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By MATTHEW HOLT
Sooner or later I needed to crawl out of my gap and put pen to paper on the election debacle that simply befell, and what the following lunacy is perhaps like for the well being care system. So that is my try and do exactly that.
It’s actually arduous to know why Trump gained this election or why Harris and the Democrats misplaced. There was numerous weirdness happening. Do not forget that earlier than the vote Harris was usually praised for working a gradual marketing campaign, the Democrats had tracked to the best on immigration (making an attempt to go what IMHO was a horrendous invoice ), and Harris stored 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 slim exception of Pennsylvania) voted for Democratic senators. For President they solely went 3% towards the place they had been in 2020. Even weirder was that tons of 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. (Should you actually wish to dig in, Charles Gaba has put collectively a great spreadsheet)
The best clarification is that the teeny center in American politics voted towards the incumbent. And the “center” is getting teenier. In 1964 Johnson received 61% of the vote. Nixon (1972) and Reagan (1984) gained with practically 60% of the vote. Obama’s massive 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 seemingly 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 regardless that he received the blame. It additionally seems {that a} first rate slug of Arab-Individuals and much left Democrats stayed dwelling or voted for Jill Stein due to Gaza.
And let’s not neglect the affect of the Electoral Faculty which reduces turnout outside of swing states (not completely). Certainly if we had a well-liked vote through which each vote counts, turnout could be larger, together with within the massive 2 states which are Dem strongholds (NY & CA).
Nonetheless, even in the event you 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 it is a snake consuming its personal tail. There are such a lot of repugnant egos circling round Trump that it’s greater than seemingly they’ll activate one another, and little to nothing will get accomplished. That doesn’t imply nothing will occur.
The Republicans absolutely gained’t miss the possibility 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 working round saying that there’s $2 trillion to be lower from the Federal funds, however a) there isn’t and b) historical past means that Republican congresses are inclined to do the simple tax lower and quite than do the arduous work of lowering spending, they’ll depart 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 severe try might 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 vitality tax credit however it additionally contains each the flexibility for Medicare to barter prescription drug costs and the additional subsidies for the Inexpensive Care Act. It’s fairly attainable the entire thing may very well be “repealed and changed” with out really being changed. However Trump and RFK Jr (nonetheless lengthy he’ll final) don’t appear to be conventional followers of huge Pharma, and there’ll be numerous push-back from the folks benefitting from the ACA subsidies in the event that they get lower (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 might be. There’s numerous discuss block grants. However it’s value 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 an honest proportion of Medicaid recipients. However not at all all these Medicaid recipients are black, and lots of are prototypical Trump voters, in addition to the aged. And naturally a lot of these states have now expanded Medicaid, and their hospital methods is not going to be too eager on seeing these cuts. My sense is that Medicaid will see cuts however no elementary change.
Medicare Benefit plans can count on to normally get much more sympathy from Republicans. However my guess is that whoever finally ends up working CMS gained’t have extra abdomen for important change on both the FFS program or how MA plans get scored and paid. Then again, among the regulatory modifications that CMS has pushed on the MA plans this yr (which has damage their income & inventory value) might be arduous 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 received from Harris in the course of the marketing campaign. And whereas many within the enterprise and personal fairness world have been extremely important of her, apart 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 non-public fairness behaving badly with hospitals or doctor teams. Once more it’s arduous to see that an administration that claims it needs 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 kind of positive what, and there’s a sense that plans, suppliers and lots of intermediaries are doing the identical factor. I think 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 embrace 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 attainable that he actually tries to go after the FDA. There are for positive some issues with conflicts of curiosity, however usually it’s a effectively 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 simple 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 surface at our well being and meals infrastructure is one factor. For higher or worse, really making important modifications is kind of one other. I believe childhood vaccines will proceed for use near universally–a minimum of I hope so.
The one space which 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 could be one much more of diploma than throwing the cat among the many pigeons.
So my preliminary conclusion is that the Trump administration will in the long run not change American well being care very a lot.
I want I believed the identical for immigration, freedom of the press, and nationwide safety.
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