Trump Guts Healthcare on Global Scale

The Trump Administration while busy guilding everything in sight with gold and expanding the White House ballroom, has still managed to cause a massive curtailment in public health resources. Here is the list of his administration’s actions in order of priority, which are most deleterious to global health.   

Cutting billions in grants for medical research causing public universities and research groups to layoff thousands of scientists. These cuts include 16 billion in economic losses and 60,000 in jobs. Some of the research programs have been in existence for fifteen years and the lead investigators will take their programs to other countries to continue their work. France, Switzerland, and Canada are all global research centers. It is estimated the loss of these experts, value of medical technology and treatments generated by medical research will cause a permanent four percent reduction in GDP for the United States.

      Stopping the funding of USAID destined for disease prevention and treatment in the developing world, and demonically highlighted by the Trump Administration’s order to burn 9.7 million dollars of birth control products in Belgium, on August 7, 2025. This despite a U.S. based nonprofit’s offer to distribute the IUDs. hormonal implants, and birth control pills for free within the United States. Apparently, people in the Trump Administration are still confused on basic birth control, as none of these products were abortifants, the reason cited for their destruction. And where were these often life saving devices destined, to Africa, where lack of basic maternal health is rife and loss of life for mother and child is common. Albeit, thanks to the originalist conclusions of the U.S. Supreme Court, maternal deaths are on the rise here too. A further curtailment of Medicaid funding will only worsen the access for prenatal and postnatal care. Many maternal deaths occur after discharge from a hospital, where follow-up care is limited. When a tree falls in the forest and no one hears it, does it make a sound?

          Removal of clinical and scientific experts on the Food and Drug Agency (FDA) review board for approval of medical interventions, including drugs, which will result in more specious, extremely expensive, and dangerous treatments offered without due diligence in the United States. In June, HHS Secretary Kennedy fired all seventeen experts on the review board for vaccines, which were replaced by eight persons, including vaccine skeptics. (Mandavilli, 2025) This action undermines the credibility of the FDA for drug and treatment standards, which has been considered the gold standard globally.

      Direct cuts to public health programs including vaccine development, disease surveillance, and access to care will result in the closure of many clinics and hospitals in rural areas. The Trump Administration’s One Big Beautiful Bill Act (BBBA) disqualifies legal immigrants from Medicaid benefits eligibility and makes draconian cuts to Medicaid which will eviscerate coverage for 16 million people. (Mia Ives-Rublee, 2025) The crowning achievement of permanent tax breaks for the rich and claw-backs for the poor cuts Medicaid by a trillion dollars and only offers rural hospitals fifty billion in subsidies, which are not guaranteed and are subject to new constraints. Further the rural hospital subsidies are only budgeted for five years. Any state that reimburses more than the miserly Medicaid cap determined at the federal level will face funding cuts, further limiting resources and access to care. This is just another way for the Republicans to kill the Medicaid Expansion under the Patient Protection and Affordable Care Act, which has been adopted by 41 of the states. (Kaiser Family Foundation.org, 2025) It appears healthcare has been brought to its knees by nine predominately southern outlier states.

Republicans who voted for the bill essentially are ripping off their own people. It is estimated that 700 hospitals, about a third of all rural facilities will close. Here is a statewide list of rural hospitals that have the most at risk because of the shortsightedness of the Trump Administration Medicaid cuts. (Data is current as of July 2025)

 In this analysis, several states had no hospitals at risk of closure because of the BBBA.

 (Center for Healthcare Quality and Payment Reform, 2025)

Stopping the approval and funding of the highly effective Rna vaccines, which were developed quickly and saved thousands of lives during the Covid Pandemic, which was of course, preceded by appointing the anti-vaxer, with no medical background, Robert Kennedy, Jr. as Secretary of Health & Human Services. (Manadivilli, 2025)

          Further restrictions on access to birth control, reproductive rights, and maternal and child health, with a patchwork of state laws since the Trump appointed-Catholic dominated-Originalistic-Supreme Court overturned Roe-v-Wade in 2022. Women forced to fly outside their state of domicile to obtain urgent medical care during pregnancy complications, even those which are life threatening. Doctors are refusing to provide care for fear of losing their medical license in Idaho, Texas, and other states.

      Eviscerating healthcare savings to taxpayers if the healthcare entity donated to the Trump Campaign; case in point, overriding the Centers for Medicare and Medicaid decision not to reimburse for some of the outrageously costly and no more effective skin coverings for diabetic wound care. Because some of these products come under the biologic rulings, they are considered a new treatment and are more-or-less allowed to charge whatever they want, because the Medicare rules stipulate reimbursement at 6% of whatever the medical device company charges. Diabetic foot ulcers represent 16% of the total Medicare population, but the cost just for the skin coverings is over 10 billion annually for taxpayers. (Pinder, 2025) The Medicaid payment system does need reform, but allowing lobbyists in the medical supply sector to decide that outcome is not in the best interest of the nation. Other countries assess both the efficacy and the price of a medical treatment, weighed against what is currently available, for potentially less money before approval of a treatment device or drug. The U.S. government and the workers who contribute payroll taxes to pay for Medicare and Medicaid programs are not obligated to provide profitability for medical device, pharmaceutical, or medical supply companies. If the United States wants to reduce the cost of Medicare, it must adopt the evidence-based-practice recommendations for the most clinically and financially practical applications. Everyone does not drive a Rolls Royce or a Rivian and the government should not be expected to supply medical devices or applications that are unaffordable. Having a market rate reimbursement system saps resources from other primary health care needs, and for treatments which already have adequate substitutes.

 This article was written by independent journalist, Roberta Winter who received no compensation and is not intended to provide medical advice. Except, when agreeing to medical treatments of an inpatient variety, do stipulate that for which you consent and which you decline. If you do not have a medical directive or a POLST, get one. And this is the healthpolicymaven signing off.

References

Center for Healthcare Quality and Payment Reform. (2025). Rural Hospitals At Risk of Closure. Center for Healthcare Quality and Payment Reform. Center for Healthcare Quality and Payment Reform.org. Retrieved August 7, 2025, from ruralhospitals.chqpr.org

Kaiser Family Foundation.org. (2025, May). https://www.kff.org/statedata/collection/measures-to-identify-states-at-greater-risk-if-federal-medicaid-spending-is-reduced/. Retrieved August 7, 2025, from https://www.kff.org/affordable-care-act/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&selectedDistributions=status-of-medicaid-expansion-decision&sortModel=%7B%22colId%22:%22Location%22,%22sort%

Manadivilli, A. (2025, August 7). On Vaccines, Kennedy Has Broken Sharply With the Mainstream. The New York Times. Retrieved August 7, 2025, from On Vaccines, Kennedy Has Broken Sharply With the Mainstream

Mandavilli, A. (2025, June 24). Vaccine Panel Gutted By Kennedy-Loses Member Ahead of First Meeting. The New York Times. Retrieved August 7, 2025, from https://www.nytimes.com/2025/06/24/us/politics/rfk-jr-cdc-vaccine-panel.html

Mia Ives-Rublee, K. M. (2025, July 3). The Truth About the One Big Beautiful Bill Act’s Cuts to Medicaid and Medicare. Progress.org. Retrieved August 7, 2025, from https://www.americanprogress.org/article/the-truth-about-the-one-big-beautiful-bill-acts-cuts-to-medicaid-and-medicare/#:~:text=The%20bill%20will%20put%20rural%20hospitals%20at%20risk&text=Rural%20hospitals%20have%20some%20of,risk%20when%20rural%20hospita

Pinder, J. (2025, July 21). https://clearhealthcosts.com/blog/2025/07/in-turnaround-administration-proposes-limits-on-skin-substitute-industry/. Clear Cut Costs. Retrieved August 7, 2025, from https://clearhealthcosts.com/blog/2025/07/in-turnaround-administration-proposes-limits-on-skin-substitute-industry/

 

Explanation of Healthcare Tax Subsidies in the USA-Medicaid-Insurance Exchanges-Group Insurance Programs-Medicare

 

Health Care is Not Free

In an election year, it is important to discern facts from fiction and this article addresses the subject of free or subsidized health care in the United States. First, there is no free health care, someone is paying for the care. For Medicaid eligible persons or families, the state and federal government do provide health care without an insurance premium to those who qualify. This does not mean there are no copayments for the Medicaid participants, but these are generally modest. Access to health care providers is not guaranteed, because many clinics and clinicians do not treat Medicaid patients or have a limit on the number they will accept. This is because of the low level of reimbursement from the government for providing care.

 Medicaid-Eligibility

Medicaid, also known as Apple Health, Medi-Cal or whatever label each state chooses, is a government run medical insurance program for low-income residents. To be eligible for Medicaid, the individual or family must meet certain criteria, for example, living within the United States for at least five years, having legal residency status, meaning a work permit, student visa, permanent resident status, or citizenship. Citizenship in the USA is based on birthright, taking the oath of citizenship, or marriage. The funding for the Affordable Care Act requires legal residency criteria, to control costs and to avoid adverse selection from potential high-medical-needs immigrants. There are exceptions to this, which are for immigrants who have refugee status for humanitarian reasons (torture), Protected Juvenile Status, Temporary Protected Status and Victims of Trafficking. Here is a complete list of the immigrant standards for qualification for Medicaid or government health care subsidies, like tax credits under the insurance exchange plans for the Affordable Care Act (Obamacare): https://www.healthcare.gov/immigrants/immigration-status/

 Finally, if someone is blind, disabled, pregnant, or caring for a child on public support (foster child) you may be eligible for Medicaid, if you meet the residency status requirements. In other words, people without means who are immigrants do NOT have unlimited access for free or subsidized health care. Wealthy people, including medical tourists with private insurance, who can pay, will be able to have carte blanche access to the US healthcare system.

 State Medicaid Eligibility Varies

Most states have now expanded their Medicaid eligibility to match the 2010 Patient Protection and Affordable Care Act standard of 133% of the federal poverty level (FPL). In 2024, this is $15,060 for a single individual and $31,200 for a family of four. So, the baseline for receiving medical insurance through a state Medicaid program which has chosen the Affordable Care Act standard and receives federal matching funds is: $20,030 for a single individual and $41,496 for a family of four. Some states, where the cost of living is very high, have more generous subsidies, like California, which offers pregnant women with incomes up to 208% of the FPL and children under 18 are covered up to 261% of the FPL.

Federal government handy interactive chart to determine your state’s Medicaid eligibility standards.

https://www.medicaid.gov/state-overviews/state-profiles/index.html

 The federal Children’s Health Insurance Plan or CHIP has been around since 1997 and was reauthorized by both Democrats and Republicans in 2009.This is a positive thing because it is good public health investment to make sure we are creating healthy children, which is after all our future work force. Investing in the health and well-being of our citizens is a public good. This is why we have parks and recreation, air and water quality standards, sanitation systems, and standards for food safety.

Tax Credits Under Affordable Care Act

All the insurance exchange enrollments require persons applying for medical insurance coverage to disclose their incomes, because the Affordable Care Act provides federal tax credits for the purchase of the insurance. The government is advancing an income tax credit, that you would be expected to receive upon filing your annual tax return. If your income varies from this declaration, the government will refund any unused tax credits or require you to pay back some of the advance credits you received. It is the onus of the insurance exchange participant to notify the agency of any material change while enrolled. The tax credits are not free, but reflect earned income federal taxes. If someone has no earned income and qualifies for some insurance subsidy, this is determined through the process.

 Tax Credits Under Employer Group Insurance Plans

The federal government provides significant tax incentives for employers to provide health insurance, by allowing a tax deduction for the entire expense which are paid by the company. Additionally, employees are often given the opportunity to use pre-tax income to pay for their covered dependents or elective benefits, through a Section 125 plan. These tax credits do not have to be repaid, as long as the programs are administered correctly.

 Medicare Eligibility

For persons reaching age 62, their eligible spouses, and certain disabled people, the federal government provides Medicare, which has components which are fully paid by the government, Part A for hospitalizations and Part B, which is for outpatient care and requires an insurance payment monthly. There is also a prescription drug program which requires an insurance premium, unless the enrollee chooses a Medicaid Advantage Plan with an integrated drug program.  And there are Medicare supplements, which cover the many deductibles and co-payments that Medicare requires.

 Obtaining age 62, 65, or 70 does not automatically mean that person is enrolled in Medicare. The individual must apply for Social Security Benefits first, and that process takes two months. During this time, the Social Security Administration will verify residency status, address, and determine the number of quarters the applicant paid the necessary payroll taxes to qualify. Social Security is NOT FREE, the applicant must have earned wages and paid payroll taxes for Social Security and Medicare for no less than ten years. Some, myself included, think this is too liberal, because what other entity, government or private provides a pension after only a decade? Social Security is financed through a trust fund and current payroll taxes from employees and the self-employed whom are still working.

 In addition to the age qualification, Social Security is eligible to persons who have end-stage renal failure (kidney) and are on dialysis and for those who are blind. It is possible for other individuals with disabilities to qualify for benefits, but this is not easy and is not guaranteed.

 Conclusion

The United States does not offer FREE HEALTH CARE, rather it provides various targeted programs for enrollment, based on eligibility. These standards require individual tax contributions at all levels, based on the Internal Revenue Service Code. Only billionaires and a few hedge funders seem to manage tax exemptions. If you earn wages in the U.S.A. you will pay into the Social Security and Medicare programs. Residents in the country may be eligible for Medicaid or Insurance Exchange subsidies based on the duration of their residency and their immigration status. Americans are raised with the ethos that we work and earn that which we acquire and utilize. Though our tax code is arcane, it does provide incentives for programs the nation is trying to encourage and those it discourages. Universal healthcare is a myth, for even in countries with national health systems (France, Germany), there are populations whom are not covered under the safety net, primarily based on residency status.  Where the US goes off the rails is in the affordability of health care, ranked as the most expensive health care in the world. And of course, there are more persons without medical insurance and access to care in the US than in other nations with national healthcare systems. That said, this bellicose nation does not appear ready to move away from its current system in the near future.

 And this is the healthpolicymaven signing off, encouraging you not to sign blanket releases when you agree on a surgical procedure or a hospitalization, do specify that for which you agree and decline. It is best to do this with an Advanced Medical Directive or a POLST agreement. Make sure your emergency contact is aware of this document and be prepared to present to healthcare administrators.

 Roberta Winter is an independent healthcare analyst and journalist who receives no money from any sector of US healthcare. She is the author of Unraveling US Healthcare-A Personal Guide, published by Rowman & Littlefield in 2013. She has been a speaker at international and national healthcare events.

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

Trumpcare Versus Obama Care-What You Need To Know

How the Republican Healthcare Act Compares to the Affordable Care Act

The Republican plan, euphemistically referred to as Trumpcare addresses insurance and not improvements in healthcare delivery. Insurance is NOT health care. This analysis examines how the proposed healthcare plan in House Bill 277 differs from the Affordable Care Act, known as Obamacare. For information on ACA improvements in health care at the patient level, refer to the link below.[1]  This article cites credible sources from nonprofit entities or government agencies and only facts are used, not false proclamations.

Criteria

Obamacare

Trumpcare

Medicaid Coverage is medical insurance for low-income folks Eligibility Standards	Expanded eligibility for Medicaid to 138% of the federal poverty level; 32 states opted to expand coverage, increasing access to healthcare for 11 million people.[2]	Beginning in 2020, repeals the Medicaid expansion, allowing existing Medicaid participants to remain, but with the inability to re-enter later if you lose your eligibility; Millions would lose their medical insurance. (Gunja, 2017)
Mental Health Benefit Mandate	Expanded to include mental health parity, to increase access to health treatment for mental conditions under the essential benefit provisions of the ACA. (Kirsten Beronio, 2013)	Insurance companies would no longer have to offer mental health benefits under insurance contracts.
Substance Abuse Treatment Mandate	Plans were required to offer coverage for substance abuse treatment, comparable to other illnesses and it is estimated 5 million people have used this benefit. (Kirsten Beronio, 2013)	Insurance companies are not required to offer treatment for drug addiction, which is problematic given the national crisis in opioid addiction, currently killing 91 people a day. (Centers for Disease Control and Prevention, 2016)
Employer Insurance Mandate	Required employers to offer medical insurance within standardized benefit levels, or pay a fine.	Employers will no longer be required to offer medical insurance for their employees and no fines will be levied. Small business tax credits, to help businesses offer medical insurance are cancelled in 2020.
Impact on Individuals in Insurance Exchanges	Required pooled rates, which were spread across age bands, not individual levels; creating more affordability. (Jost, 2016)	Insurance companies can age rate, to increase pricing toward older participants (those most likely to need more health services). Cost sharing provisions which helped low income people are eliminated.
Taxes to fund the plan	Follow the link to a previous article which detailed the taxes.[3] Most sectors of the healthcare system contributed to taxes to fund the provisions of the Affordable Care Act which is self-funding.	Would eliminate most of the taxes except the “Cadillac Healthplan Tax”, lower capital gains for the top 2.5% of income earners, and charge all employees covered on insurance plans through their employers, a Value-Added Tax (like the Canadians charge on services).
Women’s Healthcare Mandates	Mandated insurance plans cover birth control and women’s gynecological exams annually.	Defunds all Planned Parenthood Services and removes the requirement to provide wellness services or birth control.
Financial Impact on Individuals	Older low income people had greater subsidies so they could buy medical insurance.	Older low income folks will pay thousands more per year for medical insurance. Young people will pay less for insurance, but since there are no penalties for not participating enrollment will decline, eroding the overall viability of insurance exchanges.
Employer Provided Medical Plans	Employers can deduct the full cost of their medical and other benefit plans and employees are not taxed on these benefits.	Eliminates the tax advantage for employers which will cause the cancellation of many health plans across the nation because this is a very expensive benefit for employers to offer. Example, your employer pays $12,000 in insurance plan premiums for you, these would now be taxable as income to the employee and nondeductible to the business.
Individual Penalties for Not Participating Tax Laws	Proof of insurance is required at income tax filing. A tax penalty up to $695 per adult ($2,085 family) is due unless you qualify for one of the many exemptions, which include your inability to afford insurance.	No requirement to have medical insurance, but if your coverage lapses, you will pay a penalty (up to 30%) upon re-enrollment regardless of your income. The penalty would be meted out by the insurance company.
Medicaid Funding	Affordable Care Act provides additional subsidies to states for the expansion of Medicaid, to increase insurance coverage and access to medical care across the nation.	Republican plan wants to cap any federal Medicaid contribution to a flat amount per person, without cost-of-living increases and not based on actual plan costs.

A quick analysis of this doomsday health insurance scheme, eliminates most incentives, especially for the bottom 25%-of-income-households and a swath of the middleclass, to obtain medical insurance. By removing the tax incentive for employers to provide health plans more Americans will lose medical insurance through their employment, throwing more people into the chasm of the uninsured. By removing the tax credits for small firms, fewer of those will be able to offer medical insurance to their workers. And the piece de resistance of this Trump sanctioned health plan is to further destabilize the insurance exchanges, by removing the accountability requirement that residents have medical insurance. Plus, allowing the insurance companies to eliminate or reduce specific medical conditions will harm treatment for public health needs. Older individuals will face steep premium increases as the Republican plan allows insurance companies to charge older Americans up to five times what they charge the younger ones. In other words, back to business as usual for the insurance industry, where they can eliminate an entire “class” of people from their contracts and of course, charging those most in need significantly higher premiums.

Finally, there isn’t one thing about this “plan” that addresses the improvement of health care, lowers the cost of your health care treatment, or encourages transparency and accountability from any of the price gouging suppliers. More to come on the provisions which will impede consumer protections and create road blocks on price and quality transparency for consumers. Of course, can we really expect anything else from an administration which felt ethics classes were unnecessary, and refuses to allow adequate time for public comment on a bill which would be so harmful to people?

For the best interactive tool to see how you would fare under the Republican Health Plan, follow the link below to the nonprofit, Kaiser Family Foundation site and search for your age and county to get your tax credit information. The Republican plan only provides tax credits based on age, not on income, with a phase-out at $75,000.[4]

And this is the healthpolicymaven signing off wishing you fully informed consent for any medical procedure, contract, or act. Roberta E. Winter is a former insurance broker and healthcare consultant,  who has been devoted to healthcare reforms since 2002 and is the author of https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972 .

References

Centers for Disease Control and Prevention. (2016). Drug Overdose Deaths Continued to Increase in 2015. Health and Human Services, Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Retrieved March 12, 2017, from https://www.cdc.gov/drugoverdose/epidemic/index.html

Gunja, S. R. (2017, March 7). Why Millions Would Lose Coverage Under the Medicaid Expansion Changes in the House Affordable Care Act Repeal Bill. To the Point-Quick Takes on Health Care Policy and Practice. Retrieved March 12, 2017, from http://www.commonwealthfund.org/publications/blog/2017/mar/why-millions-would-lose-coverage-under-affordable-care-act-repeal-bill

Jost, T. (2016). Affordability: The Most Urgent Health Reform Issue For Ordinary Americans. Health Affairs.org. Health Affairs . Retrieved March 12, 17, from http://healthaffairs.org/blog/2016/02/29/affordability-the-most-urgent-health-reform-issue-for-ordinary-americans/

Kaiser Family Foundation.org. (2017). Tax Credits Under the Affordable Care Act Versus the American Health Care Act. The Henry J. Kaiser Family Foundation. The Henry J. Kaiser Family Foundation. Retrieved March 7, 2017, from http://kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/

Kirsten Beronio, R. P. (2013). AFFORDABLE CARE ACT EXPANDS MENTAL HEALTH AND SUBSTANCE USE DISORDER BENEFITS AND FEDERAL PARITY PROTECTIONS FOR 62 MILLION AMERICANS. Health and Human Services.gov, Office of the Assistant Secretary for Planning and Evaluation. U.S. Department of Health and Human Services. Retrieved March 12, 2017, from https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parity-protections-62-million-americans

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[1] http://healthpolicymaven.blogspot.com/2017/02/expected-program-cuts-to-affordable.html

[2] http://www.commonwealthfund.org/publications/blog/2017/mar/why-millions-would-lose-coverage-under-affordable-care-act-repeal-bill (Gunja, 2017)

[3] http://healthpolicymaven.blogspot.com/2017/02/expected-program-cuts-to-affordable.html

[4] http://kff.org/interactive/tax-credits-under-the-affordable-care-act-vs-replacement-proposal-interactive-map/

Expected Program Cuts to Affordable Care Act and Federal Budget Impact

Orthopedic surgeon, Dr. Tom Price is now in charge of Health & Human Services and here is an analysis of the laws he may try to dismantle, programs which could lose government support, and the ensuing federal budget implications. This article is based on actual facts, not “alternate facts” which are popular with the Trump Administration.

Budget Implications

The Patient Protection and Affordable Care Act has been a revenue generator, while also providing medical insurance for 20 million low income people and has helped to reduce the federal deficit. (ObamaCareFacts.com, 2017) According to the Office of Management and Budget (OMB) and the Joint Committee on Taxation (JCT), repeal of the Affordable Care Act would cause the federal deficit to grow by $137,000,000,000 by 2025. (Congressional Budget Office, 2015) That’s right, a repeal of the ACA would increase the deficit by 137 billion dollars.  Here are some of the provisions which have generated money for the government, which are likely to be repealed by the Republican Congress under the Trump Administration.

Pay or Play-Taxes generated from income tax filers who did not have an exemption to the requirement for obtaining medical insurance and are required to pay a tax penalty.

Luxury Plan Tax-This tax is applied to health insurance plans which cost more than twice the national average for an enrollee.

Insurance Company Tax-Insurance companies pay a premium tax which goes into the fund to pay for medical insurance for low-income residents and the provisions of the Affordable Care Act.

Medical Device Tax-Orthopedic and cardiac device manufacturers have been required to pay a 2.9% tax on the cost of the device, which funds provisions under the ACA including healthcare for low-income people.

Estate and Trust Tax-This tax applied to undistributed net income, which affects larger trusts, and is 3.8% of that income.  Again, the money goes toward health insurance subsidies for low income persons.

Employer Tax-Failure to offer minimum essential benefits in a health insurance plan will generate a tax, up to $3,000 per effected employee.

Medicare Payroll Tax Increase-The payroll tax used to fund Medicare, was increased by .90% (less than 1% not 90%, if Sec. of Education DeVos is quoting this). This tax is paid equally by the employee and employer and is used to pay for Medicare programs. Don’t kid yourself, Congress will never reduce your payroll tax as this is necessary to shore up Medicare.

Medicare Changes from the Affordable Care Act

Most of the Centers for Medicare and Medicaid(CMS) changes under the ACA involve improving health quality (clinical quality based on patient results) and transparency (in terms of payment and performance). Will these programs also be terminated under HHS Cabinet Secretary Price?

1.       Subsidies for Medicare Advantage (HMO) payments based on counties with a higher density of low income residents-This benefits rural areas as well as the urban poor.

2.       Health care quality rankings impact how much the facilities receive, as well as the Medicare Advantage enrollment population. This is a pay-for-performance initiative.

3.       Insurance companies selling Medicare Advantage Plans must use 85% of annual collected premiums to pay for enrollee claims and plan services, which caps opportunistic accounting charges which contribute to inflated premiums. Insurance companies should be able to administer their plans for 15% as Medicare does it for 6%.

4.       Designating medical homes for patients, is a patient management tool, and has been shown effective in care management, especially for diabetes and other chronic diseases.

5.       Mandatory 90-day review period before the government will pay for durable medical equipment, which is frequently marketed to senior citizens without regard to efficacy or best fit analysis.

6.       Fraud Detection-A special commission in Health and Human Services was established to compare tax records to aid in identification of criminals who are stealing money from our government through fraudulent claims, etc.

Medicaid Changes from the Affordable Care Act

Under the Trump Administration many programs impacting low-income Americans are likely to be modified, reduced or cut and here is the list:

1.       Expansion of Medicaid to include all low-income people, not just children. This was modified through a court order and now applies to 33 states which opted to expand their Medicaid coverage, thus reducing stress on state health systems. Will these states lose the federal matching money they are currently receiving for providing this coverage for low income residents with incomes within 138% of the federal poverty range?

2.       State employees became eligible to enroll their children on the Children’s Health Plan (CHIP) because of the Affordable Care Act, will this be repealed?

3.       Free standing birth centers, such as midwifery and other women’s health facilities, such as Planned Parenthood, became eligible to receive Medicaid funding for additional services under the ACA. Congress has already indicated a desire to defund Planned Parenthood, but what about the other facilities under this provision? This means program cuts for preventive care for women. I guess Trump expects women to build a wall around the uterus, just like Mexico.

4.       Creation of Medical Home designations for patients with at least two chronic conditions, which provides funding for better care management. Participating medical facilities received additional compensation to assume enhanced care coordination through the medical home provisions. Will community health organizations lose this funding?

5.       Hospital Safety-net Demonstration Project-This is an initiative involving several hospitals to identify vulnerabilities in hospital systems across the nation, which are primarily urban trauma centers, to prevent hospital closures. Tom Price has said he does not favor the Centers for Medicare and Medicaid Demonstration Projects. (Pear, 2016)

6.       Greater mental health treatment funding for hospitals with a significant population of indigent patients (urban trauma centers) was part of the ACA. Will there be funding cuts for vulnerable populations and will the mental health parity insurance mandate be repealed?

7.       Medicaid Waiver or Section 1115 Programs have been around a long time and they are primarily a vehicle to increase cost sharing for recipients and reduce expenses for the states which fund them. The standardization of this process will probably not go away as states continue to seek relief from spiraling Medicaid costs.

8.       Improvement of funding for state Medicaid matching for noninstitutionalized care programs-will this be torpedoed?

Improving Health Quality and Paying for Performance

Accountable Care Organizations

The Accountable Care Organization Act became effective in 2012 and is administered by the Centers for Medicare and Medicaid. This program saved CMS over 700 million in the first five years, through better monitoring of preventable health events. (David Blumenthal, 2015) At present, 15% of all Medicare enrollees are served through Accountable Care Organizations. The ACO program identifies high cost health care events, such as hospital re-admissions and links improved clinical outcomes to performance, by paying health systems more money for achieving these targets. Health systems voluntarily participate in the program. There are 480 participating health care organizations within the U.S. and nine million people benefit from accountable care provisions. (Centers for Medicare Services, 2017)The Centers for Medicare and Medicaid have indicated this program saved the government 466 million in 2015. (Centers for Medicare and Medicaid, n.d.)

Financial and Clinical Efficacy

The Accountable Care Act created the Federal Coordinated Health Care Office whose purpose is to study health programs, gauge results, and seek ways to optimize the government expenditures with patient care. Will this agency be terminated because Dr. Price, who is a member of the Tea Party coalition, thinks doctors and hospitals should have less oversight? Hospitals are now huge corporations, often controlling entire regions, dictating prices, and are not typically subject to anti-trust laws. Shouldn’t some independent government agency be reviewing their programs, the costs, and the impacts on consumers?

Clinical Effectiveness and Research

The Institute for Clinical Effectiveness, known as the Patient Centered Outcomes Research Institute (PCORI), was created to identify and promote best healthcare practices for patient safety and clinical health, based on the following criteria:

1.       Assessment of preventative, diagnostic, and health care treatment options

2.       Improving health systems

3.       Improving health care decision making and patient communications

4.       Addressing health disparities (why patients in different demographic groups have different health outcomes/services)

5.       Accelerating patient centered research to identify ways to economically and clinically improve health

Funding for the PCORI agency was provided through the American Recovery and Rehabilitation Act in 2009, which taxes insurance companies $1 to $2 per enrollee. PCORI is taxed with identifying ways to cut waste, reduce unnecessary procedures, and improve disease surveillance to improve health outcomes.  The oversight organization has put a spotlight on medical suppliers, pharmaceutical companies, insurers, and other agents in the national healthcare landscape. For more information on this, read Chapter 3, pages 27-29 in my 2013 book, Unraveling U.S. Healthcare-A Personal Guide. (Winter, 2013) https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 Of course, medical lobbyists have been deluging Congress with appeals to remove the “onerous taxes” which impact their businesses adversely (hardly at all) resulting in higher costs for American consumers. These companies simply want more money to reward their shareholders and enrich their stock option plans. No one in Congress is exempt from the influence of healthcare industry lobbyists, because even stalwart Democrats, Elizabeth Warren (MA) and Al Franken (MN) have lobbied to get the 3% medical device tax removed, because Boston Scientific, St. Jude Medical, and Medtronic are big employers located in their respective states. Removal of this tax would not result in lower costs for any patient or health system which buys any of their devices.  Increasing pricing transparency for cardiac and orthopedic devices would potentially result in savings for health systems and patients, but you don’t hear any lobbying for that. If anything, this scenario illustrates more acutely why we need independent government agency oversight for our healthcare system.

Returning to the 1950’s model for healthcare will not lower costs across the health system and it is important for consumers to understand that your insurance premiums are but one aspect of the healthcare system. We all need to be concerned about that for which we pay for our health care, the conflicts of interest inherent in the system, and that which is negotiable. Isn’t this how we would handle any other significant purchase? Keep reading this column for up-to-date information on healthcare concerns, actions, and facts. And this is the healthpolicymaven signing off wishing you fully informed consent for your next vote, purchase, or procedure. Read the fine print and do use “actual facts” from vetted sources for decision-making.

Roberta E. Winter, MHA, MPA is a freelance journalist and consultant, with analytical experience in the insurance industry, hospital systems, regulatory analysis, healthcare research, and patient advocacy.

References

Centers for Medicare and Medicaid. (n.d.). 2016 Fact Sheets Medicare Shared Savings Program. Retrieved February 15, 2017, from Centers for Medicare and Medicaid.gov: https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2016-fact-sheets-items/2016-08-25.html

Centers for Medicare Services. (2017, February 15). CMS Medicare Shared Savings Programs. Retrieved from CMS.gov: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/All-Starts-MSSP-ACO.pdf

Congressional Budget Office. (2015). Budgetary and Economic Effects of Repealing the Affordable Care Act. United States Congress. Washington, D.C.: Congressional Budget Office. Retrieved February 15, 2017, from https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf

David Blumenthal, M. M. (2015, June 18). The Afforable Care Act at 5 Years. (M. Mary Beth Hamel, Ed.) The New England Journal of Medicine, 372, pp. 2451-2458. doi:10.1056/NEJMhpr1503614

ObamaCareFacts.com. (2017, February 15). ObamaCareFacts.com. Retrieved February 15, 2017, from ObamaCareFacts.com: http://obamacarefacts.com/sign-ups/obamacare-enrollment-numbers/

Pear, R. (2016, November 28). Tom Price, Obama Care Critic is Trump's Choice for Health Secretary. Retrieved from The New York Times: https://www.nytimes.com/2016/11/28/us/politics/tom-price-secretary-health-and-human-services.html

Winter, R. E. (2013). Evidence-Based Planning-What It Means and Why You Should Care. In R. E. Winter, Unraveling U.S. Healthcare-A Personal Guide (pp. 27-29). Lanham, Maryland: Rowman & Littlefield.