Obama's respiratory health legacy
Authors: Bryant Furlow
Journal: The Lancet Respiratory Medicine (2016)

Despite a hostile Congress, unfinished work on tobacco control, and problems with implementation of his signature health insurance reforms, President Barack Obama's respiratory health legacy will be substantial, according to experts contacted by The Lancet Respiratory Medicine. “During President Obama's two terms in office, the US has made significant progress reducing its tobacco burden”, said Katie McMahon (American Cancer Society Cancer Action Network, Washington, DC, USA). “There has been substantial and steady progress made to reduce tobacco use, primarily through increased tobacco taxes, improved prevention and cessation efforts, and critical regulatory changes.” The Administration's stricter vehicle-emissions rules and Clean Power Plan, which will curb electricity plants' coal-fire emissions, are expected to reduce air pollution and the number of associated premature deaths and asthma exacerbations. The Affordable Care Act (ACA, also known as Obamacare) dramatically improved insurance coverage of tobacco cessation services, established the National Prevention Council—which is chaired by the US Surgeon General, and coordinates prevention services among 20 federal departments and agencies nationwide—and helped to fund tobacco prevention and cessation efforts like the US Centers for Disease Control and Prevention's (CDC) Tips from Former Smokers media campaign, McMahon noted. The ACA also created online marketplaces where people whose employers do not offer health insurance can buy their own policies, and offered federal subsidies to encourage states to expand enrolment in Medicaid, the public health insurance for low-income and disabled families and children; Medicaid covers most approved medical expenses for its beneficiaries, though they must still pay a limited amount in out-of-pocket co-pay fees for some services. The ACA also levies income tax filing penalties against Americans who remain uninsured. But among experts contacted by The Lancet Respiratory Medicine, assessments of the ACA's implementation were decidedly mixed. “If I were to give a grade to the conglomerate of accomplishments of President Obama's Administration as it relates to health-care issues, a C− would be a generous score”, said David Gozal (University of Chicago, Chicago, IL, USA), president of the American Thoracic Society. “There is no doubt that over the last several years, reductions have occurred in the proportion of uninsured people, particularly among immigrants or underserved populations, but the data also shows that it is the sicker and needier patients that have joined in, rather than enrolling in parallel those who are healthier.” The ACA struck a bargain between the government and insurers: insurers would be prohibited from denying coverage to people with pre-existing diseases, and the government would require healthy Americans—whose costs to insurers are negligible—to secure insurance policies as well, to keep private insurers solvent. But that agreement has not gone as planned in many regions, because although people with illnesses secured health insurance coverage, healthier people—particularly young adults—did not, prompting steep hikes in insurance premiums. And that, in turn, has made insurance unaffordable for many people, Gozal said. The ACA facilitated expansion by each state of Medicaid public health insurance for low-income families and children, although some Republican governors did not participate, refusing to expand Medicaid coverage for their states' poor. For working-class and middle-class families that don't qualify for Medicaid but whose employers do not provide insurance, the ACA also established subsidised online health insurance marketplaces as one-stop shopping centres for consumers to foster competition among private insurers and keep policy prices low. However, fewer healthy Americans than anticipated purchased these policies, leading many insurers to withdraw from ACA marketplace exchanges. The ACA gets “good marks” for implementing rules that prohibit insurers from denying coverage for pre-existing health conditions and for increasing coverage for screening services, Gozal said. But enrolment in health insurance under the ACA has fallen short of overall goals, with more than 31 million people still uninsured, he emphasised. “The overall outcome of these initiatives is mixed, and [they are] therefore still quite vulnerable to the political battles that are part and parcel of our national reality”, Gozal said. Congress' “continued resistance to adequately fund many pieces of the ACA”, including health insurance enrolment and public outreach efforts, is largely responsible for problems with the law's implementation, believes George C Benjamin (American Public Health Association, Washington, DC, USA). Those opposed to the ACA said companies would fire employees or refuse to hire new employees because of the law's requirement that businesses provide health insurance coverage for full-time workers. “The doom and gloom—it didn't come true”, Benjamin said. “We're beginning to see a clear division between those states that expanded Medicaid and those that did not, in terms of insurance coverage and early signs that health outcomes are better, improved access to care, and more people having regular providers”, Benjamin said. The ACA's Hospital Readmissions Reduction Program, a quality-of-care improvement initiative that went into effect in 2012, reduces federal government payments made to all acute care hospitals in the USA with high rates of patient readmissions, and that provision seems to be working as planned, according to Benjamin. “30-day hospital readmission rates have really been coming down”, he said. Citing the ACA's CT-based lung cancer screening provisions and funding for universal access to smoking cessation services, James Mulshine (Rush University, Chicago, IL, USA), a board member at Lung Cancer Alliance, believes that a decade from now, the Obama Administration's respiratory health legacy might well be seen as “a transcendent accomplishment.” In addition to lung cancer, CT screenings are identifying “significant early and treatable” cases of coronary artery disease and COPD, Mulshine told The Lancet Respiratory Medicine. “These three diseases are driven by tobacco exposure and are the main drivers of premature death in our society, accounting for roughly $300 billion in annual US health-care cost.” Cancer screenings must be covered under the ACA. CT lung cancer screening—especially if routinely delivered with best-practice smoking cessation—might save more lives than any other single intervention since President Nixon declared the War on Cancer in 1971, Mulshine believes. The Obama Administration has made important strides on tobacco control. The Pentagon has eliminated price discounts for tobacco at military commissaries and stores, and expanded smoke-free areas on military bases, McMahon noted. In 2015, the Administration proposed—but has not yet adopted—a smoke-free rule for all federally-funded low-income housing, which would protect 760 000 children from exposure to second-hand smoke. One challenge is how to enforce that rule without leaving some low-income smokers homeless, Benjamin said. Pro-tobacco industry Members of Congress have sought to cut funding for the CDC's Tips from Former Smokers campaign “precisely because it is successful”, said Chris Bostic (Action on Smoking and Health, Washington, DC, USA). Some Members of Congress have also repeatedly attempted to halve the budget for the CDC's Office on Smoking and Health, which leads tobacco control efforts. The 2009 Family Smoking Prevention and Tobacco Control Act was a “crowning achievement”, according to Bostic. “This is the first omnibus federal anti-tobacco legislation, the most important aspect of which was the granting of FDA oversight of tobacco products. [FDA] jurisdiction came with some important caveats designed to ensure the survival of the tobacco industry, but this was necessary for [the Act's] passage.” The anti-smoking law's public health legacy will probably “rival the ACA in many ways”, Benjamin said, noting that ushering it through Congress was “a major accomplishment” for the Obama Administration. But much like President Obama himself—who has relapsed more than once in his efforts to quit tobacco and reportedly uses nicotine-replacement gum frequently—the Obama Administration has struggled at times to fully implement tobacco control policies. “Unfortunately, the FDA has done precious little with their new powers”, Bostic said. “Fearing industry lawsuits are inevitable, the [FDA] Center for Tobacco Products has moved at a snail's pace in putting in place regulations mandated or allowed by the 2009 Act.” In 2012, the FDA mandated graphic health warnings on cigarette packs but the tobacco industry sued successfully, arguing that the policy violated corporations' free speech rights. “4 years later, [the] FDA has not tried again”, Bostic lamented. Nor has the agency banned use of menthol in cigarettes or moved to require lower nicotine levels in cigarettes, as allowed under the Tobacco Control Act, he noted. The 2009 law bans most cigarette flavourings, which has helped to reduce tobacco-uptake rates among teens, Bostic said. That ban initially exempted menthol, however—an additive now present in a third of cigarettes in the USA, which is heavily marketed to, and disproportionately smoked by, black Americans and youth. The law allowed the FDA to examine menthol research and then, if deemed justified, to regulate it. In 2013, the FDA acknowledged that the available science showed that menthol makes it more difficult to quit smoking, and therefore harms public health. But to date, the agency “continues to consider regulatory options”, according to an agency spokesman. The Tobacco Control Act allows flavourings—such as candy—for hookah, e-cigarettes, and cigar products, all of which have seen increased use by youth. The FDA should use its authority to “rein in unfettered marketing and eliminate all tobacco flavourings, including menthol”, McMahon said. Menthol remains one of the major tobacco control issues yet to be addressed by the Obama Administration, Benjamin and others agreed. The Administration successfully pushed congress for a $0·62-per-pack hike in federal tobacco excise taxes on cigarettes in 2009, but lawmakers have not passed the president's subsequent calls for an additional $0·94-per-pack tax hike. The 2009 tax increase was followed by a 10% drop in cigarette sales. “Perhaps the most surprising change in tobacco policy under the Obama Administration came under the heading of trade rather than health”, Bostic said. The draft Trans Pacific Partnership agreement will exempt tobacco control measures from investor versus state dispute-settlement mechanisms, meaning that tobacco companies will not be able to demand arbitration over health-protecting tobacco control laws—a “first” for a major international trade agreement, achieved despite strong opposition from pro-tobacco Members of Congress, according to Bostic. The Obama presidency might also have lasting effects on medical research. Vice President Biden's Cancer Moonshot initiative and President Obama's Precision Medicine research initiative have secured hundreds of millions of dollars in additional research funding, for example. Scientific integrity policies at the CDC and FDA have also improved under Obama, according to Gretchen Goldman (Center for Science and Democracy, Union of Concerned Scientists, Washington, DC, USA). “We've not heard the same levels of complaints from scientists or seen as much political interference in science as we saw under the George W Bush Administration”, she explained. “But what we found is that policies are not enough; we need to do more to get policies fully implemented”, Goldman said. “It was a big, important step that the Obama Administration put scientific integrity policies in place and it's important for future administrations to have policies in place, in writing, to safeguard against future abuses.” Goldman surveyed federal scientists and found that concerns remain among CDC researchers about their ability to publish, particularly on politically-sensitive topics. The scientific transparency of US federal agencies remains a concern, Goldman said, with many science journalists reporting that the Obama Administration is even worse than the Bush Administration about allowing scientists to speak to the news media. “The Obama track record on transparency has been very mixed”, Goldman reported. Congress has frequently sought to interfere with how federal agencies can use science, chilling agencies' willingness to aggressively exercise their authorities under the Clean Air Act (which the Obama Administration has used to implement its Clean Power Plan) and other laws, Goldman was quick to add. “That's a new tactic but the Obama Administration has been good about exercising its veto threat when it happens.” Time is short for the Obama Administration to address menthol regulation and other unfinished respiratory health business. It is not entirely clear who will replace him in the Oval Office, or whether his health-care legacies will be built upon or rolled back by that person. “I hope the next administration runs with what the Obama Administration has done”, said Benjamin. “It's a relay race.” Obama's Clean Power Plan: a breath of fresh air“An unacceptably high and potentially catastrophic risk to human health” was how a 2015 Commission published by The Lancet described the risks posed by climate change. With this in mind, the Clean Power Plan, unveiled by President Barack Obama and the US Environmental Protection Agency (EPA) on Aug 3, should be welcomed with open arms by the respiratory medicine community, both in the USA and further afield. Full-Text PDF