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Healthcare policymakers and practitioners need to prepare for a series of major challenges in the year ahead, Norman Ornstein, resident scholar at the American Enterprise Institute, said during a healthcare conference hosted by the UCI Paul Merage School of Business.

The U.S. needs to address four major challenges, Ornstein said: political tribalism, economic inequality, a regional divide and a crisis of legitimacy. All four challenges relate directly to the widening divisions in American society today — between Republicans and Democrats, between rural and urban regions, between the haves and the have-nots.

Ornstein spoke at the annual Health Care Forecast Conference, which is in its 28th year and is hosted by the Merage School’s Center for Health Care Management & Policy. The conference brings together scholars, members of the business community and others to foster a dialogue on healthcare reform, policy and politics.

Ornstein described how growing economic inequality has led to a situation in which 40 percent of Americans cannot come up with $400 in cash in the event of an emergency, according to a recent study from the Federal Reserve.

“The most likely emergency that Americans will face is a health emergency,” Ornstein said, “which tells you why health policy issues keep moving to the the top of the list of concerns.”

Ornstein warned that these socioeconomic factors, combined with structural weaknesses within the political system, may build to a feeling of political illegitimacy among Americans.

For instance, by 2040, 70 percent of Americans will live in 15 states and half of Americans will live in just eight states. “What this means is that the electoral college, which is already skewed towards small, rural states, will become even more skewed in their favor,” Ornstein said.

Ornstein believes that Democrats will try to ensure that actions taken by the Trump administration don’t further undermine the Affordable Care Act.

He expects to see a strong push to allow Medicare to negotiate prescription drug prices and to allow for the importation of drugs from other countries. He also believes there will be more moves to redistribute rebates so they directly benefit patients, rather than sellers and buyers.

“But we have to keep in mind that we have a large group of elected representatives, most of whom have no clue how (the health system)works in the real world, who don’t know how to strike a balance,” Ornstein added.

With presidential contenders already taking to the campaign trail, and political polarization reaching new heights, the national debate on healthcare is likely to intensify. But heated rhetoric won’t necessarily lead to fundamental change, Ornstein suggested.

“It’s entirely possible there will be more smoke and fury than action,” Ornstein said.