On January 20, 2017, Donald J. Trump will be sworn in as the 45th President of the United States of America. He comes into this role after what many consider to be the greatest political upset in modern day history. The uncertainty ahead that many speak of is not meant necessarily in a positive or negative way, but rather speaks primarily to what happens when a self-proclaimed political outsider joins what is largely considered a “club” of lifetime politicians. There is no track record to look to for predictions of his policy directions, leadership style, or of his ability to work across party lines. Nothing about this election cycle has been typical and there is no reason to expect that to change anytime soon.
Joining President-elect Trump in Washington will be a Republican-led Congress, as Republicans held on to the majority in the House and the Senate (although their Senate margin narrowed to a 51-seat majority). It has been 10 years since Republicans controlled the White House and both chambers of Congress and this shift will have significant impacts on policy making. Most notably, even without a filibuster proof majority in the Senate (60 seats), Republicans will now have the advantage of using other procedural maneuvers, such as budget reconciliation to pass significant policies and will no longer have the constant threat of a presidential veto. Depending upon if/how/when Democrats plan to use their filibuster power, however, we could see increased use of reconciliation, continued partisan gridlock or even the end of the filibuster as we know it if Republicans feel as though Democrats are blocking them at every turn.
One area where we are most likely to see significant changes is in health care, specifically around the Affordable Care Act (ACA). President-elect Trump, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell have all promised swift action to repeal (either in whole or in part) the ACA. Doing so without a clear alternative, however, could leave 20 million Americans without health care coverage. So although this promise has been made, it may be more difficult to achieve than many expect. Republicans and the president-elect have put forth several health care proposals over the years but will need to be able to coalesce around those policies that would ultimately replace those in the ACA if repeal is to truly be considered.
Some areas in the ACA that could be vulnerable to repeal include the individual and employer mandates, the subsidies to purchase health insurance, and funding to expand Medicaid. Despite several Republican governors expanding Medicaid via the ACA, there is significant opposition from Republicans in Congress to the current structure of the Medicaid expansion. Additionally, although there is widespread, bipartisan consensus on the need to transition from a fee-for-service world to that of value-based care, the future of the many value-based delivery models being implemented by CMS remains uncertain. Much of the work around these models has been via the Center for Medicare & Medicaid Innovation (CMMI), which has been under significant scrutiny, both for its breadth of authority and pace of implementing new programs. With the significant and often-scrutinized funding that CMMI receives, it, too, could be vulnerable to efforts to scale back if not repealed in its entirety.
So what does all of this ambiguity mean for hospitals? Oftentimes, with uncertainty comes more confusion. Hospitals have spent years preparing for and implementing the ACA, often leading the charge towards value-driven health care. Without clear policies ready to take the place of the ACA, it is certainly possible that hospitals could see drastic reductions in insured patients as well as potential halting of federal, value-based delivery system programs that are already underway. That, of course, may be a worst-case scenario, but it’s certainly something to consider.
For a deeper dive into what a Trump administration might look like and its potential impact on health care and hospitals, see our analysis.
When Congress returns next week, they will likely only take up two initiatives: funding the government past Dec. 9, when the current continuing resolution expires; and considering legislation often referred to as 21st Century Cures to increase NIH funding and streamline the FDA’s review of drugs and devices to help advance biomedical innovation.
Once they have (hopefully) completed work on those initiatives, Congress will leave town, President Obama will transition out, and Washington will prepare itself for the changes to come in 2017.
