News

New Crew 2018

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                    [post_content] => We are beginning 2018 with a new Associate Editor, Dr. Jennifer Beard, three new writing Fellows, Sampada Nandyala, Chrissy Packtor, and Erin Polka (introduced below), and with continuing gratitude to our growing number of readers. It’s an honor to start this second year of publication, posting a new piece of Public Health every day with a weekly wrap-up on Fridays, at a moment when the U.S. has seen two consecutive years of declining life expectancy and our nation’s health is increasingly endangered. We plan to expand our stories, research, viewpoints, interviews, and databytes in ways that surprise you and keep your attention on the important ideas and solutions that can make us all healthier.  —Michael Stein, MD, Executive Editor

I am delighted to be joining the Public Health Post team in the role of associate editor because I believe passionately in our mission to provide a forum for stimulating, evidence-based conversations about topics critical to the health of all. PHP’s guiding metaphor has been an ongoing dinner party featuring fascinating guests and whip-smart graduate students talking about everything under the public health sun: from safe injection facilities to self-care when reporting difficult stories, preventing sexually transmitted infections in Detroit, and health care professionals who participate in torture. A key theme running through this conversation is how we translate and communicate the science and ethos of public health into policy and practice. What background knowledge should we assume our audience to have? What words do we use? How do we define those words? And what, for that matter, do we mean by “public health.”

These are questions I am eager to debate during our editorial meetings and in the articles we publish in 2018. I come to PHP as a faculty member in a Department of Global Health by way (a long time ago) of a PhD program in English literature followed several years later by a master’s degree in public health. I’ve been teaching writing in one form or another since 1991 and doing my best to train public health students to write clear, succinct, arguments grounded in evidence for over a decade. I find the topic of how we talk about what we do with one another and the rest of the world to be endlessly fascinating and critically important. Over the next year, I plan to explore these topics and encourage our readers to contribute your thoughts on public health language, communication, writing, etc. Are you interested in the language of public health and the ways in which we communicate? Please share your ideas with me at jenbeard@bu.edu.

I will kick off the conversation tomorrow, by returning to a question David Jones posed in our first week of publication with some thoughts on the definition of “public health. —Jen Beard, Associate Editor

Public Health Post Fellows 2018

Sampada Nandyala is an MPH candidate at BUSPH studying epidemiology and infectious diseases. She received her BS in public health with a certificate in Public Health Management from Rutgers University’s Edward Bloustein School of Planning and Public Policy. She was a Scientific Strategy Intern at the healthcare marketing agency McCann Echo, Public Policy Intern at Hyacinth AIDS Foundation, and Sustainability and Community Development Intern at Greener by Design. She wrote weekly articles as an intern for College Fashionista for two years. Chrissy Packtor is an MPH candidate at BUSPH studying health communication & promotion and sex, sexuality, and gender. She received her BS in biology and psychology from West Virginia University with a minor in women’s and gender studies, graduating Magna Cum Laude with University Honors.  She was the Outreach and Communications intern for West Virginia Focus: Reproductive Education and Equality (WV FREE), Public Affairs Intern for Planned Parenthood South Atlantic, and the President and Social Media Chair of WVU Students for Reproductive Justice. Erin Polka is an MPH candidate at BUSPH studying biostatistics and epidemiology. She received her BA from the University of Colorado, Boulder in Ecology and Evolutionary Biology. She works as a research assistant at the Harvard Museum of Comparative Zoology, and was an an Agricultural Extension Officer for the Peace Corps in Tanzania where she worked alongside community members on grassroots agricultural and health projects. She received a grant from the President’s Emergency Fund for AIDS Relief and is fluent in Swahili. Feature image: left to right: Chrissy Packtor, Erin Polka, Michael Stein, Sampada Nandyala, Jen Beard. Photo: Michael Saunders.  [post_title] => New Crew 2018 [post_excerpt] => We're delighted to welcome our new cohort of PHP fellows: Sampada Nandyala, Chrissy Packtor, and Erin Polka! Executive Editor Michael Stein and Associate Editor Jennifer Beard also join the PHP team. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => new-crew [to_ping] => [pinged] => [post_modified] => 2018-02-06 18:53:06 [post_modified_gmt] => 2018-02-06 23:53:06 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_news&p=3686 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

We’re delighted to welcome our new cohort of PHP fellows: Sampada Nandyala, Chrissy Packtor, and Erin Polka! Executive Editor Michael Stein and Associate Editor Jennifer Beard also join the PHP team.

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News

Success and Setbacks in Rural Health Systems

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                    [post_content] => Ripton, Vermont, a tiny town of 588 in Addison County, was described by Jessica Ravitz of CNN as “…the kind of place where cell service fails more often than it works…and the fog lifts to reveal a white horse grazing in a field." 2093 miles and 32 driving hours away is Ten Sleep, Wyoming, a tiny town of 260 located in the western foothills of the Big Horn Mountains.

Both towns are located in the most rural states in America: Vermont and Wyoming are ranked 49th and 50th respectively in terms of population and each state has only one representative in the U.S. House. The states have striking similarities on many fronts: per-capita income is nearly the same, the unemployment rate is 3.9% vs. 3.2%, and both states have a historic hunting pedigree.

But there is a striking difference between the two states in terms of the performance of their healthcare systems. The Commonwealth Fund Scorecard on State Health System Performance ranks Vermont first in terms of overall performance, while Wyoming ranked a distant 25th. Vermont ranked first in access, defined by the uninsured rate, the number of people who went without care because of costs, and adults without a dental visit in the past year. Wyoming ranked 34th. (For more information on methodology, see the report’s methods section.)
One of the most important dynamics of the years since the ACA’s passage is that the states with the worst health system performance and worst health outcomes tended to be the staunchest opponents.  
Attention is shifting to states in the aftermath of the failed attempt by Donald Trump and Congressional Republicans to repeal the Affordable Care Act (ACA). One of the most important dynamics of the years since the ACA’s passage is that the states with the worst health system performance and worst health outcomes tended to be the staunchest opponents. Research from The Commonwealth Fund shows that: “…states that accepted federal funding to expand their Medicaid programs under the Affordable Care Act outperformed states that did not expand Medicaid.” As Vermont expanded Medicaid and decreased the uninsured rate to 6%, Wyoming rejected Medicaid and has even seen its uninsured rate grow to 14%. The following figure shows three key ways that Medicaid expansion states have outperformed non-expansion states: Graph showing improvement in healthcare access in states that expanded Medicaid There is a lot more to health than insurance and access to care. Wyoming has a pretty high “healthy lives” ranking at 18th compared to Vermont at #5. But as the ACA remains the law of the land and opposition remains entrenched, there is a real risk that the disparity between high and low performing states will widen even further. Feature image: faungg's photos, The view along the Scenic Drive 287 in Wyoming, used under CC BY-ND 2.0  Graph by The Commonwealth Fund.   [post_title] => Success and Setbacks in Rural Health Systems [post_excerpt] => Vermont and Wyoming have similarities on many fronts, but there is a striking difference between the two states in terms of the performance of their healthcare systems. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => success-setbacks-rural-health-systems [to_ping] => [pinged] => [post_modified] => 2017-10-10 07:00:03 [post_modified_gmt] => 2017-10-10 11:00:03 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_news&p=2947 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Vermont and Wyoming have similarities on many fronts, but there is a striking difference between the two states in terms of the performance of their healthcare systems.

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News

New Budget, Old Problems: Public Health Challenges in Illinois

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                    [post_content] => Illinois had no state budget for more than two years, causing myriad public problems in one of the most populous states in the U.S. On July 6, 2017, the Illinois state legislature enacted a full budget with bipartisan support, over the veto of Republican Governor Bruce Rauner. I highlighted some of the public health impacts of the Illinois budget crisis for Public Health Post in December 2016, including disastrous funding issues for local and state public health organizations and social service providers. While the new budget is a critical first step towards restoring vital public health programs and services, policymakers, service providers, and citizens face ongoing uncertainty and long-term repercussions across Illinois.

The budget passed in July 2017 is focused on re-establishing state funding in several key areas, accomplished largely through increases in personal and corporate income taxes. First and foremost, the budget helps Illinois begin to pay for both the ongoing costs of state functioning and the $15 billion in unpaid bills resulting from the two-year budget crisis. Achieving this basic level of financial functioning was also essential to Illinois’s recovery as it stabilized the state’s credit rating, which plummeted during the budget crisis but just barely avoided hitting “junk” status. This would have been an unprecedented and extensive financial problem for the state. Even with a budget in place, Illinois continues to face significant financial problems, including the yet-unresolved challenge of meeting its $130 billion obligation in pension liability, which in part prompted the budget crisis in 2015.

The continuing problem of the state’s pension debt and the ongoing negative impact of the state’s poor credit rating serve as present threats to the stability and reliability of all state funding and therefore are critical components of Illinois’s commitment to public health and well-being. The new budget allocates vital funds to health, education, and social service providers, but many institutions and agencies remain anxious about rebuilding programs and rehiring staff with the specter of the budget crisis so present. The new budget includes regular funding for suffering K-12 public education, decimated social service providers, and desperate public universities, many of which were facing the prospect of shutting their doors if money did not arrive this fall. However, this year’s funding does not resolve the challenges these organizations face in repairing the problems created over the last two years.
...Illinois’s most vulnerable students stand to suffer most from the budget crisis’s impact on public higher education, exacerbating disparities in higher education achievement along income, race, and socioeconomic lines.  
Public higher education is not the most direct influencer of public health in a state, but ample scientific evidence links more education with better health, and Illinois’s most vulnerable students stand to suffer most from the budget crisis’s impact on public higher education, exacerbating disparities in higher education achievement along income, race, and socioeconomic lines. The budget crisis delayed or eliminated critical grant and scholarship funding otherwise available to low-income and first-generation college students, and the new budget cuts prior public higher education funding by 10%. Financially vulnerable students, and first-time college students facing other barriers and alternatives to college attendance, may have been unable to begin, remain in, or continue full-time in college due to the budget crisis. Under the new budget, many of these students may still face financial barriers to college from reduced state funding, or they may question, with good reason, the state’s reliability as a funder of their educations. Further, universities (like Chicago State University) and community colleges (like that in Kankakee) dedicated to the education of students with fewer financial and network resources to attend other institutions felt the sting of the budget crisis particularly strongly, losing scores of faculty and staff, serving fewer students, and eliminated important supports like campus-based child care for students, none of which can be remedied quickly, even with a new budget in place.
Compared to those without, people with a college degree live longer, have lower rates of chronic illness, and experience risk factors like high stress and smoking at lower rates.  
All of these factors matter to public health because education is a clear social determinant of health. Compared to those without, people with a college degree live longer, have lower rates of chronic illness, and experience risk factors like high stress and smoking at lower rates. Research has gotten sophisticated enough to separate out direct impacts of education on health from correlations that might reflect common causes of both lower education and poorer health (like systemic racism, or childhood trauma). For instance, scholars at the National Bureau of Economic Research offer evidence that college education directly impacts mortality, particularly related to access to health insurance, health care, and opportunities to practice health-promoting behaviors among those with college degrees. In Illinois, the two-year budget impasse and the ongoing effects of the budget crisis on public higher education have disproportionately harmed those college students and potential college students who are already most vulnerable to poor health outcomes due to poverty and racism. Renewed public funding for K-12 schools and health, mental health, and social service agencies is essential to promoting public health in Illinois, but the state’s higher education institutions and the students who rely on them face continued challenges with clear negative consequences for individual and community health. Feature image: Tom Shockey, Springfield Illinois, used under CC BY 2.0 [post_title] => New Budget, Old Problems: Public Health Challenges in Illinois [post_excerpt] => The ongoing effects of the Illinois budget crisis, in particular on public higher education, have clear negative consequences for individual and community health. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => illinois-new-budget-old-problems [to_ping] => [pinged] => [post_modified] => 2017-09-21 14:08:25 [post_modified_gmt] => 2017-09-21 18:08:25 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.publichealthpost.org/?post_type=bu_news&p=2964 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

The ongoing effects of the Illinois budget crisis, in particular on public higher education, have clear negative consequences for individual and community health.

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News

UPDATE: The Refugee Crisis and Returning Home

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                    [post_content] => In March I wrote about the world’s response to a massive refugee and displaced persons crisis. The United Nations High Commissioner for Human Rights (UNHCR) has since come out with new data showing that the problems are getting even worse.

Three statistics jump out at me as particularly important:

• 67.75 million people are now considered to be ‘persons of concern.’ Persons of concern is a catchall designation that is made up not just of refugees, but also of internally displaced persons (IDPs), asylum-seekers, stateless persons, and returnees, among others. The number of persons of concern is nearly 4 million more than at the end of 2015.

• 5 million people have returned to their country of origin. This is the biggest data swing in the 2016 data. For example, more than 600,000 displaced Syrians returned to their original homes even though much of Syria is left in ruins. In Iraq, 1.40 million people have made their way home with UNHCR help. In Yemen, bombing campaigns and drought are still ravaging the country, but 974,059 have returned.

• The number of IDPs in Colombia increased from 6.9 million to 7.4 million, very nearly matching the number at Syria’s peak during their civil war. IDP numbers have also gone up in the Democratic Republic of the Congo (DRC), Somalia, Afghanistan, Ukraine and South Sudan because of war, drought, famine, disease, and extreme poverty.

[ictt-tweet-inline]The number of returnees in 2016 was higher than any year in the past three decades.[/ictt-tweet-inline] The emotional connection to ‘home’ is not easily pushed aside; given the chance, many are going back. Abo Adnan, a Syrian refugee, wrote, in a plea to European leaders to help refugees move back home, “All the Syrians [in Germany] are so grateful for the welcome people have given us but we want to live in Syria, not Germany.” [ictt-tweet-inline]The UNHCR helps refugees return to their country of origin via their ‘voluntary repatriation’ program. [/ictt-tweet-inline]The organization provides safety and security, including essential infrastructure, in order to facilitate the process of return. The UNHCR writes that the return program is “…the durable solution of choice for the largest number of refugees…” Feature image: UNHCR Population Statistics interactive website [post_title] => UPDATE: The Refugee Crisis and Returning Home [post_excerpt] => Three important statistics from new data released by the United Nations High Commissioner for Human Rights (UNHCR) on the world's refugee and displaced persons crisis. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => refugee-crisis-returning-home [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:42:14 [post_modified_gmt] => 2017-09-02 02:42:14 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=2519 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Three important statistics from new data released by the United Nations High Commissioner for Human Rights (UNHCR) on the world’s refugee and displaced persons crisis.

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Trump Voters for Single Payer

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                    [post_content] => Mitch McConnell has hit another stumbling block in his quest to repeal Obamacare. At least four Senators have announced they will not support the replacement bill Senate leadership has been trying to advance. Jerry Moran (R-KS) and Susan Collins (R-ME) oppose the bill because it's too aggressive while Rand Paul (R-KY) and Mike Lee (R-UT) say it's not aggressive enough. This is a very tough needle to thread given that McConnell can only afford to lose two votes.

Four Options

Republican leaders have four options at this point: 1) work with Democrats to do reforms that both sides agree are needed, 2) try again to find a compromise that would appeal to exactly 50 Republican Senators, 3) give up and move on to something else, or 4) follow calls from President Trump and Ben Sasse (R-NE) to vote now to repeal the Affordable Care Act (ACA) but with an effective date a few years down the road, giving Republicans time to work on a compromise. Working backwards through these options, delay and replace is a terrible idea that almost certainly won't work. Republicans have had seven years to come up with a replacement to the ACA, there is little reason to believe that anything will change in the next year or two. I'm skeptical enough Senators would agree to this. I need to ask my lawyer and parliamentarian friends, but [ictt-tweet-inline]could delay and replace be done through reconciliation? [/ictt-tweet-inline]If not the vote threshold would be 60 instead of 50. There are not 60 votes for this in the Senate. Moving on makes the most sense politically. The people who are under the most pressure to repeal Obamacare can say they did everything possible and it's not their fault repeal failed. The House can blame the Senate. Conservative Senators can blame McConnell or the moderates. In any case, Republican members of Congress may rather oppose Obamacare than replace it. It's much easier and politically more valuable to continue criticizing something than to have to figure out how to fix it or risk being blamed for all the negative implications of the fix. [ictt-tweet-inline]Is it too cynical of me to suspect that some Republicans hope they can't get a bill through?[/ictt-tweet-inline] If I had to bet money I would guess that McConnell chooses option two, keep trying to thread the needle to get exactly 50 votes to support something – anything. I don't know what that compromise would be, but the path would likely be to cast the moderates aside and try to win over hard-liners like Mike Lee and Rand Paul. I don't expect McConnell to work on a bi-partisan compromise. He told Republicans that if they couldn't agree among themselves he would would work with Democrats and the product would be more moderate than they would like. His comments in the day since the latest bill failed suggest he was not serious and that this threat of bi-partisanship was merely an attempt at leverage to convince hold-outs to give in.

Single Payer?

There is a fifth option that won't be considered but maybe should be: single payer. I have heard a lot more chatter about single payer lately, but I have dismissed it as coming from young naive students who don't appreciate the level of opposition to expanding the role of government or from liberal New Englanders out of touch with the rest of the country.
But then the most interesting thing happened – she pivoted to saying that Reagan didn't fully oppose Canadian-style health care and that if he were around now he would support it. "I think the way Canada has it is it. We want it!"  
A conversation I had last week with a Trump voter in Mississippi changed my perception about the source and degree of support for single payer. This person works in healthcare, dislikes Obamacare, and is proud to support Trump. "He's got a mouth. He's bold. We need that," she told me. "We are bold people down here. We're stand-up people, mouthy. Some of us feel like the forgotten and the only way to be heard is to be heard. I like him for that." She is furious that no one in Washington is standing up to the insurance industry. She is not optimistic about the bills advanced by Paul Ryan and Mitch McConnell because they retain a prominent role for private insurers. She thinks it is obscene that insurance companies are making record profits while squeezing patients with higher premiums and higher deductibles while also squeezing providers with lower reimbursements. "No other industry gets to decide its prices," she told me. "We feel fortunate to get 20% of what we billed... Whether we have Obamacare, the new Republicans, or whatever, we won't solve the problems until we get a hold of that." I tried to unpack her perspective by asking if she would support a system in which the government would set prices for all procedures. We could keep private insurance but change their role from a for-profit industry with a fiduciary responsibility to make money to having more of an administrative function. I didn't tell her I was describing key elements of the French health care system. She loved it. I inquired further, this time telling her about a fascinating article I read suggesting that Trump voters would support a  single payer health care system. This time I told her I was thinking of Canada as a model. Before I could even finish my question she was saying "Amen. Amen. Yes please!" She would love that her practice could focus on care rather dealing with insurance companies who make money by denying claims. She could build a business model around predictable prices. I pointed out that Bernie Sanders and Democrats going back to the 1960s and beyond have proposed government-run universal health care but that people like Ronald Reagan killed it by labeling it big government socialism. She swooned at the mention of Reagan, interrupting herself to say how much she loves him. "That president was good. He had common sense." But then the most interesting thing happened – she pivoted to saying that Reagan didn't fully oppose Canadian-style health care and that if he were around now he would support it. "I think the way Canada has it is it. We want it!"   This obviously should be taken with a grain of salt as one conversation with one Trump voter, but her comments are consistent with what others have been hearing and with what Donald Trump himself said during a meeting with the Australian Prime Minister. A recent Kaiser Family Foundation poll found that a majority of Americans now favor single-payer. Support is considerably lower among Republicans, but more work needs to be done by pollsters to understand how Trump supporters think about single payer. Trump clearly does not play by the same partisan left-right rules as everyone else, but might be the best positioned president in decades to advance single payer. Feature image: Daniel Lobo, Sanidad universal, used under CC BY 2.0.  Graph from Kaiser Family Foundation. [post_title] => Trump Voters for Single Payer [post_excerpt] => Senate Majority Leader Mitch McConnell has four options now that his latest bill has failed. Single payer probably isn’t one of them, but maybe should be according to many Trump voters. Could Donald Trump be the single payer president? [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => trump-voters-single-payer [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:40:41 [post_modified_gmt] => 2017-09-02 02:40:41 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=2584 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Senate Majority Leader Mitch McConnell has four options now that his latest bill has failed. Single payer probably isn’t one of them, but maybe should be according to many Trump voters. Could Donald Trump be the single payer president?

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On to the Senate

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                    [post_content] => The U.S. House did something that just a few days ago I was skeptical would happen—pass legislation repealing Obamacare. Well, they passed more than 50 repeal bills between 2010 and 2016, but none of those had a chance to become law. The issue on everyone's mind now is what the Senate will do. Here are my thoughts on eight key questions:

1) How many votes are needed to pass legislation in the Senate? Usually 60, but Republicans are trying to use a special process called reconciliation that allows them to pass a law with a straight majority of 51. Democrats can't criticize because this is how they passed Obamacare in 2010. For reasons that are too complex for me to get into here but that are explained very well by Andrew Prokop of Vox, this option of passing Obamacare repeal with 51 votes won't last forever. Republicans will need to get this done sooner rather than later if they want to move on to tax reform and other issues.

2) Republicans have 52 seats in the Senate. Does that mean they have enough votes to pass the law that just passed the House? Probably not. Every concession given to  conservatives in the House makes it harder for moderate Senators to vote yes. There are only two votes to spare, so the margin is really tight. Key Republicans have made it clear they aren't just going to take the House bill as is. Take for example Lindsey Graham (R-SC) who said that "any bill that has been posted less than 24 hours...needs to be viewed with suspicion."

3) Does that mean Obamacare will likely survive and the Republican plan will be a failure? Not necessarily. I have heard/read a lot of liberals in the last 24 hours console themselves by saying the Senate will never go for the AHCA. While probably true, that's not the point. I think the main goal for House Republicans was to pass something conservative enough to appease their base and to say they have done their part to fulfill seven years of promises to repeal Obamacare. Now if it doesn't become law they can blame the Senate. In fact, Senate inaction might be their best case scenario.

4) What happens if the Senate passes something different from the House Bill? Leadership from each chamber would appoint legislators to serve on a special ad hoc conference committee to hash out a compromise between the bills passed by each chamber. The negotiations would be intense but would happen behind closed doors rather than in public or on C-SPAN. That new compromise bill would then go back to each chamber for a vote.

5) Wouldn't that conference committee bill die in the House for not being conservative enough? Supporters of the ACA shouldn't put all their hope in the idea that the positions of the far right in the House are irreconcilable with the moderates in the House and Senate. The conference committee bill likely wouldn't have everything the House Freedom Caucus wants or fought to have included in the AHCA. But at that point they will already be on record voting for the more conservative bill and so might be more willing to compromise. In fact, if we get to this point I expect House conservatives to make some surprising concessions, sort of like that House Democrats were willing to accept in 2010 when the choice was between passing the Senate bill or nothing.

I watch my students face this calculation every year during our simulation at the Edward M. Kennedy Institute on the U.S. Senate (an amazing place by the way - everyone should go). The final choice facing my students is whether to let a few things they don't like stop them from voting to pass a bill they sort of like. Each year I am amazed at the compromises they are willing to accept to get a win and secure their "legacy" of having passed something - anything!

6) Who will be given credit/blamed for the effects of the AHCA? This bill is so incredibly unpopular it's hard to imagine anyone wanting credit. None of the major stakeholders on health care support the bill, including groups that have historically played a major role such as the American Medical Association (AMA). A poll in March found that only 17% of Americans liked the AHCA. House Republicans think so little of the bill they passed yesterday that they exempted themselves from being affected by any of its provisions. But they think they will be able to avoid being blamed for increased premiums and decreases in coverage because of how the bill is structured. State flexibility on Medicaid financing and essential health benefits means that the really hard choices on cutting eligibility and benefits will have to be made by state leaders.

7) What does all this mean for the midterm elections in 2018? You should have seen the disappointed look on the faces of my students when I showed them the 2018 Senate electoral map. Democrats only need a net gain of 3 seats but there are so few opportunities that it's hard to imagine this happening, regardless of how the health reform debate plays out. The left is feeling renewed excitement about the House after a strong showing in a special election for an Atlanta seat previously held by Tom Price and Newt Gingrich. Republicans have an advantage that many districts are blatantly gerry-mandered and in many cases Democrats are too concentrated in urban centers. But Democrats are targeting the handful of Republicans who voted for the AHCA even though they live in districts won by Hillary Clinton in 2016. I don't think Democrats will win back the House, but they might be able to make up important ground and narrow the margin.

8) What about the 2020 elections? OK, I haven't heard much talk about 2020, but there should be. This is a census year in which the congressional maps are redrawn. Winning big in 2010 is a major reason Republicans have dominated the House and state legislatures over the last decade. Liberals will be hoping for a similar effect in 2020 and will be heavily motivated to stop Donald Trump's second term. Health reform will be one of their major selling points. The effects will likely spill down-ballot. Republicans voting for the AHCA could survive 2018 but still be heavily vulnerable in 2020.

I'm not sure where that leaves us, but it's going to be a fascinating summer in the Senate.

Feature image: Taken by author at the Edward M. Kennedy Institute for the U.S. Senate
                    [post_title] => On to the Senate
                    [post_excerpt] => What happens now that health reform shifts to the Senate? David Jones reflects on 8 key questions. Spoiler alert: It will be tighter than many liberals hope.
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What happens now that health reform shifts to the Senate? David Jones reflects on 8 key questions. Spoiler alert: It will be tighter than many liberals hope.

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AMA on the AHCA

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Public Health Post hosted its first live event yesterday! I sat down with Editor in Chief and Boston University professor David Jones to talk about the current state of health reform politics (and North Carolina basketball). Watch the video below to hear his thoughts on why the American Health Care Act failed, what Donald Trump and Paul Ryan will do next, and what it will mean for the midterm elections. We also talked about why Members of Congress should take more road trips together.

[post_title] => AMA on the AHCA [post_excerpt] => PHP Fellow Madeline Bishop talks with PHP editor-in-chief and Boston University professor David Jones about the current state of health reform politics (and North Carolina basketball) in our first Facebook Live broadcast. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => ama-on-ahca [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:46:41 [post_modified_gmt] => 2017-09-02 02:46:41 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=1540 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

PHP Fellow Madeline Bishop talks with PHP editor-in-chief and Boston University professor David Jones about the current state of health reform politics (and North Carolina basketball) in our first Facebook Live broadcast.

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‘Home’ and Human Rights

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                    [post_content] => Aisha Yussuf Abdi, a Somali mother of seven fleeing to Ethiopia, painfully recounted her family’s suffering to Diana Diaz of the UN Refugee Agency (UNHCR): “All of our cows, everything, died before our eyes.” She is part of a desperate exodus as a result of severe drought and absence of food occurring across Africa. A continent away, the Iraqi government is intensifying military operations in Mosul and citizens are exiting en masse. Ahmad, a former tea shop owner speaking from a camp outside the city reported to Caroline Gluck of the UNHCR: “The treasure that was Mosul is gone…”

[ictt-tweet-inline]The world is facing the worst refugee and displaced persons crisis in history[/ictt-tweet-inline] as people all over the world are fleeing their homes, states, and countries by the tens of millions. The magnitude of the crisis is not something humanity has encountered before, making it difficult for the media, policymakers, and the general public to digest the seriousness of the problem. Ultimately that magnitude is ever increasing. The public needs to understand the massive scope of the situation we face as a global community. Perhaps translating data can drive change.

The Data Tells the Story

The UN Refugee Agency (UNHCR) compiles data on Persons of Concern (PoC). Persons of Concern include refugees, but also internally displaced persons, asylum-seekers, returnees, stateless persons, and a designation of ‘others.’ The total number of PoCs has tripled between 2000 and 2015. There are now four million more refugees worldwide. There is also a more than six-fold increase in the total number of internally displaced persons (IDPs), increasing from about 6 million in 2000 to 37.5 million in 2015. Some countries, such as Colombia and Syria, have seen a particularly large increase in IDPs (6.9 million and 6.6 million respectively). The global response has been alarmingly underwhelming. The total number of refugees and asylum seekers accepted by major countries only increased 1.2 million people between 2000 and 2015. The United States and the United Kingdom actually accept fewer now. This response has been like watering a forest fire with a garden hose. The Trump administration’s approach of refusing to accept refugees is effectively turning that garden hose off. Some countries have stepped up. Most notably, Germany now accepts 350,000 more asylum-seekers and Turkey accepts 2.5 million more refugees in 2015 than in 2000. Table showing UNHRC Data 2000-2015 on Persons of Concern The following GIF, made with UNHCR maps, visually conveys the rapidly progressing scale of the crisis.  

A Home as a Human Right

[ictt-tweet-inline]The global community has failed to protect the human rights and dignity of the victims of widespread disaster.[/ictt-tweet-inline] It must be understood, as the International Convention on Economic, Social and Cultural Rights (ICESCR) stated in 1966, that the inherent dignity and equal and inalienable rights of all humans are “the foundation of freedom, justice and peace in the world.” Of particular interest are articles 11 and 12 of ICESCR, which establish the right to housing and the right to the highest attainable standard of physical and mental health. For the tens of millions of displaced persons, these rights may seem more like far off dreams. If the Trump administration dismisses these rights as superfluous idealisms or ignores the plight of displaced persons entirely, it will be acting in direct contrast to the principles the U.S. was built on. The UNHCR cannot solve this crisis alone. The powerful and wealthy nations of the world, including the U.S., have an undeniable obligation to confront this massive pandemic with the full force of their laws, coalitions and resources. Nothing less is acceptable. This is a growing catastrophe that will transcend all geopolitical lines, all walls and borders, and all isolationist policies. But above all, it will define the character, compassion, and humanity of the world in the 21st century for all of history. Feature image: IRIN Photos, "Somalia1, A woman and her young children stand in the evening light at an IDP settlement in South Galkayo, Somalia with armed police standing by. Thousands of people have been internally displaced from the South of Somalia and Mogadishu by renewed fighting in the region since the Transitional Federal Government, (TFG) backed by the Ethiopians seized control from the Islamic Court (ICU) in January 2007." Photo: Kate Holt/IRIN. Used under CC BY-NC-ND 2.0/cropped from original.  [post_title] => ‘Home’ and Human Rights [post_excerpt] => There are now four million more refugees worldwide. In the face of the worst refugee and displaced persons crisis in history, powerful and wealthy nations of the world have an undeniable obligation to confront this massive pandemic. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => home-human-rights [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:50:20 [post_modified_gmt] => 2017-09-02 02:50:20 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=1233 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

There are now four million more refugees worldwide. In the face of the worst refugee and displaced persons crisis in history, powerful and wealthy nations of the world have an undeniable obligation to confront this massive pandemic.

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March Madness

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                    [post_content] => Exciting. Fascinating. Interesting. These are some of the euphemisms I use to describe what it’s like these days to be an academic whose focus is the politics of health reform. Madness is a better word.

In the past 24 hours alone, Republican leadership has done everything they have attacked Democrats for over the last seven years. They are rushing legislation without giving the public or even each other time to know what they are voting on. It says a lot that Republicans passed a bill through multiple committees without a CBO report and that they are pushing to vote on the amended bill without an updated CBO score. They are adding sweeteners reminiscent of the cornhusker kickback. They are creatively spinning the implications of their reform for regular people. The campaign ads make themselves with quotes from President Trump and others far more egregious than “if you like your insurance you can keep it.” Ezra Klein says the AHCA could be Trump’s Iraq War because it was “sold on lies, poorly planned, deadly to thousands, and a catastrophe for its authors.”

The changes happening in the House right now make it clear that [ictt-tweet-inline]the Republican plan is a political solution to a political problem, not a policy solution to a policy problem[/ictt-tweet-inline]. After seven years of campaigning on repealing Obamacare, Republicans need to pass something – ANYTHING – to give them enough cover to move on.
In the past 24 hours alone, Republican leadership has done everything they have attacked Democrats for over the last seven years.  

“A Big Fucking Deal”

The 7th anniversary of the ACA’s passage has been honored in lots of different ways. Joe Biden returned to Capitol Hill yesterday to join Nancy Pelosi, Chuck Schumer, and other Democrats fighting to save the law. Medicaid enthusiast and former HHS staffer Emma Sandoe baked her annual birthday cake for the law, this time adding a 7th layer. One of the main reasons Paul Ryan seems to be pushing so hard for the AHCA vote to happen today seems to be for the symbolic effect of repealing the ACA on its anniversary. That would be a pretty big deal. But so would the AHCA’s defeat.

Political Realities

As I write this it is unclear whether the AHCA passed the House or even whether Ryan actually goes ahead with the vote. (Update at 5pm on 3/23: The vote has been postponed, supposedly until tomorrow morning). There are reports that he is willing to play a high-stakes game of chicken by holding the vote even if he is unsure he will win, daring conservative and moderate Republicans to follow through with threats to vote against Obamacare reform. Regardless of what happens to the AHCA in the House, there are six political realities that will drive the next chapter in the fight over health reform: 1) Most of the compromises designed to win support in the House make it harder to pass the bill in the Senate. It will be very hard for moderate Republican senators in states that have expanded Medicaid to vote for the AHCA – especially in states with Republican governors advocating for stability. 2) Paul Ryan knows this. The goal isn’t to convince the Senate to pass this version of the AHCA. The goal is to make it to a conference committee where the true compromises will happen. That final negotiation is easier if the House and Senate bills are close to each other, but passing just about any version of an ACA repeal and replace bill gets Republicans to that crucial juncture. 3) The clock is ticking. Republicans are well ahead of schedule compared to where Democrats were at this point in 1993 and 2009 in terms of moving legislation. They may pay the price for moving too quickly, not doing the work to build consensus. But passing such a complex law will only become more difficult the longer they wait, distracting from other parts of the Trump/Ryan/McConnell agenda and becoming increasingly ensnared in midterm politics. If the AHCA fails it is hard to imagine Republicans regrouping in such a way to pass something else. Republicans are highly aware that Democrats suffered historic losses in 1994 and 2010 after spending so much political capital on health reform. However.... 4) The midterm map in 2018 favors Republicans to such a great extent that Democrats will have a difficult uphill battle to take back control of either chamber, regardless of the AHCA’s outcome. With some exceptions, Republicans are more likely worried about challenges from within their own party than from the left. Will a Republican primary opponent criticize the incumbent for taking away insurance from millions of people? 5) The most important person in the fight over health reform is not Donald Trump, Paul Ryan, or Mitch McConnell. It’s Elizabeth MacDonough. As Senate Parliamentarian she will be called on to make crucial rulings about issues such as whether the provisions added at the 11th hour prevent the Senate from considering the AHCA through the reconciliation process. If not, Republicans will face tough choices about how to maintain conservative support while taking elements back out, whether to try to win over some Democrats to get to the filibuster-proof majority, or whether to go nuclear and change Senate rules governing the filibuster. 6) Republicans now own the problems of the U.S. health care system. Even successfully passing a law won't help them in the long-run given that nothing they are proposing solves the underlying problems of cost and access to care in America. While watching the Michigan game tonight (Go Blue!) I will have an eye on C-SPAN and my Twitter feed. I’ve restrained myself from over-extending the analogy between health reform and the NCAA tournament, but both are turning out to be pretty exciting – or dare I say, maddening. Feature image: North Charleston, Boeing 787-10 rollout with President Trump, used under CC BY-SA 2.0, cropped from original Cake photo by @emma_sandoe [post_title] => March Madness [post_excerpt] => Chaos ensues on the 7th anniversary of the ACA: PHP editor-in-chief David K. Jones gives us six political realities that will drive the next chapter in the fight over health reform.  [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => march-madness [to_ping] => [pinged] => [post_modified] => 2017-09-01 22:48:10 [post_modified_gmt] => 2017-09-02 02:48:10 [post_content_filtered] => [post_parent] => 0 [guid] => http://www.publichealthpost.org/?post_type=bu_news&p=1472 [menu_order] => 0 [post_type] => bu_news [post_mime_type] => [comment_count] => 0 [filter] => raw ) [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [view] => BUPHP_Post_View Object ( [multipage] => [extra_args] => Array ( ) [owner] => BUPHP_Post Object *RECURSION* [_trigger_error:WPLib_Base:private] => 1 ) [extra_args] => Array ( ) [owner] => [_trigger_error:WPLib_Base:private] => 1 )

Chaos ensues on the 7th anniversary of the ACA: PHP editor-in-chief David K. Jones gives us six political realities that will drive the next chapter in the fight over health reform. 

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Public Health Post: Live from the Red Carpet

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                    [post_content] => In celebration of the 89th Academy Awards, the Public Health Post editorial team looks back at our favorite movies with public health themes. Whether we’re watching Marion Cotillard stop a pandemic with the World Health Organization in Contagion or Richard Gere confront HIV in And the Band Played On, these films tackle conversations on public health. If you’re looking for a way to nerd-out over social determinants on the big screen and you missed Ohio State University College of Public Health’s list from 2013, here’s ours. Tag us and your votes with #publichealthmovie on Twitter.

And the Oscar goes to…

1)    13th (2016)
An in-depth look at the prison system in the United States and how it reveals the nation's history of racial inequality.

2)    Contagion (2011)
Healthcare professionals, government officials and everyday people find themselves in the midst of a worldwide epidemic as the CDC works to find a cure.

3)    Food, Inc. (2008)
An unflattering look inside America's corporate controlled food industry.

4)    Still Alice (2014)
A linguistics professor and her family find their bonds tested when she is diagnosed with Alzheimer's Disease.

5)    Living in Emergency (2009)
In the war-zones of Liberia and Congo, four volunteers with Doctors Without Borders struggle to provide emergency medical care under extreme conditions.

6)    Sicko (2007)
A documentary comparing the highly profitable American health care industry to other nations, and HMO horror stories including shotgun deaths.

7)    And the Band Played On (1993)
The story of the discovery of the AIDS epidemic and the political infighting of the scientific community hampering the early fight with it.

8)    Wall-E (2008)
In the distant future, a small waste-collecting robot inadvertently embarks on a space journey that will ultimately decide the fate of mankind.

9)    The Invisible War (2012)
An investigative documentary about the epidemic of rape of soldiers within the US military.

10)  It’s a Girl! (2012)
Every year in India and China, millions of babies are killed, neglected or abandoned simply because they are girls.

Feature image: mark lorch, cinema seats, used under CC BY NC 2.0/cropped from original 

Movie summaries from IMDB.com
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In celebration of the 89th Academy Awards, the Public Health Post editorial team picks our top ten favorite movies with public health themes.

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