| Today's Managing Health Care Costs Number is 145 |
The New England Journal published "Health Effects of Dramatic Societal Events — Ramifications of the Recent Presidential Election" last week. The editorial worries that the election will cause
- Increased racial hostility
- Hostility in the larger environment
- Hostility toward immigrants
- Worries about reductions in health and social services
The editorialists offer providers hints about how to address their patients' emotional distress, help protect their patients' rights, and create safe spaces. This is all well and good -but I feel that the writers are missing a broad swath of the harms that are likely to come from this presidency. I blogged about this on November 9,and the first 145 days of the Trump administration don't leave me feeling any more optimistic.
Here's the reprint of my conclusions about the profound dangers the Trump presidency poses to health of Americans:
On the macro side, many of the most important determinants of health have nothing to do with how health care is financed.
1. Environmental protection has added years (and quality) to our lives – and Donald Trump wants to dump clean air and water regulations and burn more coal.
2. Global warming is an existential crisis – and Donald Trump is a climate denier –and is surrounded by those who just can’t abide by science.
3. Poverty is a major cause of bad health outcomes –and Hillary Clinton had a plan to eliminate childhood poverty. Goodbye to that!
4. Trade helps prevent war and increases standards of living. Donald Trump doesn’t listen to economists.
5. Immigration is critical to moving the economy ahead in western democracies with low birth rates. But who cares?
6. Diversity leads to more intellectual achievement – hard to know this when you live in an insulated bubble with reverential syncophants.
In health care, the worries include:
1. The exchanges are likely to be unsuccessful even if the Affordable Care Act (ACA)is not immediately repealed. They need to have more (healthy) people join. The least irresponsible Republicans have suggested that those already insured in the exchange could stay but there would be no new enrollees. That means each capped plan will get no new healthy members, and will create a death spiral. Insurance companies know this- so there will be no exchange plans offered!
2. Most of the innovation in payment reform has come from the Centers for Medicare and Medicaid Innovation (CMMI). It’s part of the ACA. If Medicare isn’t paying via alternative methods – I think fee for service will continue to dominate payment. I’d worry we’ll see a real slowdown in provider efforts to move from “volume to value.”
3. Insurance market reforms in the ACA have been critical to help be sure that patients are protected as consumers. This could be endangered. Remember – an employer was successful in restricting HIV care to $5000 per lifetime back in the pre-ACA days. McGann vs. H&B Music, 1988. An unregulated insurance market will not meet our clinical needs. I fear that the emboldened Republican majorities could seek to preempt enlightened state regulations in health insurance.
4. National Institute of Health funds are likely to be cut to help fund massive tax cuts for corporations and the wealthy
5. There will be no further Medicaid expansion in the states that haven’t yet expanded it –and there will be a push to convert Medicaid into state block grants – which are likely to lead to far fewer dollars to address the health care needs for the working poor.
Since November, we've learned more about what Trump really intends to do - and if anything things look worse. The administration all told wants a 50% cut in Medicaid, and has shown nothing but hostility toward any type of regulations, whether to protect the environment or to protect the health of workers.
Providers do need to create safe spaces, for sure. But the dangers that this Administration and its Congressional allies pose to health transcend the increasing sense of hostility.
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