Obamacare: Not everyone thinks the same way you do

“Everyone I know agrees that President Obama’s problem is that he isn’t liberal enough.  Everyone I know believes that the problem with Obamacare is that it gives insurance companies too much power, when what we really need is a single payer system where the government runs everything, like Canada.  Everyone I know believes that  the answer to gun violence is to ban guns,  and if the Supreme Court won’t allow that, to at least license, regulate and restrict them. After all, no one I know would even think of owning a gun.”

“Everyone I know agrees that President Obama’s problem is that he is too liberal — heck, he’s probably a socialist.  Everyone I know believes that the problem with Obamacare is that it gives the government too much power, when what we really need is a free market system that gets government out of the way. Everyone I know understands that banning or restricting guns won’t reduce injuries and deaths — guns don’t kill, people do. After all, everyone I know owns a gun, it is the way we’ve grown up, and every gun owner that I know is a law abiding citizen.”

I made up the above quotes, but they are representative of what I hear from many physicians (and others).  Recently, I received an email from an ACP member who is very unhappy with how I graded the Affordable Care Act; his view is that Obamacare is a failure and, “this is the sentiment of 100% of the physicians that I meet.”  I have heard from liberal members of ACP who similarly claim that everyone they know wants strict gun control and a single payer system, and wonder why ACP doesn’t do more to speak for them.

And therein lays the problem: Just because everyone we know agrees with us doesn’t mean our views are right or representative of how others think.  Surely, in a country as large and diverse as the United States, there is someone with a contrary perspective, informed by their own cultural influences, circumstances, gender, age, ethnicity and place of residence and life experiences. But we would never know it if we surround ourselves only with people who think the same way as us.  And if information about how others might think comes mainly from the vitriol and distortions of cable TV and talk radio and blast e-mails, well then, we’ll never really understand why others might hold opposing views.

Regrettably, a major, new survey of 10,000 adults by the Pew Research Center shows that more of us choose to be surrounded by people who think just like us, creating the greatest polarization in decades. “Republicans and Democrats” the researchers found, “are more divided along ideological lines — and partisan antipathy is deeper and more extensive — than at any point in the last two decades. These trends manifest themselves in myriad ways, both in politics and in everyday life … these divisions are greatest among those who are the most engaged and active in the political process.”

One consequence is the “growing contempt” and “mutual antipathy” between Republicans and Democrats; “among all Democrats, 27% say the GOP is a threat to the well-being of the country. That figure is even higher among Republicans, 36% of whom think Democratic policies threaten the nation.”

It gets worse.  The researchers found that committed liberals and conservatives love to talk about politics but usually within their own ideological echo chambers. “For many, particularly on the right, those conversations may not include much in the way of opposing opinions.”

The growing polarization even carries over to where we choose to live.  “People on the right and left also are more likely to say it is important to them to live in a place where most people share their political views, though again, that desire is more widespread on the right (50%) than on the left (35%).”   Conservatives prefer to live in places where the houses are larger and farther apart but schools, stores and restaurants are several miles away; liberals where houses are smaller and closer to each other but schools, restaurants and stores are within walking distance.

There is a center — about 39% of the population — that does not hold consistently or mostly liberal or conservative views, but they are less likely to vote and participate in politics than the ideologues on the right and left.  “Most Americans in the center of the electorate think that Obama and Republican leaders should simply meet each other halfway in addressing the issues facing the nation” yet “an equitable deal is in the eye of the beholder, as both liberals and conservatives define the optimal political outcome as one in which their side gets more of what it wants.”

And, to be sure, while views have hardened on both ends of the political spectrum,  the “partisan antipathy is more pronounced among Republicans, especially consistently conservative Republicans … Fully 66% of consistently conservative Republicans think the Democrats’ policies threaten the nation’s well-being. By comparison, half (50%) of consistently liberal Democrats say Republican policies jeopardize the nation’s well-being. Conservatives also exhibit more partisan behavior in their personal lives; they are the most likely to have friends and prefer communities of like-minded people.”

All of this bodes very poorly for the American system of governance.  Unlike parliamentary systems, where the majority party controls all the levers of government until they are voted out, the United States is founded on a system of  checks and balances as established by the U.S. Constitution.  Especially at a time when one party (Democrats) control the White House and Senate, and another party (Republicans) control the House of Representatives, the only way to advance legislation is through bipartisan compromise.  Yet committed ideologues don’t see compromise as a virtue.

I don’t have the answers, only a hope that at some point, the tide will turn and voters will choose to cast their votes for politicians who are committed to getting things done.  In the meantime, I see little prospect for achieving a consensus on changes that might be made in the Affordable Care Act, or to reach agreement on reforming entitlement programs or creating a fairer tax system.

There are some things each of us can begin to do, though, on our own and together, to try to reduce polarization.  Support policy and advocacy organizations, like ACP,  that ensure that  the people who sit on their policy committees  represent the broad range of views, partisan leanings, and experiences of the membership.  For instance, the ACP committee that developed our new position paper on preventing injuries and deaths from firearms, which was published in the Annals of Internal Medicine, included physician gun owners from conservative communities and non-gun owner physicians who hailed from more liberal communities. They were able to openly share their perspectives, listen to each other, and reach a consensus informed by evidence.

We can all try every day to listen to what the other side has to say; I personally follow people on Twitter who are from all across the political spectrum.

We can get out of our echo chambers and travel to other parts of the country and meet people who have different experiences and views,  like I do when I travel to a dozen or more ACP chapter meetings each year. (Over the next several months, I will be attending chapter meetings in Bozeman, Montana; Pierre, South Dakota; Seattle, Washington; and San Francisco, California.) Sure, for me, listening to ACP members who have different views and political leanings, and being able and willing to consider a wide range of opinions from politicians, think tanks, and advocacy organizations across the spectrum of right to left, is built into my job description.  But even if it wasn’t, I have an inherent curiosity about how others view things and the circumstance that inform their views.

And finally, we all need to constantly remind ourselves that even if everyone we know thinks the same as we do (or at least we think they do), there are many other Americans who have a different view that also needs to be considered and respected.

Bob Doherty is senior vice president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog

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  • ninguem

    I remain puzzled why anyone would belong to the American College of Physicians.

    • James O’Brien, M.D.

      Any internist in private practice who pays dues to ACP is a turkey voting for Thanksgiving. They fully supported ACA.

  • QQQ

    The government is supposed to handle a few basic things:

    Keep our infrastructure sound

    Protect our border.

    Protect our interests here and abroad.

    The states are to control their own individual interests within their own state lines

    Each state is (or was) supposed to be a sovereign nation unto itself.
    That’s why we’re called “The United States of America”. That is why the
    ACA is unconstitutional and that’s why the FEDERAL government should
    stick to what the founders defined it’s limited powers to be, and the
    states to keep the powers THEY were given to do what’s best for each
    individual one.

    BOTH parties need a thurough cleansing.

    Thomas Jefferson was quoted as saying the government should be cleared
    out and completely re-elected every 25 years because by then big
    business and corruption will taint the representaion of its people.

    And now we have GOONS in the White House and many more in the Senate, the House and the Supreme Court..

  • John C. Key MD

    I visited (socially) with a patient today who liked Obamacare. First, she has qualified for a huge subsidy and had a very low premium. Secondly, she had not tried to use any of her coverage. I suspect the worm will turn for her eventually.

  • James O’Brien, M.D.

    Examples of bipartisan coming together:

    The farm bill.
    The Iraq war.
    Community Reinvestment Act.
    Bailouts for investment banks.
    Medicare Part D, unfunded by any increase in taxes.

    Here’s a different way of looking at it: getting along isn’t as important as doing what’s best for the country or the patient.

    If one side says 2+2=4 and the other 2+2=6, then 2+2=5 isn’t an honest compromise.

    Speaking of the farm bill, the American food supply is a harbinger of what will happen with ACA. Food is the most basic component of health, and they completely screwed that up for the benefit of Monsanto. ACA is already being screwed up since EHR benefits no one but the crony capitalist IT vendors on K Street.

    The government could give a damn about poor people except manipulating them for their votes. Proof: state lotteries, inner city public schools, and subsidizing junk food.

    • Dr. Drake Ramoray
      • James O’Brien, M.D.

        Dr. Jane Orient gets it and reminds us of the history of the AMA and ACP:

        http://www.westernfreepress.com/2013/10/02/no-we-dont-have-a-plan-to-blow-up-the-bridge-or-the-healthcare-system/

        “Publications of the American Medical Association and the American College of Physicians in the late 1970s and early 1980s put a generally positive spin on the Cultural Revolution. They never ever alluded to the mass casualties. The terms for things they admired in Mao’s China permeate the American healthcare reform literature today: wellness, prevention, and “team effort.” The Maoist hostility to private profits and instigations to class warfare are echoed in the constant drumbeat about “disparities” in the U.S. healthcare system.”

        “The changes in healthcare in China would, I believe, have been impossible except in the context of revolutionary change in the entire society,” wrote Victor Sidel in 1975 in the Archives of Internal Medicine. “As we think about the necessary changes in our healthcare system, we will…have to examine those changes in the light of the maldistribution of resources and of power in our entire society.” He thought that the Chinese experience “teaches us that we must broaden [our efforts] to include major social changes as well.”

  • DeceasedMD

    yes but how can we ban Doherty?

    • James O’Brien, M.D.

      Only one side lives in an echo chamber. If you are against ACA, you are constantly exposed to pro ACA propaganda. There is no escaping it. If you are for it, and you work at an academic center, you can live in an echo chamber.

      • DeceasedMD

        true but I grow weary of these so called “thought leaders”.

        • Gibbon1

          I’ve be weary of people yammering how we ‘can’t afford’ stuff we’re already paying for. Which is to say, the percentage of the united states economic output devoted to ‘heath care’ is 50% higher per capita than other developed countries.

          So the problem isn’t we don’t have enough ‘money’ it’s that the way health care is paid for an billed creates perverse incentives that increases expenditures. The ACA probably aligns incentives to be somewhat more humane and less perverse. Sure it’s a band aid. But with our political process, self interested oligarchy at the top empowered by ‘mostly’ conservative nutter peons at the bottom, a band aid is all we’re going to get.

          • DeceasedMD

            Also known as the MIC (medical industrial complex.)

  • SteveCaley

    American medicine has had the dwindles for twenty years. Obamacare is just the merciful pneumonia at the end.

  • Patient Kit

    Our healthcare system in the US was a mess long before the ACA/Obamacare. I have plenty of issues with the ACA myself (and yes, I would prefer a single payer system) but I’m not about to start romanticizing healthcare in the US pre-ACA. It hasn’t been working for many Americans for a long time.

    On the bright side, I think we do a pretty good job of having some good lively discussions here at KMD, with plenty of different experiences and points of view represented. I know that many here disagree with liberal me on numerous things. But I enjoy talking to and learning from people with very different experiences and ideas. For example, the doctors here have taught me a lot about what it’s like in rural medicine in this country. They jolt me out of my NYC bubble.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I think the polarization described here, between the two dominant political parties, is as old as the Republic, but unfortunately it is not genuine any longer. Sooner or later, probably later and most likely much too late, this artificially stoked polarization will be rendered irrelevant for all practical purposes, and it will be supplanted by the real and growing polarization of interests between the immensely rich and their hired guns, versus the rest of the country.
    I can’t wait for the day when all of us finally begin thinking the same way about these things, instead of tearing each other to pieces over the availability of marijuana brownies, or the brand of contraceptives that should be covered by this or that job creator, or whatever large chunk of raw meat is thrown our way to distract us from the real issues.

  • guest

    Quite honestly, I don’t really think that the hijacking of our healthcare system (and our legislative system) by special interests such as giant insurance companies should just be of concern to “liberals.” It should be of concern to any patriotic American.

  • Thomas D Guastavino

    Before I attended medical school I obtained a Masters Degree in chemical engineering. It was my engineering training that thought me critical thinking and how to analyze a problem thoroughly with one goal in mind. Simply put, what is the best way to solve a problem. With that in mind I approached every problem with one dictum: “Do What Works”
    So perhaps the the reason you don’t understand why we can’t come to consensus on Obamacare is precisely because everyone is looking at it is from a politicians viewpoint when they should be looking at it through the eyes of an engineer.
    Years ago when I first heard about Obamacare I made that exact analysis. Suffice it say what I thought was going to happen happened, except even I was surprised how badly they handled the website.
    By the way, is it OK now to call it Obamacare, or the ACA?

    • Patient Kit

      Obamacare and ACA are both used pretty interchangeably. It’s a free country. We can all call it whatever we want to call it. Although, as you no doubt know, Obamacare is used more by people who hate the ACA and aren’t too fond of our president. For better or worse, the ACA is and will remain President Obama’s legacy legislation.

      Full disclosure: I worked on President Obama’s first presidential campaign and I’m disappointed in the ACA. But I also know that it’s easier to modify and amend existing legislation than it is to either pass it or repeal it. (It was no easy thing to get something like the ACA passed). And I hope we can do that by keeping the parts that work and changing the parts that don’t work. Or moving to a single payer system. I have a feeling that my former senator, Hillary Clinton, might have a few ideas about what to do with the ACA.. ;-) You may wonder why I didn’t work on President Obama’s re-election campaign. That would be because I was busy dealing with my own newly diagnosed ovarian cancer more than a year before the pre-existing conditions clause of the ACA kicked in.

      • Thomas D Guastavino

        I am sorry to hear about your health issues. We are all in agreement that the goal is make sure patients can get the care they need. It the method of achieving that goal where the disagreement lies.
        First: Let just call it the ACA and be done with it.
        Second: The ACA passed when the Democrats had monopolistic control. I doubt it would pass today.
        Third: If the problem is solely that there are parts that need to be “fixed” then the question arises as to why these problems were not addressed in the original legislation? Were they ignored? Did we lie to ourselves as to what was the Democrats actual goal? Did the Democrats believe they could lie their way past it? All I know is anyone who took the time to critically analyze the law as written could have predicted what was going, and for matter, what is, going to happen.

        • Patient Kit

          Thank you for your well wishes. It’s been a real struggle since my dx but I’ve been very lucky. My cancer was caught at an early stage, I have an awesome GYN oncologist and I’m still alive and kicking. I’ve told my personal story too many times here at KMD but the short version is: layoff from 18-yr job > loss of insurance > OVCA dx. You’d think the cancer would be the hard part. But accessing the medical care I needed and dealing with our system was harder than cancer.

          My dx sent me into a financial downward spiral since it happened while I was uninsured and my new pre-existing condition made new insurance inaccessible. When I was broke enough to qualify for Medicaid, it covered truly excellent care at one of NYC’s teaching hospitals/academic medical center systems. An expensive way — for the system — to get care, I know. But also my only personal option. The need to stay on Medicaid until the pre-existing conditions clause of the ACA kicked in on Jan 1, 2014 opening other insurance options, delayed my job hunt because I couldn’t risk losing Medicaid coverage.

          Now I’m working freelance with no insurance benefit while job hunting for a job that does provide good insurance. For now, I’m covered by transitional Medicaid. But if that gets cut off before I’m covered by a new employer’s insurance plan, I may have to check out the exchange plans to cover the gap period. I hope I don’t have to personally test one of those exchange plans but, if I do, I’ll be sure to report about my experience with it here. I do know that the hospital where I am currently receiving my care does accept at least 6 of the exchange plans. So, at least, I wouldn’t have a plan that nobody accepts. I’m not looking forward to being an exchange plan guinea pig though. But you can probably understand by now why, from my POV, the ACA is better than nothing (I hope).

          As for why it passed in the state it was in, my take is that it was pushed through while the small window of opportunity was open. Some liberals think it was a sell out to the insurance companies and some conservatives think it was set up to fail so we could next move to single payer.

          I think healthcare reform in this country is still a work in progress and that we should all be involved and make our voices heard. People like me were tragically falling through the cracks pre-ACA and millions of Americans are still falling through the cracks. I don’t know where healthcare reform will go in the future. All I know for sure is that we can’t go back to what we had pre-ACA. If our system was working well then, there would not have been the opportunity to change it so radically (even though the changes aren’t radical enough for some of us).

          I hope it can be worked out so that we have a system in which all Americans can access good, affordable healthcare. That’s what I want. I’m open to any way that will provide that. But I don’t really see how we do that unless healthcare stops being, first and foremost, a big huge enormous profit-driven business.

          I do love that KMD is a place where we can discuss this from very different points of view. I’m not a fan of preaching to the choir or listening to echos. Whatever you think of me, my mind is always open to new ideas.

      • Dorothygreen

        The ACA is flawed because our politics is flawed to the core. We need a health care system not continued patches. We don’t have much time. The cost of health care in the US is unsustainable and we are on a financial cliff’s edge. It can be fixed, it must be fixed. Or those players in health care who have accumulated millions unfairly at the expense of individuals and the government will just become part of the moneyed ruling class in the evolving inequality paradigm of rich and poor and no middle.

        The history of how this mess came about is well documented from over 100 yrs ago until 1983 by Paul Starr in The Social Transformation of American Medicine – The making of a sovereign profession and vast industry,. With regard to hospitals, it was Rosemary Stevens book – In Sickness and in Wealth. The titles speak to the greed. And it has only gotten worse since.

        As long as there continues to be a belief that the “free market” should play a major role in healthcare we cannot have a system. As long as we separate the poor with Medicaid we cannot have a system.
        Subsidies for health care (insurance) will always be needed but can be accomplished separate from the health care system.

        Having a health care system means starting with a level playing field for all the players – physicians, hospitals, Pharma, Lab, Medical equipment etc. And insurance companies. I add insurance companies because a single payer (i.e) government administration of the system is not the way to go. A single payer will not provide the choice, administration of the program will make government bigger and pull jobs from the private sector for administration. It is better done by insurance companies. However, as Switzerland did, for-profit premiums for basic services must be outlawed. And the companies allowed to sell supplemental insurance for services beyond the basic. The system is functioning very well at half the cost/capita of US healthcare.

        Physician organizations should be studying the Swiss system seriously as a better way than a single payer. . Cease the tedious discussions about the ACA and spend the time understanding how health care should be – inclusive of what is fair for physicians – so the ACA can morph into a system. Be ready to negotiate

    • buzzkillerjsmith

      Chem eng is a good field, 80k or something at a bachelor’s level. A lot of beer for a 22 year-old guy. But you do need to understand non-homogenous linear differential equations and eigenvectors and suchlike. Keeps out the riffraff.

      Why the heck are you doctoring when you had such a bright future ahead of you?

  • buzzkillerjsmith

    Let me see if I’ve got this.

    There is much political disagreement in the US about many things, including Obamacare. Moreover, people with liberal views are irritated by those with conservative views and vice versa. Then of course there are a lot of people in the middle who aren’t paying much attention. And it’s kinda hard to know what to do about all this.

    Bob, your insights are truly astounding. What would we do without you?

    • Patient Kit

      It is painfully obvious that not everyone thinks like me. The OP really didn’t need to point that out. ;-). My dad, who was conservative and somehow raised two very liberal daughters, always told us that he was just glad we were paying attention to what is going on and that we had strong informed opinions about important things even if we disagreed with him. I think he thought we’d get more conservative as we got older. Didn’t happen. Personally, I have a harder time with all the people in the middle who are oblivious or apathetic and don’t know what is going on or have opinions about them. I’d much rather discuss things with people who disagree with me than talk to people who aren’t paying attention at all. Sometimes we even learn from each other when we talk to people who don’t think just like us.

  • Karen Ronk

    Our system has been so corrupted by money that it is difficult to see a way forward. When a former president and his wife can become multi-millionaires just for giving speeches and then call it “hard work”, we are truly through the looking glass. Until we find a way to take money out of the equation, there is no incentive for agreement. Politicians know that staying in power is the way to map out the path to riches and therefore continue to raise as much money as possible. Big Donors tend to be on the extremes. Figure it out.

  • Ava Marie Wensko George

    Considered and respected….Therein lies the problem. The extremes of both sides are not respectful. As you can see by some of the commentary below, civility has gone out the window. Our Democracy works best when opposing views come together in compromise. On one side we have the Party of NO! On the other, we have …. well, I am not sure what, but they certainly do not fight for their beliefs. This is a powder keg waiting to blow. Unfortunately, for one side compromise is out of the question and for the other….they keep pushing for it with no results….I’m not sure what will happen, but this I do know….Respect, civil discussion, and work on our nation’s problems starts with me….a committed progressive. Any conservatives out there willing?

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