On November 8, 2016 Donald J Trump was elected the 45th President of the United States. After a long and brutal campaign season, Trump’s victory demonstrated the economic frustration many Americans have been experiencing. Many of the economic frustrations felt by Americans were due to perceived changes that resulted from the passage of the Affordable Care Act (ACA). President-elect Trump has stated that repealing and replacing the ACA will be one of his first priorities when he takes office. What does that mean for the future of health care in the United States?
Passing the ACA was a challenge for President Obama; implementing it has been an even greater challenge. Overall the goal of the ACA was to ensure that everyone has access to affordable health insurance, prevent insurance companies from denying insurance to individuals due to preexisting conditions, and allow individuals to receive health insurance through parent coverage up to age 26. In the discussion about how to reform the ACA, most individuals (including Trump), agree on these basic principles. The challenge becomes how to implement and achieve these goals without bankrupting the US economy.
The Trump campaign has released very limited policy proposals with respect to health care and health insurance. As a result it is difficult to understand which direction the Trump administration will choose to take. The policy positions released indicate that President Trump will support policies in line with the business principles that have made him successful—ensuring an adequate amount of competition and choice for the consumer as a mechanism to improve health care. Beyond that he has stated his desire to eliminate the individual and employer mandate, allow insurance to be sold across state lines, remove many restrictions on minimum coverage standards, convert Medicaid to a system of block grants, and explore options for obtaining pharmaceuticals from Canada. In terms of individuals and employers, the plan advocates for higher deductible plans and health savings accounts, which in theory encourage consumers to shop for the best value in health care.
Philosophically it seems that Trump will support the use of free market principles to achieve greater efficiency in the delivery of health. Markets work when a consumer has enough information to make an active choice about purchasing a product or service. The process of actively choosing results in increased competition among suppliers to deliver greater value for the consumer. Only those suppliers who understand what is of value to the customer and how that value can be delivered succeed while others tend to diminish due to decreasing volumes. In health care there are 2 markets—1 for insurance and 1 for health care delivery.
Health care is expensive, especially for complex surgical procedures and other hospital care. Health insurance is vital to the delivery of health care and the lifeblood of the industry. Government regulation, poorly constructed policy, or lack of regulation can have a disastrous impact on access to and quality of care. The value of insurance is that it mitigates the risk of financial loss due to illness or injury now and in the future. Consumers (employers and individuals) in comparing plans seek to minimize cost while maximizing access to quality care. A more competitive health insurance market place is seen as a way in which employers and individuals are provided greater choice and thus they can optimize value. The Healthcare Marketplace (insurance exchanges) was supposed to mimic a competitive market for individuals entering as a result of the individual mandate. However, the value proposition is far from clear for individuals who are young and healthy. This was the Achilles heel of the ACA—the “young invincible” have been reluctant to purchase insurance that is overpriced while those with preexisting conditions see the insurance premiums as a bargain.
Trump’s plan also suggests that he would work with states to establish high-risk pools for such individuals. If this has the trickledown effect of lowering premiums for lower risk groups then more individuals may choose to be insured. Greater insurance participation is important to the maintenance of a healthy health care industry.
Price transparency has been identified as one of the aims of a Trump administration. With this transparency patients are becoming more active purchasers and consumers of care. Coupled with the increasing amount of financial burden patients are facing with health care insurance, there has been an increasing trend for patients to become more active “purchasers” of care.
There are several unanswered questions in the terse policy statements released by the President-elect and his emerging administration. Will his policies assure that the 20 million who have become insured as a result of the ACA continue to have access to affordable insurance? Will the additional 27 million still uninsured find better options in the competitive market envisioned by Trump? What will be the impact of high deductible plans paired with health savings accounts? How will this affect consumer choices? Missing in the discussion has been the profound effect of malpractice laws and the practice of defensive medicine. As providers comply with evidence-based guidelines will they be protected from frivolous lawsuits? It is clear that tremendous savings can be achieved with effective malpractice reform.
Government health policy and market trends have been forcing providers to increasingly compete on outcomes that are of value to the patient. Through price transparency and employer initiatives purchasers of care are better able to perceive value. How to achieve high value for consumers, purchasers, and providers will require changes in strategy, organizational structure, operations, and financial incentives among providers. Fundamentally it will require a change in the basic business model of health care delivery.
Since the launch of Clinical Spine Surgery, the mission of the journal has been to publish articles that are useful for the practicing spine care provider. Beyond the articles focused on scientific research on various spine topics, the Journal has published articles in the Business of Medicine section on topics that can help spine care providers understand the broader organizational and system level issues that affect the delivery of spine care. There is no question that spine care providers will face a tremendous amount of uncertainty over the ensuing 4 years. Regardless of which policy direction the Trump administration chooses, determining how to deliver greater value to the patient will continue to be the goal that our health care system needs to achieve.
Achieving that goal will not be easy—as Editors of Clinical Spine Surgery we are committed to publishing articles that will continually inform and empower our readers with the knowledge and information to succeed in this new era of value-based care.