I'm a native New Yorker, but I've been living in Ohio long enough to know that Buckeyes aren't the attention-seeking sort. Still, when the biggest show in the nation rolls into our backyard, it's only natural that even polite Midwesterners have a thing or two to say.
On Tuesday, Oct. 15, the fourth Democratic presidential debate will be held in Westerville, a leafy suburb of Columbus. Because Ohio is likely to play an important part in deciding next year's presidential election; because the debate will take place not too far from where I live and work; and because it will touch on healthcare, a field in which I've spent my entire career, I'd like to offer its moderators a few questions to ask.
To be clear, I'm not talking about the Affordable Care Act, drug prices, or any of the other topics that have already been discussed in previous debates; instead, I'm interested in the essential issues that are frequently ignored even as they're keeping millions of Americans unwell.
Five questions in particular come to mind:
1) What are you going to do to address the social issues that affect people's health, referred to as the social determinants of health?
You hardly have to be the CEO of a large health system to realize that the social, economic and environmental factors in your community—such as access to safe housing, fresh fruits and vegetables, and quality education—impact your health. Earlier this year, for example, Ohio's Health Department sponsored a survey that found that the poorer Ohioans were, the more likely they were to suffer from poor health. Thirty-six percent of the state's least affluent residents reported their health as fair or poor, the lowest possible designation, while among the most affluent, 91% reported themselves to be in good or excellent health.
That's the kind of gap that shouldn't exist in a prosperous nation like the United States.
Where people live and their level of education are rarely thought of as having an impact on health, but they do, and hugely so. Health systems across the country are realizing this, which is why they're investing in everything from subsidized farmers' markets to improve nutrition to educational classes that give less fortunate patients the leg up they need.
It's time for all the candidates to say what they would do to address these systemic inequalities and help more Americans get healthier.
2) How are you going to fight the opioid crisis?
In 2017, the last year for which data is available, Ohio had the second-highest rate of opioid-related deaths in the nation, losing 4,293 people—a rate of 39.2 deaths per 100,000 persons—to what is inarguably one of the worst public health crises we've seen in years. Despite this tragedy, we have some good news to report at Ohio State, including a recent 60% reduction in the rate of opioid prescribing at our medical center, but we could use all the help we can get from Washington.
The folks attending Tuesday's debate are almost certain to have witnessed a friend or family member struggle with addiction, so it behooves the women and men on stage to present a bold vision to address this scourge. That vision should combine new approaches—like our state's current effort to study the genetic markers that make people more prone to addiction—as well as investment in infrastructure that helps people feel less hopeless and alienated, and less dependent on substances for relief.
3) What are you going to do about the suicide epidemic and the state of mental healthcare in America?
Here are a few grim statistics: An American dies by suicide every 12 minutes. In 2017, for example, 47,173 Americans took their own lives, or seven times the rate of all American casualties in the Iraq and Afghanistan wars combined. Suicides now account for nearly three times as many casualties as homicides.
Presidential candidates like to remain cheerful and upbeat, and there are few topics more somber than suicide, so these troubling numbers rarely get discussed. And that's exactly the problem: While we speak about cancer, heart disease, and AIDS publicly and openly, the mental health conditions that often lead to suicide are too frequently still seen as taboo. It's time those who wish to lead us tell us what they can do to help change the conversation around suicide and mental health before we lose more loved ones.
4) How will you address our doctor, nurse and residency shortages?
Earlier this year, the Association of American Medical Colleges released a report that should concern anyone who might at some point see a doctor. The AAMC found that while the number of available spots in medical schools had grown by 52% since 2002, the number of available residency positions has increased by a meager 1% per year. This means that on a typical year, more than a quarter of all graduating physicians will have no place to practice their desperately needed profession.
In large part, this is a question of funding: Congress has capped federally supported residency programs for decades now, and the candidates on stage should share with us their plans for making sure we match every talented and passionate medical school graduate with a community that needs his or her skills.
We also need to work together to develop new ways to alleviate student debt.
5) What will you do to improve access to telehealth?
Thanks to telehealth, doctors can now remotely examine patients using video cameras and a fast internet connection, a huge boon for those elderly or impaired patients for whom traveling to a hospital or a clinic is a challenge, or who don't have access to a specialist in their hometowns. Earlier this spring, the CMS announced that it will expand Medicare Advantage plans to allow additional telehealth benefits, which is a step in the right direction. To my earlier point about mental health, telehealth is growing as an effective way to address access, cost and even reduce unease for patients in seeking treatment. But we need to do much more to make sure the advantages of digital technology are made available to all Americans. The presidential hopefuls on stage in Ohio should propose new and innovative ways to use digital platforms to improve how we provide excellent care to those who need it the most.
These are weighty topics, but we need continued help from our elected officials to allow us to meet these challenges.