Donald Trump’s surprising win in last week’s presidential election still has pundits scratching their heads. Some attribute it to economic anxiety, or characterize it as a repudiation of elite-based politics. But the recently announced hikes in health care premiums for millions of Americans insured through health exchanges and the exit polls that underscored a fiercely partisan divide on our country’s direction for health care tell a more tangible story. For many Americans, the election was a referendum on the Affordable Care Act.
We came to this realization separately on Nov. 8 as we sat in different parts of the country and watched election results trickle in. As swing state after swing state turned red, one of us consoled an ardent Clinton supporter in Missouri on the verge of tears, worried that her mother — who has a preexisting condition — would lose her health insurance in a Trump administration. The other sympathized with the concerns of a reluctant Trump voter in Rhode Island, who felt like he was out of options at the ballot box after learning that his insurance premium will double next year.
Globalization, immigration, national security, and economic prosperity certainly played important roles in shaping this messy and polarizing election cycle. But despite the lofty rhetoric of politicians and the pontificating of commentators, it is hard to imagine that many American voters weighed heavily the acronymic abstractions touted by the press, like NATO and NAFTA, the TPP, and ISIS.
For most Americans, few issues are as visceral and ubiquitous as health care. Voters tend to focus more on the immediate events in their lives, like hospital bills and treatment plans or affording chemotherapy for our mothers and prescription drugs for our fathers.
A clear chronology of developments in health care policy links the shortcomings of Obamacare to Trump’s victory. Despite the law’s best intentions, 30 million Americans are still uninsured, vulnerable to bankruptcy if they fall ill or are suffering from diseases they cannot afford to treat. For the newly insured and those who switched to the health care exchanges, increasing premiums burden low-income working families. At the same time, sky-high deductibles force them to pay hefty out-of-pocket sums before their insurance kicks in. Adding insult to injury, the promise by President Obama that patients would be able to continue seeing the same doctors they’ve seen for years was broken for many as insurers increasingly narrowed their networks and limited provider choice.
With a Trump presidency now imminent, we can reasonably expect that the Affordable Care Act will be fundamentally altered, even if more popular aspects of the law remain standing. Yet as we wait in this purgatory — uncertain of what direction our federal government will take on health care reform — we ought to take note of the law’s successes and challenges and critically assess the state of our conversations in health policy today.
Perhaps most importantly, we should ask ourselves: How did health care come to engender the ugliest of partisan influences and so fiercely divide our country? How can we preserve what is working in this law and do even better in the future?
Major health policy reform in the United States has been historically driven by consensus, not partisan bickering. The creation of Medicare and Medicaid in the early 1960s garnered support among both Democrats and Republicans in an era fraught with tensions on social issues. The Medicare Modernization Act of 2003, which created Medicare Part D, passed both the House and the Senate with bipartisan support. So did the Children’s Health Insurance Program in 1999, and its reauthorization 10 years later.
In contrast, from its very inception, the Affordable Care Act has been a highly politicized pitched battle. It was passed into law through archaic technicalities and legislative maneuvers, failing to earn the vote of a single Republican. Once embedded within our health care system, it did manage to resolve important injustices by extending access to health insurance to millions of previously uninsured Americans, to formulate patient-centric initiatives like accountable care organizations, and to experiment with alternative payment mechanisms.
That said, the bill itself remains cryptic and incomplete, embodying much of the resentment that our electorate feels about the “elite policymakers” in Washington who are disconnected from the lives of average Americans. For better or worse, the Affordable Care Act politicized health care in our country.
The act has become entrenched as a partisan issue rather than a human one, a litmus test for party affiliation rather than a set of innovative, but imperfect, ideas geared towards increasing access to health care and containing costs.
As students, we feel and experience this politicization in our schools, where experts discuss the churnings of health policy in our country and dissect American health care. Too often we’re presented with stories highlighting the strengths of the Affordable Care Act that are largely apparent to academia and the press and are then discouraged from talking about its substantial flaws, such as its explicit ban on cost-effectiveness studies in the Patient-Centered Outcomes Research Institute charter, its difficulty attracting healthier individuals to buy insurance policies sold on the exchanges, and its challenges with fairly assessing quality in pay-for-performance measures in parts of the country where the data needed to do that are lacking.
Publicly criticizing the act for these very real limitations in a classroom or a lecture hall tends to draw glares from peers and professors. Instead of being seen as a meaningful effort to improve upon our collective progress, questioning the law often yields dismissive answers laced with assumptions about your political affiliation, your personal support for the Obama administration, and even your moral stance on providing health care for the disenfranchised.
Rather than discuss the human stories of Americans accessing health care, or the policies which directly affect them, we’ve chosen to accept a status quo where our debates on health policy hinge upon supporting or opposing a complex law and refrain from exploring its details.
Aspiring clinicians of our generation have no clear vision of what the medical profession will look like in a few years. But today, and for the foreseeable future, we have an opportunity to shape that outcome and an obligation to remove politics from major health policy reform. That means conducting a sober assessment of the Affordable Care Act — partisanship aside — and reaching consensus on the values we choose to fight for. It means focusing on the details. And it means working to translate the stories of our patients and voters on election night into meaningful, human-centered policy.
Doing anything less than that means accepting that our profession will be subjected to games of political football played by opposing parties, and that our health system will fumble in helping the people who need it most.
Vishal Khetpal is a first-year medical student at the Alpert Medical School of Brown University. Suhas Gondi is a senior undergraduate student at Washington University in St. Louis.