Eric Bradner, writing for the Evansville Courier Press has an article entitled BRADNER: Pence, some lawmakers at odds on Medicaid expansion. Rep. Clere’s HB 1581 is the vehicle for Indiana’s Medicaid expansion. Gov. Pence doesn’t like it.

The back story, for those who haven’t been following, is that Obamacare was designed in two major pieces – one as an expansion of Medicaid for those between the current threshold up to 133% of the poverty line. Those above the 133% line have to buy insurance; with subsidies being supplied to poorer people who are required to buy that insurance. The Supreme Court decision threw a monkey wrench into the process by saying that the legislation had to allow the States to decide for themselves whether to implement Medicaid expansion. This leaves the people between the current Medicaid threshold and 133% of the poverty line in a bad way when it comes to paying for healthcare.

And, as we have recently learned from Steven Brill’s long piece in Time Magazine (and a recent Indiana Supreme Court case), these people in the gap are the most at mercy of the bloated prices of the hospital chargemasters. (Nobody else actually pays these prices except for the uninsured.)

Other very conservative governors have agreed to sign on to the Medicaid expansion — paid for almost entirely by the federal government. So, Pence has political cover if he wants to do what’s good for Hoosiers and their health. That’s what a number of Republican and Democratic members of the General Assembly would like to do. It remains to be seen if Gov. Pence wants to continue battling a fight against Obamacare that’s already been lost.

I am in the middle of reading what looks to be a very important piece by Steven Brill in Time Magazine entitled Bitter Pill: Why Medical Bills Are Killing Us. I’ll be keeping an eye out at my new favorite medical policy blog, the Incidental Economist to see if they have any thoughts on it.

Early on in the piece, he talks about the chargemaster and how the hospital administrators would try to steer discussions away from it:

However, I quickly found that although every hospital has a chargemaster, officials treat it as if it were an eccentric uncle living in the attic. Whenever I asked, they deflected all conversation away from it. They even argued that it is irrelevant.

People rarely pay those prices, was usually the reason for being dismissive about it. One problem with that rationale in Indiana, however, is that our state Supreme Court has told Hoosiers that, in the absence of contractual language to the contrary, they’re bound by the prices in that chargemaster. By virtue of Indiana Rule of Evidence 413, the chargemaster rates also effectively set the default amount you’ll have to pay for someone’s medical expenses if you get in an accident with them — regardless of how much that person actually paid.

Brill’s article shows that this chargemaster rate can be on the order of 1,000% of the market value of the service. I expect this article is going to make me very angry by the time I get to the end. “[W]e spend more on health care than the next 10 biggest spenders combined: Japan, Germany, France, China, the U.K., Italy, Canada, Brazil, Spain and Australia.” In return we get outcomes that are no better and often worse.

This post by Kyle Stokes entitled Why So Many More Teachers Hate Their Jobs Now was written almost a year ago; but I just stumbled across it. It meshes with what I know from teachers I’m friends with.

These are not lazy people or people who want to coast or people who resent changes to the status quo. But, they are tired of a lot of things; not least of which is being a political punching bag for those who want to liberate education money from the public sphere and get it into the pockets of the right sorts of people.

I’d regarded it as sort of background noise, but I guess I’m becoming a little concerned about narrowing curricula focused on teaching to the test. I’m all for my kids learning the fundamentals; but if they don’t develop agile minds, I’m going to be doomed to boring Thanksgiving dinner conversations for the next 30 years.

Happy President’s Day/ Washington’s Birthday. According to Wikipedia the designation “President’s Day” is more of an advertising thing that started in the 80s. Washington’s Birthday is Feb. 22, but this day at least started as a commemoration of his birthday.

I’ve always respected Washington and admired what he did, but his Presidency never had quite the emotional appeal to me as some others. I think it’s because his time in history seems so far removed as to be an abstraction for me — moreso than even, say, Lincoln. Maybe it’s the imagery with the powdered wigs and whatnot.

Be that as it may, Frank Herbert wrote in “Dune” that “A beginning is the time for taking the most delicate care that the balances are correct.” With Washington we are fortunate that he was mindful of the balances and, while I’m sure we could quibble with this or that, he did a fine job of it.

Aaron Carroll’s Testimony on the Medicaid Expansion to the Indiana General Assembly.

One of the things Indiana has to decide this year is whether to expand Medicaid to include those up to 138% of the poverty line. The Affordable Care Act reforms were designed assuming that the Medicaid expansions would happen. The Supreme Court threw a monkey wrench into that assumption by saying that the state expansions should be optional. (Seemed a bit like legislating from the bench; but given the alternatives, not necessarily the worst thing that could have happened in that ruling.) Folks above the 138% mark can get subsidies to buy insurance under the ACA. But, absent state expansion, people in the no-man’s land between the current Medicaid levels and the 138% mark will be left out in the cold.

Carroll makes an important point, which often gets lost in the noise: Medicaid is good for health. These are people’s lives. The only ones they’ll ever get. Making those lives better is one of those bleeding heart things that never really shows up in the spreadsheets. But we shouldn’t forget it. This decision will affect something like 400,000 of your fellow Hoosiers. I think that works out to something like 6% of us in that middle ground between Medicaid and subsidies.

Through 2019, Indiana pays $478 million versus the federal government’s $8.5 billion. I’m always a little leery of this talking point. It’s important because we’re going to be paying these federal tax dollars regardless; the question is whether we’ll do what’s necessary to get health care services in return. But, it leaves opponents feeling smug because they’ll ask, “yeah, but what about after 2019” as if they just caught the grifter palming the ball in a shell game. But, at the end of the day, tomorrow isn’t guaranteed and nothing in this world is certain. Other countries have been managing to provide health services to their populations for many years. We probably just have to have faith in ourselves that we can do at least as good.

Carroll argues that this will actually save us money though. In addition to the direct costs we currently incur with the Healthy Indiana Plan, we also will save in areas such as the provision of uncompensated care for the indigent and hidden expenses such as cost shifting and higher premiums caused by care provided to the uninsured.

Long time readers know I get a bit intemperate when the Old Confederacy is at issue. Here is more fuel for that particular fire with a modern spin. Sam Tanenhaus has an article in The New Republic that’s getting a lot of attention entitled Original Sin. He talks about the modern conservative’s roots going back to John C. Calhoun by way of William F. Buckley and the National Review.

The true problem, as yet unaddressed by any Republican standard-bearer, originates in the ideology of modern conservatism. When the intellectual authors of the modern right created its doctrines in the 1950s, they drew on nineteenth-century political thought, borrowing explicitly from the great apologists for slavery, above all, the intellectually fierce South Carolinian John C. Calhoun. This is not to say conservatives today share Calhoun’s ideas about race. It is to say instead that the Calhoun revival, based on his complex theories of constitutional democracy, became the justification for conservative politicians to resist, ignore, or even overturn the will of the electoral majority.

Calhoun was a voice of aggrieved elitism that seems to have characterized the planter class. As Samuel Johnson put it, “How is it that we hear the loudest yelps for liberty among the drivers of Negroes?” Echoes of Calhoun will end up hurting the modern conservative; just as his nonsense led to the ruin of the South when Gen. Sherman undertook to show them what oppression really looked like, if only for a time.

That said, however, I don’t buy the notion that the GOP is in any real danger (let alone “grave” danger) of ceasing to be a national party. They’ll re-calibrate sooner or later, and then the Democrats will be on the defensive nationally.

Brian Howey has a good column entitled HOWEY: Gerrymandering prolongs lack of fair representation. He’s quick to point out that it’s a bipartisan enterprise, but this cycle gerrymandering seems to be advantage: Republican. Nationally, they received 1% fewer votes than the Democrats but won 54% of the House seats. In the state, they took 54% of the vote but 69% of the House seats.

This go-round, Republicans are making soothing sounds about how redistricting should take place, but you can be reasonably sure nothing will happen. Democrats are probably a little more earnest about a non-partisan redistricting plan simply because they’re on the losing end of it. My guess is that Libertarians, if asked, would give you an earful about electoral reforms that need to happen; gerrymandering being only one.

The problem is that structurally, the people who have to agree to the changes are the people who (in the short term anyway) necessarily have benefited from the status quo.

The only way significant changes are likely to be made is if it gets attention and a critical mass from below among the people.

Richard Longworth, writing at the Midwesterner, has an interesting entry entitled Failing Economies Shorten Lives.

He takes a quick look at some of the differences in lifespan among socioeconomic classes, genders, and races.

Genetics may have something to do with it. But not as much as economics and the fallout from economic differences. Poor people get less schooling, which leads to worse jobs, which leads to poorer lifestyles, which leads to stress, which leads to more smoking and drinking, which increases the chances of joblessness, which means no health insurance, all of which adds up to the kind of debilitating despair that never lengthened anyone’s life.

The biggest gap he points out – Native American men in one part of South Dakota versus Asian females in a high-rent district of New Jersey are separated by an average 33 years – with the former living to 58 years and the latter living to 91 years. But that’s maybe a sideshow – there are real and important differences between races and/or socioeconomic classes living side by side; and the expected lifespan for uneducated white people has actually gone down in recent years.

Aaron Carroll, writing at the Incidental Economist has a post entitled The zombie infant mortality explanation. He takes the Wall Street Journal to task for trotting out a discredited chestnut apologizing for the abysmal ranking of the U.S. in infant mortality statistics.

This is of particular interest to me since I heard a lot of this explanation when we were discussing the necessity of health care reform on my blog in the lead up to the Obamacare legislation. The argument is that the infant mortality comparisons are apples to oranges. Our metrics are so much more sensitive, so of course we rank last – because we’re so damn good and try so hard to save babies, we report more deaths. Turns out, not so much.

Let me quote directly from the study (page 66-7):

The high rate of adverse birth outcomes in the United States does not appear to be a statistical artifact, such as a difference in coding practices for very small infants who die soon after birth (MacDorman and Mathews, 2009). Indeed, country rankings remained identical even when Palloni and Yonker (2012) recalculated the rates to exclude preterm births (less than 22 weeks of gestation).

There are lots of reasons why our infant mortality is terrible. This isn’t one of them. It’s a zombie idea.

Reminds me of a good “Usual Suspects” quote about Keyser Soze: “The greatest trick the Devil ever pulled was convincing the world he didn’t exist.” That’s what I think of sometimes when the discussion turns to problems we have that other countries are better at addressing. So often, there is an attempt to claim that either our condition isn’t really a problem or, if it is, it’s a problem that the other country never really had to deal with. Either the problem doesn’t exist or the solution doesn’t exist. That means we can keep on with the status quo.

Chris Hedges has a good column about neo-Confederacy in Memphis entitled Chris Hedges: White Power to the Rescue. Apparently there is a battle over whether a city park should be named after KKK founder and Confederate traitor in defense of slavery, Nathan Bedford Forrest or after black journalist, Ida Wells.

Like Tony Horwitz before him, I think Hedges is noting that the Civil War remains unfinished. Hedges draws parallels with Yugoslavia in the 90s. In Yugoslavia, ethnic groups discarded history in favor of myths of a glorious past that never existed. Consequently, those groups couldn’t talk to each other any more.

The embrace by nationalist groups of a nonreality-based belief system made communication with other ethnic groups impossible. They no longer spoke the same cultural language. There was no common historical narrative built around verifiable truth.

In this episode, set in the modern Confederate States of America, Nathan Bedford Forrest is no longer a man who grew wealthy in the slave trade, committed treason to defend that gravy train, and then, having lost, created a terrorist group devoted to bigotry. No, no!:

Forrest “promoted progress for black people in this country after the war.” Boyd argued that the KKK was “more of a social club” at its inception and didn’t begin carrying out “bad and horrific things” until it reconstituted itself with the rise of the modern civil rights movement.

I see another parallel. Good white Southerners who are not particularly racist and do not have any special antipathy toward nonwhites are likely nevertheless annoyed at the prospect of downgrading the status of the heroic white traitors they grew up admiring; such as Forrest, Robert E. Lee, Stonewall Jackson and the rest in favor of, say, civil rights leaders, journalists, and abolitionists. David Wong, writing for Cracked.com (yes, I am a consumer of fine literature) gives us “5 Ways You’re Accidentally Making Everyone Hate You.” These all revolve around unspoken power struggles. Number 1 is “You Assumed That Because You Were OK With a Situation, Everybody Was.”

“Why do they have to rock the boat just when things were going good?”
“Why complain now, when we’ve always done it this way?”

He points out that one of the main advantages of power is not having to think about it. You might not think about money when you’re eating at a restaurant; but you sure think about it when you’re starving. (Wong cites this article from the Slacktivist with similar thoughts about Christianity and tribalism.) So, the powerful groups can just put up monuments to icons who are hateful to non-powerful groups and just go about their business without paying much attention; and then start squealing like a stuck pig when the less powerful groups start trying to change things.

At the end of the day, a society’s monuments tell the tale of where the heart of the majority lies. We don’t put up monuments to Cornwallis and King George to pay homage to their solid effort or to celebrate our heritage. When Southerners name their parks after guys like Forrest and put up monuments to him, it tells you that they’re still conflicted about whether or not they’re committed to the Union.