I was delightfully dazed and confused the morning after Susan Collins, Lisa Murkowski and John McCain launched us into the next phase of the healthcare debate by giving the ACA a last minute reprieve. In a mix of ecstasy and disbelief I watched the video of John McCain walking into the Senate chamber again and again. As I wrote in the following Tuesday’s Strategy Healthcare posting,


John McCain resolutely walked to the front of the Senate chamber and raised his right arm to signal that he wanted to cast his vote. Then without a word he abruptly turned the thumb on his outstretched right hand down and then walked to his seat as some in the chamber gasped and others gave a muted expression of their positive surprise.


Just like the replay of the end of the Super Bowl, the down turned thumb of McCain never changes. No matter how many times you play it, the Patriots always ruin the evening for the Falcons. Now we ask, “What’s next?” Before trying to imagine where the road goes from here it is important to understand why the ACA still lives after a vigorous seven year effort to kill it. The House, the Senate and the Presidency are controlled by a party that has promised the public that they would repeal the ACA as job one. I was amazed that during the 2016 presidential election season, after Bernie Sanders was sidelined, healthcare was barely mentioned. When it was, it was a disaster as when Bill Clinton said that the ACA was “the craziest thing.” I thought I knew what he meant, but those words were easily twisted by Donald Trump and all the Republican candidates running against the ACA.


It was not until Trump was elected that the threat of repeal, and especially the plan to repeal the ACA with a delayed effective date and just a promise to replace it in the future, that things began to get scary. President Obama wrote a “Perspective” piece in the New England Journal that appeared on January 26, 2017. I have referenced President Obama’s paper before but his concerns expressed in there deserve your review. Here is a nugget for you to think about:


What the past 8 years have taught us is that health care reform requires an evidence-based, careful approach, driven by what is best for the American people…Rather than jeopardize financial security and access to care for tens of millions of Americans, policymakers should develop a plan to build on what works before they unravel what is in place.


I have been amazed that the last six months of debate over “replace and repeal” has finally begun to educate the public. More citizens are finally beginning to understand that the law has  given a lift to everyone and are asking their representatives in Congress to “repair and improve the ACA.” With the ACA we all share the guarantee that we can buy coverage. We can not be denied coverage because of a preexisting condition. I still do not think that a majority of people understand that any policy that they buy, even one with a huge copay, will cover them for the services they need for preventative care, and that there are limits to what they can be charged even for the most complex care that they might need. We all understand that our children have access to our policies until age 26. What really became clear to everyone was that imagining 20 million people losing care was painful to the majority and they made their feelings known by attending “town meetings,” writing letters to politicians, making phone calls, and showing up for protests and rallies.  


I doubt that before the discussions of the last six months many voters understood the role and the extent of Medicaid services. For most people it was a welfare program that they never imagined might be something they or someone in their family might need. People began to notice the reciprocal relationship between Medicaid and tax breaks for the most wealthy members of society.  With these epiphanies a few minds were changed, and some people began to have a new appreciation for the benefits of the ACA.


Comedians, late night television hosts, and the “fake news” press like the New York Times, the Washington Post, and the New Yorker pulled out the stops and bombarded their readers with analyses and editorial comments that attracted new viewers and readers. I would wager that more people now know what the CBO does. More people understand the reconciliation process that serves as a foil against filibusters and allows a  limited law to pass the Senate with a simple majority. In a perverse way the ineffective Republican efforts to repeal and replace the ACA has been a good process. Political scientists have always known that once an entitlement becomes a law it is very hard to take it away. What we have also seen is that when threatened with a loss for themselves or others, many Americans will study, discuss, and develop an opinion about facts and policies.


Since McConnell’s last stand collapsed under McCain’s thumb, we have heard several announcements from the powers that be. Senator McConnell seemed ready to absorb his loss and move on to other things. Senator McCain suggested that the Senate go back to work and follow a normal process that would benefit all Americans. Ironically, that was exactly what President Obama suggested in an amazing article that he published in JAMA in August of 2016. He also offered an analysis of what worked in the ACA and what did not work and needed to change. President Trump festered for a few minutes after the last stand in the Senate and then began threatening to use all of his administrative options to kill the ACA. The Times cataloged and explained three things he is already doing.


I do not think that most people realize that when Republicans talk about the failure of the ACA and insurers leaving the market, or the need for the mandate, we are mostly talking about the “individual market” or in terms of the ACA, the exchanges. As of February the exchanges covered about nine million people. That is a lot of people, but is still a single digit percentage of all of us who benefit from some component of the ACA. There are numerous articles documenting the benefits that the ACA has given the country as a whole over a very short time. Even the struggle against the rising cost of care has been aided and progress made through the ACA. Do thoughtful Republicans really want it killed?


I know that there are a host of healthcare policy wonks and thoughtful journalists who could go give testimony to the many possible ways to do what Obama advocates, and fix what isn’t working about the ACA. These experts are ready to testify before Lamar Alexander’s  Senate Health, Education, Labor and Pensions Committee and Orrin Hatch’s Senate Finance Committee, the two committees where most of the ground work for the ACA was done. Job one, even before the Senate starts working to repair and improve the ACA, is to move to assure consumers and insurers that the exchanges will be adequately supported. Outside the Senate all of us need to continue the shift in how we manage and practice as we continue the shift of the payment for care from “volume to value.” CMS has jump started that process with shifts in Medicare payment plans associated with the bipartisan passage of MACRA, by a large majority, in 2015. Years from now historians may debate what had the greater impact, the ACA or MACRA.


I am a hopeful person when it comes to imagining a day when we have universal healthcare coupled with healthcare finance mechanisms that lower the cost of care to sustainable levels, freeing up public resources and allowing us to invest in improving the social determinants of health. If my hopes come to be true it will be because more people actually understand what President Trump was surprised to discover when he said “who knew healthcare was so complicated.” That was one of his most truthful pronouncements of the last six months. The foundation of my hope is based on the experience of more consumers and more healthcare professionals becoming educated to the complexity of healthcare over the last six months. It is no longer quite the longshot it once was that someday we might have:


…Care better than we’ve seen, health better than we’ve ever known, cost we can afford,…for every person, every time,…in settings that support caregiver wellness…


Hope is not the same as optimism. Optimism is what the Falcons had in the early part of the fourth quarter of the Super Bowl. Hope is what grew and grew for the Patriots as one amazing thing after another happened in the waning moments of the game. Optimism is what the Republicans had in January. Hope is what those of us who care about better care had when John McCain’s thumb went down. President Obama wrote the Audacity of Hope before he became president. It is a book that is about core values that evolve into a political philosophy.  In contrast, Trump’s The Art of the Deal, is a book that seems to mostly be about getting what you want from other people. Trump’s ghost writer has suggested that a better title would have been,The Sociopath.


As Obama’s presidency was ending and before we knew that he would be followed by Donald Trump, he summed up what he had learned from his struggle to move toward universal coverage with the ACA. I have extracted some wisdom from his closing lines. Reading these words is a good way to start the next leg of the journey ahead of us.


Obama’s wisdom from the ACA Struggle as Noted in JAMA


While historians will draw their own conclusions about the broader implications of the ACA, I have my own. These lessons learned are not just for posterity: I have put them into practice in both health care policy and other areas of public policy throughout my presidency.

The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported…Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more ground more quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid.


The second lesson is that special interests [like big pharma] pose a continued obstacle to change...we also need to reinforce the sense of mission in health care that brought us an affordable polio vaccine and widely available penicillin.


The third lesson is the importance of pragmatism in both legislation and implementation… the nation typically reaches its greatest heights when we find common ground between the public and private good and adjust along the way.


While the lessons enumerated above may seem daunting, the ACA experience nevertheless makes me optimistic [hopeful?] about this country’s capacity to make meaningful progress on even the biggest public policy challenges… I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere. As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great.