Day One: Trump Begins ACA Take Down

MedPage Today

Jan. 21, 2017

WASHINGTON — Just hours after his inauguration, President Donald Trump enabled a federal agency to pull back on critical provisions of the Affordable Care Act (ACA).

Trump signed an executive order on Friday pressing government departments to “change, delay or waive provisions of the law that they deemed overly costly for insurers, drug makers, doctors, patients or states, according to the New York Times. The move will essentially allow the U.S. Department of Health and Human Services (HHS) to begin unraveling the law before Congress can repeal it.

Rep. Ralph Abraham, MD, (R-La.) told MedPage Today in a phone interview on Friday that Trump was “going to work, right after he finishes lunch,” although he did not specify if orders related to the ACA would be enacted.

The order outlines its aim “to minimize the unwarranted economic and regulatory burdens of the [Affordable Care] Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market,” according to CNN. This includes the potential weakening of the “individual mandate,” which requires most Americans to have health insurance or pay a tax penalty.

Abraham noted that Rep. Tom Price, MD, (R-Ga.), currently Trump’s nominee for HHS secretary, would have the authority to change and undo many key regulations.

Asked whether such changes could hurt patients if a replacement plan has not been implemented, Abraham said he was optimistic. “[Price is] a very logical, measured man. He will make decision that are best for the patient,” he stated.

In a press release, Sen. Lamar Alexander (R-Tenn.), chair of the Senate Committee on Health, Education, Labor and Pensions, stated that “President Trump is right to make the urgent work of rescuing Americans trapped in a collapsing Obamacare system a top priority on his first day in office.”

Alexander noted that he was looking forward to repealing the law but also to “replacing it simultaneously with concrete, practical reforms that give Americans access to truly affordable health care.”

Med Students Assail Proposed ACA Repeal at D.C. Event

WASHINGTON — Medical students descended on the nation’s capital on Monday to protest the proposed repeal of the Affordable Care Act (ACA).

Hailing from all over the country, including as far away as Los Angeles, more than 50 medical trainees met with dozens of senators and legislative assistants, delivering petitions and hoping to dissuade Congress from doing away with the ACA. Medical students at over 30 other academic institutions in others states gathered to protest locally.

Also, around 25 members of #ProtectOurPatients participated in a FacebookLive Chat organized by Sen. Chuck Schumer (D-N.Y.) where they discussed the consequences of repeal with dozens of Senate Democrats in an online forum.

“Our main ask for today is for bipartisan work to be done on opposing repeal and working together to improve the existing ACA,” Sidra Bonner, a medical student at the University of San Francisco and lead organizer of the protest, told MedPage Today.

The grass-roots campaign #ProtectOurPatients, represents 4,000 medical students, including nursing students and other allied health professionals, Bonner explained.

While the group fundamentally opposes repeal, if it does happen, Bonner said, “there needs to be an immediate and better plan in place … [one that’s] better than the existing ACA in terms of access, quality, and cost,” she said.

The medical students may get their wishes granted to some extent — on Jan. 10, 2017, a group of Republican lawmakers introduced an amendment to extend the deadline for budget reconciliation, the promised “repeal bill,” from Jan. 27 to March 3, 2017.

“By providing more time to come up with legislative solutions, we have a better opportunity to produce a thoughtful, workable replacement that ensures Americans have access to affordable, diverse insurance plans that meet their needs,” Sen. Susan Collins (R-Maine) said in a press release.

The Senate is expected to vote on the preceding step in the repeal process, approving a budget resolution this week that would serve as a blueprint for repeal.

Lukewarm Republicans

Only two Republican senators met with protesters directly: Collins and Sen. Jeff Flake (R-Ariz.).

Protester Margaret Hayden, a second-year medical student at Harvard Medical School in Boston, grew up in Brunswick, Maine, and described her encounter with Collins, who is considered a more moderate Republican.

“I told her how I talked to the hospital CEO from Brunswick; talked to the chairman of the Maine Lobstermen’s [Community] Alliance and both said the same thing: That the Affordable Care Act isn’t perfect, but it’s providing essential services and protections for the people they care for and work on behalf of,” Hayden stated.

Hayden said she asked Collins to vote against repeal unless an immediate replacement offering “the same or better coverage” can be implemented.

Hayden described Collins as “responsive and understanding” especially regarding access to coverage for those with pre-existing conditions. “She’s committed to working on a replacement plan that will offer that for [Maine residents].”

As for the request to vote against repeal without a replacement, Collins said “she’s taking it under consideration,” Hayden reported.

A meeting between Flake and Kyle Ragins, MD, MBA, an emergency medicine resident at the University of California Los Angeles, had a less positive encounter.

Ragins wrote in a follow-up email on Tuesday that Flake was “evasive” and “noncommittal” regarding the request to vote “no” to a repeal without a simultaneous replacement.

Students also met with Republican staffers from the offices of Sen. Lamar Alexander (R-Tenn.), Sen. Roy Blunt (R-Mo.), Sen. Tom Cotton (R-Ark.), Sen. Rob Portman (R-Ohio), Sen. Marco Rubio (R-Fla.), and Sen. Pat Toomey (R-Pa.).

Democrats Engage

During the Facebook Live Chat, protester Maria Phillis, JD, a fourth-year medical student at Johns Hopkins University in Baltimore reported speaking with Sen. Elizabeth Warren (D-Mass.).

Phillis, who plans to specialize in obstetrics and gynecology, expressed concern to Warren that if the ACA is repealed, requirements to cover maternity care for women would disappear.

“[I]t’s really important to have that prenatal care,” Phillis said, noting that it’s not uncommon for life-threatening conditions to emerge during pregnancy. One example is pre-eclampsia, she said, noting that when it is caught early, clinicians can decide how to proceed to protect the mother and her baby.

“If we don’t have those people coming in and getting care, we may have them coming into deliver and having a seizure, and possibly even dying,” Phillis emphasized.

Following his Live Chat, MedPage Today asked Sen. Cory Booker (D-N.J.) if he was hopeful about saving Obamacare.

He said that he hoped warnings against repeal without replacement from groups such as the American Medical Association and the American Enterprise Institute (a conservative think tank) would prevail.

“Any action related to repeal is going to produce a lot of uncertainty that could destabilize markets and really cause a healthcare crisis in our country,” he said.

Sen. Ron Wyden (D-Ore.) and Sen. Amy Klobuchar (D-Minn.) were more cautious.

“Those who are saying they’re for repeal are saying ‘Nobody’s going to get hurt. Nobody’s going to lose any services.’ Tell that to the hundreds and thousands of women who depend on Planned Parenthood and depend on it for vital and preventive services,” Wyden told MedPage Today.

Klobuchar added that Republicans “just want to say ‘repeal.’ That sounds good on a bumper sticker, but you’re basically threatening the healthcare of millions of people.”

Sen. Kamala Harris (D-Calif.) made a pocketbook argument against repeal, saying that financially ACA repeal affects “all of us.” If “people are going to emergency rooms as the first place they seek medical care. It’s about all that we will benefit from in terms of having a healthy society and a productive society.”

Some medical students also participated in #ProtectOurPatients events at their own schools elsewhere in the country. Following are photos submitted to MedPage Today from Oregon Health & Science University, Yale University, Stanford University, and University of California branches in San Francisco, Los Angeles, Irvine, and Davis.

RNC: And Now for a Different Take on Obamacare ACA

CLEVELAND — Could a Republican administration repeal Obamacare? That was the topic up for discussion at a briefing Tuesday, held outside the Republican National Convention.

“I do not believe … that my political party is going to be able to put together a complete repeal, and I don’t think it should,” said Tommy Thompson, JD, a fellow of the Council on Foreign Relations, who served as Secretary of Health and Human Services under President George W. Bush, and four terms as governor of Wisconsin.

Thompson was the keynote guest at the briefing hosted by RealClear Politics, and sponsored by Walgreens, the American Association of Nurse Anesthetists, the American Nurses Association, and the American Podiatric Medical Association.

He said attempting full repeal would create “real chaos. The Affordable Care Act has got lots of problems, but there’s some good parts of it, and most Republicans will recognize the good parts,” he told reporters after the briefing.

Republicans should focus on fixing Obamacare, by reducing its taxes, lowering premiums, and giving people an incentive to buy health insurance, he said.

“Why is it that you and I don’t get a tax deduction when we pay for health insurance, but the company that employs us does?” he said at the briefing.

Thompson argued for giving everyone a refundable tax credit to incentivize more people to buy into plans. He also said that the government should maintain parity laws, so that sick people aren’t charged more or kicked off their health plans — he called the latter move “un-American.”

When asked who the best person would be to navigate these “meaningful changes”, Thompson didn’t hesitate: “Without a doubt, Donald Trump.”

Policy analysts and journalists speaking on a separate panel were more skeptical, given Trump’s unpredictable nature and his changing opinions on healthcare reform.

“Donald Trump would be well-advised to outsource the making of policy to [Speaker] Paul Ryan (R-Wisc.),” said Lanhee Chen, PhD, JD, a research fellow at the conservative think tank, the Hoover Institution at Stanford University in Stanford, Calif. Chen was also the policy director for the Romney-Ryan 2012 campaign.

“Presumably, that’s what would happen,” he said, and then clarified “In an ideal world for conservatives, I think that’s what would happen.”

“I think we are in a phase of the conversation now, where we’re trying to do our best to imagine what a Trump administration would look like, when in reality, none of us really knows. This is like a freak wild card,” he stated.

Chen told MedPage Today, that full repeal would be “tough” but “a large amount of repeal” could happen through the budget reconciliations process, which requires fewer votes — a path that has already been tested.

If Trump wins the election, Chen anticipates a Republican administration would attempt repeal.

“It’s important for him to realize that just saying you’re going to repeal Obamacare alone is not enough, that there has to be a coherent plan to replace it,” he said, which is where turning to Ryan’s blueprint makes sense. “Otherwise, politically I think he’s in very dangerous water.”

If repeal weren’t achieved, Chen argued for developing more tailored plans to fit people’s needs that cost less, made possible by loosening some of the essential benefits requirements; paring back subsidies; developing a more “open architecture” to create a more competitive marketplace; and giving states more flexibility around Medicaid expansion on the front-end, instead of relying on the back-door 1115 waiver process.

If Secretary Hillary Clinton wins the presidency and Republicans maintain a majority in Congress, “they’ll want to try to work together,” Chen said. “It will be incumbent on [Senate Majority Leader] Mitch McConnell (R-Ky.) and Paul Ryan to lead that negotiation with her.”