In the March 2025 Issue of the Quarterly: Population Health Imperiled

Since the start of the second Trump administration, hardly a day has gone by without a major Presidential action shaking the federal government to its core. The most far-reaching action has been the establishment of a Department of Government Efficiency (DOGE) without Congressional approval. Under the leadership of Elon Musk, DOGE has broad powers to cut federal spending, including firing federal personnel at will and eliminating entire agencies deemed by Mr. Musk and President Trump to be unnecessary. Many of its first actions pose serious threats to the nation’s biomedical research enterprise, most notably the suspension of all federal grants and contracts, and the imposition of a 15% cap on indirect costs for federal biomedical research grants. But several other actions by the Trump administration gravely threaten population health, such as the withdrawal of the United States from the World Health Organization (WHO) and the Paris Agreement on climate change, as well as the dismantling of the United States Agency for International Development (USAID).

It’s no wonder that these actions have generated strong opposition and outrage from various quarters in both the public and private sectors. Former Secretary of Health and Human Services Kathleen Sebelius has called the withdrawal from the WHO a disaster for global health, and no fewer than five former Secretaries of the Treasury recently joined together to sound the alarm that “our democracy is under siege” from DOGE. Although the suspension of federal grants and contracts has been temporarily rescinded, the administration’s intent to disrupt operations is clear, with state Medicaid programs and other federal safety net programs continuing to remain vulnerable to such funding cuts. Indeed, House Republicans have proposed a federal budget that would significantly cut federal spending on the Affordable Care Act’s Medicaid expansion, leading to the loss of Medicaid coverage for as many as 20 million people. The Affordable Care Act marketplaces also are at risk, with the administration having reduced by 90% the funding for navigators to assist consumers in selecting appropriate health plans. The across-the-board capping of indirect costs on federal biomedical research grants at 15% is an apparent assault on science and evidence-based medicine that could presage an exodus of researchers from careers in academic science.

These are but a few of the most recent actions, many of which are being challenged in the courts. However, as I wrote in the December 2024 issue of the Quarterly, the President’s nominees for cabinet positions and other high-level offices are also deeply troubling. They are based largely on personal loyalty to him rather than professional qualifications and competencies.  A prime example is the appointment of Robert F. Kennedy Jr. as Secretary of Health and Human Services. Mr. Kennedy is well known as an avowed vaccine skeptic who has spread misinformation about the safety and efficacy of vaccines and has sown public distrust of science and evidence-based medicine. Despite the strong objections raised by leading medical and public health organizations and professionals, the Senate voted on February 13^th to confirm Mr. Kennedy’s appointment. Apparently, he made promises that convinced certain key Republican members that he would “do no harm” to federal vaccination policies and instead would focus on fighting chronic diseases. However, it will take more than verbal promises to assure that the federal public health infrastructure remains strong and well prepared to tackle the next pandemic. Mr. Kennedy now embodies the MAHA (“Make America Healthy Again”) movement, which, on the surface, seems to be a laudable goal. But its achievement ultimately will depend on whether policy decisions will be based on sound, data-driven scientific evidence. Life expectancy, disease burden, and other accepted measures of population health in the US have compared unfavorably to those in many other nations over the past decade. Any further decline in US vaccination rates will lead to higher mortality, with children in particular suffering and dying needlessly from preventable childhood diseases. In addition, the withdrawal of financial support for USAID will globally impact the poorest in the world, and federal funding cuts in biomedical research will cause America to lose its preeminent position as a leader in science and medicine. These threats to population health are very real and were unthinkable just a short time ago.

Sadly, this is the predicament in which we find ourselves at this time, and it would appear that kakistocracy has come to America in the 21^st century. Simply defined, it is government run by the least qualified, most inept, and unscrupulous individuals. A kakistocracy poses an existential threat to all forms of human endeavor in a society and should be avoided at all costs. Unfortunately, the Trump administration seems to revel in it and its recent actions imperil the lives and wellbeing of all Americans. In confirming Mr. Kennedy’s appointment, members of Congress promised to hold the administration accountable. Let’s hope that they remain true to their commitments, but it also will be incumbent upon all in the public health and medical communities to hold these officials accountable for any policy action that affects population health.

For insightful commentaries on these and other policy issues, we invite readers to visit the Quarterly’s website. Recent contributions include:

• Paul Kim on the Food and Drug Administration in the second Trump administration;
• David Rosner on Robert F. Kennedy Jr.’s unsuitability for the position of Secretary of Health and Human Services;
• Kristi Martin and Meena Seshamani on how to get things done in large organizations, with lessons learned from the Medicare drug price negotiation program;
• Patricia Hong and Ezekiel Emanuel on leveraging artificial intelligence to bridge the mental health workforce gap and transform care; and
• Jennifer Dowd and Neil Mehta on anti-obesity medications.

This issue of the Quarterly opens with a thoughtful Perspective on equity in evidence-informed decision making, and is followed by original scholarship on an array of policy topics, including: insurance to improve patient access to cell and gene therapy; essential medicines in the World Health Organization’s Model Lists; access to mental health treatment; principles for embedding health equity language in policy research and practice; comprehensiveness in primary care; and whole person health assessments.

Evidence-informed decision-making (EIDM)—the process of searching, appraising, synthesizing, adapting, and implementing evidence into policies and practices—is intended to improve the effectiveness and efficiency of interventions. Despite growing calls for equity to be considered in EIDM, there is no consensus regarding how equity should be defined and evaluated in the EIDM process. In “Centering Equity in Evidence-Informed Decision-Making: Theoretical and Practical Considerations,” Bomi Hirsch and colleagues offer both theoretical and practical recommendations with which population health could begin to structure a synthesized approach to centering equity in EIDM, organized in four areas: (1) understanding historical context (the root causes of disparities and inequity); (2) understanding intervention design and intended beneficiaries; (3) understanding differential impact and intersectionality; and (4) understanding community context before implementing or scaling interventions. The authors reflect on how the field can employ EIDM to advance equity, and note the unique role that evidence clearinghouses can play in EIDM.

Cell and gene therapies (CGTs) that treat rare, often lethal, diseases are very expensive, and insurers commonly restrain patient access to these therapies, erecting barriers that may create or perpetuate existing disparities among patients. In “Innovative Insurance to Improve Patient Access to Cell and Gene Therapy,” Rena Conti and colleagues simulated the incremental annual per-person costs to cover CGTs existing or expected between 2023 and 2035 for the US population and by payer type, based on previously published estimates of expected US spending on CGTs. The authors estimated that annual incremental spending on CGTs 2023—2035 would amount to $20.4 billion, or $15.69 per person. Total annual estimated spending is expected to concentrate among commercial plans, with sickle cell-targeted CGTs adding a monthly maximum of $0.78 per person in costs to all payers but especially within state Medicaid programs. The authors call for new policies that improve CGT coverage and affordability.

The World Health Organization Model Lists of Essential Medicines (WHO EML) is intended to help countries select essential medicines based on the priority needs of their populations.  However, the pharmaceutical sector has evolved toward the production of  complex, high-priced medicines that challenge WHO decision making. In “The Political Economy of the World Health Organization Model Lists of Essential Medicines,” Kristina Jenei conducted document review and semi-structured interviews with diverse stakeholder groups that had direct experience with the WHO EML, and used Donabedian’s Structure-Process-Outcome framework together with the Three I’s framework (ideas, interests, and institutions) to understand how political factors shape the WHO EML. She argues that the concept of essential medicines evolved from an original focus on generic medicines in resource-constrained countries and that WHO never explicitly addressed for whom its decisions are intended. While some believe the Model Lists have a “symbolic” price-lowering mechanism, others do not (e.g., the pharmaceutical industry is more concerned with profitability). A lack of data and human resources has inhibited evaluation, exacerbated the influence of external actors, and led to inconsistent recommendations for essential medicines.

Access to mental health treatment in the United States is both inadequate and unevenly distributed. Although there is strong justification for government action on mental health treatment, it is unclear whether there is a political constituency for such action. Stigma and the “othering” of people with mental illnesses contribute to reduced support for  intervention. In “Mental Health Treatment Access: Experience, Hypotheticals, and Public Opinion,” Jake Haselswerdt used original questions from a 2023 nationally representative survey of 1,000 American adults to measure respondents’ agreement with statements about barriers to mental health treatment access as well as support for statements in favor of change to address mental health. He analyzed the demographic and political correlates of agreement with the barrier statements and used regressions to examine their possible causal effect on support for change.  is analysis found that agreement with statements about access barriers followed expected patterns in some cases (e.g., socioeconomic status) but not in others (e.g., race/ethnicity). He also documented a notable partisan and ideological divide in respondents’ experiences and beliefs, finding that Americans who agreed that material factors were a barrier to access were more supportive of action on mental health, whereas those who agreed with statements suggesting discomfort or skepticism were less supportive. He asserts that these findings suggest that personal experience and perspective-taking should be integrated into the study of public opinion on mental health, complementing existing work on stigma and othering.

Science communication and health policy language often fail to define and contextualize systemic barriers, such as structural racism and wealth inequity, that contribute to disparities in health outcomes. Health policy practitioners need to understand best practices for communicating research and policy findings to various audiences in ways that are culturally and linguistically responsive to different community needs. In “Naming and Framing: Six Principles for Embedding Health Equity Language in Policy Research, Writing, and Practice,” Kamaria Kaalund, Jay Pearson, and Andrea Thoumi conducted an environmental scan and synthesized themes across commonly used and publicly available health equity language guides to provide specific guidance to health policy practitioners to inform their policy research, analysis, writing, and dissemination. The authors identified six guiding principles to dismantle systems that work against the goals of health equity in policy-focused research, writing, and communications: (1) avoiding blaming language; (2)  contextualizing health inequities; (3) acknowledging that systems are not passive; (4)  understanding that one-size-fits-all terminology does not exist; (5) seeking input from community members; and (6) paying attention to omissions.  They contend that applying these principles will better equip health policy practitioners to develop or inform equitable policies and engage in dialogue with community members to advance equitable health policy.

A key element of high-quality primary care is comprehensiveness. However, there is growing concern that comprehensiveness is declining and that primary care physicians are providing a narrower range of services.  Efforts to address this perceived decline have been hampered by the various and sometimes vague definitions of comprehensiveness currently in use. In “Comprehensiveness in Primary Care: A Scoping Review,” Agnes Grudniewicz and colleagues explored definitions of comprehensiveness to map its attributes in support of research, practice, and policy. The authors identified 9 attributes of comprehensiveness in primary care that mapped into two conceptual domains: breadth of care (services, settings, health needs and conditions, patients served, and availability) and approach to care (one-stop-shop, whole person care, referrals and coordination, and longitudinal care).  They also identified 3 enablers of comprehensiveness, namely structures and processes, teams, and competency. They assert that the domains and attributes identified in their scoping review can be used to develop better definitions and measures appropriate to research, practice, and policy contexts, thereby enabling more precise efforts to improve primary care systems.

Most measures in health care are focused largely on diseases and care processes, with a lack of measures regarding what matters to people, such as how they are doing in terms of their whole health. Owing to the lack of consensus on an ideal whole person health instrument for use in practice, Stephanie Gold and colleagues undertook a review of past work to provide a foundation for assessing whole person health. In “How Are You Doing… Really? A Review of Whole Person Health Assessments,” the authors reviewed concepts and instruments using a grounded theory approach, and identified 4 overarching categories of whole person health, consisting of 9 domains: body and mind (physical well-being, mental/emotional well-being, meaning and purpose [spiritual well-being], sexual well-being), relationships (social well-being), living environment and finances (financial well-being, environmental well-being), and engagement in daily life (autonomy and functioning, activities). Global well-being was used as a tenth domain for instruments that assessed well-being as a whole. Of the 281 instruments examined, most were specific to a single domain or subdomain, although 50 instruments assessed at least three domains. The authors believe that the lack of consensus on how best to measure health presents an opportunity to develop a new instrument to support a shift to whole health care, but they also recognize that a shift to whole health care would require broader system transformation in payment, care delivery, and the ecology of measurement.

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