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Trump presidency could mean changes for endocrinologists, patients
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The election of Donald J. Trump as the 45th president of the United States ushered in much speculation about the future of health care in the country; namely, what could become of the Affordable Care Act he has promised to “repeal and replace.”
Debate among proponents and critics of the law known as Obamacare has only grown with Trump’s recent nomination of Rep. Tom Price, R-Ga., as HHS secretary. Price, a sharp critic of the Affordable Care Act (ACA) who has written a full replacement bill, has also proposed overhauling Medicare and Medicaid, which was widely expanded under the ACA.
As part of a 100-day action plan released during the campaign, Trump pledged to repeal the ACA and replace it with health savings accounts, the ability to purchase health insurance across state lines and allowing states to manage Medicaid funds.
Although the real fate of the health care law remains unknown, any changes could have far-reaching effects for patients living with diabetes, according to experts.
“The [ACA] has been a game changer in terms of health insurance in the U.S. — about 20 million more Americans now have health insurance,” William H. Herman, MD, MPH, professor of endocrinology and epidemiology at the University of Michigan, told Endocrine Today. “The key provisions — mandating coverage for preventive services and prohibiting denial of coverage of pre-existing conditions — have been incredibly important both for diabetes prevention as well as diabetes treatment. The key provisions expanding coverage for young adults who can stay on their parents’ plan until age 26 [years], and the health insurance marketplace for people who don’t receive insurance through their work, all benefited people with diabetes.”
Changes to diabetes care
In a 2015 study published in Diabetes Care, Vivian A. Fonseca, MD, FRCP, of Tulane University School of Medicine, New Orleans, and colleagues examined the effect of the ACA’s Medicaid expansion provision — a voluntary action on the part of the states — on diabetes treatment and care. Using the Quest Diagnostics database, researchers assessed cases of newly identified diabetes during a defined, pre-Medicaid expansion control period (January-June 2013), as well as during a defined post-expansion period (January-June 2014). Included patients were Medicaid enrollees who had at least one test through Quest Diagnostics in the preceding calendar year.
In the 26 states and District of Columbia that accepted the Medicaid expansion, researchers found that the number of Medicaid-enrolled patients with newly identified diabetes increased by 23% (14,625 vs. 18,020) vs. a 0.4% increase in the 24 states that did not accept the Medicaid expansion.
“There may be other factors that were unmeasured, but our conclusion was there were a lot of people who became eligible for Medicaid who went and had themselves tested [for diabetes],” Fonseca told Endocrine Today. “I will be surprised if the Medicaid expansion, to the degree that it happened, will remain with the new administration, new governors and Congress. I think that might be detrimental for people who would otherwise get Medicaid.”
In an editorial accompanying Fonseca’s study, Herman noted that the Medicaid expansion likely improved outcomes for patients with diabetes.
“We know from natural experiments that people with diabetes use more services ... that they have better control and better outcomes, and from some experiments, it has been suggested that they have reduced mortality when they receive medical coverage,” Herman said in an interview. “All of those things are good, and all of them are, I think, potentially at risk.”
Richard O. Dolinar, MD, a senior fellow in health care policy at the Heartland Institute, said any attempts to change the health care law will most likely be gradual, but that changes can bring opportunities for improvement.
Health savings accounts, according to Dolinar, will likely rise dramatically with any proposed replacement to the legislation.
“I also believe that you will see insurance companies allowed to sell their products across state lines,” Dolinar, an Endocrine Today Editorial Board member, said in an interview. “This should help lower the rate.”
Rising cost of care
According to the 2016 long-term budget outlook prepared by the nonpartisan Congressional Budget Office (CBO), federal spending for the major health care programs will continue to rise substantially as the population ages and health care costs per beneficiary continue to grow faster than potential gross domestic product (GDP) per capita.
By 2046, federal spending for Medicare and Medicaid will rise to 8.9% of GDP, about 60% greater than it is estimated to be in 2016, according to the CBO. Growth of Medicare spending will account for about three-quarters of the increase in federal spending for the major health care programs as a share of GDP, the report states.
“At some point in time, politicians must own up to the cost of promises made,” Alan J. Garber, MD, PhD, FACE, chief medical editor of Endocrine Today, said in an interview. “You don’t promise your children a BMW when they graduate high school, if you can’t afford a BMW when they graduate high school. Set aside any question about the wisdom of giving them such a car. But when you have a situation where the government promises everybody a BMW, but then wants to turn around and pay at the price of a Yugo, you’re not going to get a BMW, you’re going to get a Yugo. That’s, unfortunately, economics 101.”
Some changes, Garber said, could be beneficial if the focus is put on quality of care.
“It really depends on the federal bureaucracy,” Garber said. “If the notion of cost containment continues rather than quality care, then putting dollars first puts care second.”
Access to diabetes drugs, devices
As an additional part of Trump’s 100-day plan, he has promised to “cut red tape” at the FDA to speed the approval of life-saving medications and devices. However, experts predict that little, at least initially, will change for the pipeline of diabetes drugs and devices.
“We don’t have quite the backlog that some other FDA divisions have, like the oncology branch,” Garber said. “So, I expect there will be a minimal acceleration in the endocrine and metabolic products. Generally, the FDA concern has been focused on safety, and I don’t see that changing greatly, notwithstanding Mr. Trump’s desires.”
Herman agreed.
“I don’t see any game changers in [diabetes] treatments and devices,” Herman said. “The real critical issue now is giving people access to the medications and tools we need to treat and control diabetes.”
Business of endocrinology
For practicing endocrinologists, current economic realities will likely lead to a “doubling down” on price controls, Dolinar said, potentially affecting the specialty.
“A movement is underway to pay physicians based on value — but value is subjective,” Dolinar said. “Physicians will have their revenues cut even further with this approach, and have little recourse. These events will discourage entry into endocrinology.”
“Currently, there are approximately 2,500 endocrinologists in the U.S.,” Dolinar said. “As the number declines, at what point will [endocrinologists] be considered extinct?”
Leaders in the field are continuing to advocate on behalf of endocrinologists to ensure that the specialty has a voice in any proposed changes with a Trump administration. Henry M. Kronenberg, MD, president of the Endocrine Society, said the election results will not change the organization’s efforts to advance the science, policy and practice agendas that support its members.
“We are reaching out to share and advise the presidential transition team on the society's priorities and how we can play an effective role in the future,” Kronenberg told Endocrine Today. “We will continue to advocate for endocrinology in Congress with old friends and new. We will continue to engage in partnerships domestically and globally to move our work forward and link to both seasoned and new leaders who care about health care, endocrine science and practice, and biomedical research.” – by Regina Schaffer, with additional reporting by Amber Cox, Cassie Homer and Jill Rollet
References:
CBO 2016 Long-Term Budget Outlook. Available at: www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51580-LTBO.pdf. Accessed Dec. 1, 2016.
Kaufman HW, et al. Diabetes Care. 2015;doi:10.2337/dc14-2334.
Herman WH, Cefalu WT. Diabetes Care. 2015;doi:10.2337/dc15-0348.
For more information:
Richard O. Dolinar, MD, can be reached at the Arizona Endocrinology Center, 15640 N. 28th Drive, Phoenix, AZ 85053; email: dolinar@heartland.org.
Vivian A. Fonseca, MD, FRCP, can be reached at Tulane University Health Sciences Center, 1430 Tulane Ave. - SL 53, New Orleans, LA 70112; email: vfonseca@tulane.edu.
Alan J. Garber, MD, PhD, FACE, can be reached at Baylor Clinic, 6620 Main St., Suite 1100, Houston, TX 77030; email: agarber@bcm.edu.
Henry M. Kronenberg, MD, can be reached at Massachusetts General Hospital, Endocrine Unit, 50 Blossom St., Boston, MA 02114; email: kronenberg.henry@mgh.harvard.edu.
William H. Herman, MD, MPH, can be reached at the University of Michigan, 3920 Taubman Center, Ann Arbor, MI 48109-0354; email: wherman@umich.edu.