Pres­i­dent Trump’s health­care plate is full, and it won’t go down easy

Modern Healthcare - - NEWS - By Har­ris Meyer

Pres­i­dent Don­ald Trump ran for elec­tion pri­mar­ily on the is­sues of jobs, fair trade and tougher im­mi­gra­tion en­force­ment. He only spo­rad­i­cally dis­cussed health­care. In vague terms, he promised to re­place Oba­macare with “some­thing ter­rific,” pro­tect Medi­care and Med­i­caid from spend­ing cuts and changes, and rein in ris­ing pre­scrip­tion drug costs.

But as he takes of­fice after be­ing in­au­gu­rated Fri­day, he faces the very real prospect that his first year in the White House could be dom­i­nated by com­plex and bit­terly di­vi­sive health­care is­sues, car­ry­ing big po­lit­i­cal risks for his pres­i­dency and his party.

Eras­ing the Af­ford­able Care Act could dis­rupt in­sur­ance for nearly 30 mil­lion Amer­i­cans cov­ered in the in­di­vid­ual mar­ket and un­der Med­i­caid ex­pan­sion, in­clud­ing many of his white work­ing­class sup­port­ers. He must over­come sharp di­vi­sions in his party about how to re­place the law’s cov­er­age, and con­vince at least some Se­nate Democrats to go along with his al­ter­na­tive.

The week be­fore his in­au­gu­ra­tion, Trump promised “in­sur­ance for ev­ery­body” with “much lower de­ductibles.” Claim­ing his plan was near com­ple­tion but of­fer­ing no de­tails, he boasted that it would be “great health­care” that left peo­ple “beau­ti­fully cov­ered.”

If he fails to ful­fill his vow to re­peal and re­place the law with some­thing much bet­ter, Re­pub­li­cans could be in a vul­ner­a­ble po­si­tion de­fend­ing their con­trol of Congress in the 2018 elec­tions, putting the sec­ond half of Trump’s pres­i­dency in jeop­ardy.

A more im­me­di­ate risk is that Trump’s and con­gres­sional Re­pub­li­cans’ broader agenda on taxes, the econ­omy, trade, dereg­u­la­tion, im­mi­gra­tion, mil­i­tary ex­pan­sion and other is­sues could get de­railed by health pol­icy bat­tles. “The Trump ad­min­is­tra­tion is in dan­ger of be­ing swamped by health­care,” said Jonathan Ober­lan­der, a health pol­icy pro­fes­sor at the Univer­sity of North Carolina. “A num­ber of pres­i­dents have taken on health­care and found it was more than they could chew.”

Con­gres­sional Democrats also are play­ing for high po­lit­i­cal stakes. If they al­low Pres­i­dent Barack Obama’s his­toric ini­tia­tive to pro­vide health in­sur­ance for nearly all Amer­i­cans to die with­out an ad­e­quate sub­sti­tute, it would deeply de­mor­al­ize their sup­port­ers. But if they can block GOP ef­forts to roll back key parts of the law with­out be­ing seen by the pub­lic as ob­struc­tion­ists, that could vault them back into power and en­able them to fin­ish the job of cre­at­ing a univer­sal health­care sys­tem. Their chal­lenge will be to stay uni­fied, even as 10 Demo­cratic sen­a­tors ner­vously eye 2018 re-elec­tion races in states won by Trump.

And it’s not just Oba­macare at stake. There are many big health pol­icy is­sues on the ta­ble this year, and no one knows how they will play out. Some Re­pub­li­cans, led by House

As Trump takes of­fice, he faces the very real prospect that his first year in the White House could be dom­i­nated by com­plex and bit­terly di­vi­sive health­care is­sues, car­ry­ing big po­lit­i­cal risks for his pres­i­dency and his party.

Speaker Paul Ryan, are ea­ger to move on their party’s long­stand­ing goal of re­struc­tur­ing Medi­care and Med­i­caid to re­duce fed­eral spend­ing on the two gi­ant pro­grams. Trump and some Se­nate Re­pub­li­cans, how­ever, have ex­pressed reser­va­tions, par­tic­u­larly about mak­ing changes in the Medi­care pro­gram that’s beloved by their core con­stituency of older vot­ers.

“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 low­er­in­come 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.

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.

Pres­i­dent Don­ald Trump made no men­tion of health­care dur­ing his in­au­gu­ral ad­dress on Fri­day.

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