Elections can elevate issues, build consensus for action, and frame agendas for those elected. That’s why it’s important that the 2020 discussion of health issues expand beyond coverage and cost. Those who care about health should expect candidates at all levels, and in both parties, to tell us how they will protect us from health threats, build healthier communities, reform the delivery system to provide greater value, and address social determinants of health.
Health care, not health, is the leading issue for 2020
Health was the leading issue in the 2018 midterm elections, and remains top of mind for 2020. President Trump has promised a Republican alternative to the Patient Protection and Affordable Care Act, and Democratic contenders debate variations of plans to move toward universal insurance coverage. A Supreme Court decision on Texas v. Azar could alter the trajectory of the general election.
The preponderance of attention is on coverage and financing, and rightfully so. Insurance saves lives, access is a moral imperative, and cost is a key factor in both. Politically, as long as access to health care is a challenge for significant percentages of the population, the debate over coverage will crowd out efforts to address more fundamental drivers of our health and vitality. And to be sure, some other issues are making their way into the public discussion: there is bipartisan attention to opioid addiction and mental health; on the Democratic side, a focus on climate change, gun violence, and rural health; and the Administration has launched initiatives including HIV and kidney disease.
These issues are important and compelling. Addressing each is necessary, but not sufficient for achieving fundamental change in a health system that is widely regarded as falling short.
It’s not too late to broaden the conversation
Early caucuses and primaries are still 5 months away, and there will be countless debates, town halls, and other forums where important issues can be raised by the public and the media. Importantly, this isn’t just about the Presidency – health issues will play an important part in campaigns for 11 governorships and countless mayors, state legislators, and city council races. As the campaign evolves over the next year, we need to broaden the debate by getting candidates to engage on more fundamental public health issues:
- Our public health infrastructure isn’t up to the task of protecting the population from disease, or effectively promoting healthy communities. Despite proposals to spend up to trillions more on insurance, no serious proposals have emerged for supporting investments in sustaining or modernizing the infrastructure that keeps our food safe, ensures our children are vaccinated, prepares for health emergencies, and promotes healthy communities. A recent study by the Bipartisan Policy Center and the Public Health Leadership Forum found a $4.5 billion gap in funding for even the most basic public health systems at the state and local levels. While there is always support for short-term funding to address the costly consequences of public health emergencies – Ebola, hurricanes, pandemics, a local measles outbreak – elections can help generate the political will to sustain investments in the infrastructure needed for prevention and effective response capacity.
- Policy is an undervalued tool in shaping the health and vitality of communities. There are evidence-based policy options across a wide spectrum -- education, housing, transportation, public safety to name a few – that have significant positive impact on our health. Particularly at the state and local level, health-focused voters can engage candidates around existing compilations of recommended policy tools to jump start a discussion, and often identify multi-sector coalitions that are pursuing policy change and would value a health perspective in their approach to candidates and elected officials. Health impact can also be an important consideration in policies across all sectors.
- Initiatives to address underlying social and economic factors that drive health need to be reinforced and better integrated with health systems. As awareness of the importance of social determinants grows, the social consensus around public social services spending has frayed. And while there is significant innovation and experimentation in health care (e.g., initiatives of CMMI; Medicaid waivers), there is comparatively little in programs like SNAP, housing, and TANF. Though poverty and social needs are interwoven with health and health care, public policies and programs are still compartmentalized in silos that are inadequate to meet needs at either the individual or community level.
- The health care delivery system needs help moving “upstream” to invest in primary prevention and address social needs of patients. Even without fundamental changes in the system, public policies could help rebalance health spending to achieve greater value and improve health outcomes. For example, with greater political consensus, there could be greater flexibility granted in Medicare Advantage, new rules for Medicaid managed care, and ultimately changes in other Federal programs to address more “upstream” factors in an effort to forestall progression toward disease and costly treatment. Though there are promising public and private initiatives underway, health care and social services sectors remain largely without an electronic or financial infrastructure that connects them in the service of patients or communities.
- Candidates can help reinforce science and evidence as critical elements in decision-making. This includes steps to promote research, demonstrations, and experimentation that help grow the evidence base, including on topics like gun violence where solutions are lacking. It involves tackling issues like climate change and vaccine hesitancy, where candidates and elected officials play an important part of educating the public. Finally, it includes building on steps like the Evidence-Based Policymaking Act that reinforce the importance of data for decision-making, and safeguard the integrity of public science and data organizations.
It’s not too late to engage candidates at all levels, and in both parties, in exploring these issues. Platforms at the federal level remain undefined, and candidates at the state and local levels have an untapped ability to move on issues independent of national party orthodoxy. Those who care about the public’s health need to seize every opportunity to change the debate.