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
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.
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
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.”
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.