Elections always have consequences. The midterm elections in the US were not solely a referendum on the xenophobic, misogynistic, and hateful rhetoric of President Trump and the inability of his flimflam appointees to dismantle most of the progressive reforms of the Obama administration. The election results, somewhat surprisingly, were also driven by the increasing value Americans are putting on the Affordable Care Act (still, unfortunately, referred to as Obamacare) and the reliance that 20 million Americans have developed on it for securing affordable insurance.
PICKING UP SPEED
The cry of ‘Repeal Obamacare’ has changed over time to ‘Fix Obamacare’ and the door has been opened to serious discussion about methods to achieve universal coverage, advocated in the US since before the First World War but defeated repeatedly. The two relatively easy-to-understand government-funded or subsidised insurance programmes — Medicaid for individuals on low incomes and families, and Medicare for everyone over the age of 65 years, are being used by Democrats as examples of how expansion of either or both of those programmes might move the country towards the goal of universal coverage. For the first time, a majority (56%) of Americans want the government to ensure healthcare coverage.1 And no one is pounding the table decrying ‘socialised medicine’!
During the most divisive, hateful, and uncivil period in the modern era, the ACA, the most consequential progressive social reform since the 1960s, is gaining voter support. This might seem oxymoronic. It isn’t. Business writer Jim Collins used the idea of a flywheel as guidance to companies and social organisations trying to move from good to great.2 He writes how an initial huge effort overcomes the inertia and begins the flywheel turning, and constant pressure over a long period of time will move it faster and increase momentum. The ACA — Obamacare — is a flywheel, now in its ninth year, and is picking up speed rather than slowing down.
FEMALE VOTERS HOLD THE KEY
Why is support for the ACA growing all across the country with Trump as president? One major factor is women. Women voters truly understand and appreciate the need for reliable health care for themselves and their families. Women are the ‘deciders’ for their family’s health insurance and the increasing percentage of single working mothers have seen real benefits from the ACA. The election saw a large swing in women voting for Democrats and health care was their biggest concern.
Second, more families are depending on it. Poor and underemployed families have come to rely on the expansion of Medicaid for coverage. More states, regardless of their politics, have used the ACA guidelines to expand Medicaid to include the working poor in addition to women on low incomes and children. Part-time workers in the ‘gig economy’ with no health insurance benefits can also receive subsidised coverage. Everyone loves Medicare, and, as 0 000 baby boomers become eligible each day, any threats to decrease coverage or increase fees threaten to mobilise millions of outraged older people who see it as one of the few safety net programmes for them.
OPIOID OVERDOSES
Finally, the opioid crisis. Overdose deaths and opioid use disorders are increasing dramatically since the turn of the 21st century and are overpowering community resources and primary care clinicians.3 Fortunately, the ACA mandated mental health parity just in time to include treatment programmes for substance misuse and addiction. Currently close to 50% of patients being treated for opioid addiction treatment receive Medicaid.4 The majority of patients with opioid use disorders are white and live in more rural and small-town communities. An article in 2017 found that US counties with greater than average opioid use voted 60% Republican in the last presidential election compared with counties with lowest opioid use, which voted less than 40% Republican (includes some very revealing maps).5 Why, exactly, voters who live in the poorest, most disadvantaged communities in the country supported a party and a candidate that threatened to take away what little health care they had will be the stuff for political science and sociology dissertations for decades to come. But voters in Republican counties now know that, without the ACA or expanded Medicaid to help with treatment, their communities would feel even more hopeless. The narrowing gap in the midterms is evidence that perhaps people are beginning to understand that the government is not the enemy, particularly when people are losing family, neighbours, and friends daily to overdose deaths.
SAPPING THE SPIRITS OF DOCTORS
Organised medicine and the primary care groups in particular have been stalwarts against the effort to diminish or undermine the ACA. Before the 2016 presidential election (I use the phrase in the same way as one might say ‘before the Plague Years’) reform was moving to increase funding for primary care and change the method of payment for health care from fee-for-service to a more risk-adjusted capitation. The election stopped reform in its tracks. Meanwhile, the increasing burdens of ‘value-based care’ with its constant addition of yet more screening and management tasks and electronic documentation without any increased help to carry it off have been sapping the spirits of both younger and older family doctors. The primary care dysphoria is genuine.
MEDICAL SCHOOLS
From a workforce perspective, medical schools and academic health centres refuse to be socially accountable for guiding students towards careers in primary care that would be needed if the country ever achieved a system of universal coverage, claiming that medical students should be free to do whatever they want (that attitude reminds me of an old Tom Lehrer song containing the line ‘once they go up, who cares where they come down. It’s not my department says Wernher Von Braun’).
The $16.3 billion that the government spent supporting graduate medical education in 2017 has not addressed the deficiency of primary care physicians and has resulted in an overproduction of medical and surgical subspecialists. Any business with a similar return on investment would fire its leadership, replace its board of directors, and demand results that customers want. Evidently not the federal government. The Association of American Medical Colleges, in the meantime, is asking for ‘more study,’ which is an old strategy for ignoring a report and hoping it just goes away.
However, there is a danger that Trump might find out and use the money to build a wall to keep out doctors from other countries.
- © British Journal of General Practice 2019
REFERENCES
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