What a Clinton Administration Could Mean for Government Health Programs

So the people spoke and we are heading for an epic cagematch smackdown general election between reality TV star Donald Trump and former Senator and Secretary of State Hillary Clinton.  And you’re asking, what’s going to happen to Medicare, Medicaid and ObamaCare? The answer is plenty — below the waterline and out in the states.  Stakeholders will need to pay attention or get left behind.

First, the likely scenario is that Hillary is going to win this thing big.  While other Republicans may have had a chance to capitalize on her high negatives with likely voters, nobody’s negatives trump Trump’s.  He’s the most unpopular major-party candidate since polling began.  Most polls have him losing by double digits in November.

At this moment, Trump’s likely to lose so bad that many down-ticket Republican Senate and House seats are now in play. So: Hillary in the White House, Democrats likely running the Senate again, and poor Speaker Paul Ryan trying to corral an even more radical, noisy and smaller Tea Party caucus in the House. The only people those guys hate more than President Obama are the Clintons. So betting on more gridlock is safe money.  Little or nothing gets done in Congress except the bare minimum to keep government running.

That means most of what happens in Medicare, Medicaid and ObamaCare will occur “below the waterline” in Administrative policy, regulation, and guidance, or is driven by the states.  Here’s what that could look like:

  • Medicare: the forced march to value-based payment across the program will continue.  The recent MACRA rule makes it clear that a fundamental change to traditional Medicare is coming and that fee-for-service is dead. By the end of Hillary’s term, a majority of Medicare dollars will be tied to provider performance.  Medicare Advantage will continue its steady 5-7% annual growth and exceeding 25 million enrollees in 2020. But CMS raises the bar through a rapidly-maturing Star Ratings program and an aggressive compliance and auditing initiative carried over from Obama’s last year in office. Regulations and guidance are pumped out in regular order, drafted by newly-emboldened career CMS staff and making the program a laboratory of continuing performance improvement with claws and teeth.
  • Medicaid: on the heels of the biggest regulation in 12 years, Medicaid converges more than ever with Medicare Advantage and ObamaCare, but also goes down some very strange alleys.  With Obama out of office, several more red states like OK and TN finally take the Medicaid expansion deal from the Affordable Care Act.  But with it they insist on “conservative principles” like work requirements and drug testing that dampen coverage and introduce new complexities to the program. At the same time, blue and red states alike flood CMS with new home and community-based services waivers to force dual eligibles into health plans and implement managed long-term care programs.
  • ObamaCare and health insurance exchanges: health plans in the public exchanges continue a market correction and shakeout for another two years.  During that time, CMS issues even more regulations dove-tailing exchange operations with Medicare Advantage rules, and several states currently running their own marketplaces like CO revert to healthcare.gov.

Health plans and other stakeholders in these programs will need to pay more attention than ever to stay ahead as government solidifies its role as their biggest customer.  These are changes that won’t necessarily be splashed across major media, but rather in trade rags and expert blogs. The only thing that’s certain: it won’t be dull.


The Centers for Medicare & Medicaid Services (CMS) issued the final Medicaid “mega-rule,” a huge regulation that makes changes to every part of the current managed care rules. Read more >>

Under the provisions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA), physicians and other practitioners will face a Hobson’s choice: live with a more aggressive risk-based adjustment to payments or join forces with an alternative delivery model, like an Accountable Care Organization (ACO), that is taking risk. Read the full article >>

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