Massachusetts Medical Society: View from Capitol Hill: Health Care and the 115th Congress

View from Capitol Hill: Health Care and the 115th Congress

By Alex Calcagno
MMS Director of Advocacy, Government and Community Relations

While no one can predict the impact of the Trump presidency on the federal agenda, one thing is certain: the health care issues facing the new president and the 115th Congress are formidable. The dynamic that evolves between President Trump, Congress, and the cabinet will be an early litmus test for his administration, and potentially the status of health care in the nation.

An Emerging Dynamic

Donald Trump is not a traditional Republican. He ran on a number of positions that are in direct opposition to those that have been espoused by Republican Party leaders for years. A most notable example is his promise to preserve and protect Medicare and Social Security. He also wants to allow Medicare to negotiate the price of prescription drugs, a proposal historically and staunchly opposed by the Republican party. With Republicans in the majority in both chambers, any legislative success will require their support.

Also to be determined is President Trump’s leadership style. Congressional Republicans have long anticipated the day when they controlled all three domains — House, Senate, and White House. Whether President Trump — emboldened by his unorthodox campaign and equally unexpected victory — will believe he knows what is best or whether he will defer to the seasoned party leaders remains uncertain.

Adding to the overall power play during the 115th Congress will be the role of the governors and the Democrats. The governors will serve as a reality check on the impact of the various proposals on their constituents (think: repeal of the Affordable Care Act, or ACA, without a replacement plan). The Democrats hold just enough votes in the Senate to be a reckoning force. Republicans hold 241 seats in the House and 52 in the U.S. Senate — 8 votes shy of being able to stop a filibuster under current Senate rules. The Democrats could prove to be a surprising ally to the president on such issues as infrastructure reform, where Republicans are opposed to anything that could substantially increase the deficit.

Use of Executive Power

The most direct impact of Trump’s presidency may be evidenced through his use of executive power and regulatory authority, and his appointments to the Supreme Court. His staff has compiled a list of hundreds of executive orders, which President Trump will attempt to rescind early in his term. It is anticipated that the Trump Administration will seek to minimize regulations and administrative burdens on physicians and businesses.

Generally, there are two overarching health care issues that will define this administration’s and Congress’ position on health care issues, the repeal of the ACA and the elimination of entitlement reform.

Repeal of Patient Protection and ACA

The first most politically charged test for President Trump and his administration will be their ability to deliver on the promise of repealing the ACA on day one without causing harm in the process and finding a better way to ensure that everyone — sick, old, poor, and infirm — has access to health insurance and health care.

Opposing Repeal

A “full repeal” of the ACA would require a law to be passed, which will be difficult given the Democrats’ ability to stage a filibuster in the Senate. The ACA is a comprehensive law dealing with much more than health insurance, although most repeal advocates are only focused on these sections. Should the 115th Congress repeal the revenue-related provisions in the ACA through the budget reconciliation bill — which only requires a simple majority to be passed — the challenge of developing and passing a true replacement plan will be formidable. The ramifications on patients for repeal without a true replacement plan are staggering. Even if the implementation of the repeal legislation is delayed several years, insurers who are already losing money in the market may pull out given the uncertainty of the future subsidies to help pay for the chronically ill, the low income, and persons with preexisting conditions.

Democrats and diverse groups of national advocacy organizations strongly oppose repeal of the ACA, particularly without a replacement bill in place. A growing number of Republicans are concerned about a quick repeal strategy without a replacement bill. There are currently more than 20 million Americans who receive health insurance through the ACA — the numbers have been steadily increasing as the threat of repeal looms — who will be at risk during the transition process. Adding to the dynamic are the 32 states that have expanded access to the exchanges through Medicaid and are worried about their constituents losing health insurance. There is also the issue of what repeal of the ACA will mean to the budget. Current estimates are that repeal of the ACA would increase the federal deficit by $137 billion over a 10-year period — a significant problem for the very conservative Freedom Caucus.

End of Entitlements?

President Trump’s top chief for health care reform — Dr. Tom Price, Secretary of HHS — steadfastly believes that entitlement reform is the Holy Grail to “making this country great again.”

Current Expectations

They have developed plans to eliminate entitlement programs, turning Medicare into a premium support program, and to block grant Medicaid. President Trump, on the other hand, having focused his campaign on working class Americans, is promising to preserve and protect Medicare and Social Security. While President Trump and candidate Trump don’t always agree, he is unlikely to support proposals that could directly antagonize those voters who were the key to his success and his base.

Philosophically, proposals to end entitlement programs — no matter how they are structured — represent a dramatic and fundamental shift in this nation’s commitment and responsibility to health care for its citizens. The aptly named entitlement programs were designed to fulfill the government’s promises to help those people in need who, by definition of their status, were entitled to the benefits from the program. Any proposals that restructure these programs away from entitlement status will basically allow the federal government to decide how much money it chooses to appropriate for these people to purchase health insurance or other services. Fundamentally, these programs are designed to save the federal government money; funding streams, by definition, will be decreased. In keeping with Republican philosophy, states will be given more flexibility (albeit not total) to do as they choose, but with fewer dollars.

Current expectations are that the House could move early in the session on a proposal to block grant Medicaid and wait until later in the term to pursue changes to make Medicare a premium support program. Seniors historically have been unequivocally opposed to this change. Picking a fight with this powerful constituency before the midterm elections would not be politically astute. Other options to change Medicaid include modifying the federal state matching formula and basing payment on per capita allotments.

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