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Promises kept? On health care, Trump's claims of 'monumental steps' don't add up

By Julie Rovner and Phil Galewitz, Kaiser Health News on

Published in News & Features

In addition, Medicare will cap the price of insulin at $35 per prescription starting in 2021 for people getting coverage through some drug plans. More than 3 million Medicare beneficiaries use insulin to control their diabetes.

Trump also signed a law banning gag clauses used by health plans and pharmacy benefit managers to bar pharmacists from telling consumers about lower-priced drug options.

The administration's plan to require drug companies to provide prices in pharmaceutical advertising has been beaten back in court.

The administration points to the increased number of generic drugs that have been approved since Trump was elected, but many of those drugs are not on the market. That's because generic companies sometimes make deals with brand-name manufacturers to delay introducing lower-cost versions of their medicines.

At the same time, several bills the president supported to lower prices have stalled in Congress because of partisan differences and industry opposition.

"I don't think there has been any meaningful action that has had meaningful effect on drug prices," said Katie Gudiksen, a senior health policy researcher at The Source on Healthcare Price and Competition, a project of UC Hastings College of the Law in San Francisco.

Yet, she said, it's possible Trump's harsh criticism of the industry has had a chilling effect that led to lower prices.

Still, out-of-pocket costs for many individuals continue to climb as private and government insurance shifts more responsibility to the patient via higher cost sharing. Good Rx, an online site that tracks drug prices, noted this month that prescription drug prices have increased by 33% since 2014, faster than any other medical service or product.

MEDICAID

The Trump administration has tried - but largely failed - to make many major changes to the state-federal health insurance program that covers more than 70 million low-income Americans.

Efforts by Republicans to repeal the Affordable Care Act would have ended the federal funding for the District of Columbia and the 38 states that expanded their programs for everyone with incomes under 138% of the federal poverty level, or about $17,609 for an individual. About 15 million people have gained coverage through the expansion.

Trump administration officials have argued that Medicaid should be reserved for the most vulnerable Americans, including traditional enrollees such as children, pregnant women and the disabled, and not used for non-disabled adults who gained coverage under the ACA's expansion. Since Trump took office, seven states have expanded Medicaid - Idaho, Maine, Missouri, Oklahoma, Nebraska, Utah and Virginia.

In 2018, federal officials allowed states for the first time to require some enrollees to work as a condition for Medicaid coverage. The effort resulted in more than 18,000 Medicaid enrollees losing coverage in Arkansas before a federal judge halted implementation in that state and several others. The case has been appealed to the Supreme Court.

The administration also backed a move in Congress to change the way the federal government funds Medicaid. Since Medicaid's inception in 1966, federal funding has increased with enrollment and health costs. Republicans would like to instead offer states annual block grants that critics say would dramatically reduce state funding but that proponents say would give states more flexibility to meet their needs.

When the congressional attempt to establish block grants failed, the administration tried through executive action to implement a process allowing states to opt into a block grant. Yet only one state - Oklahoma - applied for a waiver to move to block-grant funding, and it withdrew its request in August, two weeks after voters there narrowly passed a ballot initiative to expand Medicaid to 200,000 residents.

Medicaid enrollment fell from 75 million in January 2017 to about 71 million in March 2018. Then the pandemic took hold and caused millions of people to lose jobs and their health coverage. As of May, Medicaid enrollment nationally was 73.5 million.

The administration's decision to expand the "public charge" rule, which would allow federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid, has discouraged many people from applying for Medicaid, said Judith Solomon, senior fellow with the Center on Budget and Policy Priorities, a research group based in Washington, D.C.

MEDICARE

Seniors were among Trump's most loyal voters in 2016, and he has promised repeatedly to protect the popular Medicare program. But not all his proposals would help the seniors who depend on it.

For example, invalidating the Affordable Care Act would eliminate new preventive benefits for Medicare enrollees and reopen the notorious "doughnut hole" that subjects many seniors to large out-of-pocket costs for prescription drugs, even if they have insurance.

Trump also signed several pieces of legislation that accelerate the depletion of the Medicare trust fund by cutting taxes that support the program. And his budget for fiscal 2021 proposed Medicare cuts totaling $450 billion.

At the same time, however, the administration implemented policies dramatically expanding payment for telehealth services as well as a kidney care initiative for the millions of patients who qualify for Medicare as a result of advanced kidney disease.

 

SURPRISE BILLING

Trump in May 2019 promised to end surprise billing, which leaves patients on the hook for often-exorbitant bills from hospitals, doctors and other professionals who provide service not covered by insurance.

The problem typically occurs when patients receive care at health facilities that are part of their insurance network but are treated by practitioners who are not. Other sources of surprise billing include ambulance companies and emergency room physicians and anesthesiologists, among other specialties.

An effort to end the practice stalled in Congress as some industry groups pushed back against legislative proposals.

"The administration was supportive of the pretty consumer-friendly approaches, but obviously it doesn't have any results to speak of," said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy in Los Angeles.

"At the end of the day, plenty of people in Congress did not really want to get something done," he said.

Taking a different route, the administration finalized a rule last November that requires hospitals to provide price information to consumers. The rule will take effect Jan. 1. A federal judge shot down an attempt by hospitals to block the rule, although appeals are expected.

Brian Blase, a former Trump adviser, said this effort could soon help consumers. "Arguably, the No. 1 problem with surprise bills is that people have no idea what prices are before they receive care," he said.

But Adler said the rule would have a "very minor effect" because most consumers don't look at prices before deciding where to seek care - especially during emergencies.

PUBLIC HEALTH/OPIOIDS

Obesity and the opioid addiction epidemic were two of the nation's biggest public health threats until the coronavirus pandemic hit this year.

The number of opioid deaths has shown a modest decline after a dramatic increase over the past decade. Overall, overdose death rates fell by 4% from 2017 to 2018 in the United States. New CDC data shows that, over the same period, death rates involving heroin also decreased by 4% and overdose death rates involving prescription drugs decreased by 13.5%.

The administration increased funding to expand treatment programs for people using heroin and expanded access to naloxone, a medication that can reverse an overdose, said Dr. Georges Benjamin, executive director of the American Public Health Association.

Meanwhile, the nation's obesity epidemic is worsening. Obesity, a risk factor for severe effects of COVID-19, continues to become more common, according to the CDC.

Twelve states - Alabama, Arkansas, Indiana, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Oklahoma, South Carolina, Tennessee and West Virginia - have a self-reported adult obesity prevalence of 35% or more, up from nine states in 2018 and six in 2017.

Benjamin said some of the administration's other policies, such as reducing access to food stamps and undermining clean air and water regulations, have made improving public health more difficult.

But the pandemic has been the major public health issue this administration has faced.

"We were doing a reasonable job addressing the opioid epidemic until COVID hit," Benjamin said. "This shows the fragility of our health system, that we cannot manage these three epidemics at the same time."

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(Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.)

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