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ID experts anxious, uncertain about Trump presidency
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Days after winning the White House, President-elect Donald J. Trump declared during a TV interview that he would try to keep in place parts of the Affordable Care Act guaranteeing coverage for patients with pre-existing conditions and allowing children to remain on their parents’ health care plans until age 26 years — comments that seemed at odds with his persistent campaign pledge to “repeal and replace” President Barack Obama’s signature health care law.
Trump, the real estate developer and former reality TV star-turned-politician, has handled other campaign issues in a similar fashion, said Jeanne Marrazzo, MD, MPH, director of the division of infectious diseases at the University of Alabama at Birmingham School of Medicine.
“You just don’t know what was manipulation and bluster, and what he really is going to do. The unpredictability has everyone on edge,” Marrazzo told Infectious Diseases in Children. “You don’t really know what you’re going to get when you wake up in the morning, which sometimes can be interesting and sometimes very unnerving.”
Infectious disease experts described feelings of anxiety and uncertainty about Trump’s surprising election and how it will affect patient care, but also showed a willingness to be patient to see how the political newcomer will govern.
Among their biggest concerns are what will happen to the Affordable Care Act (ACA) and how major government health agencies will be run in the new administration.
“This is a president-elect who has never served in public office before,” Peter J. Hotez, MD, PhD, Dean of the National School of Tropical Medicine, Baylor College of Medicine, and Texas Children’s Hospital Endowed Chair in Tropical Pediatrics, told Infectious Diseases in Children. “He’s never really needed to be informed by scientists or about science in any significant way. As a result, we’re dealing mostly with a blank slate and I hope President-elect Trump reaches out to the scientific community to discuss these important issues.”
President-elect Donald J. Trump could move to repeal the Affordable Care Act and ease FDA regulations.
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The anxiety and uncertainty seem to be products of Trump’s penchant for offering conflicting or controversial statements, both as a candidate and in the time before seeking the Republican nomination. These include remarks on several infectious disease-related topics, such as when he complimented American volunteers who became infected during the Ebola outbreak in West Africa, but urged the U.S. government not to let them back in the country, saying they “must suffer the consequences” of traveling overseas to help.
Trump has aligned himself with the anti-vaccination movement, hinted that he might loosen FDA regulations, and once said that climate change, which can affect the spread of infectious diseases, was a hoax invented by China.
“I think if Hillary Clinton was elected, we might have expected to see some continuity with the current administration’s policies. But equally, there may have been some changes as well,” William G. Powderly, MD, president of the Infectious Diseases Society of America, said in an interview. “Clearly this transition has created anxiety. Whether that anxiety will ultimately be justified remains to be seen.”
Uncertain future for ACA
Keeping parts of the ACA that guarantee coverage to patients with pre-existing conditions and allow children to remain on their parents’ health care plans into their mid-20s means more access to care for patients, including those with infectious diseases. But the ACA also includes mandates for screening and prevention services for HIV, hepatitis C virus infection and various sexually transmitted infections without copays, and penalties for health care centers that experience a significant number of health care-associated infections.
It is unclear how these services will be affected under Trump, or how he views them, but infectious disease experts are worried about economically and socially marginalized populations losing access to any critical medical care.
“In a population that already has a difficult time accessing health care, further distancing them from it can have a profound effect on prevention and transmission,” Wendy Armstrong, MD, professor of medicine at Emory University and chair of the HIV Medicine Association, said in an interview.
Marrazzo categorized it as a social justice issue.
“The concern is that [Trump’s] real drive is a relentless worshiping of capitalism and a belief that money can solve everybody’s problems. The commitment to the underserved informs a lot of what we do in infectious disease,” she said. “We’re anxious and concerned that our ability to provide the kind of care we need and advocate for our patients is potentially going to be undermined.”
Though it was a major platform in Trump’s campaign, repealing and replacing the ACA is easier said than done, according to Sara Rosenbaum, JD, professor of health law and policy at George Washington University. Rosenbaum said there is an increasing sense that repealing the law without a ready replacement is “not rational” considering the millions of patients whose health care coverage is connected to it.
So far, no detailed idea of what a replacement would look like has been offered by Republicans.
“I don’t think anyone really knows what would replace it,” Rosenbaum told Infectious Diseases in Children. “There have been vague discussions about what would replace it, but none of these vagaries have been reduced to elements that are specific enough to be judged from a policy perspective, and they certainly have not been converted into the actual language of legislation, which is a very long and complex process.”
Speculation about FDA
Like so much else about his policies, Trump’s feelings about the FDA appear unclear. A clue may be found in the health care plan on his transition website, which says he plans to “reform” the FDA “to put greater focus on the need of patients for new and innovative medical products.”
FDA spokesman Jason Young told Infectious Diseases in Children that the agency was not able to speculate whether this means Trump will pursue deregulation and had no comment on his election as president.
The Trump transition team did not immediately respond to requests from Infectious Diseases in Children for comment.
Powderly indicated that there could be some agreement between Trump’s plans for the FDA and what he says is a desire to get new drugs to patients more rapidly and develop new diagnostic testing for infections.
“If we can deliver on streamlining the processes within the FDA while continue to protect the public, everybody is going to benefit,” he said.
There may be common ground elsewhere, too, including Trump’s proposal to keep public health exempt from a federal employee hiring freeze meant to thin the federal workforce, Powderly said. Marrazzo would like to see Trump live up to his campaign pledge to focus on parts of the country that are economically depressed. Such areas have been hit hard by the worst opioid epidemic in U.S. history, which has contributed heavily to the burden of infections such as HIV and HCV.
“If there is a willingness to partner around the science of prevention, and a recognition of where those preventive tools need to be deployed, that can be transformative and that would be fantastic,” Marrazzo said.
Eying appointments
Hotez said an early test of Trump’s health and science policy will be who he picks to run public health agencies like the CDC, NIH and HHS.
So far, Trump has selected Rep. Tom Price, MD, a Republican from Georgia who opposes the ACA, as HHS Secretary, and health care consultant Seema Verma, MPH, who has helped Republican governors in Indiana, Iowa, Kentucky and Ohio develop conservative Medicaid expansion models for their states, to lead the Centers for Medicare and Medicaid Services. Her efforts in developing the Medicaid expansion program Healthy Indiana Plan 2.0 could provide insight as to what reforms she may advocate.
“We continue to have significant concerns about what a repeal of the ACA would look like for our vulnerable patients who often fall through the cracks in safety nets,” Armstrong said. “I live in a Medicaid nonexpansion state where we already struggle and see challenges without Medicaid expansion. For our lower-income patients who are getting subsidized plans through the ACA, if those were to disappear as well, we will have an increased number of patients who don’t have access to the health care system.”
A matter of speculation
Trump’s repeated alignment with certain anti-vaccine views — including the debunked claim that they cause autism — might be especially troubling to infectious disease experts. During the Republican debates, he said he favored vaccines, but believes they should be delivered in smaller doses over a longer period.
“The same amount, just in little sections, and I think you’re going to see a big impact on autism,” Trump said during a debate in September 2015.
Hotez, who also heads the Sabin Vaccine Institute, has an adult daughter with autism. He said he gives the inexperienced president-elect the benefit of the doubt when it comes to vaccines and hopes Trump receives good advice on the topic.
“It doesn’t sound like anyone has really sat down with him and explained why that’s not plausible, why vaccines don’t cause autism,” Hotez said. “So, just like he made comments during the campaign that he’s changed or modified, I’m hoping that he’ll do the same for things like vaccines.”
Until Trump’s policies are fully realized during his presidency, how he will treat these specific areas of health care is a matter of conjecture.
“We don’t know how his election will influence our patients,” Armstrong said. “All of us are speculating, but there’s been a lack of clearly articulated plans to help us know for certain what’s going to happen.” – by Gerard Gallagher
Disclosures: Armstrong, Hotez and Rosenbaum report no relevant financial disclosures. Marrazzo reports serving on the board of the International Antiviral Society-USA. Powderly reports serving on advisory boards for Gilead Sciences and Merck, and receiving research support from Astellas Pharma and Merck. Young is a spokesman for the FDA.