Out with Obamacare, in with Trumpcare? Radiology thought leaders mull possibilities

As the GOP prepares to take charge of the executive branch of the federal government while maintaining its majority in both legislative chambers, it’s not just healthcare watchers who are wondering if Obamacare may soon be history and nothing but. Much of the country if not the world is watching to find out. And many are wondering: What will Trumpcare really look like?

Three radiologists with policy expertise offer their predictions on the matter in an opinion piece published online Jan. 10 in the Journal of the American College of Radiology.

Andrew Rosenkrantz, MD, MPA, of New York University, Joshua Hirsch, MD, of Harvard and Gregory Nicola, MD, of Hackensack Radiology Group in New Jersey and chair of ACR’s committee on MACRA introduce their educated speculations by encouraging radiologists to “maintain an awareness of the likely developments, as their practice and payment models stand to be influenced by changes in federal legislation.”

Whither the Affordable Care Act?

Noting the written plans of both House Speaker Paul Ryan (R-WI) and likely HHS secretary Tom Price (R-GA) to repeal the Affordable Care Act (aka Obamacare) as soon as feasible, along with President-Elect Donald Trump’s frequent campaign promise to “repeal and replace,” Rosenkrantz and colleagues write that such dismantling could unfold in any of several scenarios.

For example, is there a possible middle ground between outright repeal on the one end and, on the other, piecemeal defunding—which some of Trump’s more recent comments have seemed to hint at?   

Indeed there is. Congress could pursue legislation that repeals the ACA while simultaneously calling for a delay in implementing any alternative, Rosenkrantz and colleagues write.

“Even with this approach, the unpredictable outcome could accelerate the departure of private insurers from the exchanges established by [the Affordable Care Act], thereby still destabilizing the insurance market and threatening the current level of insurance coverage,” they write. “Whichever approach is ultimately pursued, maintaining a reasonably high proportion of insured Americans will be important for its success.”

Either way things go, they add, several popular elements of Obamacare—mandated coverage of preexisting conditions and of children till they’re 26 years old, for example—are likely to remain in place with any new system.

And yet, the authors write, “successfully funding such legislative regulations without a corresponding insurance mandate will be uncertain.”

Innovation center, payment advisory board: Low-hanging fruit?

Two initiatives key to the Affordable Care Act that will probably be targeted for elimination or severe weakening are the Center for Medicare and Medicaid Innovation (CMMI) and the Independent Payment Advisory Board (IPAB), Rosenkrantz et al. predict.

“Although early small-scale CMMI initiatives were voluntary on the part of providers, more recent CMMI initiatives calling for mandatory participation (e.g., a new bundled payment model for hip and knee replacements termed the Comprehensive Care Joint Replacement Model) have been particularly controversial, indeed serving as one of Price’s top targets,” they write.

“Congressional Republicans have previously lobbied unsuccessfully to reduce the scope, authority and funding of CMMI,” they add. “Nonetheless, with heightened power, Republicans are positioned to, and likely will, more effectively reduce the agency’s power.”

As for the IPAB, the Affordable Care Act-created board working to curb Medicare spending, congressional Republicans have “heavily criticized the greater degree of control over healthcare spending being afforded to this single agency headquartered in the executive branch, introducing unsuccessful bills to bring about its appeal,” the authors point out. “It is thus expected that the new Congress will seek to eliminate IPAB as well.”

MACRA’s pedigree will probably protect it

And what about the Medicare Access and CHIP Reauthorization Act (MACRA)?

This 2015 legislation, which reformed the Medicare payment system to base a substantial fraction of Medicare payments on the quality and cost of care, was originally drafted by congressional Republicans, Rosenkrantz and colleagues note, adding that it passed with strong majorities of both parties.

“In view of this legislative background, MACRA is unlikely to have the same potentially drastic fate as [the Affordable Care Act] under the new administration,” they write.

However, they add, MACRA may well end up modified or weakened. They base this on Price’s lead-authoring a letter to CMS on behalf of congressional physicians—Price himself is an orthopedic surgeon—describing MACRA in practice as overly complex.

“[T]hough MACRA is anticipated to remain overall in place, its long-term effectiveness in shifting physicians to value-based care may be altered once the new administration is in place,” the authors write.

Tort reform could go national

Finally, medical malpractice tort law is likely to come up for reform, Rosenkrantz and colleagues predict.

“The Republican Party has a long-standing record of supporting such reform, for example supporting bills during previous administrations that set caps on compensation for noneconomic damages,” they write. “In addition, prior legislation introduced by Price included a number of tort reform provisions, including a cap on noneconomic damages, a shortened window for filing suits, and administrative tribunals to evaluate new suits before proceeding to court.”

The authors note that malpractice reform, generally considered a matter of state authority, could “reemerge as a national issue in light of the new Republican mandate.”

They close by acknowledging that their predictions reflect their own perceptions.

“Ultimately, patients, payers and radiologists and other physicians alike,” they write, “will need to closely follow the federal health policy landscape once the next administration assumes power.”