“A marathon at sprint pace”: David Bowen ’82 on the crafting of the Affordable Care Act and more

In his ASL senior yearbook, David Bowen ’82 predicted that, in 10 years’ time, he would “either be sequestered away in a research laboratory or writing a book.” Some 25 years later, he found himself more or less at the intersection of the two, serving as health policy director for Senator Ted Kennedy (D-Mass.) and writing the Affordable Care Act—among many other critical pieces of US health policy. Today, David works on pandemic preparedness and public health. He recently sat down to give ASL an exclusive inside look at the messy, fast-paced world where health and policy meet.

“We used to joke that we had very flexible hours: You could work any 18 hours a day you wanted,” says Dr. David Bowen ’82 of his decade-long tenure in the office of Senator Ted Kennedy (D-Mass.). Between 1999 and 2010, David progressed from legislative fellow in Kennedy’s office to deputy staff director of the Senate Health, Education, Labor, and Pensions (HELP) Committee—which Kennedy chaired until his death in 2009—to staff director of the committee, bringing his science background to pressing policy questions as he took on increasingly broad responsibilities.

“It wasn’t busy in the way that a more conventional job is busy: We were all there because we really cared about the mission. You just put in the time that was needed to get the mission done. That was a lot of work. And occasionally—not that occasionally—it was a phenomenal amount of work,” David recalls with evident nostalgia. For his 10 and a half years on Kennedy’s team, David worked tirelessly on, among other things, the Affordable Care Act, or ACA; what is often still called ‘Obamacare.’ “All of us who worked on it were running a marathon at sprint pace.”

That time paid off, and then some: The ACA, a landmark piece of legislation allowing millions more US citizens to afford and access healthcare, was passed by Congress and signed into law by President Obama in March of 2010. To this day, David says that people come up to him and say things like, “‘The ACA made a major difference in my life,’ or ‘it saved my life,’ or ‘it helped us avoid bankruptcy.’”

“It was never not on Kennedy’s radar that we should have comprehensive healthcare reform,” David says. “That said, he had a very clear sense that there were windows of opportunity for different things.” For David, Senator Kennedy, and the rest of the politicians and Capitol Hill staffers who came together to build and pass the ACA, that window seemed to start creaking its way open in May of 2008, as it became clear that Barack Obama would be the Democratic nominee for that November’s presidential race.

“Kennedy’s time was incredibly scheduled,” David remembers. “He never waited around if anyone was late—which they never were. But we had a rare moment where he was actually waiting for someone, and we had some time.” The two discussed the health policy reforms they had been making as of late: genetic nondiscrimination; tobacco; mental health parity. The stage, they agreed, was set for meaningful progress on health insurance.

The pair also discussed the Clinton administration’s narrow failure to enact substantial healthcare reforms: in large part due to that administration’s diligent—and ultimately, too slow—work toward a bill that they considered perfect. (AKA the enemy of the good.)

“Kennedy’s point to me was, ‘I want my bill ready to go on day one’ of the Obama administration,” David says. “Consistently, it was ‘Speed, speed, speed. Get a bill done.’”

Born in New Jersey but raised in London—complete with a British primary school education and accompanying accent, which stuck with David until his family moved to Canada during his middle school years—David grew up spending only the summers back in the state his parents had called home. “As a kid, I formed a view that the Jersey Shore was representative of the United States,” he laughs. “For a time, I honestly felt that there would be a miniature golf course every two miles in America.”

When his family moved from Canada back to the UK, David was set to enter high school. His parents ‘decided [he] should attempt to become an American,’ so he enrolled at ASL.

He remembers his peers at the School as being roughly “a third, a third, a third,” sketching a breakdown of the population as one-third lifelong expat (“they had ridden the bus with each other in Singapore six years ago”), one-third adrift in their first international move (“‘Oh my gosh, I had the football team; I had what I was used to; I was in Syracuse or Rochester or Tulsa’”), and one-third absolutely thrilled to suddenly find themselves in London after a childhood spent in a small, corporate American city (“‘Oh my god, I’ve spent my entire life wanting to get out of Tulsa or Rochester or Syracuse. Now I’m in London: This is the greatest thing ever’”).

In his four years of high school, David participated in theater productions, model UN, quiz bowl, and more—and then went on to study neural science at Brown University, followed by the University of California Medical Center in San Francisco, where he earned his PhD in neurobiology. For some years after that, as he had predicted while still a senior at ASL, he worked as a scientist.

“There are some people who are absolutely happy to be in a lab and just focus on one molecule, or one neural pathway, for their whole lives. I wasn’t that person,” David admits. “I’d seen ads in the back of Science for the American Association for the Advancement of Science (AAAS) Fellowship. I got to a point where I said, ‘Either, David, you’re going to apply for one of these or shut up about it.’ So I applied, and got it, and loved it.”

He goes on to explain, “Some get the fellowship and realize that policy is not for them. They don’t like the imprecision of it; the politics of it. We are there to provide science advice so that policy decisions are informed by science—but there are all sorts of things that go into policy decisions, all of them legitimate. Stakeholder interests; moral judgments,” etc. Many scientists end up unable to manage the mess, compromise and speed required of the fellowship’s policy work. But David loved it, and he stayed.

“For some of the issues I worked on, it really did make a difference to know the science. Like antimicrobial resistance, and later, bioterrorism; biodefense; stem cells; cloning; genetic nondiscrimination. All of these had a sizable science component and a sizable non-science component,” says David. “By the time I left, I was [HELP] staff director and I had responsibility for everything; not just the science-based things. And the Affordable Care Act was the biggest thing that anyone had ever worked on. That remains the case.”

The core Senate team that wrote the ACA was “surprisingly small,” as David tells it, comprising a few engaged senators and about 12 staffers from across the Senate’s HELP committee, the finance committee, the office of Senator Harry Reid (D-N.V.), and the White House. David’s first move was to rally a majority of HELP members to agree to the same thing, and then the finance committee had to create a “similar but different” bill of their own. 

“And then there was putting those together into a bill that could get 60 votes, which was exactly the number of Democrats we had, to move it to the floor,” David says. “And then it was finding something that would get 60 votes to move off the floor. And all of that was a process of, ‘Oh, Senator So-and-So has this objection to such-and-such. Either we have to explain it to them so that they’re fine with it, or we have to fiddle with it. If we fiddle with it, it drives up the score. Or it drives down the number of the uninsured. Well, we’ll have to do something else. And if we do that, the American Hospital Association will be mad and they’ll kick up with us, so we’re going to go talk to them…’”

Once all of this had been completed for one subsection of the bill, the team would go back to the drafting table, and return to the conflicted Senator So-and-So to run the adjustments by their team. 

All of that, David notes, “a zillion times a day.”

“I think one of the reasons that we succeeded,” he reflects, “is that people didn’t litigate issues in the press or through stakeholder groups.” David remembers a reporter who, as the bill became law, told the writers of the ACA with some combination of annoyance and awe, “‘You guys were a vault. People talked about the ACA, but none of you guys in the room ever talked to us.’” 

That was the only way to get it done, David still believes. By agreeing to keep the internal workings of the bill entirely out of the press, its writers created their own safe space to debate the good ideas and the bad ones, and work out complex politics and necessary compromises in private.

Senator Kennedy was “unusual in that he really used staff well,” David says. “There’s kind of an informal metric on the Hill of people who staff well. Some members are too insecure to have really talented people around them. Some are too abrasive and unpleasant to work for, so they don’t keep people. I would say that the most effective members, if you look at their staffs, you will find—particularly in key roles—that people have been with them for years, if not decades.”

The bargain that drove Kennedy’s ability to retain staffers was simple, David explains: “You got to have an enormously substantive impact on policy. In return, he wanted to make sure that he was always the best-prepared senator in any room he was in. And he did more, and pushed more.” David frequently tells friends that if the position of being Kennedy’s health policy director were still available, he would still hold it.

When Kennedy died of a brain tumor in 2009, David stayed on to see through the signing of the ACA the next year, and then moved into global health—a topic which had long interested him. He served as deputy director for global health policy and advocacy at the Gates Foundation, which he really enjoyed, and “a long, weird chain of events” there led him to do quite a bit of exciting work in Japan, executing a series of funding deals with the Japanese government.

After his time at the Gates Foundation, David spent two years as CEO of a smaller organization focused on minimizing malaria deaths worldwide, and later serving as a healthcare and life sciences consultant across two firms.

Now David is very happily back in the world of public health. He is working on a pandemic preparedness and response project, which is being supported by PAX sapiens, an organization committed to preventing catastrophes ranging from pandemics to nuclear war. 

“My psychological roots are in public service,” David says, “whether that’s through science or through policy. It’s nice to come back to that.”

Asked whether he believes that the US will be better prepared for its next pandemic as a result of COVID, David is uncertain. “I think we have learned health lessons as a result,” he says. But he also admits that the events of the past five years proved him wrong on a key question of vaccine uptake. 

“I worked on the National Vaccine Injury Compensation Program, and the question was always raised, pre-COVID, of why US vaccination rates are low,” David remembers. “My theory at the time was that it’s because we don’t see the diseases that are being prevented by vaccines… I thought that if there were ever a disease where we saw the impacts, vaccine skepticism would dramatically decline. In fact, events proved just the opposite.”

“You don’t hear a lot of, say, gravity skeptics, who think you can walk off a cliff and not fall. Or electricity skeptics. But there is a significant level of health skepticism and recourse to completely unproven—and sometimes dangerous—ways of addressing diseases,” he continues. “So to the extent that we haven’t conquered that, I don’t know that we will do any better.”

The science that can help mitigate the spread of disease now, David adds, is fantastic. During the COVID pandemic, he says, “We went from sequence to vaccine in about five minutes—through a technology, mRNA, that had been responsible for precisely zero effective vaccines ever before in its entire existence.” And it was highly effective, and altogether remarkable, in his view. “People talk about the ‘last mile problem’ of getting medical supplies that last mile into the village. A colleague of mine used the phrase, ‘last inch problem’: Getting the vaccination that last inch into someone. That’s where we failed.”

But that isn’t completely unsurprising for a species that, like ours, behaves irrationally, as David is also quick to note. “We all know that eating red meat, which I do with great glee, increases our chances of getting cancer and heart disease by a certain percent, but we’re like, ‘Oh, it won’t happen to me,’” says David. “And then the lottery comes out, and we have a 1 in 384 million chance of winning it, and we’re like, ‘I’m gonna buy a ticket, because I feel lucky!’” 

“When you think about it,” he says, “those are A) completely human, and B) nuts. It is an insane way of looking at the world,” David says, “but we have this bias toward optimism. And so we seem to have an incredible, willful amnesia about the pandemic. It’s like, ‘Well, we got through that. We’re all just not going to think about that ever again, because it was unpleasant. So, since it was unpleasant, it can’t happen again.’” 

At least we can take comfort in the fact that David Bowen is thinking about it—and working on it, tirelessly, as ever.