The well-respected Commonwealth Fund has revisited earlier studies, finding anew that the United States “spends more on health care as a share of the economy — nearly twice as much as the average [industrialized Western European] country — yet has the lowest life expectancy and highest suicide rates among the 11 nations. The U.S. has the highest chronic disease burden and an obesity rate that is two times higher than the average [in comparable Western industrialized and European countries.] Americans had fewer physician visits than peers in most countries, which may be related to a low supply of physicians in the U.S. Americans use some expensive technologies, such as MRIs, and specialized procedures, such as hip replacements, more often than our peers. Compared to peer nations, the U.S. has among the highest number of hospitalizations from preventable causes and the highest rate of avoidable deaths.”
Even while spending more than any other nation on health care and getting poorer outcomes, which Americans bear the heaviest burdens of the system’s costs? Here’s what researchers at the nonpartisan and independent RAND Corporation have found in a newly published study:
“Higher-income American households pay the most to finance the nation’s health care system, but the burden of payments as a share of income is greatest among households with the lowest incomes … Households in the bottom fifth of income groups pay an average of 33.9% of their income toward health care, while families in the highest-income group pay 16% of their income toward health care … Previous research has examined the distribution of health care financing, but the new RAND study considers payments made to finance health care, the dollar value of benefits received, and the impact on different groups by age, source of insurance and size of income. The RAND study also is the first to consider the burden of health costs among people who are in nursing homes and other institutions, a calculation that led to higher estimates of health spending. The burden is particularly large on low-income people who need long-term care because in order to qualify for public benefits they must first spend most of their savings.”
Now what has been the Trump Administration’s response to the persistent problem of health care’s sky-high cost, weak outcomes, and disproportionate burdens of those least able to afford this all?
Why, of course, in the wealthiest country on the planet, let’s slash programs that try to help the poor, sick, elderly, and children.
This is occurring in two recent ways, with attacks on Medicaid and Social Security.
A bureaucratic hit on Medicaid
The administration assault on Medicaid may be wonky and hard to follow, because it involves a trade-off and the use of block grants to states. Under a GOP-cherished plan, states would vow to offer more residents health coverage under Medicaid, in exchange for receiving a fixed amount from the federal government in a block grant, which would come with fewer strings on how the money would be spent.
Critics assail this approach for two central reasons: It severs by administrative action the decades-old promise by Congress to decide how and to fund the Medicaid program, giving bureaucrats, instead, decision-making on the sums allocated by block grants to states. They also say that states that go this route likely will impose, as several already have tried, draconian eligibility requirements on beneficiaries, thereby slashing in actual practice the numbers of Americans receiving Medicaid.
Republicans, including in the administration, have tried to sell Medicaid “reforms” since the program was launched, always talking about allowing greater innovation and reducing bureaucracy. As recently as 2017, as part of the unceasing GOP attack on the Affordable Care Act, aka Obamacare, which expanded the Medicaid program, Trump officials talked up Medicaid changes, including the block grant plan. Advocates knocked that effort down, in part by making clear, as Money magazine did, who benefits from Medicaid and how — let’s reprise some of that:
“Contrary to popular belief, Medicaid is not just a benefit for low-income Americans. It’s actually the nation’s largest health care program, covering 74 million enrollees, or about one in four Americans. Some 60% of Medicaid’s spending is for the elderly and the disabled, many of whom come from middle-class households … Although they number only 15% of program enrollees, 40% of Medicaid spending goes to the disabled — and millions of families, many middle class, would suffer immeasurably if they alone had to carry these costs for loved ones with development disabilities, severe handicaps, and mental illnesses. Many of these Americans require costly, lifetime care. The elderly are just 9% of Medicaid participants but get 21% of program spending. Relatively few Americans, even those with means, adequately prepare for care when they’re old. Many run out of money, with 70% of nursing home residents ending up on Medicaid … Because Medicaid shoulders huge financial burdens for high needs Americans, the rest of us don’t see these sky-high costs factored into our health insurance, which is less expensive, accordingly.”
Let’s remember, please, that President Trump, notably, and the GOP continue to make an unacceptable and untruthful claim — that they support efforts to protect patients from insurers who would drop them or charge them more based on pre-existing health conditions. That protection, and others — including allowing parents to keep their kids on their health insurance up to age 26 and bars from insures imposing lifetime limits on benefits — are part and parcel of the ACA. And the administration and Republican attorneys general are locked in court still, seeking to kill Obamacare, including its pre-existing condition protections. The GOP has not proposed an ACA alternative, despite Trump assertions.
Meantime, while some states keep expanding the Medicaid program under the ACA, other governments have tried to burden the elderly, chronically ill, and poor and working poor recipients with paperwork and dubious work requirements. Media reports have shown these administration-approved requirements to be ineffective and costly, even as building research has shown health improvements in states that have expanded Medicaid versus those that have not.
A plan to slash Social Security disability rolls, too
Even as the administration is attacking Medicaid, officials also have made another bureaucratic foray to derail beneficiaries of Social Security disability benefits. This crucial coverage for those with severe mental or physical impairment go to 16 million Americans, about half of whom are poor and another half of whom have worked for at least a decade and paid into the government kitty for this worst-case economic lifeline. It is, for the record, not a snap to qualify for the program, with individuals and their loved ones needing to undergo rigorous review.
Trump officials have provoked an outcry, however, by proposing to review millions of disability cases, including forcing some of the most vulnerable among us to be subject to more frequent, burdensome eligibility checks. Opponents have reminded in Op-Eds that this plan costs as much as it purports to save, it proved disastrous under the Reagan Administration — which saw a similar plan rebuked and revoked on a bipartisan basis — and it does nothing but illustrate a bureaucratic cruelty to those in dire need (including patients on respirators, those in long-term care, and frail elderly).
(By the way, to get an appreciation of just how perilous life can be for the poor and beneficiaries of various programs under administration fire, the New York Times has posted a nifty interactive quiz online. Look at the mail stacked up on the kitchen counter and give it a try.)
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 health care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which prove to be dangerous drugs.
Republican claims about improving care, reducing costs, fostering innovation, and improving the efficiency and effectiveness of safety-net health programs, frankly, rings hollow when so many campaigns target the least among us. It is hard to watch one-time deficit hawks (oh, how those Tea Party dudes have changed their tune) and those espousing religious beliefs (charity for the weak and poor) rip and tear at social programs for the weakest, while emptying the public treasury with giant military budgets and astronomical tax breaks for wealthy companies and the richest few. Really, partisans: It pleases you to nip and tuck at the costs of health care while waving and cheering for adding $1 trillion-a-year to the national deficit for the next decade?
Trump, in recent days, has hinted that his administration has yet more plans to slash, too, at Social Security itself. With 10,000 baby boomers turning age 65 each day and for roughly the next two decades, such talk may be political dynamite — and the president has sought to walk back his comments.
The fall campaign and the voting — up and down the electoral ticket — will be as important as any time in recent memory. Get engaged, get out and vote.