Trump's Election: What Now for Healthcare?

Greg A. Hood, MD


November 10, 2016

American voters have been angry for a long time. The seeds of discontent that finally boiled over in this election cycle have been simmering for years. Healthcare reform has been at the center of these feelings throughout President Obama's terms in office. Until the Republicans retook the White House and maintained control of the House and Senate, there was no path for substantively changing this expansive law and its even more extensive regulations.

In a move that surprised all of the pollsters, most experts, and perhaps the majority of Americans, this is exactly what happened on the 8th of November. This was a notably unprecedented election result.

However, there are some precedents which the President-elect and GOP may do well to keep in mind if they start to craft their repeal-and-replace plans—notably the ACA's passage itself. Much anger was generated in the passage of the ACA because the Democrat super-majority led to a monstrously long bill being passed without a single Republican "aye" vote. Avoiding the appearance of strong-arming Obamacare repeal solely by the "unified Republican government," as House Speaker Paul Ryan recently referred to it, may be an important start towards quenching some of the heat and tension that this country currently feels.

A number of votes on the ACA, or elements of it, have been brought to Congress since its passage. Some of these votes, such as December 2015's 90-10 Senate vote to repeal the "Cadillac tax" on expensive health plans, have shown that there is potential bipartisan common ground for revision of elements of the ACA. This is important for a number of reasons.

A complete repeal of the ACA is not the same proposal that it once was.

First, a complete repeal of the ACA is not the same proposal that it once was, in spite of its "catastrophe" status, as assigned by the President-elect. This law and its regulations have, depending on your position, either transformed or metastasized through most every aspect of healthcare delivery. To resect it now is a very different prospect than it would have been 5 years ago.

Second, despite its bloated, problematic, bureaucratic nature, a number of elements of the ACA have proven useful, such as the wellness program, transitional care initiatives, and chronic care management. It is important to not lose what momentum has been positive and constructive from such elements of Obamacare. These have shown great promise in reducing overall care expenditures in our own accountable care organization, an ACO that has provided savings every year in operation.

Additionally, we employ staff members in our practices who are solely committed to patient care delivery through these initiatives. These are trained and valuable staff whose jobs are important.

Third, although there are already those who are publicly aligning themselves to oppose Trump at every turn, there may be a brief honeymoon period in which Trump, along with Mitch McConnell in the Senate and Ryan in the House, would not only work together but would also reach across the aisle and begin to bridge that deep chasm with some bipartisan actions. If the co-author of The Art of the Deal can prove himself to be an effective steward of pro-American, bipartisan reunification, then there could be a spark lit from this bloodless revolution that could reverse the shortcomings of the last couple of Administrations and improve Washington and the tone of the nation as well.

Should he not do so, there is little sign within their tepid and contentious relationships with Trump that Ryan and McConnell will simply give Trump carte blanche as Reid and Pelosi gave Obama. The power Democrats will have to filibuster the Senate, along with potential conflict around policy disagreements between the White House and Republican congressional leaders, appearing to underscore the merits of the separation of powers established within our mode of governance. It should suffice to prevent the trite media gloom-and-doom prognostications of a sociopathic ego gone wild on Pennsylvania Avenue.

In spite of rhetoric and promises, it remains to be seen how Trump will respond to the outlays of political capital which may be required should his efforts to reform healthcare face filibuster, or even opposition from the "Never-Trumps" from both parties. The Kaiser Family Foundation surveys have shown that healthcare in general and Obamacare were not top-tier issues for voters this cycle. The accuracy of surveys or polls in the modern world notwithstanding, should Trump face sufficient opposition against healthcare reform, it would not be surprising for him to turn his attention and focus to other macroeconomic problems which may be soundly in his wheelhouse.

We may find that discontent among the public, as well as within Organized Medicine, over the escalating cost of prescriptions, for example, is a very populist and more readily achieved goal than the wholesale, immediate replacement of the healthcare delivery system. Twice as many Americans were interested in this (74%) than in making repeal of Obamacare priority number one (37%).

The state exchanges that have failed or are failing were plainly financed for failure in their original design. The projected changes in premiums do create an urgency to address common-sense reforms. Additionally, the more that election-result uncertainty persists in the investment markets and in the healthcare industry, the greater the potential for negative economic consequences. This would be ill-timed, given high rates of provider disaffection with healthcare financing, board certification processes, the tort climate, electronic record keeping, the escalating costs of maintaining a practice, and other concerns. Prolonged uncertainty may have far-reaching repercussions.

Pharma, hospital associations, device manufacturers, insurers, and doctors—who are notoriously poor at representing their self-interests inside the Beltway—may find themselves in the position of being dependent on the goodwill and motivations of the President-elect.

For insight into Trump's mind, we must rely on his public positions. He lists his vision for healthcare reform on his webpage.

Campaign rhetoric aside, we have no past performance data nor other means to gauge the expectations we should have for what he will actually try to do, and with what vigor. For now, we are watching a moment in history. This election result was a defiant act of anger, frustration, and, to an extent, hope. The current president may have assumed that hope would be enough. In 2016, hope may have sprung from another direction, but 2017 will dictate whether this wellspring will nourish the tree of liberty or wash away the hopes of those who wish to make America great again.


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