A Report Card on National Government: How Will a New Government’s Policies Impact Population Health?

It’s time for a National Dashboard – a report card on how well policy-makers are supporting the conditions that allow people to be healthy.

Population health is about assuring the conditions in which people—all people—can be healthy. This effort has never been more important.  I will be monitoring these conditions in the United States and reporting on them here on the IAPHS blog every six months.  I welcome your input on which benchmarks should be included.

I will begin by monitoring six key issues. Each one has a significant impact on population health, and each can be measured reliably and objectively each year.  I’ve chosen these issues for two reasons: each one informs the conditions where health happens (or doesn’t), and each responds relatively quickly to policy changes. Together these metrics make a good start for a report card for the new administration.

1.The Number of Uninsured Americans.  With control of Congress, the Republican Party may dismantle several aspects of the Affordable Care Act. For example, Republican Speaker Paul Ryan has promised to dramatically curtail Medicaid by block-granting it to the states.  He would also like to end Medicare as we know it and replace it with a system of subsidies and insurance exchanges (sound familiar?) that are supposed to create improved quality at reduced costs through what one conservative analyst calls “the magic of competition.”  We don’t know what the Senate will come up with, but the issue goes far beyond repealing and replacing Obamacare.  Outside of that process, Congress and the administrative have control over the Medicaid and Medicare programs and waivers and rules governing the exchanges, some of them arcane.  The policies get into some very wonky weeds (risk corridors, bundled payments, MACRA), but one good summary measure of the population-health impact of this weediness is how many Americans lack health insurance.  The source I’ll use is the Gallup Healthways Well-Being survey, supplemented as necessary for detail by the Annual Report on Health Insurance Coverage by the U.S. Census.

2. Opportunity.  As a proxy for general opportunity, I’ll track the proportion of students who graduate with a standard high school diploma 4 years after starting 9th grade.  This is a Leading Health Indicator for Healthy People 2020, and I’ll use the same definition and data source.

3. Income. The median wage in the U.S. has been stagnant for decades, and because of the importance of adequate income to health and well-being, this stagnation impacts population health. Donald Trump pointed out that the median U.S. income was lower in 2014 than in 2000, and he implied that he would raise incomes for the middle class. I’ll track the median household income from the U.S. Census (series MEHOINUSA672N), supplemented by the most recent data from Sentier Research.  I’ll also track the percent of children living in households with incomes below the line of the Supplemental Poverty Measure, and the percent of children living in rent-burdened households across the U.S., as measured in the KidsCount data. I would like to track the post-tax distribution of income as calculated annually by the Congressional Budget Office, but this statistic is reported with a two-year lag.  Anyone have any ideas for a more timely estimate?

4. Taxes. Donald Trump has claimed that the U.S. is one of the most highly taxed countries in the world.  In fact, in the U.S. our total taxes as a percentage of GDP are among the lowest in the developed world.  Taxes are what pay for investments in children and the caretaking of the most vulnerable.  The largest share of all government workers is teachers; other major categories of people paid by government resources are professors, healthcare workers, bus drivers, librarians, and social workers.   For that reason, a country without an adequate tax base will decline. As the State of Kansas has discovered, taxes that are too low can be just as bad for population health as taxes that are too high.  I’ll track the percent of GDP collected in total taxes from all levels of government at the OECD Statistics website.

5. Tailpipe Emissions. Climate change presents an enormous threat to human health. I would love to track greenhouse gas emissions overall, but these respond very slowly to policy. There was no notable progress during the Obama administration, relative to previous administrations, in greenhouse gas emissions per dollar of GDP, and data are reported with a large lag.  The electricity sector is doing relatively well (relatively!) at reducing emissions, but the transportation sector is seriously lagging.  So I’ll track the University of Michigan’s Eco-Driving Index (EDI), which combines the sales-weighted average fuel economy of new vehicles sold with the average miles-driven per driver.  Ideally this index would also track changes in mode share—the percent of people driving as opposed to walking, biking, or taking transit—so I might also report a mode-share adjusted EDI if mode-share shifts dramatically.

6. Corruption.  Transparency International tracks a Corruption Perceptions Index.  I’ll keep track of that as well as their other measures of governance, including freedom of the press and the rule of law.  The Culture of Health Action Framework from the Robert Wood Johnson Foundation recognizes that civic engagement is an essential part of making health a shared value.  Corruption robs us of our democratic franchise.

Rate of GDP Growth.  And finally, a bonus.  I’ll also track the rate of GDP growth from the U.S. Bureau of Economic Analysis.  Donald Trump has promised 4% growth per year, and suggested that 5% would be achievable. Let’s see how close he gets.

What do you think?  Are there other metrics that you’re watching? Can you suggest refinements to the ones I’ve listed here? Share your ideas in the comments section, and please suggest an objective source of data for a concrete, trackable metric that you think underlies the conditions in which people can be healthy.

Why no health outcomes?  The point here is to examine the conditions in which people can be healthy.  If you’re looking for health outcomes, check out Healthy People 2020, which publishes its own dashboard of progress.

President Obama did very well on some of these metrics (e.g., health insurance and taxes), not so well on others (tailpipe emissions), and did not pay much attention to some others, or perhaps just couldn’t get traction. If these measures improve, then Republicans are succeeding in the stewardship of our country.  If they start to head downhill, let’s make a lot of noise.