It’s no secret the United States has one of the most complex health care systems in the world. For many undergraduate students, the intricacies of private insurance, Medicare, Medicaid, the Affordable Care Act (ACA) and other structures can quickly become confusing. With a 2020 election that will determine the future of American health care, the demand for a solid educational framework in the subject is arguably more important than ever.
Fortunately, the Department of Community Health has addressed this demand by enlisting the help of Amy Lischko, an associate professor in the Department of Public Health and Community Medicine at the Tufts University School of Medicine (TUSM). In her 13 years at TUSM, Lischko has taught several public health courses at the graduate level, including biostatistics, epidemiology and policy analysis.
Lischko has her fair share of accomplishments throughout her career. Prior to joining TUSM in 2007, she served as the commissioner of health care finance and policy and director of health care policy under then-Gov. Mitt Romney. Together, they passed a landmark Massachusetts health care reform bill in 2006, which significantly expanded health insurance coverage in the state and set the stage for the passage of the ACA in 2010.
Last fall, Lischko took the opportunity to bring her expertise in public health policy to the undergraduate level. She began teaching Healthcare in America, a course designed for first-years and sophomores to understand the American health system, as well as apply that knowledge when comparing it to health systems of other countries.
Although Lischko had taught the course to graduate students before, she quickly found that the students on the Medford/Somerville campus were keen to grasp the material.
“Basically, the course I teach at the undergraduate campus is very similar to the Healthcare in America class that I teach on the Boston campus,” Lischko said. “I find the undergraduates are very sharp.”
In addition to preparing potential pre-health students for their careers, Lischko said the primary goal of Healthcare in America is for her students to apply what they learn to both their academic endeavors as well as their personal lives.
“I also have a desire for all students to understand how their health plan works and how health insurance works,” Lischko said. “Some students are still on their parent’s plan, and they rely on their parents to kind of help translate that for them. Hopefully, the course also helps them navigate their own health care moving forward as they move into adulthood.”
Although she has significant knowledge in the health care policy sector, Lischko did not always know what exactly she wanted to do in public health. In the first decade of her career, Lischko explored different opportunities, and said these experiences helped shape her as an academic.
“I like to share that my road to getting to where I am now was not a straight trajectory,” Lischko said. “Students like to hear that.”
In 1982, right after graduating from college with a degree in nutrition and food science, she joined the Peace Corps and traveled to Liberia. There, she worked in a rural village and witnessed firsthand the impact that public health could have at the community level.
“After the Peace Corps, I was really ginned up about public health,” Lischko said. “I wasn’t sure if I wanted to do global public health or domestic public health … I loved traveling, being in a new country, learning [about] new cultures.”
Upon returning to the United States, Lischko experimented with different job opportunities both related and unrelated to public health. At one point, she even found herself working as a quality control inspector at a fish factory in Boston.
“We had to wear boots and slosh around in fish water all day,” Lischko said. “So yeah, I didn’t last too long there.”
Soon after, Lischko returned to graduate school, where she received a Master of Science in health policy and management. After earning her degree, she worked for the Massachusetts Department of Public Health before finding a position at the New England Health and Poverty Action Center at TUSM.
It was during her time at the New England Health and Poverty Action Center that Lischko realized that in order to enact lasting change, she would have to find a job in public health policy. At the center, Lischko and her team worked with community-based centers on programs to benefit vulnerable and at-risk populations.
Although she witnessed the value the programs had on communities, she also noticed many problems remained unaddressed, such as those regarding children and proximity to violence.
“These programs were great, and I’m sure they were having an impact on the populations, but there were just so many problems that weren’t getting addressed,” Lischko said. “When these kids went back home, there was violence all around them, and poverty. It reinforced the idea that … to really have change, you had to work at a higher level in policy.”
With this in mind, Lischko waited until a position was open at the Massachusetts Division of Health Care Finance and Policy, where she started in 1993. Over the next several years, she rose through the ranks in the agency, where her team studied the health care system in Massachusetts and uninsured populations in the state. Eventually, she was appointed as the commissioner of the agency by Gov. Romney in 2006, after having served as the assistant commissioner for research and policy since 2003.
According to Lischko, when Romney assumed the role of Governor in 2003, he presented himself as a businessman determined to pass statewide health care reform.
“He came on and had heard from lots of business owners that health care was really a mess,” Lischko said. “His advisors were all saying ‘no, no, no, don’t do health care’ … But he really pursued this.”
With the support of the Massachusetts legislature, Lischko and her team worked for years to help formulate a plan that aimed to increase health care coverage by requiring most adults in the Commonwealth to have health insurance.
“It was several years of really working with the different parties trying to sell the idea and come up with an idea that was workable in the state,” Lischko said. “It was a real entrepreneurial environment, where you would be at work at six in the morning and you would work until late at night. It was very intense for a long time.”
The bill passed with bipartisan support in 2006, granting near-universal health insurance coverage in conjunction with federal funding to subsidize coverage. Although the bill has been modified in years since, its impact remains apparent 14 years later. In 2019, Massachusetts had the lowest uninsured rate in the country, at 3%.
The law eventually became a model for the ACA, which was passed on the national scale in 2010 under President Barack Obama. However, unlike the 2006 bipartisan coalition in the Massachusetts state government, the ACA was immediately met with strong opposition from Republican lawmakers. In the past decade, the law has been challenged multiple times, even making its way to the Supreme Court in 2012. Romney himself has argued against the ACA.
Lischko explained why she believes that health care reform is often polarized at the national level. In reference to Romney’s 2006 bill, she attributed its success to a cooperative, bipartisan coalition that specifically tailored the law to Massachusetts, a feat that was harder to pull off at the national level.
“We [had] this kind of coalition that really agreed that even if things went south, they would pull back and look at [the law] again, and make the changes that needed to be made,” Lischko said. “That’s much easier to do in a state than it is to do at the federal level. At the federal level, there was no chance that if things went wrong with the Affordable Care Act, that the legislators would go back and revisit it.”
The ACA continues to face many challenges to this day. In the upcoming weeks, the law will face arguably one of its biggest hurdles yet as the Supreme Court is scheduled to hear oral arguments in California v. Texas on Nov. 10. The court will decide whether or not the individual mandate of the ACA — which, like the Massachusetts law in 2006, requires that most adults achieve minimum health insurance or be subject to a fine — is constitutional.
Proponents of the ACA worry that if the individual mandate is deemed unconstitutional by the now 6–3 conservative-leaning Supreme Court, the entirety of the law could fall apart, potentially stripping millions of their health insurance.
Lischko said although she is not an attorney, she remains optimistic that key elements granted by the ACA can survive, regardless of whether or not the individual mandate is ruled to be unconstitutional. While she is uncertain of how the case will play out next week, she explained that many states have been preparing for a possible overturn of the ACA.
“States have been preparing since the Supreme Court said that they were going to take that case,” Lischko said. “States that want to maintain the pieces of the ACA are going to put pieces in their place. And I’d say if Biden is successful, then [it] will be easier to have an administration that supports that.”
On the topic of the future of health care, Lischko emphasized the importance of today’s election.
“If [Democrats] win the House, the Senate and the presidency … it will make it much easier to move forward even if the ACA is struck down,” Lischko said. “I feel like [this] is a really important election, probably the most important one in a while.”
Lischko sees the United States eventually developing a health care system where around 80% of the population will receive health insurance through some sort of public option. While she doesn’t anticipate such a change happening in the near future, she remains hopeful current undergraduates will see such a system implemented in the United States.
On her own time, Lischko is passionate about traveling the world and hiking with her family. Her background on Zoom is a mountain range in the Alps, which is a favorite for her.
“I love to hike in Europe, any of the Alps, we’ve been to most of them now,” Lischko said. “I love to go hiking there as I’ve gotten older, because you can take the gondola or the lifts up into the mountains and hike all day … there’s nothing as spectacular as [the] views.”
Lischko said health care reform in America is, at its core, a complicated structure. However, she also stressed the importance of learning about health care on a personal level, and encourages people to engage in discussions about their health care with members of their community.
“I still try to always talk to people about health care,” Lischko said. “Health care is really … more personal than some other things, so you can grab hold of it more and make sense of it.”