Quora Query: Will Trump Turn Out To be the Best Thing That Happened to the Affordable Care Act (ACA)?

[From 2016, slightly modified]:


We are in for a rather wild ride, and I don’t mean that in the most pleasant or interesting way. The Trump administration – or should I say anti-administration since Trump has appointed government haters to his cabinet, from the Secretary of Education to the Director of Management and Budget, to say nothing of his Breitbart Chief of Staff – having come to power on the strength of lies, will soon betray the people who voted for him. Indeed, the very Cabinet members I refer to is the beginning of this betrayal, not just to his voters, but to our planet, but more on that later.

In classes I’ve taught, a complex issue will come up with no obvious way to perform analysis. I often remind my students that they should at least start the analysis by finding some part of the problem of which they have knowledge, and work from there. This does not, of course, guarantee final successful analysis of the entire problem, but it does provide a start point. In the same way, we will deal with this President-elect and what are likely to be the contours of his policies. And we will do this by studying, in the detail available, his plans for health care.

Some years ago, after reading the legislation that produces the Patient Protection and Affordable Care Act (ACA) – yes, I ACTUALLY read it, the first 600 pages which dealt with acute care; I didn’t read the last several hundred dealing with chronic care, although I probably should have as the issue of chronic care becomes more and more important in our health system. But, as opposed to the fools, in and out of our Government, who were screaming about “death panels” and “preferential care being given to Muslims”, idiots who had not bothered to read anything, yes, I read the law – I wrote several pieces detailing what we had in place just before the ACA came into being, and what we might expect to see with its’ implementation:



I stand by the analysis of these pieces, although my hopes for what the ACA could bring us may not have lived up to the reality of a Congress that wanted President Obama to fail, coupled with an apparently innate conservativeness of the President and his colleagues. Indeed, my final statement at the end of Part 3, was:

Conclusion: Having now reviewed all of this material several times, I see how the complexity may make some of us a little confused. However, the central tendency of this legislation is to provide care for the American people when they need it and in the most high quality and cost effective manner. The politicians who have obfuscated and prevaricated about this legislation seem to have no concern for the American people; this behavior borders on criminal. I encourage you to read and re-read this material. It is not perfect, but this legislation results in a major improvement in the American Health System. We should thank – not punish – our legislators for having the courage to pass this. Over 100 years after the first attempts were made, this 111th Congress succeeded.

But we have punished our Legislators, ourselves actually, for daring to take this step. First, we voted Tea Party thugs into Congressional office – the 2018 mid-term elections corrected this – and then we gave the Office of the President to a lying, violence-promoting, sexual assault bragging, racist, with a Cabinet chock-full of racists, anti-semites, billionaires and millionaires, the leader of which may be a tool of Vladimir Putin. Yes, we have stuck our thumb into our own eye; we have shot ourselves in the foot…and any other metaphor one might want to use.


With the above as background, and knowing that we can’t analyze – at least now – all of what will come, what might we see with the incoming Administration related to healthcare ? And how will this understanding inform us as to other changes this Administration will rain (reign?) upon us ? Below this is outlined. It is merely a beginning, for discussion.

First of all, the money. As I have laid out previously

this is where the attack on healthcare will begin. Tax cuts that predominantly go to the top 1% (about 45% of the cuts go to this group), with tax INCREASES for low-income and single parent families; so much for Trump “looking out for the little guy”.

These cuts in taxes upon the wealthiest (Clinton would have raised them, demanding the rich pay their fair share Changes in Taxation 2) will blow a $ 10 Trillion hole in the Federal Budget over the next 10 years. Trump may wring his hands and say there is nothing he can do about this, as if an act of god caused the budget hole. But make no mistake about it, Trump’s policies are the cause; and he and his über-rich cronies will be laughing all the way to the bank (the banks that they probably own). Because there is no longer enough money, Trump will point out that he will have to cut “entitlements”.

And what will the cuts look like ? We already have some indications (Cassidy – The New Yorker). Representative Tom Price, an Orthopaedic Surgeon and Republican Congressman from Georgia is Trump’s pick to become Secretary of Health and Human Services. He has offered his Empowering Patients First Act (Price – Proposal) which would have done several things:

  1. It will offer more help to the young, healthy and rich, and less to the sick, old, and poor.
  2. It will eliminate or significantly weaken the ban (that came into existence with the ACA) against discrimination against people with pre-existing conditions.
  3. It will eliminate the essential health benefits package, which mandated that all insurers cover a set of 10 different types of care, including, for example, maternity services and pediatric care. Price’s plan would allow insurers to cut whatever benefits they wish to cut: maternity benefits might be cut to make their plans less attractive to women who plan to become pregnant. Plans for healthy people, with less coverage and a lower price, will be, well, cheaper. But the more comprehensive plans needed by those with pre-existing conditions would skyrocket in cost.
  4. Tax credits proposed by Price would help the older and richer more than others.
  5. There is no provision to replace the Medicaid expansion that will be removed with the elimination of the ACA. Fifteen million to 20 million people who are now covered – some analysts say this could climb to as high as 30 million – will say goodbye to their health insurance.
  6. The tax exclusion on employer-provided health plans may be eliminated. This is not a bad thing but, dollars-to-donuts, I predict it will not happen.

Sarah Kliff’s review of Price’s plan is linked to the Cassidy – New Yorker piece (above); it is worth a read.

There are other possibilities, as well as those from Price. Paul Ryan has suggested that The Republicans will ensure “access” (Ryan Plan), that is, the possibility of buying insurance; there will apparently be no mandate requiring insurance. The result will likely be – as in the Price Plan – expensive options for those who are sick, cheap options for the young and healthy….until they become ill with, say, leukemia, a traumatic brain injury after a fall, assault or car crash, and so forth. Ryan, et al (see above, Ryan Plan) claim that the prediction that 20 million people will again be uninsured is a “great lie”.

We will see. I have zero expectation of these men and women who now call themselves my “governors”. They are the indentured servants of the powerful and rich. They will do nothing to help the American People. They will obfuscate, dance around the facts, create their own “facts” (lies in other words) and, when their plans to “Make America Great Again” (by the way, frighteningly similar to Hitler’s campaign promise, see WL Shirer, The Rise and Fall of the Third Reich) fail, expect smoke and mirrors that will result in either internal or external ( a war) strife.

These are not good times for Democracy.


About AJ Layon

AJ Layon was, for 28 years, at the University of Florida College of Medicine, in the Division of Critical Care Medicine, in Gainesville, FL. For the approximately 10 years until September 2011, he was Professor and Chief of Critical Care Medicine at UF; In September of 2011 he became System Director and Co-Chairman of Critical Care Medicine in PA; this ended in 2017. He served as a Physician in the Surgical Group with Médecins sans Frontières (MSF, Doctors without Borders) through 2018 and is presently an intensivist in Florida, struggling through the SARS-CoV-2 crisis. While his interests are primarily related to health care, health care reform, and ethical issues, as a citizen of our United States and our world, he will occasionally opine on issues of our "time and destiny". Follow on Twitter @ajlayon
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