It's been a topsy-turvy decade in health care. Public debate has been intense. Political fortunes have been decided. And real people have been through the meat grinder. As the 2010s end, here are the winners and losers of the past decade.
Blue and purple states. The Supreme Court allowed states to go their own way on whether to expand Medicaid to people making up to $17,000 a year under the 2010 Affordable Care Act. When the expansion began in 2014, those that did – all the blue states and many of the purple ones – saw gains in health outcomes, financial yardsticks and economic activity. The five-year studies are conclusive in every measure. And because federal taxpayers pick up 90% of the tab, those that didn't choose to expand, particularly Texas and Florida, are subsidizing these gains without realizing any of their own.
Barack Obama. Having succeeded where many presidents before him tried and failed, Obama began the decade on a triumphant note with the passage of the ACA and the eventual expansion of health care coverage to millions of Americans. By the middle of the decade, with a glitchy website launch and over 1,000 state and federal Democratic seats lost, things didn't look as good. Now, however, the battles for health care are being fought on ground Obama gained. Even Republicans who worked to repeal the ACA are forced to acknowledge that protections for people with preexisting conditions are here to stay.
"Big" Health Care. As the decade started, health plans, pharmaceutical companies and the many moneyed interests in health care bemoaned the law. A system designed to allow insurers to exclude people for any reason was going away and new rules would be coming. Every new regulation has been accompanied by a threat that innovation would stop and companies would be killed. A decade later, after many mergers, record profits, record stock prices and some big corporate tax breaks, corporate health care has adjusted. But Americans appear as weary and suspicious as ever of profit-making at their expense.
Our health. A frightening picture of the country emerges from a series of data. Suicide rates are up across the country, dramatically among teens and preteens. Nicotine use is on the rise among youth after dramatic reductions, thanks to vaping companies. Addiction from prescription opioids and heroin have ravaged many families and small towns. School shootings not only threaten our kids but also are part of a rise in teenage anxiety and depression. And for three years running, our life expectancy is declining, heretofore unheard of in a wealthy nation.
Donald Trump. Candidate Trump's populist proclamations were quickly co-opted by the conservative, nihilistic, anti-Obamacare agenda once he won. The public didn't like it and the agenda not only failed, it cost him his majority in Congress – which now threatens his presidency. He jumped on the anti-ACA bandwagon at just the wrong time, when the public was waking up to the benefits they could lose. The ACA is almost 10 points more popular than Trump.
GOP Congress. Republican lawmakers were never so much against the content of the ACA as they were good political opportunists. To this day, the marketplace exchanges are more of a Republican idea. But Republicans were better than the people who passed it at defining what it was, and saw it as the ticket to massive fundraising and political gains. They used their most powerful weapons once the ACA was in place – sabotage and inaction. Rather than fixing the law's flaws, they exploited and exaggerated them. But dozens of failed attempts to repeal the law came back to haunt them once they won power and it became obvious that they had no palatable ideas to replace it.
Democrats in Congress. The political lesson of the decade is that when it comes to health care, the party that appeals to the fear of losing something tends to make the winning case. Republicans benefited when they could point to anyone who lost their doctor and Obama's "if you like your doctor, you can keep it" pledge. Democrats were able to do the same when Republicans went after the ACA and preexisting condition protections. But Trump will argue that Democrats' secret desire is to strip them of the coverage their employers provide for them even as he uses the courts to actively cut their care.
The 2018 Democrats won the health care argument, but the 2020 Democrats are in the midst of a debate over how they would expand coverage if they win, including "Medicare for All" plans that would eliminate employer coverage and private insurance. Despite all the rest of the noise surrounding Trump, health care has become the top political pocketbook issue. Democrats' existential bid to turn him out of office could be decided by making the case that there is much more to fear from Trump than from them.
Andy Slavitt, board chair of United States of Care and a member of USA TODAY's Board of Contributors, is a former health care industry executive who ran the Affordable Care Act and the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter: @ASlavitt.