>

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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