On March 30th, 2017, we sat down with Roy Grant, associate editor at the American Journal of Public Health, to talk about the Affordable Care Act and its impact on public health.  We also explored current policy proposals for its replacement as well as how we, as scientists, can be better communicators to policymakers and the public.  For his most recent editorial on the need for public health professionals to adopt better communication methods, please click here.

Interview Transcript

L:  Hi Roy, welcome to the Viral podcast.

R:  Pleasure to be here.

L:  Roy Grant is a public health research and policy consultant in New York City. Following three years on the editorial board of American Journal of Public Health (AJPH), he is now an associate editor for AJPH. Previously, Mr. Grant was Research Director at Children’s Health Fund for 15 years and Associate Director for community pediatric programs at Mount Sinai Medical Center in New York. Mr. Grant has published more than four dozen book chapters and papers on diverse topics including access to care and service needs of vulnerable populations, mental health, child development, and the interface between public health research and public policy.

Q:  All right, so we just read your article and we were talking about how last week the Affordable Care Act basically, well, survived the week. That’s about what we could hope for.  We don’t know it’s long-term future but it’s still alive as far as today.  I thought that we could talk a little bit about the Affordable Care Act and also, more broadly, the relationship between research and how it informs (or doesn’t inform, in this day and age) policy.

R:  I think that the survival of the Affordable Care Act is somewhat debilitated because there have been steps to eliminate some of the taxpayer-based provisions and let me put it this way:  I think that it’s well within the capacity of this administration to systematically undermine it without a legislative repeal and replace.  And that’s being played out now politically where Trump asked for Democrat support and the Democrats said, “sure, if you rescind your executive orders and abandon the talk of repeal.”

I think there’s a cognizance even to the extent that we can’t get–or I should say “they” can’t get–legislative consensus to repeal the Affordable Care Act.  They can chip away at it and, in fact, that happened some years ago when Marco Rubio got through a provision that destabilized the health insurance market within the Affordable Care Act. That took away some federal subsidies that would have supported insurers that had difficulty with their risk pool.  That contributed directly to the exit of a lot of these insurers so now the Republicans are screaming that the law is a failure because insurance entities are leaving the exchanges.  Part of the reason they are leaving the exchanges is because of a Republican legislative act that undermined some of the provisions of the law.  So, this is the long way of saying my optimism is really not there.

Q:  Yeah but they could really pay a political price by hurting the same people who are their voters.

R:  Yeah and oddly enough it’s the Trump voters, the hidden and forgotten Trump voters, that I would characterize as older, white, residents of rural counties, not only in red states but in blue states like Pennsylvania, who haven’t voted as much as others.  In polls of likely voters they were undersampled and I think that’s part of the reason that the polls were a bit off.  But it’s really rural counties that are going to be hit the hardest if the Affordable Care Act were to disappear because you would see an immediate uptick in uninsured people and, over time, a huge uptick in, as many as 24 million, people would become uninsured and they would seek care anyway.

The difference between an insured person seeking healthcare at, let’s say, a community clinic or safety-net hospital, and an uninsured person is that they both get care but for one of them, the clinic or hospital gets paid (insured) and for the other, the clinic or hospital doesn’t get paid (uninsured).  It’s in rural counties that are sparsely populated, a lot of them have less than 20,000 people total, so even relatively small changes in the payer mix can have a devastating impact on the financial stability of the clinic or hospital.  We’ve already seen rural hospital closures in states that did not expand Medicaid and if you take away Medicaid expansion, you’re going to see a whole lot more of that and that harms the availability of healthcare throughout the country.

Q:  What is a block grant?  I wonder if you could explain that because we see that term around a lot.  And why do some politicians seem obsessed with it?

R:  Well, full disclosure:  in the 1980s, I was a professional Reagan-basher.  That’s what we called ourselves.

Q + L:  [laughter] Okay.

R:  Yeah, it’s a happy little club of those of us that didn’t buy into the “Shining City on a Hill” business and all of that.  You know, and were just immune to–

Q:  Yeah, the “rising tide lifts all boats.”

R:  Yes, exactly.  Let me say this about Reagan:  he was much more transparent about trying to dismantle the safety net.  These guys are covert about it and they’re dancing around about the idea that this could actually harm people.  The Reagan people were very clear about it.  The other phrase that was used, not only by Reagan-bashers but even in the New York Times as early as 1981, was “the War Against the Poor.”  And that’s what Reagan’s domestic policy was referred to.  The idea was to have a double benefit of lowering taxes for rich people so rich people get richer and simultaneously, the phrase they used was “starve the beast;” take money out of the federal budget so that safety net programs will disappear.  That was the notion.  It turned out not to work and–

L:  Imagine that.

R:  It turned out that even federal spending went up anyway and budgets went up so those programs were funded by deficit.  One of the techniques they tried to use was block granting. For example, without block grants, if one thousand more people are on Medicaid then you receive your Medicaid allotment to cover one thousand people in addition to what you’re already getting.  That happened after the 2009 recession when a lot of people lost their jobs and employer-provided health insurance.

In a block grant, you get a fixed amount.  It does not go up.  So if more people need Medicaid, you don’t get any more monies so you either have people leaving Medicaid or you cheapen the service, cut to fewer services, you reduce your reimbursement to physicians.  It’s a way of controlling expenditures by taking needed services away from people.  Very clear about that.  The original intent–the other original intent of block granting, as I said, Reagan was very transparent about this–was the give the States less.  What they sometimes did was consolidate different federal programs with this kind of formula; if you have three programs at 10 million dollars each, I’ll give you a $25 million block grant.  Well, you just got a $5 million cut and therefore you’re going to have to do something to accommodate that.  So it would force the States to be the bad guy in reducing services or eliminating programs.  The Reagan administration was very clear that this was their intention.  This was startling in the starkness of it; the idea was that the Feds hands wouldn’t get dirty by being responsible for reducing services.  They would force the States to do that through block grants.

There’s a lot of data to show that block grants–that block granting Medicaid, for example–results in fewer people being served and States having to make really onerous budgetary decisions like reducing reimbursement, which makes fewer providers want to treat Medicaid patients, or change their eligibility requirements so that they kick people off [Medicaid].  That’s why the advocates are so concerned about block granting.

But the intention is to have a backdoor way of cutting the program; there’s nothing positive about block granting.  The other deceptiveness that you hear now is that the reason for block granting is to give States more flexibility.  States already have flexibility about how to manage their Medicaid programs; they have to apply for a waiver.  It’s as simple as that.  It’s not that they lack flexibility or anything of that nature so that’s not an argument for block granting–it’s an excuse.

L:  So this sounds like a really good example of how, instead of research informing policy, it’s more politically motivated or ideologically motivated.  And I know you’ve done a lot with policy, so can you talk about that process of making sure that research informs policy or good examples in the past, that you’ve been involved in, that we can learn from or apply to what we’re doing now?

R:  Well, yes and no.  Yes, there are good examples in the past.  No, it’s highly unlikely that any of this is going to be applicable now.

Q: Yay…

R:  We have people who don’t consider facts to be factual so the idea that we can influence policy is, in Trump world, an oxymoron.  It’s really not going to happen.

Q:  Well, with different definitions of the truth…

R:  Yes, actually, I have many apps, and one of them is a dictionary app where I have the ‘Word of the Day.”  The “Word of the Day” today was nescient.  That means ignorant but what’s interesting etymologically about nescient is that it means “non-science.”  The root of the word, the “scient” part means “science.”  So nescient means “negating science.”  I think that might be a good word for this administration.  It’s ignorant and it negates facts, evidence, and so forth.

But there are good examples in the past.  There’s a program for infants and young children with disabilities called the Early Intervention Program that really came about, in part, in response to a huge wave of scientific findings and evidence about early brain plasticity and how that period of time covered by that program (birth to 36 months) is the  time when you can have interventions that are most effective for children with developmental problems.  You can have the best impact, in terms of improving development, and the best savings, in terms of preventing a long-term or reducing long-term service needs.  It’s a beautiful example of science to policy to program.  That program is under consistent financial pressures.  I wrote an article about the emerging actions that states were taking against it, contrary to policy, that was published in 2005.  Attacks on the program were already prominent then so we have more than a decade of people chipping away at it.

Q:  What is it that we can do?  Do scientists need to do a better job of joining policy conversations or do legislators and policymakers need to understand science better or is it a little bit of both?

R:  It’s a little bit of both, I think, depending on who you are talking to.  I’ve been very, very impressed with the knowledge base of the more sophisticated legislative aides, particularly in the Senate.  So, it’s not as if these offices don’t have knowledgeable people–they just increasingly ignore them.  I think that our primary responsibility, in the public health research community, is to push back against misappropriation of our work.  When Budget Director Patrick Mulvaney, comes out and says, “we’re going to defund Meals on Wheels.  We can’t keep funding programs just because they sound good.  They don’t work.”  Well, we know it works.

Q:  We know it works.

L:  Exactly, we have research.

R:  We have research to show that it works.  [Budget Director Mulvaney] went on to say, in the same breath, that the school lunch program is supposed to be an educational program and it doesn’t work for education.  That’s absolutely false.  There’s a very strong body of evidence, not that you really need science to tell you, that when children are extremely hungry, they have a hard time concentrating.  They can concentrate better if they’ve had a meal and they don’t have to worry about being hungry.  There is evidence to demonstrate that it is, in fact, true.  It’s not just a free peanut butter and jelly sandwich; it really is an investment in the educational success of low-income children.

L:  As well as–I don’t know–we shouldn’t just let children starve, in general, regardless if they have educational attainment.

R:  Well, that’s the direction of the budget.  You know, they made a huge cut in WIC, the Women, Infants, and Children Program, that provides nutrition assistance to pregnant women and young children.  There’s a huge body of evidence that [shows] not only that it’s important to prevent anemia during the pregnancy, which can affect birth outcomes, but that early nutritional deficits, as it gets more severe and gets towards malnutrition, has very, very severe and long-term developmental implications for young children.  I mean we know this–actually that was one of the arguments that we made back in the Reagan-bashing 1980s.  There’s nothing new about the fact that WIC works; in fact, when they [the Reagan administration] went after WIC big time, there was an increase in anemia among pregnant women and there was an increase in low birth weight births with all of the developmental risk associated.  That so that’s why I can’t say I’m optimistic about the application of science because this really is ideologically-driven.

The most remarkable thing I heard through all of the crazy stuff from people on the conservative right have been saying about repealing the Affordable Care Act was in an interview.  This interview was one of those really combative, belligerent interviews with a former senator, Coburn, I believe it was, who is now a senior fellow at the Manhattan Institute.  He pushed back against the scoring of the Congressional Budget Office about the loss of insurance and all of that.  He said, “That’s the wrong metric, that’s the wrong thing to look at.  They are not looking at the big picture.”  What’s the big picture?  “This is a way of implementing a free market principle.”  He actually prioritized the free market ideology [over the actual details of the policy] that leads these folks to believe, for example, that selling insurance across state lines will drive down prices even though there is evidence that it doesn’t.  We know that it doesn’t work.  Under the Affordable Care Act, it’s allowed–we don’t need to repeal the Affordable Care Act to allow insurance across state lines.  Insurers don’t want to do it because they don’t want to be responsible for managing networks in others states.

Q:  It’s cumbersome.

R:  Yes, it’s cumbersome.  It’s really not in their interest. But it’s allowed and nobody wants to do it and when it’s done, the outcomes are terrible.  Ideologically, if you believe that the price of flat screen TVs will go down when more brands are on the market or more vendors are on the market, that’s true.  People that bought flat screen TVs when they first came out are probably really unhappy with how much they paid.  They could have gotten so much more for so much less money years later.  However, healthcare is not a flat screen TV; it is not a commodity that works that way but they believe that it is.  They promote this free market ideology and they prioritize the expected outcomes of the ideology over the real world outcomes of the policy.  I don’t think you can get further away from evidence-based policy than that.  And that is what is driving the “Repeal and Replace.”

L:  So we know that if it is ideologically-driven, it is kind of on us to be better scientific communicators.  How can we be better scientific communicators especially to non-scientists, you know, the broader constituency of the United States?

R:  Language.   We tend to, and I probably lapsed into jargon–I try to avoid acronyms.  But the way that we think.  We are all very well-trained and we do things according to methodological rigor and we’re very concerned about not drawing conclusions that exceed the scope of our data.  We tend to be tentative about how we say things for that reason; we have to get over that.  We can’t say, “at least, for this cohort, under these circumstances, we can conclude that there is, in at least in this association…”–at this point you’ve lost everybody.  People are going to think that you don’t know what you’re talking about.  You certainly can’t conclude a research study with “we conclude that more research is necessary;” we have to affirmatively, clearly state what we know to be true.  We have to stop using words like “association” [despite] the need to avoid “causality” when it hasn’t been established.  We have to find a way to better communicate something that is affirmative and positive.  The worst example of that is the perpetuation of [the notion of] vaccines causing autism.  That is an affirmative, positive, wrong statement and people prefer something that’s affirmative and positive even if it is wrong.  There [is considerable] uncertainty about the etiology of autism.

Q:  And we as scientists have a tendency to try and be as objective as possible, not make waves, say as little as possible, really, so we don’t draw negative attention to yourself.  But at the same time, you have to address the issues of your study.

R:  Yes, I think that everything you just said is what we have to get over.  We have to make waves.  We have to be willing to be perceived as being political.  That’s not the same as being political.  I think that when you take the stand that “facts matter,” you’re acting as a partisan because we have a party that says “facts don’t matter.”  You can’t stand up for facts, protect the facts, without taking a position that’s against the current state of the Republican party and that’s extremely unfortunate given the amount of power that they are wielding and the kind of control they have over government.  We have to get over the idea that taking a strong position is unscientific and is a loss of objectivity and is biased.

I’ve gotten a lot of reviews [of papers] that I’ve submitted to journals that were variations on this statement: “if you talk about the policy implications of your study, you are revealing bias and losing your objectivity.”  That’s completely wrong.  I don’t see the value of studies that have no real world implications.  But that is a very strong misperception within the public health field.  I think that we need to work on overcoming that.  We especially have to be willing to go out on a limb and call people out.

[Paul] Ryan is another one, Speaker Ryan, is allegedly the policy “wonk.”  His poverty report that he published on the 50th anniversary of [President Lyndon] Johnson’s War on Poverty — I published an editorial in the American Journal of Public Health that just ripped that apart. [It discusses] every deceptive game that he played to distort public health research to make it appear as though his ideologically-based conclusions were valid when they were not.

Q:  In defense of the scientists here, I don’t want to bash them.  Looking at how they are operating within the systems, that make it really hard to break outside of the mold, you’ve got millions and millions of dollars supporting thousands of scientists at the CDC, the NIH, and public universities, where they are told that whenever they publish something, it has to go through a system of clearance that touches 15 different people.  They all have the opportunity to say, “well, you can’t say this or dumb this down.”  And sometimes I’ve seen papers that have come through that have a bold statement and it gets diluted because we’re bashed over the head and told that we have to be good stewards of public, tax-payer dollars, you can’t take a position on something or recommend a policy.  You can only educate and not advocate.  So people are afraid for their jobs–they don’t want to say something that they could lose funding for.  An individual scientist doesn’t have a lot of power in that situation.  It’s a culture change.

R:  The individual scientist, in that situation, has to behave exactly as you said and I should have said that I exempt people that are on, especially, federal grants because there are very strong prohibitions against taking anything that could be construed as a political position.  That’s also true of the people that work in the agencies–even the AHRQ (Agency for Healthcare Research and Quality) has gone out on some limbs that probably some other agencies haven’t.  They are on the hit list for being eliminated in every Ryan budget–they zero out the Agency for Healthcare Research and Quality–probably because they are responsible for publishing health disparities reports and they are more politically [engaged] than other agencies.  And by the way, it is the smallest or second smallest thing in the NIH, I think–no money at all.  They do enormous work with very little money.

So yes, you are absolutely right.  I should have made a distinction people like me who work in the not-for-profit sector and people that work for the government.  People that work for the government have to be very, very careful.  And also, I am hearing that is true of people that work for local health departments.

Q:  Yeah, you don’t even have to [work] for a government agency to be tied with government money.  It’s spread out everywhere.   There are state and local health departments that get government money but it also goes out to non-profits and non-governmental organizations and other sub-parties, stuff like that.  The guidance comes down and they say that you can’t advocate for a position; you only have to do this.

R:  Well, I would say, having worked in the not-for-profit world and private sector:  we should not feel bound by that. We should not accept money with strings attached.

Q:  That’s a really good point.

R:  I used to, the people I worked for, get a lot of corporate money, including from some of the pharmaceutical companies–

Q:  Oh that’s tricky.

R:  No, it’s not tricky.  It’s called an unrestricted education grant. We got money, for example, from a manufacturer of a leading asthma medication and it did not influence decisions about what to prescribe for asthma.  The language that you use, what you negotiate is an unrestricted education grant and they need to know that you’re going to be independent and you need to feel absolutely zero responsibility to promote that corporation’s product.

But that’s not something you can do in government and I’m very sympathetic to what people who are under those kinds of restrictions are dealing with but I’m even more sympathetic because the budget that’s out there is taking a one-third chunk out of NIH research grants.  And they are justifying it–I was frankly amused–by saying that’s how much the people we give money to take because their indirect.  So that’s going to totally turn the whole issue of federal grants on its head if the sponsoring institution doesn’t get it’s indirect, which in my mind, I think it’s higher than thirty percent for most.  I’m used to hearing indirects as high as sixty percent and I’m sympathetic that it’s a lot of money that’s not going into the research.  But that’s the justification for cutting NIH research money by a third so everybody’s federal money is touch-and-go at this point.  Especially on the research side.

L:  It’s just crazy because basically the idea behind is that instead of working with universities to figure out the operational costs, let’s just take it all away.

R:  They look for excuses; I don’t think that someone sat around and found the mean and median indirect among the largest hospitals and educational institutions.  I think they said, “let’s cut by a third and figure out a way to justify it.”  Which is no different than saying, “we’re cutting meals on wheels because it doesn’t work” without checking to see if it does.  So, from the standpoint of evidence-based policy-making, these are very, very dark times.

That doesn’t mean that we shouldn’t try but I think that, at this point, our job is to push back.  And how we break into the kind of disinformation that’s coming out on cable TV, twenty-four hours per day, I think that’s a real challenge and I don’t have any easy answers to that.  But I think that when people start saying all of this untrue stuff.  There’s a small number of the cable TV hosts that will push back on it but the majority of them just let the most outrageous stuff be said.  Like, “why aren’t they investigating Hillary Clinton’s ties to Russia?”  I read today that Jeffrey Lord, one of the least credible of the Trump apologists, wants an investigation of collusion between the ranking member of the House Intelligence Committee and Nancy Pelosi because they are saying similar things.  They will say anything to deflect and distract.

L:  I was just going to say that this is all distraction.

R:  And when it involves public health research, we really need, like a national Twitterer or somebody who develops a huge following and monitors this stuff and just gets out there in real time.  “So and so said this–not true.  Check this out.” and a link to a study or something like that.

Q:  Well, on a much lighter note, we like to, in this show, try to show people that scientists are people too and we have interests outside of our labs and journals.  So what are you reading right now and why?

R:  Well, as you might have gathered, I’m more than a little pre-occupied with this political situation; the trainwreck that I can’t take my eyes off of.  I got to tell you, people from New York come from two camps:  I can’t take my eyes off of it and I can’t watch another minute of it.  There’s very little in between.  So this has put me in the mood for espionage.  So I’m reading Len Deighton’s book The Ipcress File.  Definitely a time for a spy novel.

Q:  Excellent.

L:  Thank you so much for spending some time with us today, Roy.  It’s been wonderful to hear your refreshing take on policy and research, especially, like you said, in these very dark times.  But there’s still hope.

R:  Oh, absolutely and I really appreciate what you’re doing.  I love the question you asked about how can we, public health professionals and researchers, find a way to do more and exert more influence.  I hope we continue that discussion and find some productive ways to do just that.

Q:  Yes.  We hope to talk to you again on a brighter day.

R:  Here’s to brighter days.

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