Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.

The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.

“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.

“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”

Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.

The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.

“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.

In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.

“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent.  “I think that integration of services and programming is very much at the forefront of what is the right way to go.”

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Cost-effectiveness Analyses

Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.

The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.

Gillian Sanders-Schmidler, a professor of medicine at Duke University Medical Center and former assistant professor of medicine at Stanford Health Policy’s Center for Primary Care and Outcomes Research, addressed the colloquium about recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine.

“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”

The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.

The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.

The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”

They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.

“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.

“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.

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Case Studies

Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.

Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.

The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.

“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.

Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.

William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.

Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.

“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”

He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.

“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.

Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.

“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”

As the leading cause of death for young people in the United States, traffic accidents are a major risk to health. Around the world, they kill 1.3 million people per year and seriously injure more than 80 million. David Studdert, a professor of medicine and law and a Stanford Health Policy core faculty member, wanted to bring those numbers down. In his study, "Exploring the relationship between traffic citation history and crash risk among elderly drivers in Florida," Studdert looked for a way to find high-risk drivers based on demographics and driving records. He found that drivers who have a quick succession of traffic violations or have particular types of violations may be at a higher risk to cause serious accidents. Studdert hopes to use the study's results to make driving safer without encroaching on civil liberties.

In a shack that now sits below sea level, a mother in Bangladesh struggles to grow vegetables in soil inundated by salt water. In Malawi, a toddler joins thousands of other children perishing from drought-induced malnutrition. And in China, more than one million people died from air pollution in 2012 alone.

Around the world, climate change is already having an effect on human health.

In a recent paper, Katherine Burke and Michele Barry from the Stanford Center for Innovation in Global Health, along with former Wellesley College President Diana Walsh, described climate change as “the ultimate global health crisis.” They offered recommendations to the new United States president to address the urgently arising health risks associated with climate change.

Bangladeshi children make their way through flood waters.

The authors, along with Stanford researchers Marshall Burke, Eran Bendavid and Amy Pickering who also study climate change, are concerned by how little has been done to mitigate its effects on health.

“I think it’s likely that health impacts could be the most important impact of climate change,” said Marshall Burke, an assistant professor of earth system science and a fellow at the Freeman-Spogli Institute for International Studies.

There is still time to ease — though not eliminate — the worst effects on health, but as the average global temperature continues to creep upward, time appears to be running short.

“I think we are at a critical point right now in terms of mitigating the effects of climate change on health,” said Amy Pickering, a research engineer at the Woods Institute for the Environment. “And I don’t think that’s a priority of the new administration at all.”

Health effects of climate change

Even in countries like the United States that are well-equipped to adapt to climate change, health impacts will be significant.

“Extremes of temperature have a very observable direct effect,” said Eran Bendavid, an assistant professor of medicine and Stanford Health Policy core faculty member.

“We see mortality rates increase when temperatures are very low, and especially when they are very high.”

Bendavid also has seen air pollutants cause respiratory problems in people from Beijing to Los Angeles to villages in Sub-Saharan Africa.

“Hotter temperatures make it such that particulate matter and dust and pollutants stick around longer,” he said.

In addition to respiratory issues, air pollution can have long-term cognitive effects. A study in Chile found that children who are exposed to high amounts of air pollution in utero score lower on math tests by the fourth grade.

“I think we’re only starting to understand the true costs of dirty air,” said Marshall Burke. “Even short-term exposure to low levels can have life-long effects.”

Low-income countries like Bangladesh already suffer widespread, direct health effects from rising sea levels. Salt water flooding has crept through homes and crops, threatening food sources and drinking water for millions of people.

“I think that flooding is one of the most pressing issues in low-income and densely populated countries,” said Pickering. “There’s no infrastructure there to handle it.”

Standing water left over from flooding is also a breeding ground for diseases like cholera, diarrhea and mosquito-borne illnesses, all of which are likely to become more prevalent as the planet warms.

On the flip side, many regions of Sub-Saharan Africa — where clean water is already hard to access — are likely to experience severe droughts. The United Nations warned last year that more than 36 million people across southern and eastern Africa face hunger due to drought and record-high temperatures.

Residents may have to walk farther to find water, and local sources could become contaminated more easily. Pickering fears that losing access to nearby, clean water will make maintaining proper hygiene and growing nutritious foods a challenge.

Climate change will affect health in all sectors of society.

All of these effects and more can also damage mental health, said Katherine Burke and her colleagues in their paper. The aftermath of extreme weather events and the hardships of living in long-term drought or flood can cause anxiety, depression, grief and trauma.

Climate change will affect health in every sector of society, but as Katherine Burke and her colleagues said, “….climate disruption is inflicting the greatest suffering on those least responsible for causing it, least equipped to adapt, least able to resist the powerful forces of the status quo.

“If we fail to act now,” they said, “the survival of our species may hang in the balance.”

What can the new administration do to ease health effects?

If the Paris Agreement’s emissions standards are met, scientists predict that the world’s temperature will increase about 2.7 degrees Celsius – still significant but less hazardous than the 4-degree increase projected from current emissions.

The United States plays a critical role in the Paris Agreement. Apart from the significance of cutting its own emissions, failing to live up to its end of the bargain — as the Trump administration has suggested — could have a significant impact on the morale of the other countries involved.

“The reason that Paris is going to work is because we’re in this together,” said Marshall Burke. “If you don’t meet your target, you’re going to be publicly shamed.”

The Trump administration has also discussed repealing the Clean Power Plan, Obama-era legislation to decrease the use of coal, which has been shown to contribute to respiratory disease.

“Withdrawing from either of those will likely have negative short- and long-run health impacts, both in the U.S. and abroad,” said Marshall Burke.

Scott Pruitt, who was confirmed today as the head of the Environmental Protection Agency (EPA), is expected to carry out Trump’s promise to dismantle environment regulations.

Despite the Trump administration’s apparent doubts about climate change, a few prominent Republicans do support addressing its effects.

Secretary of State Rex Tillerson, the former chairman and CEO of Exxon Mobile, supports a carbon tax, which would create a financial incentive to turn to renewable energy sources. He also has expressed support for the Paris Agreement. It is possible that as secretary of state, Tillerson could help maintain U.S. obligations from the Paris Agreement, though it is far from certain whether he would choose to do so or how Trump would react.

More promising is a recent proposal from the Climate Leadership Council. Authored by eight leading Republicans — including two former secretaries of state, two former secretaries of the treasury and Rob Walton, Walmart’s former chairman of the board — the plan seeks to reduce emissions considerably through a carbon dividends plan.

Already an issue, malnutrition will increase with droughts in Sub-Saharan Africa.

Their proposal would gradually increase taxes on carbon emissions but would return the proceeds directly to the American people. Americans would receive a regular check with their portion of the proceeds, similar to receiving a social security check. According to the authors, 70 percent of Americans would come out ahead financially, keeping the tax from being a burden on low- and middle-income Americans while still incentivizing lower emissions.

“A tax on carbon is exactly what we need to provide the right incentives and induce the sort of technological and infrastructure change needed to reduce long-term emissions,” said Marshall Burke.

Pickering added, “This policy is a ray of hope for meaningful action on climate.”

It remains to be seen whether the new administration and congress would consider such a program.

What can academics do to help?

Meanwhile, academics can promote health by researching the effects of climate change and finding ways to adapt to them.

“I think it’s fascinating that there’s just so little data right now on how climate change is going to impact health,” said Pickering.

Studying the effects of warming on the world challenges traditional methods of research.

“You can’t create any sort of experiment,” said Bendavid. “There’s only one climate and one planet.”

The scholars agree that interdisciplinary study is a critical part of adapting to climate change and that more research is needed.

“If ever there was an issue worthy of a leader’s best effort, this is the moment, this is the issue,” said Katherine Burke and her colleagues. “Time is short, but it may not be too late to make all the difference.”

The Trump administration’s reinstatement of a policy that bans U.S. foreign aid to agencies that provide abortion counseling abroad was a predictable move that could have unintended consequences, Stanford researchers say.

The move freezes funding to nongovernmental organizations that provide abortion services or discuss abortions as a legitimate  family-planning option. It revives what is known as the “Mexico City Policy,” so called because it was announced by President Regan in 1984 during a U.N. population conference in Mexico City. It’s a highly partisan policy, which has been implemented under Republican administrations and suspended by Democratic presidents.

From that standpoint, the move to revive the policy was no surprise, said Grant Miller, PhD, an associate professor of medicine at Stanford and core faculty member at Stanford Health Policy. But Miller’s research has shown that the policy actually appears to have the unintended effect of increasing, not decreasing, abortions in the developing world.

“The bottom line is that it doesn’t matter what you think about abortion and the morality and ethics of it,” Miller told me. “I don’t think either side of the disagreement would think a good policy is one that leads to an increase in abortions. Neither side wants to see more abortions.”

In 2011, Miller published a study with Eran Bendavid, MD, on the impact of the policy between 1994 and 2008 in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Family planning agencies provide a range of family planning services, including contraception, so when their funding is cut, the availability of contraception declines, said Bendavid, the study’s lead author and another faculty member at Stanford Health Policy. This results in declining use of safe contraception and an increase in abortion rates, the researchers found.

“Sure enough, where you see this relative decline in use of contraception is where you see this uptick in abortion,” said Bendavid, an assistant professor of medicine. “Our theory of what is underlying this is this notion that when women have more restricted access to modern contraception, they rely on abortion. If the intention was to curb abortion, then what we observe is that cutting support to family planning organizations led to the  opposite effect.”

Miller followed that up with another study published in 2016 that focused on Nepal during the period when the government legalized abortion, making it more widely available. The policy change gave him the opportunity to test the idea of abortion and contraception as substitutes — i.e. that use of one method to limit family size reduces use of the other. In fact, as the number of abortions rose, use of contraception declined, he found.

“What is remarkable is that this is clear evidence on this interchangeable use that women make in use of contraceptives and abortion services,” Miller said.

In other words, women are trying to control the number of children they have and will use one or the other, depending in part upon what is most available. “If contraception is available, they won’t have to resort to abortion,” Bendavid said.

He said these results have subsequently been corroborated in other studies in sub-Saharan Africa.

Herman Shaw was a 30-year-old cotton farmer in Tuskegee, Alabama, when he saw a flyer offering free medical care by the U.S. government.

This was back in 1932 and the Great Depression was bearing down hard on the already poor black farmers in the Deep South. Shaw jumped at what he said seemed like a godsend at the time.

“Every year they would give us a full examination and a free meal,” Shaw told The Baltimore Sun for a story in 1997. The men were also offered free burial insurance.

What Shaw would learn 40 years later was the U.S. Public Health Service was unwittingly testing him for syphilis, a little-understood sexually transmitted disease that was devastating black communities in rural Alabama.

What’s worse, even after Shaw tested positive for the disease — which can cause blindness, paralysis, heart failure, bone deformities and even death if left unchecked — he was never told, nor treated.

“The thing that disturbs me now is that they found a cure,” Shaw told the Baltimore Sun. “They found penicillin. And they never gave it to us. It vexed me awfully sadly.”

Shaw was one of the 600 African-American men chosen for the “Tuskegee Study of Untreated Syphilis in the Negro Male.” They were told they had “bad blood” and many underwent painful spinal taps. Of those 600 men, 399 had syphilis.

Even after the Centers for Disease Control in 1945 approved penicillin to treat the disease, the study that began in 1932 would continue until 1972 without the men being treated — all in the name of medical research.

Stanford sophomore Javarcia Ivory (right) talks to a patron of the Station 33 Barber Shop in downtown Oakland for the Oakland Health Disparities Pilot Project. Photo by Nicole Feldman

Stanford sophomore Javarcia Ivory (biology, ’19), remembers hearing this medical horror story growing up in neighboring Mississippi. He vowed to become a doctor and help revive the lost trust in public health in the Deep South.

When Ivory learned about a Stanford-led research project in Oakland, one that would dig deeper into this legacy of mistrust stemming from Tuskegee, he jumped.

“As an African-American and someone who aspires to one day become a doctor, I just knew I had to get involved,” he said.

Researchers connect Tuskegee trials to lower life expectancy

“The (Tuskegee) study’s methods have become synonymous with exploitation and mistreatment by the medical community,” write Stanford Health Policy’s Marcella Alsan and her colleague Marianne Wanamaker at the University of Tennessee.

The two have found that the disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality among African-American men. They published their findings in a working paper for the National Bureau of Economic Research last year.

Using publicly accessible data, the researchers estimated life expectancy at age 45 for black men fell by up to 1.4 years in response to the disclosure, accounting for about 35 percent of the 1980 life-expectancy gap between black and white men.

Alsan and Wanamaker used data on medical trust, migration and health utilization from the General Social Survey and the National Health Interview Survey, as well as morbidity and mortality data from the Centers for Disease Control and Prevention.

Their paper touched a nerve among some prominent African-Americans, some of whom praised the work as a model for understanding medical mistrust today.

“The story that Alsan and Wanamaker uncovered is even deeper than the direct effects of the Tuskegee Study,” wrote Vann R. Newkirk II in the Atlantic.

“Their research helps validate the anecdotal experiences of physicians, historians, and public health workers in black communities and gives new power to them,” Newkirk wrote. “These findings are also useful in framing health-care debates and discussions of health disparities today.”

Health disparities run deep

African-American men today have the worst health outcomes of all major ethnic, racial and demographic groups in the United States. Life expectancy for black men at age 45 is three years less than their white male peers, and five years less than for black women.

In the years following the disclosure of the Tuskegee trials, medical researchers have repeatedly pointed to the U.S. Public Health Service experiment as one reason African-Americans remain wary of mainstream medicine and health-care providers.

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“Mistrust may function as a tax on the price you pay to see a doctor,” said Alsan.

To further test this hypothesis beyond their data research, Alsan launched a pilot project in Oakland this past summer to evaluate the willingness of black men to seek preventative medical screenings.

The Oakland Health Disparities Pilot Project partnered with Dr. Owen Garrick, president and COO of Bridge Clinical Research, an organization based in Oakland that helps clinical researchers find patients from targeted ethnic groups.

Alsan and Garrick worked alongside Stanford and UC Berkeley students, as well as recent EMT students from the Oakland community to help run the project.

“We believe that even if you remove all the obstacles: transportation, access to health care and insurance — if you don’t trust the provider, you won’t follow their advice,” said Garrick, a physician whose mission is to get more people of color involved in clinical trials.

“But if you can push through this issue of mistrust, then you really begin to reap the benefits of the wealth of our health-care system, and then take advantage of the things that we as Americans have been afforded,” he said.

Oakland barbers partnered with the researchers and the barbershops served as recruitment sites. Uber also donated rides to the clinic for screening services.

Some 200 men filled out a medical survey; of those, 60 then agreed to clinical care.

Chris Colter, a master barber and manager for Station 33 Barber Shop in downtown Oakland, was pleased to participate in the pilot.

“It feels good that we’re helping out the community and that we’re instrumental in helping black men with health issues,” said Colter.

The pilot results are encouraging, Alsan said, given the high number of those who took up the offer for medical screenings. The team is hoping to scale up the research if they secure additional funding.

Ivory spent his summer in the Oakland barbershops, urging patrons to fill out the surveys and get the free checkup.

“I was really surprised at how easily they opened up with me and how interested they were that I went to Stanford,” said Ivory, who intends to go to medical school and return to rural Mississippi to practice medicine.

African-American men have a 70 percent higher risk of developing heart failure than white men, prompting Ivory’s desire to become a cardiologist.

“Working in the barbershops really gave me an in-depth understanding of how important diversity and inclusion in medicine are for some American populations,” said Ivory. “Medical mistrust does not have to dissuade black men from seeking health care in contemporary America — but it does. And this has galvanized my passion for wanting to become a doctor.”

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Berkeley graduate student Grant Graziani, three years into a PhD in economics with a focus on health policy, helped design and implement the Oakland study.

“One area that I think has gotten too little study is how race affects health outcomes,” said Graziani. “I think really zooming in on race and studying a diverse population pool is going to open up a new area of research with a lot of interesting policy implications. Ultimately we just want to help people have healthier lives.”

A Presidential Apology

Shaw was one of eight Tuskegee survivors invited to a White House ceremony in 1997, to meet President Bill Clinton, who formally apologized for one of the most macabre clinical trials in American history.

The last of the Tuskegee survivors, Ernest Hendon, died in 2004 at the age of 96.

Ninety-four-year-old Herman Shaw (R) embraces President Bill Clinton after receiving a public apology for being victimized in the Tuskegee Syphilis Study in ceremonies at the White House in Washington, D.C. on May 16, 1997. For almost 40 years, Shaw and 600 other black men were part of a government study following the progression of syphilis, who were told they were being treated, but were not. Photo: Stephen Jaffe/AFP/Getty Images

“The wounds that were inflicted upon us cannot be undone,” Shaw said at the White House ceremony, after being helped to the podium by Clinton. “I’m saddened today to think of those who did not survive and whose families will forever live with the knowledge that their death and suffering was preventable.”

The valedictorian of his 1922 high school class had wanted to go to college to study engineering, but his father insisted he stay back to run the family farm. He died in 1999 at the age of 97.

Two years earlier, at the White House ceremony, Shaw still found it in his heart to say it was never too late to “restore faith and trust.”

“In order for America to reach its full potential, “Shaw said, “we must truly be one America — black, red, white together — trusting each other, caring for each other, and never allowing the kind of tragedy which has happened to us in the Tuskegee study to ever happen again."

Robert MacCoun, a professor of law and a senior fellow at the Freeman Spogli Institute for International Studies, relays the potential risks and benefits of legalizing marijuana. His research focuses on drug policy, and he has written extensively about the effects of marijuana from a legal and health perspective.

California, Massachusetts and Nevada all legalized marijuana in the last election. Does this mean the legalization movement has reached a tipping point?  

If Hillary Clinton had won the election, it would probably feel that way, not because she’s a legalization advocate, but because she’d have bigger fish to fry and would probably continue President Obama’s laissez-faire approach. With the Trump administration’s new cabinet, all bets are off. Still, one in five Americans now live in a state where recreational use of marijuana is legal, and that’s a big market. And as the market grows, the industry’s lobbying clout grows.

What are the health risks post-legalization?

That depends on how much consumption levels increase. There are good reasons to expect marijuana prices to fall, which will increase consumption. Because many people use marijuana without health consequences, I worry less about an increase in the number of people using marijuana than about an increase in the number who use it one or more times daily. There is growing evidence that heavy marijuana use is associated with an increased risk of psychosis. We don’t know if it is a true cause-and-effect relationship; let’s hope it is not. But I think the biggest health threat is dependence, which for marijuana is something like getting stuck in the La Brea tar pits — your world just gets smaller and smaller as you get more dysfunctional.

Robert MacCoun, PhD

How can legalizing states combat these risks?

The good news is that legalization makes possible all sorts of regulatory options that weren’t available under prohibition. States should insist that no marijuana products are to be packaged in a way that entices children. Doses should be standardized, and there should be accurate labeling about the THC content. States should discourage products with high levels of THC, and perhaps encourage products with higher levels of cannabidiol (CBD), an ingredient that seems to counteract some of the harmful effects of THC.

The bad news is that the state ballot initiatives didn’t do much more than give lip service to public health and safety, and industry entrepreneurs are pushing back hard against state regulators. I think the industry is being foolish here — they’ve won eight states but still have 42 states to go. I don’t think they realize how quickly a backlash could emerge if those eight states show rising rates of various adverse outcomes.

Could there be any positive health effects of marijuana use?

Absolutely. There are plenty of lines of evidence suggesting medical benefits for some patients. Intriguingly, several new studies suggest that medical marijuana states may be experiencing reduced levels of opioid use and opioid overdoses. The Catch 22 is that the DEA decided not to reschedule marijuana because there isn’t enough rigorous evidence, but there isn’t enough rigorous evidence because the Feds have made such studies almost impossible to conduct.

Some of the biggest health benefits of marijuana will occur if it turns out that marijuana use is a substitute for binge drinking. There are both physiological and economic reasons to think that might be the case, but while some studies show substitution, others show complementarity. For a researcher, one big benefit of legalization is that it is going to help us finally answer a lot of these research questions.

Stanford Health Policy faculty members Michelle Mello, David Studdert and Laurence Baker discuss repealing the Affordable Care Act (ACA) and how it could affect health coverage in the United States.

Now that the United States has elected a Republican president and Congress, what is likely to happen to the Affordable Care Act (ACA)?

Michelle Mello and David Studdert: Exactly what will happen is unclear at this point, particularly since President-elect Trump’s own position on the ACA seems to be evolving by the day. In an interview on Nov. 11, he said he is interested in keeping some of the key provisions of the law, such as a ban on insurers discriminating on the basis of pre-existing conditions and provisions allowing young people to stay on their parents’ plans until age 26. But his opposition to other provisions, including the cornerstone provision requiring individuals to purchase insurance coverage, likely will remain. At this point, about the only thing one can say with certainty is that substantial change is coming.

Is the ACA likely to be repealed fully, or will some components be spared?

Mello/Studdert: On the campaign trail, President-elect Trump said repeatedly that repealing Obamacare is a priority. House Republicans have said the same. A complete repeal seems unlikely in the short term, though. There’s more opposition to some provisions of the act than to others, and millions of Americans now depend on health insurance coverage made available through the ACA. More likely, Republicans will target certain key elements – the individual mandate, minimum essential coverage rules, the subsidies available to low-income purchasers of health insurance and federal financing arrangements for the Medicaid program. Eliminating all of these features would spell the end of Obamacare as we know it. Eliminating any one of them would seriously threaten its viability, because the ACA’s strategy depends on having all major legs of the stool in place.

What is the legal process for repeal, and what issues would likely arise?

Mello/Studdert: Although Republicans will have a majority in the House and Senate, they fall just short of a filibuster-proof majority (60 votes) in the Senate. This is why a repeal is not likely to occur – at least not straight away – unless several Senate Democrats break ranks in the vote. A more likely scenario is that Republicans will use the budget reconciliation process to make the kind of changes mentioned above. Bills of this kind require only a simple 51-vote majority in the Senate, which they have.

Laurence Baker: Republicans have substantial ability to remove parts of the law under budget reconciliation. They can make changes to aspects of the ACA that involve financial in- and outflows to the federal government, but not other things. Reconciliation thus allows them to make changes to the major things like the mandate – because it involves a tax penalty – the subsidies and Medicaid. But they would not be easily able to repeal things like the exchange structures, guaranteed offers of insurance regardless of health status and other provisions. Guaranteed issue would be a real problem for insurance companies without the mandate, so repealing one but not the other threatens significant disruptions in insurance markets.

Most of the discussions thus far have focused on efforts to repeal the ACA’s expanding coverage aspects, but there are other aspects of the ACA that could be addressed. The ACA set up and funds the Center for Medicare and Medicaid Innovation (CMMI) and Patient-Centered Outcomes Research Institute (PCORI), two organizations that have not been discussed much in the repeal debates and which are seen by some Republicans in a more positive light. The ACA also makes changes to Medicare payments. It seems likely that repeal debates will focus more on coverage and less on these things, but it’s hard to tell at this point.

How will this affect Americans who current receive subsidies for health insurance?

Mello/Studdert: Elimination of the subsidies would have a major effect on the ACA’s core objective to cover the uninsured. By 2017, about 25 million people will have purchased their health insurance on the exchanges set up under the ACA, and about three-quarters of them will receive subsidies to help make premiums affordable. If the subsidies disappear, we should expect that health insurance will become unaffordable for many of these people or no longer look like a good deal. The tax credits and health savings accounts currently being discussed won’t make up for what is lost, and many people who currently have insurance can be expected to drop it. Elimination of the individual mandate will further open the way for this to happen.

Baker: The reality of the health care system is that there are not easily available alternatives to the ACA that would protect coverage and be palatable to broad groups of Republicans. Single-payer, or national health insurance, is a non-starter, so they’d be left with market-oriented reforms, and there are not obvious ways to pursue those without at least some core features of the ACA. Most of the proposals recently put forward for a replacement, including those highlighted by the Trump campaign, like cross-state competition, tax credits for insurance purchase and block granting Medicaid, would not really offer coverage to a large number of the people who would lose it under repeal. So a key question is what alternatives the Republicans come up with. In a similar way, the ACA and its provisions have become increasingly woven into our insurance system. Insurers and employers, among others, have made decisions and investments incorporating the ACA. Undoing those threatens disruptions and political challenges.

Michelle Mello is a professor of law and of health research and policy.

David Studdert is a professor of law and of medicine.

Laurence Baker is a professor of health research and policy, chair of the Department of Health Research and Policy in the School of Medicine and a senior fellow at the Stanford Institute for Economic Policy Research.

The U.S. Preventive Services Task Force now recommends adults ages 40 to 75 with no history of heart disease — but who nevertheless have at least one risk factor and an elevated risk of cardiovascular disease — take a low- to moderate-dose statin.