Over the coming months, the strategic plans of healthcare leaders across America will need review and adjustment in the gradually dawning light of new policies emanating from Washington.
A few things are already certain. The nation's move toward universal health insurance is over. The movement to shift providers from fee-for-service medicine to value-based care is on hold.
The seven-point nonplan offered on the Donald Trump for President website is a compilation of nostrums that have been offered for decades by conservative Republicans in Congress. They hold out no chance of achieving universal health insurance. Not a single word in his plan addressed delivery system or payment reform.
Until his first appointments are made, it's fair to say no one has a clue what healthcare policies President-elect Trump will pursue once he sits in the Oval Office.
But there's a larger issue that ought to be on every healthcare leader's mind. Will he govern as he campaigned? The answer will have huge implications for the nation's health and ultimately the healthcare delivery system.
He began his run for the presidency by calling into question the birthplace of the nation's first African-American president. He built a winning coalition by bashing immigrants, Muslims, Mexicans 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.
Indeed, his campaign represented one of the most destructive acts against public health and mental well-being in the history of our nation. Racism, misogyny, xenophobia and hatred are like viruses. Brought out of the closet and left unchecked, they spread and grow.
Their validation in the public arena by the winning candidate left in its wake incalculable psychic pain and suffering. Research has repeatedly shown that that inevitably leads to increased chronic disease and early mortality among groups already at deficits.
Can he change? Will he change? Can he repair the social fabric torn asunder by his campaign? We can only pray that he sticks to the conciliatory themes laid out in his victory speech.
For healthcare institutions, there is greater certainty. Change is coming—big time. The Republicans in Congress and Trump have as their starting point the immediate repeal of the Affordable Care Act.
How they change or unwind coverage for the more than 20 million Americans that benefited from the law is impossible to predict since there was no flesh on the bones of the word “replace” in “repeal and replace.” Experts give the policies outlined on his website—tax credits, selling insurance across state lines, health savings accounts—no chance of moving the needle toward meaningful universal coverage. The most likely outcome is we'll move backward on coverage.
The wing of the party led by House Speaker Paul Ryan also has no love for Medicare as currently constructed. It's been on a tight budget since passage of the Balanced Budget Act in 2011. Will Trump hold fast to his promise not to change Medicare, or will he side with the conservatives in Congress and look to convert Medicare to premium support of privately sold plans?
Turning Medicaid into state block grants with few guarantees as to coverage will also be high on the congressional agenda. Trump endorsed it during the campaign, and Republican governors who supported Medicaid expansion under the ACA will probably welcome total control of their Medicaid budgets as long as there are few or no strings attached.
The outlook is a little less bleak on delivery system reform. The physician pay overhaul proved there is bipartisan support on Capitol Hill for payment reform. Both parties realize it is the only hope for achieving more affordable care without denying people needed services.
But this is where appointments really matter. Will the new leaders at HHS and the the CMS support continued moves toward coordinated care and value-based reimbursement and away from fee-for-service medicine? Those choices will send a clear signal on the fate of delivery system reform.