Trump Presidency’s Impact on Gastroenterology Uncertain

Issue: January 2017

With a Republican majority in both the House and the Senate, President-elect Trump is expected to deliver on his campaign promise to repeal and replace the Affordable Care Act.

Aside from this, the new administration’s health care priorities and their potential impact on the field of gastroenterology remain uncertain.

Even the details of when and how the ACA will be dismantled are unclear.

ACA repeal and replace

During his campaign, Trump said he would take action on the ACA immediately after taking office. While more than 20% of Americans reported they want the President-elect to focus on health care when he takes office on January 20, according to a recent Reuters/Ipsos poll, Trump failed to mention repealing the ACA in his acceptance speech, nor in the video statement released in November outlining his priorities for the first 100 days of his administration.

Timothy C. Wang

“People are wondering exactly how committed he is to doing this initially,” AGA President Timothy C. Wang, MD, from Columbia University Medical Center, told Healio Gastroenterology. “But if he does, this would impact gastroenterology because many of the patients who we treat were unable to get insurance before Obamacare, primarily because they have diseases or conditions — for example, inflammatory bowel disease — that were considered pre-existing conditions.”

Since the election, however, Trump has indicated he may keep some aspects of the ACA in place, including the requirement that insurers cover people with pre-existing conditions. Ultimately, this may not be an easy feat, according to Wang.

“Allowing pre-existing conditions and removing the universal mandate would be difficult, because it would face some challenges from the insurance industry who may be reluctant without the guarantee of universal coverage to spread the risk like the individual mandate,” he said.

Even if this aspect of the ACA survives, millions of people who have gained coverage are now uncertain about whether they will be able to obtain affordable — if any — health insurance under an as yet undefined alternative.

“The devil will be in the details,” Joel Brill, MD, chief medical officer at Predictive Health, told Healio Gastroenterology. “Millions of people have gained coverage, so to repeal that without having a plan in place to offer coverage to those people obviously could be of great concern to them.”

The exact figure of Americans who now depend on the ACA for health coverage exceeds 20 million, “which makes wholesale repeal of the law much more difficult than it would have been even a year ago,” according to ASGE President-elect Karen L. Woods, MD, FASGE.

While Speaker of the House Paul Ryan, Senator Bill Cassidy, MD, (R-LA) and others have recently proposed alternative plans — floating ideas like tax credits to make insurance more affordable and high-risk pools for especially sick patients — the specifics of the ACA rollback are still unknown, leaving several other issues relevant to gastroenterologists in question.

Joel Brill

“One of the things that the ACA did was to extend coverage without patient co-pay for preventive services that had a grade A or B by the U.S. Preventive Services Task Force, and as a result of more patients obtaining coverage, many more patients have been eligible for colorectal cancer screening,” Brill said. “However the ACA never fixed the glitch.”

This “glitch” causes asymptomatic Medicare patients to incur out-of-pocket costs for colonoscopy as a result of colorectal cancer screening if they have a positive result on another test, changing it from a screening to a diagnostic procedure. “Perhaps that will get fixed when the ACA is repealed and replaced,” Brill said. “On the other hand, the mandate that services with a grade of A or B from the USPSTF are covered could also be attacked.”

The Medicare glitch and other shortcomings of the ACA notwithstanding, even people who did have insurance faced significant impediments to preventive care before it was enacted, according to Woods.

“We are disappointed that Congress has not acted to improve the colorectal cancer screening benefit for patients who have a polyp removed during their screening and who are unfairly liable for paying a coinsurance,” Woods said on behalf of the ASGE. “Whatever changes are made to the ACA by the 115th Congress and the new administration, we hope the preventive benefits without cost sharing will be maintained and the colorectal cancer screening coinsurance gap filled.”

In addition, Brill said that, if repealed, the Misvalued Codes Initiative — an ACA provision that led to adjustments in payment for endoscopic services — could lead to a respite from further future attempts to revalue payment for gastrointestinal endoscopic procedures.

“On the other hand, under a repeal and replace scenario, the question would be whether there’d be any incentive or mandate to increase payment for cognitive services, to pay specialists for providing care coordination, collaborative services for patients with chronic diseases such as end stage liver disease, IBD, chronic pancreatitis or the like, where the gastroenterologist might be the primary care giver,” he added.

Unlike the ACA, the Medicare Access and CHIP Reauthorization Act was bipartisan legislation, and while Trump has not publicly expressed his views on MACRA, “all signs lead to the fact that it will continue to be implemented on schedule,” according to Wang.

MACRA

So far the Trump administration has given no indication that it would delay or alter the MACRA law, which is set to take effect January 1, 2017.

The experts we interviewed agreed that given the bipartisan support for issues related to MACRA — like eliminating the sustainable growth rate (SGR) and transitioning to value-based payment systems — implementation is likely to continue.

“From the GI standpoint, much of what we do is focused on outpatient rather than inpatient procedures, so we hope that under MACRA, we will continue to have an environment where it will support the development of new initiatives that are not necessarily hospital-based and are physician-focused in their nature to improve care and deliver value to patients,” Brill said.

Karen L. Woods

Woods also expressed confidence that MACRA implementation would move forward as scheduled.

“ASGE members are preparing for the implementation of the new Quality Payment Program on January 1st,” she said. “Throughout the implementation process, the Centers for Medicare and Medicaid Services has been generally responsive to the concerns conveyed by the physician community. There is always room for improvement in large-scale reforms such as MACRA.”

However, while hopeful that the key components of MACRA will continue, Brill does not consider it “a slam dunk.”

For example, Congressman Tom Price, MD, (R-Ga.), who Trump has nominated for secretary of Health and Human Services, recently raised concerns in a letter to over 100 colleagues about whether the Center for Medicare & Medicaid Innovation (CMMI) was creating initiatives outside the scope of what MACRA permitted.

“So if there is a rollback of CMMI, it remains to be seen whether those changes could also impact the ability of physicians to develop new risk-bearing payment models,” Brill said.

In addition, staff turnover during the transition to the new administration is also a concern for MACRA implementation, according to Wang.

“With every new administration, there is staff turnover at the agencies, so it’s unknown at this point which career staff will stay on and who will depart, and if they lose a lot of their key staff who are guiding the MACRA transition, this could really impact the rollout,” Wang said. “This could affect gastroenterology and other physicians given the institutional knowledge that would be lost if there were a large turnover of staff.”

Like MACRA, NIH funding has also received bipartisan support, as the House of Representatives has recently demonstrated by passing the 21st Century Cures Act, which would designate $4.8 billion in NIH funding over 10 years if passed by the Senate.

However, President-elect Trump has not yet expressed his position on biomedical research funding.

NIH Funding

NIH funding is of great concern to gastroenterologists, who are “waiting with bated breath” to see what will happen, according to Wang.

“Given that the Republicans now control the presidency and both houses of congress, there’s an opportunity to now move things forward, but given that President-elect Trump wants to enact a large infrastructure bill that will require billions of dollars in spending, it is uncertain how NIH will fare in his list of priorities,” he said. “However, Congress still has the power of the purse and there is tremendous support for increasing the NIH budget, although with a Republican-controlled Congress, there is concern among the research community that NIH funding would lag behind other Republican priorities.”

The AGA, he said, will continue to educate the new members of the House and Senate on these issues, and is committed to working with the new administration to advance the science and practice of gastroenterology.

“We’ll also continue to work with our champions in Congress to ensure fair reimbursement, patient access to specialty care, reduced regulatory burden for the practicing gastroenterologist and increased funding for the NIH and other agencies,” he said. – by Adam Leitenberger

References:

Kahn C. Americans want Trump to focus on healthcare first. http://www.reuters.com/article/us-usa-trump-poll-idUSKBN13C2HM. Published Nov. 18, 2016. Accessed Dec. 2, 2016.

Disclosures: Wang and Woods report no relevant financial disclosures. Brill reports consulting and/or advisory board relationships with Blue Earth Diagnostics, Lilly, Indivior Pharma, Braeburn Pharma, AstraZeneca, Nestle Health Sciences, EndoChoice, EndoGastric Solutions, Medtronic, Halt Medical, Gene News and Sonar MD.