Nursing in the Trump era
Nursing in the Trump era
Donald Trump’s victory in the US presidential election in November stunned the world. As he appoints his top team ahead of his inauguration on January 20, Alison Moore considers what the next four years will mean for nurses and health care in the US
Do American nurses know what to expect from President Trump?
The predominant mood at the moment is one of uncertainty, according to editor-in-chief of the American Journal of Nursing Shawn Kennedy. While presidential candidate Trump had a lot to say about health care, it is far from clear what President Trump will do. One reason for this is that he has been inconsistent in his views. He was pro-choice in 1999, for example, and anti-abortion afterwards. Another is that the reality of politics may limit his power.
‘With most people you can look at a track record and say "this is what he was thinking", but there is no consistency in how he approaches things,’ says Ms Kennedy.
Didn’t he promise to scrap Obamacare?
He has said he wants to repeal and replace Obamacare, the landmark domestic reform of President Obama’s administration, which extended health cover to 22 million people. His appointment of Tom Price as health secretary makes this more likely. Mr Price, an orthopaedic surgeon by background, has consistently opposed Obamacare.
Obamacare (a term originally intended as an insult) refers to the reforms in the Affordable Care Act, brought in by Mr Obama. It included the requirement that everyone buy health insurance and introduced subsidies for many lower income groups.
The federally funded Medicaid for lower income families was also extended, although this relied on individual states choosing to sign up.
Insurers were told they could no longer refuse to insure people with pre-existing conditions. Generally, Obamacare has been seen as a move towards universal healthcare coverage.
How have President Obama's health reforms affected nurses?
Many nurses have been enthusiastic about Obamacare. In the past, people without health insurance often did not seek treatment for long-term conditions because of the cost. This meant they might turn up in an emergency department in crisis, with uncontrolled conditions that had deteriorated. Now they are more likely to get an early diagnosis and intervention.
Obamacare has also contributed to the growth in the number and importance of advanced nurse practitioners and advanced practice nurses. Increasingly, they are taking on some of the work that might, in the UK, be undertaken by GPs, and are licensed to work independently in many states, with the formation of nurse-led clinics. Obamacare also included some provision for funding nurse development, to allow them to take on extra responsibilities in community settings.
In addition, some changes to the way hospitals were reimbursed encouraged them to recruit more highly educated nurses (typically those with at least a four-year degree).
Many hospital groups had to make radical changes to embrace Obamacare, such as coping with a Medicaid payment system based on a defined episode of care, rather than a pay-per-service model. Some hospitals moved away from offering acute facilities (such as emergency rooms) towards a more primary and community care-based service.
The system brought in by Mr Obama seems to have moderated increases in healthcare costs. And it is calculated to have prevented hundreds of thousands of early deaths.
Are there flaws in Obamacare that make it vulnerable?
Although 22 million more people have gained access to health care under Obamacare, around 27 million Americans are still not covered. The reforms did not go as far as Mr Obama would have liked in extending healthcare cover.
Buying health insurance is a confusing and time-consuming task for many Americans, with little guarantee they have bought the best policy for their needs. ‘Obamacare did have a lot of issues. The system would have been better if there was a single payer,’ says Ms Kennedy.
Health insurance costs are expected to rise significantly in 2017, but some people are also finding that they have to pay more in ‘deductibles’ (the ‘excess’, or part of an insurance claim to be paid by the insured person) and what they are covered for is diminishing. This may be affecting public support for the healthcare reforms. Many Republicans attacked Obamacare during the election campaigns, claiming it affected the doctor-patient relationship and amounted to ‘socialised’ healthcare.
How likely is it that Obamacare will be scrapped?
President-elect Trump’s tone mellowed after he met the outgoing president. He suggested he wanted to keep some elements of it, including young adults being able to remain on their parents’ policies and insurers being prevented from excluding pre-existing conditions. However, the selection of Mr Price as health secretary has been interpreted as a hardening of his stance. And in a speech to wealthy conservatives in the first week of December, vice president-elect Mike Pence said one of the president’s first priorities would be to repeal the Affordable Care Act ‘lock, stock and barrel’.
Mr Trump may try to replace parts of Obamacare by setting up tax-deductible savings accounts to pay for future health care, and allowing insurers to sell insurance across state lines – policies supported by Mr Price. Some of his key allies, such as retired neurosurgeon and former candidate for the Republican nomination Ben Carson, have said any replacement will need to be appealing and easy to understand and, crucially, plans would need to be well advanced before Obamacare is dismantled.
‘How do you repeal and replace it with something that offers people coverage?’ Ms Kennedy says. She points out that it would be difficult to suddenly leave 22 million people without any health cover.
Is there an opportunity for nurses to influence the new president’s policy?
Possibly. ‘The one thing that does seem consistent is that if he trusts you, he listens to you,’ says Ms Kennedy. ‘He is swayed by what he hears. But he surrounds himself with people who agree with him all the time.’
However, the American Nurses Association (ANA) publicly supported Hillary Clinton in the election, so may not be on his Christmas card list. Its president, Pamela Cipriano, said the association was ‘ready to work with his administration to advance health care that is accessible, affordable, equitable, integrated and innovative’. The question may be whether Mr Trump wants to work with the ANA.
One concern is that the man who will be health secretary often seems to approach issues from a doctor’s perspective. For example, Mr Price has opposed an extension of the nurse practitioner role in providing health care for veterans. The New York Times has said he could use his post ‘to protect fellow physicians in myriad ways’. Nurses may feel sidelined by his approach.
The Department of Health and Human Services does have some high-level nurses, but it is uncertain if they will continue under the new health secretary.
So how much will change under President Trump?
The new president may find it hard to push changes through the House of Representatives and the Senate, although he could make some without Congressional support, such as exempting more people from the requirement to buy insurance. It may be years before major changes come about. And with mid-term elections in 2018 affecting all the House of Representatives and around a third of the Senate seats, it might be political folly to leave 22 million people without healthcare cover.
Mr Trump’s election feels like a ‘watershed moment’, says Ms Kennedy, who is worried that there has been a shift towards a society that increasingly blames individuals for making poor decisions. ‘A lot of people don’t buy in to the fact that some people can’t make the right choices because of their education and environment,’ she says.
What impact will the Trump presidency have on abortion and sexual health services?
One of the key policy battles in the US is always abortion rights. Both Mr Trump and Mr Price are intensely anti-abortion. At the moment, abortion rights are upheld by the Supreme Court in the groundbreaking Roe v Wade judgement. However, Mr Trump will be able to nominate one and possibly several Supreme Court judges during his four-year term, and a more conservative court could overturn this.
More immediately, there are fears that federal funding for the Planned Parenthood Federation, which provides many sexual health services, including abortion, could be affected. Nearly three million people use its services each year, and much of the funding for this comes from the central government (although it can’t be used for abortion). Some Republicans have called for funding for other services to be cut, which would affect nurses working there.
Another possibility is that the requirement to provide birth control in employer-provided health insurance could be relaxed. Some US media have reported that women have been making appointments for long-lasting contraception, as they fear it will no longer be covered by health insurance.
Are US nurses generally opposed to Mr Trump?
Many fear the new administration will not reflect their values, but opposition is far from universal. ‘A lot of nurses are conservative and pro-Trump,’ says Ms Kennedy. Some nurses have agreed that Obamacare has contributed to increased job pressure and even led hospitals to reduce nurse numbers.
There are some Trump policies that nurses may applaud. For example, he has promised that childcare and elder care expenses could be tax deductible, which would benefit many nurses.
Overall, are things going to get worse for nurses under President Trump?
The nursing market in the US is buoyant and the demographics point to increased demand for nurses, with forecasts of a 16% growth in demand in the decade to 2024.
But the Trump presidency could lead to a halt or even a reversal in some of the progress nursing has seen in recent years, such as the growth in advanced roles. And it could lead to big changes for nurses involved in sexual health.
What is clear is that some nurses are hoping Mr Trump delivers on his election promises, while others find the prospect terrifying.
Alison Moore is a freelance health writer