Identify a policy that is not usually intended to be a health policy but that you think may have important health implications.
There have been multiple recent policy changes that may have ramifications for health, including the new tax cut law, not just because of it doing away with the ACA’s individual mandate (and the possible direct implications for the future of the ACA/health care access), but also in terms of the potential to increase or decrease taxes for some populations, the widening of disparities between the top 1% of earners and the general population, and the deficit increase. In terms of potential tax increase related to changes in itemized reductions, if people/families experience an increase in taxes it can impact their spending on health care, whether they pay the co-pays for medications, etc., and their health may suffer. Conversely, if people/family experience reduction in taxes from the new policy, they may spend more on health/medications, and their health may improve. In terms of widening disparities, there is prior evidence to suggest that income inequality is a risk factor for poor health, thus the potential increase in wealth disparities may produce worse health outcomes. The increase in federal deficit could have implications for future Medicare/Medicaid funding, and health care access for the elderly, medically complex and underserved.
· Describe why an evaluation of that policy is informative (e.g., determining effects of the policy, or primarily a test of hypothesized mediators).
An evaluation of tax reform is informative as it can shape future policy changes based on its implications, and potentially help bring about more timely policy reform if the policy is noted to have either beneficial or detrimental impacts on health (may prompt more immediate modifications). Given the multiple avenues that the policy can impact health, it is important to study how the changes interact and their implications on health.
· Specify the outcomes and populations you think most affected or least affected by the policy.
As with many policy changes, it is most likely that the most vulnerable will be most affected, e.g. those with less economic reserve and ability to respond to changes in taxes and most likely to weight pros-/cons- of paying for health vs. other basic needs, whereas those with the most economic reserve may have the least health impacts (given they are likely already readily accessing high quality care). In terms of outcomes, the tax reform may have ramifications for all levels of health case, especially so those that are influenced by social determinants of health, such as diabetes, obesity (though SDH can be linked to health outcomes in all specialties related to access/quality).
· Propose a study design to evaluate the policy.
Given we cannot randomize who is and is not impacted by the tax reform, I would propose a pre-/post-analysis, looking at a specific health outcome (or outcomes), such as blood pressure control or BMI, or cardiovascular events/mortality (power likely greater if pick one outcome). Evaluating a health outcome pre- and post-tax reform, controlling for confounders, would allow for an examination of the association tax reform and health. You would ideally have access to a large dataset (one way mortality data may be easier to look at), to look at health outcomes across the U.S., or at least at a regional level.
· Describe biggest challenge to implementing and drawing inferences about the impact of the policy on health.
One of the biggest challenge is being able to control for all the various confounders that could be affecting individual patients and communities, given that many things influence health, and it may be hard to parse out on what levels a policy is influencing a person’s health, and how much of changes in a person’s health is due to policy or other life factors. Relatedly, being able to track changes through time (more related to research feasibility/cost/retainment) can be very challenging.