By Sandro Galea
November 19, 2018
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This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.

The past midterm elections were widely seen as being among the most consequential in our nation’s history. In the lead-up to the election, voices on both sides of America’s political divide characterized the result as potentially transformative. President Trump emphasized the country’s changing demographics, stoking fears of immigrants with pronouncements like, “If you don’t want America to be overrun by masses of illegal aliens and giant caravans, you better vote Republican.” Former President Obama, for his part, said the midterms “might be the most important election of our lifetimes,” and that nothing less than “the character of this country is on the ballot.”

Last week, the country spoke, and we saw what the tide of marching, organizing, debating, phone banking, tweeting, and door-knocking has led to: Republicans expanded their Senate majority, while Democrats gained control of the House of Representatives. Time will tell if this result proves truly transformative. History, however, has shown just how significant electoral change can be, when shifts in the balance of political power overlap with a societal demand for change. Such a convergence can make seemingly intractable problems give way, even after decades of gridlock.

Perhaps the 1964 election, some fifty years ago, offers a useful example. In that election the Democratic party won significant majorities in the House and Senate. Until that time, the cause of providing health coverage for older and low-income Americans, long part of the national political conversation, had been unable to overcome Congressional resistance in order to become law.

In the House of Representatives, much of this resistance came from Congressman Wilbur Mills, chairman of the House Ways and Means Committee. Mills believed such a health care program would be fiscally irresponsible, and so refused to bring it to a vote in the committee. The election results “persuaded” Congressman Mills. As the election paved the way for Democrats to add liberal legislators who supported health care to the Committee, Mills saw he had been beaten, and not only relented, but became an ally of what he had opposed, helping to shepherd through Congress the landmark legislation that would become Medicare.

Mills’ about-face in the wake of an election teaches an important lesson. It shows that apparently intransigent forces can be swept aside by changes to the political power dynamic. These changes culminate at the ballot box, but they begin with changes in our national conversation, which create the demand for a new status quo. Democrats led by Lyndon Johnson may have brought Medicare to fruition, but moving the US towards a system of universal health care had been part of the political conversation since at least the days of Theodore Roosevelt. Johnson added to existing arguments for health care a moral appeal based around honoring the legacy of the recently-murdered President John F. Kennedy, who had supported universal health care.

This appeal, which fit within the broader social and political shifts of the 1960s, informed a demand for the government to do more to help the vulnerable and the dispossessed. This new context meant that when Democrats won power, the stage was set for fundamental changes in how the country cared for the health of its people.

There are signs that the US may again be on the cusp of such change. According to a 2018 Gallup poll, “the availability and affordability of health care” is at the top of the list of Americans’ concerns. This concern was reflected by the outcome on November 6, when, across the country, voters embraced Medicaid expansion, coverage for preexisting conditions, and, in many places, single-payer health care.

But voters went even further than their support of health care, to endorse policies that improve the social, economic, and environmental foundations of health. We cannot be healthy if we lack the money to afford the resources that generate health, or if we are threatened by gun violence, or if our basic civil rights are in doubt. It is therefore heartening that voters in Washington state endorsed a ballot initiative raising the legal age for purchasing assault rifles, that voters in Arkansas opted to raise the state’s minimum wage, and that voters in Massachusetts chose to reject a ballot measure that would have stripped transgender people of their right to navigate public spaces without fear of discrimination.

Taken together, I would suggest that Americans in this election voiced their desire not just for health care, but for health. And in the case of guns, in Washington state and elsewhere, we are seeing how a particularly stubborn status quo—resistance to commonsense gun safety reform—can change in response to a demand for health, when this demand is wedded to political action.

These results suggest that shifts as seismic as those that led to Medicare may be on the horizon. We are living during a disjunctive national moment, when established norms are evolving and the demand for health has converged with electoral change.

Yet these changes, notwithstanding the historical echoes they evoke, do not guarantee progress. And certainly, there were mixed results on other issues important to health, particularly around reproductive rights. But this election reminds us that to create a healthier country, we must continue to demand health.

For many, the social and political shifts of recent years have been disorienting, and moves towards progress may seem tentative and incomplete. Yet these moves are steps in the right direction, a start. Just as we should not let our history lull us into thinking progress is inevitable, we should not let present challenges stop us from seeing the many opportunities at hand.

For years, progress towards Medicare was slow, piecemeal, until suddenly it was not. As much as Medicare’s passage was a part of John Kennedy’s legacy, it may have been his brother, Robert, who best expressed the process that brought it about, when he said, “Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance.”

The results of the midterms suggest we are living at a time that could indeed be transformative, with many ripples converging toward the creation of a healthier world. To keep them flowing in the right direction, we must keep the national conversation focused on the social, economic, and environmental causes of health, and on the policies that shape them. The stakes are nothing less than the health of our children, grandchildren, and all who will one day look back at our age and wonder if we were clear enough in demanding health.

Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book, Well: What we need to talk about when we talk about health, will be published in May 2019. Follow him on Twitter: @sandrogalea

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