White Coat, Black Art·White Coat Black Art

How a Trump presidency could affect health care in Canada

A Trump administration could have a huge impact on Canada’s appetite for private health care, says @NightshiftMD in his weekly House Doctor column.
U.S. President-elect Donald Trump speaks at his election night rally in Manhattan, New York on Nov. 9, 2016. (Carlo Allegri/Reuters)

Donald Trump's surprise victory as U.S. President likely means big changes on the health file in the U.S. During the campaign, he called Canada's health care system a disaster. That got me wondering just how a Trump administration might affect health care in Canada.

Obviously, the most immediate impact will be felt in the U.S., where, during the campaign, Trump promised to "repeal and replace" the Affordable Care Act - something Republican leaders in Congress have also pledged. That can't happen until the 115th Congress early in 2017. It won't be a complete repeal for three reasons. First, the Republicans hold 51 seats (barring recounts), well short of the 60 needed to prevent the Democrats from filibuster - effectively shutting Senate business down. Second, it's not one bill but many implementations that run more than 1,000 pages. 

Third, and most important, repeal would mean canceling health care for millions of Americans. It would also mean the end of popular provisions of Obamacare that could get lots of pushback from the public. Late last week Trump said he's prepared to keep popular provisions such as providing coverage for pre-existing health conditions and allowing young adults to remain on their parents' plans until age 26. That signals to me he'll keep more of Obamacare than he's letting on.

Assuming a complete repeal of Obamacare is unlikely, there are things Trump can do instead. A Congress controlled by Republicans is likely to phase out a planned expansion of Medicaid coverage.Medicaid is the agency that provides health care to Americans who can't afford it.  U.S. federal taxes were supposed to cover much of the cost of the expansion, but that could change under Trump.  Vox estimates that 15 million Americans have signed up for Medicaid coverage since the Obamacare's expansion began.

Individual states that can't afford to expand Medicaid can apply for waivers in the rules - for instance, forcing people who receive Medicaid to pay premiums and requiring them to work in order to be eligible. Obama tended to reject these kinds of waivers, but Trump might be different. Trump has also vowed to get rid of red tape. The big thing he has proposed is to pay states a block of cash for Medicaid and allow states manage the money as they see fit. 

Prior to the U.S. election, Americans and Canadians saw huge increases in the price of prescription drugs. No one is sure what a Trump administration is likely to do about that. On the one hand, Trump has proposed things that the American people may like but are opposed by drug companies. He is in favour of transparency for drug prices. He wants to import drugs from India and other countries. He wants Medicare (the agency the provides healthcare to U.S. seniors) to negotiate the prices it pays for prescription drugs. He has also promised to do battle with drug company lobbyists. 

So why then are shares in drug companies like Pfizer and Merck up substantially? Perhaps it's because whatever populist ideas Trump has will be less onerous to deal with than the proposal of Hillary Clinton to set up a federal task force to evaluate increases in drug prices. According to a recent survey of investors, 80 percent believe that drug pricing reforms won't happen under a Trump administration. 

The Zika virus could be another hot file during the Trump presidency. In August, Trump was asked how he would handle the Zika outbreak.  He said Congress should approve additional funding to combat the virus. Trump voiced approval of the plan by local officials in Florida to hand spray affected areas to control the virus. 

I am speculating that Trump would also approve of the plan by a county in the Florida Keys to have the British biotech company Oxitec release millions of genetically-modified mosquitoes to combat the virus. The FDA approved a clinical trial in August, but to move forward in a plebiscite.  Last Tuesday, Monroe County voters gave the study its approval. But some communities voted the proposal down. Trump's impact on this situation is unclear.

Canadians are watching events unfold in the U.S., and are wondering how might Trump have an impact on health care here in Canada.

I think the spill-over effect could be enormous. In voting for Trump, Americans voted for a president who railed against the status quo.  If, under his watch, deregulation leads to faster approval of pharmaceutical drugs and cheaper drug prices because they're imported from countries such as India, there will be enormous pressure on Canada to follow the same path.

I think his impact may be even bigger than that. I think we're coming to a time when an articulate politician in Canada could make the case that publicly-funded health care as currently set up has outlived its usefulness.That politician (likely provincial) might state that the provinces should stop being a provider of health care, and let the private sector pick up the slack. Trump is on record approving something called Health Savings Accounts. Basically, this a fund that Americans would contribute to tax-free - with the fund being used to pay for personal health expenditures. 

I could see an advocate of private health care in Canada setting up Health Savings Accounts for all citizens regardless of their ability to pay, and providing a means-tested cash infusion to those below a certain income level. To get widespread buy-in and to ease the transition, there would likely be generous tax credits across most income groups.

I don't agree with any of the foregoing. I believe that a publicly-funded health care system with the government as the provider of care is the most efficient and fairest system going. However, we'd be mistaken to think Canada's health care system is immune to massive upheaval and an appetite for change.

(Note: This is a print and audio version of Dr. Goldman's weekly House Doctor column which airs across Canada on local CBC stations. It does not air on White Coat, Black Art). 


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