“We have a free society. We have to deal with these issues through persuasion and appropriate regulation rather than coercion, but I think we have substantial public health challenges that relate to commercial incentives to push us in an unhealthy direction. So, I’m hoping that we can deal with them.”

Harold Pollack currently serves as the Helen Ross Professor at the Crown Family School of Social Work, Policy, and Practice. Professor Pollack is the co-founder of the University of Chicago Crime Lab, co-director of the University of Chicago Health Lab, and a committee member of the Center for Health Administration Studies at the University of Chicago. 

Professor Pollack’s expertise lies in poverty policy and public health. His current NIH-funded research concerns improved services for individuals at the boundaries of the behavioral health and criminal justice systems (Pollack, 2019). 

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I want to begin with focusing on an interview you did with Jonathan Cohn in 2012 for The Curbside Consult. At the time of the interview, Cohn described healthcare reform as a Washington DC story that was just beginning to sprawl throughout the 50 states. How has this statement changed, and how will that impact this election?

One of the most striking things that’s happened is the way that ObamaCare, the Affordable Care Act, has become part of the firmament. For instance, in the vice presidential debate, Senator Vance, not entirely correctly, argued that President Trump had saved Obamacare. It has become toxic to pursue repealing Medicaid expansion, to pursue repealing Medicaid expansion, to overturn the Affordable Care Act. Republicans have already backed away from that. 

What’s really striking in the policy landscape is the idea that no one should be able to discriminate against you because you have an illness when you apply for insurance. It’s become accepted in society that poor people who are sick need to be covered, that we have to address issues like the opioid epidemic by making sure that people have access to evidence based treatment. These are not things that are being debated in a partisan way. Whereas, when President Trump was first elected, one of the major battles in American politics was overturning the Affordable Care Act, and it came within one vote, Senator McCain’s.

To emphasize, that was the 2017 Republican attempt to push the HCA through the Senate to repeal the Affordable Care Act. I think a big take away for the American people from this event was the lack of bipartisanship in our government. Do you still see that in our government today being an issue heading into our government? And how would this impact health policy going forward?

We certainly are in a polarized environment. There’s no question about that. What’s interesting is a lot of Republican states need a politically dignified path to embrace Medicaid because they’re facing problems like the opioid epidemic, but they can’t identify with an openly Democratic initiative. So when I talk to policy experts around the country who are in very red states, a lot of them say, “here’s what we want to do. We have to figure out a way to get there politically where we’re not identifying ourselves with Obamacare or with Medicaid, but Medicaid is actually the tool that we need now.” Now, one of the interesting things that’s happened is a lot of Republican states have actually expanded Medicaid, basically everywhere outside the Old Confederacy. 

One of the interesting things about President Trump is that he’s, in a lot of ways, in an extreme position. He’s an extreme figure in American politics. He’s a comprehensively unworthy figure that shouldn’t be getting more than 10 to 20% of the vote in a healthy democracy. Many of his policy views are actually more moderate than many of the traditional Republican views on things like health care. He has an economic populist framework that he embraces, he’s not a free market fundamentalist. He’s not saying we need to trim Medicare, we need to cut the deficit. Instead, he’s talking about high tariffs on foreign goods, things like that. Which, if you think about traditional free trade arguments, is the polar opposite of that. 

A lot of your research focuses on the economic and social impact on health. How do you see these economic policies that Trump is pushing out impacting the foreground that is health care reform, if he is to get elected in the 2024 election?

That’s a very good question. One of the interesting things is the addiction use issue has not been polarized in the same way as many of the other issues. Under the Bush, Obama, Trump, Biden, administrations these have had major initiatives done to try to expand access to addiction services. The Support Act was a major piece of legislation passed during the Trump years. Republicans have not chosen to go after addiction as a polarizing issue.

When the Affordable Care Act (ACA) was passed many of us were very worried. You’re probably too young to remember Willie Horton, but at the 1988 election, George H. W. Bush and Michael Dukakis were the two candidates. Dukakis was the Governor of Massachusetts and a prisoner named Willie Horton was let out on a furlough, and he committed an atrocity. He became the campaign trope for “the Democrats are soft on crime.” He was a “scary” black man and people didn’t explicitly say that, but that was clearly part of the framing. 

A lot of us were afraid when the ACA passed that there would be some person who would get out of jail, enroll in the Medicaid expansion, stab a nurse and become the Willie Horton of the Affordable Care Act. Republicans have not chosen to do that. They have not taken that approach towards addiction. For example, they’re taking it towards the migrants.  When a migrant commits a crime, that becomes a political trope. So I do think that there’s a lot of areas where a Trump victory would lead to very dramatic and unfortunate policy change. I think in the addiction space, we would see less of that than some of the other spaces

Yes, and with that I think a statement many Americans would agree with is that the health care system is complicated, and it’s essentially met with equally complicated law. Therefore, how do you propose the candidates approach healthcare policies moving forward to avoid Americans feeling this way? 

Health care has to be addressed in a very incremental way. I don’t think that we can do a radical reform. I think the Democrats are vulnerable to that too. Some of the ambitious single payer proposals, there’s just no possible way because those things would end up getting 25 senate votes if it actually came down to it. I admire the candor with which Senator Sanders and others described what they wanted to do, but the tax increases that would be required to accomplish those at the federal level would be so massive, that it’s not going to happen, at least in one jump. 

I think what Democrats and Republicans sometimes can do effectively is solve concrete problems. It tends to work out better when these are things that are not on the front page. Democrats and Republicans have a common interest in improving aspects of Medicare to make it more efficient. There are times when it’s not a polarized issue, where they really can get together and do problem solving now. 

Now, whether President Trump can do that, given the figure that he is and the reaction that he would elicit from all the Democrats, that’s another question. But there are certainly areas, and you see things, for example, in disability policy, where there’s just a lot of work that’s done that is quietly bipartisan. 

On the discussion of front-page topics, I want to bring up one of Kamala’s policies that is approved through 2025, which is her proposition of a per child tax credit for eligible families. Could you walk me through the potential benefits and the potential harms of this? 

I’m not the best person to give you a fully granular description of that, but one of the interesting things that happened during Covid was that we really expanded the child tax credit and in many ways, dramatically reduced child poverty in the United States. This is also something where a lot of Republicans, I think, see the value of that. Mitt Romney and others had similar proposals that were part of this. One thing is that many Americans feel we have to support parents and there are people who think that we need to have a higher birth rate so that we can support seniors over time. 

You have to take a pro-life perspective, which I respect, although that’s not my own personal view. One of the things that people have said is we have to show people that it’s actually viable. If I have this child, then I can economically support this child. In fact, when Medicaid expansion was passed in Ohio, Governor John Kasich actually had a PlannedParenthood, he had the pro-life groups, he had everybody supporting Medicaid expansion. What some of the pro-life people said was, we need to provide support for young parents so that people don’t have to have abortions because they can’t support a child. There are some areas like that whereI think the Child Tax Credit speaks to some of those values.

My final question discusses another front-page topic, in regards to the concern around the American diet. Do you think it can be fixed by strengthening public infrastructure such as grocery stores? 

Our diet is a fundamental public health challenge, and we have to speak it through culture. We certainly have to make sure that we have public policies that give people access to nutritious food, but we also have to deal with this as a society not just through government, but in other ways. We are marinating in images in our popular culture that encourage us to eat unhealthy food. This is where we look to the political system, sometimes to address issues that we have to address throughout the whole society. 

Our culture has to really promote healthy living in a more profound way. I do think, for example, Surgeon General Vivek Murthy is very aware of that. A lot of what he tries to do is to talk to people about the importance of a healthy diet, of attending to your mental health, of all the things we have to do to live in a healthy way. One of the things that’s really concerning is the way that we see this tremendous education gradient in health. If you look at things like smoking, there’s an incredible difference in smoking prevalence by people’s education. Hundreds of thousands of people die every year from smoking. We have to deal with that, and we have to deal with other things where the commercial determines health sometimes pushes in a very unhealthy direction. 

One of the things that concerns me now, that’s related to nutrition in certain ways, is if you look at any sports show, you’re going to be marinated in ads for FanDuel, for sports betting that you can now do on your phone. Anybody who studied addiction, you look at all these ads, they’re really hitting addiction cues around betting and and they aim at young people. They aim at communities of color. We have to really address it as a society. Society, the ways that there’s commercial incentives to promote an unhealthy way of living in lots of different domains. 

We have a free society. We have to deal with these issues through persuasion and appropriate regulation rather than coercion, but I think we have substantial public health challenges that relate to commercial incentives to push us in an unhealthy direction. So, I’m hoping that we can deal with them. 

References 

Pollack, H. A. (2019). Predictive Analytics Applied to Integrated Administrative Emergency Response Datasets in Chicago (Grant No. R01-MH117168-01A1). National Institute of Mental Health