Intended for healthcare professionals

Observations Yankee Doodling

Obama turns his hand to health policy analysis

BMJ 2016; 354 doi: (Published 15 August 2016) Cite this as: BMJ 2016;354:i4442
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
  1. dkamerow{at}

But the US president’s JAMA article was not externally peer reviewed

As someone who writes about health policy, I was interested to see Barack Obama’s recent article in JAMA assessing the Affordable Care Act.1 It is not uncommon to see a US president commenting in a newspaper op-ed column, and a few previous presidents have also written commentaries for medical journals. But Obama’s six page JAMA “special communication,” with six graphs—several with new data—and 68 references, seemed more like a research article than an op-ed piece.

Unsurprisingly the article received a lot of attention from the journal and from readers. Not many medical journal articles have three accompanying commentaries (one by the editor) when they are published. Fewer still stimulate a near full page editorial in the New York Times.2 Obama’s article invites questions about its content, of course, but also about its provenance and JAMA’s review policies. It is an election year, after all, even if the president himself is not running.

Not just a puff piece

To the president’s credit this was not just a puff piece singing the praises of Obamacare. He first marches through the accomplishments of the law in its initial six years, documenting increases in insurance coverage rates and some measures of decreasing healthcare costs and increasing healthcare quality. He also acknowledges some (not as many as his critics would like, of course) of the problems with the law: health insurance premiums are rising; many people can afford only basic, essentially catastrophic, coverage; and more than a third of states have not expanded Medicaid coverage. The article concludes with recommendations to improve the law—again, not what his critics would like to see, but still an attempt to be both even handed and proactive.

Critics have jumped in and pointed out many problems with the article.3 4 Were the decreases in the growth of healthcare costs that we’ve seen really due to Obamacare? Is there any evidence yet of real improvement in healthcare outcomes, rather than just increased care? Has competition kept prices down, as promised? Is there any political support for the further changes he suggests, such as a new “public option” plan to increase competition? And many more.

He is a smart guy and a science nerd, but it seems unlikely that he has the time or the skills to do this kind of data analysis

Overall, I thought the piece was well done. Aside from its content, however, its publication inevitably leads to questions about who really wrote it. That is: did the president, who is the lone credited author, actually conceive of it, do the data analysis, and write it himself? I understand that he is a smart guy and a science nerd,5 but it seems unlikely that he has the time or the skills to do this kind of data analysis. After looking at the oddly titled “additional contributions” acknowledgments section of the paper, which lists two well known senior economists who “assisted with planning, writing, and data analysis,” I wonder what their contributions really were. Shouldn’t they have been coauthors of the article? I think so.

Special treatment

I get that presidents have uncredited speechwriters, but this is not a speech. It has all the trappings of a research article, or at least a review article, both of which have to be written and reviewed to certain standards. JAMA says that the article received “rigorous internal review”6 and did not get special treatment. Don’t believe it. If you or I had submitted such a substantive piece to JAMA you can bet it would have been peer reviewed.

In addition to the authorship question, why wasn’t it peer reviewed? It is good that JAMA commissioned two outside editorials (although one of them was by a sympathetic former Obama aide and cabinet member), but accompanying editorials are not the same as external peer review. Comments from peer reviewers would have resulted in a stronger piece, one in which the president had to deal with more questions about where the Affordable Care Act has been less successful and what could be done about it.



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