Donald Trump’s promise for Obamacare both during the campaign and after his election. What does it this actually mean for President’s Obama’s signature legislative accomplishment? Specifically, how might ophthalmology be impacted? The short answer is we don’t know. Trump may have sent signals as President-elect, but until he assumes office it’s pure speculation.
Can Trump repeal and replace Obamacare by simply sending out a Tweet? Constitutionally a law must be repealed by Congress, both the House and Senate, before the president can sign the repeal into law. That alone is no slam dunk, evidenced by over sixty attempts by Congress to repeal Obamacare, only to have their efforts thwarted by Obama’s veto pen. The Senate filibuster is another potential roadblock, although the reconciliation process, as used to pass Obamacare, may be used to bypass the 60-vote filibuster threshold. As an aside, how ironic that this same legislative trick used to enact Obamacare could also be used to destroy it. If all else fails, Trump has at his disposal the Obama, “I’ve got a pen and I’ve got a phone” approach using executive orders to dismantle the beast. What then? Repeal without replace is not practical. President-elect Trump and Speaker Paul Ryan have both promised a replacement.
What might TrumpCare or RyanCare look like? Health savings accounts, already part of the landscape, are likely to proliferate. Patient-centered healthcare promoting value and choice will grow. We are likely to see patients purchasing insurance across state lines and only the insurance they want and need, whether catastrophic or comprehensive. An easy initial repeal target is the Independent Payment Advisory Board, existing now on paper, but not in practice, with its potential to limit expensive drug therapy or surgery. Trump has taken aim at Big Pharma and high drug prices. He wants Medicare to be able to negotiate prices down, meaning that the $2000 per dose intravitreal anti-VEGF drugs may drop in price. This is a two-edged sword. Less handling payment back to ophthalmologists for the same amount of ordering and inventory effort, but smaller patient out-of-pocket costs. Speaking of big pharma’s undue influence, Trump wants a ban on lobbying for executive branch officials. Such lobbying is one reason Medicare can’t negotiate drug prices. Will millions of our patients be kicked off their insurance plans? Some might, but most won’t. Most new Obamacare enrollment has been through Medicaid expansion. And two-thirds of those newly enrolled under Medicaid were already eligible, but never signed up, meaning that they will still be covered under Medicaid even if Obamacare goes away. Ophthalmologists will still have plenty of patients to see. Between Medicaid and a more diverse and competitive insurance marketplace, there will be fewer uninsured patients in our practices. Tort reform has always been part of Republican healthcare reform plans. Expect to see federal guidelines limiting the excesses of the current medical-legal system. In keeping with Trump’s private sector experience, there will be an emphasis on competition and fiscal responsibility. Through lower cost options including physician extenders, telemedicine, generic drugs, streamlined drug approval, and incentives for less expensive service sites. Trump is a businessman, filling his cabinet with like-minded individuals who have succeeded in their endeavors by doing it better, faster and for less money. Think FedEx, Costco and Amazon. Expect the same approach to healthcare, now one-sixth of the US economy. Whatever finally emerges from Washington DC this year, it won’t be as drastic or draconian as many hope for and others fear. But it won’t be business as usual either.
