The 'Change Election' Happened -- Now What?
"Wish we could turn back time, to the good ol' days
when our mama sang us to sleep but now we’re stressed out."
-- Twentyone Pilots
I chose the above verse because it captures so many emotions that have nearly paralyzed our nation for the past 18 months. During the past year, each of us has probably wished at some point that we could just crawl into bed and hide under the covers. AAFP President John Meigs, M.D., wrote an excellent editorial in AAFP News last week in which he captured the wide range of emotions aligned with the election and its outcome.
Nov. 8 brought to a conclusion one of the most aggressive and divisive elections in our nation's history and certainly the most negative campaign of the modern political era. Although the results of the election have spawned mixed reactions, it is now clear who will lead our government for the next four years. There is much work to do, but I would suggest that there already was much work to do on Nov. 7.
In the early morning hours of Nov. 9, after securing more than 270 Electoral College votes, Donald J. Trump became president-elect Donald J. Trump. On Jan. 20, he will be sworn-in as the 45th president of the United States of America.
A few hours after President-elect Trump delivered his speech to the nation, accepting the results of the election, his transition team received a letter from the AAFP congratulating him and outlining our priorities for the next four years. Our advocacy work with the 45th president and his administration started before sunrise on Wednesday, Nov. 9 and will continue for the next four years. In our letter we outlined five policy priorities and pledged our commitment to working with the new administration to develop and implement policies that would achieve those priorities. Here are those five priorities:
- health care for all;
- delivery system and payment reform;
- health care affordability;
- primary care physician workforce; and
- promotion of prevention and wellness.
On Jan. 3, when the 115th Congress convenes, Republicans will have majorities in the Senate and the House. These majorities are smaller than those in the 114th Congress, but they are working majorities. Those margins coupled with Trump's victory mean the federal government will be under unified Republican control for at least the next two years.
We are entering a legislative session that has the potential to fundamentally reshape our nation's health care system and safety-net programs. In addition, we likely will see policies proposed in Congress that will challenge many long-standing AAFP policies related to health care coverage and access, women's health and public health programs.
It is impossible to predict with any accuracy what will happen in this Congress. As I have said many times in the past few days, "campaigning is easy, governing is hard." The process of drafting and enacting policy is much more involved and time consuming than candidates imply during campaigns.
However, we do have a decent understanding of policies that the Trump Administration and the 115th Congress likely will focus on. The following are five issues that we see as items in focus for 2017:
Patient Protection and Affordable Care Act -- The full repeal of Obamacare has been a priority for the Republican Party since 2010. To quote Vice President-elect Mike Pence, "We will repeal Obamacare lock, stock and barrel." This point of view is shared by a majority of House and Senate Republicans. Despite campaigning on the full repeal of the law, Trump has begun to nuance his policy position on the law. In an interview with The Wall Street Journal, he suggested that he would be willing to keep certain parts of the law.
Repealing the ACA outright is, in reality, improbable. Any such action would unravel the insurance market and create a financial crisis for individuals and businesses. Therefore, we will see efforts to replace certain policies and, possibly, create new programs that would extend access to health care coverage -- think health savings accounts and high-risk pools.
Despite the complexity of repealing the ACA, I am confident that the ACA will be altered and damaged in a significant manner on Jan. 20 or shortly thereafter.
MACRA -- The Medicare Access and CHIP Reauthorization Act was approved by overwhelming bipartisan majorities in the House and Senate. In fact, 91 percent of the House and Senate voted for this law. Additionally, reducing the cost of health care remains a priority. Due to the continued focus on costs and the bipartisan support the law secured, MACRA will continue to be implemented.
There may be slight modifications to improve the law, but these changes needed to be made regardless of who won the election. The AAFP continues to make available valuable resources on MACRA, and I encourage you to review the options available to you under the Pick Your Pace program that is available for 2017. Remember, if you participate in the program at any level in 2017 you will not face negative payment updates in 2019. (I discussed these options in my Oct. 25 post.)
Medicaid -- The Medicaid program, like the ACA, has been a priority for Republicans for the past several years. Speaker Paul Ryan, R-Wis., has developed and advanced an alternative to the current federal-state partnership funding formula that would utilize a state-by-state per-capita cap to fund the program. This is different than the more traditional "block grant" proposals advanced by Republicans in the past, but the two proposals would significantly alter the Medicaid program, essentially turning the program over to individual states and eliminating the current role of the federal government in the program.
I anticipate that Medicaid will get significant legislative attention in 2017. I am not confident that Republicans can rollback Medicaid expansion or change the underlying funding formula, but I am confident that they will pursue these changes aggressively.
Administrative simplification -- Trump discussed the negative impact of regulation on businesses throughout the campaign. Although his comments were not specifically focused on health care, we see an opportunity to potentially reduce the administrative burden of participating in the Medicare and Medicaid programs under his administration. A priority for the AAFP will be a reduction in documentation guidelines for physician services under Medicare.
Workforce -- The issue of physician workforce did not come up during the campaign, but we see opportunities. Republican majorities are largely a result of rural and exurban communities, predominately in the south and west of the Mississippi River. These communities are more likely to face physician shortages as compared to urban and suburban communities on the East and West Coasts. I don't see workforce as a top-tier issue, but it is a place where we will be pushing hard.
On Jan. 23, 2009 President Obama stated, "Elections have consequences." This statement was true then, and it is true today. We, as a nation, experience political disruption every few years. The specific consequences of this year's elections are unknown, but the AAFP is not resigned to being a passive participant in the next four years. We see opportunities to shape our specialty's future, and we will be grinding the policy levers daily to ensure that family medicine and patient-centered policies are front and center.
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