President Donald Trump signed an executive order on Jan. 20 to reduce the economic burden of the ACA. Fourteen academics and leaders of healthcare companies and hospitals discuss the executive order's implications on hospitals and physicians.
Michael Abrams. Co-founder and Managing Partner of Numerof & Associates (St. Louis). "The takeaway for healthcare industry players (and consumers) is that Trump intends to follow through on his promise to revamp the fundamentals of the ACA. The executive order outlines Trump's vision for a healthcare policy that minimizes economic and regulatory burdens, decentralizes control to the states and creates a more open, market-based model. It's entirely consistent with his campaign statements and shouldn't come as a surprise to anyone. There's also no reason for physicians, hospital executives or pharmaceutical companies to hit the panic button. The order itself acknowledges that any action taken by agency heads is subject to applicable rules and regulations regarding review and comment periods."
Alejandro Badia, MD. CEO of OrthoNOW (Doral, Fla.). "President Trump's executive order on the ACA indicates a spirit that change is imperative. This is a first step toward unwinding the law, specifically by limiting further expansion of the federal government's reach, which has been deemed to be financially unsustainable as it has had zero impact on cost. Furthermore, this allows a more common sense approach to changing healthcare delivery in the U.S., and having an orthopedic surgeon leading the primary government agency involved will allow a more realistic methodology to developing an improved plan. Having healthcare providers, including hospital executives and pharmaceutical companies, involved in decision-making will bring about more cost-effective change that will enable providers and empower patients who demand the industry's quadruple aim: better costs, better outcomes, better patient experiences and better clinician experience."
Dan Ehlke, Assistant Professor of Health Policy and Management at SUNY-Downstate School of Public Health (Brooklyn, N.Y.). "In the short term, I think there's likely to be little impact. The order is very vaguely worded, and I suspect most of the relevant bureaucrats at [the] state and federal level will await congressional action before changing course dramatically. Insurers are unlikely to drop out of exchanges to which they are signed on for 2017, though some could opt out for 2018, given that the order may signal the marketplaces' eventual demise. Should that occur, hospitals will likely see greater numbers of uninsured, and this could, in turn, lead to greater amounts of uncompensated care. However, this will be highly contingent on what any 'replacement' legislation looks like, and less the result of the order itself which, while symbolically important as a sign of administration policy intent, is unlikely to be substantively significant on its own."
John Greenbaum. National Practice Leader of Employee Benefits of Risk Strategies Company (Boston). "The executive order could open the door for low value (limited coverage) insurance that will result in a significant increase in uncompensated care as individuals who had objected to the broad coverage offered under ACA plans seek to move to lower cost alternatives."
Terry Hush. President and Co-founder of Roji Health Intelligence (Chicago). "President Trump's executive order is largely a signal at this point that he will proceed with supporting a repeal of the ACA. In particular, he has made it clear that there will be no consequences for individuals who don't have health insurance in terms of penalties. But it leaves open the huge question of what a replacement will look like, and it also creates other questions for hospitals and physician companies about what will happen to other provisions under the act. One of these uncertainties is the future of ACOs, which were begun by hospitals under the ACA and were intended to stem the rising costs of Medicare. The executive order may well have the effect of slowing down action by providers to develop or participate in risk programs, until the future is clearer."
Gary S. Kaplan, MD. Chairman and CEO of Virginia Mason Health System (Seattle). "While it is too soon to address with any certainty the implications of the executive order, I do urge President Trump and Congress to be mindful of the importance of access to affordable, high quality and safe healthcare for all Americans. They must focus on the fundamentals of healthcare, such as adequate access, appropriate care, value and transparency, which are all necessary for positive outcomes and patient experiences. Their decisions must be based on facts, not political fervor, and in the long term interest of everyone. The ACA, while not perfect, was a step forward in the right direction. Our nation should build on this momentum. I also encourage the president to launch a national initiative involving healthcare providers, payers, patients and lawmakers from both political parties with the goal of understanding and addressing the underlying broken processes across the nation's healthcare system that negatively affect quality, efficiency and cost. This is the strategic, big picture perspective we urgently need. Healthcare deserves an open-minded, thorough search for the meaningful path forward because it is essential to the quality of life for all Americans."
John Kelliher. Managing Director of Berkeley Research Group (Washington, D.C.). "Trump's executive order has more symbolism than actual impact. New regulations promulgated by Trump administration agencies under the executive order would take more the six months to process and would have effective dates in 2018 or beyond. Before such regulations could be in place, Congress is likely to have changed the underlying laws — making new regulatory interpretations moot. The issuing of the executive order does reaffirm — yet again — that Republicans, including President Trump, are committed to significant reform of the U.S. healthcare system including revisiting the structure of the ACA and even going beyond that to a complete overhaul of the Medicaid program."
Steve Look. Executive Vice President of The Medicus Firm (Dallas). "Initially, the greatest impact of Trump's executive order regarding the ACA will be uncertainty among the healthcare workforce and employers, whether it's warranted or unwarranted. That's because this week's executive order signifies change is coming, while it's still quite unclear what that 'change' will look like, or when said 'change' will actually occur, and that will cause some uncertainty. It will be very difficult to make sweeping changes, given the complexities associated with replacing the current programs, while fulfilling his promise of 'having insurance for everybody,' as he told The Washington Post last week. A truly significant shift will likely take place over years, not months. By executing this order to alleviate the financial burden of the ACA, I think it means that the president is committed to making as significant changes as possible to the ACA and to healthcare legislation in general."
Simon Lorenz, PhD. Co-founder of Klara Healthcare Messaging App (New York City). "From a physician's perspective, repealing the ACA will have an impact on business operations with the most pressing issues stemming from the financial side. Physician-owned smaller practices will be hit the hardest, especially in poorer or rural communities, although many physicians in diverse areas will still be affected.
Potentially 20 million Americans will lose insurance coverage, creating gaps in the patient base of doctors, ultimately hurting their income. Not only would [fewer] people actively schedule services and appointments due to lack of insurance, patients who do seek treatment may not follow through with fulfilling prescriptions due to increased costs.
Doctors will have increasing pressure to take a hard look at income, profits and business operations. This would be an excellent time to audit your practice operations to see how much money is tied to areas that may be impacted. From a business standpoint, doctors need to stay on their toes and adjust to the changes that will come as a result of these executive orders."
Adam Powell. President of Payer+Provider Syndicate (Boston). "While the executive order provides a mandate, it leaves it up to others to determine how it will be implemented. Sections 2, 3, and 4 are all prefaced by the phrase, 'To the maximum extent permitted by law.' We will have to wait and see how various parts of the government determine what changes are permitted. Secondly, while the executive order provides a command to reduce the fiscal burden on various participants within the healthcare system, reducing the burden on one may increase the burden on another. As the goal is to reduce the burden on both healthcare organizations and families, some trade-offs will have to be made. It is currently unclear how the government will make these trade-offs."
Jay Reddy. President and CEO of VitreosHealth (Plano, Texas). "There will likely be some concessions made due to lobbying from poor-performing entities. However, we believe that CMS will not budge on its overall payment model, where the expectation is that 50 percent of all CMS payments in 2018 will be capitated and 80 percent of the payments will be quality-based. Otherwise, companies will just stick to the old way of doing things, hoping that the government will keep pushing out or revising their mandates."
Marc Samuels. CEO of ADVI and Former Health Policy Advisor to President George H.W. Bush and George W. Bush (Washington, D.C.). "As a lifelong businessman, Donald Trump is used to moving quickly, but if the new administration follows through with its self-imposed pressure to accomplish so much so fast, it is certain to result in reckless policy decisions. As alumni of the Bush administrations, we saw this occur in President George W. Bush's time in D.C., compared to his experience as governor. Mr. Trump will need to focus on what really matters to the people who elected him. Right now, there's no bigger issue than what comes next for healthcare."
Julie Scott Allen. Senior Vice President of Drinker Biddle's District Policy Group (Washington, D.C.). "The executive order provides for flexibility by CMS to make adjustments to their current ACA regulations and/or what had been their interpretation and enforcement of current regulations under the Obama administration. Revised regulations could be issued, or more likely, new sub-regulatory guidance could be released by CMS as such efforts would not require legislation or legislative approval. For hospitals that have sought changes in implementation, such changes could be made while Congress plans its ACA repeal and reform strategy. For example, hospital systems have argued that hundreds of quality measures and threat of penalties for not meeting measures have made it a challenge to comply with the ACA's effort to improve quality. Recognizing that a value-based payment system is not going away, even with repeal of the ACA, lessening the number of measures would be a win for many hospitals."
Vernita Todd. Senior Vice President, External Affairs of Health Center Partners of Southern California (San Diego). "For safety-net providers, this could increase the number of people accessing care in the costly halls of emergency rooms, decrease patients' access to specialists and cause patients to forgo any type of preventative care in order to manage the expenses of daily life. As reimbursements decline, it will be inevitable that providers will have to modify their practices to survive. While community health centers will continue to provide access to affordable primary medical and dental care, it is possible that even health centers will be forced to close sites, lay off staff and scale back on services."