We Spend Billions of Dollars Advancing Medicine But Deny Care to Millions of People
Looking at the balance of forces improving healthcare against those making it harder to get, it’s clear needed care will reach fewer people in the next three to five years. And, most of the new roadblocks to getting care come from Trump, his Department of Health and Human Services and congressional Republicans.
Already, obstacles to care are growing faster than opportunities. There’s no real chance to turn these trends around sooner than three years at the earliest.
There’s a huge tug of war in U.S. healthcare between forces pulling it up and pulling it down. On the “up” side, there are many efforts and investments to expand and improve care. Drug companies and medical device makers, backed by researchers in universities, the National Institutes of Health and elsewhere, make advances every day. Some strides are revolutionary, like immunotherapy for many cancers. Hospitals, doctors, insurance companies and government agencies run thousands of programs for health education, disease management, preventive care, smoking cessation, counseling and much more.
If you have good insurance, you can tap into this vast array of improved care according to your needs. Without good insurance, it’s almost impossible to take advantage.
So, what’s pulling healthcare down?
First, millions of people are about to lose insurance. The tax law passed last December, Trump’s key congressional victory, effectively repealed Obamacare’s mandate that everyone have health insurance. This will lead about 6 million people to drop insurance next year, according to the Urban Institute. By 2021, the Congressional Budget Office predicts, the repeal will lead 12 million people to go uncovered.
Second, another part of Obamacare, Medicaid expansion, is being whittled down by giving states more authority to push people off the rolls even if their incomes are low enough to qualify. The Obama Administration took small steps in this direction, such as allowing low monthly premiums, while the Trump people are taking giant leaps. Under federal rules, many states are adding requirements—none of which are in ordinary health insurance—such as mandates to work or be in school; mandates to stop smoking, submit to drug tests or follow personal-health plans; and time limits on coverage.
Already, more than 100,000 people have been lopped off rolls in various states for failure to pay premiums, which are usually $10 to $15 per month. About 1 million are behind on payments and may be dropped in the next year or so.
It’s too early to tell how many more will be cut from Medicaid. Much depends on the 2018 elections, how the economy is doing and how aggressive GOP states are in pursuing these strategies.
Third, still more millions will get health insurance, but only loophole-ridden, “skinny” policies that don’t cover the care they need. Rules issued April 9 by Trump’s Health department allow policies that have weak drug coverage and sharply limit doctor visits. In the 39 states that use the federal online healthcare exchange, insurers will be able to offer fewer benefits than Obamacare had required. Another new set of rules gives insurers more leeway to deny coverage to people with pre-existing conditions, cancel when patients have major illnesses such as strokes or cancer and offer no mental health coverage.
These insurance policies come with high deductibles and copays, making even routine care like checkups and visits for colds and minor injuries expensive. Many such plans pay only about 50 cents for health care, out of every dollar in premiums that patients pay, compared with the minimum standard in Obamacare of 80 cents. These “skinny” plans are ripoffs, plain and simple.
Republicans defending these rule changes, such as House Speaker Paul Ryan (R-Wis.), say they let people buy the insurance they can afford. That is often true; many of the plans are cheaper than Obamacare plans because they don’t cover much. But if you’re seriously ill or injured—or give birth prematurely—you’re out of luck; and if you want routine care, you’re out a lot of money. Many people end up paying for these plans, but never use them because of high out-of-pocket costs.
Also constricting access to good insurance are massive price hikes on plans that meet Obamacare standards. Despite the higher prices, insurers have lost money and quit the market. Obamacare is far from perfect; perhaps its worst feature is concentrating cost spikes in the online exchange market. So, people who can’t get employer or government plans also can’t get good coverage at affordable prices, unless their incomes are low enough to qualify for tax credits to help pay premiums and for discounts on copays and deductibles. That’s why millions coming off Medicaid or exchange plans will end up with “skinny” ripoff plans.
Instead of trying to make the exchange market work and help people get the coverage and care they need, Trump the Health department and congressional Republicans have done everything they could to weaken the exchange market and raise consumer costs.
- Last fall, Trump stopped reimbursing insurers for exchange-plan discounts, even though Obamacare requires insurers to give the discounts. His action raised prices for all Obamacare policies. For instance, Maryland approved roughly 15% increases for 2018 in response to Trump’s move and those increases will be locked in Maryland’s 2019 rates. And his action may actually cost the government more in added tax credits than it saves in discount reimbursements.
- Then last December in the new tax law, Trump and the GOP again raised Obamacare plan costs by repealing the mandate to have health insurance. That’s because the repeal leads mainly young, healthy people to drop insurance and then leads to higher premiums for everyone remaining, probably a 5-10% increase for 2019 and more in later years. Tom Price, Trump’s former Health secretary—until he was forced to resign for travel expense abuse—made that point on May 1. (Price tried to take the statement back the next day. And it’s the opposite of what he said last year as secretary.) You can add the effects of the insurance mandate repeal and discount reimbursement cutoff, coupled with the underlying problems of the Obamacare exchange plans and you come out with increases of about 30%—the average proposed May 7 for Maryland’s 2019 rates. Sicker and older patients will pay the higher prices or just “go without” because they can’t afford them.
- Directed by a Trump executive order, the Health department has shortened the time to sign up for exchange plans and nearly eliminated funds to advertise the signup and pay for customer service reps to help people compare and enroll in plans.
It’s hard to total up how many people will lose insurance altogether—or lose good coverage that actually meets their health needs—from these Trump/GOP initiatives because they’re in their early stages with market impacts still developing. Despite the problems with estimates, at this stage, it seems very likely that at least 20-25 million Americans who now have good health coverage will lose it in the next three to five years due to:
- Insurance mandate repeal
- Coming cutbacks in Medicaid
- Expansion of “skinny” plans
- Much higher costs of good plans bought on the exchanges
From one important perspective, healthcare in the United States is already getting worse: the overall life expectancy of Americans actually fell slightly in 2015-16, reflecting the opioid crisis. This 2-year decline was the first in 55 years. Overdose deaths—which exceed those from gun violence and auto accidents combined—are concentrated among young and middle-aged adults who lack good health insurance. Life expectancy among older people—who have good insurance, Medicare—is still rising.
Important steps are being taken to control and reduce overdose deaths. Walmart’s action May 7 to constrict opioid prescriptions in its pharmacies will help, especially if followed by its major competitors. State and local governments have launched initiatives against some doctors and drug makers, distributors and retailers.
But outside the addiction area, why is there so little chance to change direction on insurance coverage losses sooner than the next three years? Two reasons, one simple, and one more complex.
First, Trump has more than 2.5 years remaining in his term.
Second, the initiatives removing people from insurance rolls will take years to reach their full effects in the marketplace and with patients and providers. They will take more years to reverse. And, Trump’s people are working hard to advance these policies, not reverse them.
The biggest of these initiatives is repealing the insurance mandate. Republicans will block any attempts to bring back the mandate or unwind the tax law. Regardless of the outcome in the 2018 elections, they still will be in position to exercise those “vetoes.”
The point here is not whether these Trump policies are right or wrong. These are simply the facts on whether people can get healthcare. The Trump/GOP moves will have their real-world effect on what insurance people can or can’t get, and through that, their real-world effect on the care received. Republicans will have to run in 2018 and 2020 on their record of making healthcare much harder to get for at least 20-25 million people, when they could have it more accessible instead.
It may seem to be “comparing apples and oranges” when the health benefits of research, new drugs and health improvement programs are weighed against the health losses that individuals suffer from losing insurance or Medicaid or from getting “skinny” policies instead of good coverage that meets their needs. It’s comparing the health impacts of the billions of dollars for research versus the millions of people who lose coverage.
The comparison is not really so hard. People without good coverage can’t get new medicines, many of which are very expensive and realistically available only through good insurance plans. Many health improvement programs are run by insurers for their subscribers. Most importantly, people without good insurance not only have no access to innovations, they also have no or limited access to the whole gamut of care that already exists, from doctors, surgery and drugs to X-rays, labs and physical therapy, and on and on and on.
The reality is that the forces and moves, mainly Trump administration actions, that will take good coverage away from at least 20-25 million people will almost surely outweigh the care improvements between now and 2021-23. Shocking as it may be to think that healthcare is actually getting worse in our country, there is virtually no conceivable way that the good trends will impact nearly as many patients as the bad trends will in that time frame.
Vic Simon, a freelance writer, covered healthcare for nine years as a business and legal reporter. Contact him at @vtime492.