My brother and the failure of TrumpCare

Why, please ask yourself, do the Republicans, after years of wishing to replace the Affordable Care Act, have no replacement even they can support? One clear answer is illustrated by my brother, Jason Levitis, an unsung American hero. I've mostly kept quiet about this, because he has, but the cat is out of the bag, Jason is out of government, and the time has come. In his recent article in Vox, his byline reads, "Jason A. Levitis is a senior fellow at the Solomon Center for Health Law and Policy at Yale Law School. He led ACA implementation at the Treasury Department during the Obama administration." That's all true, but Jason was on this long before the ACA was law. He was the single most frequent visitor to the White House throughout the entire Obama administration, and he wasn't there for the tour. I feel safe in saying that no one in the world knows the Affordable Care Act better than my brother, or has thought more deeply about why each part of it functions as it does. When President Trump said, "Nobody knew health care could be so complicated," my response was, "actually, my brother knows exactly how complicated."

I can clearly remember Jason telling me that he was going to reform the U.S. healthcare system in the year 2000. He and I were both recovering from injuries, limping through the newly reopened Hayden Planetarium at the American Museum of Natural History. Both of us, as patients, had been screwed by the healthcare system. Our parents, both physicians, had recently retired early because they just couldn't stand being part of that system anymore. As we crept along, two very similar looking young men on canes, to an evening planetarium show, he explained matter-of-factly that he had decide that the most important thing he could do was fix American Healthcare. This, he explained, would require years of work to understand the system, probably a law degree, the building of connections in the policy world, and an activist White House brave enough to succeed where "HillaryCare" had failed. His younger brother, I had to admit he was talented enough to carry out each step, and still found it improbable.  As we watched billions of years of galactic evolution whiz around us, I wondered how long my always swirling brother could focus on this very long-term plan.

Seventeen years later, he is still following his plan. He built his detailed understanding of the system as a Senior Analyst in the health economics department at the Greater New York Hospital Association. Then he got his law degree at Yale. Then he built connections and expertise in health law at Connecticut Voices for Children. He moved from there to being a Senior Analyst and Counsel at the Center on Budget and Policy Priorities, a DC think tank that is just as wonkish and unflashy as its name implies. He testified before various state legislatures about earned income tax credits and other stuff that I only understand because he explains it well, and I thought his singular focus on health policy had melted. I was wrong. He had become a respected part of DC health policy wonkdom, and with his co-wonks was working up a national policy resembling Massachusetts’s health reforms, aka RomneyCare. By 2008, when Obama ran for president, their framework was far better developed than the final TrumpCare bill that failed today.

President Obama appointed Jason as Senior Advisor to the Assistant Secretary for Tax Policy, Department of the Treasury. In practice, Jason worked day and night, often over 100 hours a week, writing the text of the bill that would come to be known as the Affordable Care Act. He would come to an important family event and would pull out two Blackberries, communicating on both simultaneously with the half dozen other people writing the bill with him. He would go into the bathroom and be arguing with somebody about the wording and punctuation of some sentence that was likely to be challenged in court.  He fought for fine policy details that his training in both law and economics told him would actually help the American people, not just make good TV. He sat next to Obama's people as they testified before Congress, feeding them the details they needed to give full answers. He undertook endless last-minute rewrites to try to meet the demands of that one last wavering Democratic Senator. Once the bill became law, he spent years writing the regulations needed to implement it. He, with a few close colleagues, is the policy brain of the Affordable Care Act.

I tell you all of this not only to praise my brother, although he clearly deserves it. The Affordable Care Act has brought health coverage to millions of Americans, slowed the increase in healthcare costs, spurred needed innovation and raised standards across the American healthcare system, and in the process saved countless lives. My purpose here is not to litigate the merits of the law, but to point out the intellectual rigor at the heart of the Affordable Care Act, and contrast it with the mushy sloganeering and flailing demagoguery that is the Republican approach to health legislation. The entire Republican machine spent years scheming to replace the ACA, made that their mantra, and have utterly failed to find any solution that isn't demonstrably, disastrously worse. There is no Republican reflection of my brother, no Nosaj Sitivel, because one can't take the details and ramifications as seriously as Jason does without rejecting conservative "principles." There is no health policy wonk taken seriously by Republican leaders who saw these problems  two decades ago and resolved, without ideological baggage, to learn how to increase healthcare access and quality. There is no one in the Republican establishment willing to fight for effective policy that is hard to explain and harder to sell. So as many years as they spent railing against Obamacare's imagined failings, and promising to replace it with bottled heaven, they remain incapable of offering any substance. TrumpCare failed because nobody involved in writing it actually cares.

You want to know how to improve on the ACA? Ask my brother. He, of course, has detailed, well researched, carefully considered lists of fixes. Will our current all facade, no building, leaders implement any of that? Of course not, they want the ACA to fail so they can blame Democrats. But with the defeat of the American Health Care Act of 2017, it seems much more likely that government with an honest interest in good policy will be back. Facts matter, logic matters, policy matters, even in politics. And that is reason for hope.