Tuesday, March 1, 2016

Uncertain Health in an Insecure World – 76

“Health Suffrage”

Elections anoint country leaders.

Their politics and policies dramatically influence many aspects of our lives. The economy and terrorism are often the biggest issues on voters’ minds these days. Around the world, people exercise their franchise with remarkable commonality when it comes to such matters. Healthcare is another day-to-day reality for most citizens, and a key issue for the general electorates of the world. Different countries still vote their consciences on healthcare, with diverse outcomes.

Over the course of history, suffrage has rightly expanded to include women and younger voters. Politicians have increasingly been forced to respond to their pressing health issues – vaccination, reproductive rights, legal marijuana, suicide, childcare, addiction, and mental illness (including gun control).

Another seismic shift has occurred in recent years – the dramatic growth of millennial and senior voting blocs. The former population is characterized by perceived health invincibility, while the latter is increasingly burdened by chronic diseases.

In every developed world jurisdiction, the ever-rising cost of drugs and medical technologies has become a troubling issue for both politicians and patients. In many countries, the pharmaceutical and device lobbies are mighty, often citing this sector’s economic impact (jobs) as rationale for being afforded protected status. Their campaign donations are permitted, Hell encouraged, and this flow of dollars is highly influential among mainstream politicians.

Diseases do not favor poorer liberals or monied conservatives.

Whatever a government’s social policy bent or economic forecast, the core demands of the healthcare sector remain immutable. Public payer and private insurance systems are essential job creators, and a hospital is as critical to a community as a school. The social and economic fabric of many communities is inexorably linked to healthcare – its providers, clinics and facilities.
Generational change is an undeniable force in both politics and healthcare. But some politicians ignore healthcare in favor of other popular issues, viewing young voters as generally healthy and unconcerned, and older voters as locked-in. Politicians do this at their own considerable risk.

In 1988, the two most populous countries on their respective continents passed constitutional amendments reducing the voting age from 21 to 18.


There were 309M voters in India’s 1989 Parliamentary election. In 2014, 554M voters vied to elect Prime Minister Narendra Modi (above). With 50% of its current 1.3B population aged <30 years, India is the world’s most youthful democracy. Their support was wooed by parties from across the entire political spectrum. While young Indian voters are far from apathetic, the proactive Youth Elect 2014 drive was designed to get out their vote. It worked – 150M votes were cast by 18 to 23 year olds!  The primary youth voting issues were sexual violence against women (rape), basic human rights (child labor & trafficking, gay rights) and economic inflation.

India’s present healthcare system is predominantly private, with high (~70%) out-of-pocket costs. Less than 10% of the population has healthcare insurance. The quality of care in the largely rural public sector and primary care programs is considered poor (India ranks 112 of 190 countries overall). Universal health coverage is being actively discussed as a focus of India’s twelfth 5-year plan.


The same year that Brazil reduced the voting age from 18 to 16 years, constitutional reforms enshrined health as a citizens’ right, requiring universal equal access to healthcare.  There were 71M voters in 1990, and 113M voters in 2014 when Dilma Rousseff (above) won the Presidential election in a runoff. Of 205M Brazilians, 2.3% of the total electorate was aged 16 and 17 years, turning out from Sao Paolo to Amazonia to vote. Unlike 18-69 year old Brazilians, voting is not compulsory for this teenage cohort. Before the election, youth activist and protesters (below) focused on issues like education (cost, access, quality), the environment (Green movement), progressive social programs (legalizing marijuana, anti-crime) and political corruption (the World Cup).

According to Deloitte, in 2015 Brazil had a mixed public (75%) and private (25%) healthcare system. Most inpatient facilities are privately run, and most outpatient care is provided by the “free” universal public healthcare system (SUS). Care is rated as bad to mediocre by 80-90% of the population, with lengthy waiting times and difficult access to complex medical procedures. Governmental policy is now turning to a revamped family healthcare strategy that primarily targets the poor.

In the 1970’s, the world’s biggest and oldest democracies (U.S., U.K., Canada, Australia, and France) reduced the voting age from 21 to 18 years (Japan has yet to follow suit).

United States

 In the U.S., this change was prompted by the Viet Nam draft anti-war movement (see SCOTUS’ Oregon v Mitchell, 1970); the U.S. Congress passed the 26th Amendment in 1971. Several U.S. states (California, Florida, and Alaska) and some European countries (Denmark, Austria, Scotland, and Germany) have recently dallied with 16 year olds voting.

Twenty U.S. states (above) permit 17 year olds to vote in Presidential primary & caucus elections if they will turn 18 by Election Day. Many of these states are early momentum changers for both Democratic and Republican candidates. As such, the ‘youth vote’ is curried with great ardor. One of the key youth-oriented planks of the 2010 Accountable Care Act was the extension of parental insurance coverage to 26 year olds.

In the 2016 U.S. political cycle, adversaries from opposite ends of the spectrum – Donald Trump and Bernie Sanders – are to varying degrees, both embracing the ‘mandate’ for healthcare insurance enrollment. Sanders wants a “universal” national healthcare plan, as supported by 58% of Americans in a 2015 Kaiser Family Foundation poll. And while Trump would repeal Obamacare (“a disaster”), Hillary Clinton is doubling down on it. As college aged debt-burdened voters now consider the cost of Obamacare-mandated private insurance, they are getting sticker shock!

In both 2010 and 2014 Pew Research Center surveys of likely U.S. Presidential voters, 77% identified healthcare as a priority. In 2014, 69% of 18-29 year olds identified healthcare as “very important” to their vote, as compared to 79% of those >65 years of age. Similar >10% age splits were observed for terrorism (68% vs 82%), foreign policy (51% vs 71%), immigration (49% vs 69%), economic inequality (68% vs 55%) and the environment (64% vs 48%).

A 2015 Fusion Massive Millennial Poll of 1,000 Americans aged 18-34 (born in 1981 to 1999) showed greater engagement; 90% intend to vote in 2016! They listed the following as “important” in selecting the next U.S. President: economy/jobs (19%), healthcare (11%), education (7%), budget deficit (6%), and border security/immigration (4%). These domestic issues far outweighed millennial's interest in foreign policy (3%), terrorism (2%), and defense (1%).  Conventional wisdom aside, 74 year old Bernie Sanders’ movement has masterfully leveraged these age splits.

In European countries like Austria, lowering the national election voting age to below 18 was proposed in 2007 as a way to acutely reverse declining election participation, while creating a future voting habit. Critics of the under 18 vote argue that teenagers lack the maturity and motivation to participate effectively in the electoral process. They point to relatively low turnout in this demographic group. While teenage cognitive neuro-developmental maturity is comparable to that of young adults, their engagement may be lower due to the early phase of their life-cycle. 

After the stunning 2007 electoral defeat of President Mahmoud Ahmadinejad (above), Iran’s hard-line Guardian Council reversed the voting age from 15 to 18 years. In totalitarian states with a vote, politicians are more interested in suffering than suffrage. Ahmadinejad is gone, but Iran’s youthful voters courageously remain.

"What's the point?", you ask.

Millennial voters are more independent, tech-savvy and diverse than the general population.

Leading up to a big vote, politicians shamelessly shill for these youthful supporters. Sadly, once general election polls close, regardless of age, healthcare for the poor remains generally poor.

Whether evolving subtly or extremely, youthful electorates are increasingly impactful. As a direct result of their growing political power, national healthcare policies around the world are in flux.

With their first ballot, youthful voters begin a lifelong civics experiment that favors future social change. And like older voting blocs, these young people will legitimately vote in their self-interest.

Youthful idealism aside, it's in the enlightened self-interest of this cohort to foster future economic growth and societal stability by casting a vote for health today.

If the youth of the world so choose, they can make health suffrage their New Day social cause. We in the Square are pragmatic enough to believe in the power of such a political movement.    

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