Make America healthy again? A moment of reckoning for healthcare

Next week the US president elect, Donald Trump, will take office with a mandate to make radical changes to the government’s approach to medicine and public health.

Health insurance coverage in particular faces massive, potentially harmful, reform (doi:10.1136/bmj.q2801).1 Republicans in Washington plan to shrink Medicaid, the programme for people on low incomes, potentially leaving millions of Americans uninsured. Traditional Medicare (for people over 65 and those with disabilities) could also reduce to the point that it covers only a small fraction of the current Medicare population.

In the meantime, public frustration with insurers has been evident after the murder of Brian Thompson, chief executive of UnitedHealthcare (UHC) (doi:10.1136/bmj.q2879).2 It has exposed the healthcare giant’s high rate of insurance coverage denial and the misery this has caused. The fact that Luigi Mangione, who is accused of the murder, left a note accusing the US healthcare system of corruption and greed has been widely reported and reflected on social media. The pillorying of UHC in the month since Thompson’s murder, and the astounding lack of public sympathy for the killing (in a recent poll, 41% of 18-29 year olds found the murder acceptable), is a moment of reckoning for the industry.

The focus of this lack of sympathy is the insurance industry—with UHC, the fourth largest company in the US, being a particularly egregious example. One surgeon, for example, was pulled out of cancer surgery by UHC to be asked whether a hospital stay was medically necessary. Now UHC shareholders are demanding to know the human toll of its policies (doi:10.1136/bmj.r64).3 The key question is, did company practices lead to the delay or abandonment of medical treatment and to serious adverse events for patients?

Some of Trump’s more radical choices for high ranking jobs in health will, if confirmed, be at the helm of the reforms (doi:10.1136/bmj.q2485).4 A small army of 18 000 doctors made their opposition heard this week against one such cabinet pick (doi:10.1136/bmj.r60),5 Robert F Kennedy Jr, who is slated as the new health secretary. They called on the Senate to reject the nomination, calling it a “slap in the face” to every health professional. At the heart of this is Kennedy’s long record of spreading misinformation about established vaccine safety, including claiming that vaccines cause autism. He has also linked gun violence in schools to the use of antidepressants and has promoted discredited treatments for covid-19, such as hydroxychloroquine (doi:10.1136/bmj.q2791).6

The doctors are of course right to call on the new US administration to prioritise science and evidence based medicine, but there’s no doubt that Trump will inherit a system that can allow expensive but low value, often ineffective, treatments (doi:10.1136/bmj.q2402).7 The recent “Shkreli awards” highlight the worst examples of profiteering and dysfunction in US healthcare (doi:10.1136/bmj.r57).8 One winner (or loser, as the case may be) was the drug company Amgen, which is selling its cancer drug Lumakras in a high dose formulation despite a trial showing similar benefit with less toxicity at a much smaller dose. Amgen, which would lose $180 000 (£146 000; €174 000) per patient per year if it switched to the lower dosage, has argued that the US Food and Drug Administration already approved the higher dose.

There is more hopeful news for public health: the US surgeon general’s latest move to put a health warning on alcoholic drinks (doi:10.1136/bmj.r15),9 for example, and the FDA’s proposal for long overdue labelling of pulse oximeters for all skin colours (doi:10.1136/bmj.r59).10 Research shows that these devices may miss three times as many cases of occult hypoxaemia in black patients. Can we hope for similarly positive moves under the new regime?

This week Vikas Saini, president of the Lown Institute healthcare think tank, said of the Shkreli awards, which the institute runs, “All these stories paint a picture of a healthcare industry in desperate need of transformation.” As the sun sets on another US administration, impending change is the one thing we can be sure of.