Cartoon of the Day: Trumpcare vs. Obamacare

It has been a while since I have written in this space. Partly this was a result of a personal medical problem (I am OK now and perhaps one day I will regale you with stories of my treatment) and partly because I do not have much new to say. I practice and teach family medicine in the deep south. My state, Alabama, has declined to expand Medicaid. 90% of White Alabamians have the luxury of having health insurance and feeling, well, entitled. 84% of Black Alabamians have health insurance. Only 70% of Hispanic Alabamians report the same. My practice has been colored by these facts ever since the passage of Obamacare. Much of what I have written has been about the passage, implementation, trials and tribulations of Obamacare in Alabama.

My lack of writing in this space recently has been, in part, because health policy wise there has been not much to write about. The last three and a half years have been about the states that have chosen to expand working to correct other gaps in care while those of us in non-expansion states have been watching. In what is likely not a coincidence, many of the people live in the states that have chosen not to expand Medicaid which are also those states which chose to enslave humans (92%). From a policy standpoint, I have to admit that when I am asking for money to study a healthcare problem (hospital closure, unnecessary hospitalization, vaccination gaps) and the reviewers ask “Why not expand Medicaid instead of my giving you money” I don’t have a good answer.

What are we missing out on? Improved health outcomes, for one. This includes patient based outcomes (an improvement in healthy days in the month, reduced overall and disease specific mortality), provider based outcomes (improvement in the physicians’ bottom line), state based outcomes (less money spent on healthcare). In addition, because people are more steps away from bankruptcy, they report in general being better off (reductions in rates of food insecurity, poverty, and home evictions). In short, we in Alabama are much worse off for not having expanded.

In just over a month we will select a president. The incumbent, Donald Trump, ran for office 4 years ago with the promise to “repeal and replace Obamacare.” As part of that he vowed to “block grant” Medicaid. He promised to replace the ACA with something “terrific,” “phenomenal” and “fantastic.” In 2020 alone he has promised an Obamacare replacement plan five times, each time promising to unveil it “within 2 weeks.” The plan has never materialized. Instead, his administration has joined a lawsuit with 18 non-expansion states to gut the law (an unusual stance for the federal government to work towards the nullification of one of the federal laws, but as the kids used to say, WHATEVER). If they prevail they will take health care access away from 25 million people. In addition, for the last six months the lack of federal leadership regarding Covid-19 has also put us in a bind because we are a low tax state, meaning that we rely on the federal government to work on matters such as this. The result of the last three and a half years has been that, in Alabama, we have been in health policy limbo, waiting for President Trump to drop the other shoe.

Joe Biden, on the other hand, had an active role in the passage of the Affordable Care Act. He understands healthcare and healthcare policy. He has a viable plan to effectively get universal coverage in the United States. Although, one can never underestimate the ability of the powers that be to do something dumb, maybe even Alabama can’t screw this up.

Which brings us to last night. I was asked to watch and comment on the health policy aspects of the debate. Here is what we learned: Short answer, nothing new. Long answer, the candidates argued, obfuscated and hurled accusations over a range of health issues, including but not limited to: coronavirus, Obamacare, abortion, drug prices, vaccines, trust in science, stay-at-home orders, private health insurance, the public option, and the Trump administration’s ongoing lack of a health care plan. Specifics were as follows –

The President repeated assertions that he’d done a “great job” managing the public health threat and urged states to reopen, contradicting the head of the CDC whom he appointed.

Joe Biden believes that 200,000 deaths were way too many from Covid-19. The President disagrees.

Joe Biden understands that the future of care access in America is intertwined with the Supreme Court nomination, the President disagrees.

The President believes he has reduced the price of insulin, which, he has not for most people.

The President accused Joe Biden of wanting to take over all of medicine. Joe Biden pointed to the work he had already done and said he would not.

For me, as someone who has watched the poor of Alabama suffer from a failing of the healthcare infrastructure brought on by failed federal policies, needless deaths from preventable illnesses and now from Covid-19, and unnecessary bankruptcies for the past three and a health years, I am ready for a change. Last night did not convince me otherwise.