By MATTHEW HOLT
In some unspecified time in the future I needed to crawl out of my gap and put pen to paper on the election debacle that simply came about, and what the following lunacy may be like for the well being care system. So that is my try and do exactly that.
It’s actually laborious to grasp why Trump gained this election or why Harris and the Democrats misplaced. There was plenty of weirdness happening. Keep in mind that earlier than the vote Harris was typically praised for operating a gradual marketing campaign, the Democrats had tracked to the precise on immigration (making an attempt to go what IMHO was a horrendous invoice ), and Harris saved speaking about having a Glock, being a prosecutor and campaigned with a Cheney. The swing states (which vote at a a lot larger proportion than everybody else) all (with the slender exception of Pennsylvania) voted for Democratic senators. For President they solely went 3% in opposition to the place they have been in 2020. Even weirder was that a whole bunch of hundreds of Trump voters didn’t seem to vote down the poll in any respect. But nationwide the swing was sufficiently big for Trump to win the favored vote. (In the event you actually need to dig in, Charles Gaba has put collectively a great spreadsheet)
The best rationalization is that the teeny center in American politics voted in opposition to the incumbent. And the “center” is getting teenier. In 1964 Johnson acquired 61% of the vote. Nixon (1972) and Reagan (1984) gained with practically 60% of the vote. Obama’s huge 2008 victory was with simply 53% of the vote and he gained by 7%.
Biden gained in 2020 with simply over 51% and Trump will find yourself profitable whereas probably getting simply lower than 50% of the vote. This isn’t an amazing mandate. It’s a small minority of voters switching as a result of they’re pissed off with the established order. This yr the bug bear was inflation, which actually wasn’t Biden’s fault though he acquired the blame. It additionally seems {that a} first rate slug of Arab-Individuals and much left Democrats stayed house or voted for Jill Stein due to Gaza.
And let’s not neglect the affect of the Electoral School which reduces turnout outside of swing states (not solely). Absolutely if we had a well-liked vote wherein each vote counts, turnout can be larger, together with within the huge 2 states which can be Dem strongholds (NY & CA).
Nevertheless, even for those who suppose it’s inconceivable {that a} majority would vote for Trump due to what occurred in 2016 to 2021 (particularly on January 6, 2021!), apparently that’s not sufficient of a disqualifier. He’s going to be President.
So what occurs subsequent? Significantly in well being care.
My expectation (and hope) is that this can be a snake consuming its personal tail. There are such a lot of repugnant egos circling round Trump that it’s greater than probably they’ll activate one another, and little to nothing will get executed. That doesn’t imply nothing will occur.
The Republicans absolutely gained’t miss the prospect to chop taxes like they did in 2017. The query is, will they make any important makes an attempt to chop spending? I do know Elon Musk is operating round saying that there’s $2 trillion to be reduce from the Federal price range, however a) there isn’t and b) historical past means that Republican congresses are likely to do the straightforward tax reduce and relatively than do the laborious work of lowering spending, they’ll go away the Chinese language bond holder (and future generations) with the tab. You’ll bear in mind Dick Cheney telling W Bush that “Reagan confirmed deficits don’t matter.”
However what might change?
I don’t suppose a critical try can be made to overtake or repeal the ACA–McCain’s thumbs down in 2017 was the excessive water mark of that drama. However a full repeal of the Inflation Discount Act is on the desk. Most of that is about renewable power tax credit but it surely additionally contains each the power for Medicare to barter prescription drug costs and the additional subsidies for the Inexpensive Care Act. It’s fairly doable the entire thing may very well be “repealed and changed” with out truly being changed. However Trump and RFK Jr (nonetheless lengthy he’ll final) don’t appear to be conventional followers of massive Pharma, and there’ll be plenty of push-back from the individuals benefitting from the ACA subsidies in the event that they get reduce (and even simply not prolonged). So my wager is that the well being care associated components of the act keep in tact.
I’m additionally not too positive how draconian cuts to Medicaid can be. There’s plenty of speak about block grants. However it’s price remembering that the states that proportionally do greatest (i.e. get the best Federal funds in comparison with their state funds) are the crimson voting states within the South. Clearly there’s not a lot love misplaced between among the white Republican voters in these states and the black residents who make up a good proportion of Medicaid recipients. However not at all all these Medicaid recipients are black, and plenty of are prototypical Trump voters, in addition to the aged. And naturally a lot of these states have now expanded Medicaid, and their hospital techniques is not going to be too eager on seeing these cuts. My sense is that Medicaid will see cuts however no basic change.
Medicare Benefit plans can count on to normally get much more sympathy from Republicans. However my guess is that whoever finally ends up operating CMS gained’t have extra abdomen for important change on both the FFS program or how MA plans get scored and paid. However, among the regulatory modifications that CMS has pushed on the MA plans this yr (which has damage their income & inventory value) can be laborious to unwind of their favor. I imply they and their lobbyists are on the coronary heart of the swamp!
Equally Lina Khan at the FTC appears to have heard more support from Vance than she acquired from Harris in the course of the marketing campaign. And whereas many within the enterprise and personal fairness world have been extremely vital of her, aside from a few remarks there wasn’t a lot curiosity from the FTC in going after hospital chains merging into trans-state monopolies or addressing personal fairness behaving badly with hospitals or doctor teams. Once more it’s laborious to see that an administration that claims it desires to cut back regulation goes to vary an excessive amount of.
The one well being care factor that the final Trump administration actually made occur was for hospitals to publicize their costs. So far as I can inform “value transparency” has made the sq. root of bugger all distinction in how well being care is purchased and bought within the US. However there’s bipartisan settlement that PBMs are getting away with one thing, even when nobody is sort of positive what, and there’s a sense that plans, suppliers and plenty of intermediaries are doing the identical factor. I believe that there’ll be many extra employee, employer and union lawsuits about this than Federal motion. However perhaps there’ll be one thing there and, who is aware of, it would embody some extra HSA pleasant laws.
In the meantime, there was a collective gasp heard from everybody who thinks there’s such a factor as science when RFK Jr was proposed as head of HHS. It’s doable that he actually tries to go after the FDA. There are for positive some issues with conflicts of curiosity, however normally it’s a nicely understood system and possibly would wish important laws to massively overhaul it. I’m not satisfied that anybody in Congress cares that a lot to make any modifications, or that there’s any actual consensus on what these modifications must be. And whereas there’s loads of grumbling from insiders about Epic, I don’t see what straightforward modifications could be made to a well being tech system that’s so built-in into the present cost system. RFK Jr could attempt to have an actual go on the meals system, however wait until he runs into the agriculture committee within the Senate. Screaming from the skin at our well being and meals infrastructure is one factor. For higher or worse, truly making important modifications is sort of one other. I feel childhood vaccines will proceed for use near universally–not less than I hope so.
The one space that will see a regulation & enforcement change is that if Don Rucker comes again to ONC/ASTP and strikes interoperability past the present TEFCA & QHIN initiatives to more direct API access ++. However to be honest present ASTP Director Mickey Tripathi has been getting extra vocal about improving API Access. Whereas this could make some variations to the gamers on this sector it will be one much more of diploma than throwing the cat among the many pigeons.
So my preliminary conclusion is that the Trump administration will ultimately not change American well being care very a lot.
I want I believed the identical for immigration, freedom of the press, and nationwide safety.
