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The New US Administration and Health Care – A Walkthrough

Late last year, I posted part 1 of my commentary of the US election and healthcare.

Since then, a wild array of things have happened. Amidst the chaos, my aim is to explore and explain recent executive orders and how they affect healthcare and delivery.

1) Executive order: “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal”

What’s that all about?

This executive order (signed on the eve of Donald Trump’s presidency, Jan 20th, 2017) essentially suggests that there has been a large economic burden secondary to the ACA. It asks that, wherever possible, all organizations be exempt from enforcing portions of the ACA that could lead to a ‘fiscal burden’.

How does that impact healthcare?

The executive order suggests that a repeal is inevitable. It is unfortunate that the executive order has left everyone, including insurers in the dark. Preliminary talks seem to suggest decentralizing Medicaid and allowing for interstate expansion of insurance in an attempt to create more options.

It seems clear that this order was largely politicized. While the ACA has it’s issues, it is not a clear black-and-white story. The politicized polarized discussion often disregards a number of basic facts.

  • Through the ACA, the number of uninsured has hit a record low.
  • It has allowed for Medicaid expansion with federal support in several states.
  • It granted insurance with pre-existing conditions
  • It allows for children to remain on their parent’s plan until the age of 26.
  • One harsh piece of criticism is that the number of options in the open market has declined, leading to the notion that health care is not affordable.
  • While premiums and deductibles have increased, reports suggest that they are not as high as the rate of increase prior to the ACA.

On a related note, the new administration pulled all the ACA ads (including ones that were paid for in full) due for the last week of open enrollment. In response to this, a gofundme account was created to help put some of these ads back up. This led to a decrease in the number of people who enrolled through

What’s the big deal?

Programs such as Masshealth receive significant federal support.  I fear that these planned changes will result in destabilization of Masshealth and similar programs. Although it may offer more options for coverage, it is unlikely to offer ones that are in the best interests of patients.

Unfortunately, I’m left with beliefs instead of facts, as, we don’t have any solid proposed plans to allow for educated opinions. It is disturbing that the current administration believes in limiting current healthcare without offering a meaningful replacement.

2) Executive Order: “Protecting the Nation from Foreign Terrorist Entry Into the United States”aka The Travel Ban

What’s that all about?

This ban [signed Jan 25th, 2017] called for a 90 day ban on legal immigrants from seven predominantly Muslim countries and a 120 day ban on refugees.

How does that impact healthcare?

This ban affected ~60-100,000 individuals. It has the potential to affect ~10,000 practicing physicians who went to medical school from the seven named countries, 1800 current residents and fellows. The ban, along with the administrations comments of prioritizing Christian refugees over Muslim refugees is troubling. Not only is it founded on unconstitutional principles of discriminating by religion, it sets a bad precedent for the future under this current administration.

Further data, suggests that ~20-30% of the US medical workforce consists of immigrants.

What’s the big deal?

Limiting, or discriminating against certain sects of legal immigrants causes untold harm and fear among the immigrant population, and, will likely affect mental health.

Most underserved and rural areas receive care from immigrant health care workers. Recent data also suggest similar, if not slightly improved outcomes for patients treated by international medical graduates. Reducing the immigrant pool of healthcare workers, or, threatening them with travel bans, will disproportionately affect underserved and rural portions of America.

3) Presidential Memorandum Regarding the Mexico City Policy

What’s that all about?

The Mexico City Policy memorandum [also known as the ‘global gag rule] is a policy that prevents US federal funding for Non governmental organizations that provide preventive medicine services that include offering abortions or referring patients to centers that perform abortions. This time, unforunately, it was expanded further to block all global funding, affecting up to 9.5 billion dollars [instead of the previously reported 600 million USD of foreign aid]

How does that impact healthcare?

Regardless of your personal beliefs, it is scientifically proven that abortions are necessary in varying circumstances, and, when performed under medical supervision, reduce the risk of illegal abortions [which amount to increased maternal infections and death].

What’s the big deal?

The global gag rule is an unfortunate political policy that adversely affects millions of vulnerable women, as, it also bans resources allocated for all other services provided by NGOs that have some association, however loose, with abortions. It can only serve to widen inequity to satisfy political agenda.

4) Federal Employee Hiring Freeze 

What’s that all about? 

On Jan 23rd, it was announced that there would be a federal hiring freeze, effectively ceasing all further federal employment [“except for the military”].

How does that impact healthcare?

It appears that this wasn’t well thought out, as, it brought up major concerns over the functioning of VA Hospitals.

  • Patients were worried that they would have long wait times to see health care providers.
  • Hospital staff were worried that they would not be able to sustain or improve health care delivery.
  • Training programs and residents were concerned about their future ability to work at VA’s, given that they are employees that have annual contracts.

Should we still be concerned?

Thankfully, on Jan 27th, Robert Snyder, the acting Secretary of Veteran Affairs, signed a memorandum, essentially acknowledging that an exemption should apply for the VA.

With regard to medical training, he specifically wrote “Given the critical role that VA plays in training the Nation’s health care providers, the above exemptions should be interpreted in a way that does not disrupt ongoing health profession training programs and residencies within VA.”

Bottom line, exceptions to the federal freeze will apply to the VA Hospital for a number of positions, including medical officers, physician assistants, nurses, pharmacists, physical and occupational therapists, all health profession training programs [including residents], and a number of allied services and essential staff.

Surprisingly, I was unable to find attending physicians of varying subspecialties on the list of exceptions. I presume that they are included under the title of Medical Officers, but, that remains to be seen.

In addition: Here’s a link to brief excerpts of the President’s conversation with pharmaceutical experts. Although it suggests a poor understanding of drug development, I appreciate his call to reduce drug costs, especially given the recent increased price of Narcan to 4500 dollars.

To sum up,

The way things are going, we will have an increase in inequity internationally due to the global gag rule, and, will likely have wider gaps in coverage among the most vulnerable members of American society.

It is up to us to continue to voice our concerns, as medical professionals; committed to healing and to reducing inequity. 


2 comments on “The New US Administration and Health Care – A Walkthrough

  1. Excellent points, Yuvaram. Without tipping an ideological hand (and noting for myself as well that these are my opinions over those of BMC or BU), it’s not been a reassuring start to the Trump administration in terms of healthcare. And in terms of global health, we really still don’t know how they’ll go, though some statements by administration officials and some documents have referred to massive cuts in the (very small already) foreign aid budget. The reinstatement of the Mexico City Gag Rule was not a surprise, though it remains policy that undermine’s women’s health, and as you note, the broadening of that policy may have a more pronounced effect on US support for women’s health.

  2. Very thoughtful points raised in the post. I totally agree with you that we, as health care professionals should voice our concerns for the undermining the idea of inequity.

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