President Trump’s 2021 budget proposal is thicker than an old-fashioned phone book. Lots of the document became little more than chaff the instant it was printed, due to the likelihood of big changes in the spending plan by congressional Democrats and lawmakers of the president’s own party.
The fiscal wish list, unsurprising at its contents were, may raise a big political question: How, with evidence like this, does the leader of the free world campaign on a counter-factual argument that his policies and practices protect and advance the health of the American people — a prime concern, pollsters say, of the voting public?
The $4.8 trillion Trump budget, for example, proposes to slash the Medicaid and food stamp programs by $1 trillion over a decade, with presidential critics noting the various, sometimes bureaucratic means to do so, ultimately, will reduce desperately needed social supports and throw millions of vulnerable Americans off aids for their health care. (Federal courts, including the appellate panel overseeing Arkansas, have rejected the latest way the administration and GOP states have sought to reduce Medicaid costs by imposing draconian work, reporting, and qualifying rules.)
Even as this occurs, of course, the administration still envisions a tsunami of red ink washing over the federal government, which, even with its rosy-eyed optimistic projections, would add $3.4 trillion to the national debt by 2024. This is due in large part due to the GOP’s decision to push through a $1 trillion-plus tax cut for the rich corporations and the wealthiest few.
The president has insisted that he is not hacking at the popular federal network of social protections. But, besides how his budget plan rips at Medicaid, the administration has proposed cost-reductions for Medicare. Budget wonks insist these for now don’t touch benefits in the senior health care plan and similar moves were suggested by the Obama Administration. Realists, however, may ask whether providers (hospitals and doctors) will blithely accept a cut of a little less than a half a billion dollars from Uncle Sam without somehow recovering such sums from patients? The president has walked back his remarks in an interview about whether Social Security might get on the chopping block, too, though it must be mentioned that his officials want to increase reviews of already difficult to obtain disability benefits under this program. That move could put a peril sustaining help for millions of Americans with severe mental and physical impairments.
Though Republicans long have attacked Medicaid, painting it as a program for lazy freeloaders, it has risen — particularly due to its expansion under the Affordable Care Act, aka Obamacare — as a bulwark not just for the poor but also for the working poor and the middle class.
Medicaid, for example, already provides major help to millions of seniors. That’s nothing to shrug at, with the U.S. Census Bureau reporting that, by 2060, a quarter or so of U.S. residents will be older than 65, and life expectancy will reach an all-time high of 85 years. The giant population of elderly baby boomers has failed to save well for retirement. How will they afford, for example, nursing home care when they need it without Medicaid help?
The Medicaid cuts were proposed, even as the federal Centers for Disease Control and Prevention, at long last, unveiled new, even worse than expected metrics for maternal mortality in this country. As the Pulitzer Prize-winning investigative web site ProPublica reported:
“Now, here it was, from the CDC’s National Vital Statistics System: 17.4 maternal deaths per 100,000 live births in 2018 — an estimated 658 lives lost. It was worse than the last official calculation, 12.7 deaths per 100,000 births, and it placed American maternal health outcomes where experts suspected they would land, worst among wealthy nations, and 55th among all countries, ahead of Ukraine but just behind Russia. The new U.S. rate was widely assumed to reflect the cutting edge of maternal mortality research. But as the Illinois experts [meeting in an already planned session] quickly discovered, there were gaping holes. The rate didn’t include the types of cases they had been reviewing that day — suicides and drug overdoses, which may not seem like it at first but are often linked to pregnancy and childbirth. It didn’t include new mothers who had died more than 42 days after giving birth, missing a huge chunk of relevant deaths. It underestimated the deaths of women 45 and older as well as those whose pregnancies had been overlooked by doctors and coroners.”
The CDC, it turns out, to keep apples and oranges comparisons, had its own data to show the terrible state of how America treats its new moms, but it could not roll those out without creating matching problems with global information provided by the World Health Organization. So, the United States, with awful stats, likely is underestimating its problems.
It also is not an understatement to say that Medicaid offers crucial assistance to moms most affected in pregnancies with risk, with the safety net program helping poor, working poor, and minority mothers.
It also is huge for middle class families, if they must deal with premature births, even if they have good health insurance through their employers, as the New York Times reported:
“The number of preterm births, or babies delivered earlier than 37 weeks, rose for the fourth year in a row in 2018, according to a November report from the National Center for Health Statistics. And as the number of preterm births rises, so does the number of babies in the neonatal intensive care unit. Even full-term babies of normal birth weight are increasingly likely to be admitted to the NICU, according to a 2015 study of babies born between 2007 and 2012. ‘I’ve been to a lot of NICUs and we’re partners with a lot of them. It’s rare to hear that a NICU is not at close to 100 percent capacity,’ said Stacey D. Stewart, the president and chief executive of March of Dimes. The March of Dimes estimates that the average societal cost of each preterm birth, which includes medical care, early intervention services and lost productivity, is $65,000. But there is very little research on the costs shouldered by families. For many families, Medicaid and Supplemental Security Income, or SSI (a program administered by the Social Security Administration that pays benefits to disabled adults and children), help cover the medical bills.”
Meantime, if the administrations slashes at Medicaid, how will millions of patients and their loved ones secure the mental health and medical services to deal with the nation’s opioid and overdose crisis? Hopes have run high that consolidated lawsuits against makers of the potent and addictive painkillers would provide desperately needed dollars for victims and their care. But “21 states are rejecting an $18-billion offer by McKesson Corp. and other opioid distributors to resolve nationwide litigation,” the Los Angeles Times and other news organizations have reported.
By the way, as the administrations tries in the weeks ahead to promote its health care efforts to voters, critics — especially Democratic presidential candidates — may make more hay over the hanging court case in which state Republican attorneys general and Trump officials have sought do kill the ACA. The lawsuit, opposed by state Democratic attorneys general, went up to an appellate court and back down to a conservative federal judge in Texas.
But Alex Azar, the head of the giant Health and Human Services agency, in congressional questioning, has conceded that, unlike what has occurred in past years, the administration did not dwell on an ACA repeal in the budget. Officials also won’t discuss what they might do about courts killing Obamacare or what a second-term Trump administration offer instead of the ACA.
Now, health policy and budget matters can make eyes glaze over — with reason. But at least one other aspect in the whopping Trump submission to Congress has raised more than the usual eyebrows: The president and his men say they want to see a new agency created to oversee tobacco use and vaping. Officials say the regulatory concerns and resource demands, now put on the federal Food and Drug Administration, put too much of a strain on an already busy agency. It may be hampering the bureaucrats’ oversight of the wealthy and powerful interests in Big Pharma and medical device makers.
Critics, however, say this idea is a nonstarter, because it would put any novel bureaucracy in the immediate and relentless target of Big Tobacco. Further, if the agency were launched in the Trump era, the president has now built a convincing record of putting industry executives, lobbyists, and ill-informed leaders to oversee too often the very enterprises in which they built their careers. The president also has picked chiefs who were outspoken about dismantling agencies he asked them to run.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This has become an ordeal due to the relentless increase in the cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.
Contrary to what some partisans may argue, the federal government has a significant role to play in Americans’ health, and it’s hard to figure other cuts that won’t be touched on here to medical and scientific research, environmental programs, and important programs to combat global disease, such as the viral outbreak in central China.
All of us need to keep calm, get informed, and to carry on a great American democratic necessity of voting this fall. These elections will demand more than ever that we be skeptical, open minded, careful researchers, and good neighbors, colleagues, and friends who might enlighten and disagree with us. A fundamental tactic that has been on fulsome display for almost a full term is repeating inaccurate information and claiming it to be true. Don’t buy falsehoods. We’ve got a lot of work to do in the next few months and beyond.