Americans got a reprieve last week when the president decided to pull the American Health Care Act (AHCA) from consideration in the House. It was a stunning development and an acknowledgement of the complexity of the issues and the deep concerns Americans have about health care. It also reflected an astounding level of dysfunction both within the GOP and in the party’s relations with the White House. But this is only a temporary reprieve. Trump has made it clear, through the deals he made to try to pass the AHCA and through his 2018 budget, just how willing he is to compromise the health coverage of millions of Americans.
He spent months during the campaign declaring that his first act as president would be to repeal and replace Obamacare with a “wonderful plan” that would “cover everyone” and be “better and cheaper.” Responding to pressure from the right in his own party, he showed just how committed he is to those ideals by offering to abandon maternity and emergency care benefits, preventive screenings, and mental health and substance abuse services. The proposed elimination of Medicaid expansion would have further threatened the coverage of 24 million people.
It doesn’t take a health expert to know that if you remove preventive services from the benefit mix you will ultimately push people into a sicker and sicker state before they show up for care. Also, just because you remove a disease from the covered benefit list doesn’t mean the disease disappears. It still happens, and ultimately everyone—taxpayers, insurers and providers—must shoulder those costs. Even those with employer-based health insurance would have been harmed by this plan.
Speaker of the House Paul Ryan also revealed exactly where his priorities lay by counseling the president to rush into “repeal and replacement” of Obamacare before the Republicans even had a viable and acceptable plan. His long-term goal of wanting to rein in entitlements, cut the deficit and privatize Medicare bears special watching in the weeks and months ahead.
But it was the right wing of the Republican Party, the Freedom Caucus, that held all of the cards on this one. They were the ones holding out for more cuts in benefits and higher tax credits for the wealthy. In the end, both Trump and Ryan came to realize that they were being held hostage and that the demands of the Freedom Caucus would only escalate.
There may be some good news. The events of the last week just might spark a bipartisan effort in the House and Senate to actually try to fix those parts of Obamacare that all agree need fixing. But a word of caution. Trump opined shortly after the AHCA was pulled that “the best thing politically would be to let Obamacare explode,” reflecting a sort of “I told you so” approach to governing (The Washington Post, 3/24/17). Sadly, he might be able to accomplish this through regulatory decisions that do not require Congressional approval. Were the administration to engage in this sort of sabotage, it would be an odd way to demonstrate its compassion and concern for the health of the American people. “The Democrats will make a deal with me on health care as soon as ObamaCare folds—not long,” he tweeted after the AHCA debacle. “Do not worry, we are in very good shape!”
Other developments of grave concern
Many of the critical institutions that we rely upon to monitor our health (the Centers for Disease Control and Prevention), protect our food and drug supplies (the Food and Drug Administration), protect our air and water (the Environmental Protection Agency), study climate and weather (the National Oceanographic and Atmospheric Administration) and provide ground breaking biomedical research (the National Institutes of Health) are under siege in ways that we have not seen in our lifetime. Trump’s current budget proposal calls for a $6 billion, or 20 percent, cut in the N.I.H., a $2.6 billion or 31 percent, cut in the E.P.A, and a $15 billion, or 26 percent, cut in the Health and Human Services budget that includes the CDC and the FDA.
Worth noting is that had the attempt to repeal Obamacare succeeded, it also would have eliminated the Public Health and Prevention Fund, a major source of funding for the CDC and state and local health departments. Among other things, the fund supports 40 percent of the CDC’s immunization program and provides varying levels of funding for childhood lead-paint poisoning prevention and chronic disease prevention as well as nearly half the funding for epidemiology and laboratory services in the U.S. The impact on Vermont would have been more than $14.5 million over the next five years.
A war on science and public health
While many of these cuts likely will not be sustained by the Congress, the president has gone out of his way to find appointees for some of the most critical health and science agencies whose careers have been built on attacking and demeaning the very agencies they are now directing. Critics have characterized these moves as a “war on science.” It’s hard to conclude otherwise when Trump budget director, Mitch Mulvaney, says: “Regarding the question as to climate change…we’re not spending money on that anymore; we consider that to be a waste of your money”. (March 17, 2017)
What’s shocking about our president is not that he knows nothing about health care, public health or science—not many presidents do—but that he shows little inclination to learn. Freedom Caucus members who met with the president during AHCA negotiations were “shocked” by how little he knew about the content of the very bill they were discussing. Going forward it is likely that this will embolden the ideologues in his party to do as they wish with governmental agencies that do not produce results that conform to their political orthodoxy.
Trump’s proposed budget sends savings to the military, a $54 billion increase, Homeland Security, a $2.6 billion increase (Immigration and Customs Enforcement, the Border Patrol and a down payment on the wall), and Veterans Affairs, a $4.4 billion increase. Threats of pandemic flu, emerging diseases and disease vectors, global environmental change, bioterrorism, air and water pollution, and the opioid epidemic all require that we ramp up not tear down our technical and scientific capacity.
The rhetorical and fiscal assault on our scientific and health infrastructure is not much different from the smashing of priceless artifacts in Palmyra, Syria, by the ideological zealots of ISIS. Granted our public health and science infrastructures can be rebuilt. But at what cost in terms of human life and suffering—and for what end?
Will we be safer and healthier under a Trump administration? Based on the first 75 days, few people I know would say yes.
Jim Hyde is a professor emeritus of public health at the Tufts University School of Medicine. He lives in Charlotte.