What does a Donald Trump presidency mean for healthcare? 15 responses

Fifteen people from around the healthcare industry discuss how they expect President-elect Donald Trump to affect healthcare in the future.

The responses were lightly edited for accuracy and length.

Elise Barajas, Associate at Gray Reed & McGraw — a full-service law firm (Dallas): "Donald Trump's election, and Republicans' control of both houses of Congress, will certainly alter the current healthcare landscape, and our healthcare clients should expect some big changes, although the exact ramifications are still unclear. The repeal (or at least significant paring back) of the Affordable Care Act, as promised by Mr. Trump, could potentially change the current model that pushes providers away from traditional fee-for-service medicine and toward the delivery of value-based healthcare.

Mr. Trump has not proposed a detailed plan for the ACA's replacement, although he has expressed his intent to implement reforms that follow free market principles. Mr. Trump and Congressional Republicans will likely push to eliminate the individual and employer mandates, eliminate certain ACA insurance reforms such as minimum essential benefits packages, expand the use of health savings accounts and modify existing [laws] to permit the sale of health insurance across state lines. Mr. Trump has also proposed to block-grant Medicaid to states, providing states with annual lump sums and affording more latitude to run their programs; this most likely means an end to Medicaid expansion in the states that have not yet implemented it, and potential jeopardy for those states that have implemented expansion.

Additionally, as Mr. Trump's election ensures a conservative majority on the U.S. Supreme Court, there could be a potential rollback in women's abortion rights. Federal agencies may also look more favorably on mergers and consolidations in the healthcare industry."

Jamey Edwards, CEO of Cloudbreak Health — a telehealth company (Columbus, Ohio): "Unfortunately, his plan is fairly general with little detail on what he would like to do besides repealing the ACA. His presidency will certainly put healthcare under the microscope again and it may present the opportunity for all of us to hopefully analyze and reexamine what is and isn't working. What's in front of us now is a decent amount of uncertainty on healthcare's direction, requiring healthcare leaders to stay engaged, informed and maintain a vigilant watch over the regulatory environment."

Matthew Hawkins, President of Sunquest — a company focused on diagnostic IT (Tucson, Ariz.): "We are in the midst of the most exciting decade in healthcare. We've never been able to do more with technology, we've never known more about the sciences than we do now; but at the same time, we have some big challenges facing healthcare in the U.S. We are spending more than $3 trillion a year on healthcare, at approximately 18 percent of our nation's GDP, and that is significantly higher than other highly developed, high income producing nations — and our outcomes aren't better.

The way to make our healthcare system better is to focus on the engines that help diagnose and treat patients more effectively, at a lower cost, with a higher degree of quality and with the ability to care for more populations with chronic diseases."

Gary Herschman, Member of Epstein Becker Greens — a national law firm (Washington, D.C.): "It is very likely that a new system will be implemented to amend and/or replace ACA's mandate and current exchange system with regard to how citizens obtain healthcare coverage. The cost of purchasing coverage on the exchanges has risen precipitously, and is not working as initially planned. Certain aspects of Trump's campaign platform — including eliminating state lines — likely will be pursued to enhance competition among health plans across the country and may lead to more affordable costs of coverage. This would involve substantial legislation and amendments to existing law."

Michael Jarjour, President and CEO of ODH — a company focused on behavioral health and technology fields (Princeton, N.J.): "President-elect Donald J. Trump's seven-point plan for healthcare focuses on expanding healthcare access across state levels to encourage lower costs in a competitive market. However, currently, mental health systems are resource-constrained. With this proposed approach, it is absolutely essential that resources be allocated in the most efficient way possible for the plan members. A major problem in mental healthcare is pervasive fragmentation of care and the data systems that guide and manage that care. This fragmentation leads to suboptimal and inefficient treatment of these patients. We all recognize that there is an abundance of healthcare data being captured. Because of the potential implications of the seven-point plan on the healthcare system, including mental healthcare, we must leverage important data to help individuals with mental illness."

Jonathan Kaplan MD, Founder and CEO of BuildMyBod Health — an online marketplace for physicians and patients (San Francisco): "Do you repeal all of Obamacare? The president-elect and Republican Congress will no doubt want to repeal Obamacare. But what about the aspect that forbids denial of coverage for someone with a pre-existing condition? Politically they'll want to keep that. But that's expensive. So how do you pay for it? Subsidies for healthier individuals paying higher cost insurance to cover the sicker folks with a pre-existing condition. Does this sound familiar? It's one of the signature aspects of Obamacare."

David Lareau, CEO of Medicomp — a company focused on clinical solutions that provide actionable insights to clinicians at the point-of-care (Washington, D.C.): "The Republicans now control both houses of Congress and the presidency; they are going to have to do something. They are going to have to be aggressive but cautious and also worry about getting legislation past the filibuster vote in the Democratic Senate. The reality is that there has to be some compromise to change the system. I don't think the change will be cataclysmic. It will be evolutionary, rather than revolutionary. More importantly, the Trump presidency still doesn't change the need to provide better information, better data and better tools for physicians at the point of care. I am not as worried about it as some people in the industry."

Harry Nelson, Founder and Managing Partner of Nelson Hardiman — a law firm focusing on healthcare (Los Angeles): "It will be interesting to see how much Donald Trump weighs in on healthcare as an independent populist or defers to the more conservative politicians and policy wonks who are likely to surround him. Our best guess is a rollback — rather than a complete repeal — of the ACA individual and employer mandates, minimum essential benefit requirements and other elements. We expect to see the state insurance exchanges killed off or die a slow death. The big initiative of Trump's healthcare policy is likely to be a shift to global capitation for all Medicare beneficiaries. The big questions ahead will be whether he can overcome the legal challenges to enact national underwriting in place of state-by-state insurance regulation, also how much will be done to soften the blow of lost insurance coverage from the Obamacare rollback."

Adam Powell, PhD, President of Payer+Provider Syndicate — consultants focused on healthcare (Boston): "Donald Trump seeks to make America great again, not to make America 2008 again. If he executes on his platform, the state of the American healthcare industry will look a bit different than it did before the ACA. If he succeeds in allowing people to purchase health insurance across state lines, the health insurance market may grow more competitive in some areas.

Regional health plans with networks close to state borders may have an easier time selling to customers in states that were previously not economically viable to address. Furthermore, Donald Trump's platform promotes modifying Medicaid so that it consists of block grants to states. This may increase the variation in the nature of Medicaid programs that exist between states. While Trump's call for price transparency in healthcare may change how healthcare organizations operate, it is not unprecedented. In Massachusetts, Chapter 224 of the Acts of 2012 has implemented similar price transparency requirements."

Arvind Rajan, CEO and Co-Founder of Cricket Health — a company focused on value-based kidney care (San Francisco): "The results of election, which saw the GOP take the presidency and retain control of both houses of Congress, could have lasting and profound effects on the future of the ACA. For now, the biggest concern is uncertainty. What happens next? The Republican leadership in Congress have committed to repeal and replace the ACA, but what that replacement will be has yet to be clearly articulated. For its part, the incoming Trump administration has been vague — at best — on specific policy proposals.

It's this uncertainty that's likely to cause the greatest consternation with healthcare's stakeholders in the immediate term. While it was clear that a Clinton administration would desire to modify the law and mitigate some of its shortcomings, the GOP's vision of healthcare is not at all settled.

The political landscape is often more complicated and surprising than headlines and pundits would have you to believe. Time will bring developments into view. That said, I think that the path toward accountable care will continue, regardless of what happens to the ACA; hospitals and insurers have staked tremendous money and resources to lower the cost of healthcare while improving outcomes for patients."

Manish Shah, CEO and Co-founder of PeerWell — a prehabilitation program for hip and knee replacement (San Francisco): "No matter who the president is, healthcare costs need to be reduced. Some reforms are more likely to be changed by a new administration than others. State-based programs affected by the ACA like Medicaid and insurance exchanges are the more likely targets for a Trump administration. Alternative payment models like bundled payments are a linchpin of MACRA, which is a bipartisan law separate from the ACA. Since they have already been rolled out and are working, if anything, they are candidates for acceleration as the new administration looks for proven tools to reduce cost."

Joseph Smith, MD, PhD, President and CEO of Reflexion Health — a digital health solutions company (San Diego): "With U.S. per capita healthcare spending already leading the world, any reform by either candidate was destined to focus on carefully assuring value for money. Innovative companies are already innovating around total cost of care, democratizing and decentralizing healthcare and moving care to the home where it is most convenient and least expensive. Going forward, we believe that claims around lowering total cost of care will be even more carefully scrutinized, and in echoing [W. Edward] Deming's advice, 'In God we trust, all others bring data.'

While details of President-elect Trump's repeal and replace strategy remains to be determined, the often-mentioned repeal of the medical device tax would help to lower costs and amplify the gains already being made by the innovative medical device sector."

David Squibb, Chief Sales and Marketing Officer of Xpertdoc — a global software company (Terrebonne, Canada): "The impact the Trump presidency could have on healthcare and the ACA in particular are significant. If, as Trump has mentioned on the campaign trail, he will dismantle the ACA completely, there could be several key takeaways. Carriers could halt investments in insurance technology due to uncertainty over future legislation and compliance efforts, which could negatively impact customer engagement and experience if investments are not being made.

In addition, without a mandate like the [Summary of Benefits and Coverage] — where carriers must meet certain requirements as it relates to documents and communication — insurers may regress with member communications because there will be no standard format. Overall, the dismantling of the ACA will have repercussions both large and small, and insurers will need to be prepared for that option."

Mike York, COO of PracticeMatch — a physician recruitment company (St. Louis): "It will be interesting to see what impact a Trump presidency will have on the ACA, particularly with Republicans controlling the House and Senate as well. It was a campaign message of Mr. Trump's to repeal and replace the ACA, and there are already different versions for the repeal sitting in Congress, ready to go when the new regime takes charge. It could have a positive impact, since most insurers were starting to pull out of state exchanges, limiting people's choices for healthcare coverage and access. Also, the recently announced very large premium hikes for 2017 will have a negative impact on individuals signing up for insurance. The impact to hospitals could be severe, as less people may have insurance. Let's hope there is a solution that can tackle these issues coming next year."

Sue Kressly, MD, Medical Director of Office Practicum — a company focused on pediatric EHR (Philadelphia): "What are the implications of the elections for healthcare and for physician practices? Of course, only time will tell, but for pediatricians the biggest immediate concerns are implications for Medicaid payment, families affected by ACA plans and adjustments in HITECH.

It is likely that Medicaid funding will change based on the shift of party control. Block grants to states that then individually make decisions on how that money gets distributed will necessitate that advocates for children are mobilized in each state. It will be necessary for pediatricians to create partnerships and work to ensure that the case for investing in our children is heard and the American Academy of Pediatrics' Blueprint for Children is distributed.

While only a small percentage of children are covered under ACA plans, many of the 20 million Americans who have ACA-sponsored insurance are parents of the children we care for. We know that the healthcare of parents has significant impact on the health and well-being of their children. With one in five children currently living in poverty, adding potentially uninsured parents can increase our population at risk. The details of changes including whether young adults can remain on their parent's plans until age 26 and how pre-existing conditions will be impacted have far-reaching implications for the families we care for.

Many physicians have been struggling with meaningful use and other implementations of the HITECH Act. Information blocking, reporting burdens and lack of universally applied robust standards have left many practicing pediatricians seeking a much-needed pause to catch their collective breath. In addition, only 50 percent of pediatricians received any incentive EHR monies due to the Medicaid threshold requirements.

The change in leadership might give us the opportunity to let the usability of systems catch up to the projected roadmap. In addition, MACRA and MIPS have been primarily focused on delivery of healthcare to adults. A slowed timeline to move toward alternate payment models gives pediatricians the opportunity to advocate for how such models might include children. While children consume only a small portion of the healthcare dollars, they are 100 percent of America's future and future healthcare expenditures."

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