To Advance Health Coverage, New Health Secretary Can't Neglect Employers

    November 29, 2017

    By Daniel V. Yager

    The Hill 

    President Trump’s pick for the next secretary of Health and Human Services, Alex Azar, goes before the Senate Committee on Health, Education, Labor and Pensions (HELP) today. If confirmed as secretary, Azar will have a real opportunity to bolster health care in this country — but in an area that does not get the same kind of attention as the battle over the Affordable Care Act (ACA): that of employer-sponsored coverage.

    The debate over the ACA has focused mostly on dealing with those who rely upon the individual market for coverage. The costs and uncertainties in that market have led to unacceptable levels of uninsured individuals. This problem is indeed worthy of policymakers’ attention. But what is often overlooked in the debate is the fact that employer-sponsored insurance, which covers 177 million Americans, is the cornerstone of the U.S. health-care system.  

    Employers compete to attract and retain talent by offering employees the high-value health-care benefits they expect in the workplace. It is for this reason that my organization, the HR Policy Association, which represents the chief human resource officers of over 270 large companies, has focused on the potential impact of the ACA, and any revisions thereof, on this system. Likewise, the American Health Policy Institute (AHPI) conducts research to find how large employers are responding to the challenges they face in providing health coverage.

    First, government should continue to incentivize employers to provide health benefits to employees. Employers are good at both getting people covered and maintaining manageable risk pools, and public policy should be aimed at encouraging these goals.

    Maintaining the strength of the employer market also provides stability for the health-care system overall. As indicated in a May 2017 AHPI paper that looked at employer concerns, 91 percent of large employers say that policymakers should encourage and facilitate the development of a robust and competitive market for individual health-care coverage. In fact, if all ACA penalties were removed such that employers could voucher some or all of their employees into the exchanges, 53 percent would consider such an option, which would help develop a strong individual market.

    Azar should also note that innovations in employer-sponsored health benefits are helping to reduce health-care costs. However, regulations imposed by the ACA serve as a barrier to cost-savings. In 2014, an AHPI study found that over the next decade the cost of the ACA to large U.S. employers will be $4,800 to $5,900 per employee, and over the same time period, the total cost of the ACA to all large U.S. employers will be $151 billion to $186 billion. As health-care reforms move forward, federal policies should leverage and encourage innovation by reducing unnecessary and costly mandates and burdens on employer-provided health benefits that limit flexibility.  

    While some regulatory guardrails may be needed, too many "one size fits all" decrees hinder employers from providing quality benefits and needlessly increase costs. Employers should have the flexibility to design health-care programs that ensure a healthy workforce and enable access to affordable health care coverage in the way that best fits their business goals, company culture and talent needs.  

    Although health-care costs have somewhat moderated in recent years, they continue to escalate at an unsustainable pace, flummoxing politicians from both parties and challenging ordinary Americans in their efforts to secure health services for themselves and their families.  

    According to the Kaiser Family Foundation, annual premiums for employer-sponsored family health coverage reached $18,764 this year, up 3 percent from last year, with workers on average paying $5,714 towards the cost of their coverage. One way a Secretary Azar could expand affordable coverage is to relax the regulations on health reimbursement arrangements. According to an AHPI analysis of large employers, 95 percent of large employers support expanding access to and permitting more liberal use of tax-free health savings accounts. Aggressively implementing value-based payment models with provider input would also leverage employer efforts to reduce costs as well. 

    It is imperative that lawmakers on both sides of the aisle work together to bring down costs and to minimize unnecessary or inappropriate burdens on the individual market and employer-sponsored coverage.

    Lack of transparency is another major concern when it comes to cost. Employers would like to see increased transparency of underlying financial transactions and contractual commitments in services provided by health-care vendors. In the aforementioned AHPI study, 92 percent of large employers say that complete and transparent access to health-care cost and quality data should be mandated so that a more competitive marketplace can be achieved. And 94 percent said that purchasers of health care, including corporate benefit managers and consumers, need greater insights into the relative cost and quality of the services and products available to them through the health-care supply chain.

    Lasting cost-cutting steps will need legislation, which will require bipartisan compromise. Fortunately, transparency tends to get support on both sides of the aisle, something that a Secretary Azar could use to secure a legislative victory.

    Finally, employers could not provide top-flight benefits without the protections of the Employee Retirement Income Security Act (ERISA). ERISA enables employers to offer uniform low-cost health-care benefits to employees and their dependents, no matter where they live or work. By allowing employers to offer the same benefits in multiple states, ERISA is crucial to the continued success of the employer-based system.  

    An August 2017 AHPI paper looked at this issue, and warned that:

    “Key stakeholders involved with current health care reform efforts favor a state-driven solution that would enable states to tailor individualized health care regulatory schemes, but may not recognize the importance of maintaining preemption protections.”  

    Given ERISA’s importance, a Secretary Azar should ensure that well-meaning initiatives to increase flexibility for states to run their Medicaid programs and reduce costs in the individual and small group markets are carefully crafted so as not to disrupt ERISA’s protections.

    Taken together, these steps will help create a healthier and more productive workforce, which in turn will make the American health-care system more fiscally sustainable. Employers have a vested interest in reducing health-care costs for employees, retirees and their dependents, and driving innovations that lead the way for the system overall. Alex Azar is an experienced and knowledgeable nominee, and he has a real opportunity to work with employers to bring about these badly needed improvements. The employer community stands ready to help.  

    Daniel V. Yager is the president and CEO of the HR Policy Association.   

    Combating opioid epidemic in the workplace starts with the boss

    November 16, 2017

    By Henry C. Eickelberg

    The Hill 
     President Donald Trump recently addressed the rapidly escalating epidemic of drug addiction in the U.S., declaring the opioid crisis to be a “public health emergency.”  He is right that we are facing an emergency: 59,000 Americans died from drug overdoses in 2016, more than those killed by homicide and traffic accidents.

    The public health emergency declaration allows some grant money to be used for a broad array of efforts to combat opioid abuse and eases certain laws and regulations aimed at addressing it. In addition, the White House has created a commission on opioids, which calls for more drug courts, greater training for doctors, and penalties for insurers who do not cover addiction treatment.

    While these actions are a good start, coping with an epidemic of this magnitude will require solutions from both the public and the private sector. For their part, large employers are assessing the opioid epidemic’s effect on their organizations, employees and dependents, and are taking specific steps to address it. To capture these actions and suggest additional solution, the American Health Policy Institute recently released a paper on Chief Human Resources Officers’ response to prescription drug use among the workforce, “The Opioid Crisis: Thoughts from the CHRO Suite.”

    One of the most important aspects in addressing opioid dependency is being able to face and engage the problem. Given the current negative social stigma attached to an opioid dependency, doing so can be difficult.Employees may not reach out for help for either themselves or their dependents because of concern over how others will perceive them and their capabilities as an employee, parent or spouse. In response, employers should advertise that the health plans they offer cover medical, behavioral, and pharmaceutical treatments for substance abuse. This can help in reducing the stigma associated with opioid abuse so that employees will feel comfortable coming forward for help.

    Identifying drug use among employees can be complicated. The traditional intersection of drug use and employment come in the form of pre-employment testing. Many employers have instituted some level of pre-employment drug testing, while others impose either random or “for cause” drug testing. However, none of these tests are designed to engage employees and their dependents in dealing with drug dependence. The typical outcome for failing a drug test is some form of discipline or termination. These processes are not designed to engage employees or their dependents and leaves a huge hole in the net meant to help individuals caught up in opioid abuse.

    Additionally, with the advent of high-deductible plans and the fact that opioid medications are relatively cheap, organizations may find employees taking opioids and deliberately not running their prescriptions through the company’s health plan to avoid any restrictions or limitations that may be in place. Such claims wouldn’t be managed within any safeguards the employer’s plan may have implemented and make identifying and engaging opioid dependent employees (or their dependents) that much more difficult.

    Employers should ensure that their health plans use data analytics to identify physicians with a practice of excessive dosing of opioids, excessive duration of opioids. When opioid abuse is identified, employers may first reach out to the employee and the doctor prescriber. Second, employers may ask their Pharmacy Benefit Manager (PBM) to put a “pharmacy lock” in place, which means that the PBM will only allow prescriptions to be filled from a single designated pharmacy, and once the prescription has run out, no refills will be allowed.

    The opioid epidemic has lowered the overall life expectancy of the U.S. population for the first time in over two decades and is currently running around 10 overdose deaths per 100,000 people. In order to combat this problem, government and the private sector need to work in tandem to address prescription drug abuse and provide proper treatment. Employers can contribute by encouraging employees to seek treatment, as well as engaging with the health care provider community to advocate for prescription quantity control. In addition, health plan administrators and PBMs can work closely together to identify and reach out to those who have been prescribed opioids for more than a given timeframe.

    Solutions to this crisis must come soon, and they will, if employers, health care providers, government, and the pharma community work together at addressing the problem.

    Henry C. Eickelberg CPA, JD, LLM, is a Senior Fellow of the American Health Policy Institute in Washington, D.C., and a former corporate vice president of Human Resources and Shared Services for a Fortune 100 company. 

    Expanding HRAs Would Bolster Individual Market

    October 27, 2017

    Tevi Troy, Axios 

    From our Expert Voices conversation on plans for health care reform after Trump's executive order:

    One under-reported part of the order is its direction "to increase the usability of Health Reimbursement Arrangements (HRAs), to expand employers' ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage."

    Prior to the ACA, HRAs were used by some employers who wanted to reimburse their employees' health care premium expenses rather than offer their own plans. However, in 2013 the Obama administration decided that standalone HRAs violated the ACA. Loosening or reversing those restrictions on using tax-preferred HRAs could fundamentally transform how employers provide health care benefits.

    In a recent Mercer survey, 16% of employers said they would consider a standalone HRA for all eligible employees if there were no penalty, and 21% said they might consider it depending on the strength of the individual market. Notably, the Health Insurance Portability and Accountability Act (HIPAA) specifically prohibits employers from gaming the system by dumping less healthy employees onto the individual markets.

    The bottom line: If done right, an HRA expansion could strengthen the individual market by adding healthy customers and expanding the risk pools, an outcome that should be cheered by Democrats and Republicans alike.

    Other voices in the conversation:

    • James Capretta, resident fellow at the American Enterprise Institute and former associate director for health programs at the OMB: Alexander-Murray deal a flawed first attempt at bipartisanship
    • John McDonough, professor at the Harvard T.H. Chan School of Public Health and former Senate adviser on health reform: Obamacare is dead. Long live the Affordable Care Act.
    • Jeanne Lambrew, senior fellow at the Century Foundation and deputy assistant to the president for health policy in the Obama White House: Health care fix today could be undone tomorrow
    • Christopher Condeluci, principal at CC Law and Policy and former tax and benefits counsel to the Senate Finance Committee: Clearing the air on AHPs

    In Hurricane Relief, 2 out of 3 Ain’t Good

    October 2, 2017

    When it comes to natural disasters, a president is remembered for faltering, not for succeeding.

    By Tevi Troy

    The Wall Street Journal 

    The federal government deserved the rave reviews it earned for its responses to back-to-back hurricanes in Texas and Florida. The Federal Emergency Management Agency worked well with state and local officials and predeployed key resources and personnel. It seemed as though Washington had learned from its failed response to Hurricane Katrina in 2005. Yet as President Trump visits a Puerto Rico devastated by Hurricane Maria, cheers for FEMA have turned to boos. What went wrong?

    First, Puerto Rico is an island. Getting resources in place before landfall was much more difficult than using the Interstate Highway System to move people and supplies. A FEMA official told me that “to say it’s logistically challenging is an understatement.”

    The logistical challenge was compounded by the devastation on the island. The first responders in Puerto Rico were also victims, which meant many were unavailable to help with the response effort. The result is that FEMA must transport supplies as well as distribute them, which is typically a local responsibility and not FEMA’s real expertise.

    In addition, it was harder for the residents themselves to evacuate when planes and boats were the only means of escape. We saw the lines of cars on Interstate 95 headed north from Florida before Hurricane Irma. Such an escape route was not available to Puerto Ricans or Virgin Islanders. At the same time, being cut off from the mainland made it that much harder for Good Samaritans to assist. A Dallas kosher caterer brought badly needed food to observant Jews in Houston who had been subsisting on Chex Mix after Hurricane Harvey. Dallas is 239 miles from Houston. Puerto Rico is only 110 miles wide, and the Virgin Islands even smaller, limiting the geographic range from which those willing to help could come.

    FEMA must learn how to cope with serial disasters. As we saw with Harvey and Irma, post-Katrina reforms in 2006 improved FEMA’s “surge capacity”—its ability to handle more than one disaster at a time or in quick succession. But Texas and Florida are two of the best-prepared emergency-response states, which made FEMA’s job easier. Puerto Rico is less well-equipped.

    Like any government agency, FEMA has limited resources. Its appropriations run out quickly in one disaster, let alone three, requiring a less-than-nimble Congress to vote for disaster funding. And FEMA personnel, who have been doing heroic work, are only human. They are subject to exhaustion when faced with a month of constant deployments and redeployments.

    Finally, there is the issue of presidential focus. While Puerto Rico and the Virgin Islands reel, the president has also engaged in a feud with the National Football League over recent protests—perhaps not the best fight to take on during a series of natural disasters. This was made worse by failing health-care legislation, a new tax-reform effort and the Alabama special election, not to mention continued saber rattling from North Korea. The White House seemed ready for Harvey, but less prepared to cope with a spate of hurricanes for an entire month.

    The lesson here is that presidential leadership is about continued effort in the face of ongoing challenges. As George W. Bush learned with Katrina, you can do a great job in dealing with weather disasters for four years, but the one you falter on is the one for which you’ll be remembered.

    Mr. Troy, a former deputy secretary of health and human services, is author of “Shall We Wake the President? Two Centuries of Disaster Management from the Oval Office” (Lyons Press, 2016).

    How Republicans Might Bring About Single-Payer Health Care

    September 13, 2017

    By Tevi Troy


    The efforts to repeal Obamacare came tantalizingly close to fruition. Republicans succeeded in passing a bill in the House, only to fall just a few votes shy on a different bill in the Senate. But had that hurdle in the upper chamber been overcome, a president in the White House was ready with pen in hand to sign almost any negotiated settlement sent to him by the GOP House and Senate. Instead, Obamacare survived. More than survived. It became politically stronger in the course of the debate and its aftermath, and in the wake of the Republican failure, a more radical measure even more pleasing to the left has suddenly been infused with new life.

    The episode is a case study in the challenge of rolling back the welfare state. Republicans believe as a general rule that government provides too many services and should be pared back—but is there any specific case in which their elected officials are willing to attempt such reforms? If the Republicans could not repeal Obamacare at a time when they hold the House, the Senate, and the White House, and when nearly all of these GOP officials were elected in no small measure on the basis of their personal commitments to repeal and replace Obamacare, when might they ever repeal it—or any large-scale government program? As GOP policymakers ponder what comes next, they might consider the fact that, while they will remain the only game in town when it comes to resisting the growth of government, educated voters are unlikely to accept any future promises that Republicans might make about shrinking government’s size.

    The GOP effort to repeal and replace Obamacare in 2017 was flawed from the start. The Republican leadership on Capitol Hill chose the formal “budget reconciliation” process as the legislative path to force a replacement of the Affordable Care Act. It is the only way a bill can pass the Senate with a simple majority (without having to weather an initial “cloture” vote ending debate on a measure, which requires 60 votes). There are 52 Republican senators, and there was no chance of securing a single Democratic defection. Under these conditions, Republicans needed to be in a state of almost total unanimity in getting rid of the old law and finding another, better approach. It turned out that too many Republicans were too nervous about what might come next to agree to Obamacare’s complete elimination. Meanwhile, there were too many anti-Obamacare stalwarts who would have voted against merely cosmetic Band-Aid fixes to the law to make a face-saving “we’re doing something” a possibility.

    Some critics have argued that the GOP flopped on health care because the party was not prepared for victory in 2016. Preparation was not the problem. House Republicans, under the direction of Speaker Paul Ryan, had been working on an alternative health plan in case the Republicans won the 2016 election. Ryan’s plan, labeled “A Better Way,” stitched together most of the standard Republican reform ideas: a refundable tax credit, expanded Health Savings Accounts, the ability to purchase health insurance across state lines, medical-liability reform, and allowing people to band together to purchase insurance in association health plans. But only some of those policy elements could be passed through the reconciliation process, under which every measure must have a direct budgetary impact on the federal government. The bill that finally succeeded in the House was necessarily a patchwork quilt rather than a comprehensive approach.

    More problematic, and to a degree heretofore underappreciated, were stark differences within the Republican ranks. For the past seven years, Republicans denounced Obamacare, nearly unanimously, and claimed they would repeal and replace it if elected. It was a standard, and immensely popular, talking point in almost every Republican campaign. What is more, Republican leaders in Washington may have assumed that elected officials had signaled implied consent for the Ryan plan. Because there were no official condemnations of it within the GOP caucus before the surprise results of the 2016 election, Ryan and others likely had a false sense that there was consensus among Republican legislators on both repealing and replacing Obamacare. But when the GOP bluff was called by an electorate that handed the Republicans total control, some Republicans blinked, and in sufficient numbers to sink the entire project.

    More discomfiting still, Republicans found themselves unable to make the honest case that passing any of the bills before the House and Senate actually made for good policy. The arguments for the bills tended to center on process and raw politics. Republican legislators were told by their leaders that they needed to pass something because the GOP had promised “action” on health care and that a failure to do so would reveal Republican impotence.

    The bills with which they were presented, however, were impotent themselves in fundamental ways. None of these measures would have done a thing to drive down the cost of insurance premiums in the short term. And as a matter of practical politics, no GOP legislator who wanted to keep his promise could seriously claim that any of the bills would have repealed all of Obamacare.

    It is true that almost all of those who would have had no problem voting for a total repeal did vote for one of the alternatives. But they could not strongly advocate the legislation without looking false or hypocritical. Nor would any of the alternatives drive down the cost of insurance premiums in the short term.

    Meanwhile, Democrats were arguing relentlessly that the Republican bills would end health care for tens of millions, using two studies from the nonpartisan Congressional Budget Office as their battering ram against the GOP. When comparing the number of people “covered” under Democratic and Republican health proposals, Democratic initiatives “cover” more people.

    The CBO’s analysis found that 15 million people would “lose” coverage solely because the GOP bills would have ended the Obamacare “individual mandate”—the law mandating that everyone in the country purchase coverage whether they wish to or not. (Overall, the CBO found that the GOP bills would drop 22–23 million from coverage). The CBO did not take into account the potential impact of cost- and quality-based incentives. Instead, it focused on the linear effect of the federal government’s power to demand that something happen and then make it so. With this as the dominating assumption of their studies, all Republican attempts to incentivize Americans to buy health care by lowering costs and increasing choices were found wanting.

    There is a fundamental flaw to the CBO’s logic. First, people who would have chosen of their own free will not to buy coverage could not properly have been said to have “lost” coverage or have had coverage “taken away” from them. Second, if better coverage at lower prices could result from building a more robust and competitive market, the product itself would generate customers in massive numbers that the CBO’s entirely static analysis could not possibly foresee.

    And yet it is impossible to deny that Republican plans designed to reduce the involvement of the government in health care would result in fewer people receiving coverage from the government. If you are going to subsidize something and require the purchase of that something, you will get more of it. Democrats are willing to spend more, to provide costlier subsidies, to subsidize people at higher levels of income, and to mandate that people purchase coverage. This is what Obamacare did. But in doing so, Obamacare has not provided better care, or affordable care, or even accessible care. Its results have been parlous. But the number of people who report having insurance is unquestionably higher than it would have been if nothing had changed in 2010. And when the argument devolved to the binary question of whose plan would cover more people, the Democrats won.

    Republicans are now scrambling to figure out what, if anything, they can still get done on health care. Some, like Senator Lamar Alexander of Tennessee, are seeking a bipartisan solution that would likely include additional funding for Obamacare subsidies to stabilize its failing state-level exchanges and without significant conservative reforms that would cause Democrats to balk. Some conservatives are looking for another attempt to repeal the ACA, but they lack an explanation for how taking the same approach again would bring about different results.

    While Republicans scramble, Democrats flush with victory will not stand pat in the months ahead. They will take the opportunity created by the GOP’s failure to move aggressively in the direction of single-payer health care on the model of Canada’s or Great Britain’s. Such a system would be more government-directed, more Washington-centric, with less choice, fewer incentives to develop life-saving cures, and more rationing than our current system. But Democrats are optimistic that Obamacare’s many problems, coupled with the Republican failure to deliver on a workable alternative, are creating a path. Liberals may celebrate the salvation of Obamacare, but they know it is unworkable in the long run.

    Furthermore, the way the debate has shifted is smoothing the path to single-payer. If coverage is the ultimate good, a system that “guarantees” coverage with no exceptions will have a leg up in all arguments, regardless of its impact on cost, quality, access, and freedom. The success of Democrats in pushing the coverage issue to the exclusion of all else, combined with a Republican inability to counter the Democratic arguments, has brought us to a point when single-payer is more likely than it has ever been—despite the Republican electoral triumphs over the past seven years.

    Those triumphs mean that Republicans have the presidency through 2020, of course, and control of the House and the Senate through at least 2018. But if Democrats manage to recapture the House, Senate, and White House after the 2020 election—a not implausible scenario given President Trump’s historically low approval ratings—it appears single-payer will be one of their top legislative priorities.

    Democrats have long been wary of single-payer, not so much for ideological reasons, but out of concerns that it was a political loser. In his recent book, Al Franken: Giant of the Senate, Minnesota Senator Al Franken notes that “the simpler solution would’ve been to just go to a national single player plan like Canada’s; Medicare for everyone.” But, he writes, the problem with such an idea in 2009 was that “we needed 60 votes to pass anything, and we were, oh, about 50 votes short.”

    Add to that hesitation the real-world experiences with single-payer in the United States, and you might think Democrats would continue to be wary of it. In 2011, Vermont passed a single-payer plan called Green Mountain Care. Vermont’s Democratic governor pulled the plug on it three years later, citing high costs and the concern that going forward with the plan at that point might have harmed Vermont’s ability to secure a different single-payer plan in the future. In 2016, a single-payer ballot initiative in Colorado went down to defeat. And California’s State Senate recently passed a single-payer bill called Healthy California, only to have it shelved in the State Assembly by Democratic Speaker Anthony Rendon.

    But there is evidence that the tide is shifting. California progressives threatened a recall campaign against Rendon, who subsequently called for hearings on universal coverage to take place this fall. Kamala Harris, California’s newly minted senator, announced at the end of August that she would introduce single-payer legislation—a grandstanding move indicating that her almost-certain 2020 presidential bid will be devoted to the issue. She is trying to get ahead of Bernie Sanders, who has promised to present the Senate with a version of a “Medicare-for-all” measure co-sponsored by more than 100 House Democrats. Sanders said recently that the pursuit of single-payer “is a fight that has to be waged, because it is the only rational solution to the health-care crisis that we face.” Senate Minority Leader Chuck Schumer said on ABC’s This Week “We’re gonna look at broader things: Single-payer is one of them.” Franken’s 2009 pessimism is a thing of the past.

    To be sure, the Democrats still face major obstacles in this regard that go beyond Republican domination of the government. Not only has single-payer been consistently unpopular with American voters, it also faces a host of logistical hurdles. The transition away from our current, admittedly imperfect system would probably be disruptive for millions. Remember this essential fact about our current system: The majority of Americans have employer-sponsored care, and they are, by and large, happy with their coverage.

    A single-payer plan would also be incredibly costly. Even the attendant tax hikes necessary to pay for it would be insufficient to cover the increased costs. California’s aborted plan would have had the government cover premiums, copays, and deductibles. Lack of consumer involvement would mean even more costly health care than we have seen thus far.

    A single-payer plan with more cost controls would cause massive problems of its own. Government-run programs such as Medicare and Medicaid reimburse doctors for their services at lower rates than private-sector insurance does. This is why we frequently hear about doctors refusing to take on new Medicaid patients: It is often not worth their while to accept new patients they are not paid enough to treat. A single-payer system would exacerbate this problem. All doctors would, in essence, become employees of the government. They would be subsumed in a rationing system—in which the care they provide would be governed not by their relationships with patients or their own decision-making but by the rule of the queue. All of this could lead to a wholesale departure of medical professionals from the system, with consequences we cannot begin to imagine.

    Even with all the challenges ahead, the Republican failure to pass any kind of health-care alternative is still a political disaster of the first order. It has left Obamacare in place, stronger politically than it has ever been because it is more popular than any Republican alternative. This is a double whammy: Republicans are now tagged both with advancing approaches no one likes and an inability to get anything done. A recent headline in the Onion may have summed it up best: “Repeated Attempts at Eradicating Obamacare May Have Created Ultra-Resistant Super Law.”

    We are now in a place where Obamacare is the new baseline, and the battle ahead is likely to be over an even more intrusive system. If an effective battle against single-payer is going to be waged, that battle would have to come from Republicans. From what we have seen thus far, it is not at all clear that the Republicans will be able to wage that fight successfully unless they hold on to power indefinitely. What should have been a long-sought GOP triumph has instead brought us closer than ever to single-payer health care, the fondest desire of the American left and the waking nightmare of America’s conservatives.

    Trump’s Reassuring Hurricane Response

    August 29, 2017

    By Tevi Troy, The Wall Street Journal

    President Trump visited Texas Tuesday to assess the damage from Hurricane Harvey and show concern for its victims. So far, his administration is largely getting praise for effective handling of the crisis. Washington’s disaster authorities appear to be in sync with the state on roles and responsibilities; the Federal Emergency Management Agency and its leader, Brock Long, deployed resources as Harvey approached; and the government response as a whole appears well coordinated.

    “I give FEMA a grade of A-plus, all the way from the president down,” Texas Gov. Greg Abbott told “Fox News Sunday.” Yes, Mr. Abbott is a fellow Republican, but he is also interested in protecting Texas and would not have said “A-plus” if the state weren’t getting what it needed. That assessment is backed up by Rear Adm. W. Craig Vanderwagen, a former career emergency manager who is plugged into the Harvey effort. “Early read,” he told me in an email, “is that Executive Branch is performing well under this President.”

    Two reasons suggest themselves for the apparent success: personnel and preparation. Mr. Trump has surrounded himself with leaders experienced in this area. John Kelly, the president’s chief of staff, is fresh off his stint as the secretary of homeland security. He brought to the White House his own deputy, Kirstjen Nielsen, a veteran of George W. Bush’s Homeland Security Council.

    Tom Bossert, another Bush alumnus now advising Mr. Trump on homeland security, has acquitted himself well on television, projecting calm and expertise as he discusses the hurricane response. It may be premature to conclude that Mr. Kelly has succeeded in bringing order to the Oval Office, but Harvey has demonstrated a reassuring ability to focus on a disaster when needed.

    Beyond the White House, Mr. Trump still lags behind his predecessors in filling political appointments, but he appears to have prioritized the right ones. The president has made nominations for about half the slots at the Department of Homeland Security, more than at most departments. Some nominees, such as Mr. Long’s two deputies at FEMA, await Senate confirmation hearings. Mr. Long is an experienced hand, having previously served as Alabama’s head of emergency management. He has been a reassuring and take-charge presence throughout the Harvey response.

    Mr. Long began preparing for the next disaster the day he was sworn in, when he presided over a cabinet-wide tabletop exercise on emergency management. Frank Cilluffo, a homeland security aide in the Bush administration, says this showed the White House was taking disaster readiness seriously. “Training is everything here,” he told me. “You want to make mistakes on the practice field, not in the actual event.” Then in early August, weeks before Harvey showed up on the radar, Mr. Long hosted the president and other cabinet officials at FEMA for a briefing on the coming hurricane season.

    Thus far, the most controversial part of the president’s hurricane response has been communications. On the positive side of the ledger, Mr. Trump has used his vast Twitterfollowing both to provide useful information and to convey that the White House is actively monitoring events. On Tuesday he retweeted an urgent alert from Brazoria County saying that a levee at Columbia Lakes had been breached and residents needed to get out immediately.

    Mr. Trump’s tweets about the storm have been informative and responsible, with a tone appropriate to the human tragedy. To the extent he has been criticized, it has been mostly for tweeting on unrelated topics, such as his pardoning of former Sheriff Joe Arpaio and the “great” new book by Sheriff David Clarke. Although it isn’t realistic to expect the White House to eschew all other subjects during a crisis, perhaps the president could avoid tweeting about unessential matters until the storm passes.

    Outside Twitter, the administration has relied on experts like Messrs. Long and Bossert to reassure the public, which seems an appropriate strategy. Message discipline matters. When responding to a disaster, Mr. Cilluffo says, you “can’t have one message here, another message there, and a tweet saying a third thing.”

    It’s reassuring that the White House understands the importance of relying on trusted messengers during a crisis—especially given the backlash to Mr. Trump’s comments this month after the violence in Charlottesville, Va. During an emergency, the government needs wide cooperation from the public, which may not be possible under any president with credibility problems. Messrs. Long and Bossert have the standing to appeal to Americans across the partisan divide during Harvey and whatever disaster may come next.

    Mr. Trump’s handling of the hurricane response thus far is to be commended, but this is no time for complacency. The recovery in Texas will take a long time, and new disasters are always in the offing. The Trump administration would serve Americans well by following its successful approach to this first crisis with a continuing focus on disaster management. Today it’s Harvey. Tomorrow, who knows?

    Mr. Troy, a former deputy secretary of health and human services, is author of “Shall We Wake the President? Two Centuries of Disaster Management from the Oval Office” (Lyons Press, 2016).

    Appeared in the August 30, 2017, print edition. 

    How Republicans Can Fix Obamacare Now

    August 1, 2017


    Lanhee J. Chen is a research fellow at the Hoover Institution and director of domestic policy studies in the public policy program at Stanford University. Tevi Troy is a former deputy secretary of health and human services and author of “Shall We Wake the President?: Two Centuries of Disaster Management From the Oval Office."

    The failure of Senate Republicans to pass even their “skinny” repeal bill is a serious disappointment to critics of the Affordable Care Act. Despite campaign rhetoric suggesting otherwise, “repeal and replace” of the ACA is something Republicans are apparently unable and likely unwilling to do. The only silver lining for conservatives is that the failure has demonstrated what the political market will bear when it comes to changes to the law.

    Even if Republicans had succeeded in their recent efforts, skinny repeal would have come nowhere close to solving the problems that plague our health-care system, especially rising costs and declining choices. Of course, the ACA also failed to solve those problems and in many ways exacerbated them. Republicans — hopefully working with Democrats — should not give up on reform that would lower costs, improve quality and ensure more widespread adoption of exciting health-care innovations. The recent failed effort highlights what some of these reforms might be.

    On the legislative front, there are several rifle-shot provisions that could be attached to must-pass pieces of legislation, such as continued funding for the Children’s Health Insurance Program. The Congressional Budget Office estimates that medical liability reform could save almost $50 billion over 10 years. And allowing the purchase of insurance across state lines would help expand insurance markets, consequently, improving options for consumers in states burdened by heavy insurance mandates. Republicans could also eliminate the Independent Payment Advisory Board, a government body that has drawn bipartisan criticism for the extraordinary power it has to make significant cuts to the Medicare program.

     Beyond legislation, the Trump administration can improve the ACA through the regulatory process. As Health and Human Services Secretary Tom Price has said: “There are 1,442 citations in the Affordable Care Act where it says, ‘The Secretary shall .?.?.’ or ‘The Secretary may .?.?.’” That gives the administration significant flexibility to shape the law how it chooses. Price should use that authority to promote choice in insurance marketplaces, enhance innovations in state Medicaid programs and advance policies that help to lower premiums for more Americans.

    On the Medicaid front, Republicans typically put a lot of faith in state innovation and the ability of federal authorities to work with governors to expand coverage and lower costs. Now, it is up to federal officials to make sure that these experiments lead to results. That means working with both Republican and Democratic governors to address continuing challenges around coverage and, more important, fiscal sustainability.

    The Trump administration can also work with states that are interested in taking advantage of the innovation waivers in Section 1332 of the ACA, which allow states to fashion health reforms that suit their citizens best. The Obama administration placed significant constraints on what it would take for states to get these waiver requests approved. Trump could take a different course by issuing regulatory guidance that makes clear it is open to a wide variety of state-based approaches to lowering costs, expanding choices and ultimately increasing coverage.

    Finally, the challenges of policymaking in the current environment highlight the need to go beyond government for solutions. The legislative experiences of the past decade — both the failed skinny reform and the ACA alike — have taught us that Congress is not the best medium for promoting innovation in health care. It is too bogged down in partisan politics and less concerned with evidence of what works to bring about real payment reform. Medicare and Medicaid should instead look to the private sector for innovations in care delivery.

    Employer-sponsored plans, which cover the largest share of Americans, can provide guidance on customer satisfaction and the incorporation of new technologies, areas in which government-run plans are often lacking. Similarly, the Centers for Medicare & Medicaid Services usually sends signals to the private sector regarding which new therapies should be covered. We’d be better off if the government took signals from the private sector about what works.

    Moving forward will be difficult, as recent congressional debate has shown. But the Senate’s failure should not mean the end of GOP efforts to improve health care. Already, progressives across the country — including Senate Minority Leader Charles E. Schumer (D-N.Y.) — are opening the door to a single-payer health-care system. If Republicans are unable to use the tools at their disposal, a government-run health-care system will move from being a liberal pipe dream to a realistic possibility. 

    Opioid Abuse Is a Public Health Crisis—Here’s How Trump Can Beat It

    May 30, 2017

    The Observer

    A look to see how FDR, JFK and Reagan defeated polio, smoking and AIDS

    By Tevi Troy 

    The Trump administration has created a commission, led by New Jersey Gov. Chris Christie, to address the opioid crisis, which killed over 30,000 Americans in 2015. In crafting its recommendations, the commission should look to lessons from previous presidents. During the 20th century, three presidents faced major public-health crises: Franklin Roosevelt and polio, John F. Kennedy and smoking, and Ronald Reagan and HIV/AIDS.

    Of these presidents, FDR is most closely associated with his. This is, of course, because Roosevelt himself was a polio victim. Polio first appeared in the United States in 1894, but didn’t become a recurring problem until the 1940s and the early 1950s, when it crippled about 35,000 people annually. The disease hit its peak in 1952, with a record 57,628 polio cases. The numbers themselves, however, do not convey the full intensity of the crisis, which panicked millions of parents and children alike.

    As president, Roosevelt took a philanthropic approach to dealing with polio. He helped create a series of “Birthday Balls” to raise money for victims. The first ball, in 1934, raised $1 million for the Georgia Warm Springs Foundation. In 1944, he used martial language to speak to the nation about a war on polio and made an explicit analogy to the nation’s ongoing efforts in World War II: “The dread disease that we battle at home, like the enemy we oppose abroad, shows no concern, no pity for the young.”

    Donations to the National Foundation for Infant Paralysis went to good use. A 1943 grant from the NFIP to the U.S. Army Neurotropic Virus Commission helped provide funding for Albert Sabin, who created the oral polio vaccine. The vaccine changed everything: The 14 years from 1937 to 1950 saw about 230,000 cases of polio in the U.S., which is about the number of cases that would appear over the next 50 years.

    According to FDR biographer Conrad Black, the development of the vaccine stood as “Roosevelt’s ultimate victory over his illness.” Roosevelt’s use of his stature and his own considerable communications talents constituted a successful and largely non-government focused approach to a severe public-health crisis.

    As for smoking, in 1962, President Kennedy directed Surgeon General Luther Terry to create an Advisory Committee on Smoking and Health to consider the health effects of smoking. The committee’s report, which came out after Kennedy’s tragic assassination in Dallas, found that smoking was deleterious to one’s health and even specified a 70 percent increase in mortality among smokers over non-smokers. These were such controversial findings that Terry timed the release of the report for a Saturday, to minimize the report’s impact on the stock market.

    Official U.S. government policy since then has been to oppose smoking. In 1965, Congress approved a warning label on cigarettes. Beginning in 1970, the warning was issued in the name of the surgeon general. Since 1970, the government has banned tobacco advertising on both TV and radio, and the campaign against smoking has been an ongoing priority for the surgeon general. The government’s anti-smoking efforts have had a real impact. In 1964, over half of U.S. men—52.9 percent—smoked, along with 31.5 percent of women. By 2014, smoking had dropped to 16.8 percent of all U.S. adults—18.8 percent of men and 14.8 percent of women.

    A third public health crisis was HIV/AIDS, which killed 19,000 New Yorkers in the 1980s and about 698,000 Americans overall. Ronald Reagan, who was president during the crisis’ early years, had long been criticized for his hands-off approach to the crisis. Spending on HIV/AIDS research increased under Reagan’s watch: The U.S. government spent over $5.7 billion on HIV/AIDS under Reagan. Columnist Deroy Murdock observed that “Reagan’s signature inaugurated federal action on AIDS research and treatment.”

    In addition, Reagan’s Surgeon General C. Everett Koop was outspoken on AIDS. And as early as 1983, Health and Human Services (HHS) Secretary Margaret Heckler visited a dying AIDS victim in the hospital and held his hand, a gesture that demonstrated both compassion and made the point that the disease was not communicable through incidental contact. In 1986, Reagan visited HHS and said, “One of our highest public health priorities is going to be continuing to find a cure for AIDS.” In April 1987, he declared AIDS to be “public health enemy number one.”

    This brief history teaches us some lessons for presidents interested in taking on public health crisis. It is important to recognize expectations placed upon government have increased. To be sure, Roosevelt advocated for polio research, but instead of mobilizing an entire government, he promoted donations for research. With respect to smoking, Kennedy’s administration got involved slowly at first but led the way for future government-wide efforts. With AIDS, Reagan’s critics denounced him for his apparent indifference, but he and top aides spoke out on the issue and his administration allocated significant amounts of money toward combating the disease.

    Another lesson is how public-health issues have become politicized over time. If FDR were alive today, polio advocates would likely criticize him for devoting insufficient government resources to the disease and for failing to highlight his own paralysis. Today, everything can and will be viewed through a political lens.

    A workable approach to a public health crisis such as opioids calls for an appropriate level of presidential rhetoric and action in the form of government resources and activity. A president’s personal commitment to an issue is important in that it ensures that the issue will be prioritized throughout the bureaucracy. Finally, presidential leadership is important, but governmental response should be set up to continue beyond one administration. Government messaging can have a big impact on behavior, but it must be sustained over the long term. 

    No one of these strategies is a silver bullet. Taken together, however, a president can use them to follow in the footsteps of predecessors like Roosevelt, Kennedy, and Reagan who have taken on, and in some cases defeated, even more trying public-health challenges.

    Presidents and Public-Heatlh Crises

    April 28, 2017
    National Affairs, Spring 2017 Edition

    By Tevi Troy


    Over the course of the 20th century, the United States faced three major public-health crises: the polio epidemic, excessively high smoking rates, and HIV/AIDS. Each of these crises took place over a multi-year period, and multiple presidents dealt with both their effects and the national response to them. Nonetheless, certain presidents came to be specifically identified with each of these crises: Franklin Roosevelt and polio, John F. Kennedy and smoking, and Ronald Reagan and HIV/AIDS.

    Each crisis posed quite different challenges. In polio and AIDS, the nation faced terrifying and mysterious diseases that required the mobilization of the private and public sectors toward finding cures and disseminating accurate information. With smoking, new information revealed secret dangers lurking in a popular product previously thought to be harmless; and, while the news saved millions of lives, it posed an immediate threat to the national economy. Each health crisis came with its own rhetorical challenges as well, beyond just raising awareness. And, with each new public-health crisis, each of these presidents faced a public with growing expectations about the government's responsibility for solving the problem.

    As the United States grapples with its latest public-health crisis — obesity — there is much to learn from the national responses to polio, smoking, and HIV/AIDS. Though Roosevelt, Kennedy, and Reagan all faced different challenges, how they handled the crises is instructive for determining how the U.S. has dealt with public-health crises in the past, and for determining how to address new public-health challenges in the future.


    Of the three presidents who came to own the public-health crises in question, FDR is most closely associated with his, that of polio. This is, of course, because Roosevelt himself was a victim of the dread disease, coming down with it in 1921 at the age of 39 at his vacation home in Campobello. FDR's doctor, W. W. Keen, paid a house call and misdiagnosed the illness — twice — and then charged Roosevelt $8,000 for the misdiagnoses. The illness paralyzed Roosevelt's lower body.

    Roosevelt became president despite his illness. While today we associate Roosevelt with polio, it is important to remember that Roosevelt worked hard to make sure that the voting public did not know the full extent of his condition. As David Blumenthal and James Morone put it, "FDR's public life after polio focused on denying his illness." We can see how successful he was in this effort by the fact that Roosevelt, despite being one of the most frequently depicted presidents on the silver screen, was never shown in a wheelchair as president until the musical Annie was adapted for film in 1982. For non-musical depictions, movie fans would have to wait until the 2001 film Pearl Harbor to see FDR as a wheelchair-bound president.

    Polio was devastating not just to Roosevelt, but to the entire nation. Polio first appeared in the United States in 1894, but didn't become a recurring problem until the 1940s and the early 1950s, when it crippled about 35,000 people annually; the disease hit its peak in 1952, with a record 57,628 polio cases. The numbers themselves, however, do not convey the full intensity of the crisis, which panicked millions of parents and children alike every year.

    As president, Roosevelt took a philanthropic approach to dealing with polio. By the time he moved into the White House, he had already started a foundation in 1927 in Warm Springs, Georgia, run by his colleague Basil O'Connor. Roosevelt had discovered the restorative powers of the warm springs for polio sufferers and became an evangelist for their use. Once Roosevelt became president, he worked with O'Connor to begin a series of "Birthday Balls" to raise money for polio victims. The first ball took place on Roosevelt's birthday in 1934 and raised $1 million for the Georgia Warm Springs Foundation. Four years later, Roosevelt created a new charity, the National Foundation for Infantile Paralysis. The annual Birthday Balls helped to fund the newly formed NFIP, as did its grassroots fundraising campaign, the March of Dimes. (The NFIP eventually adopted the name of its popular fundraiser.)

    Roosevelt used his presidential pulpit to promote his philanthropic efforts on polio. In January of 1944, he used martial language to speak to the nation about a war on polio, and made an explicit analogy to the nation's ongoing efforts in World War II: "The dread disease that we battle at home, like the enemy we oppose abroad, shows no concern, no pity for the young." Despite the strong words, Roosevelt's request was for donations, not military sign-ups. As Roosevelt put it, "The generous participation of the American people in this fight is a sign of the healthy condition of our Nation."

    In Roosevelt's case, his use of the radio to promote the fight against polio was a sign of how seriously he took the disease. This was before the days of the president's weekly radio address. Roosevelt, despite being known as a master of radio, took to the airwaves relatively infrequently, in an effort to avoid overexposure. Even his famous Fireside Chats, which revolutionized the political use of radio, usually only took place two or three times a year. If Roosevelt was using one of those rare opportunities to promote polio research, it showed that combating polio was one of his top priorities.

    The March of Dimes recognized the importance of Roosevelt's efforts to its success. In an official history, March of Dimes notes that "efforts to launch the March of Dimes were boosted by radio, Hollywood, and the personal appeal of the president." And the March of Dimes put its funds to good use. A 1943 grant from the NFIP to the U.S. Army Neurotropic Virus Commission for studying polio in North Africa helped provide funding for researcher Albert Sabin. Sabin would go on to create the oral polio vaccine, which followed the discovery of the original polio vaccine in 1952 by Jonas Salk, himself a March of Dimes grantee.

    O'Connor announced the discovery of the polio vaccine on the 10th anniversary of Roosevelt's death. According to FDR biographer Conrad Black, the development of the vaccine stood as "Roosevelt's ultimate victory over his illness." In addition, according to Black, Roosevelt's fundraising on behalf of polio research was so important that the discovery "would not have occurred, at least until decades later, without him." Roosevelt's use of his stature and his own considerable communications talents constituted a successful and non-government focused approach to a severe public-health crisis. March of Dimes also helped fund distribution of the vaccine, and in 1955 President Dwight Eisenhower announced plans to help states fund distribution of the polio vaccine.

    Creation of the vaccine changed everything when it came to polio. The 14 years from 1937 to 1950 saw about 230,000 cases of polio in the U.S., which is about the number of cases that would appear over the next 50 years. In recent years, polio has become even more infrequent. Naturally occurring polio has not appeared in the U.S. since 1979, and that case occurred within the vaccine-skeptical Amish community. The NFIP quickly became obsolete, so the organization changed its name and its mission; the March of Dimes now focuses on birth defects.


    Rarely does a public-health campaign ever so completely eradicate a public-health threat as was the case with polio. But there have been instances of public-health campaigns reducing threats, and even changing societal behavior. In 1962, for example, President Kennedy directed Surgeon General Luther Terry to create an Advisory Committee on Smoking and Health. This effort came in response to a 1961 letter to Kennedy from the American Cancer Society, the American Heart Association, the National Tuberculosis Association, and the American Public Health Association asking him to look into the health effects of smoking. The committee, comprised of 10 expert scientists, met nine times over the next two years to review the scientific evidence regarding smoking.

    The committee's report came out in 1964, the year after Kennedy's tragic assassination in Dallas. The report found that smoking was deleterious to one's health, and even specified a 70% increase in mortality among smokers over non-smokers. At the time, these were controversial findings. Terry intentionally timed the release of the report for a Saturday, so as to minimize the report's impact on the stock market. Even so, Terry recalled, the report "hit the country like a bombshell. It was front page news and a lead story on every radio and television station in the United States and many abroad."

    As a result of the committee's report, official U.S. government policy since then has been to oppose smoking, and it has done so in a variety of ways. In 1965, Congress approved a warning label on cigarettes. Beginning in 1970, the warning was issued in the name of the Surgeon General. And since 1970, the government has banned tobacco advertising on both TV and radio. Furthermore, the campaign against smoking has been a continual effort of the office of the Surgeon General, with some Surgeons General, particularly Dr. C. Everett Koop under Ronald Reagan, making anti-smoking efforts their signature cause.

    The government's anti-smoking efforts have had a real impact. In 1964, the year of the initial Surgeon General report warning of the dangers of smoking, over half of U.S. men — 52.9% — smoked, along with 31.5% of women. By 1970, when the advertising bans went into effect, those numbers had dropped to 42.3% for men and 30.5% for women. By 2014, according to the Centers for Disease Control, smoking had dropped to 16.8% of all U.S. adults, 18.8% of men and 14.8% of women.

    Even with these dramatic behavioral shifts, tobacco smoking continues to have a real health impact in the United States. Almost 40 million Americans still smoke, mostly among the young and the poor. According to the CDC, smoking still causes over 480,000 U.S. deaths annually — one of every five deaths. The economic impact of smoking remains considerable as well: more than $300 billion annually, split between nearly $170 billion in medical costs and $156 billion in lost productivity. Still, these figures would have been much higher without the concerted effort by the United States government over the last 50 years to reduce smoking, an effort stimulated by that letter to President Kennedy in 1961.


    During President Reagan's tenure, the United States was dealt another public-health crisis: HIV/AIDS. Unlike smoking, which had long been on the agenda of public-health organizations, HIV/AIDS caught America and the world by surprise. Throughout the 1980s and early 1990s, HIV/AIDS cases and annual deaths skyrocketed, from 451 deaths in 1981 to 50,628 in 1995. The mysterious and fast-moving illness shocked people, and devastated entire communities. Over 19,000 New Yorkers alone died of AIDS-related causes in the 1980s. Overall, about 698,000 Americans have died from AIDS, more than the 675,000 deaths from the Great Influenza of 1918.

    The surprise emergence of AIDS created considerable controversy about whether the U.S. did enough to combat it in its earliest years. In a piece written shortly after Reagan's death, the New York Times' Robin Toner and Robert Pear wrote that "Advocates for people with AIDS have long asserted that Mr. Reagan's lack of leadership on the disease, which was first reported by the Centers for Disease Control in 1981, significantly hindered research and education efforts to fight it." Randy Shilts, whose 1987 book And the Band Played On helped establish the image of a Reagan disengaged or even hostile to combating AIDS, wrote that "Reagan had never publicly spoken the word AIDS or ever alluded to the fact that he was aware that an epidemic existed." After Nancy Reagan's March 2016 death, Hillary Clinton was blistered by the left for even suggesting that President and Mrs. Reagan "started a national conversation" about AIDS in the 1980s.

    Others have made the case against Reagan on HIV/AIDS far less judiciously. AIDS advocate Larry Kramer has called the 40th president "Adolf Reagan," and said that "the world would have been better off if he [Reagan] had not been president." Building on his Hitler theme, Kramer has called Reagan "a monster and, in my estimation, responsible for more deaths than Adolf Hitler." According to the pro-Reagan author Steven Hayward, "Leftist attacks on Reagan over AIDS would come to compete with civil rights agitators to reach the furthest hyperbole." Historian Gil Troy, who has acknowledged that "President Reagan was slow to address the [AIDS] issue," has also decried the unfortunate phenomenon of "AIDS activists accusing the Reagan administration of complicity in a gay genocide."

    The case against Reagan on AIDS is well known. But does it correspond to the reality? According to Gary Bauer, the Reagan domestic-policy aide often painted as the villain in this saga, U.S. spending on HIV/AIDS research increased under Reagan's watch, and Reagan's relative silence on the issue stemmed from his philosophical belief in cabinet government, in which the Surgeon General should lead the charge on public-health issues. On the first point, funding definitely increased, as the U.S. government spent over $5.7 billion on HIV/AIDS under Reagan, a level that would later be designated as "disproportionate" in relation to other diseases. The columnist Deroy Murdock looked into the dramatic increases in AIDS funding under Reagan and concluded that "Reagan's signature inaugurated federal action on AIDS research and treatment" (emphasis in the original).

    On the second point, Surgeon General Koop was indeed outspoken on AIDS. In addition to smoking (as discussed above), Koop also made a big splash with his statements on AIDS. However, according to journalist Carl Cannon — son of top-notch Reagan biographer Lou Cannon — "Contrary to the prevailing wisdom, Reagan dragged Koop into AIDS policy, not the other way around."

    Furthermore, Reagan may have been slow in getting a complete handle on AIDS, but he was not alone, and he was not shy about the issue once he caught on. According to Richard Reeves, contrary to suggestions Reagan was unaware of the issue, "he obviously did know about the AIDS debate going on in the White House" in 1986. In early 1986, he visited the Department of Health and Human Services — a relatively rare step for a president — and told staffers there that "one of our highest public health priorities is going to be continuing to find a cure for AIDS." The next spring, in April 1987, he declared AIDS to be "public health enemy number one."

    Regardless of one's thoughts on Reagan and AIDS, it is important for backers and critics alike to remain in the realm of fact on the issue. For example, the oft-repeated canard that Reagan did not mention AIDS for seven years is just plain false. According to Carl Cannon, Reagan first mentioned AIDS in 1985, four years into his term. Furthermore, Bauer's role as the villain is overstated and inaccurate, given that he did not even become White House domestic-policy advisor until 1987. In addition, as early as 1983, HHS Secretary Margaret Heckler visited a dying AIDS victim in the hospital and held his hand, a gesture that demonstrated both compassion and made the point that the disease was not communicable through incidental contact.

    The point is not that Reagan was some kind of far-sighted visionary in dealing with AIDS. Not even his strongest partisans would make that case. However, what we have seen in the evolution of government responses to public-health crises is the degree to which, as in so many other areas, expectations placed upon government have increased. Roosevelt advocated for polio research, to be sure, but he did not mobilize an entire government to fight the disease. He instead promoted private-sector charitable research. With respect to smoking, the government got involved slowly at first, perhaps too slowly, and was even tentative in the release of that first Surgeon General's report because of the possible impact it could have on the stock market. With AIDS, however, Reagan's critics denounced him for his apparent indifference, and for not spending enough, even though he did speak on the issue and allocated significant amounts of money toward combating the disease.

    Another lesson is how public-health issues have become politicized over time. If FDR were alive today, it is possible, perhaps even likely, that polio advocates would criticize him for devoting insufficient government resources to the disease, and for failing to use his own paralysis to advance the cause of polio eradication. The attacks against Reagan on AIDS were a product of a far more political era, and should give pause to future presidents in dealing with the public-health crises of the future. Everything can and will be viewed through a political lens, and the expectations of government action will be far higher than they have been in the past. Studying history is usually a useful tool for dealing with a new phenomenon. In the world of public-health crises, however, the old playbooks clearly will not be sufficient to counter the critics and to meet the populace's mounting expectations.


    Obesity, America's most prevalent public-health crisis today, is the flip-side of what has until recently been seen as one of this country's great advantages. In the classic 1954 work People of Plenty, historian David Potter identified economic abundance as one of the essential characteristics of the American experiment. We now face a situation in which cheap and plentiful food, combined with the diminution of physical labor and the increase of passive forms of entertainment — TV, movies, computers, and video games — has led to an obesity epidemic. According to the CDC, "American society has become 'obesogenic,' characterized by environments that promote increased food intake, nonhealthful foods, and physical inactivity."

    The American Heart Association reports that about one in three American kids and teenagers is overweight or obese, a rate that tripled from 1971 to 2011. As of 2014, the figure remains almost constant at 33.2%, according to the CDC.

    While the causes of the epidemic are complex, the existence of the epidemic is undeniable. Over two-thirds of Americans are now considered overweight or obese, and this presents significant challenges to American policymakers. Given the relative novelty of the problem, we have little experience from previous legislators who have dealt with it. The experiences of FDR with polio, Kennedy with smoking, or Reagan with HIV/AIDS can provide some (but not enough) help to future presidents facing this new kind of crisis.

    Although the obesity problem has certainly worsened in recent years, it has been imposing significant costs for a long time. According to a study by Anne Wolf and Graham Colditz, obesity costs amounted to $99.2 billion in 1995, of which $3.9 billion stemmed from lost productivity, reflecting 39.2 million lost days of work. Loss of productivity has become an even more acute problem since then. An analysis by Eric Finkelstein, Marco daCosta DiBonaventura, Somali Burgess, and Brent Hale estimated the cost of obesity among full-time employees to be $73.1 billion, which they found to be "roughly equivalent to the cost of hiring an additional 1.8 million workers per year at $42,000 each," about the average annual wages of U.S. workers.

    Clearly, many individuals are willing to accept the personal and financial costs of obesity, and the U.S. political system may be willing to digest the economic costs of obesity. However, one frequently under-examined aspect of obesity is its impact on America's ability to shape world events and, more frighteningly, defend itself from harm. This was a concern raised in 2010 by Generals Hugh Shelton and the late John Shalikashvili when they asked, "Are we becoming a nation too fat to defend ourselves?" Shelton and Shalikashvili worried that the U.S. will have trouble finding future recruits for its all-volunteer military, especially since the Army found 27% of Americans in prime years for military recruitment — 17 to 24 — were "too overweight to serve in the military." In fact, they note, "being overweight or obese has become the leading medical reason recruits are rejected for military service," as the proportion of recruits who failed physicals due to their weight has risen by almost 70% since 1995. Add all of this up, they say, and "[o]besity rates threaten the overall health of America and the future strength of our military."

    If there were ever a public-health crisis that called for a government-sponsored intervention, this would seem to be it. But despite the near-universal and bipartisan agreement that obesity is a problem, our presidents have thus far been unable to address the problem in a meaningful way, let alone begin to solve it. The reasons for this failure, as with the reasons for the underlying problem, are varied, but they do not diminish the need to find a workable public-policy solution.

    We have in recent years seen presidents of both parties jump into this issue and try to use the bully pulpit to alleviate the situation. President George W. Bush not only led by example by maintaining excellent physical health, but he also directed HHS to start an obesity initiative and promoted healthy eating and exercise from the White House bully pulpit. The HHS initiative, led by Secretary Tommy Thompson, included a Food and Drug Administration report on the size and scope of the problem, and recommendations that included increasing evaluation and scrutiny of food labels, encouraging manufacturers and restaurateurs to provide more guidance, improving research on causes and fixes of obesity, updating FDA guidance on weight-control products, and improving messaging regarding obesity.

    The Obama administration followed suit in this regard, and made combating obesity one of First Lady Michelle Obama's signature initiatives. In February of 2010, she launched "Let's Move!," a campaign designed to end obesity in a generation. Although she acknowledged that the goal was ambitious, she implicitly noted that previous efforts had not seen much success, telling USA Today that "We've got to stop citing statistics and wringing our hands and feeling guilty, and get going on this issue."

    Although the "Let's Move" rhetoric may have been more ambitious than previous attempts to address obesity, the litany of familiar activities consisted of a "multifaceted campaign that will include more healthful food in schools, more accurate food labeling, better grocery stores in communities that don't have them, public service announcements and efforts to get children to be more active."


    Given the challenges of coming up with anti-obesity proposals that are effective, not overly prescriptive, of manageable cost, and not divisive, policymakers face a relatively narrow band of options. As public-health experts Jeff Stier and Henry Miller write, "We are as concerned as anyone about obesity's effects on public health, but we believe that governmental, taxpayer-funded approaches to it should be evidence-based, cost-effective and non-authoritarian."

    If the approaches taken thus far are unlikely to solve the obesity crisis (as seems to be the case), President Trump and his successors will have to come up with a new range of options. Having the president get the rhetoric right on obesity will be essential to ensuring that we can beat back this problem.

    On the substantive side of things, Arizona has proposed an innovative approach that calls for an annual Medicaid surcharge for "obese people who don't follow a doctor-supervised slimming regimen." Unfortunately, this strategy will not promote positive health behaviors in all cases, especially among the very poor. Still, it makes sense that the government should begin to take at least a small step in the direction of incentive-based approaches.

    Presidents have a great deal of power in the regulatory space, and they should use that power in the fight against obesity. These efforts should take place in arenas where the government has the most leverage — specifically, where the government is footing the bill. According to the Manhattan Institute's David Gratzer, two areas that come to mind are subsidized agribusiness and school nutrition programs, where the federal government spent a combined $19.3 billion in 2009. With respect to the $9.5 billion for agribusiness subsidies, a report that compared government subsidies of junk food and of fresh fruit found that junk food gets the better end of the bargain. The report found that, of the 37 ingredients that go into Twinkies, "at least 14 of them are made with federal subsidies, including corn syrup, high fructose corn syrup, corn starch, and vegetable shortening."

    In addition, the federal government provides $9.8 billion for school lunches, giving the government significant leverage in determining the content of these lunches. Per Gratzer, we can take a bite out of obesity by cutting or reducing agribusiness subsidies to end the use of "taxpayer dollars to produce and market unhealthful foods," by imposing limitations on high-fat foods, and by issuing stricter food guidelines for government-subsidized school lunches. Indeed, as first lady, Michelle Obama championed the Healthy, Hunger-Free Kids Act, which set ambitious goals for better nutrition in schools, though those efforts have met with mixed results.

    Some proposals have gone too far, however, threatening to destroy or prevent the development of consensus on how to address the obesity issue. One such proposal suggests that states put dangerously obese children into foster care to protect them from poor parenting. There has been at least one real-life example of this: In October 2011, a 200-pound Ohio third grader was placed into foster care, and a county spokeswoman cited "medical neglect" as the reason for the child's removal. National Review's Jonah Goldberg characterized his objection to the proposal as follows: "I don't trust these people. Once you establish the idea that the state can take away kids from loving parents because the state thinks they're not good parents, you really are off to the races."

    The alternatives listed above may not go as far as some obesity experts would like. Taxing "bad" food, banning certain food additives or substances, or even placing obese children in foster care seem to be on the agenda of public-health experts. While these kinds of suggestions may make for interesting thought experiments, they are not realistic from a political or a commercial perspective. The fact remains that presidents of the future will have to face the obesity challenge in a world of constrained resources and sclerotic politics. Given this situation, future presidents should look to a series of less costly, more realistic policy recommendations in order to start turning back the tide of obesity. In addition to evaluating alternatives, though, presidents must have the will and the wherewithal to carry out these policies, regardless of political challenges.


    Fighting obesity, or handling any public-health crisis, requires the use of a limited presidential playbook. Even if a president engages in the rhetorical, regulatory, research, and fiscal steps outlined above, so much of the work in fighting obesity, like all public-health crises to a greater or lesser degree, takes place at the individual level. Diet and exercise are, of course, the most important steps that an individual must take in this regard. So any first step at addressing obesity at the individual level must incorporate a healthy diet and regular exercise.

    Beyond diet and exercise, individuals have a number of other options for combating obesity. Finding effective obesity treatments remains one of the biggest challenges to both the medical and scientific communities to date, and more options will increase the number of weapons available. The existing options for supplemental obesity intervention are primarily in three categories: pharmacological, surgical, and psychotherapeutic. All three employ relatively new methods or technologies, which demonstrates that one of the keys to solving the obesity puzzle will be humanity's continued ingenuity in finding technological solutions to knotty and contentious problems. At the same time, all of them involve real costs which must be borne by individuals, companies, the government, or a combination of the three.

    Our obesity problem has serious consequences for our health, our economy, and our national security. These problems, already significant today, appear likely to worsen in the future unless we begin taking steps to stem the tide of obesity and work toward becoming a healthier, more fit society. Unfortunately, no president has yet initiated an effective anti-obesity strategy, and it does not appear likely that our new president will do so either. Furthermore, our perilous fiscal state, combined with our hyper-partisan and divisive political situation, creates severe limitations on the options available even for presidents interested in addressing obesity. For this reason, any realistic solution to our obesity problem needs to include a menu of reasonable, non-partisan, effective, and affordable alternatives.

    For presidents, a workable approach calls for an appropriate level of rhetoric, better leveraging of existing government funding and subsidies to manage behavior on a large scale, and promotion of informed individual behaviors, as well as the use of effective individual therapies to help people cope with weight issues. No one of these strategies is a silver bullet that can solve our obesity problem. Taken together, however, a president can use them to follow in the footsteps of predecessors like Roosevelt, Kennedy, and Reagan who have taken on, and in some cases defeated, even more trying public-health challenges.

    Tevi Troy is a presidential historian, former White House aide, and ex-Deputy Secretary of Health and Human Services. He is the author of Shall We Wake the President? Two Centuries of Disaster Management from the Oval Office (Lyons). 


    Getting a Better Return on Our Health Dollars

    February 15, 2017

    The Ripon Forum

    Volume 51, No. 1, February 2017

    by TEVI TROY

    The U.S. spends more on health care than any other developed country – 50 percent more per capita than the next highest OECD country. The average American pays over $9,000 for health care each year – more than twice the average of other developed nations – and yet the life expectancy of the average American ranks 42ndin the world.

    For all of our health spending, the average American can expect a shorter lifespan than the average Frenchman, Swiss, or Swede.  Over 17.5 percent of our GDP goes to health care, up from only about 5 percent of GDP devoted to health in 1960.  We are clearly spending a great deal on health care and not getting the results we should, particularly given the enormous size of our investment.

    In addition to the lack of sufficient return on our health care spending, there is also the fact that we are spending at an unsustainable rate.  Consider the following: In 2025, Medicaid costs are expected to surpass $1 trillion per year, and the worker to retiree ratio will dip below 3:1.  In 2029, all of the baby boomers will have reached the standard retirement age of 65.  And in 2030, the Medicare Hospital Insurance trust fund is scheduled to be depleted. Clearly, fixing our health care spending situation is not just an issue of getting better results, but also essential for our economic security.

    With the recent election of a Republican president, along with a GOP House and Senate, Republicans have a chance to change this trajectory. Doing so will not only help generate much-needed better health outcomes, but could also stave off a looming fiscal crisis based on our enormous and unsustainable health care spending.  Addressing this problem will take a multi-pronged strategic approach.

    First, we need to address the problem of waste in our health care system.  Medicare waste is estimated to be around $60 billion per year.  The Obama administration claimed to go after “waste, fraud, and abuse” as part of the Affordable Care Act, but in reality clamped down on Medicare Advantage, a popular program that gives choice to seniors.  What we really need is a more aggressive anti-fraud effort by the new Trump Administration that uses tools like biometric screening of recipients and secret shoppers to root out rampant fraud.

    Second, the replacement of Obamacare with a more consumer-friendly system will go a long way towards reducing costs and bringing down overall health care spending.  The Obamacare approach was to increase costs for all, make insurance mandatory, and provide costly subsidies for a select few.  A better way is to try to reduce costs across the system, and thereby incentivize individuals to purchase coverage on their own.  Elements of such a plan include: expanding access to consumer-directed health arrangements like health savings accounts; allowing the purchase of tax-preferred health insurance through mechanisms other than just through one’s employer; tort reform to cut back on excessive lawsuits and defensive medicine;  enabling the purchase of insurance across state lines; and, replacing Obamacare’s exchange subsidies with a refundable tax credit or some other tax benefit to help lower-income Americans afford health insurance.  A Congressional Budget Office analysis of a plan along these lines found that it would have the effect of reducing the average cost of health care premiums.

    Third, we should maintain the employer-based system and be wary of the recent trend of moving away from employer-sponsored care and toward more government-provided insurance.  Employers cover 177 million people.  In doing so, they take pressure off the government-based parts of the system.  Employers have proven themselves to be very good at getting people covered, in contrast to government-sponsored programs, which struggle in that regard.  Furthermore, the cost per covered life is greater for people in government-sponsored coverage than those in employer-sponsored care.  Obviously, government programs tend to cover higher cost populations.  But to the extent that we can limit the movement of individuals away from employer-sponsored care and towards government-sponsored care, it will save taxpayers money.  Keeping employers in the health care game is vital to this effort, which means that public policy should both maintain the current tax preferred treatment for employer-sponsored care, as well as the ERISA preemption that allows employers to provide multi-state plans without running afoul of a crazy quilt of different state regulations.

    The fourth plank is more long-term, but no less important.  We need to think about significant reforms to our costly Medicare system to make it more efficient and more sustainable.  President Trump has said he does not want to change Medicare, so it’s unlikely to be an early administration priority.  But we cannot push off the problem forever.  Speaker Paul Ryan has put forward a serious proposal for Medicare reform based on the premium support concept.  This plan, which has bipartisan origins, does not appear to be on the front burner right now.  But it could start a needed conversation on Medicare reform later on, perhaps after the midterm election.

    None of these steps will be easy.  If they were, someone would have done them already.  But if we as a society want to start getting more out of our health care dollars, this four-part plan is the place to start.  Otherwise, we will continue to get poor returns on our health care investment, and face a serious chance of a long-term health care-driven fiscal calamity.

    Tevi Troy is the CEO of the American Health Policy Institute and a former Deputy Secretary of Health and Human Services.  His latest book is “Shall We Wake the President? Two Centuries of Disaster Management from the Oval Office."