Immediately after the election, health care leaders locally and nationwide were in wait-and-see mode as they tried to predict what might happen to health care policies and agencies under a Donald Trump presidency.

That future is slowly coming into focus now, with Trump announcing this week his picks to run the federal Department of Health and Human Services, and its Center for Medicare and Medicaid Services. HHS operates a $1 trillion annual budget.

The announcements prompted both optimism and wariness in the health care arena. In Washington state, which has successfully expanded Medicaid and built an online insurance exchange, leaders are hoping the new agency directors won’t seek to undo what’s already been accomplished once the administration transitions next year.

Rep. Tom Price, a Republican from Georgia, was tapped to helm HHS, while Seema Verma, CEO of a national health policy consulting company, will head up CMS. Price is an orthopedic surgeon and a staunch critic of the Affordable Care Act in Congress. Verma is known for recently helping expand Medicaid in Indiana under a federal waiver that allowed the state to require Medicaid patients to pay a monthly premium or be locked out of coverage for several months.

Price has made his position on so-called Obamacare “fairly clear,” says Dr. Mike Maples, CEO of Community Health of Central Washington. But, he said, neither Price nor other proponents of “repeal and replace” have yet clarified how they’ll manage to retain and pay for some of the law’s most popular provisions while ditching the ones they don’t like.

“For example, wanting to preserve guaranteed issue — no (denial based on) pre-existing conditions — but also ... no individual mandate ... They’re going to get a lot of pushback from the insurance industry when they try to disassemble things that are inextricably linked,” Maples said.

Medicaid is managed on a state-by-state basis, so Verma’s waiver in Indiana doesn’t necessarily reflect something that could be implemented in Washington.

And both Verma and Price have indicated they want to give states wide latitude in how they manage health care.

“My anticipation is that, to the extent they’re successful at dismantling things at a federal level, it will change the focus for the discussion from D.C. to Olympia,” Maples said.

However, state Medicaid relies heavily on federal funding. The Medicaid expansion, which opened up coverage to all individuals making up to 138 percent of the federal poverty level, or about $34,000 a year for a family of four, was fully funded by the federal government from 2014-2016 and will phase down to 90 percent federal funding by 2020. So decisions at the federal level could have a significant impact on what individual states are able to do with their programs.

In Washington state, about 600,000 people have gained expansion Medicaid coverage through Obamacare.

Jennifer Hanscom, CEO of the Washington State Medical Association, says she knows Price favors allowing states flexibility in addressing how to use funding and regulating their own insurance markets.

“But we didn’t get a clear answer on will funding follow through for the states in order for them to have that flexibility,” she said. “I think that’s the question that remains front and center on our minds.”

The American Medical Association yesterday expressed its support for Trump’s choice of Price, and Hanscom said that appointing a doctor to that position has unique advantages.

“At first glance, for us, having a practicing physician in this position is kind of an ideal situation when it comes to looking at the heaps of regulations that have been put on health care and some of the challenging components that come with health care reform,” she said.

The state Medical Association embraces the ACA’s broad goal of reducing cost and improving quality of care, she said, and Washington state has been “one of the few states” that really understands the shift from fee-for-service care to paying for value.

“But along with that, as regulations are addressed to kind of move us in that direction, there appears to be a lack of appreciation for how that impacts patient care,” Hanscom said. Every additional documentation or billing requirement distracts from time spent actually providing patient services. “Tom Price, he’s a practicing physician; he understands that.”

Access remains everyone’s top concern and priority, said Mary Kay Clunies-Ross, vice president of membership and communications for the Washington State Hospital Association.

Diminished access would be especially harmful in places “where there’ve been big changes in industry and where we haven’t seen new industries arise where people can access employer-based health care,” Clunies-Ross said.

Medicaid is not always a long-term solution; often, she said, “It’s an affordable safety net while they transition to something else.”

No one is saying Obamacare is perfect, though, Clunies-Ross said, prior to the health care law, there were some markets in the country where people had no options for individual coverage if they did not have health insurance through their employer.

Everyone will be closely watching for developments of the Republicans’ replacement plan.

“They have written legislation to repeal Obamacare before,” Clunies-Ross said. “But the legislation you write when you know it’s going to be vetoed is a little different from the legislation you write when you’re going to be taking away insurance from people in your home state, and weakening the providers in your home state, and filling up the emergency rooms in your home state.”

Under the new administration, she said, “What I hope is there’s a sincere and open look at how we can make the health insurance system and health delivery system work better.”

• Molly Rosbach can be reached at 509-577-7728 or