Published 12/1/2016
Elizabeth Fassbender, Catherine Boudreaux, Stacie Monroe; Manthan Bhatt

Republican Sweep Portends Changes for Health Care

Trump presidency, Congressional control may result in repeal of ACA
In an unexpected sweep of the executive and legislative races, Republicans not only clinched the White House but also retained control of both the House and Senate. Although Donald Trump proved to be a polarizing nominee, exit polls showed that 9 out of 10 Republicans voted for him. Wins in states such as Michigan and Wisconsin enabled Mr. Trump to earn more than the 270 electoral votes (Fig. 1) required to secure the presidency. With a campaign focused on "Making America Great Again," Mr. Trump rallied voters around issues such as illegal immigration and the loss of American jobs due to what he called "bad trade deals."

It is expected that the Trump administration will immediately work to repeal or roll back the Affordable Care Act (ACA) and implement proposals outlined in the Republican policy platform. Just days before the election, Mr. Trump called for a "special session" of Congress to repeal the ACA. Since the election, he has reaffirmed that healthcare reform is a priority.

Speaker of the House Paul Ryan (R-Wisc.) has called the ACA a failure that is "collapsing under its own weight." Although he has expressed confidence that a Republican Congress could coalesce around healthcare legislation, many Republicans remain divided on the details of a healthcare overhaul. An outright repeal of the ACA could be complicated, given that the legislation extended healthcare coverage to more than 20 million people, and includes popular provisions such as leaving young adults on their parents' health insurance plans until age 26 and access to free contraception. In addition, Democrats in the Senate still have enough votes to filibuster legislation.

However, if Republicans are able to pass a budget resolution, they could use a procedure called "reconciliation" to repeal parts of the ACA. The procedure was tried earlier this year but was vetoed by President Obama.

A replacement plan will likely feature the sale of health insurance across state lines, tax-free health savings accounts, and healthcare premium deductions on personal income tax returns. Additionally, although Mr. Trump has released no details on his Medicare plan, a new transition website says the incoming administration will want to "modernize Medicare, so that it will be ready for the challenges with the coming retirement of the Baby Boom generation." Despite bipartisan support for the Medicare Access and CHIP Reauthorization Act (MACRA), some efforts could rein in the Center for Medicare & Medicaid Innovation.

Mr. Trump will likely spend many of his first 100 days as president getting his Cabinet confirmed, addressing the nation's immigration system and border security, and looking at jobs and the economy. He is also likely to nominate a replacement for the late Justice Antonin Scalia on the Supreme Court.

The House and Senate results
As expected, Republicans maintained control of the House and were able to limit losses (5) to single digits (Fig. 2). Reps. Lee Zeldin (N.Y.), David Young (Iowa), and Rod Blum (Iowa) coasted easily to victory. However, GOP veterans who had the most trouble on election night included those, like Florida's John Mica, whose districts were recently reshaped. Rep. Bob Dold of Illinois lost in a rematch to former Congressman Brad Schneider.

Despite recent opposition from the House Freedom Caucus, Rep. Ryan was re-elected to serve another term as speaker of the House. The official vote that will install him as speaker will occur in early January, after the next session of Congress is underway. In 2016, Rep. Ryan proposed several ideas "to address some of the biggest challenges of our time," and has stated that he intends to "execute and implement that agenda."

On the Senate side, Democrats captured only two seats; although the Louisiana Senate race will remain undecided until a runoff election between the top two contenders on Dec. 10, they will not achieve a majority. Because Republicans were on the defensive—24 of the 34 seats up for grabs were held by the GOP—most insiders had expected the Democrats to gain enough seats to take back the majority. Now, with Republican majorities in the House and Senate, Democrats will have little ability to oppose legislation.

Governor's races
Republicans will hold at least 32 governorships in 2017, tying the modern record set in 1998 for the most GOP governors in the post-World War II era. Millions of dollars were spent on competitive races in North Carolina, West Virginia, Indiana, Missouri, Montana, New Hampshire, and Vermont. Overall, the 12 governor's races split evenly between Democrats and Republicans.

Gov. Steve Bullock (Mont.), a Democrat, won reelection in a traditionally Republican-held area by campaigning on his expansion of health insurance in the state. Republicans flipped two states—Missouri with Eric Greitens and Vermont with Phil Scott. As this issue of AAOS Now went to press, the race in North Carolina, between Gov. Pat McCrory and challenger Ray Cooper, had not been decided.

"Lame-duck" policy issues
When Congress reconvened on Nov. 14, it was in a "lame-duck session," so named because not all of the sitting members of the existing Congress will be returning in the new Congress. During this period, Congress is expected to begin work on the only must-do action: funding the federal government through the next fiscal year and avoiding a government shutdown.

The election results will set the tone for the year-end negotiations. Tough decisions on spending will likely wait until the Dec. 9 deadline forces negotiators' hands. Democrats are worried that Republicans will pass only a few appropriations bills, relying instead on continuing resolutions that would maintain flat funding on domestic priorities for other agencies. House Minority Leader Nancy Pelosi (D-Calif.) has said that Democrats will only support several minibuses if they add up to an omnibus. However, conservatives will surely pressure GOP leadership against any bipartisan deals, which may result in a potential stalemate.

Healthcare legislation
Returning lawmakers will also confront whether to move ahead with two major healthcare packages or kick the work to the next Congress. First up on a potential agenda is the 21st Century Cures Act, a major medical innovation bill that's been stalled in the Senate for more than a year due to funding concerns. However, the day after the election, Senate Majority Leader Mitch McConnell (R-Ky) and Energy and Commerce Committee Chairman Fred Upton (R-Mich.) both expressed enthusiasm for getting the legislation "across the finish line."

"There are two priorities for me … how are you going to fund the government … and the 21st Century Cures bill," said Sen. McConnell. "The president's interested in the precision medicine part of that, the vice president is interested in the cancer moonshot part of it, I'm interested in the regenerative medicine part of it. I'd like to see us finish that important new measure this year."

The second major piece of legislation is a mental health reform bill, which the House overwhelmingly approved this summer. However, language friendly to the National Rifle Association could stall the measure in the Senate. Additionally, Sen. Brian Schatz's (D-Hawaii) CONNECT for Health bill, which would expand telemedicine payments by Medicare, has growing bipartisan support in the Senate and a companion bill in the House. It could be considered as a rider to a larger bill.

Elizabeth Fassbender is the communications manager in the AAOS office of government relations; Catherine Boudreaux is the senior manager, government relations; Stacie Monroe is the political affairs manager, and Manthan Bhatt is the manager, state government affairs.

Orthopaedic PAC investments
In addition to advancing legislative and regulatory priorities, the American Association of Orthopaedic Surgeons (AAOS) supports pro-surgeon candidates through the Orthopaedic Political Action Committee (PAC), the only PAC in Washington, D.C., dedicated to solely representing and fighting for orthopaedic surgeons on Capitol Hill.

The Orthopaedic PAC's tiered structure for political giving ranks issues, leadership, committees with key health jurisdiction, and physician relationships. Every contribution is determined, with thoughtful consideration, by the AAOS office of government relations, PAC Chair, and the PAC Executive Committee. This election season, the Orthopaedic PAC invested more than $2.5 million toward candidates from both political parties who are important to the orthopaedic specialty, often on different issues. Although one of the largest healthcare PACs, the Orthopaedic PAC does not endorse or support presidential or vice presidential campaigns. Instead, Orthopaedic PAC funds are directed to House and Senate races, which provide more visibility and access.

The Orthopaedic PAC supported 231 candidates running for seats in the House and enjoyed a 97 percent "win rate." It also invested in independent expenditures for seven candidates—including surgeon Neal Dunn, MD (R-Fla.), and internist Ami Bera, MD (D-Calif). Six of the seven were successful. Due to a large spike in retirements from the House this year, at least 11 percent of the lower chamber will be new to Congress. The Orthopaedic PAC plays a major role in these seats, supporting these candidates early and helping connect and grow relationships with AAOS members back in their congressional districts.

The Orthopaedic PAC played a prominent role in 32 Senate races, with a 91 percent win rate. Considering that Republicans had 24 seats to protect, and incumbents were expected to face difficulties in holding their seats, AAOS support made a noticeable difference.