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Tag: "health care"

Structural Inequality and Infant Mortality

[ 114 ] April 2, 2014 |

I can’t recommend this Stephen Bezruchka essay on structural inequality and infant mortality strongly enough. Just a quick excerpt:

Everyone in a society gains when children grow up to be healthy adults. The rest of the world seems to understand this simple fact, and only three countries in the world don’t have a policy, at least on the books, for paid maternal leave—Liberia, Papua New Guinea, and the United States. What does that say about our understanding, or concern, about the health of our youth?

Infant death rates, those occurring in the first year of life, are a particularly sensitive measure of health in a population. According to a U.S. Centers for Disease Control and Prevention report released in 2013, our infant mortality rate is about 6.1 deaths for every thousand live births. Sweden has an infant mortality rate less than half of ours, 2.1 deaths per thousand births. If we had Sweden’s rate of infant deaths, the United States would have around forty-seven fewer infants dying every day in the United States. That is what is achievable: every day forty-seven babies wouldn’t die if we had Sweden’s rate of infant deaths.

Differences in mortality rates are not just a statistical concern— they reflect suffering and pain for very real individuals and families. The higher mortality in the United States is an example of what Paul Farmer, the noted physician and anthropologist, calls structural violence. The forty-seven infant deaths occur every day because of the way society in the United States is structured, resulting in our health status being that of a middle-income country, not a rich country.

There is growing evidence that the factor most responsible for the relatively poor health in the United States is the vast and rising inequality in wealth and income that we not only tolerate, but resist changing. Inequality is the central element, the upstream cause of the social disadvantage described in the IOM report. A political system that fosters inequality limits the attainment of health.

Resist changing? For Republicans, rising inequality is the stated goal, with an underlying racial tone that gets poor whites to buy in against their own economic interests.

The only thing I’d add that Bezruchka leaves out is how the decline of labor unions has played into this problem. He suggests worker-owned businesses as part of the strategy to overcome this structural inequality, but that he mentions this and not unionized workplaces says a lot about just how desperate organized labor’s situation has become. In all of American history, only labor unions have allowed workers to have a real voice on the job and provided a powerful and long-term voice for the American working class. Without that voice and the potential of delivering (or withholding) votes and money, politicians have little reason to care very much about structural inequality.

But otherwise, an outstanding essay.

Uncle Sam the Rapist

[ 52 ] September 19, 2013 |

Not sure what the Koch Brothers are getting at in this anti-Obamacare ad portraying Uncle Sam as a rapist. Given that he seems be to using the same transvaginal ultrasounds that conservatives like the Koch Brothers support when a woman wants an abortion, is Uncle Sam just practicing on all women?

In any case, it’s hard to imagine the Germans or Japanese during World War II using Uncle Sam in a more offensive and anti-American way than this ad.

….If you want to make Uncle Sam creepy, at least go old school Committee on Public Information style.

Stand Beside Her And Guide Her

[ 69 ] August 9, 2013 |

As you probably heard, Karen Black died. A key actress to so many major films of the 70s, she succumbed to cancer. She could have had a dignified end of life. Or maybe even defeated her cancer. Instead, she lived in the United States, where our disastrous health care system (even after the significant improvements of Obamacare) forced Black and her husband to crowdsource her cancer treatments after they used up all their savings.

At least Black had the name to do this. How many thousands of people just die because they don’t have the ability to put up even a basic fight against illness?

The Greatest Country in the World

[ 34 ] July 1, 2013 |

Oh beautiful for spacious skies, for amber waves of grain:

Financially, they suffer the consequences. In 2011, 62 percent of women in the United States covered by private plans that were not obtained through an employer lacked maternity coverage, like Ms. Martin. But even many women with coverage are feeling the pinch as insurers demand higher co-payments and deductibles and exclude many pregnancy-related services.

From 2004 to 2010, the prices that insurers paid for childbirth — one of the most universal medical encounters — rose 49 percent for vaginal births and 41 percent for Caesarean sections in the United States, with average out-of-pocket costs rising fourfold, according to a recent report by Truven that was commissioned by three health care groups. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying out an average of $18,329 and $27,866, the report found.

Women with insurance pay out of pocket an average of $3,400, according to a survey by Childbirth Connection, one of the groups behind the maternity costs report. Two decades ago, women typically paid nothing other than a small fee if they opted for a private hospital room or television.

How long until American families start going to Canada to give birth? For all that conservatives complain of so-called “anchor babies,” by foreigners supposedly coming to the U.S. to give birth, doesn’t it make sense for everyone who can to flee to a country where you can give birth for free? Does it cost more to give birth in Canada or pay for things that should be but aren’t provided by the government in the United States?

Obama’s War on the NFL. And America Of Course. Let’s Not Forget His War on America

[ 39 ] June 27, 2013 |

This is even stupider than the usual Republican paranoia. Evidently, Obama is trying to destroy the NFL–by planning to run ads during NFL games this fall explaining the details of the health care bill as it goes into effect.

It’s just one scandal after another with this administration. Did you see that it is now trying to destroy the NFL? This is what’s happening, according to certain quarters of the Internet. Here’s the skinny: the Health and Human Services department is ”in talks with the National Football League to promote [Obamacare]’s insurance marketplaces that begin enrolling people Oct 1.” Who knows how deep this corruption goes — HHS secretary Kathleen Sebelius also ”said the administration is also talking to other major sports franchises about improving public awareness of the Obamacare online insurance exchanges.”

Kaiser Health’s story also notes that during the media push for Massachusetts’ similar health care law, “the campaign was advertised during Red Sox games at Fenway Park. That marketing is widely credited with helping build public acceptance.” Once again in the health care field, the federal government is just following Mitt Romney’s lead.

Conservative media outlets are getting upset at this co-opting of America’s favorite sports franchises, coerced to do the dirty work of promoting the most evil law in the history of the universe. Perhaps this top comment, on The Hill’s story, left by one “MR FOOTBALL,” epitomizes the attitude: “Goodbye NFL!” MR FOOTBALL’s presumably got all sorts of things goin’ on and with football, he can take it or leave it.

We’ll see if this deal comes to fruition. It may turn out that the NFL’s rates are too high to justify the expenditure. And not everywhere in the country is like Massachusetts, where Red Sox players can order any person in the state to do anything – fix up a pre-game cheese plate for them, enroll in subsidized health insurance plans, whatever – at any time.

Poor football fans.

Chronicles of Mayo

[ 46 ] June 6, 2013 |

A year and a half ago, a friend and former student had a sudden, unexpected medical emergency. She’s telling her story here, and it’s fantastic stuff. Start at the beginning:

I peered over my doctor’s shoulder to have a look for myself at the CT scan on the computer screen. He was pointing to what looked like an Easter egg shaped blob which was situated in my sinus cavity. I nodded my head at him waiting for him to tell me that it was something easy to fix. To my frustration all he did was look at me.

“So what is it?” I asked after a few seconds of silence. Up until now, I had thought he would tell me I had a sinus infection. My head had felt stopped up for weeks and my right eye hurt whenever it moved. My GP had been giving me antibiotics and prednisone for the past month until he threw up his hands and referred me to an ENT specialist. I just figured this guy would have stronger meds and we could be done with it already.

Spare the Brush and Spoil the Teeth

[ 18 ] May 26, 2013 |

Good advice.

Date unknown, but early 20th century.

Today at the Supreme Court

[ 10 ] June 28, 2012 |

I’ll have a piece up shortly at Salon about why it’s basically nuts that John Roberts gets to decide what sort of health care system America has. It quotes a good point made by Richard Posner earlier this week in the context of the life without parole for teenagers case:

I don’t object to a loose construction of the Constitution; there isn’t any sensible alternative, given how old and out of touch the document is, how unrecoverable the actual thinking of its authors and ratifiers, and how vaguely worded so much of it is.

Posner’s point is that, under the circumstances, “constitutional interpretation” must give justices — or, in the case of 5-4 decisions, one justice — the power to do pretty much whatever they want in regard to the sorts of issues that end up before the Supreme Court.

Whether this is a desirable state of affairs is another question entirely.

Here’s the Salon piece.

DeMint Goes Full Calhoun

[ 89 ] June 28, 2012 |

Not that we should be surprised that Jim DeMint is calling for nullification of the health care law.

“I urge every governor to stop implementing the health care exchanges that would help implement the harmful effects of this misguided law. Americans have loudly rejected this federal takeover of health care, and governors should join with the people and reject its implementation.”

I wonder what else DeMint would like states to nullify….

Kindergarten Libertariansim, With Prof. Althouse

[ 298 ] April 2, 2012 |

Adam Litpak had a good article noting that Verrilli’s oral argument appealed to Kennedy with the freedom-enhancing qualities of the Affordable Care Act. This motivated Ann Althouse, who didn’t seem to even understand the argument, to respond like a member of their junior high school’s Ayn Rand club participating as their team’s third-stringers at the forensics meet:

“Liberty” is a high abstraction. What is it about the liberty of compulsion to buy an expensive health insurance policy that Justice Kennedy is supposed to find appealing? Just because someone loves liberty doesn’t mean they’re going to love everything you slap a “liberty” label on!

Obviously, as a complacent reactionary who benefits from the security of taxpayer-funded health insurance Althouse can’t grasp why universal health care might be freedom-enhancing, but it’s not at all complicated:

  • First of all, Althouse seems to assume that everyone who is uninsured wouldn’t want affordable insurance if they could get it, as if many people don’t have health insurance because of pre-existing conditions or because it’s not affordable for ordinary workers under the status quo.
  • Once we move past this silly assumption, it’s not difficult to see the point the SG was making.   Universal health care has freedom-enhancing properties in a lot of ways: it allows you to move, or engage in entrepreneurial activities, without losing the employer-based coverage that is the only practical means of obtaining insurance for those who aren’t poor or extremely wealthy.  Mobility, particularly in American constitutionalism, has always been a treasured liberty.  Bankruptcy is, to put it mildly, detrimental to liberty in all kinds of ways.   Beyond that, whether you want to call the security that comes from health coverage freedom-enhancing is a matter of taste, but this security is certainly more valuable to most people that the “freedom” of knowing that you can be bankrupted by an accident or unforeseen illness.
  • The even bigger problem here is that the rugged individualists who go without health insurance are not making a “choice” to be free of state constraint and state-provided benefits.  They are, in fact, making a choice to stick the taxpayers with the bill if they have a medical emergency. Even a moderately sophisticated libertarian understands that the “freedom” to free ride is no freedom at all.   Perhaps Althouse, like the judicial idol she defended so feebly,  would prefer a libertarian dystopia in which people who aren’t lucky enough to have taxpayer-funded health insurance are just left to die from accidents or treatable illnesses.   But whatever they would like the policy baseline to be, what matters both for public policy and for the question of whether the mandate is a necessary and proper part of a concededly constitutional regulatory framework is what the policy baseline under federal, state, and common law actually is.  Kennedy actually showed some signs of understanding this, one of the few bright spots to come from the three days of depressingly inept work by he and his Republican colleagues.

Today in Green Lanternism

[ 280 ] March 31, 2012 |

Robert Wright is wondering why the Affordable Care Act wasn’t just a straightforward use of the tax power, and his analysis is of course focused on the median votes of the Senate and the leverage these conservatives had over the legislative process.

Hahaha, just kidding! When discussing the ACA, as Drew Westen has taught us, we have to consider a fantasy of politics “in which the president in the not only the most important figure, but his most powerful weapon is rhetoric” rather than actual American politics:

If the Supreme Court rules against President Obama on the constitutionality of the Affordable Care Act, there’s a sense in which he’ll deserve it. After all, there was an easy way for him to make the act impervious to this fate, and it wouldn’t have entailed a single change in how the program works.

[...]

I’ve long thought President Obama wasn’t using the bully pulpit creatively enough–particularly on the issue of taxes. As establishment Democrats said the “political climate” didn’t permit him to let the Bush tax cuts for the rich expire, he made no attempt to change the climate by using his considerable oratorical skills. (It seems to have taken Occupy Wall Street to clue him in to the fact that there’s some class resentment out there to be harnessed.)

Granted, it might have taken a bit of extra rhetorical work to sell a health care bill with the word “tax” in it. But the tax wouldn’t have applied to most voters, and, anyway, the upside would have been that the bill would seem less like coercion and more like an incentive. A bit of courage and creativity a few years ago might have prevented what could be a major policy disaster come June

Um, no.

  • There is no evidence that the bully pulpit can shift public opinion, and voluminous evidence that it cannot. Conveniently, Ezra Klein has laid this out in extensive detail in the New Yorker. Whatever Aaron Sorkin or Aaron Sorkin-influenced shows and movies have told you, politics is not a debating society.    It’s nice to think that we’d have public policy outcomes like Denmark had Michael Dukakis just thought up that clever rebuttal you wrote for him after the fact, but this isn’t actually how politics works.
  • But let’s leave that aside, and assume that Barack Obama could change public opinion on the issue.   Perhaps we may want to consider how the American legislative process actually works, and why the architects of the ACA may not have wanted to use straightforward taxing and spending.   It’s not 2 or 3 extra percent of the public you have to worry about.  It’s, you know, Evan Bayh and Ben Nelson and Blanche Lincoln and Joe Lieberman and every other conservative Democrat in the Senate who would love to use the excuse that you’re proposing the Biggest Tax Increase In Recorded Human History to vote against a bill they don’t care about and their corporate paymasters don’t want.    And using public opinion as leverage — even leaving aside the fact that the president can’t move public opinion — doesn’t work against senators who 1)aren’t running for anything again but are planning on cashing big paychecks from the kind of entrenched interests who don’t want the ACA, or 2)are running in states where the president is extremely unpopular.   I agree that this was dumb, but take it up with James Madison.
  • Let’s assume that Barack Obama could have engaged in a Game-Changing Use of the Political Capital of the Mandate and Bully Pulpit on Steroids to Throw Oily Conservative Democrats Who Are Really Secret Socialists Under the Bus to get the funding for the ACA structured as a “tax” rather than a “penalty” and still get 60 votes for it.    Why on earth would you think that this would make the bill impervious to legal challenge?    What’s to stop the Court from discovering that this particular tax is an invalid use of the federal taxing power, or that the use of the federal spending power that would inevitably be involved is too “coercive” to be constitutional?   Yes, nobody would have thought while the plan was first being formed that these arguments would be taken seriously, but then at the time nobody could have thought that the mandate would be considered unconstitutional either.

Sometimes A Devastating Defeat Is Just a Devastating Defeat

[ 141 ] March 30, 2012 |

Given the amount of pushback, I decided to make my argument about legitimacy and the ACA at much greater length. A lot of people seem to think that this particular politically controversial decision with substantial elite support will somehow be different than the many other politically controversial decision with substantial elite support the Supreme Court has made. I don’t see it:

It is true that a decision striking down the ACA would inevitably be 5-4, which many legal observers believe would decrease the legitimacy of the decision. The problem here is that evidence that the vote lineup influences public or elite support for judicial opinions is scant. Consider the most divisive Supreme Court decisions in recent history. Miranda v. Arizona was 5-4, but that’s the exception. Brown v. Board and Cooper v. Aaron—both of which the directly affected states and their representatives not only bitterly opposed but refused to implement—were of course unanimous. Engel v. Vitale—the 1962 school prayer case that generated more hate mail than any case in the Warren Court era and also had serious implantation problems—had a mild solo dissent. Roe v. Wade was 7-2. It’s substantive results—not the number of dissents—that determines the reaction to Supreme Court decisions.

One potential counter to this is that a decision striking down the ACA would be different, it would be a 5-4 decision that would break down along strict partisan lines. By showing the Court to be nakedly political, it might undermine the Court in a way that previous rulings have not. My response to that would be simple: Kelo v. New London. The fact that the opinion was written by one Republican nominee and joined by two others didn’t stop it from being fiercely criticized by Republicans and sparking a legislative reaction in many states. And this makes sense when you think about it. In essence, the argument that the partisan breakdown changes things assumes an audience sophisticated enough to be aware of recurrent ideological vote patterns on the Supreme Court but unsophisticated enough to think that the Court is nonetheless apolitical if these ideological divisions map onto 1950s party coalitions rather than 2010s party coalitions. I’m not sure how big this audience is, but I’m confident that it could comfortably fit in a single-occupancy freshman dorm room. No conservative Republicans think of John Paul Stevens or David Souter as being on their team no matter who appointed them.

This is not to say that the Court can do anything it wants and remain its standing with elites and the public. A decision completely lacking in elite or popular support might have this effect. Unfortunately, this scenario wouldn’t describe a decision striking down the ACA. Such a decision would have the strong support of the political party that controls the House of Representatives and 48 seats in the Senate, and if current polling holds up would have the support of a majority of the public as well.

I also think some people are way too optimistic about the policy that would emerge should the Court just strike down the mandate, but…well, read the whole etc.

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