1) Former HHS Secretary Mike Leavitt believes that while the path of healthcare reform under Trump is uncertain, the transition away from fee-for-service medicine to value-based care will continue due to bipartisan support and market forces. 2) Experts predict that Republicans will amend the ACA through executive action and legislation rather than an immediate repeal, likely retaining some popular provisions while rolling back the individual mandate and Medicaid expansion. 3) A long-term transition period to a hybrid public-private system incorporating elements of both the ACA and Republican replacement plans is envisioned, with the marketplace continuing to play a key role in healthcare delivery.

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amended, or it will be repealed and replaced.”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. 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