Saturday marks President Trump's 100th day in office, and in that time his administration has taken several key actions that have roiled the health care industry. Daily Briefing took a look back at Trump's health care agenda thus far and identified the five key policy issues that have dominated his first 100 days in office.
1. Trying—and failing, and maybe trying again—to repeal and replace the Affordable Care Act
This was one of Trump's biggest campaign promises, and on day one of his presidency Trump signed an executive order directing federal agencies to "ease the burden" of the health reform law. It remains to be seen, however, how that order will be carried out.
As for repeal and replace, the fate of the ACA remains unknown. In Trump's 100 day action plan, he vowed to "work with Congress to introduce" legislation that "fully repeals Obamacare and replaces it with Health Savings Accounts, the ability to purchase health insurance across state lines, and lets states manage Medicaid funds."
But the bill he negotiated with Republican lawmakers, called the American Health Care Act, would keep in place several ACA provisions, and would allow states that expand Medicaid under the ACA by Jan. 1, 2020 to let individuals enrolled under the expansion to maintain coverage—at least as long as their Medicaid eligibility did not change. Eric Cragun, senior director of health policy at Advisory Board, said, "For providers, the fate of Medicaid expansion and Medicaid funding reforms like per capita caps holds the greatest potential impact."
Those provisions also made waves among conservative lawmakers who characterized the bill as "Obamacare Lite," as well as some moderate Republicans who were concerned about the Congressional Budget Office's projected coverage losses. The opposition, ultimately forced House Speaker Paul Ryan (R-Wis.) to pull the bill from a scheduled House vote last month.
However in recent days, the AHCA has returned from the dead. The latest plan to unify Republicans around the bill would allow states to apply for waivers to opt out of certain ACA requirements, which providers' groups warn would increase patients' health care costs, increase the number of uninsured Americans, and allow insurers to discriminate against individuals with pre-existing conditions. And while the changes have earned the conservative House Freedom Caucus' stamp of approval, some moderate Republicans have said they remain opposed to the measure. "While House Republicans may eventually pass a repeal and replace bill—possibly as soon as next week—passing similar legislation through the Senate remains an even bigger hurdle, especially given the arcane rules governing legislation passed through reconciliation," Cragun said.
2. Tightening restrictions on the individual insurance markets
The Trump administration earlier this month released a much-anticipated final rule outlining changes—which, among other things, restrict when consumers can enroll in coverage during special enrollment periods—for the 2018 open enrollment period. Insurers are weighing whether to participate in the exchanges for the 2018 coverage year, and at least one insurer—Humana—has said it will no longer participate in the exchanges in any markets next year.
The final rule was well received by insurer and provider groups, which said the changes would help sustain the marketplace for insurers and consumers. The biggest criticism from those stakeholders was that the rule did not address the Trump administration's plans regarding the ACA's cost-sharing reductions, which help low-income consumers pay for out-of-pocket health care costs and are being challenged by the House in court. American Hospital Association EVP Tom Nickels characterized the payments as the "most critical challenge facing the marketplaces today."
Cragun said, "In the short-term, the stability of the individual insurance market rests on whether the administration continues to make CSR payments moving forward."
After weeks of uncertainty, White House officials this week told House Minority Leader Nancy Pelosi (D-Calif.) that the administration would continue making the payments for now, though it remains unknown whether the payments will be made long-term.
3. Granting states more flexibility to adjust Medicaid enrollment requirements and benefits
Trump's decision to tap Seema Verma, who is known for her work with Indiana officials to reform the state's Medicaid program, to head CMS was an early indicator that his administration would be more lenient with the types of Medicaid waivers states could approve. This was later confirmed by a letter from HHS Secretary Tom Price and Verma encouraging state governors to submit waivers to change their Medicaid programs by implementing initiatives such as work requirements.
And it appears several states are planning to take them up on their offer. Maine recently joined Arizona, Florida, Kentucky, and Ohio in signaling its intention to submit a waiver to require able-bodied adults to work a set number of hours, or demonstrate they are actively job hunting, to qualify for Medicaid.
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In the letter, Price and Verma said such policies could "help working age, non-pregnant, non-disabled adults prepare for private coverage" and give states needed flexibility to administer tailor their program designs to their state's specific needs. But a Health Affairs study released earlier this month highlights some of the controversy around the proposal: Many beneficiaries who would be affected by an able-bodied work requirement have physical or mental conditions that impede their ability to work but do not qualify them as disabled.
4. Signaling that value-based care is here to stay—even while delaying expansion of mandatory bundled payment models
Price, secretary of HHS, is a longtime critic of the Center for Medicare & Medicaid Innovation's mandatory payment models, so it was not too surprising when CMS last month announced plans to delay by three months the mandatory cardiovascular bundled payment model as well as an expansion of the current mandatory joint replacement model that had been set to take effect in July.
However, Price has signaled overall support for MACRA and the industry's transition to value-based care. During his confirmation, Price highlighted MACRA as an example of bipartisanship and noted that the new system established by the law, "if implemented properly, will help ensure that seniors have better access to higher quality care."
Cragun said Advisory Board expects "payment reform to continue moving forward, though it will certainly evolve. There remains strong bipartisan support for shifting away from fee-for-service, and the Quality Payment Program established under MACRA will be a key driver of that shift."
5. Pushing to address the opioid misuse epidemic
Trump has made the United States' ongoing opioid misuse epidemic a key focus for his administration. Since taking office, he has announced plans to assemble a "SWAT team" of top business leaders to tackle opioid misuse and other national issues, held a roundtable discussion on efforts to address the issue, and most recently, allocated $485 million in grants to help states combat opioid misuse.
Further, Trump's pick to head FDA, Scott Gottlieb, has indicated the epidemic will be his top priority if confirmed by the full Senate. Gottlieb told lawmakers on the Senate HELP committee that the epidemic is "a public health emergency on the order of Ebola and Zika" that will "require dramatic action."
What the next four years will hold
Trump has made it clear that he will continue to work with Congress to pass a bill to repeal and replace the Affordable Care Act, even if it is not within his original timeframe. And his picks to head HHS, CMS, and FDA suggest Medicaid waivers, Medicare value-based payment programs, and the fight against opioid misuse will continue to be areas of focus over the next four years.
What does health care reform beyond the ACA look like? Join us on May 2nd
Stuart Clark, Managing Director
The first part of the Health Care Advisory Board’s latest “State of the Union” explores what the Trump administration and GOP-controlled Congress will mean for the future of coverage expansion, payment reform, and federal entitlement programs.
The presentation provides an objective analysis of the next era of health care reform, unpacking the potential futures of Medicare, Medicaid, and the private insurance market—and what those changes would mean for provider strategy. The presentation also includes a detailed assessment of the accomplishments, shortcomings, and unintended consequences of the Obama-era reforms.