July 16, 2021
Dear Interested Readers,
Are Voting Rights Critical To Improving The Social Determinants Of Health?
These are tense times for me. I wish that I could just turn off the television, cancel all my newspaper and magazine subscriptions, give my computer to some worthy cause, and pass my time reading old books that I have always meant to read or in an even better use my time try to improve my rudimentary musical skills. It’s hard to admit that I am probably addicted to the struggle for some causes that will never see victory in my lifetime.
From the beginning of the “quality movement’ in the nineties through the passage of the ACA, I was convinced that we were riding a wave of enlightenment and commitment that would usher in a new day of healthcare equity as part of a noble movement that would finally give everyone the healthcare piece of “The American Promise.”
In March of 1965, shortly after John Lewis got his head bashed in on the Edmund Pettus Bridge on a “bloody Sunday” in Selma, Alabama prior to the passage of the Voting Rights Act of 1965 the following August that the Supreme Court has recently gutted this June, Lyndon Johnson addressed a joint session of Congress about the “American Promise.” He said:
Mr. Speaker, Mr. President, Members of the Congress:
I speak tonight for the dignity of man and the destiny of democracy.
…
At times history and fate meet at a single time in a single place to shape a turning point in man’s unending search for freedom. So it was at Lexington and Concord. So it was a century ago at Appomattox. So it was last week in Selma, Alabama.
There, long-suffering men and women peacefully protested the denial of their rights as Americans. Many were brutally assaulted. One good man, a man of God, was killed.
There is no cause for pride in what has happened in Selma. There is no cause for self-satisfaction in the long denial of equal rights of millions of Americans. But there is cause for hope and for faith in our democracy in what is happening here tonight.
For the cries of pain and the hymns and protests of oppressed people have summoned into convocation all the majesty of this great Government–the Government of the greatest Nation on earth.
Our mission is at once the oldest and the most basic of this country: to right wrong, to do justice, to serve man.
In our time we have come to live with moments of great crisis. Our lives have been marked with debate about great issues; issues of war and peace, issues of prosperity and depression. But rarely in any time does an issue lay bare the secret heart of America itself. Rarely are we met with a challenge, not to our growth or abundance, our welfare or our security, but rather to the values and the purposes and the meaning of our beloved Nation.
The issue of equal rights for American Negroes is such an issue. And should we defeat every enemy, should we double our wealth and conquer the stars, and still be unequal to this issue, then we will have failed as a people and as a nation.
…
This was the first nation in the history of the world to be founded with a purpose. The great phrases of that purpose still sound in every American heart, North and South: “All men are created equal”—“government by consent of the governed”—“give me liberty or give me death.” Well, those are not just clever words, or those are not just empty theories. In their name Americans have fought and died for two centuries, and tonight around the world they stand there as guardians of our liberty, risking their lives.
Those words are a promise to every citizen that he shall share in the dignity of man. This dignity cannot be found in a man’s possessions; it cannot be found in his power, or in his position. It really rests on his right to be treated as a man equal in opportunity to all others. It says that he shall share in freedom, he shall choose his leaders, educate his children, and provide for his family according to his ability and his merits as a human being.
To those who seek to avoid action by their National Government in their own communities; who want to and who seek to maintain purely local control over elections, the answer is simple:
Open your polling places to all your people.
Allow men and women to register and vote whatever the color of their skin.
Extend the rights of citizenship to every citizen of this land.
LBJ goes on from there to talk about his personal experience with prejudice and inequity as a teacher of Latinx children in a small Texas town in 1928. After LBJ signed the Voter Rights Act a few months later, the bipartisan coalition for civil rights that had existed between liberal Republicans and liberal Democrats began to fall apart and we began the long journey toward this moment of deeply divided government and the current Republican attempts to reinstitute substantial barriers to minority voting.
Most of us know that there are currently two voting bills that have been passed by the House that appear to be doomed in the Senate unless the filibuster is abolished. Since Joe Manchin of West Virginia and Krysten Sinema of Arizona seem disinclined to end the filibuster these two bills are probably dead. What many may not realize is how close the connection is between voting rights and the future of healthcare. Let me explain.
The current strategy of the Republicans against Biden’s efforts to achieve progress toward social justice and progress on our difficult issues like the environment and improved gun control as well as the revitalization of public support for education and better jobs has been threefold. First, a significant majority of Americans voice support for many of the plans for reform and improvement in the Democratic platform like more focused support for families, better programs of education at all levels, better gun control, and efforts to mitigate climate change. Biden’s agenda is a long and popular list that will transform America toward its stated ideals. Since Republicans realize that they can not win on a debate of these important issues, they want to change the conversation. To win they must introduce fear about an impending financial collapse, a concern among White Americans that crime is out of control and their way of life is endangered, and substitute the debate on the important issues of our time with a debate over cultural issues like “critical race theory” and the rights of the unborn. Second, they must stand together to block the passage of any significant social legislation by refusing any cooperation toward the resolution of critical issues in the bills while simultaneously espousing a false desire to be “bipartisan.” Thirdly, they must parlay the “big lie” into a process of faux “election reform” at the state level in many “red states.” That last tactic has the objective of making it hard for the large majority of minority voters who were essential to Biden’s narrow victory in places like Arizona and Georgia to vote in 2022 and 2024.
If most of Biden’s legislative agenda is blocked and elections are more difficult for minorities then there is an excellent chance that Republicans will take back the House in 2022 and perhaps the Senate in 2022 or 2024 and the presidency in 2024. Many Americans do not understand how legislation moves from being an idea, to becoming a bill, and for a very few bills, eventually becoming the law. They also do not understand how the combination of the electoral college, the disproportionate power of small states, and the filibuster all work together currently to make minority control of government a much more likely prospect than a bipartisan “Kum ba yah.” It is a reality that midterm elections are hard for the party of the president and that the electorate is fickle and will give the out-of-power party a chance at control if the president’s agenda fails. Analysis of President Biden’s legislative agenda reveals that it would initiate substantial improvement of many of the problems that cause the social inequities that create healthcare disparities. There are many items that Biden has proposed that Republicans claim to support, but these programs must fail to pass for Republicans to have a chance to regain power.
Biden surely recognizes the Republican strategy to defeat him and his agenda. Biden knows that the key to the maintenance of our democracy and continuing efforts to block the ascendancy of a powerful minority with a self-serving agenda is to defend the voting rights of minorities and to expand more convenient opportunities for minorities to vote. The president was clear about the danger to voting rights in his speech delivered at the National Constitution Center in Philadelphia this week. The Washington Post reported his words:
“This is a test of our time,” he said to a crowd of 300 civil rights advocates, top advisers, and local officials.
“Hear me clearly,” he added. “There’s an unfolding assault taking place in America today, an attempt to suppress and subvert the right to vote and fair and free elections. An assault on democracy, an assault on liberty, an assault on who we are.”
He urged Americans to channel their concern into action.
“We’re facing the most significant test of our democracy since the Civil War,” he said. “That’s not hyperbole. Since the Civil War — the Confederates back then never breached the Capitol as insurrectionists did on January the 6th. I’m not saying this to alarm you. I’m saying this because you should be alarmed.”
Biden also mounted a robust defense of the election that led to his presidency, one that Trump and his allies have repeatedly and falsely said was conducted fraudulently.
“With recount after recount after recount, court case after court case, the 2020 election was the most scrutinized ever,” Biden said. “The ‘big lie’ is just that: a big lie!”
I always check the Internet to see if other people share my concerns about an issue. When I typed in “voter rights and healthcare” or “voter rights and the social determinants of health” in various forms I came up with several articles that confirm my concern that any move to curtail voter rights is in fact a challenge to the social determinants of health and the future of equitable healthcare.
There is one review paper that uses comparative data from over forty studies done in the US, Canada, and Europe to address the question. You may enjoy checking out “Voting, health, and interventions in healthcare settings: a scoping review” by Chloe L. Brown, Danyaal Raza, and Andrew D. Pinto from the University of Toronto that was published in 2019. Their conclusion was:
This review has supported the association between voting and health. Communities marginalized by disability, mental and physical health, race, and age tend to be the most affected by the positive association between health and voting. Differences in voter participation related to health inequities can have some effect on overall electoral outcomes, shaping overall policy and possibly deepening healthcare inequities. Future research should study the long-term effects of voting on health, the effects of other forms of democratic engagement on health, and the impact healthcare practitioners can have on voting activity in their community through intervention and advocacy.
The American Journal of Family Practice published “Addressing Health Disparities Through Voter Engagement” by Nicholas Yagoda, MD in 2019. Dr. Yagoda articulated my concerns:
Finally, health organizations can promote voter protection by combating voter suppression techniques, including debunked myths of voter fraud.27 In collaboration with local nonpartisan community advocates, these health organizations can lobby against restrictive laws and practices that make it difficult to vote, such as voter ID laws, inflexible voting hours, polling place closures, voter registry purges, voter caging, and unfair voter challenges. Additionally, advocacy to eliminate gerrymandering, a practice utilized by both political parties to dilute the value of select votes, would promote the equitable impact of every voter.
The promotion of voter engagement among marginalized communities—people of color, low-income Americans, and people living with disabilities, among others—could increase equitable health policy and mitigate costly and preventable health disparities. By integrating voter engagement as a health equity strategy, nonprofit and private health organizations can help communities leverage health-promoting change through more representative government and more equitable health policy.
Finally, on July 6, last week, Physicians For a National Health Program (PNHP) published an opinion piece by Susan Rogers, MD a recently retired attending from Stroger Hospital of Cook County in Chicago (the recently renamed Cook County Hospital, one of the nation’s most famous DSH hospitals) who remains active as a volunteer at Stroger and as a force in PNHP. Her article directly addressed my concerns and is entitled “Voting Rights Are Health Care Rights: When politicians are no longer accountable to voters, they serve their most powerful and deep-pocketed donors, such as for-profit hospitals and the commercial health insurance and pharmaceutical industries.” Here are her powerful words:
Republican lawmakers in 43 states have introduced proposals that will severely limit Americans’ ability to vote, both in person and by mail. And last week’s Supreme Court ruling on Arizona’s voting rules opened the door for states to impose even more restrictions on voting. As a result, our most vulnerable neighbors—primarily low-income and people of color—will not be able to freely and fully exercise their constitutional right to vote.
As a physician who spent my career treating underserved communities, I know that when my patients lose their right to vote, they lose their right to the health care they need and deserve.
What do voting rights have to do with health care? In a free and functioning democracy, elected officials would implement health policies that are both popular and proven to best serve the needs of their constituents. But when politicians are no longer accountable to voters, they serve their most powerful and deep-pocketed donors, such as for-profit hospitals and the commercial health insurance and pharmaceutical industries.
When it comes to health care, the stakes couldn’t be higher. The U.S. spends $4 trillion per year on health care, almost twice as much as any other industrialized country, but we suffer from the worst performance on nearly every measurable health outcome, from life expectancy to maternal mortality. Thirty million Americans are uninsured, and an additional 40 million are underinsured. Nearly every family has a health care horror story: surprise bills, insurance company denials, medical bankruptcy, and—as I have seen much too frequently in my own practice—patients who delay treatment until it is too late.
Meanwhile, the industries that profit from our fractured health system are thriving: UnitedHealth Group, the nation’s largest insurer, reported 2020 profits of $15.4 billion; Cigna’s 2020 profits of $8.5 billion marked a staggering 66% increase over 2019.
Not surprisingly, Americans are outraged, and a majority of voters now support Medicare for All, which would improve Medicare’s benefits to also include necessary health services such as dental, vision, mental health, and reproductive care, and then expand coverage to everyone in the nation. Many studies, including a recent report from the Congressional Budget Office, show that Medicare for All could vastly improve our nation’s health outcomes while also decreasing overall health care costs.
If most voters want Medicare for All reform, why are we still trapped on the sinking ship of our fractured health system? Members of Congress (like all elected officials) respond to power, and political power comes in two forms: money and votes.
When it comes to money, the hospital, pharma, and insurance industries will always have ordinary people beat.
How can the average American compete, since these same industries have caused so much financial harm? Almost half of U.S. adults have skipped paying for essential items and bills so they could afford their medications, and nearly one in five skipped treatment for a health problem in the last year because of cost. The pandemic has pushed millions more Americans—particularly people of color—into poverty.
But, the one thing that every American should have, regardless of our income, zip code, or the color of our skin, is our vote. In an era of unprecedented corporate influence (the lobbying group America’s Health Insurance Plans spent nearly $4 million on lobbying so far this year), our vote is increasingly our only voice in the health care debate; our vote is the firewall that keeps health care from being entirely shaped by those that seek to profit from it.
Any attempt to restrict Americans’ ability to vote, particularly in communities of color, will result in worse health care and worse health outcomes for the most vulnerable.
My patients are desperate for equitable and universal coverage that can only be achieved with Medicare for All. But we won’t get real health care reform until we elect representatives that actually represent us. Health care will never be a right unless voting is a right—for all.
I will be figuratively holding my breath until there is a final conclusion to this important debate. If the forces that try to limit voter rights prevail, all is not lost, but the road gets much steeper and harder and the challenge will be to mobilize all caring voters using the sense of violation that the majority of Americans should share. We will need a force even more powerful than Georgia’s Stacy Abrams in every red state. Without the universal ability to vote, it is clear that health equity will likely remain a distant dream for a long, long time.
Cycles of Gloom, Sweat, and Enlightenment
There was a time when sunny days with low humidity and a light breeze were what I could expect on most summer days in New Hampshire. There would be an occasional summer that was a little chillier and wetter than normal. Rarely the summer would be hotter. This summer has been unique. We have had a few of those pristine days that once dominated the season. They seem to occur briefly as we cycle from chilly days with continuous gloom and drizzle to sweltering days with the killer combo of heat and humidity. A week ago it was mid-nineties one day and the next evening I built a fire in the fireplace to dispel the damp chill of the mid-forties. It is amazing how cold forty-five can feel in July.
I feel sorry for the unfortunate folks who live for months anticipating a week at the lake and then face the disappointment of a week of suboptimal weather. They joyfully anticipated a week full of swimming, boating, and hiking in the forest during the day and outdoor barbeques in the evening only to find that they are dodging downpours if they go out for a little shopping or sightseeing. All that is left for them to do as they watch their cherished week fade away while sitting in their Air B and B with their frustrated children is to play games like Mexican Train or Monopoly or do jigsaw puzzles while looking out the window at the fog, drizzle, and gloom while their children repeatedly say that they are bored.
I think we had a half good day last on Saturday last weekend. Each time I see the sun my hope is rekindled that maybe things will get back to normal, but then I realize that we are just passing through a sunny day as we cycle between gloom and sweat.
For several reasons, I recently decided to sell my RV. Perhaps the deciding factor was when I realized that the bad news was that I needed to pay a four-digit sum for tax and insurance for it to sit in my driveway until sometime in the late winter or early spring of 2022. There is so much going on in my life that a decent RV adventure was out of the question for many months. The other factor was that the current “Blue Book” value of my rig was about $20K more than I had paid for it. The fellow from whom I had bought the RV said that he had a very low inventory, and it would likely sell within two weeks. Fate and circumstances play a larger role in life than we sometimes want to admit.
I say all this to explain the header for this post. Monday was one of those days of gathering gloom in preparation for several days of downpour. As you can see from the picture, Mount Chocorua appears somewhat hazy. I took the picture from the side of the road near Conway, New Hampshire which is where I was headed to drop off the RV for sale. I wish that I had a wide-angle lens because for the spot where the picture was taken Chocura was to the far right of an expansive vista of the White Mountains. Despite the haze, I could see for miles and miles. Chocorua is the easternmost mountain in the Sandwich Range of the White Mountains. To me, with its distinctive bare rock conical peak, it looks like a “mini Mount Blanc.” One of my sons has climbed Chocorua as part of his multiyear childhood summertime New Hampshire sleepover camp experience. I always meant to climb this beautiful mountain but never took the time. It is a challenge even though it is only about 3,500 feet tall. Now that I have difficulty walking it is unlikely that I will ever look out from its peak. Too bad there is not a bike trail to the summit. I guess the lesson the mountain has taught me is that in real life to delay what you want to do can be the equivalent of permanently giving up the option. Now I must be content with occasionally viewing Chocorua from a distance.
Take a lesson from my experience. Gloomy days, sweaty weather, and the chance to do what you want can pass before you know it. The weather will always eventually get better even if only for a few days in the transition, but some options when gone may never be renewed. Don’t miss any Chocouras in your life. I hope that you will get out this summer whenever you can and take advantage of every chance for a great experience that comes your way. Don’t fall for the concept that you can “do it later.” That “later” may never come again.
Be well,
Gene
