Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
The Tax Cuts and Jobs Act (TCJA) of 2017 was not directly intended to be a health policy. Major elements in this policy include reducing tax rates for businesses, a simplification of standard deductions, limiting deductions for state and local income taxes and property taxes, and reducing the alternative minimum tax for individuals while eliminating this for corporations. In order to increase the size of tax cuts in the bill, the bill also repeals the individual mandate of the Affordable Care Act that requires all Americans under 65 to have health insurance or pay a penalty. Further, this bill is expected to cost 1.5 trillion dollars in lost revenue. To pay for this lost revenue, congress will need to look for ways to cut spending and very well could target Medicaid, Medicare, and other such programs that older adults rely on. Combined, these could have major health implications.
Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
By eliminating the individual mandate of the Affordable Care Act, the CBO estimates that 13 million fewer people would have health insurance by 2025. Fewer people with healthcare means “lower costs for the government” and, as such, it has been estimated that this will lead to a $300 billion savings to the government. Consequently, health insurance premiums on exchanges will rise with fewer individuals receiving health care through the exchanges. Further, as a way to cover lost revenue, spending could be cut from programs such as Medicaid and Medicare, which many individuals rely on for health care needs. Due to these issues, the impact that the TCJA could have on healthcare is unknown and could be substantial. As such, an evaluation of this policy would be very informative.
Specify the outcomes and populations you think most affected or least affected by the policy.
One population that could be most affected by the policy is the elderly, especially those of lower SES. As mentioned above, to cover lost revenue, spending could be cut from Medicare and Medicaid, which are programs that many elderly rely on for health care needs. Medicare beneficiaries could be particularly vulnerable to increased costs, higher out-of-pocket expenses, and increased costs of long-term care. Those who do not have to rely on Medicare and Medicaid and are of high SES are likely to be less affected by this policy than those would rely on Medicare and Medicare and are of lower SES.
Propose a study design to evaluate the policy.
In order to evaluate this policy, one could perform a repeated cross-sectional study to examine pre- and post-policy health outcomes (e.g. strokes, MIs, diabetes incidence), comparing low income neighborhoods to high income neighborhoods.
Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
One of the biggest challenges to drawing inferences about the impact of the policy on health is that it may be many years (or even decades) until the full healthcare impact of the policy is truly seen. As such, a study examining the true impact of this policy could be extremely challenging and expensive to carry out, given the amount of time that it may take to see the true effect of this policy on health outcomes.