How the AHCA and Trump budget are addressing the decreased US life expectancy

Perhaps you saw a recent report from the CDC that the life expectancy for the US went down for the first time in decades.  The top seven causes of death for adults remained the same, although many of them became more common in 2016.

Let’s look at how president Trump’s proposed budget will address each of these conditions which are the seven top killers of American adults.

  1. Heart disease.  Heart disease causes 1 in 4 American deaths.  While it can strike persons of any age, it is most common in adults over 50.

While we have effective medications to treat heart disease, I have multiple patients who struggle to make ends meet every month.  When it’s a choice between medicine and food, my patients choose food.  These are hardworking men and women who have years before retirement, years before they will be eligible for the Medicare benefits they’ve been paying for their entire working lives.

How will the American Health Coverage Act (AHCA) affect those with heart disease?  First, it will substantially increase premiums for those whom heart disease is most likely to affect.  The AARP Policy Institute estimates that health insurance premiums will rise 13% for Americans ages 50-59, and 22% for 60-64 year olds.  For a 64 year old making $25,000, premiums are estimated to rise from $1,700/yr to $14,600/yr.  While sticker shock over that increase might not be enough to cause a heart attack, trying to cover the premiums might be enough to make the cost of life-saving medication out of reach.

2 and 3. Cancer and Chronic Lower Respiratory Disease (COPD and emphysema). While most cancer and COPD/emphysema is attributable to lifestyle causes (tobacco, diet and lack of exercise), as many as 10,000 cancer deaths a year are caused by exposure to environmental pollutants, like air pollution. 

Lung disease is one of the few causes of death that did not claim more lives than usual in 2016.  While most of that decrease in lung disease-related deaths is from decreases in smoking over the past twenty years, some of it is be attributable to the decrease in environmental pollutants.  Instead of capitalizing on the momentum of recent gains in air quality, this administration’s budget guts funding for the EPA whose regulation has been responsible for much of the improvement in our air quality.  Let’s give Beijing a run for its money.

4. Accidents and suicide.  Accidents (including overdoses) and suicides, especially among middle aged white men, were a major driver of the increased mortality in 2016.  Specifically, men aged 45-64 have had a 43% increase in suicide over the last 15 years.  Heroin overdoses have increased 20% from 2014-2015.

Despite the appalling increase in suicides and overdoses in the past few years, the AHCA removes the guarantees for equal mental health and substance abuse in the 31 states that expanded Medicaid coverage under the ACA.  But that only affects 19.7 million Americans suffering with substance abuse and more than 40 million American adults with mental health issues, so why should the AHCA provide care for them?

5. Stroke.  Stroke is another killer that is most common in adults over 50, although a third of hospitalizations for stroke occur in adults younger than 65.  According to the CDC, stroke costs the United States an estimated $33 billion each year in health care services, medicines to treat stroke, and missed days of work.  Stroke is a leading cause of serious long-term disability in the US.

The AHCA includes a provision to penalize anyone with a lapse of coverage (say, because of having to stop work because of a stroke) with a 30% surcharge on the cost of their policy.  Additionally, because of the high proportion of disability among stroke survivors, Medicare is a major insurance provider for stroke survivors.  The CBO estimates that the AHCA will make Medicare insolvent four years earlier than its current projected demise under Obamacare.  The AHCA is one more reason (in a long list) to pray you don’t have a stroke.

 6. Alzheimer’s Disease.  We should be okay on Alzheimer’s disease because we know the cause and have effective treatment for this disease that … wait, scratch that.  We don’t know how to prevent Alzheimer’s disease, nor do we have a single effective therapy to reverse the losses of Alzheimer’s disease or to stop its progress.

The Trump budget proposes a 20% cut in NIH funding, so don’t hold your breath on finding a cure any time soon for the 5 million Americans suffering from Alzheimer’s disease.

7. Diabetes and chronic kidney disease (CKD).  28.9 million Americans live with diabetes, and the disease disproportionately affects ethnic minorities.  Diabetes and hypertension, both chronic diseases, are the top two causes of chronic kidney disease (CKD).  Both diabetes and CKD are major contributors to heart attack and stroke risk, but appropriate treatment for diabetes and hypertension can delay- or prevent altogether-  many cases of CKD.

The US has a shocking disparity between rural and urban care for chronic diseases including diabetes, hypertension and CKD.  While Medicaid expansion under Obamacare sought to increase access to care in rural areas, nearly two-thirds of people without insurance lived in states that did not choose to expand Medicaid. Likewise, according to the Kaiser Family Foundation, only 51% of rural workers had employer-sponsored health insurance, as opposed to 57% in urban areas.  The combination of these two factors leaves 14% of the rural population (as opposed to 9% of the urban population) without access to affordable insurance coverage, and this is despite the ACA.

Here is a map of the states that expanded their Medicaid coverage under the ACA (blue states expanded Medicaid; orange states did not).  Thanks, Kaiser Family Foundation for the map.

Since 2010, 80 rural hospitals have closed in the US.  The National Rural Health Association estimates that by 2020, 25% of rural hospitals will have closed. Closing a hospital not only affects the health of that community and its surrounding area, but often eliminates the one of the largest employers in that region, throwing hundreds of people out of work.  For kicks, let’s look at the map of where rural hospitals have closed since 2010 (courtesy of Rural Health Research Program and Slide Share):

Rural Hospital Closures*: 57 Closures from January 2010-Present August 24, 2015 6 August 24, 2015 Created using SmartDraw®

I’m no geography genius, but there seems to be a lot of overlap between the orange parts of the top map (no Medicaid expansion) and the dots on the lower map (closed rural hospitals).

The AHCA makes no effort to address these disparities in care, or to improve the survival chances of rural hospitals.  A market-based health care exchange leaves out rural markets.  If Congress is so determined to improve the ACA, they should at least make some effort to improve the one real defect in the ACA, which is the persistent lack of rural health care access, especially in areas where Medicaid was not expanded under the ACA.

I give Congress and the Trump budget proposal and F on health care so far.  Empty words have their place (obviously, since that’s how the 2016 election was won) but when it comes to the health of our country, gutting recent gains in health care access under Medicaid expansion and removing the budget for disease research is all bad.

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