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Obamacare, at least in its original incarnation, is on its way out. The pressing question now is whether “art of the deal” health care will remain.

“The Art of the Deal” is the title of the 1987 best-seller that catapulted real estate developer Donald Trump to national prominence. Although Trump has denounced Obamacare as a “disaster,” and Republicans have voted for its repeal, their attacks have focused mostly on sections of the Affordable Care Act that expanded access to health insurance.

At least as important, however, are the lesser-known parts of the law that have let Medicare use its financial clout to push for better, safer, and less expensive medical care. In Trump’s terminology, it’s been a “terrific deal” for anyone who’s seen a doctor or gone into the hospital, saving a staggering 125,000 lives and $28 billion in just four years, according to the Department of Health and Human Services.


Unfortunately, Trump’s pick as HHS secretary, orthopedic surgeon and Georgia Republican Representative Tom Price, appears at best a lukewarm supporter of this approach. Will Trump protect Americans’ great health care deal? Or might Price be the first cabinet secretary to hear, “You’re fired!”?

The path that Medicare is following, linking provider payments to patient safety and care quality goals, began in the private sector in the late 1980s as the “buy right” strategy developed by health policy activist Walter McClure. It gained a toehold in government under the George W. Bush administration, and flourished when rebranded as “value-based purchasing” under President Obama.


Value-based care initiatives in the ACA include reducing payments for preventable hospitalizations, establishing mandatory reporting of physician quality, and payment arrangements that emphasize care coordination. Those kinds of initiatives have garnered widespread bipartisan support, albeit more vocally outside Washington.

A few years ago, Price and I were keynote speakers at a conference sponsored by a conservative Florida business group. He was applauded for denouncing the ACA; I was applauded for praising it. Price spoke about government-sponsored health insurance, while I laid out the law’s impact on the cost and quality of care.

Business leaders appreciate that HHS, the largest health care purchaser in the world, exerts leverage the private sector alone can only dream about. Or as Trump put it in his book, “Leverage: don’t make deals without it.”

Value-based purchasing saves lives and money. According to the Institute of Medicine, almost one-third of all health care expenditures are unnecessary. In the private sector, which is seeking to move in the same direction as the ACA, that magnitude of savings on health costs can keep employers from moving jobs to cheaper venues overseas.

Most physician organizations now back value-based purchasing, understanding that accountability for quality and safety is the right path to controlling spending — both morally and clinically. (It doesn’t hurt that one alternative to “buy right” is “buy cheap,” meaning cutting physician payments across the board.) Most physician groups supported the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) that made value-based purchasing Medicare’s mainstream payment methodology, and the law passed Congress with overwhelming bipartisan support.

Although some MACRA provisions went into effect on Jan. 1, 2017, implementing them can be slowed and future requirements diluted without strong support from HHS. Price, though he voted for MACRA, also belongs to a far-right physician group that seems to want to shove third-party purchasers, government or private, out of the picture. Without their support, scared and sick patients will be reluctant to challenge their doctors. Making Americans pay more out-of-pocket to become better “consumers,” as Price and other Republicans advocate, doesn’t change that equation.

Trump trumpets his ability to “think big,” but Trumpcare for health insurance doesn’t go far enough. America spent $3.2 trillion on health care in 2015, with $642 billion of that spent by Medicare. Trump needs to tell Price that the far right isn’t right, and then protect the leverage that’s giving every patient, and every doctor trying to do the right thing, a terrific deal.

Michael L. Millenson is president of Health Quality Advisors LLC in Highland Park, Ill., an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine, and author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age.”