1. Molyneux, Jacob Senior Editor


When you can't agree what the problem is, you can't begin to solve it.


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A prevailing theme connecting American public health stories of the past year is instability and anxiety. Cycles of attack and defense continue to characterize public discussion about the fate of the Affordable Care Act (ACA) and crucial safety net programs like Medicaid and Medicare. As we absorb headlines about a wave of opioid overdose deaths fed by cheap and powerful street drugs like synthetic fentanyl and heroin, the health care profession casts about for ways to assuage public concerns about opioid misuse without unintended consequences for the millions of Americans who suffer acute or chronic pain in any given year.


Does the ACA have a future? The Republican-led Congress has so far failed to repeal the ACA because of the obvious harm it would do to millions of Americans. Stories of lives saved by the care they were able to afford because of coverage made possible by the ACA or the related expansion of Medicaid eligibility are common in the media. However, so are stories of people with ACA coverage whose incomes exceed the cutoff for federal subsidies (400% of the poverty level) and who are forced to pay painfully high deductibles and premiums.


While detractors of the law express frustration that many of the poorest ACA enrollees get coverage that is free or nearly free while others pay much more, it's easy to forget why the law was enacted in the first place and the gains that have been made. According to the Kaiser Family Foundation, the ACA had significantly reduced the number of uninsured Americans, from 44 million in 2010 to less than 28 million at year-end 2016. Those with preexisting conditions could no longer be denied coverage, "essential benefits" like preventive care were provided by every plan, all insurance plans were required to meet minimum quality standards, and payment reforms had begun a transition from a fee-for-service model to a value-based payment model.


In 2017, the Trump administration changed key aspects of the ACA, which shook public and insurer confidence in the future of the health care marketplace. Most recently, the Department of Health and Human Services (HHS) cut the ACA 2018 open enrollment period in half and slashed outreach efforts while making the federal exchange website inaccessible on Sundays during the enrollment period. In addition, President Trump has ended cost-sharing reduction payments that allow insurers to offer about 6 million lower-income Americans reduced premiums and copayments, prompting insurers faced by market uncertainty to raise 2018 premiums by 20%.


As we went to press in December, Republicans in Congress had cleared initial hurdles to enacting a tax reform package that would slash taxes mostly on the wealthy, potentially trigger funding cuts to Medicare, and end the ACA's individual mandate requiring most Americans to purchase health insurance or face a tax penalty. This would remove an essential underpinning of the ACA, a move that the Congressional Budget Office predicted would result in 13 million more uninsured people by 2027, a destabilized health care marketplace, and rising insurance premiums.


But the giant underlying problem is cost. What both the ACA and Republican health plans have failed to credibly address is the untenably high cost of health care in the United States, which is an outlier among developed nations in that the U.S. government plays little role in negotiating cost of care. As Sarah Kliff described at in "The Problem Is the Prices" (October 2017), it's not hard to find stories of $25,000 MRI bills and $629 Band-Aids, or of pharmaceutical companies electing to double the cost of a lifesaving type of drug like insulin in a given year. A problem that existed well before the ACA became law, the high cost of American medications and treatment continues to drive up premiums and out-of-pocket costs like deductibles for all consumers, even in employer-sponsored health care plans.


Unfortunately, the continuing influence of industry lobbying on Congress and the appointment of those with close industry ties to key agency leadership positions-the new HHS secretary, Alex Azar, is a former top executive of Eli Lilly, a leading producer of insulin-may make meaningful government action to negotiate and control health care pricing less likely in the near future. If the focus of legislative efforts were on building on the ACA's significant coverage gains by starting to work across the aisle to enact mechanisms to control health care and insurance costs, the public debate might have a less contentious and more hopeful character. As it is, uncertainty remains the rule and no government health program or law appears to be fully secure.


The opioid misuse and overdose crisis. In late October, the Trump administration declared opioid misuse a public health emergency (stopping short of declaring it a national state of emergency) and promised to dedicate resources to drug treatment programs, advertising campaigns, and other efforts to slow the wave of overdoses currently being driven ever higher by easy access to drugs like synthetic fentanyl and heroin. It's not yet clear how such promises will translate into action, or with what funding. But ongoing Republican efforts to undercut aspects of Medicaid funding or implement a Medicaid work requirement threaten to place an already inadequate network of drug treatment programs dependent on federal dollars on uncertain footing and leave those in need of treatment with even fewer options.


Current trends. According to the Centers for Disease Control and Prevention, opioid prescribing "peaked in 2010" and has declined since then (see And recent research (Addictive Behaviors, November 2017) suggests that heroin may now have replaced prescribed opiates as the "initiating" drug of choice. The term "prescription opioids" is itself misleading. According to findings from the 2014 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration, when prescription opioids play a role in overdose deaths, a distinction rarely made in news coverage or policy discussions is that, in up to 80% of cases, the opioids were not prescribed to the user but were illegally obtained through purchase, theft, or other forms of drug diversion.


Who's really at risk? The greatest risk of opioid misuse or addiction occurs among young adults, those with untreated psychiatric disorders, a current or past substance abuse disorder, and social or family situations that set the stage for misuse. Although most patients treated with opioids do not develop an addiction, the use of opioids as a tool of pain management is regularly challenged by media coverage and policy recommendations-not just when it comes to the admittedly challenging area of chronic pain (see "Appropriate Use of Opioids in Managing Chronic Pain," July 2016), but also in the treatment of acute pain following injuries, postsurgical pain, and even in some cases acute cancer pain and pain in the final days of life.


Some observers have begun to express concern that a fervor for further reducing opioid prescribing in areas of care where there's low proven danger of misuse may return us to the not-so-distant days of widespread undertreatment of pain. Touting potentially punitive one-size-fits-all strategies is more newsworthy than promoting strategies that we know can help, like better use of prescription drug monitoring programs to prevent "doctor shopping," patient education on opioid diversion risk, research into and use of multimodal pain management, and increased access to and funding of opioid treatment programs and medications.


A broader 'crisis of despair'? A recent Pain in the Nation report from the Trust for America's Health ( placed opioid overdose deaths, which tripled between 2000 and 2015, to over 52,000, in the context of other trends of concern: in the same 15-year period, alcohol-related deaths jumped 37%, to 33,000, and suicide rose by 28%, to 44,000. According to the report's executive summary, "Many factors contribute to drug and alcohol misuse and suicide, including family and social relationships, social-emotional development, early childhood trauma." The report highlighted the absence of economic opportunity and diminished social support systems in certain hard-hit, often rural, pockets of America. These trends, it observed, are "a wake-up call to a national well-being crisis[horizontal ellipsis] signals of serious underlying concerns facing too many Americans-about pain, despair, disconnection and lack of opportunity." The report called for a "national resilience strategy" centered around prevention, early identification of issues contributing to substance abuse and suicide, and treatment.


When it comes to public health, we can at least confidently look forward to a 2018 in flux.-Jacob Molyneux, senior editor