Gaming out health policy under Trump and the GOP

Driving the news: A Republican administration and Congress would likely use reconciliation to extend the 2017 Trump tax cuts, but there is also discussion of bundling health care elements into one big package.

• House Majority Leader Steve Scalise has said that if Republicans are in control on all fronts, they want to take the Democratic "whole of government" approach to reconciliation, the way it was used in the Inflation Reduction Act, per one GOP lobbyist.
• Possible options include Medicare site neutral payments for hospitals, a crackdown on Medicare Advantage overpayments to insurers, or Medicaid cuts.
• All of those policies may be attractive because they could generate savings and help to offset the cost of a large legislative package.

It promises to be an exceedingly busy year regardless of the election outcome, with enhanced ACA subsidies due to expire along with the tax cuts and another showdown over raising or suspending the debt ceiling.

• There's also the long shot prospect of a renewed push to repeal and replace the Affordable Care Act.

What they're saying: "If Republicans run the tables in November, the margin of victory will be so narrow that repeal and replace is probably unrealistic, but I do think the IRA enhanced ACA credits are as good as dead," said Dean Rosen, partner at Mehlman Consulting. "That level of scenario planning is definitely going on."

• GOP sources say there is more planning in Republican circles than there was in 2016, when the transition was more chaotic.
• "There's a big premium on being prepared," said one GOP lobbyist. "I think K Street follows in the lead of Congress, and it's like, we have to be ready for this outcome if it happens. The new reality is that you've got to push and you've got to really do reconciliation quickly."

Reality check: It's never certain what Trump will decide to focus on.

• Paragon Health Institute, America First Policy Institute and the Heritage Foundation are among the Trump-aligned groups working on policy options.
• Brian Blase, a former Trump health official who is president of Paragon, said some in the health care industry have started to reach out to him to discuss what could happen next year.
• "You don't want to get ahead of your skis and give industry a chance to start figuring out what they're going to do and what actions are going to reduce government subsidies to industry," he added.

Between the lines: There are also plenty of executive actions a second Trump administration could take, including ones to address Trump's focus on a "most-favored nation" policy to lower drug prices.

• Trump talked about that a lot in his first term but a last-minute push to finalize it was blocked in court. He could try to revisit it, though it's sure to be challenged again.
• Lobbyists that represent pharmaceutical companies have said they're already trying to figure out how to more effectively communicate that most-favored nation is a bad policy in their view, and also counter other more populist Trump ideas.

Lobbyists are generally skeptical that full repeal of the IRA drug pricing provisions is feasible, but said Republicans could try to make some industry-friendly changes.

• Joel White, a GOP health care strategist and CEO of Horizon Government Affairs, said Republicans' desire to address recurring physician payment cuts is "a huge driver ... they want to fix that problem, that costs a lot of money."
• Site neutral payments and Medicare Advantage overpayments are two areas that could provide savings in reconciliation and help pay for a more permanent "doc fix," he said.

Inside the room: Several GOP lobbyists told Axios that client requests to help game out 2025 have intensified in the last six weeks, with more requests to connect to and build relationships with Trump world.

• The sessions are starting out with a review of how reconciliation works, said one lobbyist. Then, there's gaming out how particular health policies could affect various industries.
• There also are plenty of questions about who may be tapped for a Trump administration, though K Street feels much more prepared on that front than in 2016.
• "Our clients are generally looking for who are Trump's top allies on Capitol Hill? Who are Trump's allies when it comes to issue-specific areas? Who would the administration listen to? Who are Trump's allies at the think tanks and the policy organizations? So there's a big push to do outreach. It's a multi-pronged approach," said another Republican lobbyist.

The bottom line: Republican lobbyists and strategists were adamant that the health care push under a GOP trifecta would likely not center around another repeal and replace ACA effort (though Trump himself could always change that).

• Instead they expect a focus on targeting individual health industries' practices, with the looming possibility of a Medicaid overhaul that could include work requirements or block grants that have long been GOP priorities.