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December 2024
Quarterly Article
Alan B. Cohen
Dec 19, 2024
Back to The Milbank Quarterly
In the aftermath of the November 5th election, there has been great speculation about what a second Trump administration would mean for health and health care in the United States. Throughout his campaign, President-elect Trump continued his attacks on the Affordable Care Act (ACA), hinted at possible cuts to the Medicaid program, and signalled potential changes to key federal health agencies, such as the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Not surprisingly, many public health professionals are deeply concerned about the future of the US health care system and the prospects for population health over the next four years.
While it remains uncertain as to what policies ultimately will emerge from a second Trump administration bolstered by a Republican-controlled Congress, the President-elect’s nominees for cabinet positions and other high-level offices offer an indication of his intent to disrupt the highest levels of government. He has selected individuals based not so much on professional qualifications and competencies, but rather their personal loyalty to him and their ability to act as disruptors of the status quo. A prime example is his nomination of Robert F. Kennedy, Jr. for the role of Secretary of Health and Human Services (HHS). Mr. Kennedy is an avowed vaccine skeptic who has spread misinformation about the safety and efficacy of vaccines and fluoride in water and has sown public distrust of science and evidence-based medicine. As HHS Secretary, he would oversee the operations of the CDC and the FDA as well as those of the Medicare and Medicaid programs. Under his leadership, one might expect to see reductions in vaccination rates and the nation’s ability to respond to public health emergencies. One might also expect to see reductions in health insurance coverage for millions of Americans both through the Medicaid program and the ACA marketplaces. Rather than “making America healthy again,” as Mr. Kennedy and his proponents assert, such developments could worsen population health and well-being in the United States.
Yet, despite these grave threats, there remains hope that many of the dangers to health posed by a second Trump administration may be mitigated or neutralized. But it will require considerable effort on the part of private citizens and public officials alike in both political parties working together for the common good.
For insightful commentaries on these and other policy issues, we invite readers to visit the Quarterly’s website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/):
In this issue of the Quarterly, readers will find an engaging mix of articles, beginning with two Perspectives – one on reforming physician licensure to improve access to telehealth, and another on building a representative health care workforce. In addition, the issue contains original scholarship on a range of policy topics, including: the financial burden of childbirth and postpartum care; the population health implications of Medicaid pre-release and transition services for incarcerated populations; the implementation of policies that earmark taxes for behavioral health; the development of financial incentives that reward physician groups for improved equity of care; a framework analysis of trust-building principles within health data-sharing legislation in several European nations; and a comparative analysis of international drug price negotiation frameworks with the Medicare framework now being implemented under the Inflation Reduction Act.
During the COVID-19 public health emergency, the United States witnessed a remarkable increase in the use of telehealth services, spurred by temporary regulatory changes such as the waiver of certain licensing requirements for providers practicing telehealth across state lines. Recently, however, the reinstitution of pre–pandemic licensure regulations has impeded interstate telehealth, disproportionately affecting patients who live near a state border, patients who are geographically mobile (e.g., college students), and patients with rare diseases who may need care from a specialist outside their state. In “Reforming Physician Licensure in the United States to Improve Access to Telehealth: State, Regional, and Federal Initiatives,” James René Jolin and colleagues discuss several potential reforms at both state and federal levels to facilitate interstate telehealth. These include state exemptions to licensure requirements for certain types of telehealth, such as follow-up care, licensure registries that impose little paperwork and fees on physicians, and congressional interventions that mimic the Department of Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act of 2018 that can waive provider licensing and geographic restrictions to telehealth within federal programs such as Medicare. The authors caution that any discussion of medical licensure reform must consider the current political climate in which states are taking divergent stances on such sensitive topics as reproductive care, gender-affirming care, and substance use treatments.
The United States Supreme Court’s decision in Students for Fair Admissions, Inc., v President and Fellows of Harvard College (SFFA) has had a major impact on university admissions practices, including those affecting health profession programs. The Supreme Court decision to ban race-conscious admission practices constrains pathways toward achieving health workforce representativeness and equity. In “Overcoming the Impact of Students for Fair Admission v Harvard to Build a More Representative Health Care Workforce: Perspectives from Ending Unequal Treatment,” Vincent Guilamo-Ramos and colleagues examine the recent National Academies of Sciences, Engineering, and Medicine report for eliminating racial and ethnic health care inequities entitled Ending Unequal Treatment, which found that a health workforce that is representative of the communities it serves is essential for health care equity. The authors draw on the report’s findings that health care workforce representativeness improves care quality, population health, and equity to discuss policy and programmatic options for various participants to promote health workforce representativeness in the context of race-conscious admissions bans.
Out-of-pocket costs related to childbirth and postpartum care may cause financial hardship, depending on the type of insurance and income. In “When the Bough Breaks: The Financial Burden of Childbirth and Postpartum Care by Insurance Type,” Heidi Allen and colleagues employed the Postpartum Assessment of Health Survey to follow up with respondents to the CDC Pregnancy Risk Assessment Monitoring System after a 2020 birth in six states and New York City. The survey included questions on health care costs and financial well-being, and the authors estimated out-of-pocket spending on childbirth and postpartum care and financial strain one year after birth. Comparing Medicaid-insured births to commercially insured births, they found that Medicaid is highly protective against childbirth and health care costs in the postpartum period relative to commercial insurance, particularly for low-income birthing people, but they also found persistent medical debt and financial worry at 12 months postpartum for Medicaid recipients who had reported out-of-pocket childbirth expenses.
A large population of incarcerated people may be eligible for pre-release and transition services under the new Medicaid Reentry Section 1115 Demonstration Opportunity. Their addition to the Medicaid rolls may skew the overall Medicaid population prevalence of various diseases, suggesting a need for additional planning, data exchange, and service delivery infrastructure by state Medicaid plans. In “Population Health Implications of Medicaid Pre-Release and Transition Services for Incarcerated Populations,” Sanjay Basu and colleagues analyzed data on eligibility criteria for new Medicaid pre-release and transition services and estimated the potentially eligible populations in prisons and jails, considering various incarceration lengths and health status requirements. They also compared disease prevalence in the incarcerated population with that in the existing civilian Medicaid population. The authors found that mental illness, hepatitis C, and chronic kidney disease prevalence rates were sufficiently high among incarcerated populations to likely skew overall Medicaid population prevalence rates. Their findings also indicated that rural and smaller states would experience disproportionately higher proportions of their Medicaid populations being eligible for pre-release and transition services if new eligibility rules were broadly applied. They concluded that state Medicaid programs, health plans, and providers would benefit from advanced planning to address these challenges.
More than 200 states and local jurisdictions in the United States use earmarked taxes to fund behavioral health services. Such tax policies are viewed as positive ways to increase flexible funding. However, implementation challenges may impede long-term service delivery planning and may create inequities in the distribution of tax revenue. In “A Mixed-Methods Exploration of the Implementation of Policies That Earmarked Taxes for Behavioral Health,” Nicole Stadnick and colleagues surveyed 274 officials involved in the implementation of earmarked tax policies for behavioral health and conducted 37 in-depth interviews with officials in four states with these taxes (California, Washington, Colorado, and Iowa) to gauge their perceptions of the advantages and drawbacks of the earmarked tax, perceptions of tax policy design, and factors influencing decisions about revenue allocation. They found that a large majority of interviewees strongly agreed that the tax increased flexibility to address complex behavioral health needs and increased the number of people served by evidence-based practices. They concluded that earmarked taxes are a promising financing strategy to improve access to, and quality of, behavioral health services by supplementing mainstream state and federal financing.
Blue Cross Blue Shield of Massachusetts (BCBSMA), a large commercial health insurer, is using financial incentives to advance equity of care by patient race and ethnicity. The experiences of this payer and its contracted physician groups potentially may inform efforts elsewhere. In “Launching Financial Incentives for Physician Groups that Reward Improved Equity of Care by Patient Race and Ethnicity,” Hector Rodriguez and colleagues conducted key informant interviews of physician group, BCBSMA, and external stakeholders. They also observed equity initiative meetings and analyzed documents to identify barriers and facilitators of designing financial incentives to advance racial equity. Their analyses revealed: (1) the central importance of valid and reliable equity performance measurement and carefully designed equity improvement incentives for physician group buy-in; (2) the need for physician groups to improve their quality management systems and the accuracy and completeness of patient race and ethnicity data prior to implementation; and (3) the need to consider the populations served, the baseline maturity of quality management systems, and efforts to assess patients’ social risk factors as central elements in planning for physician group financial incentives to improve racial equity.
Public trust is vital to the successful implementation of data-driven health initiatives, and legislation is an essential instrument for building public trust by reinforcing public perception of an active regulatory system that upholds the rule of law. However, there is limited evidence on the extent to which health data-sharing legislation contains references to trust and trust-building principles for their practical implementation. In “Examining the Inclusion of Trust and Trust-Building Principles in EU, Italian, French, and Swiss Health Data-Sharing Legislation: A Framework Analysis,” Federica Zavattaro and colleagues applied an evidence-based “Public Trust in Health Data-sharing” framework to 36 pieces of legislation from the European Union (EU), Italy, France, and Switzerland regarding health data sharing. The authors assessed: (1) how the term “trust” is embedded in legislation; and (2) the presence and quality of trust-building principles within the selected legislation. They found only 9 instances in which legislation incorporated references to “trust,” with the most prevalent trust-building principles being agencies of accountability (72%) and data security (70%). Their analysis also showed that the majority of the trust-building principles were implicit in the legal text, with Swiss legislation having the highest number of explicit references. They argue that the limited and implicit use of trust-building principles in EU, Italian, French, and Swiss legislation offers the opportunity to raise policymakers’ awareness of these principles, and that the proposed framework provides a guide for policymakers to incorporate trust-building principles within health data-sharing legislation in a more recognizable and comprehensive manner.
In 2022, Congress passed the Inflation Reduction Act (IRA), which allowed Medicare, for the first time, to begin negotiating the prices for certain high-cost brand-name prescription drugs. Many other industrialized countries negotiate drug prices, but the negotiation framework established under the IRA is far more limited than other frameworks. In “A Comparative Analysis of International Drug Price Negotiation Frameworks: An Interview Study of Key Stakeholders,” Iselin Dahlen Syversen and colleagues sought to compare and contrast key features of the negotiation process across health systems in Belgium, Canada, France, Germany, the Netherlands, Norway, and the United Kingdom. The authors also analyzed the Veterans Affairs Health System in the United States. They interviewed key drug price negotiators in each system, focusing on the criteria for selecting drugs for price negotiation, procedures for negotiation, factors that influence negotiated prices, and how prices are implemented. They found that, although all eight systems negotiate the prices of brand-name prescription drugs soon after approval and rely on formal clinical assessments that compare newly approved drugs with existing therapies, the systems differed on whether the body performing clinical assessments is separate from the negotiating authority, how added health benefit is assessed, whether explicit willingness-to-pay thresholds are employed, and how specific approaches for priority disease areas are taken. Overall, they concluded that, despite differences in approach to conducting price negotiations on brand-name drugs, these various systems coalesce around a set of practices that largely will be absent from the current Medicare negotiation framework. They recommend that U.S. policymakers consider adding some of the characteristics of these other systems in the future to improve negotiation outcomes in the Medicare program.
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
