Donald Trump’s mission to dismantle his predecessor’s legacy continues apace. First, healthcare. Frustrated at the inability to get bills designed to repeal and replace the Affordable Care Act (ACA), he’s doing his best to ensure its failure by reducing subsidies and making it more difficult for people to sign up.
Sure enough, Massachusetts has already had to increase Connector health insurance rates by 18% to make up for the cuts to the Cost Sharing Reduction (CSR) programme that subsidises ACA policies, and similar actions are inevitable in all other states too. It's yet another example of ideology trumping sense. As Democratic MA congressman Mike Capuano pointed out: He will cost the federal government more than the amounts he cuts because most of those whose subsidies will be cut will now become eligible for a more expensive federal tax credit!’
The non-partisan Congressional Budget Office anticipates that this slashing of the CSR will mean health insurance premium rises of 20% will be common in 2018, yet it will also increase the federal deficit by an eyewatering $6bn. So that’s lower coverage at greater cost for both patients and government. ‘It’s an act of pure malice, plain and simple,’ said Andy Slavitt, former acting administrator of the centers for Medicare and Medicaid services. ‘A decision made solely out of spite following their failure to repeal the law. It’s going to harm millions of both sick and healthy people. There are public policies that reasonable people disagree on. Funding these payments is not one of them.’
Those with employer-based insurance may see their benefits reduced, too, with the planned introduction of Association Healthcare Plans that will allow employers, if they so choose, to go for cut-price, cut-coverage health insurance for their workers, with no obligation to cover pre-existing conditions.
Obama’s climate legacy is also under siege. Hot on the heels of the US’s withdrawal from the Paris climate change agreement, Environmental Protection Agency (EPA) supremo Scott Pruitt – yes, the same Scott Pruitt who specialised in litigating against the EPA as Oklahoma’s attorney general – has decreed that the flagship Clean Power Plan (CPP), designed to cut emissions from power plants, will be scrapped. The Republicans have spun the CPP as an attack on coal; in reality, EPA’s own data at the time of its introduction in 2015 indicated it would cut attack rates in childhood asthma, and prevent thousands of deaths.
‘Instead of fulfilling their mission to keep our air and water clean, this administration is using stall tactics to defer their legal and moral obligation to reduce pollutants that threaten American families and fuel climate change,’ said Gina McCarthy, Pruitt’s predecessor as EPA administrator. ‘And it ignores climate change solutions that are plentiful, less expensive than traditional fossil fuels and producing jobs 12 times faster than the rest of the economy.’
Further down the EPA chain of control, another of Trump’s nominees is causing consternation. He wants to appoint Michael Dourson, who founded the organisation Toxicology Excellence for Risk Assessment, as the head of the Office of Chemical Safety and Pollution Prevention. While this means that – unlike so many of Trump’s appointees – he actually has a relevant background, TERA frequently published reports (some paid for by industry) that suggested safety limits for pesticides and other chemical products should be less stringent.
While at first sight this might seem positive for the chemical industry, in practice the conflict of interest means that public confidence in the impartiality of the EPA will surely be greatly damaged. Indeed, in his Senate appointment hearing, Dourson refused to declare that he would recuse himself from any matters that might be conflicted by his former work with TERA.
Another of Trump’s swathe of announcements, on the face of it, looks positive. He’s declared the prescription opioid ‘epidemic’ a public health emergency, calling on Americans to ‘confront the opioid crisis in all of its very real complexity,’ and citing the synthetic opiate fentanyl as a particular problem.
Fine words, but with no money - and little detail. A declared public health emergency only lasts for 90 days and attracts no funding – and the public health emergency fund is close to empty, having not been topped up since 1993. Without an associated appropriations request – the mechanism by which federal funds are earmarked for specific projects – either nothing will happen, or cash will be siphoned off from resources dedicated to other important public health issues such as HIV.
The announcement falls far short of the nationwide state of emergency that has been called for by addiction experts. That would provide the resources required for real action.