ASHINGTON — In less than three months in office, President Trump has made abundantly clear he will not approach health and medicine the same way his predecessor did.
He is proposing dramatic funding cuts to the National Institutes of Health. He has already tried — and so far failed — to repeal much of the Affordable Care Act, Barack Obama’s signature legislation. The early signals of how he’ll handle the opioid crisis have recovery advocates on edge.
Yet some things stay the same. Despite Trump’s bluster on reining in drug prices, no major reforms appear imminent. The president and House Republicans sought to overturn Obamacare — but were caught up with infighting, couldn’t get the votes, and the law remains in place.
Three months ago, STAT looked at five key areas and assessed whether Trump was likely to diverge from Obama — or not. Now we’re revisiting those issues, focusing on the new president’s record so far.
President Obama signed some of the most significant funding increases for the NIH in years. His administration launched major programs like the Vice President Joe Biden’s cancer moonshot and the Precision Medicine Initiative.
Trump is moving fast in the opposite direction.
He wants to cut NIH funding by $1.2 billion this year. Next year, under his proposed budget, the agency’s budget would be slashed by another $5.8 billion. Trump’s aides have defended the cuts, and Health and Human Services Secretary Tom Price said the government has long been wasting money on overhead for universities and other institutions that receive NIH grants. But researchers across the country have warned of devastating consequences if Trump’s proposed cuts were actually enacted.
Congressional Republicans are dubious about the proposals, and they ultimately hold the purse strings. It is also possible that Trump will keep current NIH Director Francis Collins, who is seen as an effective frontman for the agency.
But the president’s budget is an inescapable tell that the agency, the engine of so much of America’s biomedical enterprise, is entering a new age of uncertainty.
OBAMACARE AND MEDICARE
The ignominious end of the American Health Care Act, the Obamacare overhaul backed by Trump and the House Republican leadership, is a reminder of how difficult it is to pass sweeping bills — even when one party controls the entire government.
The bill would have rolled back much of Obamacare’s coverage gains and fundamentally overhauled Medicaid, in apparent violation of Trump’s pledge not to cut the low-income insurance program. The consequences: 24 million more people would be uninsured in 2026, according to the Congressional Budget Office.
But revolts from the right and the middle — the former angry the bill didn’t fully repeal the ACA, the latter concerned with coverage losses — stopped the legislation in the House. House leaders and Trump are still pledging to revisit health care, but, for now, Obamacare is the law of the land.
And after this failed overhaul of Medicaid, any major changes to Medicare — which House Speaker Paul Ryan has long sought but Trump seemed to blanch from during the campaign — seem even more unlikely.
Shortly before Trump was sworn into office, Obama signed the first major bill addressing the nation’s opioid epidemic and approving another $1 billion in new spending to fund its programs. During the presidential campaign, Trump pledged to end the crisis, which is now killing more than 30,000 Americans every year.
Toward that end, he has established a new presidential commission focused on the crisis. It will be led by New Jersey Governor Chris Christie, who is generally respected for his humane approach to drug addiction. Trump has also interviewed candidates to be his White House’s “drug czar,” like former New Hampshire Congressman Frank Guinta, who fit a similar profile — though the president has not yet selected anyone for the position, to the chagrin of D.C.-based recovery advocates.
On the other hand, however, some advocates are wary of Attorney General Jeff Sessions, one of Trump’s top allies, who has infamously equated marijuana to heroin. Trump’s budget is another area of concern; he has proposed slashing the HHS budget by nearly 20 percent and singled out programs like a mental health block grant for deep cuts.
Rhetoric will only take Trump so far, and some advocates see reason to fear what policies Trump will actually implement.
Among Trump’s most unorthodox positions as a Republican candidate for president was his pledge to take on the drug industry and bring down drug prices. It would have been his chance to tame a dragon that even eluded Obama, who found himself entangled with drug makers after they backed Obamacare.
But so far, Trump hasn’t taken any significant steps to back up his pledge. Many people around Washington took note of the way Trump talked during his White House meeting with several major pharma executives — he seemed to be speaking their language. His focus was more on removing regulatory barriers, lowering taxes, and letting the free market work than on direct government intervention.
Trump could still make a big play to rein in drug costs. He has met with Democratic Congressman Elijah Cummings of Maryland on the issue, and Cummings seems to believe Trump is serious about making good on his pledges.
But with all the other issues consuming Washington, and health care in general on the back burner for now, major drug pricing reforms may be a ways off.
In his first 70 days, Trump hasn’t yet faced an outbreak on the scale of the Ebola and Zika crises that tested Obama — though an avian flu strain has been wreaking havoc in China. But public health officials remain wary, after Trump showed a predilection for health conspiracies and fear-mongering while he was a private citizen.
And, once again, Trump’s spending plans signal a major shift from the Obama years. He has proposed cutting the Centers for Disease Control and Prevention’s funding by more than $300 million this year. His 2018 budget didn’t specify funding cuts for CDC, but key lawmakers have warned that the level of spending cuts Trump wants would mean every agency would likely face some kind of reduction.
Trump has also allowed the White House Office of Science and Technology Policy, which usually helps head up the response to health emergencies, to wither away, according to a recent report in the New York Times.