America’s Health and The 2016 Election: An Unexpected Connection


Donald Trump’s stunning upset victory has occasioned a lot of searching among political analysts for an underlying explanation for the unexpected turn in voter sentiment. Many point to Trump’s galvanizing support among white working class and middle income Americans in economically depressed regions of the US- particularly Appalachia and the upper middle west “Rust Belt” – as the main factor that put him in office.

While the Democrats concentrated on the so-called “coalition of the ascendant”- voter groups like Hispanics and Millennials that are growing, Trump rode to victory on a “coalition of the forgotten”- working class Americans in economically depressed regions of the U.S. who had been left behind by the economic expansion of the past seven years.

When the Economist searched for a more powerful predictor of the Trump victory than white non-college status, they found a surprise winner: a composite measure of poor health (comprised of diabetes prevalence, heavy alcohol consumption, lack of physical activity, obesity and life expectancy). Believe it or not. this measure of health status predicted a remarkable 43% of the improvement of Trump’s vote percentage compared with the 2012 Republican candidate Mitt Romney, compared to 41% for white/non-college.

A month after the election, the Centers for Disease Control released its 2015 morbidity and mortality trends in the US.  The CDC Report showed that  Americans’ life expectancy actually declined for the first time in 22 years. Except for cancer where we saw continued progress, death rates rose for eight out of the ten leading causes of death, most sharply for Alzheimer’s Disease.  The decline in life expectancy was confined entirely to the under 65 population!

Though the obesity epidemic almost certainly bears some responsibility, other social factors may be at work.   Last fall (2015), Nobel Laureate Angus Deaton and his wife, Anne Case, found that the death rates for white Americans aged 45-54- Donald Trump’s electoral base-  had risen 11% from the 1998 through 2014, with the rise sharply concentrated among those with a high school degree or less.  This rise contrasted with steady improvement in death rates for blacks and Hispanic Americans.

According to Deaton and Case, the main drivers of the sharp fall in life expectancy among middle aged whites were:  overdoses of drugs and alcohol, which almost quadrupled, suicides, which increased by 60%, and deaths from chronic liver disease and cirrhosis, which rose by a third. If the improvements in health status experienced in the previous fifteen years had continued from 1998-2014, there would have been nearly one half million fewer deaths in this group!  The toll from this unwelcome trend was comparable to that of the US HIV epidemic.

In plainer words, white Americans in mid-life are basically killing themselves, either directly or with destructive personal habits, and in sufficient numbers to affect overall life expectancy in the country.     It is not challenging to link the despair of older voters to de-industrialization and the economic hammering many Americans took in the 2008 recession, and thus  to Trump’s surprise victory. 

About half of American households aged over 55 have no retirement savings.   http://www.gao.gov/assets/680/670153.pdf   As a direct result of the crash, millions of older Americans lost the home equity they were counting on as a retirement cushion in the wave of foreclosures and job losses.  A remarkable 86 million American households have, effectively, no spendable assets, and their asset position has actually declined in the past seven years.   

How strategically crucial to these voters was Trump’s unconventional (for a Republican, at least) promise not to cut Social Security or Medicare, since tens of millions of hard pressed baby boomers will be completely dependent on these programs in their seventies and eighties.  Trump would have lost the election if he had followed traditional Republican policy dogma and pledged to “reform” these two safety net programs.   

How the Trump Administration’s emerging health agenda will play with his core constituency of “forgotten” white middle aged voters  remains to be seen.  Trump spent little time or energy of his “high concept” campaign on health policy issues, beyond his promise to repeal ObamaCare and replace it with something “terrific”(which wags have inevitably dubbed “TerrifiCare”).

However, Congressional Republicans have long believed that the key reason for high health costs is the absence of incentives for patients to be effective “consumers” of health care. The traditional Republican formula for curing healthcare’s ills has been to compel people, including the poor and elderly, to spend more of their own money on health services.

This long standing Republican health policy principle effectively blames our nation’s health problems on moral failure by patients, and, by direct linkage, on Trump’s core constituency. I suspect there are more than a few Republicans who believe that if everyone had health savings accounts, people would take better care of themselves and there would be less obesity, alcoholism and depression, fewer suicides and overdoses, etc. 

In my view, this utilitarian view of what creates health is insulting to patients, and gives short shrift to the effects of long neglected social determinants- lack of jobs, food insecurity and poor nutrition, homelessness, unsafe neighborhoods, etc. – on health status. 

It will be an early clue about whether fiscal concerns driven by Republican economic dogma or actual health concerns drive Trump’s health agenda if mental health and substance abuse treatment coverage somehow magically disappear from the redefined benefit package of the ACA replacement, or if forcing millions of hurting Trump voters to pay more for their health coverage is the ultimate outcome. In light of the circumstances, there is nothing “non-core” about mental health and substance abuse treatment.

In my view, it is going to take more than the “right incentives” and a surge of healthcare consumerism to alleviate the despair which drove Trump’s surprise election victory.  It is easy to understand why despairing white non-college Americans found Trump’s slogan “Make America Great Again” compelling.  If the forgotten Americans who elected Trump President are forgotten yet again in his sweeping remake of US health policy, not only will we have collectively failed as a society but Trump’s remarkable remaking of the American political landscape will prove short lived.    

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