The ACA Debate Shows We Need to Change How We Talk About Health | Dean's Note

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The Trump administration is once more trying to kill the Affordable Care Act (ACA). In a recent federal appeals court filing, the Justice Department said it concurred with a federal judge in Texas, who ruled to strike down the ACA after deeming it unconstitutional.

This comes almost two years after the administration pushed to repeal the law and replace it with a plan that would have stripped health coverage from millions of Americans. The administration has never stopped trying to undermine the ACA. It has consistently chipped away at it by attempting to undermine its provisions and resisting efforts to expand the law’s reach. Yet this new attempt to undo the law through the courts is arguably its most direct challenge to the ACA’s existence since the GOP-led Senate failed to repeal the law in a dramatic, middle-of-the-night vote.

The Trump administration did not create the opposition to the ACA, of course. The law has been controversial since before it was even signed by President Obama in 2010. Beneath the din of political debate, however, has been the fact of the law’s implementation. And the fact is: The ACA has made Americans healthier .

Since the law’s passage, close to 20 million Americans have gained health insurance, giving them access to both treatment and the preventive services that can help them avoid the physical, mental and financial burden of disease. It has done this, in part, by expanding Medicaid, allowing children to remain on their parents’ insurance plan until age 26, prohibiting insurers from denying coverage based on preexisting conditions and requiring all individual and small group health plans to cover 10 core health benefits — including maternity care, mental health and substance use disorder services.

The ACA has been especially helpful to socioeconomically vulnerable populations. A 2016 study, for example, found better self-reported health among economically vulnerable adults in Arkansas and Kentucky, states that expanded Medicaid under the ACA. In the context of the opioid epidemic, Medicaid expansion has allowed people who struggle with addiction to access treatment.

Why, then, has the ACA remained controversial?

Because while we may regard health care as a useful policy tool for improving people’s lives, we do not yet see it as a political nonnegotiable. This has allowed fights over the ACA to become business-as-usual in U.S. politics.

In many ways, this reflects gaps in how we currently talk about health. Health is a product of the social, economic and environmental conditions in which we live. The food we eat, the water we drink, the air we breathe, whether our children can access quality public education or our economy affords us a decent living standard — these are just some of the foundational forces that shape our health. Yet we rarely talk about these forces when we talk about health. Instead, for the most part, we limit our health conversation to the debate over health care.

We continue to see health care as interchangeable with health. When we don’t recognize that health is the product of the world around us and the sum total of our life experience — experiences over which we often have no control — we are liable to see illness as a personal failure, a result of poor choices made by the sick person. It is then a short step to believing we should not have universal health care, because that would be tantamount to subsidizing the irresponsibility of others.

Recognizing that health emerges far more from our circumstances than our individual choices shifts our focus, helping us to see how large-scale socioeconomic forces shape our health. Creating a healthier society means addressing these forces.

Providing universal health care is an important step in this direction, though it is not the whole journey. Health care levels the playing field, providing a corrective that can help restore health, even if it does not create the conditions that stop us from getting sick in the first place. By adopting a system of universal health care, we are acknowledging that we are all human, that we all face the same reality of illness and death, and that we should therefore care for each other as best we can.

A compassionate view of health urges us to change what we talk about when we talk about health, and move the health conversation beyond the ACA, to address the forces that shape health. When we recognize that health is a product of the world around us, we can begin to see it as a public good, and to invest, collectively, in the public schools, environmental regulations, safer neighborhoods and universal health care, that allow health to flourish.

It may seem paradoxical to suggest that the key to protecting the ACA is acknowledging the many ways that health is about more than health care. However, unless support for the ACA is rooted in a recalibration of how we think about health, it will always be subject to the vicissitudes of the political moment, and health care will always be seen as a commodity for the wealthy and the “deserving,” rather than a public good that should be accessible to all.

Our continued debate over the ACA means we still don’t recognize the role health care should play in ensuring no one falls through the cracks created by a world that is not yet fully geared towards generating health. The renewed attack on the ACA, much as it is unwelcome, is a chance for us to change how we talk about health, and address the core forces that make health care necessary in the first place.

I hope everyone has a terrific week. Until next week.

Warm regards,


Acknowledgement: I am grateful to Eric DelGizzo for his contributions to this Dean’s Note.