Shapes in the Fog in Government Health Programs Become Clearer

It’s only been four chaotic weeks into the Trump Administration, but the shapes in the fog in government health programs are slowly becoming clearer.

The emerging “Herbal Tea Party” is continuing its civil disobedience into its second month, hijacking GOP town hall meetings to protest ObamaCare repeal, and the politics are shifting. U.S. Rep. Tom Price was recently confirmed as the Department of Health and Human Services (HHS) Secretary under an ethics cloud, and Seema Verma’s confirmation hearing to be the Centers for Medicare & Medicaid Services (CMS) Administrator is this week. These developments mean change is about to come at us fast.

President Trump and Congress are starting to see, right in their grills, “repeal and replace” ain’t happening. It’s going to be “repair and rebrand” instead and likely not until the fall.  It’s really the simple math of vote-counting in Congress:

  • Repeal can be accomplished by budget reconciliation, a maneuver that allows only items impacting the budget to pass with a majority vote in the Senate.
  • But at least 9 GOP Senators have said no repeal without replace, and replace legislation has to be filibuster-proof at 60 votes.
  • That means Republicans have to draw at least 8 Democrats to their side to pass any kind of replacement, which in turn limits the bill to cosmetic changes.

I think we’ll see repeal of the most odious ObamaCare taxes and mandates, conversion of subsidies to payers to tax credits to individuals, expansion of health savings accounts, and rebranding as TrumpCare. I’m starting to think this will happen in September when the Children’s Health Insurance Program (CHIP) reauthorization comes up and the GOP has the summer to get their bill together and whip votes.

I don’t see any major reforms happening to either Medicare or Medicaid at this point. Many Republican governors, especially those who expanded Medicaid under ObamaCare, are already resisting Medicaid block grants, and now AARP is opposed on grounds that Medicaid’s biggest expense is for long-term care. Speaker Ryan’s Medicare “premium support” or vouchers idea is grounds for open war with AARP and other seniors groups. Trump will tire of the delays and political cost to the rest of his agenda and will enact modest changes “below the waterline” such as rollbacks of Star Ratings measures and more “conservative principles” in Medicaid waivers. More on that to come.

Finally, I’m often asked whether Congress and Price are going to touch the Medicare Access and CHIP Reauthorization Act (MACRA). Many say, “It’s bipartisan, they’ll leave it alone.” I don’t think so, and here’s why:

  1. Nothing is sacred to the GOP anymore. What Republicans in Congress supported last year is no indication of what’s acceptable to them this year.
  2. Trump says deregulate. That sets the tone for his appointees.
  3. Price says lessen the burden on physicians. That means they’ll slow the timetable to value-based payment (VBP), make the payment reforms like Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) less onerous, and reduce many of the reporting requirements.

The march to VBP will slow to a crawl under Trump/Price.

As we begin our fourth week of Trump’s presidency, it looks like he will over-promise and under-deliver on his pledges to eliminate ObamaCare and reform Medicare and Medicaid and may hit the brakes on provider payment reform. It also means all of those things will carry on, largely intact, and all health professionals who value coverage should celebrate his future lack of success.



The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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