Making America Great

Many have searched for an explanation for the results of the last presidential election. Preelection polling mostly missed the swing toward the Republican candidate. Pundits pointed to simmering middle class economic anxiety, reaction against globalization, racial identity politics or even racial resentment, fatigue with politics as usual, and possibly the manipulation of social media by foreign powers. But could health factors have played a role?

In this issue of JGIM, Goldman and colleagues contribute to this dialogue with a cross-sectional analysis linking county level voting data, census data, and CDC mortality data.1 They showed that US counties in which the age adjusted death rates have stagnated or only minimally improved were much more likely to have an increase in the proportion of voters supporting the Republican candidate. These were predominantly non-urban counties with a high proportion of low-income less educated whites (I will call LowSESWs). Such voting patterns also correlated with county level increases in “deaths of despair” due to alcohol, drugs, and suicide.

As they note, these findings are not entirely novel. Bor showed residents of counties where life expectancy had not improved were more likely to vote for Trump.2 Goodwin and colleagues used Medicare claims data to show prescription opioid use was highly correlated with county level voter support for Trump.3 The current more extensive and detailed data including a large number of supplementary sensitivity analyses add a much greater degree of depth and detail to these existing studies. The authors also provide interesting speculative data suggesting relatively modest incremental reductions in county level death rates in three key states could have swung the election.

The Social Determinants of Health (SDH) framework posits that conditions and environments in which people “are born, live, learn, work, play, and worship” play a major role in health outcomes.4 Socio-economic opportunities, quality of our schooling, workplace safety, housing and neighborhood conditions, clean food, air, and water, all have a major impact on health. Consistent with this framework, the authors show county level declines in economic indicators such as income and increase in unemployment were also strongly correlated with an increase in Republican votership. They conclude death rates are likely markers of the “dissatisfaction, discouragement, hopelessness, and fear of cultural displacement.” Thus, it was not death rates per se that drove LowSESWs to vote Republican, but rather the underlying worsening social conditions that they and/or those around them have been experiencing.

That unhappy disenfranchised people would want radical change should not have been a surprise. Indeed in the primaries, 43% of Democrats rallied behind Sanders “Political Revolution” message. For Republicans, the slogan Making America Great Again (MAGA) was their rallying cry. Indeed, by many measures, America is falling behind. We have long lagged many other high resource nations in health indicators such as life expectancy and mortality. More troubling is that since the mid-1980s the gap with such countries has dramatically widened.5 In the 1960s and 1970s, there was tremendous progress in reducing poverty in the USA, but in the last 40 years, rates have stagnated. Adjusted incomes for most, except the exceptionally wealthy, are flat if not falling and income inequality continues to increase precipitously. The USA now leads much of the world in wealth inequality. To many lowSESWs, the logic of Trump’s approach was infallible, hearkening back to a time when they felt they had more economic and cultural power and when America was also less diverse.

Those of us who have devoted our careers to improving the health of racial and ethnic minorities empathize with the plight of LowSESWs. Steadily they are slipping into the same challenging conditions that have existed in minority communities for decades. The difference is that that the American greatness LowSESWs recall never existed in minority communities. Many minorities felt the “again” in MAGA was code for returning to a time when Whites were a larger majority in the USA and of widespread politically sanctioned prejudice and segregation. Thus, they soundly rejected Trump’s message. Of note, that period of greatness also likely never existed for vast swaths of white rural America, such as in Appalachia.

LowSESWs were not happy with traditional candidates (Republican or Democrat). Fully aware that America’s decline happened under the watch of both, they wanted immediate change which could only come from a radically different candidate, and President Trump’s style portended exactly that. Despite this mandate, many of the policies being enacted in the current administration follow traditional Republican goals and will not likely benefit low income or disadvantaged groups. Dismantling the Affordable Care Act (ACA) and further slashing of social safety net programs are but two examples of a broad shift to the right. The recently formed Lancet Commission on Public Policy and Health in the Trump Era is charged with chronicling these and other repercussions of the current administration’s actions upon all Americans.6 Yet for now, many LowSESWs remain quite satisfied.7 They perceive racially charged presidential tweets and statements as evidence that he shares their newfound frustration that a more diverse America has diminished them.8

In contrast, minority communities have been frustrated for decades, yet are forced to settle for democratic presidential candidates who champion slow incremental change. Calls for larger and more immediate changes are quickly dismissed as politically impossible rants made by left wing radicals. The ACA is a perfect example. Some wanted a Medicare For All approach that would cover everyone at much lower cost. While every other developed nation has figured out how to enact universal coverage, single payer advocates were lambasted for being politically out of touch, though recent polls show it is supported by 85% of Democrats and 52% of Republicans.9 Instead, the health insurance and pharmaceutical industry were allowed to play a prominent role in shaping ACA. Not surprisingly, 75% of uninsured Latinos saw no benefit from the ACA.10

Progressives wonder how long will it take for LowSESWs to realize they picked the wrong candidate to address the suffering that Goldman has identified. But perhaps, they should instead wonder how long it will take for progressives themselves to realize that improving Americans health requires unconventional leadership. That leadership should place a much greater value on the pressing needs of poor and working-class communities regardless of race. LowSESWs were absolutely correct that making America great will require a leader who is brash, relentless, and unafraid to deviate from political correctness and conventions.

What kind of outrageous things would such an unconventional leader say to Make America’s Great through better health policy? She might call for prosecution of the pharmaceutical executives who helped create the opioid crisis. She would prioritize health over the demands of health insurance or pharmaceutical companies. And, most outrageous of all, she would sign legislation providing every person in this country with equitable, affordable, comprehensive national health insurance. Only thus would the roots of the “deaths of despair” so poignantly described in this issue begin to be addressed.


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Editorial note

This editorial provides significant context for the Goldman article which necessarily draws upon its political implications. The editorial team at JGIM welcomes contrasting views, either in the form of letters or additional editorials.

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Correspondence to Olveen Carrasquillo MD, MPH.

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Dr. Carrasquillo is a member of the Lancet Commission on Public Policy and Health in the Trump Era. He is also on the planning committee of the 2019 SGIM annual meeting whose theme is Courage to Lead: Equity, Engagement, and Advocacy in Turbulent Times.

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Carrasquillo, O. Making America Great. J GEN INTERN MED 34, 331–332 (2019).

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