How Will Public Health Fare in a Trump Administration?

When this piece will be published, President-Elect Trump will be about to become President Trump, which makes it rather challenging to determine how much and what kind of attention will be given to public health in a Trump Administration.

The Trump campaign focused on several high-level themes such as across-the-board tax cuts for working and middle income Americans, creating 25 million jobs over 10 years, and building a wall along the US–Mexico border, unlike the policy-heavy campaign of his opponent. Campaigning using high-level themes rather than many specific policy positions is not unusual in political campaigns. It is especially not unusual in a campaign where the dominant issues in exit polling were the economy (voted as most important by 35%) and security (voted as most important by 21%).¹ Health care was a distant third. The Kaiser Family Foundation similarly reported in pre-election polling data that the economy and jobs was considered the most important issue, with national security and immigration regarded as numbers two and three, and health as number four.² Furthermore, when health was mentioned, it was usually with regard to pharmaceutical pricing or access.

BUDGET RECONCILIATION

The 2016 election occurred in a different environment from the 2008 election, where the stock market had recently crashed and health care was a major issue for voters. In both cases, however, voters indicated that they thought the country was heading in the wrong direction and wanted someone who would take them in a different direction: Obama in 2008 and Trump in 2016. Also like 2008, the party winning the White House captured the majority in the House and Senate. This is important because it is the Congress that passes legislation—not the Executive Branch.

In the case of the Congress, however, the differences are profound between 2008 and 2016. In the 2008 election, Democrats gained a “supermajority” in the Senate with 60 votes (including Bernie Sanders as an Independent and Ted Kennedy prior to his death in 2009). In 2016, the Republicans lost two seats. They retained a majority with 52 votes, but with less than the 60 votes needed for cloture (to shut off a filibuster), they will still be subject to a filibuster on issues the minority opposes. The exception will be for bills that are related to spending and the budget. Using budget reconciliation procedures, Republicans can pass budget-related bills with a simple majority. The Senate Parliamentarian reviews bills that are being voted on using budget reconciliation rules to ensure that the provisions indeed relate to the budget and spending, and will remove any provisions that do not.

What budget reconciliation rules mean for health-related bills is that they can be used to change funding, but not for making programmatic changes and only if the Republicans are in unison in support of the budget-related changes. All other legislation will require bipartisan support. However, as has been clear during the Obama Administration, the Executive Branch can have a substantial effect on policy through rule making, the use of executive guidance, and the issuance of executive orders.

NEW LEGISLATION

So what does all this mean for health in general and public health in particular? Republicans have repeatedly passed legislation that would repeal or at least defund major parts of the Affordable Care Act (ACA; Pub L No. 111–148)—most recently using a budget reconciliation process to repeal funding for the exchange subsidies and Medicaid expansion in late 2015 in the Senate and early 2016 in the House. The legislation had a two-year delay in implementation to provide Republicans time to pass alternate legislation to the ACA. However, Republicans knew that when they passed the legislation, President Obama would veto it—which he did.

If Republicans are able to sustain their majority in the Senate for a similar vote, they could pass legislation that would defund these major portions of the ACA, presumably again with a two-year delay to provide time to pass an alternative to the ACA. Senior Republican leaders in both Houses have indicated they are not going to pass legislation that would make the 20 million newly insured uninsured, and interests in political survival would suggest the same. However, passing a defunding bill first may make it very difficult to build a bipartisan coalition in the Senate to pass a replacement. So, for strategic reasons the Republicans may choose to pass them together, although this is far from clear.

“A BETTER WAY”?

The most detailed Republican health policy alternative to date is the document from the House Republicans, A Better Way (abetterway.speaker.gov), announced by House Speaker Paul Ryan and released last June. It includes several traditional Republican measure, such as the expanded use of Health Savings Accounts and high-risk pools, as well as allowing states to choose between a per capita Medicaid grant and a traditional block grant, which does not vary with the number of people covered. It also proposes refundable tax credits to support the purchase of insurance for those without employer-sponsored insurance, Medicare, or Medicaid.

If Republicans were able to pass legislation similar to A Better Way, what would this suggest for public health? It would provide far greater discretion to the types of insurance individuals could purchase and far greater flexibility in the ways Medicaid could be designed by the states without the use of waivers from the Centers for Medicare and Medicaid Services. Whether this would mean less public health focus is unclear, but it would not have the types of guaranteed coverage available in the ACA. However, its greater flexibility could also mean that states that wish to could make the care available through Medicaid and what is available through the purchase of insurance with refundable tax credits more seamless than it is now.

1332 WAIVERS

If Republicans are forced to live within the framework of the ACA for the next two-plus years while other legislation is being crafted as some Republicans have suggested, there are many ways that the ACA could be made more flexible. Section 1332 of the ACA permits a state to apply for a State Innovation Waiver to pursue innovative strategies for providing insurance. The 1332 waivers have guidance that provides for minimal flexibility by keeping any savings from Medicaid separate from any savings from the exchanges and by requiring budget neutrality in each and every year rather than over a period of three to five years, as usually occurs for Medicaid pilot projects. New guidance could be issued by a Trump Administration that undoes this rigidity. And because the Essential Benefit Plan specifics were defined in regulation rather than legislation, they could also be redefined by new regulation.

How the states use any increased flexibility could be to the benefit of public health, but worrisome to those who want such provisions to be in federal law. This may be regarded as a less favorable outcome because of the lack of a guarantee, but not necessarily less favorable to public health.

THE ECONOMY

Finally, to the extent that President Trump is successful in improving the economy and the availability of jobs, the literature on the social determinants of health would suggest that there should be a clear improvement in the health of the population.

The uncertainty about how a new Trump Administration and a Republican Congress will regard public health is substantial. However, Trump’s decision to put in place a 100-day hiring freeze, other than for those in public safety and public health, suggests that the new Administration may regard public health as different from other services in terms of its support and potentially its protection.