By Dr. Koka Improbably, a real estate tycoon turned reality TV star with no political experience has been elected president by a fiercely divided nation.
There are a number of questions about the plans of a Donald Trump administration with regards to healthcare, and patients and physicians are understandably fearful. Seismic shifts like this in the political landscape make it difficult to find certitude in predictions on healthcare policy, but there are a number of clues to suggest that the landscape of healthcare may be an improving one for patients and the physicians charged with taking care of them.
At the top of the agenda for both Trump and Congress is repealing the Affordable Care Act (ACA). Clearly, this is much easier said than done. The healthcare reform law is a complex series of expansive regulations that touches payment reform, healthcare delivery and, oh, by the way, also covers 20 million Americans. The easiest to kill of the three would seem to be the Obamacare marketplace covering all those Americans that is propped up by federal subsidies that take the form of “cost sharing” payments to insurance companies. Eliminating funding for these subsidies would make insurers exit the Obamacare marketplace and make it nonviable.
Millions of patients currently with insurance would suddenly lose their health plans. No one wants this, and Trump and the Republican Party now face intense pressure to come up with a replacement. As a result, I find it very unlikely that physicians or patients will suddenly have to deal with a large number of patients without insurance. There are also encouraging signs that the replacement plans being discussed will more than likely include health savings accounts—a Trump/GOP favorite—that will be allowed to directly pay primary care physicians in a subscription model similar to direct primary care. This capitated model puts physicians, rather than insurance companies, in the driver’s seat and would be music to the ears of primary care physicians in desperate need of a lifeline
The biggest immediate headache is the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which physicians will have to face in less than two months, but it only slightly overlaps with the ACA. The overlap relates to the Center for Medicare & Medicaid Innovation (CMMI) that was funded by the ACA, and created some of the important value-based payment models physicians were going to have to comply with to avoid reimbursement penalties. The wide latitude given CMMI to propose and deploy Advanced Alternative Payment Models (APMs) under Medicare payment reform has already come under scrutiny by Republican legislators prior to a Trump victory. One would expect that in the Trump era, CMMI is unlikely to survive in its current form. This would provide significant relief to physician practices enrolled in APMs struggling to cope with the time and cost of the seeming barrage of regulatory hoops to jump through.
The good news with regards to physician income is that the Medicare penalties set to begin in 2019 as part of MACRA for those physicians who either don’t report or inadequately report data may be moot. I have trouble believing that a party and a candidate that railed against Obamacare’s big government will continue to penalize physicians for not reporting in to Big Brother. At the very least, I am hopeful there will be other avenues provided to physicians to avoid penalties. The bad news with regards to physician income, especially for those primary care physicians already under a fair amount of duress, is that income is unlikely to go up anytime soon given the difficulties attendant in making the elephant that is the healthcare economy pivot on a dime.
One may hope that physicians may at least see relief in the form of a friendlier tax code given candidate Trump’s many promises regarding lower taxes. Trump’s stated tax plan would reduce the top tax rate from 40% to 33%, and for physicians in private practice, the tax rate for small businesses would be a guiltily low 15%. These numbers, of course, are more representative of a low opening bid to a democratic minority sure to be vehemently opposed to significant tax reduction. As is true of healthcare policy, the overwhelming likelihood is that the short-term fiscal climate will not get better or worse. Given that a Clinton administration promised more regulation and higher taxes, this should still assuage many physicians.
The effect of electing Trump has completely changed the tenor of the conversation in healthcare. Our former healthcare policy masters that long worked successfully to transfer power from independent physicians to large clinically integrated networks that employ physicians are, for the moment, on the outside looking in. The idea that we may be entering an era that empowers physicians rather than devalues them should fill all of us with great optimism.
By Dr. Koka
Improbably, a real estate tycoon turned reality TV star with no political experience has been elected president by a fiercely divided nation.