AJPH NATIONAL PUBLIC HEALTH WEEK
Trumpcare or Transformation Donald Trump’s presidency heralds public health retreat in the short term. Yet the surging opposition to his regime— redolent of the civil rights and anti–Vietnam War mobilizations of the 1950s and 1960s—could portend better things ahead. Back then, a popular onslaught swept out Jim Crow laws, McCarthyism, and racist immigration quotas, ushering in legislation that protected civil rights, voting rights, and women’s rights; aided public schools and college students; opened the border to Jews, Italians, and people of color; implemented the National Endowment for the Arts, food subsidies, and Head Start; sharply increased Social Security benefits; and created Medicare, Medicaid, and community health centers. Between 1960 and 1969, poverty fell by 45%, and by 1980, infant mortality was halved. Since then, Democrats as well as Republicans have offered too little that inspires and too much that appeases the rich and powerful. Trump won by attacking a status quo that is disastrous for many. In health care, the Affordable Care Act (ACA) extended coverage to 20 million and boosted funding for public health and community health centers. But it offered little help to 90% of the population, perpetuated a dysfunctional health care financing system, left 26 million uninsured, saddled covered families with unaffordable deductibles and narrow provider networks, and enriched drug firms, medical conglomerates, and insurers. Mobilizing for a reform that would fix these defects is a far better defense against Trump’s health-damaging
660
Editorial
plans than calls to retain the pre-Trump order. Even before the inauguration, congressional Republicans initiated repeal of key pillars of the ACA. But although Republicans are unified in their desire to destroy what Obama wrought, crafting the replacement is more complicated. Unfortunately, going halfway—repealing without replacing—would likely cost thousands of lives (Table 1).
REPUBLICANS’ DILEMMA Republican leaders face a dilemma. Repudiating the ACA means abandoning the neoliberal reform framework they long championed, an approach that props up private insurers by using mandates and taxpayers’ dollars to expand the market for their (often defective) products. Richard Nixon’s 1971 plan— offered to counter Ted Kennedy’s single-payer proposal—was eerily similar to the ACA: a requirement that employers cover their workers, Medicaid managed care–like coverage for the poor with sliding-scale subsidies for the near-poor, and insurance exchanges for individual purchasers (http://cbsn.ws/2lLKhnn). The Heritage Foundation’s 1989 plan added an individual mandate to the mix,1 an approach adopted by Senate Republicans in 1993 (http://bit.ly/2lctWvi ). And in 2006, Republican governor Mitt Romney implemented the ACA’s prototype in Massachusetts.
Himmelstein and Woolhandler
AFFORDABLE CARE ACT REPLACEMENTS Not surprisingly, the ACA replacements floated by Republicans such as House Speaker Paul Ryan and Department of Health and Human Services Secretary Tom Price amount to rebranded, meaner versions of the ACA. In place of the ACA’s sliding scale tax credits (also known as “subsidies”), they would spread the tax credits around to anyone lacking jobbased coverage, even the affluent, depleting the funds available to help the near-poor. Republican proposals would reduce federal insurance regulations while vitiating states’ consumer protections by allowing interstate insurance sales; any plan that cleared Idaho’s or Alabama’s low bar (http://bit.ly/2lLIXkH) could be marketed everywhere. Ryan’s and Price’s proposals would delay Medicare eligibility until age 67 and replace Medicare’s current guaranteed benefits with vouchers that seniors could use to buy coverage. Although Republicans are already walking back those unpopular ideas, they will likely accelerate the ongoing privatization of Medicare through another mechanism: augmenting the already massive overpayments to Medicare Advantage plans. Under the Price and Ryan plans, Medicaid and, hence, the poor, would see the largest cuts. They would eliminate the current federal commitment to match states’ actual expenditures
and instead offer fixed (and smaller) “block grants,” which states could divert to other uses, and that would grow with overall (not medical) inflation. Women’s reproductive health care is also imperiled. The ACA’s contraception-coverage mandate would likely fall victim to the law’s repeal; Republicans are edging closer to banning Medicaid and Title X reimbursement to Planned Parenthood and criminalizing abortion; and a new executive order bans foreign-aid funding to groups that even mention abortion. The new regime also aspires to repeal the ACA’s tax on wealthy investors, and enhance tax breaks for health savings accounts, which mostly benefit those in high brackets.
PRO-CORPORATE AGENDA These health care–related tax changes jibe with the administration’s broader plans to cut taxes on rich individuals and corporations, policies that would exacerbate income inequality, and thereby harm health. And the pro-corporate agenda carries other health hazards: a diminished Environmental Protection Agency and boost for coal and other fossil fuels, oil pipelines likely to despoil the land, and weakening of the Food and Drug Administration’s oversight of food and drugs. The racism, nativism, and religious bigotry that have been bedrocks of Trump’s appeal may take an even heavier toll. Lawand-order rhetoric portends
ABOUT THE AUTHORS Both authors are with the City University of New York at Hunter College, New York, NY. Correspondence should be sent to David U. Himmelstein, MD, 255 West 90th St, New York, NY 10024 (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This editorial was accepted February 14, 2017. doi: 10.2105/AJPH.2017.303729
AJPH
May 2017, Vol 107, No. 5
AJPH NATIONAL PUBLIC HEALTH WEEK
TABLE 1—Estimated Change in Deaths Associated With Repeal of the Affordable Care Act, or Implementation of a Single-Payer Reform: United States Estimated Increase (Decrease) in No. of Deaths Source of Estimate of Mortality Effect of Gaining or Losing Insurance
No. Needed to Insure to Prevent 1 Death
Because of ACA Repeal, 2018a
Because of ACA Repeal, 2019a
If ACA Replaced by Single-Payer Plan, 2018b
Cohort studies Franks et al.,2 1993
1 239
14 528
22 599
(20 984)
Wilper et al.,3 2009
1 094
16 453
25 594
(23 766)
769c
23 407
36 411
(33 810)
Sommers et al., 2014
830
21 687
33 735
(31 325)
Sommers,6 2016
300d
60 000
93 333
(86 667)
Experimental and quasi-experimental studies Finkelstein et al.,4 2012 5
Note. ACA = Affordable Care Act. A 2009 cohort study by Kronick7 estimated a much smaller effect than the similar studies by Franks et al. and Wilper et al. However, Kronick’s published results do not allow computation of the number needed to insure to prevent a death. a Based on Congressional Budget Office estimate that number of uninsured would increase by 18 million 1 year after ACA repeal, and 28 million 2 years after repeal (see: https://www.cbo.gov/sites/default/files/115th-congress-20172018/reports/52371-coverageandpremiums.pdf). b Based on Congressional Budget Office estimate that 26 million persons will remain uninsured in 2018 under current law (see: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385HealthInsuranceBaseline_OneCol.pdf). c Point estimate, which was not statistically significant. d Midpoint of range of estimates from study.
more belligerent policing, increased voter suppression, neglect of civil rights enforcement, and the extension of mass incarceration. Immigrant communities and religious minorities are already under threat. Finally, the likelihood of wars has been ratcheted up, and a bellicose and mercurial man now controls the nuclear button.
POTENTIAL DEVASTATION The health impacts of the administration’s antiscience bent are hard to gauge, but potentially devastating. Public health advance requires accurate data and honest assessment. When politicians threaten and muzzle scientists studying the environment, label inconvenient truths “fake news,” and propagate falsehoods under the guise of “alternative facts,” they chip at the foundations of scientific progress. This grim litany reflects what President Trump and his allies want to do. But their agenda is
May 2017, Vol 107, No. 5
AJPH
already fraying under the pressure of popular opposition. Republicans’ fear of a backlash has stalled the ACA repeal, the centerpiece of their legislative agenda.
BACKLASH Perhaps as important, Democratic politicians are feeling pressed and emboldened to embrace progressive policies. New York’s Governor Cuomo has proposed abolishing tuition for many students at his state’s public colleges (although his proposed budget seems insufficient). Elizabeth Warren, previously reticent about criticizing the ACA, recently opined: “Let’s be honest: [the ACA’s] not bold. It’s not transformative. . . . I’m OK taking half a loaf if our message was ‘Here’s half, now let’s go get the rest.’” Moving forward from the ACA to single payer would upend the market-based approach that has hobbled reform, allowing the redirection of hundreds of billions now wasted on
insurers’ overhead, providers’ billing-related paperwork, and excessive drug prices. With that money we could ensure access for all, lift the threat of bankruptcy attributable to illness, and free up funds for much-needed expansions of long-term and mental health care, as well as public health work.
A 21ST-CENTURY VISION FOR PROGRESS Such reform is integral to a 21st-century vision for progress, along with reparations for slavery and Native American genocide; a $15 minimum wage and guaranteed minimum income; enforcing pay equality and extending reproductive and lesbian, gay, bisexual, and transgender rights; more and better public housing, public education, and public transit; the reversal of mass incarceration and restoration of ex-offenders’ civil rights; legalization of the undocumented; expanding clean
energy, conservation, and environmental protection; and the abolition of nuclear weapons. The advances of science and industry open previously unimaginable possibilities for human health and fulfillment. Politically imposed constraints have impaired our ability to wield these tools, and threaten to incapacitate us. Yet, past periods of impasse and retrogression offer reassurance that our generations, like previous ones, can reverse society’s misdirection and deploy the extraordinary opportunities for progress that lie around us. David U. Himmelstein, MD Steffie Woolhandler, MD, MPH CONTRIBUTORS Both authors contributed equally to all aspects of this work.
REFERENCES 1. Butler SM. Assuring affordable health care for all Americans. The Heritage Foundation. 1989. Available at: http:// www.heritage.org/social-security/report/ assuring-affordable-health-care-allamericans. Accessed February 11, 2017. 2. Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort. JAMA. 1993; 270(6):737–741. 3. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. Am J Public Health. 2009;99(12): 2289–2295. 4. Finkelstein A, Taubman S, Wright B, et al. The Oregon Health Insurance Experiment: evidence from the first year. Q J Econ. 2012;127(3):1057–1106. 5. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med. 2014;160(9): 585–593. 6. Sommers BD. State Medicaid expansions and mortality, revisited: a cost–benefit analysis. 2016. Available at: https://dash.harvard.edu/bitstream/ handle/1/27305958/Mcaid% 20Mortality%20Revisited%20DASH% 20Version.pdf?sequence=1. Accessed February 13, 2017. 7. Kronick R. Health insurance coverage and mortality revisited. Health Serv Res. 2009;44(4):1211–1231.
Himmelstein and Woolhandler
Editorial
661
Trumpcare or Transformation Donald Trump’s presidency heralds public health retreat in the short term. Yet the surging opposition to his regime— redolent of the civil rights and anti–Vietnam War mobilizations of the 1950s and 1960s—could portend better things ahead. Back then, a popular onslaught swept out Jim Crow laws, McCarthyism, and racist immigration quotas, ushering in legislation that protected civil rights, voting rights, and women’s rights; aided public schools and college students; opened the border to Jews, Italians, and people of color; implemented the National Endowment for the Arts, food subsidies, and Head Start; sharply increased Social Security benefits; and created Medicare, Medicaid, and community health centers. Between 1960 and 1969, poverty fell by 45%, and by 1980, infant mortality was halved. Since then, Democrats as well as Republicans have offered too little that inspires and too much that appeases the rich and powerful. Trump won by attacking a status quo that is disastrous for many. In health care, the Affordable Care Act (ACA) extended coverage to 20 million and boosted funding for public health and community health centers. But it offered little help to 90% of the population, perpetuated a dysfunctional health care financing system, left 26 million uninsured, saddled covered families with unaffordable deductibles and narrow provider networks, and enriched drug firms, medical conglomerates, and insurers. Mobilizing for a reform that would fix these defects is a far better defense against Trump’s health-damaging
660
Editorial
plans than calls to retain the pre-Trump order. Even before the inauguration, congressional Republicans initiated repeal of key pillars of the ACA. But although Republicans are unified in their desire to destroy what Obama wrought, crafting the replacement is more complicated. Unfortunately, going halfway—repealing without replacing—would likely cost thousands of lives (Table 1).
REPUBLICANS’ DILEMMA Republican leaders face a dilemma. Repudiating the ACA means abandoning the neoliberal reform framework they long championed, an approach that props up private insurers by using mandates and taxpayers’ dollars to expand the market for their (often defective) products. Richard Nixon’s 1971 plan— offered to counter Ted Kennedy’s single-payer proposal—was eerily similar to the ACA: a requirement that employers cover their workers, Medicaid managed care–like coverage for the poor with sliding-scale subsidies for the near-poor, and insurance exchanges for individual purchasers (http://cbsn.ws/2lLKhnn). The Heritage Foundation’s 1989 plan added an individual mandate to the mix,1 an approach adopted by Senate Republicans in 1993 (http://bit.ly/2lctWvi ). And in 2006, Republican governor Mitt Romney implemented the ACA’s prototype in Massachusetts.
Himmelstein and Woolhandler
AFFORDABLE CARE ACT REPLACEMENTS Not surprisingly, the ACA replacements floated by Republicans such as House Speaker Paul Ryan and Department of Health and Human Services Secretary Tom Price amount to rebranded, meaner versions of the ACA. In place of the ACA’s sliding scale tax credits (also known as “subsidies”), they would spread the tax credits around to anyone lacking jobbased coverage, even the affluent, depleting the funds available to help the near-poor. Republican proposals would reduce federal insurance regulations while vitiating states’ consumer protections by allowing interstate insurance sales; any plan that cleared Idaho’s or Alabama’s low bar (http://bit.ly/2lLIXkH) could be marketed everywhere. Ryan’s and Price’s proposals would delay Medicare eligibility until age 67 and replace Medicare’s current guaranteed benefits with vouchers that seniors could use to buy coverage. Although Republicans are already walking back those unpopular ideas, they will likely accelerate the ongoing privatization of Medicare through another mechanism: augmenting the already massive overpayments to Medicare Advantage plans. Under the Price and Ryan plans, Medicaid and, hence, the poor, would see the largest cuts. They would eliminate the current federal commitment to match states’ actual expenditures
and instead offer fixed (and smaller) “block grants,” which states could divert to other uses, and that would grow with overall (not medical) inflation. Women’s reproductive health care is also imperiled. The ACA’s contraception-coverage mandate would likely fall victim to the law’s repeal; Republicans are edging closer to banning Medicaid and Title X reimbursement to Planned Parenthood and criminalizing abortion; and a new executive order bans foreign-aid funding to groups that even mention abortion. The new regime also aspires to repeal the ACA’s tax on wealthy investors, and enhance tax breaks for health savings accounts, which mostly benefit those in high brackets.
PRO-CORPORATE AGENDA These health care–related tax changes jibe with the administration’s broader plans to cut taxes on rich individuals and corporations, policies that would exacerbate income inequality, and thereby harm health. And the pro-corporate agenda carries other health hazards: a diminished Environmental Protection Agency and boost for coal and other fossil fuels, oil pipelines likely to despoil the land, and weakening of the Food and Drug Administration’s oversight of food and drugs. The racism, nativism, and religious bigotry that have been bedrocks of Trump’s appeal may take an even heavier toll. Lawand-order rhetoric portends
ABOUT THE AUTHORS Both authors are with the City University of New York at Hunter College, New York, NY. Correspondence should be sent to David U. Himmelstein, MD, 255 West 90th St, New York, NY 10024 (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This editorial was accepted February 14, 2017. doi: 10.2105/AJPH.2017.303729
AJPH
May 2017, Vol 107, No. 5
AJPH NATIONAL PUBLIC HEALTH WEEK
TABLE 1—Estimated Change in Deaths Associated With Repeal of the Affordable Care Act, or Implementation of a Single-Payer Reform: United States Estimated Increase (Decrease) in No. of Deaths Source of Estimate of Mortality Effect of Gaining or Losing Insurance
No. Needed to Insure to Prevent 1 Death
Because of ACA Repeal, 2018a
Because of ACA Repeal, 2019a
If ACA Replaced by Single-Payer Plan, 2018b
Cohort studies Franks et al.,2 1993
1 239
14 528
22 599
(20 984)
Wilper et al.,3 2009
1 094
16 453
25 594
(23 766)
769c
23 407
36 411
(33 810)
Sommers et al., 2014
830
21 687
33 735
(31 325)
Sommers,6 2016
300d
60 000
93 333
(86 667)
Experimental and quasi-experimental studies Finkelstein et al.,4 2012 5
Note. ACA = Affordable Care Act. A 2009 cohort study by Kronick7 estimated a much smaller effect than the similar studies by Franks et al. and Wilper et al. However, Kronick’s published results do not allow computation of the number needed to insure to prevent a death. a Based on Congressional Budget Office estimate that number of uninsured would increase by 18 million 1 year after ACA repeal, and 28 million 2 years after repeal (see: https://www.cbo.gov/sites/default/files/115th-congress-20172018/reports/52371-coverageandpremiums.pdf). b Based on Congressional Budget Office estimate that 26 million persons will remain uninsured in 2018 under current law (see: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385HealthInsuranceBaseline_OneCol.pdf). c Point estimate, which was not statistically significant. d Midpoint of range of estimates from study.
more belligerent policing, increased voter suppression, neglect of civil rights enforcement, and the extension of mass incarceration. Immigrant communities and religious minorities are already under threat. Finally, the likelihood of wars has been ratcheted up, and a bellicose and mercurial man now controls the nuclear button.
POTENTIAL DEVASTATION The health impacts of the administration’s antiscience bent are hard to gauge, but potentially devastating. Public health advance requires accurate data and honest assessment. When politicians threaten and muzzle scientists studying the environment, label inconvenient truths “fake news,” and propagate falsehoods under the guise of “alternative facts,” they chip at the foundations of scientific progress. This grim litany reflects what President Trump and his allies want to do. But their agenda is
May 2017, Vol 107, No. 5
AJPH
already fraying under the pressure of popular opposition. Republicans’ fear of a backlash has stalled the ACA repeal, the centerpiece of their legislative agenda.
BACKLASH Perhaps as important, Democratic politicians are feeling pressed and emboldened to embrace progressive policies. New York’s Governor Cuomo has proposed abolishing tuition for many students at his state’s public colleges (although his proposed budget seems insufficient). Elizabeth Warren, previously reticent about criticizing the ACA, recently opined: “Let’s be honest: [the ACA’s] not bold. It’s not transformative. . . . I’m OK taking half a loaf if our message was ‘Here’s half, now let’s go get the rest.’” Moving forward from the ACA to single payer would upend the market-based approach that has hobbled reform, allowing the redirection of hundreds of billions now wasted on
insurers’ overhead, providers’ billing-related paperwork, and excessive drug prices. With that money we could ensure access for all, lift the threat of bankruptcy attributable to illness, and free up funds for much-needed expansions of long-term and mental health care, as well as public health work.
A 21ST-CENTURY VISION FOR PROGRESS Such reform is integral to a 21st-century vision for progress, along with reparations for slavery and Native American genocide; a $15 minimum wage and guaranteed minimum income; enforcing pay equality and extending reproductive and lesbian, gay, bisexual, and transgender rights; more and better public housing, public education, and public transit; the reversal of mass incarceration and restoration of ex-offenders’ civil rights; legalization of the undocumented; expanding clean
energy, conservation, and environmental protection; and the abolition of nuclear weapons. The advances of science and industry open previously unimaginable possibilities for human health and fulfillment. Politically imposed constraints have impaired our ability to wield these tools, and threaten to incapacitate us. Yet, past periods of impasse and retrogression offer reassurance that our generations, like previous ones, can reverse society’s misdirection and deploy the extraordinary opportunities for progress that lie around us. David U. Himmelstein, MD Steffie Woolhandler, MD, MPH CONTRIBUTORS Both authors contributed equally to all aspects of this work.
REFERENCES 1. Butler SM. Assuring affordable health care for all Americans. The Heritage Foundation. 1989. Available at: http:// www.heritage.org/social-security/report/ assuring-affordable-health-care-allamericans. Accessed February 11, 2017. 2. Franks P, Clancy CM, Gold MR. Health insurance and mortality: evidence from a national cohort. JAMA. 1993; 270(6):737–741. 3. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. Am J Public Health. 2009;99(12): 2289–2295. 4. Finkelstein A, Taubman S, Wright B, et al. The Oregon Health Insurance Experiment: evidence from the first year. Q J Econ. 2012;127(3):1057–1106. 5. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med. 2014;160(9): 585–593. 6. Sommers BD. State Medicaid expansions and mortality, revisited: a cost–benefit analysis. 2016. Available at: https://dash.harvard.edu/bitstream/ handle/1/27305958/Mcaid% 20Mortality%20Revisited%20DASH% 20Version.pdf?sequence=1. Accessed February 13, 2017. 7. Kronick R. Health insurance coverage and mortality revisited. Health Serv Res. 2009;44(4):1211–1231.
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