Direct Primary Care Conference - Nuts

Physicians are starting new methods of reimbursement, to decrease operating overhead and eliminate much of the bureaucracy involved with billing health insurance plans.

Two  terms which may not be familiar to patients are 'direct pay'  and 'concierge medicine'.  Both eliminate the insurance plan as an intermediary for payment of patient services.

Health insurance as we know it today is not insurance.  It has evolved into a comprehensive health plan(s) governed my medicare and commercial health plans.  Their goal is to  increase and/or maintain profitability in lieu of patient care.  They are designed to provide reimbursement for soup to nuts. This is very inefficient and increases  cost measurably.

Purchasers of health plans no longer have a choice of tier or to opt-out of unneeded coverage. The 50 year old post menopausal woman pays for pregnancy care, and delivery even though she will never use this coverage.

The DPC and Concierge plans are designed for primary care (family practice and some internal medicine and pediatric practices)



The Direct Primary Care conference, is sponsored by 'Doctors for Patient Care' and independent non-profit organization whose mission is to alter the current health care system.

Our Principles

 

Direct Primary Care (DPC) is an innovative alternative payment model for primary care being embraced by patients, physicians, employers,payers and policymakers across the United States.The defining element of DPC is an enduring and trusting relationship between a patient and his or her primary care provider.

Empowering this relationship is the key to achieving superior health outcomes, lower costs and an enhanced patient experience. DPC fosters this relationship by focusing on five key tenets:

1. Service: The hallmark of DPC is adequate time spent between patient and physician, creating an enduring doctor-patient relationship. Supported by unfettered access to care, DPC enables unhurried interactions and frequent discussions to assess lifestyle choices and treatment decisions aimed at longterm health and wellbeing. DPC practices have extended hours, ready access to urgent care, and patient panel sizes small enough to support this commitment to service.

2. Patient Choice: Patients in DPC choose their own personal physician and are reactive partners in their healthcare. Empowered by accurate information at the point of care, patients are fully involved in making their own medical and financial choices. DPC patients have the right to transparent pricing, access, and availability of all services provided.

3. Elimination of Fee-For-Service: DPC eliminates undesired fee-for-service(FFS) incentives in primary care. These incentives distort healthcare decision-making by rewarding volume over value. This undermines the trust that supports the patient-provider relationship and rewards expensive and inappropriate testing, referral, and treatment. DPC replaces FFS with a simple flat monthly fee that covers comprehensive primary care services. Fees must be adequate to allow for appropriately sized patient panels to support this level of care so that DPC providers can resist the numerous other financial incentives that distort care decisions and endanger the doctor-patient relationship.

4. Advocacy: DPC providers are committed advocates for patients within the healthcare system. They have time to make informed, appropriate referrals and support patient needs when they are outside of primary care. DPC providers accept the responsibility to be available to patients serving as patient guides. No matter where patients are in the system, physicians provide them with information about the quality, cost, and patient experience of care.

5. Stewardship: DPC providers believe that healthcare must provide more value to the patient and the system. Healthcare can, and must, be higher-performing, more patient-responsive, less invasive, and less expensive than it is today. The ultimate goal is health and wellbeing, not simply the treatment of disease.

DPC providers are committed to ensuring that American healthcare delivers on these goals.

Tom Price Is Eager to Lead H.H.S., and Reduce Its Clout - The New York Times

Here is the "spin" Depending on your political view (Democratic vs. Republican) Price's appointment is the end of government interference in patient/provider relationships, or it is the end of health care quality and accessibility for our citizens.

I opine it is neither.  Most all practicing physicians agree that some federal and state regulation is necessary, however it is now out of control.  Neither Congress nor  HHS has shown any leadership in controlling costs other than penalties and/or incentives.  The model has been extreme, and cumbersome, with bloated HHS and CMS administration, at times overstepping it's limitations, extending to patient care and not financing.

Regardless of what either side thinks, Price is the ideal selection for the head of HHS. The reasons are:

A long history of patient management, a fluent knowledge of how congress and HHS work, his positions in budgetary matters.

As chairman of the House Budget Committee, he has tried to put a lid on federal spending. As secretary, he would be responsible for more than $1 trillion in spending, a number that will surge as the population ages.

The health secretary has immense discretion to impose, revoke and modify rules. A review of Mr. Price’s record in Congress, including his speeches and legislative proposals, suggests that he would try to reduce the burden of federal regulations on health care providers, especially doctors.

As secretary, he would be responsible for the popular Children’s Health Insurance Program, which insures eight million children at some point each year. In 2007, he opposed expansion of that program because, he said on the House floor, some children with private insurance would become eligible for “government-run socialized medicine.”  This would unnecessarily shift private funding to the tax-payer.

Senate Democrats are sure to challenge many of his positions at his confirmation hearings. Just as they distrust him on health care, he distrusts them.

I do not trust any of them. Most of us are tired of rhetoric during elections and legislative processes. That is how President-elect Trump rose to his present status.  

In 2010, he said on the House floor that he had discovered that “there were more folks in Washington who affected what I could do for and with my patients than anybody I ever met in residency or in medical school.” That, he said, “was wrong.”

Mr. Price often reminds colleagues of a sentence in the original Medicare law, passed in 1965: “Nothing in this title shall be construed to authorize any federal officer or employee to exercise any supervision or control over the practice of medicine.”

Congress has a short memory.  Perhaps that is one reason for funding more research on Alzheimer's disease.

If confirmed, Mr. Price will have a chance to practice what he has preached for decades. He could try to overhaul what he calls the “predatory trial lawyer litigation system.” He could try to stop what he calls “regulatory oppression” by the federal government. And he could eliminate some of the mandates that he calls a “death knell for quality health care.”

Tom Price Is Eager to Lead H.H.S., and Reduce Its Clout - The New York Times

AMA endorsement of Trump health secretary spurs backlash

Liberal MDs are furious after top doctors group backed Trump’s pick for health secretary

When Donald Trump this week tapped a surgeon-turned-congressman to run the Department of Health and Human Services, the nation’s largest physicians group swiftly endorsed the choice.

Liberal doctors peppered the American Medical Association with furious tweets decrying the group’s endorsement of Representative Tom Price as a betrayal of patients and physicians. And by Wednesday night, 500 doctors had signed an online open letter titled “The AMA Does Not Speak For Us” started by the Clinician Action Network, a left-leaning advocacy group.

The AMA does not truly represent grassroot physicians.  A small percentage of physicians are members of the AMA. Formerly state medical societies required membership in the AMA to belong to a state medical society. THIS IS NO LONGER THE CASE.

The outpouring of anger has exposed the bitter political rifts dividing doctors these days. Price is an AMA member, but he also belongs to a conservative doctors’ group that publishes a journal which has advanced discredited theories, such as the notions that abortions cause breast cancer, vaccines cause autism, and HIV does not cause AIDS. The same group shot into the spotlight during the presidential campaign by promoting conspiracy theories about Hillary Clinton’s health, including speculation that she’d had a seizure or a stroke.

These opinions are not true. They should not be attributed to HHS-nominee, Tom Price. Just because he belongs to an alternative medical group he does not ascribe to those statements.  As a congressman he represents all of the people of his district.  It does not mean he promote these ignorant statements.

The outpouring of anger has exposed the bitter political rifts dividing doctors these days. Price is an AMA member, but he also belongs to a conservative doctors’ group that publishes a journal which has advanced discredited theories, such as the notions that abortions cause breast cancer, vaccines cause autism, and HIV does not cause AIDS. The same group shot into the spotlight during the presidential campaign by promoting conspiracy theories about Hillary Clinton’s health, including speculation that she’d had a seizure or a stroke.

 There are left-leaning alternatives to the AMA, too, including one that has long advocated for gun control, pushes physicians to cut all financial ties with drug companies — and expressed dismay that any doctors group would back Price.

The AMA remains by far the biggest and most visible lobbying force representing doctors and medical students. The group spent $15 million just in the first nine months of this year to lobby Congress and the executive branch on everything from marijuana research to opioid prescribing to telemedicine, as well as traditional issues such as reimbursement and billing, according to federal filings.

The AMA reaps profits from insurance companies with advertisements, derives income from copyrights from Current Procedural Codes that are used by insurance companies, medicare, medical, hospitals, and medi-cal.  The lobbying funds do not come from dues. Do the numbers.

“The AMA is generally a force for the status quo in health care, a physicians’ guild in the old-school style of wheeling, dealing, and horse-trading to keep the billing flowing like a mighty stream into MDs’ coffers,” Dr. Zackary Berger, an internist at Johns Hopkins.

The AMA is a dinosaur in today's medical environment.  On the other hand specialty groups are focused on education, and are apolitical.

This article is from STAT, an internet publication about Health and Medicine and is mixed with the author's private opinionls

AMA endorsement of Trump health secretary spurs backlash

Tom Price appointed as Head of Health and Human Services

It has taken 48 hours for me to wrap my head around the announcement.  Most physicians would recognize his name as a physician and a congressman from Georgia.

I am pleased that President-elect Trump nominated Tom Price as the future head of Health and Human Services.

I did some due diligence in the manner most physicians approach any issue. My hope and expectation is that Trump appointed Price because of his education, training and experience as an orthopedic physician and surgeon as well as his experience on the House Budget Committee as  Chairman. He would also be among the most politically conservative Health and Human Services secretaries in history. And as a member of House leadership, he would bring to the Trump administration a revolutionary governing agenda closely aligned with Republicans on Capitol Hill.

As a leading member of the tea party caucus in the House, Price has led calls for dramatically cutting federal programs, particularly for low- and moderate-income Americans, and for repealing and replacing Obamacare, which he has called “monstrous legislation.”

He is the group of doctors often called in at a time of crisis, and trauma. Many do their best work at night, on weekends and holidays.  Price is no stranger to challenges in the hospital, operating room and congress.

There has been an immediate and predictable Democratic response, a knee-jerk reaction (reflex) which requires no cerebral activity to elicit with a reflex hammer. It is a lower form of neural reflex moderated only by the spinal cord and several peripheral neurons.

Georgia Rep. Tom Price has been a fierce critic of the Affordable Care Act and a leading advocate of repealing and replacing the 2010 health care law.

Price, an orthopedic surgeon from the suburbs of Atlanta, introduced his own legislation to repeal and replace Obamacare in the current Congress and the three previous sessions. Price's plan, known as the Empowering Patients First Act, was the basis for a subsequent health care proposal unveiled by House Speaker Paul Ryan, with Price's endorsement, in June.

Three of the four previous Health and Human Services secretaries were former governors. Price, an orthopedic surgeon, would be the first physician to serve as the department’s secretary since Dr. Louis Sullivan, who held the post from 1989 to 1993 under President George H.W. Bush.

Price's major complaint about the ACA is that it puts the government in the middle of the doctor-patient relationship.

"They believe the government ought to be in control of health care," Price said in June at the American Enterprise Institute event where Ryan unveiled the Republican proposal to replace Obamacare. "We believe that patients and doctors should be in control of health care," Price continued. "People have coverage, but they don't have care."

Now that President-elect Donald Trump has tapped Price to lead the Department of Health and Human Services, here are five key planks in his own health care proposal.

He would also be among the most politically conservative Health and Human Services secretaries in history. And as a member of House leadership, he would bring to the Trump administration a revolutionary governing agenda closely aligned with Republicans on Capitol Hill.

Price has said he's not wedded to his own ideas and is open to compromise, so the final proposal to replace Obamacare is likely to be a hybrid of his ideas and those hammered out with other Republican House members and presented as Ryan's plan.

Still, with Price on track to be at the helm of HHS, he would be the one writing the rules to implement whatever legislation is eventually passed.

We will see what happens after the inauguration !  The ball is already in play.

Is Being a Physician Now a Working Class Job?

The Working Class Physician

Physicians are known to be masters of self-sacrifice, and self-control. They undergo years of training and make substantial emotional and financial sacrifices until they complete their training. The reward at the end of the road is a fulfilling job where he or she can treat people who are in need and enjoy the emotional, personal, and financial fruits of their labor.

The Executive Class Physician

But is this the reality? At a time when the job satisfaction of physicians is at all time low, and burnout at all-time high, alarming depression rates, and a shocking 400 physicians suicide per year in the United States. One can’t help but wonder if physicians have finally joined the working class.

The popular belief is that working classes are comprised of those who are paid minimum wage and who cannot make ends meet, while physicians are compensated well financially, relative to those in other professions. However, this income-based classification is misleading. The working class represents workers who have lost control over their means of production, and are in turn controlled by members of another class.

With the rapid “industrialization” and “commodification” of medicine, an increasing number of doctors are deserting private practice for large heath systems and employment in hospitals. Only one-in-three physicians will remain independent by the end of 2016, and three in four medical residents will start their career as employees of a medical group, hospital, or faculty plan.

ref: doximity, By Andres Barkil-Oteo

This trend is not arbitrary; there is a strong movement facilitated by ACA to consolidate doctor networks, and to turn them into salaried employees of hospitals and health plans. The aim, is to control service utilization and make health care delivery more coordinated and efficient.

This change would not necessarily be all negative. Consolidating doctors will help to deliver more efficient services at a lower cost. Doing so may provide security and peace of mind to doctors in the current challenging financial and regulatory environment. However, this change is coming at a steep price for providers and patients. Physicians need to be cognizant that they are trading away autonomy, control over decision-making, and at times their ability to influence the work process. Giving up autonomy and means of production results in alienation of physicians from each other, alienation from the work being done, alienation from their patients, and ultimately alienation from themselves.

To meet the complex nature of service delivery, health systems have created inflated bureaucracies, with numerous administrators and middle managers to manage the system of production. This has led to two parallel sets of workers in a system, often with broken lines of communication. Over time, a distinctively antagonistic relationship has developed between physicians and the bureaucracy that controls them. A hierarchical bureaucracy now controls the daily work of physicians, and management’s power is based on the concentration of decision-making authority and information needed in planning and controlling the system. The oppression of the physician working class is a result of their exclusion from the decision-making process.

author: This last statement is the key ingredient of physician burnout and dissatisfaction.  Early education and training of physicians is to be accountable and in control of their patient's care.  Current and future plans fly in the face of their prime directive, 'do no harm'.

There have been increasing complaints about the concentration of money and power among the managers of health systems, coupled with the increasing tendency to fill the ranks of administrators and hospital CEOs with people lacking clinical background. The official explanation for this trend is that systems are becoming increasingly complex, and that managing the business of health care necessitates control by business minded people. This has created a clear split between administrators vs. doctors and nurses regarding dealing with clinical protocols and procedures.

In this challenging environment, physicians’ identities are increasingly being changed and molded to fit the chain of production. Physicians are described as a collection of FTEs (full-time equivalents). They are referred to as providers or prescribers, and they are increasingly viewed as workers whose job it is to deliver health care to costumers or consumers. The physician-patient relationship is seen as a business transaction between vendors and purchasers. “It is difficult for physicians to take themselves seriously as professionals if patients treat them with the same suspicion as snake oil salesmen.” In this system, the ability to work becomes commodified and sold in the marketplace in 15-minute units., and physicians perceive their work as simply executing the checklists and demands that are coming from their employer. In time, there is a sense that patient consultations are closer to mundane processes in a long production line, rather than a fulfilling system for improved health.

Given the nature of this situation, it is no wonder that so many patient safety and quality improvement initiatives, checklists, and “practice improvement” campaigns fail. They fail because often these campaigns are perceived as external demand, as opposed to something physicians freely choose because they believe in it.” As a result, physicians are increasingly alienated from their work. Decisions regarding who to take care of, when, where, and what therapy should be administered at what cost are increasingly determined by the employer or the insurer – and not the practicing physician. With the quality of the work delivered increasingly determined by process measures that are imposed externally, physicians will eventually be less satisfied by and fulfilled by their work.

In order to deal with the frustration of physicians, the employer provides two different types of solutions. The first is based in offering R&R, relaxation workshops, and personal growth retreats to offset the negative impact of the alienation caused by the existing unpleasant work environment. The second to ask physicians to do more training. The CME (continuing medical education) industry is growing at a fast pace especially after the introduction of the maintenance of certification (MOC) requirements, which has encountered much resistance from the medical profession.

All of the forgoing suggests that doctors need to identify the problems they face in clear terms, and need to embrace their working class identity. Only then will they be able to identify possible solutions and create a practical plan of action.

Andres Barkil-Oteo is a psychiatrist.

An Alternative Form of Mental Health Care Gains a Foothold - The New York Times

An Alternative Form of Mental Health Care Gains a Foothold

Many patients are non compliant with psychotropic medications due to very unpleasant side effects, including impotence, dysphorias and others.    Hearing Voices Network   At a support group here for so-called voice-hearers, however, she tried something radically different. She allowed other members of the group to address the voice, directly:

What is it you want?

The Big Heist – A satirical, follow-the-money film on the destruction from healthcare's status quo… And the coming redemption.

You cannot fix a tire until  you let all the air out.

The Big Heist follows the money to answer these questions.

It's the story of how and why healthcare's financial incentives are wasting trillions of dollars, bringing our country to its knees.

More than this, it's the story of real hope that together we can fix it.

The Big Heist follows the coming redemption, tracking people and organizations across the country and political spectrum that are already fixing it from the ground up.

Through satire and storytelling, The Big Heist will be both entertaining and accessible to everyone.

We've created a system that crushes the very people we trust to provide us care.

• Physician burnout is at record levels
• Nurses are expected to perform superhuman feats
• Social workers and professional caregivers lack resources to bend the demand curve
• Family members and loved ones face a labyrinth of bureaucracy and opacity

We can do better.

The Big Heist will show how some of us already are.

The Status Quo

As of 2009, the average family spends more than $450/mo on healthcare because of hyper-inflation.

Health 3.0 Future

A single program saved a city more than $200 per employee per month. It has nearly perfect patient satisfaction.

A hotel spends 55% less overall, while it's employees get $15 copays and $0 copays on 90% of prescriptions. Plus, they pay for college for employees and their children.

How did we get here?

Tower of Babel

The Big Heist – A satirical, follow-the-money film on the destruction from healthcare's status quo… And the coming redemption.

So you think Obamacare is a disaster? Here's how California is proving you wrong - LA Times

Even as turmoil in insurance markets nationwide fuels renewed election-year attacks on the Affordable Care Act, California is emerging as a clear illustration of what the law can achieve.

The state has recorded some of the nation's largest insurance choices. That means that even with rising premiums, the vast majority of consumers should be able to find a plan that costs them, at most, 5% more than they are paying this year. 

And all health plans being sold in the state will cap how much patients must pay for prescriptions every month and for many doctor visits

Donald Trumps successful election as President almost certainly means the Republican dominated Congress will repeal/amend/replace the law. Assurances have already been given regarding the pre-existing condition clause. The financial sheets will require significant cost shifting with careful analysis of where funds are going for needless regulations.

The next year will prove to be interesting. Stand by.

  

Prejudice in the Hospital

An interesting Perspective...Reverse discrimination.

How do doctors deal with discrimination?

Minority Nurse

Kimani Paul-Emile wrote,   :Patients’ Racial Preferencesand the Medical Culture  of Accommodation"  in the UCLA Law Review

The Beginning

The aftermath

Racial prejudice travels in both  directions.

What your Doctors are now facing MIPS: The New Meaningful Use -

In April 2015, due to overwhelming bipartisan support, President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law, effectively changing the playing eld. The legislation repeals Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaces it with a new Quality Payment Program (QPP).

The proposed QPP consists of two tracks in a bid to reduce quality reporting burdens; Advanced Alternative Payment Models (APMs), and Merit-based Incentive Payment System (MIPS). In this white paper we will take a closer look at MIPS, covering areas of interest such as:

• What is MIPS?
• Penalties & Incentives
• Impact of MIPS
• Ways to Prepare

Please enter your email address to access this resource

MIPS: The New Meaningful Use - White Papers - EHRIntelligence

Trump, GOP In Congress Could Use ‘Must-Pass’ Bills To Bring Health Changes | Kaiser Health News

Throughout the campaign, President-Elect Donald Trump’s entire health message consisted of promising to repeal the Affordable Care Act.

That remains difficult with Democrats still commanding enough power in the Senate to block the 60 votes needed for a full repeal. Republicans could use fast-track budget authority to make some major changes to the law, although that could take some time. In the short term, however, Trump could use executive power to make some major changes on his own.

Beyond the health law, Trump also could push for some Republican perennials, such as giving states block grants to handle Medicaid, allowing insurers to sell across state lines and establishing a federal high-risk insurance pool for people who are ill and unable to get private insurance.

But those options, too, would likely meet Democratic resistance, and it’s unclear where health will land on what could be a jam-packed White House agenda.

Given their druthers, Trump and congressional Republicans would push to end the individual and employer mandates, eliminate ACA insurance reforms such as minimum essential benefit packages, pare back and restructure the premium subsidies, and junk the CMS Innovation Center and the Medicare Independent Payment Advisory Board, said Douglas Holtz-Eakin, an adviser to Sen. John McCain's 2008 presidential campaign and former director of the Congressional Budget Office.

Experts say those measures would largely unravel the ACA system and could lead to millions of people losing coverage.

It's not clear whether or how a Trump administration would provide subsidies to help people buy or keep coverage. The House Republican leaders' plan proposed refundable tax credits for individuals without access to employer-based or public coverage. But the Trump campaign's seven-point healthcare proposal and the GOP health policy agenda don't mention any subsidy mechanism. Another issue is that if they moved to repeal the ACA and its hundreds of billions in revenue, Republicans would have no way to fund subsidies for the uninsured, noted John Goodman, a veteran Republican health policy expert.

Trump, GOP In Congress Could Use ‘Must-Pass’ Bills To Bring Health Changes | Kaiser Health News

Trump upset will force healthcare leaders to rethink the future - Modern Healthcare Modern Healthcare business news, research, data and events

Republican Donald Trump's shocking victory Tuesday will force a major shift in the healthcare industry's thinking about its future. Combined with the GOP's retention of control of the Senate and the House, a Trump presidency enables conservatives to repeal or roll back the Affordable Care Act and implement at least some of the proposals outlined in the GOP party platform and the recent House Republican leadership white paper on healthcare. 

Addressing supporters just before 3 a.m. ET, Trump struck a conciliatory tone and did not specifically mention the ACA. “It is time for us to come together as one united people,” he said. “It's time.”

But the assumption of Republican control over both the White House and Congress most likely means an end to the expansion of Medicaid to the 19 states that have not yet implemented it, and puts the expansion in the other 31 states in serious jeopardy. 

Still there are divisions even among conservatives over issues such as Medicare restructuring and how to help Americans afford health insurance. And Senate Democrats almost certainly would try to use their filibuster power to block major ACA changes.

After being behind in the polls for the entire general election campaign, Trump shocked political analysts. Democrat Hillary Clinton reportedly called Trump to concede the race. 

Healthcare leaders were not prepared or eager for the healthcare changes a Trump victory would bring about. Modern Healthcare's second-quarter CEO Power Panel, a survey of 86 healthcare CEOs, found that the chief executives overwhelmingly backed the Affordable Care Act and supported its goal of pushing providers away from fee-for-service medicine and toward delivering value-based care.

The overwhelming message from the survey was that the next president and Congress should stay the course set by President Barack Obama and the ACA. “I think the Affordable Care Act needs to stay, and we need to keep improving it,” said Dr. Gary Kaplan, CEO of the not-for-profit Virginia Mason Health System in Seattle. “I think that we can put together great minds and make some further improvements and hopefully take it out of being a pol




Trump upset will force healthcare leaders to rethink the future - Modern Healthcare Modern Healthcare business news, research, data and events

20 Questions for President Trump | Public Health Post

The last six and a half years have been uncharted territory in our nation’s century-long 

debate over health reform. For the first time the fight was about how to implement an attempt at near-universal coverage 

rather over what this plan should look like and what could win enough support in Congress. The Affordable 

Care Act (ACA) has survived major political, legislative, and legal tests, including dozens of 

repeal votes, two Supreme Court decisions, the 2012 

presidential election, and state-level resistance.

I was outside the Supreme Court on June 25, 2015 when the King v. Burwell decision was released. I was there the moment activists switched their signs from saying “Don’t you dare take my care” to “The ACA is here to stay.” I wrote that we could finally say with some certainty that they were right, the law is here to stay. They were wrong. I was wrong.

Donald Trump’s victory throws the future of health reform into complete chaos. He will take office in January 2017 with Republican majorities in the House and Senate. President Trump, Speaker Ryan, and Senate Majority Leader McConnell have all made repeated promises to get rid of Obamacare. They will face enormous pressure to follow through with their threats of repeal. Approximately 21 million people are projected to lose insurance if they follow through with their initial proposals.

The first step to figuring out where to go from here is understanding what decisions are on the horizon. Here are my first 20 questions about health reform under the Trump administration , in no particular order:

1. Will Republicans follow through with repealing the ACA? It is one thing to make threats when there is no chance they will come to pass. Where will health reform fit in the constellation of issues Donald Trump promised to focus on such as immigration and the economy?

2. If they decide to move forward with repeal in the first year—as I fully expect them to do—what will this look like? The details matter greatly. Will this be a mostly symbolic gesture to appease the conservative base without upsetting interest groups and taking away people’s insurance, or will this be a more comprehensive overhaul of the ACA?

3. Will legislation to repeal the ACA include specifics about what to replace it with or will these be two separate conversations?  The history of health reform clearly shows that it is very hard to gain consensus on the details even if there is agreement on the broad goals. It will be much harder to pass repeal legislation if Republicans have to agree on what comes next.

4. I expect they will target the individual mandate. What will they do to combat the likely adverse selection problems that will lead to weakened risk pools and increased premiums increases?

5. Will they try to keep popular parts of the law such as allowing children to stay on their parents’ plans until age 26 or banning insurance companies from excluding people because of pre-existing conditions?

6. Will Republicans re-claim ownership of policy ideas they supported before they became part of Obamacare, such as using tax-credits to subsidize the purchase of private insurance through state-based health insurance exchanges?

7. Would they repeal the ACA’s coverage expansions across the board or use a federalism approach similar to the ACA which gives states flexibility to opt-in to keeping things like the Medicaid expansion and insurance exchanges?

8. What does a repeal timeline look like? How long will insurance companies, states, and consumers have to adapt before the coverage expansions are phased out?

9. What effect will all this uncertainty have on the current enrollment period for the exchanges?

10. What will state leaders do? In particular, what will leaders do in the states that have expanded Medicaid but voted for Trump, including Arizona, Michigan, and Pennsylvania? Will they fight to keep the federal money coming into their state or will they support ending the expansion?

11. Will we finally see a voter feedback effect in which the 20 million people who stand to lose insurance mobilize and fight against the ACA’s repeal? We have not seen this in Kentucky where Governor Bevin has undone the state’s exchange and is trying to remove or scale back the state’s Medicaid expansion.

12. What happens to all the current and future negotiations over Medicaid 1115 waivers? Will the Trump administration halt conversations? Will they be more permissive and allow things like work requirements which the Obama administration has rejected?

13. Will any state try a 1332 waiver? If so, how will the Trump administration respond?

14. Assuming block grants are part of the ACA replacement plan, what does this actually look like? What will this mean for states and beneficiaries?

15. This a crucial stage in the dramatic movement away from fee for service to alternative payment models. Will the Trump administration continue in this direction or shift course entirely?

16. What is the future of Accountable Care Organizations?

17. What happens when the Children’s Health Insurance Program (CHIP) expires on September 1, 2017? Will the bipartisan coalition that has supported CHIP further erode? Check out these articles in NEJM and Health Affairs that Jon Oberlander and I wrote about CHIP politics as it stood earlier this year.

18. Will Donald Trump follow through with his early campaign promises to allow Medicare to negotiate pharmaceutical prices?

19. Will public health emerge as a health reform issue that can transcend the partisan divide? In other words, will leaders be able to move beyond the fights over insurance coverage to focus on non-partisan population health issues such as maternal and infant mortality?

20. What does the future look like for federal funding for research on health services, medical care, and social sciences through AHRQ, NIH, and NSF?

20 Questions for President Trump | Public Health Post