Trump had originally stated he'd replace the ACA with a new plan. Now he is saying he’ll keep some key elements and replace others. What changes do you think he’ll make? How could this affect Americans’ health care? Their peace of mind?
The Republicans have painted themselves into a bit of a pickle with this one. They opposed the ACA vociferously at its inception and have voted some four dozen times to repeal it. But, each time they voted, they did so with the knowledge that President Obama would veto their vote. Thus, they could earn plaudits with the far-right anti-Obama base without having to content with the fallout of actually killing the program. If they vote to repeal now, Trump will likely sign the new vote into law, immediately throwing some 20 million Americans off of the insurance rosters. Such a scenario would create hundreds of vignettes for Democrats to capitalize on politically – cancer patients who suddenly cannot afford their chemotherapy; accident victims thrown out of critical care units; etc. Moreover, 33 state governors who expanded Medicaid under the law’s provisions would be forced to fund the expansions entirely with state funds (at present, the federal government is picking up more than 90 percent of the cost of the expansion). Many of these governors are Republican, who work with Republican-dominated legislatures. All-in-all, many Republicans have a good deal vested in the continuing success of the ACA.
I suspect that the Trump White House will carefully roll back a few provisions of the law (the universal mandate, for example, requirements for employers to provide coverage, and accountable care organizations) while maintaining the bulk of it (Medicaid expansion, insurance regulation, exchange subsidies).
The law is flawed in ways too complex to discuss here. In the long-term, there will have to be a bi-partisan effort to truly re-make healthcare through price transparency, primary care training subsidies, certificate of need oversight, prescription drug price regulation, and more. I don’t think that President-elect Trump has the stomach to take this on, but an emerging class of technocrat Republican congressional leaders may choose to try.
Tell us about your current research on the obesity epidemic in our country.
I am convinced that obesity is the great scourge of our time. Rates have skyrocketed in the past generation, particularly in the young, leading to an epidemic of Type II diabetes, in addition to the collateral damage to joints, heart health, vascular health, and psychological well-being. I am writing a book-length study of obesity as it has evolved since 1950, paying particular attention to its social determinants. That is, I think that we all have less control over our eating and physical activity than we think we do, and thus an ultimate solution to the epidemic must lie with re-structuring our environment rather than shaming people into eating differently. Our adult overweight rate has grown from about 5 percent in the 1930s to nearly 70 percent today (yes, over two-thirds of American adults are overweight, although you would not know it walking around Manhattan). If you think about it, the problem cannot be simply one of “character” or “self-restraint.” Our moral fiber did not simply whither over the course of two generations, and many overweight people function at high levels with great discipline and focus in other area of their lives. Rather, the environment has changed drastically in over these decades, as has the shape of our daily lives.
I also think that it’s helpful to think of over-eating, particularly carbohydrates, as more akin to a substance disorder. We help alcoholics cope with their disease, in part, by removing the alcohol, and other triggers. Alcoholics know not to keep liquor at home, and avoid walking into bars, parties, and other trigger situations. Yet, we seem to have the idea that any one of us can walk through aisles of candy en route to a prescription counter without succumbing to temptation. We have created what I call an obesogenic environment: one in which the odds are heavily stacked against most people trying to maintain a healthy weight.
What sets apart the Marxe School of Public and International Affairs from the other institutions you’ve taught at?
I would say that extraordinary diversity of faculty experiences and robustness of the faculty research efforts distinguish the Marxe School from other places I have taught. I have been at Marxe for nine years, and I love it. My colleagues have served at senior levels in City Hall, city and federal agencies, and legislative bodies. I have other colleagues who have had successful careers in journalism, civil rights advocacy, and budgetary affairs. They conduct research into geo-spatial mapping, NGOs and civil society, healthcare outcomes, the use of humor in political discourse, social networks in university life, demographic patterns in immigrant success, and the efficacy of social welfare programs. Just last week, we were all treated to hearing one of my colleagues relate his research on the rise of the Alt-Right movement in American politics, and its prospects for influencing the incoming administration. It’s a heady mix, and a constant stimulus to explore new questions in public policy and administration.