June 7, 2024
Dear Interested Readers,
Political Dermanents of Health
I have written many letters to you that focus on the various aspects of the social determinants of health. Much less frequently I have mentioned the political determinants of health. As we are getting deeper and deeper into conversations about the issues of the 2024 election, it is a good time to emphasize that almost all potential improvements in the social determinants of health are dependent upon the political determinants of health.
One of the big take-aways following the Dobbs decision that undermined the reproductive rights of women was to underline the reality that when we try to think about the political determinants of health we need to focus on state and local government for the next few decades. Policy making and legislation about abortion rights at the state level will be as practically important as the national questions about a woman’s reproductive rights.
We are virtually two nations. There is “blue America” where progressive policies to improve the social determinants of health are often productively discussed, passed, and implemented. In “red America” the efforts to improve the social determinants of health often lead to conversations with phrases like “government interference,” “the nanny state,” and welfare abuse.
I doubt that anything I write or say will have much influence on the evolution of the political debates that will occur this year. We will have a good preview of what the next four months will bring when we hear the debate on CNN between President Biden and former President Trump on June 27.
This week, I was pleased to find two articles about the politics of healthcare in the coming election. The first article entitled The Politics of Health Care and the 2024 Election is from the Kaiser Family Foundation and was authored by Larry Levitt who is their “executive vice president for health policy.” He “oversees KFF’s policy work on Medicare, Medicaid, the health care marketplace, the Affordable Care Act, racial equity, women’s health, and global health.”
The article begins by stating the obvious:
Health policy and politics are inextricably linked. Policy is about what the government can do to shift the financing, delivery, and quality of health care, so who controls the government has the power to shape those policies.
Elections, therefore, always have consequences for the direction of health policy – who is the president and in control of the executive branch, which party has the majority in the House and the Senate with the ability to steer legislation, and who has control in state houses. When political power in Washington is divided, legislating on health care often comes to a standstill, though the president still has significant discretion over health policy through administrative actions. And, stalemates at the federal level often spur greater action by states.
Health care issues often, but not always, play a dominant role in political campaigns. Health care is a personal issue, so it often resonates with voters. The affordability of health care, in particular, is typically a top concern for voters, along with other pocketbook issues, And, at 17% of the economy, health care has many industry stakeholders who seek influence through lobbying and campaign contributions. At the same time, individual policy issues are rarely decisive in elections.
In those paragraphs Levitt underlines many important realities. Healthcare is an embedded issue even when we are talking about other subjects like the economy, taxes, immigrants, and personal freedoms. He also underlines the difficulty for progress at the federal level when we have “divided government” and the frequently overlooked possibilities for progress at the state level. How a politician talks about immigrants, the climate, election fraud, or the border can reveal a lot about how their biases may play out in a healthcare discussion even when healthcare is not a central concern of the political debate. When he tells us that whoever controls the government has the power to shape healthcare policy or to ignore healthcare concerns he underlines a reality that we should not forget even if we wish there was less inflation or think that President Biden should be doing more to reduce the loss of innocent lives in Gaza.
I enjoyed his brief review of the long and frustrating saga of healthcare reform. He reminds us that in 1948 Harry Truman offered us universal healthcare. Truman’s efforts were undermined by the American Medical Association. It is a staggering reality that one of the most effective opponents of healthcare reform over the years has been the AMA. Lyndon Johnson acknowledged Truman’s failed effort when he chose to sign the 1965 Medicare and Medicaid legislation at the Truman Library in Missouri in the presence of Truman.
The next stop in the trip down memory lane is President Clinton’s attempt at healthcare reform. He reminds us that almost the entire healthcare industry opposed Clinton’s program. After Clinton’s failure, the Democrats lost the control of both the House and the Senate during the midterm elections of 1994.
It has seemed to me for a long time that every failed attempt to pass healthcare legislation leads to a long period of recovery before there is the political energy or will to try again. It was fifteen years between Clinton’s failure and Obama’s initiation of the attempt to pass the ACA.
At the end of the “history section” of this long paper, Levitt takes us back to the 2020 election when healthcare policy was last debated as part of an election.
In the 2020 campaign, health reform was a major issue in the Democratic primaries, with a number of prominent candidates supporting a Medicare for All plan. Joe Biden’s platform was centered instead on building upon the ACA.
I was disappointed with Biden’s judgement that we would be wise to stay with the ACA and policies that might lead to very slow incremental improvements in cost and numbers covered, but perhaps the fact that healthcare is not an active debate so far in 2024 is evidence of his prudence and wisdom which brings us to the question of what happens now in this very unusual year when “democracy” and women’s healthcare rights are in a battle against inflation, border concerns, the climate, and attempts to undermine the rights and opportunities of minorities through attacks on policies to promote diversity, equity, and inclusion.
In 2024 the discussion of healthcare will continue, but not as a central issue. Levitt points out that when Trump is not railing about his treatment in the courts or illegal immigration the former president does still mention that he will once again attempt to repeal of the ACA and replace it with something which is “much better”, As was true in 2020, he has never outlined or revealed his plan.
Biden could run on what he has done. The accomplishments aren’t dramatic and I assume that most voters are totally unaware of the changes he has made through legislation and executive decisions. Levitt sums up Biden’s efforts:
In contrast, the Biden administration has reinvigorated the ACA by restoring funding for consumer assistance and outreach and by increasing premium subsidies to make coverage more affordable, resulting in record enrollment in ACA Marketplace plans and historically low uninsured rates. The increased premium subsidies are currently slated to expire at the end of 2025, so the next president will be instrumental in determining whether they get extended.
I wonder what percentage of the voters who will chose Trump over Biden because of their anger over inflation will factor into their decision the impact that Trump might have on their healthcare access and costs. The complexity and interrelated nature of the issues could create losses in healthcare as voters focus on other pocketbook issues.
One of the biggest unknowns for 2024 will be whether or not abortion and reproductive rights will continue in 2024 to be as effective defenses against Republican control as they were against the “red wave” in 2022. Levitt sees abortion as a big issue again in 2024.
The health care issue most likely to figure prominently in the general election is abortion rights, with sharp contrasts between the presidential candidates and the potential to affect voter turnout. In all the states where voters have been asked to weigh in directly on abortion so far (California, Kansas, Kentucky, Michigan, Montana, Ohio, and Vermont), abortion rights have been upheld.
…Trump recently said, “for 54 years they were trying to get Roe v Wade terminated, and I did it and I’m proud to have done it.” During the current campaign, Trump has said that abortion policy should now be left to the states.
Levitt warns us not to accept Trump’s pledge that now he will leave reproductive rights to the states. There are many federal programs that impact the reproductive health of women that Trump could cancel.
The healthcare issues that most obviously connect with inflation and the economy are the price of drugs and the increase in “out of pocket” healthcare costs. In this area Biden has made gains that he gets little credit for through the Inflation Reduction Act. In the end Levitt ends up with the same opinion that I have tried to describe to you.
Ultimately, irrespective of the issues that get debated during the campaign, the outcome of the 2024 election – who controls the White House and Congress – will have significant implications for the future direction of health care, as is almost always the case.
Unfortunately, in the complexity of our political system control of Congress and the presidency does not directly equate to progress in healthcare cost, access, quality, and equity as Levitt and history reminds us.
However, even with changes in party control of the federal government, only incremental movement to the left or the right is the norm. Sweeping changes in health policy, such as the creation of Medicare and Medicaid or passage of the ACA, are rare in the U.S. political system. Similarly, Medicare for All, which would even more fundamentally transform the financing and coverage of health care, faces long odds, particularly in the current political environment. This is the case even though most of the public favors Medicare for All, though attitudes shift significantly after hearing messages about its potential impacts.
Perhaps, the healthcare strategy of preserving the ACA and making very incremental progress that Biden favors is the safest choice to preserve what we have. If even slow improvement in healthcare and other issues that impactive the social determinants of health like housing, education, the climate, and the improvement of structural inequality are to occur, the political power necessary to accomplish those things will need to come from a second Biden victory. Biden and others will need to continue to focus on Trump’s lack of character, his threat to democracy, his threat to reproductive rights, and his threat to the health of the public.
While the presidential election is most important, we should not forget the importance of the “down ballot” races for control of state and local government where in more progressive environments there is still much that can be done to improve the social determinants of health by acting locally.
The second recent article about healthcare in the 2024 election that I want to bring to your attention is from the Milbank Foundation. It was written by Dr. Sandro Galea, who is the dean and the Robert A. Knox Professor at Boston University School of Public Health. Dr. Galea is a respected physician and epidemiologist who is widely recognized for his insights into our public health concerns. His article is entitled “A Vote for Health.” He begins by reminding us of the importance of politics on the health of the public, a fact that is sometimes forgotten or inadequately appreciated as we focus on more popular issues like the cost of gas and groceries. [I have bolded some points for your attention.]
It is well established that politics, and the mechanisms of political action, have an important impact on the health of populations. The very ubiquity of political forces—that in many ways shape all aspects of the world around us—makes it easy to forget that political action should be central to our thinking about all determinants of health. Studies that have assessed public perception of the drivers of health repeatedly show that politics ranks low among drivers of health reported by the general public.
He asks those of us who care about healthcare and the health of the population a critical question.
How can those whose work is concerned with creating healthy populations think about the challenges the United States faces before and after the upcoming presidential election?
In answer to his own question, Dr. Galea has three points that he wants to make. I am not sure that I agree with his advice to avoid partisan attitudes.
First, in a country that has been for much of the past decade evenly divided along partisan lines, the concerns of public health should not be consigned to similar partisan lines. This therefore calls on us to engage political actions and actors dispassionately, evaluating how they might affect the health of populations, without casting our lot in an explicitly partisan way. That does not mean avoiding the potential harms that can be brought about by particular political actors whose actions can harm health…It also seems reasonable to take seriously threats to representative democracy that could destabilize the country by bringing about the kind of large-scale unrest that we know harms both physical and mental health…
Second, even as we think about the influence of political action on health, it is worth keeping in mind that health itself influences political and electoral action. This was well demonstrated in studies conducted after the 2016 US election that showed how areas of the country where health had receded were much more likely to have voted for President Trump, than were areas where health had improved…If poor health is likely to lead to the election of candidates who, ironically, are less likely to invest in health, it is in our collective best interest to ensure that everyone is as healthy as possible in order to maintain a trajectory of positive health for whole populations…
His third point is interesting as he continues to seek to lift concerns about health above partisan politics. I wish it could be so.
Third, health can have a particular role to play in catalyzing ideas about candidates and sifting through electoral choices. Health became entangled with partisan considerations during the COVID-19 pandemic. This had the unfortunate consequence of aligning health recommendations with particular political parties and making engagement with health decision-making contingent on party affiliation. This also chips away at the potential unifying role that health can play as one of our few universally held values. It is, therefore, incumbent upon those who engage in the business of health to steer away from approaches that are seen as overly partisan, centering a shared aspiration for a healthier world, and acknowledging that such can come—indeed should come—about as the product of action by either political party. This pushes us to surface shared goals, such as the health of the next generation and the preservation of a planet that can sustain such health, without over-reliance on solutions that are the province of one political party or another…it remains the responsibility of those of us who are committed to a long-term vision of a healthier world to point to areas of consensus, motivated by shared concern for our collective well-being.
He then offers a possible path toward lifting health and the efforts to improve the social determinants of health up from the morass of partisan politics.
When we recognize—as we now readily do throughout the field—that health is a product of the world around us, of how we live, work, and play, it is impossible to separate decisions that influence these very conditions from decisions that influence health…in a highly partisan and divided national and cultural landscape, particular policy positions are not infrequently seen as unyieldingly linked to specific party affiliation and distant from their very real consequences for the lives of people. Issues like climate change, structural racism, and equitable wages—all central to the creation of a healthy country—are reliably divisive, and it is difficult to find rhetorical approaches that bridge these divides to the end of forging viable ways forward and generating health.
What should be obvious to all and “what is” has always been a source of confusion and disappointment to me, but I admire Dr. Galea’s attempt to find common ground between reasonable people of differing political philosophies. As mentioned above when I discussed the paper from KFF, he reminds us that progress can be made at the state and local level.
…there are grounds for optimism, even in a fraught political season. There are promising efforts, particularly at the local political level, that have taken creative approaches, forging bipartisan consensus and finding ways to invest in the structures that generate health…There is a place for health to help bridge some of these divides, to be that bridge, suggesting that our careful engagement—surfacing values that unite, highlighting what may work and may not, and not allowing ourselves to be swept away in the particular partisan fervor of the moment—may be a vote for future health indeed.
I am inspired by Dr. Galea’s hopeful prospects of lifting healthcare to a level of universal concern that is far above partisan politics. Ironically, to get there the outcome of the 2024 election is crucial. I don’t believe all of the pundits and polls that point to President Biden’s vulnerabilities to defeat. It is almost impossible for me to accept that a majority of Americans could vote for a narcissist who seems more focused on personal revenge without regard for accepted norms, but then i have the election of 2016 to remind me that what I can’r imagine can happen. Our way forward toward health equity and the lofty goals of the Triple Aim are on the ballot this year even if the direct discussion of healthcare policy doesn’t make it into the televised debates or the reports on Fox News or MSNBC. We are all vulnerable. Warn your family, friends, and colleagues.
An Important Anniversary
I have told the story before in these notes, but since yesterday was the 80th anniversary of D-Day, I will tell it again. I believe that D-Day should be a continuing monument to the previous willingness of our country to pay a very high price to preserve democrcy. Without a preservation of democracy and the order that is acheived by the rule of law that treats all of us equally, we can’t expect the preservation of a government that is by the people and for the people that ensures the freedoms that should flow to all of us
This time last year my wife and I plus four close friends were in France. The trip had two parts. The first part of the trip was a guided tour of the Normandy beaches and a visit to the bridge over the Merderet River that was the site of one of the bloodiest and most intense battles of World War II. If you clicked on the last link you would have read:
The mortal ferocity of the four-day battle for control of the small stone bridge over the Merderet River at La Fière in Normandy is testament to the bridge’s strategic importance in the D-Day invasion of June 1944. Without control of the bridge and its vital causeway, American forces coming from Utah Beach would not have been able to force their way inland.
Fought largely by paratroopers and glidermen from the 82nd Airborne Division, the battle to secure the bridge at La Fière is described as “probably the bloodiest small unit struggle in the experience of American arms.” Victory at La Fière cost more than 250 American lives, and yet the fateful engagement’s story is largely untold.
I was interested in visiting the little bridge over the Merderet because my father’s older brother had been awarded a Bronze Star for his actions in the battle. On D-Day my uncle was a sergeant in Company I of the 507 Parachute Infantry Divison (PIR) of the 82nd Airborne.
During the night before the landings on Omaha Beach and Utah Beach, paratroopers from the 505, 507, and 508 of the 82nd Airborne were dropped into the area near the little towns of Sainte Mère-Église and Amfreville to secure the road out of Utah Beach. Their assignment was labeled Mission Boston. Our military intelligence did not reveal that the Germans had flooded the wetlands around the bridge and many of our paratroopers landed in deep water and drowned tangled in their parachutes.
To add to the misery and difficulty of the mission, the weather on the night before D-Day was so bad that the pilots of the planes became confused and dropped many of the paratroopers far from their planned drop zones. My uncle had responsibility for the radio and communications equipment for his unit which was dropped separately as was much of the equipment and artillery that were part of the plan to take the bridge and the causeway to control the road out of Utah Beach. Most of the 507 had the objective of securing Amfreville, a small town near the bridge. Somehow in the confusion of the drop some of the 507, including my uncle, landed away from Amfreville and nearer the bridge and causeway over the Merderet. The units were all mixed up and the men just teamed up with others who were nearby even if they were not part of the same unit. My uncle was given his medal for exposing himself to fire from the Germans as he recovered critically important radio equipment near the bridge.
Throughout my childhood, I held my uncle in awe although I don’t remember meeting him until I was seven years old. My grandmother had a picture of him in his uniform that was prominently displayed just above the large console radio in her small living room. After I finally met him, my uncle never said anything about his service except to explain the scars on his back that I saw. The wounds were from a hand grenade blast he survived at the Battle of the Bulge. After he was wounded, he was sent to a hospital in England and returned to his unit in time to participate in Operation Varsity which was the last big battle of the war in Germany.
My uncle came back from the war and immediately headed west to Arizona and Southern California where he attended the University of Arizona on the GI bill. There was some estrangement between my uncle and my grandfather that had a long history. To get away from the oppressive mill village on the outskirts of Greenville, South Carolina where the family lived, my uncle had left home in the late thirties after high school. He joined the Army long before the war. During his initial service he had a desk job in the Quartermaster Corps. After Pearl Harbor, my uncle reenlisted with the stipulation that he could be a paratrooper.
After several years of looking at the picture my grandmother had of him and asking questions that got few answers, I first met him in 1952 when he spent several weeks with us in Oklahoma after he was severely injured changing a flat tire when his car was hit by a truck driver who was asleep at the wheel. My uncle, his wife, and stepdaughter were driving at night across the desert from Southern California to see us in Oklahoma. The accident occurred “in the middle of nowhere” in the middle of the night near the state line between Arizona and New Mexico. His wife died on the seventy-mile ambulance drive to the nearest hospital in New Mexico. Fortunately, his stepdaughter who was asleep in the back seat of the car survived uninjured. My dad traveled to New Mexico to help his brother, and when my uncle could travel he brought him to our home to recover. When he arrived at our home he was in a full-body cast.
After my uncle recovered, he returned to South Carolina, reconciled with my grandparents, and eventually became a psychologist. I spent much of the summer of 1954 with my grandparents and him in South Carolina. He was living at home while he was getting his degree from Furman University and dating the woman who would become his third wife. Those times with him in 1952 and 1954 were some of my most cherished memories of childhood. He was my cool uncle with a tattoo who drove a ‘53 Mercury convertible.
I was fascinated by his tattoo. On his left shoulder there was a ferocious looking black cat with an arched back standing on the number 13. After many inquiries he told me that he got the tattoo when he was out with some army buddies and had too much to drink. When he awoke the next morning he was surprised to see that he had a tattoo.
Over the years I have come to imagine that the tattoo was a metaphor for his unlucky and difficult life. Whether he meant it or not it must have had something to do with how he felt life was treating him. His first wife whom he met and married in a very short time before being shipped to England to prepare for D-Day took his Army pay and then divorced him while he was at war. On his third try with marriage, his luck with marriage improved a lot. He married the woman he was dating that summer of ’54. “Aunt Sue” was a perfect match for him. After teaching psycology for a few years at Georgia Military College, he and Sue moved to Oneonta, New York where I think that he was very happy teaching at the state college and working as a psychologist for the Oneonta public schools. Our family visited them once in Oneonta in the early sixties before he died of colon cancer in 1969 at the age of 52 while I was spending the summer working in a lab at the University College Hospital in London. At the time of his death he was a respected member of the Oneonta community and an elder in his local Presbyterian Church.
All that I knew about his military service for many years since he never talked about the war. and neither did my parents or grandparents, was that he had been a paratrooper and had been given a purple heart for his wounds at the Battle of the Bulge. I had no idea that he was part of the D-Day invasion. Many years later, around 2010, while visiting my parents in the Atlanta area, I was looking through my parents’ bookshelves for something to read when I discovered a small box. In the box, there were was his Purple Heart and three bronze stars and citations describing why he was given the medals. There were also several letters in the box that he had written to his parents to console them when he learned that he was terminally ill. By the time I found the box more than sixty years had passed since D-Day.
I have heard that many of the soldiers of World War II did not talk much about what they experienced. My uncle was a perfect example of the reluctance to revisit the experiences that I am sure he felt we could never really understand.
The continuing tragedy is that I can’t find the box and his citations. The box may have been lost in the several moves my dad made after my mother died in 2013. Last year I had many of my parents’ papers, journals, and memorabilia shipped to me after my sibs and I cleaned out my dad’s unoccupied office building in preparation for its sale. We had been using the small building as a storage unit. I now have dozens of boxes in my garage and basement. I hope that one day in one of the boxes I will find the medals and the citations.
If you have never been to Normandy, I would recommend that you take the trip. It is a moving experience beyond words to see acres and acres of white headstones and know that those crosses and Stars of David indicate that some young man or woman gave their life in the struggle to defeat an enormous evil and restore freedom for people that they did not know.
We were in Normandy for three days. It is a very beautiful place and I want to return sometime soon. We had a lovely local woman, Carole Duval, as our guide. As you will learn if you follow the last link, she has helped many of our D-Day veterans receive the “French Legion of Honor, the highest honor the French government can bestow upon those who have achieved remarkable deeds for France.” Prior to our visit she did research about my uncle’s unit to try to find out specifics about him but without much luck. I have a book about the 507 and there is a picture of Company I. He is on the second row.
Ms. Duval did take us to all of the places where my uncle probably fought. Her own story was interesting. Her family owned a small hotel in Vierville-Sur-Mer, the little town above Omaha Beach. Her father was ten years old on D-Day so she grew up with her dad and other family members steeping her in the history of the day. Her whole life has been dedicated to preserving the history of the invasion and honoring many of our veterans by helping them get recognition from the French government for their heroism on that “longest day.”
Even though our trip coincided with the 79th anniversary of D-Day and not a year ending with a five or a zero, everywhere we went there were banners and monuments dedicated to the memory of those who fought on D-Day and the weeks that followed in the effort to free France from the grip of the Nazis. It was a moving experience without all the crowds that I am sure are there now.
I worry that the sacrifices of those who died or were severely wounded, and those like my uncle who may have lived out their lives with deep emotional scars, will be thrown away by politicians who want to make America great again by withdrawing from our commitment to democracy and freedom for everyone.
Enjoy the weekend. I plan to sit on my dock and enjoy a few warm summer evenings like the one earlier this week when I snapped the picture that is today’s header. I am gratefully aware of the fact that I get to have those pleasures because there have been thousands and thousands of brave young Americans over the decades who served and died in places like the beaches and bridges of Normandy. They were willing to die to preserve our opportunity to relax in peace.
Be well,
Gene
