October 18, 2024
Dear Interested Readers,
Thoughts While Trying To Manage My Anxiety Waiting For November 5th and What Might Follow a Tight Election
Until recently the healthcare implications of the election have been ignored by the candidates, the pundits, and the press. The lack of interest in the healthcare implications of this election other than the focus by the Democrats on women’s reproductive rights has been a concern for me as you probably know if you have read any of these notes over the last few months. I was delighted and encouraged by the fact that over the last few weeks, the New England Journal of Medicine has been publishing pieces about the healthcare implications of the 2024 elections. The October 17 edition has three more articles about the potential healthcare outcomes of the election and a long roundtable discussion.
I hope that you will explore the healthcare articles in this week’s New England Journal, but in this letter, I would like to discuss the editorial by Drew Altman in the Kaiser Family Fund (KFF) newsletter that was published this week. Altman is the long-time CEO of KFF and a very respected spokesman on healthcare policy issues. Altman writes a regular column entitled “Beyond the Data.” I am sorry that while I was complaining about the lack of press about the healthcare implications of the 2024 election I did not check out his opinion earlier. Click on “Beyond the Data” to access his recent writing.
Altman begins by stating the uncertainty about the election that is making me so ill at ease as we endure the final two and a half weeks before the election. He writes:
I have no idea what the outcome of this very close election will be. I do, however, have a fix on several of the ways health care played a role in the election and in campaign strategy. It won’t change much by election day.
Curiously, he used the past tense in that introduction. He wrote, “I do, however, have a fix on several of the ways health care played a role in the election and in campaign strategy.” It is as if it is mid-November, the election is over, and he is about to launch into an autopsy of the role of healthcare in the outcome. I guess that is why he finishes by saying that: “It won’t change much by election day.”
Whether healthcare drives a change in the apparent “too close to call” status of the election or not, I am still holding on to the hope that there will be a measurable late surge for Harris and Walz in the polls that will accurately predict a Harris victory. I understand the power of inflation in the minds of lower and middle-class voters. What I don’t understand is the persistent idea that life under Trump was more certain or will be more certain going forward than it would be with Harris as president,
I would say that inflation was low at the end of Trump’s first term despite his trade policy, tax policy, and foreign policy adventures while in office. Things felt better then because of the persistent power of the entrepreneurial spirit and work ethic of many Americans and not necessarily because of Trump’s policies. His tax policy and spending added trillions to the national debt, and his mismanagement of the early days of COVID created much of the necessity for the recovery spending that the Biden-Harris presidency needed to do to avoid the very slow recovery seen in Europe and Asia following the pandemic.
It is easy to argue that Trump’s immigration policies were also failures. The wall was not completed and fentanyl flowed north during his term. He never established an effective relationship to manage the problem with Mexico and never used anything but non-productive rhetoric to try to address the deeply rooted problems in Mexico, Central America, and South America that were driving millions of desperate people to flee north for their survival. His tactic of separating families was shameful and consistent with his lack of empathy for anyone, even those who shame themselves with their obsequious efforts to gain his favor.
My greatest dismay in the run-up to the election is not about Trump or his daily manifestations of a lack of fitness for office going back to 2016 when the “Access Hollywood” revelations failed to stick to him. What amazes me is his success in surviving all of his nonsensical language and despicable relationships with autocrats without any change in the evidence of devotion that he draws from his legions of devoted followers. He was more than right when he claimed that he could shoot someone on Fifth Avenue and not lose any voters. I am also appalled by the emergence of his unholy connection to Christian Nationalism and right-wing white supremacy and militant groups which to me seem like opposite sides to the same coin. He should be in jail and not on the campaign trail because of his efforts to overthrow the 2020 election and his instigation of the national tragedy of the January 6, 2021 insurrection.
My greatest confusion remains as to why people vote against their own best interests in terms of their personal finances and access to affordable healthcare. I know that the theories that explain this amazing fact relate to the fear of many white voters that they are about to become a minority and to the sense that many white blue-collar voters have that the coastal elites with progressive attitudes consider them to be a “basket of deplorables” which is an ill-advised descriptive statement that may have cost Hilary Clinton the 2016 election.
The gulf between the Democrats and white men without college educations seems greater than ever. What defies my understanding is why so many young African American men and Latinos seem to be moving toward Trump. Do they really think that he will ever do anything to improve their lives? I guess that like it or not I must accept the reality of these facts without much understandable logic because the moves and attitudes are real. Perhaps there is some variant of the Stockholm Syndrome that explains why populations that are likely to be injured by Trump’s lack of fitness for office are drawn to him. Substitute “Trump” for “captor ” in the description of Stockholm Syndrome found in Wikipedia:
There are four key components that characterize Stockholm syndrome:
- A hostage’s [Trump’s supporters] development of positive feelings towards the captor [Trump.]
- No previous relationship between hostage and captor. [The base that supports Trump probably rarely stays in his hotels or plays golf at his resorts.]
- A refusal by hostages [Think the “Proud Boys”] to cooperate with police and other government authorities.
- A hostage’s belief in the humanity of the captor, ceasing to perceive them as a threat, when the victim holds the same values as the aggressor.
- Physical and psychological effects
- Cognitive: confusion, blurred memory, delusion, and recurring flashbacks. [We have had a lot of flashbacks and crazy ideas about the election and January 6]
- Emotional: lack of feeling, fear, helplessness, hopelessness, aggression, depression, guilt, dependence on captor, and development of post-traumatic stress disorder (PTSD).
- Social: anxiety, irritability, cautiousness, and estrangement. [I wonder how Mitch McConnell feels these days.]
- Physical: increase in effects of pre-existing conditions; development of health conditions due to possible restriction from food, sleep, and exposure to outdoors. [Ted Cruz and many others had real problems before Trump took over in 2016.]
Perhaps my sense that Trump supporters have a variant of Stockholm Syndrome makes sense only to me, but this year there are even more distorted concepts that threaten to bring more support to Trump and those include the conflicts in Gaza, Lebanon, Ukraine, and the potential conflicts with Iran and China. I am particularly amazed by the self-defeating potential of voters who care deeply about the Palestinian cause and those who feel like J.D. Vance that we should stay out of the way of Putin and let him have his way with Ukraine.
I am distressed every day by the circumstances that have destroyed so many innocent lives in Gaza and Ukraine. We may be further than ever from the resolution of these conflicts, but do you think Trump has the answers? What makes anyone think that voting for Trump or a third-party candidate like Jill Stein will ever fix any of these very complex problems? Giving eastern Ukraine to Russia would set us up for future grief, and no serious student of the circumstances could ever imagine that a Trump presidency would bring relief and resolution to seventy-five years of frustrating Israeli-Palestinian conflict. Do those single-issue voters who think that they can improve the lives of anyone in Gaza by denying Kamala Harris of their vote think that Trump will call his buddy, Benjamin Netanyahu to task any more effectively than Jos Biden has been able to accomplish? If you do see any wisdom in the strategy of denying Harris your vote as a protest to support the cause of Palestinians, dream on and vote against your best interest and any chance of ever helping those who suffer in Gaza and the West Bank.
Getting back to Drew Altman’s editorial piece about healthcare concerns that flow from this election, he continues:
With no big health reform debate to command the attention of the nation and no big health proposal from either candidate, this is not a “health care election,” except, of course, for the impact abortion will have on voting and turnout, whatever the outcome on November 5.
Having said that healthcare is not a focused issue in the election, Altman is about to show us how it really should be. He contends that healthcare is just buried in the rhetoric of the election in ways that most voters don’t notice. He writes:
…But health care has played a role in the campaign and the election in the following significant ways.
First and foremost, voter concerns about their medical bills are an integral part of their worries about the economy and their costs, mixed in with general inflation and other pocketbook issues such as food, gas prices, and the rent or the mortgage. Most national polls continue to miss this, treating health care as a separate issue. When you treat health care as a stand-alone issue, it ranks as a fairly low priority. However, out-of-pocket health care costs and worries about unexpected medical bills are a big part of the public’s economic worries. Exit polls have made the same mistake. Determining the role health plays on voters’ decisions requires an extra question, which takes time that short polls often do not have. The question that needs to be asked is a variation on this follow-up: “You said the economy was your number one concern. What about the economy most worries you?” …
The cost of healthcare should be a concern to the thoughtful voter who is undecided because of the economy. I wonder how many of these undecided voters in “battleground states” realize that healthcare spending needs attention because it is a huge part of the economy that won’t get any positive attention from Trump. Increased personal healthcare expenses and a loss of coverage for many are most likely to occur with Trump in office. Altman continues with thoughts about why Trump doesn’t like to reveal or can’t reveal his healthcare strategies.
The advantage Vice President Harris and the Democrats have on health has also had an impact on former President Trump and his campaign strategy. He has generally backed off [talking about] plans to repeal the Affordable Care Act (ACA), saying various things, including recently that he has “concepts of a plan,” but mostly protesting that he now wants to “make the ACA better” with no specifics. He’s also pledged that he will not cut Medicare (no such pledge on Medicaid). And he backtracked on his earlier, more bullish positions on drug costs, going silent on his plan to tie drug costs in the U.S. to what other countries pay, apparently wanting to stay away from even popular health proposals. Overall, he has ceded health care to Harris, likely wary that she will get traction with criticisms that he would take health coverage away from millions and weaken protections for pre-existing conditions.
Altman’s explanation of why Trump doesn’t talk about healthcare makes sense to me as does his analysis about how Harris is focusing on the crazy ideas that Trump has about the benefits of tariffs and other issues rather than discussing healthcare. Trump wants to talk about the economy and immigration rather than saying much about how he would manage the healthcare policy concerns that will surely come up for whomever is elected president in November because he has no healthcare policies that will improve costs, equity, or access.
Harris has taken the opposite approach on the issue that Trump has about an equivalent advantage on—immigration—by taking the offensive to try to close the gap. And she has tried to do the same on the economy with some success, according to several recent polls. (Of course, positions taken in campaigns do not necessarily presage positions a candidate will take if elected.)
The sweeping proposals made by several conservative think tanks to fundamentally change Medicare, Medicaid, and the ACA have been swept under the rug by the Trump campaign, even as Democrats have had some success making Project 2025 a symbol of right-wing extremism. That doesn’t mean the candidate and his administration will not embrace some elements of these plans if elected or appoint some of their architects to high positions. It is, however, a notable element of the campaign, and an acknowledgment that these ideas are a target for Democrats and that Trump and his campaign know that many of them would be controversial and unpopular.
I am just as concerned about the election and its potential boon to the long-term career of J.D. Vance. The damage that he could inflict far into the future worries me as much as my near-term concerns about Trump’s fitness for office. Altman touches on Vance.
Senator JD Vance’s brief and somewhat vague foray into segmenting healthy and sick people into separate risk pools as an alternative to ACA protections for people with pre-existing conditions was treated by Trump almost the same way he treated the think tank plans: he ignored it. It was as if health had become radioactive for Trump, who campaigned on other issues, including immigration, which he saw as more favorable to him.
Altman believes that voters might be more concerned about healthcare in this election if they understood that healthcare costs, access deficiencies, poor attention to the priorities of patients, and lack of equity will all be greatly affected by the selection of the next president. The three NEJM articles in the October 17, 2024 edition of the Journal do consider these issues and are entitled:
- The U.S. Elections and Health Policy: Health, Coverage, Access, and the 2224 Elections
- The U.S. Elections and Health Policy: Affordability of Health Care in the United States—Old Problems Awaiting a New Administration
- The U.S. Elections and Health Policy: Health Equity in the 2024 U.S. Presidential Election.
I have closely read all three articles, and a discussion of them would require three letters. Time is of the essence, and I think that Altman makes many of the same points as the articles make, so I will leave the exploration of the articles in this week’s (October 17) New England Journal to you. Altman has more for us to consider. He continues:
Health might have been more of an important issue in the campaign if differences between the candidates and the parties on converting Medicare to a voucher-like, premium support plan, or Medicaid to a block grant to the states, were clarified for voters by the candidates themselves, the debate moderators, or the media generally. Debate moderators focused more on the ACA, likely because of the drama associated with Trump’s earlier attempts to repeal it. Had Trump been forced to choose between embracing or rejecting either of these big and controversial policy proposals, it would have elevated health in the campaign and might have been a flashpoint.
The Democratic left’s concern that Trump might be elected has led them to hold fire on pushing for the more expansive health reform proposals they favor, instead supporting President Biden’s more moderate, incremental policies, and subsequently, the proposals made by Vice President Harris. [All bolding is my doing for emphasis.]
So, Harris’s relative silence on healthcare issues is a strategic decision. It is one that I hope she will not eventually regret. Remember, that for anything positive to happen during her presidency if she is elected will require Democrats to retain the Senate which they may fail to do, and also regain the House which is much more likely. Having Democrats regain the House would be an effective foil against another Trump effort to steal the election since it will be the newly elected House that will oversee the certification of the election.
If the Senate and presidency fall to Republicans, a Democratic House could protect us from huge changes in the long and difficult journey toward the Triple Aim which will be stalled for at least four years. Altman continues with a focus on the possibility of a Harris win.
Should Harris prevail, expect the left to feel less constrained and to hear again about Medicare for All, the public option, Medicare Buy-In, and other policies favored by the left. Passage of legislation on these ideas, or others, is an entirely different matter, especially if Congress is divided.
Harris’s new proposal to add a home care benefit to Medicare may find favor with some elderly and near elderly voters, especially senior women or their family members. That’s one thing to watch as the voters go to the polls. The idea should be popular unless voters come to doubt that Harris can deliver. So far Harris has proposed popular benefits such as extending the $2,000 cap on out-of-pocket drug costs and the $35 monthly cap on Insulin to the private sector, and she has endorsed continuing the enhanced ACA subsidies. She has avoided proposals that would inflame the powerful health care industry, such as extending drug price negotiation to employer coverage.
Altman’s last paragraph is for me an understatement:
These are some of the ways in which health care and health care costs have played a role in the presidential campaign. It’s certainly true that health care has not been decisive in this election, but it has played a role, and always will.
The journey toward better healthcare has always been a fight between the contention that healthcare should be a “right” of all Americans, and the opposing idea that healthcare is a commodity that should be governed by market forces. I expect that this election is only a battle in the conflict of a wider and longer war that includes equity and the Social Determinants of Health. No matter who wins the election, the struggle and the “war” will continue, but this election will quickly make a great deal of difference in the lives and health of millions no matter who wins. I believe that the health of the nation will be greatly benefited by a Harris-Walz victory. I pray that if Trump and Vance win, we will be able to limit the losses ahead by regaining control of the House.
I guess that I will remain in a state of anxiety and potential dread over the next two and a half weeks. Who knows what lies in the future? The election is too close to call. How did we ever get to such a vulnerable place?
The Shortest Season
Perhaps, because the color of our fall foliage doesn’t last long, and to really enjoy it you need the dying leaves to be reflecting the light from a bright sun there can be some fall seasons that are disappointing. Usually, the peak color lasts just a few days, but on rare occasions, in good years, the peak can be extended to cover a couple of weekends. The fall that I look forward to each year is truly our shortest season. Once the leaves are down it is over, and we frequently have snow by Halloween.
Last weekend, the prediction of great leaf-peeping weather created exceptionally heavy traffic coming north into New Hampshire as my wife and I were joining a similar stream of cars and RVs heading north to Brunswick, Maine to watch my granddaughter’s volleyball team play Middlebury College on Friday evening and Williams College on Saturday afternoon. The weekend was a “leaf peeper’s” delight, but when last weekend came to an end and the traffic reversed to a river of cars flowing south, the beautiful trails of our White Mountains and Presidential Range in Northern New Hampshire were covered with litter left by the hoards of visitors whom I had seen invading from the south on Friday.
As the new week began the skies darkened, the temperature fell into the low forties that felt like the mid-thirties, and heavy rains came down upon us. After three days of intermittent heavy cloud cover, blustery wind that put white caps on the lake, and three inches of rain, the sky began to clear midweek and by Thursday there was dazzling color once again from the fall foliage. During one “tease” of a partially clear sky on Tuesday, I took the picture that you can see in today’s header. That moment of partial clearing occurred while I was doing some errands with my sister who is visiting from Georgia.
My sister and her husband have come up before to see our magnificent fall display only to be disappointed by coming a week too late or by having a heavy storm prematurely strip away most of the color. Most of the beauty of this year’s foliage seems to have survived our early week gloom. As I was writing yesterday there was not a cloud in the sky and the weatherman says we have a gorgeous weekend ahead of us with clear skies, bright sunshine, and temps into the sixties.
You can be sure that I will be out and about on my bicycle this weekend to see as much as I can see. I hope the color and clear skies will be available to me for a bit longer than usual this fall. It would be great if it could last until November 5th because my bike rides are one of the few ways other than writing to you that I have of diminishing my anxieties about what might happen no matter who wins the election.
Another joy this week has been how easy my recovery from my surgery last week has been. It is amazing that one week post-op from my left carpal tunnel release I can grip the handlebars of my bike and my Canadian crutches without the pain and numbness that was an instant reality before the surgery.
The care process and patient-centeredness of this most recent personal use of healthcare have been remarkably positive. The only evidence that the system and its workforce are under stress was that my nurse in the recovery room was a “traveling nurse” from Rutherford County, North Carolina where recent floods from Hurricane Helene caused so much trouble. [Click on the link to see a beautiful fall picture including Chimney Rock which is in Rutherford County.] Ironically, in the early 1900’s my great-grandfather was the only physician in Rutherford County.
The world and the leaves are constantly changing. The beauty of the fall is short-lived and the weather, as well as life, are uncertain. My mother had a little framed wisdom hanging from the wall in her kitchen. The plaque said, “Eat dessert first. Life in Uncertain.” Fall is our most uncertain and shortest season. Be sure to get out this weekend to enjoy the short display of fall before it quickly passes. I hope all the colors will give you some relief from any pre-election tension that you may have.
Be well,
Gene
