The 1,000-plus respondents to NEJM Catalyst’s Insights Council survey on the effects of the Trump administration’s health care plans were on the whole pessimistic about the outlook for patients and health care providers. In speaking with individual Insights Council members, we find not only deep concern about health care in the coming years, but also nuanced opinion, pockets of support, and a little dark humor.
Many survey respondents see Republican Party health care proposals as a step backwards, with little regard for progress made by the Affordable Care Act.
“[Speaker of the House Paul] Ryan and [President] Trump are not acknowledging the good things in the Affordable Care Act. We have been able to cover so many more people and it has saved costs,” says Betsy Brown, MD, a practice lead physician at the Polyclinic, a physician-owned multi-specialty medical clinic in Seattle. “If you could repeal it and improve it, that would be great, but don’t punish those that can’t afford health care.”
Brown is among the 74% of respondents who expect the number of U.S. citizens covered to decline. She also aligns with the 70% who say insurance coverage benefits will shrink.
She worries about the impact of proposed plans on her patients, especially those with HIV, who won’t be able to get consistent treatments if pharmaceutical drug prices rise — as 36% of respondents anticipate.
Joseph Frolkis, MD, PhD, who is CEO and President of New England Quality Care Alliance, believes that pharmaceutical companies will come out of the next years of the Trump administration “looking good.” He says that in addition to drug taxes likely being removed, the government has no political will to let the Centers for Medicare & Medicaid Services negotiate drug costs.
The result, he says, will be “health care less available to those that most need it.”
Linda Butros, MD, a pediatric hematologist/oncologist who opened the Sandia Survivors Program clinic in Albuquerque, New Mexico, earlier this year, is another Insights Council member deeply concerned about drug prices, saying, “Higher drug prices prohibit patients with life-threatening disease from getting the treatments needed.” But she is not convinced that prices will rise in the coming years.
“My only hope that this administration may cause a decrease in drug prices would rest in the possibility that it is less dependent on the pharmaceutical lobby for support of their campaign finances. This administration, although not any more honest or forthright in their character, is likely not as invested in the lobby industry, which dictates many of the policies coming out of Washington, D.C.,” she says.
Nearly three-quarters (73%) of Insights Council members believe patients will be on the losing end of whatever plans the Trump administration enacts. (The survey was conducted in February, before the American Health Care Act was revealed and rejected.) Large majorities of survey respondents also believe that clinicians (63%) and provider organizations (62%) will be negatively impacted.
Frolkis explains the negativity as “a ubiquitous sort of dread because of the stakeholders that this administration seems to preferentially represent.”
He points to insurance premiums, which 69% of respondents say will increase. He expects more people will go without coverage or will have inadequate coverage, meaning greater emergency room usage. As a third-generation primary care physician, Frolkis is especially worried for the Medicaid population, which he expects will be hit hard. Three-quarters (68%) of survey respondents expect Medicaid enrollment to decline in the coming years.
“Patients will notice the difference,” Brown says. “Copays will go up, meds won’t be covered, and preventative care won’t be covered.” She worries that patients who come to see her for annual exams once a year won’t come in to get their questions answered. “They are going to wait until they are really sick,” she says.
She also is concerned that value-based care will regress because it is, in large part, driven by Medicare payment plans. But Frolkis disagrees: “Driving down costs will be a surviving trend no matter what happens.” Survey respondents are divided on the future of value-based payment: 36% say it will be unchanged, 34% think value-based payment will receive more emphasis, and 29% think it will be undermined.
Some Insights Council members are hopeful that the Trump administration will spark radical change necessary in a broken health system. For example, Gregory G. Kenien, MD, FACC, Chief Medical Information Officer at St. Joseph’s Health in Syracuse, New York, which is part of the Trinity Health system, hopes the new administration will bring about a more rational health care system where “administrative burden was not 25% of expenditures, physicians did not average 43% of their time on documentation (largely to justify billing), and where physicians average 4,000 clicks per day in the EHR.”
Kenien would like to see a system that puts patients and providers first and “simplifies the mess,” he says. “Patients would benefit by receiving the care that they need at a reasonable price, and providers would be less likely to burn out and give up.”
Daniel J. Durand, MD, Chairman of Radiology and Executive Director of Clinical Alignment Strategy for LifeBridge Health System in Baltimore, is hopeful that the new administration will follow through on letting insurers compete across state lines. “This will allow for greater pooling of risk while also promoting heightened competition. Part of the outrage over the exchanges is the number of markets with only one option, for example. I am for a uniform set of ‘basic’ standards — a national exchange with numerous products available over the whole country. There is really no reason this should not be possible.”
Another Insights Council member, Gary Mirkin, MD, FAAP, President of Allied Physicians Group in Great Neck, New York, is hopeful that flexibility and competition will result from the Trump administration’s elimination of the ACA’s essential health benefits provision. “As a big believer in free markets, I think it will offer patients a wider menu, better choice of pricing versus deductibles, networks, participating physicians, etc.,” he says. As for providers: “We already require computers and sophisticated programs to figure out what insurance plans [we are] in and what all the various plans cover and reimburse for. We’ll just have to buy a bigger computer!”
David C. Aron, MD, MS, Director of Clinical Program Research and Evaluation at the Louis Stokes Cleveland VA Medical Center in Ohio, predicts that while the ACA will stay intact for a while, the Trump administration will nibble away at it from the edges. And he predicts that nibbling, including getting rid of the employee mandate to insure employees, will have more veterans looking for more services from the Veterans Administration, which acts as a safety net.
“When LTV Steel went bankrupt [in 2000], we got 1,500 new patients in a month. That’s what’s going to happen with [these proposed plans],” he says. With research funding at organizations such as the National Institutes of Health expected to take a significant hit as well, researchers will knock on the VA’s door for a chunk of their grant budget, he says.
Though Aron is not in favor of Trump’s health care agenda, he is sympathetic to peers who are concerned about regulations and standards that restrict their choice of tests and therapy, and that lead to a loss of autonomy.
He shares a joke from one of his retirement-age colleagues: “It could be worse; we could be young.”
Disclaimer: The opinions expressed by Dr. Durand are solely his and do not represent the views of LifeBridge Health System. The opinions expressed by Dr. Aron are solely his and do not represent the views of the U.S. Department of Veterans Affairs.
This Survey Snapshot originally appeared in NEJM Catalyst on May 4, 2017.