The GOP’s proposed American Health Care Act may have gone down in flames, but health policy experts say there are plenty of other health-care reforms the Trump administration may attempt.

Michelle Mello and David Studdert, both professors at Stanford University School of Medicine and Stanford Law School and core faculty members at Stanford Health Policy, say medical malpractice reform, for one, is back on the federal policy agenda.

The two write in this New England Journal of Medicine commentary that Secretary of Health and Human Services Tom Price, an orthopedic surgeon and Republican congressman from Georgia before he was appointed to the Trump administration, sponsored several bills aimed at limiting medical liability.

House Speaker Paul Ryan and Price have both said medical malpractice is in crisis, with frivolous lawsuits driving up malpractice insurance premiums and forcing physicians out of business. Hospitals and doctors are so afraid of being sued they overprescribe costly tests and treatments, driving up the cost of health care.

But according to a study published last year, medical errors are the third leading cause of death in the United States. And those who follow medical malpractice insurance say the industry has stabilized in the last decade.

Mello and Studdert write that medical malpractice reform is worth pursuing. The liability system has a host of well-documented problems and its reform was omitted from the Affordable Care Act.  But, they argue, Republican proposals tilt too far towards protecting physicians, with harmful consequences for patients.

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“Two of the key reforms measures on the Republican agenda — ‘safe harbors’ for physicians who comply with clinical practice guidelines and the adjudication of medical injury disputes by expert panels — are promising ideas that have received a good deal of attention in the academic literature over the last 20 years,” Studdert said.

“However, design details matter,” he said. “The versions currently being considered in Congress are quite unconventional; they look more like physician-protection initiatives than reforms designed to improve safety or protect the interests of patients in other ways.” 

The “safe harbors” from liability for providers who adhere to clinical practice guidelines would involve the establishment of tribunals of medical experts who would decide malpractice claims. Price has also proposed “administrative health-care tribunals” that would be presided over by special judges with health care expertise and would issue binding rulings aided by testimony from independent experts.

One worrisome aspect of the Republican proposals is that they would replace ordinary standards of evidence with a requirement that patients prove “gross negligence.” 

“That means that if your physician was merely careless or unskilled, you’re out of luck as a plaintiff,” Mello explained. “You have to show something akin to willful and wanton misconduct — like the case in Boston where the surgeon left in the middle of an operation to deposit money in his bank.”

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Price has claimed that defensive medicine is responsible for a quarter of U.S. health-care spending, about $650 billion, but the authors’ best estimates are closer to $50 billion.

Yet, in their commentary, the authors say this could be an ideal time to pursue reform, which ordinarily rises on the policy agenda only when a “malpractice crisis” occurs and liability insurance costs spike.  “When acutely stressed providers are clamoring for 
immediate relief, cool-headed policy deliberation rarely ensues,” they wrote. 


But, they add, reforms must be fair to patients as well as providers. They note that Price articulated a vision of health system reform that puts patients’ needs front and center.

“Medical liability reform needs the same vision,” they said.

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Like any energetic 7-year-old, your daughter loves running around outside, playing with her friends and kicking around a soccer ball. So you’re concerned when she starts losing energy. She looks pale and refuses to eat. You take her to the pediatrician, and her test results show the worst: she has leukemia. Once you work through the shock, you do you what any parent would do: find the best possible care to get her through it. But where do you go?

Health care for children is different from care for adults. Treating kids requires doctors who are experienced with their unique needs, and according to Stanford pediatricians Paul Wise and Lisa Chamberlain, this experience is developed and lives in children’s hospitals.

And these facilities are highly dependent on Medicaid.

“Children are the poorest segment of the United States population,” said Wise, a Stanford Health Policy core faculty member.

Nearly one out of every five children lives below the poverty line, according to the United States Census Bureau. Very few children need extensive health care, but of those that do, about 44 percent rely on Medicaid or other public insurance programs.

Because so many of their patients use Medicaid, these children’s hospitals need reimbursements from the program to support their services. Without this income, some might have to downsize or even shut down, and if they do, services would suffer for all children.

“If you want to kill rich kids, cut Medicaid,” said Wise. “If you’re a rich kid with a serious chronic problem, you’re going to want facilities that provide high-quality care. Those facilities are intensely dependent on Medicaid.”

If the American Health Care Act (the Republican replacement for Obamacare) passes Congress, Medicaid will convert to a per capita cap system. Instead of providing coverage to all who meet its criteria — which is primarily based on income and need — the federal government would cap how much money the federal government could provide each person.

Wise and Chamberlain worry that a set amount allocated for states or individuals would not be able to keep up with health industry inflation, causing payments to effectively decrease over time. They are also concerned that children would be particularly affected by these changes because their medical needs are so different from adults’.

“Caring for seriously ill children requires a wide range of services and specialists, from pediatric surgeons to speech therapists to hospital teachers who make sure kids don’t fall behind,” said Chamberlain. “In pediatrics we work as a team — and cutting Medicaid will reduce our ability to do that.”

Not only would the funds available for child health coverage erode, but according to Wise, the focus on adult health concerns in the emerging Medicaid changes could, without immediate attention, undermine 40 years of progress in developing strong, regionalized child health systems.

Providing for children’s needs should be simple because their expenditures are relatively low. Child health care makes up less than nine percent of all federal health expenditures in the United States.

But because the health policy debate in the United States focuses on older populations, children are often left out.

“I think it’s really important that we have these conversations about the unique needs of children,” said Chamberlain.

Wise and Chamberlain hope to alert policy-makers to the fiscal needs of children and how they affect care for all kids.

“Our elected officials have to cope with a wide range of issues, and they welcome engaged professionals exchanging ideas about active legislation,” said Chamberlain. “Those conversations really matter – now is the time to let them hear what we think.”

To hear more from Wise and Chamberlain about child health and Medicaid, listen to their podcast on World Class:

About two-thirds of American patients see doctors who receive payments from drug companies, but almost none of them know it.

In a collaborative study between Drexel, Stanford and Harvard, researchers found that 65 percent of participants had visited a doctor within the last year who had received payments or gifts from pharmaceutical or medical device firms.

Payments to physicians can take the form of meals, travel, gifts, speaking fees and research.

Only 5 percent of participants knew that their doctor had received these payments.

“The concern is that physicians with financial ties to drug and device companies may be more likely to recommend those companies' products to their patients, even when other choices would be better for the patient, or just as good but less costly,” said Michelle Mello, the Stanford author and a professor of law and of health research and policy.

Open Payments, which reports pharmaceutical and device industry payments to physicians, was set up as part of the Physician Payment Sunshine Act, a provision of the Affordable Care Act (ACA). The website exists to make industry payment information available to the public.

But the study found that only 12 percent of patients knew this information was accessible. The authors stated that the act’s impact is highly dependent on whether patients know about it.

“Transparency can act as a deterrent for doctors to refrain from behaviors that reflect badly on them and are also not good for their patients,” said Genevieve Pham-Kanter, the lead author and an assistant professor at Drexel’s Dornsife School of Public Health.

Drug and device companies tend to target “key opinion leaders” who are likely to influence the choices of other physicians. During the year studied, the average American physician received $193 in payments. However, the median payment for doctors visited by patients in the study was much higher, $510 for the year.

“We may be lulled into thinking this isn’t a big deal because the average payment amount across all doctors is low,” said Pham-Kanter. “But that obscures the fact that most people are seeing doctors who receive the largest payments.”

Payments vary widely across specialties. Among patients surveyed, 85 percent of those who saw an orthopedic surgeon saw a doctor who had received payments. The next highest was obstetrics and gynecology physicians at 77 percent.

“Drug companies have long known that even small gifts to physicians can be influential, and research validates the notion that they tend to induce feelings of reciprocity,” said Mello.

Despite potential changes to the ACA, Mello believes the Sunshine Act is here to stay. The current version of the American Health Care bill, which would repeal and replace the ACA, does not dismantle it.

This leaves the question of how policymakers can make information about payments to physicians more visible to patients. The authors suggested that the Centers for Medicare and Medicaid Services (CMS) could provide a one-stop shop for patients to view industry payments and other information about their providers online. Mello added that private insurers could make this information available on their “Find a Physician” websites.

“Finding the physician who is right for you depends on a lot of factors,” said Mello. “Whether a physician accepts money from industry may or may not be important to you, but my general view is that the more informed these choices are, the better they will be for patients.”

When drug prices go up, does demand decrease? Not necessarily said Maria Polyakova, a professor of health research and policy and Stanford Health Policy core faculty member. In her study, "Out of Pocket Cost and Utilization of Healthcare among Elderly and Pre-elderly Adults," Polyakova used data from Medicare Part D — the prescription drug branch of Medicare, covered by private insurance companies — to determine how older people respond to price changes. In her preliminary findings, Polyakova discovered that people with acute conditions were less likely than patients with chronic conditions to change their drug usage when prices increased.

In a shack that now sits below sea level, a mother in Bangladesh struggles to grow vegetables in soil inundated by salt water. In Malawi, a toddler joins thousands of other children perishing from drought-induced malnutrition. And in China, more than one million people died from air pollution in 2012 alone.

Around the world, climate change is already having an effect on human health.

In a recent paper, Katherine Burke and Michele Barry from the Stanford Center for Innovation in Global Health, along with former Wellesley College President Diana Walsh, described climate change as “the ultimate global health crisis.” They offered recommendations to the new United States president to address the urgently arising health risks associated with climate change.

Bangladeshi children make their way through flood waters.

The authors, along with Stanford researchers Marshall Burke, Eran Bendavid and Amy Pickering who also study climate change, are concerned by how little has been done to mitigate its effects on health.

“I think it’s likely that health impacts could be the most important impact of climate change,” said Marshall Burke, an assistant professor of earth system science and a fellow at the Freeman-Spogli Institute for International Studies.

There is still time to ease — though not eliminate — the worst effects on health, but as the average global temperature continues to creep upward, time appears to be running short.

“I think we are at a critical point right now in terms of mitigating the effects of climate change on health,” said Amy Pickering, a research engineer at the Woods Institute for the Environment. “And I don’t think that’s a priority of the new administration at all.”

Health effects of climate change

Even in countries like the United States that are well-equipped to adapt to climate change, health impacts will be significant.

“Extremes of temperature have a very observable direct effect,” said Eran Bendavid, an assistant professor of medicine and Stanford Health Policy core faculty member.

“We see mortality rates increase when temperatures are very low, and especially when they are very high.”

Bendavid also has seen air pollutants cause respiratory problems in people from Beijing to Los Angeles to villages in Sub-Saharan Africa.

“Hotter temperatures make it such that particulate matter and dust and pollutants stick around longer,” he said.

In addition to respiratory issues, air pollution can have long-term cognitive effects. A study in Chile found that children who are exposed to high amounts of air pollution in utero score lower on math tests by the fourth grade.

“I think we’re only starting to understand the true costs of dirty air,” said Marshall Burke. “Even short-term exposure to low levels can have life-long effects.”

Low-income countries like Bangladesh already suffer widespread, direct health effects from rising sea levels. Salt water flooding has crept through homes and crops, threatening food sources and drinking water for millions of people.

“I think that flooding is one of the most pressing issues in low-income and densely populated countries,” said Pickering. “There’s no infrastructure there to handle it.”

Standing water left over from flooding is also a breeding ground for diseases like cholera, diarrhea and mosquito-borne illnesses, all of which are likely to become more prevalent as the planet warms.

On the flip side, many regions of Sub-Saharan Africa — where clean water is already hard to access — are likely to experience severe droughts. The United Nations warned last year that more than 36 million people across southern and eastern Africa face hunger due to drought and record-high temperatures.

Residents may have to walk farther to find water, and local sources could become contaminated more easily. Pickering fears that losing access to nearby, clean water will make maintaining proper hygiene and growing nutritious foods a challenge.

Climate change will affect health in all sectors of society.

All of these effects and more can also damage mental health, said Katherine Burke and her colleagues in their paper. The aftermath of extreme weather events and the hardships of living in long-term drought or flood can cause anxiety, depression, grief and trauma.

Climate change will affect health in every sector of society, but as Katherine Burke and her colleagues said, “….climate disruption is inflicting the greatest suffering on those least responsible for causing it, least equipped to adapt, least able to resist the powerful forces of the status quo.

“If we fail to act now,” they said, “the survival of our species may hang in the balance.”

What can the new administration do to ease health effects?

If the Paris Agreement’s emissions standards are met, scientists predict that the world’s temperature will increase about 2.7 degrees Celsius – still significant but less hazardous than the 4-degree increase projected from current emissions.

The United States plays a critical role in the Paris Agreement. Apart from the significance of cutting its own emissions, failing to live up to its end of the bargain — as the Trump administration has suggested — could have a significant impact on the morale of the other countries involved.

“The reason that Paris is going to work is because we’re in this together,” said Marshall Burke. “If you don’t meet your target, you’re going to be publicly shamed.”

The Trump administration has also discussed repealing the Clean Power Plan, Obama-era legislation to decrease the use of coal, which has been shown to contribute to respiratory disease.

“Withdrawing from either of those will likely have negative short- and long-run health impacts, both in the U.S. and abroad,” said Marshall Burke.

Scott Pruitt, who was confirmed today as the head of the Environmental Protection Agency (EPA), is expected to carry out Trump’s promise to dismantle environment regulations.

Despite the Trump administration’s apparent doubts about climate change, a few prominent Republicans do support addressing its effects.

Secretary of State Rex Tillerson, the former chairman and CEO of Exxon Mobile, supports a carbon tax, which would create a financial incentive to turn to renewable energy sources. He also has expressed support for the Paris Agreement. It is possible that as secretary of state, Tillerson could help maintain U.S. obligations from the Paris Agreement, though it is far from certain whether he would choose to do so or how Trump would react.

More promising is a recent proposal from the Climate Leadership Council. Authored by eight leading Republicans — including two former secretaries of state, two former secretaries of the treasury and Rob Walton, Walmart’s former chairman of the board — the plan seeks to reduce emissions considerably through a carbon dividends plan.

Already an issue, malnutrition will increase with droughts in Sub-Saharan Africa.

Their proposal would gradually increase taxes on carbon emissions but would return the proceeds directly to the American people. Americans would receive a regular check with their portion of the proceeds, similar to receiving a social security check. According to the authors, 70 percent of Americans would come out ahead financially, keeping the tax from being a burden on low- and middle-income Americans while still incentivizing lower emissions.

“A tax on carbon is exactly what we need to provide the right incentives and induce the sort of technological and infrastructure change needed to reduce long-term emissions,” said Marshall Burke.

Pickering added, “This policy is a ray of hope for meaningful action on climate.”

It remains to be seen whether the new administration and congress would consider such a program.

What can academics do to help?

Meanwhile, academics can promote health by researching the effects of climate change and finding ways to adapt to them.

“I think it’s fascinating that there’s just so little data right now on how climate change is going to impact health,” said Pickering.

Studying the effects of warming on the world challenges traditional methods of research.

“You can’t create any sort of experiment,” said Bendavid. “There’s only one climate and one planet.”

The scholars agree that interdisciplinary study is a critical part of adapting to climate change and that more research is needed.

“If ever there was an issue worthy of a leader’s best effort, this is the moment, this is the issue,” said Katherine Burke and her colleagues. “Time is short, but it may not be too late to make all the difference.”

The Trump administration’s reinstatement of a policy that bans U.S. foreign aid to agencies that provide abortion counseling abroad was a predictable move that could have unintended consequences, Stanford researchers say.

The move freezes funding to nongovernmental organizations that provide abortion services or discuss abortions as a legitimate  family-planning option. It revives what is known as the “Mexico City Policy,” so called because it was announced by President Regan in 1984 during a U.N. population conference in Mexico City. It’s a highly partisan policy, which has been implemented under Republican administrations and suspended by Democratic presidents.

From that standpoint, the move to revive the policy was no surprise, said Grant Miller, PhD, an associate professor of medicine at Stanford and core faculty member at Stanford Health Policy. But Miller’s research has shown that the policy actually appears to have the unintended effect of increasing, not decreasing, abortions in the developing world.

“The bottom line is that it doesn’t matter what you think about abortion and the morality and ethics of it,” Miller told me. “I don’t think either side of the disagreement would think a good policy is one that leads to an increase in abortions. Neither side wants to see more abortions.”

In 2011, Miller published a study with Eran Bendavid, MD, on the impact of the policy between 1994 and 2008 in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Family planning agencies provide a range of family planning services, including contraception, so when their funding is cut, the availability of contraception declines, said Bendavid, the study’s lead author and another faculty member at Stanford Health Policy. This results in declining use of safe contraception and an increase in abortion rates, the researchers found.

“Sure enough, where you see this relative decline in use of contraception is where you see this uptick in abortion,” said Bendavid, an assistant professor of medicine. “Our theory of what is underlying this is this notion that when women have more restricted access to modern contraception, they rely on abortion. If the intention was to curb abortion, then what we observe is that cutting support to family planning organizations led to the  opposite effect.”

Miller followed that up with another study published in 2016 that focused on Nepal during the period when the government legalized abortion, making it more widely available. The policy change gave him the opportunity to test the idea of abortion and contraception as substitutes — i.e. that use of one method to limit family size reduces use of the other. In fact, as the number of abortions rose, use of contraception declined, he found.

“What is remarkable is that this is clear evidence on this interchangeable use that women make in use of contraceptives and abortion services,” Miller said.

In other words, women are trying to control the number of children they have and will use one or the other, depending in part upon what is most available. “If contraception is available, they won’t have to resort to abortion,” Bendavid said.

He said these results have subsequently been corroborated in other studies in sub-Saharan Africa.