publication date: Nov. 10, 2016
Photo by Gage Skidmore
What the Trump Presidency Means for Cancer Care, the ACA, and the Moonshot
By Matthew Bin Han Ong
President Barack Obama’s legacy health care programs—the Affordable Care Act, and the National Cancer Moonshot Initiative—have been thrown into uncertainty.
Hours after Republican Donald Trump became president-elect of the United States, Washington is left in a muddle: hopeful Democratic appointees who expected to join Hillary Clinton’s ranks ended up empty-handed. At stake is leadership of federal agencies, including the HHS, NIH, NCI, and FDA.
Congress returns to work next week, but it’s uncertain whether the lame-duck session will complete and renegotiate appropriations for fiscal 2017, or pass a second continuing resolution that would extend into March.
A long-term CR would leave many federal agencies unable to reshuffle their budgets or dedicate dollars to new projects.
The timely launch of Vice President Joe Biden’s moonshot—which aims to achieve a decade’s progress in five years—depends on appropriators, and funding from the 21st Century Cures Act, a broad measure designed to accelerate drug development and modernize clinical trials (The Cancer Letter, Sept. 23).
“The community must get behind the 21st Century Cures Act, because there is substantial funding for research,” said Ellen Sigal, chair and founder of Friends of Cancer Research. “It is essential that the research community push for the bill to pass.
“We have to stay true to science and to patients and to what’s important for health,” Sigal said to The Cancer Letter. “Our community is committed to patients, research, and cancer care and what’s right for patients. That should not be a partisan issue.”
NCI officials are eager to receive funding through the moonshot. They have said repeatedly that most of these initiatives would be undertaken with or without moonshot dollars. Of course, additional money would accelerate the schedule (The Cancer Letter, Sept. 9).
Trump’s unanticipated victory upended what many in oncology expected to be a smooth transition for federal priorities in health care. Clinton had pledged to “take up the charge” on the moonshot, whereas the Trump campaign was mum on the subject (The Cancer Letter, Sept. 23).
“I haven’t heard anything from the Trump campaign at all,” said Greg Simon, executive director of the Cancer Moonshot Task Force, in a Nov. 7 Bloomberg BNA report. There might be a silver lining: Simon said it is “serendipitous” that a former coworker from Pfizer, Richard Bagger, is serving as chief of staff for New Jersey Gov. Chris Christie, who is expected to be named chair of Trump’s transition team.
Cancer research and biomedical research in general have been supported by Republicans and Democrats in Congress, and all prior presidents, said Elizabeth Jaffee, co-chair of NCI’s Blue Ribbon Panel, a committee that outlined 10 scientific recommendations for Biden’s moonshot (The Cancer Letter, Sept. 9).
“Curing cancer and eliminating suffering is important to everyone,” said Jaffee, who is also deputy director of the Sidney Kimmel Comprehensive Cancer Center, co-director of the Gastrointestinal Cancer Program, and the Dana and Albert “Cubby” Broccoli Professor of Oncology at the Johns Hopkins University School of Medicine. “We are all hopeful that this support will continue and that the hard work put into the Moonshot by all sectors of the cancer community—government, industry, academia, patients and advocates—throughout the country will be able to continue and have the impact it was meant to have—to improve the lives of people with cancer and those at risk for cancer.
“We are in a historic time in cancer research,” Jaffee said to The Cancer Letter. “We hope we will not lose the momentum.”
Advocates must make sure the Trump administration understands the benefits of scientific research, said Hudson Freeze, president of the Federation of American Societies for Experimental Biology.
“Many of us were surprised by the results of the presidential election and didn’t foresee the mood of the electorate,” Freeze said to The Cancer Letter. “One thing, however, is crystal clear: our advocacy on behalf of biomedical research is now more important than ever.
“There will be new people in key positions and—with the same party controlling the White House and Congress—the gridlock in Washington may be over during the honeymoon period of the new administration. We anticipate a lot of legislative and policy activity as the new leadership defines its agenda and seeks to create momentum during its first 100 days in office.”
Raghavan: Death Rate Could Rise
On Wednesday, Senate Majority Leader Mitch McConnell indicated that the GOP-controlled Congress would soon turn to the task of swiftly repealing the ACA.
“It’s pretty high on our agenda as you know,” McConnell said in a Nov. 9 Politico report. “I would be shocked if we didn’t move forward and keep our commitment to the American people.”
It’s unknown which legislative pathway Republicans could use to repeal Obama’s signature health care law. Budget reconciliation is one option, and Trump could, through executive action, drop the administration’s appeal of a lawsuit—House v. Burwell—filed by Republican House members in 2015.
Regardless, the death rate from cancer may increase if the ACA is dropped without a reliable replacement for the 20 million individuals who obtained coverage under the ACA, said Derek Raghavan, president of the Levine Cancer Institute at the Charlotte-based Carolinas HealthCare System.
“With the results of the election, I think it’s too early to be sure how this is going to play out,” said Raghavan, who is also professor of medicine at the UNC School of Medicine. “From what I understand, the new president has opined that he will simply reverse the decisions about the ACA and come up with a better plan.
“My concern is, I don’t know what that better plan actually is, or whether it has already been formulated. Prior to the election result, at the least, I was hoping that it would be improved.”
Republicans have little incentive to improve the ACA after vowing for six years to repeal the law: when insurance companies cancelled policies that individuals thought they would be able to keep, the GOP-led Congress declined to offer a solution. The Obama administration’s post-election blues are compounded by an expected 25 percent increase on health insurance premiums in 2017, and shrinking numbers of insurers that participate in exchanges (The Cancer Letter, Oct. 28).
The death rate from cancer spiked during the 2008 recession, when economic attrition took a toll on access to health care, Raghavan said, citing a study published June 2016 in The Lancet.
“The conventional wisdom of the time suggested that the death rate from cancer increased because people had lost jobs, didn’t have insurance, and deferred and delayed cancer treatment and care for other conditions because of financial considerations,” Raghavan said to The Cancer Letter. “In a situation where the ACA is suddenly dropped, if there is no replacement plan, I would anticipate that the death rate from cancer could easily rise, for similar reasons.”
In the worst case scenario, dropping millions of insured patients without a transition plan may contribute to a significant downturn in cancer patient volumes at hospitals and academic centers across the nation.
“As we look forward—past the campaign and toward governing—we are confident that President-elect Trump will keep his focus on consumers and patients,” said Chip Kahn, president and CEO of the Federation of American Hospitals. “We need to maintain access to health care coverage for millions of Americans, while at the same time protecting Medicare for seniors, as well as Medicaid for those with lower incomes.
“Any re-examination of ACA will take time to develop and require a workable transition for those who depend on the coverage and those providing the care,” Kahn said in a statement. “Hospitals share the president-elect’s commitment to assuring access to care and look forward to working with him and the new Congress.”
The ACA provides a safety net for individuals with chronic disease. This applies particularly to those who have lost employment because of their illness or for other reasons, and who have illnesses that don’t allow them to find other employment.
Patients are directly impacted by the disconnect between the federal government and the state governments about who should be paying, and how the insurance marketplace should be implemented.
“In the state of North Carolina, the refusal of the state government to participate in the ACA left patients and physicians without any defined safety net, and we were pretty much on our own for some years,” Raghavan said. “I am fearful that will happen again.
“The bottom line is, for an institution like the Carolinas HealthCare System/Levine Cancer Institute, which is a safety net organization in North Carolina and South Carolina, we will be faced with the challenge of our refusal to abandon uninsured patients vs. an unclear pathway to reimbursement for the work that we do.
“I think what happens next will depend on how the new president and his team wish to proceed. If he has a strong enough mandate, it’s possible that he could scrap the ACA and then insert a very good replacement. It’s more likely, based on my observation of the world of politics from the past, that he will scrap the ACA, and then announce that there is a planning process that will occur, and that could lead to patients without support.”
Groups: We Will Work with Trump
Continuous improvement in cancer care is a longstanding nonpartisan issue through each presidential administration and Congress, said Daniel Hayes, president of the American Society of Clinical Oncology.
“Virtually every American has been touched by and wants to live in a world free from the fear of this life-threatening diagnosis,” said Hayes, clinical director of the Breast Oncology Program and Stuart B. Padnos Professor of Breast Cancer Research at the University of Michigan Health System. “ASCO continues to pursue this mission by advocating for a sustained and robust federally funded research infrastructure and improved healthcare delivery system that provides high-quality, high-value care for all people with cancer.
“Our hope is that current efforts to pass 21st Century Cures legislation and momentum to accelerate progress against cancer through the Cancer Moonshot will continue,” Hayes said to The Cancer Letter. “Further, ASCO has proposals and initiatives that will improve care and control costs and we look forward to working with the Trump Administration and 115th Congress on these critically important efforts that are so vital to our nation’s health.”
Cancer research depends on robust, sustained, and predictable annual funding increases to NCI, NIH, and other health-related federal entities, said Nancy Davidson, president of the American Association for Cancer Research and director of the University of Pittsburgh Cancer Institute, and AACR CEO Margaret Foti.
“The AACR urges President-Elect Trump to stand with all Americans touched by cancer to support key elements of the Blue Ribbon Panel Report of the National Cancer Moonshot Initiative that includes 10 novel proposals for transforming the future of cancer research, treatment, and prevention in all populations,” Davidson and Foti said in a joint statement. “In this unprecedented era of scientific opportunity and precision medicine, where we are witnessing extraordinary clinical outcomes by seeking targeted treatments for each individual’s cancer at the genetic level, we must seize the momentum that exists in the field. Failure to capitalize upon the scientific discoveries of today is simply not an option.
“Therefore, we call on Trump to rally all Americans around this cause of making cancer research a national priority so that we are able to continue to make the strides required to eradicate cancer worldwide.”
The 21st Century Cures Act is a bipartisan effort to accelerate the discovery, development, and delivery of new therapies to patients, said Mary Woolley, president and CEO of Research!America.
“Senator Roy Blunt (R-Mo.), Senator Dick Durbin (D-Ill.), Representative Nita Lowey (D-N.Y.) and Representative Tom Cole (R-Okla.) are among the congressional leaders who strongly believe that support for research is key to addressing the many health challenges afflicting Americans,” Woolley said in a statement. “We look forward to working with the next Congress and the new administration to ensure that federally-funded research and private sector medical innovation rise to the top of national priorities.”
Congress has an opportunity to provide significant funding for cancer research in the upcoming lame-duck session, the American Cancer Society Cancer Action Network said in a statement.
“Cancer research funding has enjoyed strong bipartisan support and these next few weeks will be critical to accelerating progress against this disease,” ACS CAN officials said. “Among Congress’s top priorities should be increasing funding for the National Institutes of Health and National Cancer Institute through the FY 17 appropriations process and funding the National Cancer Moonshot Initiative through the 21st Century Cures legislation. The Moonshot offers clear next steps to accelerating the pace of progress against the disease including: creating a large-scale patient network to gather information about tumor profiles, developing an immunotherapy translational science network and improving evidence-based approaches to early detection and prevention.
“Making meaningful progress against cancer requires a deep and continued commitment to research and prevention. On behalf of the 1.7 million Americans diagnosed with cancer this year and all those touched by this disease, we urge Congress to make both a priority when they return to work next week.”