President Trump's healthcare plate is full, and it won't go down easy

President Donald Trump ran for election primarily on the issues of jobs, fair trade and tougher immigration enforcement. He only sporadically discussed healthcare and mentioned nothing about the issue during his inaugural speech on Friday. In vague terms, he has promised to replace Obamacare with “something terrific,” protect Medicare and Medicaid from spending cuts and changes, and rein in rising prescription drug costs.

But as he takes office, he faces the very real prospect that his first year in the White House could be dominated by complex and bitterly divisive healthcare issues, carrying big political risks for his presidency and his party.

Erasing the Affordable Care Act could disrupt insurance for nearly 30 million Americans covered in the individual market and under Medicaid expansion, including many of his white working-class supporters. He must overcome sharp divisions in his party about how to replace the law's coverage, and convince at least some Senate Democrats to go along with his alternative.

The week before his inauguration, Trump promised “insurance for everybody” with “much lower deductibles.” Claiming his plan was near completion but offering no details, he boasted that it would be “great healthcare” that left people “beautifully covered.”

If he fails to fulfill his vow to repeal and replace the law with something much better, Republicans could be in a vulnerable position defending their control of Congress in the 2018 elections, putting the second half of Trump's presidency in jeopardy.

A more immediate risk is that Trump's and congressional Republicans' broader agenda on taxes, the economy, trade, deregulation, immigration, military expansion and other issues could get derailed by health policy battles. “The Trump administration is in danger of being swamped by healthcare,” said Jonathan Oberlander, a health policy professor at the University of North Carolina. “A number of presidents have taken on healthcare and found it was more than they could chew.”

Congressional Democrats also are playing for high political stakes. If they allow President Barack Obama's historic initiative to provide health insurance for nearly all Americans to die without an adequate substitute, it would deeply demoralize their supporters. But if they can block GOP efforts to roll back key parts of the law without being seen by the public as obstructionists, that could vault them back into power and enable them to finish the job of creating a universal healthcare system. Their challenge will be to stay unified, even as 10 Democratic senators nervously eye 2018 re-election races in states won by Trump.

And it's not just Obamacare at stake. There are many big health policy issues on the table this year, and no one knows how they will play out. Some Republicans, led by House Speaker Paul Ryan, are eager to move on their party's longstanding goal of restructuring Medicare and Medicaid to reduce federal spending on the two giant programs. Trump and some Senate Republicans, however, have expressed reservations, particularly about making changes in the Medicare program that's beloved by their core constituency of older voters.

“The Republican base does not passionately want Medicare reform,” said Tom Miller, a conservative health policy expert at the American Enterprise Institute. “That's not where the politics are.”

Trump's proposal to turn Medicaid into a program of capped federal contributions to the states—which his campaign unveiled last spring after he had said for months that he wouldn't cut Medicaid—also could set off a political firestorm. While the fixed-contribution model is strongly favored by Ryan and other conservatives, state-elected officials, healthcare providers, and groups representing seniors, the disabled and the poor are likely to fiercely oppose it because it would mean cuts in eligibility, benefits and payment rates.

“It's amazing to me that Republicans would even contemplate major changes in two of our most popular programs, Medicare and Medicaid, on top of repealing and replacing the ACA, which will be a remarkable undertaking in itself,” said Tom Daschle, the former Democratic Senate Majority Leader.

Beyond that, Trump says he wants to take on the deep-pocketed pharmaceutical industry and rein in prescription drug prices. He hinted in a recent interview he would publicly shame drug companies that hike prices excessively. While reducing drug prices has strong public support, the president is likely to encounter powerful opposition from many members of his party and some Democrats in pushing the measures he has mentioned, such as letting Medicare negotiate prices or allowing consumers to buy cheaper drugs from Canada or other countries.

Other major issues on the 2017 health agenda include reauthorizing the Children's Health Insurance Program; funding a wide range of health programs including medical research, mental health and addiction services, and community health centers; reauthorizing the Food and Drug Administration's drug and medical device user fee programs; and renewing a variety of expiring Medicare provisions. In addition, the new administration will have to decide whether and how

to promote the shift from fee-for-service to value-based payment models, which was a major Obama administration priority.

There's great uncertainty about the strategy and timetable for congressional action on these issues. Some observers predict the administration—with Trump's HHS secretary nominee Dr. Tom Price taking the lead—and senior congressional Republicans will try to attach ACA replacement, Medicaid and Medicare changes, and perhaps action on drug prices to popular, bipartisan legislation renewing CHIP funding or the FDA's drug and medical device user fee programs. All three expire Sept. 30.

“If I was in GOP leadership, I'd be looking for any must-pass legislation to attach the ACA replacement to,” the University of North Carolina's Oberlander said.

But that strategy could backfire on Republicans if attaching controversial healthcare reform, Medicaid or Medicare provisions to something like a CHIP reauthorization bill sinks the legislation. Some fear it could jeopardize continued coverage for the 8.4 million lower-income children insured by CHIP, at a time when Medicaid and other coverage options for kids may shrink.

“If (CHIP renewal) is rolled into ACA repeal and replace, it's hard to see a lot of bipartisan camaraderie,” said Billy Wynne, managing partner of TRP Health Policy and a former Senate Democratic staffer.

Another commonly discussed legislative approach is for Republicans to include ACA replacement provisions and Medicaid and Medicare changes in a major tax-cut package in the second half of the year, since many Democrats also are interested in passing tax reform. But that strategy is likely to face resistance from the congressional committee chairs in charge of the tax legislation, which will encounter plenty of political challenges on its own.

“The tax people will say, 'No thanks, we don't want ACA and Medicaid politics mudding up tax reform,' ” Wynne predicted.

Some observers foresee Trump facing the same kind of extreme political turbulence on healthcare this year that Obama experienced in 2009 in passing the ACA, and that President Bill Clinton weathered in 1995 in vetoing Republican-passed legislation that would have restructured Medicare and Medicaid along the lines of what Republicans are proposing now.

The ACA fight weakened Obama and contributed strongly to the Democrats losing control of the House in 2010. In contrast, Clinton's successful showdown with Republicans gave him a political boost and helped him win re-election in 1996.

Now we'll see how Trump fares on healthcare reform, Medicare and Medicaid. “Trump could consume 140% of his political capital just doing those three things,” said Jeff Goldsmith, a national adviser to Navigant Healthcare.