Trumping the Affordable Care Act

“On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare.

However, it is not enough to simply repeal this terrible legislation. We will work with Congress to make sure we have a series of reforms ready for implementation that follow free market principles and that will restore economic freedom and certainty to everyone in this country. By following free market principles and working together to create sound public policy that will broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.”

Healthcare Reform To Make American Great Again

Donald Trump ran on a platform that, among other surreal promises ranging from building a wall on the U.S./Mexican border to banning all Muslims from entering the country, assured a full repeal of the Affordable Care Act (ACA). He said he’d do it on Day One of his administration. Just days following Trump’s win of the US electoral college, he dialed back.

In an interview with The Wall Street Journal, Trump offered two concessions to an all-out repeal of “Obamacare.”

First, he’s in favor of keeping the [2010 ACA-instituted] prohibition against health insurance companies denying coverage or charging higher rates because of a “pre-existing condition” (i.e., a health problem occurring before the date of coverage). Without this vital provision, insurance companies can (and do) refuse care to those who need it most.

A federal investigation of health coverage denials and exclusions for pre-existing conditions during the period 2007 to 2009 found that the four largest for-profit insurers (Aetna, Humana, UnitedHealth Group, and WellPoint) denied coverage to about one in seven applicants. That is, more than 651,000 people were shut out because of pre-existing conditions. In addition, each company’s business plans were dependent upon pre-existing conditions to limit expenditures for medical claims. The report stated that, “Internal company documents show that this increasing use of pre-existing conditions to deny or limit coverage would have continued unabated if Congress had not passed health reform legislation.” In other words, the health care market cannot be trusted to regulate itself.

It’s heartening to think that Mr. Trump would not unabashedly throw millions of people under the proverbial pre-existing condition bus. Yet he may cause more harm to the sick and most vulnerable if his free market principles go unchecked.

Framing Industry as Public Service

“Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.”

Trump Healthcare Reform Plan

What is clear about Trump’s health care vision from the outset is that he wants to loosen the reins on Big Pharma – or to use his plan’s language, to remove “barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products.” Safe, reliable, and cheap sounds pretty okay. But the pharmaceutical industry’s track record on these characteristics is already far below par.

All prescription drugs come with risks, including adverse reactions that range from mild to serious to life-threatening. The National Institute on Drug Abuse reports that from 2001 to 2014, there was a 2.8-fold increase in the total number of deaths from prescription drugs in the U.S. In 2014, drug overdoses killed 47,055 people – that’s 1.5 times the number killed in vehicle accidents and more than the number of women who die from breast cancer here each year. Of the 548 new drugs approved from 1975 to 1999, approximately 10 percent either had to be withdrawn for safety reasons or were labelled with a “Black Box” warning about a drug’s risks and side effects. Of the 36 cancer drugs approved by the FDA between 2008 and 2012 based on its accelerated pathway to speed up the conditional approval of drugs for serious medical conditions, later studies found that half did not improve overall survival.

Yet industry research and consulting firm GlobalData, cited in Forbes, predicts an increase in the market value of U.S. Pharma to $476 billion in 2020, a dramatic up-swing from the $359 billion valuation in 2012. The BBC reports that drug companies spend more on marketing drugs than on developing them, sometimes twice as much. An opening lecture at the 2016 Glasgow HIV Congress show drug pricing mark-ups that are sometimes more than 1,000 times higher than their production costs. In addition to making vast profits from this inflated approach to pricing in high-income countries, many of the largest manufactures avoid billions in U.S. taxes by registering their profits in offshore accounts. In 2015, Pfizer, Merck, J&J, Amgen, Abbott and BMS avoided USD $ 20, 16, 14, 9, 7, and 7 billion dollars respectively.

Screenshot from the Donald Trump Gallery

“Not Special Interests” Screenshot from the Donald Trump Gallery

Big Pharma’s efforts to protect its profitability from the potentially negative impacts of legislative reforms are also clear. The Washington DC-based group, Drug Watch, reports more than 1,100 paid lobbyists for the industry, nearly $2.9 billion spent on lobbying expenses from 1998 to 2014, and more than $15 million offered in campaign contributions from 2013-14. And Trump wants to remove the industry’s “barriers to entry into free markets.” The Washington Post counts pharmaceuticals among the 15 industries to benefit from a Trump presidency. Their stocks went up as investors anticipated a reprieve from scrutiny over ever-skyrocketing drug prices.

In addition to drug sales, statistics from the U.S. Government Accountability Office valued the U.S. medical device market alone at more than $140 billion in 2015, comprising approximately 45 percent of the global market. The International Trade Administration says of the medical device industry,

“These companies have found new opportunities for development in the face of uneven international economic growth and continually-changing regulatory systems.”

Sorry Mr. Trump, BIG PHARMA is not a public servant. It is an enormous and influential industry that makes billions each year selling drugs and medical devices, some beneficial and others deleterious. Stripping regulatory mandates to widen markets is not likely to increase the safety, reliability, or cost of drugs or medical devices. It is, in fact, more likely to weaken standards of safety and reliability while inflating costs.

Future Leaders of the Next Health Care Crisis

President-elect Trump didn’t instigate the inequalities and injustices embedded in the U.S. health care system but his free-wheeling approach to protecting public good (by not protecting it) will certainly make it worse.

The 21st Century Cures Act passed in the House on November 30, the Senate on December 6, and was signed by President Obama on December 13. Cast as a boon to medical research and faster regulatory approval, the act surreptitiously strips away at the Food and Drug Administration’s (FDA) existing regulatory controls while expanding biotech markets without doing anything to curb prices or demand stronger evidence of safety and efficacy. Two medical doctors warned in The New England Journal of Medicine that while some aspects of the bill could enhance the development of and access to new drugs, it gives considerable latitude for the use of less rigorous methodological approaches that could bring riskier drugs and devices to market, “lead[ing] to less salutary outcomes for patients and the health care system.”

"Fighting For You" Screenshot Trump-Pence Gallery

“Fighting For You” Screenshot from the Donald Trump Gallery

In the wake of the passage of Cures, President-elect Trump has thrown around the names of several questionable picks to lead his health care overhaul. He’s considering staunch libertarian Jim O’Neill as commissioner of the FDA, a person who does not believe the administration should determine whether drugs are effective before approving them for the market. In a 2014 speech he said, “Let people start using them, at their own risk.”

Trump’s nomination of Rep. Tom Price as secretary of Health and Human Services, while endorsed by the American Medical Association, does not represent the sentiment of physicians at large who see Price’s proposed policies as a threat to affordable, quality health care for many of their patients. In an open letter on behalf of the Clinician Action Network (CAN), 5000 physicians opposed the Price nomination on the grounds that his plan to dismantle the Affordable Care Act includes, among other problems, efforts to block Medicaid grants (which added coverage for nearly 16 million low-income Americans since 2014), “roll back protections for those with pre-existing conditions, remove caps on insurance premiums for older patients, and give tax credits regressively: an older, richer individual is treated the same as a sicker or poorer individual who happens to be younger.”

If the Tom Price plan is welcoming to the young, healthy and financially self-sufficient but hostile to the sick and the old, it’s not surprising that the second provision of the ACA Trump is keen on keeping is the one that allows parents to add or keep their children on their insurance policies until they are 26 years old. While this is a useful provision, it diverts attention from ongoing threats to social security, Medicare, and Medicaid as well as the fact that the Trump plan is likely to benefit insurers, drug companies, the biotech industry and other corporate stakeholders while leaving patients to fend for themselves.

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