The Election and Its Effects on Health Care!

14732357_1025154530947539_9027403258216999632_nSo, as the opponents to Mr. Trump dry their tears and the idiot protesters tell us that the elections were not correct and the Electoral College should be disbanded, or that they should not be held to the Constitution and that Mr. Trump is not their president we all need to take a deep breath What effects of this election will come to fruition? What Trump promises will become new laws or cancel other laws?

Jonathan Bush, CEO & president at Athena health stated before the election results shocked us all that this would be a great day for the “peeps”! “No matter who wins today, this election represents the single greatest opportunity for us as a people, bar none. Why? Because the next President, regardless of who takes the helm, will struggle to claim a true popular mandate. Translation: Very little will get done.”

Polls show us more than half of registered voters disliked Clinton and Trump. In fact, never before have two competing candidates incited such ire. For many Americans the choice came down to the least unfavorable candidate. Beyond the populace, Trump lacked the full support of his own party’s Speaker of the House, but that has changed. And Hillary faced a House of Representatives held by the other party. It still seems as though gridlock is ahead!

Furthermore, due to the “personal nature” of the campaign, neither candidate was able to put forward or debate, let alone build popular support behind…anything. I suppose a “wall” is an idea but its absurdity as an idea makes this point even more, but again if you listened to this Sunday’s “60 Minutes” show he backed off a bit and said that there could be a fence and maybe some walls.

So why is this an opportunity you ask? While federal mandates of past administrations will carryover no matter who takes office, it will take close to a miracle for more mandates to squeak out. This means we can become masters of the current federal minutia – which we’re well on our way to doing in healthcare – and rush the green-field where opportunity calls. While government sits still and bickers, we must raise well above the bars that federal government has inadvertently over-architected and/or set too low and remember this President and the House and Senate majority only has 2 years to make something positive happen or the majority will disappear in the next important election year and Mr. Trump will inherent a “Lame Duck” end to his term.

Mr. Bush further stated, “In my world (healthcare), innovation has been paralyzed by a six-year-long race to comply with mandates from Washington. As importantly, because they were mandates, all of the other companies in my space were working on the same things.  Competitive advantage – and the thousand incredible, esoteric inventions we might have produced to accomplish it – was neutralized. The same is true of health insurance companies who were mandated to sell the exact same set of benefits as one another. In fact, as I think about it, from energy to education to religion to sexuality, one giant voice in all of our communities has been our federal government. But aren’t we more interesting than that? More diverse? Is driving everyone by force to some centrally defined least common denominator really the best use of our collective energy? Aren’t we a nation capable of many right answers? Isn’t biodiversity – of economies and social orders as well as lakes and forests – essential to long-term survival? If so, this is our chance!

It’s just us now! It’s our states and cities, which will make the laws for a while. It’s our churches and community groups and businesses which get to have a chance to lead, to try things to shape society not by dint of force but by doing things so well that people will follow willingly. For our part, we at Athena health are going to take our post-federal energies to build a unified patient portal that works at every doctor office and hospital in the nation…even if it’s served by our competitors. We are going to help our clients follow patients and engage with them more easily and consistently than through old-school office visits. We are going to help them hire care managers that don’t have medical degrees, but can affordably be deployed to home and work. We will hack API level connections to companies like Uber and Pillpack so that these innovators can participate more fully in healthcare—whether it’s getting the chronically ill in for an appointment or ensuring that prescriptions are not just filled, but taken. Most of all, we will allow our product managers to come up with THEIR OWN IDEAS AND DO THEM. We are going to help our clients shoot for a spot on Apple’s “crazy ones” wall. “

The American Society of Plastic Surgery sent out a note pointing out that improving healthcare is about making better decisions as patients and care teams. It’s about expecting technology to delight us while improving our access to one another, to information and the results we desire. It’s about the best in healthcare doing well, and the worse ceasing to exist. It’s about knowledge sharing. It’s about being proud of what we spend on healthcare and how efficient we can be, not embarrassed by how much we spend or profiting through glut. It’s about volunteers donating their time in free clinics to serve the thousands of Americans who still fall through the cracks, or spending time with a wounded veteran dealing with PTSD. Fixing healthcare shouldn’t be a political issue, and it’s not something that’s going to happen because of the perfect government mandate, or the lack of one.

The outcome of the 2016 elections presents an opportunity for President-Elect Trump and a Republican Congress to break through the gridlock and advance legislative initiatives, especially in health care. While we can expect a period of transition to identify priorities, agendas and paths forward, we anticipate a very active 115th Congress as the Republicans work to pass legislation before the next election. The upcoming sessions may create an opportunity for the White House and Capitol Hill to take a fresh look at legislative prospects, reassess strategies, and broaden approaches to think outside the box. In particular, over the next two years we can expect to see major shifts in health policy, including numerous provisions in the Affordable Care Act being repealed or altered through regulatory actions, changes to MACRA, a new regulation to go into effect in January, and the elimination of red tape to allow for greater medical innovation.

Affordable Care Act (ACA)- Mr. Trump did not take a position on most health care issues during the campaign. Yet he was very clear in his commitment to repeal and replace Obamacare, citing higher premiums, less competition and fewer choices. As a candidate, Mr. Trump called for Congress to repeal Obamacare and:

  • Eliminate the individual mandate
  • Allow the sale of health insurance across state lines
  • Permit individuals to fully deduct health insurance premium payments the individual mandate
  • Allow individuals to use Health Savings Accounts (HSAs)
  • Require price transparency from all healthcare providers
  • Create block-grants to replace Medicaid expansion funding, and
  • Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products

We can also expect changes to Medicaid benefits and eligibility, the elimination of the Cadillac tax and the end of the employer mandate. It’s unlikely that the Affordable Care Act will be completely repealed. Democrats hold enough seats in the Senate to mount a filibuster, and the only detailed replacement proposals offered by Republicans would increase the number of uninsured Americans by at least 20 million and the federal budget deficit by tens of billions of dollars. Yet Republicans in the Senate can circumvent Democratic opposition by incorporating the repeal measures in the highly complex budget reconciliation process, which only requires 51 votes and cannot be filibustered. The Trump Administration will also have discretion to impact the law through the regulatory process and Executive orders. For instance, the Trump Administration can terminate the existing lawsuit that would end certain subsidies, which could lead to the collapse of the Obamacare insurance exchanges. A Trump Department of Health and Human Services (HHS) could also redirect the implementation of the ACA as the HHS Secretary was granted discretion on a host of key provisions.

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)- MACRA, which transitions Medicare fee-for-service payment to value-driven and outcomes-based arrangements, was crafted in a bipartisan manner, through regular committee order, and passed with overwhelming support (392-37 in the House; 92-8 in the Senate). This effort is not expected to be repealed. However, there may be opportunities to improve the implementation of the law, which has been executed by the Obama Administration. ASPS has been very vocal in its opposition to MACRA and its concerns with the manner in which the law has been implemented by the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services.

A component of MACRA, rooted in the ACA, is the “meaningful use” of certified electronic health records (EHRs). Requirements for positive payment adjustments is linked to providers’ use of EHRS, and the requirements continue to increase annually. Interoperability would likely help decrease some of these burdens. While there has been a bipartisan push to achieve interoperability of these health information technology (IT) systems, Republicans have raised concerns with the current state of EHR usability and connectivity. The medical community has urged for the development and adoption of standards to enable bidirectional exchange of health information across disparate health IT systems, including clinical data registries (CDRs). Under this new Congress and Trump Administration, efforts to address these long-standing issues could move forward at a more rapid pace.

The FDA and 21st Century Cures-The Prescription Drug User Fee Act (PDUFA) VI, which provides the Food and Drug Administration (FDA) with the authority to impose user fees to fund agency activities, must be reauthorized by September 30, 2017. Since user fees account for about half of the FDA’s total budget, Congress will work to finalize this legislation by summer 2017 to meet the deadline. This legislation is expected to include the reauthorization of the user fees for medical devices, biosimilars, generic drugs, and others. It will likely also serve as a vehicle for other related initiatives, including provisions in the 21st Century Cures legislation and efforts to address drug pricing or other FDA-related initiatives.

This medical society as well as others have been  strong advocates of the 21st Century Cures package, which:

  • Impacts the collection of registry data
  • Creates a new category for covered durable medical equipment
  • Provides Medicare beneficiaries with immediate access to new FDA-approved medical devices not currently covered by Medicare
  • Relieves regulatory burdens that can inhibit access to innovative new products
  • Repeals the Sunshine Act requirements to report on medical textbooks, peer-reviewed journals, journal reprints and journal supplements

After months of negotiations over the funding of the National Institutes of Health, Congress intended to pass this package during the 2016 lame-duck session. However, there has been a recent swell of opposition for moving the bill before the next Congress so that provisions can be included that address the affordability of pharmaceutical products. Give the Republican majority, congressional leadership may choose to hold this bill until the 115th Congress.

Can President Trump actually repeal the Affordable Care Act?? Or more important will he want to repeal the ACA?

As I have mentioned many times before, in order to repeal the ACA the Republicans and others who dislike the ACA have to have an alternative to the ACA to do all that it accomplishes but improve on the failings of the ACA. Remember, the ACA now gives 21 million people health care coverage, which they didn’t have with the alternate system that we all had before the ACA.

Remember the importance of the ACA:

Laurel Raymond wrote that “six years after passing through the House and Senate without receiving a single Republican vote, the Affordable Care Act (popularly known as Obamacare) remains a hotly contested piece of legislation. But outside of the political arena, there’s much less debate.

A mountain of evidence confirms the law’s effectiveness — particularly in its primary goal of expanding health care coverage to some of America’s neediest populations. Several recent studies have confirmed that Obamacare is positively affecting Americans, particularly those who previously couldn’t obtain health insurance or who struggled to pay their medical bills.”

Here’s how Obamacare is making a real difference in Americans’ lives:

America’s most vulnerable now have health insurance- In the years since Obamacare passed, many of the largest gains in coverage rates have been in communities that have previously faced barriers to health care access — such as low-wage workers, immigrants, people of color, and people with pre-existing medical conditions.

Between 2013 and 2014, when the law went into full effect, every minority group saw large gains in coverage. According to an analysis by the New York Times. Now, 7.2 more Hispanics, 6.1 percent more Native Americans, 5.1 percent more blacks and 5.4 percent more Asians have health insurance.

Legal immigrants and naturalized citizens also saw large increases in coverage, as did groups that are more likely to be working low-wage jobs, such as high-school graduates and Americans living in non-traditional households, which can be a sign of economic distress.

Indeed, the law was so successful in lifting up undeserved populations that it stopped a decades-long expansion of the health-insurance gap between low-income and wealthier Americans.

And the people gaining coverage under the Affordable Care Act are among America’s sickest, according to a different report from Blue Cross and Blue Shield that analyzed the claims for 4.7 million Americans newly enrolled in insurance plans. New policyholders are more likely to have significant health problems, such as diabetes or HIV, which previously would have locked them out of coverage that they desperately needed.

“It’s no surprise that people who newly gained access to coverage under the Affordable Care Act needed health care. That’s why they were locked out of coverage before,” said Ben Wakana, a spokesman for the Department of Health and Human Services.

According to a report from the Urban Institute’s Health Policy Center, Americans who have new health insurance through Obamacare — either through its state-level insurance marketplaces or through its expansion of Medicaid — are better off than the uninsured and in many areas comparable to those with employer-sponsored insurance plans.

Low and moderate-income Americans with marketplace and Medicaid coverage are more likely than the uninsured to have a source of medical care and to have had a checkup in the past year. They are also less likely than the uninsured to report unmet health needs, such as visits to specialists they haven’t been able to make it to.

The research also found that in most cases, marketplace plans were comparable to the employer-sponsored plans that existed before health reform. People insured through Obamacare didn’t struggle more to find new doctors or get timely appointments compared to people insured through their employers. Those with Obamacare’s marketplace plans were also no more likely to report problems paying medical bills or having high out-of-pocket expenses, and were just as satisfied with their premiums.

Those with employer plans were, however, more likely to be satisfied with their choice of providers and their protection against high deductibles, likely because employer plans usually resemble the highest level of marketplace plan.

And while those with Medicaid did report more difficulty getting doctors appointments than those with other types of plans, all groups with insurance were significantly better off than the uninsured — and were likely to have both regular care and lower levels of unmet need due to costs.

Poor Americans are more financially secure- The law has also helped people pay down their bills and slash the amount of debt they carry, according to another paper from the National Bureau of Economic Research.

Americans who signed up for the Medicaid program under Obamacare’s expansion reduced their collection balances by $600 to $1000, according to the researchers. The report also shows that the people who benefited from Medicaid expansion then used that extra money to pay down other debts.

“Health insurance, like any type of insurance, is first and foremost a form of financial protection,” economist Robert Kaestner, one of the study’s authors, told The Washington Post. “It is a real benefit.”

According to federal data, medical bills count for more than half of Americans’ unpaid bills, which can drag down people’s credit scores and in the long run, cost them both money and opportunity. Reducing debt can thus have a ripple effect on financial well being for years into the future.

Of course, the effect of health reform varies widely across the country. The most marked improvements are evident in states that fully implemented Obamacare, including its expansion of Medicaid to cover more low-income people.

Nineteen states opted not to expand their Medicaid programs — even though the federal government would cover the majority of the cost — after a 2012 Supreme Court case made the expansion optional. States that fully implemented the health care reform law saw an increase in residents with health insurance at nearly double the rate of the GOP-controlled states that didn’t.

So, let’s explore, next week, how the new President Trump and the majority GOP can repeal the ACA and possibly keep the good parts of the health care system know as the ACA.

In the following weeks I will explore possible suggestions for a sustainable solution to the health care system. More to come.


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