What Do the 2018 Midterms Mean for Public Health?

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: with the midterm elections behind us, it's time to consider what might be ahead of us as we prepare for a divided Congress in January and its impact on public health.

EMILY HOLUBOWICH:

What's interesting to me about bipartisanship is that both Democrats and Republicans seem to fight it, but when they do it and it works, they love it. It feels good to work together. It feels good to get things done.

JAY BUTLER:
When we're talking about health, even though many of the solutions may have partisan differences, the need for public health action and the desire for everyone to be healthy is truly not something that is driven by party.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

Today, we explore America's decision to give Democrats control of the U.S. House and keep Republicans in charge of the Senate, and we ask whether this new Congress will affect your work in public health. Shortly, we'll hear from ASTHO's past president and Alaska's former commissioner of health and human services, Dr. Jay Butler.

But first, we're talking with Emily Holubowich, executive director of the Coalition for Health Funding here in Washington, D.C. Her view: changes coming where you would expect given the results.

HOLUBOWICH:
So, in terms of policymaking, I personally don't see a lot changing—I think a lot of the dynamics will be the same. What will be different are the political dynamics. And so, I think what was already a politically vitriolic environment potentially gets worse.

Of course, the presidential election cycle again on November 7th, so we were already in that. We've got a running list of about 35 Democrats who say they're running or thinking about running for president in 2020, we've got Republicans already starting to investigate that. So, that is already happening and will begin to kind of consume the political environment. And so, everything that's going to be happening is through that lens.

I think also what will overshadow any policy-making will be oversight and investigations in the House of the Trump administration. And so, that's going to suck a lot of the oxygen out of the room. And I think that, on top of entering into a presidential election cycle, is going to make bipartisanship very hard and very challenging, and that's what's going to be required in order to move any meaningful legislation.

So, I think we'll have a lot of fits and starts. We're going to come out of the gate hot—you know, everyone's going to want to get their priority on the new members agenda—and we'll see a flurry of legislation coming out early on in the House. But that's probably about as far as it goes, and I think much of what we're going to feel over the next two years is going to feel a lot like the last two years where we haven't seen, frankly, much progress on the legislative front.

JOHNSON:
What issues do you think will become legislation now that the Democrats are running the House, whether they go on anywhere or not? What are they going to do with their lawmaking authority as it relates to public health?

HOLUBOWICH:
That's a great question. I think opioids will continue to be a priority for Democrats and Republicans—it seems to be the one issue that's bringing them together.

I think, you know, one issue to watch is going to be continuing around infectious disease—we have right now the E. coli outbreak, we have the acute flaccid myelitis cases that are occurring, you know. And so, while politicians can kind of spin their wheels and get stuck in gridlock, microbes continue to evolve and so we're going to continue to see new diseases and emerging infections as well as infections that we know of that are re-emerging—what's happening in the Democratic Republic of the Congo around Ebola and whether or not they can contain that virus. So, I think a lot of the same issues that are confronting public health—natural disasters—are going to continue to be a focus for both Democrats and Republicans.

One area that I think will be very interesting—and even seeing some Republicans early on coming out, Senator Ben Sasse, for example, taking various seriously—the Trump administration's report on climate change and what that means for humans, both in terms of natural disasters—as we're seeing in the California wildfires, as we're seeing in more intense and more frequent hurricanes—and the impact on vectors: ticks, mosquitoes, other vectors that transmit illnesses. It will be interesting to see, you know, do we see a shift now away from the, "climate science is fake science" sort of debate that's I think consumed politicians to the federal level, and to see what kind of a softening of that approach and a more bipartisan approach to climate change as a public health issue will be very interesting.

And that's one certainly you could see Democrats in the House taking the lead on, but I think more and more Republicans are going to be more vocal about that, especially as they're hearing from their constituents about—in affected areas in the South and Midwest and the West who are really feeling the effects of climate change already—and kind of saying, "What are you going to do about this?" So, that may be an interesting opportunity for bipartisanship, as well.

JOHNSON:
There wasn't much that happened when Republicans had control of everything. Now, the Democrats have a piece of the pie, moreso than in the past, with the House. It would be refreshing to be able to see some coming together on things like opioids or some of these infectious diseases. Is that just wishful thinking?

HOLUBOWICH:
I don't think so. You know, it's happened in the past, certainly—and opioids is a great example of this—of where folks are able to come together and work together to make real change, so I'm an eternal optimist.

You know, I also like to remind people—you know, I think myself included—you know, we get really frustrated that things don't happen more quickly, that things don't get done. It's why I think the latest sort of polling of Americans, you know, cockroaches have a higher approval rating than members of Congress—I'd love to meet who those folks are that love cockroaches.

But at the same time, when you poll Americans—it might be different after this last election—but in general, they like the person that represents them in Congress. So, they don't like the body of Congress per se, but they like their own member of Congress. And that's part of the problem, you know, and that is partly a function of gerrymandering and, you know, other issues that have sort of tilted the playing field and sort of, if you will, codified the sort of extreme polarization of the parties and sort of resulted in the disappearing center.

But you know, this was sort of the vision of the founding fathers. Our government is designed to be slow. Things are not supposed to happen quickly. That was the whole point of having bicameral legislature, different parties, separation of powers, three branches of government—that was kind of the whole idea, you know.

So, on average, you know, meaningful policy legislation takes seven years. And there are examples where, if you look at opioids, where we're ahead of the curve on that, you know. So, I think there are definitely opportunities—it is possible, I am an eternal optimist. That said, things were designed to happen slowly, and so they probably will.

JOHNSON:
So that said, is ACA out of the woods?

HOLUBOWICH:
You know, I think—given you have now a Democratic House and you don't have the votes in the Senate—for now, I think the ACA from a legislative standpoint is off the table. Certainly through the administration and the regulatory process, there's a lot of opportunity to make changes, as we have seen. I mean, the most significant changes to the Affordable Care Act have been all through executive order and regulations, or lack thereof. So I think, you know, there's still potential there to tinker around the edges of the ACA.

What I think is really interesting though, you had these two major wave elections in 2010 and now in 2018, and they were both health are elections. And in 2010 it was, "We hate the Affordable Care Act." And then in 2018 it was, "Don't you dare touch the Affordable Care Act!" To see that flip within a decade is really fascinating.

And so I think, you know, the next logical step in the American journey of health reform is going to be, looking forward, how are we expanding upon the Affordable Care Act? It doesn't mean it's not going to change, but I think there's an interest in—certainly among the Democrats—in doing more and building it out to actually achieve that goal of universal coverage, which of course the Affordable Care Act does not do.

So, now, is that going to go anywhere in the Republican Senate? Probably not. But I think you could see significant changes around healthcare costs. Drug pricing in particular is a real hot topic for both, I think, Democrats and Republicans. And, you know, if any of those folks that want to be president in 2020 are paying attention and they're in Congress right now and looking at this last election has healthcare as the number one issue, they're going to be wanting to be right out in front and pushing whatever health reforms are kind of most progressive, most disruptive, innovative to really appeal to voters in advance of 2020.

JOHNSON:
So, in terms of getting something done along the lines of healthcare which affects public health, it's possible?

HOLUBOWICH:
It's possible; certainly around drug pricing, I think you could see some legislation there. I think there is really fascinating growing recognition that as long as we are focused only on healthcare and the treatment of disease, we're never going to get ahead of the curve; that in order to really improve health, we need to work on preventing people from getting sick in the first place. As we look at all the drivers of healthcare costs, 75% of what we spend in healthcare is on preventable chronic disease. How do we get in front of those issues?

The Affordable Care Act was a step toward that in sort of addressing prevention and population health. There are opportunities to build on that. I think, interestingly, in the Trump administration Secretary Alex Azar has talked about new demonstrations that the Center for Medicare-Medicaid Innovation—CMI—that will allow Medicaid to pay for things like housing and the social determinants of health. You know, I don't think anyone would have expected to see that coming out of the Trump administration, that that would be this new innovation around and focus on social determinants of health. So, I think that's a really exciting opportunity and we may expect to see that built upon kind of going forward.

And if there are any major changes in health reform, really looking at the Affordable Care Act as the foundation for integrating population health and healthcare, that we only go up from here, which is really exciting.

JOHNSON:
A lot of people in our audience are always interested in the emergency response fund. What do we think will happen with that in this new world order?

HOLUBOWICH:
Great question. So, I think that there will be an interest in growing that emergency response fund. That's something that Congresswoman Rosa Deloro, who's currently the ranking member of the Labor HHS Appropriations Subcommittee—that's the subcommittee that has jurisdiction over public health funding, and she is expected to be the chair—that she has talked about really wanting to expand.

And the idea behind the emergency fund is that it provides sort of seed funding in the event of an emergency to support boots on the ground quickly while the administration and Congress, you know, prepare emergency supplemental spending requests. I think this has always been an idea, but really picked up—and I think really drove the point home the need for this—was around the Zika virus and the fact that it took nine months to get that funding for that response, which was frankly unacceptable, you know? And so, that is another bipartisan idea that I think has a lot of support and where we could see some interest.

What will also be interesting on the funding front is that, you know, over the last eight years, we've seen a lot of interest in supporting the National Institutes of Health and a lot of investment in biomedical research. And typically—I'm overgeneralizing—but when Republicans talk about health funding, they automatically, "Oh, we love the NIH." And as an advocate, we have to remind them, "Well, there's a lot of other things, too." You know, there's the Centers for Disease Control and Prevention, that's important. But typically, you know, Republicans put all the funding eggs in the NIH basket.

Democrats, of course, love to fund everything. And so, you know, it will be interesting to see that the Democrats in the House, you know—I think my prediction is there will be an interest in sort of spreading the wealth around. You know, so we're not going to see $2 billion increases a year for the National Institutes of Health—I think they'll probably still get an increase 'cause Democrats love the NIH too; but they are going to look at other areas of Department of Health and Human Services—HHS—and say maybe where have we been underinvesting. CDC, I think, is going to be among one of those next top priorities.

And so, it'll be interesting to see how Democrats in the House approach appropriations bills, cause they love all the children, they want to fund all the children. Are they going to now say, "Okay, NIH, you've gotten $10 billion of the last 10 years, now it's time to look at some of these other areas." And that would be my prediction, is that they will spread the wealth a little more equitably across the HHS agencies.

JOHNSON:
And that is next year's budget. We are coming into the end of 2018—what is the projection for the end of this year? And then we'll talk about next year overall.

HOLUBOWICH:
Sure. So, for the end of this year, this is a remarkable historic year. For anyone who pays attention to the budget, this year was the first time in 22 years that Congress enacted spending bill for most of HHS—including the Centers for Disease Control and Prevention—on time before the end of the fiscal year. Last time that happened was 1996.

So, as a public health advocate, we're largely done. The major buckets of funding that we care about: CDC, substance abuse, mental health services, administration, HRSA—Health Resources and Services Administration—National Institutes of Health; they're all done for this year.

JOHNSON:
Next year, you don't think that budget process is going to be so quick, though?

HOLUBOWICH:
No, and there are a couple of reasons why. Part of the reason this year, I think, for several of the bills—five of the major spending bills, including that that funds HHS—several factors.

One, Congress had spent a lot of time and did so very late—early this year, in fact—negotiate a bipartisan budget agreement to stop sequestration, the cuts that affect all domestic and defense programs, and it resulted in the largest spending increase for domestic programs since the stimulus. And so, it's amazing how easy it is to move appropriations bills when you actually have money to spend, when you don't have to cut things. So, I think that was a major contributing factor to the reason we were able to get so many appropriations bills done, including labor HHS—which has always the hardest, always the most controversial, it's the largest of the domestic spending bills—and to get it done on time.

The other, I think, is the unpredictability of the president and he likes to keep people guessing. And I recall distinctly on March 23rd, we had a continuing resolution, we got word that an omnibus spending bill had been negotiated. And then a tweet went out that he didn't know if he was going to sign it or not. And I remember very distinctly that day, going back and forth with my colleagues on email, on Twitter, what's he going to do? And ultimately he signed it, but he did say in that press event, "This is the last time I will sign a omnibus spending measure that has all 12 spending bills. And I think Congress took him very seriously. And so, that really motivated them to get as many spending bills done as they could through regular order during the appropriations cycle.

What we don't have coming into this year: we don't have a budget deal, and we're going to need a budget deal, I think, to move forward. The budget deal that was negotiated this year for two years actually expires at the end of fiscal year 2019. So, as we're preparing to do fiscal year 2020 in January and write those appropriations bills, we don't actually know how much money we have to spend.

If we're going under current law, there's a huge funding cliff. We are $55 billion below where we are now for non-defense discretionary programs, including public health. So, if I'm an appropriator and I'm writing to that level, I get to make massive cuts to everything. And so, until lawmakers know how much they have to spend, it's going to be really hard to write spending bills that are meaningful.

I think Democrats could come out and say with a budget resolution, "Well, we're going to assume this will all be worked out and this is the level that we want,"and it will probably be higher than what we have now. In the Senate, Republicans are going to say, "Well, maybe we're going to do a budget resolution, maybe we're not. Who knows what levels we're going to write to. Maybe we'll write to current law," which is that $55 billion cut, "or maybe we just make it up." But until there is another bipartisan budget agreement to avoid that funding cliff and stop sequestration, it's going to be really hard to do anything.

Now, I think we're going to get there. It may take some time to get everybody to come to the table. Part of the reason I think we get there is that, while domestic programs are going over to this funding cliff, the Department of Defense is as well. The president has made pretty clear he is not interested in cutting military funding, certainly not to the level that would occur when the current budget agreement expires. And Democrats have been, for the last eight years, saying, "We will not support any spending bill that increases defence that doesn't increase non-defense programs." And so, this dynamic comes into play.

And I, again, I think we're going to get there, but if I'm looking at history as a guide, there is going to be a lot of flag in the ground, I'm not moving, you're not moving, we're going to go back and forth, and we're going to do this dance, and we're going to pretend that we're not going to agree. But eventually, you know, the four corners of leadership, House and Senate, are going to come together with the White House in there to say, "All right, we're going to work this out."

So, I do think we get another budget deal. We're already three for three, so we have a pattern. It's hard to see us now suddenly saying, "No, we're not going to do it," when we've done three budget deals already. But I think it's going to be a lot of fits and starts. And so, what does that mean for public health and folks that rely on federal funding? Kind of go back to where we were just last year, where we're going to have probably multiple continuing resolutions, threats of shutdowns, it is going to happen or not, what's our funding level—we don't know, and that is extremely frustrating.

I know public health professionals don't like the uncertainty, they don't like instability. It is not efficient, it is no way to run a railroad. But at the same time, we've been through this before, so we know what to do. And it's not ideal, but that's sort of the unfortunate reality until, you know, lawmakers can kind of come together and figure it out.

JOHNSON:
Well, and that was going to be my next question or point: this is not unfamiliar territory.

HOLUBOWICH:
No. So, at least for the last 22 years, we've had at least one continuing resolution for public health since 1996. So this year, the year of regular order is really the anomaly. It's the irregular order that's become the regular order. So, we're going back to that. And then, you know, unfortunately, you know, I think we can hope going forward that maybe there are opportunities to right this process again, right the ship.

What's interesting to me about bipartisanship is that both Democrats and Republicans seem to fight it; but when they do it and it works, they love it. It feels good to work together. It feels good to get things done. You know, it was amazing to me, you know, just the energy and the excitement of both members of both parties around finishing at least five appropriations bills on time.

And I remember, I recall a couple of other appropriators who I know—won't name, but you know, are pretty outspoken on this—but saying, "You know, it's kind of ridiculous that we're patting ourselves on the back for doing our constitutional duty. I mean, this is like the one thing in the Constitution we're required to do is appropriate and yay, look at us, we got half the job done on time!" But it's a big deal, and it is to be celebrated.

I was excited as well because now I'm like kind of, you know, get to sit back this fall and not worry about—all my colleagues are worried about the shutdown, and I'm like, "Oh, you know, I'm good." Although I have two of my agencies that are still not funded—FDA and the Indian Health Service, but yeah.

You know, bipartisanship, it feels good when it works. And so, you know, I think the more Congress can kind of come together and have those wins, you know, they kinda, you know, get excited about it and say, "Hey, let's do a little bit more of this." So even in the non-public health area, I think opportunities for compromise around criminal justice reform—again, if you can get a win on that, it's like, you know, it builds momentum and then it snowballs like, "Hey, let's work together on something else."

So, and I think across the board in public health or not, any bipartisan legislation is exciting and is good news for all of us, because I think it just breeds the opportunity for cooperation and collaboration, which is exciting.

JOHNSON:
Even though both parties will be in charge starting next month, Dr. Jay Butler isn't rattled by the voter's decision to shake things up in Washington. In fact, he reminds us that we've been here before.

BUTLER:
Well, I think it's important to recognize that when there's a split in the powers by the political party, sometimes that may slow things down; but also its important to recognize that important work will continue to get done. I think we can see that in some of the actions that have taken place over the past few months in terms of passages of the SUPPPORT Act to address the opioid epidemic, as well as a bipartisan agreement in support the emergency response fund for public health.

In my experience in Alaska, we certainly saw that the opioid crisis is a non-partisan issue that can have bipartisan support. We had a requirement for a statutory authority for a standing order for naloxone under the chief medical officer and—a little background on Alaska, I served an independent governor, and we had a Republican-controlled Senate and a primarily Democratic-controlled House. Yet despite that, it was six days from introduction of the bill to it signing by the governor.

So, people can work together on important issues.

JOHNSON:
We shouldn't be sitting here thinking, you know, my gosh, nothing will get done. The world continues to revolve and things happen. So it's possible, right?

BUTLER:
It is indeed possible. And it's important to recognize that when we're talking about health, even though many of the solutions may have partisan differences, the need for public health action and the desire for everyone to be healthy is truly not something that is driven by party.

JOHNSON:
I suppose these days, given the fact that one party controlled all of Congress for the last few years, we can't even really say that a divided Congress will slow things down. It just really is hard to predict these days, right?

BUTLER:
Well, I have had experience in the past of serving under a different governor who was the same party as both of the legislative bodies, and politics was still alive and well. So, I think it's important to recognize that even within parties, there are differences of opinion and not everything that's put forward becomes a slam dunk.

JOHNSON:
Do you see any new issues moving to the top of the agenda because of what's happened in the midterms?

BUTLER:
Well think the passage of the SUPPORT Act is important because it's begun to expand the discussion of the opioid crisis to a broader discussion of substance misuse and addiction, as well as some of the social determinants of health that have created fertile ground for the opioid crisis to occur.

Specifically, I think the broader view of responding to illicit drugs—that it's not just the criminal justice issue, but it's also not just a health issue, it's not just an education issue, but it's really a broad problem that requires a more holistic and coordinated response—is something that I find very encouraging that I hear policy makers now talking about. That, for instance, the SUPPORT Act really goes far beyond just providing naloxone and addresses issues related to access to treatment and even some of the concepts of trauma-informed care, which I think are going to be important to long-term solutions to both the opioid crisis as well as some of the longstanding health issues that we've had related to substance misuse.

JOHNSON:
When state health officers are talking to members of their own Congressional delegation now—or coming back to Washington in the spring or the annual visits here—does the message change given the circumstances, or is it still the same?

BUTLER:
Well, the Congressional delegations represent the same constituencies as the state health officials. So, it's important to recognize that they're going to want to talk about the home turf.

But for the state health official, it's important to recognize that the Congressional delegation is also looking at the national picture and national policy. So, they are going to be visited by many other players than just folks from back home.

So, it does take a broad understanding of what some of the national issues are and what are the ongoing debates on Capitol Hill and not just what's going on back in the state capitol. It takes a broader horizon to, I think, to be able to provide the support to the Congressional delegations that will be most helpful.

JOHNSON:
So you're encouraged, then, that the good work of the states and territories can continue in this environment?

BUTLER:
I really am positive. I think, you know, it's important to recognize, though, that even with the vision of improved public health—I think it was actually Congressman Hal Rogers might be the one who said that vision without funding is hallucinations. So, that's why I have pointed to not just the authorities that have been approved, but also some of the funding to be able to actually implement the policies that have been passed.

JOHNSON:
The budget certainly will be an interesting process to watch in 2019 with Democrats running the House and Republicans running the Senate. There may be a little more negotiation involved in this time.

BUTLER:
Well, there certainly may be. I think it was Niels Bohr who said it's hard to make predictions, particularly about the future—that's usually attributed to Yogi Berra, but it sounds like something Yogi Berra would say, but I believe it was actually the physicist Neil Bohr—and it is very true, regardless of who said it.

JOHNSON:
What is your advice for public health colleagues, then, as they enter the new world order?

BUTLER:
Well, before we talk about, you know, how to anticipate or how to respond to what's playing out, let's go back to the earlier question and discuss it a little further. I think the approach to the new landscape in DC and what that means for budgeting again highlights the need to be able to be agile and to be responsive.

And it's important that state health officials take time to get to know their Congressional delegations; of course work with your governor's office to make sure that they're aware and that you have their blessings in doing that. But ideally, your senators and Congresspeople should have your cellphone and be able to consult with you as quickly and as often as needed.

And also recognize that you may not always be contacted by the elected official, but their staff are very influential and important people for you to know and talk to as much as you possibly can.

JOHNSON:
You wouldn't say that this is cause for concern or alarm that we have both parties running the show now in Washington—I mean, we can work through this, right?

BUTLER:
Yes. We've seen this movie before; and while it's a different landscape, as I was saying earlier, it's not a reason for panic. It's just a different strategy may be required. Keep in mind that developing policy as well as the practice of public health is really a team sport and it requires everyone working together.

It's important to realize that in the political realm, you may feel like you have a few real friends, but you probably have few real enemies also. And while you may have to take some lumps in the public arena, that is part of the political game, particularly if partisan aspect comes into play. Ideally, the state health officials—and this is one of the, I think, the values of the Association of State and Territorial Health Officials—are able to be more purple than red or blue, and really look for consensus approaches.

JOHNSON:
As we wait to see how last month elections will impact public health programs, learn more about ASTHO's advocacy priorities and federal government affairs activities by visiting the website, astho.org.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.