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Sixteen-year-old Tommy is brought to the emergency room by his very worried mother. She describes a roughly one-month period in which Tommy is getting more and more irritable, isolating himself, failing academically. Because there is a history of depression in the family, she wants Tommy to get help sooner rather than later for what looks like a deteriorating depression.
During the intake interview with the child psychiatrist, Tommy eventually discloses that his dad has been beating him. When his mother is brought into the discussion, she notes that she too is the victim of domestic violence from Tommy’s father. She also notes that Tommy’s father has struggled with alcohol abuse for some time.
Tommy tearfully admits that he is actively suicidal, and that the only reason he has stayed alive is to “protect” his mom. Tommy’s father is on disability for a serious injury he incurred at work, and his mother is working in the service industry. Although they have no means of insurance through employment, and Tommy's mom is earning too much to qualify for Medicaid, they have been able to obtain a plan through the Massachusetts Health Connector, the state version of an Obamacare exchange.
This helps Tommy be hospitalized for depression and PTSD. He also benefits from family sessions that encourage his mother and father to seek psychiatric services and help to secure them. Tommy’s parents ultimately say they're absolutely certain that the availability of quality insurance has been life-saving for the entire family.
Tommy is fictional in that he's not a real person, but his story is an amalgam of true patient-doctor experiences, mine and my colleague's, disguised only in the interest of confidentiality. And it is experiences like these that leave me extremely worried about the rapid repeal of the Affordable Care Act that President Trump set in motion within hours of taking office.
I’m not naive. I know that the Affordable Care Act is far from perfect.
Even the name falls short of its ambitions. For some people, it is increasingly unaffordable. There are plenty of people who have seen their premiums skyrocket. Whether these increased premiums are the result of sabotaging counter-legislative moves -- the refusal, for example, to expand Medicaid funding by their home states -- or by blemishes in the Affordable Care Act itself, for these people, it doesn’t really matter. The law feels particularly and infuriatingly unaffordable.
On the other hand, there are plenty of others (like Tommy’s parents) who are immensely grateful that the Affordable Care Act exists. These people are adamant that the law made it possible for them to stay healthy and even alive. When you listen to their stories, you hear them describe their desperation before the ACA was passed. Before, they had sometimes asked themselves unthinkable questions: Do you feed your family or do you pay for health care? Now, they were reasonably able to do both.
Herein lie the uncomfortably dichotomous talking points of what ought to be so simple. No one should go broke to pay for health insurance. And no one should worry that without health insurance, death and disability may be just around the corner.
I’m not a health economist or policy expert, and I have great respect for people who have spent time wading through the morass of this toweringly complex subject for our nation. Every time I try to read about the pros and cons of our nation’s health insurance battles, my eyes glaze over.
I’m just not professionally or temperamentally wired for policy discussions. I am, however, temperamentally and professionally wired for doctoring, and here's what I see: Undoing the Affordable Care Act with such rapid and angry vehemence will be bad for our health. (President Trump has promised that everyone will be covered. I have yet to understand how he'll do this.)
I’ve been working within the bounds of the Affordable Care Act since even before there was an Affordable Care Act. That’s because I work in Massachusetts, and the similarities between what Gov. Mitt Romney established in expanding health care here and what the Affordable Care Act allowed are awfully hard to ignore. They’re related, they share the same conceptual DNA, and their goals and visions are nearly identical.
Both the ACA and Gov. Romney’s plan were created to increase coverage to the untenably high number of people in our very wealthy nation who are unable to pay for their own health care.
Things don’t work perfectly by a long shot in Massachusetts. We drown, like many of the doctors in this country, in regulations and immensely burdensome paperwork that has little to do with medical care.
Undeniably, though, the overall access to care increased with Romney’s plan and increased even more under the ACA. For longer than than the rest of the nation, Massachusetts has experienced the benefits of broadening coverage. A healthy state is made up of healthy citizens, and that has been shown again and again in countless public health studies. Massachusetts remains the most broadly health-insured state in the union. For all my whining (and I whine a lot about the roadblocks in practicing medicine here) we have it pretty good.
The good stuff we got from the Romney plan is pretty similar to the good stuff that the rest of the nation got from the ACA. Particular to the ACA, the removal of preexisting conditions as reasons to refuse health coverage is paramount to providing care. Massachusetts also created an adjustable scale for healthier, more privileged individuals and used the saved money to cover patients who lacked the financial means to purchase care in the first place.
And universal health care is simply good for our health. I could argue about details. I could cite data that show that making sure we care for the most vulnerable as well as the most robust is a win-win. I could display economic indicators that prove that better access to health care decreases the overall costs of health care. I could tell personal stories — stories from my own family as well as general stories from my practice that make clear the ways that improved access to care is literally life-changing and even life-saving.
But at the end of the day, what I want most to say is what I say to my own children. Universal care – health care that is accessible and affordable for everyone – is good for our national soul. It is the central hallmark of a civil and civilized society. I don’t care what we call this kind of legislation. We can call it the New and Improved Affordable Care Act or we can call it the Trump Act. I just want people to have access to care.
Dr. Steve Schlozman is associate director of The MGH Clay Center for Young Healthy Minds and an assistant professor of psychiatry at Harvard Medical School.
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