As Donald John Trump becomes the 45th President of the United States, opinions about how his leadership will affect America’s future are divisive. Cable television has blurred the line between entertainment and journalism. In all the confusion, Trump has not backed away from his commitment to universal health coverage for all Americans.
In his book published in 2000, The America We Deserve, Trump wrote, “I’m a conservative on most issues but a liberal on this one . . . We must not allow citizens with medical problems to go untreated because of financial problems or red tape.” In a 60 Minutes interview aired in September 2015, Trump again said, “everybody’s got to be covered. This is an un-Republican thing for me to say . . . I am going to take care of everybody.”
How Trump will do this and fulfill his campaign promise to get rid of the Affordable Care Act (Obamacare) is unclear. The immediate symbolic action likely will be a budget reconciliation bill to eliminate some aspects of Obamacare, without truly repealing it. A widespread bipartisan belief in Congress is that complete repeal of Obamacare would cause chaos within the insurance and health care industries. Political analysts foresee that Republicans will benefit if complete replacement of Obamacare is delayed until after the midterm 2018 Congressional elections.
White House Chief of Staff Reince Priebus recently said, “I don’t think . . . Trump wants to meddle with Medicare or Social Security.” However, Priebus was not pressed on how Trump’s promise to repeal Obamacare could affect Medicare recipients. It should offer comfort to the “Never Trumpers” that even President Obama praised Trump as a “pragmatist” and noted that Trump has “fewer set, hard and fast policy prescriptions than a lot of other presidents might be arriving with.”
Senate confirmation hearings revealed that Trump’s cabinet nominees may have opinions which differ remarkably from Trump’s campaign rhetoric and promises. Trump’s Press Secretary, Sean Spicer, responded that Trump is “not asking for clones,” as he appoints key administrators. Look at the track records of key appointees to foresee what policy changes are likely.
Trump’s nominee for Secretary of Health and Human Services (HHS), Tom Price, is a Georgia Republican who practiced as an orthopedic surgeon before rising to Congressional leadership while advocating the privatization of Medicare. The American Medical Association (AMA) endorses Price’s nomination, citing his support for patient choice, market-based solutions, and easing of excessive regulatory burdens. Price has expressed concern about how implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) will affect doctor-patient relationships, since MACRA seeks to transform the Medicare system to link Medicare payments to physicians to quality of care and patients’ outcomes.
Trump’s choice to be the Administrator for the Centers for Medicare & Medicaid Services (CMS), Seema Verma, was Vice President Pence’s Medicaid-reform consultant in Indiana. She was criticized for simultaneously representing one of Indiana’s largest Medicaid vendors, Hewlett-Packard. Verma also provided Medicaid-reform consulting in Iowa, Kentucky, Ohio, Maine, Michigan and Tennessee. She has never led an organization comparable to CMS and its trillion dollar budget.
Verma, who grew up in a Democratic household and whose father said she “doesn’t do anything if she doesn’t believe in it,” said her subsidized healthcare philosophy “melds two themes of American society that typically collide in our health care system– rugged individualism and the Judeo Christian ethic.” She described Indiana’s program as one which “combines these diametrically opposed themes by promoting personal responsibility while providing subsidized health protection to those who can least afford it.” While Verma’s critics acknowledge that her persistence and planning skills have led to cost-cutting, they oppose some of her ideas, such as to require a recipient of Medicaid benefits to either pay a minimal participation fee or volunteer for a charity.
Although repeal of Obamacare would not end Medicare, there is programmatic intertwinement that justifies a concern of “not biting off more than you can chew,” as expressed by Chair of the Senate Health Committee, Republican Lamar Alexander of Tennessee, who once served as that state’s governor. Alexander’s concern is echoed by the long-term care industry.
McKnight’s Long-Term Care News, which is a news magazine focused on long-term care, reported that over 70 organizations joined in a letter to Trump to highlight twelve aging-related provisions of Obamacare that “have broad support and should remain intact.” Reportedly, the letter said “if changes to [Obamacare] affecting older Americans are considered, we respectfully request that you engage and work with [us] to ensure that the needs of America’s seniors are met.”
In fulfilling Trump’s challenge that she should “transform our health care system for the benefit of all Americans,” Verma is likely to seek support from Congress to move towards the decentralization of federal Medicaid subsidies to give more discretion to the states. Such legislation probably would survive inevitable legal challenges on appeal to a conservative Supreme Court. In the structuring of a plan to replace Obamacare, which is intermingled with Medicaid, this could be significant since Medicaid is the primary source of governmental funding for long-term care services which are administered by states.
Even if Trump and the Republican Congress fumble the replacement of Obamacare, most Medicare recipients need not be too concerned. If Obamacare funding currently targeted to close “the donut hole” of Medicare Part D for prescription drugs were eliminated, indigent persons will continue to receive prescriptions under Medicaid. Loss of Obamacare funding to expand preventive services of Medicare Part C Advantage Plans could be somewhat offset by increased emphasis of Chronic Care Management (CCM) services funded by MACRA.
The potential shift towards Medicare privatization and Medicaid block grants for state-based delivery of services raises questions for future consideration. Will requirements to prove citizenship be strengthened? Will allocation of limited Medicaid funds within a state cause competition for healthcare subsidies between impoverished younger residents and long-term care for older persons? Will lifetime caps be imposed to limit the total of Medicare and Medicaid funds spent for any individual or family unit? Will disparity of healthcare and long-term care services among neighboring states parallel the difference between educational curricula of urban and suburban public school districts?
America’s legacy is likely to remain as a beacon of hope that is personified and perpetuated by a substantial number of immigrants. Despite this great strength, it is virtually certain that the federal government will not have adequate resources to fund delivery of long-term care services in the foreseeable future at the same level as is currently provided. Wise baby boomers should recognize the need for financial discipline and sacrifice during working years. Not later than early-stage retirement, baby boomers should use a lawyer who knows how to exploit the opportunities and protect against the contradictions of IRS regulations, Veterans benefits, Social Security, Medicare, Medicaid, long-term care insurance and life insurance to make sure that their personal healthcare needs will neither deplete a family legacy nor depend on hands-on care by their uncompensated children.
By Dave Nesbit, Attorney