HRI regulatory center

Regulatory and legislative updates and analysis

President Donald Trump: The latest healthcare developments

Comprehensive report: Health reform 2.0: A guide to developing resilience amid an uncertain future for the Affordable Care Act

President Donald Trump and Republican congressional leadership have promised to repeal and replace the Affordable Care Act (ACA). Just how that will happen remains unclear. For the nation’s healthcare providers, payers, pharmaceutical and life sciences companies, new entrants and employers, this uncertainty makes planning for the future a complicated matter. In this report, PwC’s Health Research Institute and the firm’s strategy practice, Strategy&, present a comprehensive analysis of scenarios for repealing and replacing the ACA, along with practical steps health organizations can take in this time of uncertainty. 

Read HRI and Strategy&'s report, Health reform: 2.0: A guide to developing resilience amid an uncertain future for the Affordable Care Act

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Guide to the American Health Care Act

On May 4, House Republicans passed the American Health Care Act (AHCA), which aims to partially repeal and replace the Affordable Care Act (ACA). As passed by the House, the AHCA would repeal $663 billion in ACA taxes and fees over 10 years, phase out the ACA’s expansion of the Medicaid program, cap federal Medicaid funding and cut it by $834 billion over 10 years, replace the ACA’s income-based premium tax credits and other subsidies with age-based ones, and give states flexibility to opt out of key ACA provisions (see Figure 1), according to analyses by the Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT). All told, 23 million fewer people likely would have insurance by 2026 compared with current law, according to the analyses. 

Read HRI’s spotlight, Trump administration health policy agenda: House passes the American Health Care Act

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Trump administration weekly highlights

Highlights – July 17, 2017

Trump administration: ACA repeal and replace effort suffers critical setback
Republicans’ plan to partially repeal and replace the Affordable Care Act (ACA) suffered a series of setbacks this week, resulting in a significantly weakened effort. On Monday, Senate Majority Leader Mitch McConnell, R-Ky., was forced to delay a planned vote on the Senate Republicans’ Better Care Reconciliation Act (BCRA) after Sen. John McCain, R-Ariz., announced that he had been ordered to rest at his home in Arizona after undergoing surgery to remove a blood clot above his eye—a procedure that led to a brain cancer diagnosis. By Monday evening, Sens. Mike Lee, R-Utah, and Jerry Moran, R-Kan., had joined Sens. Susan Collins, R-Maine, and Rand Paul, R-Ky., in saying they could not support the bill, dealing the legislation a critical setback.

Undeterred, President Donald Trump told senators assembled at a White House lunch that they should not leave for the August recess until they passed a bill, prompting another round of meetings between Senate leadership and skeptical Republican members. Leader McConnell quickly announced his intentions to introduce the Obamacare Repeal Reconciliation Act (ORRA), a bill nearly identical to one passed along party lines in 2016, HR 3762. That bill, vetoed by President Barack Obama, partially repealed the ACA, rolled back its Medicaid expansion and ended nearly all taxes, fees and subsidies to help individuals afford premiums and other cost-sharing, among other features. The Congressional Budget Office estimated the ORRA would result in 32 million additional uninsured Americans by 2026, with nongroup premiums doubling by 2026, triggering a collapse of that market. The measure is unlikely to succeed given that Sens. Collins, Shelley Moore Capito, R-W.Va, and Lisa Murkowski, R-Alaska, have stated they oppose any vote to proceed with a repeal bill lacking a replacement plan. As of last night, it remained unclear which of several health reform bills would move forward, if any.

HRI impact analysis: With multiple Republican senators declining to support a move to start debate on the different repeal bills, McConnell and House Speaker Paul Ryan, R-Wis., have few options. Possibilities include proceeding with a repeal-and-delay or attempting to work with Democrats on a bipartisan repair of the ACA. In a comprehensive guide to repealing and replacing the ACA, HRI and PwC’s strategy practice, Strategy&, analyzed both options, concluding that repeal-and-delay would result in 32 million more uninsured Americans by 2025 compared with current law, the individual market’s collapse and negative consequences for healthcare providers in particular. HRI and Strategy& found that a bipartisan “repair” scenario would result in about 6 million fewer insured by 2025 compared with current law, with more neutral outcomes for industry players. Healthcare players should not sit back and wait to see what happens. They should focus instead on building enterprise resilience, steeling their organizations for whatever changes come.

Highlights – July 10, 2017

Trump administration: Senate releases new draft of health reform legislation
Senate Republicans today released an updated draft of the Better Care Reconciliation Act of 2017 (BCRA)—their legislation to repeal major components of the Affordable Care Act (ACA) and replace them with reforms meant to cut taxes, slow Medicaid growth and reduce insurance premiums for some. The legislative text is substantially similar to the lawmakers’ first version of the BCRA, released in late June, and the American Health Care Act, which passed the House of Representatives in May.

Like the Senate’s previous version, the new draft rolls back federal funding of the ACA Medicaid expansion starting in 2021; switches Medicaid to a per capita or block grant system, also starting in 2021; and allows greater flexibility in insurance plans. The bill incorporates a version of an amendment proposed by Sens. Ted Cruz, R-Texas, and Mike Lee, R-Utah, that would allow insurers to sell low-cost, low-benefit plans as long as they sell gold- and silver-level plans on the ACA exchanges. It also includes $115 billion in additional spending for opioid abuse treatment and other state-based insurance reforms. The bill retains several key ACA taxes, including the net investment income tax, the medical health insurance tax and the tax on executive compensation for health insurance executives. The bill reduces the individual and employer mandate penalties to $0 but requires individuals with a break in insurance coverage to wait six months before getting new coverage.

Just before the updated bill’s release, Sens. Bill Cassidy, R-La., and Lindsey Graham, R-S.C., announced on CNN that they would release their own healthcare proposal. They said their legislation would redirect funds raised by ACA taxes directly to states, with flexibility to spend the money as they wish. As of Thursday evening, the fate of the Senate health reform effort remained unclear.

HRI impact analysis: The Congressional Budget Office (CBO) expects to release a score for the updated bill Monday. The Senate may vote on the BCRA as early as next week, however the bill must clear several potentially significant hurdles first, including a decision from the Senate Parliamentarian on whether key provisions can be considered under reconciliation. It is unclear whether the bill has enough votes to pass; Republicans can lose no more than two votes with Vice President Mike Pence casting a tie-breaking vote. If the bill passes the Senate, it must either pass the House unedited or go to a conference committee in which House and Senate members reconcile the two bills’ differences and come up with a compromise that can pass both the House and Senate. The CBO previously indicated that the earlier Senate version would result in 22 million fewer Americans with health insurance over the next decade, slightly better than the 23 million under the House-passed version. It also found that the previous Senate bill would decrease federal Medicaid spending by $772 billion, or 26 percent, over 10 years. The report also estimated that insurance premiums could increase as fewer healthy people buy insurance, resulting in sicker—and costlier—insurance risk pools. HRI’s analysis of scenarios for repealing and replacing the ACA found that healthcare providers in particular, and consumers, would bear the brunt of legislation similar to the BCRA. Many providers, payers, consumer advocates and others have come out against the earlier version of the Senate bill in recent weeks.

Trump administration: 38 US counties at risk of having no insurers participating in ACA exchanges in the fall
A Kaiser Family Foundation analysis found that 25,000 people in 38 US counties in Indiana, Nevada and Ohio likely will have no choices of plans on the state ACA exchanges for the next open enrollment season. While some medium-sized cities such as Marion, Ind., and Carson City, Nev., may be affected, the majority of counties are largely rural, particularly in the eastern and southern parts of Ohio. In Nevada, all but three counties—Clark County, home of Las Vegas; Washoe County, home of Reno; and Nye County—could be at risk. Many of the at-risk counties had only one insurer for the previous open enrollment period. While Kaiser’s analysis found that all at-risk counties are in nonmetropolitan areas, an HRI analysis this year found that consumers in 16 metropolitan markets could find themselves in similar circumstances if an additional national insurer declines participation.

HRI impact analysis: Because insurer participation for 2018 will not be finalized until this fall, the situation could change. Apart from ACA repeal efforts, lawmakers have considered legislative solutions to these issues. Sen. Lamar Alexander, R-Tenn., and Rep. John Duncan, R-Tenn., have introduced the Health Care Options Act, which would exempt consumers from the ACA requirement that they own health insurance if no qualified health plans were offered in their area. Sen. Claire McCaskill, D-Mo., and Rep. David Loebsack, D-Iowa, introduced the Health Care Options for All Act, which would allow citizens in so-called “bare” counties to purchase premium tax credit-subsidized coverage through the District of Columbia’s small group exchange. The bills have been introduced in both houses and are awaiting committee action. 

Trump administration: Georgia health commissioner Brenda Fitzgerald named new CDC director
Health and Human Services (HHS) Secretary Tom Price has appointed Georgia health official Dr. Brenda Fitzgerald director of the US Centers for Disease Control and Prevention (CDC). Fitzgerald also will serve as administrator of the Agency for Toxic Substances and Disease Registry. An obstetrician-gynecologist, Fitzgerald has led Georgia’s public health department since 2011. She was a healthcare policy adviser to former US House Speaker Newt Gingrich and the late Sen. Paul Coverdell, both Georgia Republicans. While Fitzgerald served in Georgia’s public health department, her efforts included promoting vaccine use, supporting women’s health and family planning through the Georgia WIC program, tackling childhood obesity through physical activity programs such as Georgia SHAPE, and combating epidemics such as HIV/AIDS and diabetes through various health and wellness programs.

HRI impact analysis: Fitzgerald comes to the CDC in the midst of the opioid epidemic—which led to more deaths in 2015 than guns or car accidents—and potential budget constraints. President Donald Trump’s proposed budget—although unlikely to be enacted as proposed—would cut the agency’s allocation by $1.2 billion, or 17 percent. Fitzgerald’s views are mostly in line with those of her recent predecessors, and she likely will be welcomed by the life science industry and healthcare providers, which typically appreciate stability in public health approaches. 

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Payers: Trump administration briefs

As the debate over repealing and replacing the Affordable Care Act (ACA) moves to the US Senate, generating considerable uncertainty about the law’s future, health insurers face looming deadlines to participate in the ACA exchanges this fall. Several insurers already have announced they will drop or reduce participation, raising questions about the ACA nongroup market’s health as open enrollment begins Nov. 1.

Read HRI’s spotlight, Trump policy agenda – Exchange participation


After President Donald Trump and Republican leaders canceled a vote on the American Health Care Act (AHCA), the world became more complicated for health industry leaders and their consumers. Amid the multiple unknowns, health leaders may be tempted to wait for clarity. But in this atmosphere, it is even more important for organizations to lean into the unknowns and build resiliency. Healthcare companies can make some “no regrets” moves to build resilience amid periods of change and uncertainty.

Read HRI’s spotlight, What’s next for health reform?


As they mull the ACA’s fate, Republican lawmakers are weighing four options to replace the individual mandate. Any replacement to the mandate would need to accomplish two goals: encourage sign-ups by healthy enrollees, and discourage voluntary coverage gaps.

Read HRI’s spotlight, Replacing the individual mandate

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Providers: Trump administration briefs

After President Donald Trump and Republican leaders canceled a vote on the American Health Care Act (AHCA), the world became more complicated for health industry leaders and their consumers. Amid the multiple unknowns, health leaders may be tempted to wait for clarity. But in this atmosphere, it is even more important for organizations to lean into the unknowns and build resiliency. Healthcare companies can make some “no regrets” moves to build resilience amid periods of change and uncertainty.

Read HRI’s spotlight, What’s next for health reform?


The American Health Care Act (AHCA) aims to partially repeal and replace the ACA, by phasing out the ACA’s Medicaid expansion and capping federal funding for the program, among other things. Under the AHCA’s Medicaid plans, healthcare providers could experience a gradual increase in uncompensated care, cuts in Medicaid reimbursement rates, or both.

Read HRI’s spotlight, Implications of phasing out Medicaid expansion

Republican lawmakers are promoting Medicaid block grants as a way to control federal healthcare spending. Providers can expect a shift from an entitlement to a free market Medicaid approach, along with a possible rise in the uninsured population or decrease in reimbursement.

Read HRI’s spotlight, Medicaid block grants and per capita funding

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Pharma and life sciences companies: Trump administration briefs

As the US tax and trade reform debate continues, pharmaceutical and life sciences companies should waste no time in evaluating how different provisions would affect their business operations. Companies should model how these proposed changes could affect manufacturing and supply chains, locations of intellectual property (IP) holdings, unremitted earnings held overseas and planned capital expenditures.

Read HRI’s spotlight, Creating a pharmaceutical supply chain and business strategy amid tax and trade reform uncertainties

After President Donald Trump and Republican leaders canceled a vote on the American Health Care Act (AHCA), the world became more complicated for health industry leaders and their consumers. Amid the multiple unknowns, health leaders may be tempted to wait for clarity. But in this atmosphere, it is even more important for organizations to lean into the unknowns and build resiliency. Healthcare companies can make some “no regrets” moves to build resilience amid periods of change and uncertainty.

Read HRI’s spotlight, What’s next for health reform?


President Trump has consistently argued for lower prescription drug prices, but no specific plan has emerged from the White House. Pharmaceutical and life sciences companies are beginning to take steps to increase drug price transparency, limit price increases and explore novel approaches to demonstrate the pharmacoeconomic value of medicine, in light of pressure from all sides to justify pricing decisions.

Read HRI’s spotlight, Preparing for new drug-pricing risks

Tax proposals from the Trump administration could result in pharmaceutical, medical device and medical equipment companies restructuring their supply chains, repatriating overseas capital, and moving manufacturing back to the US. Such reforms, though, pose a sharp deviation from current global operational structures and thus could take years to be fully realized.

Read HRI’s spotlight, Tax reform proposals could impact pharma, medical device and equipment supply chains

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Health industry strategy: Trump administration briefs

Healthcare reform efforts by Congress will create challenges and opportunities that may require changes in operating models across the US healthcare industry. As the legislation undergoes debate and negotiation in Congress, healthcare organizations face considerable uncertainty. Organizations that have developed enterprise resilience—the ability to adapt the business model to change, anticipate disruption and recognize opportunities to generate a competitive advantage—may be best positioned to survive and thrive in these conditions.

Read HRI’s spotlight, Developing enterprise resilience in the face of health reform


The inaugural festivities are over, the revelers have gone home, and President Donald Trump has moved into the White House. With so much change in the air, what actions can health organizations take today?

Read HRI's spotlight, (Some) change is coming to healthcare


As the American Health Care Act (AHCA) bill makes its way through the legislative process, the nation’s healthcare industry is left to contend with considerable uncertainty. However, there are concrete steps healthcare stakeholders can take in the whirl of uncertainty to help build resilience no matter what specific policy provisions are enacted.

Read Strategy&’s article, Why Healthcare Companies Need to Focus on Enterprise Resilience

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2016 election insights and analysis

Like a chief executive hired to turn a failing company into a profitable one, president-elect Trump has said he will take an unflinching corporate approach to overhauling the US healthcare system. For an industry that prefers stability to surprises--and one that has worked to adapt to the Affordable Care Act—Trump’s “repeal and replace” agenda may create new uncertainty and opportunity for healthcare leaders.

Read HRI's report, President-elect Donald Trump: Turnaround time


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About the center

As the US healthcare system continues to undergo transformation, health industries are confronted with an evolving and complicated regulatory environment. With an eye towards how public policy impacts the business of healthcare, the HRI regulatory center serves as a vital resource for executive decision makers who must navigate the changes that lie ahead.

HRI's regulatory center is a group of seasoned professionals that analyze legislative and regulatory policy in Washington and in key states. The group, which focuses on all health sectors, publishes a weekly newsletter and more focused reports that detail the interconnection between Washington and healthcare. The HRI regulatory center calls upon key contacts in government and industry to develop a point of view that is both informative and actionable for health industry leaders.

Contact us

Benjamin Isgur
Health Research Institute leader
Tel: +1 (214) 754 5091

Trine K. Tsouderos
HRI Regulatory Center Leader
Tel: +1 (312) 241 3824

Alexander Gaffney
Senior Manager, PwC Health Research Institute, Washington
Tel: +1 (202) 414 4309

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