How will holistic medicine fare under the Trump administration?
It’s a big question with no obvious answer---yet. A lot depends on what the new administration does with healthcare at large. And that is still full of unknowns.
With a Republican majority in Congress, a voter base likely to demand action, and a new head of Health & Human Services who loathes ObamaCare, the 45th president certainly has the legislative clout to drive big changes in how healthcare is financed, and possibly how it is practiced.
But the GOP juggernaut must reckon with the rocks of political and economic reality, as it discovers “repeal and replace” is easier said than done.
First, many parts of the Affordable Care Act—like protections for preexisting conditions—are popular with Republican voters. Millions of poor and working-class Trump supporters could find themselves uninsured if the administration goes with the more extreme Republican repeal proposals.
Second, short of a complete dictatorial overthrow of checks and balances, it is actually quite difficult to unmake a US law once it’s on the books. And that’s a good thing. If rewriting laws were easy, we’d be living in a different country every time there was an administration change.
A massive law like ACA, which affects multiple branches of government, several of the largest private sector industries, 17% of the GDP, and hundreds of millions of people is not something you change with a single pen stroke.
“Nothing is Clear”
Assuming the administration will ultimately adhere to the fundamentals of legislative process, a Trump healthcare remake will face the same complex congressional wrangling as any law ever proposed—even with a Senate and House majority.
Whatever changes are coming, they won’t be fast or simple.
“There's no way we can pretend the law (the ACA) doesn’t exist, or that it can be easily repealed and replaced. There’s wide disagreement even among Republicans about what the “repeals” and “replaces” should be,” said Michael Leavitt, former head of Health & Human Services under George W. Bush, and a three-time governor of Utah.
Speaking last December at the Population Health Colloquium—a conference of healthcare administrators—Leavitt says he does expect action on healthcare in the coming year, but the direction is unknown.
“The only thing certain is that the new legislation will be called ‘repeal and replace.’ But nothing is clear.”
Leavitt added that while November 8 was a victory day for Republicans, the GOP has only a 2-vote margin in the Senate that could be easily lost come 2018. “Much of what will be proposed for repeal and replace will need 60 votes. Republicans don't have that margin in the Senate.”
Is the Price Right?
Dr. Tom Price, the new Secretary of Health & Human Services, is the Republicans’ choice to perform their Obamacare amputation. Price is an avowed opponent of the ACA, and no fan of government-funded healthcare in general, though he has benefitted from it.
An Atlanta orthopedic surgeon with a net worth upward of $13 million, and investment ties to biomedical device companies, he is a political and cultural conservative with strong positions against abortion, gun control, environmental regulations, Planned Parenthood, National Public Radio, emergency mortgage relief, and increased tobacco regulation.
He is also an outspoken voice for physician independence, direct-pay practice, health savings accounts, malpractice reform, and health insurance tax credits.
In 2015, while in Congress, Price floated a repeal bill called the “Empowering Patients First Act.” Among other things, it proposed: nullifying all Obamacare mandates; tax credits of up to $3000 on private insurance; allowing insurers to set surcharges based on health status (thus dashing protection for pre-existing conditions); expanding HSAs; blocking Medicaid expansion; and cutting constraints on private contracting between physicians and Medicare patients.
Price was lauded by the American Medical Association. Other physicians groups, like the new 6,400-member Clinician Action Network oppose him and his repeal and replace plans that, “threaten to harm our most vulnerable patients and limit their access to healthcare.”
According to a recent survey of 426 primary care physicians in the New England Journal of Medicine, only 15% say they support full repeal of Obamacare. None of the self-identified Democrats, and only 32% of Republicans support repeal. Even among the Trump voters, only 38% want the administration to kill ACA. Almost all (95%) support protections for people with pre-existing conditions.
“R n’ R” Hoochie-Koo
The White House has yet to give details about its “R n’ R” plan, and how far it is really willing to go.
But in January, House Speaker Paul Ryan updated his policy paper called “A Better Way: Our Vision for a Confident America,” which could become a blueprint for Trump’s healthcare remix. It incorporates features from Price’s bill, but retains protections for pre-existing conditions.
Key features of Ryan’s “Better Way” include:
- Repeal ACA mandates, private market rules, standards for minimum benefits and maximum cost sharing, and premium subsidies.
- Retain some private market rules, including requirement to extend dependent coverage to age 26 and prohibition on pre-existing condition exclusions.
- Provide refundable tax credits based on age (unspecified), to individuals to purchase private insurance.
- Provide for one-time Open Enrollment (OE). Individuals could obtain coverage at other times, but failure to sign up during OE forfeits continuous coverage and triggers higher premiums.
- Require insurers to offer portability protections
- Implement state high-risk pools with $25 billion in federal grants.
- Permit sale of insurance across state lines.
- Encourage use of Health Savings Accounts.
- Convert federal Medicaid funding to a per capita allotment or state level block grants.
- Raise Medicare eligibility age to 67 and combine all Medicare Savings Programs into one program with a unified asset test.
- Create a personalized care demonstration allowing physicians to enter into private contracts with Medicare beneficiaries.
It remains to be seen whether the Republicans will go with Price’s hard-line repeal, Ryan’s modified plan, or something yet to be revealed.
However, they frame it, pre-existing conditions could be their Waterloo.
Any plan that blocks insurers from cherry-picking based on health status while simultaneously nixing the ACA mandates that push healthier people to buy coverage would threaten insurance company solvency. In trying to keep the parts of Obamacare that Republican voters like while scrapping the rest, the GOP could end up pitting the demands of the insurance lobby against the needs of Trump’s much-vaunted “base.”
Even with ACA’s mandates, the cost of chronic illness is imploding individual insurance markets in some areas. Insurers are simply abandoning states where the game is not profitable. “Roughly 20% of all Americans live in regions with only one insurer,” noted Doug Badger, a senior fellow at the Galen Institute, and former healthcare advisor to George W. Bush.
“Before “Repeal and Replace,” the administration is going to need to deal with Rescue,” Badger says. “My reality-check for the President and Congress is, “You’ve got a grease fire. You’ve got to extinguish it.””
GOP emphasis on HSAs appeals to many in the holistic field.
Speaking on behalf of the American Academy of Anti-Aging Medicine (A4M), Dr. Pamela Smith said she believes a Trump expansion of HSAs will be a boon for practitioners of personalized holistic care.
Smith, who heads an anti-aging practice in Traverse City, MI, says expanded HSAs will make it possible for more people to pay for time-intensive personalized care, functional tests, supplements and other things not covered by insurers.
She supports Price as HHS secretary. “It will be great to have a doctor in that job. He understands patients, and being healthy. Any administration that tries to change healthcare, but doesn’t have enough involvement of physicians, nurses, exercise experts, pharmacists, and patients will run into problems. That’s what’s been lacking all along, regardless of administration.”
Tom Blue, the Institute for Functional Medicine’s Director of Strategic Development, is also hopeful about expanded HSAs, which are vital in many IFM members’ practices. He acknowledged, however, that HSAs do little to improve healthcare for poor people or low-wage workers who earn too much to qualify for Medicaid but not enough to afford private insurance.
Blue sees both Trump and Price as supportive of the direct-pay models many functional practitioners favor. He also believes community-based cost-sharing plans like Liberty HealthShare, will see a boost under Republicans. This, he says, is a sunny prospect for functional medicine.
Run by Christian ministries, these non-profit plans allow people to pool healthcare dollars to cover each other’s expenses. These plans cover preventive care, supplements, and other aspects of functional medicine. Monthly contributions are generally lower than conventional insurance. Programs require members to affirm “shared beliefs” and abstinence from tobacco, alcohol, drugs, and junk food.
Blue says growth of these plans has been robust. “In open enrollment, people are flocking to them. As a health conscious person, if you can find one that fits your beliefs, it’s a no brainer.” He expects enrollment to reach into the millions by the end of open enrollment this year.
He predicted that Trump’s healthcare changes would ultimately be more subtle than substantive. “If you accept the basic premise that we want the majority of Americans to have some basic coverage, then you need certain things in place to make it viable. You’re not going to win elections if you screw everyone with a pre-existing condition.”
Unique Challenge for Naturopathy
For the naturopaths, ACA repeal presents a conundrum.
Mike Jawer, Government & Public Affairs Director for the American Association of Naturopathic Physicians (AANP), also sees HSA expansion as a good thing for the profession.
But a complete repeal would kill Section 2706---the much-praised “Non-Discrimination in Healthcare” provision that obliges insurers to reimburse all categories of licensed practitioners of a given service if that service is within a practitioner’s legally-recognized scope.
Under the law insurers are supposed to reimburse licensed naturopaths for primary care. Though implementation of Section 2706 has been inconsistent, it has expanded ND reimbursement in some states. Most AANP members, Jawer says, would hate to lose it.
Despite its “liberal” public persona, the naturopathic profession is actually quite diverse politically, says Jawer. Though many NDs might disdain Trump’s autocratic style, AANP hopes to tap the iconoclastic spirit that got Trump elected.
“Our profession is very much in synch with what seems to be a lesson from the campaign: people want non-conventional solutions. That’s exactly what naturopaths are trained in---alternatives to Big Pharma and Big Medicine.”
The Affordable Care Act—and its possible demise--is only one factor affecting American healthcare, albeit a big one. There are many other ways in which the new administration could affect the clinical landscape.
The Future of FDA & EPA: Given the GOP’s extreme contempt for regulation, it is possible we’ll see major alterations at the Food and Drug Administration—which Trump demeans as, “the food police.”
The White House has been short on specifics, but their top pick to head FDA is Jim O’Neill, a libertarian who runs Trump donor Peter Theil’s Mithril Capital Management, and who in his spare time advocates for Seasteading--the construction of ocean-based utopias beyond federal reach.
Lauded by many in the investment and biotech sectors, O’Neill detests FDA’s status quo, believing that its burdensome rules block innovation and kill people.
O’Neill’s a strong supporter of the “right to try,” which would take FDA out of determining drug and device efficacy, and limit it to ensuring minimum safety. The free market, says O’Neill, is the best arbiter of efficacy.
Holistic medicine has had a long, contentious relationship with the FDA. No doubt many in the field won’t mind seeing the agency castrated. Supplement industry executives are hoping for a less restrictive, more business-friendly atmosphere under Trump’s FDA.
But deregulation could have serious blowback. In the void of a weakened FDA, state Attorneys General as well as plaintiffs lawyers could opt to pick up the slack, miring the industry in countless lawsuits. And the troubling flow of spiked, contaminated, poorly made products already tainting the market could become a torrent in a deregulated environment.
But people might not notice toxins in their supplements if the Trump administration has its way and obliterates the Environmental Protection Agency. The amount of toxins in the air, water and food supply—already a major driver of chronic disease—will no doubt increase.
Vaccine Policy: Trump’s assertions that vaccines can cause autism and his promise to create a review committee headed by liberal icon and vaccine critic Robert Kennedy, drew applause from many in holistic medicine. (See Vaccine Debate Rages Over Trump, Kennedy & the Cleveland Clinic). They see it as an indicator of his willingness to challenge medical orthodoxy.
Others see it as anti-science, likening it to his climate change denial, his willingness to censor scientists, and his propensity for making up stats about everything from his inauguration audience to the incidence of terrorism.
It remains to be seen whether the president’s anti-establishment stance on vaccines comes from genuine open-mindedness or ignorance.
Trump’s Supplement Blunder: In 2009, Trump licensed his brand to Ideal Health, a multi-level vitamin company. With Trump himself fronting the launch, this new “Trump Network” usurped concepts from personalized medicine to sell “customized wellness” protocols guided by an unverified, proprietary urine test. More than 20,000 independent sellers paid to join the network and sell the kits.
As reported by STATNews, the company was initially successful with annual growth of 300% in the first years. But management got sloppy, stopped paying commission checks, and the network tanked. Trump’s licensing agreement ended in 2011 and was not renewed.
Trump is not the only GOP heavyweight to dabble with supplements. Dr. Ben Carson, the nominee to head Housing & Urban Development, has been a paid speaker for Mannatech, one of the largest multi-level supplement companies.
Arkansas governor Mike Huckabee starred in infomercials promoting a “Diabetes Solution Kit” that promised to spare people from becoming, “loyal pill-popping, finger-pricking, insulin-shooting” customers of Big Pharma.
MACRA & MIPS Here to Stay: Physicians hoping that a Trump presidency means elimination of the fed’s new value-based payment systems will probably be disappointed, say DC healthcare insiders. Short of a GOP move to destroy Medicare and Medicaid—which no one has proposed so far—MACRA and MIPS will continue to roll out.
Aimed at tying practitioner payment to measurable clinical performance, both programs have broad bipartisan support. Republicans—even hardliners like Tom Price—have gotten behind value-based reimbursement, at least in principle. MIPS and MACRA are independent of the Affordable Care Act, and would not be directly affected even if the new administration does vanquish Obamacare.
The truth is, healthcare is as much of a political minefield for Republicans as it was for the Democrats. Beyond the name “Obamacare,” what Trump supporters generally dislike are the individual mandates, the taxes, the limitations on choice of practitioners, the rising out of pocket costs, and the “surprise” medical bills. Nobody likes these things.
But they’re not going to be easy to fix—from the Left or the Right—so long as we have an insurance-dominated system, an aging population, and staggering burdens of chronic disease.
As Thomas Miller, JD, senior healthcare analyst from the American Enterprise Institute, put it, “The Democrats have had 8 years to screw up healthcare, and now it is the Republicans’ turn.”