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  1. 1. By Dean Celia P resident-elect Donald J Trump’s campaign web site, for much of the election season, was emblazoned with the declaration: “On day one of the Trump Administration we will ask Congress to immediately deliver a full repeal of Obamacare.” Yet, days after he unexpectedly triumphed over Hillary Clinton, he told reporters “either Obamacare will be amended, or it will be repealed and replaced.” That’s a far cry from immediate delivery of a full repeal. At first blush, Trump’s latest statement comes across as a complete reversal from his pronounce- ments during the campaign. Short of a full repeal, many supporters who took him at his word might view anything else as a broken promise—and ut- terly surprising. However, Trump’s willingness to compromise should perhaps come as no surprise. He takes his cue from the business world, where you do and say what you must to stay in the game—and you always start out asking for more than you might be willing to accept in the end. In the same way the promise of a “huge impen- etrable wall” along the Mexican border might actually end up being a fence in places, a “full repeal” of the ACA could end up looking very similar to the system currently in place. First Report Managed Care spoke with government insiders and managed care experts in order to tease out the complexities of the path to a repeal, replace- ment, or restructuring of the ACA. TOO EARLY TO KNOW While many pundits, health care analysts, journal- ists, and others chime in to predict what is next for the US health care system with Trump at the helm and a Republican-controlled Congress manning the ship, Mike Leavitt reminds us that we really don’t know for sure what is in store. “It’s too early to know exactly what the Trump administration will do,” the founder and chairman of Leavitt Partners, a health care consultancy, told First Report Managed Care. As former Secretary of Health & Human Services (HHS) under President George W Bush, Mr Leavitt is no stranger to Washington politics or to the inner workings of the US health care system. He also served as governor of Utah for 11 years. One thing that Mr. Leavitt said he feels quite certain about is the continued migration away from fee-for- service medicine. So, while some speculate over “repeal and replace”, amend, or “repeal and delay,” Mr Leavitt chooses pragmatism. “We can bank on the movement to value-based care,” he stated during October’s AMCP Nexus 2016, when a Clinton win appeared to be the most likely outcome. Leavitt remains steadfast in his view. “The Republican Congress has established a clear pattern of supporting the transition from fee-for- service to value payment, as evidenced by legislation like MACRA [Medicare Access and CHIP Reauthori- zation Act],” he said during our interview. Even the nomination of orthopedic surgeon and current Georgia Congressman Tom Price, MD, to oversee HHS is not likely to slow things down—de- spite the fact that Dr Price has criticized the move to value-based payments. “There is a remarkable amount of bipartisan agree- mentwhenitcomestopaymentanddeliveryreforms,” Mr Leavitt said at AMCP Nexus, where he called MACRA “a sweepingly important law.” N0VEMBER 2016 • FIRST REPORT Managed Care WWW.FIRSTREPORTNOW.COM COVER STORY 16 TRUMPCAREThe Uncertain Path to Repeal Donald J Trump’s unexpected November win creates a number of questions about what the future holds for health care in the United States. In an exclusive interview, former HHS Secretary Mike Leavitt, and other managed care professionals, give their insight on how the GOP will most likely change the course of health policy in America.
  2. 2. WWW.FIRSTREPORTNOW.COM FIRST REPORT Managed Care • NOVEMBER 2016 17 MARKET, NOT POLITICS, DRIVING VALUE-BASED CARE Norm Smith, president of Viewpoint Consulting, Inc,agreedwithMrLeavitt’spredictions.Heexplained that “payment reform will be pretty far down the list of [Dr Price’s] priorities,” meaning that it is likely to continue to evolve due to market forces. “Value-based care is a strong trend in the market- place,” he said. Helping to prove his point, on the day Mr Smith’s made this comment, United Health care announced thelaunchofanewvalue-basedcarepaymentprogram related to certain orthopedic procedures. Mr Smith also noted that Dr Price, as an overseer of a federal agency, is bound to have a more nu- anced relationship with the value-based payment system than he does as a lawmaker or physician. “As a health care administrator, shifting risk to providers sounds like a great idea, so I am sure Dr Price will be ambivalent towards value-based care in his new job.” Additionally, Dr Price may be intrigued by how the so-called Triple Aim is being redefined as the Triple Aim plus one, “with a new focus on well-being, quality-of-life, and fair compensation for providers, especially physicians moving toward retirement age.” Mr Leavitt explained why he thinks that no matter who the HHS secretary is, the value-based system is not going away. The pressure to reduce health care’s share of the GDP has been a goal for almost 25 years. At AMCP Nexus, he speculated that there might be years to go in what may end up being a 40-year journey. For that reason, he told First Report Man- aged Care, “the transition from fee-for-service is not simply being driven by politics--it is being driven by domestic and global economics.” Mr Leavitt pointed to general agreement between Congressional Republicans and Democrats that: • fee-for-service is taking the US health system in the wrong direction; • coordinated care is better than uncoordinated care; and, • any proposals put forth will need to balance the budget. “While questions remain about what levers—mar- ket versus government—will be used, value-based payments will be embraced and accelerated under a Trump administration,” he explained. AMENDING THE LAW Mr Smith said he believes reducing health care’s share of the GDP is a noble goal, but added that the new president will be hard-pressed to pull it off. “Trump will not be able to positively impact the national debt,” he said. “Taking benefits away from citizens is extremely hard to do. We will all be lucky if medical costs stay less than double the consumer price index over the next 4 years. He’s promised way too much already and he may be pressed to spend more in health care.” So how will Trump deliver, and what is likely to change as his administration begins to tackle health care’s many challenges? For starters, wording in the Affordable Care Act (ACA) gives the Republicans a chance to make the changes it wants to make without repealing. Mr Smith has noted previously that there are hundreds of places in the ACA that contain the phrase “The Secretary shall…” This gives the new HHS administrator “the ability to adjust the law.” For example, Trump and Dr Price can order that the ACA get rid of the cost-sharing subsidies that help lower out-of-pocket deductibles, coinsurance, and copayments. They can also abandon the provision to cover contraception. However, other parts of the ACA require 51 Senate votes to eliminate—things such as the individual and employermandates,andMedicaidexpansion.Repub- licans have enough votes to make those provisions go away, but they likely know it is not prudent to do so without a plan to replace. For example, some believe Trump’s plan to roll back Medicaid expansion and instead give states a lump sum to manage will result in eliminating coverage for a substantial number of patients who have qualified under the ACA. Thus, Congress is apt to move judiciously. Additionally, given Trump’s desire to keep the pre-existing conditions provision (which requires a super-majority of 62 votes in the Senate to overturn), Congress is not likely to simply eliminate the mandate without something to take its place. REPEAL AND DELAY According to Barney Spivack, MD, national medical director of Medicare case and condition management at OptumHealth, and a member of the First Report Managed Care Editorial Advisory board, “repeal and delay” appears to be the most likely option in the end. “Given all the stories about how the law has actu- ally made a difference for many people, I don't see [immediate repeal] happening anytime soon,” he said. Repeal and delay, he noted, would also allow Republicans to “say they repealed the law,” without throwing the US health care system into tumult. It appears that they have most Americans on their side, according to a recent Gallup poll, more than half of respondents said they disapprove of the ACA. Most experts agree that the new law will be an amalgam of the “Empowering Patients First Act”— which Dr Price has introduced in Congress several times—and House Republicans’ “A Better Way” plan. The key elements of these two proposals include: • Medicaid expansion rollback; • allowing states to impose work requirements for those Medicaid recipients who are able to work; • permitting states to charge premiums or limit benefits for certain beneficiaries; • replacing the insurance mandate and premium subsidies with a flat tax credit to those who need to purchase individual insurance; • allowing insurance companies to deny cover- age or charge more for preexisting conditions to those who have a gap in coverage; and • allowing insurance companies to sell their plans across state lines. Mr Smith previously said some of the Medicaid changes might be challenging to implement, since requiring certain recipients to work and contribute to premiums might be perceived as racially biased by some. Now, he believes that Dr Price’s nomina- tion—along with putting Seema Verma in charge of CMS—“may help these changes along.” “MAGIC OF THE MARKETPLACE” Mr Smith reiterated what he told us weeks be- fore the election: of all the Republican proposals, expanding HSAs is, in his view, an easy-to-un- derstand concept that could move along quickly under a Trump presidency. Expanding these accounts would give consumers more dollars to offset out-of-pocket costs. Such a plan, he said, “would not require a large outlay of dollars, and would be easy to administer. Plus, it appeals to the middle class. People like it and it and it makes sense.” What we surely won’t see as Republicans prepare to run the show is the public option that President Obama originally wanted to include in the ACA, and Clinton probably would have considered. But her loss—coupled with the single payer Colorado Care measure being voted down on Election Day—all but assures that there will be no talk of universal health care over the next 4 years. “I believe the election results, and the strong ‘no’ vote on Colorado Care indicate that the country is not ready to migrate to a single-payer system,” Mr Leavitt said. “While there is a widely-held aspiration for all Americans to have access to an affordable insurance policy, there is still a desire for market competition and consumer choices.” Dr Spivack concurred. “There may be more sup- port than there was a few years ago, but this now has no chance in a Republican-controlled government that believes in the magic of the marketplace for the delivery of health care.” Mr Smith generally agreed, but added that “we may [eventually] migrate to a modified single-payer system, with government being the largest payer. Private exchanges will take the place of employer- based insurance. In this scenario, risk management providers will move towards a rather homogenous benefit designs.” Lest anyone think such a scenario is far-fetched, Mr Smith argued that this system is already in mo- tion, explaining that he was recently placed into a private exchange through, his spouse’s employer. ■ “While questions remain about what levers—market versus government—will be used, value-based payments will be embraced and accelerated under a Trump administration.” ~Mike Leavitt