Dartmouth Experts Discuss Future of Health Care in Age of Trump

Valley News Staff Writer
Published: 1/20/2017 12:13:04 AM
Modified: 1/20/2017 12:13:04 AM

Hanover — The Trump administration’s promised repeal of the Affordable Care Act could eventually take health insurance away from millions of people, but many of the sprawling law’s policies and effects on health care access, quality and cost may survive intact.

That was the optimistic — but far from emphatic — conclusion that emerged from presentations by a panel of Dartmouth faculty members who gathered late Thursday afternoon to look into the future of a sector where size and complexity cause problems but also slow the pace of change.

“I don’t think they are trying to blow it up,” said Elliot Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice.

Fisher was referring to the Republican health care experts whose counsel, he was led to believe, had been sought by the incoming administration.

Those experts “are very worried” about the potential political cost of repeal, Fisher added. “They know they are going to own this if 20 million people lose their health insurance.”

A standing room crowd filled a moderately large classroom at the Tuck School of Business to watch some of Dartmouth’s brightest health policy stars shine their analytic and academic lights on the health policy intentions of Trump and his team.  

The assignment was challenging. “I’ve spent the last two months trying to get my mental arms around what a Trump presidency will look like,” said Aaron Kaplan, an interventional cardiologist at Dartmouth-Hitchcock and professor at Geisel School of Medicine. 

He projected a slide of a mist-filled hillside, but said that he wasn’t sure whether the clouds on the landscape represented a “Twitter fog” that was obscuring a “classic Republican agenda” or the smoke from some as-yet undetermined wild fire.

The pledge to “repeal and replace” the ACA reverberated through the Republican primaries and it became a key theme in Trump’s successful general election campaign. But Trump has at various times embraced elements of the ACA, including provisions that allow parents to cover their adult children under family policies up until the age of 26 and require insurers to sell insurance to consumers with pre-existing conditions. He also recently pledged to develop a plan that covers everyone.

With the future so difficult to predict, the panelists instead turned their attention to summarizing the accomplishments and shortcomings of the ACA. Fisher had prepared a report card that gave the law an “A” for improving the collection and assessment of evidence on the effectiveness of new reforms and treatments, an “F” for failing to rein in the costs of prescription drug coverage and six Bs and one C in other categories.

Ellen Meara, a professor at the Dartmouth Institute, said that among Americans under the age of 65, when most get covered by Medicare, the ACA has produced “a slight reduction in the percent not getting needed medical care because of cost.”

But Jon Skinner, an economics professor, said that the ACA had not been effective in reining in health care costs: “The Affordable Care Act didn’t quite solve the affordable part.”

In what proved to be the most radical idea floated at the event, Skinner said that price controls might be the only way to rein in health care costs, but that would “make CEOs of hospitals very unhappy.”

A more modest effort that Trump has sometimes proposed — allowing Medicare to use its market power to negotiate lower drug prices — would be insufficient to bend down the broader health cost curve, according to Skinner. That’s because pharmaceuticals account for only about 10 percent of health care spending while hospital, physician and clinical services about for just over half, he said.

Kaplan said that making value a consideration in health care decisions — an initiative that preceded but was reinforced by the ACA — has had had an impact. “As a clinician in the trenches … my life has actually changed a lot in the last 10 years.” For himself and for many doctors, he said, prices and costs now figure in the assessment of treatment alternatives. 

But Kaplan, who has invented and launched startup companies for new medical devices, characterized that sector as “in a deep winter.” That’s the result of the slow pace of regulatory reviews and industry consolidation that has reduced the number of potential buyers for young companies, he said.

Panelists differed in their predictions about the impact of ACA repeal. “It looks like coverage will drop substantially,” Skinner said.

That could be part of a chain reaction, he warned: “Once insurance companies see that healthy people are (going without health insurance) they will either exit the market or raise premiums.”

But Kaplan said that his gut feeling was that the percentage of uninsured would be unchanged in a year.

Meara agreed with that forecast, mainly because change was unlikely to occur quickly, but made the surprising call that in two years the number of uninsured might fall. That wasn’t good news, as it would probably reflect a loosening of the definition of what constitutes insurance, she added.

Altogether, the panel had an optimistic tone. In an interview, Fisher said afterward that he still believed that future policies would reflect “the basic goodness of the American government and (its) commitment to protect the interests of the people.”

And Skinner said changing the health care system is like trying to change the course of “a very large tanker. You can tweak it a little bit.” 

In addition, he noted, most health care spending is accounted for by Medicare and private insurance through employers, which have not been targeted for change.

But ACA repeal would still hurt, he said. “Some people can be affected quite seriously” — especially the 20 million who could lose health insurance.

Rick Jurgens can be reached at rjurgens@vnews.com. or 603-727-3229.

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