What will a Trump presidency mean for digital health?

By Jonah Comstock
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The unexpected election of Donald Trump who, as a candidate, was weak on specific policy promises, has mired a lot of industries in uncertainty about their future, but perhaps none more so than healthcare. The Republican party has long sought to dismantle the Affordable Care Act, a landmark piece of legislation that has affected most parts of the healthcare landscape since it was passed in 2010. 

There's no way to know for certain what's going to happen come January, but plenty of writers around the web have spoken with experts to get their best bets. Below we've rounded up some perspectives on different facets of health IT, government infrastructure, and digital health.

The Affordable Care Act

While Trump has stood by his campaign promise to "ask Congress to immediately deliver a full repeal of Obamacare", in reality that could be very difficult. For one thing, the ACA consists of not only the government-run health exchanges the law is best known for, but also cost-saving and quality improvement measures with broader support. And even getting rid of the exchanges, without something to replace them with, would leave some 18 million people without health insurance, something that could be devastating for Republicans in the 2018 mid-term elections. This piece in Quartz lays out some of the challenges Republican leadership would have repealing ACA.

Update: Later in the day after we published this story, the Wall Street Journal reported that Trump now plans to leave parts of the law intact, including letting young adults stay on their parents' health insurance and keeping insurers from denying coverage based on pre-existing conditions.

In Fast Company, Christina Farr points out that health insurance startups like Oscar Health, which owe their existence to the exchanges, might land on their feet.

"Fundamentally, we hope and expect that the new administration will keep the spirit of consumer choice and competition alive in the marketplace, which is a world where we have done pioneering work—and, are ultimately both prepared and motivated to participate," Oscar said in a statement.

Here's what Trump's new transition team page on healthcare has to say about how the administration will replace the Affordable Care Act:

"A Trump Administration will work with Congress to repeal the ACA and replace it with a solution that includes Health Savings Accounts (HSAs), and returns the historic role in regulating health insurance to the States. The Administration’s goal will be to create a patient-centered healthcare system that promotes choice, quality and affordability with health insurance and healthcare, and take any needed action to alleviate the burdens imposed on American families and businesses by the law.

To maximize choice and create a dynamic market for health insurance, the Administration will work with Congress to enable people to purchase insurance across state lines. The Administration also will work with both Congress and the States to re-establish high-risk pools – a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses and who have not maintained continuous coverage."

Medicare and Medicaid
 

Trump's transition website has this to say about the administration's plans for Medicare and Medicaid: that it will work with Congress and the states to "Modernize Medicare, so that it will be ready for the challenges with the coming retirement of the Baby Boom generation – and beyond" and "Maximize flexibility for States in administering Medicaid, to enable States to experiment with innovative methods to deliver healthcare to our low-income citizens". That said, many are predicting cuts to Medicare and Medicaid, and Paul Ryan recently said on Fox News he wants to privatize Medicare.

In the digital health world, the question is what will become of the CMS Innovation Center, which supports ACOs and other value-based care reforms. While technically a full repeal of the ACA would destroy the center, a piece in Modern Healthcare quotes a number of policy experts who believe that both sides of the aisle support the Innovation Center and the work it's doing, so it could be safe. The piece also notes that the Medicare Access and CHIP Reauthorization Act, or MACRA, is a bipartisan piece of legislation.

The FDA

Trump's transition plan also includes language about the FDA, with a promise to "reform the Food and Drug Administration, to put greater focus on the need of patients for new and innovative medical products". Most people seem to think this means a decrease in regulations, but Trump's team has been more focused on the regulation of food then on drugs or medical devices. Still, Trump's general feelings about regulation bode well for the industry.

"From everything I've heard, Trump is very supportive of technology development, and very concerned about regulatory red tape. So I think we can feel confident that Trump will certainly not increase the regulation of digital health," Bradley Merrill Thompson, a partner at Epstein Becker Green who specializes in the FDA, told MobiHealthNews in an email. "The bottom line is, while the two men seem to disagree on just about everything, it would appear that the two men might actually agree on the need to support the development of digital health, and we can expect a continuation of those policies under the Trump administration."

The Precision Medicine Initiative and Cancer Moonshot

The Precision Medicine Initiative and the Cancer Moonshot were meant to be President Obama and Vice President Joe Biden's enduring legacies, but their future is uncertain. Senate Majority Leader Mitch McConnel told Fierce Biotech that he thinks the 21st Century Cures Act, a piece of bipartisan legislation that includes additional funding for the Precision Medicine Initiative, will pass in the lame duck session of the Senate, and that Trump and Pence are on board with continuing PMI and the Cancer Moonshot.

Others are skeptical, however. Trump needs to cut a lot of spending to make anything close to his tax plan a reality, and NIH grants are one place those cuts could happen. Dr. Eric Topol, who leads the Scripps Translational Science Institute, a recipient of $207 million in grants for the PMI, told Buzzfeed he was "extremely worried" about the results of the election and that NIH and biomedical research funding would "almost certainly be at risk".

The VA

Overhauling the VA -- and fighting corruption therein -- has been a hallmark of Trump's campaign promises and continues into published plans for the transition. Technology has not been part of the rhetoric, but it's easy to read the Trump administration's plans as friendly to telemedicine and other technologies that increase veterans' access to care.

"The Trump Administration will transform the Department of Veterans’ Affairs to bring it into the 21st Century by providing state-of-the-art treatment for all physical and mental health care needs of our veterans," the transition website states. "Likewise, any questions a veteran may have about benefits earned should be addressed in a complete and timely manner."