In November 2016, a group of despondent medical students including myself reached out to policy mentors for advice on how to stem the tide of repeal of the Affordable Care Act (ACA). Many of those we talked to, similarly glum, responded that with a Republican president and majority in both houses of Congress, repeal was a foregone conclusion. That was seven months ago. After the initial failure and subsequent passage in May of the American Health Care Act (AHCA) in the House of Representatives, the Senate has debated various iterations of its Better Care Reconciliation Act for months now. The vote on the latest iteration of this draconian bill will be the most serious threat in a series of attempts to repeal the ACA over the past seven years.
In true Trumpcare fashion, the AHCA earned itself a number of superlatives. The bill passed by the House has an impressively dismal 29% approval rating, making it one of the most unpopular pieces of major legislation debated in recent history. Obamacare, subjected to similar partisan rancor following the loss of Democrats’ filibuster-proof majority in a special election, had a 46% approval rating during debate in 2010. The lack of transparency in the Senate’s debate on health care is also remarkable for a bill that stands to leave 22 million more people uninsured (according to the CBO score for the Senate BCRA released in June), and to dictate how 17% of the US gross domestic product is spent.
I started college in 2008 as a history and literature major with no intention of entering the policy world, much less medicine. That all changed, however, on March 23rd, 2010, when president Obama signed into law the first major health care reform since the 1965 creation of Medicare and Medicaid. Since then, I have chased this law from its fledgling beginnings—messy and temperamental at times—to its transformative role in the lives of many Americans.
The ACA and I have both had our growing pains. Ask the Republican party—and my parents. I spent the first year following its passage making coffee and copies in Washington, DC just to be close to its implementation. At that time, there was bitterness following the bill’s last-minute wrangling through the budget reconciliation process by Democrats, which some on the right today are using to justify their own partisanship and secrecy.
Before its passage, however, the ACA was debated in five Congressional committees, including an eight-day markup in the Senate Finance Committee, the longest in 22 years. The full Senate debated the ACA for 25 days, considered more than 130 amendments, and held 100 hearings, roundtables, and walkthroughs. The House held 79 hearings, heard from 181 witnesses, and considered 239 amendments. At the end of many months, there was a bill passed along partisan lines, but it was a bill in which both parties and the American public had input and visibility.
Since then, the ACA has withstood many challenges of both intrinsic and obstructionist origins. I saw many when I returned to DC as a freshly fingerprinted federal employee, only to be furloughed six days later during the government shutdown of 2013. When I returned to work, the rocky debut of the health insurance exchanges had arrived. Despite its beginnings, I watched from a musty cubicle as colleagues worked to enroll millions of Americans in Medicaid and marketplace coverage. By the end of that first open enrollment period, Obama and Health and Human Services secretary Kathleen Sebelius had a few more gray hairs, but there were eight million newly insured Americans on the books.
Today, I find myself a first-year medical student under a new administration. Like 2.3 million of my fellow millennials, I benefited directly from the ability to stay on my parents’ insurance until age 26. When that birthday came, I purchased insurance on the exchange with premium subsidies that made my coverage affordable and my care accessible. I was, of course, not the exception. Many of my fellow Obama-generation kids made up the 77% of consumers on the exchanges who had access to coverage for less than $100 in monthly premiums. Much of this was possible because of the individual mandate—a policy that was a product of conservative thinktanks.
Armed with the stories of these Americans—and my own—I stood with fellow medical students this January outside my former employer’s office at the Department of Health and Human Services to demand that the new administration maintain the increases in coverage gained over the past seven years. We were among nearly 5,000 health professions students who called on Congress to choose patients—our friends, partners, parents, and loved ones—over politics.
Thanks to the efforts of thousands, the ACA still stands intact, seven months after the current president named its repeal a top priority, and seven years after its hard-fought gains were first won. Regardless of what the next vote brings, I fear this era will bring continued efforts to undermine the health and wellbeing of Americans in arenas far beyond health policy.
So, call your senators and your representatives to demand accountability and transparency in rejecting the the latest version of the Better Care Reconciliation Act, which poses the same threats as the AHCA while further crippling Medicaid coverage. Call your local journalists and ask them to hold your elected officials to their past promises. Help ensure that Obamacare was the beginning of a new era of enfranchisement and opportunity in American healthcare and not a premature foreclosure.
When I begin to practice medicine, I don’t want to bankrupt patients for routine prenatal care, or pull the rug out from people and families insured through Medicaid; both are real possibilities if Trumpcare replaces Obamacare. For my fellow medical students and health professions trainees, the events of the next few weeks will impact not only our future patients but our friends, families, and future selves. As Obama put it, “[I]f there’s a chance you might get sick, get old, or start a family—this bill will do you harm.” It is always easier to break down social policy than to build it. Our moral test as medical students and millennials will be to ensure that our political leaders do not tear it apart.