November 2016

While it is still too early to tell with certainty how President-elect Donald Trump's policy priorities will impact the pulmonary, critical care and sleep community and the patients we serve, if campaign promises are to be believed, then there will be some abrupt changes in policy direction coming from the White House and Congress.

Affordable Care Act: 

Repealing the Affordable Care Act (ACA) was a prominent campaign promise of President-elect Donald Trump. Republican leadership in Congress has expressed their eagerness to repeal ACA in the earlier days of the Trump Administration.  While a complete repeal of the ACA would be challenging, repealing its essential elements (such as the individual mandate, premium subsidies, Medicaid expansion) will likely be achieved early in the Trump Administration.

Other elements of the ACA – prohibition of pre-existing conditions exclusion, banning life-time caps, out of pocket cost limitation and ability for adult children to stay on parents plans until age 26 – all have bipartisan support.  What steps Congress and the Trump Administration will take to replace repealed provisions of ACA remains unclear.

During the campaign, President-elect Trump talked about block granting the Medicaid program and allowing insurance to be sold across state lines.  While both the policy proposals may address access to health insurance, they are unlikely to fully replace the expansion of health insurance coverage provided by the ACA.

On the broader issue of health care reform, President-elect Trump has proposed to:

• Repeal all of the Affordable Care Act
• Allow the sale of health insurance across state lines
• Make the purchase of health insurance fully tax deductible
• Expand access to the Health Savings Accounts
• Increase price transparency
• Block grant Medicaid
• Lower entrance barriers to new producers of drugs

Clean Air:

Another prominent campaign promise was to repeal burdensome federal regulations with EPA being a prime target. While the Trump campaign did not provide any specifics on how it would change EPA policy or re-orient EPA program priorities, it is likely the EPA will be the target of significant changes in a Trump Administration including: budget cuts, loss of personal, and shifting of priorities away from standard-setting, enforcement and research, and more emphasis on regulatory flexibility and negotiated settlement with entities that violate EPA standards.

Further, with Congressional majorities in both chambers of Congress, the Republican majority may seek to rewrite environmental laws – including the Clean Air Act – to alter EPA's authority and enforce environmental standards.

Climate Change: 

Repealing EPA's Clean Power Plan is another prominent campaign pledge of President-elect Donald Trump and can be achieved with relatively little effort by the new Administration.  Congress could pass legislation to block the Clean Power Plan, President-elect Trump could refuse to defend the Clean Power Plan from current court challenges or the EPA, under the new Administration, could just choose to take no action and let the rule die from neglect.  Regardless of the path chosen, it seems relatively certain that the Clean Power Plan will not survive the Trump Administration.

While this news is not comforting for people concerned about climate change, repealing the Clean Power Plan is not the end of the issue. The U.S. Supreme Court has already ruled that the EPA has an obligation to regulate greenhouse gases.  That obligation does not evaporate with a change in Administrations.  How the Trump Administration responds to that obligation remains to be seen.

Research Funding:

NIH has broad bipartisan support in the House and Senate so the NIH budget may fare better than other agencies under the new 115th Congress and new Trump administration.  Both the House and Senate subcommittees that oversee NIH funding, which are chaired by Republicans who are expected to keep these positions in the 115th Congress, provided  funding increases for the NIH in fiscal year 2017. The Senate subcommittee provided a $2 billion funding increase for the NIH while the House provided $1.3 billion. Although President-elect Trump has not been specific about NIH, we expect that he will defer to the strong support in Congress for NIH.

Concerning public health, the outlook is a bit more mixed and unclear. The Centers for Disease Control and Prevention does not have the widespread bipartisan support that the NIH enjoys, but the congressional appropriations leadership has recently become more interested in public health, particularly following the spread of the Zika virus. President-elect Trump has not expressed any specific views on the CDC, but he has urged action to combat the Zika virus.

Medicare: 

The Trump campaign did not make major policy proposals for Medicare during the campaign.  The few comments that President-Elect Trump did make about Medicare indicated his desire to preserve Medicare for current beneficiaries.  Policy changes from Medicare will more likely be driven by Congress rather than the Administration.

VA Health Care: 

The VA health care was a frequent talking point during President-elect Trump's campaign.  His policy positions for VA health care focus on removing unresponsive or under-performing VA employees, protecting VA whistle blowers, expanding private care options for veterans and expanding mental health services.

Key Variables: 

Cabinet Picks – who President-elect Trump chooses for his cabinet will provide some insights into how a Trump Administration will plan to govern and what its immediate priorities will be.

Congress – while Trump will enjoy majorities in both the House and the Senate, he will not have a filibuster proof majority in the Senate to enact legislation.  How aggressive the Democrats will be in using their filibuster powers and whether the Republicans will limit or eliminate the use of filibusters will be telling issues in the new Congress.

Courts – the courts will likely play an important role in the new Administration, both in terms of selecting judges to fill Supreme Court and federal judge vacancies and what role the courts play in putting checks on the Administration's authority.