The dust is still settling from the election—we have some state-level results to report and some speculation about what the new administration will mean for healthcare nationally.
Overall, the measures we identified as related to palliative and end-of-life care before the election fared well: 7 passed; 2 rejected; 1 removed from the ballot prior to the election due to invalid signatures (details below).
Notably, Arkansas, Florida, North Dakota, and Montana all approved medical marijuana, bringing the total to 20 states. (At the same time, Maine, Massachusetts, Nevada, and California approved recreational marijuana.)
The physician-assisted death proposition passed in Colorado, which joins Oregon, Washington, Vermont, and California in offering the option. Voters there, however, overwhelmingly rejected an amendment to establish a state healthcare system, and Montana voters rejected a bond measure to establish a state authority to make research grants to develop therapies and cures for brain injuries and neurological diseases.
With the surprise win for Donald Trump of the presidency, healthcare in general is headed for a time of uncertainty and turmoil. One of Trump’s signature campaign issues was to repeal and replace Obamacare, although specifics from him on the replacement have been thin. Just over the past several days, news reports have suggested that Trump is considering trying to preserve key features of Obamacare, while others suggest that the law will be repealed “on Inauguration Day.” Even in the case of a wholesale repeal pundit comments offer reassurance that effects would be phased in and unlikely to impact beneficiaries of subsidized policies until 2018. This “repeal but delay” scenario seems to be gaining steam, though not without its own chaotic effects.
In a recent presentation at the Hospital Quality Conference in San Diego, healthcare “futurist” Ian Morrison, PhD, offered predictions for what changes might be in the offing under a Trump administration, including major structural changes in the Affordable Care Act (and likely a changed name), an end to mandated participation by individuals and corporations, elimination or reduction of the tax on so-called “Cadillac” health plans, establishment of state-administered high-risk pools for people with pre-existing conditions, reduced federal subsidies for middle- and low-income and Medicaid beneficiaries, more state discretion and control over Medicaid spending (and thus more variability from state to state in benefits and services), and less regulation of insurance. Biggest implications for hospice in these changes is potential for Medicaid hospice benefits to be reduced or cut in states exercising additional discretion over spending and services.
Of course, there’s a great deal more to Obamacare, and healthcare reform generally, than “just” the insurance exchanges and Medicaid expansion, which might more directly affect palliative and end-of-life care. A healthcare policy announcement Thursday on Trump’s transition website www.greatagain.gov has some in the palliative care community concerned that Trump policies may result in a roll-back of support for advance care planning, advance directives, and patient choice in decisions around life-sustaining treatment—possibly even a resurgence of the “death panels” rhetoric and resistance. Another concern is the potential dismantling of Medicare as a system and its currently robust benefits, including hospice.
While Trump’s policy statements are vague, Paul Ryan’s conservative agenda is much more specific, and likely to significantly inform reform legislation. Although hospice is not mentioned once in the detailed policy paper, Ryan’s A Better Way agenda includes expanding Medicare Advantage programs, repealing the Medicare Independent Payment Advisory Board, combining Medicare Parts A and B, and abolishing the Center for Medicare and Medicaid Innovation (CMMI). Among many other programs, the CMMI administers the Medicare Care Choices Model, allowing concurrent curative and palliative care, which has – or had – another four years to run. Ryan’s agenda also suggests largely or wholly privatizing Medicare, moving away from direct payment for services and more toward premium support, or significantly reducing coverage.
Policies may be significantly shaped, too, by who is appointed as Secretary of Health and Human Services. In the running right now: Newt Gingrich (House Speaker in the 1990s), Bobby Jindal (former Louisiana Governor and presidential candidate), Rick Scott (current Florida Governor), and Richard Bagger (VP Celgene Corporation and former New Jersey State Senator). Ben Carson (neurosurgeon and presidential candidate) was under consideration but has taken himself out of the running. All these candidates have at least some healthcare administration or policy development in their backgrounds: Gingrich, after leaving the House, founded and chaired the Center for Health Transformation. Bagger, an attorney, has served as house counsel for Horizon Blue Cross Blue Shield of NJ and lobbyist for Pfizer. Celgene is a global biopharmaceutical company developing drugs and treatments for cancer and immune system disorders. In his mid-twenties, Bobby Jindal served as Secretary of the Louisiana Department of Health and Hospitals, and later, in the George W. Bush administration, as advisor to the U.S. Secretary of Health and Human Services. In the 1990s, Rick Scott was a cofounder of Columbia Hospital Corporation, which later merged with Hospital Corporation of America to form the largest for-profit health care company in the country.
A podcast for members from the National Hospice and Palliative Care Organization last week, however, took the view that with the new administration, Congress, and HHS Secretary, impacts on hospice were likely to be more in the nature of a “gear shift” than the “seismic shift” others are anticipating. Hospice, they noted, enjoys bipartisan support and that its “friends and champions” of both parties are “going to be back” next year. Even with anticipated changes in the Secretary of Health and Human Service and among some appointees to CMS, many longtime career personnel will remain in place. NHPCO’s message? Keep calm and carry on.
Finally, expansion of physician aid in dying laws may well hit speed bumps, because of the changed tone at the top and because of significant shifts to the right in state governments. As a result of last week’s election, four states shifted to full control (both legislative chambers and the Governor’s office) by Republicans, bringing the total to 24. In another 7 states, Republicans control both chambers of the legislature, though not the Governor’s office. While physician aid in dying has support from both parties, Republican-controlled legislatures and Governors have generally been less friendly to the issue. That said, Compassion & Choices has announced plans to pursue expansion, targeting Maryland, Minnesota, and New York.
Results of Ballot measures:
Issue 6, Arkansas Medical Marijuana Amendment of 2016 – PASSED (53–47%)
Issue 7, Arkansas Medical Cannabis Statute – REMOVED FROM BALLOT 10/27/16 DUE TO INVALID PETITION SIGNATURES.
Proposition 56, Tobacco Tax – Increase – PASSED (63–37%)
Amendment 69, State Healthcare System – REJECTED (79–21%)
Proposition 106, Colorado End of Life Options Act – PASSED (65–35%)
Amendment 2, Medical Marijuana Legalization – PASSED (71–29%)
I-181, Bonds to Fund Biomedical Research Authority – REJECTED (58–42%)
I-182, Medical Marijuana Initiative – PASSED (58–42%)
Question 4, Medical Equipment Sales Tax Exemption Initiative (a.k.a. Medical Patient Tax Relief Act) – PASSED (72–28%)
Measure 5, Medical Marijuana Legalization Initiative (a.k.a. North Dakota Compassionate Care Act) – PASSED (64–38%)