How Trump counties should instruct health reform

A few weeks ago, before the demise of the American Health Care Act, President Trump sat down for an interview with Tucker Carlson at Fox News. Citing an article from Bloomberg, Carlson informed the president that the counties which voted for him “would do far less well under the bill than counties that voted for Hillary,” were it to pass. Whether intentional or not, Trump agreed with his assessment, noting the contradictions between the bill and his campaign promises.

When Carlson mentioned “middle-class and hardworking counties,” he was probably thinking of places like Aroostook County, known for its storybook towns and potato fields. Since 1992, Aroostook County has been a stronghold for Democrats, but in 2016, political winds blew in another direction; Trump won the county by 17.3 percent.

Of course, many counties shared similar stories at the ballot box in 2016, flipping from Obama to Trump (219 total out of more than 3,100 nationally). But Aroostook doesn’t seem to fit the classic confines of “Trump Country” we’ve come to understand — of rural communities in the Rust Belt, with economies toppled by the forces of globalization, and concerns about incoming immigrant populations. The economy of Aroostook is built on agriculture, fishing, and tourism — not on manufacturing. Community leaders, over the past year, have tried to pave more paths for refugees and immigrants to settle in their county — rather than keep them away.

Clearly, there was something else going on in Aroostook.

As students studying medicine and public policy, we began to wonder how health may have impacted the voting behavior of this county, and others like it, last November. Throughout 2016, headline after headline of the Bangor Daily News, the local newspaper, documented the failures of the Affordable Care Act (ACA) for the citizens of Aroostook and its surroundings: “Maine’s largest Obamacare insurer to raise rates” (March), “Obamacare insurers request double-digit rate hikes in Maine” (May), “There’s a big problem with Obamacare: It’s not affordable for the middle class” (September). Aroostook is not alone in its struggles with the ACA. Stories from enrollees and data from think tanks indicate that rate hikes, increasing deductibles, and decreasing insurance options on exchanges are nationwide problems. To be fair, the ACA had profoundly positive effects on American health care, reflected in the 7 percent decrease in the national uninsured rate between 2012 and 2016. But in Aroostook County, the uninsured rate actually increased from 16 percent to 18 percent.

For voters from places like this county in northern Maine, perhaps it wasn’t economic anxiety or trade agreements or even elitist politics that prompted a Trump win. It was Obamacare that failed them.

We came to this conclusion after looking at voting patterns in 2012 and 2016 and discovering that they tracked changes in health care metrics collected by RWJF’s County Health Rankings.

Even after controlling for income, which accounts for factors like economic anxiety and unemployment, the story of Aroostook County does not seem unusual. Demonstrated in the graph below, the higher the uninsured rate in a specific county last year, the more likely its voters chose Trump. This association grew even stronger when we omitted adults and focused only on the uninsured rate for children.

While this analysis isn’t strong enough to establish causation, the story it tells, of partisan gridlock and frustrations with health care swaying the minds of voters, is certainly plausible. Perhaps an uninsured voter took a chance on Trump not because of Facebook memes but because of constant knee pain, and his inability to afford the painkillers, the cortisone shots, or the surgery needed to alleviate it. Another may have thought about her mother’s missed doses on her expensive prescription medications while standing in the polling booth. Pathology, and a powerlessness to treat it, could have influenced crucial votes.

Our findings suggest that health care can help explain the decisions of the electorate last November, and how to move forward today. To many, perhaps this result isn’t a surprise, given that the repeal of the ACA has served as a rallying flag for conservatives, and the hope of saving it has filled a similar role for progressives today, particularly over the past week. While access to health care improved nationwide, some communities were forgotten in the heat of bitter partisanship. Given that they tilted heavily toward Trump and his anti-establishment message, it’s likely that voters in these counties held both parties culpable for their frustrations.

The recent failure of the AHCA presents an opportunity for fresh ideas and a new wave of bipartisanship in health reform. As aspiring physicians, we hope Aroostook’s story will be instructional for policymakers on both ends of the political spectrum. Democrats ought to acknowledge that although Medicaid expansion and state-based exchanges have expanded coverage and improved access, they have their shortcomings — like increasing deductibles and narrowing provider networks. On the other hand, Republicans should recognize that block grants for Medicaid and high-risk pools, cornerstones of conservative health policy, are unlikely to rescue Aroostook.

Instead, they would threaten access to quality care for the sickest and most vulnerable Americans. Citizens of these counties are hurting, and their issues with health care warrant more than dogmatic plans built upon abstractions, and legislative sabotage done for cold political gain. Whatever path health reform takes, they deserve to share in the gains that much of the country has seen over the past few years. We owe them no less.

Suhas Gondi and Evan Beiter are undergraduate students. Vishal Khetpal is a medical student.

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