2000px-Iowa_in_United_States.svgThere are 535 days left in President Obama’s term of office. What does that mean? It means election campaigning is well under way in states like New Hampshire and Iowa. It means that approximately seventeen Republican candidates and several Democratic candidates are appearing at state fairs, famers markets, Pizza Ranches, televised debates and even a Wing Ding dinner. Therefore, as election season approaches, I’d like to take the opportunity to highlight a few public health issues (among others) that should be of concern during this election season. Also, in honor of my Iowa roots, I’ll be highlighting why the issues may have relevance to Iowans. 
Global Issues
Global Health Security. Although confirmed cases are at their lowest level in a year, Ebola is still festering in West Africa. MERS and various influenza strains, potentially of pandemic potential, are also of current concern. The U.S. is aggressively pursuing its Global Health Security Agenda and WHO is reviewing the functioning of the WHO International Health Regulations (2005) in light of the Ebola outbreak. Positive events have occurred, too, including the recent report published in The Lancet that the world may soon have an effective Ebola vaccine. NewLink Genetics, a biopharmaceutical company based in Ames, Iowa holds the license for the vaccine in an exclusive relationship with Merck. However, global health security and the development of core capacities continue to be a challenge. As a voter, I would be interested to hear whether the candidates would intend to continue pursuing the Global Health Security Agenda and their thoughts on working to prevent another epidemic similar to the Ebola epidemic.
One Health. Many infectious disease outbreaks originate from a zoonotic or vector-borne source. For example, the Ebola outbreak is believed to have originated from a fruit bat, MERS from camels, H5N1 influenza from birds, and H1N1 influenza from swine. One Health is an integrative effort to attain optimal health for people, animals and the environment. Iowans can easily attest how avian influenza outbreaks decimated chicken farms throughout the state. Similar methods were used to try to contain the spread of both the zoonotic and the human outbreaks – quarantine (e.g., road closures around chicken farms and isolating individuals upon return from West Africa) and travel bans (e.g. other states banning bird shows and sales and other countries preventing entry of individuals who had recently traveled to West Africa). I would be interested to hear if candidates could articulate the importance and interconnectedness between environmental health concerns, zoonotic health concerns and human health concerns.
Medicaid Expansion. After the Affordable Care Act (Obamacare) once again survived a Supreme Court challenge in King v. Burwell, it is time for efforts to focus on ensuring that all Americans can access some form of affordable health insurance. A new donut hole was created when states were allowed to opt-out of expanding Medicaid. Now, people who make too little money to qualify for subsidies and make too much or do not meet a certain requirement to apply for Medicaid fall in a black hole of being unable to access affordable health insurance. Iowa negotiated with CMS to customize a program to expand Medicaid without doing so through a state plan amendment. Several states have followed Iowa’s lead to work with CMS to develop a customized plan to expand Medicaid in their states. I would be interested in hearing whether the candidates would continue to promote the concept of Medicaid expansion and flexibility within CMS for states to develop their own Medicaid expansion programs. I would also be interested to hear if a candidate promoted “repealing and replacing Obamacare” what a replacement program would look like.
State-based Exchanges. King v. Burwell maintained the availability of subsidies on federally-run health insurance exchanges. The majority of states are on such an exchange. Iowa operates a “state-partnership marketplace” exchange. This means that Iowa performs certain functions, the federal government performs the rest of the functions, and Iowans enroll in coverage through healthcare.gov. The exchanges can be expensive to maintain and update. After King v. Burwell, states may be incentivized to turn over all operations to the federal government. I would interested to hear the candidates views on maintaining the federal exchange and their willingness to work with states to continue to develop and maintain their own state exchanges or to join the federal exchange.
Other events – ISIS, the Iran nuclear agreement, the economy, public infrastructure, government debt, immigration, climate change and education are of critical importance during this election season. However, overall, health issues at both the domestic and global level should also remain an issue of high importance.