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Trumpcare, President Donald Trumps first executive order regarding the Affordable Care Act

Trump Executive Order, ACA No Immediate Impact Promises Simplification and Freer Markets

Michael Arrigo weighs in regarding Affordable Care Act and Trumpcare
Michael Arrigo healthcare data, regulatory, economic and anti-trust expert witness in Federal State and Civil Courts on ACA, HIPAA, Healthcare costs in malpractice and personal injury, False Claims Act cases involving Medicare Advantage and Electronic Health Records. Contact nowAs promised, President Trump signed the first executive order regarding the Affordable Care Act.  Let’s examine what this might mean.  

The Trump Executive Order, ACA sends more of a message rather than effecting any immediate change.  It signals a reduction in administrative burden to the American healthcare economy. TrumpCare may be more like Obamacare in the end with respect to covering Americans with health insurance and more like a capitalist free market when it comes to purchasing insurance.

President Trumps’s Executive Order regarding the Affordable Care Act states that the ACA should be “efficiently implemented” and “minimize unwarranted economic and regulatory burdens,” “flexibility” and “free market place.”  It also suggests that actions should be consistent with existing rule making procedures.  That means new policy proposals should be posted for public comment before being made law. Since most of the ACA was implemented by 2014 and the next significant events are planned under the ACA in 2018 the executive order does not have much immediate impact.

Trump Executive Order, ACA : All Key ACA Provisions Are Still in Force

Trump Executive Order, ACA and key provisions:

  1. Requirement to have insurance for all Americans
  2. Tax or penalty by the IRS for failing to have insurance
  3. No citizen can be denied insurance based on pre-existing medical conditions
  4. Medicaid expansion enabling millions of Americans to continue to have insurance who live at or below 135 percent of the Federal Poverty Level
  5. The most important change appears to be that the Federally Funded Exchanges for health insurance will be re-tooled into more “…a more free and open healthcare market…”

Immediate Impact on Average Americans With Insurance or Seeking Insurance Coverage

Trump Executive Order, ACA and coverage for Americans impact: Minimal.  At this time, no American should be losing coverage or become ineligible for ACA coverage and no American should be paying more for their healthcare costs.

Impact on Employers

The Trump Executive Order, ACA has no immediate impact on employers but we expect penalties and tax burdens to be reduced particularly for smaller businesses.

Future Impact on Health IT Infrastructure

Trump Executive Order, ACA and Health IT: Several market segments are in play:
1. Insurance exchanges – we expect high impact to this market segment – “free and open market” language of Trump’s executive order will require overhaul of FFEs and State funded exchanges.
2. Provider infrastructure – revisions in the definition of value based care will require a re-tooling of MIPS and MACRA

Insurance Exchanges

Trump Executive Order, ACA and Insurance Exchange impact: Significant.  Health Insurance Exchange business models will change and we expect that there will be a significant overhaul of FFE business models and IT infrastructure.  The most important shift, and one which may be tested in the Supreme Court is the switch from State regulated health plans to allowing health plans to sell their plans in other states. This is actually  more compatible with the ACA than anti-ACA.  The ACA was the first major piece of legislation to take some power from the States as to the benefits provided in health plans.  If the Trump administration is successful switching insurance to a business that can be offered over the internet in all 50 states by a company in one location this expansion increases consumer choice.  It will require a significant overhaul of the exchanges to accomplish.

Impact on Health Care Payors / Insurers

Trump Executive Order, ACA and payors: Immediate impact is minimal.   We expect Cadillac tax repeal to help health plan profitability

Impact on Health Care Providers

Trump Executive Order, ACA and health care providers: Short term, minimal.  Long term, we expect Physician and Congressman Tom Price, MD to make it less burdensome to comply with some provisions of the ACA.

Regulations that Are Untouched – the HITECH ACT

Trump Executive Order, ACA and the HITECH Act: The American Recovery and Reinvestment Act (ARRA) HITECH Act and Meaningful Use provisions are untouched.  The U.S. paid out over $34 billion in stimulus funds to adopt electronic health records.  The payments were made to Eligible Providers (EPs or physicians), Eligible Hosptials (EH) and Federally Qualified Health Centers.   Clinical quality measures and other underpinnings of value based care remain.  The HITECH Act is NOT part of Obamacare.

Value Based Care, MIPS and MACRA

Trump Executive Order, ACA and Value Based Care: MACRA is the Medicare Access and CHIP Reauthorization Act. … MACRA combines parts of the Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBM), and the Medicare Electronic Health Record (EHR) incentive program into one single program called the Merit-based Incentive Payment System, or “MIPS”.

It is unclear what Trump and Dr. Price’s actions will be with regard to this key value based care initiative.  However given the complexity of MIPS and MACRA and their intersection with Electronic Health Records we expect changes that will be twofold:

1. Less burden on providers with respect to future provisions of Meaningful Use (such as Stage 3 which has not been adopted and for which no stimulus funds of any significance remain)
2. A repeal or slowing of forced adoption of value based care measures such as MIPS and MACRA.

Accountable Care Organizations

Trump Executive Order, ACA and Accountable Care Organizations: ACOs are overly complex and have significant data latency problems with respect to government reporting. We expect candidate for HHS Secretary Dr. Tom Price’s administration to overhaul and simplify this blend of payor and provider.

Medicare Part C / Medicare Advantage

Trump Executive Order, ACA and Medicare Advantage: We expect Medicare Part C (Medicare Advantage) to be relatively unchanged in the short term.  Longer term we expect an overhaul and simplification of risk adjustment coding and reimbursement strategies.  However, purchase of supplemental insurance (“MedSup” plans) and managed medicare plans will be impacted as Insurance Exchanges switch models.


“…Section 1.  …seek the prompt repeal of the Patient Protection and Affordable Care Act (Public Law 111-148), as amended (the “Act”).  ….imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.

Sec. 2.  … the Secretary of Health and Human Services (Secretary) and the heads of all other executive departments and agencies (agencies) with authorities and responsibilities under the Act shall … waive, defer, grant exemptions from, or delay the implementation of any provision or requirement of the Act that would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.

Sec. 3.  … shall exercise all authority and discretion available to them to provide greater flexibility to States and cooperate with them in implementing healthcare programs.

Sec. 4.  …. encourage the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.

Sec. 5.  … comply with the Administrative Procedure Act and other applicable statutes in considering or promulgating such regulatory revisions.

Sec. 6.  …(b)  This order shall be implemented consistent with applicable law and subject to the availability of appropriations….(c)  This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.



Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.

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