“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.