President Donald Trump made changing the U.S. health-care system a top priority, but his administration has struggled to accomplish the most ambitious goals he campaigned on four years ago while lower-profile policies are seeing success.
As Trump seeks re-election, he has been adamant that voters hear about his record on health care, but most of his major proposals are tied up in litigation or haven’t gotten much notice from voters. Voters consistently say health care is their most important domestic policy issue.
However, former officials from both Democratic and Republican administrations say the Trump administration has accomplished about as much as any other and hasn’t been afraid to try to change areas of the system that other presidents haven’t addressed.
In particular, the former officials pointed to the administration’s willingness to take on the pharmaceutical industry, hospitals, and the issue of kidney care. They said Trump came to Washington to disrupt, and he has done that in health care.
“President Trump has an exciting vision for health care, which we’ve articulated and worked toward this past year: a system with affordable, personalized care, a system that puts you in control, provides peace of mind, and treats you like a human being, not a number,” Health and Human Services Secretary Alex Azar said in a Thursday speech outlining his agency’s goals.
The Trump administration has made some significant accomplishments in a health-care system that is “large, complex, and has a lot of inertia against change,” said Mark McClellan, former Centers for Medicare & Medicaid Services administrator and Food and Drug Administration commissioner in the George W. Bush administration.
Its accomplishments include releasing over a dozen demonstration projects for medical providers, moving forward on regulations to encourage more home dialysis and better organ procurement, and rules that promote private Medicare plans.
What the administration lacks is a big legislative win, like the Medicare prescription drug benefit under George W. Bush or the Affordable Care Act for Barack Obama, said Chris Meekins, former Trump administration HHS deputy assistant secretary for preparedness and response.
In addition, many of the final regulations where the administration has sought the greatest change have been tied up in the courts, and the HHS has been unable to implement them. The most notable case among these involves the regulation requiring that drugmakers disclose their products’ list prices in television ads.
The HHS has tried to aggressively advance its priorities, but the courts have “handcuffed them” and limited what they—and any future presidents—can do, said Meekins.
The administration hasn’t really succeeded on the priorities that Trump had talked about consistently—repealing the Affordable Care Act, lowering prescription drug prices, and not cutting Medicare and Medicaid, said Chris Jennings, former health policy adviser in the Obama and Clinton administrations.
For example, the administration has been hampered on drug pricing because significant action requires legislation, McClellan, director of the Duke-Margolis Center for Health Policy, said.
Trump called for bipartisan legislation to lower drug prices in his Feb. 4 State of the Union address. “Get a bill on my desk, and I will sign it into law immediately,” the president said. Trump has rejected legislation passed by the House (H.R. 3) that would allow Medicare to directly negotiate drug prices.
Meanwhile, Azar’s priorities and the traditional day-to-day work of the department have seen “documentable achievements and impact,” Jennings said.
Administrative changes, including organ procurement and reforms to the physician self-referral law, have been “notable” and reflect the traditional work of the staff in the agencies.
These second-tier priorities “sometimes have the most potential to get done and can be more sustainable” because they avoid the heat of third rail issues, Jennings said.
The administration has been or looks like it will be successful in places where it hasn’t had to issue new regulations or faced pushback, like turning a corner in the opioids crisis, stymieing the spread of HIV, and encouraging more people to choose private Medicare plans over traditional Medicare, Meekins, a health-care policy research analyst at Raymond James, said.
The administration’s efforts to pay doctors and hospitals based on patients’ overall health appear to be on track, with the HHS and outside observers waiting to see how many doctors actually choose to participate.
The Trump administration is doing the hardest part of moving to value-based care, McClellan said. The Bush and Obama teams were testing out models, but to progress further, this administration needs significantly more participation by big health systems.
It’s important the administration follows through on finalizing its mandatory demonstration projects and its proposal to tie Medicare reimbursements to foreign countries’ drug prices, Adam Boehler, former HHS senior adviser and head of the Center for Medicare and Medicaid Innovation under Trump, said.
The administration has either been “ineffective” or planted the seeds for a slow movement toward success in its big visible policies, Jennings, founder and president of Jennings Policy Strategies, said.
The public “will see the things they’ve done will play out significantly over the next couple of years,” Boehler, CEO of the U.S. International Development Finance Corporation, said.
Changing the Narrative
The first thing the Trump administration had to do when trying to take on a big issue like how health care is paid for is change the narrative, William Pierce, former HHS deputy assistant secretary for public affairs in the George W. Bush administration, said.
It has been successful in that, even if its list of actual policy accomplishments is “middling” at best, said Pierce, a senior director at APCO Worldwide.
Pierce argues that the administration has moved the conversation to focus on the cost of care and the necessity of moving to value-based care rather than the issue of access, on which the Obama administration focused.
“We’re not going to talk about the cost of health care the same anymore,” and that conversation is starting to trickle down to the public, Pierce said.