America doesnt have one problem with its healthcare apparatus*, but many – including shorter lives, higher costs, and inadequate access to care. The ACA is likewise meant to ameliorate not one but several problems. One change the ACA introduced are penalties for underperforming hospitals, whose patients have a tendency to go back to the hospital within a short time of being discharged.
Hospitals are the most expensive place to render healthcare, with per-patient costs typically approaching $2000 per day, and the aggregate amounting to about one-third of all US national health expenditures. Medicare noticed that, all too often, shortly after someone is discharged from a hospital, they get readmitted for reasons that were entirely avoidable. And while high readmission rates dont speak well of patients’ health, they’re great for the health of a hospital’s bottom line, because hospital stays are highly profitable – and two stays pay twice as much as one. Churning patients out and ignoring them is great business for hospitals, but awful for patients, and costly to insurers. But under new ACA readmission rules for Medicare patients, that jig is up.
Across the country, so-called “readmission rates” vary considerably place to place and hospital to hospital. The ACA made changes in Medicare to penalize hospitals with high readmission rates – to give them a stiff incentive to see to it that their patients remain healthy after discharge – so that physically leaving a hospital does NOT also mean leaving their care altogether. The new rules only apply to Medicare patients who go to the hospital for 3 specific conditions: heart attack, heart failure or pneumonia. If, after discharge, such a patient is readmitted to any hospital within 30 days, it’s counted against the original hospitals’ readmission stats. If the rate goes too high, penalties accrue – with the size of the fine commensurate with hospital performance.
The good news is that hospitals are altering their post-discharge procedures for the better. To ensure that patients understand post-discharge care instructions, hospitals are following up with phone calls. They’re dispatching nurses to make house calls. They are GIVING AWAY FREE MEDS to their poorest patients! While all of this costs money, overall these new policies are cost-effective, simply because hospitalizations are so outrageously expensive that you can spend a small fortune avoiding them and still come out ahead. The fines are meant to get hospitals on the same page with patients and their insurers.
So far so good: According to a CEA report, growth in healthcare costs during 2010-13 were the lowest ever recorded in any 3 year period in US history, with Medicare leading the way, and hospitalizations performing especially well. In the years ahead, Medicare plans to add other diseases to the no-fly list for readmissions – and private insurers are expected to phase in their own penalties for underperforming hospitals. The US healthcare apparatus is multi-faceted, and solutions to its many issues will require creativity. But the new Medicare readmission policy so far is working as planned – for the good of senior’s health, and for the good of the nation’s financial health as well.
* some, CT included, use the term “US healthcare system” – but “system” is simply too flattering. “apparatus” is itself too kind, if easier to type than “thingamabobby.”
A nation might build the universe’s greatest hospital on the moon – but in the absence of a lunar lander, the claim that that nation has the “best medical care” cannot be made without irony. But this is what conservatives who defend America’s national healthcare apparatus must do every day. The US healthcare system, by design, keeps needed care out of reach for a large fraction of the US population. And so millions of Americans get told every day that America has “the best healthcare in the world” – though they themselves are unable to access it. For them, it might as well be on the moon – which only a lunatic could envy.
In theory, any country could improve healthcare for a fraction of its population by excluding another fraction from care. Putting aside the morality of such a system, you dont come out ahead in the bargain anyway, because you tend to lose more at the bottom than you gain at the top. The metrics, which count everyone, betray the true cost of such policies, as seen in higher American mortality, from birth through till age 75.
American babies are more likely to die before their 1st birthday than babies in other rich countries. American children are more likely to die before age 5 than children in other rich countries. American adults at all ages are more likely to die than adults in other rich countries. It’s only Americans surviving till age 75 who compare favorably with 75 year-olds elsewhere – and we’re left to wonder whether it’s their single-payer government-provided universal health insurance (aka Medicare) that’s responsible – or if it’s merely selection bias: that it’s so much harder for Americans to make it to 75 without dying, that those who succeed are hardier.
We might parse out health outcomes by income, and find the same result. Wealthy Americans live shorter lives than their wealthy counterparts in other rich countries. Poor Americans live MUCH shorter lives than their poor counterparts in other rich countries. White babies born in America are more likely to die before their 1st birthday than white babies born in other rich countries.
To put it differently, it is NOT the case that the US has a bimodal distribution of life expectancy, with rich Americans doing better and poor Americans doing worse. ALL Americans do worse – it’s just a matter of degree. Hey, if living long is important to you, it definitely helps to be born rich, white and female – but it’s also beneficial to be born elsewhere.
To give it a Rawlsian twist: imagine yourself as an Unincorporated Spirit, hovering in the ether, about to be inserted into some body to live out a life. You are given a choice of populations to be cast into randomly. If life expectancy is your sole criterion – the US would be about 30th on your list of preferred destinations. As Regina sings it: it’s all about the moon.
The government shutdown and the downgrading of the nation’s creditworthiness over the debt-ceiling was the previous high water mark for GOP cynicism. But now the GOP has outdone themselves – the toll for their refusal to expand Medicaid in 24 states might as well be measured not in dollars, but in corpses.
A new study out of Harvard Medical School estimates that between 7,000 and 17,000 people will die as a result of states’ refusal to expand Medicaid. And how much money will those states save, to justify that loss of life? Nothing at all! Zero, zippo, nada. As a kicker, businesses within those states will be subject to fines of $2,000 per uninsured – and workers within those states will still pay the same federal taxes to benefit the residents of the 26 other states who opted into expanded Medicaid. To score political points, the GOP is today killing poor working people – while local business pays for the fun. Expanded Medicaid is already paid for – state officials just have to sign on the dotted line to start receiving benefits – but conservatives would rather pay the bill and refuse the benefit, ensuring that thousands of poor people will needlessly die.
People with incomes between 100% and 138% of the federal poverty line do NOT qualify for federal subsidies to purchase private insurance. (Subsidies only go to people between 138% and 400% of the poverty line.) Their solution was Medicaid expansion. When the Supreme Court rewrote the law to let states opt out, those people were given no alternative – they were categorically shut out of the system. Plan B for the working poor is Dont get sick. Many of them now will not get screened for breast or cervical cancer; many diabetics will have to do without medicine; many others will be at greater risk of depression; many will be bankrupted by catastrophic medical expenses. And many will die – needlessly.
This study is not alone. More modest studies scrutinizing individual states tell a similar story. When a state opts out of Medicaid expansion, people die, businesses get hit with penalties, and Federal taxes effectively siphon money out of the state – paying for a benefit that they obtusely refuse to receive!
Still more studies are already documenting how opting out adversely affects the numbered of uninsured. Opt-out states have seen rates of uninsured drop by just 1.5% since September – while opt-in states have seen that rate fall by 4%. As of March, the rate of uninsured for opt-in states was 12.4% – while for opt-out states it was 18.1%.
Medicaid expansion is a sweetheart deal for states. For the first 3 years of the program, states pay nothing at all. Their share gradually increases thereafter, but will never exceed 10%. And since expansion is likely to offset other state expenditures, states’ effective share of the program is likely to be even less than 10% over the long haul. Adding perversity to perversity, conservative refusal to expand Medicaid serves to regressively redistribute wealth out of poor (GOP) states and into rich (DNC) states – yet another opportunity for the GOP to sock it to their own constituents for a hollow ideological purpose.
If it werent for the fact that real, live women are people already – complete with feelings, desires and free will – the abortion issue would be a purely intellectual matter. But recognizing the rights of zygotes, embryos and-or fetuses is a zero-sum game that necessarily abrogates the rights of the women carrying them – women whose thoughts, sensibilities and volition are NOT mere theoretical constructs, nor the invention of medieval mythologies, but observable facts. The question ultimately posed by the issue of abortion is: What duty should we place on existing people to bring subsequent people into existence?
Best we can reckon, the great preponderance of material in the universe is unconscious and dumb – water, dirt, sunlight, air. Entities like you and your dog – with the ability to see, feel, think, desire, enjoy and fear – are spectacularly rare. Instinctively to us all, life has inherent value – and accordingly, actions that create or destroy life are vested with significance. Abortion is problematic because it terminates the developmental path of a discreet, identifiable entity that had the potential to become just like us – alive, awake, aware – turning it back to the mass of dumb and insensate material that comprises the bulk of everything.
The issue as to where that path begins, or where on that path lie its most significant markers, is not easily resolved. The Monte Python bit, “Every Sperm is Sacred”, pokes fun at the absurdity of tracing the path too far back. Similarly, while seeking to make a larger point about the double standard for men and women, Oklahoma State Senator Constance Johnson tried to illegalize male masturbation. The text of her amendment read, “Any action in which a man ejaculates or otherwise deposits semen anywhere but in a woman’s vagina shall be interpreted and construed as an action against an unborn child.” All are surpassed by Bill Maher’s satirical proclamation: “Life begins at erection!”
Conception isnt nearly a guarantee of achieving anything resembling life as we value it (seeing, feeling, thinking, etc.) The data is murky, but the most thorough study suggests that miscarriage rates are greater than 30%. (The rate most frequently cited is 15-20% – but that figure is for detected pregnancies. Perhaps half of all miscarriages end pregnancies that were never detected.) If we back it up another step, we find that in any given month, 25% of women seeking to become pregnant will succeed – and so when one forgoes sex, or uses contraception, there’s an excellent chance of preventing pregnancy (which is why birth control is so popular), ending someone’s potential journey from non-existence to conscious being.
Other than birth and fetal viability, there isnt one discernibly ascendent moment in the long process through which new people are made. The imposition of Christian mythology is particularly unhelpful in resolving the matter, since it relies solely on magical thinking, not reason, fact or science. The notion of “souls” leaping into newly formed zygotes is of the same species of inanity as the theory that malevolent fairies cause laryngitis when they leap into the throat. For centuries, Christian “thinkers” deemed the quickening (when the fetus is first felt to kick) to be the magic moment of “ensoulment”, after which abortion was not permitted. This changed abruptly in 1869, when Pope Pius IX declared it to be conception. Both positions are fundamentally arbitrary, primitive expressions of animism.
Debate must exclude opinions based solely on religion, because as articles of faith they cannot be engaged rationally, and so cant be discussed, but only offered for belief without evidence or argument. The extreme zealot’s position – if you conceive it, you’re stuck with it – cannot be given any weight in a non-sectarian, polyglot society, which depends on reason as a universal language to resolve differences.
Beautiful though life may be, rights bestowed on zygotes, embryos, and-or fetuses come at the cost of rights lost by women. And so any argument for forcing women to continue an unwanted pregnancy must, at a minimum, bear a substantial burden, and be supported by fact-based, logical reasoning, not mere recourse to mythology. Since distinctions among abstinence, contraception, and termination of an early-term pregnancy are based primarily on magical thinking – not science, and surely not rationality – they do not meet the minimum standard for inclusion in the debate.
PS Death isnt an end, so much as life is a pause – between two comparably infinite stretches of nonexistence. Take a moment to look out your window, walk down your street or hold your children, and wonder at it. Life is an exceedingly brief window, between the darkness we left and the same darkness to which we’ll return. When contemplating what it will be like, consider that everyone alive today will probably experience the year 2200 the same as they experienced the year 1800, during which there were some great parties, a few disasters, some notable events, some perhaps involving family members – all of which slipped by undetected to us.
Given the brevity of it, it’s extraordinary, bizarre, miraculous and FORTUNATE – that people can get so bent out of shape by the minutia of the quotidian. (We should be grateful for our ability to be so easily distracted.) Analogously, it’s difficult to assess or express the tragedy of beings who never even attain consciousness for the short time life affords it…. Have a nice Memorial Day weekend. Make sure you take 5 to grab a beer and a hot dog, chill, and gaze into the sky. Repeat if necessary.
No issue better captures conservative vapidity than drugs. Their supposed “fear of big government” is somehow not triggered by a US police state, which over the past 40 years has eviscerated the bill of rights, subverted democracy at home and abroad, and given the US the highest incarceration rate and largest prison population in the world.
The US police state went into launch mode decades ago. Though crime rates have been falling for more than 20 years since their 1991 peak, incarceration rates have continued to rise, seemingly independent of the drop in crime. The US incarceration rate is now over 700 per 100,000 – by comparison, the rate in many European countries in under 100. When you include probation and parole, you find that 3% of the US population is under correctional supervision. Drug crimes incarcerate about half of all federal prisoners, and about a quarter of all people in all US prisons.
Press a conservative on his inane opposition to drug legalization, and you’ll hear the squeaky voice of a paternalist with no love for freedom, and no respect for the judgment of other adults on how they choose to organize their lives. Like socialists, conservatives have no trouble subjugating individual liberty to the perceived needs of the collective.
The most common conservative rationale for drug prohibition is the protection of OTHER people from the consequences of an individual’s choice to use drugs. It’s curious that analogous social concerns are never seen in the context of food stamps or welfare – in which conservatives happily let children of poor parents endure severe material privation in the name of “individual responsibility.”
But of course conservatives’ “suffer the little children” feint on drug issues is just lipstick for the pig. Conservatism’s defining trait is its lack of principle. Conservatism is NOT a political philosophy – it’s 10 lbs of shit packed into a 5 lb bag by historical accident. Lacking any principles, conservative positions hover in the ether, without foundations. A trillion dollars spent on the war on drugs hasnt saved lives, reduced usage, or even increased drug prices. And it doesnt protect children. (Ever hear of liquor store owners hawking booze in or around schoolyards?) Conservatives essentially oppose drug legalization in the same way they oppose gay marriage – for no reason at all. Like every other conservative policy position, it isnt about a convincing argument, a principle, or (heaven forbid) observational data or scientific analysis. They oppose it because they oppose it.
Three year olds behave the same. They point their finger and declare “I want that.” A three year isnt interested in the particularities of fairness, history, propriety or decency. They dont give a damn about facts or logic – they know what they want, and naked desire is the alpha and omega of their universe. A three year old’s opinion on who’s turn it is to play with the dolly (mine!) is as immutable as a conservative’s opinion on drug legalization for EXACTLY the same reason. An opinion not based in fact nor derived from logic is amenable to neither.
great all-around source: http://www.sentencingproject.org/template/index.cfm
including these greatest hits:
PS: In response to several readers’ queries on whether Wile E. Coyote (Eatus almost anythingus) ever finally caught and ate the Road-Runner (Velocitus delectiblus), I’m posting this link, in the hope that it settles the matter conclusively: https://www.youtube.com/watch?v=EuE-GpNV0sY
Texas is fairly described as a state for the young and hungry. Among US states, it has the 2nd lowest average age, and the 2nd largest under-18 population. It also has among the highest rates of child poverty and food insecurity.
Frequently trotted out as a national exemplar of conservatism, Texas does indeed have a small state government, and has seen excellent economic growth since the Great Recession. But prosperity is not shared – Texas also has one of the worst rates of income inequality, the country’s highest fraction of minimum-wage and sub-minimum wage workers – and is afflicted by social ills at rates typical of much poorer states.
We begin with poverty – Texas has the 5th highest rate in the country, which is striking because Texas is not an especially poor state. The states near Texas in poverty rankings – Mississippi, Louisiana, Alabama, Arkansas, New Mexico, Oklahoma, West Virgina – are all among the bottom 10 states for median household income and per capita income, so their poverty rates are not surprising. Texas is the odd man out, ranking 25th and 30th in those same income measures. While the other 7 states are very poor by any measure, Texas is a middle-income state that has a lot of poor people because its income in unequally distributed.
With its tiny state government – ranking near the bottom for both per capita tax collection and public spending – Texas does little to ameliorate the plight of its many poor. Texas isnt even willing to spend OTHER PEOPLES’ money to help them! Of the state’s 5 million uninsured, fully 1.5 million of them would be insured, if only Texas signed on to Medicaid Expansion, the cost of which would be borne by the Federal Government. Texas declined.
Texans’ health plight only begins with its national-worst rate of health insurance coverage, and its second-worst rate of children’s health insurance coverage. Texas teenagers have the 3rd highest pregnancy rate and the 3rd highest birth rate. Texas children are in the bottom 10 for food insecurity. Life expectancy is in the bottom half of US states.
Remarkably, Texas is the only state in which workers’ compensation is not mandatory – employers are free to opt out – and about 40% do, leaving injured employees to fend for themselves. As you might expect, Texas has among the worst records for workplace injuries and fatalities. When a fertilizer plant blew up a year ago, killing 15 people and injuring 150 more, we learned that Texas has no state fire code. Neither was there a county code where the plant was situated.
While crime has dropped in recent years, Texas is among the nation’s top 5 for incarceration rates, and has the second highest execution rate. Some conservatives point out that if Texas were its own country, it’s economy would rank 14th in the world, just ahead of South Korea. They rarely mention that if Texas were its own country, it would rank 8th in executions – just ahead of North Korea.
Environmentally, Texas has some of the worst air quality in the US, with Houston and Dallas among the 10 worst cities for ozone pollution. Texas coal- and oil-fired electric plants release more CO2 than the next two largest states combined. Rick Perry has come a long way since working for Al Gore’s 1988 presidential campaign – as Texas Governor, he’s slashed the state environmental protection budget, and sued the EPA to prevent it from regulating greenhouse gas emissions.
A few factors advantaged Texas relative to the rest of the US since the Great Recession hit in 2007. Because Texas experienced a smaller run-up in housing prices, the housing crisis left the state with a relatively small fraction of distressed properties. Also, the high, sustained price of oil over the past several years has brought windfalls to oil producers, and rescued the state from the huge budget deficits it was facing. Texas rates of unemployment – good for about 17th best in the US, about 1 pct. pt. better than the national average – fail to convey that Texas jobs come in quantity, not quality, with the largest fraction of minimum wage and sub-minimum wage workers in the country.
And so people should take notice of Texas – as a cautionary tale. From extreme inequality, to the sad state of its children, to its miserable environmental record, to a disregard for workers and workplace safety – what prosperity Texas has recently seen has been enjoyed by the few, amidst widespread poverty, and the swelling ranks of the working poor.
Objections over birth control coverage in employer-provided health insurance are no more than an attempt by employers to intrude upon, control the lives of, and impose their religious beliefs on their employees, outside the course and scope of their job. No one can stop a private employer from posting the 10 commandments in your cubicle, installing Vishnu as your screensaver, or (Christ have mercy) leaving “A Clay Aiken Xmas” on an endless loop on the factory floor. But insinuating their beliefs into an employee’s family planning decisions – medical matters reserved for consultation with one’s doctor – is offensive.
Imagine an employer is a Jehovah’s Witness – and he objects to providing health insurance coverage to his employees for blood transfusions. (Faith prohibits Jehovah’s Witnesses from donating, storing or receiving blood – though I’ve never heard of a Jehovah’s Witness making such an objection as an employer, so this is strictly hypothetical.) Next imagine that Jehovah’s Witnesses sued the US Government so they could exclude transfusions from health insurance coverage mandated of large employers by the ACA.
This is not intended to be a slippery-slope argument – that if we permit employers to deny certain kinds of health insurance coverage to their employees, it would open the door to all manner of 11th century healthcare policies. Rather the illustration is meant to highlight the absurdity of allowing one person’s religious beliefs to impinge on another person’s access to modern medicine. Few would quarrel with Jehovah’s Witness’s choice to die for their religious beliefs – but most would have a problem with their expectation that other people should die for them.
Employers, under the Civil Rights Act, cannot discriminate in hiring on the basis of a job applicant’s religion – nor can they fire an employee for practicing their religion. (Churches are exempted, and can hire and fire based on an employee’s religion alone.) This means, among other things, that an employee is free to donate a fraction of his salary to the Church of Satan, or use it on Friday to enjoy a philly cheesesteak, or purchase a condom from the corner pharmacy – and his employer cant do anything about it.
Health insurance is just another form of compensation. Whether an employee acquires birth control with salary, or with employment-based health-insurance, in either case the employer is providing the compensation, and the employee is making the final decision on how he will use that compensation – to obtain birth control, or not. Distinctions between the two cases are spurious. What an employee does with the compensation he earns is up to him – not his boss.
The company at the center of the controversy – Hobby Lobby, an Oklahoma retailer – claims to be very much concerned about employee compensation being used to obtain birth control. But it has no compunctions about sending money to its Chinese suppliers, from whom it gets the vast majority of its merchandise. China’s abortion rate is TRIPLE that of the US, with more than 13 million abortions per year – and that doesnt include another 10 million morning-after pills sold annually. Abortion in China is effectively REQUIRED by law under the one-child policy. When a woman who’s already had a child becomes pregnant, she may face fines and other sanctions if she does not obtain an abortion.
If abortion were a serious concern, Hobby Lobby could not send money to China, knowing that it’s far more likely to finance abortions there, compared to the same money being sent practically anywhere else on earth. One can only infer that their preoccupation with abortion does not rise to the level where it might cut into their profits. Hobby Lobby is happy to force its employees to make sacrifices for the firm’s religious beliefs – but the firm is unwilling to make sacrifices itself – and happy to turn a blind eye to make a buck.
Religious freedom is a good thing, if only because the alternative is so noxious. But that liberty in a polyglot society is about an individual’s freedom within his or her defined individual sphere – such freedom does NOT include an employer’s right to reach into his employees’ private lives, to impose his religious beliefs on them.