Why I voted for Obama

A couple of weeks ago, I submitted my ballot.  Because I am afflicted with a weird case of mild obsessive-compulsive disorder/anxiety, I checked and double-checked and then checked again that I had filled in the ovals by the names and choices I supported.  A friend of mine happened to be in the town office at the same time, and I actually had her check my ballot to make sure I hadn’t accidentally voted for the wrong person.  (Tune in tomorrow for the spin-off Stupid Question!)  She was happy to confirm that I’d voted for the people I’d wanted, though she left before I could have her confirm my “yes” vote on Question 1.  (Predictably, I am now slightly anxious that I somehow accidentally voted “no,” despite my having quadruple-checked it before I put it in the envelope.)

Thus, I can state with happy confidence that I voted for Barack Obama, just like I did four years ago.  (I am not, however, taking Election Day off to volunteer for the GOTV effort like I did last time, largely because I didn’t vote straight-ticket Democratic and don’t want to have to canvass in support of a Senate candidate I don’t want to win.)

The title of this post is slightly misleading.  I have lots of reasons for voting in favor of a second term for the President.  He has come out in favor of my right to get married.  His party doesn’t have a distressingly-high number of office-seekers making disqualifying statements about rape and pregnancy.  I find the mendacity of his opponent appalling, and the flagrant, gleeful obstructionism of the Republicans in Congress borderline seditious.  I trust him far more on foreign policy.  Etc.

But I have another salient reason, similar to but distinct from Tod’s.  It has to do with a conversation I overheard a few years ago.

As I’ve disclosed, I live in Maine.  For five years I worked in a practice there, before leaving that area and taking my current job in Massachusetts a couple of years ago.  In that office, my computer station was behind the front desk, but hidden behind a partial wall.  Even though I couldn’t see people as they checked in and out, I could hear their conversations.

One evening a mother with several children in our practice was checking out and the woman at the desk told her what the charge for the visit would be.  It was much more than she could afford.  For reasons I do not recall well now, her family had lost its insurance coverage through her husband’s job, but they still made too much to qualify for the state’s Medicaid program.  So they were newly part of our large “self-pay” population.  And the bill for the visit was higher than she thought it should be, and more than they could afford.

Of course, I felt terrible overhearing this.  I had nothing to do with setting the rates for the office visits, and had billed the appropriate amount for the complexity of the care delivered.  Technically I could have revised the billing code downward upon hearing that the family lacked insurance, but doing so would have been fraudulent.  (Doctors can get into oodles of trouble if they bill different patients different amounts based upon insurance status.)  I had essentially nothing to offer to mitigate the expense, but felt responsible for the hardship it had created for this woman and her family nonetheless.

I now work in a state where patients are universally covered.  Indeed, this state of affairs is in large part due to the efforts of one Mitt Romney, quondam governor of Massachusetts.  It means I never have to worry that charging patients for my services means they won’t have money for their food or utilities or rent.  I worried about this all the time in my last job, and I do not miss it now.

That mother in Maine was not unique.  She was not unique to our practice, not unique to that state, and not unique in her circumstances.  And neither was I unique in my worry for her.  I want that worry to disappear for everyone everywhere.

Do I think the Affordable Care Act is perfect?  No.  I will admit that I do not think I even understand it fully, with its mass and complexity.  At best, it solves only part of the problem, the part dealing with individual patient coverage.  It does little to control costs, which is the conversation nobody wants to have.  I am under no illusions that it is flawless.

But it is a start, and a good framework on which to build further reforms.  And, put bluntly, I have no confidence that the GOP has any intention of either meeting that challenge, or (if met) doing so in a way that will safeguard the interests of the people most in need of help from the state.  Between half a solution and no hope of a solution, I’ll take the former.

Like Tod, I admire the political courage it took to keep pressing for the ACA, despite its shaky popularity.  Unlike Tod, I am a supporter of the bill, albeit a tepid one.  Because I never want to overhear another conversation like that one I heard in Maine, I was happy to fill in the oval next to the President’s name.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. 10% off the top around here, due to Obamacare.
    “eliminating waste” they call it (and probably right.)

  2. Now you know how many of us felt about Bush in 2004 after getting No Child Left Behind passed. It was an equally flawed bill but it was a start in the right direction. That made it easy for me to give him my vote that year.

    • No Child Left Behind was….godawful in practice. I don’t recall the debate originally, or what it was supposed to do, but the end effect of the thing was pretty much what most educators I knew said: A ticking time bomb of crap.

      I recall my mother (she was a diag at the time, so her days are spent with special needs children) flat out stating that under that terms of NCLB, she’d be getting harassed to declare kids special needs almost at random while the school panicked and focused on a handful of students a year to prevent demographic slide and being labeled ‘failing’ because, oh, third grade hispanic kids scores dropped from the year before.

      Then again, she’s pretty aghast at the state of special education in general. Lot of unfunded federal mandates out there, which leads to an often antagonistic relationship between schools and parents. Parents who want schools to adhere to the law, and schools who literally don’t have the money to so try to avoid labeling needs students as such.

      (One idiotic thing I saw first hand — a Texas school district deciding to handle virtually all learning disabled students as dyslexic. Yep, no matter what variant of LD your kid was, no matter their needs, they were going to be handled as dyslexic. It was cheaper and could be done in groups. Strangely enough, did not work out in practice. Which is the sort of fun you get when your special needs department is run by someone less than five years out of college with no background in special needs and no clue about the law, but is a sibling of a big-shot school board member.

    • It was an equally flawed bill but it was a start in the right direction.

      The first clause is undoubtedly correct. I have great doubts about the second clause.

  3. I am proud to be a Canadian and to live in a country where people are covered for all of their basic and the overwhelming majority of their advanced healthcare needs. It is not a perfect system; there are cracks and flaws, and like many countries we’re just beginning to get our collective policy head around the issue of people living into their 90’s as a matter of course. This will put a great strain on home-care needs and long-term healthcare facilities, to name only two.

    Four years ago I spent Christmas in the U.S. and was able to reassure a number of old people on the bus with me that “Canadian-style healthcare” as it was then being derided by Republicans did not mean that old people were killed in hospitals or that you were forced to only go to the doctor the government picked for you or whatever the other crazy lie-of-the-day was. They stared at my Ontario Health Insurance Progam (OHIP) card as if they thought it would transform into something weird right in front of their eyes. And when I asked them why they assumed that people in other countries would tolerate that kind of thing, they had no answer. I found it a very creepy experience.

  4. Did you hear about the doctor who had a radio talk show? He did a segment on OCD and got amazing feedback — 30 calls! All from the same guy.

  5. As is probably known by now, I’m not big on leaders who put outcomes ahead of process, so I come to the exact opposite conclusion on pushing through the ACA “despite its shaky popularity.” Just taken as a piece of legislation, I’m also not at all confident it is “a good framework” for anything. Like so much other Progressive (i.e., conservative) legislation, it puts regulators and the regulated in league together, with the end result that consumers are put last — after politicians get their votes and private interests get their profits. This happened with oil and steel and banking and the auto industries 100 years ago, and ACA seems to me cut from the same cloth. What all these kinds of laws have in common is they satisfy a certain desire to create a stabler and “nicer” society. But the outcomes tell a different story.

    • I’ll say this, though.

      Regardless of your political leanings, and regardless of your other voting tendencies, if you have someone with pernicious health problems that was about to hit the lifetime cap and you know that PPACA is keeping you from going bankrupt in six months, it’s pretty likely that (a) you’re going to vote and (b) it ain’t going to be for the guy who says he’s going to repeal Obamacare on the first day of his Presidency.

      Whether or not the bill is any damn good or not (I’ve mentioned before, I don’t like it myself), there is one group of people who are highly motivated to vote Obama (D) for President on that one count, alone.

      • That’s a good point, Patrick. It makes me think, hindsight being … well … what it is, that Obama had a really big card to play there, and didn’t. Personally speaking, I think the community rating/no lifetime cap/etc issue is a huge political winner. No one wants to think that a loved one, or theirownself, could die because insurance companies were too cheap to pay out fr what you’ve already paid in for. If you know what I mean.

        • Obama doesn’t need to make hay out of it. The people that have chronic health problems in their family do it. I see the posts go by on Facebook all day.

          • Well, it’s good to know the message is out there. We’ve got a few people in our extended family who are voting Obama for pretty much that issue alone. I just haven’t seen the policy politicized, as it were.

      • As a matter of social policy, I don’t have a problem with the ban on pre-existing conditions. Balancing that against the importance of personal responsibility, my proposal would be to have periods of open enrollment, say, until the age of 25, or up to 35 or so if we’re being generous (that’s about enough time to get through the irrational risk-prone 20s). It gets a bit more expensive each year you wait in order to encourage early enrollment and cut down on moral hazard. But when the window closes, you’ve made your decision. If you quit a health plan (such as getting laid off, or any other reason), you’d have a window (say, two years) to re-enroll irrespective of pre-existing conditions.

        Seems to me that would strike the right balance between freedom/responsibility on the one hand and guaranteeing insurance to everyone who needs it. Whether they actually get care, however, is another question entirely!

        • I might be wiling to endorse an enrollment-window plan, but my preferred one would require that any one enrolling outside the window would simply have to pay a really large “initiation fee” to make up for the months they didn’t have insurance. I wouldn’t totally leave out those who decline to enroll during the window.

      • One of my FaceBook friends is a cancer survivor, is autistic and has epilepsy. She is over-joyed by the PPACA, with what I think is very good reason.

    • Well, obviously I support the law more than you do. No big surprises there.

      I am curious what kind of better process you could possibly have expected, given Mitch McConnell’s saying outright that his #1 priority was depriving the President of a second term, and numerous GOP MOCs also confirming (on the record or off) that they were told to oppose everything the President put forward. How on earth could he have used “the process” any better? If the GOP had been invested in making the bill better and then supporting it, they could have. But they chose obstructionism instead, so the process failed as much (more, in my opinion) because of them as the President

      • I’m ambivalent on the “toxicity” issue of partisan politics. On the one hand, I tend to agree that it’s abhorrent. On the other hand, there are some serious differences on really big issues about what the nature of our government in D.C. is: is it still a federal government, or is it a national government? Even on that there are sub-issues: don’t we need a more vigorous national government? Aren’t politicians just paying lip service when they talk about federalism and limited government? Etc. But opposing single-payer was a big issue. And ACA is significant beyond its role in addressing health care. In my opinion, ACA or something like it was a foregone conclusion. It was going to happen with or without Republicans. On this issue, I agree with their dissent.

        Personally, I wish “my side” would have pushed while it had the chance (e.g., during the W. years) for some measures in line with free market principles, such as deregulation to let nurses treat certain injuries and conditions without the need or expense of seeing a doctor for every minor thing, to allow insurance companies to transact across state lines, etc. That would be a desirable alternative from the pattern that has emerged in modern American regulation: We regulate an industry; the regulation triggers rent-seeking and unintended consequences and other market distortions; those problems in turn are cited as the basis for imposing yet more regulations; rinse and repeat. For once, I’d like to see one of the Parties break that cycle. Whatever good ACA might do, it is still working within that cramped and twisted model.

        • I guess I’m not seeing the substance of your objection to the ACA on procedural grounds. Given that the GOP in the Senate has used every privilege and procedural tactic they can to stymie and stall every single part of the President’s agenda, I can’t understand why you would fault him for using his own procedural advantages to advance it.

          • I have a question for you, Russ…

            I’ve been reading that, under the ACA, quiet work has been done to create a 50-state federal non-profit insurance system based on the what federal employees use — effectively gearing up to offer the same healthcare options available to federal employees to any citizen (via the exchanges).

            A public option by another name, perfectly legal under the ACA and with most of the ground work already in place (given there are federal employees insured in all 50 states).

            It wasn’t something anyone seemed to be predicting would happen — I was wondering what you thought of it?

          • morat,
            Havent’ heard of that.
            I do work for a medical nonprofit that provides its own insurance (you’ve heard of it, it’s the fifth largest independent health care provider in the country).

            I think the economies of scale weigh in towards combining insurance with the “going to be more profitable” hospital system.

            (also, the for-profit insurers really really suck)

          • Here.

            It’s not a public option. It’s a for-profit and not-profit (two plans) that is being set up by the federal government as a multi-state plan.

            They’re not extending federal insurance (I was wrong on that) — they’re basically setting up two large, multi-state group plans (one for and one not-for profit) and having insurance companies bid to provide services.

            Basically how any big multi-state employer works, really. Those plans will go on the exchanges in all 50 states. Gives insurers the benefit of a having a large group to handle instead of individual policies, gives purchasers some of that lovely big-group leverage in haggling terms.

          • I’m not familiar with what you’re describing at all, Morat. That said, if it functions in essentially the same way as a public option, I’m all for it. The lack of said public option was my signal objection to the ACA.

          • Eh, it turns out my understanding wasn’t fully correct. The federal government, to ensure there was at least one for and one non-profit option, is basically acting like a large-scale 50-state employer and soliciting bids from insurance companies.

            Two of the plans on the exchanges (or at least two submitted, as some states have limited slots) will be done by the US government, but the insurance will be third party — sorta like, oh, Lockheed offers Cigna and UHC (I have no idea what they offer) to all it’s employees in all 50 states.

            I’d prefer a real buy-in to the federal system myself.

    • Tim,

      Your objections are well noted, although I agree with Russell when it comes to asking what process one might have expected.

      I’ll add another thing. One of your critiques, that the ACA is cut from the same cloth as other regulations that put “regulators and the regulated in league together, with the end result that consumers are put last — after politicians get their votes and private interests get their profits,” could be leveled, with a high degree of accuracy, at the pre-ACA regime, with the exception that admittedly some consumers who were lucky enough to be employed by someone with a large group plan might enjoy better access to coverage.

      Now post-ACA, we have many of the bad things you note from before, along with the possibility (probably a real one) that some people will have to pay a bit more, but we have also, in theory at least, insurance plans that can’t deny people coverage.

      • Pierre, you’re completely right about the pre-ACA model. I alluded to that at the end of my prior comment, though not by name.

        I know he’s loathed, but John C. Goodman’s recent book, Priceless, was quite good in explaining how federal health policy, both before ACA and now under it, distort the delivery of both health insurance and health care (two very different things that we too often tend to conflate). I’ve been trying to find an angle to write a post on it that’s not just a Cliff’s Notes summary.

    • ” I’m not big on leaders who put outcomes ahead of process”

      In that case, you should shun the GOP altogether. Their agenda, as Russell states, was very much outcome-driven: get rid of Obama. The process, indeed, the specifics of what they were voting on, didn’t matter (4 Senators sponsored a Veteran’s Benefits Bill, then voted against it because Obama mentioned it in his acceptance speech). Obama **TRIED** process and was kicked in the teeth for it (I, again, refer you to Olympia Snowe’s actions during the PPACA debates).

      Will you stand for your principles, or will you use what I consider to be False Equivalency?

  6. “Doctors can get into oodles of trouble if they bill different patients different amounts based upon insurance status.”

    Let me ask this, as it is something I wondered about.

    When I began treatment with him, my PT was in-network and I paid a $20 co-pay. During the course of treatment, he went out-of-network. He said this was a good thing because he was willing to waive my portion of the fees. So he submits a bill to insurance, they pay out a given amount based on previously negotiated rates and fees, and I owe the rest. Only, he opts not to charge me the rest, collecting only what insurance offers him. As far as I can see from the explanation of benefits, he is charging for the appropriate procedures (no more, no less), he is simply waiving my “balance due”.

    Is this legal? Ethical? Appropriate?

    • If I understand correctly, you can waive a portion of your fees. For example, you can offer patients a lower copay if they pay cash at the time of service. But your baseline fees for service (a model, by the bye, that is slowly dying) must be consistent from patient to patient regardless of what (if any) insurance they have.

      • That seems to be the case, at least as I understand it.

        He charges me X. Insurance covers Y. Technically, I owe X-Y. He waives this. I assume he charges the same X to everyone since it is all done via coding and goes to insurance first. But I will confess to not knowing this specifically.

  7. Russell,

    I’m rooting for Obama for all the reasons you cite, and the ACA is probably also the most important one for me. However, I still have not made up my mind whether I’ll vote for him, Stein, or Johnson.

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