By Bradley Allf, Features Writer UNC Institute for Global Health & Infectious Diseases
To say that the US presidential election of 2016 was “contentious” would be an understatement. Parties were widely divided on issues and campaign rhetoric was often downright vitriolic. The two candidates held very different visions of what the future of the United States should look like.
One of the most prominent differences between the two campaigns had to do with healthcare. Democratic candidate Hillary Clinton wanted to continue President Obama’s signature healthcare law. Republican candidate Donald Trump did not.
With the election now decided and the Trump administration eager to fulfill campaign promises, the repeal and replacement of the Affordable Care Act will be the most direct impact that the election will have on health. But there are other health implications of the election—from the personal to the global level— currently being investigated by UNC researchers from all across campus.
The Affordable Care Act
We’ll start with the Affordable Care Act (ACA). Signed into law in March of 2010 by President Obama, the legislation represents the most major revision of US healthcare law in nearly 50 years.
Jonathan Oberlander, PhD, is professor and chair of the UNC Department of Social Medicine. He also has appointment as a professor of Health Policy & Management in the Gillings School of Global Public Health. His interdisciplinary work puts him at the crossroads of medicine and society—a position that makes the events of the election particularly relevant to him.
“I couldn’t sleep. I stayed up late, late, late to watch the election results,” says Oberlander. “My mind was racing with the implications because the implications are just extraordinary. The enactment of the Affordable Care Act was extraordinary. Its dismantling is extraordinary. And so I’m running through the scenarios and thinking – what’s going to happen?”
The potential for such extraordinary implications kept Oberlander up most of the night penning a paper later published in the New England Journal of Medicine called “The End of Obamacare.” In it, Oberlander outlines the major accomplishments and shortcomings of the ACA, how its repeal and replacement might unfold under the new administration, and what that might mean for the future of healthcare in the US.
Oberlander argues that the main accomplishment of the ACA was a reduction in the uninsured population. This has two main benefits.
“First of all I think it’s a matter of justice and decency,” says Oberlander. “There is no other rich democracy in the world—not Canada, not Japan, not Europe— that leaves a substantial portion of its population uninsured.”
In 2009, more than 46 million people lacked health insurance in the United States, including 6 million children under the age of 18. People without health insurance have reduced access to care, resulting in worse health outcomes. For example, women with breast cancer that lack insurance die at a 60 percent higher rate than insured women, according to the American Cancer Society.
Beyond this are the economic implications of lacking insurance. Without insurance, a serious illness or injury could bankrupt a household. Just three nights in the hospital costs an average of $30,000 in the US, and the cost of cancer care routinely reaches six figures. By reducing the uninsured population by 50 percent, the ACA reduces costs and increases access to care for the millions of people now on insurance plans, or on better plans.
So what does this mean for the future of healthcare under the new administration? President Trump has variously called the Affordable Care Act “a total disaster,” and “horrible healthcare,” and he began the process of rolling back the requirements of the law just hours into the presidency. Yet the president has also supported some of the more popular aspects of the law, like preventing insurance companies from withholding insurance from people with pre-existing conditions.
The problem is that these popular provisions cost money. Keeping them while eliminating other aspects of the law— like the mandate that people pay a penalty if they don’t get insured—would not be financially viable, according to Oberlander.
If President Trump repeals the ACA without an adequate replacement plan, then 20 million newly insured people could lose their coverage. Oberlander calls such an outcome “extraordinarily bad.”
So what will the future of healthcare look like in the US? “It is uncertain which parts of the ACA will survive past 2017 and what will follow it,” Oberlander concludes his piece in the New England Journal of Medicine. “What is certain is that Obamacare as we know it will end.”
But beyond the ACA, the election may be affecting health at much more individual level.
Keely Muscatell, PhD, is an assistant professor of psychology & neuroscience at UNC who studies how social experiences impact health. Her research supports the growing consensus that psychological stress can lead to physical inflammation, which has been implicated in numerous diseases.
One recent study led by Muscatell explored how one episode of social rejection can cause otherwise healthy people to develop symptoms associated with chronic inflammation.
In the study, Muscatell asked research participants a series of in-depth personal questions like: “what would you most like to change about yourself,” and “tell me about a time where you really disappointed someone.” These interviews were filmed and then played back to “confederates”—a psychological term for research assistants that pretend to be study participants (not 19th century Secessionists). The real participants, while inside an MRI machine, then watched these confederates respond to their interview.
“So the person goes in the scanner and when they’re in there they see this grid of adjectives,” says Muscatell. “Some of the adjectives are positive, some are neutral, and some are negative. And what they see during the scan is this little mouse cursor that moves around the screen and every ten to twelve seconds selects a different adjective. And so the cursor is supposedly controlled by the confederate and it’s their ‘real-time feedback’ of what they’re thinking.”
The research found that when study participants received negative feedback—adjectives like arrogant, boring, and shallow – they felt socially rejected.
But it goes much further. The participants who were particularly reactive to the negative feedback got more than just a sore ego. Their bodies actually had a physical response to the video as if they had suffered a physical injury like a cut.
In the paper, Muscatell and her team show that participants actually started exhibiting symptoms of inflammation in response to the negative feedback. Specifically, they found elevated levels of pro-inflammatory cytokines.
“Pro-inflammatory cytokines are basically these proteins that are secreted by immune cells that are the body’s first line of defense against injury or infection. So if you get a papercut and the area around it swells and turns red, that’s because of these proteins,” says Muscatell. “What we’ve learned in the past few decades is that these inflammatory processes can be elicited even in the absence of any physical injury or infection. Purely threats to our social standing or our social esteem can elicit these changes in inflammation.”
Muscatell’s study, which was published in Brain, Behavior, and Immunity, was further support for this connection between social stress and inflammation. Her paper showed that just this one negative experience was even altering gene expression to produce more proteins associated with inflammation. The implications for this are huge, because inflammation plays a critical role in many deadly diseases.
“The things that people tend to die from nowadays—especially things like cardiovascular disease, some cancers—have all been linked to inflammation,” says Muscatell. “So the whole mantra of ‘sticks and stones may break my bones but words will never hurt me’— I think my research would say that that is actually not true at all.”
But what does this have to do with the election? Well, if the election is leading to increased stress and anxiety there could be very real consequences for public health.
During the campaign, the current US President called for banning a religious minority from entering the US, the creation of a Muslim registry, the deportation of 11 million illegal immigrants, was found to have once boasted about sexually assaulting women, and called Mexicans entering the US criminals and rapists. Combined, these affronts against under-represented groups could be having a serious effect on the mental health of broad swaths of the US population. And, according to Muscatell’s research, this has physical health consequences as well.
“These are all slights that could be leading to these types of changes in physiological processes that we know are linked with chronic disease,” says Muscatell. “And to the extent that that’s happening over and over again, I think it really could lead to a potential uptick in chronic diseases, particularly among people who are marginalized and targeted by the negative rhetoric.”
So are minority groups actually sicker because of the election? Unfortunately, there’s no comprehensive data yet. What we do know is that during the election the majority of Americans—including equal proportions of Republicans and Democrats—viewed the election as a significant source of stress. And after the election, 35 percent of people thought their stress levels were still elevated due to President Trump’s election, including 54 percent of Hispanics. Importantly, just 12 percent of people felt their stress levels decreased after the election.
All that stress may be contributing to a sicker population, particularly if it is leading people to feel socially and politically rejected—something not far out of the question considering hate crimes against minority groups are on the rise.
But until we figure out for sure, Muscatell suggests that everyone consider how their words may be impacting the health of others.
“One of the things that I hope my work does is lead people to have a reaction when they realize ‘wow, these negative social experiences aren’t just annoying’” she says. “These are experiences that are being processed by the brain and translated into changes in our body.”
Global Health Effects
Finally, there are the health effects of the presidential campaign that reach beyond the US. Dean Harris, JD, is an associate professor of health policy and management in UNC’s Gillings School of Global Public Health. He wrote a recent article for the Groningen Global Health Law Blog exploring this very issue.
Harris outlines four major impacts of the US election on global health: a reduction in global access to reproductive health, changes to the development aid provided by the US, a reduction in progress in responding to global environmental problems, and negative health effects caused by changes to US immigration policy.
To the first point, Harris predicted that President Trump would reinstate the so-called “Mexico City Policy” (the president has indeed done this since Harris’s article was written). This policy limits access to abortion services for women all over the world that receive care from non-governmental organizations which receive US funding.
“The policy prohibits foreign non-governmental organizations (NGOs) that receive U.S. funds from using their own funds for abortion-related services, referral, or advocacy,” Harris writes in the piece. “The Mexico City policy would not prohibit using U.S. funds for abortion in other countries because that is already prohibited by another U.S. law. Rather, this policy goes much further and prohibits foreign NGOs from using their own funds for activities related to abortion, if those NGOs receive any family planning funds from the U.S. Agency for International Development (USAID),” [emphasis as written].
Critics of the policy call it a “global gag rule” because it also prohibits these NGOs from referring, advocating or lobbying for access to abortion.
But Harris believes that US healthcare aid may be limited beyond abortion services. Trump’s past stances on issues like vaccination (which he has incorrectly claimed causes autism) and the Ebola outbreak (he advocated for barring health workers infected with the virus from returning to the US for treatment) seem to suggest a limited understanding of, or appreciation for, global health.
While the President has claimed support for global health initiatives like the President’s Emergency Plan for AIDS Relief (PEPFAR), he has at the same time stated that the US should not provide foreign assistance in countries with governments hostile to the US. If the President follows through with this, it would mean a reduction in US humanitarian aid to countries like Libya— a country on Trump’s recent travel ban that also contains more than a million people living with food insecurity.
Thirdly, Harris points out the global health impact of an administration that will likely put less emphasis on responding to global environmental crises. This extends to climate change, for example, which President Trump has at one point called a hoax invented by the Chinese.
Climate change has numerous global health impacts, including decreases in water supplies and food production, and increases in disease epidemics. Without strong US leadership, it will be difficult for other countries to form a unified front against climate change.
“Climate change is a global problem, and failure to work together could have global consequences,” writes Harris.
Finally, and perhaps most surprisingly, are the global health implications of changes in US immigration policy. When the US doesn’t take in refugees from humanitarian crisis zones like Syria, as is disallowed under Trump’s recent Executive Order, it puts extra stress on refugees and the countries that are accepting them.
“[D]eporting people from the U.S.—or restricting entry to the U.S.—would limit opportunities for migrants, deprive their families of the safety net provided by remittances, increase the level of unemployment in countries of origin, and deprive refugees of a safe haven from the danger and destruction of war,” writes Harris.
All of this has obvious implications for destabilizing healthcare abroad and limiting access to quality care.
Like all elections, the 2016 US election ushered in a time of change and uncertainty. The new president is poised to take an exceptionally wide departure from the past administration which further feeds into that uncertainty—particularly in regards to health and healthcare.
What will the Trump administration mean for the future of the Affordable Care Act, for national stress levels and their associated health risks, and for global health? We are only beginning to find out, and researchers across departments at UNC are working to better answer that question.