There is always a well-known solution to every human problem – neat, plausible, and wrong. — H. L. Mencken
Consider this the reluctant editorial. These pages should be (and usually are) dedicated to what we should be and are doing, learning, and considering in practice and research to help prevent disease and improve patient care and quality of life now and in the future. When composing this piece, I tried to pretend that I had not recently read the front page of any US newspaper and that I had no idea major legislation is under consideration and sweeping budget changes have been proposed. I thought, Maybe this medical maelstrom will go away. Maybe these financial flames will ultimately be smoldered and we will be able to keep doing the work we are passionate about. Maybe the politicians do understand all the consequences of the proposed budgets and legislation and are committed to protecting the health and well-being of all and everything will work out just fine. After all, the US Constitution includes a general welfare provision!
But what happens if things get worse? Is it prudent to wait and see what happens, or do we weigh in and let our voices be heard now?
In its current format, the 2017 American Health Care Act includes a proposal to replace current Medicaid funding models with so-called block grants. Do our elected officials know data show this model will reduce state funding over time1 — that Presidents Reagan and Bush, as well as Congress (in 1995), unsuccessfully proposed the same model because health care coverage cannot be maintained at existing levels when a block grant model is used?2 Do the powers-that-would-be know the proposed changes might directly affect the majority of people we care for in rehabilitation centers and long-term care facilities since most Medicaid spending (63%) is for the care of persons >65 years of age and those who are disabled?3 How would this new payment scheme affect our ability to provide optimal care for this vulnerable population? Would we see reduced staffing levels, services, and ostomy/incontinence/wound care supplies? Unless individual states find ways to raise enough money to offset reduced payments from Washington, cost cuts will occur.
How about acute care services, which account for 30% of the Medicaid budget? As summarized by the American Hospital Association in their letter to the US House of Representatives regarding the American Health Care Act: “The effort to restructure the Medicaid program will have the effect of making significant reductions in a program that provides services to our most vulnerable populations.”4 The American Hospital Association also has voiced concern regarding the potential for decreases in the number of persons with health insurance coverage that will result from current efforts to replace the Patient Protection and Affordability Act (ACA).4 According to the Congressional Budget Office (CBO), if the 2017 American Health Care Act is passed into law, the percentage of uninsured Americans will steadily rise to 19% by the year 2026.5
Full implementation of the ACA is relatively new. Many provisions have been in effect only for 2 or 3 years, so hospitals most likely remember the days when they were among those left with many unpaid bills. Do members of Congress know what it would cost to see the percentage of uninsured persons rise above the levels we saw between 1995 and 2013?6 The CBO estimates that repealing the ACA and replacing it with the 2017 American Health Care Act will reduce federal deficits by $337 billion over the 2017–2026 period — an average of $37 billion per year.5 However, aside from the human costs, real dollar costs are associated with persons being uninsured. In fact, the Institute of Medicine (using 2003 dollars) calculated the cost to society of having 41 million people who did not have health insurance as $65 to $130 billion per year.7 But as with the proposed Medicaid “savings,” in the real world cuts in one budget usually translate into increases in another. History has shown hospitals end up with most of the unpaid bills from the uninsured population; little more than half of the total uncompensated care bill is paid for with federal funding and the remainder is paid with state or local tax dollars.8
Speaking of shifting costs, what is going to be the effect of the President’s proposed 2018 budget cuts to the US Department of Health and Human Services, which include slashing more than $400 million earmarked for physician and nurse training programs?9 How much will medical and nursing school tuition bills increase as a result? Will the number of physicians and nurses needed to care for our aging and increasingly ill population decrease? If the proposed 2018 budget or even a less draconian version is adopted, the number of people who need health care providers certainly is not going to decline. Programs that help keep people with low incomes (often the elderly) warm via heating cost assistance, that keep the home-bound fed (eg, Meals on Wheels), and that keep everyone safe from the vagaries of contaminated food, drinking water, and air are all on the chopping block. The White House hopes to lay off 3200 of the Environmental Protection Agency’s 15 000-person staff, effectively reducing (among others) toxic site cleanup and environmental monitoring programs.10 The anticipated impact on the latter is particularly ironic given the most recent findings about the effects of climate change on human health. The patients we typically care for (the elderly and persons with chronic health conditions) are among those likely to experience serious adverse effects from extreme temperatures, poor air quality, extreme weather events, and water- or food-borne diseases.11
Then there are issues that should be addressed in the ACA but are not. The cost of prescription drugs such as insulin comes to mind. While we worry about securing the best care for a patient with diabetes mellitus and a foot ulcer, reports about people cutting back on their insulin are increasing as costs for diabetes medicines have increased $100 to $200 per month to $400 per month or more.12
Do we just stand by and see what happens or do we speak out now? Do we wait for the smoldering fires to die down during the legislative process or do we remind legislators there are many aspects to health and well-being and that the law of unintended consequences can be very, very harsh? That a nursing or medical doctor shortage, once developed, takes many years to fix? That preventing disease and contamination is usually a lot easier (and less expensive!) than managing or ameliorating it?
I’ve asked myself these questions many times and found the answers by considering our nursing code of ethics, especially provisions 2, 7, 8, and 9.13 With 4 of 9 provisions clearly indicating a professional’s responsibility for population health, health policy, health disparities, and social justice, the choice is obvious: we must sound the alarm. The fires that may end up making our patients sicker also consume our ability to provide the best care we can.