OP-ED

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

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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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Steven FindlayAlan_Pitt_M_D_Robert BowmanKeith BerndtsonJeff Goldsmith Recent comment authors
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Steven Findlay
Member
Steven Findlay

Great piece, Jeff. And good comments and dialogue. This political transition affords us the second opportunity in the past decade to air ideas to enhance public health and reform the insurance system. I completely concur that one thing we should NOT do is shift more risk (and cost) to consumers and families. We have pushed that as far as it should go given other trends such as middle class wage stagnation, etc.

Peter
Member
Peter

“I completely concur that one thing we should NOT do is shift more risk (and cost) to consumers and families.”

Yes, I look forward to Republicans finally reducing co-pays and deductibles, reducing premiums without reducing coverage, continuing the ACAs elimination of caps and keeping the pre-exist inclusion, providing a fairer subsidy for all income levels and getting rid of narrow networks.

It will be a refreshing change to the ACA.

Alan_Pitt_M_D_
Member

Jeff, Thank you for the interesting article. I agree with comments regarding the social determinants of care. America talks about Moon Shoots, winning the war on cancer etc, when what may be needed is a trip to the grocery store- better food and housing for the underserved. Other interviews with Trump voters have shown what they really want is to know there will be care and they won’t be bankrupted getting it. As a society, our addiction to the new and sexy- new treatments for cancer, transplants, orphan disease- tends to have a voice, pushing out things like mental health,… Read more »

Robert Bowman
Member

There is a teachable moment regarding the close relationship between health outcomes and the major factors that shape outcomes – the people and community factors and certainly not clinical interventions or digital clinical interventions. We live in a strange time where it is politically correct to talk about social determinants, situations, environments, and behaviors as the major determinants of health outcomes, but this is rarely integrated into studies or policy strategies. We have added trillions to health care costs without significant outcome improvements and declare value based to be important despite decades of moving the opposite from value and in… Read more »

Keith Berndtson
Member

It’s got less to do with population / voter demographics than what I would call the unexplained dynamics of chronic illness–something that our vaunted health care system is blind to–the effects of environmental exposures on chronic illness. Stop trying to analyze health problems from a partisan political perspective. Join with the physicians in the trenches who are evaluating and managing environmental effects on health and disease. From our standpoint, nobody’s listening to what we have to say and prove. But at the end of the day, when it comes to bottom lines and teachable moments, it’s about biological realities first.… Read more »

Keith Berndtson
Member

From Enron to Wells Fargo we’ve seen Gung Ho capitalism find ways to screw unsuspecting American consumers who are befuddled by health care rules, credit card policies and all manner of small print shackles. The smartest guys in the room on Wall Street will always find routes to obscene profits and bonuses. They can all pretend to be ethical when moral responsibilities are blurred by large organizational schemes and hard-to-trace communications. Trump told his hopeless rust belt constituencies what they needed to hear. That, plus an insipid Clinton campaign sealed the deal for change. Now his cabinet reflects income and… Read more »

Peter
Member
Peter

“Meanwhile, America is entering a period of identity crisis that may well drive citizens of all classes to drink, despair, and the deepest sense of hopelessness we’ve ever seen under the guise of making America great again.”

Legal marijuana is just in time. : >)

Keith Berndtson
Member

Yeah, or whatever the equivalent of Aldous Huxley’s “Soma” turns out to be. “Snow the beast” may be preferable “starve the beast” for the powers that be.

Peter
Member
Peter

“Believe it or not. this measure of health status predicted a remarkable 43% of the improvement of Trump’s vote percentage”

I think this article may reflect the reality for many of voting Trump and Republican.

http://www.cnn.com/2017/01/05/health/obamacare-florida-republican/index.html

It shows Americans want what they want with no cost to them.

Allan
Member
Allan

That is precisely the reason they ask for single payer. As soon as they are faced with the bill and the economic consequences they no longer want it.

I think Trump won because the economy is terrible for too many people plus Hillary had a lot of negatives such as corruption, lying and deception. Whoever released the emails did the American public a favor. They demonstrated that the DNI was corrupt and through deceptive means were not allowing their own people to choose the candidate of their choice.

Peter
Member
Peter

“That is precisely the reason they ask for single payer. As soon as they are faced with the bill and the economic consequences they no longer want it.” The bills will come either way – just less with SP. Ask the citizens of all other industrialized countries with some form of government run/regulated SP if they would prefer the U.S. costs and system – and yes, Trump too. “Hillary had a lot of negatives such as corruption, lying and deception” Russian fake news. By the way, have you been paying attention to all the Trump policy pullbacks? Seems WE are… Read more »

Allan
Member
Allan

“Ask the citizens of all other industrialized countries with”

Why not ask them if they prefer to speak German.

“The bills will come either way ”

True, but with the ACA they get both the bills and the lack of care. However, I must admit more people under this administration have Medicaid, food stamps etc. and for around a half a century Obama holds the record for the most Americans not participating in the labor force.

Peter
Member
Peter

“and the lack of care.”

How do you figure that? And before Obamacare how did these Americans get care?

“Obama holds the record for the most Americans not participating in the labor force.”

Politifact:

“Of the 101.7 million people who are not employed, 37.5 million are age 65 and over — an age when Medicare kicks in and many Americans head into retirement. Another 11.9 million are between 16 and 19, meaning they’re either high-school-age or starting college. And another 8 million are age 20 to 24, when many are in college or graduate school.”

“we rate it Mostly False”

Allan
Member
Allan

“And before Obamacare how did these Americans get care?” Their premiums weren’t as high, nor were their deductibles. Today, under Obamacare, most are essentially paying cash for their care. I am not saying that I was satisfied before Obamacare. Massive government involvement increased costs tremendously over the recent decades. In fact, one can see the prices rise in Medicare everytime government had a brilliant idea. Stop relying upon the mindless left wing responses and read what was said and then look up the number and compare it to the numbers in previous decades. It is around 94 million Americans that… Read more »

Peter
Member
Peter

“Their premiums weren’t as high, nor were their deductibles.”

Then why did they sign up for the ACA. They are only required to carry insurance, not sign up for Obamacare.

“Politifact tries to confuse people like you by providing all sorts of numbers”

Yes, like all Trump supporters the FACTS don’t mean anything and are just a liberal plot.

Allan
Member
Allan

Obamacare’s interference in the marketplace cost people their jobs and their insurance.That doesn’t mean that prior government intervention hasn’t also made things worse. It did. In fact things have gotton so bad that an intolerable amount of our GDP is spent on healthcare and the government is involved in all too much of it. “Yes, like all Trump supporters the FACTS don’t mean anything and are just a liberal plot.” Mindless soundbite. Not unusual. The problem with your argument is that these numbers are known and can be produced in black and white while you try with slight of hand… Read more »

Steve2
Member
Steve2

It is also a fact that people have looked at why these numbers are higher. We have many, many more people now dying from heart disease than we did in 1790. That is a FACT. Is that because our medical care is worse? Nope. (I trust you are bright enough to figure that one out.) So people have looked at the components of that 94 million, including population growth and the Boomer bulge retiring. (You are aware of that I hope?) They have looked at why that number is larger. Now, if you don’t care, just say so.

Steve

Allan
Member
Allan

Yes, they have looked and found a lot of things including more people leaving the labor force because they can’t find jobs and a lot of people ending up on all sorts of government programs, more than before. (I don’t want to expand the argument, but we should also be looking at the type of jobs and the number of hours worked.)

I note how you didn’t bother, other than say “they have looked” to show comparative numbers. Perhaps that is above your pay grade.

Your 1790 argument is rather lame probably due to being uninformed.

Peter
Member
Peter

Here’s some raw “under Obama” numbers for you Allan.

*The economy has added more than 9 million jobs, and the jobless rate has dropped to below the historical median.
*The number of long-term unemployed Americans has dropped by 614,000
*Corporate profits are up 166 percent; real weekly wages are up 3.4 percent.
*There are 15 million fewer people who lack health insurance.

Allan
Member
Allan

Take note how the numbers you produce don’t give any idea of whether things are better or worse. I will give only one example for this type of foolishness. If 90% of Americans were unemployed adding 9 million isn’t satisfactory if one is looking towards a normal unemployment rate. That is why one has to always look at the numerator and the denominator. 94 million aren’t participating in the labor force. That is higher than any other time over the past ~50 years. Take a look at the entire past 7plus years as people discussed the unemployment rate [U-3]. Then… Read more »

Jeff Goldsmith
Member
Jeff Goldsmith

I keep hearing the single payer thing from so many otherwise smart people it makes me wonder. What was the result of the Peoples’ Republic of California’s last ballot measure on single payer? 25% voted in favor? What did our friends in Vermont discover it would cost them? A 19% state sales tax? And who would have to actually draft the legislation: the Senate Finance Committee?? Come ON, Matthew. . . .Do we really trust OUR federal government to manage a $3.4 trillion economic activity when it has given us the VA and healthcare.gov?

Peter
Member
Peter

“What was the result of the Peoples’ Republic of California’s last ballot measure on single payer? 25% voted in favor?” That’s probably because most people get SUBSIDIZED insurance coverage through their employer. “What did our friends in Vermont discover it would cost them? A 19% state sales tax?” SP in of itself is not a fix to our high prices – which everyone seems to agree are too high, maybe even you Jeff. Unless SP also incorporates price controls it will not solve the cost problem. Germany uses price/cost controls in it’s system and has about an 11% GDP expenditure… Read more »

Jeff Goldsmith
Member
Jeff Goldsmith

Peter, the price controls are the rub, hence my reference to the Senate Finance Committee. Can you imagine the state of economic emergency that would be required in the US to put a $3.4 trillion industry in irons? We may be there someday but we’re not there yet. I’m not disputing that costs (read: incomes) are too high in the US. It is just that our culture is constitutionally incapable of reducing them. Germany is an orderly, highly unionized society. Price controls work great over there because of their conflict averse egalitarian culture. Why did Hillary lose in the Rust… Read more »

Peter
Member
Peter

“Because people thought, correctly, that the Democratic party she represented was coterminous with economic power in the US, that it was in the pockets of entrenched economic interests that would neuter any effort to restrict their incomes.” Jeff, I can’t believe you actually think that’s the truth. Look at Trump’s cabinet picks – are those the people not in control of the country’s economic power and influence? They’re the same Goldman Sachs that led the financial mortgage fraud. Those in control of our government ARE the same corporate individuals that send droves of lobbyists to DC to bribe and reward… Read more »

Jeff Goldsmith
Member
Jeff Goldsmith

Not defending outcome of this ugly, mean-spirited election. I am merely explaining why I think Hillary lost. Trump played brilliantly on the humiliation and class resentment of working class white voters. We can only pray that he does not transit the rest of the way to mob rule if he doesn’t get his way. My forecast is that a lot of Trump voters are going to be fairly pissed off to be forgotten yet again. By no means am I suggesting that the Republicans are going to rescue them from the moneyed interests in the US either. Both parties have… Read more »

Matthew Holt
Editor

The net result is that when they discover what they voted for (I guess, if they figure it out), the white working class are ripe for a Sanders type Democrat next time, with single payer as the likely result. If you look at the various complaints about the ACA from the Trump voting white working class, they’re all solved by Canadian style single payer. The health care industry should be petrified of this, given that Obamacare kept the private sector in business and handed it gobs of cash

BC
Member
BC

Jeff – very good read and I wonder if one could attribute poor economics to such. If one has less disposable income one is probably relegated to buying more processed food because it costs less. To the extent that many in the rust belt are hurting economically perhaps they suffer from depression and therefore drink more. The question is if such people had more disposable income would they change their lifestyles? No idea. I have no idea what the Republicans intend to do to make health care better and more affordable. I don’t think fixing HC is an easy undertaking… Read more »

Peter
Member
Peter
Allan
Member
Allan

“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. ”

The fact that this group voted for Trump demonstrates the likelihood that the failure in morality was of government and the left, not Trump. Along with a failure in morality, the government and the left failed to promote economic growth which is probably the basic reason for the Trump win.

Peter
Member
Peter

Given the economic mess Obama inherited from Bush Republicans and the lack of financial regulation, by what measure are you saying there was a failure to promote economic growth? Non-college whites sitting on their butts with little education and the health status given by Jeff cannot be rescued by anybody.

If Republicans were running on this economy they’d say it’s a success from negative growth around 2008/09 even with 10 years of less than 3% growth. The U.S. was knocked on it’s ass by the mortgage fraud recession – before Obama.

Allan
Member
Allan

“Given the economic mess Obama inherited from Bush ” Blaming Bush again? Eight years after the fact?. Along with the morality issue, the left can’t seem to accept any blame. Obama was a disaster with regard to the economy and though a few of his points regarding foreign policy had merit he was a disaster there as well. Obama is gone in a few days and he seems to be spending his last days making as much of a mess as he can along with spending the taxpayer’s money on travel. Understanding he will maintain a residence in DC I… Read more »

Steve2
Member
Steve2

Read Rogoff and Rinehart (sp?). After a major international banking crisis the historical norm is 5-8 years of slow growth.

Allan
Member
Allan

Yes, Steve2, one should read it. You are basing your response on your interpretation of Reinhart and Rogoff ‘s thesis and using it as your excuse to promote the belief that the Obama administration successfully managed the economy. Balderdash! The authors studied the world’s economies. The particular bit of argument you provide doesn’t necessarily apply to the United States where recessions tend to have faster recoveries than the rest of the world. Even Obama’s economic team didn’t believe your thesis of such a slow recovery and predicted much greater growth than we have seen. The basic underlying argument of Reinhart… Read more »

The_PPAL
Member

Allan, would be more open to debate if you were to be a bit more open about the possibility that the partisan divide was as much a drag on economics as any other variable that can be identified. And your initial comment was totally dismissive of the major point of the blog, which is that there is a link between economic stress and poor health. The years when this link was most manifest in inner cities led to the growth of social services and economic development programs. We can only hope that now that this is manifesting in the rural… Read more »

Allan
Member
Allan

PPAL I was unable to tell if you were criticizing me or someone else because of the comma, the pronoun use and the positioning of the reply. I also had a bit of difficulty understanding your points and their relationship to each other. My response below assumes constructive criticism. I wasn’t writing a brand new blog. I was answering a single statement and even quoted that statement so one would know exactly what I was talking about. Therefore, I don’t know how you can say I was “totally dismissive of the major point of the blog”. Of course I respond… Read more »

Steve2
Member
Steve2

Actually, we did have a faster recovery than most of the world.

Allan
Member
Allan

I don’t even know if that is true. However, it appears from Rogoff’s book that the US generally recovers faster, but this was a slow recovery. Obama did a terrible job and probably made things worse than they should have been leaving us with a debt that doubled in size.

BC
Member
BC

The lack of regulation on Wall Street has been bipartisan unfortunately and has a lot more to do with Congress and lobbying than any given president. Derivatives were never properly regulated, the tech boom of the late 90s was a Ponzi scheme (and I feel in violation of security laws), Glass-Steagall was repealed bipartisanly and the mortgage scam got going with the idea that everyone should own a home credit be damned (Freddie/Fannie would buy any piece of paper). Underlying all of this has been a huge govt. debt bubble. The 80s weren’t any better with LBOs and junk bonds.… Read more »

Peter
Member
Peter

“The lack of regulation on Wall Street has been bipartisan unfortunately”

That I will agree with. Both parties have been in the pockets of financial industry. But it was on Bush’s watch that it grew to disgusting levels. This was also the time of Tom Delay – “pay to play”. it was a feeding frenzy on Wall Street and who shows up on Trump’s team, millionaires and billionaires and that perennial link to Goldman Sacks.

I was angry Obama did not send anyone to jail, even the bankers were surprised..

Paul @ Pivot ConsultingLLC
Member

Re your statement that Republicans think the answer is to compel people to spend more of their own money: 1. That is what ObamaCare adopted…..the deductibles of ObamaCare plans are what I call Frankenstein deductibles….forcing people to spend as much as $10,000 of their own money before benefits get paid. And you may recall it was the Democrats who passed this. 2. I think it is more accurate to say many Republicans think an important element is for people to have a financial benefit from prudent health care consumption….creating consumer pressure on providers to provide good value (quality and price).… Read more »

William Palmer MD
Member
William Palmer MD

Good, Paul, on all points…especially giving patients the subsidy. And indemnity for all, Oh Yes–ie all claim money goes to patients first. They pass out this dough and can hassle the providers if the service was sub par. This causes delayed accounts receivables on providers books. Declare these book entries non-recourse loans to patients (providers can’t go after other assets); all this engenders everyone being very nice to one another. How can the left be against this? It is so egalitarian….unless it is bed with the Big providers–Big Insurers Industrial Complex? For heaven’s sakes, ALL the money comes from the… Read more »

Peter
Member
Peter

Paul, show me single plan private insurance coverage cheaper than Obamacare with less deductibles and no pre-exist exclusion – with the same risk factor group and coverage. These plans are PRIVATE INSURANCE RUN and they still complain they can’t make money. Obamacare stipulated the regulations and subsidy, it did not stipulate the premium.

Before Obamacare were these same people able to buy insurance at lower cost, lower deductibles, same coverage?

Paul @ Pivot ConsultingLLC
Member

Agreed, insurance companies are part of the problem…..the cost of claim processing should be around 7%….not the 12-15% they take now. ObamaCare made the cost situation worse by mandating that everyone have a Cadillac plan with all kinds of things covered and is an elaborate way to dramatically raise premiums on some in order to redistribute to others…..and it did next to nothing to rein in the insurers. We know the Republicans will try to fix the system by moving back toward market forces and empowerment of patients….we will see how they do.

William Palmer MD
Member
William Palmer MD

I don’t understand. The life expectancy at 65 was exactly the same in 2014 and 2015. So the added deaths must have occurred in younger age groups. But the added deaths only amounted to a tenth of a year of overall decreased life expectancy [sic!]; 78.9 in 2014 ==>78.8 in 2015 in one year, the impact all felt before the age of 65! Yet the mortality rate for heart disease was greater…..from 167.0 in 2014 to168.5 in 2015. Why isn’t this cardiac mortality rate affecting the life expectancy at 65? The numbers don’t make sense to me. It is hard… Read more »

Steve2
Member
Steve2

“comprised of diabetes prevalence, heavy alcohol consumption, lack of physical activity, obesity and life expectancy”

Add in smoking and you just described so many of our patients.