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May 29, 2025
Quarterly Article
Alan B. Cohen
Apr 24, 2025
March 2025
September 2024
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At his Senate confirmation hearing last December, Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. assured Senator Bill Cassidy, a physician, that he would take a measured approach to federal vaccination policies and would focus his energy on fighting chronic diseases. Upon taking office in January of this year, Mr. Kennedy promised “radical transparency” in his agency’s actions. However, despite these pronouncements, Mr. Kennedy’s opaqueness on many public health issues has been blinding. He has underplayed the severity of the measles outbreak in Texas and New Mexico that so far has exceeded 1,000 cases and has led to 3 deaths; he has promoted unproven treatments like Vitamin A and cod liver oil as preventive measures for measles, and he has said that vaccination is “a matter of personal choice.”
Mr. Kennedy is aligned with the “Make America Healthy Again” (MAHA) movement. Have you ever wondered what MAHA really means? The poor health of the American population relative to that in other nations — specifically, declining life expectancy, high rates of various chronic diseases, and high infant and maternal mortality rates — is well documented. Mr. Kennedy and the MAHA movement would have you believe that these longstanding health problems can be effectively mitigated in short order by ridding the food supply of food additives and chemicals, by eliminating fluoride from public water supplies, and by avoiding vaccines for many preventable diseases. He has called the COVID mRNA vaccines “the most deadly vaccines in history” despite clear evidence that it has saved millions of lives globally. And he has indiscriminately cut thousands of positions in his department, weakening the National Institutes of Health, the Centers for Disease Control and Prevention, and many other federal agencies that play vital roles in public health and epidemiologic preparedness.
Imagine my surprise when Mr. Kennedy recently testified before the Senate that his opinions are irrelevant and that people should not take medical advice from him. What an astounding statement! If the American public cannot rely on the Secretary of HHS for sound, evidence-based medical advice, then who can they trust? Mr. Kennedy’s statement only reinforces his lack of qualifications for such an important government position. The American public deserves better.
One of his most egregious actions as Secretary has been to promote the long-discredited connection between vaccines and autism. Although the lack of evidence of any such connection is well established in the scientific literature, he persists in seeking answers that fit his pre-conceived theories. That’s why he hired a discredited researcher and vaccine skeptic to undertake a study to determine the causes of autism. He’s desperately seeking a connection between autism and vaccines to bolster his theories. This simply is bad science. As the late Senator Daniel Patrick Moynihan famously said, “Everyone is entitled to his own opinion, but not his own facts.” In this case, Secretary Kennedy believes he is entitled to his own science.
Mr. Kennedy is neither a physician nor a scientist, and his “science” is ethically irresponsible. Despite his claim that his views are irrelevant, in truth, it is his worldview that is driving policymaking within HHS, including an FDA policy to mandate placebo-controlled trials for all new vaccines. New vaccines should be tested head-to-head against proven vaccines that already exist, not against placebos that would pose unnecessary risk for thousands of individuals in clinical trials. This policy undoubtedly will delay the development and approval of new and more effective vaccines for many diseases, including influenza, COVID, HIV, and respiratory syncytial virus (RSV), among others. If Mr. Kennedy is truly committed to improving the health of Americans, he should facilitate the development of the next generation of mRNA vaccines rather than place regulatory obstacles in its path under the guise of “more rigorous safety testing.”
In case you are wondering how far Mr. Kennedy will go to pursue his theories, consider the fact that he recently persuaded President Trump to appoint Casey Means as U.S. Surgeon General. Dr. Means does not have an active medical license and lacks a background in public health. She is an entrepreneur who has praised unproven psychedelic therapy and touted the benefits of MDMA (also known as ecstasy) for helping people with post-traumatic stress disorder (PTSD). The Food and Drug Administration last year declined to approve the use of MDMA for treating PTSD, stating that the research was flawed and that its use contained significant risks. Her appointment as Surgeon General appears to be motivated primarily by the fact that her worldview of health aligns closely with that of Secretary Kennedy.
Once again, it would seem that kakistocracy is alive and well in the halls of HHS. Can the appointment of Sybil the Soothsayer be far behind?
In view of these developments and the continued onslaught of Trump executive orders (151 at last count – many of which focus on health), we invited leading thinkers and researchers to write opinions on the potential health effects of Trump administration actions. Recent contributions include:
For insightful commentaries on these and other policy issues, we invite readers to visit the Quarterly’s website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/).
In this issue of the Quarterly, readers will find two insightful Perspectives and eight original scholarship articles. Policy topics include commercial determinants of health, care redesign principles, Medicaid enrollment before and after the Affordable Care Act, the effects of Medicaid expansion on cardiovascular disease outcomes, the consequences of unpredictable insurance coverage, a statewide contraceptive initiative in Delaware, lessons learned from an evidence-based community health worker program, a longitudinal study of suicide trends and police-perpetrated killings in the United States, the relationship between incarceration and emergency department visits among Black Americans, and state health care cost commissions.
Commercial practices increasingly influence population health, often in negative ways. In “Towards Monitoring and Addressing the Commercial Determinants of Health: Where Can We Go from Here?” Raquel Burgess and colleagues outline ways to develop systems for monitoring commercial practices in order to address commercial determinants of health (CDH). The authors discuss corporate nonfinancial reporting as a mechanism for obtaining data on commercial practices affecting population health and suggest several key considerations to inform the World Health Organization’s forthcoming policy recommendations for addressing CDH.
As health care organizations expand across markets and state boundaries and are owned by various entities, including private equity, there is a growing need to improve data collection and required reporting to assist with antitrust enforcement. In “A Policy and Regulatory Framework to Promote Care Delivery Redesign and Production Efficiency in Health Care Markets,” Jillian Harvey and colleagues propose a framework for Care Delivery Redesign (CDR) that may lead to increased production efficiency and improved quality of care. The authors believe that regulators and policymakers can use the framework to develop empirical measures to assist in understanding changes in production processes as well as changes in resultant outcomes.
The Affordable Care Act (ACA) expanded Medicaid eligibility starting in 2014. During the COVID-19 pandemic, states were required to provide continuous coverage to Medicaid enrollees, but this policy ended in April 2023, with resulting coverage losses during the “unwinding” of this policy. In “Who Enrolls in Coverage and Who Remains Uninsured? Medicaid Take-Up Before and After the Affordable Care Act and During Unwinding,” Rebecca Brooks Smith, Gabriella Aboulafia, and Benjamin Sommers used household data from the American Community Survey and state-level eligibility criteria to assess Medicaid participation among U.S. citizens under age 65, and compared results before the ACA (2008 – 2010), after the ACA (2017 – 2019), and during “unwinding” (2023). They found that Medicaid take-up rates among eligible individuals increased, with these gains persisting during the beginning of the unwinding period. However, areas of vulnerability remained among young adults, working adults, American Indian and Alaska Native individuals, and those in rural areas.
Evidence suggests that Medicaid expansion has improved cardiovascular disease (CVD) outcomes, especially among those of lower socioeconomic status. However, less is known about the cost-effectiveness of Medicaid in achieving these outcomes and reducing CVD disparities. In “Medicaid Expansion Among Nonelderly Adults and Cardiovascular Disease: Efficiency Vs. Equity,” Luke Barry and colleagues developed a Monte Carlo Markov-chain microsimulation model to examine lifetime changes in CVD outcomes and disparities as a result of expansion and the associated cost and quality-of-life impacts. The authors found that Medicaid expansion was associated with a reduction of 11 myocardial infarctions, 8 strokes, and 4 CVD deaths per 100,000 person-years compared to no expansion, with the largest reductions occurring for those with lower income and education, and those of Black and Hispanic race/ethnicity. They concluded that Medicaid expansion was both cost-effective and equity-enhancing in reducing CVD outcomes but with a high degree of uncertainty.
Health insurance reform in the United States has focused on expanding enrollment, but research has shown that it increases consumers’ challenges in anticipating needs and making informed choices. Enrollees’ inability to reliably predict what insurance will cover leads to “coverage uncertainty” and may potentially deter policy purchases. In “The Shadow Price of Uncertainty: Consequences of Unpredictable Insurance Coverage for Access, Care, and Financial Security,” Mark Schlesinger and Deepon Bhaumik draw upon a multi-wave survey with nationally representative data to assess consumer experiences and expectations in 2009, 2014, and 2021. Respondents identified worries about the reliability of health insurance coverage, and experiences of insurance not covering major medical expenses. They also reported on whether they delayed access to needed care, had been unable to effectively care for chronic health conditions, or felt anxious about future medical expenses. The authors found that 32% of households reported intense worry about coverage reliability in 2009 that declined to 27% in 2014 and then rebounded to 31% in 2021. Experiences of coverage shortfalls declined from 27% to 17%, then rose back to 21%. Based on their analysis, the authors estimate that, by 2021, coverage uncertainty had deterred timely access to care for 1 in 5 American households, and had become the predominant barrier to timely access.
Launched in 2015, the Delaware Contraceptive Access Now (DelCAN) initiative was motivated by the state having among the highest rates of unintended pregnancies in the United States. By providing greater contraceptive access, especially to long-acting reversible contraception, the initiative was expected to reduce Delaware’s unintended-pregnancy rates substantially. In “What Happened in Delaware Following a Statewide Contraceptive Initiative?” Constanza Hurtado-Acuna and Michael Rendall used the Pregnancy Risk Assessment Monitoring System data with difference-in-difference estimators to compare the planned status of pregnancies ending in births in Delaware with 6 states in 2007 to 2020 and with 14 states in 2012 to 2020. The authors found that the DelCAN initiative was not associated with reductions in unintended pregnancies ending in births in Delaware relative to comparison states but was associated with an increase in pregnancies that were wanted sooner. DelCAN also was associated with an increase in planned pregnancies among Medicaid-insured women. However, they assert that pregnancy intentions and pregnancy planning should be treated as distinct concepts in contraceptive-access program design and evaluation, and that programs should address both pregnancies wanted later and pregnancies wanted sooner to achieve public health goals associated with enhancing women’s reproductive autonomy.
Community health worker (CHW) programs are a key strategy for addressing social and structural drivers of health and have the potential to improve patient health outcomes while reducing health care costs. However, challenges such as high staff turnover, lack of program infrastructure, and inadequate support and supervision can hinder implementation. Moreover, few CHW programs have been successfully scaled across multiple organizations and communities. In “Scaling an Evidence-Based Community Health Worker Program with Fidelity: Results and Lessons Learned,” Molly Knowles and colleagues evaluated the implementation of the Individualized Management for Person-Centered Targets (IMPaCT) model across 5 geographically and structurally distinct sites serving diverse and varied patient populations. They found that core program components were implemented consistently across sites, and that 3 sites were able to sustain implementation over a three-year period, demonstrating significant reductions in acute care use consistent with previous randomized controlled trials of the program.
Despite documented inequities in suicide trends and police perpetrated killing for Black Americans, there has been little research investigating how structural factors like government expenditures may drive these outcomes. In “Longitudinal Associations from U.S. State/Local Police and Social Service Expenditures to Suicides and Police Perpetrated Killings among Black and White Residents,” Devin English and colleagues analyzed 2010 – 2020 U.S. Census of Governments-tracked state and local government expenditures and CDC tracked years of potential life lost (YPLL) to suicide and police perpetrated killing. They found that a $100 per capita increase in annual police expenditures translated to 14,385 more YPLL to suicide, and 2,877 more YPLL to police perpetrated killing one year later for the 41.1 million Black residents in the United States. There were no associations between police expenditures and outcomes for White residents. Conversely, every $100 per capita increase in housing and community development expenditures was associated with 29 fewer YPLL to suicide per 100,000 Black residents five years later, and every $100 per capita increase in K-12 education expenditures was associated with 4 fewer YPLL to suicide per 100,000 White residents one year later. The authors contend that reducing police expenditures and increasing housing expenditures may decrease Black-White inequities in YPLL attributed to suicide and police perpetrated killing.
As of August 2024, 17 states had established health care cost commissions that aim to reduce the growth in health care costs using a variety of methods, such as collecting health care utilization and spending data and setting spending growth targets. States that lean politically Democratic were more likely to have established these commissions, particularly states with higher commercial hospital prices or higher Medicaid spending as a share of the state budget. In “State Health Care Cost Commissions: Their Priorities and How States’ Political Leanings, Commercial Hospital Prices, and Medicaid Spending Predict Their Establishment,” Brent Fulton and colleagues estimated a regression model to understand how political and economic factors are related to these commissions being established. The authors reviewed prior reports, supplemented by their own research on state websites and from organizations that track state-level legislative and executive activity in health care. They argue that because health care reform is difficult to enact at the federal level, many states are enacting their own reforms tailored to their needs and political feasibility, and that future research should study the impact of these commissions on health care spending, including the feasibility and impact of increasing spending on primary care services, as well as the impact of spending on new health care technologies that may increase short-term spending but lead to moderate long-term spending.
Growing opposition to equity and equity-related concepts, coupled with a changing information environment, has made communicating about health equity increasingly challenging. Although public health communicators often discuss health equity–related concepts, it is unclear what strategies they use and what resources are available to support them. In “Strategies for and Barriers to Communicating About Health Equity in Challenging Times: Qualitative Interviews with Public Health Communicators,” Sarah E. Gollust and colleagues interviewed 36 communicators (public health leaders, journalists, thought leaders, and health advocates/organizers) from late 2022 to mid-2023 regarding the strategies they employ, the challenges/barriers they face, and the resources they rely upon. The authors found that communicators face consistent challenges, including concerns about audience resistance, lack of public understanding of terminology, and a fragmented communication landscape. Communicators rely on a range of resources, but mostly colleagues and interpersonal support, with the use of research-based resources being relatively uncommon. They argue that academic researchers, foundations, and nonprofit organizations can play roles in building infrastructure for resource sharing, research dissemination, and the convening of communicators to build stronger connections and support.
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He formerly was a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
