As the results of the 2016 US Presidential election clearly show, change is the only constant.

Now that Donald Trump is US President elect, the future of the Patient Protection and Affordable Care Act (ACA, commonly referred to as “Obamacare”) is anything but guaranteed.

Whether the new President will repeal the 2010 law and replace it in its entirety or keep some parts and kill others is still largely a point of speculation among pundits, physicians and the general public. (The US Court of Appeals for the DC Circuit is, however, delaying a case against Obamacare—House v. Burwell—until President Trump takes office, which would make a repeal easier.)

Americans are divided on what they want to see lawmakers do to the Affordable Care Act with one-fourth wanting to see President-elect Donald Trump and the next Congress repeal it, while an additional 17 percent want them to scale back what the law does. Thirty percent of the public wants to see the law expanded, and 19 percent want it to move forward as it is. These are among the main findings of a November Kaiser Health Tracking Poll, conducted one week after the 2016 presidential election.

There are definitely more questions than answers at this point. “I’m not sure anyone really knows exactly how the new administration will impact dermatologic surgery patients and our members, but as a businessman we hope President-elect Trump understands how important great healthcare is for his employees and their families,” says Thomas E. Rohrer, MD, of Skin Care Physicians of Chestnut Hill and the President of the American Society for Dermatologic Surgery and the American Society for Dermatologic Surgery Association. 

“We also trust he recognizes the impact undue burdens government has placed on physician practices. If patients don’t have the ability to access needed healthcare services, both the patients and their physicians lose. We have to assure our patients access to first-rate healthcare and healthcare providers of their choice,” continues Dr. Rohrer, also an Adjunct Associate Professor of Dermatology at Brown University in Rhode Island.

Dream Team?

Here’s what we do know so far: Mr. Trump tapped Representative Tom Price as his Secretary of Health and Human Services. Dr. Price, an orthopedic surgeon and Republican from Georgia, is vehemently and vocally opposed to the Affordable Care Act. This appointment, in and of itself, tells us which way the wind is blowing.

The Price bill, the Empowering Patients First Act, would get rid of many key facets of ObamaCare including the government-run insurance exchanges in every state, the mandates on individuals and businesses and federal tax credits to subsidize the insurance of lower income Americans.

Instead, Dr. Price wants fixed tax credits based on age not income, which allows individuals to buy insurance policies in the private market and supports expanded use of health savings accounts to allow people to save income before taxes. Dr. Price would repeal Obamacare’s expanded Medicaid coverage in 32 states and the District of Columbia for able-bodied single people.

As with Obamacare, people with pre-existing medical conditions or chronic illnesses won’t be denied coverage under Dr. Price’s plan. That said, individuals must have had continuous insurance for 18 months before choosing a new policy. He would also likely provide grants to states to insure the “high risk” population. (Mr. Trump also wants to keep the popular provisions of Obamacare, namely allowing 26-year-olds to remain on their parents’ plan and barring restrictions based on pre-existing conditions.)

Mr. Trump also chose healthcare consultant Seema Verma, MPH to run the Centers for Medicare & Medicaid Services (CMS). “Together, Chairman Price and Seema Verma are the dream team that will transform our healthcare system for the benefit of all Americans,” Mr. Trump said in a statement.

What’s at Stake for Derms?

Front and center in some dermatologists’ mind is likely the status of MACRA under TrumpCare. In April 2015, Congress repealed the Sustainable Growth Rate formula by passing MACRA. In essence, MACRA aims to shift physician payment so that it rewards value and quality over volume via the creation of the Quality Payment Program (QPP). The QPP offers two pathways for reimbursement: The Merit-based Incentive System (MIPS) and Advanced Alternative Payment Models (APM). (MIPS comprise the Physician-Value Based Payment Modifier, Physician Quality Reporting System and the Medicare EHR Incentive Program).

Some of MACRA is tied up in the ACA, but it is likely safe, experts tell Practical Dermatology®. A repeal or delay of MACRA is unlikely given overwhelming bipartisan support. As opposed to the ACA, MACRA passed the house 392-37 and the Senate by 92-8. “I’m not sure there will be much appetite to change anything with that kind of bipartisan support...but some people feel that with this election result, all bets are off,” says Mark D. Kaufmann, MD, an associate Clinical Professor of dermatology in the department of Dermatology at the Icahn School of Medicine at Mount Sinai in New York City.

“The ASDSA understands that the passage of this was part of a bipartisan effort to incent quality care and reform physician payment,” Dr. Rohrer agrees. “We expect the Trump Administration to be fair in recognizing those regulations that adversely impact quality patient care.”

There are other issues that are important to dermatologists and may or may not be on the chopping block in the Trump administration.

For example, “dermatologic surgeons favor repeal of the Independent Payment Advisory Board (IPAB),” Dr. Rohrer says. Created by ACA, the IPAB is a government board that is charged with cutting Medicare spending once it reaches an arbitrary level. “Such significant health care decisions should not be made by Presidential appointees who have little to no clinical experience and who are not subject to administrative or judicial restraint,” he says. “It is predicted that the IPAB will go into effect in 2017, decreasing provider reimbursement without appropriate oversight, stakeholder input or transparency.”

He adds that if the IPAB fails to report recommendations, this responsibility will rest in the hands of the Secretary of the Department of Health and Human Services. “It should be the responsibility of the Congress to create policies that meet the needs of their constituents and design a health care system that can respond to their diverse communities.”

ASDSA members are also concerned about the way the Centers for Medicare and Medicaid Services (CMS) has handled the coding for physician payment, particularly related to the global surgery codes and requirements as set forth in the 2017 Medicare Physician Fee Schedule final rule, Dr. Rohrer says. “The ASDSA will continue to work for a fair global surgical package and we hope to work with the incoming Administration to help physicians spend more time with patients and less time on administrative work.”

Another sticking point for ASDSA members is the FDA’s interpretation of the Drug Quality and Security Act (DQSA, P.L. 113-54). “This has been interpreted narrowly by the FDA, and therefore limits our physicians in providing timely care to their patients,” Dr. Rohrer says. “ASDSA, along with other medical and pharmaceutical societies, have worked together to make drug compounding a safe in-office practice while ensuring patients have access to these medications without being hindered by government rules.”

There’s a lot at stake, he says. “Dermatologic surgeons need to stay active politically, donate to worthy candidates and make themselves available to advocate for their patients whether it be legislative, regulatory or other quasi-governmental bodies who seek to influence healthcare.” n