Improved Health: A Bipartisan Opportunity to Expand the Scope of Health Reform

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on our findings of earlier death
due to maternal causes would be
minimal.
6,7
Most women in our
study gave birth for the first time
between 1940 and 1950. After
application of age-specificUS
maternal mortality rates from
1945 among women giving birth
at age 20 to 24, 25 to 29, and 30
to 34 years to the corresponding
age-at-first-childbirth categories
in our study, an estimated total
of only 22 women would be
expected to have died from
maternal causes before entering
our study.
7
We conducted an additional
analysis among the youngest
group of women (aged 50–59
years) who enrolled in the
Women’s Health Initiative
(WHI) and observed a signifi-
cantly lower risk of death among
those aged 25 to 29 years (hazard
ratio [HR] = 0.82; 95% confi-
dence interval [CI] = 0.76, 0.88)
and 30 years or older (HR = 0.83;
95% CI = 0.74, 0.93) at first
childbirth than among those
younger than 25 years. This
result lends support to our find-
ings because it suggests that even
younger women enrolled in the
WHI did not appear to die of
competing causes associated with
later age at first childbirth.
Given that age at first child-
birth is increasing in the United
States, understanding how this
trend is related to women’s
long-term health is important.
It appears that later age at first
childbirth is an indicator of not
only underlying health but also
many factors throughout the
life course. Future studies in-
volving life course data are war-
ranted to confirm and extend our
findings.
Aladdin H. Shadyab, PhD
Andrea Z. LaCroix, PhD
CONTRIBUTORS
A. H. Shadyab wrote the editorial. Both
authors participated in the interpretation
of the data and critical revisions of the
editorial.
REFERENCES
1. Willcox BJ, He Q, Chen R, et al.
Midlife risk factors and healthy survival in
men. JAMA. 2006;296(19):2343–2350.
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JE, Gaziano JM. Exceptional longevity in
men: modifiable factors associated with
survival and function to age 90 years. Arch
Intern Med. 2008;168(3):284–290.
3. Rillamas-Sun E, LaCroix AZ, Waring
ME, et al. Obesity and late-age survival
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4. Perls TT, Alpert L, Fretts C. Middle-
aged mothers live longer. Nature. 1997;
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5. Crawford SL. What explains the
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6. Centers for Disease Control and
Prevention. Leading causes of death,
1900–1998. Available at: https://www.
cdc.gov/nchs/data/dvs/lead1900_98.
pdf. Accessed June 17, 2017.
7. Grove RD, Hetzel AM. Vital statistics
rates in the United States, 1940–1960.
Available at: https://www.cdc.gov/nchs/
data/vsus/vsrates1940_60.pdf. Accessed
June 17, 2017.
Improved Health: A Bipartisan
Opportunity to Expand the Scope of
Health Reform
Health reform has been a po-
litical lightning rod split along
partisan lines. Democrats are
fighting to save the Affordable
Care Act (ACA), and Re-
publicans are anxious to fulfill
seven years of promises to repeal
Obamacare while also minimiz-
ing political backlash from those
who have been helped by the
law. This division seems irrec-
oncilable. The current fight in
Congress and the states presents
an opportunity for public health
to broaden the terms of the de-
bate over health reform, which
historically has been dispropor-
tionately dominated by talk of
insurance and medical care. Al-
though access to quality health
care is an important component
of what makes someone healthy,
focusing on the foundational
social determinants of health is
an equally important approach
to improving the health of a
population.
Public health can be the
bridge if both sides are willing to
reframe the debate so that the
goal is improved health. This
would require a focus on im-
proving the foundational de-
terminants that shape health.
Such a strategy should appeal to
Democrats for whom universal
coverage was more of a means to
better health than an end unto
itself. Republicans should also be
drawn to a message that allows
them to say that they are im-
proving population health even
if their approach to replacing
the ACA leads to fewer people
having health insurance.
We highlight three examples
of such an approach and offer
some warnings about the risks of
this strategy. We are not na¨ıve
about the challenge of advancing
policy on these issues, especially
given the deeply entrenched
positions and history of opposi-
tion among key interest groups.
However, this is not a reason to
not attempt advancement on
these issues, particularly when
solutions need not be partisan.
OPIOID OVERDOSES
First, opioid overdoses are the
leading cause of accidental death
in the United States: in 2015,
55 403 people died of opioid
overdoses, and just over 2.5
million people had a substance
use disorder involving opioids.
1
Nearly half of these overdoses are
from prescription drugs.
2
While
on the campaign trail, President
Trump made repeated promises
to address this crisis, increasing
the already appropriately high
level of attention to the issue.
Opioids are a political priority
for both sides of the aisle. In the
five states (West Virginia, New
Hampshire, Kentucky, Ohio,
and Rhode Island) where the
epidemic is most acute, there is
a nearly even partisan split of
representation in Washington:
Donald Trump won three of
the five states and representation
in the Senate is nearly split,
with six Democrats and four
Republicans.
Policy options that would
address the foundational drivers
of this epidemic might include
expanding and improving pre-
scription drug monitoring
ABOUT THE AUTHORS
All of the authors are with the Boston University School of Public Health, Boston, MA.
Correspondence should be sent to David K. Jones, PhD, Boston University, Department of
Health Law, Policy and Management, 715 Albany St, Boston, MA 02186 (e-mail: dkjones@
bu.edu). Reprints can be ordered at http://www.ajph.org by cl icking the “Reprints”link.
This editorial was accepted June 10, 2017.
doi: 10.2105/AJPH.2017.303970
AJPH PERSPECTIVES
September 2017, Vol 107, No. 9 AJPH Jones et al. Editorial 1383

programs, providing states with
increased resources for treatment
and prevention, and improving
the timeliness and quality of the
data needed to study the epi-
demic so that we can craft
effective interventions.
2
TRAFFIC INJURIES AND
FATALITIES
As a second example, there are
more than 30 000 traffic fatalities
every year in the United States,
and traffic accidents are the
leading cause of death among
children aged 5 to 19 years.
2
Traffic injuries and fatalities
resulted in more than $44 billion
in medical costs and lost work in
2015.
2
Safer road environments
are a proven antidote to traffic
injuries and fatalities.
This is also a bipartisan issue.
The two states where traffic
injuries and fatalities have the
greatest economic impact are
California and Texas. There
are 51 Democrats and 41 Re-
publicans between the congres-
sional delegations of these two
states. Furthermore, Trump
often discussed infrastructure
improvements while campaign-
ing as a means to address un-
employment. It is essential that
public health researchers be part
of the infrastructure policy
conversation.
OBESITY EPIDEMIC
Finally, population-based in-
terventions designed to address
the obesity epidemic may be able
to garner support in this new
political environment. Obesity
has been one of the most signif-
icant public health crises of the
last 20 years. It affects 36.5% of
adults and 17% of children and
adolescents in the United States
and costs almost $150 billion
annually.
2
Food policies have the
potential to influence this epi-
demic and stem its rapid spread.
In the next year, Congress is
poised to consider the farm bill.
This piece of authorization leg-
islation is passed every five years
and sets national policy on
everything from school lunch
programs to agricultural sub-
sidies. It presents an opportunity
for lawmakers to demonstrate
that they are addressing a major
public health crisis and actively
working to alter food policy so
that making healthy food choices
becomes easier and affordable.
UNCOMFORTABLE
STRATEGY
Although these are only three
health issues that can be addressed
though shifting the focus to
population health, we think that
the reasons these issues are well
situated to garner bipartisan
support can be applied to other
public health topics.
We are proposing a strategy
that may seem uncomfortable to
many of those who are priori-
tizing improving access to health
insurance in this country. To be
clear, we believe that repealing
the ACA is a step backward and
that a more effective and less
disruptive way to improve public
health in the United States would
be to build on and improve the
law. We are deeply concerned
about the millions of people who
are projected to lose coverage or
be switched to weak coverage
through a high-risk pool or
high-deductible health plan un-
der the versions outlined by Paul
Ryan and other Republican
leaders. ACA repeal would mean
drastic cuts for public health,
including $3 billion cut from
state and local public health
departments over the next five
years.
3
Public health does not have
significant clout on Capitol Hill
right now. Congress did recently
pass a major bipartisan health
bill—the 21st Century Cures
Act—but drastically cut the
Prevention and Public Health
Trust Fund in the process. Even
so, Congress is looking for poli-
cies that allow members to say
they improved Obamacare
without harming current
enrollees. Public health leaders
therefore have an opportunity to
work in good faith to advance
policies that do just that. State and
local leaders may be best posi-
tioned to develop and implement
important population health
measures but will struggle with-
out financial help from the fed-
eral government. Funding for the
Prevention and Public Health
Trust Fund should be restored.
BIPARTISAN FRAME
There is a risk that opponents
of the ACA will use a public
health argument as political cover
without adopting evidence-
based population health policies.
Adoption of this framing should
require high levels of account-
ability to support policies that
actually improve health. There is
also a risk that public health ideas
that would otherwise be non-
controversial will become di-
visive along party lines; political
scientists have shown that issues
become more partisan when
a president makes them a priority,
in part because the stakes are
elevated for interest groups and
because the opposing side is
hesitant to give the president
a legislative victory.
4
At the same
time, political science research
has shown that support on either
side of the aisle for public health
ideas about issues such as obesity
can increase depending on how
they are framed.
5
Now is an important time for
public health leaders to engage
in the political debate over the
future of health reform in our
country. Shifting the terms of the
debate over health reform to
include and prioritize improving
health would be a victory for
public health.
David K. Jones, PhD
Molly Simmons, PhD
Sandro Galea, MD, DrPH
CONTRIBUTORS
D. K. Jones and M. Simmons took the lead
in writing the first draft of the editorial. All
authors contributed equally to the con-
ceptualization and editing of the editorial.
REFERENCES
1. Opioid Addiction 2016 Facts and Figures.
Bethesda, MD: American Society of
Addiction Medicine; 2016.
2. Centers for Disease Control and Pre-
vention. CDC home page. Available at:
https://www.cdc.gov. Accessed July 2,
2017.
3. Juliano C. ACA repeal would mean
massive cuts to public health, leaving cities
and states at risk. Available at: http://
healthaffairs.org/blog/2017/03/07/
aca-repeal-would-mean-massive-cuts-
to-public-health-leaving-cities-and-
states-at-risk. Accessed June 23, 2017.
4. Lee F. Dividers, not uniters: presidential
leadership and Senate partisanship, 1981–
2004. J Polit. 2008;70(4):914–928.
5. Gollust SE, Niederdeppe J, Barry CL.
Framing the consequences of childhood
obesity to increase public support for
obesity prevention policy. Am J Public
Health. 2013;103(11):e96–e102.
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