Health Reform In The Trump Era: A Big Step Back, But Possibilities For Bigger Steps Forward

The 2016 election turned on racism, xenophobia and anger at the status quo, including the Affordable Care Act (ACA). The law covered about 20 million, and modestly improved access to care. But it didn’t address the health care problems facing most working families, feeding the perception that the Democratic Party had neglected them. Trump seized on the ACA as a symbol of the establishment’s false promises, and has placed repeal at the top of his to do list.

There are many indicators of what Trump has in mind to replace the ACA, but they’re pointing in different directions. We suspect that the likeliest replacement is a meaner (and rebranded) facsimile of the ACA that retains its main structural element — using tax dollars to subsidize private insurance — while imposing new burdens on the poor and sick.

For Republicans, the ACA poses a difficult dilemma. Its model was conceived by Richard Nixon’s henchmen in 1971, celebrated and elaborated by the Heritage Foundation in 1989, and first implemented by Mitt Romney in 2006. Obama’s version, like these earlier ones, called for sliding-scale public subsidies to help low-income individuals purchase private coverage through insurance exchanges, along with a mandate that individuals (and sometimes employers) buy coverage. For the poor, Obama (like Nixon) relied on expanding Medicaid, but almost all of the ACA’s new Medicaid coverage was channeled through private Medicaid-managed-care insurers. And Obama added progressive elements to the Republican formula, e.g. requiring insurers to cover essential benefits (notably contraception and preventive care) and a new “Medicare” tax on some investment income.

Will Republicans reclaim their health care heritage after years spent rabidly attacking its Obamacare variant? Paul Ryan’s recent pronouncements (and the abiding interests of powerful insurance, drug and hospital firms) suggest that they will. Ryan would rebrand the Obamacare premium “subsidies” as “tax credits,” but make them available to anyone who lacks employer-paid coverage, including the wealthy. In essence, he’d shift some of the subsidy money up the income scale and undermine employer-based coverage. He’d maintain (at least for the time being) Obamacare’s boost to Medicaid funding, but let states cut Medicaid coverage and divert the funds to other uses. And he’d hasten the privatization of Medicare, which has already been proceeding apace.

If there’s a brighter side to this dark picture, it’s that Trump and his allies will reclaim ownership of the Nixon/Heritage/Romney/ACA model. This shift seems likely to unmuzzle single-payer supporters who closeted themselves during the ACA era, fearful that calls for more radical reform would fan right-wing attacks. Already Elizabeth Warren, previously reluctant to criticize the ACA, has been liberated: “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.'”

A similar strategic perspective motivated PNHP’s founding at a conference of clinicians caring for the poor. After years spent parrying Reagan’s assaults on Medicaid and community clinics, we concluded that a defensive stance was untenable. The U.S. health care system, even with Medicaid intact, prioritized corporate greed over patients’ needs, and was politically indefensible. It wasn’t possible to fix health care for the poor without fixing it for everyone.

That conclusion holds today. For the working class, incomes have stagnated and out-of-pocket costs have soared. For whites without a college education, death rates are rising, driven by diseases of despair like suicide and substance use. Trump spoke (disingenuously) to that despair; Clinton failed to. The resonance of Bernie Sanders’ single-payer message is backed up by polls that show three-fifths of Americans – including a majority of those who want the ACA repealed, and 41 percent of Republicans – favor a “federally funded healthcare program providing insurance for all Americans.”

In health care, reform must address the pressing problems of the majority who have private coverage and Medicare, as well as those who are uninsured or on Medicaid. Only single payer can do that.

A few suggestions for work in the months ahead:

1. Colleagues are, more than ever, receptive to the single-payer message. Let’s talk about it in corridors, conferences, lecture halls and national meetings; use Facebook, Twitter, email and snail mail to recruit new PNHP members; and push journal editors to end their virtual blackout on single payer.

2. With Medicaid under attack, in many states we’ll need to join in its defense. But we must simultaneously declare that this halfway measure is no substitute for real reform. Let’s not repeat the error of ACA backers who tried to convince people that their health care problems had been solved. Similarly, defense of Medicare should not paper over that program’s flaws.

3. We need to help focus the anger at elites onto the real health care elites: insurance and drug firms, and corporate health care providers.

4. In the past PNHP has focused narrowly on single-payer reform, avoiding participation in most broad-based coalitions. We should reconsider that stance in the context of the broad opposition to the Trump regime, and the urgency of threats to our communities. Effective action will require coalitions that span many issues. We should participate in those that include a demand for single payer.

5. It’s time to ramp up organizing for H.R. 676. Politicians can no longer seek refuge in the fiction that health reform is a “done deal” and is working. While work for state-based reforms can provide a useful organizing tool, it cannot address the nation’s most acute health care problems, which are concentrated in states with little hope of local legislation.

Drs. Woolhandler and Himmelstein are professors of health policy and management at the City University of New York School of Public Health at Hunter College and lecturers in medicine at Harvard Medical School. They co-founded Physicians for a National Health Program. The views expressed here are their own.

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Heart Disease in Cats: A Silent Killer

Last week, a client brought her senior cat to have a pre-anesthetic blood test drawn by one of my certified veterinary technicians for a future dental procedure. Unexpectedly, this client also brought her recently adopted handsome young cat, named Apollo, for a nail trim. Since Apollo was a new patient to our clinic, my technician recommended a complete physical examination before the nail trim. Without any hesitation, the owner elected to have Apollo examined by one of my veterinary associates.

While Apollo was awaiting his examination, he let out a blood-curdling scream while sitting on my client’s lap. Only a few feet away, my technician raced back into the room to find a non-responsive cat in my client’s arms. My technician scooped Apollo up and immediately took him to our treatment room where we started cardiopulmonary resuscitation. After 15 minutes of aggressively trying to revive him, we regrettably could not resuscitate him.

Heart disease in cats is a life-threatening medical condition. Tragically, in some cats it can be a silent killer. At least once or twice a year, one of my feline cat owners will come home to find their supposedly “happy and healthy” cat suddenly limp on their floor. Unlike most dogs with heart disease, many cats with heart disease show no symptoms: no cough, no lethargy and no decline in appetite. Some may show subtle signs of increased respiratory rate (greater than 30 breathes per minute at rest) or greater abdominal effort with each breathe but these changes frequently go unnoticed by even the most observant cat owner. In the midst of a cardiac crisis, these pets will have labored breathing, pale mucous membranes, profound weakness, severe pain, and /or may experience numbness in their limbs

Who is at risk for developing heart disease?
Any aged cat and breed is at risk for developing heart disease but it is unlikely to be seen in cats less than 6 months of age. According to a number of studies, 16% of all apparently healthy cats have heart disease.

In the Maine Coon and Ragdoll breeds there is an inheritable, genetic mutation that predisposes them to heart disease. If you own either breed, ask your veterinarian if it would be advisable to test your cat for this mutation. In the future, I anticipate geneticists will discover other mutations responsible for heart disease in other breeds of cats.

How does one diagnose heart disease in cats BEFORE they have a crisis?

1. A physical examination by your veterinarian is essential but no guarantee that your pet is free of heart disease. Using a stethoscope, your veterinarian may detect a heart murmur (an audible turbulence of blood flow in the heart) or an irregular rhythm of heartbeats. Regrettably, the absence of a heart murmur does NOT mean heart disease DOES NOT exist – for only 50% of cats with heart disease have a heart murmur. An irregular heart rhythm is more consistently recognized in pets with heart disease. However, there is a 50% chance that your cat with a heart murmur has heart disease and it should be investigated further.

2. Radiography of the thorax (chest) is a quick, non-invasive diagnostic test that can be performed in almost every veterinary clinic. A thoracic radiograph provides meaningful information about the overall size and shape of the heart, as well as the character of the lung tissue. Unfortunately, the sensitivity and specificity of this tool for heart disease is not as great as we would like it to be. In the most common heart disease in cats, called Hypertrophic Cardiomyopathy, the walls of the heart are thickened, the interior chamber size is reduced, but the overall heart size may appear normal on the radiograph especially in the early stage of this disease.

3. The Cardiopet pro-BNP Test by IDEXX Diagnostic Laboratory is a screening test for heart disease in cats. This blood test measures the NT-proBNP hormone that is released by stretched or stressed muscle cells in the heart. The rise in the level of this hormone is proportional to the abnormal stretching and stress of heart muscles. This test has an 85% sensitivity for detecting heart disease in cats. False positive and false negatives do exist with this test. Non-cardiac patients with hyperthyroidism (overactive thyroid gland), hypertension (high blood pressure), or/and kidney disease can have elevated NT-proBNP levels. Cats with elevated levels of this hormone should have a cardiac ultrasound to verify the diagnosis of heart disease.

4. A Cardiac Ultrasound is the gold standard for diagnosing and staging heart disease in cats.
If a heart murmur or an irregular heart rhythm is detected in a cat, I strongly recommend a veterinary cardiologist perform a cardiac ultrasound. The good news is that 50% of apparently healthy cats with heart murmurs have normal cardiac ultrasounds. So having a heart murmur is not necessarily a death sentence for your cat – but just a warning light that there may be a problem.

Unfortunately, a single normal cardiac ultrasound does not eliminate the possibility of heart disease to develop in the future. For high-risk breeds, like Ragdolls and Maine Coons, and cats with heart murmurs that may vary in intensity over time, your veterinarian may recommend periodic repeat cardiac ultrasounds.

Cats are very secretive and easily hide their illnesses from their owners. Apollo’s death reminds us all about the fragility of life, to appreciate good health, and enjoy the time we have together. Although we cannot cure heart disease in cats today, it can be medically managed to extend your pet’s quality of life. Please don’t forget to schedule your pet’s annual physical examination appointment with your veterinarian so your cat can live its’ best life.

Dr. Donna Solomon is a veterinarian at Animal Medical Center of Chicago and invites you to email her your questions or future topic ideas to [email protected]

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Republican Part-Time Nation: Going Involuntary

One of the lines the Republicans often used to attack Obamacare was complaining that it would lead to a massive switch to part-time work. The argument was that employers would cut all their workers to less than 30 hours a week. This would exempt them from the employer mandates in the Affordable Care Act (ACA). The line “part-time nation” was a regular refrain on Fox News and other conservative news outlets.

It didn’t turn out that way. The share of workers who are employed part-time is virtually the same today as it was when the ACA was fully implemented at the start of 2014. It turns out that covered employers, those with more than 50 workers, have more important issues to consider in scheduling their workforce than avoiding the ACA requirements. Of course, since more than 90 percent of these employers already provided health care for their workers, it is not surprising that they didn’t change their behavior.

However the aggregate numbers on part-time work conceals an important shift that has largely gone unnoticed. While total part-time employment has changed little over the three years the ACA has been in effect, there has been a huge shift from involuntary part-time work to voluntary part-time work.

The number of people who report that they are working part-time involuntarily — they could not find full-time jobs — has fallen by 2.2 million since December of 2013, the last month before the ACA took full effect. By contrast, the number of people who report that they are working part-time because they have chosen to work part-time has risen by more than 2.4 million. Both parts of this picture are good news and almost certainly are attributable to the ACA.

The reason the ACA increased voluntary part-time employment is that the exchanges allowed people to get insurance without having to rely on an employer. Typically employers require people to work full-time in order to get health care insurance.

As a result, many people who would rather work part-time jobs, such as parents of young children and older workers nearing Medicare age, were forced to work full-time jobs to get health care insurance. This was especially likely if they or someone in their family had a serious medical condition that would make insurance very expensive or unobtainable.

In an analysis done the first year after the exchanges were in operation, Cherrie Bucknor and I found that voluntary part-time employment was up by more than 8.0 percent among young mothers. A separate analysis found that voluntary part-time employment was up by almost 5.0 percent in 2014 for the workers between the ages of 55-64 who are still too young to qualify for Medicare.

This is one of the major unsung successes of Obamacare. Millions of people who wanted to work part-time jobs so they could spend more time with young children now have the option to do so. Similarly, many older workers, some who are in bad health, now have the ability to cut back their hours and still get affordable health care insurance.

The flip side of the movement to voluntary part-time employment was also good news. The decision by millions of people to voluntarily leave full-time jobs to take part-time work opened up these jobs for people seeking full-time employment. Since the ACA, the rise in voluntary part-time employment closely mirrors the decline in involuntary part-time employment. People who needed full-time jobs were now much more likely to get them.

We can expect this story to go in reverse with the Republicans’ repeal of Obamacare. Young parents and older people in bad health who would prefer to work part-time will again be forced to get full-time jobs so that they can get insurance through their employer. When these workers take full-time jobs, it will displace workers who want and need full-time employment. There may be little net change in part-time employment under the Republican plan, but fewer of the people who will be working part-time will be people who actually want part-time employment.

Extending health care insurance to 20 million people was a really big deal and an important driver for the ACA. Arguably an even bigger deal was providing security to people who already had insurance.

The surge in voluntary part-time employment was evidence of this security, as was a 6.0 percent jump in the number of people who are self-employed. But providing security to the nation’s workers is obviously not the Trump-Ryan agenda.

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Protecting Medicaid’s Promise

With the start of the new Congress and new Administration, health care policy is on the front burner in Washington. The future is very uncertain, and the stakes are high. Health care touches all of us and affects nearly 20% of the U.S. economy. AARP is very focused on making sure any health care reforms protect older Americans and their families, particularly from rising costs that push many to the brink. We are especially concerned about plans for Medicaid, which provides health care and long-term services and support coverage for millions of Americans, including 17.4 million low-income seniors and people of all ages who have disabilities.

For these individuals and their families, Medicaid is a vital lifeline. Without it, they would not be able to afford health care, nursing home care, or the help they need to live independently in their homes and communities. Because they have chronic conditions or disabilities, many need ongoing assistance for life’s daily tasks – such as eating, bathing, dressing – as well as support managing medications, getting to and from doctor’s appointments and more.

Many people think Medicare covers this kind of long-term care. It doesn’t. In fact, Medicaid is the main source of funding for this kind of support.

To be sure, Medicaid is complicated. It’s a federal-state partnership where states provide a package of services to qualified individuals based on federal guidelines. Today, everyone who meets the criteria knows that their health care will be covered. In return, the federal government picks up part of the tab, sharing the actual cost of services with the states. The cost-sharing formulas and other details are very complex, but that’s it in a nutshell.

One of the proposals on the table in Congress is to “block grant” the Medicaid program – that’s Washington-speak for providing each state with a fixed sum of money and significantly fewer, if any, restrictions or guidelines on how they spend it.

There are a number of problems with that approach.

First, if the federal government decides in advance how much money to send out to states, there’s a good chance that, at the end of the day, it won’t be enough to cover actual costs. Things like rising health care costs, more people who need Medicaid assistance because of an economic downturn, or emerging acute health needs like the Zika outbreak or opioid addiction are hard to predict ahead of time. So what happens if the federal outlay is insufficient? States would need to cover the difference out of their own coffers or cut services to those most in need.

And, a block grant approach means that individuals who currently are guaranteed access to care – for example, an older American of modest means with Alzheimer’s or a child with a severe disability – would no longer have the assurance that their needs would be covered.

That’s why AARP opposes block granting Medicaid. It would end the individual guarantee of coverage and cut services for America’s most vulnerable citizens while shifting a lot more cost of providing care to states and their taxpayers.

As Congress considers changes to Medicaid, one common-sense approach is to give states more flexibility under the program to provide home and community-based services- things like home care aides, durable medical equipment and adult day-care – without a lot of red tape and restrictions, the same way they currently provide nursing home care. Our AARP surveys show that 90 percent of older adults want to stay in their own homes and communities as they age. We also know that providing home and community based services is cost effective. On average, the per person cost of services delivered in homes and communities under Medicaid is one-third the cost of institutional care. This seems like a win-win – a way to help people they way they want to be helped while reducing overall costs.

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Free at Last: HIV, Parenthood and Caregiving

I’m not a parent. I have three nephews, however, and I’m happy having the role of uncle. I wasn’t always satisfied with being childless. In fact, one of my early struggles with having HIV was mourning the loss of potential parenthood.

Fortunately, when it comes to being a mother or a father, things are much different now for people living with the virus. The chance of passing on HIV to your child through conception has been virtually eliminated by the use of biomedical prevention, which includes pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP).

2017-02-13-1487010354-4515126-POZMarch2017.jpgThese two science-based methods are now solid prevention options for mixed-status couples considering conception. However, just as with PrEP and TasP in general, the understanding that both methods prevent transmission of the virus for potential parents and children is not yet widespread. Dispelling misconceptions about conception and HIV is needed.

That is why two babies–Memory Amya Hunte and Mila Vreeland–grace the cover of this issue of POZ. Memory’s parents relied on TasP, and Mila’s parents used PrEP. Both babies were born free of HIV, and each of the HIV-negative parents stayed that way. Click here to read more about their stories.

Although it’s true that children and caregiving are stereotypically associated with women, it’s also the case that both are important to all people regardless of gender. Babies need care, no matter who is giving it. As it turns out, babies aren’t the only ones who need care among those affected by HIV.

In the early years of the epidemic, caregiving was primarily about easing the suffering of those who were dying followed by tending to those with serious HIV-related conditions that too often led to death. There just wasn’t much time for thinking more broadly about caregiving. People were dying.

As the decades passed, it seemed that the need for caregiving on a mass scale was over, thankfully. People weren’t dying in the numbers they once were. Too many people still succumbed to the virus, but the era of caregiving related to HIV/AIDS was in the past–or so we thought. Long-term survivors are now proving that assumption to be wrong.

The long-term effects of having survived the trauma of the early years of the epidemic have finally surfaced in the past few years. The symptoms vary, but the similarities to posttraumatic stress disorder are striking. Depression, isolation and survivor’s guilt are wreaking havoc. The nature of caregiving now is certainly different, but the need is real and urgent. Click here to learn more.

Women represent about a quarter of people with HIV in the United States, yet still they often struggle for visibility. Further, women have unique HIV concerns, from the obvious anatomical differences to the sometimes less obvious obstacles like sexism and economics.

As a result, advocacy groups such as WORLD (Women Organized to Respond to Life-threatening Disease) seek to spotlight the needs of women living with HIV. Click here to read our Q&A with Cynthia Carey-Grant, WORLD’s executive director.

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