When Indiana Health Commissioner and United States Surgeon General nominee, Jerome Adams, spoke before a House subcommittee hearing two years ago about what state governments were doing to combat the national opioid drug crisis, he made an impassioned plea for more treatment programs for people with addition.
“If people don't have hope, they will increasingly turn to and stay on drugs,” said Adams, whose brother, he revealed to Congress, had an opioid addiction. “If we focus on education, patient-centered care, and community and patient empowerment, I am confident we can successfully combat the scourge of opioid abuse.”
Adams, an anesthesiologist and assistant professor of clinical anesthesiology at Indiana University School of Medicine, was nominated last month by President Trump to be the new surgeon general.
The surgeon general is the leading government spokesperson in the United States on matters of public health.
If approved by the Senate, Adams would succeed Dr. Vivek Murthy, an appointee of former President Barack Obama, whom Trump ousted in April.
He also would be the second African-American appointed to a high-level position in the Trump administration, along with Housing and Urban Development Secretary Ben Carson.
Since his nomination for the position, Adams has been described in press reports as one of Trump’s best and least controversial cabinet picks.
Several news organizations have pointed out that as Indiana’s health commissioner, Adams was a vocal advocate for opioid addiction treatment and staunch supporter of needle exchange programs to prevent the spread of HIV.
But what many news reports on Adams have neglected to mention is that while he ultimately voiced support for clean needle exchanges, it was only after he opposed them on moral grounds during a state public health crisis.
Adams declined Healthline’s request for an interview for this story.
Adams and Mike Pence in agreement
In October 2014, Vice President Mike Pence, then governor of Indiana, named Adams as the state’s health commissioner.
As governor, Pence clung to the belief that needle exchanges increase drug abuse.
According to the Foundation for AIDS Research (amfAR), multiple studies have established that needle exchange programs do not increase crime or drug use, and instead provide a gateway to drug treatment and HIV prevention services.
But even after rural Scott County, suffered an HIV outbreak that quickly became a public health crisis, Pence refused to intervene.
The virus rapidly spread, primarily by intravenous drug users who were sharing needles to inject the prescription opioid oxymorphone, also known as Opana.
As Politico noted last year, when confronted with the crisis, Pence “dragged his feet” before agreeing to approve the free distribution of clean needles.
Some say enabling the HIV outbreak was Pence’s defining moment as governor. The Huffington Post noted that nearly 200 people contracted the virus while Pence “twiddled his thumbs over harm reduction and de-emphasized public health spending.”
And Adams defended Pence’s hesitation.
“The governor wanted to make sure if we went this route it was absolutely necessary,” Adams told The New York Times last year. “I believe he was praying on it up until the final decision.”
Adams did eventually have a change of heart about needle exchanges and, along with the Centers for Disease Control and Prevention (CDC) and others, reportedly helped convince Pence to establish the program.
Pence ultimately declared a public health emergency in Scott County, and issued an executive order legalizing “targeted” and “clean” syringe exchanges in Indiana.
But the governor still wasn’t keen on the idea.
“I am opposed to needle exchange as antidrug policy,” Pence said after issuing the order. “But this is a public health emergency and, as governor of the state of Indiana, I’m going to put the lives of the people of Indiana first.”
At the time of the executive order, Pence also reportedly signed legislation that left in place a ban on funding for the needle exchange programs.
This placed the financial burden for purchasing sterile needles on Indiana’s rural, often cash-poor counties.
In a press release written just days before his nomination last month, Adams wrote that 219 people in Scott County have been diagnosed with HIV in the past two years.
Adams said that number would have been much higher if not for the needle exchange program.
But what Adams didn’t say was that the toll would have been much lower had Pence, and arguably Adams, acted sooner.
“Syringe exchanges aren’t pretty. They make people uncomfortable. But the opioid epidemic is far uglier,” Adams wrote.
Who Is Jerome Adams?
The country is still learning about Adams.
He was born in Mechanicsville, Maryland, was a national merit scholar, and earned bachelor's degrees in biochemistry and biopsychology from the University of Maryland, Baltimore County, in 1997.
He then earned a master's degree in public health from the University of California at Berkeley, and a medical degree from the Indiana University medical school.
Adams, who lives with his wife, Lacey, and their three children, has not publicly shared many of the details of his brother’s opioid addiction.
Most public health observers interviewed for this story believe Pence is the one who convinced President Trump to nominate Adams as surgeon general.
If Pence does have a big influence over public health policy moving forward, America’s public health priorities may likely look a lot like Indiana’s when Pence ran that state.
As governor, Pence signed legislation cutting some of Indiana’s public health programs.
Despite its many public health challenges — from the opioid addiction crisis, to obesity, to infant mortality rates — Indiana is near the bottom now in terms of both state and federal public health spending, according to Trust for America’s Health, a nonprofit, nonpartisan organization that focuses on disease prevention.
As NPR reported last year, Pence also opposed funding for such health programs as the State Children's Health Insurance Program and the Prevention and Public Health Fund.
HIV prevention advocate is optimistic
Public health advocates are wondering if Adams will provide a positive influence and perhaps nudge the administration forward on various public health issues the way he did with Pence on needle exchanges.
Will Adams have the backs of people with opioid addiction like his brother, or will he defer to Pence, Trump, and others who are more inclined to impose more deep cuts to public health programs?
Beth Meyerson, PhD, co-director of Indiana University Bloomington’s Rural Center for AIDS/STD Prevention and an associate professor of applied health science at the university, worked with Adams and knows him well.
She told Healthline that Adams is one of the few people she knows who actually has the ability to change Pence’s mind on public health issues.
She’s optimistic that Adams can influence the Trump administration in a positive way.
“I have worked with Dr. Adams since his appointment as the Indiana Health Commissioner. We have worked on several issues together including HPV, and, as you know, on syringe access policy,” she said.
Meyerson said the fact that Adams changed his position on needle exchanges is a “testament to his way of working with colleagues and public health evidence. While he personally may have not been supportive, I was not aware of that fact as we initially began our process of providing the legislature with evidence for their policy deliberation.”
Meyerson was critical of the way Pence’s administration addressed public health when he was Indiana’s governor.
But the criticisms, she said, were not directed at Adams but “were really focused on then-Governor Pence and the legislature for not investing in public health.”
Meyerson said Adams was “likely the pivotal partner” in Pence’s turnaround on syringe exchange.
“While I think there were likely others involved, such as Dr. Jen Walthall, then assistant commissioner for health, and now head of our Medicaid agency, Jerome was key,” she said.
It’s likely Adams will take on the role of surgeon general, and Meyers said she expects him to continue to be “interested in health inequities, with a focus on the nation’s opioid epidemic, and with an approach that engages partners from across the spectrum.”
She also expects he will “bring public health evidence to the table, and that he will navigate the highly ideological administration with aplomb — just as he did Pence’s administration.”
Others not so optimistic
But several other public health experts interviewed for this story said they aren’t sure Adams can or will affect positive change in this administration.
Jonathan Gruber, PhD, a Ford professor of economics at the Massachusetts Institute of Technology (MIT), and director of the Health Care Program at the National Bureau of Economic Research, said he doesn’t expect Adams will have much influence on Trump.
“There is no example that I’m aware of a person coming into the Trump administration and changing Trump’s mind,” Gruber told Healthline.
“Trump has his views. They change day by day, but they are his own, and there is no reason to expect that Adams will come in and change that, that he will make the administration more pro-public health. It’s a scary time for many reasons, and this is one of them.”
Gruber, who also serves as president of the American Society of Health Economists, said the $45 billion Republican senators added last week to their now-stymied health bill is about 25 percent of what is needed.
“The bill is designed to replace what the current Medicaid expansion does for opioid addiction, but just to replace it would cost $200 billion over 10 years,” Gruber said last week.
“The money the Senate says will go to opioid addiction treatment is a slush fund. They are replacing mandatory entitlement where addicts are actually getting help with a fund that could be cut by the Congress during the very next budget crisis.”
Gruber said the GOP senators have said nothing about where the people currently on Medicaid would actually go to receive their addiction treatment under such a healthcare plan.
“We don’t know where they would go. No answer has been given by the Senate,” he said. “They just say, ‘Don’t worry, states will know what to do with it.’”
Despite the Senate’s failure to approve a healthcare reform bill this week, Gruber said it is clear what will happen to public health issues under the Trump administration.
“You can understand what it’s going to look like as the president continues to slash the budget for the safety net, including public health programs,” Gruber said.
Gruber said it is unlikely that Adams will have the same kind of influence on Trump that he had on Pence at the state level.
“What we need is to move forward and treat the other 80 percent, and we were moving forward with the states expanding Medicaid. We were doing more, and it was cost effective,” he said. “The Medicaid expansion is moving this issue in the right direction. This would be a step backward.”
Opioid addiction treatment
Pence was one of 10 Republican governors who accepted the Medicaid expansion.
He has also been an outspoken supporter of the House and Senate health bills to repeal and replace the Affordable Care Act (ACA).
Each of those bills has called for slashing Medicaid, which many sources for this story said would reverse the progress that has been made in trying to prevent opioid addiction.
In a Los Angeles Times report last week on the “hidden horrors” of the Senate GOP’s health bill, health writer Michael Hiltzik noted that the Medicaid cuts in the Senate bill would “force more of that expense onto states that simply can’t afford it.”
And the projected loss of medical coverage for as many as 23 million Americans under this repeal of Obamacare, he wrote, “will keep many victims of the epidemic from finding treatment.”
Hiltzik added that the cost of fighting the epidemic and treating the secondary health problems related to diseases such as HIV and hepatitis C has been estimated at as much as $183 billion over 10 years. The Senate bill had provided $45 billion over the next decade.
AMA endorsement raises questions
Last month, the American Medical Association (AMA) strongly endorsed Adams as the new surgeon general.
In a statement, Dr. David O. Barbe, president of the AMA, said that as Indiana state health commissioner, “Dr. Adams has advocated strongly for physicians to play a leading role in reining in the opioid epidemic, fought to reduce infant mortality, and pushed for a needle exchange program to tackle his state’s HIV outbreak.”
Barbe said Adams is an AMA member who will “bring unique experience and energy to this office. We look forward to his prompt consideration by the Senate.”
The AMA declined to comment for this story.
Several public health analysts told Healthline they don’t know how Adams will reconcile his call for more programs to treat opioid addiction with the fact that the Trump administration champions a healthcare bill that industry analysts have said would be devastating for people with opioid addiction nationwide.
Last month, Dr. James Madara, chief executive officer of the AMA, blasted the first version of the Senate health bill precisely because of its call for draconian cuts to Medicaid.
“Medicine has long operated under the precept of ‘primum non nocere,’ or ‘first, do no harm,’” Madara said. “The draft legislation [of the first Senate healthcare bill] violates that standard on many levels.”
Madara added, “The Senate proposal to artificially limit the growth of Medicaid expenditures below even the rate of medical inflation threatens to limit states’ ability to address the healthcare needs of their most vulnerable citizens.”
Will Adams make a difference?
It remains to be seen how Adams navigates his new federal role and how he and the Trump administration will deal with public health issues.
But unless Adams nudges his bosses the way he did with the needle exchanges issue in Indiana, opioid addicts will likely find it even harder to get treatment in the near future than it is now.
But Meyerson, Adams’ former colleague in Indiana, said Adams is undoubtedly aware that a large percentage of the people in America who are being treated for opioid addiction are on Medicaid.
“I am sure he is quite aware of these issues, and likely thinking about how best to approach his public health advocacy with this particularly ideological administration when it comes to health,” she said.