How will the Trump administration change healthcare?

Donald Trump’s surprising win in the presidential election has put a renewed focus on what will happen to healthcare under the new administration.

For now details are scarce, but one thing president-elect Trump has emphasized throughout his campaign is repealing the Affordable Care Act (ACA) and replacing it with something better, saying in some stump speeches that it will happen on his first day in office.

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Republicans have tried to repeal the ACA, or Obamacare, since its inception, but now with control of both houses of Congress and the presidency, they have the power to do so. Repealing the ACA would result in 22 million people losing health insurance, according to the Congressional Budget Office, creating the question of what happens to those affected, and what, if anything, would replace the ACA.

Based on last year’s Republican repeal attempt that President Obama vetoed, there are some clues to what provisions of the ACA might be repealed and which ones might remain in some form. The vetoed bill would have:

·      eliminated programs providing Medicaid coverage for Americans near or below the poverty line,

·      eliminated subsidies that helped people buy insurance on the exchanges,

·      eliminated taxes that fund the ACA, and

·      eliminated the tax penalties for not having insurance

Parts of the law would have remained, including requiring insurance companies to cover young adults on their parents’ policies and to sell insurance to anyone, regardless of medical history. Medicare reforms also would have remained. Whether next year’s Congress will follow the same blueprint remains to be seen.

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In speeches, Trump has often mentioned replacing the ACA, but offered few details on what that would look like. His campaign website makes no mention of replacing it, but states that his free market principles “will broaden healthcare access, make healthcare more affordable and improve the quality of care to all Americans.”

John Meigs, Jr., MD, president of the American Academy of Family Physicians made clear in a letter to Trump that affordable and accessible care needs to be a priority. He also urged the new administration to reduce administrative burden, implement reforms that emphasize the value of primary care and reduce the financial burden to patients in obtaining primary and preventative care.

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The fate of the Medicare Access and Chip Reauthorization Act of 2015 (MACRA) that goes into effect January 1 remains unknown, as it has not been mentioned as a target for reform or repeal by the Trump campaign. However, the law was passed with bipartisan support, making an immediate repeal unlikely.

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Reaction from physicians to the election outcome has been mixed, with some excited about the possibility of fewer regulations interfering with the practice of medicine, while others wonder how those currently covered under the ACA will pay for care.

“If Donald Trump does what he said he was going to do, medicine is in for an exciting ride through the removal of useless regulations …,” says H.L. Greenberg, MD, a Las Vegas, Nevada-based dermatologist. “Physicians will be happier and have more time to focus on caring for patients instead of checking useless boxes in an electronic record that no one cares about or will ever read. Removing the ridiculous Obamacare mandates will ultimately lead to reduced costs and healthier and happier patients.” 

The potential for less regulation has Christopher Claydon, MD, a Grass Valley, California-based internist, hopeful.

"There is finally a glimmer of hope that the crushing burden that government has placed on medicine may be lifted under a new president," says Claydon. "I am still stunned at the results but grateful we have a proven business owner elected to take the helm of a broken country. Get the bureaucrats off our backs and out of medicine."

Carla Lambert, MD, a Beltsville, Maryland-based family physician, says Obamacare is flawed, but thought it was moving in the right direction. She wonders what will happen if the law suddenly disappears in the early days of Trump’s presidency.

“Unless he creates something to replace the current system, roughly half of my patients will be affected and likely be without insurance once again,” she says. “I'm really not sure my solo practice can survive an abrupt change like that.”

Jeff Kagan, MD, a Newington, Connecticut-based primary care physician, says the minimal financial penalty for not having insurance didn't convince enough people to sign up, limiting its effectiveness.

The lack of a defined plan has many waiting for more detail, including Charlotte Kohler, CPA, RN, CHBC, of Kohler Healthcare Consulting. "Trump has vowed to get rid of the ACA, but has provided no guidance, or even thoughts, to give us some ideas of how the future health care arena will be shaped," she says. 

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Along with repealing Obamacare, Trump’s website lists six healthcare objectives, offering some clues as to his administration’s initial priorities:

·      allow health insurance to be sold across state lines to increase competition,

·      make individual health insurance premium payments tax deductible,

·      make some changes to how health savings accounts work, including allowing them to be passed on to heirs,

·      require price transparency from all healthcare providers,

·      give Medicaid funding to the states in the form of block grants and allow them to manage the funds, and

·      remove barriers to entry into free markets for drug providers

Howie Mandel, MD, an ob/gyn in Los Angeles, says the change in leadership presents a great chance for Trump to address flaws in the healthcare system. “He has an opportunity in many areas, including healthcare, to allow for a coming together of practicing physicians, allowing them time to diligently replace Obamacare with a balanced program that gives patients access and physicians autonomy.”