Insights from RAND – State of the Union 2020

Last night, President Donald Trump delivered the final State of the Union address of his four years in office. The speech came between Monday's first race in Iowa to nominate his general election opponent and this afternoon's expected Senate vote on whether to impeach the president.

These unprecedented circumstances are likely to form the lens through which many will view the evening. Tuesday's speech, however, addressed a number of policy challenges that will remain, regardless of the shape of politics in 2020.

If policymakers want to develop effective solutions, they will need to have good, objective and unbiased resources. Below are excerpts from the President's speech, followed by context based on RAND's research, analysis and experience.

Addressing the opioid crisis in the United States

“We will not give up until the opioid epidemic is finally defeated.”

As part of the Opioids Uncharted initiative, RAND researchers are mapping the contours of the nation's opioid crisis, analyzing its understudied consequences and exploring a comprehensive understanding of the problem to find solutions.

The initiative's first major study offers the most comprehensive look at fentanyl and other high-potency synthetic opioids. The authors recommend viewing the fentanyl problem as a mass poisoning rather than a traditional drug epidemic. They also stress that innovative and controversial solutions, such as controlled drug consumption sites, should be included in the debate.

Other recent RAND studies have examined national policies that punish pregnant women for drug use. The results show that in states that have adopted these punitive approaches, babies born are more likely to suffer opioid withdrawal. The researchers recommend that, rather than punishing women, the emphasis should be on prevention and access to treatment.

Surprising hospital bills and healthcare reform

“The American patient should never be surprised by medical bills.”

In fact, patients can receive large and unexpected bills, even when they are treated at hospitals in their own insurance network (just ask two RAND researchers and a young mother who gave birth at the same hospital within weeks of each other and discovered that one had been billed and the other had not).

Recently, California has attempted to address this problem by passing a law limiting the fees that out-of-network physicians can charge for hospital care. According to a RAND study, the law appears to protect patients from unexpected bills. But it has also had unintended consequences. The ability to negotiate payments is shifting in favor of insurance plans.

“The good lives of American families also depend on the most affordable, innovative, high-quality health care system in the world.”

The president expressed concern about single-payer healthcare proposals being debated in the Democratic primaries. After studying the potential impact of New York State's proposal for a single-payer system, RAND researchers analyzed a hypothetical national plan that would provide comprehensive health insurance to all Americans, including long-term care benefits and no cost-sharing.

They estimate that, under such a plan, total health costs would be 1.8% higher in 2019 than under the status quo. This would be a relatively minor change. However, federal healthcare spending would have increased by about 221%.

The RAND study, released last week, provides important context for the broader health care debate by examining how costs and payments are distributed in the current system. The findings: health care payment in the U.S. may be even more reactionary than previously thought. The researchers found that the bottom fifth of U.S. households spend an average of 33.9% of their income on health care, while higher-income families spend only 16%.

The value of remedial education

“Our booming economy has […] given many former prisoners the opportunity to find a good job and start over. This second chance at life has been made possible by the significant legislative reform we have achieved.”

President Trump was referring to the First Step Act, a bipartisan criminal justice bill he signed into law in December 2018. Among other things, the bill provides funding for education and work programs in U.S. prisons.

A RAND study found that inmates who participate in some type of training program are up to 43% less likely to return to prison. These programs also save taxpayers money. Every dollar invested over three years saves nearly five dollars in recidivism costs.

Moreover, RAND experts have studied policies that might encourage employers to hire ex-offenders. Researchers also sought new solutions based on the experience of people who know the system from the inside: ex-offenders.

Improving U.S. infrastructures

“We also need to rebuild America's infrastructure.”

The RAND study concludes that while the U.S. has infrastructure problems, “not everything is broken” when it comes to funding transportation and water infrastructure. But leaders need to reach consensus on priorities while making specific changes in spending and policy.

“Spreading federal money around to fund short-term, ready-to-go projects without a national focus or priority will not get the country where it needs to go,” says Debra Knopman, who led the study.

Other RAND studies have underscored the importance of building flexibility into transportation planning. This ensures that transportation systems are not compromised or, if they are, that they can withstand a shock.

Caregivers and Military Families

“War takes a heavy toll on our nation's exceptional military families, especially spouses.”

Over the years, RAND experts have conducted a great deal of research on the needs of military spouses, children, and caregivers. It would be impossible to list all of our research here, but here are a few examples.

A groundbreaking study of America's “hidden heroes” – the 5.5 million military caregivers who help current and former service members with physical and mental health issues.
A comprehensive analysis of how military families cope before, during and after deployment.
And a survey of military spouses to learn what challenges they face and what resources they use, if any.