Healthcare Madness in 2017

This article was written on July 12, 2017 by Elizabeth Samit, and was first published on July 13, 2017 on LinkedIn:

Healthcare Plan Madness in 2017 – How Trump’s Budget Weakens the Health System

The strength and capacity of any country depends greatly upon the health and abilities of its people. Economic growth, innovation, and global leadership are all reliant upon healthy human beings with intact brain functioning to problem-solve, think creatively, work, and learn. It is not rocket science to understand that a healthy population (and prevention of population-wide disorders) is central to the well-being of a nation. Yet, President Trump and the Republican-led Congress have crafted policies designed to limit health insurance—and healthcare access—to anyone but the most healthy, fit, and rich. The rest of us be damned.

Healthcare Reform Attempts from 1935 to Present – Why So Much Failure?

Franklin Roosevelt, Truman, and Nixon all attempted to reform the US healthcare system, but failed to garner enough support in Congress.1-3 Similarly, the 1,000-page Clinton-proposed Health Security Act (HSA) was defeated in 1994 in Congress.4 While primarily thwarted through intensive insurance industry lobbying of targeted conservative Congress members within both parties, it was also opposed by progressive legislators in the Democratic Party—since this federal health plan created a two-tier health insurance system based on ability to pay.

Historians focused on this legislative healthcare issue have noted the following pattern across many health system reform attempts, and deduced one particular conclusion. These health reform attempts have resulted in failure because rapid congressional approval is necessary. The reason rapid approval is crucial is that individual differences of opinion regarding merely single provisions can quickly lead to unraveling of any agreement—even when a substantial number of legislators favor its passage!5-7

Four Health System Stakeholder Groups – Differing Priorities

Along with political stakeholders, there are four key healthcare delivery system stakeholder groups in the US. Each of these four groups has goals and needs that differ from those of the other three stakeholder groups. These groups are:

  1. Medical (and other clinical) providers and hospitals;
  2. Health insurance companies;
  3. Pharmaceutical and biotech companies;
  4. Medical, nursing, and allied health schools

Organizations representing these stakeholder groups—plus other interested individuals and organizations—have donated generously to Political Actions Committees (PACs) to represent their interests. For example, there are 1,149 reported pharmaceutical/health products lobbies at present in Washington, DC,8 and their expenditures for influence-peddling in 2016 totaled $245,842,399.9

On the other hand, the billionaire Koch brothers (Charles and David H. Koch) are the chief funders of PACs donating to candidates who support conservative legislation related to healthcare system reform. Through their organizational networks—and due to the Supreme Court’s Citizens United ruling in 2010 (that reversed caps to corporate spending on election campaigns)—the Koch brothers’ nonprofit networks are currently planning to spend at least $300 million during the 2018 political cycle towards electing those Republican candidates for Congress who concur with their aim of complete Affordable Care Act (ACA) and Medicaid elimination.10

Special Interest Group Influence – Strategies for Resistance

Proposed by Oberlander in the peer-reviewed journal Health Affairs as a crucial reason that the ACA was actually able to achieve passage in 2010 was that President Obama (plus Reid and Pelosi as Democratic congressional leaders) grasped the necessity of rapidly neutralizing special interest group opposition,11 before such groups could irrevocably fracture the ACA’s fragile support and derail the entire legislative reform process.

Four strategies to resist the influence of special interest groups (based on those described by the Work Group for Community Health and Development of the University of Kansas) are as follows:12

  1. Understand your opponent (e., the beliefs, background, and position) and their strategy.
  2. Turn negatives into positives (g., use opponent positions as opportunity to examine a review of the group’s pressure tactics).
  3. Set the agenda (g., in mass media exposure, public debates, Twitter feeds).
  4. Publicly state the strategy of the opponent [special interest group] for acquiring their influence and power.

Snapshots of The Affordable Care Act (ACA) and American Health Care Act (AHCA)

The 2,300-page13 ACA—termed Obamacare by its opponents—passed in the Senate by only a 219-212 vote. No congressional Republicans supported its passage. Bearing some resemblance to the Clinton plan, it enabled three-tier health insurance plans of gold, silver, and bronze; the bronze plans generally entailed the highest deductibles and co-pays.

Importantly, the ACA expanded Medicaid eligibility so more Americans qualified for its health coverage; provided governmental subsidies to lower-income workers to purchase health insurance; required businesses with 50 or more employees to provide employee health insurance; required insurance plans to cover preventive healthcare, and funded innovative projects to promote increased care quality while reducing cost (among its thousands of provisions).

Immediately following the ACA’s passage, Republican legislators—with the backing of the Koch brothers’ organizational network—began working for its repeal. Mind you, not improvement, but repeal. The ideal of replacement has only been a goal since Donald Trump promised simultaneous repeal and replacement at his election campaign rallies. Among elected Republicans, a major recipient of Koch brothers’ financial support has been Paul Ryan (House Speaker), who successfully promoted House passage of the second AHCA version on May 4, 2017 (following defeat of the first AHCA version in March of 2017).

In contrast to the different House and Senate versions of the ACA under President Obama—which embraced a core goal of universal health insurance coverage, in an effort to increase healthcare access for all US residents—all versions of the American Health Care Act (AHCA) crafted by the Republican-led House (and, afterwards, by the Republican-led Senate) hinder access to comprehensive health insurance and/or health services for a large proportion of our country’s population.

Indeed, the Congressional Budget Office (CBO) reported on June 26, 2017 that 22 million people across the US would lose their health insurance within a decade if the Senate’s first AHCA version passed14 (and, previously, that 23 million people would lose their insurance if the second House AHCA version was affirmed15).

While no CBO assessment of the Senate’s second AHCA version (just unveiled to the public on July 13, 2017) has been made, the loss of health insurance accessibility is likely as high as for the Senate’s first AHCA version—both of which have been intensively promoted by Senate Majority Leader Mitch McConnell.

Public Health and Provider Opposition to the Republican-Crafted AHCA

Many associations representing huge numbers of public health professionals, physicians, and hospitals oppose passage of the AHCA, such as:

  • American Medical Association – around 218,000 members.
  • American Public Health Association – around 25,000 members.
  • American Hospital Association – around 43,000 individual members, along with representing nearly all hospitals and healthcare systems/networks.
  • American Academy of Pediatrics – around 64,000 members.
  • American Congress of Obstetricians and Gynecologists – around 58,000 members.
  • National Physicians Alliance – around 20,000 members.

AHCA Proposals – Divergent Perspectives Among Senate Republicans

Unlike previous time periods of congressional health system debates, all House and Senate Democrats have been united in their opposition to the AHCA. Senate Republicans have not yet been able to garner the necessary 50 Republican affirmative votes as of July 12, 2017 for AHCA passage. Fortunately, some moderate Republicans appear reluctant to support this worrisome bill (that reduces aid to the poor, while providing more tax subsidies for the wealthiest people in the nation)!

AHCA Enactment – Who is Penalized and Who Benefits?

While not all Americans will be catastrophically affected by passage of the AHCA, some segments of the US population —especially people with incomes below 100 percent of the Federal Poverty Level—are especially targeted. These especially-targeted subpopulations are pregnant women, older citizens between 55-65 years of age, disabled individuals, people suffering from mental health and/or substance use disorders, and nursing home residents. Due to their dependency upon  parents/legal guardians, children in low-income families are also unfortunate targets.

Notably, President Trump’s proposed 2018 budget, entitled A New Foundation for American Greatness16—and considered in conjunction with the expressed cost-cutting policies of his cabinet members (e.g.DHHS Secretary Tom Price, CMS Administrator Seema Verma, and HUD Secretary Ben Carson )—present the Trump Administration’s intent to cut spending on nearly all support services that these same targeted subpopulations depend upon for their survival.17

In reality, the CBO’s three estimates of the vast numbers of Americans who will lose health coverage under the various AHCA versions do not fully convey the existential threat that AHCA enactment poses to these targeted subpopulations. Since dead individuals will no longer have a need for healthcare or other services, the Trump budget-cuts can effect a near-term reduction in health-oriented spending—but in a cruel and despotic fashion historically-associated with tyrannies and dictatorships, rather than a society espousing democratic values.

How Pregnant Women Suffer Under Trump and Republican Congress Policies

Limiting contraceptives—never mind limiting abortion access—promotes a higher likelihood of sexually-active women becoming impregnated. Census data and other sources show that women in the US bore more children prior to the legalization of contraceptives. Likewise, more women and newborns died in the past during childbirth or following delivery than in recent history. From just 1950-2010, the US newborn death rate (under 28 days of age) decreased as follows:18

  • 1950 – 26.5 (per 1,000 live births)
  • 1960 – 26
  • 1970 – 20
  • 1980 – 12.6
  • 1990 – 9.2
  • 2000 – 6.9
  • 2010 – 6.1

One reason for the very high rate of newborn deaths prior to 1950 was the far lower receipt of adequate prenatal care by pregnant women. A second reason was the lower level of understanding regarding the role of specific nutrients and health factors upon fetal development and following delivery of the baby. Thirdly, a much lower level of obstetrical knowledge and/or intervention options existed, which also resulted in higher overall mortality among newborns.

Mandating Essential Health Benefits (EHBs) in Health Plans – Why It Matters

Publicly-revealed on June 22, 2017, one modification by the Senate to the Republican-led House of Representatives’ AHCA was a roll-back of the ACA’s Essential Health Benefit (EHB) insurer requirement—thereby allowing insurers to eliminate entire categories of coverage. There were 10 EHB categories mandated by ACA enactment as follows:19

  • Ambulatory patient services;
  • Emergency Services;
  • Hospitalization;
  • Maternity and newborn care;
  • Mental health and substance use disorder services (including behavioral health treatment);
  • Prescription drugs;
  • Rehabilitative/habilitative services and devices;
  • Laboratory services;
  • Preventive and wellness services/chronic disease management;
  • Pediatric services (including oral and vision care)

Based on diverse insurance industry research studies, insurers have concluded that their payments for beneficiary mental health services, substance abuse treatment, prescription drugs, hospital emergency room services, and maternal/postpartum care drain their net profits. Therefore, eliminating the ACA’s EHB requirements paves the way for insurers to lower their expenditures by limiting or excluding coverage for these services. Again, it is not rocket science to understand that insurance companies—if legally permitted—will sell health plans to consumers that do not contain those services particularly draining to insurer net worth.

In tandem with a major funding-cut to Medicaid and the de-funding of all Planned Parenthood services for at least one year—under the AHCA—pregnant women may decide for financial reasons not to obtain prenatal care and/or follow-up after childbirth. In only a few years, the result will likely be needless suffering for millions of pregnant women and their offspring. No doubt our country will eventually pay an exorbitant cost in lost productivity (and high poverty in various subsectors) due to the increase in individuals born with permanent disabilities.

How The Mentally Ill Suffer Under Trump and Republican Congress Policies

Individuals with mental illnesses are generally able to live a full life, earn a living, and care for family members if receiving treatment—even those with such major illnesses as bipolar disorder. Psychological disorders often become apparent in adolescence, and treatment can prevent these teenagers from behaviors resulting in school difficulties and/or juvenile justice system entanglements.

Living in poverty is well-linked to the development or worsening of mental health disorders. According to the website of the Substance Abuse and Mental Health Services Administration (SAMHSA), around 9.8 million adults in the US have been diagnosed with a serious mental illness, and 2.5 million live below the Federal Poverty Level20—placing them at high risk of homelessness. Indeed, around 33 percent of the homeless have serious mental illnesses.21

Therapy and/or medication management can enable most mentally ill persons to avoid the need for inpatient hospitalization. On the other hand, a lack of mental health insurance coverage will most likely result in a lack of access (or limited access) to mental health services—as well as a draining of savings by family members to pay for the non-covered mental health care, and/or increased suicide/homicide attempts resulting in costly inpatient stays.

Substance abuse (e.g., opioid abuse) is often found in individuals living with mental illness, since alcohol and/or narcotics are often used as a means of self-medication by those not receiving treatment for their underlying psychiatric disorders. Anxiety disorders and PTSD are are frequently linked to individuals dependent upon narcotics, and a high incidence of PTSD in Afghanistan and Iraq-war veterans is well-documented. At least 20 percent of the 2.7 million Afghanistan and Iraq veterans had PTSD/depression as of 2014 (per a study conducted by the Rand Corporation).22

Since many veterans do not live in proximity to a Veterans Affairs Administration (VA) mental health center, the capacity of these veterans to seek treatment at private mental health centers (through privately-purchased insurance) is vital for these Vets and their families. Essentially, the elimination of mental health coverage by insurers can have a dire effect on Americans suffering from a mental illness—including US military veterans—plus have adverse consequences for our nation as a whole.

 How US “Minority” Populations Suffer Under Trump and Republican Congress Policies

African-Americans and Latinos are far more likely to hold low-wage jobs than their white counterparts, and are likewise more likely to suffer from chronic conditions due to injuries sustained in the workplace. Around 24 percent of African-Americans and 21 percent of Latinos live in poverty, as compared to 9 percent of Caucasians (per the Kaiser Family Foundation).23 Medicaid cuts will disproportionately affect African-Americans and Latinos. In addition, Trump’s housing, education, and industrial pollutant policies disproportionately impact African-American and Latino communities.

Disabled youth and adults are also a “minority” subpopulation, and the quality of theilives will be negatively impacted by the combined effects of Trump Administration policies. Considered at epidemic levels in the US, the increasing problem of childhood Type 2 diabetes necessitates adequate and long-term treatment to prevent its known complications in adulthood (e.g., atherosclerosis, blindness, heart disease, stroke, and peripheral neuropathy in arms and legs).

Since obesity is a major factor in the development of Type 2 diabetes until around age 60, preventative health services can be a key factor in addressing this national epidemic. Likewise, disabled adults (and those with chronic disorders, such as rheumatoid arthritis) are more apt to become impoverished due to their out-of-pocket medical costs—as well as difficulties maintaining full-time jobs. Ditto for people who have hearing losses, vision impairments, and untreated joint (e.g., hip or knee) problems!

According to a US Department of Labor webpage, the unemployment rate in 2016 for adults with a disability was 10.5 percent, as compared to 4.6 percent for those without a diagnosed disability.24

Based on their domestic cost-cutting goals, the unspoken manifesto of the Trump Administration and Republican congressional members seems to be “kick them when they are down.” An agenda of curbing both insurance coverage and “safety net” programs just erects more daily living obstacles for disabled individuals and their families.

How Seniors and their Caregivers Suffer Under Trump and Republican Congress Policies

Assisted living costs exceed the financial resources of most Americans, so seniors typically remain in their own homes or apartments as long as possible. Obviously, most people want to remain living at home rather than in some type of institution. For elders who just need some home-based assistance in order to remain independent (rather than institutionalized), the Trump-proposed budget reductions to community block grants (that fund community-based senior support services) do not bode well for older Americans’ quality of life—and, especially, in conjunction with federal cuts to Medicaid and the conservative Republican goal of privatizing Medicare.

Moreover, when living independently is no longer possible (as eventually occurs with Alzheimer’s disease), an elderly person may truly require nursing home care. However, without sufficient Medicaid reimbursement, many nursing homes will have to file for bankruptcy and/or permanently close their doors (as described in an online article focused on recent nursing home closures in just one state).25

In the next decade, adult children may find that they are even more burdened with caregiving their elderly family members (and/or housing them in a tight space) due to fewer societal options. It is sobering to consider that around one in ten seniors (aged 60 and older) in the US has experienced elder abuse (per the National Council on Aging).26

How Public Health Suffers Under Trump and Republican Congress Policies

Antibiotic-resistant bacterial infections are increasing, as well as viruses transmitted by birds, mammals (especially pigs), and mosquitos. The Zika epidemic in Brazil—resulting in numerous cases of otherwise rare megalocephaly in newborns—should stand as a stark warning of the consequences of a weak public health infrastructure.

The occurrence of a pandemic in the twenty-first century is only a matter of time (per a report by the National Academy of Medicine).27 Meanwhile, the Centers for Disease Control (CDC) is entirely dependent upon National Institutes of Health (NIH) funding. Thus, Trump’s proposed budget cuts to the NIH may not only put the “brakes” on grant-funded public health research, but also adversely impact the CDC’s disease prevention/treatment funding.

In summary, Trump’s proposed budget cuts will probably weaken the CDC’s ability to respond to an upcoming public health crisis. Yet, failure to quickly stop a flu epidemic will definitely cost the nation billions if this occurs (and far more than federal cost-cutting could potentially save for financing President Trump’s domestic priorities, such as constructing a border wall with Mexico).

De-Funded Research on Special Populations – Trump Administration Morality Play

Research into healthcare issues of subpopulations (e.g., LGBT people) is particularly targeted in President Trumps proposed budget for de-funding. Trump’s budget also proposes funding reductions or elimination of most HIV/AIDS programs/services, including:28

Roll-Backs of Medication Safety Regulations

Pharmaceutical safety regulations of the Food and Drug Administration (FDA) have already been reversed due to Trump Administration policies. One consequence of this deregulation is that ineffective supplements and unfounded remedies can continue to flood the marketplace with no federal oversight.

Lab analyses have shown that many of these nutritional/herbal supplements do not contain the ingredients claimed on their manufacturer labels.29 Most individuals purchase these substances in an effort to prevent illnesses or self-treat diagnosed disorders (e.g., cancer). In the US, $30 billion annually is spent “out-of-pocket” on these supplements by around 59 million Americans, per a study conducted by the National Center for Complementary and Integrative Health.30

Cancer Survivors and Trump Administration Healthcare Policies

Cancer survivors (especially those who have survived breast, colon, and bone cancers) have good reason to worry if the AHCA is passed. Should these cancer survivors experience a new cancerous tumor—but not have insurance coverage for pre-existing conditions—their out-of-pocket costs may preclude receiving any future cancer treatment, and result in needless premature death.

In both newly-diagnosed cancer patients (and those who have already survived cancer), a lack of comprehensive insurance to pay medical bills may result in a financially-based decision by the individual to postpone needed treatment—despite recognition that early intervention is well known to be more apt to effect a cure or foster remission. Prior to passage of the ACA, 25 percent of all cancer patients chose not to fill a medication prescription due to its cost, and 23 percent were in debt by 20 months following their cancer diagnosis.31 Therefore, the Trump proposed budget and AHCA send an explicit message to cancer patients/survivors that their lives do not matter.

Special Interest Lobbies and the Supreme Court

Special interest lobbies (i.e., those representing the National Rifle Association [NRA]) have ensured that both Democrats and Republicans in Congress are unwilling to pass legislation opposed by these lobbies. Meanwhile, too many super-PACS—supportive of the Trump and Republican Party agenda—are exerting a huge amount of congressional pressure (through their campaign contribution clout) in order to eliminate federal “safety net” programs and governmental involvement in the US healthcare delivery system.

Supreme Court power should not be underestimated. The decisions of Justice Neil Gorsuch—Trump’s first Supreme Court appointee (whose nomination was approved by Congress in April of 2017)—have already tilted our Supreme Court in a more right-wing direction, due to his arch-conservative viewpoint. Moreover, his prior judicial record suggests that future Supreme Court decisions will be more likely to affirm a “states rights” position and socially-conservative values than before he joined the Court. (This is because Gorsuch’s perspective is considered “to the right” of conservative Justice Antonin Scalia—his deceased predecessor.)

Since four currently-serving Justices are over 75 years old, another Trump appointment to the Supreme Court is probable. The currently-configured Supreme Court already has a 5-4 rightward “tilt”; even one more conservative Justice will shift the Supreme Court further rightward for decades.

Conclusions and Final Thoughts

Democrats in Congress simply do not have mitigating power against the array of very conservative political forces pushing the US towards elitism and away from a civil society. Therefore, moderate Republicans need to stand up to pressure and threats from arch-conservative Republican legislators and lobbies.

Moreover, moderate Republicans need to align with Democrats in Congress to resist the pervasive and persistent efforts of conservatives to deregulate and destabilize the US healthcare delivery system; they need to work across the partisan aisle to fix our health delivery system into one that fosters the nation’s health. These moderate Republicans need to resist the pressure from conservatives to acquiesce solely for the sake of Party unity.

The concept of “America Strong” is critically-tied to a US population that is healthy, and that enables future generations in the US to have lives that are even healthier and more satisfying. States simply do not have the capacity to shoulder the federal government’s role in protecting the health (and access to healthcare) of the entire US population.

Our physical and psychological health—and the nation’s future well-being and even prosperity—are indeed threatened by Trump Administration policies that promote tax cuts to the wealthiest citizens, while increasing the financial strain on our nation’s hospitals, healthcare providers, allied health staff, charities, and the population as a whole.

References:

  1. Henry J. Kaiser Family Foundation. Timeline: History of Health Reform in the U.S. Webpage: https://kaiserfamilyfoundation.files.wordpress.com/2011/03/5-02-13-history-of-health-reform.pdf
  2. Boston Globe. (June 28, 2012). History of attempts to reform US health insurance coverage. Webpage: https://www.bostonglobe.com/2012/06/28/healthcare/QoZG14x1iMlwREEDkvJgTJ/story.html
  3. Oberlander J. (2007). Perspective – Learning from Failure in Health Care Reform. New England Journal of Medicine 357: 1677-1679. Webpage: http://www.nejm.org/doi/full/10.1056/NEJMp078201#t=article
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  13. Harper J. (March 8, 2017). One is Actually Readable: Obamacare 2,300 pages, Trumpcare 46 pages. The Washington Times Webpage: http://www.washingtontimes.com/news/2017/mar/8/inside-the-beltway-obamacare-2300-pages-trumpcare-/
  14. Jost T. (June 26, 2017). CBO Projects That 22 Million Would Lose Coverage Under Senate Bill. Health Affairs Blog Webpage: http://healthaffairs.org/blog/2017/06/26/cbo-projects-that-22-million-would-lose-coverage-under-senate-bill/
  15. Pear R. (May 24, 2017). G.O.P. Health Bill Would Leave 23 Million More Uninsured in a Decade, C.B.O. Says. New York Times Webpage: https://www.nytimes.com/2017/05/24/us/politics/cbo-congressional-budget-office-health-care.html
  16. US Office of Management and Budget. Budget of the US Government: A New Foundation for American Greatness. Fiscal Year 2018. Webpage: https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/budget.pdf
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  20. Substance Abuse and Mental Health Services Administration (SAMHSA). (November 15, 2016). Serious Mental Illness Among Adults Below the Poverty Line. The CBHSQ Report Webpage: https://www.samhsa.gov/data/sites/default/files/report_2720/Spotlight-2720.html
  21. TreatmentAdvocacyCenter.org. How Many People with Serious Mental Illness Are Homeless? Webpage: http://www.treatmentadvocacycenter.org/fixing-the-system/features-and-news/2596-how-many-people-with-serious-mental-illness-are-homeless
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  28. Fenway Health. (May 24, 2017). Trump’s Proposed Budget Would Sharply Cut HIV And Chronic Disease Prevention, Eliminate HIV Care Programs. Fenway Focus Webpage: http://fenwayfocus.org/2017/05/trumps-proposed-budget-would-sharply-cut-hiv-and-chronic-disease-prevention-eliminate-hiv-care-programs/
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  30. National Institutes of Health, National Center for Complementary and Integrative Health. Americans Spend $30 Billion a Year Out-of-Pocket on Complementary Health Approaches. Webpage: https://nccih.nih.gov/research/results/spotlight/americans-spend-billions
  31. Szabo L. (March 15, 2017). Treatments – As Drug Costs Soar, People Delay Or Skip Cancer Treatments. Health News from NPR Webpage: http://www.npr.org/sections/health-shots/2017/03/15/520110742/as-drug-costs-soar-people-delay-or-skip-cancer-treatments
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