Lies and cowardice screwing almost everybody's health care coverage

There is usually more than one way to look at a situation. Often referred to as “point of view”, it is good to consider this, particularly in personal relationships, as the way you see things might not be the way the other person does. In the Trump years most of us have become more aware of a different basis for disagreement, not based on different interpretation of the facts but upon different facts. This is not just a difference in emphasis-- you and I both believe X and Y are true, but I think X is more important than Y and you think Y is more important than X.

We are in a situation in which a large portion of the population believes lies are facts, believes that things that are not true are true. Of course, this has always been the case, like when most folks thought that the Earth was flat, or that the sun and stars revolved around the Earth. These were definitively disproved, we know the truth, and yet there are other just as ridiculously incorrect beliefs (and, here, I except, for brevity, religion) that many people still cleave to. Heck, there are still flat earthers! I doubt that most of the leaders of the Republican Party or members of the administration in Washington – or even Fox News commentators -- actually believe most of these falsehoods (except Donald Trump, who seems too demented or stupid or isolated or all three to know), but they find them convenient ways of keeping the public’s attention focused away from what they are doing to benefit themselves and their buddies. This could be called the “Wizard of Oz” technique, and misdirection is a core part of most magic acts, but it is also a core component of fascist tyrannies.

These outright lies in the Era of Trump are incredible, both in number and the real impact on people. In the area of health, the focus of this blog, they have been amazing in terms of their scope and impact. Vaccines, among the few actual preventive things that medicine can do, have been attacked and criticized and completely wrongly said to cause worse problems than they solve. Not to put too fine a point on it, this is pure evil coming from RFK, Jr. and his team of loons. Yes, there are individual people who should not get one or more individual vaccines, because of a serious prior allergic reaction, or even worse a rare effect like Guillain-Barre, but for the vast, vast majority of children and adults vaccines are all good. They basically eliminated smallpox from the world, and essentially eliminated terrible killers like measles in this country – until a new movement endorsed by the Secretary of HHS brought them back. Your measles as a kid wasn’t too bad? Neither was mine. But lots of kids got sick. A bunch died. You never had measles because you’re too young? Because even your parents are too young? And you all had vaccinations? Sadly, maybe you’ll see it in your children. Mumps made people deaf and infertile, meningococcus dead or brain damaged, H influenza the same. Polio made people dead or paralyzed, in wheelchairs or in iron lungs. When I was a medical resident, we saw H influenza meningitis and epiglottitis, meningococcal disease, even some measles and polio. All eliminated by vaccines. Until we stop using them.

    

Smallpox                                Measles               Polio (in iron lung)

There are many, many other health disasters promulgated (it seems on purpose) by this administration. Eliminating or cutting back infectious disease surveillance – cyclospora, E. coli, salmonella -- anyone? Enjoying that? How about animal diseases? And funding for medical research – being heavily cut back especially for researchers that the administration doesn’t like.

But one HUGE area is health insurance, financial coverage for our medical care. I have written about the terrible US health care non-system which is designed to make money for private corporations (insurance companies, big hospitals and health systems, Pharma) instead of being designed to deliver the best actual health care for our people, and how it needs to be replaced by a system of covering everyone, as in every other wealthy country – improved Medicare for All. People need financial coverage because all those big corporations are owned by investors who demand ever-increasing profits, so the costs of the overall system (highest in the world by far), and to individuals, keeps going up.

Under the current administration, the opposite is happening. In a recent editorial in the NY Times, the cuts to coverage are enumerated and documented. The most dramatic of these are cuts to the Medicaid program and the subsidies for purchasing individual insurance on the marketplace created by the Affordable Care Act (ACA, “Obamacare”). The Medicaid cuts target the most vulnerable and needy, the poor and disabled, and the cuts to the ACA subsidies means that the poor-but-not-quite-poor-enough-to-qualify-for-Medicaid population that was finally insured through ACA will lose it. (If you want to know how poor you must be to qualify for Medicaid, you can look it up by state, but it is always very poor. When you look it up, remember that while many states tie eligibility to about 135% of the Federal poverty level, many others have much lower qualifying incomes.) This is really bad because it is going to kill people, is going to strain many physicians and hospital systems – especially those that cannot afford it, like rural hospitals – and create a lot of misery.

There are several other bad things related to health coverage that the Times does not even address. One of these is the aggressive promotion of Medicare Advantage (MA) plans for Medicare eligible people. These plans are not actually Medicare, a federal government run program, but private insurance products that use Medicare money (and gets paid more per patient than traditional Medicare, TM). On the one hand, if you get a good, comprehensive MA plan it can save you money (with TM you probably need to pay for a Medicare supplement and Part D plan as well as the Part B premium taken from your Social Security payment). But it can also have bad results because the insurance companies that run it can, and often do, deny payment for your care, just as they do for regular insurance.

Another health insurance problem the Times does not address is the fact that even in the best situations (in those states that chose to expand Medicaid and before Trump), the ACA did not cover everyone. Both this and Medicare Advantage are also areas not addressed by those making policy for the Democratic Party. It is not coincidental that the Times and that portion of the Democratic Party called (depending on where you stand) “centrist”, “moderate”, “Wall St.” or “right-wing” are similar, because both share a similar ethos. This is to be better than the GOP on a lot of social issues affecting individuals but to not threaten the basic status quo: corporate America making a lot of profit, and enriching its investors, at the expense of the rest of us, particularly but not only the poor, who get screwed out of medical care and/or bankrupted by the bills. Oh, and, by the way, if you one of the majority of people who have employer-sponsored health insurance, you’re still not safe. Costs for insurance to employers (with much or all of the increase passed on to employees) is expected to go up 11% in 2027!

The “centrist” branch of the Democratic Party does not support eliminating or strictly regulating Medicare Advantage, not to mention Improved (covering everything) and Expanded (covering everybody) Medicare for All. The same tired and inadequate reasons are given: “we can’t afford it” --- ridiculous given that every other wealthy or middle-income country does -- when what they mean is “we don’t want to alienate the billionaires who continue to support us”. They say that they need to “be moderate” because they don’t want to turn off independent voters, which results in policies that do not significantly help most regular people. Like Improved and Expanded Medicare for All (see the Jayapal House, HR 3069, and Sanders Senate, S 1506, bills) would.

We should be terrified of what the Trump Administration and GOP are doing, especially trying to disenfranchise voters before the election, and the huge cuts to our health care. But voters are not going to be excited by “Republican lite”; they need to hear about bold programs that will change their lives for the better.

Veterans, Trans People, Medicaid, Women: To whom else can we deny coverage?

It is, at the same time, very easy to write about the healthcare abuses enacted and proposed by the Trump administration and its GOP legislative sycophants, and very difficult to do so without seeming repetitive. I have written recently about cuts to Medicaid, changes in Medicare, evil mis-messaging about vaccines, and the promulgation of false treatments that range from an ineffective waste of money to downright harmful. What else is there to say? Essentially, the administration is doing anything that they can do to hurt people’s health, and they continue to do more of it.

Eleven million people are likely to lose their health coverage with the Medicaid cuts now proposed in the Senate, which are even more extensive than in the House. Virtually none of them will be the able-bodied-but-not-working-or-looking-for-work-person Medicaid deadbeat trumpeted by the GOP. Most Medicaid recipients are children and their caretaker mothers, most Medicaid dollars are spent on long-term care for seniors, and most adults receiving Medicaid are already working, at a job, often more than one job, that pays so little that they are Medicaid-eligible. Frequently, these are jobs working for the very corporations (run by the very rich individuals) who will benefit from the tax cuts that are to be funded by the Medicaid cuts! Sigh. There is nothing close to morality, or humanity, here. Since Medicaid is paid to healthcare providers, not to patients, when fraud occurs it is usually on the part of providers, mostly hospitals and other institutions such as nursing homes (also owned by the very wealthy). On the other hand, rural hospitals that are often dependent upon Medicaid (people are older, sicker, and poorer) are likely to close. It’s a good thing no Senators are dependent upon them for healthcare!

The Commonwealth Fund’s “2025 Report Card on State Health System Performance” reports that

Every state has reduced its uninsured rate over the past decade, and today there are fewer adults who are skipping needed care because of the cost. This progress is largely due to the Affordable Care Act’s Medicaid expansion, marketplace plan subsidies, and consumer protections. 

That progress is now at risk. Proposed Medicaid funding cuts, work requirements, new requirements for enrolling in marketplace plans, and the expiration of enhanced ACA premium subsidies could together leave millions of Americans uninsured and drive up costs for many more.

The report is full of useful graphs, like this one:

Cutting Medicaid, and other associated cuts like kneecapping the Affordable Care Act (ACA) including by eliminating the eligibility for Medicaid for those a little above the poverty level, and increasingly converting Medicare into for-profit Medicare “Advantage”, are mean. Also heartless, cruel, vicious. But there are other changes being made that are even meaner and discriminate against groups of people. Not surprisingly, one of the main groups being attacked is trans people, long a focus of Trump and his coterie of orcs. They talk incessantly about “men” who will play “girls’” sports, as if this is a main, or even significant, reason, people go through the painful, arduous, socially difficult, and expensive in every way process of transition (not to mention the lack of discussion of “women” playing “boys’” sports!) People do not “choose” to be trans as if they were choosing a pair of shoes; they are acknowledging that who they know they are is different from the label that society has assigned them. Among the circumstances that they have to face is worse health status and worse healthcare, including worse health insurance, and much worse mental health status. This is a real problem, unlike the silly sports discussions.

But it’s not just trans people. Another group that is getting targeted for worse health care is veterans. While they are less often publicly demeaned than trans people (and, of course, there are many trans people who are veterans), veterans are seeing their health care cut. This is happening globally, with decreased funding to already-stretched thin VA clinics and hospitals. It is happening more for certain veterans who fall into categories that the administration can identify for particular abuse. As reported first in The Guardian, and now elsewhere, physicians and other healthcare providers are being given permission to refuse healthcare to people who, among other things, are unmarried or Democrats!

Medical staff are still required to treat veterans regardless of race, color, religion and sex, and all veterans remain entitled to treatment. But individual workers are now free to decline to care for patients based on personal characteristics not explicitly prohibited by federal law. Language requiring healthcare professionals to care for veterans regardless of their politics and marital status has been explicitly eliminated.

I certainly hope that the physicians and other providers at the VA have the ethical and moral commitment to their profession to never refuse care for these completely unacceptable reasons that violate the most central tenets of medicine. But the executive order by the President goes even farther. The providers themselves, if they meet these same conditions, can be fired because of them! The idea that people who are armed services veterans, who have served and now need health care, can be divided into those whose characteristics completely unrelated to that service, are worthy of treatment and those who are not, is an infamy. It is, of course, completely impossible to reconcile these directives with democracy, freedom, or ethics of any kind.

What is even more damning (probably not objectively “worse”, but certainly adding insult to injury) is that the administration’s order allowing discrimination against some veterans – particularly women – is titled “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government”. !!! This is a real-world version of the satire of Lewis Carroll’s Humpty Dumpty (“a word means whatever I choose it to mean”), but goes farther, to George Orwell’s “1984” by using words to mean the opposite of what they actually mean. War is Peace, Freedom is Slavery, Ignorance is Strength. Donald Trump would have fit right in! 

On a more positive note, a judge recently decided that the cuts made to grants from the National Institutes of Health (NIH) to researchers based on the fact that they studied the health problems of minority groups, including LGBT+ people, were illegal and must be reinstated. Moreover, the language he used was damning:

Judge William G. Young of the Federal District Court for the District of Massachusetts delivered a damning assessment of the Trump administrations’ motives in targeting hundreds of grants that focused on the health of Black communities, women and L.G.B.T.Q. people. He ordered the government to restore much of that funding for now, pending an appeal.

“This represents racial discrimination and discrimination against America’s L.G.B.T.Q. community,” he said. “That’s what this is.”

Judge Young, a Reagan appointee with 40 years of experience added that:

…over the course of his career he had “never seen government racial discrimination like this,” and that he felt duty bound to state his conclusion about the government’s intent.

“I would be blind not to call it out,” he said.

He is obviously correct, but what is most distressing is that the administration is trying to enact such discriminatory criteria, into both research grants and, as in the VA, the clinical care of people. [See the Bethesda Declaration, by NIH researchers.] Of course, it is not as if such orders have no precedents. The “Nuremberg Laws” in Nazi Germany come to mind!

There apparently are no limits on what bigoted, racist, discriminatory, undemocratic, un-Constitutional, and generally mean, petty, and vicious policies that Donald Trump and his administration seek to implement in healthcare, as in so many other areas of our polity. The question is whether there will be any limits on them from Congress (so far no) or the courts. The latter is so far yes, but Judge Young’s decision will be appealed, and it is far from certain that, should they review it, the Supreme Court will support it.

While it is more reassuring and easier to have a system that protects us by ensuring freedom and non-discrimination that we can passively accept, when this system is under attack, as it is today, it is ultimately up to us to make sure those practices are maintained.