So, Now What? How a Trump Presidency Will Impact Labs & the ACA

Needless to say, the election of Donald Trump will have major ramifications on not just labs but the entire health care industry. But while changes are a certainty, it is far from clear what and how dramatic they will be, especially with regard to "Obamacare," aka the Affordable Care Act (ACA). Although we do not have a crystal ball, based on what we know and what we are hearing from our sources, we are in a position to make an informed—albeit preliminary and unscientific judgment about what Trump will and will not do to the ACA and other federal initiatives affecting labs.

Immediate change faces significant hurdles
ACA repeal was a central theme of the Trump campaign. But like the dog chasing the car, now that Trump and Republicans have captured the prize, they face the challenge of figuring out what to do with it. Additionally, here are some challenges that will slow down any major changes:

• Filibuster. Our existing legislative processes do present a challenge to repealing ACA entirely. "One would assume once you have Republican control of both the House and Senate you should have an easier time enacting legislation," said Bill Hoagland, senior vice president of the Bipartisan Policy Center. But he explains that while the Republicans have control of both the house and the senate, there are fewer than 60 Republicans in the Senate which is the "critical number to overcome a filibuster." "There is a firewall or a check and balance against policy," he explains. Thus, any action taken through a regular process will require some bipartisanship," he explains, particularly in the Senate.

• Unpopularity. Not only does President-elect Trump enter the office with a low popularity rating—as evidenced by demonstrations in which many constituents angrily declare he is "not [their] president"—but the members of Congress are also plagued by popularity woes, with a November Gallup poll revealing only 11% of Americans approve of Congress. The silver lining is that this unpopularity could be an incentive for both sides to work together, suggests Hoagland.

• State insurance role. One of the proposed changes to health care insurance is to allow insurers to sell across state lines. Hoagland points out, however, that state policies could be a stumbling block—state insurance commissioners set rates and policies. Additionally, there is concern that such sales could create a race to the bottom, he adds.

• Packed agenda. "Congress has a lot on their plate," notes Hoagland. As he discussed in his keynote presentation at G2's recent Lab Institute in Washington, D.C. the federal debt limit comes up in March—requiring Congressional attention— and Congress also will need to address Supreme Court, Cabinet and other appointments. That packed agenda could delay or slow down any legislative action with regard to health care.

Complete repeal already scaled back
Although significant details of any plan remain to be revealed, President-elect Trump has already stepped back from total repeal by indicating in an interview with 60 Minutes and in other statements that he intends to keep the ACA provisions concerning pre-existing conditions and children remaining on parent's health insurance until age 26.

It is also noteworthy that in a Nov. 21 video update about the policy plans for the first 100 days, President-elect Trump mentioned several initiatives his administration will tackle in the first 100 days with executive actions that will be implemented "day one." The only reference to health care at all came when he stated his agenda is based on a core principle of "putting America first" and making sure the "next generation of production and innovation" happen in America, whether it be "producing steel, building cars or curing disease"—and this statement was made in the context of creating jobs and wealth for American workers.

Budget reconciliation option for change
There is one alternate route to make changes more swiftly or easily for the new administration and that is the budget reconciliation act process—which only requires a simple majority, Hoagland says. He cautions that if that reconciliation path is used to repeal the ACA without any democratic support it could cut a rough path forward for any policies approved in that process.

Alan Mertz similarly cautioned the attendees at G2's recent Lab Institute to watch what might be included in any budget reconciliation legislation—and highlighted the risk that lab copays could make a reappearance.

Value focus unlikely to change
Another question on the forefront of laboratories' and providers' minds is any potential impact on reimbursement reforms such as PAMA and MACRA and the shift to value-based health care delivery and payment models. "Republican and democratic policy analysts [agree] that fee for service reimbursement system is part of the problem of cost escalation," responds Hoagland. He doesn't foresee a change in that focus on shifting from fee for service to value based reimbursement. "It's hard to argue against paying for value."

Takeaway: Though change to ACA and health care systems may be coming, it may not come quickly or be as wholesale as promised or anticipated.