Regulatory reform takes hold during Trump's first 100 days

Updated at 11 p.m. ET

President Donald Trump stormed into office on a pledge to drastically alter the landscape in Washington, D.C. From draining the swamp to revamping the nation's healthcare system, he laid out an ambitious agenda built on a populist message.

By virtually all accounts, Trump's first 100 days in office have been mired by missteps, miscalculations and missed opportunities—other than securing Justice Neil Gorsuch's confirmation to the Supreme Court bench, where he will have numerous opportunities to interpret healthcare law. At the same time, the president has set the wheels in motion to fulfill major campaign promises of easing the regulatory burden and, particularly with healthcare, giving states more flexibility in how they fashion health services.

Trump's pledge to repeal and replace the Affordable Care Act by April 29—day 100—has dominated the political landscape and eclipsed virtually all other issues on the healthcare agenda. The president and GOP leadership suffered a major setback last month when House Speaker Paul Ryan (R-Wis.) opted to withdraw the American Health Care Act before a scheduled vote.

Although House leadership hoped a revised version of the AHCA would reach the floor for a vote on Friday or Saturday, House Majority Leader Kevin McCarthy (R-Calif.) said late Thursday night that wouldn't happen. The fractured GOP House majority will continue to negotiate a version of the AHCA they hope will be palatable to both moderates and the ultra-conservative Freedom Caucus, which supported the latest iteration.

Even if a measure does get through the House, passage in the Senate is unlikely.

The AHCA aside, the president has initiated efforts to reduce regulatory burden, largely through executive action. One of his first actions as president was to sign an order that froze all pending Obama-era regulations until they could be reviewed by his administration. The order impacted rules aimed at combating Medicare and Medicaid fraud. Trump also signed an order in late January that required agencies to identify two rules to be repealed for every new proposed rule. Most recently, the proposed inpatient prospective payment system rule includes a request for information on how the CMS can continue to ease regulatory burden. "We would like to start a national conversation about improvements that can be made to the healthcare delivery system that reduce unnecessary burdens for clinicians, other providers, and patients and their families," the agency wrote.

Similarly, the Trump administration used the first 100 days to advocate for giving states more power in shaping their healthcare markets. On March 13, HHS Secretary Tom Price sent a letter to the nation's governors encouraging them to apply for Section 1332 waivers under the ACA. "State innovation waivers that implement high-risk pool/state-operated reinsurance programs may be an opportunity for states to lower premiums for consumers, improve market stability and increase consumer choice," he wrote.

Trump's other top healthcare leader, CMS Administrator Seema Verma, is another cog in the wheel to provide states with more flexibility in their healthcare regimes, according to Chip Kahn, president and CEO of the Federation of American Hospitals.

"My takeaway from meeting with her is that she wants to unleash innovation through the states and give states more flexibility," Kahn said.

While 100 days may seem like a long time, it isn't, as Kahn noted. For any new president, advancing their agenda relies on having people in place at the department and agency level. At least in terms of top level officials at HHS, Trump is on par with previous administrations. The president has nominated four officials for top positions at HHS, which compares to six for President Barack Obama, five for President George W. Bush, nine for President Bill Clinton and five for President George H.W. Bush, according to Mallory Barg Bulman, vice president of research and evaluation at Partnership for Public Service, which monitors agency appointments.

Trump has two confirmed leaders in place at HHS: Price and Verma. Dr. Scott Gottlieb is expected to be approved by the Senate in the coming days to head the FDA. By their 100th day, Obama and George W. Bush had just one; Clinton and George H.W. Bush had two.

While Barg Bulman didn't have exact data on sub-agency head levels, reports are that progress is slow in filling those leadership roles.

"The administration has laid out some very broad goals," she said. "You need people in those positions to implement those policies. It will take time to get leadership in place."

Nonetheless, industry observers worry that the pace of appointments threatens progress in some key areas. For instance, the 21st Century Cures Act, enacted late last year, includes several provisions that require action by various parts of HHS. Mari Savickis, vice president of federal affairs at the College of Healthcare Information Management Executives, noted that the law aims to improve interoperability of electronic health records and seeks to address data blocking.

Delays in filling leadership voids will slow down rulemaking.

Ultimately, Trump's first 100 days is sure to be measured by the debate of repealing Obamacare. "They put a lot of energy into repeal and replace," Kahn said. "It has sucked up a lot of oxygen."