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Health of the Union 2018

One of the weird things about Donald Trump’s State of the Union speech was how much he sounded like a normal president– ignore the parts about the wall and MS-13 and the digs at kneeling NFL players and you could easily picture an alternate universe where a President Mitt Romney or a President Jeb Bush was giving the same speech.

Partly that’s just the nature of the State of the Union– it’s a laundry list of policy accomplishments/goals, and for all the talk of Trump being an “outsider” candidate, his actual policies are generic Republican stuff– but it was also partly in how he defended those policies.

We’ve probably fact-checked hundreds of statements about healthcare from politicians on both sides of the aisle, and it’s actually pretty rare to catch them straight up lying. They say things that are false all the time, but they typically do that by starting with a grain of truth and then spinning it wildly out of context. So for example, during the 2012 campaign Mitt Romney claimed that Obamacare “robbed” $716 billion from Medicare– in truth Obamacare didn’t take any money out of Medicare, it simply lowered the reimbursement rates that would be paid to hospitals, insurers, and other providers, saving $716 billion. Or to give an example from the other side, there’s President Obama’s “if you like your plan, you can keep it” claim. It’s true that the Obamacare contained a provision that exempted pre-ACA plans from the ACA’s rules, but there was nothing in the law to prevent insurers from canceling those old plans, and many did.

President Trump is different. From the size of his inauguration crowd to the ratings of his State of the Union, Trump’s tells lies that don’t contain even a grain of truth– and he does it constantly. However, in the State of the Union, at least on healthcare, he spun and mislead like a normal politician. Here’s how…  

The Individual Mandate

“We eliminated and especially — an especially cruel tax on Americans making less than $50,000 a year, forcing them to pay tremendous penalties, simply because they could not afford government-ordered health plans. We repealed the core of the disastrous Obamacare, the individual mandate is now gone.”

Let’s break this down. Republicans did eliminate the ACA’s individual mandate when they passed their tax plan in December (although as NPR’s Alison Kodjak points out, “Technically, the law still requires people to have coverage, but with no penalty available, most people consider the individual mandate to be dead”). It’s also true that most (79%) of the people who paid the individual mandate penalty last year had incomes below $50,000.

Whether they paid the penalty because they couldn’t afford coverage is another story. For starters, if you can’t find coverage for less than about 8% of your income, you don’t have to pay the penalty (on top of that, there’s also a long list of hardship exemptions). Many people– especially those with incomes between $10,000 and $25,000– seem to be paying the penalty by mistake. It’s also important to remember that the individual mandate is relatively weak– for individuals making between $25,000 and $50,000 it’s often cheaper to pay the penalty than buy insurance. If they’re young and healthy, they may feel that they don’t need insurance even though they can afford it and opt for the penalty instead.

In any event, the individual mandate is far from the “core” of Obamacare– the ACA will go on, it just won’t work as well. The Congressional Budget Office estimates that as a result of repealing the mandate 13 million fewer people will have coverage and premiums will increase by about 10%. Even with those losses, up to 20 million people who would have been uninsured will still have coverage thanks to Obamacare.

Veterans Health

“And we are serving our brave of veterans, including giving our veterans choice in their health care decisions.”

We’re not totally sure what Trump is talking about here, but he’s probably an extension of the Veterans Choice Program that Congress approved in August. The Veterans Choice Program was passed in 2014 under the Obama administration, and was meant to reduce wait times for veterans seeking care. It provided $2.5 billion for hiring more medical staff at VA hospitals and $10 billion for vets to get care outside of the VA system. The program was about to run out of money, and Congress couldn’t agree on how to pay for a long term extension (this is the same GOP-controlled Congress that didn’t pay for its $1.5 trillion tax plan), so they passed a $2.1 billion extension to “keep the program alive and buy more time to develop a legislative solution.” We guess that’s better than nothing, but also not something to brag about.

 

“Last year, Congress also passed, and I signed, the landmark VA Accountability act. Since its passage, and my administration has already moved more than 1500 V.A. employees who fail to give our veterans the care they deserve.”

We’ll let the Washington Post handle this one:

Congress passed the legislation in June making it easier to fire VA employees and shortening the time employees have to appeal disciplinary actions. But the law’s impact on improving accountability at the department remains unclear: More VA employees were fired in former President Barack Obama’s last budget year, for instance, than in Trump’s first.

Prescription Drugs

“To speed access to breakthroughs, cures, and affordable generic drugs, last year, the FDA approved more new and generic drugs and medical devices than ever before in our country’s history.”

This is true: the FDA approved 56 new drugs last year and 1,027 generics, a record in both categories. It also looks like an instance of Trump taking credit for something that his administration had little to do with. As NPR points out, “President Barack Obama signed the 21st Century Cures Act into law on Dec. 13. It offers ways to speed drug approval by pushing the FDA to consider evidence beyond the three phases of traditional clinical trials.”

Also, with drug approvals faster isn’t necessarily better. Before 2017, the FDA was already approving drugs three to four months faster than its counterparts in Europe and Canada, but that speed came with consequences: nearly a third of the drugs approved from 2001 through 2010 had major safety issues years after the medications were made widely available to patients. These issues were more common for drugs that were granted “accelerated approval” and drugs that were approved near the regulatory deadline for approval.

 

“We also believe that patients with terminal conditions, terminal illnesses, should have access to experimental treatment immediately that could essentially save their lives. People who are terminally ill should not have to go from country to country to seek a cure. I want to give them a chance right here at home. It is time for Congress to give these wonderful, incredible Americans the right to try.”

Here Trump is referring to a federal Right to Try Act, which on its surface sounds great– give patients with no other options the chance to try experimental therapies that haven’t been approved by the Food and Drug Administration. However, as Michael Becker, a former biotechnology executive who has been diagnosed with terminal cancer, notes, patients like him already have access to experimental therapies:

Under the Federal Food, Drug, and Cosmetic Act, patients can seek expanded access, sometimes called compassionate use, to investigational therapies, meaning those that are being studied for safety and effectiveness but that have not been approved by the FDA. Since expanded access was enacted in 2009, the FDA receives approximately 1,000 requests for expanded access each year. It approves more than 99 percent of these requests, and makes meaningful changes approximately 10 percent of the time to improve patient safety.

Becker also points out that Trump’s own FDA Commissioner has serious reservations about the bill, and with good reason:

The FDA retains oversight of expanded access treatments. It can use the results of these treatments to judge the safety and effectiveness of the experimental therapy. As currently drafted, the federal right-to-try bill eliminates or reduces that oversight — a concern noted by FDA Commissioner Scott Gottlieb in testimony before the House Energy and Commerce Committee’s Subcommittee on Health.

Put simply, under the right-to-try bill, a death caused by the use of an experimental drug could not be considered by the FDA in deciding whether to approve or reject the therapy. While this may help address pharmaceutical and biotechnology industry concerns that expanded access programs could jeopardize ongoing studies, it is simply unethical at its core.

I’m also worried about the financial, legal, and medical protection afforded to patients and their families under the proposed right-to-try bill. Do patients undergoing right-to-try therapies lose their coverage for hospice? Would insurers be absolved of any responsibility for covering further medical expenses once a patient starts a drug under right-to-try? What if the experimental drug causes hospitalization or leads to additional treatments — who would pay for that?

In his testimony, Gottlieb also raised the concern that, if the federal right-to-try was enacted without changes, sponsors and others providing investigational drugs to patients would not be subject to a number of rules and regulations related to clinical trials, premarket approval, and labeling. That would, in essence, preclude the FDA from taking enforcement actions based on those provisions. In other words, cutting out the FDA as a gatekeeper increases the risk of patients being harmed through the peddling of false hope and snake oil.

It’s not just Becker who’s worried: dozens of doctors, medical ethicists, and lawyers have urged Congress not to pass the legislation.

 

“One of my greatest priorities is to reduce the price of prescription drugs. In many other countries, these drugs cost far less than what we pay in the United States. And it is very, very unfair. That is why I directed my administration to make fixing the injustice of high drug prices one of my top priorities for the year. And prices will come down substantially. Watch.”

As a candidate, Trump promised to stand up to the pharmaceutical industry, and, unusually for a Republican, argued that Medicare should negotiate directly with drug companies to bring down prices. As President he has done… nothing.

Meanwhile, his State of the Union address gives no details on how his administration plans to fix the “injustice of high drug prices” this year– and given that he chose Alex Azar, a top executive at the pharmaceutical giant Eli Lilly, as his Secretary of Health and Human Services, we’re not holding our breath.

Opioid Crisis

“In 2016, we lost 64,000 Americans to drug overdoses. 174 deaths per day. Seven per hour. We must get much tougher on drug dealers and pushers if we are going to succeed in stopping this scourge. My administration is committed to fighting the drug epidemic and helping get treatment for those in need. For those who have been so terribly hurt, the struggle will be long and it will be difficult. As Americans always do, in the end we will succeed. We will prevail.”

Trump’s figures are correct, but so far his administration has done little to actually address the opioid crisis. In the spring he created an opioid commission to study the epidemic and make recommendations– the commission finally release its report in November, but the Trump administration has yet to act on any of them.

In an interim report released back in August, the commission recommended that he declare the opioid crisis a national emergency, which would open up billions of dollars in federal funding. Two waited two months and then in October issued a limited “public health emergency” declaration, which allowed some regulations to be waved, but it opened up just $57,000 (no we’re not missing any zeros) in additional funding– that’s two cents for each individual in the U.S. struggling with opioid addiction. Meanwhile, CNBC reports that “the Trump administration has actually taken steps that will hinder federal efforts to fight opioids […] It has proposed slashing federal substance abuse programs, as well as Medicaid funding, which supports addiction services.”

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