President-elect Donald Trump says that he will be the president for everyone. I can’t imagine how he will do that if he dismantles, or drastically alters, the Affordable Care Act.
In his first interview with the press following the election, Trump took aim at the ACA. And by nominating for Secretary of Health and Human Services Republican Congressman Tom Price — a man who authored the Empowering Patients First Act of 2015, which aims to repeal and replace the ACA — it is clear that Trump plans to follow through on this key campaign promise.
Throughout his campaign, Trump vociferously championed “the forgotten ones.” All Americans, and especially health care providers, need to hold him to his word and make sure he acts as the president for everyone. But by overthrowing or radically altering the ACA, Trump will be creating a new legion of “forgotten ones.”
With respect to health care access and coverage, “forgotten ones” aren’t necessarily minorities. Instead, they are individuals who will be affected by altering the ACA, including many working-class white Americans who voted for Trump.
As a practicing obstetrician-gynecologist, I care for such “forgotten ones” every day. Before Trump makes any health policy decisions, I sincerely hope he and his transition team familiarize themselves with their stories. All of us who work closely with such individuals must reach across the extraordinary political divide in America to make sure their voices are heard.
Take the story of my patient Tamara, a 35-year-old African-American woman with a long family history of breast cancer. Without the ACA, she would not have been able to access genetic screening to see if she tests positive for a gene that would affect the course of her treatment and outcomes.
Or what about Ted? He is a 50-year-old white factory worker. His wife was diagnosed with recurrent breast cancer. As he transitioned from one job to another, he and his wife weren’t denied insurance coverage because of her pre-existing cancer conditions — thanks to the ACA.
Such stories abound.
The ACA provides coverage to 20 million Americans who didn’t previously have health insurance. Any repeal would severely impede health care access, health care delivery, and ultimately the health of Americans.
The ACA is not perfect. Many patients still struggle to get the proper health care because of the complexities of access, coverage, copays, co-insurance, and other out-of-pocket costs. Yet because of it, more patients now have access to care and are receiving it, which prevents further disease and saves patients, and the health care system, real money.
Take Annette, a 45-year-old white woman who had health care coverage for the first time in two decades through the ACA. On her first physical exam, she was diagnosed with type 2 diabetes, high blood pressure, and an abnormal pap test, signaling precancerous changes in her cervix. Treatment will help her control these.
And Mary, a 38-year-old immigrant from China, who just became a US citizen and is employed at a local startup tech company. Under the ACA, she was able to buy insurance that covered her and her husband, who had been diagnosed with lung cancer last year.
For women, repealing parts of the ACA will eliminate coverage for lifesaving cancer screening and follow-up, along with essential preventive services, including contraception. According to the National Academy of Medicine, contraception is effective at reducing unintended pregnancies and abortions. The evidence strongly suggests that complete insurance coverage of contraceptive services and supplies is a low-cost — and even cost-saving — strategy when compared with unintended pregnancies.
The elimination of insurance subsidies could cause millions of men and women to lose their health care immediately, because a clause in the agreement between the government and insurers lets insurers get out of policies if subsidies end. A study by the Commonwealth Fund and RAND showed that ending subsidies would increase the cost that individuals pay for health insurance, even if health savings accounts and tax credits are available.
Quick modifications to the ACA will likely focus on elements related to the budget. But such changes run the risk of poor outcomes, including an increase in costs and the number of uninsured Americans.
Cutting the ACA mandate that all Americans have health insurance would also increase the costs of health insurance. People with poorer health would be more likely to obtain insurance while those who are healthier would be less likely to buy insurance. Insurance companies would then have to raise premiums for everyone to cover a patient base of mostly ill individuals who require costly care.
Health care providers have an opportunity to teach, to lead by example, and to move forward by being the best listeners, acting as thoughtful critics, and sharing our own and our patients’ stories of just how important is the support provided by having health care coverage under the ACA and what would happen if it is drastically modified or repealed. We can amplify our patients’ voices far more poignantly than if we articulated the impact of the ACA in our own words.
It will be important to have and to facilitate uncomfortable conversations with individuals from all sides of the political and ideological spectrum. Only through true, open, and evaluative discourse will we learn about each other’s differences. The discomfort of the conversations could well lead to understanding and bridges that will help us heal.
We cannot give up, nor can we assume that everything we have worked so long and hard to champion in health care will be undone. We must not allow anyone to sideline the fight ensuring that all of us have the chance to attain and maintain good health. No one can be left behind, especially not the forgotten ones.
Melissa Simon, MD, MPH, is professor of obstetrics and gynecology, preventive medicine, and medical social sciences at Northwestern University Feinberg School of Medicine. All patient names in this article were changed to protect confidentiality.
