As we reflect on the 2018 U.S. midterm elections, we see that health care coverage once again played an important role. The frequent mention of health care as a campaign issue prompted us to reflect on our bike listening tour of 2016.1 When we began our tour in the late spring of 2016, peddling across the northern tier of the United States, there were 16 candidates in the Republican presidential primary race. During our trip, at the Republican National Convention, Donald Trump was chosen as the Republican presidential candidate. In those parts of our journey that ultimately became “Trump Country,” we had conversations with 115 people. A common thread among the themes we identified in these conversations was the rampant misunderstanding of health insurance coverage and the central role that politicians had in the creation of policy. Our travels took us through the rural heartlands where we found the greatest opposition to the Affordable Care Act (ACA). Living in a rural as opposed to an urban area was the strongest predictor of a negative opinion about the ACA. In this Invited Commentary, we explore the results of the 2018 election in areas through which we traveled to see if anything has changed.
The ACA’s Role in the Election
In the run-up to the 2018 midterm elections, Blendon and colleagues2 reviewed multiple surveys of voters’ attitudes and priorities. The authors saw a distinct change in attitude toward the ACA. The same ACA that was poisonous during the 2010 midterm elections under President Obama became an important campaign issue for both Democrats and Republicans in 2018, although their priorities regarding health care policy differed.2 Suddenly every politician wanted to protect those with preexisting conditions and maintain the ability for children to stay on their parents’ insurance until the age of 26. However, although everyone expressed interest in protecting and preserving these provisions of the ACA, campaign marketing revealed significant differences in truthfulness and depth of discussion.
Health policy is extremely complicated. Campaign sound bites are not. North Dakota Senator Heidi Heitkamp’s campaign pointed out that her opponent, Representative Kevin Cramer, voted against coverage of preexisting conditions. The facts are a little more complicated in that the bill in question actually only allowed states to opt out of provisions covering preexisting conditions.3 Republican ads expressing support for coverage of Americans with preexisting conditions made no pretense to explain how candidates proposed paying for this coverage. The premise of these ads seemed to depend on a limited knowledge of how health care financing works, confirming what we learned during our bike listening tour: Most Americans do not understand health care financing.
Missouri Senator Claire McCaskill focused on consumer protections in health care and support of coverage for preexisting conditions. Her opponent, State Attorney General Josh Hawley, was part of the lawsuit brought by 20 Republican governors and state attorneys general to overturn the ACA in its entirety, including Title 1 protections for preexisting conditions. (A Texas judge ruled for the plaintiffs in this case, but the decision will be appealed.4) In Hawley’s campaign, however, he supported coverage for preexisting conditions, noting that his son suffers from a rare medical condition. When asked to reconcile his participation in the lawsuit with his support for coverage for preexisting conditions, his campaign maintained that there are other ways to cover preexisting conditions besides the ACA, without naming any alternative possibility.5 The underlying concept of the ACA was that, to be able to cover preexisting conditions, the risk pool would have to be very large, which the ACA achieved through mandated coverage. Interestingly, during his campaign in 2008, President Obama was initially opposed to an insurance mandate. He then realized that there is no other feasible way to pay for such care through our existing, employer-based, private insurance system.6
Both Senators Heitkamp and McCaskill were defeated in their bids for reelection. Were the voters once again influenced by misunderstanding of our health care system, or were the polls misleading regarding the importance of health care in determining their vote?
Separately, new Medicaid expansion measures were on the ballot in Idaho, Utah, and Nebraska. In Montana, there was a measure to continue the expansion, which was slated to end in 2019. The new ballot expansion measures won handily in all three states7; the Montana measure was defeated. The tobacco industry spent heavily to defeat the initiative in Montana, using inaccurate financial concerns to mislead voters.8
On our 2016 bike trip,1 we found that those most opposed to the ACA lived in states that had not at that time expanded Medicaid (Idaho and South Dakota; unpublished data).9 In South Dakota, the incumbent congresswoman who voted to end the ACA was elected governor. In Idaho, the only incumbent congressman who had voted to end the ACA was reelected. In Utah, all of the incumbent members of Congress who voted to repeal the ACA were reelected, except one. Now, despite the fact that voters in Utah and Idaho approved Medicaid expansion, elected officials are moving to curb these expansions.10 Here, again, we see a disconnect between candidates’ voting records and peoples’ votes and their respective expressed priorities.
Another of our interviewees’ concerns was that their taxes should not pay for other people’s medical problems. As people realized that they would personally lose health benefits if the ACA were repealed, they become invested in seeing it continue. It appears that people need to have personal experience with health care coverage to understand its benefits. The reason this did not translate into votes for candidates who supported those policies is either that other factors weigh more heavily in voting decision making or that people do not understand the connection between candidates and their policies. It may also be true that people vote for the party they feel has historically voted in their interests. These patterns may be difficult to change.
Physicians’ Role in the Debate
We previously opined that physicians, as knowledgeable professionals, have a moral obligation to make the health care system the best it can be for the most people.11 As Farzon A. Nahvi says, our patients’ lives are at stake and politicians do not seem to understand that it can be a matter of life or death.12 We believe our role is to discuss health policy in general terms, as differentiated from the fundamentally dangerous role of advocating for individual candidates.
So, as physicians and academics, what can we actually do? Health policy is very complex and has many moving parts. How can physicians convey this to patients in the setting of a brief office visit? On our trip across the country, the few people we met who had changed their minds about the ACA told us stories. One told us that although she was fervently opposed to the ACA, when her sister was diagnosed with breast cancer, it was through the ACA that she was able to receive lifesaving treatment. But physicians are scientists who rely on evidence-based medicine. We use data and statistics to help inform patients to make reasonable medical decisions. As our travels and recent elections have demonstrated, our patients do not always make decisions based on evidence. Can we help patients tie their personal experiences into an understanding of health insurance coverage? Can we learn to weave our patients’ stories of inability to afford a treatment into an understanding of the connection to the local legislator’s votes against appropriate health policy?
Are there other ways we can encourage a more informed approach to health policy? Is organized medicine, including the American Medical Association and medical specialty societies, currently playing this role? They have supported the ACA, but is there a way to do so more effectively? Other groups, such as Physicians for a National Health Plan and Kaiser Family Foundation, have advocacy materials to help educate patients. Might physicians work with politicians to craft messages that more accurately reflect the truth about health care?
Health care policy will continue to be used to persuade people to vote in certain ways that do not necessarily translate into rational policy. Lacking optimism that politics will change, we fear that voters—our patients—will continue to be misled for partisan purposes. Further, the importance of universal health care as a crucial element of a healthy society and as the only feasible way to cover preexisting conditions equitably will continue to be disparaged. As clinicians and educators in the health care system, supporting policies that promote available, accessible, and acceptable health care is both an ethical imperative and a professional obligation. Let us continue to explore ways to advocate for the interests of all the people of the United States, and may these people, our patients, come to understand how universal health care can benefit them both individually and in community with others.
Acknowledgments: The authors wish to acknowledge the comments and feedback provided by Dr. William Ventres.
1. Gordon PR, Gray L, Hollingsworth A, Shapiro EC, Dalen JE. Opposition to Obamacare: A closer look. Acad Med. 2017;92:1241–1247.
2. Blendon RJ, Benson JM, McMurtry CL. Health care in the 2018 election. N Engl J Med. 2018;379:e32.
11. Gordon PR. How can physicians educate patients about health care policy issues? Acad Med. 2016;91:1333–1336.