Trump Administration Pretends to Care About Health Insurance in Order to Restrict Immigration

The Trump administration’s latest attack on immigrants uses medical care as a tool to deny visas to all but the wealthiest applicants. In a proclamation issued last Friday, October 4, the government announced that it will require those seeking a visa to enter the United States to prove that they will have health insurance within thirty days of arrival or the funds to pay for medical expenses. The proclamation, which is set to take effect on November 3, will primarily affect immigrants sponsored by family members and recipients of the diversity visa lottery program. Experts estimate that it could bar 375,000 people each year who qualify under the current system, blocking nearly two-thirds of those who apply for green cards from abroad.

The proclamation doesn’t outline standards for deciding how those seeking visas would satisfactorily demonstrate financial means; it will be up to consular officials to make the determination. But it does specify the types of insurance that will count toward the requirement that an immigrant have health insurance once in the United States. Unsubsidized marketplace (ACA) plans, employer-provided coverage, short-term plans, association health plans, and catastrophic plans will all count; Medicaid and subsidized marketplace plans will not.

As its rationale, the Trump administration cites high uninsured rates among immigrants, which result in care for which hospitals and providers go uncompensated; these costs, it claims, are passed on to “the American people” in the form of higher taxes, higher premiums, and higher costs for medical care. In fact, studies have not shown that the costs of uncompensated care result in higher insurance premiums for the insured. Hospitals bear much of the burden, with the federal government picking up most of the tab.

It is true that immigrants are more likely than citizens to lack health insurance: 23% vs. 8% for non-elderly, legal immigrants, according to the Kaiser Family Foundation. But immigrants, overall, have less access to health insurance than those born in the US. Legal immigrants, for instance, are subject to a five-year waiting period for Medicaid.

The Trump administration’s ruse of using health insurance to restrict legal immigration is completely nonsensical as a strategy to hold down costs. It is, instead, a barely disguised attack on people of color and the working and middle classes. If the administration were genuinely interested in reducing the cost of health care, it would stop its constant undermining of the Affordable Care Act and its support of states’ efforts to trim Medicaid rolls by, among other things, imposing additional eligibility requirements. States that expanded Medicaid under the ACA actually had a greater decline in uncompensated care costs and a reduced risk of hospital closures than non-expansion states.

Medical care and insurance premiums are undoubtedly too expensive, and the Affordable Care Act does nothing to address escalating costs. Due to political pressure, the Affordable Care Act passed without a public option. Instead, twenty-three non-profit coops (Consumer Operated and Oriented Plans) were supposed to serve as a check on prices. The coops ran into financial trouble almost immediately. Many set their premium prices too low and found themselves with large pools of patients who needed more expensive care than anticipated, while others had trouble attracting subscribers. $10 billion in grants promised by lawmakers turned into $3.8 in loans several years later. By early 2019, nineteen of the original twenty-three coops had failed, leaving just four in operation. Furthermore, while the coops might have served as a control on the price of insurance premiums, they did nothing to address directly the cost of care: medications, diagnostic tests, surgical procedures, emergency room services, and so on.

The solution is not to force immigrants to pay out-of-pocket for needed care or to purchase bare-bones coverage to meet an arbitrary governmental requirement. Rather, the goal should be to reduce costs and expand access to affordable coverage so people who need medical attention can get it at rates they can actually pay. If the real problem is high costs and high prices, then the administration should work on bringing these down for everyone. Blaming immigrants for the failures of our health care system is neither a sound public health strategy nor a viable immigration policy.

Measles and Vaccine Hesitancy

Last month, Mayor Bill de Blasio declared a public health emergency in New York City in response to a measles outbreak that has sickened hundreds in ultra-Orthodox Jewish communities since last fall. His requirement that unvaccinated individuals in Williamsburg and Borough Park, Brooklyn submit to mandatory vaccinations or face possible fines brought to light the tension between civil liberties and community welfare that underlies the basic principles of public health.

As I wrote here several years ago, vaccines have easily been one of the major public health successes of the twentieth century, especially for the childhood diseases that were once leading causes of mortality. Instead of dying from diphtheria or rubella, we’re now vaccinated against them. Other illnesses such as polio and chicken pox that are not necessarily fatal but could cause lifelong complications are now avoidable with a series of immunizations.

Yet despite these victories, rates of vaccine-preventable diseases, notably measles, continue to rise. According to the Centers for Disease Control, there were 75 new cases of measles across the country last week, for a total of 839 cases so far this year, already double the entire number for 2018.

When a measles outbreak hit California in late 2014 and early 2015, the state responded by tightening its restrictions. At the time, it allowed parents to opt out of vaccines for personal reasons; now, it allows exemptions only for medical reasons. States that allow fewer exemptions generally experience fewer outbreaks. In Oregon, for example, which has been affected this season by an ongoing measles outbreak next door in Clark County, Washington, parents are still permitted to decline vaccinations for philosophical reasons; they can self-certify their status as objectors by watching a video module online and printing out and signing a form.

Although numerous studies have debunked any link between vaccines and autism, including one in Denmark published this spring, vaccine hesitancy remains so alarming that the World Health Organization declared it one of the top ten threats to global health in 2019, along with climate change, antimicrobial resistance, and weak primary health care. Parents in the United States who resist vaccinations are not necessarily uneducated or ill-informed; more often, they’re getting their information from a set of sources that confirm what they’re already likely to believe. In ultra-Orthodox neighborhoods in New York City and surrounding counties, anti-vaccination handbooks and pamphlets have been circulating and spreading misinformation within the insular community. In Oregon and Washington, middle-class parents who distrust big pharma and chafe against governmental interference are likely to encounter in their communities like-minded peers who reinforce their views.

One of the obstacles in overcoming to vaccine hesitancy is the inherent difficulty of proving a negative. Scientists will state a lack of correlation between vaccines and adverse health consequences, but for methodological reasons won’t claim that the former never causes the latter. To parents who resist vaccinations because of (discredited) fears of autism, the danger lies in the risk of triggering the disorder. This risk, in its uncertainty and unknowability, is more frightening than the disease against which the vaccine is designed to protect.

Several months ago, I was chatting with a recently married young woman, who told me that she and her husband weren’t sure they would vaccinate their children when the time came. They both, she said, personally knew of kids who were never the same after receiving childhood immunizations, whose personalities changed from outgoing and sociable to withdrawn and introverted. I trotted out the standard scientific and public health arguments in favor of vaccination, but she remained unmoved. It reminded me of the challenge of arguing against the evidence of personal experience, of trying to convince someone that what he or she has witnessed firsthand might be unreliable. It’s hard to argue a contrary position when the cause-and-effect seems so convincing. And how certain can one really be that the former didn’t result in the latter? Such are the complexities of countering vaccine hesitancy.

The battle against vaccine hesitancy will necessarily be multifaceted, and must include broad educational campaigns as well as one-on-one outreach. But governmental mandates play an important role, as well. We enjoy many rights in this society, allowing us to live, speak and assemble with a great deal of freedom. The right to endanger others with a dangerous and easily preventable disease should not be among them.

An End to HIV by 2030?

In his recent State of the Union speech, President Trump made an ambitious pledge in the area of public health: to eliminate the HIV epidemic in the United States within ten years. The actual plan, released that week by the Department of Health and Human Services, aims to end new HIV infections by 2030. HHS proposes to do this by targeting “geographic hotspots”: forty-eight counties, plus Washington, DC and San Juan, Puerto Rico that account for more than 50 percent of new HIV diagnoses, as well as seven states with high rates of infection in rural areas. The plan calls for diagnosing the disease quickly, starting treatment as soon after as possible afterward, and increasing the use of PrEP (pre-exposure prophylaxis), a medication for people at high risk for HIV.

Researchers and HIV/AIDS advocates call the initiative aggressive but achievable, as all of its medical components—diagnostics, anti-retroviral therapies, PrEP—have been available for some time. However, many remain skeptical of the Trump administration’s actual level of commitment to ending HIV, given its ongoing assault on LGBTQ communities, immigrants, and people of color, populations with high rates of new infections. Furthermore, the administration has continually attacked and undermined the Affordable Care Act and Medicaid, making health insurance both more difficult to obtain and more expensive to use. Premiums continue to rise, and seven states have implemented work requirements that have had the effect of kicking people off Medicaid, with applications pending in eight more.

As both a social and a medical endeavor, public health must engage communities, where local norms and cultural attitudes can affect disease transmission. Take for example the recent measles outbreak in Clark County, Washington, a state that allows exemptions to mandatory vaccinations for medical, religious, and philosophical reasons. As NPR has reported, some schools have vaccination rates under 40 percent, rather than the 90 percent or so required for a community to be protected. Parents who are responding to inaccuracies and rumors on social media and from other parents forego vaccinations for their children, placing entire communities at risk. Combating such fears requires not only a tightening of applicable laws, but also a campaign to address vaccine misinformation in locations where it can itself spread like a virus.

If the Trump administration is truly committed to eradicating HIV, then it must combine social with medical approaches. It’s not enough simply to diagnose more people and subsidize new PrEP prescriptions. Resources must also go toward affordable housing, nutrition assistance, and counseling to ensure that patients are emotionally supported and are adhering to regimes of treatment. Stigma and discrimination remain obstacles to meaningful care in affected populations; any far-reaching plan must tackle social attitudes among those affected, including families and healthcare providers. We may have in hand the medical tools to end new transmissions, but success will not rest on these components alone. The Trump administration must understand this if it genuinely wants to succeed in its goal.

Addiction News: E-Cigarettes vs. Nicotine Patches; OxyContin and Recovery

Here are two recent noteworthy items in addiction news.

In Smoking Cessation, E-Cigarettes Trade One Form of Nicotine Addiction for Another

A study by British researchers published last week in the New England Journal of Medicine found that e-cigarettes were nearly twice as effective as traditional nicotine-replacement methods at helping smokers to quit. After one year, 18 percent of e-cigarette users were still not smoking, compared with about 10 percent of those who used nicotine patches, gum, lozenges, and inhalers. Without any kind of aid, the success rate for smoking cessation is around 3 percent.

The downside of using e-cigarettes to quit is that people often ended up addicted to them. Vaping is less harmful than lighting up a conventional cigarette, which contains numerous toxins including tar, formaldehyde, arsenic, and carbon monoxide. In terms of harm reduction, e-cigarettes are an improvement over regular cigarettes. But nicotine itself is a highly addictive chemical that can be lethal in concentrated doses; for centuries, it has been used as an insecticide. Furthermore, vaping products often contain flavoring agents to make them taste of mint or cinnamon or different kinds of fruit, and no long-term studies have been done on their safety.

When e-cigarettes were first introduced in the US a decade or so ago, I wondered if they would re-normalize the act of smoking—or inhaling a nicotine-laden vapor—in a culture where it had become increasingly disparaged. E-cigarettes are popular among young people and have been specifically marketed to them by manufacturers such as Juul, which until an FDA crackdown last fall, sold vaping pods in flavors of mango, cucumber, fruit, and creme at gas stations and convenience stores. Even if e-cigarettes may be useful in weaning some adults off tobacco, they’re not being used that way by young people. Instead, they’re introducing a new generation to nicotine addiction through an act that mimics conventional smoking, popularizing anew a behavior that public health advocates worked for decades to stigmatize.

OxyContin Maker Sought to Enter Addiction Recovery Business

In Massachusetts, attorney general Maura Healey has filed a lawsuit accusing Purdue Pharma, the manufacturer of OxyContin, of creating and perpetuating the opioid crisis. The suit claims that the company, and the Sackler family which controls it, aggressively marketed the medication while knowing that it was addictive, promoted higher doses to increase profits, and hired the management consulting firm McKinsey & Co. to boost its image in the fact of negative publicity. The allegations are disturbing and have been covered previously; Patrick Radden Keefe’s article in the New Yorker, in particular, is a comprehensive look at the Sackler family and how it made OxyContin into a blockbuster drug.

To me, the most intriguing part of the lawsuit is the allegation that Purdue Pharma at one point considered getting into the addiction recovery business. In an initiative code-named Project Tango, company executives and at least one member of the Sackler family proposed acquiring the rights to sell Narcan, a medication used to reverse overdoses, and Suboxone, which is used to treat opioid addiction. The project was later abandoned. But it highlights the ways in which actual people shaped the making and the contours of the opioid epidemic. Employees at the company and members of the Sackler family were aware of the growing crisis, yet they acted cynically and shirked any moral responsibility in perpetuating it, even aiming to profit off it by expanding their business to treat those who were suffering from it.

We often think of addiction in terms of individual behavior: a man who starts taking oxycodone to treat pain after a car accident and becomes dependent on it; a young woman who starts smoking to relieve stress and finds herself unable to quit. But those who work for pharmaceutical companies, cigarette manufacturers, and advertising agencies have played and continue to play an active role in creating and promoting desire for their products. They help to determine access to them, and, in the case of tobacco companies, cover up research about their harms. Addiction is a disease, but it doesn’t originate solely in brain chemistry or physiology. It exists within a broader social environment that affects one’s exposure to addictive substances, as well as one’s experiences of addiction and recovery. That’s why I find the lawsuit against Purdue Pharma so fascinating. It reveals the usually invisible workings of those individuals behind the scenes whose decisions affect people’s physical and emotional health in ways that are neither natural nor inevitable.