President-Elect Trump and the Future of Healthcare

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

Can you believe the campaign and election are FINALLY over? It seems like this process lasted forever. But now that it’s finished, I’m sure half of you are happy and looking forward to new beginnings and the other half are disappointed and worrying about what is to come.

Working in healthcare, the big issue for me is what kind of healthcare changes are coming? I thought I knew what to expect if Secretary Clinton won — maybe some needed revisions to the ACA, but it would have remained. However, I’m not sure what it will be like under President-elect Trump. Will the Affordable Care Act (ACA), also known as Obamacare, really be repealed? Will over 21 million people lose their healthcare benefits, or will the ACA just be replaced with other alternative options? If so, what might those be? What will happen to those who have pre-existing conditions? Will children up to the age of 26 continue to be included in their parents’ plan? Will other principles, policies, and practices established over the past six years to support the ACA (Triple Aim, the move from fee-for-service to value-based care, ACOs, etc.) also be eliminated? Will health information technology (HIT) be affected? Will Health Information Exchanges be eliminated? Millions of dollars have been spent building an infrastructure to support the ACA. Will all that be useless now?

Of course it’s too early to predict what will happen, but there are some optimistic hints that some of the rhetoric of the campaign is changing. President-elect Trump said during the campaign that he would "repeal and replace" the ACA on his first day as president. I think we all knew that really wasn’t possible, but many felt he might at least begin the repeal process on day one by overturning President Obama’s Executive Orders. Then he could start the 1-2 year process to dismantle the ACA by using the complex budget reconciliation process to defund the ACA, developing new meaningful options, and passing legislation and finally rolling out his new healthcare program (Trumpcare??).

However, this week, on 60 Minutes, he said he wants to keep some of the ACA aspects that worked (pre-existing conditions and coverage to children up to 26 years old) and roll out the new healthcare plan at the same time the ACA program is terminated, so participants will not have any lapse in coverage. So, take a big sigh of relief; things are looking better already!

The Current Trump Healthcare Plan

Now that he has been elected, more details are beginning to emerge about what his new healthcare plan may include. The original 7-Point Plan, from his campaign website, has been replaced on his transition website with a 309-word document that outlines his current Healthcare plan.

• Repeal ACA and replace it with a solution that includes Health Savings Accounts (HSAs).
  
• Return the historic role in regulating health insurance to the States.
  
• Create a patient-centered healthcare system that promotes choice, quality and affordability with health insurance and healthcare.
  
• Take any needed action to alleviate the burdens imposed on American families and businesses by the law.
  
• Maximize choice and create a dynamic market for health insurance by enabling people to purchase insurance across state lines.
  
• Re-establish high-risk pools — a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses and who have not maintained continuous coverage.
  

It notes that the Trump Administrations will also work with Congress and the states to:

• Protect individual conscience in healthcare
  
• Protect innocent human life from conception to natural death, including the most defenseless and those Americans with disabilities
  
• Advance research and development in healthcare
  
• Reform the Food and Drug Administration, to put greater focus on the need of patients for new and innovative medical products
  
• Modernize Medicare, so that it will be ready for the challenges with the coming retirement of the Baby Boom generation — and beyond
  
• Maximize flexibility for States in administering Medicaid, to enable States to experiment with innovative methods to deliver healthcare to our low-income citizens

While the document does not explain exactly what will be done, it does point out areas he feels are important to include in the new healthcare model. However, there are items missing from the new document that were in his original 7-Point Plan. Are these still going to be included or are they no longer being considered?

• Eliminate the individual mandate that requires people to buy insurance.
  
• Allow individuals to fully deduct health insurance premium payments from their tax returns.
  
• The HSAs described in his previous plan could accumulate contributions, be used by any member of the family without penalty, and become part of the individual’s estate that could be passed on to heirs without any death penalty.
  
• Require price transparency from all healthcare providers, so individuals can shop to find the best prices for procedures, exams or any other medical-related procedure.
  
• Remove barriers for drug providers that offer safe, reliable and cheaper products. Allow consumers access to import, safe and dependable drugs from overseas.  

The Republican House’s Healthcare Vision

The Republicans in the House of Representatives have also published A Better Way, a 37-page document that explains their vision for America’s healthcare system. This proposal is built on five key principles that seem to be in line with President-elect Trump’s goals:

1. Repeal Obamacare (ACA).
   
2. Provide all Americans with more choices, lower costs, and greater flexibility. Insurance companies should be competing against each other to offer the most affordable, highest-quality options for consumers. Choice, portability, innovation, and transparency are essential elements of successful reform.
   
3. Protect our nation’s most vulnerable. Patients with pre-existing conditions, loved ones struggling with complex medical needs, and other vulnerable Americans should have access to high-quality and affordable coverage options. States and individuals should have better tools, resources, and flexibility to find solutions that fit their unique needs.
   
4. Spur innovation in healthcare. From new procedures to advanced, life-saving devices and therapies, the U.S. has always been at the forefront of medical discoveries. Today, it costs $2 billion and takes 14 years to get a new drug through the byzantine clearance process at the Food and Drug Administration. Last year, the House passed the 21st Century Cures Act, which would pave the way for new ideas and support advancements in cures and treatments.
   
5. Protect and preserve Medicare. Today, more than 50 million seniors and individuals with disabilities rely on Medicare for access to health care and millions more are counting on Medicare to provide health security when they reach retirement. Medicare must be protected for today’s seniors, and it must be strengthened for future generations. This can be done by slowly phasing in improvements that will provide future generations with greater choices.
   

Health Information Technology (HIT)

This is a topic near and dear to my heart. Technology is a HUGE part of healthcare and is becoming more integral each year. Technology platforms are used for documentation, predictive analytics, billing, accounting, communications, decision-making, clinical procedures, telehealth, and a myriad of other uses. Thanks to the Meaningful Use initiative, EHRs are now part of the fabric of healthcare with 95% of hospitals and nearly 80% of physician offices using certified EHRs. Hopefully these advances will continue to be part of the new system. Every indication is that these platforms and processes have bipartisan support and will be used, with adaptations, in the new healthcare system.

• During his victory and acceptance speeches, Mr. Trump promised to improve healthcare and hospital infrastructures.
  
• He also talked about telehealth for veterans, which hopefully meant he is interested in extending that to other programs and populations.
  
• Cybersecurity, interoperability, digital infrastructure, support for decision-making tools, and usability and optimization of EHRs have been supported by both parties.
  
• What will happen to Health Information Exchanges remains to be seen. Hopefully, the infrastructure that has already been created will be kept and modified for use in the new system.
  

Other Healthcare Issues

In addition to the ACA, there are also other key aspects of healthcare that are in doubt. The ACA brought about many changes and we made great strides to bring about meaningful results in areas, such as: quality improvement, patient empowerment and satisfaction, payment reform and cost reduction. We need to keep an eye on these key initiatives to see how they will be handled:

• Healthcare Reimbursement: The move from fee-for-service to value-based care, bundled payments, risk-based models, pay-for-performance, and Accountable Care Organizations will probably be maintained because of their cost reduction results. There has been bipartisan support for these efforts.
• The Medical Access and CHIP Reauthorization Act (MACRA): This Medicare Physician Reimbursement Model pressures physicians to adopt alternative payment models. It will probably not be changed, since it has significant bipartisan support (92-8 in the Senate and 392-37 in the House).
  
• The 21^st Century Cures Act: This program provides funds ($9 billion over five years) for biomedical research, high-risk and high-reward research, and early stage investigations. It has been stalled for months but is mentioned in the Republican House’s Vision document as an example of a program that can spur innovation. Examples include the Precision Medicine Initiative and Vice-President Biden’s Cancer Moonshot program.
  
• Funding for large, costly programs may be in jeopardy. These include the Agency for Healthcare Research and Quality (AHRQ), The Centers for Medicare and Medicaid Innovations (CMMI), and the Patient-Centered Outcomes Research Institute (PCORI).

Given the above, what do we really know about the changes that are ahead for healthcare? Are our best guesses going to be accurate? Using what we learned from the outcome of the election, I don’t think we can depend on anything. Things are too unpredictable. But, we can hope that healthcare reform will:

• Use the best of ACA and the best of the new system to develop an even better system than we have today; keep what is working.
• Provide healthcare to the 21 million current participants, plus many more that need it.
• Include all patients without exclusions for pre-existing conditions.
• Transition from ACA to the new system without disruption to patients or healthcare providers.
• Continue to focus on Triple Aim (quality, value, and patient experience).
• Use as much of the current technology infrastructure as possible, without making a lot of changes. After all the time, effort, and money spent to build these systems, it would be a disaster to have to discard them and start over again.
• Incentivize providers and organizations to optimize health outcomes and deliver appropriate, cost-effective care.
• Continue to focus on moving from fee-for-service to value-based care, providing Accountable Care models, and using payment reform models (bundled payments, pay-for-performance, etc.).
• Streamline government regulations to make the system easier for consumers and providers.
• Develop improved processes for obtaining new and less costly medications, as well as providing advancements in cures and treatments.

Our main goal as case managers, regardless of what changes are made, is to support the patient and their families. We need to keep up-to-date on the changes, so we can explain them to our patients and know what is available for them and how to get it. Our advocacy is going to be more important now than ever before, especially if there are a lot of changes.

Whether you were for Donald Trump or Hillary Clinton, the time for disagreement is over. It is now time to come together, so we can move forward. Hopefully we will have bipartisan support to take the best of ACA and build upon those aspects to develop an even better healthcare system. By working together we should be able to accomplish that. Let’s hope both parties can keep that in mind as they begin to build our new, revised, improved healthcare system.

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.