AJPH PERSPECTIVES Could the President and Congress Precipitate a Public Health Crisis? Statements by candidate and then President-Elect Donald Trump, as well as by Republican leaders of both houses of Congress, could, if translated into policy, precipitate a public health crisis. Up to 22 million Americans could lose health care coverage from private insurers and Medicaid that they are receiving under the Affordable Care Act (ACA; Public Law 111-148). The health impact of a potential crisis in insurance coverage could be exacerbated by cutbacks in subsidies for other determinants of population health such as social services, income support, nutrition, housing, and education. Numerous articles in peerreviewed journals and reports from prestigious organizations over many years have documented that expanded health service coverage yields measurable improvements in the health status of both individuals and populations. Although the methods of some of these studies have been challenged, widely shared agreement about their findings predicts a pending crisis for public health, a crisis to which hospitals, health systems, clinicians, community health centers, religious groups, and philanthropies may struggle to respond, especially if the extent of their funding becomes uncertain.
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EFFECTS ON HEALTH STATUS OF COVERAGE EXPANSIONS Several recent studies of expansions in health insurance have revealed substantial linkages between coverage and improved health status. The authors of a 2014 quasi-experimental study of changes in mortality in Massachusetts after health care reform concluded that “reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group after access improved.” Moreover, “these changes were larger in counties with lower household incomes and higher pre-reform uninsured rates” and were associated with “significant gains . . . in self-reported health.” The standard “number needed to treat” was “approximately 830 adults gaining health insurance to prevent 1 death per year.”1(pp585–586) There are also benefits that still must be harvested. In 2015, the authors of an article focusing on the effects of health insurance expansions on adults with hypertension projected that “currently anticipated health insurance expansions would lead to a 5.1% increase in [the] treatment rate among hypertensive patients” and, as a result, would “lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and
95,000 fewer [deaths related to cardiovascular disease] by 2050.” They concluded that “federal and state efforts to expand coverage among nonelderly adults could yield significant health benefits . . . and narrow the racial/ ethnic disparities in health outcomes for patients with hypertension.”2 The authors of a 2012 review of the literature evaluating expansions in Medicaid coverage over several decades prior to the ACA concluded that these expansions had resulted in a reduction in mortality among adults, infants, and children.3 More recently, many have cited the Oregon Health Study because of its superior randomized controlled methodology and have highlighted the study’s finding that Medicaid addresses the two primary purposes of health insurance: financial protection and improved access to health services.4 Although we focus on the implications of ACA repeal for the health of individuals and populations, it is important to recognize that health insurance allows individuals to obtain care when they are sick and in
need without becoming impoverished as a result of high medical bills. Indeed, perhaps as a consequence of the peace of mind that insurance affords, the Oregon Health Study also showed a 30% reduction in the rate of depression and a 20% increase in self-reported good health.5 Although the study did not reveal any improvements related to specific laboratory tests (e.g., prevalence or diagnosis of hypertension or high cholesterol levels, or the use of medications for these conditions) during an 18-month time frame, its authors’ overall conclusion was that Medicaid improves well-being.6
AVERTING A PUBLIC HEALTH CRISIS These positive results associated with expanded coverage would not necessarily be automatically reversed for all or some of the 22 million people who are at risk for becoming uninsured as a consequence of changes in national health policies. An important reason to avoid such a heroic assumption is that only a small number of relevant studies have been published to date. Moreover, if employment rates rose and wages increased (as a result of various factors),
ABOUT THE AUTHORS Daniel M. Fox is with the Milbank Memorial Fund, New York, NY. Sandro Galea is with the School of Public Health, Boston University, Boston, MA. Colleen Grogan is with the School of Social Service Administration, University of Chicago, Chicago, IL. Correspondence should be sent to Daniel M. Fox, PhD, 100 W 12th St, 3T, New York, NY 10011-8242 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This editorial was accepted November 28, 2016. doi: 10.2105/AJPH.2016.303597
AJPH
February 2017, Vol 107, No. 2
AJPH PERSPECTIVES
many newly uninsured individuals might gain coverage through their places of work or be able to purchase it themselves. In addition, some of the health risks faced by the newly uninsured could be offset by federal and state policies that subsidize coverage and the uncompensated care provided by hospitals and community health centers.
A NEW CHALLENGE FOR PUBLIC HEALTH A substantial reduction in coverage would, however, create new problems for public health agencies and professionals. The most difficult of these problems is likely to be meeting the growing demand for preventive, diagnostic, and treatment services from already underfunded public hospitals and clinics. Reductions in coverage would also require substantial changes in community benefit activities designed by health systems, in collaboration with public health agencies, in response to the new 501(r) section of the Internal Revenue Code included in the ACA. New federal and state policies
could, moreover, curtail the many new state programs, established under federal waivers, that restructure delivery of care paid for by Medicaid and Medicare to further the “triple aim” of improving access and quality and containing costs.
AN UNUSUAL PUBLIC HEALTH CRISIS These new problems would create, for the first time in this country since the Great Depression of the 1930s, a public health crisis caused by loss of access to care. Such crises have continued to occur in countries that have been invaded or have experienced violent internal revolutions. Unlike public health crises caused by outbreaks of infectious disease or the increasing incidence of chronic degenerative diseases, few interventions have evolved to address a sudden loss of access to services to prevent, diagnose, and treat disease and respond to injury. Before the vast expansion of access that began during the Second World War, public health officials in this country confronted numerous crises
resulting from loss of access to care during downturns in the economy. A considerable historical literature documents variation in the success of interventions implemented on these occasions by public officials, individual philanthropists, and charities created by religious and ethnic organizations.7 Although care provided by local voluntary organizations was somewhat effective in addressing sudden loss of access, on the whole the volunteer approach resulted in extremely fragmented and unequal access to care. In part because services were not extensive enough, moreover, the response to the loss of access included rationing care by applying criteria based on acuity of symptoms and, disturbingly, on race, ethnicity, and social class. In summary, although their magnitude and consequences for health status cannot yet be predicted with precision, the health policies advocated by many people prominent in the new administration and in Congress will, if implemented, likely have an adverse impact on the health status of many Americans by reducing or capping spending for health
How Will Public Health Fare in a Trump Administration? When this piece will be published, President-Elect Trump will be about to become President Trump, which makes it rather challenging to determine how much and what kind of attention will be given to public health in a Trump Administration.
February 2017, Vol 107, No. 2
AJPH
The Trump campaign focused on several high-level themes such as across-the-board tax cuts for working and middle income Americans, creating 25 million jobs over 10 years, and building a wall along the US–Mexico border, unlike the policy-heavy campaign of his opponent.
Campaigning using high-level themes rather than many specific policy positions is not
insurance, preventive services, and investments in social conditions that affect population health. Daniel M. Fox, PhD Sandro Galea, MD, DrPH Colleen Grogan, PhD CONTRIBUTORS The authors contributed equally to this editorial.
REFERENCES 1. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med. 2014;160(9): 585–593. 2. Li S, Bruen BK, Lantz PM, Mendez D. Impact of health insurance expansions on nonelderly adults with hypertension. Prev Chronic Dis. 2015;12:150111. 3. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025–1034. 4. Kronick R, Bindman AB. Protecting finances and improving access to care with Medicaid. N Engl J Med. 2013;368(18): 1744–1745. 5. Baicker K, Taubman S, Allen HL, et al. The Oregon experiment—effects of Medicaid on clinical outcomes. N Engl J Med. 2013;368(18):1713–1722. 6. Muennig PA, Quan R, Chiuzan C, Glied S. Considering whether Medicaid is worth the cost: revisiting the Oregon Health Study. Am J Public Health. 2015; 105(5):866–871. 7. Gordon C. Dead on Arrival: The Politics of Health Care in Twentieth Century America. Princeton, NJ: Princeton University Press; 2003.
unusual in political campaigns. It is especially not unusual in a campaign where the dominant issues in exit polling were the economy (voted as most important by 35%) and security (voted as most important by 21%).1 Health care was a distant
ABOUT THE AUTHOR Gail R. Wilensky is a Senior Fellow at Project HOPE, Bethesda, MD, and a former Administrator of Medicare and Medicaid. Correspondence should be sent to Gail R. Wilensky 7500 Old Georgetown Road, Suite 600 Bethesda, MD 20814 (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This editorial was accepted November 28, 2016. doi: 10.2105/AJPH.2016.303594
Wilensky
Editorial
235
234
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Fox et al.
EFFECTS ON HEALTH STATUS OF COVERAGE EXPANSIONS Several recent studies of expansions in health insurance have revealed substantial linkages between coverage and improved health status. The authors of a 2014 quasi-experimental study of changes in mortality in Massachusetts after health care reform concluded that “reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group after access improved.” Moreover, “these changes were larger in counties with lower household incomes and higher pre-reform uninsured rates” and were associated with “significant gains . . . in self-reported health.” The standard “number needed to treat” was “approximately 830 adults gaining health insurance to prevent 1 death per year.”1(pp585–586) There are also benefits that still must be harvested. In 2015, the authors of an article focusing on the effects of health insurance expansions on adults with hypertension projected that “currently anticipated health insurance expansions would lead to a 5.1% increase in [the] treatment rate among hypertensive patients” and, as a result, would “lead to 111,000 fewer new coronary heart disease events, 63,000 fewer stroke events, and
95,000 fewer [deaths related to cardiovascular disease] by 2050.” They concluded that “federal and state efforts to expand coverage among nonelderly adults could yield significant health benefits . . . and narrow the racial/ ethnic disparities in health outcomes for patients with hypertension.”2 The authors of a 2012 review of the literature evaluating expansions in Medicaid coverage over several decades prior to the ACA concluded that these expansions had resulted in a reduction in mortality among adults, infants, and children.3 More recently, many have cited the Oregon Health Study because of its superior randomized controlled methodology and have highlighted the study’s finding that Medicaid addresses the two primary purposes of health insurance: financial protection and improved access to health services.4 Although we focus on the implications of ACA repeal for the health of individuals and populations, it is important to recognize that health insurance allows individuals to obtain care when they are sick and in
need without becoming impoverished as a result of high medical bills. Indeed, perhaps as a consequence of the peace of mind that insurance affords, the Oregon Health Study also showed a 30% reduction in the rate of depression and a 20% increase in self-reported good health.5 Although the study did not reveal any improvements related to specific laboratory tests (e.g., prevalence or diagnosis of hypertension or high cholesterol levels, or the use of medications for these conditions) during an 18-month time frame, its authors’ overall conclusion was that Medicaid improves well-being.6
AVERTING A PUBLIC HEALTH CRISIS These positive results associated with expanded coverage would not necessarily be automatically reversed for all or some of the 22 million people who are at risk for becoming uninsured as a consequence of changes in national health policies. An important reason to avoid such a heroic assumption is that only a small number of relevant studies have been published to date. Moreover, if employment rates rose and wages increased (as a result of various factors),
ABOUT THE AUTHORS Daniel M. Fox is with the Milbank Memorial Fund, New York, NY. Sandro Galea is with the School of Public Health, Boston University, Boston, MA. Colleen Grogan is with the School of Social Service Administration, University of Chicago, Chicago, IL. Correspondence should be sent to Daniel M. Fox, PhD, 100 W 12th St, 3T, New York, NY 10011-8242 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph. org by clicking the “Reprints” link. This editorial was accepted November 28, 2016. doi: 10.2105/AJPH.2016.303597
AJPH
February 2017, Vol 107, No. 2
AJPH PERSPECTIVES
many newly uninsured individuals might gain coverage through their places of work or be able to purchase it themselves. In addition, some of the health risks faced by the newly uninsured could be offset by federal and state policies that subsidize coverage and the uncompensated care provided by hospitals and community health centers.
A NEW CHALLENGE FOR PUBLIC HEALTH A substantial reduction in coverage would, however, create new problems for public health agencies and professionals. The most difficult of these problems is likely to be meeting the growing demand for preventive, diagnostic, and treatment services from already underfunded public hospitals and clinics. Reductions in coverage would also require substantial changes in community benefit activities designed by health systems, in collaboration with public health agencies, in response to the new 501(r) section of the Internal Revenue Code included in the ACA. New federal and state policies
could, moreover, curtail the many new state programs, established under federal waivers, that restructure delivery of care paid for by Medicaid and Medicare to further the “triple aim” of improving access and quality and containing costs.
AN UNUSUAL PUBLIC HEALTH CRISIS These new problems would create, for the first time in this country since the Great Depression of the 1930s, a public health crisis caused by loss of access to care. Such crises have continued to occur in countries that have been invaded or have experienced violent internal revolutions. Unlike public health crises caused by outbreaks of infectious disease or the increasing incidence of chronic degenerative diseases, few interventions have evolved to address a sudden loss of access to services to prevent, diagnose, and treat disease and respond to injury. Before the vast expansion of access that began during the Second World War, public health officials in this country confronted numerous crises
resulting from loss of access to care during downturns in the economy. A considerable historical literature documents variation in the success of interventions implemented on these occasions by public officials, individual philanthropists, and charities created by religious and ethnic organizations.7 Although care provided by local voluntary organizations was somewhat effective in addressing sudden loss of access, on the whole the volunteer approach resulted in extremely fragmented and unequal access to care. In part because services were not extensive enough, moreover, the response to the loss of access included rationing care by applying criteria based on acuity of symptoms and, disturbingly, on race, ethnicity, and social class. In summary, although their magnitude and consequences for health status cannot yet be predicted with precision, the health policies advocated by many people prominent in the new administration and in Congress will, if implemented, likely have an adverse impact on the health status of many Americans by reducing or capping spending for health
How Will Public Health Fare in a Trump Administration? When this piece will be published, President-Elect Trump will be about to become President Trump, which makes it rather challenging to determine how much and what kind of attention will be given to public health in a Trump Administration.
February 2017, Vol 107, No. 2
AJPH
The Trump campaign focused on several high-level themes such as across-the-board tax cuts for working and middle income Americans, creating 25 million jobs over 10 years, and building a wall along the US–Mexico border, unlike the policy-heavy campaign of his opponent.
Campaigning using high-level themes rather than many specific policy positions is not
insurance, preventive services, and investments in social conditions that affect population health. Daniel M. Fox, PhD Sandro Galea, MD, DrPH Colleen Grogan, PhD CONTRIBUTORS The authors contributed equally to this editorial.
REFERENCES 1. Sommers BD, Long SK, Baicker K. Changes in mortality after Massachusetts health care reform: a quasi-experimental study. Ann Intern Med. 2014;160(9): 585–593. 2. Li S, Bruen BK, Lantz PM, Mendez D. Impact of health insurance expansions on nonelderly adults with hypertension. Prev Chronic Dis. 2015;12:150111. 3. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025–1034. 4. Kronick R, Bindman AB. Protecting finances and improving access to care with Medicaid. N Engl J Med. 2013;368(18): 1744–1745. 5. Baicker K, Taubman S, Allen HL, et al. The Oregon experiment—effects of Medicaid on clinical outcomes. N Engl J Med. 2013;368(18):1713–1722. 6. Muennig PA, Quan R, Chiuzan C, Glied S. Considering whether Medicaid is worth the cost: revisiting the Oregon Health Study. Am J Public Health. 2015; 105(5):866–871. 7. Gordon C. Dead on Arrival: The Politics of Health Care in Twentieth Century America. Princeton, NJ: Princeton University Press; 2003.
unusual in political campaigns. It is especially not unusual in a campaign where the dominant issues in exit polling were the economy (voted as most important by 35%) and security (voted as most important by 21%).1 Health care was a distant
ABOUT THE AUTHOR Gail R. Wilensky is a Senior Fellow at Project HOPE, Bethesda, MD, and a former Administrator of Medicare and Medicaid. Correspondence should be sent to Gail R. Wilensky 7500 Old Georgetown Road, Suite 600 Bethesda, MD 20814 (e-mail: [email protected]). Reprints can be ordered at http:// www.ajph.org by clicking the “Reprints” link. This editorial was accepted November 28, 2016. doi: 10.2105/AJPH.2016.303594
Wilensky
Editorial
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