Not News, But History - A New Look at Medicaid Expansion

                لمشاهدة الفيديو كامل HD 
              والتحميل مجانا

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Now that 2014 and Obamacare are both here, there will be plenty of stories about Affordable Care Act implementation.  Some will be newsworthy; but others will just be history. 

Last week, we got our first history story characterized as exploding news.

The Washington Post reported on a newly-released Harvard study that analyzed the impact of the 2008 Oregon Medicaid expansion on hospital emergency department visits.  The study found that there was a 40 percent increase in the number of emergency department visits made by the new Medicaid enrollees.

For the Post article, an MIT health economist (I guess no Harvard ones were available!) commented  that he viewed it “as part of a broader set of evidence that covering people with health insurance doesn’t save money,” something he went on to characterize as a “misleading motivator for the Affordable Care Act.”

And Forbes went farther, claiming the study results are “undermining [the] central rationale” for ACA.

But the Oregon expansion increase wasn’t really news by itself, and it tells us nothing about the Affordable Care Act, either.

There are three reasons for this.

The first reason is that Medicaid recipients, as a group, have always been the most frequent users of emergency department care. 

I learned about this up close when I was involved in a community health project in Austin, TX, more than a decade ago. 

We compared the use of emergency departments for non-emergent reasons by privately insured, Medicaid-insured, and uninsured residents.  About half the visits made by privately insured or uninsured people were for non-emergent reasons.  But 60 percent of those made by Medicaid recipients were for non-emergencies. 

The same thing was true when that analysis was repeated in other hospitals in other parts of the country.

So the new study simply confirms what we have known to be the case for years.  Medicaid recipients use hospital emergency departments for non-emergent care more frequently than those who are not on Medicaid.

The second reason is that we also know why Medicaid recipients have historically gone to emergency departments for their non-emergency care. 

It isn’t that emergency rooms are more conveniently located than private doctors and walk-in clinics.  Or that some hospitals now use billboards, texting, or other mass media to advertise shorter emergency department waiting times.

It is simply because – unlike many private primary care providers – hospitals have historically been paid enough to take part in the Medicaid system. 

But there are new realities under the Affordable Care Act.  More federally-qualified health centers are being approved, and other private primary care providers are seeing increased rates – rates comparable to Medicare – for treating Medicaid patients.

While change won’t happen overnight, this means that over time more private providers will be signing up for Medicaid in the expanded Medicaid program, and more Medicaid patients will be choosing them over hospital emergency departments because they can.

And that makes the results of an expansion program that took place six years ago an interesting history lesson, but as poor a predictor of what will happen in the future under a different set of rules as historical stock market performance is of future returns.

The third reason is that cost-savings was not a “misleading motivator” for supporting the Affordable Care Act.

Despite the suggestion of the MIT economist and the Forbes headliner, it wasn’t actually a reason at all.  When the Act was debated in 2009 and 2010, it was clear to all that it was essentially cost-neutral. 

Both the CBO and the Administration projected that we were going to be spending about the same amount on health care overall for the next ten years whether or not we passed the law.  But the law would distribute the costs and savings differently.

Medicare and Medicaid would take on a slightly greater share of costs.  Out-of-pocket costs not covered by public or private insurance would go down (especially for those with chronic diseases and conditions who could not afford insurance in the past).  And private insurance would continue to pay just about one-third of the nation’s health care bill.

While not everyone in the media may have known this at the time, all the people voting on the law did.

That’s not news.  That’s history.

Just like the new Harvard study.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

B4Stage4

For the past several months, I've been traveling around the country for Mental Health America.

I have been delivering two messages.  The first is that it was a mistake to use a "danger to self or others" standard as a trigger to treatment for people with serious mental illnesses.  Because this has made mental illnesses the only chronic diseases we wait until Stage 4 to treat, and then often only through incarceration.

The second is that if we are to treat people with mental illnesses the same way we treat people with other chronic conditions, we have to act before Stage 4.  We have to start with prevention and then invest in early identification and intervention.  We have to integrate health, behavioral health, and other services.  And we have to give people an opportunity to recover at all stages in the disease process.

May is Mental Health Month. Since 1949, it has been a signature program of Mental Health America, formerly known as the National Mental Health Association.

This year's theme is B4Stage4.  It succinctly gets the message across that we need to turn our attention upstream if we're going to prevent tragic outcomes, and if we're going to change the trajectories of people's lives for the better.

By May 1, more than 3,500 organizations had downloaded MHA's materials to share with others - and many more have downloaded them since.  That's no surprise.  We've had millions of social media impressions with #B4Stage4, and advocates around the country are rallying to its simple and straightforward message.

Mental Health Month materials are available free of charge here, and help explain the importance of B4Stage4 thinking - and action.  They are available in English and Spanish, and there are videos and infographics that go along with them.

It's no secret why this matters to me.  I've had too many all-too-personal experiences with Stage 4 thinking.  It has cost a lot of people like my son Tim the opportunity to lead happy and productive lives.

And we can do a whole lot better than we have in the past - if we're willing to try.

Order a copy of Paul's book, Losing Tim, from your local or online bookstore or directly from Mental Health America.  Read more of Paul's occasional blogs at the MHA website, at Health Affairs, or at Psychology Today.

The Best and Worst States for Your Mental Health, 2015

Where our nation's mental health is concerned, disparity, not parity, rules.

Mental Health America released a new report today.  It's entitled Parity or Disparity: The State of Mental Health in America, 2015.  The report offers the first cumulative ranking of mental health status and access to services for all fifty states and the District of Columbia.

Source:  Data from www.mhascreening.org

The report includes measures of mental health status and access for adults and children, drawn from national databases that are regularly updated.  Altogether, they paint a very interesting picture of how states measure up to one another in protecting the mental health of their people.

The best states for your mental health?  Massachusetts leads the list, followed by Vermont, Maine, North Dakota, and Delaware.  Rounding out the top ten are Minnesota, Maryland, New Jersey, South Dakota, and Nebraska.

There are traditionally liberal and traditionally conservative states in the top ten, so what does that tell us?  Two things at least.  First, neither party has a monopoly on mental health policy, and so political compromise and consensus are more than possible when everyone works together.  Second, treating investments in mental health as a priority matters.

How about the bottom ten?

Idaho, Arkansas, Montana, Oklahoma, and New Mexico are in the next-to-last group of five.  And the bottom five are Louisiana, Washington, Nevada, Mississippi, and - last of all - Arizona.  As it turns out, no single region dominates the bottom ten.  And there's room for improvement most anywhere.

What's the best way to reduce the disparities among the states?  A concerted effort to invest in early identification and intervention would be a start.

Why are mental health conditions the only chronic conditions we wait until Stage 4 to treat, and then often only through incarceration? By that late stage, treatment is expensive and recovery is difficult to achieve - just as it is with Stage 4 cancer or Stage 4 heart disease.

When half of mental illnesses manifest by age fourteen, why do we wait ten years - until the diseases have robbed people of schooling and jobs, broken apart families, cost people insurance and housing - before we step in?

The problem is that too many policy makers are trapped in Stage 4 thinking.  They wait too long for crises to occur, and then respond inadequately when they do.

We could change this way of thinking, and change the trajectories of people's lives.  And - whether you think your state should have been ranked higher or lower - this report can help us do this.

To read the full report, click here.

For more information, email me at pgionfriddo@mentalhealthamerica.net.

In the Aftermath of the Marysville Shooting

I was sitting at my desk at Mental Health America when the news broke on Friday afternoon that a fifteen year old student at Marysville-Pilchuck High School in Washington had opened fire in the school cafeteria, killing at least one other student before taking his own life as well.

Another fourteen year old who was shot died over the weekend, bringing the death toll to three – all young teenagers.

It is hard to know what to make of these kinds of tragedies, because we don’t really understand them.  

The shooter, Jaylen Fryberg, was said to be popular and well-liked.  The victims – two of whom remain in critical condition – were his family and friends.  Some form of bullying may have been involved, but no one had any reason to believe that when he walked into school on Friday he intended anyone harm.

In recent years, shootings – whether or not they are related to a mental illness in the shooter (and most frequently they are not) – have shone a bright light on how poorly we handle mental health concerns in our country.

Half of all mental illnesses manifest by the age of fourteen – roughly the age of Jaylen Fryberg and his friends on the day that they were shot.  And yet, it typically takes ten years from the time symptoms first manifest to the time we get an accurate diagnosis and treatment.

We can - and should - do much better than that.

Suppose for the moment – and we do not know this today – that Jaylen Fryberg’s actions were the result of an undiagnosed mental health concern.  Were there other signs of such a concern present in the days, weeks, and years leading up to the Friday he died? 

In hindsight, some people think so.  A week before he died, he wrote on Twitter that “I know it seems like I‘m sweating it off, but I’m not.  And I won’t ever be able to.”

It’s hard to say what that implies, but it hints that there’s really only one course of action to prevent tragedies like this one – early identification and early intervention before crises occur.

At Mental Health America, we believe strongly that we need to intervene long before people die as a result of their mental health condition or someone else’s.  We need to think of mental health concerns in the same way we do other chronic conditions.  We need to screen early and often and – when we detect concerns – we need to stop waiting until they reach Stage 4 to do something about them.

Our screening tools – at www.mhascreening.org – are available online to anyone who is concerned about whether they, a family member, or a friend has a mental health problem.  More than 150,000 screenings have been completed since the beginning of May, and a thousand more are completed every day.

And they tell us something extraordinary - while as many as two-thirds of those who screen have an early mental health that warrants attention from professionals, two-thirds of those indicate that they have never before been diagnosed with a mental health condition.  

There are things we can do to prevent both crises and tragedies related to mental illnesses and to promote recovery  – and both state and federal legislators ought to start paying a lot more attention to these, and a little less attention to what we do to or with people after they reach the late stages of a disease process.

Because by then, it is often too late to make much of a difference.

This week, the children and young adults of Marysville are starting down a new path, leading lives that will be affected by the trauma they all experienced last Friday.  So the question we must ask ourselves is this:  Will we act on their behalf today, or will we wait ten years, until some of them are in crisis, before we do?

Only time will tell.

A version of this blog was also published by Mental Health America as its "Chiming In" blog for 10/27/14.  For more information on mental health issues in America and Mental Health America's #B4Stage4 efforts, visit MHA at www.mentalhealthamerica.net.

The Missing Mental Health Element in the Ferguson Story

By now, everyone has heard the news from Ferguson, Missouri.  An unarmed 18 year old named Michael Brown was shot and killed by a police officer.  Michael Brown was black.

Some of the events surrounding the shooting are in dispute.  But what isn’t in dispute is that for the past two weeks, a community has been torn apart by race – a community that until recently was best known for its proximity to St. Louis and its designation as a Playful City, USA.

Picture credit: Health Affairs

Media reports since the August 9^th shooting have focused almost entirely on one angle – race relations. 

We’ve heard about unrest in the city, the National Guard, police in riot gear, and danger in the streets.  We’ve heard about the District Attorney’s ties to law enforcement, and concerns that a too-white Grand Jury may be racially motivated not to indict the police officer involved in the deadly shooting.

But the media have been strangely silent about a different angle – this community is experiencing an ongoing trauma.  And where are the mental health services it so desperately needs?

Make no mistake about this.  Race matters.

I have written in the past about people such as Anna Brown, Miriam Carey, and Allen Daniel Hicks, Sr., a mother, a dental hygienist, and a coach.  None survived encounters with the police during times of crisis.  

And we know they are not the only ones.

But what these people had in common was that the final crises they experienced were in part medical. In some respects, that makes them more sympathetic than Michael Brown.  In others, unfortunately, it allowed media to dismiss what happened to them as aberrations brought on in part by their medical emergencies and suspicion of mental illness (an assumption that proved to be fatally incorrect in all three cases).

So the message frames in those stories quickly dissolved.

But when we’ve got a community at “unrest,” the story frame lives on. 

But let’s read between the lines.  This isn’t just a community at unrest, this is a community in distress.

And it is time we did something about that.

I have posted a version of this blog on Mental Health America’s web site, which you can find here.  In that blog, you’ll find several resources to help communities in distress, ranging from local MHA affiliates to national helplines, to tools and training aimed at helping communities recover from tragedies.

You’ll also find a call to action to join our #B4Stage4campaign, which launches in September, at Mental Health America.  You will hear much more about this campaign in the coming months.  It is designed to move our attention around mental health to where it belongs – on prevention, early identification of concerns, and early intervention. 

And it is designed to get public officials and the media to recognize that managing distress comes first and prevents violence, and to demand that they put resources into families and communities before mental illnesses progress to “Stage 4,” when “danger to self or others” is the only standard we have – a standard that leads too frequently to incarceration or tragedies like these.

Finally, you’ll find mental health screening tools and other resources you can use for yourself or with family and friends, especially if you – like me – keep imagining what your life would be like if your child were the victim here, or if your community was the one falling apart.

Losing Tim

Losing Tim: How Our Health and Education Systems Failed My Son with Schizophrenia is now in the Columbia University Press catalog.

Cover Photo Credit: Hartford Courant, Shana Sureck

You can find it using this link: http://cup.columbia.edu/book/978-0-231-16828-1/losing-tim

It will be available in the Fall of 2014.  It is a story of how the mental health policies of the last generation of policymakers (of which I was a member) failed my son, and how the policies of this generation of policymakers continue to fail him, and so many like him.

I can't say that I hope you will enjoy it, but I do hope you will find it moving.
 
And that it will help move us all - including the next generation of policymakers - to action.  It is long past the time we could pretend that neglect is a synonym for common sense and compassion.

Mental Health, America

اضغط هنا لمشاهد الفديو كامل 

I started writing Our Health Policy Matters three and a half years ago, right after the 2010 mid-term elections.

Since then, I have written about two policy areas about which I am passionate – public health and mental health.  As I explain below, I am about to change my professional focus.  And while I will be speaking about one more than the other in the future, for me these two areas are related. Let me explain why.

Mental health and public health are first and foremost about wellness.  They are about identifying risk factors for disease and eliminating or mitigating them.

Many of the same environmental risk factors contribute to poor health, especially poor mental health.  These include poverty, violence, abuse, and neglect.  When we address or mitigate these risk factors, we improve our nation’s health and mental health together.

We often place the burden of responsibility for maintaining one’s health squarely on the shoulders of individuals.  But this is a too-narrow approach.  We cannot prevent every physical illness by eating right and exercising, nor can we prevent every mental illness by simply willing it away.

What we forget sometimes is a simple, self-evident concept about wellness – the brain is a part of the body, and there is no health without mental health.

This leads to two unintended consequences.  The first is this.  In our effort to help people understand the linkage between mental illnesses and addictions, we use a term – behavioral health – that often implies to laypeople that these illnesses are bad behavior, and nothing more.  Mental illnesses therefore seem less serious than other chronic diseases – even though they shave twenty-five years or more from life expectancy.

The second is that we divide health care and mental health care into two non-integrated treatment systems.  We know the result.  Mental health care is poorly supported.  Our community support systems are inadequate.  People with serious mental illnesses are overrepresented in the homeless population.  Our jails and prisons have become our new state hospitals.

When we ignore the importance of promoting mental health and preventing mental illness and integrating care and treatment, we underestimate the power of recovery. 

Mental illnesses can be managed, just as any other chronic conditions can.  Recovery from cancer is possible – and even the norm for many – and so, too, should recovery be the norm for many mental illnesses.

When do not put resources into prevention, integrated care, and recovery, we make mistakes.  Because mental illness is often a childhood disease and there is a long lead time between the emergence of symptoms and the receipt of appropriate care, we make two mistakes in particular.  We overburden both our educational and primary care systems.

Our educators never expected to confront – as first-line responders – such needs in their classrooms.  Our primary care providers never expected to become experts in the early identification of mental illnesses.  Yet half of mental illnesses appear by age 14, and the vast majority of medications for mental illness are prescribed by primary care providers.

This system leads to failure.  I have explained why in other columns, and in an essay I wrote in 2012 for Health Affairs.  And I have written a book about the subject – Losing Tim – that will be published by Columbia University Press in the fall of this year.

But now I have been offered an extraordinary opportunity to do something more.

In a few weeks, I will become President and CEO of Mental Health America.

MHA is a Washington, D.C. area group that has advocated for mental health for over a century.  With 228 local affiliates scattered around the nation, MHA has an extraordinary history of leadership in the modern mental health movement in America – one that I hope to continue.

I am already part of an MHA family.  My wife Pam is, and will remain, CEO of the MHA Palm Beach County affiliate – the Mental Health Association of Palm Beach County.  And my daughter Lizzie works in direct services for the MHA affiliate in Connecticut, the Mental Health Association of Connecticut.

But my professional life is about to change.  For now, this will be my last Our Health Policy Matters column. 

I’ve appreciated the platform this column has given me, and hope that I have used it responsibly.  And I’m grateful to the thousands of readers who have come to this site each month.

I hope our paths will cross often in the future.  And I hope that when you think about Mental Health America, you will always think about mental health, America.  And about the work we still need to do to make mental health the norm for everyone.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

The Climate Change in Insurance Exchanges

A different kind of climate change was in the news this week, as Gallup reported that the percentage of people who are uninsured declined rapidly from 17.1 percent to 15.9 percent in just three months.

That is a pretty substantial drop, and one that began when people started signing up for Obamacare.

According to Gallup and others, it translates into an additional 3 million people who now have health insurance, consistent with the numbers of people signing up for Affordable Care Act coverage.

That’s good news for Obamacare – perhaps. 

One of the more interesting – and sometimes frustrating – things about health policy is that like climate change it unfolds slowly over time, and so it is often difficult to see the change in climate while it is happening.

For one thing, there are always other variables.  For example, the unemployment rate has also gone down during this period, from 7.2 percent last October to 6.7 percent today. It is possible that some of these 3 million newly-insured people obtained insurance through employment, and would have gotten it anyway.

And there’s always the glass-half-empty view to consider.  Both the unemployment rate and the uninsured rate are just about back to where they were in 2008, right around the time that the economy was collapsing.  So most of the progress we’ve made so far amounts to dragging ourselves out of a deep hole.  We’re still just back to where we were before we fell in.

But if we look too closely at this, we miss the bigger picture.

In spite of all of the initial problems with Obamacare exchanges, and despite the unpopularity of the Act itself (54 percent still disapprove of the law, according to the Real Clear Politics average of recent polls), and despite those who believe that they may have lost their insurance because of Obamacare, the trend today is clearly in one direction.

More people are becoming insured.  And that means something in the long run. 

For one thing, it means that health and mental health providers who have been holding out from participating in insurance plans until they are sure that there will be patients there will need to start signing up.  There will be patients there, and they will be looking for providers who accept their insurance.

For another, it means that individuals who can afford insurance but have been choosing not to buy it – betting that the law will go away before they ever have to pay a penalty – are probably not going to win that bet.  As more people pay up to become insured, there will be increasing pressure on everyone else to pay their fair share, too.  Insurance is becoming more of an individual's responsibility.

People may not like their health insurance very much, but once they have it, they never want to lose it again.

So in all probability the fates of the Affordable Care Act and private health insurance are intertwined now and for the foreseeable future.  The structure of our health insurance system is changing before our eyes because of the Affordable Care Act.  But it isn’t going to undermine the idea of insurance – just the way we pay for it. 

Here is a parallel example to explain what I mean.  When IRAs were created, they were like today’s exchanges.  They were a small thing.  Defined benefit plans – or pensions – were the norm for employees (as employer-based insurance is still the norm today).  But IRAs, 401(k)s, and other tax-deferred savings offered a retirement savings option that took a savings burden off of employers and transferred it to workers.   This changed – in a single generation – the nature of how we will pay for our retirement years. 

The same thing could be happening now with health insurance.  The exchanges may seem like a small and controversial thing today – perhaps 5 million or so will be insured through them at the end of the 2014 sign-up period.  But this number is growing every day, and will grow a great deal more in the future. 

And as a result new small employers – the creators of so many new jobs in our society – may increasingly decide not to offer health insurance as workers find deals that are just as good on the open exchange markets. 

Shifting from employer-based insurance to individual insurance does reflect a change in climate.  As we argue over the details, who really knows how significant this change will be?

We've Grown Accustomed to Disgrace

It sometimes seems like policymakers go out of their way these days to pick on people with mental illness.

According to a report released last week by the American Mental Health Counselors Association, 3.7 million people with mental illness will remain uninsured because of the decisions of states not to expand Medicaid. 

And if you believe some earlier data from the Kaiser Family Foundation about the total number of people who will be left uninsured because of states' failures to expand Medicaid, then you can only conclude people with mental illnesses account for nearly 80 percent of all those who are being denied insurance coverage in non-expanding states.

This includes 652,000 in Texas and 535,000 in Florida, and around 200,000 each in Pennsylvania, Indiana, Georgia, North Carolina, South Carolina, Tennessee, and Louisiana.

The association characterizes this as “dashed hopes” and “broken promises.”

You might also call it a national disgrace.

For those of us who live in one of the non-expanding states, we’ve grown accustomed to disgrace.  Our states are often held up as examples of what not to do.  We have poorer health status, and usually spend less on mental health services.   We also have the life expectancies of Libyans.

Our policymakers often blame Washington for all of our troubles.  But Washington isn’t to blame for this one. Washington’s recent decisions on health policy did not contribute to our current staggering debt.  Fighting two interminable wars on a credit card at the same time our banking industry nearly collapsed took care of that. 

No, these decisions reflect a lack of understanding and empathy on the part of elected officials.   Their decisions have consequences, and cannot always be blamed on someone else.

Perhaps those who live in more progressive states are feeling a little superior right now.  But they should not be.  Legislators in those states also didn’t clamor to expand Medicaid for all these people with mental illness before the federal government stepped in and offered to pay for it. 

So we are really all in this together.

We are all pushing nearly 4 million people even farther out on the fringes of our health care delivery system. 

These are people living with at least one serious, often life-threatening, illness.  They are living near or below the poverty line.   They cannot afford to pay for health care.  And to top it off they are often subjected to stigma and discrimination. 

This is a group of people who are frequently homeless or incarcerated. 

And when they do need medical care, this is what we say to their providers.  Treat them for free.

We ask hospitals to care for them in their emergency rooms for free.  We ask community mental health centers to provide inpatient and outpatient services for nothing.  And we ask clinicians to donate their care.

The solution for this is simple and involves us all.  If we want to do so, we can bypass those non-expanding states entirely.

All we need to do is to ask Congress to amend the Affordable Care Act to allow people living below the poverty level the option of purchasing insurance on the exchanges at the same price as those living at the poverty level. 

Right now, they cannot.  The reason is that the price of insurance for someone living below the poverty level isn’t subsidized.  But it is for everyone between the poverty level and 400 percent of poverty – over $90,000 per year for a family of four. 

There are plenty of people who think we treat people below the poverty level like millionaires with our entitlement programs.  Ironically, in this one instance they happen to be right. 

If Congress were to make this change, the immediate result would be that 3.7 million people living with mental illness could get decent basic health insurance for little or no cost. 

Of course, it would cost the rest of us something.  But Medicaid expansion costs all of us something, too – even those of us living in non-expanding states. 

And the money would be put to good use. It would reimburse providers of necessary health care, stimulating the sector of the economy that accounts for one-sixth of our GDP (and a similar percentage of our jobs).

So everyone would win if we did this.

Who could object to that?

My guess?  Many of the same politicians who don’t favor Medicaid expansion.  Because when you get right down to it, where people with mental illness are concerned, some of these politicians may in fact be our biggest national disgrace.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Why Our Health Policy Matters More Than Ever in 2014

A single health policy issue will decide who controls Congress after the 2014 election.  Here’s why.

You may have noticed the relative dearth of partisanship emanating from Washington over the past couple of months. 

Congress approved a budget with little fanfare and passed a debt ceiling increase with no hint of strings attached.

There is a reason for this newfound spirit of bipartisanship, and it is not what you think. 

Congress isn’t suddenly taking to heart its relentlessly low approval ratings in 2013.  And it hasn’t just become aware of how unproductive it has been.

Barring an unforeseen catastrophe like 9/11, Katrina, or Sandy, it’s just that members of Congress already know which issue will swing the upcoming election.  And they are not interested in muddying the waters at this relatively late date. 

The Democrats know that they have an advantage in the improving economy, their stand on women’s issues, and their strong support among minorities.

The Republicans know that they gain support because of a still-too-high unemployment rate, unbalanced budgets and the increasing national debt, and an unpopular foreign policy.

But the issue that will swing the Congressional elections in November is the one in which the political advantage then is a little less clear today.  It’s Obamacare.  And that’s proof that our health policy matters more than ever in 2014.

The partisan Congressional lines are arguably drawn more sharply over Obamacare than any other public policy.  We all know of the dozens of party-line Obamacare “repeal” votes that have been taken in the House since its equally partisan passage in 2010.  No other issue comes close for purely partisan controversy.

So what might this mean in the fall?

The current generic Congressional ballot reflects a near dead-heat for the 2014 election, which (because of gerrymandering) would keep the make-up of Congress roughly as it is for another two years.  And the parties have been pretty even on the generic ballot since last October.

What happened in October was that the Democrats lost ground quickly when the initial Obamacare web site problems overwhelmed the news cycles for a month.

As a result, recent polling data suggest that Obamacare is less popular now than ever, with an unfavorability rating 12 points higher than its favorability rating as of February 15. 

From Republicans’ perspective, this is all they can hope for.  Obamacare is the issue that can protect the Republican majority in the House and give the party a fighting chance of picking up the Senate.  Republicans do not want to squander this opportunity by picking new fights they can’t win (and might even cost them their primaries) over deficits and debt ceilings in particular.  So they’ve stopped talking about these for now.

But the Democrats are standing pat because they’re betting that Obamacare will be much more popular in six months than it is today.

The reason is that we’re all beginning to see who is benefiting from the new law – people over the age of 55.

This is a high-voting constituency that went heavily Republican during the 2012 election.  Romney won the 45 to 64 year old demographic by 51-47 percent, and the 65+ demographic by 56-44 percent.

Ever since that election, people on Medicare have been enjoying free annual physicals and improved prescription drug benefits.  And they have not experienced the collapse of the Medicare system that some feared.

As it turns out, baby boomers are flocking to Obamacare, too.  According to one source, 31 percent of the new Obamacare enrollees are 55 years of age or older.  Until now, many of these people had no reason to vote for a Democrat this year.  They had lost their jobs and their insurance during the recession. But now they have insurance again.

Democrats are banking on the fact that they will not risk losing their insurance a second time by voting for a repealing Republican in 2014.

While most people may never understand Obamacare in its entirety, they are just beginning to understand how it affects them personally.  That’s ultimately what matters.

There may still be hand-wringing over fewer than 7 million Obamacare sign-ups this spring or too few young, healthy people in the exchanges, but that will just be background noise to actual voters in the fall. 

What will matter is what this election means for them personally, and that’s why Obamacare may still spring some November surprises.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/