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American medical experts are expressing alarm at the risks to healthcare posed on three fronts by the policies and budget plans of President Donald Trump.
The first area of concern, as recently analysed in the Medical Independent (MI), is the Affordable Care Act (ACA). If the President decides to revive his aborted plan to repeal former President Obama’s ACA, or simply lets it “implode”, as he now suggests, this could result in 24 million Americans losing health insurance.
Obamacare remains the law of the land after the failure of the repeal effort on 24 March. But for how long and in what form? An angry President Trump has vowed to let it wither on the vine. Speaking in the White House after the failure to repeal the ACA, he said: “The best thing we can do, politically speaking, is let Obamacare explode and it’s exploding right now. It’s imploding and soon it will explode.”
However, the failure by Trump and his Republican Party has started to embolden Democrats, who have now begun to push plans not just to protect Obamacare, but to aim for more drastic reforms. Chief among them is their suggestion that the government’s Medicare insurance programme for seniors should be expanded to cover everyone. ‘Medicare-for-all’ has become their catch-cry. But unless they can win back control of Congress in elections next year, it may be just a pipe dream. For now, Obamacare survives but is on life support.
Then there is the President’s proposed travel ban. Experts say his immigration controls and travel ban on six majority-Muslim countries will stall medical research projects and lead to a shortage of doctors in parts of the US, particularly in rural areas.
The chances of the travel ban going before the Supreme Court increased on 25 March when, in a boost for Trump, a Virginia judge ruled that the executive order was justified.
The third area of concern is the President’s planned budget cuts for 2018. These cuts will hit key agencies like the Centres for Disease Control and Prevention (CDC) and leave others straining to fulfill their missions to uphold standards and advance medical research and public health.
“The current administration’s proposal will significantly curtail efforts by the biomedical and scientific communities to move our country forward,” Prof William J Brown, Professor and Chair of the Department of Molecular Biology and Genetics at New York’s Cornell University, told MI. He said the flow of scientific data is essential and warned against any policies or cuts that impacted it. He stressed that this would be “near-sighted, counterproductive and possibly even dangerous”.
The President sees it differently. He says all these policies are about helping to “make America great again”. Indeed, his budget is titled ‘America First. A Budget Blueprint to Make America Great Again’. President Trump says it will make the country stronger by upping military spending and “re-prioritising’’ federal spending in other areas of government.
“The core of my first Budget Blueprint is the rebuilding of our nation’s military without adding to our federal deficit. There is a $54 billion increase in defence spending in 2018 that is offset by targeted reductions elsewhere. This defence funding is vital to rebuilding and preparing our armed forces for the future.”
But a closer examination of what he is proposing shows that concerns expressed by medical professionals are well founded. Indeed, by any standard, the extent of the proposed cuts will have a chilling impact. While defence spending would gain $54 billion, other agencies, especially in the health sector, would see drastic cuts. The budget of the National Institutes of Health (NIH), the primary agency responsible for biomedical and health-related research, would be cut by $5.8 billion, meaning it would lose about 20 per cent. The Department of Health and Human Services would see a $15.1 billion, or 18 per cent, budget cut. The budget would also eliminate entire programmes, such as $403 million in respect of health professionals and nursing training programmes.
The President does not give a specific funding figure for the CDC but indicates his proposals would “reform” the CDC, to give states more control over public health by creating a $500 million block grant that would “increase state flexibility and focus on the leading public health challenges to each state”.
Though thin on details, there is some good news. The President’s budget spells out a plan to create a Federal Emergency Response Fund for a rapid response to public health threats like Zika. The proposal includes $500 million to expand opioid abuse prevention and treatment efforts. There is also a mention of an investment in “mental health activities”, but no specifics. The budget would include some money for international health efforts, including funding for the fight against malaria and HIV/AIDS.
The reaction to the budget was as swift as it was negative. Statements from a number of medical organisations expressed alarm at the consequences for ongoing medical research in areas like cancer and other diseases.
“As scientists, we make decisions based on evidence. What this budget does is ignore evidence and undermine our very ability to collect it across the board,” said Dr Andrew Rosenberg, Director of the Centre for Science and Democracy with the Union of Concerned Scientists. Like others, Dr Rosenberg believes the proposed budget could hurt the US government’s mission as an international leader in health and science research.
The American Medical Association (AMA) said in a statement that it “has grave concerns with proposed deep cuts to the NIH and their impact on patient health. Patients across the country who benefit from NIH research and advancements can attest to its value.” AMA President Dr Andrew W Gurman added: “NIH conducts vital research into cancer, chronic diseases and other illnesses, all of which are major drivers of healthcare costs.”
The American Cancer Society’s Cancer Action Network was equally alarmed at the proposed cuts, saying its effects would “turn back the clock” on cancer research.
“The proposed reduction in NIH funding of $5.8 billion would represent a significant setback for millions of American cancer patients, survivors and their families. It would also dramatically constrain the prospect for breakthrough American medical innovation — an essential American economic driver,” said network President Mr Chris Hansen in a statement. “We are at the cusp of tremendous breakthroughs in cancer research, making it exactly the wrong moment to turn back the clock on progress against a disease that continues to kill more than 1,650 people a day in this country.”
The American College of Physicians said the President’s proposed cuts would undermine health research: “Unfortunately, this budget proposal fails to make those investments [in biomedical and health services research] and would make America less ‘great’ by undermining our commitment to science, medical and health services research, medical education and research on climate change.”
However, the President’s recently-appointed head of the Department of Health and Human Services (HHS), Dr Tom Price, expressed his agency’s support of the budget. “HHS is dedicated to fulfilling our department’s mission to improve the health and wellbeing of the American people. This budget supports that mission and will help ensure we are delivering critical services to our fellow citizens in the most efficient and effective manner possible.”
Dr Tom Price
The NIH cut of $5.8 billion marks “the first time a President has proposed a cut of this magnitude since the NIH received its first appropriation in 1938”, pointed out the New England Journal of Medicine (NEJM). “The proposal has far-reaching implications for public health, research and drug development and keeping America at the forefront of innovation,” the journal declared. “It also threatens young scientists who are the future leaders of academia, biotechnology and the pharmaceutical industry.”
The NIH plays a pivotal role in the US medical innovation sector as the world’s largest funder of biomedical research, it stressed. Companies frequently leverage basic and clinical research supported by the NIH to develop new therapeutics and technologies. Up to 47 per cent of drugs approved by the FDA between 1988 and 2005 benefited in some way from public sector support.
“NIH-funded research has led to major reductions in deaths from heart disease, stroke, cancer and infections. Rates of US deaths from all causes dropped by 43 per cent between 1969 and 2013. NIH-supported research has also contributed to the discovery of 153 new FDA-approved drugs, vaccines and new indications for current drugs in the past 40 years. Most experts agree that cuts of any magnitude will ultimately hamper the scientific enterprise and adversely affect local, national and global economies, while inhibiting discoveries that are essential for fighting disease worldwide,” stated the NEJM.
“Even as the medical community was still smarting from news of the proposed cuts, it learned further bad news on 28 March, when the White House suggested that immediate additional cuts are also coming this year. These proposals would slice $1.2 billion from the $31.6 billion budget of the NIH.
The reductions are part of $18 billion in cuts the President wants this year. These proposed cuts would also target health and science programmes across other government agencies, including plans to take $350 million from the National Science Foundation’s $6.9 billion budget.
President Trump also wants to cut in half the $101 million Teen Pregnancy Prevention programme; reduce FDA staff spending by $40 million; cut domestic and global HIV/AIDS programmes by $100 million; and cut the $4.3 billion budget of the Presidential Emergency Programme for AIDS Relief (PEPFAR) budget by $242 million. PEPFAR has provided aid for prevention, treatment and care of HIV infection in many low-income countries in an effort to control the global epidemic and is credited with averting more than 700,000 deaths of adults within the programme’s first four years alone. The Trump budget would also delete the $72 million Global Health Security fund at the State Department and cut other global health programmes by $90 million and $62 million for global family planning.
The President’s proposed travel ban and immigration controls are also setting-off alarm bells in the medical community. His 2018 budget requests $1.5 billion to detain and remove undocumented immigrants and $314 million to hire 500 new border patrol officers and 1,000 new Immigration and Customs Enforcement (ICE) officers. Such measures may bolster his pledge to limit immigration but they could also lead to a shortage of doctors in parts of the country and stall research in some universities and medical schools.
Take the case of Dr Seyed Soheil Saeedi Saravi, a top young scientist in Iran. He had been hired by Harvard Medical School to study how diabetes affects the way cells talk to one another in the cardiovascular system, but Trump’s ban put an end to the endeavour in the United States.
Harvard Medical School professor Thomas Michel, who hired the Iranian scientist, said Dr Saravi got a visa after many months of vetting but it was suspended when Trump barred people from Iran and six other Muslim-majority countries from entering the US for 90 days and all refugees for 120 days, except those from Syria, whom he banned indefinitely. The original ban in January was struck down by a number of courts but has now been reformulated by the White House and is likely to withstand further legal challenges.
“To keep America great, I think we need to ensure that the best and the brightest continue to want to come here,” Prof Michel told the media.
An open letter from the Association of American Universities signed by more than 7,000 academics, including 43 Nobel laureates, described Trump’s order as “detrimental to the national interests of the United States [and] significantly damages American leadership in higher education and research”.
The AMA also urged the Trump administration to reconsider its proposed immigration ban and consider its impact on the provision of doctors across the country.
“While we understand the importance of a reliable system for vetting people from other nations entering the United States, it is vitally important that this process not impact patient access to timely medical treatment or restrict physicians and international medical graduates (IMGs) who have been granted visas to train, practice, or attend medical conferences in the United States… Specifically, there are reports indicating that this executive order is affecting both current and future physicians, as well as medical students and residents who are providing much-needed care to some of our most vulnerable patients.
“Many communities, including rural and low-income areas, often have problems attracting physicians to meet their healthcare needs. To address these gaps in care, IMGs often fill these openings. To date, one out of every four physicians practising in the United States is an IMG.”
A team from Harvard Medical School and the Massachusetts Institute of Technology (MIT) analysed data to understand the contribution of physicians from targeted countries to the healthcare workforce and confirmed that the travel ban could reduce the number of doctors in rural areas.
Harvard Medical School
“The results of our analysis are clear,” according to the team. “Physicians from banned countries provide an important contribution to the healthcare workforce of the United States. There are more than 7,000 physicians trained in countries targeted by the executive order working in the United States. Together, they see an estimated 14 million visits from patients each year.
“We find that the areas of practice most affected by the ban include cardiology, neurology, gastroenterology, pathology and internal medicine. In remote areas, a single cardiologist or neurologist can be responsible for management of life-threatening conditions for hundreds of individuals. Given the shortages of specialists in these areas, their departure can have deleterious consequences for the management of these conditions.”
Patients are also suffering because of the travel ban. Some clinicians have said their patients who are already in the US illegally are not seeking the medical care they need or using other vital public services for fear of being jailed and deported. Of the 11 million illegal immigrants in the US, some 50,000 are Irish.
Immigrants make up a sizeable proportion of the US healthcare workforce. In 2010, those who were foreign-born accounted for 16 per cent of those employed in healthcare occupations in the United States. In some healthcare professions, this share was larger, according to figures from the Migration Policy Institute. More than one-quarter of doctors and surgeons (27 per cent) were foreign-born, as were more than one out of every five (22 per cent) people working in healthcare support jobs like nursing, psychiatric and home-health aides.
Silence in the face of these policies and budget cuts is not an option, according to the organisers of a recent March for Science event. Under the heading ‘Science, not silence’, its website proclaims: “It is time for people who support scientific research and evidence-based policies to take a public stand and be counted.” Prof Brown at Cornell agrees. “Science will prevail in the end. It always has and always will,” he told MI.
Meantime, some members of President Trump’s own party also oppose his cuts, particularly those affecting the NIH. Among them is Mrs Ann Romney, wife of former Republican Presidential candidate Mr Mitt Romney.
“I will be the first one down lobbying against this if someone will sign me up for that,” she said last month. Mrs Romney, who has multiple sclerosis, said it is important that the NIH continues receiving funding so that medical progress can be made and people can eventually be treated due to new research. “Nothing comes from nothing. If you don’t have that funding, there will be nothing,” she said. “There will be no new treatments, there will be no new drug therapies. Progress in medicine will come to a halt.”
She said she does not believe members of Congress will necessarily support cuts to NIH funding. “I’m not sure it would be such a hard sell for me to go to Congress and say ‘do not defund NIH’, because I’m sure a lot of those people will understand how significant that funding is.
“But people just need to be educated on it and understand that if we are going to be leading with advancements in science and in helping people break through with these horrific diseases… then NIH is absolutely critical to making that happen.”
Trump’s failure to repeal Obamacare may also serve as a salutary lesson. He will be aware that he has to walk a fine line, because polls show Americans do not want more spending on defence if the price they have to pay is cuts to sectors like healthcare.
A Reuters/Ipsos poll in March, for example, found 51 per cent support reducing defence spending and only 28 per cent want to cut health programmes for the poor or elderly, like Medicare and Medicaid.
So it may not be all plain sailing for Trump’s budget when it gets to Congress. While the President puts forward budgetary requests, it is Congress that makes the final decisions on spending, since it controls the main lever of US political power — the purse.
Doctors and patients ‘greatly concerned’
Dr Hassan Majeed is an international medical graduate (IMG) from Pakistan working in the US on an H-1B visa. He is a child, adolescent and addiction psychiatrist and recently shared his views with the Medical Independent (MI) on President Trump’s immigration ban and its effects on US healthcare.
Dr Majeed believes most Americans are probably not aware of how dependent the US healthcare system is on doctors who are IMGs.
A quarter of the doctors in the US were trained abroad and many come from Muslim-majority countries. In addition, last year, almost 4,000 non-US citizens were needed to fill residency positions in American hospitals. That’s 13.5 per cent of all doctors entering the US health system.
“Trump’s promise during the campaign to overhaul the H-1B visa programme could affect thousands of IMGs who have completed residency programmes and are now working in under-served communities or working in hospitals throughout the country,” according to Dr Majeed.
“This programme has helped me and thousands of other physicians stay in the US in exchange for our service to under-served communities. Plans to revamp the H-1B visa — or the even more extreme talk of eliminating it altogether — jeopardise all of these positions. This is of great concern, not only to physicians, but also to patients. Sadly, if these physicians are required to leave their positions, there is likely no-one to replace them.”
The immigration ban has already affected many doctors and medical scientists, he says. “Suha Abushamma, an internal medicine resident from the Cleveland Clinic, was deported from JFK Airport hours after she arrived from Saudi Arabia. She has a Sudanese passport, with a visa to travel to the US. Around the same time, Samira Asgari, an Iranian-born human genomic scientist, was denied boarding a plane to Boston to start a post-doctoral fellowship at the Harvard-associated Brigham and Women’s Hospital. Another Iranian, cardiovascular scientist Seyed Soheil Saeedi Saravi, was set to join the cardiovascular medicine department at Harvard Medical School but his visa was suspended.
“Americans deserve the best and brightest physicians to take care of their medical needs, and IMGs are as skilled as American medical school graduates. The irony is that the government trusts us to take care of its most vulnerable population — the sick and unwell — but not enough to let us live in this country,” said Dr Majeed.