Public Health

Surgeon general’s nomination hearing begets forum on public health

The Senate confirmation hearing for surgeon general nominee Jerome Adams, MD, and the candidates for four other health care-related government posts also served as a forum on public health policy and a platform to announce that traditional legislative hearings have been scheduled for the week of Sept. 4 to explore bipartisan solutions for stabilizing and strengthening the individual insurance market for policies sold in 2018.

“There are a number of issues with the American health care system, but if your house is on fire, you want to put out the fire—and the fire in this case is the individual health insurance market,” Sen. Lamar Alexander, R-Tenn., chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee, said at the start of the confirmation hearing. “Both Republicans and Democrats agree on this.”

Alexander called for a short-term 2018 stabilization package that was “small, bipartisan and balanced,” that would include money for cost-sharing reductions (CSRs) and greater flexibility for states. He added that hearings would include participation from state health insurance commissioners, patients, governors, health care experts and insurance companies.

That approach would be in stark contrast with the recent proposals to repeal and replace the Affordable Care Act, which were drafted in closed-door meetings and were not discussed in public hearings before being voted on.

Alexander also called on President Donald Trump to approve continuation of CSRs through August and September. An Aug. 3 joint statement from the AMA, the American Academy of Family Physicians, hospital associations, insurance industry groups and the U.S. Chamber of Commerce also called on Trump to continue with CSRs, noting that they “help those who need it most—low- and moderate-income consumers.”

“Without these funds, consumers’ access to care is jeopardized, their premiums will increase dramatically, and they will be left with even fewer coverage options,” the AMA and the other groups said in the statement. “As medical professionals, insurers providing health care services and coverage to hundreds of millions of Americans, and business leaders concerned with maintaining a stable health insurance marketplace for consumers, we believe it is imperative that the Administration fund the cost-sharing reduction program."

Public health focus of hearing

The confirmation hearing itself focused heavily on the nation’s opioid epidemic in general and the response to an injection drug-related HIV outbreak in rural Indiana in particular. That response was led by Dr. Adams in his role as the state’s health commissioner. The hearing also touched on supervised injection facilities and gun violence as a public health problem.

Other issues covered included insurance-coverage parity for mental health and substance-use disorders, needle-exchange programs, treatment issues for pregnant women with opioid-use disorder, medication-assisted treatment for opioid-use disorders, regulation of e-cigarettes, honoring patients’ wishes for end-of-life care, and the proper relationship between science and politics.

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Dr. Adams said that evidence-based public health policies need to be implemented in a “sympathetic and empathetic way.” When advocating for beginning a needle-exchange program in Scott County, Indiana, the epicenter of the state’s HIV outbreak, the local sheriff had concerns about the exchange and about “the revolving door of his jail.” Dr. Adams told him how an exchange can become “a touch point to connect people to care.” He then told senators how the program was used to initiate addiction and recovery treatment for more than 100 people, led to testing for hepatitis C and HIV, and directed individuals to job-training programs.

Sen. Christopher Murphy, D-Conn., noted that both the AMA and the American Public Health Association endorsed Dr. Adams and that both have listed gun violence as a public health issue. Murphy then asked Dr. Adams, a gun owner, if he would address gun violence as a health issue.

Dr. Adams cited his work as a physician in a level one trauma center and noted that he “took care of a gentleman last week who was shot six times.” He added that there was a need to “separate the tool from the perpetrator” and for those on either side of the issue to “stop demonizing each other.”

Evidence sought on harm reduction approaches

Sen. Elizabeth Warren, D-Mass., asked Dr. Adams for his views on supervised injection facilities and asked if he was aware that the AMA recently voted to support pilot programs to test their effectiveness.

“I am. I was there when they debated it,” Dr. Adams, an AMA member, replied.

He said he believes “the science wasn’t quite there yet” for supervised injection facilities compared with needle exchanges. But Dr. Adams added that there were two pilots in progress, and he looks forward to reviewing the data on their operation.

The Senate confirmed Dr. Adams as surgeon general via a voice vote the day following the hearing.

The chamber also confirmed the nomination of Elinore McCance-Katz, MD, who will be the first Health and Human Services assistant secretary for mental health and substance abuse. The post was created with the 2016 enactment of the Helping Families in Mental Health Crisis Act.

During the confirmation hearing, Murphy instructed Dr. McCance-Katz about how her office has the power to issue guidance and conduct audits to enforce compliance of the Mental Health Parity and Addiction Equity Act that requires insurance coverage of treatment for substance-use disorders and mental health ailments be equal to medical or surgical benefits.

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