Here’s How Trump Will and has Already Started to Change Obamacare

16832291_1114393575356967_1937264909174955317_nBut the effect is already being felt. Consider, an article written by Peter Orszag, the Ninth Circuit Court of Appeals in San Francisco on Feb. 9 upheld the restraining order on President Trump’s immigration ban. A key argument used by the States of Washington and Minnesota was the negative impact of the ban on higher education, but an important corollary is the impact on medical care in the U.S. While the world waits for a final decision on the matter, potentially from the Supreme Court, it’s critical to look at the potential ramifications of the ban.

Regardless of the ultimate ruling, the travel ban has already had significant consequences for people from the seven targeted majority Muslim countries and American citizens. Doctors are among those people directly affected – and that has big implications for health care delivery in U.S. hospitals, particularly those in rural America and inner city safety net hospitals. Physicians who are citizens of these nations who were traveling outside the country at the time of the ban have been detained or refused access to the U.S.

Larger-scale, lasting effects of a ban on the graduate medical education system are likely to be even more severe and may further strain an already overstretched health care system and affect the care of communities across the U.S. Indeed, the president of the American Medical Association already has written a letter to the Department of Homeland Security, explaining how the ban could affect those who are already underserved by limiting doctors from other countries.

As physicians involved with educating and training the next generation of doctors, we see dire consequences for health care delivery in our country if the travel ban is reinstated. There is a looming deadline that even though the ban has been temporarily lifted, the timing could not be worse for international applicants hoping to train in the U.S. While new resident physicians typically begin on July 1, the match process that allots positions occurs much sooner. On Feb. 22, residency program directors must submit their rank list of which applicants they would like to have in their program.

Therefore, without clear signs that travel for foreign applicants will be possible by July, program directors who want to protect their training program from staffing shortages may decide against ranking these applicants. The loss of a single incoming class of international medical graduates will significantly decrease the number of residents in training and physician capacity in hospitals and health care systems across the U.S.

Graduates from outside the United States constitute 26 percent of the U.S. graduate medical training. These foreign medical graduates usually fill resident training positions that are left vacant after medical schools match U.S.-based students to residency programs. Why is this and what are we doing wrong in this country not to fill the training spots?

Therefore, foreign graduates typically do not take spots away from graduates of American medical schools, but instead provide medical care in hospitals that will otherwise be understaffed. These include rural hospitals around the country, where it is especially hard to recruit physicians, and safety net hospitals serving the poor.

Consider the effect on primary care and that even if all current residency positions could be filled with U.S. medical school graduates and eliminate the need for any additional resident physicians from outside the U.S., the projected demand for physicians in the near future will still not be met.

Physicians in graduate medical education provide a significant proportion of all health care in the U.S., with teaching hospitals accounting for 40 percent of charity care (US$8.4 billion annually) and 28 percent of Medicaid hospitalizations. Without sufficient residents to care for patients, teaching hospitals are ill-equipped to maintain this role for the poorest patients and may not continue to meet this critical societal need.

Physicians who are both foreign-born and U.S.-born and trained outside the country constitute more than a quarter of all practicing physicians in the U.S. While the country of origin of these doctors is not often reported on a country-by-country basis, a recent interview with the Association of American Medical Colleges reported 260 physicians in training were from the seven targeted nations last year.

Expanded travel bans could dramatically increase that number as, between 2008 and 2010, 16 percent of these international medical graduates taking a required licensing exam were from Middle Eastern countries. It is predicted that the most severe effect will be felt as a drop in primary care providers. These international physicians also disproportionately work in primary care fields that are the hardest hit by the ongoing U.S. physician shortage crisis.

Currently, primary care programs have 50 percent of their residency slots filled by nonallopathic students and international medical graduates, whose absence could cripple primary care capacity.

Having a primary care doctor leads to increased access to care, reduced emergency department visits, decreased hospitalizations and improved management of chronic conditions, and decreased acute care utilization can lower overall health care spending. Similarly, general surgery has seen a 13 percent decrease in U.S. graduates in the specialty; however, this shortcoming has been buffered by influxes of international medical graduates. Delays in scheduling operative cases have also been associated with increased health care costs, making adequate numbers of surgeons another cost containment strategy.

Without international physicians entering the graduate medical education workforce, it would require substantial changes to maintain the current level of physician staffing in health care systems, such as replacing physicians with midlevel providers which may further inflate health care costs.

While physician shortage is a challenge for many communities across the U.S., the pain will not be distributed equally among all Americans. Minority and low socioeconomic status patients are more likely to suffer from increased physician shortages, are most likely to be impacted by increased wait times to get care, and stand to lose the benefit of having a primary care doctor that has also shown to confer benefits to at-risk populations.

President Trump’s immigration ban has the potential for immediate ramifications for the hospital and health care system workforce in the U.S. Long term, decreases in the number of international medical graduates in training will result in fewer primary care physicians and general surgeons, just as the country is likely to need more.

This immigration policy can have significant adverse impacts on health care delivery and the health of Americans. These consequences should be critically considered in related immigration and travel ban policy decisions moving forward.

There is something really flawed in our education system if we can’t educate and train sufficient physicians, nurses and ancillary staff to care for the patients in our own country.

Consider other effects on health care if Trump and the GOP get their way and repeal the Affordable Care Act. Promises made by Donald Trump and Republicans in Congress to repeal and replace the Affordable Care Act are proving to be more complicated than they sounded on the campaign trail. With reality now setting in, what’s most likely to happen?

I expect to see Republicans stage a dramatic early vote to repeal, with legislation that includes only very modest steps toward replacement — and leave most of the work for later. Next, the new administration will aggressively issue waivers allowing states to experiment with different approaches, including changes to Medicaid and private insurance rules. At some point, then, the administration will declare that these state experiments have been so successful and that Obamacare no longer exists.

In other words, the repeal vote will be just for show; the waivers will do most of the heavy lifting. I predict something like this will happen and I am pretty sure of this outcome because of two core challenges that stand in the way of Republicans’ replacing the ACA through legislation: the need for so-called community rating and the need to have 60 votes in the Senate to pass a comprehensive new health-care law.

First, consider the importance of community rating. It is one of the basic building blocks needed to create a workable private insurance market — whether Democrats or Republicans are doing the building. If your insurance covers a pre-existing condition but at a cost of, say, $100,000, that doesn’t really help. Community rating requires that your premium be the same as that of other people in your area, no matter how unhealthy you are.

With community rating in place, the next step is to recognize how easy it is to game the system: People can just wait until they get sick, then buy insurance at the community rate. To discourage that practice, the system needs to give people some strong incentive to purchase insurance before they get sick. The Affordable Care Act used an individual mandate; most Republican plans instead propose a requirement for continuous coverage. That is, people enjoy access to community-rated premiums in the future only if they have kept themselves insured over some period of time in the past.

Given the costs involved, subsidies are also needed to ensure that low- and moderate-income households can afford the coverage. This overall structure means that younger, healthier people implicitly subsidize older, sicker people.

Such are the inescapable constraints imposed by community rating. Community rating could be discarded, as Mark Pauly of the University of Pennsylvania has argued. Pauly instead proposes that insurance companies be allowed to vary people’s premiums according to their health status, and that general revenue be used to pay sicker people’s higher premiums. This would require substantial new taxes, however, which is presumably a nonstarter in a Republican plan. In any case, it would only make the transfers to older, sicker people more explicit.

The second challenge is more nakedly political: Without a substantial change in Senate procedure, a bill to fully replace the Affordable Care Act, including changes to insurance rules, will require 60 votes. Republicans have only 52, so at least eight Democratic senators would need to be persuaded to go along. This is a much tougher assignment, especially since the administration will already be calling in legislative favors on ongoing confirmations, the debt limit, tax reform and other issues.

The Republicans’ desire to hold an early partisan vote repealing the ACA (through the reconciliation process that requires only a simple majority in the Senate) seems too strong to resist. The repeal will probably be set to become effective in the future, perhaps 2019 or 2020.

This vote will probably be closer than many people think, given the concerns that some moderate Republican senators have expressed about repealing the ACA with no replacement ready. Some far-right Republicans may also balk at anything less than a full immediate repeal. For the White House, however, the closeness of the vote will be a feature rather than a bug, because it will create the impression that the vote is significant.

The repeal legislation will probably include some modest steps toward replacing the ACA, but these will be mostly symbolic measures such as allowing insurance companies to sell across state lines (which by itself would do little to lower people’s premiums). The hard work of a creating comprehensive replacement is then likely to get bogged down in legislative muck.

But the administration can use its expansive waiver authority to allow states to experiment with both Medicaid and the individual insurance markets. As these 50 flowers bloom, President Trump could at some point declare victory and assert that the ACA has been sufficiently reformed.

This approach, whatever its potential substantive shortcomings, provides a major political benefit: The administration would not necessarily own the many problems that inevitably would remain. In response to any particular complaint in a specific state, the administration could simply shrug its shoulders and direct the inquiry to the relevant governor.

This outlook assumes that the Republican leadership in Congress isn’t willing, or lacks the votes, to change the Senate’s traditional rules, and that a comprehensive replacement for the ACA will indeed require 60 votes. If that changes, all bets are off.

This Week’s Outline of GOP plan to replace ACA has few surprises

Shannon Muchmore sums up the “progress or lack of progress in health care reform.

  • An outline of the Republican plan to replace the Affordable Care Act was leaked Thursday after a meeting among Senate Republicans, The New York Times reports.
  • The document is a blueprint modeled after the House Republican’s plan called A Better Way, with age-based tax credits to help people buy insurance and more reliance on health savings accounts.
  • President Donald Trump said in a tweet early Friday that repeal and replace of the ACA is “moving fast” and House Speaker Paul Ryan said earlier this week he expects legislation to be introduced possibly as early as next week.

The GOP plan leaked Thursday contains few surprises but does leave out some key areas. It makes no mention of changing Medicare into a premium support plan, which Ryan has supported but Trump has been wary of.

The plan also makes no mention of how it would be paid for. Bloomberg has reported, however, that the GOP may be considering capping the tax breaks on employer-sponsored health insurance. This would be a major tax policy change. Policy analysts tend to support the idea but it could be a tough sell for lawmakers eyeing reelection.

The plan does address Medicaid, and essentially guts the expansion put forward by the ACA. It would roll back the generous cost sharing for states that expand eligibility and give states either a fixed sum per beneficiary or a block grant. Either way, far fewer people would be covered, leading to more uninsured and without access to care. Medicaid, even though I hate the reimbursements to physicians for the health care that they provide to their patients for those who need health care and can’t afford third party insurance.

“This would mean fewer people could afford health insurance and that the health insurance would likely cover less,” says Larry Levitt, senior vice president at the Kaiser Family Foundation.

Under the plan, states that expanded eligibility for Medicaid would see their supplemental federal funding rolled back. The program would also be converted from a federal-state program that pays for all the health care beneficiaries get, to one where Washington sends a fixed amount of money to each state for each Medicaid enrollee.

To help people who don’t get insurance through their employer buy coverage, the bill offers age-based tax credits that start at $2,000 for individuals under age 30. It would rise to $4,000 for those over 60. Those credits are unlikely to cover the full cost of a plan that pays for routine health care, but could potentially pay for insurance that protects against a catastrophic health event.

Levitt says those credits are less generous than the subsidies offered under Obamacare. This could be unpopular, even among fellow Republicans. A handful of GOP governors in expansion states have said the move has improved healthcare access and their state’s economy.

One of the most politically explosive pieces in the draft of legislation, which is currently unnamed, is defunding Planned Parenthood, a move that some Republicans see as too dangerous. According to the draft, no federal funds could go to a “prohibited entity.” The bill includes abortion provider in its definition of “prohibited entity.”

Congress returns again and Republican leaders will push for legislation to be introduced as soon as they receive more guidance from the Congressional Budget Office, which is scoring some of their proposals.

So, is there any news about the Trump Care Act? Not Really.

Remember my suggestion…..modify Obamacare to retain the good parts, modify the parts that don’t work and figure out how to pay for the system that doesn’t financially “screw” the young healthy workers who presently shoulder the financial burdens with outrageous premiums and even worse deductibles. Even physicians don’t want to get rid of all in the Affordable Care Act. One of the biggest impediments to an affordable health care system that covers everyone is sustainability. In the next few weeks I will report on the advances or frustrations in the GOP/Trumpcare healthcare system and attempt to out line what would really happen if Obamacare is repealed as well as a true plan for a successful sustainable health care system…..Really???!!!???!!!

 

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