King v. Burwell and the Role of Scholarship in Health Reform Implementation.
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In early 2012, I wrote that what the Affordable Care Act (ACA) ultimately accomplishes would depend as much on how it is implemented as on the compromises that led to its passage. At that point, the fate of the law rested on the Supreme Court’s decisions on the individual mandate and the Medicaid expansion, and on the outcome of the upcoming elections. After the Court’s ruling and President Obama’s re-election, I wrote, “We can finally say with some certainty that the ACA is here to stay.”
I could not have predicted that, two years later, the ACA’s future would still be so uncertain. The 2016 elections loom large, with the possibility that a Republican president will work with a Republican-controlled Congress to undo major portions of the reform. This week the Supreme Court heard oral arguments in King v. Burwell, a case about whether the ACA prevents the federal government from providing financial assistance to people in states that chose not to create their own insurance exchange.
A ruling for the petitioners would have dramatic consequences for consumers, insurers, and providers, resulting more than 8 million people in 34 states losing health insurance coverage, causing premiums to increase by as much 47 percent. Federal and state leaders will feel pressure to mitigate the negative effects of such a ruling, but there are several reasons this will be difficult.
The fight over health insurance exchanges is a good example of politics affecting population health. It is also a good example of the role that academics can play in contributing to policy debates. The lawsuit before the court is largely the work of a professor at Case Western University. On the other side, I am one of 36 health policy history scholars that signed a brief relying on the legislative history to argue that Congress intended to extend tax credits to people in every state, not just those that created an exchange. Similarly, Dean Sandro Galea, David Rosenbloom, and Wendy Mariner signed a brief with leading public health scholars describing the negative effects of a ruling for the plaintiffs. Justice Anthony Kennedy’s much-scrutinized line of questioning this week about unconstitutional coercion can be traced to a brief written by BU law professor Abby Moncrief.
All this activity has caused me to reflect on Dean Galea’s recent message that “an activist academic public health agenda is a core feature of a mission-driven school of public health.” This is an exciting charge, challenging academics not just to generate high-quality scholarship answering relevant questions, but also to then transmit this knowledge across sectors to inform the leaders who make policy that shapes health.
Having spent the last four years studying the ACA’s implementation, I have learned a lot about the challenges and opportunities of becoming involved in policy debates that are intensely political. For one, the legislative calendar moves much faster than the academic timetable. While doing interviews for my dissertation on insurance exchanges, I was encouraged to testify before the Michigan House Health Policy Committee and share what I was learning about exchanges in other states. I accepted with some trepidation, knowing that my research was still ongoing and had not yet been published. But the moment would have been long gone had I waited for peer review.
This experience also helped me see that I won’t be listened to just because I rely on evidence. While testifying, I noted that only one legislator made eye contact with me, and a few others were not very subtle about reading something else. No one asked a question, and the committee’s decision ignored my recommendation. By contrast, audience members clapped each time someone compared President Obama to Adolf Hitler and the ACA to Nazi Germany.
Similarly, the debate over King v. Burwell has taught me how little control I have over how my scholarship is used by the media and others once it is out of my hands. An article I co-authored on this Supreme Court case was published last December in the New England Journal of Medicine. I was pleased that the article received attention, including by the New York Times and as the lead story on the Huffington Post. The reaction was mostly positive, though one scholar did write to chastise us for “doom-saying.” I suspect this reaction had less to do with the content of our article and more to do with the Huffington Post’s overly dramatic headline: “Be Very Afraid.”
Despite these challenges, I have found the experience to be exciting and deeply rewarding. Examining policy development in real time helps me know what questions to ask and how to contribute. It has opened doors for collaboration, funding, and publication that may not have been available otherwise. It has also helped me see that much of the other work I do—or that we do in a school of public health—has an underlying political context, whether we confront it or not. Participating in such debates requires a willingness to be vulnerable, flexible, and patient, but it is very much an important element of “an activist academic public health agenda.”
David Jones is an assistant professor of health policy and management at SPH. He can be reached at dkjones@bu.edu.