In health policy circles, President Donald Trump can be viewed as the other side of the same coin from his predecessor, Barack Obama. Both have caused seismic shifts in the healthcare landscape but in different ways.
“President Obama developed an entirely new national health insurance system,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. “President Trump has demonstrated just how easy it can be to tear it apart.”
Since Trump took office, work requirements have started to be imposed on some Medicaid expansion enrollees, cost-sharing subsidies on the individual market have been canceled, risk payments to insurance companies have been turned off and then on again, funding has plummeted for navigators who help people sign up for coverage, and the penalty for noncompliance with the individual mandate was zeroed out.
“The actions of the Trump administration all share a common theme: halting and reversing the historic progress the U.S. has made in reducing the ranks of the uninsured,” said Edwin Park, a Georgetown University professor of public policy.
Others argue that Trump's focus hasn't been on clawing back coverage gains made under Obama but creating a healthcare system that's more affordable with coverage options that consumers actually want. To that end, states are now allowed to define essential health benefits that individual and small-group insurers must offer. His administration also extended the availability of short-term plans and is hoping to do the same with association plans.
Also, coverage protections for people with pre-existing conditions and the ability for individuals up to the age of 26 to stay on their parent's coverage remain intact.
“The way to think about the Trump administration's relationship with the ACA is that it's separating the wheat from the chaff,” said Christopher Pope, a senior fellow at the Manhattan Institute, a conservative think tank. “He is focusing on which things provide the best value and which are more burdensome than beneficial.”
There's been so much focus on Trump's ACA-related work, that other things haven't been properly noticed, according to Robert Graboyes, a senior researcher at the free-market focused Mercatus Center. Those topics include the administration's drive to reduce legal and regulatory burdens on healthcare stakeholders. Trump also signed into law right-to-try legislation enabling gravely ill patients to get experimental treatments more easily. “It's still early, but if the Trump administration has an enduring legacy in healthcare, these non-ACA actions will likely be the reason,” Graboyes said.
Trump is also trying to follow through on a campaign promise to find ways to lower drug costs for consumers and the federal government. A rule is now under review at the White House that aims to remove legal protections for drug rebates. Drug companies now pay rebates to pharmacy benefit managers to either make their products the only ones available for coverage to consumers or to make the co-pay less than those for competing products. But these discounts aren't always passed on to consumers. The average large PBM generates 15% to 20% of its total profits from retained rebates and associated administrative fees, according to a Barclays analyst note.
The CMS is also now planning to allow Medicare Advantage plans to impose prior authorization requirements on Part B drugs. The plans currently have this ability for Part D drugs. Humana has claimed the idea could save Medicare as much as 23% on immunology drugs like Remicade, Stelara and Simponi in 2019.
This approach separates the Trump administration from prior ones, according to Lindsay Bealor Greenleaf, a director of healthcare consulting firm ADVI. Instead of merely condemning the drug industries for prices, it is angling to use the drug supply chain to reduce costs.
“The FDA has started exploring what they can do on drug pricing, and HHS has at least rhetorically shifted attention to drug pricing in a way that prior administrations haven't been able to,” said Yevgeniy Feyman, a Republican health policy analyst.
Politics aside, it's Trump's broad impact on the entire industry that landed him atop 2018's 100 Most Influential People in Healthcare ranking.