Don’t repeal the ACA without a replacement

Whether rejoicing or mourning, millions of Americans awoke on January 21st feeling suddenly at the threshold of a new and uncertain era. However, in public safety-net emergency departments across the nation — like Harborview Medical Center in Seattle, where we work — the service of healing continued seamlessly, paying no heed to the national drama that has unfolded for the past several months.

That day and into the night, there were simple moments that typify and define our work. Picking up an elderly homeless woman’s shoes. Using a translator phone to ensure a Somali teenager had the right insulin dose. Jumping into action when medics arrive with a young cyclist struck on his way to work. It was comforting to lose oneself in the tide of humanity, the true cross-section of society that streams through our doors 365 days a year.

Though health care is undergoing unprecedented evolution, our fundamental mission to serve remains steadfast. At the entrance to Harborview, there is a banner that states, in seven languages, “Harborview welcomes and respects ALL.” Regardless of our political identities, physicians choose to rise above politics to carry out the principles of service that underlie our profession every day.

However, we now find ourselves at a crossroads in U.S. health care and politics that threatens those that rely on us most for their well-being. The desire to remain apolitical in our duties must not silence our collective responsibility to protect our patients.

Although the new administration has viewpoints on health care that substantially differ from those which preceded it, the one thing that most everyone can agree on is that there is plenty of room for improvement. However, we must speak firmly and act swiftly against reactionary changes that reflect political posturing without thoughtful policy to back them up. President Trump’s day one mandate to repeal the Affordable Care Act (ACA) without offering a carefully formulated plan for revision or replacement endangers our patients. It also threatens the principles of fair and accessible health care for all Americans — regardless of party lines.

In Washington State alone, over 500,000 people have obtained insurance through the ACA, and the uninsured rate has dropped by 54 percent since 2010. Nationwide, there are over 20 million newly insured, mostly working-class citizens and those afflicted by pre-existing conditions over which they have no control. In the ER — often the last resort for those that are uninsured — we experience alongside our patients the tragedies that befall people without access to health care; they are heartbreaking for us to witness, let alone for our patients to live. Physicians, nurses, and other health care providers have important, on-the-ground perspectives that must shape these debates.

We can accomplish this by advocating for a principle-based approach to improving U.S. health care. The core tenants that must guide health care reform are simple and bipartisan, outlined in the Triple Aim of the Institute for Healthcare Improvement (IHI): Improve access to health care, improve the quality of care, and decrease overall costs. Utilizing thoughtful observation, rigorous research and careful data analysis to solve complex problems is the hallmark of modern medicine, and we must take on the enormous task of reforming health care policy with this approach at the forefront.

Congressional Republicans can still put forth a rational replacement that does not abandon the millions of Americans who currently depend on the ACA for health care access. If our newly elected leaders can communicate concrete ideas for how to improve access, increase quality, and decrease costs, the health care community should engage with them in a collective effort to make our system better.

Until then, we must constantly remind ourselves that the eyes we look into on a daily basis at our hospital are not merely a backdrop. The easy thing to say is, “This is not my role,” and to bury our heads in the daily tasks at hand. Our mission and principles are clear — but there is much work to be done. For us to simply hope for the best and stand by as mute stakeholders is an abrogation of our duties as health care workers, healers, and Americans.

Anna E. Condino, Andrew G. Lim, Paul W. Charlton, and Sabiha K. Barot are emergency medicine residents. The opinions expressed in this article are the authors’ own and do not necessarily reflect the official views of the University of Washington or Harborview Medical Center.

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