The Next Four Years: Health

Issues related to health — at the personal, community and global scales — will challenge the next president, both in his or her first 100 days and throughout the next four years. In the third part of a Q&A series on challenges that will face the new president, Princeton University researchers Janet Currie, Heather Howard, Adel Mahmoud and Uwe Reinhardt examine a number of these issues.

Currie is the Henry Putnam Professor of Economics and Public Affairs and director of the Center for Health and Wellbeing (CHW) at Princeton's Woodrow Wilson School of Public and International Affairs. Currie, who is also chair of the Department of Economics, focuses her research on the health and wellbeing of children. She has written about early intervention programs, programs to expand health insurance and improve health care, public housing, and food and nutrition programs.

Howard is a lecturer in public affairs at the Wilson School and a faculty affiliate at CHW. She is the director of two programs funded by the Robert Wood Johnson Foundation: Advancing Coverage in States, which provides technical assistance to states implementing the Affordable Care Act (ACA), and the State Health and Value Strategies program, which supports state efforts to enhance the value of health care. Previously, Howard served as New Jersey's commissioner of health and senior services.

Reinhardt is the James Madison Professor of Political Economy at the Wilson School. He is recognized as one of the nation's leading authorities on health care economics. He is a past president of the Association of Health Services Research and, from 1986 to 1995, he served as a commissioner on the Physician Payment Review Committee, which was established by Congress. He is a prolific researcher and serves or has served on a number of editorial boards.

Mahmoud is a lecturer with the rank of professor at the Wilson School and Department of Molecular Biology. A leading expert on vaccine development and infectious diseases in the developing world, Mahmoud previously served as president of Merck Vaccines, a management committee member for Merck Co., chairman of medicine at Case Western's School of Medicine and physician-in-chief at University Hospitals of Cleveland. 

Q. Within your area of expertise, what issues will the next president face in the first 100 days?

Howard: The health care sector is approaching one-fifth of our economy. After a period of slower growth, costs are now increasing at a rate twice inflation. Only 31 states have expanded Medicaid, and Congress has voted to repeal the ACA more than 60 times since its enactment in 2010. However, health policy has not become a major issue during the current presidential campaign. The next president will take office in the middle of the fourth open enrollment period under the ACA, with millions of Americans purchasing their 2017 health coverage. Less than three months later, Americans will be filing taxes and paying steep penalties under the individual mandate if they did not have coverage. At the same time, we are confronted with the threats posed by the continuing spread of Zika virus in southern states.

Donald Trump has spoken repeatedly about his desire to see the ACA repealed, which is echoed in the Republican Party platform. However, neither he nor Republicans in Congress have provided details of a replacement program that would address the nearly 20 million Americans who would lose their coverage as a result of repeal. So his first 100 days would present a challenge on the health care front; after years of the proverbial dog chasing the car, what would a Republican in the White House (and perhaps one or both chambers of Congress), actually do once they've caught it?

Hillary Clinton's proposals have been more detailed and are less disruptive because she embraces the ACA and has talked of staying the course and building on it, with specific proposals to address rising health care costs and continue to expand health insurance coverage.

Currie: Health care reform will have to be a continuous, ongoing process regardless of whether our next president "repeals" the ACA. Within the ACA framework, it will be necessary to work on replacing the insurers who are withdrawing from the exchanges, and to also address price transparency as well as transparency about the networks of providers that are included in each plan. If the ACA is "repealed," there will have to be a substitute for the millions who would become uninsured. It is not at all clear at this point what that substitute will be.

I'm glad Heather mentioned Zika because it is a national disgrace that, through our inaction, we have ensured that babies will be born in the next few months with horrible defects that could have been prevented. Helping the affected children and their families and preventing the further spread of the disease will be an ongoing challenge.

Federal leadership also would be useful in terms of addressing the lead hazards the crisis in Flint, Michigan, has brought to light. Although what happened in Flint is extreme, kids are affected by lead poisoning in many parts of the country every day. We need to know more about how to help children who have been poisoned, and what the most effective programs are to prevent such poisoning in the first place. While in Flint the problem is lead in the water, many more kids are still poisoned by lead paint and residual lead in soils.

Finally, and controversially, one can look at violence as a public health issue. The uptick in violence that we have seen in cities like Chicago is a cause for serious concern. Research into gun violence is greatly hampered by restrictions Congress has placed on the Centers for Disease Control and Prevention (CDC) and even on our ability to collect data about the deaths. That makes it impossible to objectively evaluate claims about the causes of gun violence or about policies that might be effective. The next president should re-evaluate these policies.

Mahmoud: The immediate task is to ensure the security of our population as well as the global population against emerging infections. Witness what happened with Ebola in West Africa and the human toll. Now, we are facing Zika, and we have far less capabilities to allocate funds to work on understanding the virus, how it causes multiple disease manifestations, how to interfere in its transmission to humans and, more significantly, how to develop a vaccine. Responding to emerging infections cannot be left hostage to the complicated political process or to surprises. The U.S. government needs allocated funds to respond and to develop counter measures.

Reinhardt: There still are millions of Americans who do not have health insurance of any kind, paying out of pocket for health care they need (if they have the money) or relying on charity care where available. Many Americans, although not all, view that as a social problem public policy should address. Even Americans who have procured health insurance through the ACA often find themselves saddled with high deductibles and coinsurance that makes access to needed health care difficult. It is a uniquely American problem.

The problem is exacerbated because we have the most expensive health system in the world, with prices twice as high or higher for identical health care goods (especially drugs) and services.

The U.S. health system has been carefully structured, often through enabling legislation triggered by special interest groups, to allow the supply side of the health care sector to extract enormous sums of money from the rest of society. Nowhere is this clearer than with specialty drugs, whose prices per year of treatment now routinely exceed $100,000. Yet on Capitol Hill, this system has always had its staunch defenders, for obvious reasons.

Q. Within your area of expertise, what issues will the next president face over the course of his or her term?

Howard: The next president will face a health care landscape that is vastly different from that President Obama faced upon taking office in 2009. At that time, nearly 50 million Americans were uninsured, and now, as a result of the ACA, we are experiencing the lowest rate of uninsurance since enactment of Medicare and Medicaid in 1965. But despite the strides that have been made as a result of the ACA, there is still much work to be done. Health care costs, especially prescription drug costs, continue to rise. Public health crises, like the Zika virus and the opioid epidemic, will continue to demand attention. Additionally, there will continue to be conversations about the aging of our population, our nation's mental health system and gun violence. Just as important as who the next president will be is the composition of the next Congress, as this will have a significant impact on the president's ability to build upon, or undo, the reforms that have already been enacted.

Since major federal legislation (even to fix parts of the ACA where there is bipartisan agreement) is unlikely, I expect future changes and innovations to develop at the state level. Indiana Governor Mike Pence, the Republican vice presidential candidate, has developed controversial changes to his state’s Medicaid program that require even the poorest beneficiaries to contribute financially to their coverage. I would expect that under a Trump administration there would be more leeway given to states looking to tie Medicaid to work requirements and increase the amount of cost-sharing for beneficiaries. The Clinton campaign has proposed new flexibility for states to implement "public option" health insurance plans, an idea that was left out of the ACA and represents an interesting pathway for states to address affordability concerns. Clinton also has expressed support for providing an option for those 55 and older to opt into Medicare, while the Trump campaign has discussed allowing the sale of health insurance across state lines. Interestingly, both campaigns have talked about allowing Medicare to negotiate with drug companies to rein in prescription drug costs, but that idea has never garnered support in Congress. And finally, there is a growing recognition of the importance of addressing the long-term care needs of our aging population — perhaps the most significant piece of unfinished business of the ACA.

It also will be interesting to see the ways in which this election might impact state decisions on whether to expand Medicaid, as 19 states have opted not to do so, despite clear evidence of the economic benefit to doing so. Can a new administration provide the incentive for many of these states, which are largely concentrated in the South, to take up the option to expand and provide coverage to many low-income residents? Arizona was the last state to implement Medicaid in 1982, 17 years after its passage. It is possible that under a new administration, health reform will become less controversial as it loses its political ties to President Obama. But in the meantime, nearly 3 million low-income Americans live in this coverage gap.

Currie: The opioid crisis is pressing and especially concerning because, arguably, it originated in the health care sector. Many people seem to have become addicted because they were given opioids by their doctors. They then subsequently transition to illegal drugs such as heroin. The only silver lining is that it should be possible to change the behavior of providers once they realize the harm they are doing. The federal government should take the lead on this. Many people do not realize that mental health problems are the leading cause of working days lost in the United States. Many people lack access to mental health services and the services that are available are uncoordinated, unaffordable and often unhelpful. Stigma also prevents many people from seeking help. Federal leadership removing the stigma and pushing health insurers to improve their coverage of these services is sorely needed. Support for nonprofits operating in this space (like the National Alliance on Mental Illness) could also help.

Mahmoud: The next medium-term challenge is to develop a comprehensive vision for health care in the United States. The ACA was a great step in securing coverage for many people but not yet for all of our citizens. The cost structure for delivery of health care in this country has to be re-examined to help affordability and to reach the needs of our population. These two issues should form the basis of any attempts to reform the system.

Q. How have you examined these issues in your research?

Howard: As the former New Jersey commissioner of health and senior services and the director of programs focused on the implementation of health reforms at the state level, I am particularly interested in the ways in which the election could impact the balance in federal-state relations. A key finding since the ACA was enacted has been the degree to which the states have been responsible for its successful implementation and the varying levels of commitment that they have shown to doing so. While some states have led in these efforts, whether by establishing their own health insurance marketplaces or by expanding Medicaid coverage to offer coverage to low-income residents, others have not been as willing to embrace the law and have resisted doing so, even at the peril of their own residents. This variation in state implementation activity provides natural experiments to study in the years ahead.

Our programs have provided technical assistance to aid the states in their health reform journeys, providing expertise in areas in which states may have limited capacity and face significant resource constraints. In particular, our work has examined the state-level economic impact of Medicaid expansion and assisted states in understanding the opportunities provided by waivers included in the ACA, which could shape the roadmap for their future efforts. It is clear that no matter the result of the election, states — which purchase health insurance coverage for approximately one-quarter of all Americans — will continue to be the center of the action on health care, and I look forward to continuing to study and work with states as they endeavor to add value to their health care systems.

Currie: I have been examining the spread and causes of the opioid epidemic with my students, with a view toward trying to determine what policy responses might be most effective. I am also looking at patterns of prescribing for other mental health drugs including ADHD drugs, anti-depressants and anti-psychotics to try to understand how they are used. Despite the fact that millions of Americans use these drugs, we have very little understanding of the most basic facts about these markets.

I also have investigated the long-term consequences of treatment for ADHD among young children. It is sobering that although there do seem to be positive effects on health – for instance young children who are treated are less likely to be injured – there is little evidence of positive effects on educational attainment. It seems we need to look into other ways to reach the 5 to 10 percent of children with ADHD symptoms in schools.

I am currently working on measuring the impact of low levels of blood lead in preschool children on their later test scores as well as delinquency and crime. The issue is that the number of children with blood lead levels above the old threshold of 10 micrograms per deciliter of blood has fallen sharply but there are still many children with levels of, say, three to five micrograms per deciliter. My preliminary work on this suggests that we should be very concerned about these children and that greater exposure to lead can explain some of the disparities in outcomes between minority and other children.

Mahmoud: My research focuses on how to anticipate and respond to emerging infections. Last year, we proposed a Global Vaccine Development Fund to help develop much-needed vaccines for emerging infections such as Ebola, West Nile and Zika, among others, and those needed for less economically capable people. These vaccines cannot be developed by resources of the private sector alone and their potential market returns are not clear. The proposed fund will address the gap in the development process and make us ready and prepared to respond.