Editor’s Note: Laurie Garrett is a senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize-winning writer. The opinions expressed in this commentary are hers.
Laurie Garrett: The life expectancy of Americans is lower than those living in some third-world countries
The GOP health care bill would have decreased it even more by cutting funding to life-saving preventative care, she writes
As House Speaker Paul Ryan pulled the Republican health care bill from voting, I could almost hear the giant sigh of relief from Atlanta and across the nation’s health care establishment.
Hidden in the nooks and crannies of the American Health Care Act (AHCA) was a provision to eliminate $1 billion in disease prevention funds from the US Centers for Disease Control and Prevention: Those cheers I imagine I hear right now in Atlanta are huzzahs from the CDC headquarters.
According to the GOP plan, “Our Step-by-Step Approach,” the first of three steps towards reshaping the American health care market was thwarted on Friday when the White House, recognizing that splits within the Republican Party could not be resolved to allow passage of the AHCA, instructed Ryan to pull the bill. Step two, led by Secretary Tom Price and his team at the Department of Health and Human Services, may still proceed: “going through every page of regulations and guidance related to the Affordable Care Act to determine whether or not they work for patients,” with an eye to eliminating the rules laid out by the Obama administration.
And under step three, Congress would have passed a series of laws aimed at lowering malpractice liability, enhancing cross-state-line insurance marketing and eliminating all forms of family planning provisions covered with federal funds. Republicans now know that all three steps will be tough, if not impossible, for them to accomplish.
After seven years of bashing Obamacare and 60 prior votes to repeal the ACA, Congress discovered over the last five weeks that:
- Americans didn’t want the ACA repealed until Congress created a replacement for Obamacare.
- Replacing the ACA is much harder than repealing it. As President Trump put it on February 27, “Nobody knew that healthcare could be so complicated. I have to tell you, it’s an unbelievably complex subject.”
- As debate unfolded over ACA replacement millions of Americans learned, apparently for the first time, that “Obamacare” and the “Affordable Care Act” are the same thing. In early February, a survey found that 35% of Americans were unaware that the federal health insurance system that many of them were relying upon was “Obamacare,” and as realization sank in, opposition to changing or repealing the ACA swelled. By mid-March nearly 60% of Americans opposed changing or repealing the ACA, and members of Congress were hearing complaints from constituents all over the country about AHCA provisions that would decrease or eliminate many types of coverage, and increase costs to most individuals.
- The AHCA’s reliance on individual tax credits to offset elimination of direct subsidies for health care never won favor with most voters, as only the wealthiest Americans would garner sufficient tax deductions to cover their health costs.
- The GOP leadership touted the AHCA as “health freedom,” liberating average Americans from the chains of federal mandates and control. But they would accomplish the liberation by passing funds to the states in the form of Medicaid block grants, which each state would use as it deemed fit. Republican governors howled in protest, realizing this “freedom” simply shifted the burden of health regulation and most costs from Washington to the cash-strapped states.
- It is impossible to separate the “healthy” from the “sickly” and affordably place them in different insurance pools. Obamacare could only satisfy the insurance industry’s financing needs if it mandated pooled enrollment of both healthy young adults, people suffering from chronic diseases, and the sicker older adults.
How the GOP angered constituencies
As the debate unfolded, advocates for the GOP plan made statements, or offered amendments, that angered a succession of constituencies and health organizations. A call to insert provisions allowing employers to conduct genetic tests on job applicants, eliminating all funding for Planned Parenthood, questioning the wisdom of “forcing” men to pay for insurance coverage of maternity care, childbirth and newborn services, undermining access to treatment for opioid addiction, telling poor Americans that they need to choose between buying the latest iPhone and purchasing insurance – these and countless more tone-deaf statements and initiatives from Republican politicians had the nation crying foul.
Perhaps the coup de grace came with Vice President Mike Pence’s tweet of a White House meeting with members of Congress, discussing cuts in women’s health and maternity coverage to reduce the overall cost of the AHCA. Twitter exploded with protest over the optics of a room full of white men – and not a single woman to be seen – deciding the fate of the nation’s female population.
On social media many compared the all-male discussion of women’s health coverage in the White House to Saudi Arabia’s creation of a Girl’s Council composed of men.
Widespread opposition from the experts
Nearly every major medical and public health professionals’ organization in the nation opposed the GOP plan, even before the Congressional Budget Office released its nonpartisan assessment of the bill’s likely impact. Opposition grew when the CBO concluded that by the end of 2018 the AHCA would bump 14 million Americans out of insurance coverage – a sorry lot that would swell to 21 million by 2020 and 24 million by 2026. Though President Trump had vowed to provide “insurance for everybody,” the AHCA would roll the total number of uninsured Americans back to pre-2009 levels.
So under the ACA the $1 billion Prevention and Public Health Fund was created, in the CDC. The CDC used those funds to support everything from diabetes diagnosis and care programs to elimination of lead poisoning. A third of the funds ($324 million) were for vaccines and child immunization programs. Another $12 million targeted adolescent suicide efforts and $160 million subsidized epidemic surveillance and the safety of drinking water and food from bacterial contamination. All of these programs would have disappeared – 12% of the CDC’s total budget – with repeal of the ACA.
Health trends in America, particularly when compared to those in other developed nations like Germany and Japan, are terrible. Eliminating the CDC’s vaccination budget would effectively propel an already dangerous anti-immunization movement that finds parents across the country refusing to vaccinate their children.
The CDC program that would have been eliminated covers eighty 80% of the nation’s efforts to control heart disease and strokes – the No. 1 cause of death in the US Stockpiles of drugs and medical equipment that are rapidly deployed in catastrophes, outbreaks and natural disasters would have disappeared.
Americans are dying younger – especially white, middle-aged men. One reason: fentanyl, heroin and other opioids. In 1999 drug overdoses claimed the lives of 6.1 of every 100,000 Americans, and that soared to 16.3 per 100,000 in 2015. Most of the overdoses in 2015 were white Americans aged 45-54 years. Whether from drugs, accidents or any other cause, premature death rates are worst in rural America, where health care is least accessible.
Life expectancy in America took a backwards turn in 2015 for the first time since the mid-1990s peak of the AIDS epidemic, falling to 78.8 years on average, combined for men and women. Cancer death rates fell, but more Americans in 2015 died from unintentional injuries, suicides, respiratory diseases and Alzheimer’s. The CDC concluded, “In 2015, a total of 2,712,630 resident deaths were registered in the United States — 86,212 more deaths than in 2014. From 2014 to 2015, the age-adjusted death rate for the total population increased 1.2%, and life expectancy at birth decreased 0.1 year.”
More Americans are dying from drug-resistant infections – the garden variety staph and strep bugs that used to be swiftly cured with a course of routine antibiotics. But last year Congress only approved $14 million for CDC research to identify ways to preserve the utility of antibiotics. Given the scale of the crisis, it was a pittance. The arrival, to US hospitals, of forms of bacteria can be so extremely resistant to treatment that, in the case of a Nevada woman last year, 26 different antibacterial drugs failed to save her life.
Startling decline in Americans’ life expectancy
Comparing American survival to that of other nations can be startling. The United States ranks 37th in the World Health Organization’s annual health systems assessment, behind not only the longest-lived societies like Japan, and the entire continent of Europe, but also below tiny Costa Rica. With a GDP per capita, in 2015, of only $9,200, Costa Ricans live an average one year longer than their far wealthier US counterparts. US male mortality is 18% higher than in Costa Rica; American female mortality is 10% higher than Costa Ricans for women under 65 years of age. The biggest differences between Costa Ricans and Americans are for deaths due to lung cancer, influenza and heart disease.
Why do people in the tiny Central American nation live longer, for less money, than their United States counterparts? It’s simple: the Costa Rican government ensures that every single citizen has equal access to basic care and prevention services, while the United States fails to do so, and Costa Rica’s health system provides better care based on individual wealth or quality of private insurance.
Nicholas Eberstadt of the American Enterprise Institute wrote a startling essay entitled “Our Miserable 21st Century,” in which he linked the rise of nationalism and victory of Donald Trump to the nation’s declining life expectancy, soaring opioid crisis and falling social mobility. In conservative Eberstadt’s view the very conditions that led campaign crowds in 2016 to scream for the death of Obamacare are what the Affordable Care Act is meant to address.
According to a 2009 Harvard study a whopping 62% of family and personal bankruptcies filed in the United States before Obamacare were caused by financially overwhelming medical expenses. That translates to a little more than 640,000 people, and makes health care the primary cause of pre-ACA American financial catastrophe.
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The Commonwealth Fund Biennial Health Insurance Survey found that after four years of Obamacare the number of Americans claiming bankruptcy or financial difficulty due to medical bills fell from 75 million in 2012 to 64 million two years later, “And for the first time [since 2001], there was a decline in the number of people who had problems paying their medical bills or who are paying off medical debt over time.” Moreover, the survey found, “The coverage gains are allowing working-age adults to get the health care they need while reducing their level of financial burden because of medical bills and debt.”
And so I breathe a sigh of relief as the GOP’s American Health Care Act goes to its grave. As long as the maligned Obamacare and its Prevention and Public Health Fund remain funded and functioning there is reason to hope that America can once again see improvements in its population’s life expectancy, women can safely give birth to healthy babies, and families can afford to confront tragic catastrophes like paralyzing injuries or cancer without fear of bankruptcy and medically-induced poverty.