Implications of the Opt-In Medicaid Expansion

I've been sitting on this for a while, but here is a table I threw together, expanding on some data presented on the Economix blog:

What strikes me are all the high-poverty states at the top of the list who have Republican governors who are likely to reject the Medicaid expansion now that it is optional.

--
NOTE: RI's governor is a liberal independent so marked blue.
DATA:

SOC 201: Bedside Manner?

Ugh. This article on changes to pre-med education is making me angry. Let's walk through some choice points:

In addition to the hard-science and math questions that have for decades defined this rite of passage into the medical profession, nearly half of the new MCAT will focus on squishier topics in two new sections: one covering social and behavioral sciences and another on critical analysis and reading that will require students to analyze passages covering areas like ethics and cross-cultural studies. [emphasis added]

So, the social and behavioral sciences are "squishy?"

In surveys, "the public had great confidence in doctors' knowledge but much less in their bedside manner," said Darrell G. Kirch, president of the association, in announcing the change. "The goal is to improve the medical admissions process to find the people who you and I would want as our doctors. Being a good doctor isn't just about understanding science, it's about understanding people." [emphasis added]

So, the social and behavioral sciences are not science?

Yes, absolutely, let's bring the social sciences--and particularly sociology--into the training of our physicians. The way that this is being framed, however, misses the point of doing so. Health and disease are radically social. Race gives us one example of this. Blacks in the U.S. have poor health outcomes compared to whites. For example, blacks are far more likely to suffer from hypertension, even after we take things like diet, income, occupation, eduction, and genetic predisposition into consideration. (See Unnatural Causes: Is Inequality Making Us Sick? for an excellent explanation of the social factors in our physical well-being.) Good bedside manner is important, but sociology doesn't teach about this. Sociology makes students aware of the social, but that is no guarantee of sociability. As I've written before, "...[I]ronically, sociology is about the most misanthropic discipline there is. We are the Debby Downers of academia." I'm confident, though, that the inclusion of social science into the medical curriculum will have beneficial outcomes regardless of the misunderstandings of those who implement the changes. The next generation of physicians will have a better understanding of the social causes and consequences of health and disease, and this will be good for all of us.

Supreme Speculation

So, what's going to happen with SCotUS and healthcare? From what I understand, there are three likely outcomes. 1) The Justices will uphold Obamacare, a win for PotUS and Democrats (and the nation). 2) The Justices will strike down the so-called individual mandate and also take an axe to the related items, like requiring coverage of preexisting conditions, a win for Tea Party Republicans but only a comparatively mild defeat for PotUS and the Dems (although a major loss for the nation.) 3) The Justices will strike down the individual mandate but allow the related items to stand, a major defeat for PotUS and the Dems (and the nation).

Why, exactly, would the third option be so horrible? The Affordable Care Act does indeed increase government spending over the medium term; however, it increases spending at a much slower rate than the status quo, in effect lowering the nation debt. It does this by giving the government more bargaining power and cost control and by spreading out the costs among the ill and the healthy. Without the individual mandate and as has been the case in states with this situation, the cost of insurance will skyrocket. This turns a major political/moral victory into a liability. Why a liability? A system that must accept all comers but that cannot compel participation puts Congress in a dilemma. They can either A) allow the provisions to stand, knowing that it will cause insurance rates to balloon, or B) gut the Act, returning those with preexisting conditions to the draconian realities of the status quo.

That decision will be bad enough, but throw the politics of Republicans vs. Democrats into the mix, and my fear is that it gets even uglier. One or both parties could decide to make this decision a weapon. The Republican controlled House could either gut the law as they have always desired or refuse to gut it as to be able to (for the first time accurately) claim that the Affordable Care Act increases the national debt. The Democratic controlled Senate could allow the remaining provisions to stand and blame the added debt on the most conservative SCotUS in modern history or gut the law and use the legal and political fallout as campaign fodder. All of these options are deplorable on several levels.

If I were a betting man, I'm not exactly sure where I'd put my money. Immediately after hearing and reading about the three-day marathon arguments, it seemed to me and many others like option 2 was most likely. After hearing more analysis from lawyers and scholars, I'm cautiously optimistic that option 1 is plausible. In part, I feel this way because of what it is to argue in front of the Supreme Court. It is theater. It is posturing. Justice Thomas doesn't really play along, but everyone else asks questions and challenges the attorneys who make their arguments. It could be that Kennedy, and possibly others, were grilling the Solicitor General to signal a seriousness and a thoroughness and to avoid any claims of impropriety after a decision is rendered. Perhaps I delude myself.

I am terrified that option 3 is equally likely, though.


Here are a few other pieces that you should read:

• Reinhardt at Economix on the "logic" of the potential SCotUS decisions and the irrationality of the anti-mandate argument
• Krugman's NYTimes column on the widespread misunderstanding of the mandate narrowly and Obamacare broadly
• Reich's blog post on a political alternative available to congressional Democrats

Follow-up to "On Bacon and Birth Control"

A follow-up on a recent post. Commenter Warner shared this blog post from Sarah Posner over at Religion Dispatches. It's a nice take-down of a straw man argument put forward by several Catholic bishops. It's not quite the same hypothetical that my student proposed in class, but there are similarities. Regardless, and I forgot to mention this in the previous post, this whole issue is one created by our peculiar system of employer-based health insurance in the U.S. A public single-payer system doesn't eliminate all of these "religious liberty" concerns, but it does better. Really, a seemingly logical conclusion would be for employers to give the money they would pay for group insurance directly to the employees in the form of higher wages with which the employee would then be forced by the new healthcare law to directly purchase insurance on the open market. It's all very convoluted, and that's kind of my point.

The more I think about this, the more it would make sense to eliminate employer-based health insurance all together. So long as there is third-party oversight in the transition so that employers aren't pocketing any of the benefits that rightfully belong to their employers, Liberals are happy since all people are required to purchase insurance already; Republicans will be happy because it will be a market-based system. If the federal government is going to organize opaque insurance exchanges, why not just let the public filter themselves into the plans that match their values? Many people would choose fairly broad coverage that would require coverage for birth control and abortion. Religious minorities would have the option to choose more narrow coverage that would not cover services that consumers find morally objectionable. The broader coverage would end up being less expensive since we know that preventative services like birth control are far less expensive than non-preventative obstetric services and STI treatments. Morality and the market: isn't that what the right wants?

Greedy Teachers, Indeed

I had to share this from my friend, John, over at Memoirs of a SLACer:

John writes:

In class, I displayed the graph and asked my students what they hear people blame for the rise of health care costs.  They mentioned insurance companies and the uninsured.  Then I asked them what they hear people blame for the rise of education costs.  The first thing they mentioned was teacher pay.  These reasons are given despite the fact that in the past 15-20 years teacher pay has barely outpaced inflation while physician’s salaries have increased a good deal more.

The rhetoric surrounding both of these increases is fascinating because of how clearly it illustrates the low value we place on teachers and the work they do.

I found this informative beyond its usefulness as a classroom example. Thanks, John.