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.

Improving health has been a focus of Indonesia as it strives to implement universal healthcare nationwide. Yet as the government tries to achieve that ambitious goal, it finds not unlike other developing countries that poorer patients are struggling to access care, due to a number of environmental and financial constraints.

A set of conditional cash transfer (CCT) programs—a system in which patients are incentivized to seek care upon the promise of a stipend—were introduced in 2007 as an approach to improve health among poor households in Java, Indonesia’s most populous island, and a few provinces outside of Java. The programs specifically sought to better maternal and child health outcomes.

Evaluating those pilot CCT programs is the focus of a newly published paper by former Asia Health Policy Program postdoctoral fellow Margaret Triyana: “Do Health Care Providers Respond to Demand-Side Incentives? Evidence from Indonesia,” an outcome of her research completed at Stanford’s Shorenstein Asia-Pacific Research Center from 2013-14.

Triyana found that the CCT programs increased demand for healthcare providers, and consequently, prices for healthcare services. While the programs led more patients to show up for services, they also may have limited access for some patients who were unable to afford services following an eventual bump up in cost.

Triyana concludes that policymakers should forecast effects on supply and demand before implementing CCT programs in order to plan and adjust the quantity of healthcare providers as needed. Such an approach could keep prices steady and in turn allow a greater pool of patients to access care, she writes.

The paper appears in the November edition of American Economic Journal: Economic Policy.

Triyana, now a professor at Nanyang Technological University in Singapore, shared in an earlier interview her research plans and initial findings. Read the Q&A here or tune in to a podcast from her research presentation here.

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.

Stanford researchers have determined that more than 15 million children are living in high-mortality hotspots across 28 Sub-Saharan African countries, where death rates remain stubbornly high despite progress elsewhere within those countries.

The study, published online Oct. 25 in The Lancet Global Health, is the first to record and analyze local-level mortality variations across a large swath of Sub-Saharan Africa.

These hotspots may remain hidden even as many countries are on track to achieve one of the U.N. Sustainable Development Goals: reducing the mortality rate of children under 5 to 25 per 1,000 by 2030. National averages are typically used for tracking child mortality trends, allowing left-behind regions within countries to remain out of sight — until now.

The senior author of the study is Eran Bendavid, MD, MS, an assistant professor of medicine and core faculty member at Stanford Health Policy. The lead author is Marshall Burke, PhD, an assistant professor of Earth System Science and a fellow at the Freeman Spogli Institute’s Center on Food Security and the Environment.

Decline in under-5 mortality rate

The authors note that the ongoing decline in under-5 mortality worldwide ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million a year in 1990 to fewer than 6 million a year in 2015, even as the world’s under-5 population grew by nearly 100 million children, according to the Institute for Health Metrics and Evaluation.

“However, the amount of variability underlying this broad global progress is substantial,” the authors wrote.

“Mortality numbers are typically tracked at the national level, with the assumption that national differences between countries, such as government spending on health, are what determine progress against mortality,” Bendavid said. “The goal of our work was to understand whether national-level mortality statistics were hiding important variation at the more local level — and then to use this information to shed light on broader mortality trends.”

The authors used data from 82 U.S. Agency for International Development surveys in 28 Sub-Saharan African countries, including information on the location and timing of 3.24 million births and 393,685 deaths of children under 5, to develop high-resolution spatial maps of under-5 mortality from the 1980s through the 2000s.

Using this database, the authors found that local-level factors, such as climate and malaria exposure, were predictive of overall patterns, while national-level factors were relatively poor predictors of child mortality.

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Temperature, malaria exposure, civil conflict

“We didn’t see jumps in mortality at country borders, which is what you’d expect if national differences really determined mortality,” said co-author Sam Heft-Neal, PhD, a postdoctoral scholar in Earth System Science. “But we saw a strong relationship between local-level factors and mortality.”

For example, he said, one standard deviation increase in temperature above the local average was related to a 16-percent higher child mortality rate. Local malaria exposure and recent civil conflict were also predictive of mortality.

The authors found that 23 percent of the children in their study countries live in mortality hotspots — places where mortality rates are not declining fast enough to meet the targets of the U.N. Sustainable Development Goals. The majority of these live in just two countries: Nigeria and the Democratic Republic of Congo. In only three countries do fewer than 5 percent of children live in hotspots: Benin, Namibia and Tanzania.

As part of the research, the authors have established a high-resolution mortality database with local-level mortality data spanning the last three decades to provide “new opportunities for a deeper understanding of the role that environmental, economic, or political conditions play in shaping mortality outcomes.”  The database, available at http://fsedata.stanford.edu, is an open-source tool for health and environmental researchers, child-health experts and policymakers.

“Our hope is that the creation of a high-resolution mortality database will provide other researchers new opportunities for deeper understanding of the role that environmental, economic or political conditions play in shaping mortality outcomes,” said Bendavid.  “These data could also improve the targeting of aid to areas where it is most needed.”

The research was supported by a grant from the Stanford Woods Institute for the Environment. 

China’s recent initiatives to deepen health reform, control antimicrobial resistance, and strengthen primary health services are the topics of ongoing collaborative research by the Asia Health Policy Program (AHPP) at Stanford’s Shorenstein Asia-Pacific Research Center and Chinese counterparts. For example, with generous support from ACON Biotechnology and in partnership with the ACON Biotech Primary Care Research Center in Hangzhou, China, AHPP hosts an annual conference on community health services and primary health care reform in China.

The conference, titled Forum on Community Health Services and Primary Health Care Reform, was held in June at the Stanford Center at Peking University (SCPKU) in Beijing. It featured distinguished policymakers, providers and researchers who discussed a wide-range of topics from China’s emerging “hierarchical medical system” for referring patients to the appropriate level of care (fenji zhenliao), as well as the practice and challenges of innovative approaches to primary care and integrated medical care systems. Yongquan Chen, director of Yong’an City Hospital and representative for the mayor’s office of Sanming, talked about health reforms in Sanming City, Fujian Province, a famous example within China. He discussed the incentives and reasoning behind the reforms, which focus on removing incentives for over-prescription of medications, demonstrating government leadership for comprehensive reforms, consolidating three agencies into one, monitoring implementation and easing tensions between doctors and patients. He pointed out the feasibility and early successes of reform by comparing public hospitals in the city in terms of their revenues and costs, reduced reliance on net revenue from medication sales, and other dimensions of performance. Finally, he addressed reform implementation and future plans on both the hospital's and the government's part.

Xiaofang Han, former director of the Beijing Municipal Development and Reform Commission, shared her personal views on the challenges patients face in navigating China’s health system (kan bing nan) and the need to improve the structure of the delivery system, including a revision to the incentives driving over-prescription in China’s fee-for-service payment system. She emphasized that patients’ distrust of primary care providers can only be overcome by demonstrating improved quality (e.g. with a systematic training program for general practitioners, GPs), and that referral systems should be based on the actual capabilities of the clinicians, not their formal labels. To reach China’s goal of over 80 percent of patients receiving management and first-contact care within their local communities will require improved training and incentive programs for newly-minted MDs, a more flexible physician labor market, and innovations in e-health and patient choice regarding gatekeeping or “contract physician services” (qianyue fuwu).        

Guangde County People's Hospital Director Mingliang Xu spoke about practices and exploration of healthcare alliances and initiatives to provide transparent incentives linking medical staff bonuses to metrics of quality. Ping Zhu from Community Healthcare Service Development and Research Center in Ningbo addressed building solid relationships between doctors and residents and providing more patient-centered services.        

Professor Yingyao Chen from Fudan University School of Public Health discussed performance assessment of community health service agencies based on his research in Shanghai. He introduced the strengths and weaknesses of the incentives embedded in the assessment system for China’s primary care providers, and concluded with suggestions for future research. Dr. Linlin Hu, associate professor at Peking Union Medical College, discussed China's progress and challenges of providing universal coverage of national essential public health services.

Professor Hufeng Wang of Renmin University of China discussed China’s vision for a “hierarchical medical system”– bearing resemblance to “integrated care,” “managed care,” or NHS-like coordination of primary and specialized care – with examples of pilot reforms from Xiamen, Zhenjiang and Dalian cities. Dr. Zuxun Lu, professor of Tongji Medical College of Huazhong University of Science and Technology, also discussed hierarchical medical systems and declared that China currently had a “discounted gatekeeper system.”

Dr. Yaping Du of Zhejiang University presented his research on mobile technology for management of lipid levels and with the help of a volunteer, demonstrated “Dyslipidemia Manager,” a mobile app-based product for both patients and doctors. Innovative strategies for primary prevention of cardiovascular diseases in low- and middle-income countries were the focus of remarks by Dr. Guanyang Zou from the Institute for Global Health and Development at Queen Margaret University, including its connections to international experiences with China’s current efforts in that area.  

In sum, the 2016 Forum elicited lively, evidence-based discussions about the opportunities and challenges in improving primary care and sustaining universal coverage for China.  Plans are underway for convening the third annual ACON Biotech-Stanford AHPP Forum on Community Health Services and Primary Health Care Reform in June 2017 at SCPKU. Anyone with original research or innovative experiences with primary care in China may contact Karen Eggleston regarding participation in next year’s Forum.