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It Isn’t News That Trump Wants to Keep Pre-Existing Condition Reforms

Nov 13, 2016• 3

By ROBERT LASZEWSKI

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The Wall Street Journal, The Washington Post, CBS News and other news outlets have led with headlines over the weekend touting the big news that Donald Trump is willing to keep parts of the Affordable Care Act––notably the pre-existing condition protections and the ability for children up to the age of 26 to stay on their parents policies.

Except this isn’t news.

In May, Trump’s policy advisor told Healthline that a Trump administration would consider keeping the children to age 26 provision.

And, then there is this February debate exchange between Trump and a CNN moderator:

TRUMP: “I want to keep pre-existing conditions [the Obamacare provision that prohibits insurers from denying coverage]. I think we need it. I think it’s a modern age. And I think we have to have it.”

DANA BASH: “Okay, so let’s talk about pre-existing conditions. What the insurance companies say is that the only way that they can cover people is to have a mandate requiring everybody purchase health insurance. Are they wrong?”

A Vote For Trumpcare

Nov 12, 2016• 59

By NIRAN AL-AGBA, MD

The world is not going to end. We witnessed a revolution earlier this week. The people have spoken and they chose the anti-establishment, street smart, government shrinking candidate who bucks the status quo. We find ourselves in uncharted territory, with an unpredictable President-elect, who has unclear plans for healthcare. Here is what we do know. Mr. Trump is a successful entrepreneur. Forbes describes the entrepreneurship pathway as having no clear story line, but a “sense of chaos, hectic decision making, and moments of great fear and doubt.” Improving our broken healthcare system will involve decision making in the face of great uncertainty. Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job.

Mr. Trump won over the white working-class individuals in small rural areas. Sluggish economic recovery in these areas played a significant role in his unanticipated victory. It is these disenchanted individuals watching the American Dream slip through their fingers who voted for Mr. Trump. Those same people want the freedom to buy the insurance they need, and not what the bloated government shoves down their throats. 25% of the population lives in rural areas yet only 10% of the physicians practice in there. Physicians are leaving the system in droves, closing their patient panels, and not keeping up with demand, thereby threatening patient access in these isolated locales.

So what does Trump mean for new health tech?

Nov 11, 2016• 23

By MATTHEW HOLT

Matthew-Holt-color I’m a pundit who like everyone else was surprised by Trump’s victory in the (profoundly undemocratic and hopefully-to-be-abolished-soon) electoral college, and everything I say here is prefaced by the fact that there was very little discussion of healthcare specifics by Trump. So there’s no certainty about what will happen–to state the obvious about his administration!

What we do know is that Trump said he’d repeal & replace the ACA and the House has voted to repeal it many times (but the Senate has only once & Obama has always vetoed that repeal). A full and formal repeal requires 60 votes in the Senate which it won’t get with the Democrats holding 48. Note that the Democrats needed 60 votes to to forestall a Republican filibuster in order to pass the ACA in 2010. That 60 vote total is a very rare state of events which existed for only only one year–from Jan 2009 until Scott Brown won Ted Kennedy’s old seat in Jan 2010 and one we likely won’t see again for many years.

But this doesn’t does not mean things will continue as usual for two reasons. Congress can change the budget with the Republican 52 seat Senate majority, and the Administration can change regulations and stop enforcing them. So we have to assume that the new Administration and its allies(?) on the Hill will roll back the expansion of Medicaid which was responsible for most of the reduction in the uninsured (even if it didn’t happen in every state). They’ll also reduce or eliminate the subsidies which enable about 10m people to buy insurance using the exchanges. Both of those were in the repeal bill Obama vetoed, although in the bill the process was delayed for 2 years.

This of course may not happen or may be replaced by something equivalent because many of the people who voted for Trump (the rural, white, lower-income voters) fall into the category of those helped by the law, and in a few of his remarks he’s also said that he’ll be taking care of them. Even this week Senator Wicker (R-Mississippi) said that they weren’t going to take away 20 million people’s insurance. In Kentucky which went from a Democratic to Republican governor 2 years ago, the new administration ended their local exchange (from 2017), but in fact not much consequential happened as people were sent to the Federal exchange. If there are changes to the exchanges and the individual mandate or they’re both abolished, there’ll be lots of commotion but it won’t be completely system changing.

My day job at Health 2.0 involves running a conference and innovation program based on a community of companies using SMAC technologies to change health care services and delivery–either by starting new types of health care services or selling those technologies to the current incumbents. So I’m acutely interested in what happens next, albeit somewhat biased about my preferences!

Overall I think that (unlike many other areas of American life) health care technology won’t be that greatly affected. Continue reading…

Deciding the Future of the Veterans Health Administration

Nov 11, 2016• 4

By JOEL KUPERSMITH, MD

The waitlist scandals of 2014 opened a broad discussion on the future of the Veterans Health Administration (VHA). The immediate Congressional response was an Act that funded the Choice Program whereby VHA enrollees could obtain care in the community under certain circumstances. The same Act also mandated the blue ribbon Commission on Care Report and VA’s Consolidation Plan, both of which had wide-ranging plans to change VHA as have similar documents by veteran service organizations (VSOs).

A central component of these plans and proposals are options for community providers to care for VHA enrollees. Although VA had only 90 days to implement the Choice Program and it has had administrative difficulties, 1 million of the 9 million VHA enrollees have received part of their care in the community via the Choice Program.

Repealing and Replacing the ACA: A Whole New Ball Game. Same Problems Though.

Nov 11, 2016• 6

By STEVEN FINDLAY

I’ll dive right in, with the stipulation that this blog is initial reaction in a very fluid, unprecedented and soon-to-be even-more-intense political environment. Fasten your seat belts!

The ACA. Replace is the critical word in “repeal and replace.” Consensus is already emerging that Trump and the Republicans will indeed repeal the ACA in early 2017, via the reconciliation process Congress used earlier this year. That resulted in the Senate’s first an only full ACA repeal vote. Obama vetoed the bill, of course. But Republicans demonstrated the do-ability of the reconciliation process. Lacking 60 votes in the Senate, they’ll very likely try repeal again that way.Continue reading…

Dancing on the Grave of Obamacare: Questions

Nov 10, 2016• 8

By JOE FLOWER

I hate to interrupt the festivities, but I have a few questions. There are one or two little unknowns here. The answers to these questions are matters of life and death to many in the industry, literal life and death to many thousands of patients, organizational life and death to thousands of companies, hospitals and systems.

Tuesday’s extraordinary events obviously present an enormous challenge for anyone who wants to think about the future of healthcare. The challenge is far more than simply trying to imagine the healthcare industry without Obamacare, or under whatever Trumpcare will turn out to be. A much more powerful effect will be come into play far earlier: the uncertainty over that future will have reshape the industry before we even get to the actual “repeal and replace” part.

An Early Prognosis: What Will Become of Healthcare IT in the Age of Trump?

Nov 9, 2016• 5

By PETER WILEY

In the United States, it’s the Day After. The future of American policy – from immigration to foreign trade to national defense – is full of kinetic uncertainty. One thing is certain: that Donald J. Trump – who has brought something very different from palpable policy proposals to the American electorate – is President Elect of the United States.

There is no shortage of morning-after polemic: some are crying, some are celebrating, and others still are sleeping off the night. Whatever one’s political belief, our industry is perhaps at the center of the new sea of trumpian uncertainty. Indeed, the future of healthcare in the United States, and particularly the role of technology in healthcare, is neither bright nor grim. Unlike last night, it’s too early to call.

What we know about Trump and healthcare is both frustratingly limited but also widely telling. Trump has summarized his post-Obamacare vision as a system that boasts “lots of plans” that will function amorphously across state lines, toppling a partly imagined barrier against competition among plans in different states. We know he views the Affordable Care Act as a “disaster” and, like other drivers of federal spending, sees dealing with corruption, overspending, and “bad deals” at the core of the still-unknown solution to healthcare’s many woes.

Post-Election Analysis: Making Healthcare “Great Again”

Nov 9, 2016• 14

By PAUL KECKLEY

The election results are in and Donald Trump will be the 45^th president of the United States. His appeal to “Make America Great Again” resonated across the heartland sparking an unprecedented political upset that surprised even the most astute prognosticators and pundits.

When he takes office in January, he’ll face enormous challenges domestically and globally. Healthcare will be at the top of the list: he promised to “Repeal and Replace” the Affordable Care Act, and he pledged changes that strengthen the system in his campaign’s seven-point plan. In this effort, his team will face harsh realities:

Containing health cost will to be the dominant issue. Total healthcare spending will increase 6% annually for the next decade. Utilization is up. Demand is increasing and traditional reimbursement is not keeping pace with underlying costs. That’s not sustainable. Something’s got to give.
The fundamental structure of the health system is shifting. Healthcare is no longer a cottage industry. Mega deals across the board are pending: the Anthem-Cigna, Aetna-Humana, Dignity-CHI and more. And in most communities, half of the physicians are employed by hospitals that are affiliated with multi-hospital systems. The health system’s future will play out against new ways of competing.
Alternative payment programs (APMs) are changing incentives for providers. With MACRA payments to physicians and mandated bundled payments for heart failure, coronary artery surgery and joint replacements for hospitals coming on line next year, providers are anxious. What’s next? What’s their future?
Competition from non-traditional entrants is increasing. Investors are flocking to start-ups that challenge the status quo in healthcare. Their ranks include retail clinics, micro-hospitals, telemedicine, urgent-care centers, disposables, smart implantables, hybrid insurance models and others that challenge stakeholders to innovate faster and more effectively. It’s a huge industry that’s historically made its own rules and kept outsiders out. That’s changing.
And the public is divided about the Affordable Care Act: half believe it a necessary impetus for expanding insurance coverage and lower costs, and half feel it’s an over-reach by federal bureaucrats that want a government-run health system.
Continue reading…

No, I Didn’t Expect That Either.
What’s Next?

Nov 9, 2016• 5

By MATTHEW HOLT

As a Democrat, I can only hope this is a Dewey defeats Truman moment, but at 2.00am ET on Nov 9, President Trump with a Republican House and a open Supreme Court seat seems to be our new reality. For the health care establishment, this is a bombshell. It’s been easy for Congressional Republicans to vote to repeal the ACA when they knew Obama would veto it. But what happens next when Trump is happy to sign the “repeal”?

It’s hard to figure out what’s there in terms of putting together to “replace” either in the Congressional Republicans or in what passes for policy in what passes for the Trump camp. As Margalit Gur-Aire said on THCB recently other than one speech with some stale talking points about block grants for Medicaid and selling insurance across state lines, Trump seems to have no ideas about health care. (To be fair he doesn’t seem to have any ideas about anything, or he claims they’re a secret).

Then we have the issue of his relationship with Congress. Now he’s President he may declare a truce, but then again he might decide to tweet into oblivion Paul Ryan and the many others who wouldn’t support him. And he might of course self-immolate as he tries to manage his business, his relationship with Russia and his soon to be launched TV network–while actually having to be President.

But if he’s going to end Obamacare, Trump is going to have to worry about two things. First, he has said that he wants to repeal it but is going to make sure everyone can buy health insurance, even if they have preconditions. When the middle aged white working class who voted for Trump discover that their Medicaid and their health insurance goes away, and that insurers wont sell them insurance if they’re not a good risk, they might be unhappy.

Second, the other people who are going to be unhappy are the health care industry stakeholders. Health care is a series of complex legislative and market interactions. As a consequence of the ACA, most health insurers, providers and even pharma or device companies have made huge changes to their business strategy. Those business strategies and investment are now six years old. Like Wall Street and corporate America, Trump is going to make the health care establishment deeply uncomfortable. The question is, once big pharma, insurers and providers lean on the Administration, will anything actually change, or will we see the route towards value-based care continue?

Not only that, but the sea-change that is just starting in the shift from FFS to value-based payments from Medicare & CMS is underway because the country can’t afford continued health care cost growth. That remains the same. Eventually that reality will impinge even on a Trump administration.

So what happens next? Well it’s amateur hour and we’ve all failed to predict it thus far, so it’ll be tough to do it now. But health care will be a sideshow.

Oh, and time to repeal the frigging electoral college.

Death and Readmissions

Nov 8, 2016• 4

By ANISH KOKA, MD

Eugene’s wife is on the phone. She has been taking care of Eugene for 41 years. I supposedly take care of his heart, weakened by two prior heart attacks. I say supposedly because his wife does all the heavy lifting. She makes sure he takes his medications when he should. She watches his weight every day and occasionally administers an extra dose of diuretic when his weight climbs more than a few pounds in a day. And perhaps most importantly, she calls me when Eugene’s in the hospital and things seem wrong to her. This is one of those phone calls. They were in the ER, Eugene hadn’t been responding to his diuretic as he normally does, and his breathing seemed more labored to her. The ER physician wanted to send them home – she was hoping I would weigh in. Not surprisingly, she was right, Eugene needed to come into the hospital. I used to be surprised when the ER wouldn’t call me for complex cardiac patient having an acute cardiac problem. Not any more.

There is a clear culture shift that is obvious to those who have spent any time in the ER over the past ten years. Low risk patients used to be managed and discharged from the ER, and higher risk patients were quickly admitted to the hospital for management by specialists. This used to be a source of tremendous friction with the ER in my younger years, as I would try to explain to ER physicians that every single chest pain in a patient with known coronary disease did not deserve admission. I seldom have this conversation with the ER anymore. What changed?