The next administration is already charting its healthcare course

Fewer than 120 days are left before Inauguration Day, and both presidential candidates at this point have plausible paths to the White House. That means they are assembling transition teams that will be tasked with identifying priorities for 2017, populating Cabinet positions and working with the current administration to coordinate the handoff.

Neither camp has publicly floated names of the people likely to lead HHS and its component agencies, which include the CMS, the Food and Drug Administration, the Office of the National Coordinator for Health Information Technology, the Centers for Disease Control and Prevention and the National Institutes of Health. Other key positions in the executive branch wield huge influence in the healthcare industry and healthcare services, too, including the attorney general, the Federal Trade Commission chairman and the secretary of Veterans Affairs.

But Democrat Hillary Clinton and Republican Donald Trump have reportedly tapped policy experts with some healthcare experience for their transition teams. Clinton has Neera Tanden, president of the Center for American Progress and a former HHS adviser. Trump's crew may or may not include former CMS adviser Tomas Philipson, a University of Chicago economist who served as a healthcare policy adviser to John McCain's 2008 presidential campaign. Politico reported late last week that Philipson may already be off the team.

Both teams have set up shop near the White House with the help of funds Congress appropriated to ensure adequate planning for the massive transition. A guide document from the nonpartisan Center for Presidential Transition suggests teams create 100-day plans for each policy area, develop potential executive actions and outline administrative policies by cataloging campaign commitments from candidate speeches and public statements.

In March, Congress passed bipartisan legislation requiring the government to create transition councils and designate an executive at each agency to manage transition activities. While lawmakers have focused on the need for an adequately prepared administration to focus on national security issues, there are grave implications for the healthcare industry in how the new administration acts on the ongoing implementation of the Affordable Care Act and the imminent rollout of Medicare's new payment system for physicians.

Beginning Jan. 1, just weeks before Inauguration Day, the CMS will start gathering performance data that will drive payment bonuses and penalties for physicians in 2019. The final rule that will codify the measurement framework and reporting timeline is expected in November, which means both teams will have to figure out how to establish the infrastructure to execute the policy and help providers adjust.

Another big question with immediate ramifications is what happens with Medicaid expansion. Clinton, in a bid to continue coaxing more of the holdout states to expand eligibility under the ACA, has advocated extending the 100% federal funding match for the first three years. That policy would require cooperation from Congress.

But so would Trump's stated policy of scaling back or eliminating federal support for the ACA's Medicaid expansion and converting Medicaid funding to a block-grant model.

Either is likely to face a sharply divided legislative branch, no matter which party ends up with the majority in either or both chambers.

Jim Manley, a former top aide to Democratic Sens. Harry Reid and Ted Kennedy, said each candidate's team will try to identify changes to the Affordable Care Act that could get bipartisan support. Trump has vowed to repeal the law, but that would be impossible to achieve given the likelihood of Democratic gains.

Clinton has proposed establishing a government-run health plan to compete with private insurers in the ACA exchanges and ensure all Americans are able to find coverage in the marketplaces as some carriers, including Aetna and UnitedHealthcare, scale back their participation.

Clinton's transition staffers will be trying to hash out ideas for keeping insurers in the exchanges and finding the votes for issues such as the so-called public option, Manley said.

“Politics on the Hill will be tricky since it's difficult to see where the votes are for it, but I'm sure they're looking to see how to deal with that.”

Trump, meanwhile, has yet to propose a detailed plan for replacing the ACA if he were able to get the votes to repeal it. Asked about it recently on “The Dr. Oz Show,” he said only that the replacement would “be great.”

Tom Miller, a fellow at the conservative think tank American Enterprise Institute, said it's tough to know what the Trump transition team is working on because the candidate himself has said so little about health policy. The first year or so in the next administration would likely involve more health policy work through congressional channels than the White House.

It's unclear what Trump's apparent lack of interest in healthcare policy details might mean for the many initiatives already underway or being planned by the Obama administration under the authority granted by the ACA to experiment with new payment and delivery models in Medicare.

While the candidate makes statements to grab headlines, policy staff are working in a more realistic and professional environment, Miller said. “Just like drafts of a speech that don't go anywhere, this is a lot of just seeing who will go in a room and do some make-work efforts because we have many more unknowns than we have knowns.”

Clinton's transition team is led by Ken Salazar, a former Colorado senator who served as secretary of the interior during the Obama administration's first term. Others on the team include former Michigan Gov. Jennifer Granholm and Maggie Williams, director of Harvard's Institute of Politics.

Tanden was a senior adviser for health reform at HHS under Obama and worked for Clinton's campaigns for the U.S. Senate and the 2008 Democratic presidential nomination. She recently co-authored an essay about what the ACA has accomplished, particularly in helping people of color obtain coverage, and she called on Republican governors to stop blocking Medicaid expansion.

Tanden is considered a candidate for HHS secretary if Clinton wins. Another contender is former Kentucky Gov. Steve Beshear, a Democrat who expanded Medicaid in the mostly red state and continues to advocate for the ACA.

Trump, meanwhile, has tapped his GOP primary rival New Jersey Gov. Chris Christie to lead his transition team.

Names floated among D.C. insiders for HHS secretary in a Trump administration include another primary rival, Dr. Ben Carson, as well as former Louisiana Gov. Bobby Jindal, who worked at HHS under President George W. Bush, and Florida Gov. Rick Scott, former CEO at Columbia/Hospital Corporation of America (now HCA).

Philipson, the University of Chicago economist rumored to be advising Trump, has also been mentioned as a possible pick for the cabinet post. He has written several commentary pieces for Forbes on health policy. In particular, he has argued that current attempts to incorporate value into healthcare pricing have ignored what patients view as valuable and steered away from the marketplace, which is best equipped to determine value.

For example, he wrote in August, “Future approaches for measuring treatment value should avoid one-size-fits-all approaches that do not capture factors that patients care about, while at the same time maintaining the primacy of the patients and physicians decisionmaking process.”