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Beware Unintended Consequences: What the ReThink Health Dynamics Model Tells Us about the Impact of President Trump’s Policies
By now, we are all too familiar with the tragedy in Flint, Michigan. As of December 2016, 13 former state and local officials face criminal charges for failing to protect Flint citizens from health hazards caused by contaminated drinking water. “The leaders in charge at the time could have prevented this disaster, but they didn’t,” said Flint Mayor Karen Weaver. Ironically, despite the fact that decisions made by these leaders were intended to save money, that never came to be. In fact, long-term costs for infrastructure repairs alone are now estimated to be at least $200 million, and some say up to $1 billion may go to legal liability.
Flint provides a clear lesson on the consequences of choices–on policy decisions to be exact. Core to every policy decision is a statement about what or who is valued, whether explicit or implicit. Additionally, we also are limited in our capacity to see fully the intended and unintended consequences of any policy decision that is made. We find ourselves asking: Could the consequences in Flint have been predicted? Was critical evidence ignored? If Flint teaches us any lesson, it is the need to fully understand, as best we can, the potential consequences of policy decisions before they are made.
Based upon positions he has articulated so far, and those already being put in place, President Trump intends to usher in new policies, reverse some, and replace others. Certainly, this is expected with each new administration. But now is the time to ask: What might be the consequences of President Trump’s policies? More specifically, for ReThink Health, what could be the consequences on the health of our people? And what do these decisions say about what is valued?
For nearly 10 years, ReThink Health has been dedicated to understanding how policy decisions impact health, health care, costs, equity, and worker productivity. Using the ReThink Health Dynamics Model–a realistic, evidence-based computer simulation model of the U.S. health system–we are able to see the potential impact of various investments and policies. Our model makes it possible to look at a range of policies alone and in various combinations in order to assess their potential impact years into the future. One of the model’s key developers, Dr. Jack Homer, did just that with four of the new president’s stated policies. His white paper may be found here.
Let’s take a closer look at what the model says about the president’s policy changes in health, the economy, the environment, and crime. Based on numerous accounts, these policies will likely include repealing and replacing the Affordable Care Act (ACA); imposing increased trade restrictions, deregulating the financial sector, and other actions that could bring on an economic recession; pulling out of climate change agreements, supporting coal, and abandoning the Clean Power Plan; and, encouraging stop-and-frisk and police gun use together with abandoning community policing methods. We have seen several of these policies already shifting based on recent Executive Orders.
For the ACA repeal, the model suggests that fewer people would use health care services and cumulative costs could drop by $67 billion by 2021, the end of the president’s first administration, and $363 billion by 2029. That may sound like a great deal of money that could be used for other needed services or investments. However, ACA repeal could also bring an additional 72,000 deaths by 2029 and more than 4.5 million additional person-years of chronic illness. History shows that lack of coverage would cause many people to defer treatment that they can no longer afford. With fewer people healthy enough to work regularly–or at all–this translates into a $104 billion loss in worker productivity by 2029.
If some of Mr. Trump’s economic policies go into effect even without repealing the ACA, healthcare costs could go down by $32 billion by 2021 and as much as $178 billion by 2029, presumably because people cannot pay for clinical care or insurance coverage. Again, that might sound like a good outcome. But at the same time, these proposed policies could increase deaths by 360,000 by 2029 (even more of an impact than repeal of the ACA), due to a likely recession that drives up unemployment, making it far more difficult to pay for doctors’ visits and leaving the poor and the unemployed at significantly higher risk of death.
Were Mr. Trump’s environmental policies to go into effect, air and water quality are likely to suffer. Healthcare costs could go up by $22 billion by 2021 and $104 billion by 2029, as more people seek treatment for environmentally triggered illness and disease. The number of deaths could increase by 49,000 by 2021 and by 255,000 by 2029. As a result of these effects, workforce productivity is likely to decrease by $37 billion by 2029.
Implementation of tough-on-crime policies, which many predict may actually escalate street crime, would likely increase deaths significantly, second only to a recession, with an additional 60,000 premature deaths by 2021 and 288,000 by 2029. Healthcare costs would rise by $171 billion by the year 2029. This is largely due to people seeking treatment in emergency rooms as well as exacerbation of chronic diseases made worse as people bar their doors and stay inside.
If all four of these policies were implemented together today, there may be a cumulative total of almost 1 million unnecessary deaths by 2029, an extra 19.1 million person-years of chronic illness, and a loss of $3.2 trillion in productivity. Cumulative healthcare costs would also go down by $369 billion in that time period.
Using the ReThink Health model, we can see and discuss the possible consequences of policy changes, whether they are executed singly or in combination. Importantly, our model also can identify combinations of policies and strategies that would both lower healthcare costs and improve health. Our recent article in Health Affairs outlines a very different and much more positive scenario. In it we show how it is possible to reduce healthcare costs by as much as 14% and chronic illness by as much as 20%, and increase workforce productivity by approximately 9% beyond where they would otherwise be within 25 years.
We hope that our new president will take the necessary time to explore the full and potential consequences of his policies. We have the capacity to make changes for the better without doing harm. Wouldn’t that be a better path to pursue?
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