Respectful Insolence

Tomorrow, as mandated by the Patient Protection and the Affordable Care Act (PPACA, often called just the Affordable Care Act, or ACA, or “Obamacare”), the government-maintained health insurance exchanges will open for business (that is, assuming the likely government shutdown doesn’t stop them temporarily). This post will be basically a followup to a post I did almost a year ago that used a statement by Mitt Romney during the height of the Presidential campaign as a jumping off point to look at the relationship between health insurance status and mortality. Unfortunately, it is not entirely possible to disentangle science from politics, and we have to dive in. Also, politics is the art of the possible; so, policy-wise, what is best as determined by science might well not be what is possible politically.

The reason I wanted to revisit this topic is because of a political battle that went on for quite some time over the last several months to expand Medicaid in Michigan according to the dictates of the ACA. The reason that this battle is occurring in many states is because when the Supreme Court ruled last year that the individual mandate requiring that citizens have health insurance was Constitutional, one provision that it ruled unconstitutional was the mandatory expansion of Medicaid in states participating in the Medicaid program to cover all people under 65 up to 133% of the federal poverty level. States thus had to decide whether or not they would accept the Medicaid expansion. In our state, Governor Rick Snyder supported the expansion. Even though he is Republican, he is also a businessman and realized that it was a good deal, with the federal government covering 100% of the cost for the first three years and then phase down to 90% of the cost in 2020. The bill to expand Medicaid managed to pass the House of Representatives, but then it stalled in the Senate. Unfortunately—and this is what got me involved—my state senator led the opposition to the Medicaid expansion in the Senate, much to my chagrin, disappointment, disapproval, and even anger. His argument, which is being repeated elsewhere in the blogosphere, is that Medicaid is worthless and doesn’t improve health outcomes. Instead, he endorsed an alternative that (or so he claimed) place Medicaid-eligible patients into in essence low cost, high deductible concierge practices, with health savings accounts like this one. Ultimately, my state senator lost, and Medicaid was expanded in Michigan in a plan that was characterized by John Z. Ayanian in this week’s New England Journal of Medicine as “a pragmatic pathway to link Republican and Democratic priorities for health care.”

The drama in my own state notwithstanding, the whole kerfuffle got me to thinking. In my post a year ago, I basically asked what the evidence was that access to health insurance improves health outcomes, but I didn’t really stratify the question into kinds of health insurance. Rather, I just looked at being uninsured versus having health insurance. After my little Facebook encounter with one of my elected representatives, I wondered what, exactly, was the state of evidence. So I decided to do this post. In the U.S., currently we have in essence three kinds of health insurance, broadly speaking: Private insurance, Medicare, and Medicaid. Medicare, for those of our readers from other countries, is a plan that covers the medical care of people 65 and over and those receiving Social Security disability benefits. It is funded through payroll taxes and directly paid for by the federal government. Medicaid, in contrast, is a plan designed for low income people who fall below certain income levels. Also in contrast, it is jointly funded by the states and the federal government with each participating state administering the plan and having wide leeway to decide eligibility requirements within the limits of federal regulations that determine minimal standards necessary for states to receive matching funds. Indeed, the loss of this leeway to determine the income level at which a person is eligible for Medicaid is one of the reasons the provision for Medicaid expansion was part of the Supreme Court challenge to the ACA. These days, most Medicaid plans hire private health maintenance organizations (HMOs) to provide insurance. Finally, what needs to be understood is that, compared to private insurance, Medicare reimbursement rates tend to be lower and Medicaid reimbursement rates are lower still, which is part of the reason why a lot of doctors don’t accept Medicaid. Increases in reimbursement under the ACA might well help this situation.

Observational evidence

With that admittedly lengthy introduction behind us, let’s look at the science of the question of whether Medicaid is as useless as my state senator and others claim that it is. It’s a huge set of studies, many conflicting and many also unable to control completely for confounders that interact with insurance status, such as socioeconomic status, risk factors like tobacco and alcohol abuse, and the like. Not surprisingly, unlike claims of Medicaid detractors, it’s complicated, and, like most complicated issues in medicine, there are studies that can be cherry picked by anyone to make whatever point he wants (which is exactly what my state Senator tended to do). A good place to start (for me, at least) is my back to my original post from a year ago, because there was one study to which I alluded that showed differences in outcomes in cancer patients that correlate with their insurance status, specifically the University of Virginia study from 2010, which found that Medicaid and uninsured status were independently associated with increased risk-adjusted mortality. I mentioned that, but didn’t dwell on it, because the question I was examining was not Medicaid versus private insurance but rather having health insurance versus no health insurance. In this study, however, the authors noted the multifactorial causes of poorer outcomes in Medicaid patients. There are other studies that find similar outcomes disparities. For instance, using the National Inpatient Sample (NIS) database, which is a stratified random sample of all hospital discharges in the United States maintained by the Agency for Healthcare Research and Quality as part of the Healthcare Cost and Utilization Project, a 2003 study from the University of Michigan found that for abdominal aortic aneurysms (AAA) uninsured and Medicaid status were associated with higher mortality and rupture rates:

Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%).

Of course, in this study, Medicaid patients did better than the uninsured for some outcomes. For instance, if you look at the adjusted odds ratio for AAA rupture, Medicaid status had no effect, with an odds ratio of 0.84 (0.55-1.3, p=0.41), while no insurance produced an odds ratio of 2.3 (1.5-3.5, p=0.001). From the point of view of this study, it is better to have Medicaid than to be uninsured but not as good as having private insurance. This is not entirely surprising because of the low reimbursement rates of Medicaid, which limit the choices of physicians and institutions for Medicaid patients and make it prohibitive for many private primary care doctors to care for Medicaid patients. Similar results were found in a 2011 study of cardiac valve replacement from the University of Virginia, which showed the best outcomes in terms of mortality and in-hospital complications in patients with private insurance, followed by Medicare patients, Medicaid patients, and the uninsured, who had the worst outcomes of all. They also reported that Medicaid patients accrued the longest hospital stay and highest costs. Consistent with this, a 2013 study from the University of Virginia of pediatric surgery patients undergoing mostly urgent surgery for appendectomy, intussusception, decortication, pyloromyotomy, congenital diaphragmatic hernia repair, and colonic resection for Hirschsprung’s disease showed that uninsured patients were at increased risk for mortality, while Medicaid patients were at increased risk of morbidity.

Of course, the question really boils down to whether it is equivalent to be uninsured versus having Medicaid, which some studies seem to indicate, or not. Again, this is a very complicated question, because studies looking at specific outcomes can be confounded by uninsured patients getting Medicaid. For instance, uninsured patients who are diagnosed with cancer in our state frequently qualify immediately for Medicaid and are no longer uninsured. This leads to a rather frustrating situation for some of my patients who are uninsured and suspected of having cancer but can’t afford the biopsy necessary to prove it and make them eligible for Medicaid. We have other resources, including limited state funds and charitable funds administered through our cancer center that can fund such biopsies, but it’s very frustrating to cancer doctors that such resources are even necessary, given how great the need is.

All of this leads to a potential explanation, and quite a reasonable explanation at that, as to why Medicaid patients do more poorly than patients with private insurance, in some studies (the ones touted by my state senator as indicating that Medicaid is worthless and doesn’t improve health outcomes), and that’s delay in treatment. This was alluded to as a possible cause in the AAA study from 2003, but it’s suggested more explicitly as a cause in a 2012 study from the Brigham and Women’s Hospital examining outcomes after surgery for spinal metastases. This study found higher mortality rates for the uninsured and Medicaid patients, as well as higher complication rates. However, these were crude estimates. When the investigators adjusted for acuity of presentation, there was no significant differences in the risk of death or complications between privately insured patients and Medicaid patients or the uninsured, leading the authors to conclude that, “This nationwide study suggests that disparities based on insurance status for patients undergoing surgery for spinal metastases may be attributable to a higher acuity of presentation.” A recent systematic review of outcomes in lung cancer patient mortality came to similar conclusions:

The mechanisms underlying care disparities for patients without insurance and for those who receive Medicaid are unclear but probably multifactorial (6 6. Woods LM, Rachet B, Coleman MP. Origins of socio-economic inequalities in cancer survival: a review. Ann Oncol 2006;17:5–19. View Full Reference List , 41 ). There are likely patient-related factors, such as individual differences in health behaviors such as smoking, income, education, and comorbidities. Others may stem from a differential ability to interact with the healthcare system, differences in the care provided by institutions that serve Medicaid and uninsured patients, and less access to better-quality care. Our review indicates that some of these latter mechanisms may be important based on studies that show differential rates of receiving guideline-concordant care (31, 32), receiving care at a university cancer center (29), receipt of surgery or radiation therapy (20), and receipt of care at high-volume centers (27, 28). Although uninsured patients and those with Medicaid may be more likely to be treated at certain centers, no studies directly adjusted for center-level effects, so we cannot determine their role on the assessed outcomes (42).

Taken together, from my perspective, the evidence is consistent with a conclusion that having Medicaid results in better health outcomes than not having Medicaid but that those outcomes are not as good as those associated having private insurance (although one study did find a paradoxical result). Most likely this is due to a combination of socioeconomic status and lack of primary care resources, all leading to their presenting at a later stage in their disease, as these studies, which are just a more recent sampling of existing studies, clearly indicate. For some conditions, Medicaid patients do as poorly as the uninsured, and those are the studies cited by legislators like my state senator to argue against Medicaid expansion. Sometimes they are intermediate in their outcomes, not as good as patients with private insurance but not as bad as the uninsured. These tend to be the studies ignored by legislators like my state senator and the pundits that he cites. However you analyze the evidence, however, it is clear that Medicaid patients do have worse outcomes, sometimes a lot worse, than patients with private insurance, and that the cause is almost certainly multifactorial in such a way that simply getting access to bare-bones health insurance like Medicaid can’t remedy. Many of these studies have unmeasured confounders that resort in worse outcomes in Medicaid patients. As Frakt et al have argued that selection bias in these studies explains a lot of the results:

It’s far more likely that such results are driven by selection bias. Medicaid enrollees (including dual-eligible recipients of both Medicaid and Medicare) tend to be sicker than uninsured patients and to have lower socioeconomic status, poorer nutrition, and fewer community and family resources. Medical and social service providers may also help the sickest or neediest patients to enroll in Medicaid — a more direct cause of selection bias. Few of these potential confounders can be completely addressed using commonly available clinical or population data.

Health economists use an alternative approach in analyzing Medicaid’s outcomes that seeks to eliminate selection bias related to unobservable factors affecting enrollment and health outcomes. By exploiting the variation in Medicaid eligibility rules or other program characteristics influencing states’ enrollment rates, scholars have consistently found that Medicaid coverage leads to health improvements.4,5 The assumption behind these “instrumental variables” approaches is that Medicaid enrollment depends on state-level eligibility rules but patients’ health status does not.

Personally, I suspect that there is a lot of selection bias in these studies. Young healthy adults without insurance who are eligible might not enroll in Medicaid because they don’t think they need it and also tend not to need the procedures examined in the studies I discussed. In contrast, if you’re sick and eligible for Medicaid, you’ll be more likely to enroll because you need the treatment. Also, as I’ve pointed out before, in studies of cancer, there is a lot of crossover between the uninsured and Medicaid recipients, because in some states like mine a cancer diagnosis makes an adult who might not have been eligible for Medicaid (remember, some states restrict Medicaid eligibility using more than just income) will suddenly become eligible. I’ve lost count of the number of patients I’ve taken care of for whom this was true. The same thing happens in emergency rooms all over the place, where hospitals, confronted with an uninsured patient, help him apply for Medicaid during the course of an acute illness.

Would expanding Medicaid result in better health outcomes?

Of course, the name of this blog is Science-Based Medicine, and the question that results from the confusing and conflicting mass of studies sampled above is whether expanding Medicaid would result in better health outcomes for the people who receive the expanded coverage. This is a much more difficult question to answer, but there have been studies designed to address this question. The two most prominent are frequent “targets” of discussion. The previous studies that I’ve cited are all retrospective studies, with all the attendant shortcomings of retrospective studies, and none of them address this question. They simply found correlations, and some of them tried to explain these correlations.

One study that is often touted as strong evidence that expanding Medicaid eligibility will likely result in better health outcomes was a study published in the NEJM a year ago. What the investigators did was to identify states that had expanded Medicaid to cover childless adults (in many states childless adults have not been eligible for Medicaid coverage) between 2000 and 2005 to allow comparisons for a five year period before the expansion and after the expansion:

Three states met our criteria: Arizona, which expanded eligibility to childless adults with incomes below 100% of the federal poverty level in November 2001 and to parents with incomes up to 200% of the federal poverty level in October 2002; Maine, which expanded eligibility to childless adults with incomes up to 100% of the federal poverty level in October 2002; and New York, which expanded eligibility to childless adults with incomes up to 100% of the federal poverty level and parents with incomes up to 150% of the federal poverty level in September 2001.

The controls selected were neighboring states without Medicaid expansions that were closest in population and demographic characteristics to the three states with Medicaid expansions. The primary outcome examined was annual county-level all-cause mortality per 100,000 adults between the ages of 20 and 64 years (stratified according to age, race, and sex), obtained from the Compressed Mortality File of the Centers for Disease Control and Prevention (CDC) from 1997 through 2007, totaling 68,012 observations specific to an age group, race, sex, year, and county. Secondary outcomes included percentages of persons with Medicaid, without any health insurance, and in “excellent” or “very good” health (from the Current Population Survey, a total of 169,124 persons) and the percentage unable to obtain needed care in the past year because of cost (from the Behavioral Risk Factor Surveillance System, a total of 192,148 persons). Multivariate analyses were carried out, and prespecified subgroup analyses, and as an additional test the same analyses were carried out for people over 65, who were eligible for Medicare and whose Medicaid eligibility was therefore not affected by the Medicaid expansion. Overall, the investigators found a 6.1% relative reduction in the risk of death among adults between the ages of 20 and 65, leading them to estimate this:

A relative reduction of 6% in population mortality would be achieved if insurance reduced the individual risk of death by 30% and if the 1-year risk of death for new Medicaid enrollees was 1.9% (Table S4 in the Supplementary Appendix). This degree of risk reduction is consistent with the Institute of Medicine’s estimate that health insurance may reduce adult mortality by 25%, though other researchers have estimated greater35 or much smaller36 effects of coverage. A baseline risk of death of 1.9% approximates the risk for a 50-year-old black man with diabetes or for all men between the ages of 35 and 49 years who are in self-reported poor health. The lower end of our confidence interval implies a relative reduction in the individual risk of death of 18%.

This study did, of course, have a fair number of confounders and shortcomings. For one thing, it was not a randomized design, and it was an ecological study, which tends to overestimate effects. Also, as the authors point out, states tend to decide to expand Medicaid when the economy is doing well and they can afford to do it. Also, there is a correlation between states willing to expand Medicaid and investment in other measures designed to improve public health. On the other hand, the authors reported found that new Medicaid enrollees tended to be older, disproportionately minorities, and twice as likely to be in fair or poor health as the general population, all of which to them suggested a higher risk of mortality. In other words, this study was promising, but by no means slam-dunk evidence that Medicaid expansion will result in better health outcomes.

The Oregon study

No discussion of this issue is complete without a consideration of a study in Oregon designed to look at the effect of Medicaid expansion. Its most recent results were reported in the NEJM five months ago and were seized upon by advocates on all sides, but in particular the “Medicaid expansion doesn’t work” and “Medicaid is harmful” side. It’s a curious study in that, had it been proposed to me before I already knew that it had been begun, I would have seriously questioned whether the study was ethical and would pass an institutional review board. Obviously it did, and the reason is that it wasn’t the investigators who did the randomization. Rather, Katherine Baicker and her colleagues took advantage of an existing randomization. What happened is this. In 2008, because its legislature found the money to fund additional Medicaid coverage, Oregon used a lottery system to determine who of a waiting list of 90,000 would have a chance at getting Medicaid. Selected adults won the right to apply for Medicaid and got it if they met the eligibility requirements. A sample of adults who won the Medicaid lottery were compared to adults who participated in the lottery but didn’t win. Outcome measures examined included blood-pressure, cholesterol, and glycated hemoglobin levels; screening for depression; medication inventories; and self-reported diagnoses, health status, health care utilization, and out-of-pocket spending for such services. This sample was limited to the Portland metropolitan area because of logistical constraints and consisted of 20,745 people: 10,405 selected in the lottery (the lottery winners) and 10,340 not selected (the control group), of which a total of 12,229 persons in the study sample responded to the survey. Interviews were conducted between September 2009 and December 2010 and took place an average of 25 months after the lottery began.

This was a rare opportunity to take advantage of an existing natural experiment in whether providing Medicaid coverage to the uninsured actually does what it is intended to do. Unfortunately, given its timing, the results of the study have become a political punching bag with the Oregon study in essence being used as a weapon against the whole of Obamacare and misrepresented as being slam dunk evidence that Medicare is at least useless. In essence, as Ashish Jha put it, the Oregon Study became a Rorschach test of sorts, confirming people’s biases about whether Medicaid is “good” or “bad.”

So what did it show?

The results were mixed and rather disappointing in some respects but not entirely unexpected given the short followup time of only two years:

We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P = 0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.

As has been pointed out at The Incidental Economist, this led those opposing Obamacare to declare the experiment a failure. Some go so far as to declare that the ACA has completely failed, that Medicaid is a horrible thing, and that anyone who tries to argue against this is a “Medicaid denier.” (I kid you not; unfortunately, this is a person known for making seriously bad arguments.) Unfortunately, my state Senator buys into these arguments. I also agree with Jha when he challenges physicians to go through all 62 pages of the supplementary appendix describing the methodology in detail because this study is as good as any study on the matter likely to be done in a generation.

So is it really as bad as that. Of course not. The study is, as are most studies of this type, messy and early results are disappointing, but by no means is it time to declare failure yet. For one thing, improved mental health outcomes are improved outcomes. The way critics of Medicaid ignore this result or pooh-pooh it to me is consistent with how we short shrift mental health in this country, viewing mental illness as somehow not being “real” illness. Also, the marked decrease in financial distress reported in this study is no small thing. For another thing, lack of statistical significance doesn’t necessarily mean that there is no treatment effect. It can mean that, but it can also mean that the numbers are too small and the study is underpowered, which it could well be. Indeed, the authors themselves concede as much:

Hypertension, high cholesterol levels, diabetes, and depression are only a subgroup of the set of health outcomes potentially affected by Medicaid coverage. We chose these conditions because they are important contributors to morbidity and mortality, feasible to measure, prevalent in the low-income population in our study, and plausibly modifiable by effective treatment within a 2-year time frame. Nonetheless, our power to detect changes in health was limited by the relatively small numbers of patients with these conditions; indeed, the only condition in which we detected improvements was depression, which was by far the most prevalent of the four conditions examined. The 95% confidence intervals for many of the estimates of effects on individual physical health measures were wide enough to include changes that would be considered clinically significant — such as a 7.16-percentage-point reduction in the prevalence of hypertension. Moreover, although we did not find a significant change in glycated hemoglobin levels, the point estimate of the decrease we observed is consistent with that which would be expected on the basis of our estimated increase in the use of medication for diabetes. The clinical-trial literature indicates that the use of oral medication for diabetes reduces the glycated hemoglobin level by an average of 1 percentage point within as short a time as 6 months.15 This estimate from the clinical literature suggests that the 5.4-percentage-point increase in the use of medication for diabetes in our cohort would decrease the average glycated hemoglobin level in the study population by 0.05 percentage points, which is well within our 95% confidence interval. Beyond issues of power, the effects of Medicaid coverage may be limited by the multiple sources of slippage in the connection between insurance coverage and observable improvements in our health metrics; these potential sources of slippage include access to care, diagnosis of underlying conditions, prescription of appropriate medications, compliance with recommendations, and effectiveness of treatment in improving health.

The Incidental Economist thinks that most likely the reason that the results, although trending in the right direction, didn’t achieve statistical significance was because the study was underpowered. Jha thinks it’s because Medicaid only addresses access to care and not quality of care. Both are likely contributors, but I tend to think that The Incidental Economist is likely to be closer to being correct. Contrary to analyses claiming that this study was not underpowered, for a controlled study of this type, the fraction of subjects with each condition very much matters. If only 5% of the population have a condition, that’s only around 300 subjects in each group. When looking at all these subgroups, absent dramatic improvements in certain parameters or high prevalence of the conditions being examined, it is hard to detect statistically significant differences, particularly in a short time frame. Finally, these measures are all surrogate measures. What will really be interesting to determine will take considerably more time than two years to determine, namely whether Medicaid coverage decreases morbidity and overall mortality. Indeed, The Incidental Economist asks a very pertinent question: “What is reasonable to expect? How much does private insurance affect these values? Do we know? No. There is no RCT of private insurance vs. no insurance. No one claims we have to have one. We just “know” private insurance works.”

The bottom line

As I stated earlier, as much as we would like political policy to be science-based, particularly in health care, it can’t be said enough that politics is the art of the possible, and the ACA is what was possible at the time it was being negotiated. As a product of a messy political process, it is far from perfect. The question is whether the claims made for the ACA and its provisions are supported by evidence. Because a large part of mechanism by which the ACA will decrease the number of uninsured is through the Medicaid expansion, studies like the Oregon study are very important for determining whether it has a reasonable chance of succeeding in improving the health outcomes of these people. As is all too frequently the case, the the error bars are large surrounding the data relating Medicaid and health outcomes, and unfortunately the most recently reported results of the Oregon study come after too brief a time to make any definitive pronouncements, attacks on it by anti-Obamacare pundits notwithstanding. Moreover, when it comes to public policy, science is certainly a major consideration, but so are economics and justice. Reasonable people might disagree on where the balance should be struck, but nothing is served by distorting the science for political ends. Unfortunately, there is a lot of that going on right now, and, I suspect, it will only get worse before it gets better.

Comments

  1. #1 elburto
    September 30, 2013

    The whole thing just seems overwhelmingly mind-boggling and frustrating. The wealthiest superpower should not have the situation where someone is too bloody poor to afford the tests that would prove that they have the conditions that make them eligible for healthcare.

    It’s needlessly cruel, especially given that low-income women have higher risk of developing certain cancers, and that for many woman, the one organisation that could have provided them with means-tested access to preventative and diagnostic care has been attacked and then gutted, because 3% of its remit was providing medical and surgical abortions.

    Unfortunately our current tinpot dictator Prime Minister is so enamoured of profit and wealth that he admires the American model, and wishes to emulate it. It seems that the poorest households in the UK aren’t quite suffering enough for him. Yet,

  2. #2 Pris
    The Dark Side of the Force
    September 30, 2013

    I am very glad to live in a place where having health insurance is both mandatory and affordable.

    It is interesting that one of the nations with the highest national spending on health care has one of the highest percentages of uninsured people and some of the worst health outcomes.

  3. #3 Chris HIckie
    September 30, 2013

    I think making science-based healthcare affordable and accessible to all is a very good thing to happen, and it needs to happen, even more so than the ACA does.

    That being said, I have concerns for the survival of my pediatric practice with the ACA, given its smaller size (2 1/2 physicians). Despite this October 1 date where the exchanges open, I’ve heard remarkably little from the insurance companies. But I have heard from parents that they are being told by some insurers I am contracted with that I may soon no longer be “in network”–which is ominous news to me. I don’t know if this has anything to do with the ACA or not, but the timing is suspect. I will take any insurance plan as long as I don’t lose money on it (I have staff and rent and expenses (did I tell you vaccines are 1/3 my total gross expenses?) to pay. My income is what is left. If I have nothing left, I can’t put food on my table. I am not sure I can afford to be dropped by any of the plans I do take (and as far as I know, I’m in good standing with all of them)

    Additionally, my health plan for my staff and me goes away December 31st (thanks to the ACA). I have already been told by my insurance agent to expect substantially higher premiums, with no subsidies to help me or my staff out. I will pay them, but I don’t feel this is going to be a fair sharing of the burden to help others be insured. I am not a “rich” doctor (pediatricians are the lowest paid of physicians) by any means.

    I believe I run a fair practice. I have people who pay out of pocket, and they don’t pay more than the discounted rates I take from insurers, and they can pay in interest-free installments. I currently can’t afford to take any medicaid plans, as their much lower reimbursement and paperwork load (multiple re submissions of every claim) works out to losing money on them.

    I think both sides of the ACA debate (not sure what’s to debate–it is law) are much prone to over exaggeration, one side saying everything with be rosy and the other acting like armageddon is here. But, I will be very sad (and directly impacted) if smaller practices are hurt by this big changeover.

  4. #4 Anj
    September 30, 2013

    This whole thing has been transparently about destroying any increased access to health care.

    It’s annoying. NPR has been doing a lot of reporting and Texas (one of the highest percentages of the uninsured) is allocating no money to help the uninsured find policies.

    The message certain politicians are sending is that access to health care should be reserved for the privileged and the rest? I don’t know. Soylent Green maybe?

  5. #5 Calli Arcale
    September 30, 2013

    It should be no surprise that Medicaid is the worst kind of insurance to have, given the systematic attacks it has endured politically for years, which have resulted in very low reimbursement rates and poor coverage. It is better than nothing, but not much. That the political process has rendered it such a poor option is now used by that same political process as an argument against its very existence. This has of course happened before in politics, and will happen again, but it will never stop depressing me.

    • #6 Orac
      September 30, 2013

      One notes that under the initial Medicaid expansion, the federal government is increasing reimbursement rates to almost equal those of Medicare, at least through 2014. This should help the problem of no doctors taking Medicaid.

  6. #7 Mephistopheles O'Brien
    September 30, 2013

    You get the kind of food you can afford to buy. You get the kind of housing you can afford to buy. You get the kind of transportation you can afford to buy. You get the kind of clothing you can afford to buy. You get the kind of experiences you can afford to buy.

  7. #8 BTB
    September 30, 2013

    If the ACA only affected medicine then it would be a good deal, unfortunately you have to read what is in it to know what it does. I would like for you to read the article that this http://freedomoutpost.com/2013/08/obamacare-provision-forced-home-inspections/ points too. As you can see the healthcare law has as much to do about how you raise your family than anything else. As a veteran I find it very interesting that the government thinks it needs to inspect my house but there is no mention of convicted felons or any other family that has a criminal as a member. I suggest you read the actual bill and think of the unintended consequences and how words can be twisted by the bureaucrats to give themselves authority to do things that would never be granted in a separate bill held to public scrutiny. You have my email address, if you wish to discuss this further I would be more than happy to.

  8. #9 BTB
    September 30, 2013

    If the ACA only affected medicine then it would be a good deal, unfortunately you have to read what is in it to know what it does. I would like for you to read the article that this http://freedomoutpost.com/2013/08/obamacare-provision-forced-home-inspections/ points too. As you can see the healthcare law has as much to do about how you raise your family than anything else. As a veteran I find it very interesting that the government thinks it needs to inspect my house but there is no mention of convicted felons or any other family that has a criminal as a member. I suggest you read the actual bill and think of the unintended consequences and how words can be twisted by the bureaucrats to give themselves authority to do things that would never be granted in a separate bill held to public scrutiny. You have my email address, if you wish to discuss this further I would be more than happy to.

  9. #10 Andrew Dodds
    September 30, 2013

    Mephistopheles -

    So, I assume that you are in favor of a 100% inheritance tax? No one ever earned an inheritance (if they worked for it, they should have been paid).

    You are happy for kids to die of treatable conditions if they make the mistake of having poor parents? You want access to education determined by wealth? Hard working adults to die through the bad luck of catching an expensive disease?

    Work for a big house, a nice car, an early retirement, yes.. hard work should have rewards. But stamping on the poor or unlucky is nothing about hard work and rewards, it’s about fear and class warfare.

  10. #11 Rick Meidell
    Alhambra Ca
    September 30, 2013

    I am a neonatologist practicing in the LA metropolis. I would be curious to see such a study comparing outcomes in the neonatal age group as it relates to MediCaid and private insurance. My experience tells me there would be little or no difference as here in California as MediCal (California’s MediCaid) is keen on providing pregnancy and newborn care to poor women and children.

  11. #12 Rick Meidell
    Alhambra Ca
    September 30, 2013

    I am a neonatologist practicing in the LA metropolis. I would be curious to see such a study comparing outcomes in the neonatal age group as it relates to MediCaid and private insurance. My experience tells me there would be little or no difference as here in California as MediCal (California’s MediCaid) is keen on providing pregnancy and newborn care to poor women and children.

  12. #13 madder
    September 30, 2013

    Continuing M O’B's litany–

    One gets the transportation infrastructure one can afford to buy. And police/fire protection. And national defense. And meat inspections. And public parks. And elections*. And intellectual property protections. And OSHA protections, and education, and…

    Seriously, was that intended to pass as intellectual discourse?

    Healthcare is a public utility. It is in everyone’s interest to have a healthy and functional workforce.

    For example: Imagine that my neighbor loses his job because of illness, and health coverage with it, leading to bankruptcy. Should I celebrate the resulting foreclosure on his home as the free market in action? That affects my home’s value.

    But to continue the litany of dumb: you get the neighbors you can afford to buy, right?

    I usually agree with you, Mephistopheles, but unless this was intended more subtly than Andrew Dodds and I thought, you’ve hit T h i n g y levels of stupid here.

    * Well OK, Citizens United and all that. But I’m talking about the costs of putting the things on in the first place.

  13. #14 Denice Walter
    September 30, 2013

    I would call ‘sarcasm’ for MOB’s comment.

  14. #15 Denice Walter
    September 30, 2013

    I suspect sarcasm ( IRT MOB)

  15. #16 Shay
    cookie-faehig
    September 30, 2013

    BTB — as one veteran to another, take anything you read on that site with a heaping tablespoonful of salt. Actually, I have found it best to take anything on a website with “Freedom,” “Truth,” or “Patriot” in the title with a heaping tablespoonful of salt.

    http://www.snopes.com/politics/medical/homeinspections.asp

  16. #17 Denice Walter
    September 30, 2013

    Sorry about that connection woes.

  17. #18 madder
    September 30, 2013

    @Mephistopheles O’Brien–

    After a cup of coffee, I think DW is right, and you were being sarcastic. Deepest apologies for flying off the handle like that: a weekend of listening to ignorant people has rather badly colored my judgment. So my vitriol is directed at others.

    Oops.

  18. #19 Johanna
    September 30, 2013

    I thought M O’B was being facetious…

  19. #20 Mephistopheles O'Brien
    September 30, 2013

    Yes, there was sarcasm and facetiousness. There’s also an attempt to understand something. I’m hoping someone can enlighten me on their views.

    The basic question: why do some people consider health care a fundamental human right? There are multiple statements made that frankly seem unjustified, like:

    Statement: Nobody should go broke or die because they got unlucky and got sick.
    Response: People go broke and die from being unlucky in all kinds of situations. What is so special about illness?

    Statement: There are things that are just part of the normal social contract.
    Response: And why is health care one of them?

    I would sincerely appreciate a reasoned response. I’d also like to understand at what level health care turns from a human right to a luxury item (it does, you know, just like anything else).

    Thanks.

  20. #21 JGC
    September 30, 2013

    BTB, many thanks for providing another sterling example of a fallacious attack on Obamacare.

  21. #22 Mephistopheles O'Brien
    September 30, 2013

    Just a note on my list above – I freely acknowledge that in most advanced countries, there are government run (as well as charitable) programs to provide some amount of food, shelter, and to a lesser extent, clothing, transportation, and experiences for those who are categorized as poor. I can certainly see that society could very well come to a consensus that some amount of medical care should be provided by a government program.

  22. #23 Eric Lund
    September 30, 2013

    Calli @5: I tried to respond earlier, but that attempt seems to have fallen into the bit bucket.

    One important thing about Medicaid is that it is designed to serve the population with the poorest socioeconomic status. (This is related to the political issues you mention.) Not surprisingly, there is a strong correlation in this country between socioeconomic status and overall health: money may not buy happiness, but it lets you buy your way out of the most common forms of unhappiness. So somebody on Medicaid will get to see a doctor reasonably promptly compared to an uninsured person (who may find a single office visit ruinously expensive) once a problem develops. But Medicaid patients are less likely to get preventive care than people on private insurance, so they are more likely to have confounding medical issues. Thus the result that Medicaid is better than nothing but not as good as private insurance is exactly what you would expect in a system like ours.

    As for the dustup starting with MO’B's post @7: One reason to provide basic medical care at public expense for poor people is that often it is cheaper than waiting to deal with their problems until they get to the emergency room (where taxpayers end up paying for it anyway, because unless you’re either rich or insured, you are unlikely to be able to pay for it). This notion of spending a little now so that you don’t have to spend a lot later is, in sane political environments (which is not true of the US), considered a fiscally prudent thing. It’s the same argument as for spending money on infrastructure and education: a sound economy requires a transport network adequate to move goods and people around as needed, as well as a workforce that is capable of performing the needed work. Said workforce performs better when healthy, too.

  23. #24 Mephistopheles O'Brien
    September 30, 2013

    I shouldn’t do this, as I know it’s going to get me into trouble, but in the interest of improving (well, in my view) the general level of debate here are my answers to some of the comments above. Please take them in the spirit of intellectual and philosophical discourse, like they’re intended.

    @Andrew Dodds:

    So, I assume that you are in favor of a 100% inheritance tax? No one ever earned an inheritance (if they worked for it, they should have been paid).

    That appears to be a non sequiter. At no time did I comment on what people earn, only on what they can afford.

    You are happy for kids to die of treatable conditions if they make the mistake of having poor parents?

    Happy? Of course not. Do you argue that it is government’s role to make me happy in all things?

    You want access to education determined by wealth?

    You may not have noticed, but it is to an extent. While we’d all like to believe that our fine public institutions of learning are the best they can be, that is tragically not always the case. If a local school is not as good as a parent would like, those who can afford it buy a different education. This continues into college – not everyone who could benefit from, say, a Hahvahd education can afford the costs including tuition, books, room, board, and other living expenses in Cambridge, MA – even counting scholarships, grants, and loans. And they don’t go.

    Hard working adults to die through the bad luck of catching an expensive disease?

    I don’t want people to die from disease. I don’t want people to die because of bad luck that doesn’t involve disease. But what does that have to do with government policy?

    But stamping on the poor or unlucky is nothing about hard work and rewards, it’s about fear and class warfare.

    Please point out where I talked about “stamping on the poor or unlucky”?

    @madder

    One gets the transportation infrastructure one can afford to buy. And police/fire protection. And national defense. And meat inspections. And public parks. And elections*. And intellectual property protections. And OSHA protections, and education, and…

    I fully grant you there are multiple programs that one benefits from whether one pays taxes or not (though I would argue that intellectual property protection is, in fact, one of those where you get what you can afford rather than what is merely due you). Explain why medicine must be one of those.

    Healthcare is a public utility.

    Based on the definition I’ve heard, it’s not in the United States to date. Electrical generation and the post office, yes. Health care is a regulated marketplace.

    It is in everyone’s interest to have a healthy and functional workforce.

    True, which is why we have public health offices, inspection of food, sewer systems, public water supplies providing fresh water, and so on. However, that argument doesn’t say that every single worker needs to be kept healthy and functional as long as there are sufficient workers to do the jobs. The “health workforce” argument would justify preventing epi/pandemics which would take a substantial number of workers out of the workforce for a period of time; it might not justify saving a single worker. When you start talking about people in groups (like workforce) then you don’t necessarily talk about the benefits to the individuals.

    For example: Imagine that my neighbor loses his job because of illness, and health coverage with it, leading to bankruptcy. Should I celebrate the resulting foreclosure on his home as the free market in action? That affects my home’s value.

    Of course you shouldn’t celebrate. However, if your neighbor were to gamble away his/her/its life savings at the dog track, what should be done about the resulting foreclosure? Or if the sole breadwinner were to lose his/her/its job and go into foreclosure? Or had any of the countless things one might consider “bad luck” happen that ended up with the same foreclosure? Which do we choose to use government action against and why?

    you get the neighbors you can afford to buy

    Well, in a manner of speaking, to an extent, yeah. If you’re lucky. If you’re really lucky, you may get neighbors who are better than you can afford.

  24. #25 Mephistopheles O'Brien
    September 30, 2013

    @Eric Lund – that sounds like quite a reasonable and pragmatic argument. What does the data say about how much is saved? Thanks!

  25. #26 Narad
    September 30, 2013

    I’m going to leap in here without having read the entire post or the extant comments.

    His argument, which is being repeated elsewhere in the blogosphere, is that Medicaid is worthless and doesn’t improve health outcomes.

    I happen to be located in Cook County, which received a waiver to implement the Medicaid expansion early. It was only through a simple twist of fate that I heard about the program.

    As a point of anecdata, and without going into too much detail, I can guaran-f*cking-tee you that this has been a good-value proposition all around. Just the prescription benefit means that I don’t have to worry about the cost of controlling HTN, and that’s the tip of the iceburg. Kind of nice to discover that one’s vitamin D level is 7 ng/ml. I can get a freaking flu shot. I could go on, but the screamingly cost-effective examples are in the realm of too much information.

    For the time being at least, I don’t have to worry about going through the process of applying for financial aid for an ED visit, which has happened once, and the hospital wouldn’t have to worry about eating the entire cost.

    I’m very fortunate in that there’s a fine university hospital in the area with a long tradition of accepting Medicaid (and I even get a bus pass each way), which sure the f*ck isn’t my alma mater’s, for which I would be absolutely ineligible absent this instantiation of PPACA.

    Now, I just landed a promising new client, so things are looking up on both the internal and external landscapes, but I’ll be utterly screwed once again when I hit 133% of the FPL if something with group health doesn’t turn up. Not having an epidermoid/sebaceous cyst the size of a kumquat hanging over my left eye though, I suspect, will at least level out my odds on the interview front. Selah.

    Medicaid, in contrast, is a plan designed for low income people who fall below certain income levels.

    As an aside, I’ll note that Medicare and Medicaid aren’t mutually exclusive; those with the former may still be eligible for the latter to cover some of the holes.

  26. #27 Shay
    September 30, 2013

    Reasonable people might disagree on where the balance should be struck, but nothing is served by distorting the science for political ends.

    Why, in the 21st century, has the GOP chosen contraception as the hill they want to die on?

    http://politicalticker.blogs.cnn.com/2013/09/28/gop-to-add-conscience-clause-to-spending-bill/

  27. #28 Denice Walter
    September 30, 2013

    OT- but is a shamelessly self-promoting, VPD-promoting, pseudoscience-promoting alt media honcho assisting another** shamelessly self-promoting, VPD-promoting pseudoscientist to opportunistically make films about a dead, autistic teenager
    EVER TRULY OT @ RI?
    I should think not.

    MIkey @ Natural News is asking his myriad followers to help Andy make his film about Alex. And to support another antivax opus, “Bought”.

    ** who according to my map live within 10 miles of each other yet. Fancy that.

  28. #29 Bob G
    Los Angeles
    September 30, 2013

    The California version of the ACA will apparently be open for business tomorrow, October 1. You can use the online tool to estimate what insurance coverage would run, based on annual income, age, and the level of insurance.

    http://www.coveredca.com/

    For example, I typed in a hypothetical person of age 30 with an annual income of $25000, and found that subsidized coverage would run somewhere between $110 and $210 a month. The income level, by the way, is based on the modified gross adjusted income, so it will be lower than the total gross pay.

    The lower number is for something called Bronze, and has a fairly high deductible ($5000), but office visits are $60, and preventive visits are free. That’s a long way from being an uninsured person walking into a clinic for the first time, being handed a stack of papers that look like an application for a home loan, and being told to sign for costs in excess of $120, or not uncommonly, upwards of $200.

    I did a similar calculation for someone I know from another online forum, and found that for a 55 year old with an income of $14,000, coverage at the lower tier could be obtained for as little as a dollar a month.

    In other words, under the ACA, you can get coverage, it won’t cost you a huge amount if you have only a modest income, and you will presumably enter the cohort of people who will enjoy longer life expectancies.

    Reply to MOB: I’ve been through the process of having my words misinterpreted, so I sympathize. I recognize that there is a substantial gulf between the libertarian side and the liberal side in American politics. I join the liberal side in arguing for universal access to coverage, which is a huge swing away from the current system in which people have been arbitrarily denied the ability to buy health insurance. I see this as first of all a moral question. But it also has a pragmatic component, in that universal coverage, even at a price, will result in a huge reduction in personal pain and suffering for those who get the right kind of treatment in a timely manner, and it will result in huge decreases in end of life treatment for those who would have otherwise been successfully treated.

    The argument that health insurance eligibility is something that should be socialized (just as we socialize police and fire services) has been made by one of the better known conservatives of the Austrian school.

    How the costs are spread around is ultimately a political question. My personal answer is that base level coverage should be provided to all Americans and simply billed as part of the annual federal income tax returns. This would save scads of money all around, would provide for “Medicare for all” that so many of us support, and would spread the overall costs according to the progressive taxation model.

  29. #30 Rich Woods
    September 30, 2013

    @Mephistopheles #20:

    The basic question: why do some people consider health care a fundamental human right?

    Compassion, motherfucker.

  30. #31 Stella B
    September 30, 2013

    Chris Hickie – It’s unlikely that the ACA will affect your patient base since the “narrow networks” will apply only to people who are currently uninsured and are unlikely to affect most of your patients with employer based insurance. If you see a lot of cash patients, you may notice some change since many of them will now have insurance.

    Your premiums for yourself and your staff may or may not go up. If they do go up, then most of the increase probably would have occurred anyway. Most small businesses are reporting reduced premiums, however. Additionally due to the ACA, you are receiving tax credits as a small business that provides insurance to its employees. Your accountant would know more about this than your insurance broker.

  31. #32 Shay
    September 30, 2013

    If I wanted to be cynical I would point out that it’s in the best interests of the State to guarantee a good supply of healthy and able-bodied eighteen year olds for conscription.

  32. #33 Mephistopheles O'Brien
    September 30, 2013

    @Rich Woods – Thanks. What else does your compassion say should be paid for by government as a fundamental human right that currently is not, or at least is not to the extent you feel is important?

  33. #34 Mephistopheles O'Brien
    September 30, 2013

    @Shay – As the US does not currently use conscription, I’m not sure that’s a scenario that’s likely to come up. I’d also think that given the rigors of military training that if that were the goal there’d be more of an emphasis on physical training and less on health care. But thanks.

  34. #35 Shay
    September 30, 2013

    Ah, but you can take a healthy, unfit teenager and run the flab off him. It’s the ‘healthy’ part that’s important.

  35. #36 Mephistopheles O'Brien
    September 30, 2013

    Shay – True, but considering that we currently have enough healthy 18 year olds to staff the armed forces strictly with volunteers, it may not be a big issue. The topic I keep hearing in the discussion of the health marketplaces is that 18 year olds (well, 24 year olds) don’t want to participate because they’re, well, too healthy.

  36. #37 Mephistopheles O'Brien
    September 30, 2013

    I actually do have two problems with the answer “Compassion, motherfucker.” The first, and least significant, is that it’s technically inaccurate and describes acts that I have neither committed nor contemplated. Had I done so, my ‘nym might be Oediipus. But I digress.

    The other is that you can justify just about any policy you want based on “compassion, motherfucker”, while simultaneously demonizing anyone who disagrees with you. People believe that the government should fund abortions out of compassion. People believe the government should forbid abortions out of compassion. People believe the government should go to war in Syria out of compassion. People believe the government should avoid all wars out of compassion. I’ve heard people make a case for requiring women to wear hijabs or to have genital mutilation out of compassion.

    I’m all for compassion, but I’m not sure it’s sufficient.

  37. #38 Mephistopheles O'Brien
    September 30, 2013

    This is an add-on to my comment in moderation.

    I’m sure there are people who oppose the mandatory nature of the ACA out of compassion. How is it compassionate to require someone to buy something they don’t think they need and don’t think they can afford?

    On the other hand, there are people who argue the exact opposite.

  38. #39 Antaeus Feldspar
    September 30, 2013

    BTB -

    You done got suckered, son. You got fooled into believing, and repeating, one of the biggest myths out there about Obamacare. What makes it especially hilarious is that you told us “unfortunately you have to read what is in [the ACA] to know what it does” and then demonstrated that you were taking someone else’s (completely inaccurate) word about what was in it.

    Or would you like to cite the exact passage of the ACA where the home visiting programs, which already exist, and are ways that women in pregnancy who want and need extra help can get it, become mandatory “home inspection” programs? Because I don’t think you can.

  39. #40 Chris HIckie
    September 30, 2013

    @ Stella- I hope you are correct, but I’m still waiting to hear back on what is available–and I do need to speak with my accountant on this as well.

    BTW, does anyone know when lactation consults are supposed to start being covere/reimbursed by the ACA?

  40. #41 Marry Me, Mindy
    September 30, 2013

    I want to hear BTB’s response to having his/her undies exposed.

    BTB, now that your mis-information has been corrected, does that change you opinion about the ACA? Will you acknowledge that the people you have been looking to for information have been lying to you?

  41. #42 Chris,
    September 30, 2013

    M O’B: “How is it compassionate to require someone to buy something they don’t think they need and don’t think they can afford?”

    How do they know they won’t need health care? Who ever plans on tripping on a hike and breaking a bone? (some in our dorm) Slicing a tendon? (spouse, twice… once from a broken glass while washing dishes in college, a couple of years later with a circular saw while while working on our first house) Or getting a virus that causes them to vomit themselves into dehydration? (college age son, called his dad to take to the emergency room) Or getting cancer? (see link)

    I hope the “can’t afford” bit will be taken care of. The more who pay into the system, the more the costs will be spread out.

    We have a 25 year old son who has learning disabilities and some health concerns. He had open heart surgery over a year ago that was paid by insurance because of the ObamaCare stipulation that includes children age 25 and younger to be included on parent’s health insurance. Hopefully he will get a job, which we are encouraging, otherwise we will be looking into something to help him. Even though he can be described as high functioning autistic (he was diagnosed under DSM III), he did not qualify for the state’s Department of Developmental Disabilities, so his options are limited.

  42. #43 Yohei72
    September 30, 2013

    To piggyback a bit on the topic – I’m sure that a few months ago I read of a poll that found that most people who oppose the ACA – the individual mandate in particular – do so out of misinformation and that once the pollster read the actual provisions of the law to the opponents, they switched to majority supports, even among Republicans.

    Can’t for the life of me find it now, though. Anyone? (And yes, this is for a Facebook argument, so it’s super-important!) Thanks.

  43. #44 Narad
    September 30, 2013

    The income level, by the way, is based on the modified gross adjusted income, so it will be lower than the total gross pay.

    Erm, no. MAGI is AGI with certain deductions added back in. In fact, depending on state income exclusions, for instance, early withdrawals from retirement accounts to keep a roof over one’s head with essentially no other income, one might find oneself completely and utterly screwed by the switch to MAGI.

  44. #45 Damian
    October 1, 2013

    MOB -
    I would argue that it’s almost constitutionally necessary to provide healthcare to the people, given that one of the governmental duties specifically mentioned in that document is to “provide for the general welfare,” and I can’t imagine a welfare more general that that of health.

    In addition, given the inordinate amount of money we pay for healthcare in this country versus the rest of the world, if you want to look at it that way, the government ought to adopt the system which provides the best outcomes for the least cost. And whether you like it or not, the most efficient healthcare delivery mechanisms are government-based, given the nature of healthcare which makes it inimical to free market provision.

    So, I would argue that the government has a duty to provide healthcare to its citizens for the same reason as it must provide an army: both moral and fiscal necessity.

  45. #46 Politicalguineapig
    October 1, 2013

    Shay: Why, in the 21st century, has the GOP chosen contraception as the hill they want to die on?

    Cause God hates women and wants them to be miserable, pregnant and uneducated. Not a stance I endorse, which is why I’m not a Christian.

  46. #47 Khani
    October 1, 2013

    Lots of Christians don’t believe that either.

  47. #48 Politicalguineapig
    October 1, 2013

    It’s kind of late, and I don’t want to have *that* argument again. Let’s just agree to disagree and move on.

    M’O'B: ACA would free up a lot of the economy. A lot of employers are reluctant to add people onto their rolls because they’ have to pay benefits and health insurance, and people are stuck in jobs that they dislike because of insurance. If they weren’t worried about insurance, they could quit, fiddle around with the basement lab, open restuarants, write that new novel..

    People who aren’t worried about going bankrupt contribute to the economy. Families able to take vacations, get their kids presents, instead of trying to squeeze every penny so they can pay for Dad’s hospital stay, Mom’s stay after the latest addition, kid 1′s broken arm.. Plus, there’d probably be more people having babies, so there isn’t a ‘graying effect’ like in Japan.

  48. #49 Bob G
    Los Angeles
    October 1, 2013

    Narad: Thanks for the correction. I took a loss on a business and the magi went south for me as a result. It could go up for somebody with a different set of parameters. I guess that’s why they call it “adjusted.”

    As for the argument over whether it is good, bad, or indifferent to force some people to buy coverage who might otherwise not do so, I find absolutist arguments to be lacking in persuasive power. It is obviously a value judgment when we make an overtly political decision about taking money from some people to subsidize other people. The point is that we have to make a decision collectively — for a very long time, the decision (made through our system of representative government) has been minimal government regulation and a market system that, through its own logic, denied even the chance to buy insurance to millions of people. Actuarial science ended up denying insurance eligibility for something as ultimately minor as a history of basel cell carcinoma, or being overweight, or any of hundreds of other conditions. There are some issues on which our history and tradition demand the maximum attainable personal autonomy. There are other issues which point towards shared collective duties and responsibilities. For example, the requirement that you not be reckless about endangering other people when you have a case of tuberculosis implies a personal responsibility on the part of the TB patient which is backed up by governmental authority and power. This site has been carrying on a discussion about the moral responsibility to maintain your level of immunization against pertussis and measles. Some questions are complicated. The Republican Party opposition to the ACA based on perceived weaknesses and flaws falls flat because when they had the chance to perfect the bill, they chose merely to obstruct.

  49. #50 lilady
    October 1, 2013

    Can you ever forget the oldsters at Tea Party rallies holding up placards stating “Keep Government Out of My Health Care”?

    Those *GOGs, who have the benefit of Medicare and Medicaid if they are indigent, actually believed Palin who told them that doctors who provide end-of-life counseling, which is billable under the ACA, would be participants in “death panels”.

    * Greedy Old Geezers

  50. #51 Delurked Lurker
    On a gas covered planet whizzing around a nuclear fireball
    October 1, 2013

    MOB

    You can judge a society on how it treats its less fortunate citizens. Yours does not fare so well I am afraid to say.

    I would expect such ramblings from that disgusting pile of offal but your similar mindset to his shocks me. I expected so much more :(

  51. #52 Mephistopheles O'Brien
    October 1, 2013

    @Politicalguineapig – that’s a very nice point. Thanks.

  52. #53 Mephistopheles O'Brien
    October 1, 2013

    Chris – I agree with you. I think that young people who opt for no coverage or very cheap coverage are acting less wisely than they might.

  53. #54 Mephistopheles O'Brien
    October 1, 2013

    Damian – That’s a nice point. I’m not sure the constitutional scholars would currently agree that publicly funded health care is mandated by the constitution, but I can see what you say. I can also buy – to an extent – that a system that provides better outcomes at lower prices is better than one that provides worse outcomes at higher prices.

    I’m not sure you spoke enough to the “moral necessity” part of your argument though. That seemed to come out of left field.

    Thanks.

  54. #55 Mephistopheles O'Brien
    October 1, 2013

    @Delurked Lurker – I’m sorry to have disappointed you. Perhaps I was not clear – I am in no way arguing against PPACA, government provided health care, or any other means of providing at least some amount of health care to people. My question to people – which I’ve expanded in my ramblings – is why this particular issue is so important. Indeed, it’s important enough to people that apparently they don’t want to discuss why they feel it is so important and feel a need to attack anyone who asks why it’s important.

  55. #56 The Danish Salmon of Doubt
    In a country where everybody has health care
    October 1, 2013

    I must admit I find myself puzzled by the whole Obamacare debate and to some extent the discussions here as well. In Denmark, where I come from, and in Ireland where I live, we have universal health care. More so in Denmark where all doctors visits are free, and therefore get abused a fair bit as it happens with all that is free. An interesting point is that this universal healthcare is accepted by all parties elected to parliament AFAIK in both countries.

    To my mind there is no doubt, and Orac has given some data above to indicate same, that the old US system has caused people to die or suffer needlessly from preventable diseases.

    Would it make sense to augment the US constitution so that everybody have the right to life, freedom, affordable healthcare and the pursuit of happiness?

  56. #57 Denice Walter
    October 1, 2013

    @ Mephistopheles O’Brien:

    Alright, I think I can see where you’re at…

    Philosophers and psychologists have contemplated from whence come moral ideas for centuries and some like Kohler would argue that there *is* a place for ‘value in a world of fact’. In other words, scientists should think about these things. But morality isn’t my strong suit…..

    HOWEVER we do know that moral judgment appears to develop in children in stages ( Kohlberg) that roughly correspond to cognitive stages ( from concrete to abstract) and that that might have some interesting political applications. ( Esp in the US and UK these days).

    In brief, kids seem to think that right and wrong are determined by benefit/ loss for an increasingly expanding circle which originates with the actor ( pre-conventional/ egocentrism) – “It’s wrong if I get caught”/ “It’s right if I benefit”- to a more generalised rule-based mechanism ( conventional- what others would call ‘right or wrong”/ what benefits most people) to a more abstract, societal framework wherein sometimes conventional rules or laws are recognised as not being fair for ALL people ( post-conventional).- sometimes you might have to break a rule to correct a wrong ( see the Good Samaritan, Ghandi, King, Mandela). The stages usually are age based- think roughly grade school through university- delinquents’ are lower, despite age.

    One might argue that wealthy societies have an obligation to provide for those who can’t provide for themselves- earlier efforts ( some based on religious ideas) would distribute food, later on, there were governmentally created educational systems and housing for those who could afford none- healthcare seems to be part of this expansion especially in modern soocieties where technology has made it expensive..

    In all of these, it looks like the benefits purely for the self will be eclipsed by benefits for the larger society, eventually even encompassing exceptions( see same sex marriage debate). Obviously different philosophies will argue that the individual’s benefit may trump the society’s or the converse.The developmental argument would applaud the wider focus of the post-conventional. Is there something biological underlying this? Good question. But we do often admire people who put others’ needs before their own or that recognise that their own situation is not the only consequence of interest. Why do we see non-egocentric as more advanced? Well, at least most of us do.

  57. #58 Pareidolius
    Rocking in fetal position . . .
    October 1, 2013

    Jeeez MO’B, what, are you channeling my dad or something? Really, I’m having a flashback to dealing with my dad after he’d had a few shots of scotch. “I’m just trying to get you kids to think . . .”

  58. #59 Mephistopheles O'Brien
    October 1, 2013

    @Pareidolius – Wait, that was YOUR dad?

  59. #60 Mephistopheles O'Brien
    October 1, 2013

    Denice Walter,

    If I may summarize slightly, then:
    - People see altruism as inherently noble.
    - People want to be considered noble.
    - Access to health care is a problem that can be fixed by liberal application of money.
    - People who advocate for applying liberal amounts of money to improve access to health care see themselves as motivated by altruism and, therefore, a witch..er…noble.

  60. #61 Mephistopheles O'Brien
    October 1, 2013

    In my previous, feel free to substitute “government action” where I wrote “money”.

  61. #62 Shay
    October 1, 2013

    Cause God hates women and wants them to be miserable, pregnant and uneducated. Not a stance I endorse, which is why I’m not a Christian.

    Thank you for reminding us what a judgmental bigot you are.

  62. #63 madder
    October 1, 2013

    @M O’B:

    I also see where you’re coming from; I want “my side” to be founded on good arguments. And you’re right: where I said healthcare is a public utility, I should have said “should be viewed as” and added “in my opinion.” I hold that opinion because I view expanded healthcare access as a particularly wise social investment.

    So out of all the services we have to offer each other, why should we make sure that this one is approximately guaranteed? Why should we minimize the economic burden of individuals’ medical catastrophes, as opposed to any other form?

    We cannot legislate away all of the consequences of poor decisions. An economy that rewards good decisions and penalizes poor ones, with some safety net to prevent starvation and homelessness, is probably the one that offers the greatest long-term stability and growth. So we have to pick and choose against which kinds of catastrophes we’ll defend everyone.

    Our society has decided that no one needs to bleed to death in the street. Care for acute conditions is available free of charge to the individual, at substantial cost to the rest of us. ER visits for the uninsured, and all that. Given that social priority, we have settled on a very expensive and inefficient way to deliver that care: wait until somebody is in extremis from a condition that would have responded to early treatment, and then send ‘em to the ER. We can reduce that cost by offering routine and preventive care to everyone.

    So the short answer is “given our decision to provide emergency care regardless of ability to pay, expanding healthcare access will save money.”

    The longer answer is that healthcare provides a similar benefit as public education, transportation infrastructure, meat inspections, national defense, and so on. Economic inefficiencies will be reduced by offering approximately universal healthcare. The same is not true of defending people against gambling debts and the like.

    So that’s my 2 cents. In an ER, of course, it would cost $10.

  63. #64 Denice Walter
    October 1, 2013

    @ Mephistopheles:

    I would add that people in *particular* societies might agree to provide those services by voting for like-minded politiicians.

    Is it really about seeing themselves as noble or is it because they think it’s FAIR? I don’t know.

    I think that religious underpinnings/ traditions of the society in question ( compare what Krebiozen said- on another thread- about why perhaps Indian culture might tolerate extremely visible misery-maybe it’s karma and they deserve it) may lead to different results: the Christian emphasis on assisting the poor might have influenced beliefs in the western world.. I don’t know.

    Of course we can argue that even the Christians are – at heart- not really altrusitic because their good works would lead to rewards for them- in heaven- or to good press and admiration here on earth.

    And sometimes Christians don’t necessarily support assistance for the indigent.

    I just find the parallels to children’s development interesting.
    (This is post-Piagetian and they usually look at cross-cultural studies so I don’t think that the patterns are a fluke.)

  64. #65 Mephistopheles O'Brien
    October 1, 2013

    Madder – Thanks heaps!

    Denice Walter – As usual, you give a lot to think about. Thanks.

  65. #66 Politicalguineapig
    October 1, 2013

    Shay: Not a bigot, I’m just boiling down what actual self-identified Christians have said. There may be a chance that God is loving..but considering all the history and the devastation that godly armies have wreaked..it’s a very, very, very slim chance.

    M’O'B: Another point; emergency care is costly, and eats up personnel hours and energy. I’d rather tax dollars paid for anti-seizure medication and insulin shots so people don’t have to go to the hospital in the first place.

  66. #67 lilady
    October 1, 2013

    @ pgp: Just. Stop. Posting. Your. Warped. And. Bigoted. Stereotypical. Comments.

    You have a history here of condemning all men, male OB/Gyns and people who have a religious belief…based on your narrow preconceived opinions.

    If you have met one Christian/Jew/Muslim/Atheist who seems to be self-absorbed and selfish…why do you think all Christians/Jews/Muslims/Atheists are that way?

  67. #68 Denice Walter
    October 1, 2013

    @ PGP:

    I think that readers might have less negative comments about what you say if you just were more specific instead of making generalised comments. e.g. saying “I’ve met many Christians who said/ believed THIS” as opposed to saying, “Christians believe THIS”. I actually agree with SOME of your statements about a SEGMENT of Christians who do hold CERTAIN beliefs.

    In other words, SOME is not equal to ALL. Be clear. It may be a majority of them or not. We can look these things up. Many are true.

    Opinion surveys and questions about attitudes are real and can be quoted. Suppose we find that 40% of evangelical Christians believe Y but only 20% of mainstream Christian do and 9% of atheists do. We can say this. We can be very specific including talking about trends ‘ “Christians are more likely to support Social Policy A than Another Group”.

    Social Psychology and Demographics are REAL.
    G-d bless them!
    No wait. I’m an atheist.

  68. #69 Antaeus Feldspar
    October 1, 2013

    Not to mention, the opinions people espouse are not necessarily a good predictor of how they act. There was a famous social experiment many decades ago when racial discrimination was the rule rather than the exception, and practiced openly, where the experimenters wrote to a number of establishments across the US and said he’d be making a road trip with a Chinese companion, and wanted to know if they would be allowed into that establishment. He collected one hundred responses where the establishment said “No, you would be turned away if you tried to bring a Chinese person in here,” and he made the trip, visiting those establishments to see what they would actually do. Only one of the hundred actually turned them away.

    Sadly, facts make no impression on PGP’s adamantium skull, so I’m sure she will continue to insist that her loathsome bigotry isn’t bigotry at all, because when she’s generalizing about entire states, entire religions, or one-half of the entire human race, she’s starting from some little shred of factual basis such as “I met someone in this category once who was definitely awful, so everyone else in the category is too.”

  69. #70 Shay
    October 1, 2013

    Denice: you can’t be an atheist. I know an atheist who is a misanthropic, narrow-minded excuse for a human being and hates everybody..

    Ergo, all atheists are misanthropic, narrow-minded excuses for human beings and hate everybody.

    Getting back to the Affordable Care Act and M O’B's question, I am going to have to dig for it but a DOD study on nation-building that was issued about three years ago found that access to healthcare was a major factor in political stability.

    My work PC crashed and took a lot of stuff I had squirreled away, including that document. It may take a while because while I have lost my access to a lot of DOD sites. Bear with me.

  70. #71 RandomDude
    October 1, 2013

    Altruism does not mean forcibly taking money from one person to give to another! An armed robber who mugs you to buy his grandma some food is not altruistic. So what is the difference with government wealth redistribution?

    If you truly, honestly, deep-down, believe that government spending is altruism, then you should be overjoyed at the opportunity to pay the tax bill the government sends me next April 15.

    Just let me know where to direct the IRS for payment, and I thank you.

    If you support welfare programs on grounds of altruism but are not eager to altruistically pay the tax bill the government assesses for me, then you are revealed to be a hypocrite.

    “I have never understood why it is “greed” to want to keep the money you have earned but not greed to want to take somebody else’s money.”
    – Thomas Sowell

  71. #72 Shay
    October 1, 2013

    Are you in the right thread? One of your fellow travelers is spouting much the same philosophy elsewhere.

  72. #73 lilady
    October 1, 2013

    Random Dude: I pay my own Federal Income Tax as well as State Income Tax…both due on April 15th.

    Why would you expect any taxpayer to pay your share for the privilege of living in the United States?

  73. #74 RandomDude
    October 2, 2013

    lilady: I am pointing out that it is not altruism to force other people to pay increased taxes to fund wealth redistribution programs.

    If you want to help other people, then get off your butt and help other people yourself, but don’t petition the government to take other people’s money and believe that makes you a better person who can comfortably sit on the sofa watching TV believing that you’ve done some great service to humankind by doing nothing more than voting to fund social programs with other peoples’ money – that’s just a cop-out.

    If you want to help people, then help people. Yourself. Volunteer. Your own effort is what makes the world a better place, not government busy-bodies.

  74. #75 Chris,
    October 2, 2013

    RandomDude: “Yourself. Volunteer. Your own effort is what makes the world a better place, not government busy-bodies.”

    Oh, you have no idea of the idiocy of that sentence.

  75. #76 lilady
    October 2, 2013

    RandomDude: If you don’t want to pay your fare share of Income Taxes, there is nothing preventing you from leaving the United States to find a country that is run by a dictator backed up the military…such as Syria or North Korea.

    What have you ever done to improve the world RandomDude?

  76. #77 Chris,
    October 2, 2013

    I suggest RandomDude go to Somalia.

  77. #78 Pris
    The Dark Side of the Force
    October 2, 2013

    Why is socialized insurance a good idea?

    1. If everyone who can pays in a little to provide for everyone who can’t this will reduce costs over all. If I wait until I can be considered for emergency treatment I will need much more expensive treatment. The hospital where I get this won’t be reimbursed for this. To keep running they will add a premium on all their procedures to cover the treatment of free emergency treatments.
    So, in a way you’re already paying for the medical care of other people.

    2. A healthy workforce is good for the economy. If a sick worker can get treatment early they will get better faster, be off a shorter time and return to work sooner. A healthy workforce s a more efficient workforce.

    3. Right now many people are on the brink of bankruptcy due to medical costs. Many people have a lot of their disposable income tied up in insurance.
    Spreading the burden out over more people is will enable more people to spend money on stuff that isn’t related to health care. Which will be beneficial for the economy.

    RandomDude: You don’t want to pay for other people. But other people are paying for you already. You use roads, the government subsidizes farmers and raises custom duties on imported goods to ‘protect’ the internal economy. You rely on the police to keep you safe. You rely on the TSA to keep the number of air traffic incidents down.
    If you truly want to live without relying on others you need to move somewhere with no contact to the outside world and scavenge your own food from the stuff you find there and completely espouse money, modern crops and modern farm animals.

  78. #79 RandomDude
    October 2, 2013

    lilady: Good and evil. Right and wrong. How do you define them? Have you ever even bothered to define them?

    I would posit that a bare minimum of acceptable behavior, not actually good merely a bare minimum of acceptable behavior, is to not initiate aggression against another person who has not aggressed against another person or their property.

    This is a bare minimum.

    So what is your view on taxation? You claim I owe taxes merely for having been born? I have aggressed against nobody. If I don’t pay these taxes I didn’t ask for and never agreed to, would you advocate armed goons come rough me up and take it anyway?

    Do you believe that I am a serf and wherever I happen to be born I must give my pound of flesh to the aristocracy who own me? That wherever I go, the aristocracy has some magical right to take from me because… well because you say so.

    Or else you later imply that I ought to be exiled from my friends, family, and home? Why? What have I done to you to earn your scorn? Where does this vile anger and venom come from within you?

    What sort of ethics is that?

    How do you define good vs. bad behavior?

  79. #80 RandomDude
    October 2, 2013

    Does anyone have any reply to me other than sophistry and demagoguery?

    Perhaps a rational argument based on principle? That would be nice on a site supposedly dedicated to science.

    It seems I am the only one actually promoting a peaceful, voluntary method of interacting with other people. It is ironic for people who can’t imagine beyond the use of violence to claim that *I* am the anti-social one…

    Roads, police, yawn. So the government here has taken for itself a monopoly on these things, so what? That is a non-sequitur. The Soviets had a monopoly on automobile and clothing production as well as just about everything else. Would you claim that someone living in the Soviet Union ought to stop whining about a lack of freedom, after all they rely on the food, cars, and clothing provided by the Communists?

    Isn’t that just blaming the victim?

  80. #81 lilady
    October 2, 2013

    What are you blathering on about Dude?

    If you have the privilege…and make no mistake it is a privilege…to be born in the United States or any other non-repressive country, then you have been provided with a free education K-12 and the opportunity to continue your education at public universities.

    There’s the matter of our infrastructure that needs constant maintenance, police and fire protection and paying for health care available 24/7…that you can access, even if you do not have health insurance. (See above for the topic of this thread).

    Are you disabled where you cannot be gainfully employed…or do you think that you shouldn’t pay your fair share in the form of Income Taxes according to our progressive tax code, for some “special reason”?

    I’m thinking you never were schooled in basic economics or if you had that background, you didn’t understand micro and macro economics.

    BTW Dude, you never answered my question. What have you ever done to change the world for the better?

  81. #82 Pris
    The Dark Side of the Force
    October 2, 2013

    Is it just me or do RandomDude’s postings read like the ‘What die the Romans ever do for US?!’ scene from ‘The Life of Brian’?

  82. #83 lilady
    October 2, 2013

    Random Dude’s postings read like the dental student’s posts on the other thread.

    Didn’t the dental student flounce off?

    Does the dental student think he can use a sockie on another thread?

  83. #84 Narad
    October 2, 2013

    It seems I am the only one actually promoting a peaceful, voluntary method of interacting with other people.

    Then it would appear that you have no reason to be tacking on another comment bemoaning your failure to drum up any particular interest.

  84. #85 lilady
    October 2, 2013

    Did I misinterpret the Dude’s comments? I thought they were provocative and silly.

  85. #86 herr doktor bimler
    October 2, 2013

    RandomDude
    Does anyone have any reply to me other than sophistry and demagoguery?

    Apparently you want to discuss definitions of ‘altruism’. That is nice, but I am wondering why — of all the threads, in all the blogs, in all the internet — you walked into this one, where no-one was talking about altruism (apart from Mephistopheles O’Brien mentioning it back at comment #60).

  86. #87 herr doktor bimler
    October 2, 2013

    Is it just me or do RandomDude’s postings read like the ‘What die the Romans ever do for US?!’ scene from ‘The Life of Brian’?

    I was reminded more of

    Yes, but I came here for an argument!!
    OH! Oh! I’m sorry! This is abuse!
    Oh! Oh I see!
    Aha! No, you want room 12A, next door.

  87. #88 Mephistopheles O'Brien
    October 2, 2013

    @RandomDude – I’m with herr doktor bimler on this – nobody has said that government spending is altruistic. People may desire the government to take certain actions based on altruistic motives (“principle or practice of concern for the welfare of others”), as well as on a mix of other motives (desire for efficiency, desire for improved outcomes, self interest, enlightened self interest, whim).

    If you want to help other people, then get off your butt and help other people yourself, but don’t petition the government to take other people’s money and believe that makes you a better person who can comfortably sit on the sofa watching TV believing that you’ve done some great service to humankind by doing nothing more than voting to fund social programs with other peoples’ money – that’s just a cop-out.

    1. You have no idea what people who comment here do to help other people or how they spend their free time.

    2. There are in fact issues that are sufficiently general, large, and significant that they require the efforts of large groups to resolve effectively. While for profit and non-profit organizations can (and do) provide substantial good, sometimes the efforts of the government are the most effective way to get a desirable end result.

    And yes, you have to pay your own taxes, and you owe them to pay for the services provided by the government, regardless of whether you requested them or benefit from them.

  88. #89 Krebiozen
    October 2, 2013

    Does anyone have any reply to me other than sophistry and demagoguery?

    You appear to have mistaken this for an undergraduate dorm room around 2 am with someone passing around a bong. Still, since you ask, good and evil, ethics and morality are merely aspects of aesthetics, in my opinion. I would prefer, for purely aesthetic reasons, to live in a society/world where everyone is fed, clothed, housed and has decent medical care. I am empathic enough to find other people’s suffering extremely unpleasant so I wish to minimize it as much as I can. I am willing to consider any form of government or other political notions that would lead to this most effectively. So far it seems to me that some form of socialist democracy is the most likely to achieve this in practice, but I’m willing to be persuaded otherwise.

    Blindly following any kind of ideology or dogma seems dumb to me. I think that we should use the scientific method to figure out which are the best ways of governing ourselves and providing all the various services that we all need, which ones work best when run by the state and which work better as competing private enterprises, for example. It should be possible to do this somehow, with randomized groups and/or matched controls to see which works best.

  89. #90 Chris,
    October 2, 2013

    RandomDude:

    Or else you later imply that I ought to be exiled from my friends, family, and home? Why? What have I done to you to earn your scorn? Where does this vile anger and venom come from within you?

    Well you want to be part of a society and its benefits without paying the taxes that support those benefits. That is why.

    If you do not wish to pay taxes, that is fine. But then you must commit to not using anything or any service that is tax supported. That means you must not use any public roads, use any water that comes from a public utility, not consume any food where government rules/regulatory powers have been in effect, live where public taxes support fire/police service, and on and on.

    Just find a small piece of wilderness (that is neither publicly owned, nor that someone else pays property tax on), hunker down and don’t bother us with your whining.

  90. #91 Politicalguineapig
    October 3, 2013

    Shay: I’m actually not nearly as misanthropic or as bitchy as I act on the net. I just prefer to have low expectations of people; that way I won’t be disappointed. And when I’m dealing with people in categories that could harm me, it’s simply safest to plan for and expect the worst.
    Also, knowing what to expect from people will save me from embarrassing errors.
    Like, for instance, if I have a guest from a suburban area, I will know not to give them any food that’s not American and is spicy. I have friends who go to church- since I already know their political beliefs, there is no need to ever discuss the subject.
    And also I’ll know to alter any explanation I might be tempted to give about the exhibits at the museum I work at should I encounter a family with more than three children.

  91. #92 Khani
    October 3, 2013

    “Like, for instance, if I have a guest from a suburban area, I will know not to give them any food that’s not American and is spicy.”

    … why? Lots of people from surburbia love spicy food, not all of them grew up in the US and even those that did, some have an ethnic heritage quite at home with spicy food.

  92. #93 Antaeus Feldspar
    October 3, 2013

    I once said that the trolls of RI were so compelling because it was like an ignorance safari – you got to see, close-up and first-hand, breathtaking majestic forms of ignorance you might have heard of, but never dreamed you’d see in the wild.

    PGP is like that, but with bigotry.

  93. #94 Politicalguineapig
    October 3, 2013

    Khani: Almost all of the suburbanites I know are of the white-bread churchgoing variety. ‘Round here, suburbs skew pretty white. Most resturants in the suburbs are, as a result, bland-chain and their patrons would never consider eating any thing that’s not on a bun, in a sandwich or that doesn’t come with bread sticks.

    That last sentence should’ve read a ‘white family with more than three kids of their own.”

    AF: How is it bigotry if I’m talking about people of my own race?

  94. #95 Mrs Woo
    The buckle of the Bible belt
    October 12, 2013

    I have recently been hit by my own ability to be easily misled. When the whole discussion about the Affordable Care Act discussed immigrants, there was this knee-jerk “Of COURSE we won’t protect immigrants with this bill; we don’t need a whole bunch of foreigners coming over here stealing our super amazing All-American health care!” sheep-like, I nodded to this. Well, yes, we don’t want to encourage the abuse of the system, right?

    Well, then it hit home. A very close friend who is a legal immigrant, working here, paying taxes here who was even INSURED here until the first bout of cancer made insurance unaffordable, has been struck with cancer again. Worse, like most uninsured, when he began experiencing back pain, he was sure he must have pulled things moving heavy containers of cooking food and/or huge bags of rice and cases of vegetables in his restaurant, and went for physical therapy, steroid injections, etc., without ever consulting as second opinion.

    Then he developed severe abdominal pain and swelling, and they finally began tests.

    And found stage IV liver cancer.

    He has no health insurance – he only insures his family because of his cancer survivor status (and he does insure them – he is doing everything that the conservatives would applaud – running his own business, paying his own way, paying his taxes – he is EVERYTHING they would like, except he isn’t an American citizen yet.

    Medicaid cannot cover him in our state under any kind of emergency fund, and the ACA won’t cover him, either.

    What was I thinking? How could I have been so selfish and blind and been misled even that little bit when the last Presidential election showed me so clearly that the Conservative agenda is to protect the pockets of special interests and the wealthiest among us while doing its best to eviscerate the middle class and possibly disenfranchise the poor?

    I swallowed it, though. Now I feel so guilty.

    I also know that, if he had had access to regular medical check-ups and still been insured he might have had a primary care physician stop him months before now and say, “Let’s do some other tests to be safe; this should have gotten better by now,” especially with his history.

    I sincerely believe that his lack of insurance has done a lot to possibly affect his outcome, and I kick myself for not having considered all the law-abiding, hard-working legal immigrants in this country who are being denied access to what their tax dollars should be providing them.

    It also drives home, even if it isn’t statistically, the reality of what lack of access to medical coverage can do to clinical outcomes.

  95. #96 Mrs Woo
    October 12, 2013

    @PGP – I would consider myself Christian (please don’t stone me), and I, and many of my friends, actually sincerely, seriously ascribe to the whole “live like Jesus” mantra, with the providing everything we can for those who need it, loving the ‘sinners’ (that always drives me nuts the whole “hate the sin” people… SMH), etc.

    There was a time that some churches were the MOST active in both anti-slavery and suffrage. Quakers had women ministers before women could vote (Susan B Anthony’s aunt was one).

    I know that part of being human is our brain’s penchant for ‘categorizing’ everything, including people, based on what we know about some we’ve met that fit in a certain ‘list,’ but please be a little more open-minded. You might find a Christian who truly believes in loving everyone, giving to the point where it changes their own lifestyle, and, well, just loving everyone.

  96. #97 Khani
    October 12, 2013

    #94 I would conclude that you don’t know enough suburbanites, then. Also, I know plenty of white people who love spicy food that could take the roof off the top of your mouth.

  97. #98 Chris,
    October 13, 2013

    Mrs. Woo, thank you.

    (weird thing, my second landlord was a Mr. Woo, his real last name, the nicest and most accommodating landlord a college student could ever ask for)

  98. #99 Antaeus Feldspar
    October 13, 2013

    Mrs. Woo! So good to see you commenting again! Haven’t seen you in much too long!

    Re: PGP – she actually understands very well about the brain’s tendency to categorize. Her problem is that she views this as a good thing. She thinks that “the category system” is a brilliant way to know useful things about people without having to know anything about them as individuals – i.e., if they’re from Ohio, they’re creeps; if they’re white males, especially in the Catholic Church or in sports, they’re “murderous and rapey”; if they’re any denomination of Christian, they’re rabid right-wingers, and so on and on without end.

    The rest of us recognize that wild generalizations such as those her “category system” depends upon, and judging individuals based on assumptions derived from their social class and religion or geographical location is bigotry, but she shows no signs of understanding why she shouldn’t write off all suburbanites as brainless provincial drones, etc. etc.

  99. #100 Denice Walter
    October 13, 2013

    Antaeus, altho’ I do agree with you, I think that PGP has the makings of a fierce sceptic as we have already seen from her fearless responses to scoffers-
    HOWEVER it may take a while for her to temper her over-shooting about particular demographic groups- which I believe is a defensive posture that many people adopt after unfortunate experiences early in life- the alarm bells go off too easily. This is not uncommon.

    She’s young- adaption like this takes a while. She is now surrounded by positive influence, liberalism and reasonability- ie. us. And she’s smart.

    So we should perhaps hold off throwing her to the sabre toothed cats and piranhas as of yet.**

    ** I’m JOKING – there are no sabre toothed cats.

  100. #101 Chris Hickie
    October 14, 2013

    Ok, so I go to sign up at healthcare.gov, and it has to be one of the worse online experiences I have had in the last 10 years.

    1. It doesn’t work on Google Chrome
    2. It does “work” in Firefox, but I keep getting logged out when I actually try to go get insurance
    3. When I entered all my family’s info during registration, each little entry (like a click box to tell them the gender of a child) took > 10 seconds to get entered into their database. All the while you get to watch a green circular arrow spin.
    4. I had to stop the registration process and was told by one of their “chat” people that all the info entered so far would be saved. It wasn’t completely and social security numbers for entered family members that were saved were transposed.
    5. When I finished the registration process and clicked “Submit”, I had to do it 6 times before it was accepted. The first 5 times the green circle arrow spun for about a minute and then went away and nothing was updated on the page.

    Honestly–this stinks. To be fair I don’t think it would have mattered was for or against the ACA. The implementation is abysmal.

    And why did I do this application? I have a private plan that I will likely keep, but I have patients asking me if I’ll still be able to see them if they sign up (or when, if they have no choice) for the ACA plans. I can’t find out if I can be their PCP unless I register my family and then shop for insurance. That is INSANE. Just INSANE.

  101. #102 Khani
    October 14, 2013

    Do remember that they have until Dec. 15 to sign up and still have plans take effect on Jan. 1.

    … that’s no excuse. I’ve heard the same thing from a *lot* of sources.

    Man. I expected it to go down the first day; what I can’t work out is why it’s taking so long to make it work again.

  102. #103 Shay
    October 14, 2013

    Our health department got some grant money and hired 3 people to walk clients through the ACA process. It does not appear to be a well-designed website but what else is new…

    Chris, see if your local HD has set up something similar. They might be referred to as Patient Navigators or In-Person Counsellors (IPC…a silly name but better than Assistors which was first chosen until someone realized that everybody thought they were being referred to nuns).

  103. #104 Narad
    October 14, 2013

    a silly name but better than Assistors which was first chosen until someone realized that everybody thought they were being referred to nuns

    I seem to recall Jeremiah Ostriker* raising a similar objection to the term “recessional velocity.”

    * Well, it was somebody of stature.

  104. #105 Chris HIckie
    October 14, 2013

    Chris, see if your local HD has set up something similar.

    Of course, my local HD just has links to the web site and the phone number for the Federal Help Center. Of course, they are closed today, too.

  105. #106 ebrillblaiddes
    October 14, 2013

    A category based system of deciding things about people is fine as long as every result it produces is treated as a hypothesis, not a conclusion.

    For example, I live in Texas. So any time I’m out in public and notice another human being, in the absence of data to the contrary I suspect that they may be on the conservative side on a variety of levels. So, when BF and I are grocery shopping together and people assume we’re married, we don’t correct them because why start a thing for no possible gain? I also have no problem believing that many people wouldn’t have any issues, I just don’t want to find out which ones do by live test!

  106. #107 Politicalguineapig
    October 14, 2013

    Chris Hickie: The implementation is abysmal.

    Well, the implementation was always going to be abysmal. The US is simply too diverse for a health care system to work. Notice that the only countries where a health care system works have an almost totally homogenous population? Yeah, that’s no accident.

    Khani: Maybe. However, I don’t really plan to have much dealing with suburbanites, since I find suburbs hopelessly bland.
    AF: I’d like to point out that I find categorizing necessary since I was born without ‘girl social skills’ and prefer not to learn through trial and error, since it’s a stupid and slow way to learn to deal with people. Categorizing and then formulating reactions to the category is much faster, easier and safer.

  107. #108 AdamG
    October 14, 2013

    Categorizing and then formulating reactions to the category is much faster, easier and safer.

    What evidence do you have that it’s faster, easier, and safer? What does ‘safer’ even mean here?
    Why is it necessarily better to judge a person in a manner that’s ‘fast, easy and safe?’

  108. #109 Shay
    October 14, 2013

    Everyone was born without social skills.

  109. #110 Denice Walter
    October 14, 2013

    @ PGP:

    Adaption doesn’t have to be ‘by trial and error’- you can learn vicariously, through tutelage, through reading. Psychologists write books about acquiring these skills; you can interact over the ‘net as an experiment.
    .
    Or you can seek out like-minded people by their interests- perhaps you’ll gravitate to locales ( as well as websites) where mysogyny/ classism/etc is *verboten* – I notice you mention PZ’s place ( and RI) not an evangelical Christian’s blog.

    You can navigate the world similarly to how you navigate the web: find topics and interests similar to your own. Visit Portland, Seattle, Boulder, SF, NYC, Montreal, London etc.

    In a certain way, most people may feel like they don’t understand others or that they’re being mis-understood- even those with good people skills. Trust me.

  110. #111 Khani
    October 14, 2013

    #107 … you don’t interact with everyone you meet where they live. I have a lot of friends whose homes I can only name by city, because I interact with them elsewhere. Are you telling me that if you had a friend from, say, Los Angeles, and found out they lived in a suburb rather than a city proper, you would stop hanging out with them? Or do you simply do a screening process with everyone you meet somehow?

    Also, just because where a person lives is bland doesn’t mean that they’re dull. That extends to bland cities (yes, there are some) and bland small towns.

  111. #112 Chris HIckie
    October 14, 2013

    Ok…so I finally get through registration and am able to download this pdf file on the eligibility of me and my family. Problem is, the pdf file left off one of my kids on this table of what to do next and then very confusingly gives “next steps” for only 1 of the 4 of the 5 of us. And since I didn’t ask for any subsidies, it basically says we are eligible to purchase health coverage through the Marketplace. Well, no duh…if it won’t even allow that, what was the damn point of this anyhow?

    So I tried to log back in 10 times this afternoon, only now just succeeding, and the next section of this web site for the Arizona exchange and there’s this big giant orange NEXT button, but NOTHING happens when I click on it. I feel like a damn Skinner pigeon waiting for a reward with this thing. And then you go to the chat thing and all they tell you is “GLITCHES”.

    This is so discouraging. If this were a private corporation, the whole online fiasco would have bankrupted them, as people would immediately have gone elsewhere to another company’s web site and never come back. As it is, it feels like a lesson in abuse to a rather captive audience.

  112. #113 Politicalguineapig
    October 14, 2013

    AdamG: Mostly because I don’t like to waste time code breaking. I can’t take it for granted that someone actually meant ‘that hat looks nice’ until I’ve examined it from all angles. At my workplace, when I work in the exhibits or at the front desk, I have to make snap decisions on who I approach, how I handle exhibit-related activities, and who I may have to call security on. Profiling may be unfair, but so is me expecting a kid from a religious school or a home-schooled kid to appreciate science. Out and about-well, I don’t travel in a pack, so it’s up to me to keep me safe.
    Shay: Sure, but most people develop social skills fast- like within first three years of life.

    DW: I don’t trust self-help books. As for interests- I have a lot of them, but none that can be enjoyed in a social setting.

    Khani: No, I don’t. Living in the suburbs does tend to have a flattening effect on people, but that doesn’t disqualify them from being good company. It’d be nice if I had more than one friend that I could talk about my interests, hobbies or music with, but you can’t have everything.

  113. #114 ebrillblaiddes
    October 15, 2013

    @PGP: If you think three-year-olds have social skills, I have to categorize you as “hasn’t been around many three-year-olds.” They’re just barely capable of interaction, being skilled at it comes later.

    Also, if your job is to talk about science and you’re dumbing it down for the homeschooled kids, I resent that on a personal level, because I grew up as one of the kids that you’re shortchanging. I was curious and annoyed my mom with wanting to know details rather than goddidit (my standard response was “OK, but how does it work?”) and did extra reading she didn’t know about and picked up a certain amount of crap in the process and it bothers the ever-lovin’ crap (I’m really trying to behave about the cuss filter, o great and powerful Orac) out of me that your job is to set people like me straight about things you know better about but you’re too fvcking (oops) busy judging them to be bothered to do your job.

    Be tentative with people based on their category, if you have to, but deal with the fact that people might sometimes not fit everything you think about their category, and give them a chance to show themselves as exceptions, or your ideas about people are no better than someone else’s ideas about prehistory based on Genesis since both have unwillingness to consider new evidence and modify as a founding principle.

  114. #115 Julian Frost
    Gauteng East Rand
    October 15, 2013

    @Politicalguineapig:

    Profiling may be unfair, but so is me expecting a kid from a religious school or a home-schooled kid to appreciate science.

    Firstly, that’s a bigoted remark no matter how you cut it.
    Secondly, I don’t know what schooling is like in the US, but some of the best schools in South Africa are run by the church. Holy Rosary Convent School is regarded as one of the best in the East Rand, if not Gauteng.

  115. #116 Anne Pierce
    the Carolinas
    October 15, 2013

    @Politicalguineapig

    So, you have no problem with arrests for ‘driving while black’, not offering a woman a job because they are just going to get pregnant and quit, strip-searching ‘Araby’ looking people because they are all terrorists, etc, etc. Face it, PGP, you are a bigot as bad as any Boss Hogg of the Old South. How about this: I know to feed Hispanic people spicy foods wrapped in cornmeal.

    You admit that you have no interests that can be enjoyed in a social setting. Why on earth do you expect to have any social friends?

  116. #117 Anne Pierce
    the Carolinas
    October 15, 2013

    Does your employer know that you routinely ‘dumb down’ the information based on bigoted snap judgements?

  117. #118 Antaeus Feldspar
    October 15, 2013

    PGP, let’s imagine that a commenter (let’s call her Viola) showed up here at RI and started telling people why she’s never going to get colon cancer or diabetes or hypertension: because she follows this “miracle diet” where she only eats grapes and uncooked carrots.

    Well, of course, I’m sure that you would be right along with the rest of us in saying “Hold on, hold on! Where on earth is any evidence that a diet of just grapes and carrots will perfectly prevent all those diseases?”

    Viola starts chattering about how there’s this chemical in grapes and uncooked carrots and that chemical has been shown in one study that huge doses of it seem to eliminate cancer cells in test tubes and therefore obviously it will prevent colon cancer inside the body, not to mention diabetes, et cetera. Well, I’m sure you would be right alongside the rest of us explaining to Viola that she’s drawing massive conclusions on way too little evidence; that you can’t go from “might be what’s killing cancer cells in a test tube” to “what will wipe out tumors in a living body, plus fix diabetes and hypertension just because those are also bad things”.

    So when she’s confronted with the precarious foundation of her “miracle diet”, Viola admits that it’s rooted in her need to believe. She has a family history of colon cancer and diabetes and hypertension and the thought that any of these diseases might strike her gives her anxiety – so her response is to pretend to herself that her “miracle diet” can give her perfect protection against those things. But she still doesn’t seem to understand that her need to believe is not reason to believe; she writes as if the comfort she gets from thinking the miracle diet is her way to guard against all health woes actually means it does guarantee her health. And she won’t listen when we try to explain to her that, if anything, her miracle diet is a danger to her health; she’ll miss out on vital nutrients by restricting herself to such a narrow choice of allowable foods.

    What I don’t understand, PGP, is how you can not see that your “category system” is just the social equivalent of Viola’s “miracle diet”. It doesn’t give you robust protection against what you fear, it just lets you pretend it to yourself. Its real effect is to leave you a badly diminished quality of life – and actually less protection against what you fear, because you’ve cut yourself off from so many strengthening resources. It’s woo. I really don’t understand how you can not see that.

  118. #119 Shay
    October 15, 2013

    Profiling may be unfair, but so is me expecting a kid from a religious school or a home-schooled kid to appreciate science.

    I’ll pass that along to the faculty at Fordham, Georgetown, and Boston College.

  119. #120 Denice Walter
    October 15, 2013

    You can’t judge a book by its cover.

    Seriously. If you saw me, you probably couldn’t guess my politics and education- I might look more conservative than I am: I’m (very) white, middle aged- not poor. I have recently attempted more artfully disheveled hair styles to signal others about my proclivities.

    Similarly, one of my gentlemen looks like a middle-aged, sporty business man- he has short blond hair- but is a total hippie, socialist, leftie, comes from less affluence and is a semi-Christian. The other one looks more as he believes – artsy agnostic with twisted ideas. Still, he somehow succeeds in business- no one rejects him because he looks less conservative.

    You can’t tell what people are like unlike you know them- and even then, not everyone reveals all.

    Differences make people interesting. Not that I want to meet n-zis, racists, misogynists or loons. I do know people who are much further to the right than I am who still have redeeming qualities and are worth knowing. The world isn’t black and white. Or simple. It won’t kill you to tolerate their differences if you want them to appreciate your own.

  120. #121 Denice Walter
    October 15, 2013

    UNTIL you know them.

  121. #122 Narad
    October 15, 2013

    Notice that the only countries where a health care system works have an almost totally homogenous population?

    Not since the last time you trotted this one out, no.

  122. #123 Denice Walter
    October 15, 2013

    On the other hand, Narad looks rather liberal.

  123. #124 Narad
    October 15, 2013

    On the other hand, Narad looks rather liberal.

    Well, I clean up OK. Somehow, overpriced footwear and French cuffs don’t trump an aversion to barbers, though.

  124. #125 Denice Walter
    October 15, 2013

    Narad:
    For those of us over 40, indeed hair length/ style may be the measure of how our liberality – or lack thereof- is judged ( see my #120 above) but for the kiddehs, anything goes.

  125. #126 Shay
    October 15, 2013

    Notice that the only countries where a health care system works have an almost totally homogenous population?

    You mean, like Canada?

  126. #127 herr doktor bimler
    October 15, 2013

    Like New Zealand? Or the UK?

  127. #128 Krebiozen
    October 15, 2013

    PGP,

    Notice that the only countries where a health care system works have an almost totally homogenous population? Yeah, that’s no accident.

    Why do you continue to repeat this falsehood? Not least it depends very much on what you mean by “homogenous”. The USA population is 88.8% White, Hispanic or Latino, i.e of broadly European Christian origin (yeah, I know, I’m making a point), whereas the English population, for example, is only 79.8% White British and 13.7% non-White*. Is that an unfair way of categorizing “homogeneity”? Probably, but in what way does diversity affect the provision of a socialized health care system anyway? What matters? Culture? Language?

    The US is, by various measures, less culturally diverse than Belgium, Switzerland and Canada all of which have some sort of system of socialized medicine that seem to work perfectly well.

    * 3.5% Black (African or Caribbean), 2.0% Mixed Race, 7.8% Asian (Indian, Pakistani, Bangladeshi etc.) or Arab. There are also a considerable number of Whites from Ireland and other parts of Europe, and even a few Americans.

  128. #129 Krebiozen
    October 15, 2013

    Denice,

    For those of us over 40, indeed hair length/ style may be the measure of how our liberality – or lack thereof- is judged ( see my #120 above) but for the kiddehs, anything goes.

    I alternated between extremes until a receding hairline and tonsuresque bald spot made long hair look sadly ridiculous. Still, I am proud to say that people have shouted at me in the street both, “Get your hair cut!” and “Get some hair!” at different times, obviously. These days I shave my head, which makes people a little confused – is it East London skinhead bald? Shaolin bald? Chemotherapy bald? Hairy Krishna bald? I embrace the ambiguity, of course, but I suspect PGP would run on sight, which would be sad.

  129. #130 Alain
    October 15, 2013

    For those of us over 40, indeed hair length/ style may be the measure of how our liberality – or lack thereof- is judged ( see my #120 above) but for the kiddehs, anything goes.

    37 here with no hairs or beard and yes, my pic is posted on the intarweb; want to take a look at it?

    Alain

  130. #131 Alain
    October 15, 2013

    oh, and left of extreme left thought I support capitalism.

    Alain

  131. #132 Denice Walter
    October 15, 2013

    - btw- Narad looks fabulous.
    I’m sure that Kreb also looks fabulous.

    If I array my hair neatly I might be mistaken for a suburban supermom thus, if I am not seeing clients, I just let it do as it wishes-
    I am so d@mned white bread looking I need something to make me stand out- and blondish Euro-dreads ( waves actually) does the trick so I can forego the blue or lilac dye.
    What’s great is that I can look radically different by adding or subtracting a hair clip.

    @ Alain: Why not link to a photo so we can see you, svp?

  132. #133 Alain
    October 15, 2013

    @ Denice,

    @ Alain: Why not link to a photo so we can see you, svp?

    http://scholar.google.ca/citations?user=TknNZcAAAAAJ&hl=fr

    Do I look like a motorbike racer (grin)?

    Alain

  133. #134 Denice Walter
    October 15, 2013

    Alain, you look fabulous!
    I was expecting someone smaller and possibly darker.

  134. #135 Jubilee
    October 21, 2013

    I’ve volunteered at a major science museum, and in our docent training we actually were given guidelines on how to respond to visitors that object to the contents of our exhibits, especially on evolution. But we certainly do not, and would never, premeptively deem some people “unworthy” of the best information we have to offer based on family size or apparel or any other categorization. And some of the smartest questions I’ve been asked have been by home-schoolers.

    Also, the church denomination into which I was baptised has made official statements regarding their support for access to abortions since 1971, before I–and I suspect PGH–was born.