A purported Chinese curse -- “May you live in interesting times” -- seems apt for this current chaotic period of American public policy. (It appears that the quote does not actually have Chinese origins and was simply coined by an English politician in the 1930s to sound sagacious.) As a student (and teacher) of health policy, there is no question that the past year, during which Congress and President Trump tried repeatedly to repeal the Affordable Care Act (ACA), had high political drama, with fingernail-biting day by day action and revelations, backroom deals and arm-twisting, heroes and villains and all the stuff of front page news in the Trump era.
A team of intrepid health policy analysts faced the challenge of trying to analyze the potential effects of these controversial policy changes. My colleagues in the Milken Institute School of Public Health's (Milken Institute SPH) Department of Health Policy and Management (Erika Steinmetz, Erin Brantley, Brian Bruen, Nikhil Holla and Drishti Pillai) and I wrote several widely-read reports about the potential effects of repeal legislative proposals on employment and economies at the state level between January and September 2017. (The reports are listed at the end.) We sought to be rigorous and careful, using state-of-the-art methods and data, but also needed to be speedy because of the rapid Congressional timetable.
The insight that something was urgently needed came immediately after the November 2016 election. The unexpected confluence of a Republican President and Republican majorities in the House of Representatives and Senate opened the door for repealing the ACA; this had been a Republican Party priority for several years, but had been blocked by the President during the Obama years. President-elect Trump and Republican leaders announced that repeal would be the first priority in Congress in January. Repeal became a real possibility. Quick independent analyses were imperative.
We anticipated that other organizations, of which the Congressional Budget Office (CBO) is the most prominent, would conduct important analyses of the legislative proposals, focusing on federal costs or savings of the proposals and the effects on insurance coverage. Organizations like the Urban Institute and others had well-respected microsimulation models suitable for such analysis. We also knew that numerous experts, including HPM’s Professor Sara Rosenbaum, would be providing timely policy and legal analyses of the pluses and minuses of the proposals and insights into critical policy details that might not be noticed in tweets or newspaper headlines.
But we felt we could make a unique contribution by examining the broader economic consequences of major changes to the ACA and to the nation’s health sector which comprises almost one-fifth of the overall economy. Changes in the ACA could have repercussions that could shake employment levels in every state and shift states’ economies. While changes in insurance coverage are critical, many stakeholders would care about how the major legislation could affect jobs or businesses. After all, virtually all policy officials want to expand jobs and economic growth. These analyses could be meaningful to those outside the health sector. Some critics had labelled the ACA as a “job killer” and it could be important to assess the effects of repeal on job growth or loss. We also believed that translating national estimates to state levels would make the findings more germane across the country.
In doing this research, we faced three big challenges:
- Finding Funding. Doing serious research takes money and we needed it fast. We had not expected or planned to do this work before November. Because of the legislative timeframe, we wanted to begin analysis in December to release something in January. Funding was needed to acquire specialized, but expensive, software (REMI’s PI+ regional economics model), as well as to cover staff costs. Getting a grant from foundations or the government usually takes several months at least. That would be too slow.
We scrambled. Fortunately, others recognized the urgency and importance of this work and we secured initial funding in December from the Commonwealth Fund, the Milken Institute SPH and the Geiger Gibson/RCHN Community Health Research Collaborative. More funding to continue the work also came from the Commonwealth Fund.
- Conducting the Analyses and Keeping Up with Rapid Changes. Because these bills were being rushed through Congress, it was challenging to even keep abreast of the active legislative proposals, much less to analyze them. We read hundreds of pages of legislation and summaries. To ensure that we were using fair and trusted estimates of how funding levels would change; we decided to rely on federal budget estimates from CBO. Once CBO estimates were available, we could allocate federal funding changes to every state and every year and use them as inputs to our economic model in order to estimate the effects on employment levels and state-level economic impacts. As part of this we had to rapidly develop and analyze multiple data sources, including Census and administrative data. Team members swung into action and worked evenings and weekends (plus over the winter holidays in December) to meet tight deadlines.
A huge challenge was that as soon as a Congressional proposal was released, it would be criticized and amended to address complaints of various members or interest groups. The legislation was an ever-moving target. We had to both keep up with the legislative details, as well as to figure out how to adapt our models on the fly. Sometimes this meant that as soon as we completed an analysis, we had to throw it out because the legislative proposal changed and start over again. In the waning days of the Senate’s repeal debates in July, we completed analyses of the Obamacare repeal bill and the skinny repeal bill, but by the time our analyses were done the measures had failed, so there was no point in posting our findings. For our final analysis of the Cassidy-Graham proposal, our brief was posted just two hours before the Senate announced the bill lacked sufficient support and there would be no floor vote.
- Communicating the Findings. It is regrettably true that most academic research is published in peer-reviewed academic journals a year or more after the work is completed. For much research, this is fine. The credibility associated with the peer-review process and publication in a journal makes up for the delays. For these policy analyses, we skipped the peer-reviewed journal system as too slow and worked with the Commonwealth Fund and the School of Public Health to release the work as policy briefs. The reports were posted on websites and disseminated using press releases, social media and other approaches.
Kathleen Fackelmann, Director of Media Relations for the Milken Institute SPH, and staff of the Commonwealth Fund swung into action and helped us to format the reports, develop press releases and infographics, and disseminate the results. We did numerous press interviews and public events to get the word out. We worked with other organizations to further amplify the impact. The outreach resulted in massive coverage with major news organizations in the United States and internationally featuring the research. For example, the first report alone garnered stories in more than 500 media outlets including USA Today, CBS News, National Public Radio, The Atlantic, NBC News, The Miami Herald and newspapers around the country. The research was also mentioned in influential niche media such as Kaiser Health News and Congressional Quarterly.
The impact of the research/media promotion includes the fact that the research was cited by members of the House of Representatives and Senate during the heated floor debates on Capitol Hill about the Affordable Care Act, in addition to being discussed by legislative bodies at the state level. Our findings were also discussed at meetings, and we even saw that some of our findings were used in signs held at rallies across the nation.
In the end, did our efforts matter? Despite being the highest Republican priority this year, repeal and replacement bills repeatedly failed and the ACA remains the law of the land. Of course, there was a massive nationwide response that included efforts from other experts and policy wonks, health care providers, major trade associations, advocates and everyday Americans who spoke out about how they could be hurt by ACA repeal. And there were brave and thoughtful Senators and Congressmen who made the final voting difference. Polls suggest that, after sustained attacks, the ACA is more popular with the public than ever.
Despite all our sweat, we don’t really know if our analyses affected outcomes. But, at the very least, we shed light on important issues and spoke truth to power. These are worthy goals for researchers and policy analysts.
And we lived through interesting times. I sure hope times are less interesting next year. Interesting times are challenging, but a purpose of health policy analysis is to step up to the challenges and to help create opportunities.
Acknowledgements. My colleagues at the Milken Institute SPH's Department of Health Policy and Management, Erika Steinmetz, Erin Brantley, Brian Bruen, Nikhil Holla and Dristi Pillai, were vitally involved in this work. John Bennett and Fred Treyz of REMI also helped with the analysis. Kathy Fackelmann of the Milken Institute School of Public Health and the staff of the Commonwealth Fund helped get the studies out into the world. We remain grateful to funders, including Sara Collins and David Blumenthal of the Commonwealth Fund and Feygele Jacobs of the RCHN Community Health Foundation, for supporting this work under unusual circumstances.
List of Reports
Repealing Federal Health Reform: The Economic and Employment Consequences for States. Brief, Commonwealth Fund, Jan. 6, 2017.
The Economic and Employment Consequences of Repealing Federal Health Reform: A 50 State Analysis. Milken Institute School of Public Health, George Washington University. Jan. 6, 2017.
The American Health Care Act: Economic and Employment Consequences for States. Commonwealth Fund, June 14, 2017.
The Better Care Reconciliation Act: Economic and Employment Consequences for States. Commonwealth Fund, July 6, 2017.
“The Graham-Cassidy Proposal Would Eliminate a Third of a Million Jobs,” To the Point, The Commonwealth Fund, Sept. 26, 2017. Methods appendix. at http://www.commonwealthfund.org/~/media/files/publications/blog/2017/gc-methods-appendix_final.pdf
Leighton Ku, PhD, MPH, is a Professor and Director of the Center for Health Policy Research at the George Washington University’s Milken Institute School of Public Health. He is also an Executive Board member for the District of Columbia’s Health Benefit Exchange Authority.