miércoles, 28 de octubre de 2026
National Academy of Medicine’s 2026 Annual Meeting (Scientific Symposium on Chronic Disease) 2026 Victor J. Dzau Keynote Address by Drew Altman, PhD: The Big Challenges Ahead in Health Policy, and Where Chronic Illness Fits Author: Drew Altman Published: Oct 28, 2026
https://www.kff.org/health-costs/national-academy-of-medicines-2026-annual-meeting-scientific-symposium-on-chronic-disease/?utm_medium=email&_hsenc=p2ANqtz-95Kzy5Vp48hg7z-CXcJ5rOLV_9gCox5jkV1LLt-QSr2__z3aLRFA4xyeweOq1V4aaZbnwNEkRR3dHvtKOKHwJ_2AmDSA&_hsmi=446348638&utm_content=446348638&utm_source=hs_email
National Academy of Medicine’s 2026 Annual Meeting (Scientific Symposium on Chronic Disease)
2026 Victor J. Dzau Keynote Address by Drew Altman, PhD: The Big Challenges Ahead in Health Policy, and Where Chronic Illness Fits
Note from Drew Altman: On October 10, 2026, I had the honor of delivering the keynote address at the annual meeting of the National Academy of Medicine (NAM), where I am a member and former member of the Institute of Medicine (IOM) Governing Council. As the event drew closer, I asked to convert the formal remarks to a fireside chat, feeling that format is more accessible to audiences. The discussion was moderated by the program head for the day, Brendan Lee, MD, PhD, the distinguished – in title and in fact - professor and chairman of the Department of Molecular and Human Genetics at Baylor. Subsequently, many requested that I write down what I had said that day, which I have done with as much fidelity to what I actually said as possible. The program focused on chronic disease, and I had been asked to paint the policy and political environment and discuss how chronic illness fits.
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The Health Policy Agenda and Where Chronic Illness Fits
A long time ago in government, I was described in a major newspaper as “a nice guy trapped in a deadly serious face.” So, I hope it shines through the mask what a special privilege it is to be the first Victor Zau Keynote speaker this year. Victor has always led with science, values, transparency and tremendous honor.
He led through a transition from IOM to NAM that I was on the other side of, feeling it was a mistake for IOM to lose control of so many of its substantive programs, even co-authoring a dissenting report when I was on the Governing Council, but I have nothing but admiration for how Victor has guided us through the changes, and now we have superb new leadership at the Academy, which we just witnessed in action.
I have transitions on my mind, making my own after 37 years since founding KFF.
A million years ago, when I received a PhD in political science at MIT, I received a note from my 96-year-old grandmother which simply said: “Congratulations, so what are you going to do, open a political science store?” Those of you who know KFF know I sort of did. I started what is now KFF back in the early 1990s based on a simple idea: Health was becoming a bigger issue and the country would need a trusted independent source for health policy information. We do that by doing lots of policy analysis, polling and survey research, and through our newsroom, now the largest health newsroom in the country, with bureaus across the U.S. We are not a policy research shop, although we do tons of policy research. We are not a polling organization, although we are well known for that. Nor are we a news organization. We are a “unicornish” combination of all three, and it’s the combination of all three, coordinated and focused on the same issues, that gives us the power and presence to play our national role and reach the different audiences we want to reach.
For those of you who may remain confused about this: We do not have and never have had any connection to Kaiser Permanente, and we are not a foundation. We are a public charity – or endowed nonprofit – based in San Francisco.
One important thing about us is that we never take positions or make recommendations, but I certainly understand that data and analysis are not neutral in national health policy. In fact, we are built to annoy all sides at one time or another, and we do.
Big health policy debates come in cycles and health policy is heating up again, driven by voter concern about cost of living and health care costs, the midterms, wins by progressive Democrats pushing more expansive reform ideas again (whether they go anywhere or not), controversial administration policies, and much more. They will continue to grow through 2028 and a potentially big legislative agenda beyond. Today, I want to talk about a few of the biggest challenges we face in health policy, and how your topic today – chronic illness – is central to them, obviously viewed through the lens of a hard-core health policy organization. I recognize that there are lots of different folks here with different perspectives and NAM has its own priorities, and I have no quarrel with that. There will be overlap, but we are a different animal in health policy.
There are three problems I want to talk about:
Rebuilding Medicaid and Affordable Care Act (ACA) coverage after almost a trillion dollars in cuts in federal spending in the two programs over the next 10 years, the largest cuts in coverage and federal health spending in our history.
Reconstructing federal agencies – a task which is receiving inadequate attention and will mean daunting decisions about funding, staffing, and most challenging of all – redesigning what agency missions should be. Lest we forget, nobody was happy with the primary Health and Human Services (HHS) agencies before, but we are so unhappy with the state of affairs now we forget that.
And third, there is a new zeal to take on health care costs. But what do we even mean by that? Have we discovered the courage we never had before to do it, and, in particular, to take on underlying costs driven mostly by hospital spending and high prices?
Finally, a bonus theme: we can’t deal effectively with any of this unless we make some progress restoring trust in evidence and facts, and the people and institutions that convey them, especially government scientific agencies. I am more optimistic than many people about this big challenge based on our survey data, and I will touch on that.
Two points weave in and out: 1) these challenges will compete for space on the agenda and funding. No president, secretary, or new Congress will take them all on simultaneously in a meaningful way and 2) I have written often, there is an invisible crisis of costs and affordability affecting the chronically ill and people with major diseases. And I don’t use the over-used word “crisis” lightly. It’s why I am so pleased with your focus today.
To start…
The One Big Beautiful Bill (OBBB) included almost a trillion dollars in cuts in federal health spending over ten years. Then, following on the heels of that, was the failure to extend the ACA enhanced premium tax credits, which our widely cited analysis showed, on average, doubled premiums for almost 24 million enrollees, leading millions to drop coverage and driving many more into plans with big deductibles averaging 7k a year. Effectively that’s not insurance if you drive an Uber or work in hair salon or work on a farm and make, say, 35k a year. (Fun KFF fact: 1/3 of farmers and ranchers get their coverage through the Marketplaces.)
All told, estimates are that these cuts will result in about 14 million more uninsured people over the decade, reversing progress made in recent years and bringing the number of uninsured back up to close to 40 million. But that’s not the only effect.
As a former state Human Services Secretary, I can tell you that states will try to replace some but far from all of these cuts, especially blue states. When they do, something else in the state budget will have to give. It may be education or higher education or environmental protection or corrections. Few to none will raise taxes.
The single biggest cut—330 billion over 10 years—comes from the Medicaid work requirements, a popular but highly questionable policy.
It’s popular because Americans love the idea of work and personal responsibility. Medicaid work also draws on a conservative view of Medicaid dominating current policy as a “welfare program,” a dividing line between Rs and Ds. Seventy-four percent of Democrats see Medicaid as a “government insurance program for low-income people.” By contrast, more than half or Republicans see it as “a welfare program.” If you view it as welfare, like cash assistance, you are likely to want to impose requirements to get it and cut it if you can. If you view it as “insurance,” you want to protect it and expand it if you can. The difference in underlying views is fundamental.
I was a leader in the welfare reform movement many years ago as state human services secretary, actually for a Republican governor. I can’t stress enough how different this is from what I thought I was doing then. Welfare reform then was built on what Bill Clinton called a “reciprocal obligation.” Beneficiaries were asked to take steps towards self-sufficiency and government committed new resources to help them do that, for job training and childcare, job search and more. In my state, that meant historic new commitments to childcare and other employment-related supports. In “Medicaid work,” only the beneficiary has an obligation. That’s one reason why CBO says it produces no new work. Let me repeat that, NO new employment gains - only red tape that forces people off the rolls (5 million more uninsured says CBO). It’s a popular policy that’s a huge administrative lift for any governor, which doesn’t produce work but is popular because it sounds like it promotes work and personal responsibility.
A Second Big Challenge Is Rebuilding the Federal Agencies
I was a young academic at MIT when I got a job working for the head of what is now CMS, an agency I was later asked to run. It changed my career and my life, which became all about public service, whether in the public or nonprofit sectors. Can that happen anymore? How do we revitalize rather than demonize public service? What does it mean that 60% of the graduates of the Kennedy School go to big consulting firms (the last time I looked)?
I don’t need to tell this audience about the staffing cuts in the federal agencies, the dismantling of agencies of special relevance to this audience such as AHRQ, the warping of missions and science, including jarring recent reports from research arms of HHS asserting that enrollees dropping coverage all did so because they were there fraudulently. I have had hundreds of calls from expats from HHS looking for help and so have many of you.
Interestingly, by far the largest of the agencies in terms of budget, CMS, protected by Dr. Oz, has been largely immune from the storms that have swept through other agencies caught up in the science and culture wars.
I don’t want to present a lot of data about staffing cuts, and a lot of it is fluid and unreliable or from advocacy groups. To me, these are the critical points:
It will take a Marshall Project to rebuild the HHS agencies
No secretary will be able to do it and do everything else he or she needs to do. (I know how daunting it will be. I have been offered that job too and looked it in the eye.)
If plans are not made ahead of time, it will be two years into an administration before much is done, and that could be too late; likewise if it is done agency head and agency by agency over time
For those reasons, it would be timely for some distinguished nonpartisan group (KFF, NAM, a new commission funded by foundations) to take this on now. If I were a Secretary, I would appoint, in effect, a reconstruction czar, who would focus solely on plans and proposals for the reconstruction of CDC, FDA, the PHS agencies and NIH, including mission, staffing and funding.
How to formulate an updated commitment to equity across HHS will by itself be a daunting challenge, but it must be done.
This is a tough one because no candidate will run on restoring federal agencies, but this audience understands how essential it is.
Third, there is a new zeal to take on health care costs. But what do we even mean by that? At all the conferences I speak at, I find that we are often talking past each other as if we operate in a Venn Diagram with sets that only somewhat overlap and often conflict. Often in my world, we are talking about federal health spending. Cutting that often puts pressure on a different problem we sometimes talk about, state health spending. Employers are entirely concerned about their annual premium increases, and they should be. Our annual survey shows the average cost of a family policy is now almost $28,000 a year, the equivalent of buying a Toyota Corolla each year. Then there is “value” – a concept which encompasses at one and the same time the most forward-looking reforms in payment and delivery and the most backward rear-guard actions to forestall either real market competition or government regulation that might address underlying costs. In general, beware of any idea that is popular with everyone.
Then there are the two really big cost problems.
There is the one experts have always cared about most, national health care spending, measured as the share of GDP we spend on health care or per capita health spending. For reasons we debate endlessly in my world, health care as a share of GDP, long predicted to blow through 20% of GDP, has been pretty stable for a long time at about 18%. That’s much higher than other wealthy nations but reasonably stable. It’s predicted to rise more sharply again, and the main culprit as always is our high prices, which we don’t deal with much, focusing more on volume and utilization in bits and pieces.
And then there is the cost problem, which is driving the rising concern about health care nationally and has made health care a political issue. It’s none of the above; its “affordability” – the cost of health care to people. That—and only that—is what has made health care a voting issue.
If you look at the polls, the economy always emerges as the voters’ top concern. So, in our monthly tracking poll, we asked voters and I paraphrase: You said the economy was your top worry, what about the economy worries you the most? Health care costs were at the top of the list, ahead of the cost of food, housing, and even gas prices.
Assuming gas prices would eventually eclipse health care, we continue to ask every month and health care costs have remained number one, just ahead of gas prices, until tying with them recently.
But they are all closely clumped together, and it makes sense that health care costs are a top “worry” since they are less predictable than some other costs. The uncertainty makes people worry about it more.
The best way to understand this: voters see health care costs as one dimension of a set of inter-related cost-of-living concerns they are concerned about. It’s not number one, two or three…it’s all one concern.
While I am talking about the midterms, it’s also useful to always remember that issues are only one factor that drive votes. Think about your own vote. Partisan affiliation matters. The candidates and voters’ feeling about them matter a lot. Their feelings about the mood and direction of the nation and about President Trump matter (especially for turnout). All these things matter more than issues and a lot more than candidates’ policy plans to address issues. Polling assesses these factors as well, but issue rankings tend to get featured the most.
So, there are six different cost problems – national spending, people’s health costs, federal spending, state spending, employer premiums and value – and often we talk past each other as if they are the same. Often, they conflict: cut federal spending, for example, and you drive up state spending. The real challenge is to take on underlying costs but there is little evidence that the country has the stomach for that, nor do Democrats and Republicans have anything resembling agreement on how to do it except for some incremental measures that will have impact only at the margin. It means aggressively taking on hospital spending either through market forces (tough in a very consolidated industry) or government regulation, which is off the table with Republicans in charge and industry strongly opposed. For at least the next two years we are destined for “small ball” on costs, typically dressed up to sound more impactful than it is. A bright spot now is the action in several states to take on hospital costs.
It Turns Out that Chronic Illness Is at the Heart of the Affordability and the Complexity Problems
When we do surveys, we generally find that about 25% of the American people have trouble paying their health care bills and skipped or delayed care as a result.
Partly for this talk, we did a survey of 20,000 people looking at people with chronic conditions and serious illnesses such as asthma, cancer, heart disease, diabetes, and mental health conditions.
I am not going to give you a lot of numbers without slides, but for people with those conditions, the shares having problems paying their medical bills approach 40%; as many as 59% say they skipped or delayed needed care in the past year; around a quarter said their health got worse as a result; and, around a quarter said they had to cut back on other basic household needs as a result.
They also get caught in the health care maze more often: between 40 and 50% say their insurance company denied or delayed their care.
You could simply say, sure, of course they have the most problems; they use the most care. You could also say that the most basic obligation of any health system is to take care of people who are sick and we are not doing that. If I leave you with any big message today it is this: the chronically ill are the heart of the health care affordability crisis in the country.
But wait there’s more….
Again, not surprisingly, but tellingly, the worst thing you can be in our health system is chronically ill AND UNINSURED.
Among uninsured adults with multiple chronic conditions, 72% had problems paying or were unable to pay their medical bills. Seventy-one percent skipped or delayed needed care.
Forty-three percent said they got sicker as a result, and half said they had to cut back on other household needs.
To use a technical term, the chronically ill and uninsured are probably the most screwed group of all in our health system, and now with all the cuts, their ranks will grow.
Finally, I don’t believe we can make real progress without dealing with declining trust; in government agencies, the news media, medicine and science.
We have to have shared trust in information and science. A shared belief that government can make a difference, even if we disagree over how. And a shared understanding that access to affordable health care, and health coverage, make a difference in people’s lives.
We have polled extensively on this and it has made me somewhat more optimistic. The polling doesn’t show a country drowning in health misinformation and mistrust on social media.
It shows a small group of hard-core disbelievers, but smallish; just 1% believe all of the vaccine myths, for example.
It shows another group who trust the science. Let’s call them the NAM Americans.
But most Americans are stuck in the middle, uncertain about what is true and who to believe on almost every key question. They have heard the lies, but they don’t necessarily believe them. They say they don’t believe what they see on social media.
They are “up for grabs.” The situation is far from hopeless. A few hundred thousand or even a million posts on social media are NOT the whole country. Usually, its folks reinforcing views they already hold. And the most trusted messengers are still physicians and nurses and pharmacists–MANY OF YOU. It’s up to us to reach the vast majority in the middle and turn this around. Many of us seek discovery or to fill knowledge gaps in our work. We also need to keep people and relevance centered in everything we do.
Thank you very much for having me and for honoring Victor.
Study suggests gut microbiome determines vaccine reaction News brief October 27, 2026 Stephanie Soucheray, MA
https://www.cidrap.umn.edu/misc-emerging-topics/study-suggests-gut-microbiome-determines-vaccine-reaction?utm_campaign=KHN%3A%20First%20Edition&utm_medium=email&_hsenc=p2ANqtz--oTnw8I48d_b9SmMPFryn3H8iPHGrdxdWmyd7KtZr1bnXdGW_E23Dzidmia0Dx6YGu7MCqtfOO8pw3NEs3AZlGyaaJrA&_hsmi=446332176&utm_content=446332176&utm_source=hs_email
CIDRAP: Study Suggests Gut Microbiome Determines Vaccine Reaction
A new study shows a person’s gut microbiome, specifically levels of inflammation in the intestine, may be behind post-vaccination fevers. The study was published earlier this month in Science. Fever is a common reaction to a number of vaccines but can be a factor in vaccine hesitancy, the authors wrote, especially for vaccines against seasonal influenza and COVID-19. The study was based on 171 healthy adults whose fecal microbiomes, body temperature, and blood-based immune markers were measured before and after receiving mRNA COVID-19 vaccination. (Soucheray, 10/27)
Trump says he’s ending restrictions on climate-warming methane from oil drilling
https://apnews.com/article/trump-methane-oil-climate-change-257f28c07cda5146a40dbf7a2c8ba790?utm_campaign=KHN%3A%20First%20Edition&utm_medium=email&_hsenc=p2ANqtz-_vfRKhV6xQtp9uKsKUv9SLui3Q-3fzTRNfCtN72KltwzZZ7pF0QnfHMgCzs7nFjVAY2irQAYooqPiOo40gawrjRNVpWg&_hsmi=446332176&utm_content=446332176&utm_source=hs_email
AP: Trump Says He's Ending Restrictions On Methane Emissions From Oil Drilling
President Donald Trump said Tuesday that his administration is “terminating” a Biden-era rule that aimed to cut planet-warming emissions of methane from oil and gas drilling. Trump said during a campaign rally in Texas that the change would save companies and consumers billions of dollars and unlock 210 million barrels of oil. That’s equivalent to about 10 days of U.S. petroleum consumption. ... Methane is responsible for about a third of planet-warming greenhouse gas emissions, scientists estimate. (Brown and Gruver, 10/28)
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