The jet set

I'm off to Amsterdam this afternoon for the International Conference on Communication in Healthcare. I'll be presenting a poster and a talk. With luck, something interesting will happen at the conference for me to tell you about. But my schedule will of course be disrupted.

You may think this is a glamorous life but it's pretty much a PITA. I have to spend the minimum possible money which means no extra nights in the hotel, economy class in the cheapest possible flight, and the upshot is I'll get a brief impression of Amsterdam and that's about it. But I'll do the networking and presentationalizing necessary for academic success. Maybe even learn something.

Howzzat again?

A couple of days ago I heard Neko Case on National Pubic Radio recalling that as a child, she heard the Rascals Hit "Groovin'" as "That would be ecstasy, You and me and Leslie, Groovin .. . " She thought that was great that they could hang out with Leslie. Actually I heard it the same way, but I thought, "Who the fuck is Leslie?" Is it a menage a trois? Do they have a kid? A dog?

Actually it's not "and Leslie," it's "endlessly," but the singer (that would be Eddie Brigati) for some reason put the accent on the wrong sillobble. It's weird because endlessly scans just fine with ecstasy. If you look for the song lyrics using your favorite search engine (and no, Kleenex isn't the only brand of tissue either) you will find that even some official-looking versions drag Leslie into the picture.

I've come across a lot of similar mis-hears in my young life. Somebody, can't remember who, said they heard Jimi in Purple Haze sing "Excuse me, while I kiss this guy." That would be interesting news about Jimi, but the fact is he never hid anything. It's kiss the sky.

I was on a shuttle bus between a low-rice Marriot in an industrial park and a conference venue in Manchester, CT when a fellow sufferer told me that she heard John C. Fogarty singing "There's a bathroom on the right." Apparently John was in a hotel and needed to relieve himself, but in fact there was a bad moon on the rise.

My mother heard the old hymn "Gladly the cross I'd bear" as "Gladly, the cross-eyed bear." Funny name for a bear.

Anyhow, you may have a few of your own but I should go on to more serious matters. As you have likely heard, CDC thinks it's possible there could be 1.4 million cumulative Ebola virus cases in Liberia and Sierra Leone by the end of January. This is based on the assumption of no increase in the current level of intervention, and doubling every 20 days. So will this be the Big One, that plunges the planet into a new Black Death?

As I and most knowledgeable commenters have said, no. The catastrophe is happening because these two countries are among the poorest in the world and they lack adequate health care and public health infrastructure. Liberia has 1 physician for every 100,000 people. There aren't enough hospital beds for infected people so most of them just end up remaining in the community where they can infect others. The disaster multiplies because health care is unavailable for people with other endemic diseases such as malaria, while those few health care workers there are, lacking adequate personal protection, flee the field. Even the relatively poor countries of Nigeria and Senegal have so far successfully contained the outbreak because their infrastructure is just good enough. 

But, smug and safe as you may feel in your First World citadel, you should not. Ebola happens to be transmissible only in ways that make it controllable where resources are adequate, but the next emerging infectious disease might not be. It's likely to start in a poor country where initial containment fails, and then yes, given that people can be in Freetown in the morning and eating lunch in London the same day . . .

So, while it's easy to raise the money to bomb stuff, it's apparently impossible to raise the money to build an adequate public health infrastructure in poor countries. Maybe someone can explain that.

Let's you and him fight

U-Cal prof As'ad AbuKhalil breaks down the Syria clusterf* for you.

Point number 1 (and I said it here before), the "moderate, progressive" Free Syrian Army is and always has been bogus. They are a small conglomeration of various people who ducked under the umbrella in order to get U.S. support. Many moderate factions are actually allied with the Assad regime (which was always secular, NB). For the most part, the contending rebel factions represent various strains of Wahabism.

Then you have and Iran vs. Saudi proxy war, a Saudi vs. Qatari proxy war, the Sunni vs. Shia thing which was mostly conjured up by the Saudis as part of proxy number 1, U.S. vs. Russia but that's inoperative now because it was about deposing Assad which is no longer the issue, Lebanese factions, Moslem Brotherhood vs. localized factions . . .

The point is, it doesn't have a damn thing to do with the U.S. or Islam vs. Christendom or any of the other bullshit you have been told. And it certainly is not the job of the U.S. to straighten it out, with bombs or otherwise. So just stop it.

Bombolicious

Very interesting to hear that Saudi Arabia somehow "participated" in the attack on the Islamic State in Syria, since, as we noted on Sunday, IS was originally a project of Saudi intelligence. More confirmation of that here. Of particular note is John McCain praising the Saudis even as Bush family pal Prince Bandar was financing and organizing ISIS.McCain is the single individual in the United States who is most ignorant of world affairs. That's why he gets to talk about the subject so much on TV.

According to the linked article by Steve Clemons, King Abdullah has apparently decided this wasn't such a good idea after all and has relieved Bandar of the intelligence portfolio. All I can say is at this point, you poke a hornet's nest, you should know what to expect.

The fact is the Arab states that are said to have "participated" in this action probably just lent their names to it, like the honorary committee on the stationery. They're still expecting the U.S. to clean up their messes and the result is just going to be an ever bigger mess. The U.S., with an occasional extra kaboom from France, has been bombing IS in Iraq for a few weeks now, and while the activity has helped the peshmerga hold on to territory and recapture the Mosul dam, that's about all it's accomplished. There is no comparably effective and credible proxy force in Syria as of now, so this is unlikely to have any substantial territorial consequences for a long time to come.

Whether King Abdullah can stop his 247 half, quarter and 8th brothers from writing checks to IS, and whether the Turks can shut down the black market in IS petroleum, remains to be seen. Those are the only measures that are likely to matter. Oh yeah. John McCain needs to STFU.

What Matt Stoller says . . .

Here. Thou shalt read.

Al Qaeda and the Sept. 11, 2001 attack on the U.S. were financed by Saudi princes. So was (and probably is) the so-called Islamic State. The Saudis are great friends of the Bush family. The 9/11 Commission report apparently names the financiers, but that part of the report is classified. It would not be in the national interest, it seems, for you to know who paid for the attack.

The entire basis and rationale of U.S. foreign policy, as represented by the corporate media, is horseshit. And yes, it's all about petroleum and the money that flows to the places from which it comes. It's not that long of a story; please do follow the link.

Dr. Innumerate will see you now

I don't know if you riffraff are allowed to read this, but anyhow Christopher Martyn in the new BMJ points to some jaw dropping findings. If you've been a long-time reader you will recall that I have discussed Bayes Theorem many times. It's really important to critical thinking to understand it. He refers to: Manrai AK, Bhatia G, Strymish J, Kohane IS, Jain SH. Medicine’s uncomfortable relationship with math: calculating positive predictive value.JAMA Intern Med2014 174.

I won't bother with a link because I know you can't read it. But I'll tell you what it says. They presented physicians with the following proposition:

There is a disease which has a prevalence in the population of 1 in 1,000. There is a test for this disease which has a false positive rate of 5%. If your patient has no symptoms of the disease, but the test for your patient comes back positive, what is the chance your patient has the disease?

Think about it. (Jeopardy! music plays.)

Okay, if your answer was 95%, you're thinking like  doctor. Which means you're wrong. That's how most physicians answered the question, but the right answer is about 2%.

This is easy if you just take a minute. One person in 1,000 actually has the disease. Of the other 999, 5% (in the average trial) will have a false positive test. That's actually, on average, 49.95 people but close enough to 50. So to be exact, there is a 2.002% chance that your patient has the disease.

This test is said to be 95% specific. Sounds really great, doesn't it? But if the condition is uncommon, it's pretty much useless. It's because doctors, patients, and advocacy societies can't seem to understand this that we have too many screening tests and too many people walking around with disease labels and getting unnecessary additional tests and treatments. And it is so blatantly, obviously, fucking simple. Aarrrggh.

A bit more about domestic violence

If  you inhabit the same precincts of the blogosphere as I do, you have probably read plenty of late about the Men's Rights Movement and Men's Rights Activists. Their basic claim seems to be that they have a right to be jerks and they are oppressed by people who claim otherwise; and they seem to favor tactics such as death and rape threats against women who disagree with them. I'm sure there are people who consider themselves MRA's who behave better and make more credible claims, e.g. that men are discriminated against in child custody disputes, but it's the former category that's been getting the attention.

Anyhow, I'd like to discuss a specific area of controversy. Linking to Wikipedia is maybe an easy out, but in this case it's a good place for an overview. The fact is, as I mentioned in my last post, surveys generally find that violent acts by domestic partners occur at about the same rate by women against men as by men against women. An academic who is well known for loudly proclaiming this fact is Murray Strauss who complains, rightly perhaps, that it is widely ignored. However, although he tends to bury the lede, he also notes in the journal Partner Abuse (2010, sorry no link available):

The exception to gender symmetry is that the adverse effects of being a victim of PV are much greater for women than for men. This can be considered a difference in context, but the fact that adverse effects are consequences rather than causes of PV needs to be kept in mind.

Attacks by men cause more injury (both physical and psychological), more deaths, and more fear. In addition, women are more often economically trapped in a violent relationship than men, because women continue to earn less than men and because, when a marriage ends, women have custodial responsibility for children at least 80% of the time. On the other hand, the adverse effects of emotional abuse, while not a focus of this article, are often greater than those of physical PV, with a comparable impact on both men and women victims (Hamel, 2009; Lawrence, Yoon, Langer, & Ro,
2009; Taft et aI., 2006)

Still, the greater adverse effect of physical PV on women is an extremely important difference, and it indicates the need to continue to provide more services for omen victims of PV than for men victims. In addition, as will be explained later, the greater adverse effect on women is one of the things that underlie denial of theevidence on gender symmetry.

In other words, you can lie with statistics. Strauss comes in for a lot of heat from feminists, but he really doesn't deserve it. He's trying to get us to work with the true facts, which actually forces us to think more deeply.

About those foobaw players

I haven't done primary research on intimate partner violence, but as a sociologist I have studied a bit about it and taught the subject. It is possible for couples to get into the occasional fight, push or hit each other, throw things -- surveys find that the percentage of relationships in which that happens are pretty high, and the gender direction is actually pretty symmetrical. That said, since men tend to be bigger and stronger than women in most cases they have an extra responsibility to forebear.

But abusive relationships are something different. These are characterized by a pattern of coercive control. The abuser is obsessively jealous and possessive. He -- and in these situations it is indeed usually he -- uses all sorts of tactics to maintain control, not just physical violence but humiliation, economic coercion, spying, selective withholding of affection, lying, threatening, you name it. Women often end up staying in these relationships out of fear -- if they leave, he might kill her. He may well have made credible threats to do so. She may have no economic resources and fear for her children's welfare. You get the idea. (This can happen in homosexual relationships as well, by the way.)

So what about Ray Rice? We don't have any evidence, that I know of, that the incident in the elevator was anything but isolated. However, the video is deeply disturbing because he is so callous. He shows no concern for her welfare, drags her out of the elevator like a sack of potatoes, and seems not in the least upset that he has just struck his fiancee in the face and knocked her unconscious. That is very odd, to say the least. And given that he spends hours in the weight room and his muscles are nearly bursting out of his suit, see the last sentence of paragraph one.

Now, if the average accountant or material handler is accused of domestic violence, he ordinarily won't lose his job unless he winds up in jail. In fact, his boss probably will never even learn about it. With public officials it's different obviously. A Massachusetts state legislator was recently convicted of domestic violence, refused to resign, and the House expelled him. So what about athletes?

It seems to go without saying for most commenters that professional athletes, and for that matter prominent college athletes, must be held to a high standard of conduct away from their jobs.  The reality is that athletes throughout their youth, including college, are entitled and can get away with a lot of bad behavior. The fans seem to love their bad boys regardless. At least this has historically been true, but now the zeitgeist is changing, and more and more people are reacting against the tradition. There is a strong feminist strain in this reaction but there are plenty of men who feel the same way not only because they are feminists, but also because they don't like the old definition of proper manhood.

I'm not exactly sure how I feel about this. Obviously athletes should be held to the same standards as everybody else, and be as accountable. But should they be more accountable? Public officials have to make and enforce the law. Eliot Spitzer properly resigned because as Attorney General he had prosecuted prostitution rings and as Governor he was responsible for enforcing laws that he violated. We can't have that, as far as I'm concerned. But are athletes really role models? Have they ever been? Some are, in some ways. Jackie Robinson, for example. But generally speaking, they're just entertainers, and we certainly don't disqualify actors or musicians for bad behavior. Rice probably should have been prosecuted, given the egregiousness of the assault, but should he never play football again? I think that may be a category error. He's just a guy who plays a violent game.

In case you haven't been following the existential threat . . .

It's not actually from religious fanatics (unless you count the Christian right).

August, 2014 was the hottest August globally since records have been kept starting in 1880. Our relatively cool summer here in the northeast U.S.? Actually no, it was normal. It's just that we've gotten used to it being hotter. Also, too, no El Niño so far, which is normally associated with high temperature anomalies. And the biggest temperature anomaly? West Antarctica, where the ice sheet is already collapsing.

I actually won't feel terrible when Miami Beach is under water. It's kind of an abomination. But it's too bad about Back Bay and East Boston. I have a certain affection for those places.

War! What is it good for?

What David Frum says.

Speaking for myself -- and I've sort kinda said this before -- yes, these Islamic State characters are evil doers. But so are our Saudi and Qatari "allies" (when they aren't actually financing al Qaeda and similar) and so, for that matter, are we. I suppose you could say it's a matter of degree and that counts for something, but still it must be acknowledged.

That acknowledged, the following perhaps less controversial points.

1) The only substantively interesting statement in Obama's speech last night was that we are going to arm Iraqi and Kurdish forces. In diplomatic terms, that is extremely significant because it explicitly admits that the peshmerga are not part of the Iraqi armed forces and Kurdistan is not part of Iraq. That said . . .

2) It is ridiculous to pretend that this has anything to do with protecting the territorial integrity of Iraq or the preservation of national borders more generally. That ship done sailed. Which is inevitable because these are borders drawn arbitrarily by European colonial powers 100 years ago. Nature is taking its course . . . 

3) And, since the Iraqi army is in fact a sectarian Shiite army, we are also going to arm and train Sunni Arab militias, which means we're just going to further encourage the breakup of Iraq because we know the Sunni Arabs aren't about to join the Iraqi army, since it's not their army and that's the whole reason IS has been successful in Iraq in the first place .. .

4) That said, this bullshit about an "inclusive" Iraqi government is obviously just that.

5) The Islamic state is a threat to the region, to be sure -- and mostly immediately to regimes we claim not to like, i.e. Iran, Bashar al-Assad, and the totally non-inclusive Baghdad regime. Obviously they also make the Kurds and Turks nervous, but Turkey has already said it's not going to join the coalition of the willing. They make the Saudis nervous but that's their own blowback, now isn't it? So . . .

6) We now find ourselves in a weird alliance with Iran, the Shiite Baghdad government, the Saudi and other gulf monarcho/theocracies, and a motley crew of ideologically diverse warlords in Syria, plus the Kurds, for the purpose of protecting the interests of all of them at our expense.

This is completely nuts. IS is 7,000 miles away from the closest point of the U.S., which I believe is Provincetown, Massachusetts. This is a problem, and it's partly our fault, so we owe people something. But it's not a problem we can fix, and it's certainly not a cause that the U.S. can lead.

We owe humanitarian aid to the refugees. I'm not knee-jerk averse to a bit of bombing here and there at the request of the Kurdish or Baghdad governments to avert further catastrophe and maybe help them roll back IS where they can. We do owe them any help that will actually be useful. But a war between the United States and Muslims of any kind is just playing into the hands of IS. That's the world they want to portray, and the last thing we ought to do is make it real. The Saudis and Iranians actually have powerful militaries with plenty of air power. Yeah, they hate each other. That's not our problem either. Let them do what they think is best.

Also too. According to the sacred Constitution of the United States, the Congress has the sole power to declare war. Anybody still remember that little detail?

Tranks

One of the difficulties with pharmaceutical regulation is the length of follow-up in clinical trials. Typically, drugs are approved based on trials of no more than six months duration. This is true even for drugs that people may take for a long time, even for many years. Sometimes the FDA requires post-marketing surveillance or longer term follow-up studies after a drug has been approved, but they often don't, and these requirements aren't even enforced in many cases.

Benzodiazepines are very commonly prescribed tranquilizers. Very common brand names are Xanax, Librium, and Ativan. (Rohypnol, also in the class, is a popular date rape drug. Sorry to bring that up.) They are addictive, and are often drugs of abuse. Many people doctor shop for them just as they do for opioids, they are often sold on the street, and they are often found in conjunction with opioids in overdose victims. They are prescribed for anxiety, but as I often say, anybody who isn't paranoid nowadays is nuts.

Well now, it turns out that a carefully done case-control study links even moderate-term consumption of benzos to Alzheimer's disease. By moderate term I mean more than three months worth. By links I mean an elevated odds ratio of 1.84 for more than six months of consumption.

The odds ratio is not the same as the risk ratio -- since math is hard I don't want to digress to explain this here. A case control study does not allow for computation of the actual relative risk in the population, but in this case, we can figure out that it translates to an approximately 50% increased risk. There are other studies that point to the same conclusion; the strength of this study is that it attempts to account for the possibility that people who have symptoms that might be associated with a higher risk of Alzheimer's are more likely to be prescribed benzos. (That's called confounding by indication.)

This is a very disturbing finding. If someone is anxious for a reason, such as the fact that we live in a dangerous world, taking a pill is not going to fix the real problem. If there is in fact a disease that causes people to feel anxious all the time and we don't understand why and can't do anything else about it, having them take a pill for the rest of their lives that causes drowsiness, dizziness, lack of coordination, decreased libido and amnesia -- even without the Alzheimer's disease --- is probably not a good idea. In fact, they are recommended only for short term use -- alcohol withdrawal, termination of seizures, brief (2 - 4 weeks) treatment of anxiety. There is no condition for which long-term use is helpful or indicated. Yet these investigators had no trouble finding 22% of people in a sample from Quebec who had been prescribed benzos for more than six months. (That was the rate of long-term prescribing in the controls, in other words. The rate in the cases was 33%.)

To reassure you, there was no finding of increased risk of Alzheimer's associated with short-term use. That indication is not affected by this study. The point is, doctors should not be doing this.

Looking forward, not back

It turns out that tomorrow is the 40th anniversary of Gerald Ford's pardon of Richard Nixon. For any not-olds who may read this the act was greeted with widespread outrage at the time, but now we're all supposed to believe that it helped bind up the nation's wounds and let us move forward yadda yadda yadda.

Well, while we're on the subject of looking ahead and not back, there has been almost no attention paid so I may need to remind you that the Senate Intelligence Committee has prepared a report on the CIA torture program which has yet to be released to the public because the administration is trying to censor the nasty bits. For some reason, a British newspaper, the Telegraph, has to do the journalistic enterprise to tell us what they are. This came out last night but I have not found a single U.S. media outlet that has covered it. Take it away, Peter Foster:

The CIA brought top al-Qaeda suspects close “to the point of death” by drowning them in water-filled baths during interrogation sessions in the years that followed the September 11 attacks, a security source has told The Telegraph. The description of the torture meted out to at least two leading al-Qaeda suspects, including the alleged 9/11 mastermind Khalid Sheikh Mohammed, far exceeds the conventional understanding of waterboarding, or “simulated drowning” so far admitted by the CIA.

“They weren’t just pouring water over their heads or over a cloth,” said the source who has first-hand knowledge of the period. “They were holding them under water until the point of death. . ."

Despite the destruction of video evidence, however, a third source familiar with the still-classified accounts of the most severe of the CIA interrogations, said that the practices were much more brutal than is widely understood. “They got medieval on his ass, and far more so than people realise,” the source told The Telegraph referring to the treatment of Mohammed and Nashiri, but declined to provide further details because of the still-classified nature of the material.

The destruction of video evidence refers to destruction of video tapes of the torture sessions by CIA Officer Jose Rodriguez, who was severely punished by a sternly worded letter. B. Hussein Obama has already promised not to prosecute anybody for torturing prisoners. Congress did impeach Bill Clinton for receiving fellatio, however, so there is still a spirit of accountability in the land.

Could this be the most outrageous thing I've ever heard of?

Just about. I mean, it's not the holocaust but it's pretty damn evil. Graham Cole and Darrel Francis in BMJ tell the horrific tale.

It starts with one of my least favorite things, scientific fraud. A schtickdreck named Don Poldermans published a series of clinical trials testing whether giving beta blockers before surgery reduces the risk of mortality. The trial reports said it did, by a lot. Even though other studies didn't find this, the European Society of Cardiology relied on Poldermans's studies to recommend the treatment, which is not surprising since Polderman chaired the task force the developed the guidelines.

Only problem: Polderman made it all up. There were 5 trials in the series. He made up patients, made up data, even made up collaborators. Without his trials, meta-analysis shows that giving beta blockers increases the mortality rate. Cole and Francis calculate that something like 800,000 people have died because of the fraud. Polderman of course has been fired, but I haven't heard anything about a murder prosecution.

Anyhow, the first trial in the series, DECREASE 1, was more than ten years old at the time of the investigation so it was not reviewed. But as Cole and Francis show, it is obviously bogus as well. It contains impossible data and internal contradictions. However, the ESC continues to rely on it and has not reversed its recommendation! The guideline setting process is secret. The Society's journal, the European Heart Journal, has resisted accepting the new meta-analysis. There is more detail about the whole contretemps that I won't go into.

Arrogance, secrecy, vested interests, lies -- and people die. I don't know what the guidelines are for this practice in the U.S. or how the situation has played out here, but guidelines committees are certainly plagued by conflicts of interest and lack of transparency. This must change. It's your life that's at stake.

The Other Side of Rising Health Care Costs

In the public sphere, we tend to hear that the increase in health care spending as a share of GDP is a bad thing which is unsustainable and represents the evil machinations of the Medical-Industrial complex. I may sound like that sometimes myself, but it isn't exactly accurate. There is a lot of waste and misallocation of resources in the medical industry, and yes, we need to do what we can to fix that.

But us health policy wonks know there's more to it. To some extent -- maybe not the actually existing extent, but some extent -- we would expect the share of GDP spent on health care to increase secularly, and that's actually a good thing. This by Hall and Jones is one analysis along those lines, but lots of people make similar arguments.

There are really two mechanisms at work here. The first is that over time, medical technology has gotten better. We can cure many cancers that we couldn't before, or at least give people years of decent quality life. The age-adjusted death rate from heart disease has plummeted. Orthopedic surgery can very effectively fix osteoarthritis, which is one of the worst things about growing older. (It did for me!) But all this costs more. Unlike electronic gadgets, the price doesn't keep going down. We need highly trained experts, million-dollar machines, and  drug and device prices that repay expensive research (since that's the model we've chosen). Yes, new technologies can occasionally be cost-saving (though much less often than you might think) and the price can come down over time (as when drugs go off-patent), but in the real world, technological advance produces a net increase in costs.

So yes, it costs more, but it's often worth it.

The second mechanism is that as people grow more affluent, once they've met their basic needs for food, clothing and shelter and whatever else they really, really want, health care is high on the list for disposing of income. We get the elective surgery; we go to the doctor and get checked out, and yes, they'll always find something. And yes, most of us pay only a small share of  our health care expenses out of pocket, but consumer and public demand that insurers cover expensive treatments is irresistible. When they try not doing it, there is an outcry. (Although weirdly, many of the same people who do the outcrying have no problem with some people having no health insurance at all.) So Medicare and private insurance will pay the $200,000 to keep someone with terminal cancer alive for three months.

But even that is not necessarily wrong, up to a point. When we have little time left, each day is more precious. And median survival conceals the exceptions who live a long time. And that also means hope --if you can hang on a bit longer, they might come up with a new treatment. This actually happens. For example, not-so-great HIV drugs kept some people alive  long enough to get better ones.

So, in principle, we could be happy to see medical expenditures increase as a percentage of the economy. That's a choice we can make and feel wise about. That's happening everywhere, including Canada and the UK with their single payer and socialized systems, respectively. But those parallel lines are much lower. They are spending more over time, and reaping benefits, but they are also spending a lot less than we are. Both can be true.  

The real problem with Medicaid expansion

As you may have heard, the Republican Governors' united front against Medicaid expansion is fracturing. They never had a really good explanation of why they would not accept free money from the federal government to cover their uninsured working poor, except that ideologically it's just wrong to spend tax money to make people's lives better and  they'd have to kick in a few percent down the road. But now Pennsylvania, Arkansas, Arizona, Wyoming and others are implementing Medicaid expansion in one form or another.

Many observers considered this inevitable in the long run because a) people can see that neighboring states are better off, not worse off, when they accept Medicaid expansion, b) hospitals and other health care providers are a powerful constituency in favor of Medicaid expansion and c) so are employers with low-wage work forces. There doesn't seem to be any way, politically, for Republican politicians to get away forever with screwing their citizens and major employers.

But now Dylan Scott, in TPM, drawing on an observation by Nelson Lichtenstein of UCSB, explains why many states still resist: they are the former Confederate States of America and the large majority of beneficiaries of Medicaid expansion would be African Americans (and Latinos in many cases, I might add). Arkansas and Kentucky are expanding Medicaid, but they have Democratic governors.

Let's face facts here folks: the reason that many low and moderate income white folks are opposed to government programs that would benefit them is that they think more of the benefit goes to people who are unworthy, and said people's unworthiness is predicated on their pigmentation. It is because racism divides our working class that we have the stingiest social welfare state among the wealthy countries, and that is why we have so many people who vote against their own self-interest and are seduced by the unalloyed bullshit of libertarianism.

Oh yeah. That's also why we have a War on Drugs. And  a whole lot else that's wrong.