This Thursday the House will vote on the Republican health care bill, or AHCA. While the bill is facing strong opposition from both sides of the aisle, what do physicians make of it? Doctor Ann Dominguez, a board certified family practitioner who’s been working in community health for 20 years, discusses how the AHCA will affect the seven major causes of death in the U.S. (Cross-posted with Ann’s permission from Learning As We Go.)
The CDC recently reported that the life expectancy for the US went down for the first time in decades. The top seven causes of death for adults remained the same, although many of them became more common in 2016. Let’s look at how president Trump’s proposed budget will address the seven top killers of American adults.
1. Heart disease. Heart disease causes 1 in 4 American deaths. The AHCA will substantially increase premiums to people most likely to be affected by the disease. Heart disease is most common in adults over 50, and the AARP Policy Institute estimates that health insurance premiums will rise 13% for Americans ages 50-59, and 22% for 60-64 year olds. For a 64 year old making $25,000, premiums are estimated to rise from $1,700/yr to $14,600/yr. Sticker shock over that increase might not be enough to cause a heart attack, but might be enough to make the cost of life-saving medications out of reach.
2. Cancer and 3. Chronic Lower Respiratory Disease (COPD and emphysema). While most cancer and COPD/emphysema is attributable to lifestyle causes (tobacco, diet and lack of exercise), as many as 10,000 cancer deaths a year are caused by exposure to environmental pollutants, like air pollution.
Lung disease is one of the few causes of death that did not claim more lives than usual in 2016. Lung disease-related deaths have decreased thanks to a reduction in smoking and in environmental pollutants. Instead of capitalizing on the momentum of recent gains in air quality, this administration’s budget guts funding for the EPA whose regulation has been responsible for much of the improvement in our air quality. Let’s give Beijing a run for its money.
4. Accidents and suicide. Accidents (including overdoses) and suicides, especially among middle aged white men, were a major driver of the increased mortality in 2016. Specifically, men aged 45-64 have seen a 43% increase in suicide over the last 15 years. Heroin overdoses have increased 20% from 2014-2015.
Despite the appalling increase in suicides and overdoses in the past few years, the AHCA removes the guarantees for equal mental health and substance abuse in the 31 states that expanded Medicaid coverage under the ACA. This will affect 19.7 million Americans suffering with substance abuse and more than 40 million American adults with mental health issues.
5. Stroke. Stroke is another killer that is most common in adults over 50, although a third of hospitalizations for stroke occur in adults younger than 65. According to the CDC, stroke costs the United States an estimated $33 billion each year in health care services, medicines to treat stroke, and missed days of work. Stroke is a leading cause of serious long-term disability in the US.
The AHCA includes a provision to penalize anyone with a lapse of coverage (say, because of having to stop work because of a stroke) with a 30% surcharge on the cost of their policy. Additionally, because of the high proportion of disability among stroke survivors, Medicare is a major insurance provider for stroke survivors. The CBO estimates that the AHCA will make Medicare insolvent four years earlier than its current projected demise under Obamacare. The AHCA is one more reason (in a long list) to pray you don’t have a stroke.
6. Alzheimer’s disease. We don’t know how to prevent Alzheimer’s disease, nor do we have a single effective therapy to reverse the losses of Alzheimer’s disease or to stop its progress. The Trump budget proposes a 20% cut in NIH funding, so don’t hold your breath on finding a cure any time soon for the 5 million Americans suffering from Alzheimer’s disease.
7. Diabetes and chronic kidney disease (CKD). 28.9 million Americans live with diabetes, and the disease disproportionately affects ethnic minorities. Diabetes and hypertension, both chronic diseases, are the top two causes of chronic kidney disease (CKD). Both diabetes and CKD are major contributors to heart attack and stroke risk, but appropriate treatment for diabetes and hypertension can delay—or prevent altogether—many cases of CKD.
The U.S. has a shocking disparity between rural and urban care for chronic diseases including diabetes, hypertension and CKD. While Medicaid expansion under Obamacare sought to increase access to care in rural areas, nearly two-thirds of people without insurance lived in states that did not choose to expand Medicaid. Likewise, according to the Kaiser Family Foundation, only 51% of rural workers had employer-sponsored health insurance, as opposed to 57% in urban areas. The combination of these two factors leaves 14% of the rural population (as opposed to 9% of the urban population) without access to affordable insurance coverage, and this is despite the ACA.
The map below shows the states that expanded their Medicaid coverage under the ACA (blue states expanded Medicaid; orange states did not).
Since 2010, 80 rural hospitals have closed in the US. The National Rural Health Association estimates that by 2020, 25% of rural hospitals will have closed.Closing a hospital not only affects the health of that community and its surrounding area, but often eliminates the one of the largest employers in that region, throwing hundreds of people out of work. Let's look at the map of where rural hospitals have closed since 2010:
There seems to be a lot of overlap between the orange parts of the top map (no Medicaid expansion) and the dots on the lower map (closed rural hospitals).
The AHCA makes no effort to address these disparities in care, or to improve the survival chances of rural hospitals. A market-based health care exchange leaves out rural markets. If Congress is so determined to improve the ACA, they should at least make some effort to improve the one real defect in the ACA, which is the persistent lack of rural health care access, especially in areas where Medicaid was not expanded under the ACA.
I give Congress and the Trump budget proposal and F on health care so far. Empty words have their place (obviously, since that’s how the 2016 election was won) but when it comes to the health of our country, gutting recent gains in health care access under Medicaid expansion and removing the budget for disease research is all bad.
Ann Dominguez is a a writer, a mom of four, and a board certified Family Practitioner working in community health for 20 years. Her medical adventures have taken her through the US, Haiti, Thailand, and Guatemala. Her writing has appeared in JAMA, Medical Economics, Venn Magazine, Mothers in Medicine and The Well.