The Gutting of the Affordable Care Act

A number of people have asked me if I’m watching the impending annihilation of the Affordable Care Act as the new administration gears up to take office this week. The answer is yes, both because I’m interested in public health and health policy and because I get my own health insurance through the ACA. The assault on the law is already underway, and the consequences will be dire. For those of you who are concerned about what’s happening and what could happen but haven’t been following the news that closely, here’s a primer.

·      Although House Speaker Paul Ryan and President-elect Donald Trump have been crowing for months about repealing Obamacare, they don’t have enough votes to overturn the law outright. In the Senate, where Republicans have a 52-48 majority, they’d need 60 votes to overcome a Democratic filibuster. This means that eight Democrats would have to vote to repeal the ACA, which is extremely unlikely.

·      Since the Republicans lack a filibuster-proof majority in the Senate, they’ve chosen instead to gut major provisions of the ACA through a process called budget reconciliation. In short, this process allows them to get rid of sections of the law that are funded through the federal budget, but only those sections. They can reverse the Medicaid expansion. They can rescind the subsidies that most consumers receive to purchase insurance on the exchanges. They can also repeal the individual mandate to buy insurance. Both the House and the Senate voted last week to approve budget measures that will allow them to take these actions.

·      The Affordable Care Act is more than a program that allows individuals to purchase insurance plans through state exchanges. It contains a number of provisions that affect everyone who has health insurance, whether through an employer or on the individual market. These features of the law appear to be safe for now, because they’re untouchable through the budget reconciliation process. But it’s unclear whether they’ll ultimately be at risk. They include:

o   Free coverage of preventive services, including mammograms

o   Free coverage of birth control

o   Allowing young adults to remain on their parents’ health insurance until the age of 26

o   No denial of coverage for pre-existing conditions

o   An end to lifetime caps on how much an insurer pays to cover someone, which is crucial for those with conditions that are costly to treat

·      Republican leaders have proposed several ideas that they claim will provide people with better coverage at lower costs than Obamacare. They include:

o   Increased use of Health Savings Accounts. HSAs, however, are not the same as health insurance; they simply allow individuals to move pre-tax dollars into an account that can be used to pay for medical expenses out-of-pocket. They do nothing to ensure access or affordability.

o   Allowing insurance companies to sell policies over state lines. However, out-of-state insurers would probably just end up buying into existing networks of providers, so it wouldn’t actually improve anything. In addition, states have varied requirements for minimum coverage. New York State, for example, just passed a bill (which is not yet law) that provides free birth control coverage for women. Therefore, insurers would probably choose to sell their policies in states with the least, not most restrictive requirements.

·      Republicans, including Tom Price in his confirmation hearing today, have been asserting that no one will have their health insurance pulled out from under them when the ACA is gutted. They’ve said they will replace it with a plan that has people “beautifully covered,” to quote Trump. But the timing of Obamacare’s replacement is uncertain, as no one has offered a detailed blueprint of what it will look like, and health economists agree that it would be impossible to design a plan that offers better coverage and is cheaper for both individuals and the government than what we have now. An immediate repeal of the ACA’s individual subsidies would throw the insurance market into chaos, as companies would pull out to avoid the uncertainty that is sure to follow, since no one knows what the replacement plan will look like and when it will come.

The Affordable Care Act expanded health insurance coverage to 20 million Americans, although about 25 million more remain uninsured. Despite the law’s problems—high deductibles, rising premiums, small networks of providers, limited choice of plans in many parts of the country—removing its protections from those who need them strikes me as inhumane. The nonpartisan Congressional Budget Office released a report yesterday which said that a repeal of the ACA would cost 18 million people their insurance in the first year alone. We’ll probably never have single-payer health insurance in the U.S., as in every other industrialized country. But until we can implement a program that increases access while controlling costs, we have to work on improving what we’ve got, not destroying basic protections that are saving lives.

Theranos and the Allure of Numbers-Based Medicine

The recent announcement that Theranos CEO Elizabeth Holmes has been banned from the blood-testing industry for two years is the latest chapter in the company’s rise and fall, a cautionary tale in what can happen when media hype and millions of dollars in investment funds collide with the revolutionary but untested claims of a driven, dynamic founder.

Until Theranos came under scrutiny from federal regulators, much of the laudatory press coverage focused on the company’s origin story—the turtleneck-clad Stanford dropout who idolized Steve Jobs and wanted to change the world through technology. Holmes landed on the covers of Fortune, Forbes, Inc. and T: The New York Times Style Magazine, and the New Yorker and Wired published lengthy profiles. At its peak, Theranos was valued at $9 billion, making Holmes the youngest self-made female billionaire in the world, at the helm of an enterprise whose board was packed with luminaries including Henry Kissinger and former Secretary of State George Shultz.

Holmes claimed her company had developed a process that would upend American medicine by allowing dozens of laboratory tests to be run off a few drops of blood at a fraction of the cost of traditional methods. But whether its technology actually works is still an open question, as Holmes has never allowed it to be examined by outside researchers, nor its data to be peer-reviewed. Last fall, the Wall Street Journal reported that Theranos’s proprietary Edison machines were inaccurate and it had been running tests on the same equipment used by established labs such as Quest Diagnostics and Laboratory Corporation of America. This set in motion a spate of bad news for the startup: investigations by the Center for Medicare and Medicaid Services, Securities and Exchange Commission and U.S. Department of Justice; the cancellation of an agreement with Walgreens to open blood-testing centers in pharmacies nationwide; the voiding of two years of Theranos blood results; and class-action lawsuits from consumers who say their health was compromised by faulty data. (For an excellent summary of the company’s rise and fall, check out this graphic from NPR.)

The excitement over Theranos was based on its claim of proprietary technology that, if real, had the potential to revolutionize lab testing and the healthcare decisions that are based on it. But at the core of its vision was a less sensational though equally central premise: that direct-to-consumer blood testing is the future of American healthcare. As Holmes put it in a 2014 TEDMED talk, enabling consumers to test themselves for diseases before showing any symptoms would “redefine the paradigm of diagnosis.” By determining their risk for a condition before developing it, people could begin treatment at an earlier stage. Take, for example, Type 2 diabetes, which Holmes says drives 20 percent of our healthcare costs and can be reversed through lifestyle changes: 80 million Americans have a condition called prediabetes, and most of them don’t know because it generally produces no symptoms—no headache, no muscle pains, no nausea or fever or chills—and is detectable only through a blood test.

The removal of the subjective experiences of the patient from the act of diagnosis has been a part of medical practice since the mid-1800s, when the modern stethoscope made it possible to observe the internal workings of the body in a non-invasive way. By the beginning of the twentieth century, an assortment of new instruments gave doctors access to technical information that patients could neither see nor interpret. The laryngoscope and electrocardiograph offered data independent of an individual’s perceptions, while a new device to measure blood pressure found its place in the doctor’s medical bag. Hemocytometers and hemoglobinometers enabled microscopic examination of the size and number of blood cells, allowing hematologists, as these specialists became known, to read the blood and manipulate it to treat various disorders. Together, these instruments reduced the physician’s reliance on a patient’s subjective description of symptoms in favor of precise, quantifiable data.

As diagnostic technologies have grown more sophisticated, a number of symptomless conditions have appeared that didn’t previously exist. Many of these are defined by deviation from a numerical threshold: high blood pressure, for instance, or prediabetes. But as physician and historian Jeremy A. Greene has written, these numbers can change due to shifting medical opinion or adjustment by pharmaceutical companies, which have an incentive to make the population of patients who are candidates for their drugs as large as possible. When the American Diabetes Association lowered the threshold for prediabetes in 2003, the population of prediabetics instantaneously expanded. No one’s health changed that quickly, just our definition of which patients had a condition and who should take medication for it.

The assumptions underlying a medicine-by-numbers approach are that disease is detectable with diagnostic instruments before the onset of experiential symptoms, and more data is always better. Our blood does contain an immense amount of crucial information about our well-being, from levels of vitamin D and electrolytes to the presence of bacteria and antibodies. But as the history of blood testing shows, the idea of blood as an infallible roadmap to one’s health, a substance that with the proper analysis will inevitably reveal incipient disease, has not always held up. More data is not always more useful, especially if we lack the tools to understand it or if the medical meaning of the information is in flux. Three separate readings of the CA 15-3 biomarker for breast cancer may look nearly identical to a physician, writes Eleftherios P. Diamandis of the University of Toronto, but in a patient could prompt a range of reactions from anxiety to jubilation, depending on where the numbers fall as predictors of cancer recurrence.

Defining diseases solely by numerical thresholds invites the possibility that these numbers could be manipulated, and with them the boundary between health and disease. Today’s normal cholesterol might be tomorrow’s borderline hyperlipidemia. Numbers-based medicine may hold enormous appeal in its apparent ability to translate the opacity of blood into quantifiable data, but treating every out-of-range figure as a marker of proto-disease is no guarantee that we’ll end up any healthier. We may just end up with more information.

 

Sources:

Eleftherios P. Diamandis, “Theranos Phenomenon: Promises and Fallacies.” Clinical Chemistry and Laboratory Medicine 53, 7 (June 2015).

Jeremy A. Greene, Prescribing By Numbers: Drugs and the Definition of Disease. Johns Hopkins University Press, 2006.

Keith Wailoo, Drawing Blood: Technology and Disease Identity in Twentieth-Century America. Johns Hopkins University Press, 1999.

Zika and Risk

As the Zika virus spreads north from Latin America, Central America and the Caribbean, the list of public health recommendations and scientific unknowns continues to grow. Zika is not new; it was first identified in 1947 in Uganda, and although scientists have found consistent evidence of antibodies in primates since then, few documented cases were reported in humans until recently. Current statistics are grim: the virus has now been confirmed in over thirty countries in the region, with hundreds, perhaps thousands of additional cases likely in the coming months as mosquito season peaks in the Northern Hemisphere.

Although Zika has been linked to a number of health issues, including fever, joint paint, and Guillain-Barré syndrome, most adults who are infected will have mild symptoms, if any, and no lasting effects. The risks for pregnant women, however, are more severe. The virus has been found to cause microcephaly, a condition in which babies are born with abnormally small heads, leading to brain damage and developmental issues. Mounting fears of a virus for which no vaccine or cure exists are prompting increasingly dire warnings from public health agencies, including the World Health Organization, which recommends that pregnant women avoid traveling to areas of ongoing Zika transmission. Officials in a number of affected countries have advised women to postpone pregnancy for a period of months or years; in El Salvador, health ministers have told women not to get pregnant until 2018.

While we know that Zika causes microcephaly, a deeper understanding of the ways in which the virus works is severely lacking. Take the following catalog of unknowns from the website of the Centers for Disease Control:

"If a pregnant woman is exposed

  • We don't know how likely she is to get Zika.

If a pregnant woman is infected

  • We don't know how the virus will affect her or her pregnancy
  • We don't know how likely it is that Zika will pass to her fetus.
  • We don't know if the fetus is infected, if the fetus will develop birth defects.
  • We don't know when in pregnancy the infection might cause harm to the fetus.
  • We don't know whether her baby will have birth defects."

While I’m by no means trying to minimize the implications of having a baby that tests positive for Zika or a child with microcephaly, I find that the uncompromising public health recommendations around the virus’s transmission are a reflection less of the absolute risk to a pregnant woman (which we lack the information to conclusively determine) than of the inadequacy of what medicine can offer in the event of infection. The anxiety surrounding the virus is understandably based in fear and uncertainty, as pregnancy is a 40-week state of perpetual uncertainty that entails a constant balancing of input versus outcome. As with alcohol and caffeine, which pregnant American women are advised to avoid entirely, there is no safe level of exposure to Zika; one must assume that a developing fetus is at risk, even if the mechanism of infection is not fully understood.

I realize that the calculation of risk will be different for women who travel to areas of active Zika transmission and those who reside there. I’m also aware that birth control and abortion are not available to most women in a number of affected countries, including Brazil, and sexual violence and coercion mean that many women are not fully in control of their sexuality. Zika may not be a new disease, but it is a newly emerging threat, and millions of women who are pregnant, thinking of becoming pregnant, or simply of childbearing age will have to weigh questions of risk and responsibility as they make essential decisions about travel and reproduction.