2024 Presidential Election Outcomes and Potential Impact on Healthcare Policy w/ Marc Ryan

Erik Sunset: [00:00:00] All right. Hello and welcome back. I’m your host of the DocBuddy Journal, Erik. And we’ve got a very special guest to cover some very important subject matter today. We’re joined once again by Marc Ryan, who is the Chief Solutions Officer with Lilac Software. He has launched and operated multiple health plans and served in senior government positions.

Erik Sunset: Marc is also the author of the Healthcare Labyrinth. Marc, thanks so much for joining us again.

Marc Ryan: Erik, it’s great to be here. I enjoyed the last time and I know we’ll have a great engaging conversation.

Erik Sunset: That is the truth, and so did I, and so did our listeners, for that matter. And unless you have been, not only living under a rock, but maybe living under a rock on another planet, you’ll know that we had our presidential election just last week, and that’s why you’re here. Uh, potentially big impacts to healthcare here in the U.S.

Erik Sunset: and with your background, Marc, there is nobody better to discuss this with.

Marc Ryan: Sounds great. Look forward to it.

Erik Sunset: So for that, that very small segment [00:01:00] of the audience that maybe is living under a rock on another planet, talk us through the outcomes of, uh, the elections for the House, the Senate. White House. And what do you see as significant?

Marc Ryan: Absolutely. So, you know, we, everybody thought that this was going to be a very close race, right? And to some degree it was, but it is true that I think Donald Trump had a fairly major win in the electoral college, right? I think very few people voted for him. Going into election day, thought that he would win all seven of those sun belts and Midwest blue wall States, but he did.

Marc Ryan: Right. Uh, and what we really saw was that, uh, the former president and now future president actually had major coattails, right? And people did not think that Trump’s coattails were very good. And coattails for your listeners are when the top of the ticket sort of brings Other folks, the [00:02:00] Senate was always expected to go Republican, uh, with maybe 51, uh, seats, um, because of those Trump coattails, they became 53, right?

Marc Ryan: So that’s, that’s pretty amazing. And the House was always expected to be really, really tight control. I think all of the prognosticators, including myself out there were saying. This could go either way. There was talk about a slight chance for the GOP and probably a greater chance for the Democrats based on the local flavor of given elections, but these coattails also helped the Republicans retain house control, uh, and that was largely because of really good performance by, uh, Donald Trump and the Republicans in North Carolina.

Marc Ryan: Which flipped three states, uh, three congressional races in that state. And over in California, although it’s a deep blue state, uh, there were some wins in some swing [00:03:00] districts by the Republicans that allowed them to keep the house. Now we don’t know that count yet. It is a tight margin because of the way the house is lately.

Marc Ryan: Uh, but they will probably add a. Few more to their, uh, seat count from 220, uh, going up a little. So in the end, there was the so called trifecta of politics where the White House, the Senate, and the House, uh, now will be in Republican hands. And again, close race, but I don’t think anybody expected that that was going to be the outcome.

Erik Sunset: No, that was a big surprise. And you see sort of the post mortems on, uh, general voting trends. I’m sure everybody’s seen the red arrows to the right, you know, almost universally across the country. A lot of red arrows pointing right, very few blue left pointing arrows. So that was a little bit of a surprise to me.

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Erik Sunset: Uh, did anything surprise you now that we’re a week or so removed from election day?

Marc Ryan: Um, I was predicting that the former president would win the race. Um, I’m a fairly moderate Republican, so I was doing that just from my history with polls and stuff, right? Because you can sort of see that surge coming, but my surprise was how A big that red wave was right, notwithstanding a close election.

Marc Ryan: As you point out, that New York Times graphic is all over the place, right? And that is a little bit surprising to me when it comes to health care. You know, your, your, your next point that you made to me to cover [00:05:00] was. What does it really mean? Right? And I will tell you there will be a major change in health care policy.

Marc Ryan: No question about it. But I think it’s an open debate about will it be seismic change versus more budgetary change. And I’d like to sort of explain that a little if it makes sense. When I think about seismic change in health care policy, We’re talking about bills that go through Congress, sponsored perhaps by the White House, that get rid of the Affordable Care Act, a repeal and replace, or a major restructuring in Medicaid, moving from the current funding schemes with an entitlement to something less than that.

Marc Ryan: And those kinds of things, right? Um, I do, I am not certain that we will see those seismic changes despite the so called GOP trifecta, [00:06:00] but I do say that we will have major changes to healthcare programs, nonetheless. Really through budgetary reductions that the GOP will probably sign on to in lieu of seismic change that will still have the impact of lowering coverage and things like that in the United States.

Marc Ryan: So that’s a bit of a subtlety. Uh, seismic change could happen. I’m not sure it will, and we can go a little more into that, but I do think Uh, the tax cuts and what Trump wants to do in terms of extending the tax cuts probably will mean budgetary changes that will have consequences on healthcare and coverage.

Erik Sunset: And I, I want to point out one, uh, one thing for our listeners, really your experience. If you’re not familiar with Marc and the healthcare labyrinth or his work at lilac software, you actually served as an appointed official appointed official maybe a high level overview of what that looked like.

Erik Sunset: So, um, You know, I’m a, I’m just a guy with an opinion, you have bona fides, [00:07:00] uh, talk us through what those are.

Marc Ryan: Yeah, yeah, sure. I was a state management secretary of Connecticut for a number of years during the Bush years. And I was very privileged to be part of one of the task forces that implemented Part D back in the mid 2000s. So it was really from a state perspective, integrating state drug programs with the Part D program coming out.

Marc Ryan: So we worked within HHS’s, uh, You know, department to do that. Uh, and so I’m proud to have played a very small role there. Uh, and then later on in life, I was also a, uh, appointee to, uh, a Medicaid reform policy task force in the state of Florida. So work both at the Medicare in and the Medicaid level at the state and federal level, and obviously as management secretary of Connecticut, I did a lot of work in Washington, D.

Marc Ryan: C. during, um, You [00:08:00] know, the Bush years primarily, uh, on healthcare policy and things like that. So,

Erik Sunset: Well, that’s helpful as a refresher for me. And again, just want to point out that this is a much more than just one perspective. I mean, this is a career’s worth of perspective and a really well informed one at that. So we, we touched on the, uh, the so called trifecta the GOP has, it’s sort of a matter of how much of a trifecta it becomes, as you pointed out, there’s still some.

Erik Sunset: ballots being counted. Forgive me there. Um, one thing we do want to point out there is around coverage. Is there, is there anybody that should be concerned across the U. S. Where their coverage may be in question now as a result of the outcomes of the election?

Marc Ryan: yeah, I, I do think there should be concern, right? And let’s talk about the, uh, ACA first, right? While again, we don’t know if Donald Trump and the Republicans in Congress will go after the ACA [00:09:00] again for repeal and replace, let’s talk about that for a moment. So. The president, the future president, uh, actually, for the most part, tried to steer away from repeal and replace language during the campaign.

Marc Ryan: At the same time, his vice president candidate, J. D. Vance, did talk about the idea of, again, restructuring the exchanges into low end, uh, high risk pools and things like that, and devolution to the state. So there was a bit of a mixed message. Speaker Johnson, who likely will be in control again, we don’t know for sure, he did the same sort of things.

Marc Ryan: He downplayed the idea that the ACA would be repealed, but that, uh, there would be health care changes. So a bit of a mixed message from them. I tend to believe that there’s some moderates in the House and swing districts. There’s two moderate senators and some other [00:10:00] cautious conservatives in the Senate that would probably militate against sweeping ACA changes, right?

Marc Ryan: So, uh, that’s one point. It’s not a guarantee, uh, but I think there is that moderation force in Congress that might say, Are the votes there? Do we want to go through another 2017 repeal effort? That failed primarily because there wasn’t a good alternative, right? I support the ACA. As I said last time, there was not a good alternative.

Marc Ryan: It made no sense. It would have meant coverage, a declined in the uninsured rate increase. So I think we’re sort of in that same mode, no guarantees, but I’m a little optimistic that Congress may have enough forces to say, we don’t want this. And Trump as a populist and wanting to leave a legacy. May not want to go there again.

Marc Ryan: We have the budgetary issues that may be different, right? And we’ll talk about [00:11:00] those. However, the enhanced premium subsidies are probably very vulnerable. As your listeners may know, these were put in place enhancements to the permanent ACA premium subsidies in the exchange. And they are markedly higher and they have driven over the past several years enrollment in the program.

Marc Ryan: Millions of more people are now covered because those enhanced premiums drove that enrollment. It actually meant more health plans in greater access and things like that. Do I exactly love the levels? No. But I would extend them and potentially, uh, have some permanent solution because it’s coverage and it has helped, right?

Marc Ryan: Those enhancements expire at the end of 25. And Republicans probably don’t have a great appetite to extend them. Uh, they could [00:12:00] probably let them lapse and sort of blame the prior administration. Right. Uh, even though there could be some impacts in some red states. I always talk about the fact that the exchange program is actually a Republican program, that.

Marc Ryan: Because about three quarters of enrollees in the exchanges are actually from red states or states that Trump had just won. So some of these folks that would let them lapse do it at their own potential detriment, but they would probably politically say, well, you know, that was the Biden administration and they were going away, I will say.

Marc Ryan: In another way of thinking about it, some of these moderate senators might come around and say, you know what, we have a stopgap bill that has to be passed to stop a government shutdown at the end of December under the old Congress. Maybe we should just allow these things to continue on because I don’t want to deal with it right now.

Marc Ryan: Or maybe in 25, there’s a master budgetary [00:13:00] settlement because things are so tight that potentially allows things to be extended. So I think the premium enhancements could be vulnerable, uh, depending on what some of the moderate forces in the GOP party are thinking, I think the ACA repeal is open, but I’m less worried about that, uh, because I do think there’s a whole lot of different forces that would really come to bear about that ultimate repeal.

Erik Sunset: Well, it seems to me, and I will certainly look to you to correct me if I’m off base here, you know, there isn’t anybody I don’t think clamoring, you know, outside of Washington, like, let’s get rid of Obamacare, let’s get rid of the ACA, but on the other end of this, the common knock through the years has been, yes, more individuals are covered, but not everybody is able to utilize the health care coverage that they, that they now have under the ACA.

Erik Sunset: So is there any fine tuning or is there any sort of minor restructuring that you think is possible to provide greater utility or [00:14:00] what’s in your crystal ball there?

Marc Ryan: Yeah. Um, I think it’s a great point. I think that the Republicans even have sort of said the Obamacare and Johnson said the Speaker Johnson is part of the fabric of America now. It’s been in place for 10 years. And so even the Republicans feel that way. I do agree that sometimes exchange coverage is exceedingly expensive, right?

Marc Ryan: The premium subsidies for moderate income people are not very good. And even if you are getting a subsidy, um, the cost sharing sometimes makes it prohibitive to really take full advantage, right? I’ve made the case that maybe we’re too generous at the lower income ranges and less generous at the top.

Marc Ryan: But that’s why I wouldn’t want to fool around with the premium enhancements right now. They seem to have work, and I think they’re fairly cost effective. I really hope. [00:15:00] That maybe it’s possible as long as we get over this idea of ACA repeal, that maybe there are better ways to incent coverage, make things more affordable.

Marc Ryan: I think part of this has to be driving down price. You could provide so many subsidies to everybody on the cost sharing and premium side, and frankly, still have unaffordable coverage. Because the price in our system is so bad. And we talked a little bit about that last time, right? I think you need to act on the price side.

Marc Ryan: There’s price transparency movements. There’s movements for site neutrality. I think coverage and affordable access and on the other side, reforming price would be the best way to allow people to truly access their insurance and really have. Upfront wellness and prevention. And that to me is the secret moving forward.

Marc Ryan: Now, will that happen in a really divided Congress? Perhaps not. I’m wishful [00:16:00] and I hope it does. I’m also hoping that I’m right about not repealing the ACA. Uh, but we’ll have to wait and see.

Erik Sunset: Yeah, a lot, a lot to be determined here in the fairly near term, you know, as we are staring Thanksgiving in the face, practically speaking.

Marc Ryan: Absolutely. Yep. And things are going to move pretty fast. Uh, and the Trump administration is moving fast to get their people in place. But the reality is they got this vote at the end of December to keep government, uh, open. Uh, they have major things to do on the budgetary front in 25. To really get a permanent budget in place, which has always been a goal, hasn’t happened in a long time.

Marc Ryan: And then, of course, they have this whole tax cut package that expires that they also have to pass next year. And that’s where the nexus of health care and coverage come together with all of these fiscal activities in Congress next year.[00:17:00]

Erik Sunset: You were so right about that. And then to turn our attention towards maybe a little bit more on the conjecture side here. A lot of conservative think tanks are putting out blueprints for what they think will happen with Trump 2, uh, as it were. What are you seeing? Uh, what impact do you think they’ll have?

Erik Sunset: Are they going to influence any of the incoming president’s thinking or policy? Um, you know, some of these names are, uh, Heritage Project 2025, Paragon, the Republican Study Committee in the House. What do those look like for those that are maybe not so well versed? As

Marc Ryan: Well, if we sort of take all three of them together, so everybody knows the Heritage Foundation, been around for decades. pretty conservative. I think they become more conservative over the years and some of their proposals, including in Project 2025, which Trump has sort of disavowed. He says, That’s not my blueprint.

Marc Ryan: I’m not telling you. I believe in all [00:18:00] those, but it certainly is a source document for how conservatives might want to change, right? And so there are some things Fairly major proposals in that document. The Paragon Institute, also a fairly conservative think tank has also proposed some similar changes.

Marc Ryan: And then the Republican study committee is essentially a house caucus, part of the GOP, which is really more conservative. Um, and they have made their own proposals in various areas. I’m not going to attribute exactly what all three did, but I’m going to get a, give you a bit of a breakdown of what the, maybe the ACA changes they’re proposing, what the Medicaid changes are and what some of the Medicare are across all three of these, not necessarily one or the other in the ACA.

Marc Ryan: Again, some of those are traditional repeal and replace efforts, right? They want to get rid of [00:19:00] the exchanges. They say they’re too expensive. They want to restructure Medicaid. Some of them talk about block creating to the states to deal with both Medicaid and the uninsured. They want to really. Uh, focus more in on individual coverage and empower individuals to purchase their own coverage.

Marc Ryan: So that’s sort of how that coverage or the Affordable Care Act would change based on some of these groups in Medicaid. Again, it sort of rolls up into the ACA. Uh, they would probably roll back some of the expansions in Medicaid. They would go more toward work requirements and having differential benefits in Medicaid, again, block granting or something like that, or at least migrating from a strict funded entitlement to.

Marc Ryan: What is known as a per capita cap, which is a middle ground between a strict funded entitlement [00:20:00] and just the fixed block grant. The per capita cap is something in there that is said to be a little more friendly toward consumers, but still saves dollars. So those are some of the ideas in Medicaid. In Medicare, many people are saying that the pre, the, former and the now future president will be very friendly toward Medicare Advantage and potentially even make Medicare Advantage the default choice.

Marc Ryan: For people and maybe phase out Medicare fee for service over time. I’m not sure that will happen, but I do believe that the president will be much friendlier to Medicare Advantage over time. That doesn’t mean that they may not also ask for more accountability in Medicare Advantage at the same time, right?

Marc Ryan: They can support Medicare Advantage and still tackle things that. Capitol Hill lawmakers on both sides of the aisle, and maybe even a president Trump is [00:21:00] concerned about. Some of, some of the populist Republicans and even conservative Republicans are convinced that there’s a bit of corporate welfare going on in Medicare Advantage, right?

Marc Ryan: So we like the program. It’s best for people, but maybe we have to rein in some of that corporate welfare and the excess, right? So. Again, um, those are some of the things that are proposed by these conservative groups. I think some of them could be adopted. Um, in this budgetary process to pay for the pay, uh, for the pay for the tax cuts, I’m not sure the more radical proposals of repealing the ACA or a fundamental restructuring in Medicaid or Medicare advantage as the default option.

Marc Ryan: I’m not sure those will happen, but during this tax package, you are going to get proposals coming along that, uh, will save in different areas [00:22:00] of health care. and will have impact on coverage and they will feature it not as seismic change or ripping something away from people but it’ll be packaged up in these budgetary savings and they’ll sort of be muted and behind the scenes and they will I still think impact coverage in a lot of healthcare policy.

Erik Sunset: you mentioned, uh, with, with Trump as a, as a populist, that seems to be, and again, I don’t want any spears thrown at me. So depending on the echo chamber with. Which with which you in the audience have been listening to because they all are to some extent or another, you know, these things and project 2025 that are labeled as really far, right?

Erik Sunset: You know, I don’t see things like that coming to pass as that is not what the country, uh, as a whole seems to want seem to be more of a stepping back to the middle. Um, and that may get some spears thrown at me and that’s okay. But overall, if you can remove yourself from all of the media that you [00:23:00] consume, it seemed to be a little bit more of a step back towards the middle, at least to me, do you have any thoughts on that?

Erik Sunset: Mark? Yeah.

Marc Ryan: the, the popular conception is we have now swung from, uh, what you would call as a rather progressive Biden administration, uh, although the president has always tried to sort of look moderate, but. I think you would argue it was a more progressive administration to now the mainstream media are talking about a really rightist agenda and and to some degree.

Marc Ryan: I think that’s a fair representation, but. The country is still rather mainstream and middle of the road and, uh, there’s support for the ACA, there’s support for Medicaid and Medicare. And, um, people are going to probably articulate to their representatives and senators that change is needed and maybe efficiency is needed, [00:24:00] but we don’t want to radically rip apart things.

Marc Ryan: And I think president Trump is. Probably a little bit sensitive to that, given some failures in his first term on ACA as one example, but I’ll also point out to you that for good or bad, Washington, D. C. is the most political animal in the world. Uh, we are fresh off the 24 elections, but guess what they’re already talking about.

Marc Ryan: They’re talking about the 2026 elections and raising money. Yeah, and people are going to start to get emails asking for donations there. Again, the house can flip control in two years by the change of maybe, I’m going to call it four to six seats. Let’s say, right. The Democrats, if they win four to six seats, we’ll be back into control.

Marc Ryan: The Republicans don’t want to give that up and they don’t want to make political missteps, right? The Senate, again, it’s 53, [00:25:00] 47 for the Republicans, but the way these things work in 2024, Democrats had two thirds to roughly one third of the seats up. I believe roughly that in 2026, 20 seats are have to be defended by Republicans and about 13 seats by Democrats.

Marc Ryan: It flips. So the Senate is already thinking about these issues. So. That will tend probably, although you’ll hear a lot about major changes and reforms from the Trump administration, because in some ways, the president will not be able to run for a third term under the constitution. He’ll just say, I want to make change, but really the politics of Congress.

Marc Ryan: margins and who’s up in 26 and some moderates will probably play a very important role. And that’s probably a good thing for healthcare coverage overall, [00:26:00] although there will be impacts.

Erik Sunset: Let’s, let’s talk about healthcare coverage a little bit. When you joined us last, we went in depth into, into Medicare and Medicare advantage, you’ve already touched on that a little bit. Um, at the time it was said there was some turmoil and you predicted some changes Uh, does the outcome of these elections, uh, mean anything to those predictions?

Erik Sunset: I guess, did they alter your predictions from the last time we spoke?

Marc Ryan: Not materially, again, um, the Republicans may want to create some policy initiatives to make Medicare Advantage sort of the primary source of enrollment. That’s happening in and of itself anyway, just because of the better value proposition of MA versus fee for service. If the Democrats were in power, I think you would have a lot of push to add benefits to the Medicare fee for service program to sort of equalize the so called value.

Marc Ryan: I think that dies. That’s not going to happen now. Uh, [00:27:00] and so Medicare advantage will still continue to be the, the, the. The program that’s growing, right? I’m a big supporter. I think reforms are needed, but I think I think it makes more sense for the nation. Private plans can do it more efficiently as long as they’re accountable, right?

Marc Ryan: So, uh, the default option we talked about. Could happen, but I tend to think that that’s probably a bit of a stretch as well. Um, there’s also some talk of, uh, one of the reforms and this could be on the agenda, whether it passes or not, would have to go through the moderates where, um, Medicare would still be an entitlement, but there would be a set amount of money given to seniors each year.

Marc Ryan: And otherwise it would come out of their pockets either in cost sharing or through premiums through MA and it would inflate over time. But the thought is, is that that would control Medicare [00:28:00] spending, but it would clearly impact affordability for seniors, right? That’s another option that’s been talked about by Some conservative outfits, again, not sure that will happen, but it could.

Marc Ryan: And on the regulatory side, many people are saying, Oh, Trump is now going to be president. So all of this focus on MA plans will go away. They’re not going to be talking about the marketing. They’re not going to be talking about the supplemental benefits spending, which appears very low. They won’t be talking about overpayments.

Marc Ryan: Those are sort of the big three things that regulatorily we’re being focused on. My prediction is, uh, the Trump administration may try to do some favors to MA in the short term on the rate side, because they are really struggling and a number of different things came together to create problems. So that’s a possibility.

Marc Ryan: But I still [00:29:00] believe that there are Democrats and Republicans in Congress that are worried about the MA accountability. They are worried about that so called corporate welfare, if we can call it that. And I think they, on a bipartisan basis, will be looking at it still, and that will force, uh, You know, probably the Trump administration, whether they like it or not, to look at those issues and agree to reforms there over time, maybe they slowed out a bit, but I don’t think those issues are going away.

Marc Ryan: So, and they plans really have to make sure that they’re operating well, accountably and transparently and make some reforms on their own, because I think those will still be issues coming up.

Erik Sunset: Well, this is going to take us off script a little bit, Marc, but the, uh, the Medicare 2025 final payment rule was published, um, in the very recent past. And there’s been, it’s been screeching almost universally. It doesn’t seem like anybody is happy about [00:30:00] this, uh, 2025 final payment rule. Granted, there were some, uh, positives to take from it, like additional funding to Indian health services.

Erik Sunset: Um, it’s more of the, I don’t want to call them niche programs, but you know, Your general provider is disgusted. Your anesthesiologist is disgusted. So when you talk about reforms to CMS, Medicare, Medicare Advantage, what can we do if you had a magic wand? How can we get everybody at least a little bit happier instead of having most of the stakeholders here just disgusted?

Marc Ryan: Yeah. So I think you’re absolutely right. And I recently wrote a blog and did a podcast on the Medicare doc issue. And I will tell you, I think there’s an amazing opportunity, even though it will cost money for the Trump administration and Congress to get together to solve it. It would take money. But there’s a source of payment for [00:31:00] that as well.

Marc Ryan: Now they may want to take this source of payment to pay for tax cuts, but I think Democrats and Republicans have to get together to really understand that the decades of, uh, ignoring doctors in actually primary care has cost the, the, the, the system overall in the government more money than it has saved.

Marc Ryan: And so. I am actually cautiously optimistic, believe it or not, that maybe it’s finally time to get a Medicare doc fix. Right? Um, stop the shenanigans of having to override the law 20 times. In the last several decades and letting doctors, uh, basically be unable to run a practice and having to sell out to private equity or health and health and hospital systems and fix it.

Marc Ryan: Right? Um, primary [00:32:00] care, especially has been ignored to the degree that specialists maybe have survived a little. care physicians have not formula is broken. It’s p specialists. Um, and it i part of Medicare. And the It does help fee for service, but it also is a constraint in the Medicare Advantage world to write these rates are based on that.

Marc Ryan: But I think they should get together and say, let’s fix this. The source of funding is site neutral payments for hospitals. There are tens of billions of dollars a year, if not more. That can be saved by going to site neutral payments. Part of that could be used for the Medicare doc fix and maybe part of it could be used to pay for taxes if that’s where the country goes, right?

Marc Ryan: But I think also investing in primary care, investing [00:33:00] dollars in medical education and things like that. Is an absolute must because unless we have a foundational primary care system in the country, we are only going to see prices increased dramatically, right? I’m a believer in coverage, but I’m also a believer in primary care and the two go together.

Marc Ryan: And until we get those done, We are in this ever ending, six to 8% increase in the employer world, and we are in the government sector. Gonna have to, uh, put more money on the, uh, on the poor, uh, recipient or, or we’re gonna have to cut their benefits in order to survive. And it’s, it really is time for everybody to get together and say, let’s build a rational system.

Marc Ryan: Let’s not, let’s not do these radical changes to coverage. Let’s try and put together a healthcare, healthcare [00:34:00] reform agenda. And you know what? I guess I’m not going to predict that, but if president Trump wanted to leave a legacy. He would recognize that maybe that’s an imperative for the country. And maybe that is one of his legacy items of working and really creating a very rational system.

Marc Ryan: In some ways he’s freed up, uh, essentially being a lame duck from day one. Uh, to try and make those kinds of decisions, right? He’s, and maybe he can bring Democrats along and Republicans along to really fashion something that makes sense. My problem though, is the reason I don’t think it’ll happen is this big tax package that will dominate Republicans attention and that sort of thing that’s militating against, um, good policy on healthcare.

Erik Sunset: Well, it either needs to be Trump 2’s legacy [00:35:00] or it’ll end up being somebody’s legacy not too far down the line because something, something’s got to give, you know, primarily for the patient. But if there’s no providers that want to treat patients anymore, then you have a whole other type of, you know, we’re approaching that precipice, you know, you’re already seeing with the anesthesia specialists, whether they’re doctors or CRNAs or a PA. But to bring us back to the point, you mentioned both on the last Podcast you joined us on. And then just now this massive consolidation. So private equity, buying provider organizations, independent practices and independent practitioners selling to the health system. You know, I have the point of view.

Erik Sunset: That’s not necessarily a good thing. What do you, what’s in your crystal ball for how Trump will view this, uh, massive consolidation as opposed to the Biden administration? Well,

Marc Ryan: So again. Republican talking to you today, fairly moderate, fairly traditional Republican. But I thought the [00:36:00] Biden administration’s focus on antitrust was a very good thing. And that goes for health plans. It goes for providers. It goes for hospital systems to me across the board. I think what we’ve seen through mergers and massive consolidations and acquisitions of physician groups.

Marc Ryan: Price, right? And higher costs in the system. And as a sort of corollary, we haven’t seen quality increase by the way. It’s either stayed flat or in some cases it’s actually gone down. So, so that’s, those are fundamental truths. Um, the hospitals will fight you on that, but I think there’s enough studies out there that.

Marc Ryan: That basically say that’s a fundamental truth. And so I applauded the Biden administration for having this antitrust agenda across the healthcare sector. A lot of my health plan friends don’t like me here, hear me saying that, but that is just sort of the fact of life. It raises price and [00:37:00] it’s not a good thing.

Marc Ryan: Change healthcare cyber attack is a good example of the inattention. Uh, that happens when, uh, entities, no matter what kind of entities they are, get too big and too powerful. Right. Um, so I liked that. The popular wisdom is that Trump is more pro business. And will not pay attention to these kind of massive consolidations. I’m not entirely sure that I will argue that there will probably be some, some step back from a vigorous antitrust agenda. But there’s probably two things I’d point out, uh, about why don’t say it’s going away entirely. One is J. D. Vance. Uh, J. D. Vance has sort of been demonized, uh, in the popular mainstream media.

Marc Ryan: But the [00:38:00] guy is a fairly thoughtful guy. I think he actually is sympathetic to coverage, and I know he was on the campaign trail talking about we need to make changes. But I also think he’s a bringing in, if you read his sort of hillbilly elegy, it’s actually quite fascinating about what he went through in life and how he sees things perhaps different from a traditional Republican.

Marc Ryan: Right. Uh, but J. D. Vance is actually very sympathetic and very knowledgeable on the issue of Consolidations in the impact to price and the impact to consumers. So he could weigh in on this concept. I really do believe that. Number two, you have a good deal of hardworking bipartisan lawmakers in the Senate and to some degree, the house.

Marc Ryan: But when I used to lobby the Senate, I got to know Democrats and Republicans really well, and they were more alike than they were. [00:39:00] And, and, and so I still think you got some of those good people there and they are actively raising questions about massive consolidations, about the vertical integrations of health plans, about the power of, of health systems and the dominance they have on physicians.

Marc Ryan: And so Congress. On a bipartisan basis, we’ll still weigh in on this. And as an equal part of government, and I still think we’re going to have an equal part of government, they’re going to weigh in. And I still think that the Trump administration is not totally unsympathetic to the plight of the consumer in rising prices.

Marc Ryan: And again, as a populist, Trump likes business. But he also wants accountable business and he hasn’t been afraid to say too big is perhaps too big, right? Not withstanding the fact that Elon Musk will be in his administration. Uh, but I [00:40:00] think the populism of Trump. And the Congress being sensitive to competition issues will mean there will still be a tension and it will be heightened compared to many years ago, perhaps not at the level of Biden.

Marc Ryan: I predict that the PBM lawsuit through the Federal Trade Commission will continue. Because that is a major controversial issue. And I think that Trump’s picks for some of these consumer protection agencies like the FTC will actually be more activists than not. I really do. I think that will be part of his legacy as well.

Marc Ryan: And again, Congress has an active interest here. It takes a while to get their interest into act, but I think they will be very active on these issues. Yeah,

Erik Sunset: to that too, Marc. With all this consolidation, that is a direct driver of physician burnout, being a physician in a large, uh, organization, whether it’s, uh, privately owned [00:41:00] or a healthcare system in a region or in a city or in a county. But this is going to have to be somebody’s legacy sometime soon, because all of this physician burnout is leading to an outright lack of providers.

Erik Sunset: And before we hit, before we hit 2030, we’re going to hit this critical mass where there are just not enough providers to deliver care. To all of those that need it. So something’s got to give, and that’s our soapbox here at DocBuddy and my own personal soapbox. It is insane to think that we will allow mergers of this scale and of this size.

Erik Sunset: Number one, you raise the issue around PHI and centralized data, and we can spend as much time as we want talking about meaningful use and all the promises made around interoperability, but maybe not today. Uh, but then just the simple nuts and bolts of keeping providers. Providing being a doctor, you know, through their expected retirement age.

Erik Sunset: And I certainly don’t hold it against anybody to do whatever they want with their life, but systemically. You’ve got to keep doctors practicing for as long as you can [00:42:00] right now. Otherwise your shortage date gets sooner and sooner and sooner. And this lack of autonomy that you find yourself with as a provider in a large organization, that’s killing the profession.

Marc Ryan: absolutely. And this has been going on for years. You know, I was shocked a number of years ago when my wife’s gynecologist became a real estate agent, it was more lucrative. He was close to retirement. He didn’t want to retire, but he said, you know what? Between the cost of a practice and malpractice and all these different things, I’m going to sell real estate.

Marc Ryan: I’m going to make more money. That really says a lot, right?

Erik Sunset: That says everything that needs to be said perfectly encapsulated there. And to turn our attention back to the matter at hand, looking nationally, most Americans will have insurance through their employer. I think it’s about half, maybe more than half. Um, there is a [00:43:00] topic that is employer tax deductibility, and this is well out of my wheelhouse, but I know it’s a very complex issue.

Erik Sunset: Uh, can you walk us through, uh, what that exactly means and then what you think might change, uh, in respect to it?

Marc Ryan: Sure. In addition to some of those budgetary things, and maybe I’ll cover a little more of that too, but this could be one of those budgetary things that are not seen as seismic change in healthcare, but because they take savings here and there, have major coverage impacts. And so a number of these conservative groups have raised the issue, and this has come up in the past, that the tax deductibility Of insurance premiums, what employers pay, and then obviously what consumers pay.

Marc Ryan: It’s all tax deductible. It’s written off of income and therefore, uh, you’re, you’re, you’re not paying for it. Now it is a [00:44:00] deduction and not a tax credit, which is different, right? So employers. Take it off of income and it saves them. They’re 20 some percent if they’re paying that much in corporate taxes, but they’re still paying the lion’s share of that, um, a number of conservative groups and some lawmakers have even said.

Marc Ryan: Maybe it’s time to revisit the value of that. That is worth hundreds of billions of dollars a year, theoretically in taxes. Now I’m a defender of it for the most part, because we have an employer based system. If we started, uh, already employers are taking on the lion’s share of increases in costs from year to year, right?

Marc Ryan: And the evidence sort of says that the vast majority of cost increases each year are being taken by the employer. Some is shifting to the employee, but by and large, the employer is doing it. It has economic impacts to the business, but at least part of it is offset by [00:45:00] employer tax deductibility of health care costs.

Marc Ryan: Um, if they somehow limited it, I don’t think they’re ever going to take it away. But if somehow they capped it or limited it. You could see how employers would either push more on to the employee or have to reduce benefits, which creates, uh, you know, affordability issues on the cost sharing side, for example, but the only outcome to limiting it is, you know, Uh, for the most part is it moves over to the employee.

Marc Ryan: There’s just no two ways around it. And it creates coverage issues. People probably become uninsured because of it. Or as you know, Erik, they become underinsured, right? They can’t afford to use whatever they have left. Right. So I’m not a big fan of getting rid of it. I do think that limiting it could be on the table as part of the tax cut [00:46:00] savings.

Marc Ryan: Now, I will tell you that there are a subset of plans that I do think drive costs up. A lot of these conservatives argue that the tax deductibility creates. Ever increasing costs in the system, right? Because there’s no accountability and they want to move it over to the individual. And I do agree with them to some degree.

Marc Ryan: There is a inefficiency of that tax deducted tax deductibility that drives costs. I still support it because it’s. What a majority of Americans essentially are, are, are, are dealing with. That’s the way they get their healthcare. So we’ve got to be careful, but there is a subset of plans, certain employer plans, and I would say some labor welfare plans in the employer world that are extremely expensive.

Marc Ryan: Intended drive utilization and even back during the ACA. There was something known as the Cadillacs tech Cadillac tax [00:47:00] Which was essentially an excise tax and some of these really really expensive Employer and labor welfare plans that was proposed. I actually thought it was a good idea But it was closely crafted and it would have things in those plans back to the norm and not maybe driven costs.

Marc Ryan: That was actually repealed because there was an uproar, uh, the labor unions and some employers sort of got both sides of the house, uh, to say, and Senate to say, Oh no, we got to repeal this. And the Republicans wanted to do it just to say it was a bad idea. And Obamacare was a bad idea overall. Right. Um, Um, so you actually have this proposal out there that could have some legs, maybe some, uh, reduction, uh, in how much and at what level it can be taken.

Marc Ryan: Uh, but we also have evidence that, uh, Lobbying made sure [00:48:00] that that thing quickly went away at the same time.

Erik Sunset: Funny how that

Marc Ryan: it’s, it’s fascinating, right? It’s very fascinating. Yep.

Erik Sunset: Well, it’s a good way to tie in, uh, the The tax cuts that are proposed and will be on the docket here before too long with employer sponsored plans. I want to touch on it one more time too. I’m not sure we did it justice, the CMS final payment rule. I want to be sure to get a link to both your blog and the podcast into these show notes around the Medicare doc fix issue.

Erik Sunset: I just want to add one quick piece before I turn you loose on that one. We’ve got a lot of friends in the ASC space. We’ve got a lot of users, a lot of providers and their staffs, um, in the surgery center space. That was nothing less than a slap in the face to really what should be Medicare’s shining jewel of a, of a venue of care where all three parties, Medicare, the provider and the patient are all aligned.

Erik Sunset: So we’re really looking to see a positive [00:49:00] development there. And I know our friends at ASCA are working hard in Washington to make their voices heard.

Marc Ryan: Yep.

Erik Sunset: With that quick aside, tell us a little bit more about, about what you wrote in your recent podcast appearance there.

Marc Ryan: Yeah. Uh, you’re saying on the Medicare doc fix and things like that. Is that, is that correct? Yeah. So again, my, my, my plea was to solve the problem, decades of ignoring it. Uh, and it basically drove up costs by making most physicians, a majority now go into health care systems. And what happened when that happened?

Marc Ryan: Rates went up because they suddenly could bill, bill in some cases, facility fees, or they were told to practice at higher cost hospital owned settings, whether they were in the community. Or Pat are part of outpatient. So [00:50:00] those physician costs went up. They were practicing at higher cost facilities, and you actually over the year spent more money than if you gave independent physicians a fair rate.

Marc Ryan: And on the issue of, for example, the lower cost of care, whether it’s physician or specialist or ambulatory surgery centers, which are notably much lower cost. Why are we not incenting those lower cost services in the rate structure? Compared to a rather, and I know that there’s some gradation, but it’s a rather monolithic system that rewards, uh, higher costs in general.

Marc Ryan: I would say there’s no question about it. The way we do rate setting, we reward higher cost settings because they’ve had the lobbying dollars to come forward and say, give us more. And the lower cost settings don’t have that. We see it [00:51:00] in ASC, we see it in physicians. Now, some of them are known by health systems now, but there are independent docs that have no voice.

Marc Ryan: And we see it even in home care agencies and things like that, which are lower cost settings that really should be in reimbursed better. And there’s a number of models out there. In terms of reimbursement, that will actually give lower cost providers more dollars than higher cost providers to make sure that they survive and thrive.

Marc Ryan: And we need something like that for sure. Across the board, for sure. Yep.

Erik Sunset: Well, Marc, uh, this has been a fantastic episode. Thank you so much for joining us again.

Marc Ryan: Absolutely. Great to see you again, Erik, and look forward to any future appearances sometime.

Erik Sunset: Oh, you’ve got a standing invite. Before we go, where can folks connect with you?

Marc Ryan: Sure. Um, I am on LinkedIn. Just [00:52:00] search for Marc, M A R C S, Ryan, uh, in the healthcare labyrinth. Uh, is my website, healthcare labrinth.com, and my new company is lilac software.com. A data analytics firm seeking to bring better transparency, improve health count health outcomes, reduce costs, uh, really to benefit all of America and to make everybody healthy.

Erik Sunset: Love it. We’ll of course have links to all of those destinations in the show notes. And on behalf of the entire DocBuddy team, I want to thank you for listening. Be sure you’re subscribed on Apple podcasts, Spotify, and YouTube. So you always get the newest episodes of the show. And until next time I’m your host, Erik.

Erik Sunset: Thanks.