The Obama administration's public health efforts focused on acknowledging that social factors such as poverty and food insecurity affect the health outcomes of communities. The election of Donald Trump worries public health experts such as Dr. Georges Benjamin, executive director of the American Public Health Association, who sat down with Modern Healthcare reporter Steven Ross Johnson to discuss what's next for public health under a Trump administration and where he sees opportunities for collaboration in a potential post-ACA world. The following is an edited transcript.
Modern Healthcare: How do you see public health moving forward in this current political environment?
Dr. Georges Benjamin: We need to move forward with full force and action. The Trump administration has its agenda and we have ours. Our agenda is absolutely to improve the health and well-being of the people of America, for sure. We're not sure what their agenda is.
MH: Do you still see opportunities to collaborate with the administration?
Benjamin: Yes. Despite the enormous skepticism we all have, we've always been able to find a sweet spot on something to move an agenda forward. The truth is also that stuff happens. Tragically, there's going to be a disease outbreak. There'll be some new disease problem that we have to address, and we'll have to do that collaboratively, otherwise it doesn't work.
MH: There's been a steady decrease in the number of state and local public health workers across the country. The recent budget proposal by the president looks for substantial cuts across the board in discretionary spending. How does this affect efforts to rebuild that public health professional workforce?
Benjamin: We had hoped to start 2017 under the mantra of now that we've done health insurance reform, let's do population health reform, which included public health as a component of that. But we're going to have to step back and do some different kinds of battles. We're going to have to make sure that members of Congress remain supportive of things like core research, public health infrastructure, building public health preparedness programs, addressing things like the opioid epidemic and the obesity epidemic.
The problem is it seems like they just decided, "These are programs we simply don't need." And they just cut them out of the budget with an idea of trying to find a figure to fund some of the increases in the military and the wall (along the Southern border), and, of course, that's not the way to do public policy, and that's absolutely not the way to put together a budget. They really have undermined (some efforts) and it doesn't have policy coherence. So, we're hoping that Congress will put some coherence to that as they put together at least a 2018 budget.
MH: Did the messaging against the Republican plan to replace Obamacare provide any lessons in terms of how to use, for lack of a better term, the bully pulpit, in situations when the administration is not being very receptive to what you're advocating?
Benjamin: We've been concerned for some time the last few years that the bully pulpit didn't matter, that people weren't hearing the message. The question is why are people voting against their best interest? And, in retrospect, it turns out they really weren't. They didn't believe that the incoming administration would do some of the things they said they were going to do and thought it was all just politics and rhetoric.
It turns out they meant to do what they're doing, so I think the core basic principles of activism and advocacy are still in place. The public just needs to be well-informed, and I think once they know what's not in their best interest, they're willing to fight against it. The country is in no mood right now apparently to tolerate things that are not in their best interest.
MH: Does the election of Donald Trump and the moves his administration has taken so far require public health to change its direction in terms of promoting prevention and population health, and instead solely focus on maintaining its capacity to respond to public health emergencies?
Benjamin: I think the cat is out of the bag on population health. We're moving very quickly to value-based healthcare on the healthcare delivery side. We can't get to those goals without population health. And I think that's a train that has long left the station. We have numerous experiments where we've shown, by working across sectors (business, faith, community), trying to tackle problems in a collective way, that you can have dramatic improvements in not just the health of the population but in the economics of a community. There's leveraging of resources, money and reductions in overall cost for everyone.
I think that is well within the concepts that even this administration was talking about, such as state flexibility and engaging communities.
MH: What would you attribute the growing popularity of the ACA to?
Benjamin: We weren't sure that people were valuing it, but when people started talking about taking it away it became a kitchen-table issue where folks said, "If I don't have health insurance, then this is what happens to me." We know there are parts of the country where the rates are going through the roof, and that needs to be addressed. I think the question about whether or not healthcare is a right in this country is over. I think that debate has been won.
I think the next thing we need to do is make sure people understand that the Affordable Care Act is a public-private partnership; it's not government healthcare. The government regulates a lot of things. They regulate how we drive, how we build buildings, and they've been regulating components of our healthcare system.
The healthcare system does not function like a regular market. Patients do not have the same power in healthcare as they have when buying a car, or cereal, or a house. It's not an equal playing field at all, and until we get that kind of transparency in pricing and an understanding of what you're buying in terms of quality and value, then it's not going to be an equal playing field.
MH: Do you feel healthcare providers will want to continue their community engagement activities even if Obamacare is repealed?
Benjamin: I do. And this is not the only way to provide healthcare, but it is a way for them to deal with those intractable problems—the patient that you've been trying to get to lose weight or get to stop smoking, trying to improve substance misuse.
But we have these other tools to address them in a broader sense, that group of patients in which their healthcare doesn't seem to be making progress, and addressing those social determinants makes it easier for them to make the healthy choice, the easy choice. It transforms the community into a more productive place, and, in my mind, aids the clinician. They will need some tools. We need to help them with data collection. We need to give them the feedback on performance.
MH: Have you had a chance to speak with the new HHS secretary, Dr. Tom Price?
Benjamin: I have not had a chance to meet with Dr. Price. We do have a letter in asking for a meeting, so I'm hoping that we will have a chance to meet with him soon.
MH: What are your initial impressions so far, given everything that's occurred?
Benjamin: Well, you always give anyone the benefit of the doubt and I think that, clearly, he's got a lot to learn. He's coming from both a practice of clinical medicine as well as being a legislator, and now he's got to be the chief health official of the nation, so it's a very different role.
We hope to work with him in a productive way to both help him make that transformation and help him move along an agenda that is certainly much bigger than one person.
MH: On what issues do you think there might be the best chance for you to work collaboratively with the new administration?
Benjamin: We're hoping that we will be able to work collaboratively around building on the public health infrastructure. Defining what every community should have in terms of public health capacity—what is the role at the local, state, federal level.
While we know there is a role for each of those pieces, it has evolved over the years, and if we can get some better understanding of what those roles should be, who should fund what part of that, and how to adequately finance the public health system so we don't have yo-yo funding—up one year and down the next—I think all of that is important.
There's no question that if we can reach a goal of the United States being the healthiest nation, that clearly aligns with the president's position of making America "great again."
MH: In terms of public health threats, what keeps you up at night?
Benjamin: I still think climate change is the greatest public health threat we have. The thing that keeps me up at night is the infectious disease threat that we don't see coming. We've had, almost every year, a new threat of some kind and of various magnitudes. The most significant terrorist that we have is Mother Nature. Nature has the capacity to evolve organisms to impact our health in significant ways and for many years. We've always been worried about the disease process that's coming from some place, only for it to come from someplace else.
I remember when Zika first hit in Brazil and we were kind of watching it and everybody said, "Well, it's only Zika. It could be something worse." Well, it turns out that it was a mutated form of Zika and it was something worse.
I remember Ebola and people were worried about Ebola, but we've had lots of little outbreaks of Ebola. But we hadn't seen anything like the one we saw. So it's that kind of thing. We all worried about bird flu and while we were watching for bird flu, we got SARS and that was a pretty significant outbreak. So that keeps me up at night.
