Q&A with Health Affairs’ Alan Weil: What reporters should watch for in Trump presidency

Journalists covering health reform face a lot of uncertainty at the moment. While President-elect Donald Trump repeatedly pledged to repeal and replace the Affordable Care Act, he also said this week he’s open to keeping some of its most popular provisions.

To help health journalists navigate the tumultuous road ahead, we spoke to Alan Weil, the editor-in-chief of Health Affairs, a leading peer-reviewed journal that covers the intersection of health, health care and policy.

“There’s certainly many reasons to expect significant change, but we also know that change is hard and health is complex,” Weil said. “The hardest part, from a reporting perspective, is trying to focus on the moments when the specifics start to become clear, and then trying to capture the implications of something more specific than the rhetoric we’ve heard thus far. That’s the key role the media can play.”

In the edited Q&A below, Weil discusses the future of the ACA, urges reporters to humanize health policy stories, and highlights other health topics to watch, from transparency and consolidation to prescription drugs and Medicare.

Q: What do you see as the future of the ACA under a Trump presidency?

A: We don’t know yet what will happen. That said, there’s the policy imperative to repeal the Affordable Care Act. We have a president who ran on that platform, he has a majority in Congress, and a Congress that has acted on it many times, the House in particular. We should be looking for that effort to be made. What gets complicated, then, is that there are things about the law that people like, including things that President-elect Trump says he’d like to keep. The law is very complex and the provisions very interwoven. If you pull one piece of it, others pieces are affected.

Q: What are your thoughts keeping aspects of the law, such as the pre-existing condition provision and allowing children to stay on their parents’ insurance until 26?

A: The young adult coverage one isn’t that hard to keep. It’s an arbitrary age. That’s something that doesn’t ripple in major ways through the system. The pre-existing conditions elimination is a much more complex matter. That’s the way the ACA was built: If you make it possible for anyone to buy coverage, you can’t let people wait until they’re sick to get it. If you remove everything else and leave in this requirement, that’s very destabilizing. Some critics of the ACA have proposed soft barriers to entry, such as only getting in once a year. There are also what conservatives might call market-based approaches to make it possible to have some preservation of this provision, but those aren’t very well tested and it’s hard to know how well they’d work.

Q: What about the new administration’s plan do you find most concerning?

A: I don’t think there’s any way to sugar coat it: If the subsidies in the exchanges and Medicaid expansion are removed, there’s no reason to think it wouldn’t just reverse the gains in coverage over the last several years and that just leaves a whole lot of uninsured people. Without an alternative, we can hope all we want that people will get jobs with benefits, but that’s just hope. There’s really no evidence that it will happen.

As for Medicaid, the position of Republicans in Congress for some time has been to convert it into block grants to the states, compared to now where the federal government sets substantial eligibility standards and matches Medicaid spending dollar for dollar. If you go to a block grant, and states can’t figure out efficiencies, you would anticipate a gradual erosion of coverage.

Q: Trump has said he wants health care price transparency so that consumers can better shop for providers and services. What’s your take on that?

A: Transparency is a word that’s often used and it can be overused. It’s very hard for consumers to get information about prices, and analysts to get information on the cost behind the prices. Cost is very hard to understand because of all the subsidies within the system. The piece to keep an eye on is quality. This is very expensive to quantify partly because we don’t have standard definitions to measure quality. One of my questions would be: If the goal is a better-functioning market and you want better consumers, Is the government willing to put in the resources, and would the Trump administration be as enthusiastic about investing in understanding quality vs. price? Price is just a number whereas quality is multi-dimensional. I think it’s an area to watch but it needs to be watched in context.

"I don’t think there’s any way to sugar coat it: If the subsidies in the exchanges and Medicaid expansion are removed, there’s no reason to think it wouldn’t just reverse the gains in coverage over the last several years and that just leaves a whole lot of uninsured people. Without an alternative, we can hope all we want that people will get jobs with benefits, but that’s just hope. There’s really no evidence that it will happen." — Alan Weil, Health Affairs

Q: What less obvious issues are you tracking beyond “repeal and replace”?

A: One of the things both Trump and Hillary Clinton talked about is affordability around prescription drugs and health care premiums, two things that are quite visible to people. It’s still way too early to see what solutions will make their way through. Watch to see if there’s follow through that helps address affordability.

Medicare didn’t get much attention in this campaign. Keep an eye on the movement for seniors to use a financial voucher to buy coverage, as well as Medicare Advantage.

There’s also this whole movement afoot within health care to pay more for value and outcome rather than procedures and interventions one by one. It’s transforming the health care system. Government has played a real leadership role in the whole quality movement and getting health care reoriented toward outcomes. That’s very consequential for patients but hard to report on.

Q: Do you have any suggestions on how to better report on value-based care?

A: Find the leaders of health care organizations and get them to talk about this in language people can understand. Find ways to personalize the story: Where is the patient in all of this? Find real people whose medical records are available when they go to their internist after seeing a specialist. Talk to a diabetic who is now getting routine care. We all have examples of poor coordination and care. Our general expectations are so low that we don’t even know what it could be like. Once you’re in a system that’s actually doing what it should be doing, you can’t believe that wasn’t the norm. Try to find people who are making that happen.

"Health care is such a personal issue within any community. People and institutions are so directly affected by the health system and the federal and state laws. Get out and talk to people. I don’t know any community where either the patient advocates or the people who focus on issues of immigration, poverty or children are not thinking about the possible implications of these issues. The people who run hospitals, the clinics, the people who are practicing medicine, the educational institutions — they’re all thinking about this, too." — Alan Weil

Q: Any other advice for journalists covering the new administration from a health perspective?

A: There are two ways to cover this: one at the personal interest level and the other as a business story.

On the business side, you have a natural experiment in the fact that Medicaid expansion was only taken up and exchanges really only embraced in some states: “If this goes away, we’re going to look more like these folks than these folks.” Compare a rural hospital in a state that expanded Medicaid to one that did not, and examine their ability to keep the doors open. Look at communities where hospitals have closed, and see how that is playing out.

Health care is such a personal issue within any community. People and institutions are so directly affected by the health system and the federal and state laws. Get out and talk to people. I don’t know any community where either the patient advocates or the people who focus on issues of immigration, poverty or children are not thinking about the possible implications of these issues. The people who run hospitals, the clinics, the people who are practicing medicine, the educational institutions — they’re all thinking about this, too.

It’s hard to write a story that says, “This is what people are worried about” because it doesn’t quite catch reader attention in the same way, but that’s where you are going to find the stories.

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