The earthquake of Donald Trump's presidential election victory casts a completely different light on the healthcare politics and policy developments that preceded it this year.
Healthcare generally did not play a top-tier role in the campaign rhetoric or advertising of Trump, Hillary Clinton, House or Senate candidates of either party, or gubernatorial contenders. Despite polarized public views of the Affordable Care Act, the law was not expected to be a pivotal election issue.
Yet Obamacare's deep unpopularity with Republican voters helped Trump mobilize his supporters and win the presidency. Hostility to the law was bolstered by HHS' announcement two weeks before the election that premiums for individual-market plans on the federal exchange would rise by 22% on average around the country.
A Kaiser Family Foundation post-election survey found that 50% of Trump voters wanted the law repealed, and 29% wanted it scaled it back—even though the ACA was credited with expanding coverage to nearly 20 million Americans and slashing the uninsured rate to about 9% in 2016 from 16% before it was implemented.
“Healthcare wasn't the top issue that dominated,” said Dean Rosen, a Republican lobbyist who formerly served as a senior GOP Senate staffer. “But it was always there. The people who voted for Trump were very motivated by it. Fairly or not, President Barack Obama was blamed for everything that was going wrong in healthcare, and the overall message of insuring more people wasn't translating for people who were saying, 'My premiums and deductibles are going up.' ”
In the 10 months before the election, there were any number of developments that seemed to foreshadow major healthcare changes ahead—or were deemed likely to go nowhere. Then the earthquake hit. Here's a sampling of the pre-election events that look very different now. Healthcare industry leaders are racing to make rapid adjustments in their business plans given the unexpected new landscape.
Topping the list, most healthcare industry observers thought the belligerent calls for repeal and replacement of the Affordable Care Act by Trump and his fellow Republicans—crystallized by Congress' party-line passage of repeal legislation in January that was vetoed by Obama—were so much hot air. Stakeholders firmly believed the ACA was here to stay. Not now. That expedited repeal bill was a practice run for what may be the GOP's first legislative move of 2017.
Everyone was worried about the instability of the ACA's individual insurance markets, which were struggling with a shortage of younger enrollees, rising premiums, and failing or retreating insurers. But most experts thought at least some of those problems would be fixed after the election by Clinton and/or Congress. Now that's far less likely to happen.
Following the heated Democratic primary battle between Clinton and socialist Sen. Bernie Sanders, it looked likely that the next administration would try to implement a public health plan option to compete with private insurers in the individual market, and let people in their 50s and early 60s voluntarily enroll in Medicare. That's over.
During the election campaign, Trump and other Republicans touted proposals that were widely panned by many health policy experts. These included proposals to let consumers buy health plans from out-of-state insurers, expand health savings accounts, and kill the ACA's mandate that nearly everyone has to buy insurance while keeping the requirement for insurers to accept all customers regardless of pre-existing medical conditions. Now insurers and regulators are scrambling to figure out how to live with these likely Republican policy changes.
Consumers and providers were expressing growing dissatisfaction with the affordability of the high-deductible health plans that have proliferated in the individual and employer health plan markets. Hospitals complained that high-deductible plans and resulting uncollectible patient debt were hurting their operating margins and ability to take care of patients. Clinton promised relief in the form of new tax subsidies to help people with out-of-pocket costs. Now, however, Republican-crafted policies are expected to strongly promote high-deductible plans, HSAs, and giving patients more “skin in the game.”
“We are certainly looking at more cost-sharing under Republican plans,” said Jeff Goldsmith, a national adviser to Navigant Healthcare, who predicted that will intensify patients' demands on providers and drugmakers to improve performance and outcomes.
House Budget Committee Chairman Dr. Tom Price--now Trump's nominee for HHS secretary--said congressional Republicans would push quickly for dramatic restructuring of Medicare and Medicaid.
Montana's and Louisiana's expansion of Medicaid under the ACA to low-income adults in 2016, along with expansion proposals by Republican governors in Oklahoma, South Dakota, Utah and other red states, made it seem like the momentum for extending coverage in the 19 holdout states was irresistible. Hospital leaders hoping to reduce uncompensated-care costs were cautiously optimistic. The only question seemed to be whether state leaders could win federal approval for adding conservative patient-responsibility features. Now Medicaid expansion appears dead, and premium contributions and work requirements for beneficiaries are a near certainty.
Throughout the year, top Republicans led by House Speaker Paul Ryan talked up turning Medicare into a defined-contribution, “premium support” program, and converting Medicaid into a capped, state block-grant program. Democrats and many health policy wonks scoffed, noting the political popularity of both programs and that candidate Trump had repeatedly said he wouldn't touch them.
But immediately after the election, Trump's team announced plans to “modernize” Medicare, and House Budget Committee Chairman Dr. Tom Price—now Trump's nominee for HHS secretary—said congressional Republicans would push quickly for dramatic restructuring of Medicare and Medicaid.
“It's amazing to me Republicans would even contemplate major changes in two of the most popular programs we have,” said Tom Daschle, the former Democratic Senate majority leader who helped craft the ACA.
On prescription drugs, many observers thought policymakers were getting ready to take action to curb rapidly rising prices, following scandals over big price increases for older products such as Mylan's EpiPen and mounting concern over dizzying prices for specialty drugs.
Clinton proposed a federal review process to determine if “outlier” price increases for long-established prescription drugs were justified. Bipartisan groups of lawmakers proposed bills to make it easier to bring generic products to market and require drugmakers to tell HHS in advance why a price increase of more than 10% is justified. Trump also criticized high drug prices and called for giving consumers access to cheaper drugs from foreign countries.
But all bets are off with business-friendly Republicans in complete control of the government, though the president-elect did say in December that “I'm going to bring down drug prices.” Democrats who had hoped to insert drug-cost provisions into the 21st Century Cures Act passed in December got nowhere.
“The issue has gone quiet,” said Ceci Connolly, CEO of the Alliance of Community Health Plans. “We are very worried that the issue of unsustainable drug prices is falling off the national agenda.”
2016 was a year when sure things turned out to be illusory. It could happen again.
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