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Any Mental Health Treatment Is a Pre-Existing Condition

[ 75 ] January 16, 2017 |

This is one among many of the points that should be remembered as we face the threat of ACA repeal.  Here’s a Blue Shield underwriting table from just before the ACA.  Once a week therapy for even mild  depression, anxiety, or any adjustment problem puts you in the “possibly eligibility at a higher tier rate,” adding a medication to that then introduces the possibility that coverage will be denied entirely.  If are diagnosed with any other mental illness, that’s another pre-existing condition.  Any treatment for ADHD gets you X’s in the columns for”possibly eligibility at a higher tier rate,” and “possible or probable decline”.   If you attempted suicide, your application would just be auto-declined without a review of your application for three years following your attempt.  Anyone with bipolar or a psychotic disorder was also automatically declined.  Pre-existing conditions don’t just affect people on the individual market: before the ACA, your employer’s insurance could refuse to cover you for a year.  The pre-existing condition exclusions before the ACA created strong incentives to avoid treatment for mental illness, or to pay out of pocket if you possibly could and lie about your treatment history.  If you accepted treatment for mental illness, you would heavily compromise any treatment for physical illness down the line.  More generally, this analysis by the Department of Health and Human Services before the ACA found that as many as 1 in 2 non-elderly Americans might have a pre-existing condition.
chart_americans_at_risk_by_age

The number of people who have been protected by the ACA is massive, and the elimination of pre-existing condition exclusions is just one of the protections afforded by the law.

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One For Today

[ 22 ] November 21, 2016 |

You may have done this already!  If not: Paul Ryan is conducting a survey to measure support for Obamacare via an automated telephone poll. Call Ryan’s office at 202-225-3031.  I had to call twice, and the system behaved inconsistently.  Both times I was told the mailbox was full, but only the second time did I get the option to take the survey.  You press 2 for the survey, you listen to some anti-Obamacare propaganda, and then you press 1 to say you support the ACA.   If the voicemail box is not full when you call, you can also leave a message for Ryan.

A strong show of support for the ACA would hopefully also be read as a message about the political costs of touching Medicare.

More Targets for Action

[ 16 ] November 18, 2016 |

I know this blog has very highly politically aware and active readers, but some people expressed gratitude for my previous post suggesting people to call regarding Bannon, so here are some more targets for action I’ve seen passed around yesterday and today.

I think Yglesias states well the gravity of the potential corruption in the Trump administration.  Katherine Clark introduced the Presidential Accountability Act:

Current law prohibits federal office holders from engaging in government business when they stand to gain profit. The President and Vice President are currently exempt from this statute. Clark’s Presidential Accountability Act removes this exemption and requires the President and Vice President to place their assets in a certified blind trust or disclose to the Office of Government Ethics and the public when they make a decision that affects their personal finances.

If your representatives are like mine, they are probably hard to reach right now, but if you can, this one’s a good thing to put in your questions for them.  If I can’t reach mine, I’m also going to post my questions on social media.

I’ve also seen it recommended to contact the House Oversight Committee (202-225-5074) to support the call for a bipartisan review of Trump’s financials and apparent conflicts of interest.  It took me a couple tries to get through to leave a message, but I eventually did. One caller reported that a staffer said they are tallying calls, and today is effectively the last day to call because they are out the week of Thanksgiving. Jason Chaffetz is the Chairman, which doesn’t make me optimistic, but as I tried to communicate to Espaillat’s staffer, the only chance we have to change this is to act as if we can.

 

Let’s Not Roll Over

[ 38 ] November 16, 2016 |

bannon

Two days ago, in a round of calls to my representatives asking them to vocally organize against Bannon, I talked to an employee of incoming Congressman Adriano Espaillat named Martin Smith. When I said what I was calling about he literally burst out laughing at me, and said there was very little they could do. The congressman would decide the best way to respond. He then told me we needed realism right now. He had taken six constituent calls that morning, and had already told a woman worried about her son, an (undocumented?) immigrant who had been in trouble for drugs already, that there was very little they could do for her son. I tried to communicate that my state of mind was not exactly optimistic at this moment, but that that didn’t argue for defeatism. He gave me the an email address to use to express my concerns. So Espaillat has someone working for him who is just telling all callers that we’re all screwed. I mean, we are, but only behaving like it is possible for us to exercise power will ever create that possibility.

So let’s do that!  I think Bannon is a very important target for organizing right now. It seems at least possible to win, and in so doing to send a message that there are limits. If Bannon stays, it bodes ill, to put it mildly. Some things you can do are: call your reps and urge them to be very forceful in denouncing him, if they have not already, or thank them if they have. Contact journalists and media outlets who use normalizing or “both sides do it” language about him. If you know influential people, reach out to them, and ask them to speak out against him.

Below the fold, more detailed recommendations from some provenance I don’t know, but I think they’re good.

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The #Nevertrump Republican Senators

[ 145 ] November 13, 2016 |

Hi all,

I started a semester so crushing in the fall I couldn’t even find the time to wrap up loose ends or write a goodbye post.  But in the wake of the election I’m reevaluating my plans and priorities.  I want to have time for myself and others, and to do my best to contribute to resisting whatever is coming.

On that note, what do people think of the idea of organizing to try to convince the #nevertrump Republican senators not to caucus with the Republicans?  Which senators on this list seem like better targets than others?  I’m not making any claims that this is likely to work, but I don’t think it can hurt.  I am not one of their constituents, but I still plan on writing them all letters.

A Controversial Stand

[ 354 ] August 15, 2016 |

Cargo-Shorts-for-Men

I don’t think there’s anything wrong with cargo shorts. I know the Great Cargo Shorts Controversy of 2016 is a bit last week, but but bear with me; something just happened to me that prompted this revelation. Just as foods can’t really be evaluated as “healthy” or “unhealthy” without considering them in context of a diet, articles of clothing can’t be evaluated outside the context of a style. I think people observe the correlative relationship between men with an undeveloped, poorly-thought-out style and the wearing of cargo shorts, and think cargo shorts are causing the problem, but if someone is wearing some oversized polo shirt, cargo shorts, and sandals with socks, giving that person a slim cut pair of shorts is not going to solve anything, and further, cargo shorts can look good—I just witnessed it yesterday. This man greeted me on the street and I was admiring his unusual hat (at least unusual for these parts, maybe it’s a common style elsewhere). It was made of straw, basically panama style, but painted in colors and with a kind of knob shaped like an inverse teardrop emerging from the crown. He was also wearing a white ribbed tank top, black flip flops, maybe some wooden earring situation (I didn’t quite catch it before he disappeared into the store) and olive green cargo shorts. It looked like some of the straps that would normally seal the pockets were unbuttoned, to create an overall flowy, draping effect. This was clearly a person with style, and I tried to mentally substitute any other pair of shorts to see if they would look any better, and I could not. He was wearing the ideal shorts.

Let me be clear as to my argument: I don’t claim that it doesn’t matter how you look, as long as you have a place to put your cell phone. I think it does matter. I have a mild preference for environments where people tend to care about fashion and self-presentation, at least on some days, both because I tend more to how I look in those environments, and also because they are more visually interesting and offer more to admire. The ideal environment, in my opinion, encourages making a bit of an effort but does not punish its absence. The ideal environment also does not enforce one normative style, but encourages expression that can borrow from lots of different sources. To the extent to which cargo shorts are symptomatic of people not caring, or of men caring less than women, I, again in a mild way, share the sense that it would be nice if median man cared more about prettying himself up. (Though I must acknowledge that just as diversity in paths toward a personal style is appealing, diversity in values about effortful and creative fashion allows some self-sorting into environments that feel comfortable.)

But individual articles of clothing don’t constitute style or lack thereof, and just forbidding them because they are supposedly ugly doesn’t promote independent thinking about how to develop a style. So I think people should stop demonizing cargo shorts and instead come up with positive ways to teach and encourage self-expression through clothing. Just telling people to ditch some practical and comfortable item of clothing isn’t going to solve any problems.

Dara Lind on the Varieties of Protest

[ 115 ] August 3, 2016 |

This Dara Lind piece articulates a typology of protest that I found illuminating: protest with a specific demand, that will be at least partially satisfied when that demand is met versus protest aimed at delegitimizing a politician (or system).

This is the question that left dissenters need to ask themselves about Hillary Clinton, if they haven’t already: is there anything that Hillary Clinton can do to redeem herself to you?

If there isn’t, you can continue to protest her existence, but don’t be upset if she doesn’t respond — you wouldn’t accept a response if you got it.

If there is, figure out how you can make her do it — especially (if she is elected) in January. You won’t be alone. In fact, you might be surprised to see that some of the people who supported Clinton in 2016 are right alongside, waiting to remind her of what she owes.

I had never worked this out so clearly for myself before. It captures well a distinction that predicts what kind of protest I think is deplorable (chanting “lock her up” at the convention) and the kind of protest that’s smart (having signs that say “No TPP” at the convention). It also captures something I find frustrating in the rhetoric around Hillary Clinton: in some sectors, her favorable movement is never acknowledged. Overturning Citizens United was the only concrete policy proposal she made in her acceptance speech. If you want Citizens United overturned, you should give her a cookie; that’s how you shape politician’s behavior. I’m not saying anyone should cheer a campaign promise with all of their heart; no one should just believe anything Clinton (or any politician) says. They should continue to work to create the political conditions that ensure that she follows through. But it’s not very strategic to send the message that there’s no reward for any leftward motion she makes. Fortunately, I don’t think she’s getting that message overall.

There maybe needs to be a third category: in a sense, chanting “no more war” at the convention articulates one big demand, but in another it’s more an effort to challenge a narrative. I don’t think it belongs in the same category as “lock her up” (and I may be parting with Lind here). It rejects an interventionist military, and the nationalist theater of trotting out generals as evidence of strength and patriotism, but I don’t think it necessarily communicates that Clinton herself is illegitimate.

Edited to add: I think JL’s comments are worth highlighting in their entirety. A selection:

My observation is that some people will give politicians a cookie when they take steps in the right direction and some won’t, and that having a mix of such people can be useful – the politician gets some cookies and the pressure stays on. Whether it’s useful or not, it’s what’s likely to happen anyway, because some activists are good at framing things around partial victory and others aren’t. In general, different activists are going to fill different tactical, rhetorical, and other niches.

Sometimes you want to delegitimize a system – there are a lot of folks out there right now trying to delegitimize existing systems of policing, for instance, and there was a lot of work in past decades to delegitimize Jim Crow – but delegitimization is not particularly useful for, say, trying to get things into the Dem platform.

I agree that sometimes systems need to be delegitimized, and was reaching towards that at the end, but I don’t have this worked out for myself and I’ve decided that if I get a little bit less perfectionistic about blogging everything I’ll do more of it. I actually thought of writing about different kinds of policing protest in the post. I like this protest going on now at New York City Hall, even though I myself am just far too uncertain to either favor or disfavor anything as radical as police abolition. But I think the radical critique needs to be made. Even though I’m sure presence in the current occupying force is highly correlated with strong dislike of Hillary Clinton, a protest that critiques a system seems different, and much more useful then, the some of the highly personal delegitimizing discourse in some of the protest movement. But I’d appreciate any assistance in articulating the difference! Maybe JL already got there:

I strongly agree that “No more war” and “Lock her up” are not in the same category. I would say the former is both challenging a narrative and making a demand of the coalition that goes beyond Clinton.

When you make Clinton the face of the evils of the world, it fails to acknowledge that Clinton has to respond to a broad coalition, and it’s everyone’s job to make the coalition be more bold and more just.

Ambiguous Dog Whistle?

[ 88 ] July 27, 2016 |

A friend pointed out that in two tweets, Trump managed to get a Jewish politician’s name or twitter handle into parentheses.  Only one set of parentheses, not three, as is the style of white supremacists, but that would be too obvious.  I am genuinely on the fence as to whether this one is a clumsy use of punctuation or a dog whistle.  Obviously, Trump says a lot of things that more obviously sit somewhere on the spectrum from “dog whistle” to “shrieking noise the pod people make in the remake of Invasion of the Body Snatchers to identify remaining humans,” so Trump’s status as a white supremacist doesn’t exactly hang on this verdict.  I’m just curious what commenters here think.  He later called Debbie Wasserman-Schultz “highly neurotic.”

AAAAAARGH

[ 19 ] July 13, 2016 |

The thrilling conclusion to the replication saga is coming, I swear, and in fact I was working on an amendment today, when this happened.

In brief, the Right to Know Act, which I’ve posted about before, comprises two bills before New York City Council: one that requires police to provide identification during a stop, and the reason for a stop, and another that requires police to inform people that they have a right to refuse a search without probable cause, and to obtain evidence of consent.  Hundreds of community groups and thousands of people (including, in a small way, me) have been organizing for years for these laws. Melissa Mark-Viverito, City Council speaker, and Chief Bratton just made a private deal to prevent the bills coming to a vote (the bills easily have the votes to pass, though only the ID bill has a veto-proof majority), because Bratton promises the NYPD will do it on its own:

The procedures, agreed to by Council leaders, the de Blasio administration and police leaders, may significantly change interactions between officers and people on the street in certain encounters. Officers would soon be required to hand out business cards when asked; officers seeking to conduct searches in the absence of a legal basis would be trained to request consent by eliciting a yes-or-no response and walk away if it is declined.

But the administrative changes proposed would not have the force of law. Compliance would be contingent on the Police Department’s enforcing the new rules, to be set forth in the Patrol Guide, the agency’s rule book.

Communities United for Police Reform issued this statement:

At such a crisis moment where people are literally losing their lives due to a lack of police accountability, including in New York City, it is beyond disappointing that our city will fail to set an example by allowing the failures in police accountability to continue without legislative oversight. The frequent abuses in people’s most common everyday interactions with police that go unaccounted for are what perpetuate and lead to police brutality and killings. New York City will fail to address this by pursuing this administrative agreement instead of legislation.

The Right to Know Act has the votes to pass the Council, is supported by over 200 community groups from across the city, and the policies it advances have been endorsed by the President’s Task Force on 21st Century Policing. An agreement with the NYPD does not hold the weight of legislative oversight and these administrative changes are watered down and on top of existing NYPD rules that are already frequently violated without repercussion. There should be no confidence that this agreement will provide meaningful change for communities – without real accountability and enforcement mechanisms, police abuses that leave community members at risk of harm will continue in everyday interactions.

I think the single part of this article that makes me the angriest is this one:

Mr. Bratton told the Council last year that he opposed measures like the search bill as “unprecedented intrusions” into the management of the Police Department. Instead, he said at the time, the department would have preferred to “collaborate” with the Council and reach common ground without legislation.

That’s right.  God forbid the elected representatives of the people of the city of New York intrude upon the guys with guns who act with effective impunity.  Oh, you were busy harassing, humiliating, and violating people?  Well then, we’re sorry to intrude.  If these measures are not too burdensome to enact as voluntary policies, then there is just no reason for Bratton and NYPD not to bloody well think about what the words “public servant” actually mean and accept that they are bound by the force of law.  Communicating with the people they stop on the street about who they are, the reason for the stop, and a citizen’s right to refuse violations of body and privacy should not be at their discretion.   

Another Facet of Racism and Classism in Health Care

[ 14 ] June 15, 2016 |

Sorry for the delay in the riveting conclusion of the Replication in Psychology series.  I miscalculated days before my vacation swung into higher gear and wound up traveling for a bit.  So conclusion soon, but first I wanted to link to this report on an audit study that finds something shameful, though I guess not surprising: it’s a lot easier for white people and middle class people to get concrete offers of appointments for psychotherapy than black people and working class people.

For the study, Heather Kugelmass, a doctoral student in sociology at Princeton University, selected 320 therapists from the directory of Empire Blue Cross Blue Shield’s HMO plan in New York City. She then had voice actors call them and leave voicemail messages saying they were depressed and anxious. They asked for a weekday evening appointment. She distinguished between different income groups by altering the vocabulary and grammar in the scripts, and she used studies on African-American vernacular and Black-accented English to craft the African-American callers’ scripts. The lower-income white callers spoke in a heavy, New York City accent. All of the callers mentioned they had the insurance that the therapists purportedly accepted.

Screen Shot 2016-06-15 at 8.56.20 AM

As you can see, the way racism seems to primarily influencing therapists in their treatment of prospective clients who are marked as middle-class (although whether they perceive prospective black clients as middle-class is another question).  Prospective clients marked as working class were equally unlikely to get an appointment offer. 

Heather Kuglemass, the author of the study, posits a number of possible causes, including biases toward blacks as antagonistic, toward working class people as lazy.  Another possibility is that therapists have in-group preferences.  Most therapists are white and middle class and therapy is a close relationship.  And they might explicitly reason that black and working class people are less able to pay (though all callers said they were in-network for the therapist), or that they’re not culturally competent to treat someone different than them.  Therapists in private practice have total discretion about who to take and no one is witnessing their decisions, so there’s not as much incentive to examine and safeguard against bias as there would be if treatment decisions were more public-facing. 

Looking for mental health treatment can be really dispiriting even when you fall into the favored categories (the low overall rate of callbacks gives a flavor of this, though that graph doesn’t include therapists who leave a message with an ambiguous request to call back).  I’m glad I read this article just so, when I work in a setting where I have more discretion, I know to watch myself.  The Atlantic article suggests an app that matches therapist and client might be helpful, the way ride hailing apps strip race and class markers from a person hailing a cab, which simultaneously seems like a good idea, and sort of depressing, in that these narrow technological solutions could make one important thing get better, but are tiny measures in the way race and class inequities permeate every aspect of American life. 

Replication Crisis in Psychology: Part Five

[ 8 ] May 24, 2016 |

Parts one, two, three, and four.

On the question: How should a lab regard its own “failures”?

In a paper in the Journal of Experimental Social Psychology, Baumeister offers another sort of explanation for why experiments might fail (not open access — sorry!):

Patience and diligence may be rewarded, but competence may matter less than in the past. Getting a significant result with n = 10 often required having an intuitive flair for how to set up the most conducive situation and produce a highly impactful procedure. Flair, intuition, and related skills matter much less with n = 50.

In fact, one effect of the replication crisis can even be seen as rewarding incompetence. These days, many journals make a point of publishing replication studies, especially failures to replicate. The intent is no doubt a valuable corrective, so as to expose conclusions that were published but have not held up.

But in that process, we have created a career niche for bad experimenters. This is an underappreciated fact about the current push for publishing failed replications. I submit that some experimenters are incompetent. In the past their careers would have stalled and failed. But today, a broadly incompetent experimenter can amass a series of impressive publications simply by failing to replicate other work and thereby publishing a series of papers that will achieve little beyond undermining our field’s ability to claim that it has accomplished anything.

Having mentored several dozen budding researchers as graduate students and postdocs, I have seen ample evidence that people’s ability to achieve success in social psychology varies. My laboratory has been working on self-regulation and ego depletion for a couple decades. Most of my advisees have been able to produce such effects, though not always on the first try. A few of them have not been able to replicate the basic effect after several tries. These failures are not evenly distributed across the group. Rather, some people simply seem to lack whatever skills and talents are needed. Their failures do not mean that the theory is wrong.

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Replication Crisis in Psychology: Part Four

[ 14 ] May 23, 2016 |

Parts one, two, and three.

On: How should scientists respond to failed replications?  What kinds of responses contribute to a progressive science?

Another major news story surrounding replication in the last few months was the failure to replicate the ego depletion effect.  It’s an interesting case because the psychologist famous for naming and discovering the ego depletion effect, Roy Baumeister, both demonstrated some exemplary behavior in response to a replication failure, and has maybe also engaged in the kind of motivated reasoning that might be dangerous (at least in the absence of the exemplary behavior).

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