One of the more endearing Saturday morning cartoon shows of my generation was The Rocky and Bullwinkle Show in which a segment was devoted to a short film starring Dudley Do-Right of the Canadian Mounties. Dudley was forever coming to the rescue of his girlfriend, Nell, who would be abducted and tied to the railroad tracks by the sinister arch villain Snidely K Whiplash, whose handlebar moustache and black top hat and cape marked him as a bad guy. Snidely’s frustration at being out-foxed by the inept and clueless Dudley came at the end of each segment as he shook his fist and uttered the bad guy regret: Curses! Foiled again!!
Well, Snidely K Whiplash (AKA Mitt Romney and the Republican Party) was foiled again in last year’s elections and the president was neither inept nor clueless. One clear analysis of the election is that the Obama motto ‘Forward’ (which happens, ironically, to be the State motto of Wisconsin which, for a change moved forward by electing our first woman senator, who happens to be gay, by a much larger margin than anyone predicted) is ringing true, particularly for the Affordable Care Act (ACA) which will move forward. Universal health care will, eventually, become a reality.
GEOGRAPHY AND HEALTH DISPARITIES
One of the many electoral ironies is that, in general, the states that voted solidly Republican are the ones with the largest burden of health inequalities. The US maps with data on health issues such as obesity,1 chronic diseases such as diabetes,2 and social determinants such as poverty (http://visualeconsite.s3.amazonaws.com/wp-content/uploads/percent_in_poverty.gif), unemployment (http://www.bls.gov/web/laus/mstrtcr1.gif), and social capital (http://nercrd.psu.edu/social_capital/index.html) can almost be superimposed on the final electoral map.3 Some states that supported the president and the Democrats despite poor health and social indices were driven into the president’s column by Latino voters (Nevada, New Mexico, Florida, and Colorado) and others are beginning to close the current gap even in (gasp!) Texas where the percentage of Latinos and African–Americans will be almost a majority by the next election.4
Since the election, the flat-earth Republicans in Congress resemble more and more the Wicked Witch of the West as they continue to pound the table and scream vile things about the Constitution and balancing the budget as they melt away to nothing. On the other hand, the rational Republicans, still an endangered species, are furiously backpedalling to help immigration reform and are having deathbed conversions about same-sex marriage. Some Republican governors are sneaking around to the back door and agreeing to accept ACA funding for expanded care for the poor because they realise that a lot of money will be left on the table.
Other governors are willing to sacrifice their constituents and their budgets on the basis of the ‘principle’ of refusing any funds (except tax breaks and subsidies for farmers, manufacturing, and banks) from the federal government. There is a pun in there somewhere about ‘principle versus principal’ but I will leave that to you.
ECONOMICS VERSUS POLITICS
While the run-up to both the enactment of the legislation itself and the Supreme Court decision about the constitutionality of the law was featured in the political sections of newspapers, the implementation phase is being acted out on the business pages. The people who want to get the ACA to start working for large numbers of the uninsured are in the financing trenches, finding that the complexities of a 1000-page law have often created problems rather than solved them. Regulations in a country with economic, geographic, cultural, and health system diversity (some may say ‘confusion’) like almost no other in the world are bound to be a bad fit for many states. New Mexico, where we live part of the year, has a population that is 60% Latino and Native American, with a population density equal to that of Kazakhstan, in a geography the size of Poland; in contrast to New Jersey, which has the population that is 74% white and a density of the Netherlands in a geography comparable to Slovenia.
The ACA train has been out of the station for a while now, such that by 1 October all the states, either on their own or managed by the federal government, will have pools of insurance products that are required to have a great deal of transparency for all Americans to choose from for health insurance coverage. The feeling in the air is less and less ‘whether’ and more and more ‘how’. Some effects are beginning to be felt, such that many states are beginning to see a decrease in insurance premium costs and that is likely to make the flat-earth Republicans almost apoplectic.5
As we welcomed a new group of medical students in their postgraduate training in family medicine, I always remind them that the world of medical care in this country will be theirs to make. Although my generation was committed to getting universal coverage and a more rational system, many of us will be out of the game before the real thing finally begins in March 2014. Right now, I feel like a World Cup fan whose team is up by a goal in injury time. I am counting the seconds until it is over.
- © British Journal of General Practice 2013