Following the election of Donald Trump as the next U.S. president, Physician’s Weekly Managing Editor Christopher Cole received the opportunity to ask select physicians and healthcare experts what a Trump presidency could mean for the U.S. healthcare system. Speaking with Cole were Pawan Grover, MD, an interventional spine specialist and patient advocate who has served as a medical correspondent for CNN, NBC, CBS, and PBS; Mache Seibel, MD, author of The Estrogen Window, former and soon-to-again-be Harvard Medical School faculty member; Carolyn Rosenblatt, RN, elder law attorney and co-author of The Family Guide to Aging Parents: Answers to Your Legal, Financial, and Healthcare Questions; and Chris Orestis, CEO of Life Care Funding, former Washington, DC, lobbyist, senior-care advocate, and author of Help on the Way and A Survival Guide to Aging.

 

What do you think will happen to “Obamacare”? Trump has said he’ll put an end to it, but information is lacking on what, if anything, he’d replace it with.

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Mache Seibel (MS): If President-Elect Trump wants to make America great again, he will have to make America healthy again. And that requires healthcare coverage for as many U.S. citizens as possible. With rampant obesity, diabetes, and other chronic illnesses, a great deal of prevention needs to be put into play. Obamacare took 2-3 years to implement. For these reasons, I believe that with 22 million people currently depending on Obamacare, the new administration is less likely to abolish it than to modify it. There are many areas that could be addressed, and which of those President-Elect Trump will address will depend on his closer look at the details, his new insights, and who his advisors are. Taking it apart would either take too long or leave people unprotected. I think the idea of privatization is less likely also. Today, there are so many different electronic medical record systems that healthcare facilities can’t talk to each other. With privatization, there would be even more obstacles to communication, as each player would lobby for how they do things. I do believe Trump will leave his mark on Obamacare, but not by immediately dismantling it.

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Pawan Grover, MD (PG): There are a number of practical and political considerations in play here. Legislatively, any major change will require 60 majority votes in the senate. That’s the minimum number of votes to override a filibuster. However, there are some built-in provisions, specifically 13222, in the Affordable Care Act that allow the executive branch to exempt states from participating in the exchanges if they can come up with creative and innovative alternatives. This allows some room to showcase and test various models that President-elect Trump wants. He has outlined some of these plans, which include health savings accounts (HSAs) that are tax free and might help individuals save money to pay for healthcare costs and allow people to deduct the cost of their premiums on their personal income tax returns. In addition, these can be inherited to family without the death tax. Trump has said he also wants to allow insurers to sell policies across state lines to increase competition and reduce costs.

On the political consideration , president-elect Trump has stated that he will keep the most popular provisions of the ACA, namely the pre-existing conditions and allowing children to stay on their parents healthcare policy until age 26. The people who are currently insured will need to stay insured. Any drastic change to that number will make further reform difficult and will be a political firestorm. The history of the massive complicated overhaul of the healthcare system by the ACA 6 years ago, and subsequent fallout with the losses in the midterms and the challenges the law has faced this year with rising premiums and insurers dropping out, should give the government pause before radically changing it again. A step-by-step logical change would, in my opinion, have the best chance for success.

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Carolyn Rosenblatt, RN (CR)
: There is talk of repealing it “rather quickly,” but this seems unlikely, as insurers are set up for it and over 21 million people are currently insured under it.  The industry wants to be more profitable, so insurers will push for some greater burden for payment to be placed on insureds. That means that if people want insurance and there is no federal or state subsidy, they will not be able to afford it and will return to being uninsured.  There has been talk by Trump campaigners of “encouraging health savings accounts.” This, again, means that people who want insurance would have to save their own money for it and would have to limit what coverage they could get to the amount they could save up themselves to pay for all or part of their premiums. The result would be that millions would lose coverage. There has also been talk of tax credits toward insurance. For lower-income people, this does no good at all. They don’t earn enough to benefit from a tax credit, which assumes you have a high-enough income to use or get help by a tax credit. Tax credits might work for middle- and higher-income earners. It is useless for low-income workers, most of whom now get a subsidy to help pay for their insurance under Obamacare. There is no information at all on what repeal and replacement would actually look like.

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Chris Orestis (CO)
: With a Republican-controlled Congress to back him, President-elect Trump has made it clear that one of his very first priorities is to dismantle the Affordable Care Act. Details are few, but he has been hedging that he will keep the “parts that work,” while discarding the rest. That means coverage for children and pre-exisiting conditions are most likely safe. Tax incentives for things such as HSAs and long-term care will be emphasized. Opening up state borders for insurance sales will be allowed. But the reality is that with a quick repeal of ACA, as many as 20 million people could find themselves suddenly without insurance coverage. In many ways, the clock will be turned back to an emphasis on private insurers operating in many ways as they did over a decade ago in the 90s, when the numbers of uninsured Americans was in the tens of millions. There will be a bit of a “Back to the Future” effect.

 

We’ve heard healthcare providers say Obamacare impacts their practice negatively, but we haven’t been given specifics. What do you think it is about Obamacare that hurts them the most and would make them happy to see it go?

MS: Obamacare is cumbersome and time consuming, and it pays smaller reimbursements than clinicians received before it was enacted. They have also not been as successful as they had hoped to enrolling “healthy” individuals. These are real challenges to providing quality care in an efficient and economical way. It also isn’t always possible for patients to keep the doctors they have or get the doctors they want. On the other hand, it is very important that people have some coverage, can stay on parents’ insurance until age 26, and not be exempted from insurance due to a preexisting illness.

PG: In general, physicians particularly point to the disruption of the patient-doctor relationship, with increased regulation, data entry, and reporting requirements. Continuity of care is also expressed as a disappointment, as these plans have narrow provider lists. Insurers have dropped out at various stages, forcing patients to scramble for coverage and then change doctors and hospitals. And it seems that everyone’s premiums and deductibles have gone up, including ours. In some polls, satisfaction is also tied to political affiliation. This is just another sign that it would be best to take political affiliation intensity out of healthcare policy, as everything is weighed as a win or loss for the party instead of what’s best for the patient.

CR: Some providers are affected by lower reimbursement rates for services they provide, which are set by insurers. The low reimbursement rates are for the benefit of the insurance industry. It wants to offset having to cover people with worse health conditions who cost them more in payouts. If they cut those people out, as they did before Obamacare, they made huge profits. The same can be said about cutting out people with pre-existing conditions. The insurers would love to eliminate having to cover those folks because they are expensive in terms of care billed to the insurer. It seems likely that while insurers under a “repeal and replace” theory would have to keep people with pre-existing conditions, they would likely charge exorbitant rates, thereby effectively eliminating them. That is what they want.

I am not sure why any healthcare provider would be happy to see Obamacare go. Fewer people would have access to any care whatsoever if it is eliminated. Millions who now get a no-cost annual physical would not get it, leading to more illness, more complications, and more unaddressed health issues. Some uninsured people will die without the vital care they need but can’t afford. Others will have costly complications without proper care. “Happy to see it go” has to be “Happy to not insure millions of folks.”

The requirement that providers go to electronic medical records did cause some providers distress when Obamacare started. Those providers may prefer old-fashioned paper records, and if so, they would like to see any requirement to go electronic go away.

CO: There has been reluctance to embrace change and computer technology office automations. Attempts to increase the use of electronic health records and telemedicine have been resisted as being costly and burdensome to convert to, despite the obvious efficiencies and improvements to care that would be realized.

 

What do you see happening to programs like Medicare and Medicaid?

MS: These are questions currently without answers. I believe President-Elect Trump will try to leverage Medicare to have more buying power and drive down some of the costs. That includes doctors’ fees, hospitalizations, and medications. We will be living in interesting times over the next 4 years.

PG: In terms of Medicaid, there will be intense discussion over the next few months regarding continuing federal regulation or allowing “block grants” so that states can control and better suit their needs. However, for Medicare, in addition to the conventional policy difference on age eligibility, negotiating drug prices, etc. will be the unknown effects of MACRA. The final rules of MACRA implementation were released on October 15, 2016, during the heat of the presidential election. All the current media attention is on the future changes the new administration will make to healthcare. It is for that exact reason that this law could blindside us; few are paying attention to what happens to be one of the most complex significant changes in Medicare since its inception.

Medicare traditionally pays doctors a fee for service. MACRA flips that to where the doctor’s or hospital’s payment is based on the success of the treatment. The intent of the law is good, but it is not well thought out. As a consequence of not thinking this through, the law will have significant unintended consequences in my opinion, including:

  • Mass exodus of doctors from Medicare, resulting in worsening of the doctor shortage crisis, according to a recent study.
  • Implementing this complex law will also be challenging to independent medical practices.
  • By 2018, 50% of a doctors fee will be tied to quality and outcome measures, with the eventual goal of 90% reimbursement tied to these measures.
  • The law does not take into account patient compliance and factors that doctors have no control over.

CR: Medicare is very popular—despite extreme opposition when it was enacted—and the basic benefits would probably not change. The improvements made by Obamacare could be trashed, which means millions of people would not get an annual no-charge physical, would not have prescription drug costs lowered (especially those in “the donut hole”), and would not retain the other improvements they now receive as a result of Obamacare. In short, their annual costs for care with out-of-pocket expenses would rise.

Medicaid is in serious danger. It is paid for by a combination of federal, state, and county funding. As the talk now is to slash budgets and cut government spending, the poorest and weakest in our society would likely be deprived of many essential healthcare services that Medicaid now covers. It has happened before. During the recession, many benefits, such as basic dental care, were eliminated. These services were only restored as we slowly recovered from the recession. Some states chose to not pay for essential Medicaid services for the poor and eliminated some healthcare altogether for these populations. That kind of ruthless cutting of programs is very likely to increase, perhaps sharply, going forward. The lowest-income people will, in many instances, have no or very little care.

CO: There have not been many details, but both programs are under a great deal of stress.  More control and discretion over Medicaid will be given back to the states. Over time, we will see criteria to qualify for both become more stringent, as emphasis continues to be placed on private pay. Waste and fraud are always cited as areas that need to be cleaned up to yield big savings. Tax incentives could be an area to help spur more private pay.

 

We polled nurses and physicians before the election and found that the majority of both felt Trump was the better candidate for them. Why do you think that is?

MS: I can’t speak for all nurses and physicians. Payments for healthcare have gone down over the past administration, and Hillary Clinton was seen as an extension of the Obama administration. That may be why the wildcard of a Trump administration seemed more hopeful.

PG: Specifics of any healthcare platform of a presidential campaign are generally sparse by design. It’s the broad strokes that affect our opinions on which candidate healthcare providers “feel” will be better for their profession. In this case, healthcare providers are generally adverse to centralized government-controlled solutions to healthcare and more inclined for pragmatic, free-market solutions.

CR: It is a mystery to me that any physicians and nurses would ignore the healthcare needs of their communities, particularly women and children. Trump has been wealthy all his life and has not been face-to-face for long with any poor people. All of the low-income programs paid for by the federal government that serve the needs of our poor are likely to be on the chopping block with the overwhelming move by the party in power to balance the budget, cut government spending, “eliminate waste,” and give large tax breaks to corporations. The corporations are not going to pay for healthcare for the needy in our country. Perhaps the physicians and nurses who thought they were doing the right thing will soon see. The majority of people who are low-wage earners will not be getting much or any healthcare. Providers will see it as the rates of preventable disease increase and more complex conditions arise from unaddressed health conditions. I think the nurses and physicians who supported Trump ignored what he still ignores in his lack of a plan for replacing Obamacare: the need for health coverage for all.

CO: It could be more of an ideologic bias toward free market-based healthcare versus “government-controlled” healthcare. As practitioners feel more stressed about increasing administrative burdens and decreasing incomes, it is not unexpected to see a preference toward what they may perceive to be an administration that could cure those ills for them.

 

What does a Trump presidency mean for patients?

MS: I don’t believe it is possible to say with certainty. His positions on healthcare have not been fully flushed out, and the opinions and positions of a more informed President Trump may differ from the rhetoric of candidate Trump. He says he wants to have people be able to afford healthcare and to be able to keep their doctors. At the moment, we’ll have to wait and see.

PG: I believe that if we come together as a community, as a nation, and as a people for the common good of the patients and the healthcare providers who take care of them, we will be fine. We need to separate allegiance to a political party from healthcare policy.

CR: In my opinion, the wealthy will be just fine. They will see fewer people waiting in doctors’ offices, and they will have all the care and coverage they need because they can afford it. For everyone else, we will see all the main causes of mortality rise with less attention to basic health issues. Trump himself is overweight, does not exercise, and sets an example for all by eating junky fast food and bragging about it. It is a tacit message that all of these things are the way to be because you can be president if you do them. He is modeling unhealthy habits. He undoes all the work Michelle Obama did to address childhood obesity, promote exercise, and many other health-focused efforts.

CO: Patients will find that they are back in the private, market-based healthcare system. In this environment, those with higher incomes and more money can afford to buy the best healthcare and coverage, and the inverse is true for those with low incomes. We can expect to see large numbers of uninsured again.

 

Is there anything else you’d like to point out on this topic?

MS: Healthcare is a disproportionate amount of the GDP and is far more complicated than it seems from the outside. There are also many powerful and well-funded interests in addition to those of patients. We also have an aging society. My hope is that our country will begin to focus more on prevention and try to decrease the numbers of chronically ill people through education and screening.

CR: As a former public health nurse who made thousands of home visits to hundreds of patients over my first career, I fear for the health of this country. Less care is not good for us. More expensive insurance premiums and locking some people out of insurance is not good for us.  Ridiculing the needy who can’t use a tax credit to offset the cost of health insurance is not good for us. Cutting government-sponsored programs that pay for women’s prenatal care and basic nutrition for infants and children is not good for anyone. It costs us more in the long run to pay for the consequences of no care. The intense desire to stop spending tax dollars on these things is very sad to me. Many times, I have seen firsthand what happens when people do not receive essential, basic health services. I think we are going to all see what happens as those in power see only dollars spent, not the real people who need them to be spent. It is likely to be a tragedy for many Americans. And maybe those who think balancing the budget is more important than the needs of millions of Americans will be very happy about it. They themselves will not feel the pain.

CO: It is highly likely that we will end up with elements of the ACA remaining intact and other aspects of the free-market system, for good or bad, returning in full force, with health insurance companies rising again to significant control of the system.