‘Boy, I think these elections will change everything for the better. I am sure things will get better.’
Heads nodded all around. I overheard this comment from a group of men sitting on the couch at a community centre soup kitchen where I help serve a monthly dinner. These men and many families get daily meals at increasingly burdened food pantries all over town. Their opinions could serve as a metaphor for what happened in the US in the mid-term elections.
In their rage against collective economic distress, unemployed and working-class people voted for a bunch of millionaires. In an ostensible criticism of ‘career politicians’ they voted out some of the most independent members of congress, including our State Senator Feingold, the only one to vote against the Patriot Act which was a blueprint for suspending civil liberties. By buying the idea of taxes and the federal deficit as a problem, voters seemed willing to threaten public services like schools, transportation, and safety that keep them and their communities operational. The public didn't seem to mind that some candidates often got a little confused when describing the constitution (like whether there is a separation of church and state which is in Article One), or that the Republicans continue to demand tax cuts for the enormously rich. As one of my friends put it, it is part of the American psyche that everyone, including the guys on the couch at the soup kitchen, is convinced that some day they, too, will be millionaires so they don't want to do anything that might keep them from enjoying the money when they do. The electorate just wanted to engage in collective fist-shaking.
A favourite cartoon, by Booth, shows a rumpled man sitting with his evening paper, yelling at his anxious dog ‘What the hell is happening?? Do YOU know what the hell is happening?’ I have no idea what the hell is happening and neither does anyone else, if they are honest with themselves – which would exclude politicians.
One explanation for the elections of 2010 is that the country is suffering from a case of recurring transient global amnesia. We forget that every poll since the early 1980s has showed a majority of citizens wanting a radical overhaul of health care and unhappiness with the status quo. In March 2010, with the Affordable Care Act, we got what was politically possible and it is not trivial. Every economist in the country acknowledges that healthcare costs are crippling our economy and will continue to do so without serious changes. Most doctors, in contrast, are members of the flat earth society.
What the most regressive election in decades means for health care is even less sure. Whatever metaphor one chooses, the health reform train has left the station and is picking up speed. There are many very good people in place in the major government–appointed positions. Thousands of officials are working to set up the infrastructure to support broadening access to insurance, are beginning to use government programmes to look at unnecessary costs, are trying to apply evidence and science to clinical choices, and are uncovering fraud and mismanagement of epic proportions in the insurance and drug industries. Technology, such as electronic health records and regional clinical data compilations, is being mobilised to support the effort. This is a train not easily derailed or slowed down. And the more Americans find that the changes are actually benefiting them, the less opposition there is likely to be. Even after the election, polls of voters found a majority thinking that the healthcare changes are about right or don't go far enough. Only a very loud 10% want it rejected.1 I remember when Medicare was passed in the mid 60s and opposed as socialism, most vocally of course by doctors, only to see it become an untouchable icon of government care and the largest single source of income for doctors in this country.
If healthcare reform is rolled back, politicians who used to rant about ‘death panels’ will be forced to publicly declare which Americans don't deserve health care or are marginally useful to their grand plans to cut spending – the unemployed, the undocumented, the uninsurable, or simply the ‘unenlightened’ who won't believe that cutting social services, education, and health care for families and children will not hurt anyone.
Even before the passing of the health reform legislation, everyone seemed to understand that family doctors really are at the core of any rational approach to turning healthcare reform legislation, everyone seemed to understand that family doctors really are at the core of any rational approach to turning healthcare costs around and ensuring quality. Serious health policy people explain that unless we change the workforce dramatically, we are in big trouble. Newspapers all around the country, even The Wall Street Journal, make the case for increasing the supply of family doctors.2 Harvard Medical School, which abruptly ended support for its Division of Primary Care in July 2009, got religion a year later (with help from a $30 million anonymous ‘gift’) and started a ‘Center for Primary Care.’
But even the meagre provisions in the new law to support primary care education, research, or reorganisation are threatened by budget cuts. Like praying for rain in the US Great Plains in the dustbowl of the 1930s, everyone is praying for a renaissance of interest in family medicine by students, but none is coming. US Medical schools continue to graduate pathetically small numbers of students interested in family medicine (1184/16 500 in 2010)3 and will oppose changes in admissions policies without substantial political and economic pressure.
More than ever, money, not moral persuasion, talks and there is little money for medical schools in primary care. Most students have been patronised by a consultant or specialty trainee and been told that they are much too smart to be a family doctor. Some students actually believe that looking at black and white negatives day after day takes more intelligence than managing complex biopsychosocial problems in unpredictable human beings. For the moment, the majority of family doctors finishing training in the US still graduate from medical schools in other countries.
Policy analysts believe that a national service programme required of all new doctors combined with credit for student loans would be the most effective way to quickly move a workforce in the direction it needs to go. But requiring anyone in this country to do anything, especially if it is for the common good, has not been a popular position. ‘I have mine, you go get yours’ seems to have replaced ‘E pluribus Unum’ on the dollar.
The big question is whether this global amnesia about recent past events will be transitory or permanent. When libraries close, school ‘days’ are shortened to 3 hours, and streets remain unplowed in winter, while millionaires read their e-books, send their kids to private schools and hire an immigrant to plow their driveways, will folks be jarred to their senses about the logic of ‘balancing the budget’ on the backs of the non-millionaires in the country? When the 30 million people who will be insured through the Affordable Care Act in the next 4 years face a 2-year waiting list to sign up for a family doctor, will politicians demand that medical education become accountable? Will government and private insurance change reimbursement from production and throughput to population-based care? Will the people of the country, one day, clear their heads, look around and say ‘what in the world were we thinking?!!’
Contrary to the ubiquitous Churchill quote about Americans finally doing the right thing after trying everything else, Americans finally did the right thing in passing the Affordable Care Act, but the newly-elected congress seems committed to trying to undo it. Churchill appears to finally have gotten it wrong.
- © British Journal of General Practice, 2011