Now they tell us

NBC News has a good, readable summary correcting common misconceptions about the Affordable Care Act.

It isn't just about extending health insurance coverage, it has provisions reforming Medicare (and others the article doesn't mention such as the Patient Centered Outcomes Research Institute) intended to constrain the cost of health care while making it more effective and better meet people's needs.

It isn't government insurance. It's a mechanism for making private insurance more available and affordable to people who don't get insurance through employment, Medicare, the military or VA. Most people don't get their insurance through the ACA. Whatever is happening to your employer-provided insurance that you don't like, don't blame the ACA. Blame your employer.

It didn't make your premiums go up. (Contrary to a recent commenter.) Health care costs have been increasing forever. If anything the ACA has slowed this process down.

Yes, premiums for many plans on the exchanges will go up this year compared to last. That wasn't caused by the ACA, it happened because insurers underestimated how much new enrollees would cost.  People who have been without health care for a while often have expensive problems such as uncontrolled diabetes. But, government subsidies will take care of most of the increase for most people, and if the ACA were allowed to remain in place, this problem would ease over time.

Here's my complaint. Throughout the campaign, indeed the last seven years, through all the screaming and yelling about how the ACA was socialism with death panels and a government takeover and government coming between you and your doctor, they never bothered to sit down and carefully explain to people that none of that is true. They just channeled whatever lies the politicians were telling. Only after the disastrous election of 2016 do we suddenly start getting these simple, factual stories about public policy.

Since we seem to have different claims about the popularity of the ACA . . .

here is recent polling from the Kaiser Family Foundation. Highlights:

While health care was not a leading factor in voters’ presidential decisions, President-elect Trump and Republican lawmakers have made it clear that one of their top priorities is the repeal of the 2010 health care law. Americans are divided on what they want to see lawmakers do to the ACA with one-fourth of Americans (26 percent) wanting to see President-elect Donald Trump and the next Congress repeal the entire law while an additional 17 percent want them to scale back what the law does. This is compared to 30 percent of the public who want to see the law expanded and 19 percent who want to see lawmakers move forward with implementing the law as it is.

While President-elect Trump and Republican members of Congress work on a replacement to the ACA, this month’s survey finds that many of the law’s major provisions continue to be quite popular, even across party lines. The notable exception is the requirement that nearly all Americans have health insurance or else pay a fine.

The problem is that people do not understand that the only way to make health insurance available and affordable for everyone is to get everyone into the pool. You can't have the popular provisions without the mandate. It is unseverable. That doesn't fit on a bumper sticker, but it's how the world works. 

They don't know why, they just know they're supposed to hate it . . .

That would be Republicans and the Affordable Care Act. This just hit my in-box.

The rate and number of insured Americans reached historic highs in the years following passage of the Affordable Care Act (ACA). In a new report, researchers from the Urban Institute — with funding from the Robert Wood Johnson Foundation — provide a granular perspective on the 19 million people who gained coverage (2010-2015) and where they live.

Coverage rates increased broadly across age, gender, race/ethnicity, education, and state. The Urban researchers found that a large share of the nonelderly adult coverage gains occurred among those without a college degree – 87 percent. Fifty-seven percent of the children and adults gaining coverage were nonwhite or Hispanic.

"In recent years we have seen unprecedented gains in health insurance coverage,” said Kathy Hempstead of the Robert Wood Johnson Foundation. "What happens next is uncertain, and the ability to maintain these gains will undoubtedly be a central issue for policymakers to consider.”     

The report includes state-by-state breakdowns by key demographics to illustrate who gained coverage under the law. Highlights include: 

·         Among nonelderly adults gaining coverage, 14.1 million did not have a college degree; within this group, 44 percent were non-Hispanic white.

·         In California, 3.8 million people gained coverage and the uninsured rate dropped 53.4 percent after state policymakers expanded Medicaid eligibility.

·         In Florida and Texas, 3.2 million people gained coverage, even though these two Southern states chose not to expand Medicaid.

·         In Illinois, Michigan, Ohio, and Wisconsin, more than 2.3 million people gained coverage – accounting for a 38 to 49 percent drop in the percentage of people without health insurance across these Midwestern states.

Notice anything about bullets 1, 3 and 4? They're about to get what they voted for. I hope they enjoy it.

Another data point on the Fermi paradox

This Phys.org summary takes a while to get to the point, but it's an enlightening while. It doesn't quite explain everything it ought to explain, so I'll fill in the blanks for those of you who may need it.

Life on earth is something more than 3 billion years old. To be sure, Republicans don't believe this, but it is true. However, the metazoans -- a fancy name for the animals, that include us -- and plants haven't been around nearly as long, only (hah!) about 800 million years. We know that what made metazoan life possible was the rather abrupt enrichment of the earth's atmosphere with oxygen, which as I'm sure you have noticed animals need. This was brought about by an explosion in the population of photosynthetic organisms called cyanobacteria (often called by the misnomer "blue-green algae"). The cyanobacteria are still around, but they also made plants possible by getting themselves incorporated into plant cells as endosymbionts that today do the photosynthesizing work for your petunias.

The metazoans were made possible not only by the availability of oxygen, but also by another endosymbiotic event in which another line of bacteria became what are today the mitochondria, our cells' power plants. And plants also have those. Both kinds need a lot of phosphorous to thrive. The problem was, it wasn't around for the first 2 billion plus years, according to this new research -- or rather, it was sequestered deep in the ocean, where photosynthesis couldn't happen. Then TaDa! It showed up in substantial quantities in shallow coastal waters, cyanobacteria were in business, and 800 million years later, so were we.

This suggests that if whatever the key event was had not occurred, earth would still be inhabited by nothing but slime. It also suggests that many or most earth-like planets might never have hit the inside straight, which would help explain the Fermi paradox. It's also all the more reason not to do ourselves in. A) The environment that supports our kind of life is fragile and it can be screwed up and B) it may be quite rate in the universe so there' s nobody out there to carry on the cause of wondering about the universe and starting to understand it.  Let's take this historical moment very, very seriously.

Not that I want to bring you down . . .

but while the New York Times was obsessing over Hillary Clinton's e-mails this was happening. (Yes, there are still newspapers in Britain.)

The warming arctic and the disappearance of the arctic sea ice have caused the jet stream to weaken and meander. This has a few consequences including pulling down cold air to the south, and warm air to the north; increasing the intensity of storms; and causing weather patterns to become static over particular regions resulting in prolonged periods of storminess, or droughts.

That one of the two major parties in the U.S. is committed to denying this incontrovertible reality should scare the shit out of you.

Zdravstvuj tovarisch

There is a whole lot that is bizarre about the impending presidency, but surely the most perplexing but at the same time revealing weirdness is the apparent acceptance by the Republican party that our new BFF is Vladimir Putin. Nina Kruscheva, who ought to know, discusses the Russian takeover of the United States. I will put this in bullet points in case your attention span is flagging.

• Trump responded to reports that the CIA had concluded Russia was behind the hacking of the DNC and John Podesta by deriding the CIA as a tool of Hillary Clinton. Quoth NK, "The idea that a US president-elect would take the word of the Kremlin over that of CIA officials and even the most senior members of his own party is already bizarre and dangerous."

•  But then there is Secretary of State nominee Tillerson,  for whom "taking Russia’s side against the US is nothing new." 

• And National Security Adviser Michael Flynn, who, "like Tillerson, has also been feasting at the Kremlin trough. After being fired by Obama for his incompetent management of the Defense Intelligence Agency, Flynn immediately began to cultivate Russian business contacts. And Putin seems to have been more than happy to see that commercial doors were opened to Flynn. There is a now-infamous photograph of Flynn seated next to Putin at a banquet for RT (Russia Today), the Kremlin-backed cable news network that was a prime source of the slanted, and even fake, news that inundated the US during the recent election campaign. "

• "As for Trump, statements made by his sons suggest that, if the American public ever got a look at his tax returns and business loans, they would find that he has also been feathering his nest with Kremlin gold for some time."

•  And of course there is Paul Manafort

Kruscheva thinks that Trump is likely involved in criminal activity. Although she doesn't specify, violation of sanctions against Russia, tax evasion, or collusion in the hacking are all possible. She doesn't mention the likelihood that Putin has information with which to blackmail Trump. All of this is just fine with the Republicans in the House and Senate. And the news media, which are largely incurious about it. How deeply strange.

Thoughts on resistance

Randall Kennedy has some.

I actually think -- and I'm probably naive -- that many of the squishes, including even some Republican politicians, who initially decided to go with the flow and pretend everything was normal and they would try to figure out ways to use the famously unfocused and flighty orange orangutan for their own purposes are now starting to realize that he is even crazier than he seemed and touching him in any way is extremely dangerous.

In other words, it's possible that the Senate won't go along with handing the country over to Vladimir Putin, and once the Republicans contemplate the likely political cost of doing all the stuff they have been promising to do for the past 8 years they may go a bit soft. Where we are definitely screwed is on the environment including the fate of you know, the planet, but we'll still be around after 4 years to change that around. Voter suppression is definitely resistible, as is intimidation of dissent and of the press. Our political culture has a much stronger reserve of democratic norms than Germany or Italy did in 1939. Robert Kuttner checks off the parallels to fascism (see section 2 of this long essay) but noting how Trumpism is like fascism leaves out how the historical time and place is different. He concludes with more or less what I am saying:

An astute observation is ascribed to Mark Twain: It is easier to fool people than to convince them they’ve been fooled. True enough, but the contradictions are piling up. Even hardcore Trump voters are starting to experience buyer’s remorse.

We can place our hope in his incompetence. As long as we can avoid a ruinous war.

Philosophy after the Enlightenment

Metaphysics is essentially dead. Speculation about the ultimate nature of reality seems a waste of time when we can actually study the universe and learn about it. Whatever metaphysical speculation you come up with may one day be proved true or false, in which case why not wait for the answer? Alternatively, there may be no means of verifying or falsifying it, in which case why bother even to think about it, when we can spend our resources on questions that might have answers?

So here's Tim Urban discussing the Fermi paradox. Basically, even using the most conservative assumptions, if life develops on earth-like planets, even fairly infrequently; and it technological civilizations subsequently evolve, again even infrequently, there should be something like 100,000 technological civilizations in our galaxy, many of them presumably far more advanced and powerful than little old us.

So where are they? We have detected absolutely nothing that is suggestive of any technological civilization. Urban's discussion is very well organized and fascinating, so do read it. But I will say that the main possibilities include that life is actually exceedingly rare. That would be surprising because cosmologists have adopted the habit of thinking that our planet is nothing special. It would also be surprising because it seem evident from thinking about evolution on earth that if you get any sort of system that self-replicates with occasional mistakes, you are going to get evolution. But does evolution necessarily have to lead to multicellular organisms and nervous systems? Maybe the universe is full of pond scum, and nothing much more than that.

Another possibility is that technological civilizations arise,  but inevitably self-destruct because they can't handle the power they gain for themselves. That's certainly plausible, we almost did it during the Cold War and we might be about to do it now. On the other hand at least some of us are wise enough to avoid that. Why couldn't even 1% of civilized beings be more generally wise?

And there is the possibility that they're out there, but we can't detect them because they aren't emitting any signals that we would perceive as coming from a technological civilization. There is also the nasty possibility that a predatory species rules the galaxy and wipes out any competitors, in which case we may be on the menu.

These speculations are mostly fairly disturbing, but the point is, we may one day -- even soon! -- know the answer. Hegel, however, could never know anything.

Just to be clear about "Repeal Now, Replace Later"

The Republican proposal to repeal the Affordable Care Act but not actually abolish it until 2019 at which time they will purportedly have figured out what to replace it with comes with a bonus: it will immediately eliminate the taxes which finance the ACA, 100% of which fall on people making more than $200,000 a year. That would be $346 billion over ten years.

So where are they going to get the money from to "replace" the ACA? Are they going to reinstate those taxes? I really don't think so. Of course, that has always been the real reason Republicans don't like the ACA. What are the chances the people who vote for them will ever understand this?

Not Stayin' Alive So Much

You may have heard already that CDC is reporting that U.S. life expectancy declined by about 1/10 of a year from 2014 to 2015. (Link is to a PDF. If you prefer, you can go to the National Center for Health Statistics home page here.)

Now, this might not mean anything. Life expectancy in the U.S., while it lags behind other wealthy countries, has been steadily increasing. That's why it's a bit of a shock to see a decrease but one year does not a trend make. It's also hard to know what to make of the internals. The age adjusted death rate increased for Black men, and for white men and women, but not for Black women or Latinos. The age adjusted death rate for cancer went down: the main contributors to increased death rates included heart disease and stroke, lower respiratory disease (which is mostly due to tobacco), unintentional injuries, and suicide. While the prevalence of smoking has been going down substantially in the past couple of decades, it's possible that the earlier smoking epidemic is catching up with people now. Obesity may also be contributing to the heart disease and stroke increase.

Unintentional injuries aren't decomposed in this report, but I suspect they're a combination of motor vehicle crashes and drug overdoses. Infant mortality increased, in substantial part due to unintentional injuries, which I would guess points to motor vehicle fatalities.

An oddity is a sharp increase in the age adjusted death rate from Alzheimer's disease. Since it's age-adjusted, it wouldn't seem to be an artifact of the aging population but that could be wrong -- I'd have to see exactly how they did the age adjustment. If they capped out at 85+, that could explain it.

Apart from that, this is consistent with the story we've been hearing about our major public health problems: obesity, cars, opioids and suicide. All problems we can do something about.

Outsourcing . . .

To Maciej Cegłowski.

Just go there. Read. Understand. This is the hinge of history.

Here's a letter I wrote to my colleagues . . .

. . . along with one of them.

This is a critical time for the future of health care policy, and all policies affecting public health in the United States. The incoming president and congress have promised to take actions that will profoundly change our health care system, along with environmental regulation, immigration policy, labor policy, and much more that will affect the health and well-being of the population. Some of the rhetoric in the recent campaign has also affected the social and political culture of the nation with unpredictable but likely worrisome consequences.

            We were deeply concerned by the scarcity of informed and even accurate discussion of public policy in the recent campaign. It appears that voters have little understanding of what government does or how government policies and practices affect their lives. The news media largely failed to explain the facts and controversies underlying policy choices, and allowed empty rhetoric and personal questions about the candidates to dominate the communal discourse.

            We believe that we, as experts in policy issues that are of the greatest importance for our nation and its citizens, can and should do more to contribute to the public discourse beyond our traditional focus on publishing in journals that are read only by our peers. We believe that we need to define an expanded role for public health researchers that brings our science out into the world and engages with people from all communities and walks of life. Voters cannot make appropriate decisions if they cannot meaningfully evaluate what candidates say and promise.

            We hope to join with our colleagues, starting within the department but perhaps expanding to the entire school of public health and ultimately beyond to other institutions, in an effort to democratize our work. By this we mean listening and engaging communities in helping us to understand what matters to people, and how we can best serve the public interest through our scholarly work, but just as importantly o through effective dissemination of knowledge and empowering people to be informed civic actors.

            We have discussed a few ideas about what some components of this effort might be. We do know that it calls for re-examining the institutional expectation for how public health scholars will focus their time and how their accomplishments will be evaluated. But there is much we can do now, that we believe we should be doing as a matter of urgency. We hope that some of you will join us in discussion leading to action. Please let either or both of us know if you want to join us, and we will convene those interested.

I'm not the only one who feels this way -- for example there's the well-publicized open letter from MIT faculty -- but I'm not just talking about writing open letters or op-eds. I'm talking about working with community-based organizations to engage people directly in understanding the facts underlying policy choices and how government matters to their lives. We cannot survive in a post-factual world.