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Op-ed: Trump's Healthcare Reforms Will Be Worse Than You Think

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The consequences for people either living with, or at high risk of getting, HIV could be devastating.

Donald Trump’s selection of Indiana Governor Mike Pence to be his vice-president should have sent alarm bells through the LGBT and HIV-positive communities. He signed Indiana’s “Religious Freedom Bill” before it was ammended to to prohibit discrimination “based on sexual orientation, race, religion, or disability.” Worse, he mishandled the biggest public health crisis in his state. As Plus reported, one of the nation's worst HIV outbreaks occured in Scott County, Indiana in early 2015. The spike in new HIV cases was traced to a rising rate of addiction to injection opioids. Although Pence allowed state legislators to allow a needle exchange in Scott County, he refused to legalize needle exchanges statewide. Other counties would still need to get permission from the state to initiate their own programs. In other words, even as experts were pointing to role the absence of needle exchanges played in the epidemic in rural Indiana, Pence prevented other counties from preventing similar outbreaks in their areas.     

Republican Presidential candidate Donald Trump not only made a poor choice of running mates, he's bad news on his own. In fact, theres a lot in his platform to suggest he would be an unmitigated disaster for Americans' health. This is a guy who said he would like to see Michael Savage — a right wing radio host, as head of the National Institutes of Health. Mother Jones details Savage's credentials (or lack thereof) and reports that Savage once described one of his callers as a “sodomite" and then suggested the caller should "get AIDS and die."

Appointing Savage as head of NIH would be a terrible decision, but then Trump’s reform of healthcare law would be even worse. Under a President Trump, the administration would repealing the Affordable Care Act. Without the ACA, insurance companies could once again refuse to cover those with pre-existing conditions like HIV; and they could go back to making profits by driving up premium costs for everyone else.

Then, Trump has said, he would do something far more troubling. On his website he states that he would modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up. Trump make's it sound like a great idea — at least in theory. The question is how would it play out in practice?

There is a case study of what happened to an industry when it is no longer governed by state regulations. In 1978, the U.S. Supreme Court ruled in Marquette National Bank of Minneapolis vs. First of Omaha Service Corporation, that the First National Bank of Omaha, being a national bank, was subject to the usury laws of Nebraska.  
This case had many ramifications in the banking industry. It is the reason all of your credit cards are headquartered in South Dakota or Delaware.  Both states have almost no regulations involving the selling of credit. Now, average credit card rates (the fee charged by banks to sell credit) have gone down but so has the U.S. prime rate (the fee charged to banks to sell money). In 1979 the average credit card rate was 17.0 percent. The prime interest rate was 11.5 percent. In 2015, the average credit card interest rate was around 14.89 percent but the U.S. prime rate for the year was 3.5 percent.

Immediately after Trump’s reforms are implemented one or two states will completely gut their regulations governing health insurance plans and all of the country’s largest insurance companies will relocate their headquarters to these states. The consequences for people either with or at high risk of getting HIV would be devastating.

Prior to ACA, insurers routinely refused coverage for pre-existing condition and insurance companies were allowed to deny or rescind coverage of those who tested positive for HIV.  One of the most notorious applications of this was the case of Chris Turner.  In 2002, she attended a business conference, where she was drugged and raped. As a precaution, a doctor placed her on anti-HIV drugs. Afterwards she lost her insurance, and could not get any other company to provide insurance. Not because she had tested positive for HIV, but by having the test, she had proven that there was a potential she might get HIV.

In addition to being able to refuse coverage, insurers would like to impose annual and lifetime caps on benefits. A cap is simple device. It sets a dollar amount that the insurer is required to spend on an individual client.

The ramifications are simple. If you contract HIV while still young, you will exceed the cap within your lifetime, and all of your HIV care would no longer be covered. You wouldn't be able to simply switch to another insurer, because of pre-existing condition language. Prior to ACA, regulation in the state where you lived determined the quality and availability of your healthcare. Post Trump reform, geography could become irrelevant. Your only options may be terrible — no matter where you live. 

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