Day One: Trump Begins ACA Take Down

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.”

Healthcare Proponents Rally at Women’s March

WASHINGTON — Among the masses that descended on the nation’s capital Saturday for the Women’s March was Katie MacMillan, a fourth-year medical student.

“This isn’t all about ‘Not-Trump,'” said MacMillan, referring to Donald Trump, who was sworn in as the 45th president on Friday. An aspiring pediatrician at Quillen College of Medicine in Johnson City, Tenn., MacMillan wants to ensure that women’s reproductive rights are respected, as are vaccination criteria for U.S. children.

“We want women to have access to anything they need to to make the right choices for their bodies,” she said.

As for vaccines, MacMillan said people mistakenly associate them with autism because symptoms of the condition often surface around the time when their children get their shots, but the two events are unrelated. “A lot of people are afraid, and I think fear motivates people in a bad way to make uninformed choices,” she emphasized.

 

Many marchers were in step with MacMillan, armed with signs and banners that promoted reproductive rights and “Medicare for All,” among other hot button issues.

Annie Kolarik, a fellow fourth-year medical student, agreed that Trump wasn’t the only reason for the protest, stating that “the need to fight for women’s rights’ existed before Trump and will exist long after he’s gone.”

MacMillan and Kolarik were joined by other healthcare professionals on the day after Trump’s inauguration. “Sister protests” were held all around the world, including in Boston, Chicago, Miami, New York, Denver, and London.

Saving the ACA

Some healthcare advocates were there to stump for the beleaguered Affordable Care Act (ACA). Late on Friday, Trump signed an executive order 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.

Elizabeth Collins, MD, a resident at Thomas Jefferson Hospital in Philadelphia who drove to Washington with friends, told MedPage Today “Our whole goal is ultimately single-payer healthcare but [the ACA] is about as close as we’ve gotten.”

Another ACA advocate, Kyle Ragins, MD, MBA, an organizer for Doctors for America and a resident at the University of California Los Angeles, said he was pleased at the physician turnout on Saturday.

“I think people appreciated seeing a doctor’s presence … to offer perspective that healthcare providers are on the side of the American people,” Ragins said in a phone interview.

Since the ACA was implemented, Ragins said he has been able to help patients, who have presented in the emergency department, gain healthcare coverage. “To be able to say [to a patient], ‘It sounds like you have a chronic condition that’s going to require specialist care … and you need to get health insurance, so that you can do that’ … to be able to do that from the emergency department is huge.”

Single-Payer Advocates

Carol Paris, MD, the new president of Physicians for a National Health Program, a single-payer advocacy group stood with fellow doctors at the march, holding “Medicare for All” posters.

Paris, a retired psychiatrist from Nashville, Tenn., told MedPage Today, that while she was pleased to see 20 million people get insurance through the ACA, she believes the law is flawed.

On the other hand, repealing the ACA will result in a “leaner and meaner” ACA under a different name, she said.

Paris said she does agree with conservatives that the ACA triggered “needless expense and bureaucracy,” but those same conservatives have told her a single payer system is not “politically feasible.”

Still, she is undeterred: “I will not tolerate another administration and another 4 years of incrementalism.”

Reproductive Rights

A call for maintaining reproductive rights was a dominant theme, with chants of “Women’s rights are human rights.” The main march was co-sponsored by Planned Parenthood, with NARAL Pro-Choice America and Emily’s List named as “social justice partners.”

Ilyse Hogue, president of NARAL, said that she was proud her organization was taking part in the event.

“The diversity driving these marches and the progressive values they represent demonstrate the strength of the grassroots political power at the core of this movement. It also sends a strong message to the anti-choice politicians trying to roll-back our right to access basic reproductive health-care, including abortion,” she said in a press release.

A representative for the American Congress of Obstetricians and Gynecologists (ACOG) said in an email that it was not participating in the march “in any kind of official capacity.” ACOG did not issue any statements regarding the march, although last week, it did officially stand against a House bill (HR 490) that bans abortion after the detection of the fetal heartbeat, which occurs as early as 6 weeks gestation, measured from the woman’s last menstrual period.

“This bill is both unconstitutional and unnecessary political interference in the practice of medicine,” according to an ACOG news release.

Donna Harrison, MD, executive director of the American Association of Pro-life Ob.gyns called the march a “pro-abortion march disguised with a more palatable spin.”

“It is interesting to us that with all the talk about focus on women, none of the participants will cover the documented association between abortion and preterm birth, abortion and breast cancer, and abortion and psychological suffering,” Harrison stated in an email, adding that the organization will take part in the March for Life on January 27.

Optimism, Excitement, and Protest: An Inauguration Day Snapshot

WASHINGTON — Before and during Friday’s inauguration of Donald J. Trump as the 45th president, MedPage Today reporters were on the phone and on the scene to talk to healthcare providers — those taking care of the inauguration crowd as well as physician members of the audience — and members of Congress who are health professionals and had their own take on the day. We also were present for one of the more offbeat protest actions at the inauguration.

Rep. Eddie Bernice Johnson (D-Texas), a former psychiatric nurse, was at the inauguration. “I really don’t know Trump, but I’m going to do my best to make the best use of my working with him for the betterment of my constituents,” she said in an interview Thursday. “I just can’t sit back and say, ‘Mine didn’t win and there’s nothing I can do.’ … I just believe that if I work hard there’ll be something I can do that will represent the people of [my] district.”

At the inauguration, Lou Provost, a member of a two-person roving medical team from the U.S. Public Health Service that was on the lookout for inauguration-goers who experienced health problems, said that things had been slow so far, “which is just the way we like it.” Any minor injuries the two had seen came from people who had tripped or fallen on the soft ground near the Capitol.

Bijender Kumar, MD, medical director of Hancock Regional Hospital in Indianapolis, Ind., said in a phone interview from the inauguration that he was excited about Trump’s presidency because “we definitely need some changes in the Affordable Care Act (ACA).” Kumar said he was “proud” of Rep. Tom Price, MD (R-Ga.), President Trump’s nominee for Secretary of Health and Human Services, and that Price and Seema Verma, Trump’s pick to run the Medicare and Medicaid programs, “might make great changes” by working together.

However, Kumar said he was not in favor of completely repealing the ACA. “Twenty million people are already on it, so completely repealing it is not a good idea,” he said.

Good Ideas for Replacement

Another supporter, Anne Galante, MD, an ob.gyn who volunteers at the Open Door Clinic of Middlebury, Vt., also did not support full repeal; however, she’s still critical of the law.

“The spirit of covering everybody is good, but in reality it wasn’t good for everybody … People technically have insurance, but they can’t use it.”

Trump has good ideas for replacing the ACA, she said — i.e., including health savings accounts and allowing health insurance companies to sell plans across state lines — and she believes that he won’t let people “die in the streets,” as he’s promised.

She admits, she is “nervous” — “I really hope the new administration doesn’t drop the ball.”

Meanwhile, a few hundred people gathered downtown Friday morning to call for President Trump to end federal cannabis prohibition. Congregating on the sidewalk just to the west of Dupont Circle in Northwest Washington, a group of event organizers with the group DCMJ handed out small joints to anyone who could show proof of being at least 21.

About 11:30 a.m., the protesters marched down 19th Street towards the National Mall. They played music as they walked, arriving peacefully in between the Washington Monument and World War II Memorial.

Several protesters headed for a nearby security checkpoint to get into the Mall, while others stayed outside and listened to the inauguration festivities via a portable speaker organizers brought. Four minutes, 20 seconds into Trump’s speech, most among that crowd of about 100 sparked their lighters and indulged.

Helping the Uninsured

Sen. Bill Cassidy (R-La.) sounded positive about Trump’s inauguration speech, in which he talked about solving the problems of the poor.

Cassidy said he wasn’t disappointed that new president hadn’t mentioned healthcare.

“If you combine his previous statements regarding the need to cover all and take care of those with pre-existing conditions with [today’s speech] about those who have not done well over the past 8 years and you put them together … it shows that I think he’s going to be where most physicians are,” he said in a phone interview. “We want patients to have coverage, and we want it to be meaningful.”

Rep. Andy Harris, MD, (R- Md.) said Trump’s speech was non-partisan. “It was an America-first speech. He was unabashedly America-first on the campaign and I think it struck a chord in the Midwest.”

Harris was also unfazed by the absence of healthcare in Trump’s speech.

“I think he’s going to to roll up his sleeves and begin to take the steps to make sure that American healthcare and health insurance becomes affordable … He’s sent clear signals in the last week that this is one of his top priorities.”

Harris characterized healthcare changes as “reform and replace” rather than repeal-and-replace, noting that Republicans can’t do everything they’d like through the budget reconciliation process.

“Without 60 votes in the Senate you really can’t repeal it… I’m just being a little more technically correct.. The end goal is to put in something that works, so I don’t think that the semantics of it matter.”

‘Repair’ Rather Than ‘Replace’

Harris’s colleague, Rep. Ralph Abraham, MD, (R- La.) took a similar view.

“I would prefer to use the word ‘repair’ rather than ‘replace,’ because we’re going to keep some things. It’s not going to be a complete replacement, but it’s going to be a pretty good overhaul,” he told MedPage Today in a phone interview, noting that preserving access for those with pre-existing conditions and allowing people under 26 to stay on their parents’ insurance plans were two of the “good things.”

Anish Koka, MD, a Philadelphia cardiologist who supported Obama prior to voting for Donald Trump, said he was optimistic about Trump’s healthcare plans. “My general feeling was we were headed on a path that’s going to make it more and more challenging for physicians — especially independent physicians — to survive, since [things like] bundled payment and large integrated care networks have a lot of [requirements] that a lot of solo or small practices don’t have,” he said in a phone interview.

“It is somewhat of a relief to feel that, based on some of the early comments Tom Price has made — certainly at his hearing — there may be relief coming for independent physicians in terms of onerous regulations that are tough to manage.”

As for the ACA, “Whether you call it repeal, or fixing it, something that allows us as physicians to take on patients in a way that’s not untenable; that’s what I’d like,” Koka said. “The vast majority of us want expanded access for patients … the question is, how do we get that? It became increasingly obvious that the ACA and the way they were going about it is not necessarily the best way to go about it.”