The ambition of the Trump Administration is to disrupt and Make America Healthy Again by dramatically changing programs that have covered Americans for decades. Could this be American health care’s “fourth turning?”
In the mid-1990’s Neil Howe and William Strauss wrote a book called “The Fourth Turning: An American Prophecy.” They argued that history is cyclical, and “turns” in four increments over a period of 80-100 years. The first turning is “The High.” This is the time after a crisis when America builds new institutions. Times are good and people are optimistic.
For health care coverage, the first turning could be the years immediately following WWII. It was a period of economic growth and a growing health insurance industry. Employers were frustrated with attracting workers in an era of wage caps. Health insurance was exempted from the caps and grew into an essential benefit for employee recruitment and retention. Today, 165 million Americans are covered by their employers.
The second turning is “The Awakening.” This is when institutions are questioned, and systems set up in the first turning are refined. This could be the late 1960’s and 1970’s when health care expenditures were rising sharply. Medicare and Medicaid coverage were established to address unaffordability of coverage by low-income Americans and seniors. President Nixon proposed and eventually passed the HMO Act of 1973, sparking our shift toward managed care.
The third turning is “The Unraveling,” a weakening of institutions and a growing distrust of the public sector. This could have been in the 1990’s and 2000’s when Hillary Clinton ran into an increasingly divided Congress, a Patients Bill of Rights was called for, and outrage in the business community over double-digit rises in health care benefits year after year. President Bush did partner with Senator Ted Kennedy to add a prescription drug benefit to Medicare during this time, but that was an anomaly in a decade dominated by faltering faith in our ability to make coverage affordable. These are also the decades when obesity and chronic disease became the norm in America.
Enter the final turning, “The Crisis.” This is a period of upheaval when institutions face crisis, people are deeply pessimistic and ready for change. The change of the fourth turning sets the stage for the new high. The fourth turning for American health care coverage could have started in 2010 when President Obama and Nancy Pelosi passed the Affordable Care Act, which the subsequent House of Representatives voted to repeal 70 times. The ACA sparked thousands of lawsuits, four of which went to the Supreme Court and another on its way there. Prescription drug costs, hospital bills and health insurance premiums become major political issues during this period. Today, the cost of health care is the leading contributor to personal bankruptcies (most of those people are covered). Chronic disease still ravages the country.
If we are in the fourth turning, we have a chance to upend the system. We could truly impact the wholistic causes of rising costs and illness in the U.S. The Trump Administration wants to get back to the basics of making healthy foods more available (a bipartisan goal), reforming physician payment, and passing policies to better address chronic disease. We need to ensure people have access to care, which is difficult when juxtaposed with rising costs, but perhaps there is a way to reimagine a better system.