The GOP Health Care Bill is Cruel and Deceitful

This morning I’m trying to wrap my head around the cynicism and hypocrisy of the GOP health care bill, which was released last night. It preserves several of the most popular provisions of the Affordable Care Act, including allowing young adults to remain on their parents’ plan until the age of 26 and requiring insurers to cover those with pre-existing conditions. But in scrapping the individual mandate, killing the Medicaid expansion and eliminating income-based subsidies that help people buy insurance, the bill would rip away coverage from millions of people while doing nothing to keep costs down.

Republicans tout the “affordability” of their plan, but it looks to me that it will be just the opposite. Right now the ACA calculates subsidies based on age, income, and the cost of premiums in the local marketplace. The GOP bill would do away with these parameters and instead give flat tax credits determined by age bracket, from $2,000 for those under 30 to $4,000 for those over 60, even for higher-income earners who currently receive nothing under the ACA—up to $75,000 for individuals and $150,000 for couples. A 40-year old man in New Haven, CT with an annual income of $20,000 now receives a subsidy of $5,040 with the ACA. Under the Republican plan, his tax credit would decrease by 40% to $3,000, forcing him to come up with $2,040 out-of-pocket just to pay his premiums, assuming they stay the same. Many people receive additional subsidies to help cover the cost of copays; these would disappear. The GOP bill would give low-income people less financial assistance, while those who need it less would get more. It shifts money from the poor to the wealthy, all in the name of “affordability.”

Tom Mihalek, Reuters

The GOP bill would roll back the ACA’s Medicaid expansion by converting what is now an open-ended entitlement to a per-capita allotment to states. Funding wouldn’t necessarily rise as costs increase, and federal funding to states would be reduced starting in 2020.

In addition to “affordability,” the other watchwords that Republican lawmakers enjoy spouting are “freedom” and “choice.” In a tweet last month regarding the ACA, House Speaker Paul Ryan (R-WI) defined freedom as “the ability to buy what you want to fit what you need.” As his party sees it, if you want to spend your life not having health insurance, that should be your choice. Of course, all the GOP talk about “choice” is a smokescreen, because their plan does nothing to address it. Not having money to buy quality health insurance makes the lack of coverage not a choice, but an inevitability. In two other particularly egregious examples, Rep. Jason Chaffetz (R-UT) said, “You know what, Americans have choices … So maybe, rather than getting that new iPhone that they just love—and they want to go spend hundreds of dollars on—maybe they invest it in their own health care.” Last week, Rep. Roger Marshall (R-KS) told STAT News that some people “just don’t want health care.”

There’s no guarantee that the GOP bill in its current version will get through both houses of Congress. Conservatives dislike it because they think its subsidies are too generous, while four Republican senators have expressed misgivings about the rollback of the Medicaid expansion. And the Congressional Budget Office is still crunching the numbers to estimate costs and the number of people who will be affected. But it seems likely, given the bill’s provisions, that millions will lose their health insurance as it becomes unaffordable or they’re kicked off Medicaid rolls when states run out of money.

I find extremely disturbing the cruel cynicism of the GOP bill, as well as the contortions of lawmakers to spin it as an improvement over the ACA for the sickest and most vulnerable. What it reveals about our priorities as a nation is deeply troubling. It will make health insurance unaffordable for the vast majority of the 20 million Americans who obtained coverage under the ACA while shifting wealth to those who already have more. We are the only industrialized nation that does not have some kind of universal, single-payer health coverage for its residents; we have already signaled that we regard health care as a privilege for those who can afford it, not as a human right. The ACA has its problems, to be sure, but it has led to the lowest uninsured rates in American history. The Republican bill will increase wealth inequality, cause many to get sicker, and roll back the protections we have gained over the past six years of Obamacare.

Here’s some worthwhile additional reading: Sarah Kliff's summary of the bill in Vox, John Cassidy's commentary in the New Yorker, Jonathan Chait’s piece in New York Magazine’s Daily Intelligencer, and Michael Hiltzik’s blistering analysis of the GOP bill in today's Los Angeles Times. The Kaiser Family Foundation has excellent, in-depth coverage of health care reform, including interactive charts to calculate subsidies under the ACA and various GOP plans.

The Gutting of the Affordable Care Act

A number of people have asked me if I’m watching the impending annihilation of the Affordable Care Act as the new administration gears up to take office this week. The answer is yes, both because I’m interested in public health and health policy and because I get my own health insurance through the ACA. The assault on the law is already underway, and the consequences will be dire. For those of you who are concerned about what’s happening and what could happen but haven’t been following the news that closely, here’s a primer.

·      Although House Speaker Paul Ryan and President-elect Donald Trump have been crowing for months about repealing Obamacare, they don’t have enough votes to overturn the law outright. In the Senate, where Republicans have a 52-48 majority, they’d need 60 votes to overcome a Democratic filibuster. This means that eight Democrats would have to vote to repeal the ACA, which is extremely unlikely.

·      Since the Republicans lack a filibuster-proof majority in the Senate, they’ve chosen instead to gut major provisions of the ACA through a process called budget reconciliation. In short, this process allows them to get rid of sections of the law that are funded through the federal budget, but only those sections. They can reverse the Medicaid expansion. They can rescind the subsidies that most consumers receive to purchase insurance on the exchanges. They can also repeal the individual mandate to buy insurance. Both the House and the Senate voted last week to approve budget measures that will allow them to take these actions.

·      The Affordable Care Act is more than a program that allows individuals to purchase insurance plans through state exchanges. It contains a number of provisions that affect everyone who has health insurance, whether through an employer or on the individual market. These features of the law appear to be safe for now, because they’re untouchable through the budget reconciliation process. But it’s unclear whether they’ll ultimately be at risk. They include:

o   Free coverage of preventive services, including mammograms

o   Free coverage of birth control

o   Allowing young adults to remain on their parents’ health insurance until the age of 26

o   No denial of coverage for pre-existing conditions

o   An end to lifetime caps on how much an insurer pays to cover someone, which is crucial for those with conditions that are costly to treat

·      Republican leaders have proposed several ideas that they claim will provide people with better coverage at lower costs than Obamacare. They include:

o   Increased use of Health Savings Accounts. HSAs, however, are not the same as health insurance; they simply allow individuals to move pre-tax dollars into an account that can be used to pay for medical expenses out-of-pocket. They do nothing to ensure access or affordability.

o   Allowing insurance companies to sell policies over state lines. However, out-of-state insurers would probably just end up buying into existing networks of providers, so it wouldn’t actually improve anything. In addition, states have varied requirements for minimum coverage. New York State, for example, just passed a bill (which is not yet law) that provides free birth control coverage for women. Therefore, insurers would probably choose to sell their policies in states with the least, not most restrictive requirements.

·      Republicans, including Tom Price in his confirmation hearing today, have been asserting that no one will have their health insurance pulled out from under them when the ACA is gutted. They’ve said they will replace it with a plan that has people “beautifully covered,” to quote Trump. But the timing of Obamacare’s replacement is uncertain, as no one has offered a detailed blueprint of what it will look like, and health economists agree that it would be impossible to design a plan that offers better coverage and is cheaper for both individuals and the government than what we have now. An immediate repeal of the ACA’s individual subsidies would throw the insurance market into chaos, as companies would pull out to avoid the uncertainty that is sure to follow, since no one knows what the replacement plan will look like and when it will come.

The Affordable Care Act expanded health insurance coverage to 20 million Americans, although about 25 million more remain uninsured. Despite the law’s problems—high deductibles, rising premiums, small networks of providers, limited choice of plans in many parts of the country—removing its protections from those who need them strikes me as inhumane. The nonpartisan Congressional Budget Office released a report yesterday which said that a repeal of the ACA would cost 18 million people their insurance in the first year alone. We’ll probably never have single-payer health insurance in the U.S., as in every other industrialized country. But until we can implement a program that increases access while controlling costs, we have to work on improving what we’ve got, not destroying basic protections that are saving lives.

Zika and Risk

As the Zika virus spreads north from Latin America, Central America and the Caribbean, the list of public health recommendations and scientific unknowns continues to grow. Zika is not new; it was first identified in 1947 in Uganda, and although scientists have found consistent evidence of antibodies in primates since then, few documented cases were reported in humans until recently. Current statistics are grim: the virus has now been confirmed in over thirty countries in the region, with hundreds, perhaps thousands of additional cases likely in the coming months as mosquito season peaks in the Northern Hemisphere.

Although Zika has been linked to a number of health issues, including fever, joint paint, and Guillain-Barré syndrome, most adults who are infected will have mild symptoms, if any, and no lasting effects. The risks for pregnant women, however, are more severe. The virus has been found to cause microcephaly, a condition in which babies are born with abnormally small heads, leading to brain damage and developmental issues. Mounting fears of a virus for which no vaccine or cure exists are prompting increasingly dire warnings from public health agencies, including the World Health Organization, which recommends that pregnant women avoid traveling to areas of ongoing Zika transmission. Officials in a number of affected countries have advised women to postpone pregnancy for a period of months or years; in El Salvador, health ministers have told women not to get pregnant until 2018.

While we know that Zika causes microcephaly, a deeper understanding of the ways in which the virus works is severely lacking. Take the following catalog of unknowns from the website of the Centers for Disease Control:

"If a pregnant woman is exposed

• We don't know how likely she is to get Zika.

If a pregnant woman is infected

• We don't know how the virus will affect her or her pregnancy
• We don't know how likely it is that Zika will pass to her fetus.
• We don't know if the fetus is infected, if the fetus will develop birth defects.
• We don't know when in pregnancy the infection might cause harm to the fetus.
• We don't know whether her baby will have birth defects."

While I’m by no means trying to minimize the implications of having a baby that tests positive for Zika or a child with microcephaly, I find that the uncompromising public health recommendations around the virus’s transmission are a reflection less of the absolute risk to a pregnant woman (which we lack the information to conclusively determine) than of the inadequacy of what medicine can offer in the event of infection. The anxiety surrounding the virus is understandably based in fear and uncertainty, as pregnancy is a 40-week state of perpetual uncertainty that entails a constant balancing of input versus outcome. As with alcohol and caffeine, which pregnant American women are advised to avoid entirely, there is no safe level of exposure to Zika; one must assume that a developing fetus is at risk, even if the mechanism of infection is not fully understood.

I realize that the calculation of risk will be different for women who travel to areas of active Zika transmission and those who reside there. I’m also aware that birth control and abortion are not available to most women in a number of affected countries, including Brazil, and sexual violence and coercion mean that many women are not fully in control of their sexuality. Zika may not be a new disease, but it is a newly emerging threat, and millions of women who are pregnant, thinking of becoming pregnant, or simply of childbearing age will have to weigh questions of risk and responsibility as they make essential decisions about travel and reproduction.

Football and the Risk of Concussion

I’ve been thinking a lot about risk lately. In medicine and public health, it’s an idea that’s always present, usually invoked toward the goal of disease prevention. Over the years, the ways in which the concept of risk has been put forth have changed as the major causes of mortality have shifted from infectious to chronic disease. In the eighteenth and nineteenth centuries, an epidemic of cholera or yellow fever might have been seen as a way to separate acceptable citizens from unacceptable, the latter premised on some combination of ethnicity, race, religion, class and moral principles. More recently, public health recommendations have focused on lifestyle practices that can reduce our risk of developing cancer, heart disease, and other chronic illnesses with multifactorial causes.

I’m interested in how we experience risk and how this shapes the decisions we make about what to eat, where to live, the types of behaviors we engage in and the situations we’re comfortable with. How does each of us choose to respond to a series of unknowns about, for instance, the dangers of genetically modified food, the possible link between cellphone radiation and cancer, or the relationship between pesticides and hormonal imbalances? If Alzheimer’s disease runs in your family, what do you do to decrease the chances you’ll develop it? If you’re diagnosed with a precancerous condition that may or may not become invasive, do you remove the suspicious cells immediately or wait to see if they spread? What does it mean for our bodies to be constantly at risk, under threat from sources both known and unknown that we cannot see or regulate?

In the upcoming months, I’ll be exploring these ideas and more in a series of essays on risk. My premise is that the ways in which we choose to deal with risk are fundamentally about control, and are aimed at addressing the illusion that we have command over disease outcomes in a world ruled by randomness and unpredictability. Cancer screenings, lifestyle habits, and the other behaviors we adopt to stay healthy are an attempt to reduce our risk, to make the uncertain certain, to bring what’s unknown into the realm of the foreseeable. As a way of managing the future, this approach assumes a linearity of outcomes; if I engage in x behavior, then I will prevent y disease. It assumes that illness can be reduced to a series of inputs and corresponding outputs, that wellness is more than a game of chance or a spin of a roulette wheel. The boundaries of what we consider reasonable measures to embrace for the sake of our health will differ for each of us based on our individual tolerance for ambiguity and what we consider an acceptable level of risk. As I delve into an investigation of the relationship between risk and health, the underlying question I’ll be concerned is this: what level of uncertainty can each of us live with, and how does it affect our behavior?

So here goes, my first essay in an ongoing series on risk.

With the Denver Broncos’ 24-10 victory over the Carolina Panthers in Super Bowl 50, the 2015 football season came to its much-hyped conclusion. I didn’t watch the game, but I have been following closely any public health news involving the National Football League. Just days before the Super Bowl, the family of Ken Stabler, a former NFL quarterback, announced that he suffered from chronic traumatic encephalopathy (CTE), a degenerative brain disease that can trigger memory loss, erratic behavior, aggression, depression, and poor impulse control. The most prominent quarterback yet to be diagnosed, Stabler joins Junior Seau, Frank Gifford, Mike Webster, and over 100 former players found to have the disease, which is caused by repeated brain trauma and can only be determined after death by a physical examination of the brain. Retired NFL players suffer from numerous chronic injuries that affect their physical and mental well-being: in addition to the multiple concussions, there are torn ligaments, dislocated joints, and repeated broken bones that can no longer effectively be managed by cortisone injections and off-the-field treatments. Many athletes end up addicted to painkillers; some, like Seau, commit suicide or die from drug overdoses, isolated from family and friends. One particularly moving article in the New York Times profiled Willie Wood, a 79-year old former safety for the Green Bay Packers who was part of the most memorable play of Super Bowl I, yet can no longer recall that he was in the NFL. And incidents of domestic abuse against the partners and spouses of players continue to make headlines, including the unforgettable video of Ray Rice knocking his girlfriend unconscious in an elevator at an Atlantic City casino.

Despite these controversies, football remains enormously popular in the United States. Revenue for the NFL was $11 billion in 2014, and league commissioner Roger Goodell pocketed $34 million in compensation that year. The NFL has managed to spin the concussion issue in a way that paints the league as highly concerned about player safety. Goodell touts the 39 safety-related rules he has implemented during his tenure, and the settlement last fall in a class-action lawsuit brought by former players set up a compensation fund to cover certain medical expenses for retired athletes (although some criticized the deal because it doesn’t address symptoms of CTE in those who are still alive). Increasing awareness of the danger of concussions has prompted discussions about how to make the game safer for young athletes. One approach that’s been floated is to have players scrimmage and run drills without helmets and protective padding, forcing them to treat each other gently in practice while saving the vigorous tackles for game day. The Ivy League just agreed to eliminate full-contact hitting from all practices during the regular season, a policy that Dartmouth College adopted in 2010. And earlier this week, the NFL’s top health and safety official finally acknowledged the link between football and CTE after years of equivocating on the subject.

But controlled violence is such a central aspect of football that I wonder how much the sport and its culture can be altered without changing its underlying appeal. Would football be a profoundly different thing with the adoption of protocols that reduce the likelihood of concussions and other injuries? How much room is there for change within the game that football has become? Players continue to get bigger and stronger, putting up impressive stats at younger and younger ages. My friend’s nephew, a standout high school player in Texas and a Division I college prospect, was 6’2” and weighed 220 pounds when he reported as a freshman for pre-season training—numbers that I imagine will only expand as he continues to train, and ones that players around him will have to match in order to remain competitive.

With mounting knowledge of the link between football and degenerative brain disease, I’m interested in the level of risk that’s acceptable in a sport where serious acute and chronic injuries are increasingly the norm. In a recent CNN town hall, Florida senator Marco Rubio asserted that football teaches kids important life lessons about teamwork and fair play, and pointed out that there are risks inherent in plenty of activities we engage in, such as driving a car. True enough, but driving a car is an essential part of daily life for many of us, which means that we have little choice but to assume the associated risks. Football is voluntary. I realize that for some, football is less than completely voluntary, from children who face parental pressure to professional athletes who feel compelled to remain in the game because they’re supporting families or facing limited options outside the sport. Still, playing football is an acquired risk to a greater degree than driving or riding in a car, the dominant form of transportation in our suburbanized communities. And if risk reduction is about attempting to control for uncertainty, then the accumulating evidence about CTE and other severe injuries is sure to change the calculus of how parents and players assess participation in a sport where lifelong mental and physical disabilities are not just possible, but probable.