The power of purple in a divided electorate

Happy New Year to you all! As we head into 2025, I'd like to introduce a new take on one of my old themes: Keep calm and remember the power of purple. I recognize that this may be very difficult in the wake of a contentious election, but mindset is key to the essential work of engaging meaningfully in the policymaking process.

Many of us were surprised by the election results, but interestingly, the National Journal, a research company dedicated to government affairs and advocacy efforts, ranked a Republican trifecta as number three on its list of likely outcomes. President-elect Donald Trump won 312 electoral votes over Vice President Kamala Harris' 226. In the popular vote, President-elect Trump received over 77 million votes compared with nearly 75 million votes for Vice President Harris. As was generally expected, the GOP flipped the Senate and now has 53 seats to the Democrats' 47. The House of Representatives was expected to flip to the Democrats, but the Republicans managed to narrowly maintain control.

Of President-elect Trump's cabinet picks, two related to health care and public health have been controversial: Robert F. Kennedy Jr. for Secretary of Health and Human Services and Mehmet Oz, MD, for CMS Administrator. ACP does not comment directly on nominees for federal offices, unless they are ACP members in good standing at the time of nomination. In the recent past, we put forward support letters for Robert M. Califf, MD, to serve as FDA commissioner and Mandy K. Cohen, MD, MPH, to serve as CDC director. The College is a bipartisan organization and recognizes that our members have varying political views, just like the rest of the country.

However, there is a difference between one's political views and the facts based on the best available scientific evidence. Therefore, ACP felt compelled to speak out about the importance of using the best possible evidence to guide medical care and health policy, as well as the need to combat the spread of mis- and disinformation. On Nov. 15, ACP issued a statement focused on vaccines, which are vital to our ability to prevent diseases that threaten public health, and the crucial need for a strong public health system to promote health in society, ensuring that the patients our members serve can live healthy lives. The College will continue to monitor the appointment and confirmation processes as they progress and stand ready to speak up further about the importance of leaders having a solid grounding in the best available evidence to help guide their decision making.

I have heard additional concerns from our members on behalf of themselves and/or their patients, particularly regarding health insurance access. Patients currently covered by plans purchased through the Affordable Care Act (ACA) marketplaces, both with and without tax credit assistance, are fearful that they will lose their coverage should the ACA, or key components of it, be overturned. While there is some validity to this fear and the GOP may indeed prioritize overturning the ACA in the coming Congress, I think that would be challenging to accomplish. The primary reason for my skepticism is that the ACA, and particularly some of its provisions, such as coverage for dependents up to the age of 26 on a parent's plan and coverage of those with pre-existing conditions, are extremely popular. More than 60% of adults in America have a positive view of the ACA (or Obamacare), according to data published in February 2024 by the Kaiser Family Foundation (KFF).

Another concern of many patients and their physicians is Medicaid coverage. It is quite possible that the new administration and Congress could enact foundational changes to the Medicaid program, such as converting it into block grants to states, capping federal funding on a per capita basis, reducing federal matching funds for ACA Medicaid expansion enrollees, and supporting work requirements. Again, I think there is validity to these fears, but the program is quite popular overall. In fact, a recent analysis by KFF found that three-fourths of the public view the Medicaid program favorably, with majorities across both political parties.

One thing is certainly clear in the lead-up to the certification of the election results and the inauguration: Every day something new is being said or taking place that is contentious on some level. The incoming administration and Congress have a great deal of interest in making changes, something that is true with any government changeover. However, the volume of statements and activities makes it hard to keep up and can be confusing even for those of us paying close attention. With that said, it is critically important to remember that not everything can happen at once! We must keep calm and find the ways we can make a difference, ideally in a proactive manner, to benefit internal medicine physicians and their patients.

We have some opportunities, particularly related to several key issues. The first is Medicare physician payment reform. Many pieces of legislation related to Physician Fee Schedule payment cuts have come from Republicans in Congress. For instance, the latest bill we are hoping to move forward is the Medicare Patient Access and Practice Stabilization Act, introduced by Rep. Greg Murphy, MD, of North Carolina. This bipartisan bill would erase the finalized pay cut of 2.8% for 2025 and would also add an inflationary update of approximately half the Medicare Economic Index (or 1.93%), resulting in an overall increase over the expected conversion factor of 4.73%. If this bill is not passed prior to the end of the 118th Congress, ACP will push for reintroduction immediately in 2025.

Another opportunity open to us under the new administration and the 119th Congress includes continued work to address administrative burdens facing our members. This was a priority under the previous Trump administration—which coined the phrase “Patients Over Paperwork,” remarkably similar to ACP's previously introduced (and still ongoing) “Patients Before Paperwork” initiative—and it will likely be a priority again.

We are also hopeful that even though Republicans overall were not supportive of the Inflation Reduction Act, they will want to continue efforts to reduce the costs of prescription drugs. The first 10 Medicare negotiated drug prices are already poised to save the federal government $6 billion in 2026 and to save beneficiaries $1.5 billion. Those results are hard to argue with for an administration poised to look for savings everywhere it can find them. Additionally, pharmacy benefit manager (PBM) reform has been on the radar of both parties in Congress for several years now, so this is yet another opportunity for ACP to achieve some wins, hopefully resulting in greater transparency and less waste.

No matter what happens over the next two to four years, ACP's policies remain in place. We will stand up for those policies and our principles and work tirelessly to achieve our goals. For members who are feeling fearful or helpless, as well as those who are pleased with the election results, now is the time to engage with ACP's advocacy efforts. Your involvement is critical to influencing both Congress and the administration to make policy that is grounded in the best available evidence, for the good of all our members and your patients.

The power of purple remains. I believe that we can find common ground if we actively seek it out and provide the education necessary to do so. Together, we must pursue our goals with compassion, grounded in our values and united by our commitment to excellence and professionalism in medicine. I urge you to get involved in advocacy. We need you more than ever this year!