Map of life expectancy at birth from Global Education Project.

Friday, June 14, 2019

Health Insurance 101 -- yet again

I just cannot understand why it is so difficult to get people to grasp what seems to me a simple idea. Let's try one more time.

The purpose of insurance is to spread risk. That's the essence of the concept. Health insurance (or health care insurance as some prefer to say) is different from other kinds of insurance in some ways, so let's just talk about health insurance.

Health care costs are unpredictable. It is true that there are risk factors associated with some conditions, most notably smoking tobacco. Nevertheless, no matter how healthful your lifestyle, you still just might need expensive health care. You might be hit by a bus. You might get breast cancer, or multiple sclerosis, or Type 1 diabetes or some other autoimmune disease. Most lung cancer is associated with smoking but some people who have never smoked get lung cancer. Your son might develop a substance use disorder, no matter how regularly your family attends church and how fervently you pray. It happens.

So-called Health Sharing Ministries are not insurance. They are unregulated and they do not guarantee payment. What is more, they explicitly cap annual and lifetime costs at a fairly low level. That's why they are cheap!* Yes, they are also cheap because they enroll only people who are healthy and don't need expensive health care, and they explicitly exclude certain risk behaviors. But even if you scrupulously obey your religious prohibition against tobacco and having unprotected sex with various people, you might eat a lot of red meat, be physically inactive, and be obese.

Not that any of that matters, because you may still be diagnosed with diabetes or MS or cancer, or get hit by a bus, whereupon you will go to the exchange and enroll in real health insurance, because now you need it and your health sharing ministry won't cover your costs. You can do that because the ACA requires the insurance companies to sell you insurance regardless of any pre-existing conditions, and they can't charge you more for it. Thanks Obama!

The only problem is that you weren't paying in like everybody else when you were healthy and didn't need a lot of expensive health care. That means real insurance is more expensive for everybody, because you are a freeloader, and you are stealing from everybody who isn't a member of your hypocritical, sanctimonious cult.

There is a commandment about stealing, I believe. Funny thing though, the Ten Commandments that "Christians" like Roy Moore want to post in courtrooms and classrooms are heavily redacted. Yep, that's the word. They are edited to omit all the embarrassing parts. You also have to pick which of the three different versions of the Ten Commandments you want to show in edited form. We'll get to that in the Sunday Sermonette series in a few weeks, but you may be very surprised by what we find.

* I made an error in the comments. HSM membership did provide exemption from the individual mandate in the original version of the ACA. Of course now with no more individual mandate it really doesn't matter.

Wednesday, June 12, 2019

A couple of thoughts about fairness and justice

Item One: You don't hear anybody say "Why should I be forced to buy car insurance? I haven't crashed my car or injured anybody with it." And you don't hear people say "Why should I be forced to buy homeowner's insurance? [Which is required if you have a mortgage]. My house isn't on fire."

So why is health insurance any different? It isn't just about whether you have a right to take a chance on not being able to pay for medical care if you do end up needing it. If you're hit by a bus the ambulance will take you to the Emergency Department and they will do whatever they must to save your life. That will cost a lot of money and somebody has to pay for it. Furthermore if you become disabled because of a condition that could have been prevented by appropriate medical care, you will not be able to support your dependents and you will become a ward of society. If you have an untreated or preventable communicable disease, you may infect others.

There are more arguments to be made here but I'll finish with this. You will get older and sicker some day and you will definitely need medical care and decide that it's in your interest to buy insurance, if you can afford it. But if there are a whole lot of people like you who decided not to buy it when they were young and healthy, it will be expensive; and you'll still  be freeloading on those young and healthy people who did buy it. These are among the reasons why every country on earth that can afford it requires that every citizen (and generally speaking non-citizen residents as well) has what amounts to health insurance, and that everybody with an income contributes to paying for it one way or another. For me, the more progressive the payment mechanism the better, and it is always somewhat progressive, but that's a matter of degree and it's arguable.

So the Affordable Care Act, in its original form, had a mandate to buy health insurance if you didn't get it through employment, Medicare or Medicaid. Like required automobile and homeowner's insurance, it also established minimal standards for what had to be covered. Finally, it included subsidies to make it affordable, which means that for most low and middle income people it was a very good deal.

There were problems for people in states that chose not to expand Medicaid, who fell into the resulting gap. That is of course the fault of Republican legislators and governors, along with the Supreme Court. There is one more category of people who felt they were harmed by the ACA, which is people with incomes too high to qualify for subsidies, and who previously had chosen to buy crappy insurance that didn't meet ACA standards. Now their insurance became more expensive. Boo hoo. If you have a behavioral health need, you're covered. And you can afford it. So stop whining.

Item Two: It is baffling to me why some people are offended, or feel that their rights are violated, because rights are extended to other people who -- for wholly irrational reasons -- they don't like. If people of the same sex are allowed to get married, how on earth does it hurt anybody else? You can still marry whoever you want to. People make the bizarre claim that  by opposing same sex marriage, they are defending "traditional marriage." That is idiotic. Traditional marriage is still available. It is completely unaffected.

Likewise, what possible harm can it do to you if transgendered or otherwise non-typically gendered people are protected from discrimination? They exist, okay? Your God made them, Pope Francis. Why do you care if they are in your workplace or your school or your favorite restaurant? That doesn't harm you, and it doesn't prevent you from practicing your religion and thinking they will go to hell. It doesn't stop your preacher from saying that in church, as a matter of fact. You can believe whatever you want, however asinine it may be, and you can pray and preach however you want as well. Why is this even an issue?

Tuesday, June 11, 2019

The Long Emergency: Politics Vs. Reality

Administrative note: I'll probably do these posts on Tuesdays or Wednesdays going forward, not Mondays.

Anyway, the United States is the only country in the OECD in which one of the major political parties -- in fact the current ruling party -- denies the reality of anthropogenic climate change. Now they are even going so far as to organize a fake "scientific" panel to discredit the established, incontrovertible scientific truth of what humans are doing to the planet, including themselves. The Resident has appointed a crank named William Happer to the National Security Panel with the specific responsibility of discrediting the scientific consensus. Now the administration is even calling LNG "molecules of freedom." This is completely insane of course.

While the Democratic candidates for president all recognize the urgency of humanity's situation, to varying degrees and with varying emphasis, the Democratic National Committee is trying to downplay the issue, whether because they think it isn't a winner with the voters or they don't want to alienate donors. I would have to say the latter is the correct explanation.

What you need to do is take action. Extinction Rebellion U.S. has arrived. This is their manifesto:

We Demand:

These demands only represent XR US. They are still in the process of development.


That the Government must tell the truth about the climate and wider ecological emergency, it must reverse all policies not in alignment with that position and must work alongside the media to communicate the urgency for change including what individuals, communities and businesses need to do.


The Government must enact legally-binding policies to reduce carbon emissions to net zero by 2025 and take further action to remove the excess of atmospheric greenhouse gases. It must cooperate internationally so that the global economy runs on no more than half a planet’s worth of resources per year.


We do not trust our Government to make the bold, swift and long-term changes necessary to achieve these changes and we do not intend to hand further power to our politicians. Instead we demand a Citizens’ Assembly to oversee the changes, as we rise from the wreckage, creating a democracy fit for purpose.


We demand a just transition that prioritizes the most vulnerable people and indigenous sovereignty; establishes reparations and remediation led by and for Black people, Indigenous people, people of color and poor communities for years of environmental injustice, establishes legal rights for ecosystems to thrive and regenerate in perpetuity, and repairs the effects of ongoing ecocide to prevent extinction of human and all species, in order to maintain a livable, just planet for all.

Creating a democracy fit for purpose. Now there's an idea.

Sunday, June 09, 2019

Sunday Sermonette: Get your story straight

You can run into problems when  you start adding plagues . . .

 Then the Lord said to Moses, “Go to Pharaoh and say to him, ‘This is what the Lord, the God of the Hebrews, says: “Let my people go, so that they may worship me.” If you refuse to let them go and continue to hold them back, the hand of the Lord will bring a terrible plague on your livestock in the field—on your horses, donkeys and camels and on your cattle, sheep and goats. But the Lord will make a distinction between the livestock of Israel and that of Egypt, so that no animal belonging to the Israelites will die.’”
You may recall that in Genesis, keeping cattle is described as an "abomination"to the Egyptians, which is why the Hebrews had to be isolated in Goshen so the Egyptians wouldn't be offended. Evidently they've gotten over it. Also, it seems a bit surprising that the Israelites, who are now slaves, are allowed to keep their cattle, but whatever.

The Lord set a time and said, “Tomorrow the Lord will do this in the land.” And the next day the Lord did it: All the livestock of the Egyptians died, but not one animal belonging to the Israelites died. Pharaoh investigated and found that not even one of the animals of the Israelites had died. Yet his heart was unyielding and he would not let the people go.
Then the Lord said to Moses and Aaron, “Take handfuls of soot from a furnace and have Moses toss it into the air in the presence of Pharaoh. It will become fine dust over the whole land of Egypt, and festering boils will break out on people and animals throughout the land.”
Sometimes God just does the miracle himself, and sometimes he need Moses or Aaron to perform some mumbo jumbo to make it happen.  Presumably the animals that get the festering boils do not include cattle, because the cattle are all dead, right?
10 So they took soot from a furnace and stood before Pharaoh. Moses tossed it into the air, and festering boils broke out on people and animals. 11 The magicians could not stand before Moses because of the boils that were on them and on all the Egyptians. 12 But the Lord hardened Pharaoh’s heart and he would not listen to Moses and Aaron, just as the Lord had said to Moses.
Then the Lord said to Moses, “Get up early in the morning, confront Pharaoh and say to him, ‘This is what the Lord, the God of the Hebrews, says: Let my people go, so that they may worship me, 14 or this time I will send the full force of my plagues against you and against your officials and your people, so you may know that there is no one like me in all the earth. 15 For by now I could have stretched out my hand and struck you and your people with a plague that would have wiped you off the earth. 16 But I have raised you up[a] for this very purpose, that I might show you my power and that my name might be proclaimed in all the earth. 17 
As I said last time, the point of all this is for God to strut his stuff and show that he's the awesomest God around, since he could have just softened Pharaoh's heart instead of hardening it, and the Israelites would have been free a long time ago.
You still set yourself against my people and will not let them go. 18 Therefore, at this time tomorrow I will send the worst hailstorm that has ever fallen on Egypt, from the day it was founded till now. 19 Give an order now to bring your livestock and everything you have in the field to a place of shelter, because the hail will fall on every person and animal that has not been brought in and is still out in the field, and they will die.’”
Oh, so the livestock aren't dead after all.  I quote from verse 6, at the top of this very page. "And the next day the Lord did it: All the livestock of the Egyptians died, . . ."
20 Those officials of Pharaoh who feared the word of the Lord hurried to bring their slaves and their livestock inside. 21 But those who ignored the word of the Lord left their slaves and livestock in the field.
22 Then the Lord said to Moses, “Stretch out your hand toward the sky so that hail will fall all over Egypt—on people and animals and on everything growing in the fields of Egypt.” 23 When Moses stretched out his staff toward the sky, the Lord sent thunder and hail, and lightning flashed down to the ground. So the Lord rained hail on the land of Egypt; 24 hail fell and lightning flashed back and forth. It was the worst storm in all the land of Egypt since it had become a nation. 25 Throughout Egypt hail struck everything in the fields—both people and animals; it beat down everything growing in the fields and stripped every tree. 26 The only place it did not hail was the land of Goshen, where the Israelites were.
27 Then Pharaoh summoned Moses and Aaron. “This time I have sinned,” he said to them. “The Lord is in the right, and I and my people are in the wrong. 28 Pray to the Lord, for we have had enough thunder and hail. I will let you go; you don’t have to stay any longer.”
29 Moses replied, “When I have gone out of the city, I will spread out my hands in prayer to the Lord. The thunder will stop and there will be no more hail, so you may know that the earth is the Lord’s. 30 But I know that you and your officials still do not fear the Lord God.”
31 (The flax and barley were destroyed, since the barley had headed and the flax was in bloom. 32 The wheat and spelt, however, were not destroyed, because they ripen later.)
This detail seems oddly gratuitous. 
33 Then Moses left Pharaoh and went out of the city. He spread out his hands toward the Lord; the thunder and hail stopped, and the rain no longer poured down on the land. 34 When Pharaoh saw that the rain and hail and thunder had stopped, he sinned again: He and his officials hardened their hearts. 35 So Pharaoh’s heart was hard and he would not let the Israelites go, just as the Lord had said through Moses.


  1. Exodus 9:16 Or have spared you

Thursday, June 06, 2019

Speaking of Faux News . . .

Holy crap, this has got to be the stupidest goddamn thing I have ever read in my life. From Tucker Carlson. whose bow tie is evidently choking off the oxygen supply to his tiny brain:

TUCKER CARLSON (HOST): Almost every nation on Earth has fallen under the yoke of tyranny -- the metric system. From Beijing to Buenos Aires, from Lusaka to London, the people of the world have been forced to measure their environment in millimeters and kilograms. The United States is the only major country that has resisted, but we have no reason to be ashamed for using feet and pounds.
JAMES PANERO: I am joining you tonight as an anti-metrite. I'm taking a stand against the metric system -- the original system of global revolution and new world orders.
CARLSON: God bless you, and that's exactly what it is. Esperanto died, but the metric system continues, this weird, utopian, inelegant creepy system that we alone have resisted.
I fear that even to comment on this is degrading. Satire is obviously obsolete, because this would be great satire but it's real. These clowns think they are serious.

The metric system was  first created in France after the revolution of 1789, which was not global and did not have any relationship to a new world order. But it did not gain formal international status until an international conference in 1875, which involved 17 nations, none of them revolutionary, including the United States. As a matter of fact the units of the British Imperial System, which is commonly used in the U.S., are defined in terms of the metric system. It is now formally called the International System of Units.

Americans who haven't already done so should familiarize themselves with the metric system, as it is the international standard of commerce and science. The system we use is indeed weird and inelegant, but the whole point of the metric system is that it is not. As the Wikipedia article says,

The metric system was designed to have properties that make it easy to use and widely applicable, including units based on the natural world, decimal ratios, prefixes for multiples and sub-multiples, and a structure of base and derived units. It is also a coherent system, which means that its units do not introduce conversion factors not already present in equations relating quantities. It has a property called rationalisation that eliminates certain constants of proportionality in equations of physics.
It makes calculations and conversions easy. One cubic centimeter of water weighs one gram. A thousand grams are a kilogram and that's also 10 X 10 X 10 centimeters of water. A thousand kilograms is a metric ton which is one cubic meter of water. Since all the relationships are multiples of ten, conversions and calculations are easy! Twelve inches in a foot, three feet in a yard, 5,280 feet in mile, 16 ounces in a pound, these are all a pain in the ass when it comes to computation. So go metric! 

B. Hussein Obama saved you a bundle

There seems to have been some question about whether the ACA actually reduced health care costs. The answer, from the Office of the Actuary of the Department of Health and Human Services, is that it cumulatively from 2010 to 2017 the ACA reduced health care spending a total of $2.3 trillion. Savings in 2017 alone were $650 billion.

No doubt this will be a headline story at Fox News.

Update: A reader has drawn my attention to certain mendacious comments by industrial shills on Dr. Emanuel's article. So let me make a couple of things clear:

In some of the state exchanges, premiums increased after the first year of the ACA. This is because insurance companies competed for customers in the first year, and to some extent underestimated what their costs would be in part because previously uninsured people tend to be expensive when they finally do get insurance. This is not to be confused with total spending on health care in the U.S. (Thanks to the subsidies in the ACA, consumers do not actually pay for these increases out of pocket, BTW.)

Second, health care spending in the U.S. has historically increased at greater than the rate of inflation, i.e. health care spending takes a growing share of GDP year after year. The ACA did not reverse this trend, but substantially reduced it. Here is a more detailed discussion:

In 2010, the government predicted that Medicare costs would rise 20 percent in just five years. That’s from $12,376 per beneficiary in 2014 to $14,913 by 2019. Instead, analysts were shocked to find out spending had dropped by $1,000 per person, to $11,328 by 2014. It happened due to four specific reasons:
  1. The ACA reduced payments to Medicare Advantage providers. The providers' costs for administering Parts A and B were rising much faster than the government’s costs. The providers' couldn't justify the higher prices. Instead, it appeared as though they were overcharging the government. 
  2. Medicare began rolling out accountable care organizations, bundled payments , and value-based payments. [Editors note: All components of the ACA.] Spending on hospital care has stayed the same since 2011. Part of the reason for this is that hospital readmissions dropped by 150,000 a year in 2012 and 2013. That’s one of the areas hospitals get penalized if they exceed standards. It resulted in increased efficiency and quality of patient care. [Also a provision of the ACA.]
  1. High-income earners paid more in Medicare payroll taxes and Part B and D premiums. For more, see Obamacare taxes.
  2. In 2013, sequestration lowered Medicare payments by 2 percent to providers and plans.
Based on these new trends, Medicare spending was projected to grow just 5.3 percent a year between 2014 and 2024. 

BTW, Ezekiel Emanuel "is the current Vice Provost for Global Initiatives at the University of Pennsylvania and chair of the Department of Medical Ethics and Health Policy. Previously, Emanuel served as the Diane and Robert Levy University Professor at Penn. He holds a joint appointment at the University of Pennsylvania School of Medicine and the Wharton School and was formerly an associate professor at the Harvard Medical School until 1998 when he joined the National Institutes of Health" So obviously he doesn't know what he's talking about.

Monday, June 03, 2019

The Long Emergency: Transportation

Many people who consider themselves to be environmentalists have a romantic vision of people living in rural communities in some form of harmony with nature. That sort of worked, or could have worked, before the demographic transition and the population explosion we looked at in the first installment of this series. But it doesn't work with 7 billion people or even 1 billion.

Remember that half of the earth's habitable surface is already dedicated to agriculture. Rural places aren't generally natural at all. And as affluent granola crunchers build their houses along the wilderness interface, they degrade what's left of the wilderness and consume resources commuting. In low income countries, rural villagers do not live in harmony with nature, they despoil it.

While we ultimately need to reduce the human population, we must understand that the most sustainable way for people to live now is for most of them to be concentrated in cities. That gets them out of what's left of the wild and has many benefits for individuals and humanity as a whole. Benefits include:

  • Better access to health care and to public health amenities is possible.
  • Shorter distance to transport goods and people saves energy and time.
  • Increase in labor productivity because you have a critical mass of people.
  • People who live in urban areas earn more.
  • Better sanitary services are possible: potable water, sanitation, transport and recycling of waste.
  • Tight grouping of people allows social and cultural integration at a level not available to people in rural areas.
  • Economic opportunities for people who would otherwise be destined to subsist without hope of economic improvement.
  • Faster technological improvement, creation and dissemination of knowledge is facilitated.
  • Reduced pressure on forest and wilderness areas from human population. 
But, if government doesn't make the necessary investments to make urban living socially and environmentally sustainable, all these good things won't happen. 

A new WRI working paper finds that though cities are hotspots for jobs and other opportunities, many urbanites are finding it increasingly difficult to access these benefits. Analysis of Mexico City and Johannesburg found that 56% and 42% of people, respectively, cannot easily get to jobs because of their location, limited transport options, or both. Many residents in these cities experience long and expensive commutes in often uncomfortable and unsafe vehicles through heavy traffic. Others have so few travel options or nearby opportunities they are essentially stranded.
The same patterns that restrict access in Mexico City and Johannesburg are present around the world. Access to jobs, healthcare, education and other opportunities are increasingly out of reach for millions of people like Emmanuel.

Okay. Take a look at this:

Most European cities feature wide sidewalks, bicycle lanes, and excellent mass transit that gets you everywhere quickly and cheaply. The Dutch have a culture of bicycling, and that's how people get to work, and to school. In those two photos from Amsterdam, there is a single car. In Basel, there are hardly any stop lights because they aren't necessary. People just don't use cars to get around town.

Here's a conception of a redevelopment proposal for New Haven. Note the transit station in the back, the mixed uses, and the food environment. If you live in this kind of a neighborhood, you can walk to get to most of what you need and take the train if you need  to go far.