Rae Woods (00:02):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. I'm Rae Woods.

Abby Burns (00:10):
And I'm Abby Burns.

Rae Woods (00:12):
Well, the election results are in, and Donald Trump will be the 47th President of the United States with a Republican senate and what is looking like a Republican house. This is a place we've been before. Remember, the last Trump administration also had a Republican trifecta, so in some ways we know what to expect from a Trump second term.

Abby Burns (00:31):
That said, things will change this time around and the full impact of the results won't be felt by health leaders until all of the next administration's positions are filled, and that's going to take time.

Rae Woods (00:42):
But we know that you, our listeners, are looking for guidance, which is why in this episode we're going to dig into the results, share what might happen next, and how health leaders can navigate the aftermath of the 2024 elections.

Abby Burns (00:55):
To do that, we've brought two advisory board experts. New to the pod is Ben Palmer, who leads Advisory Board's news team. If you read our daily newsletter, The Daily Briefing, you've come across Ben's work. We also have Natalie Trebes who leads our executive strategy and state of the industry research.

Rae Woods (01:10):
Ben, Natalie, welcome to Radio Advisory.

Natalie Trebes (01:13):
Hi.

Ben Palmer (01:14):
Thank you for having me. It's good to be here.

Rae Woods (01:16):
This is a very special episode because we are actually in the Advisory Board office recording this in person, so thank you for coming in on this lovely day in Washington D.C. We should actually timestamp this because it is the afternoon. It is 3:13 PM on November 7th. We know that the House has yet to be called as of this recording, but it is looking like it is going to remain in Republican control. While we are giving caveats, it's probably also worth reminding our listeners that Advisory Board is a nonpartisan organization, which is why the four of us are here to give you the facts, what we know, and to start to anticipate what might come next and what you should do about it.

Abby Burns (01:55):
And Rae, let's start big picture. In general, healthcare took a bit of a backseat in this campaign to issues like the economy and immigration. What can we expect Ben, Natalie from a Trump administration based on what we know maybe from his first term and what he and some of his surrogates on the campaign trail said?

Ben Palmer (02:15):
It's a little hard to tell sometimes. There wasn't a whole lot of health policy as part of Trump's campaign. There was the famous concepts of a plan line in the debate with Kamala Harris about ACA repeal, but again, it wasn't a main focus of his campaign. We do have some thoughts. Mike Johnson had briefly mentioned wanting to get rid of the ACA, but didn't really offer anything beyond that. JD Vance has talked a little bit about separating people with pre-existing conditions into high-risk pools. But again, as far as a detailed policy goes, I think our best option is to really look at what happened in the first term to at least get a rough idea of what might happen in the second term. But obviously things have changed since then too.

Rae Woods (03:05):
Things have changed since then, and I think that is the right frame to come into this second term, especially since it is looking like a second trifecta. But the operating environment going into 2025 is not the same as it was in 2017. Natalie, how is the operating environment going to be different in this Trump second term?

Natalie Trebes (03:26):
It's important to break down all the different levels here that you can think about. The past term, the past Trump presidency is a good template to start from, but we have to think about really what has changed. So we've got a totally different country than we had eight years ago. We've gone through a pandemic. We've had an economy that I think very much played into the results of this election. The way that shows up for folks. Public trust and engagement with institutions is very different as well. So that's our first layer is just what does the world look like?

(04:00):
And then there have been changes to how policymaking and the legal environment around what different positions can do through Supreme Court rulings, but also through just what's happened in the constraints of our gridlocked Congress we've had. And so Supreme Court obviously had rulings that expanded the scope of presidential power, so that plays in. Then you also had Biden and the Democrats did a lot with reconciliation. The Inflation Reduction Act, which was the most transformative legislation in healthcare of the last decade since the Affordable Care Act, that was through budget reconciliation. So requires a simple majority in the Senate to pass. I think that proved that you can do a lot, and so that's very different than the environment that the Affordable Care Act was passed in.

Abby Burns (04:47):
Natalie, I'm wondering ... We've talked about the environment itself is different, we've talked about the legislative sort of process. What about on the executive side? What about the personality side of it all?

Natalie Trebes (04:58):
Yeah. I think that's the other big thing we have to think about, and Trump is very much a huge personality, and that is obviously what a lot of the election has revolved around. In the 2016 administration, I think it was very much an environment ... And Ben, maybe you have a different perspective on this or not. The Republican Party thought that they were using Trump, I think, to be the mouthpiece or the figurehead, and then they would do all of the policies they wanted, and it was the Republican Party with Trump in the presidency, and now I think it is Trump's party, and that's what we've seen over the last several years. And so he is not running again. He doesn't have the incentive to try to play politics with the Republican Party. He's fully become in charge of it. And the folks around him I think are not going to be as focused on constraining him and using him to their own means. They're going to be focused on what he wants to accomplish because he has definitively proven to everyone that he made the comeback.

Ben Palmer (05:54):
He has definitively won this election. This isn't like 2016 where he lost the popular vote but won the electoral. He won the popular vote and he won the electoral vote, so for sure this is his party. So you're not going to have that same philosophy

Rae Woods (06:12):
And what you're talking about is exactly why we need to pay attention to the decisions that Trump will make in terms of who is in charge of specific agencies. I'm thinking HHS, FDA, CDC, even FTC. Those are going to have a big impact on what happens next in healthcare. What are you all watching for there?

Ben Palmer (06:33):
Yeah. I mean, who's in charge I think is going to be the thing that has the biggest impact. There are a lot of names. Obviously we don't know who's going to be in charge of different departments and all of that right now. There's some names being thrown around as potential heads of HHS. Seema Verma, former CMS administrator has been thrown out there. Bobby Jindal, which is a blast from the past, former governor of Louisiana, also worked in HHS under George W. Bush. And then of course RFK Jr., Robert F. Kennedy Jr., his name has been thrown out there. In some form or another, he has personally said that Trump has promised him control of federal agencies.

Rae Woods (07:09):
Which we don't know what that means. Does that actually mean head of HHS or does it mean power in some other way?

Ben Palmer (07:15):
Right. I mean, technically it is not legal to promise someone during a campaign I'll make you secretary of something. So we don't know if that actually happened. We just know that Trump has promised him a role and Trump himself has said he's going to let RFK Jr. run wild with health. So we'll see what that means.

Rae Woods (07:34):
Let's talk for a minute about what that actually means because I'm seeing a lot of conversation today about the impact of RFK in a position of power, or at least with a bigger mouthpiece might mean. And the big question here is what it means for public health. RFK's rhetoric is quite bullish about things like vaccines, things like fluoride in the water, things that we largely consider public health wins over the last century. His comments there are rolling back regulation, rolling back protections, enabling more choice. What will that mean for the future of public health?

Ben Palmer (08:10):
Well, and I think that point is also important that if RFK Jr. were to be nominated as HHS secretary, I think it would be tougher for him to be approved by the Senate because of these public health things that you mentioned-

Rae Woods (08:24):
That's a good point.

Ben Palmer (08:25):
Than somebody like Bobby Jindal or Seema Verma. And we also-

Rae Woods (08:28):
Especially Seema Verma we should say, was part of the last Trump administration.

Ben Palmer (08:33):
Exactly.

Rae Woods (08:33):
Has passed this before.

Ben Palmer (08:35):
And in the previous Trump administration, we have seen Republican members of the Senate hesitate to confirm controversial nominees in the past. Ronnie Jackson was nominated as VA secretary and withdrew. So there has been controversial nominations in the past that have not made it. So I think what we're talking about with his public health views, RFK Jr.'s, would make it harder for him to become HHS secretary.

Rae Woods (09:00):
Does that mean that the risk to changes that he could make to public health go down?

Ben Palmer (09:07):
I don't necessarily think so. I think he will have some position within the administration. What that position is, we don't know. But given his views, if he has some influence on the CDC, on FDA, some changes to public health could happen that would be very different than what we've seen in the past.

Abby Burns (09:30):
I want to bring this down to what we think healthcare leaders should do. If the idea is, hey, the folks that are leading some of these federal agencies are going to have huge influence, we don't know who those people are yet. What can leaders do now and plan to do moving forward?

Natalie Trebes (09:46):
Well, I think there is a role for healthcare leaders to be paying attention to the names that are getting passed around because I think, again, this will be a very personality dependent administration and how these leaders get along with Trump will matter a lot in how the leaders he picks are able to convince him to go one way or another. Because Trump says a lot of conflicting things, but at the end of the day, he is in charge, and so he will very much be the one who decides what his stance on vaccines is that goes forward, and that could be RFK's or it could not be if Trump decides that he likes what someone else has said, and that he likes a different position.

Rae Woods (10:25):
It is worth reminding as in the context of what can we learn from the first Trump administration that we apply to the second is that Trump has also made many comments about decreasing regulations in general. In 2016, it was for every new regulation added, we're going to remove at least two. I think he exceeded that number in his first term and was just recorded a few weeks ago saying, "In my second term, I would aim to eliminate at least 10 existing regulations for every one."

Natalie Trebes (10:55):
And regulations is a very interesting unit of measure. It doesn't mean anything to anybody who is looking at policy, but I think abortion, which we haven't even talked about yet, and I know we will probably get into details on this later because it's a huge part of the campaign discussion, Trump very much seems to indicate that he has put that to bed. And so I think that's an example of he has decided to overrule other aspects of the party that wanted to make abortion a bigger issue and he said, "This is settled. I'm not dealing with this. I have pushed this to the states." So I think that's an example of there are multiple positions he can hold in his coalition and which one takes precedent really depends on the people he's talking to and who he finds most convincing. And so bringing it back to healthcare leaders, as these decisions are taking place, the Senate is going to have to think about which battles it wants to fight.

(11:50):
The senators themselves, where they want to expend political capital to press for one nominee versus another, because a lot of this happens behind the scenes. By the time someone goes to a confirmation hearing, a lot of stuff, a lot of background work, a lot of handshaking, discussions of what the future could look like, that has all happened. And so right now, if you are seeing something that looks really important for you and your organization, your community in terms of the HHS secretary, in terms of CMS, in terms of FDA, CDC, pay attention to the names that are invoked. Pay attention to what your senator for your state is thinking about and how you and your advocacy team can get involved in influencing your senator to help them understand what will the ramifications of any particular nominee be over another. It's going to be a lot of choosing battles here.

Rae Woods (12:40):
I want to come back to implications for health leaders for a moment, and it's important to remember that the names really do matter. And in the context of RFK, one thing that we are bracing for and our listeners should be bracing for is that his rhetoric, which includes mis and disinformation, can actually make its way into public policy. For me, what health leaders then have to deal with is the result of that misinformation showing up in the doctor's office, being the conversation that patients and physicians, patients and pharmacists, patients and care teams have every day, which is a place we've been before. This was a big part of the conversation in the COVID era. What is the message that we have for health leaders today as they deal with that misinformation and that lack of trust in this moment?

Ben Palmer (13:28):
Yeah. I think that's something that should be paid attention to because if we have someone who is in charge of CDC, for example, who has similar vaccine views to RFK Jr. and then CDC guidelines change as a result, you go into the doctor's office, the doctor says, "Oh, we follow CDC guidelines here." Now as a healthcare provider, you may not necessarily be able to look towards the CDC or someone like that, or at least feel as secure in looking towards those guidelines as you did in the past. But again, that's part of the unknown here.

Natalie Trebes (14:02):
I think it'll open us up to just a lot more variation and so there will be probably different clinical societies that put up their guidance in lieu of a clear shared understanding of what the CDC should do and what's backing that guidance.

Rae Woods (14:21):
And less federal regulation, pushing more to the states. Obviously a Republican and a Trump principle would create more variation within states themselves, which is already something that is felt pretty immensely in the public health world.

Natalie Trebes (14:32):
Yeah, exactly. And so I think, again, a lot of these are trends that are just continuing, so misinformation is very much something that most doctors are familiar with having to deal with patients bringing in all sorts of information and so trying to navigate that. That has exponentially grown over the last decade. It's just now a lot more in the open and might be baked in to federal administration. You also need to think about where the science is coming from and who are the body of experts that are assembling that and packaging that in ways that are digestible for the doctors, because this is just adding to the workload for them. And we know we have a huge administrative burden, burnout issue for clinicians, and so we've just added politics, misinformation, sorting through five different bodies, evidence. There's a lot there and so health-

Rae Woods (15:22):
[inaudible 00:15:22] to care for your workforce.

Natalie Trebes (15:24):
It is a workforce story, absolutely, and the bandwidth. And it's not just figuring out what workflow support they need, what evidence support they need, but also it is figuring out what your organization's position is and how you are going to back your workers. You have to have a consistent policy here and understand what the organization's stance is in an environment where everything else is kind of varied and you can pick and choose.

Abby Burns (15:51):
Yep. I want to transition us as we're thinking about what might a second Trump term look like, moving us from a little bit of conversation around the power structures and into some of the issues that this administration is going to be dealing with. The Affordable Care Act, we didn't really hear much about it in this campaign, but it has been at the center of healthcare debate for the past decade, 15 years. It is a huge part of how healthcare is structured today. Just because it wasn't a major talking point during the campaign, it doesn't mean that by any stretch the ACA is immune from political changes, policy changes. What parts of the ACA might be impacted by a Trump administration?

Ben Palmer (16:35):
I know probably the first thing that people will think about is whether or not repeal and replace will happen again. Somewhere Bill Cassidy wakes up in a cold sweat when he thinks about 2017 repeal and replace. A lot of people listening to this podcast probably also remember 2017, and because of that and because of what happened, I honestly don't necessarily think that repeal and replace is likely to happen because I don't know that Republicans in the House and Senate have the political appetite to attempt it again. I think it's worth noting that Trump's approval ratings in his first term were among their lowest, if not at their lowest, during repeal and replace. It was not something that was very popular.

Natalie Trebes (17:16):
Partly because it was mostly repeal without replace and that was a really big sticking point.

Ben Palmer (17:21):
Poor Bill Cassidy wrote two separate entire bills. There was like five separate bills, if you remember. ACA and the BRCA and skinny repeal, and there was a million of them. And because of that chaos and because of how popular the ACA is politically, it wouldn't shock me if some people attempt a repeal and replace thing, but I just don't know that Republicans necessarily can agree on what to replace the ACA with. So that big thing probably won't happen.

Rae Woods (17:47):
And the ACA is actually more popular today than it was even in its height of popularity in 2017. So if not full repeal and replace, what changes to the ACA do we expect?

Natalie Trebes (17:59):
Yeah. Because it's probably double what it was when Trump started, about, in terms of enrollment. So you've got a bigger constituency that you've got to pay attention to there. Last term, the Trump administration did attempt to undermine the ACA in many different ways. They took away the cost sharing reduction subsidies, CSRs, they reduced funding for navigators that help people sign up and enroll and get into the right plan. So that really depressed the stability of the marketplace and just enrollment in general. Setting aside repeal and replace, there's just a lot of tweaking they can do to make it less stable. It could be direct and offensive of we actually want to weaken the ACA, or it could just be not really investing in all the things you need to do to stabilize it and continue maintaining it, and the subsidies are going to be a big issue here whether this-

Rae Woods (18:50):
Let's go there.

Natalie Trebes (18:51):
Okay.

Rae Woods (18:51):
Let's go there because you just said that the ACA marketplace is a lot bigger today than it was in 2017, and that is in part because of the ACA subsidy. So reminder for our listeners, there are these subsidies that are available to individuals to help them offset the cost of purchasing a plan on the individual market. These were originally passed as part of COVID relief. They were then extended with the Inflation Reduction Act. And this is one of the key reasons responsible for the fact that in the past few years, we've seen a huge rise in the amount of people covered in the exchanges and the amount that they pay. So more people get their coverage through the exchanges and they're happy with that coverage because it is inexpensive. Those subsidies are set to expire at the end of next year. What do we think is going to happen with these subsidies?

Abby Burns (19:40):
Get out your crystal ball.

Natalie Trebes (19:41):
Get out my crystal ball. Well, and these are enhanced subsidies, so there always have been subsidies in the ACA, but this is for more people and a greater degree of subsidization. So that's what sparked more enrollment. Because you think about the early days of the exchanges, if you didn't qualify for the subsidies, you were looking at quadruple the premiums at the point.

Rae Woods (19:59):
Yeah. We're talking about this donut hole kind of problem that people were falling into.

Natalie Trebes (20:02):
So after we moved past that, it made it more attractive for enrollees. If we take those away, then we are looking at an earlier exchange environment where it was only the people who were the most desperate for coverage who are enrolling other than the ones getting the low end subsidies, and those are going to typically be people who really need insurance and therefore costs more. It's kind of called the death spiral, is what they talk about in actuarial science.

Abby Burns (20:29):
To be clear, we do not expect the enhanced subsidies to be renewed, right?

Ben Palmer (20:34):
I would be surprised if renewing the ACA subsidies is a priority for a Republican-led Senate and House without making some kind of bigger fundamental changes to the ACA. I just don't see that being a priority.

Rae Woods (20:49):
In part because their approval among individuals aside, these come at a pretty steep cost to taxpayers.

Ben Palmer (20:54):
Yeah. I should make it clear that I don't necessarily think that they wouldn't extend those subsidies for purely political reasons where it's like, "Well, this is good for Democrats. I'm not going to extend it." I think it more plays into there are a lot of Republicans who don't like excessive government spending, and I think they're going to look at these enhanced subsidies as this is costing too much money for the government. We need to rein in spending.

Rae Woods (21:16):
Which means that premiums will go up.

Abby Burns (21:18):
For the individual exchange.

Rae Woods (21:20):
For the individual exchanges at least, which may mean that people-

Natalie Trebes (21:24):
That fewer people want to buy, which means that the people that remain are probably going to be the desperate people who are more expensive, which means that premiums will go up even more. And so it's a sort of vicious cycle, and I think it makes a big uncertainty about the future viability of the exchange as this fallback for insurance enrollment in the US will probably increase uninsurance, which-

Rae Woods (21:48):
Payer mix will change.

Natalie Trebes (21:48):
Payer mix for providers. Hits them there.

Rae Woods (21:52):
And uncertainty for insurers who want to know whether the subsidies are going to be renewed or discontinued so they can set their premiums for 2026.

Natalie Trebes (21:59):
Right. And insurance premiums in the exchanges got filed ... For 2026, those got filed in the beginning of 2024, so this takes a long time for insurers to make a bet there.

Rae Woods (22:11):
So takeaway, we expect to see greater erosion of the Affordable Care Act, and that will ultimately impact the healthcare safety net.

Abby Burns (22:20):
It bears saying also, Rae, that this has a direct impact on a lot of provider organizations, in particular safety nets who are there to do exactly what their name suggests and catch patients that have reduced access to healthcare. Safety nets have benefited over the past three years from having a greater proportion of patients move from being uninsured to being insured. If we expect that number of insured patients to decline, that's a direct hit to the financial viability of safety nets.

Rae Woods (22:48):
And the financial viability of health systems, Abby, you've talked about quite a bit is not in a good place right now.

Abby Burns (22:53):
Yes, yes. That's why we're seeing this move from, hey, on the provider side, we want to run at revenue capture. Instead, systems are really pivoting and focusing on sustainable growth so that as these price shocks happen, as market instability happens, systems can ride that out and survive for the longterm.

Natalie Trebes (23:12):
There's one other thing I want to add that affects the safety net of the individual marketplace. JD Vance has thrown around the notion of getting rid of pre-existing condition protections and a few other things, and I think that would certainly make the stability of the marketplace worse, but also that leads to challenges for health systems and providers as they would have to navigate people who think certain things are covered or not. There's going to just a lot more complexity to what coverage looks like in that kind of world, and that's hard for providers to deal with. That's hard for plans to navigate as well.

Rae Woods (23:46):
And I imagine that kind of complexity, I might even use the word chaos, churn, is going to apply to another part of the safety net, which is Medicaid, and this is another area where we can learn from Trump's first term and start to think about what he would do in the second. Remind us what happened with Medicaid and what might we expect next.

Ben Palmer (24:05):
I think one of the big things we can probably expect is Medicaid work requirements to become a big thing again. Seema Verma, especially when she was with CMS, was a big fan of Medicaid work requirements and often gave many states waivers if they wanted them to do so. If she is put in charge of HHS, which is possible, I think you could see that again. I think it'll probably happen regardless of whoever's in charge of HHS, but certainly that was a priority for her at CMS. You could see Medicaid shifting to block grant funding. I mean, these were things that were either talked about or did happen in some way or another during Trump's first term. So that's an area where I think you can take cues from his first term to take a look at what's going to happen in the second one.

Rae Woods (24:43):
Which sounds like another hit to payer mix.

Natalie Trebes (24:45):
Yes.

Abby Burns (24:46):
Well, I think it also, it reinforces the idea that organizations are going to be working with a patchwork system across states as Medicaid regulations change state by state.

Rae Woods (24:54):
Which frankly is the story of Medicaid over the last several years. That's something that we saw when the public health emergency ended. One of the big takeaways that I remember, Natalie, you saying to me on this very podcast was how provider and payer organizations would deal with the churn and having to deal with the administrative burden of figuring out where people land and do they actually retain their Medicaid or not, and where do they go. And that actually made a big impact on how much the uninsured rate rose post-PHE and I imagine we're going to be in a similar situation here with the onset of work requirements.

Natalie Trebes (25:26):
Yeah, that's right.

Abby Burns (26:22):
What about Medicare? I guess the biggest question on my mind, we had Chelsea and Max on a couple of weeks ago talking about Medicare Advantage. The volatility was the word that Chelsea used to describe it. Does that change under a Trump administration? Is Medicare Advantage likely to go back to being sort of a bounty?

Natalie Trebes (26:41):
A bunch of insurance stocks jumped when the election results came out. I think that's probably mostly with just keeping in tune with all the stocks jumping. The market likes stability, likes answers, thinks it's going to get a better tax environment, I think. So most of that I attribute to the economy. I do think Medicare Advantage and publicly traded insurers were having a rough go of it because the Biden administration was starting to tweak, scrutinize, tighten the finances of Medicare Advantage. And we have to think back ... I'm sure Max and Chelsea talked about this. Medicare Advantage has gone from 10% of Medicare enrollment to 52, 3, 4%. So that is a huge amount of people, and the Biden administration was looking at that and saying, "Okay. We might be spending more than we should. We need to take a close look at this. We need to tighten up risk adjustment and quality bonuses." And that changed the playing field. The insurers who were operating in there were obviously ... I think believed that they were operating in the financial model that existed and so they resisting the changes that have been coming. And there were a lot of lawsuits against CMS about what those changes were, whether they were appropriate or not, whether they were viable. And I think those lawsuits will now be going forward in a very different environment.

(27:57):
And I think it's a question of whether the administration is able to continue funding ... If solvency is an issue for the administration.

Rae Woods (28:06):
Because if solvency is an issue, we would see increasing pressures on Medicare Advantage.

Natalie Trebes (28:10):
Right. Because it's basically Medicare.

Rae Woods (28:12):
Yes.

Natalie Trebes (28:13):
So I don't know what happens with the trust fund, and I don't know ... We're entering in a new territory where I don't know what we think about the deficit anymore. I believe there was a projection of 7.5 trillion is what is expected to be added-

Ben Palmer (28:28):
Something like that. Yeah.

Natalie Trebes (28:29):
Through the Trump administration. And so I think it's up to Congress, which is controlled by Republicans, to decide whether they want to do the borrowing necessary to get the trust fund in order. And so it's really up in the air, but I think all of that points to a slightly more favorable Medicare Advantage climate than previous for insurers. I don't think it completely goes away though.

Rae Woods (28:52):
The conversation for me around Medicare actually rests with what's happening with drug pricing. Because one of the big things that we would be, and Abby you and I are planning on talking about on Radio Advisory in the next couple of weeks, is how a Trump-led Medicare might impact Medicare's attempts at negotiating drug prices. What do you think the future looks like here? Drug pricing, I should say, in theory, bipartisan.

Ben Palmer (29:23):
Yeah. I mean, it's something that, I mean, Trump, during his first term, it was a priority for him. I mean, he on the campaign took credit for the $35 insulin price caps, which were experimented with under his administration, obviously put in place in the IRA. But drug prices, he had his most favored nation policy, which was aimed at bringing down drug prices. So yeah, I think you could argue that this is something that Trump has said he wants to do.

Natalie Trebes (29:52):
And it plays into his image of I'm going to negotiate for the best deal.

Ben Palmer (29:57):
I'm the deal maker. Yeah.

Rae Woods (29:58):
But do we think that it is going to happen through the IRA, through what a potential Harris administration would look to next by using Medicare to negotiate the next 50 drugs?

Abby Burns (30:09):
That was the thing that Harris came out saying that she would expand the list from 15 to 50 drugs next year.

Rae Woods (30:14):
That's right.

Abby Burns (30:14):
We don't know what that would look like on the Trump side.

Ben Palmer (30:15):
Yeah. I think that's where the question is, is Trump has, in the past ... We talked about the ACA. Trump wasn't a huge fan of the ACA, mostly because it was passed under the Obama administration. The question then remains would he not be a fan of the IRA because it was passed under a Biden administration? Would he attempt potentially to create his own drug price reduction plan by reimplementing his most favored nation policy instead of expanding upon the IRA? It's hard to say.

Rae Woods (30:48):
Could we see a similar approach to the IRA as the ACA where it's not, we're going and starting from scratch, but we're actually just tinkering, perhaps weakening, perhaps stalling some of the approaches to existing legislation?

Natalie Trebes (31:03):
Yeah. We're in the first year of drug price negotiation. They just did the first set of negotiations. They're entering into the next round. The lawyers who have been building this entire infrastructure, they've learned a lot, but they're also expensive professionals. You have to staff this to continue to move it forward to something that can sustain itself and be a viable program. And you have to fund that team and keep them in place, but you also have to defend it against attacks and there are a lot of lawsuits from pharmaceutical industry and others pushing against this. And so I think it's a question of how much resistance do you want to put up to defend something that's not exactly your program. If you rebrand it the Trump drug price negotiation, you might actually want to do that. And it could be a piggy bank.

(31:59):
I think that was the push from the potential Harris administration was we could get a lot of savings that we can use for all of the policies we want. And so maybe they realized that they could get a lot of savings to fund the tax cuts that they've promised. Any other things they need to shore up in Medicare. And so I think it's on the table. I don't know how they will look at it, but it will absolutely need to be defended and supported if it is going to stay because it is not a stable program.

Ben Palmer (32:31):
I do think the piggy bank point is a good point because the tax cuts were obviously a big part of the campaign, but obviously the big question that comes with tax cuts is how do you pay for those tax cuts. And I think if this-

Rae Woods (32:43):
This could be a place.

Ben Palmer (32:44):
This could be a place to pay for that. This could be a place to try and reduce spending by getting some money through drug price negotiation. So it's all going to depend on just how much the Trump administration can stomach really using a Biden administration law and expanding upon that. Or if they decide we're going to take this, we're going to make it our own and do something slightly different or the same, but with a different name. It's hard to tell.

Rae Woods (33:10):
So drug pricing is going to continue to be an area of focus. We're going to continue to talk about it on Radio Advisory. Precisely how this administration tackles drug prices is up in the air. Is it going to be through existing legislation? Is it going to be through PBM reform? We're going to be watching for what happens next.

Natalie Trebes (33:27):
And if we've got RFK in there, he has very strong opinions on the pharmaceutical industry, right? So that might actually lead to more pushing.

Abby Burns (33:37):
I think we have ignored the elephant in the room long enough. I think we need to shift our attention a little bit and talk about abortion, which was obviously one of the biggest issues in the campaign this year. There were 10 states that had ballot measures on abortion. They split different ways. One thing I think is pretty certain, abortion access will continue to be an area of focus and access itself will continue to change. What does that mean for healthcare leaders?

Ben Palmer (34:06):
I think it means that they're still going to be operating under a patchwork of different laws throughout the entire country. Honestly, I don't think a whole lot has changed. Obviously, one of the major things that Kamala Harris campaigned on was codifying Roe v. Wade into law. But even that was going to be a giant hurdle, even if there was a democratic trifecta, because you would either have to remove the filibuster, which is a huge hurdle, or you would have to overcome the filibuster, which is also a huge hurdle. There was talk during the campaign about the potential of a national abortion ban. That's another thing that I think would be a gigantic hurdle because we talked about repeal, replace the ACA or whatever. Obviously that would be controversial, but that's something you can do through reconciliation, which only requires a simple majority in the Senate. A national abortion ban, you would not be able to.

(34:51):
So you would either need to remove the filibuster, which it doesn't sound like Republicans have any appetite to do and Mitch McConnell himself recently said he's thrilled the filibuster will stay in place. Or you would need to get some Democrats to vote for a national abortion ban and that is about as unlikely as possible. I don't even think there's even much Republican appetite for a national abortion ban. You have some Republican congressional members who are coming out as pro-choice that even say that. So I think we are where we were, and that's where we're going to stay.

Rae Woods (35:22):
I agree with you on patchwork system. Let's be clear. What does that practically mean for the people who are listening to this podcast?

Natalie Trebes (35:29):
And that's where I want to go is patchwork system is the rules, but states do not exist in a vacuum. People move between states.

Rae Woods (35:39):
Organizations operate across state lines.

Natalie Trebes (35:40):
Organizations operate across state lines. And so there are a number of other aspects to the abortion access question. Prescribing across state lines through telehealth, Mifepristone accessing through the mail.

Ben Palmer (35:56):
The Mifepristone lawsuit, the Supreme Court dismissed it because the doctors who brought it, they said they lacked standing.

Natalie Trebes (36:01):
Yeah, that's right. So that might come back and the Trump administration might not want to defend that.

Ben Palmer (36:06):
Yeah. I mean, that's a big question is will a Trump administration want to defend the same Mifepristone lawsuit if perhaps a plaintiff with better standing comes in?

Rae Woods (36:18):
Which would ultimately impact the ability to get access to abortion medication through the mail.

Natalie Trebes (36:23):
And EMTALA. In terms of requirements for hospitals to treat emergencies, the Biden administration had released new guidance to clarify how EMTALA affected pregnancy complications and emergencies. The Trump administration might change that guidance. So where the existing federal law and policies intersect with states, that is something to watch. And then practically speaking, I think we are looking at a clinical workforce that has a lot of different opinions, but many of them in the OB-GYN space, in the primary care family physician space have to deal with the results of the pregnancy complications.

Abby Burns (37:07):
Natalie, I'm so happy that you brought it to workforce because this has come up in our research time and time again. And what I think is particularly interesting ... Two things. One is on the medical education side. Are OB-GYN residents going to states that have stricter abortion bans? We'll have to track that over time to see how that affects-

Rae Woods (37:27):
We've already seen a decrease in OB-GYNs in states with strict abortion laws. Will that actually cross its path to being true care deserts is yet to be seen.

Abby Burns (37:38):
I was also talking with a provider leader in his state prior to the election that had restricted access to abortion who said they were having trouble with primary care doctor attrition because primary care physicians didn't want to be in the position of not being able to deliver the care to their patients that they wanted to deliver. So this is not just an OB-GYN problem-

Rae Woods (37:55):
Or a care delivery problem.

Natalie Trebes (37:57):
Primary care physician does not want to be operating in an environment where there are not OB-GYNs operating. And so this all is connected. It's not just abortion access that we're talking about. It is entire maternal health ecosystem.

Ben Palmer (38:12):
Yeah. It's a domino effect. And I think you're going to be looking at very large deserts too if that were to happen. I mean, with Florida not passing its constitutional amendment for abortion, that southern, southeastern area of the United States, I think Maryland is about the closest state without some form of an abortion ban.

Rae Woods (38:32):
We are talking about state level policies. How important will the balance of state and federal policy even be if we end up with a, and it looks like we're going to, a unified Republican government?

Natalie Trebes (38:45):
I still think it's enormously important. And we've talked about this before, but states ... And it's looking like it's going to land about where it already is where states, most of them are in a trifecta themselves of having the governor in both houses of their state legislature, one party. They are just simply able to do a lot more, whether it is an ideological action or whether it's just simply normal government operations, when they are not fighting with each other across a party line. And so yes, the federal government is going to most likely be fully aligned and very active, but they are going to have their hands full with a lot of different pieces. All the things we've talked about. And so the big push in reproductive care has been pushing that to the states, so we expect lots of action there and not as much from the federal government. I also think we've seen a lot from states around pharmacy access and drug policies and PBM operations. There's been a lot of experimentation there.

Rae Woods (39:42):
There's also a lot of public health focus at the state level. So to the extent that national public health trends shift and our pushed more to the states, we are likely to see more variation within states there as well.

Natalie Trebes (39:52):
Yeah. And then the states will be the ones trying to push for Medicaid waivers for how they operate.

Abby Burns (39:57):
I think it's important to note that this also brings up some health equity implications because the likelihood of a given state prioritizing health equity, given we are likely to see an administration that deprioritizes health equity, will have a direct impact on patients.

Rae Woods (40:13):
And communities.

Ben Palmer (40:14):
One of the recurring themes of this podcast has been there will be still gridlock at the federal level, even with the Republican trifecta. The Republicans have a very slim majority-

Rae Woods (40:24):
It's not a super majority.

Ben Palmer (40:25):
In the senate. It is not a super majority, which means that whatever they are not able to pass through reconciliation, they will need to overcome a filibuster which will require bipartisan support on whatever they're trying to pass. So that's going to be difficult. And even in the House, it's going to probably be a pretty slim majority. So there's still going to be that gridlock because of how slim those majorities are.

Rae Woods (40:51):
We are obviously incredibly immersed in what is happening now and what might happen next. I want to bring us to a conclusion. Ben and Natalie, you talk to health leaders every day. What's the most important thing you're going to be bringing to your conversations with leaders?

Ben Palmer (41:10):
Well, we have The Daily Briefing, which is our Advisory Board daily newsletter that I write for and edit. That gets published every single day, so make sure you are subscribed to The Daily Briefing.

Natalie Trebes (41:24):
And I think we're talking with leaders a lot about not forgetting to zoom out and look at the bigger structural changes that are happening. So yes, there's a lot of really extreme things that are chaotic and very salient right now that probably will affect the structure of the future, but you also have some big shifts in what care utilization and morbidity looks like under the surface, what payer-provider partnerships look like, what the treatment portfolio we have available as we shift from more procedures to more drugs. These are all big, big shifts in the entire operations of how healthcare works and so don't lose sight of your need to focus on adapting to those in the midst of all of this policy change.

Rae Woods (42:12):
Natalie, it sounds like your takeaway for us is the classic line, don't lose the forest for the trees. What is perhaps the first tree that our listeners should be focusing their attention on in the near term?

Natalie Trebes (42:25):
Well, technically speaking, it's actually lame duck Congress of all of the things that are going to expire soon. But I think what that practically means for healthcare leaders is we have a lot of shakeups happening to Congress. It is your job to help your congresspeople understand your problems for your organization, your community, your staff, your patients and so you need to be really looking through all these things we've talked about. How are they going to affect you and your humans in your community? And make sure that you have packaged that in a way that your congressperson cares about and can understand because we are entering a new era, a blank slate in some cases, and so it's important to educate them.

Abby Burns (43:17):
Natalie, I love that you brought that back to almost one of the first points that we make, which is the people that are in seat really matter to what happens next. We don't know who all of them are yet, but your point about relationship development and helping these folks help you and further the interests of your organizations, your stakeholder group, et cetera, is a really powerful one.

Rae Woods (43:36):
Well, we're going to be watching what comes next, what happens in the immediate term in things like telehealth, flexibilities, the hospital at home waiver. What happens when we fund the government? We're all going to be looking at these things. And Ben and Natalie, Abby, thank you for coming in person to Radio Advisory.

Ben Palmer (43:51):
Thank you for having me.

Natalie Trebes (43:52):
Thank you.

Abby Burns (43:58):
We spent a lot of time today talking about what might happen in a second Trump presidential term, but a lot also happened across 2024. So in a few weeks, we're going to be digging into some of the policy areas that have been really active across this calendar year, what we are looking at today, and moving forward, and what they mean for you. Because remember, as always, we're here to help.

(44:23):
If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Abby Burns, as well as Rae Woods, Chloe Bakst and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. Special thanks to Max Hakanson. We'll see you next week.