The Trump administration just handed a vibranium-powered shield to Obamacare supporters. Its Department of Justice is refusing to defend the ban on discriminating against people with pre-existing medical conditions.
Despite numerous promises to protect such patients, the president now proposes returning to the not-too-distant past when people with cancer, diabetes and chronic heart conditions could only buy healthcare coverage at exorbitant rates—if they could find it at all. He's backing the 20 state attorneys general, all Republican, who brought suit claiming that consumer protections in the Affordable Care Act were nullified when Congress zeroed out the penalty for the individual mandate.
Beyond its suspect legal rationale, lifting the ban makes no political, financial or medical sense. It would make medical management of people with multiple chronic conditions—a crucial element for controlling U.S. healthcare costs—exponentially more difficult.
About a third of Americans have illnesses requiring ongoing care. A June 2017 Kaiser Family Foundation poll found 70% of the public supports the ACA's ban on discriminating against people with pre-existing conditions. Should this suit succeed, its most immediate impact would be on the older, poorer and sicker people who buy coverage in the individual insurance market. They are among the 20% of the public that accounts for 80% of healthcare spending.
People who get coverage through their employers wouldn't be immune. While HIPAA and the Americans with Disabilities Act prohibit most forms of discrimination, loopholes in those laws allow employers to limit coverage for new employees with pre-existing conditions for a limited time.
In other words, removing the ACA's protections will heighten the financial and mental stress on tens of millions of people already struggling with daily life because of their medical problems.
Healthcare providers know firsthand how such stressors worsen the health of people with multiple chronic conditions. The medical literature is replete with studies documenting how financial and emotional stress increases the incidence of cardiovascular disease, migraine headaches and metabolic syndrome (the precursor to diabetes). It leads to binge eating, increased smoking and saps the will to fight disease, a sine qua non for healing.
It's also hard on providers' bottom lines. People without adequate coverage eventually get treatment, but only when their conditions are more challenging and expensive to treat. The added cost often winds up on the charitable or uncompensated-care lines of providers' balance sheets, increasing the tab for everyone.
In short, it's hard to imagine a stupider, crueler or more financially irresponsible social policy. Instead of leading a national discussion about why so many Americans are suffering from multiple chronic conditions, Trump has opted to throw those patients under the bus.
Equally depressing, none of the people in responsible positions at HHS and the CMS are objecting to the DOJ's decision. It's their responsibility to lead the national discussion about why chronic disease rates are so high. They should start by asking why our obesity rate—38% of the teenage and adult population—is the highest in the world. Or why our national suicide rate is soaring.
A new study in Health Affairs tracked how 30 medical conditions, which accounted for only 13% of personal healthcare spending in 2000, accounted for 42% of per capita growth over the next 14 years. Obesity was a major contributing factor to four of the top eight conditions on that list (diabetes, kidney disease, arthritis and cancer chemotherapy).
Since the ACA's passage, the nation's best healthcare providers have pursued population health management strategies. The goal is to improve health while lowering the overall cost of treating people with multiple chronic conditions. They've struggled to adapt to new payment models aimed at achieving both.
If the Trump administration succeeds in undermining Obamacare's insurance reforms, those efforts will be doomed.