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.
This article is politically and historically ignorant, plain and simple. Two of the problems it explicitly cites (effective ban on cost-effectiveness research being used to determine benefits (1) and difficulty getting insurers to stay in marketplaces (2)) became problematic only *after* modifications in the law forced by Senate Republicans. Aren’t the authors familiar with the “death panels” debate of 2009?! Another problem (the 30 million left uninsured) is partly due to Republican objections as well, as the law was restricted to citizens or permanent residents to appease the right wing. Someone wasn’t paying attention in 2009 or in 2014. And how have they forgotten the AMA’s and Republicans’ hysterical efforts to fight Medicare when that was proposed? Major healthcare reform has always been highly political and opposed by the right wing and, until (maybe) recently, the AMA. Medicare Part D may be the only exception.
That being said, the real issue is that US healthcare is too expensive and is still rationed by price. Those two problems predate the ACA and are the real challenges to this day. What a sad article by people who should know better. Perhaps medical students should be required to study the history of healthcare in the United States?
1. https://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=27
2. http://healthaffairs.org/blog/2016/06/27/obama-administration-threads-needle-in-risk-corridor-case-brief/
I’m sure I wrote too harshly in tone before and I apologize. Let me restate my reaction to this article:
While I commend the intent of this article, it is politically and historically misleading. Two of the problems it explicitly cites (effective ban on cost-effectiveness research being used to determine benefits (1) and difficulty getting insurers to stay in marketplaces (2)) became problematic only *after* modifications in the law forced by Senate Republicans. These problems would have easily been avoided had the bill been supported as proposed. You might recall the “death panels” debate of 2009 and Sen. Rubio’s efforts to limit the risk corridor, which helped cause these specific problems. Another problem, the 30 million left uninsured, is partly due to Republican/right wing objections as well, as the law was restricted to citizens or permanent residents and the Medicaid expansion is still being stopped by Republicans in many states. And we mustn’t forget the hysterical efforts of the AMA and right wing politicians to fight most forms of insurance, including Medicare, when they’ve been proposed throughout US history (3). Indeed, major healthcare reform has always been highly political and opposed by the right wing joined until recently by the AMA and a large share of physicians. Medicare Part D and Child Health Plus may be the only real exceptions. Healthcare is such a large part of our economy that this shouldn’t be surprising.
That being said, there are real problems in American healthcare and the medical community must encourage an open and honest debate on the issues. But that includes acknowledging that the real problems pre-date the Affordable Care Act. US healthcare has long been, and still is, too expensive and is therefore effectively rationed by insurance status. Physicians and medical students need to take the lead in supporting policies to improve these two problems, while not ignoring the political realities or our profession’s history.
1. Neumann, P. J., & Weinstein, M. C. (2010). Legislating against use of cost-effectiveness information. New England Journal of Medicine, 363(16), 1495-1497.
2. vhttp://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html?_r=0
3. http://healthaffairs.org/blog/2015/09/10/medicare-fair-pay-and-the-ama-the-forgotten-history/
Terence,
Great to hear from another medical student. No need to apologize — your candor is appreciated.
I’m glad you linked Neumann’s article in NEJM; I’ve read this article before, and frankly, the issue of cost-effectiveness should be discussed more extensively in our collective debate around health policy in the US. You frame the antagonism against cost-effectiveness on partisan lines, but I fundamentally disagree. The “death panels” might have been a talking point of Sarah Palin (and by the way, was not directly related to cost-effectiveness studies, but rather voluntary panels of physicians providing counseling sessions on palliative care), but it received both flak and support by Democrats and Republicans. Even the rationale you present is inherently illogical — why didn’t Republicans sign onto the ACA after the CEA prohibition was added on if that was their only issue with it?
Regarding your comment on Marco Rubio’s risk corridor — this was done to atrophy the bill far after it was past, to my knowledge. It would be a downstream effect from the initial politicization of healthcare which was inherently done by the ACA.
You’re right to say that healthcare has and likely will always be highly political in our country, but it is important to note that all of the efforts that you cite — Medicare, CHIP, and even Social Security — got at least some support from both parties. The effects of this bipartisanship has ultimately been to make these bills politically durable. Feel free to check the voting rolls and the voting histories of these programs, and please correct me if I’m wrong. The fact is that none of these bills have been voted for repeal even once in their long and winding histories. We simply can’t say the same about the ACA over the past few years, despite the fact that it likely did much less to change welfare in our country.
At the end of your comment on our article, you diagnose a problem in our healthcare system, as physicians and medical students are trained to do, that healthcare is too expensive and rationed by price, rather than need. I challenge you to find someone on either side of the aisle who will disagree with that statement. It is an asset to our conversations in health policy that so many people agree on the problem, but disagree on the solution. As someone who has had the chance to study health policy in Europe over the past years, it’s almost exciting to know that no country on the planet has “perfected” its healthcare system, that great ideas are found everywhere, and that today, we have an opportunity to rise to that challenge with American ingenuity and forge something better. And as we state in our article, physicians and medical students have an obligation to cut through the political noise, and advocate for policies we sincerely believe will help achieve those goals on the basis of fact and sound clinical and economic theory, rather than on blind partisanship.
Respectfully, I find this to be the kind of wishful thinking. The technocratic dream is where data, evidence, and expertise are respected and used, but we live in a time where misinformation reigns, where physicians have abdicated their potential political power, and where others have sought to heavily politicize public health, healthcare, biomedical sciences, and health communication.
Our only option is to double down on politics.