Everything changed Tuesday night.
Everything that the leaders and clinicians who manage the nation's $3 trillion healthcare system thought they knew is now called into question.
Universal health insurance? Gone. Moving from fee-for-service medicine to value-based care? On hold. More affordable care for average Americans? A chimera.
Donald Trump, a man universally condemned as unqualified for high office by thought leaders in every field, will become president next January. Republicans will control both houses of Congress.
I will leave for others to sort out the broader impact of a man with his demeanor holding the highest office in the land. He rode into office on a campaign that started by calling into question the birthplace of the nation's first African-American president and built a winning coalition by bashing immigrants, Muslims, Hispanics and the disabled. Over the course of the campaign, he revealed a character that routinely demeaned women, including one who dared to question him about his attitudes toward women on a debate stage.
Can he change? Will he change? Can he repair the social fabric torn asunder on Tuesday night? I for one hold out hope that he can stick to the themes laid out in his victory speech early Wednesday morning. Time will tell.
But for healthcare, there is greater certainty. Change is coming—big time. The Republicans in Congress have as their starting point the immediate repeal of the Affordable Care Act, aka Obamacare.
How they will manage unwinding coverage for the 20 million Americans that benefited from the law? It is difficult to predict since there was no flesh on the bones of the word “replace” in “repeal and replace.” Every right-wing Republican nostrum for achieving universal coverage—selling insurance across state lines, high-risk pools, catastrophic plans with health savings accounts—have no chance of moving the needle toward meaningful universal coverage.
We're now 70 years behind Western Europe and Japan. The U.S. still has 10% of its population short of that goal and the most likely outcome of this election is we'll move backwards.
We also know that the wing of the party led by House Speaker Paul Ryan has no love for Medicare as currently constructed. It's been on a tight budget since passage of the Balanced Budget Act and enactment of the sequester in 2011.
We'll no doubt see a renewed push in Congress to privatize the senior citizen healthcare system within that limited funding stream or less. Turning Medicaid into state block grants with few guarantees as to coverage will also be high on the agenda.
And how about the movement to transform the healthcare system into one that delivers more affordable, more efficient, more patient-centered care? On the eve of the election, I attended a forum where former Senate Majority Leader Bill Frist gave Hillary Clinton a 65% chance of winning.
And when asked what effect the election would have on the movement to value-based care, he answered by holding his arms out a couple of feet apart with palms down. One arm represented value-based reimbursement, he said, and the other fee-for-service.
“The reality,” he said as he moved his “value” arm a few inches from the other arm, “is we're still in a fee-for-service world. Donald Trump will shift it from here to here,” he concluded, moving his arm the rest of the way over.
Yet he was still optimistic about a Trump win. “I think we'll see some quite novel definitions of what it means to repeal and replace, picking the things you need to change and repealing and replacing them,” he said.
Perhaps everyone's worst fears won't be realized. But it's inevitable that big changes are coming to healthcare, and they are going to present huge challenges for every institution and special interest in the industry.
They'll survive. But the saddest part is that the biggest losers from those changes will be the very people who put Donald Trump in office.