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Why Trump Won? A Brief Tutorial for Harvard Medical Students

Mike Milligan, a Harvard medical student, recently wrote in THCB about the shock felt throughout his medical school upon the election of Donald Trump.  Seeking to understand how it may be that ‘equality, service and compassion’ were defeated, Mike settles on the narrative that appears to have taken hold of the elites on the left – Trump did not really win, Hilary lost.  While he does not say so in explicit terms, clearly we are to understand that the recent election was lost, and that in order to assure a better outcome the next election, physicians should urge their patients, and particularly their ‘poorer and less educated patients’ to register to vote.   Hopefully, these voters can then ensure that access to ‘affordable, high-quality medical care’ through constructs like Obamacare and MACRA are nevermore placed in jeopardy.

What complete hogwash.

Let me start with the factually incorrect parts.

Mike writes that ‘Mr. Trump received fewer votes in victory than the previous two republican nominees garnered in defeat.’  As of today Donald Trump has received 62.2 million votes out of a total of 126.6 million votes cast.  Mitt Romney received 60.9 million votes out of a total of 126.8 million votes, and John Mccain received 59.9 million votes out of a total of 129.4 million votes cast.  So despite the fact that his opponent raised and spent close to 1 billion dollars on ads promising the literal apocalypse if Trump was elected, no republican candidate in history garnered more popular votes than Donald Trump.  While it is true that nearly half of all Americans did not cast a ballot in this election, 3 million more votes were cast in 2016 than were cast in 2012.  The percentage of eligible voters casting their vote in 2012 was 55%.  The percentage of voters casting their vote in 2016?  Also 55%.  I realize the desire to deligitimize Trump by arguing this was a low turnout election that delivers no mandate is a very strong one among the millions on the losing side.  Unfortunately, wishes and reality sometimes find themselves in conflict.

The real story of the election is that the Donald Trump managed to flip the rust belt states of Michigan, Wisconsin and Pennsylvania by convincing blue-collar, mostly white voters that his party was now the “workers’ party”.  Traditionally blue strongholds of towns like Erie, Luzerne, and Northampton counties in Pennsylvania turned red in 2016. A Republican hasn’t won Erie County since 1984!  Obama won this county  by 16 percentage points in 2012 – Trump won this same county by 2 percentage points.  Statewide, Trump performed better than Romney in 58/67 counties while Clinton performed worse than Obama in 65 counties.  So it is absolutely true that Clinton performed worse than Obama, but not to focus on the story of the overperformance by Trump is to be willfully blind.

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As to the implication that it was the least educated sitting at home that sunk Mrs. Clinton, data would argue the opposite.  The poorly educated did vote, and by a wide margin chose Trump.  Pre-election polling showed Trump with a 30-percentage point advantage among whites without a college degree – he ended up winning them by 40 points.  Indeed, one of the single best predictors identified in counties that swung to Trump is the percentage of non-college whites.  The greater the percentage of non-college educated whites in your county, the greater the chance of Trump emerging victorious.

The only metric found to be even more predictive than your race and education?  Poor health. You are reading that correctly.  In an analysis done by the Economist , a weighted index of obesity, diabetes, heavy drinking, physical exercise, and life expectancy performed even better than race and education level in predicting counties that moved to Trump.  The poorer your health, the more likely you were to vote for Trump.

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A wonderful interactive version of the graph can be found here.

Apparently, those who stood the most to gain from affordable, high quality health care were also most likely to choose the candidate who called for repeal of Obamacare.  It is safe to say that this was a stunning repudiation.  To a great many who had voted for the promise of Obamacare, the reality of high premiums, penalties, and narrow networks left a bitter taste.  And so it came to be that those uneducated and in poor health – the losers in this economy – chose the candidate who promised change over the candidate whose campaign slogan was grabbed from the recent Lego movie – “Everything is Awesome”. What a complete shock.

There are many story lines that underlie Hilary Clinton’s defeat.  She was clearly unable to animate and connect with her base in the way Barack Obama did – but if this is the major narrative rocking liberals to sleep in these cold dark times, I would advise the overworked mental health specialists dealing with the trauma of a Trump election on college campuses to pace themselves for eight years of inconsolable sobbing.

Anish Koka is a cardiologist in Pennsylvania.

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  1. “you and other doctors complain loudly about how government and insurers make their lives more complicated” …” we’re trying to blame the doctor Give me a break.”

    Barry, of course you are trying to blame the doctor. Insurance should be the patients, not the physicians. Your policies have mandated that physicians do all sorts of things in order to practice medicine. You want physicians to pay more attention to you yet you also like electronic records and want the physician to study up on how much a procedure will cost you even if you are covered by insurance. You want a whole bunch of other things as well.

    Physicians are there to help and guide you not be your mama. Let the patient decide what type of insurance he desires if any and let the patient deal with the insurer. Don’t force the doctor to do that. If the patient wants a doctor to find one that prefers to spend time on non essentials rather than the essentials then let the patient find a doctor that is willing.

    If the state has a job it’s to make sure physicians are doing what they are contracting out to do and that they follow the law. It is very simple so I am not going to give you a break.

    “If they can’t do it, who can?” What you are looking for is an opinion by one that has a reasonable amount of experience in the field. Each patient has their own set of values so I don’t think one opinion will hold for all. But If you still feel you need such an opinion to help you determine a quality physician hire me by the hour and I will help you out. 🙂

    I will repeat what I have told you before and Anish told you again on this thread. The first idea is to get rid of the bad physician or at least convert bad to good. As I told you before we used to be able to do some of that years ago in physician hospital committees, but government rules and regulations ended those committees at least where I am.

    Remember the best physician in one thing can be the worst in another and the best physician in an area can still make bad decisions while the worst can make great ones.

  2. Anish – I can appreciate the challenges in measuring quality. For me personally, it is most important when it comes to surgical procedures though risk adjustment is a challenge there. We wouldn’t want to see surgeons pass on the higher risk cases because the risk adjustment measurement is lousy and will make his numbers look bad if he tackles to many of those.

    Primary care is about 80% of the practice for the NYC based cardiologist I’ve been seeing since 1999. I think he’s absolutely fabulous for both cardiology and primary care. He seems to know everything, is cost conscious, has a great referral network and explains things very clearly. He’s going to be hard to replace when he retires in a few years. The personal chemistry between us is also excellent which I think is important for an ongoing doctor-patient relationship that spans many years. For a surgeon, by contrast, once he does the surgical procedure I may never see him again after the follow-up visit. Personal chemistry doesn’t have to be great and I can even tolerate some arrogance as long as he’s really good at surgery.

    I would like to have either good outcome data ahead of time or a referral from a doctor that I have good reason to trust. I always wondered, though, how primary care doctors and specialists build their referral networks and how they determine who is good enough to refer their patients to and who isn’t and how accurate is word of mouth reputation. Also, when doctors themselves need to see another doctor in a patient capacity, how do they decide who to go to?

  3. I’m pretty heavily involved with education for Np’s. Care to guess how many hours of clinical training per week they have to get and for how long? Does it matter if during that clinical training the mentor is a doctor or an NP?

  4. Anish — NP’s and PA’s have education and training requirements that they must complete before they get their license. I’ve been treated by a number of NP’s over the years for primary care issues and in conjunction with workups in a hospital prior to a procedure like angiography. I’ve been well satisfied with all of them.

    Some years ago, I attended a panel discussion at the University of Pennsylvania sponsored by its School of Nursing. One of the panel participants claimed that NP’s could competently handle roughly 85% of the encounters that a primary care doctor typically sees. Hopefully, they will recognize when something is beyond their expertise.

  5. And Barry, I’m curious what training do you feel a nurse needs before becoming a ‘practitioner’? What would make you comfortable as a patient?

  6. Peter- this is a matter of faith. I can’t convince you that most of us have a good heart and are just trying to do what’s best for the patient while still trying to do what’s best for our families. I think it would be unreasonable to expect us as a group not to have any desires for ourselves and our families when it comes to control over our lives when it comes to time, autonomy and income. Clearly your experience have left you quite jaundiced with us and its unfortunate. Unlike you, I think the answer does lie in the Niran-agba’s of the world.

    Barry- I recognize that you are annoyed by my usual and many attempts to highlight what’s wrong with the current system without a solution. I honestly am not sure of what the right answer is. I realize you’re looking for someway to measure quality to deal with the asymmetry of information inherent in healthcare. And I don’t have a good answer for you. I think the recent experience would teach us the pitfalls of trying to measure quality. The answer for some (For you) clearly is that we just need a better way to measure quality. But I’m not so sure that we can be measured and quartered as you so desire. My first focus would be on trying to deal with our bad outliers. And I don’t even know how best to approach that. Quality is a very personal thing to measure anyway. Some patients hate my approach, others love it. There are variation of care – but not all variations are bad. I may, for instance, think a particular PFO doesn’t need to be closed. Another cardiologist may disagree. Who is correct? Its easy to spot gross negligence and that is frequently featured in the WSJ/nytimes.. the rest is really challenging, even for folks that do it all the time.

  7. The alternative is to just guess at why people voted. Correlation, causation, we know the drill.

  8. Uwe Reinhardt wrote in the past that healthcare quality has four components that need to be weighted in some appropriate way and also risk adjusted for differences in patient frailty, number of co-morbidities, socio-economic status, social support at home, etc.

    The four factors are (1) Process — following evidence based guidelines where they exist and deviating from them when appropriate, (2) Outcomes — did the patient recover, improve, was he cured, etc., (3) Safety — avoiding infections and other harm, and (4) Satisfaction which can include such tangential issues as the availability of valet parking at the hospital, flat screen TV, decent food, pleasant and competent nurses and the like.

    I’ve been told that in primary care, most patients evaluate doctors based on the three A’s — affability (bedside manner), availability (can get an appointment quickly) and last and least, ability (diagnostic and communication skills). The last one would be the most important to me.

  9. First you and other doctors complain loudly about how government and insurers make their lives more complicated and make the healthcare system more expensive than it needs to be. Then when someone suggests that maybe doctors who have the most expertise on the subject should suggest how to define and measure quality, we’re trying to blame the doctor. Give me a break.

    How do they define quality when they’re the patient? How are patients supposed to make an informed choice among providers if there is no consensus definition of what quality looks like in healthcare or how to measure it? I don’t know how doctors can do this. They’re the experts. If they can’t do it, who can?

  10. “I think they could do more to offer constructive ideas about how to define and measure quality of care in the various healthcare specialties including primary care.”

    Why don’t you tell us how doctors can do this?

    Is this another way of blaming the doctor.?

  11. Peter — Anish is a cardiologist. I think you would be hard pressed to find a cardiologist who could sustain a viable practice without participating in Medicare as heart disease is especially prevalent among the older population.

    Anish — With all due respect, I note that physicians have a very long history spanning decades of trying to stifle competition at every turn including more recently, opposing allowing NP’s to practice at the top of their license and to staff retail store clinics without direct supervision by a physician.

    While I can empathize with the frustration that doctors feel regarding some of the government mandates around electronic records, especially the new MACRA rules, I think they could do more to offer constructive ideas about how to define and measure quality of care in the various healthcare specialties including primary care.

    What comes across to patients in this debate is that doctors just want to be left alone to do the best they can for the patient in front of them and to have their bills paid promptly and without question. With so much of the healthcare bill now being paid by taxpayers and healthcare costs continuing to grow faster than the economy, I think the docs need to play a bigger and more direct role in finding solutions to the healthcare cost problem.

  12. ” Physicians are simply responding to the current state of affairs, that doesn’t work to give high quality care at a cost point that makes sense for patients/physicians.”

    I find most docs are “ideologically” bias for themselves. They just want to be left alone to practice (and charge) the way they see fit while getting checks from the government and insurance. Doctors are not the solution to lower care, increase access, and increase quality.

    But there is a way to accomplish this if they think that’s the solution – go cash and get off the grid. You’ll reduce your overhead, charge what you want, reduce your paperwork, and spend as much time with patients as you want.

  13. I don’t think most practicing physicians are ideologically married to any one philosophy. Physicians are simply responding to the current state of affairs, that doesn’t work to give high quality care at a cost point that makes sense for patients/physicians. The get the feds out mentality comes from years of bludgeoning physicians with beyond idiotic mandates from the center. There is clearly a balance between too much disconnected/meaningless control from far away bureacrats and leaving local communities to implement ‘segregation’. I speak for the vast majority of physicians when I emphasize that it is our goal to ensure all patients have access to high quality care. Our disagreements colored by recent experiences, make many practicing physicians wary of command and control hierarchies. The goal for all of us is the same – the debate is simply (or not so simply) how to get there.

  14. Barry, I doubt true libertarians want any government involvement in “social” programs, state or otherwise. They probably feel states should have the right to segregation.

    If we let the states handle health care alone think how bad it would be in Mississippi – in which it is already bad. Libertarians would just say the poor there could migrate to a better state – wouldn’t MS be happy then.

    Either we’re a UNION or we are not – even though I know the south is still fighting the civil war and federally imposed civil rights.

  15. Peter — If the free market / libertarian types had their way, Medicaid would be completely a state program with no federal involvement. That way, states that don’t care about their poor people could just opt to provide nothing at all to them in the way of health insurance and will recommend that they try to find ad hoc charity to help them instead. While that may be exactly the wrong thing to do, states, according to these folks, should have the right to do the wrong thing if they want to without interference from the feds. Personally, I think everyone should have insurance with help from subsidies for those who can’t afford the full premium and don’t have access to employer provided health insurance..

  16. I’m not a fan of Medicaid, reimbursement or other, but right now it is all some people can get, especially those who can’t afford Obamacare even with subsidies. Do any of your patients use Obamacare, or do you refuse them too on ideological grounds? How are independent contractors going to fund it with no government funding? Where is the magic money going to come from?

    And you think the paltry 10% that states would have to pay is too much to help those unable to afford medical care. Do states have any responsibility to provide for their citizens, or is this just another, “get the federal government out of my back yard, until I want money from the federal government”?

    So you think turning people away from medical access is better than everything else? Did those “hugs” include crocodile tears?

    And until the promised land of prosperity for everyone comes true under Trump and Republicans what will people who need help do?

  17. My state refused the bait-and-switch Medicaid funds. That’s a debacle that isn’t reported in your liberal MSM Valhalla—
    http://www.americanthinker.com/articles/2016/01/medicaid_expansion__bait_and_switch.html
    I refuse Medicaid because I’m a doctor not a pen pusher. If I take $2.69 for a 99213 office visit I will go bankrupt and then there will be zero doctor in my rural area.
    All the government has to “do” is sit down and shut up– get out of the way and go away. Let independent contractors do their thing, businesses get back to growth and hiring, and entrepreneurs take their dreams up to reality.

  18. Maybe you could tell us how many of your patients got insurance through Obamacare with a subsidy and through Medicaid? How jobs and economic “prosperity” left your the area?

    And how you want the government to bring back those jobs to the area, or even create new jobs?

  19. Wonderful piece. I know I haven’t gotten so many hugs the week after Trump’s election by my patients. They are sick and tired of being lied to, massaged, manipulated, jobs lost, Obamacare lies, heroin allover the place, and the fierce debates on who gets to use what bathroom. It’s such nonsense, Trump is the one who spoke to my patients’ angst and grief. I am a physician, considered as educated by some (!) , and I had to vote for Trump, a change in direction is needed. We see reality every day in our offices and the debacle of the past 8 years–maybe past 25 years– had to stop. I humbly suggest to the Harvard med students that they take a roadtrip into the heart of America. I’ll bet it’s more foreign to them than Harare. Listen and see what the people of this country have suffered by decades of neglect, “we know better than you, go find another job”. Witness the dead and dying towns, the loss of generations of talent and prosperity.

    I would suggest that the unhealthy are also the unemployed, the poorest and most desperate souls I’ve encountered. They don’t want a handout. They want jobs, and their pride. When you have pride in yourself, you just might pass on the Twinkies, scotch and cigarettes. You just might eat better and be more engaged in your health.

    He won, fair and free elections, get over it, and get back to work.

  20. You are always blaming someone else.

    The Democrats passed the ACA so fast it was never completed nor was the document well written from a legal standpoint. The Democrats did that because they were about to lose total control by one vote. That demonstrated the nature of their mission which was as partisan as can be on an issue that personally involves every single American.

    I hope Trump looks for some bipartisan action with regard to any legislation that has the impact of the ACA which caused a lot of misery to an awful lot of people.

    “I said there was no legislation”

    You blamed Bush at one time, but as President he doesn’t have the power to legislate (though Obama had a telephone and a pen and thought that power was his.). You should know that. He did have a plan, however, and that is something you should recognize.

    I refer you to the NY Public Library or even grade school libraries so you can brush up on the powers of the executive branch.

  21. “but the ACA was passed without one Republican vote”

    Thank Mitch McConnell for that. Early work by some Republicans in the Senate actually included some of their provisions – like a mandate, but they were eventually strong armed by McConnell to vigorously opposing the bill.

    Nothing was going to appease Repugs as they were playing pure politics.

    I wonder if your opinion on exclusive passing of bills will hold in the Trump regime.

    “On another posting I believe you said GWB didn’t have any healthcare policy suggestions. He did.”

    I said there was no legislation, except for PartD. Suggestions aren’t legislation.

    I can link you to the NY Public Library if you like.

  22. You blame Republicans from the House and Senate, but the ACA was passed without one Republican vote, unfinished, in a hurry and based upon bribes to many that ended up supporting the bill.

    According to our founders, the legislature was supposed to hold more power than the executive in domestic affairs. No such all encompassing bill affecting all American should have been passed exclusively by one party. That type of legislation ensures instability if there is a role reversal. It represents poor management and is stupid.

    On another posting I believe you said GWB didn’t have any healthcare policy suggestions. He did.

  23. Your comment is a bit unintelligible, but tells us where you come from, sloganland. Hate is what you harbor in your rhetoric and you portray it ignorantly.

  24. This from Harold Pollock- Chicago prof, health care guy – 12k followers on twitter- “Remarkable moment: Trump enters office w/striking control over three branches of fed gov+equally striking lack of public legitimacy+mandate.”

  25. “There are not that many ways to look at a loss, particularly a close one. Either view point is valid since one is analyzing the performance of two separate teams. Democrats will tell themselves that they lost because of certain failures and the Republican will tell themselves that they won because they were simply better. These two perspectives can and do exist in the same universe. They are not mutually exclusive. Unless the loss is clearly lop sided, the argument cannot be settled.”

    Agree here- I took issue with the prior posts narrative that ‘this wasn’t actually democracy since no one voted’, and ‘Trump won fewer votes than the last 2 losing republicans.’ As I acknowledge in my last paragraph there are many storylines – Hilary was unable to energize her base. I don’t think there is one reason why hilary lost, just as there is no one reason why your soccer team loses. My point was that folks shouldn’t ignore the very important story line of why formerly blue counties, some who were most likely to benefit from obamacare voted for trump.

  26. “If is unfortunate health care is so partisan. The post isn’t meant to be a republican railing against democrats.”

    But that’s what this country has come to and Trump’s victory set this path for future elections. Republicans now know demagoguery works. This is a terrible turn in this country.

    Democrats didn’t want to own Obamacare, but the party of NO would not participate in it’s creation. We’ve never heard “fixit”, “improve it” from Republicans, all we’ve heard is repel it. Republicans even challenged the mild mandate, the provision that was needed to offset guarantee issue. Mitch McConnell took a political decision to block Obama at every turn – what did he learn from this election – compromise works?

    Years ago Christine Todd Whitman wrote; “It’s My Party Too” on the swing Republicans took to the extreme and their purge of moderates fueled by rabid evangelicals. Recent Tea Party success has cemented that extreme. George Will has even left the Republican Party.

    How much “getting together” do you think Trump will promote on “fixing” health care when he needs a Republican Congress to actually write the bills.

    If we want to repel Obamacare, and still cover those who can only buy on the individual market, then we need to mandate that every employer must provide health coverage. How else are we going to include low wage workers in a plan they can afford.

  27. Thanks Niran. I hear you. To help you understand my perspective, I grew up in an 800 or so square foot post World War II bungalow in a family of five with two bedrooms and one bathroom. My wife grew up in a small row house in Philadelphia. For the last 43 years we live in a house of slightly more than 1700 square feet even though we are well off now and could easily afford far more but it works for us especially since we only have one child and he is long since on his own. I just don’t have a lot of patience for people who think they are entitled to an upper middle class lifestyle on a factory wage or office staff salary.

  28. I have played enough amateur soccer games to notice a recurring theme: “we lost to a crapy team. If we had played the way usually do, we would have easily won”.

    There are not that many ways to look at a loss, particularly a close one. Either view point is valid since one is analyzing the performance of two separate teams. Democrats will tell themselves that they lost because of certain failures and the Republican will tell themselves that they won because they were simply better. These two perspectives can and do exist in the same universe. They are not mutually exclusive. Unless the loss is clearly lop sided, the argument cannot be settled.

    Even if the correlation between poor health and likelihood to vote for Trump is more than just a coincidence or a marker of some other factor, I think it is a stretch to suggest that this was a repudiation of Obamacare. Which part of it is one actually repudiating?

    Even if that were true, is Trump the solution to their poor health? The patient may be correct about the symptoms she is experiencing, but it does not mean she has the correct diagnosis or the right treatment.

    There is no doubt that healthcare is bankrupting the American working and middle class and we (health care related professionals) are part of it. The increases in cost particularly in light of stagnating incomes are not sustainable. The fact that Obamacare did not die the early death that other health reform attempts suffered is a testament to this fact. Unfortunately not all the players are on the same page and are bent on beating each other at the expense of a large section of the American electorate.

    Whatever plan the Republicans and Trump come up with now will not improve the lot of the working american if we just reshuffle the current players and call it The Great American Heath Care Act and eliminate the effective parts of Obamacare in the name of change.

  29. Barry- Insightful thoughts, as usual. You are correct about my part-time hours. However, I am in a two income household. Combining my husbands income with an MBA and my “part-time” income should be equal or better than one physician earner many years ago. My larger point is that there still is a generational slide.
    For example, I had my own room and grew up in a 4000 square foot home. I have two children to a room in my home with 2200 sq. feet. Now I’m not complaining rather using this to illustrate my point. We are comfortable, not living above our means, and it is closer to a working class lifestyle than it was 30 years ago. A double income household (both adults with graduate level educations) cannot achieve what one single physician did only a generation (or two) ago.

  30. Thx Niran. The first stage of grief is Denial, followed by anger…the final stage is acceptance. I got frustrated waiting for folks to get through the first 2 stages. Consider this an attempt to make sure our colleagues don’t get stuck in the denial stage :). With regards to the generational slide you’re talking about, I think you’re right, though I keep seeing these darn medscape articles with impressive average salaries. Especially in the world of primary care, these numbers seem removed from reality. Here’s hoping meaningful positive change actually is on the horizon.

  31. If is unfortunate health care is so partisan. The post isn’t meant to be a republican railing against democrats. The election for many people in healthcare was a way of sending a message to the establishment that the current path we were on was bad for patients/physicians/national wallet. I’m concerned that the message isn’t quite getting to where it needs to go if the folks who make policy take the attitude that they were actually on the right path..and that the recent election somehow validates the prior path. The current path just doesn’t work for a lot of people, and while its possible the unwashed masses are just too dumb to know better, I would suggest keeping an open mind to folks like your brother in law who want health insurance for their families as much as you do, but still want money left over at the end of the year to go on vacation. Ito doesn’t take a high IQ/a high education/ or Ivy league degrees to value high cost, low quality health insurance.

    As for the word ‘elite’ – I do refer to the liberal elite here – only because they have been in charge for the last 8 years. If Trumpcare falls flat and we find ourselves in an even worse situation in 4 years, I’ll be railing against the republican ‘elite’.

  32. Read this in my in box – why did I know it was you Allan.
    Trumpland – where hate and ignorance are popular again.

  33. The word elite is tied to the Liberal becasue most elitists are Liberal as is the media. As far as your claims go, they are hogwash. The hate and intolerance is coming mostly from the left. Take note of the way the left buses in protesters and uses violence. (I use the term leftists rather than Democrats because I don’t believe a lot of Democrats agree with the left’s way of protesting.) I won’t bother with the rest of your claims that are mostly nonesense.

  34. So how do you separate the message of hate and intolerance that Trump fanned to his supporters, as well as their – “put the stick in their eye” view of politicians, from the other issues?

    Just because a voter knows to vote “HIS” interest does not mean that’s the intelligent vote.

    For the record the people who foughtfor/supported higher wages, gender equality, support for the poor, education, unions, universal health care, etc. etc. have been largely Democrats.

    When Republicans had both houses during GW Bush they did squat for health care for the masses, except the drug giveaway of Med Part D – after they were embarrassed by seniors busing to Canada.

    I suspect many who did not like Obamacare did not like being made to buy insurance – any insurance (like my brother-in-law), since their economic situation (un/low education) means they can’t plan much.

    And why is the word “elite” always tied to the word “liberal”? More hate. If being educated and economically successful makes you elite, then even Republicans are in that category.

  35. High taxes on cigarettes, alcohol and, more recently, sugary soft drinks push people in the right direction. If we want less smoking, alcohol and soda consumption, high taxes on those specific items make sense from both an economic as well as a healthcare and health insurance perspective.

  36. I think in many regards the road to hell is paved with good intentions. Companies in the vertical, public or private, have to answer to their shareholders. So whether it’s Pharma or say a device/equipment OEM the CEO is in trouble if he/she doesn’t hit earnings.

    If you look at unhealthy behavior such as diet, lack of exercise, etc.it’s not easy to change behavior nationally, but also any company selling product that enables an unhealthy lifestyle is going to lobby against change. Same goes for Sallie Mae and universities where it costs $40-70k per annum for undergraduate and med school.

    I’m sure that costs can be lessened in our current system; however, ultimately I think real savings will come via competition and more cost efficient technology. If nanobots or other can reduce the cost of a $100k operation and treatment down to say $20k then HC would become a lot more affordable. And I think and hope we will start to see some companies in Silicon Valley and elsewhere make such a reality.

  37. All great points. I do hate identity politics as well, but that may mean I have stop railing against ‘elites’ :). As many other commenters have pointed out on other posts of mine, it is much easier to find fault then it is to come up with good solutions. Solutions involve somebody giving, and among hospitals, insurers, physicians, and patients…no one wants to budge. We can start, though, by getting a better sense of the problem. We won’t get anywhere if we don’t agree with where the problems lie.

  38. Anish – nicely written. The economic recovery of the past 8 years has largely been to the upper middle class and wealthy, which is quite contrary to rhetoric of “hey we’re gonna nail the one percent.” There was also a lot of chatter about income inequality, which has only increased.

    After 8 years of such promises with no delivery it’s not surprising Trump won. I’d agree it was the rust belt that delivered the election to Trump and again I’d say it’s economics in general not just health care. While Wisconsin, Michigan and Pennsylvania certainly tipped the election one should not lose sight of Ohio either.

    As it pertains to health care, no denial for pre-existing conditions was a great step forward and I said a very humanitarian one as well. The failure of ACA was not to modify it when it became clear that there were problems with cost and narrow networks. I’m not suggesting this is easy, but people do vote with their pocketbooks.

    The truth for many with health care insurance is that if it’s not good one does not have access to high quality health care as the best doctors and hospitals won’t take it due to low reimbursements. Add to this many cannot or struggle to afford the premiums and of course the other issue is many cannot afford the deductibles. HC is a major line item in a lot of households.

    Wherever we go from here I do not think fixing HC is an easy issue. Given the advent of much more tech and pharma over the past 30-40 years it simply costs more.

    On a side note, I do not think identity politics work that well particularly the endless referencing of “uneducated voters.” The implication is they are simpletons that do not know what is best for them. Education and intelligence are not the same thing and not everyone has the same access to opportunity. This being said “uneducated voters” are not stupid and they voted for change.

    The current trend economically seems to be towards city states in the Valley, NYC, etc. This will not work economically speaking over the long term. If our society is going to continue to advance we must take care of everyone.

  39. Niran — I assume your mother’s father and your own father worked full time while you’ve said in the past that you choose to work part-time. Doesn’t that have a considerable impact on potential earning power?

    Separately, it seems that lifestyle expectations are much higher today than they were 50 years ago. What passed for middle class housing when I was growing up would be considered close to poverty level today. People just expect a lot more in terms of everything from the size of their home and the amenities within it to having two or three cars instead of one to being able to take a nice vacation out of the country to wall to wall scheduled activities for their children all of which cost money including, often, private lessons for one thing or another. Then they complain that they can’t make ends meet. Maybe the middle class squeeze has more to do with inflated expectations than stagnant wages.

    That said working class folks who lost their jobs due to automation and globalization really are worse off financially than their parents and other relatives who were able to spend their working lives doing good paying factory work that came with comprehensive benefits including excellent health insurance and defined benefit pension plans. That’s where Trump’s appeal probably resonated the most.

  40. And should we believe post election polling after this election? The economist data which is provided with a link is a fascinating signal. Counties swinging to trump were most likely to benefit from the promise of Obamacare. You think exit polling data is stronger than that?

  41. Anish, this is a most excellent post. I read the other one, and agree it is hogwash.

    There is a lot of self-soothing going on because many disappointed “intellectual elites” still cannot believe what happened. They remain in denial which is a far cry from acceptance.

    We should remind them there are roughly 30 million people without healthcare coverage in this country. Those numbers might have increased anyway as paying the penalty may be better than the exorbitant premiums now being levied on working Americans, and even on physicians in small communities across America.

    While many of us are college educated whites, we have slowly become members of the working class over the last 8 years. The standard of living in which my mother was raised as one of 8 children with a GP father and the one in which I was raised as one of four children, with a pediatrician father, is considerably better than the one in which I am raising my own four children. There was to be no end in sight without some sort of meaningful change.

  42. ” It is safe to say that this was a stunning repudiation.”

    Not necessarily. You need to see after election data to see how many of those voted on health care as an issue. The exit polls I have seen showed that health care was not considered one of the 4 most important issues. Polls actually tended to show that this was not so much an issues election as a change election. If you have polls/data showing otherwise, please share.

    As to trauma, Meh. Trump may have been the worst candidate in my lifetime, but Clinton was the second worst, and I certainly understood how you could see her as worse. We were basically screwed either way. Don’t see anything worth getting upset over, though I don’t quite understand the fanboy mindset for those touting Trump (and same for Clinton though there didn’t seem to be many of those).

    http://abcnews.go.com/Politics/election-2016-national-exit-poll-results-analysis/story?id=43368675

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