Health Care Under Trump

Leadership Survey: Anticipating the Trump Administration’s Impact on Health Care

Insights Report · October 18, 2017

Analysis of the third NEJM Catalyst Insights Council Survey on Leadership. Qualified executives, clinical leaders, and clinicians may join the Insights Council and share their perspectives on health care delivery transformation.

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Advisor Analysis

By Stephen Swensen, Namita S. Mohta, and Edward Prewitt

In February, after President Donald Trump had taken office but before any health care legislation had been put forward, members of the NEJM Catalyst Insights Council — a qualified group of executives, clinical leaders, and clinicians at organizations directly involved in health care delivery — were asked to predict the impact of the new administration on health care.

Soon afterward, the American Health Care Act (AHCA), which was the administration’s initial foray at replacing the Affordable Care Act (ACA), bogged down in disagreement in Congress. But Insights Council members were remarkably prescient in predicting several aspects of the AHCA. Council members also correctly foresaw the difficulty of passing legislation to replace the ACA.

Overall, Council members express pessimism about the health care landscape in the wake of the Trump administration’s proposed plans, citing no clear winners, only losers: patients, clinicians, and provider organizations. Some of their concerns have been proved out in the administration’s early moves.

For instance, 73% of survey respondents predict the number of U.S. citizens covered by health insurance to decrease. Subsequently, in its analysis of the AHCA’s impact, the Congressional Budget Office calculated that 14 million people would become uninsured by 2018, rising to 24 million by 2026.

In another example of foresight, nearly 70% of survey respondents anticipate insurance premiums to increase. The CBO assessment of the AHCA estimated that premiums would rise 15% to 20% for single policyholders in 2018 and 2019 (before beginning to decline in 2020).

Our survey also forecast cuts in medical research funding, with two-thirds of respondents saying funding would either decline significantly or slightly. Soon after the survey was conducted, the administration unveiled its proposed budget, which included big cuts to medical research.

Trump Administration's Impact on Health Care: Healthcare Landscape Changes Under Trump Administration

Leadership Insights Report. Click To Enlarge.

It is worth considering how this country got to a place where Republicans want to repeal and replace the ACA. The discrepancy between health care spending and outcomes in the United States is well known, with an estimated three-quarters of a trillion dollars wasted on inefficient care and spending. This trajectory of health care costs is clearly unsustainable. Republicans seek to increase competition in the marketplace and move from funding entitlements such as Medicaid to implementing tax credits and instituting health savings accounts.

In written responses to the survey, some Insights Council members express hope that the Trump administration will be able to lower drug prices, reduce the regulations imposed by the ACA, and help providers “get back in the driver’s seat,” as one says. Those supporting Trump’s early statements on health care also note they want increased insurance plan choice, restrictions lifted for payer competition across state lines, and reduced paperwork so they can spend more time with patients.

As we have already seen, repealing and replacing the ACA is not easy. More than a quarter of Insights Council members responding to the survey believe the ACA will remain substantially intact over the next year. Just over a third say the law will be repealed but its replacement will be indefinitely delayed. A quarter of respondents say the ACA will indeed be repealed and replaced within the next year.

Interestingly, Council members from the South, which consists predominantly of red states, are more positive in their assessment of the Trump administration. For example, 32% of survey respondents from the South believe the ACA will be repealed and replaced within a year, versus 23% from the Northeast.

Survey respondents are mixed on the important question of whether value-based care, and the transition away from fee-for-service payment models, will be supported by the Trump administration. Fairly equal percentages predict that value-based care will be supported (34%), undermined (29%), or be unaffected (36%). Equally unclear is the impact on innovative care delivery models. That is more likely affected by MACRA.

While we share Council members’ deep concern about the impact of the Trump administration, we hope that the ultimate outcomes will be positive — for the health care delivery system and the health of patients alike.


What are you most hopeful will change about health care under the Trump administration?

“Hopefully taking a less bureaucratic, more business oriented approach will help to get rid of the duplications and wasted clinical resources involved in interactions between payers, hospitals/clinics.”
— Clinician at a large nonprofit clinic in the Midwest

“Trump will be impeached and we can get on with the hard work of health care transformation. Otherwise, there is no hope.”
— Executive of a large for-profit physician organization in the Northeast

“I would hope that they will keep the parts of the ACA that are working and replace others and that they carefully weigh each aspect rather than repeal the entire Act due to partisan politics.”
— Department Chief at a midsized teaching hospital in the South

Download the full report for additional verbatim comments from Insights Council members.

Charts and Commentary

by NEJM Catalyst

We surveyed members of the NEJM Catalyst Insights Council, comprising health care executives, clinical leaders, and clinicians, about the effect of the Trump Administration on health care. The survey predicts the fate of the Affordable Care Act over the next year, the time frame for comprehensive new regulations from the Trump Administration, significant changes to the health care landscape, the impact of health care landscape changes on key stakeholders, consolidation trends for providers and payers, Medicaid enrollment, budgets for federal government organizations, and the future of individual market exchanges. Completed surveys from 1,058 respondents are included in the analysis.

A majority of survey respondents believe changes will be made to the ACA within one year, whether the law is fully repealed and replaced (27%) or repealed but with a replacement indefinitely delayed (35%). Insights Council members 45 years old and younger are more confident that the ACA replacement will be indefinitely delayed (43%) than their counterparts 46 years and older (34%). More respondents from the South (32%) say the ACA will be repealed and replaced than those in the Northeast (23%). Some respondents believe the ACA will morph into a single-payer system, “driven by consumer pressure,” as one Insights Council member says. Another would prefer lawmakers “tweak the ACA to make it more attractive to young, healthy people and get more states to actually participate.”

Trump Administration's Impact on Health Care: An Uncertain Future for Individual Market Exchanges

Leadership Insights Report. Click To Enlarge.

Download the full report to see the complete set of charts and commentary, including data segmentation, the respondent profile, and survey methodology.

Download Full Report

Check NEJM Catalyst for monthly Insights Reports not only on Leadership, but also on Care Redesign, the New Marketplace, and Patient Engagement.

Join the NEJM Catalyst Insights Council and contribute to the conversation about health care delivery transformation. Qualified members participate in brief monthly surveys.

This Insights Report originally appeared in NEJM Catalyst on April 20, 2017.

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