I have a confession.
There’s something I like about the Trump Administration.
It’s the way that his unpopularity taints long-standing policies or practices or beliefs, making people aware of and opposed to them in a way they weren’t when the same policies or beliefs were widely held under George Bush or Barack Obama. Many, though not all, of these policies or beliefs were embraced unquestioningly by centrists or even avowed leftists.
I’ve been keeping a running list in my mind, which I’ll begin to lay out here (I guess I’ll update it as I remember more).
- Expansive surveillance
- The presumption of regularity, by which courts and the public assume the Executive Branch operates in good faith and from evidence
- Denigration of immigrants
- Denigration of Muslims
- Denigration health insurance
As an example, Obama deported a huge number of people. But now that Trump has expanded that same practice, it has been made visible and delegitimized.
In short, Trump has made things that should always have been criticized are now being far more widely so.
But there’s one thing that Trump has escalated that has thus far — with the singular exception of the botched raid on Yemen — escaped widespread condemnation: the bombing of civilians. There was the Al Jineh mosque on March 16, a school sheltering families in Raqqa on March 21, and this strike last week in Mosul, not to mention continued Saudi attacks in Yemen that the US facilitates.
Again, I’m not saying such civilian strikes didn’t happen under Obama. And it’s not clear whether this spate of civilian bombings arises from a change in the rule of engagement put in place in December, the influence of James Mattis, or Trump’s announced review of rules of engagement. But civilians are dying.
And for the most part, unlike all the other horrible things happening under President Trump, they’re getting little notice and condemnation in the US.
Update: This NYT story on the Mosul strike says that the increased civilian casualties do reflect a change in rules of engagement put in place under Trump.
One of the things that drives me nuts about the obsessive focus on Russia right now is the claim that Vladimir Putin is the biggest risk to America, to the EU, to western civilization. That claim ignores that — to the extent Putin is engaged in policies to maximize his advantage vis a vis American hegemony right now — the opportunity to do so has been created by the failure of American hegemony. The biggest threats to the EU, for example, stem from the idiotic policies “technocrats” enacted after America crashed the global economy and a refugee crisis caused, in part, by the chaos America has sown in the Middle East over the last 15 years (and to some degree manipulated by “allies” like Turkey). Sure, Putin is making the most of the American failures, but the underlying causes that make right wing populists popular, here and in Europe, can be significantly blamed on America. Significantly, that’s about a failure of the policies dictated by American ideology to deliver on what it promises — peace, democracy, prosperity.
“For many Americans, America is starting to fail as a country,” said James Smith, chair in labor markets and demographic research at the Rand Corp., who wasn’t involved in the paper and said he was struck that mortality rates are rising for young working-class adults. “The bad things that are going on in America do not appear to be going on in Western European countries, and that’s a big deal.”
The spike in mortality, Case argues, is not about existing life conditions, but rather about “accumulating despair.”
The increase in mortality rate for working-class whites can’t be explained by declining income prospects alone. Blacks and Hispanics face many of the same income struggles but have experienced declines in mortality over the same period, the two economists argued, though their findings reveal more recent troubles for blacks, with gains stagnating the past couple of years amid an increase in drug overdoses and stalling progress against heart disease.
“This doesn’t seem to be about current income,” Ms. Case said in a call with reporters. “It seems to be about accumulating despair.”
The rising mortality of working-class white adults appears to be rooted both in worse job opportunities and increasing social dysfunction, following generations of relatively stable lives that involved job advancement and an expectation of living better than one’s parents, the researchers said.
As a number of people have noted, both today and after earlier releases of Case and Deaton’s data, one of the few precedents for such a spike is the rise in mortality in Russia leading up to and after the fall of the Soviet Union. Addiction and other despair-related health problems were significant in both.
Which got me wondering: to the extent this is driven by a failure in ideology — by the failure of the American dream — which comes first, the failed ideology or the rising mortality rates? That is, are people dying of despair in response to the recognition the American dream doesn’t deliver for people like them anymore (which, it should be said, has always involved white Americans benefitting from the unequal treatment of brown people both in the US and around the globe)? Or did a worsening lifestyle lead to a spike in mortality that has contributed to despair and the collapse of ideology?
I don’t know the answer — and admit it might be more closely tied to policy outcomes than ideology. But as we try to figure it out, we ought to be focusing at least as much on how to roll out life and meaning that can sustain Americans again as we are on blaming Putin for our recent failures to do that.
Sarah Kliff has finally done what left wonk journalists should have done years ago: go interview people from Kentucky about their understanding of and feelings about ObamaCare. KY is, with WV, the state in which ACA achieved its best results, with the number of uninsured going from 25% to 10% of the state. And yet Democrats in KY have been utterly hammered since ACA passed.
Kliff spent a lot of time actually listening to voters to understand why they voted overwhelmingly for a guy who promises to scrap ACA in its existing form (though he always promised to replace it with something better).
Definitely go read the whole thing, because the degree to which Kliff let these voters speak for themselves (and the degree to which they appear like real and often thoughtful people) is admirable.
Here’s how she summarizes what she heard.
Many expressed frustration that Obamacare plans cost way too much, that premiums and deductibles had spiraled out of control. And part of their anger was wrapped up in the idea that other people were getting even better, even cheaper benefits — and those other people did not deserve the help
There was a persistent belief that Trump would fix these problems and make Obamacare work better. I kept hearing informed voters, who had watched the election closely, say they did hear the promise of repeal but simply felt Trump couldn’t repeal a law that had done so much good for them. In fact, some of the people I talked to hope that one of the more divisive pieces of the law — Medicaid expansion — might become even more robust, offering more of the working poor a chance at the same coverage the very poor receive.
Significantly, Kliff dispels one explanation always given for why Kentuckians hate ObamaCare so much: purportedly because the state had hidden that the state’s program was actually ObamaCare. All but one of the people she talked with knew they were getting ObamaCare.
All but one knew full well that the coverage was part of Obamacare. They voted for Trump because they were concerned about other issues — and just couldn’t fathom the idea that this new coverage would be taken away from them.
Which leaves the two major complaints with the law: expense and the divisiveness associated with two-tiered benefit programs.
We’ve known since before the bill passed that it was too expensive, such that middle class families would still go into debt even with fairly normal life medical care, including normal childbirth. At the time, the wonk boys were talking among themselves about how they needed to push back against such claims.
But Kliff puts a face to the consequences of that expense, where people use precious disposable income for insurance they know they won’t use.
The deductible left Atkins exasperated. “I am totally afraid to be sick,” she says. “I don’t have [that money] to pay upfront if I go to the hospital tomorrow.”
Atkins’s plan offers free preventive care, an Obamacare mandate. But she skips mammograms and colonoscopies because she doesn’t think she’d have the money to pay for any follow-up care if the doctors did detect something.
Atkins says she only buys insurance as financial protection — “to keep from losing my house if something major happened,” she says. “But I’m not using it to go to the doctor. I’ve not used anything.”
She also focuses on something that got discussed during passage, but not in as much detail: the degree to which the two-tiered method of expansion, with some getting Medicaid and some getting subsidized shitty insurance, would poison the perception of the law, because the working poor would get fewer benefits than people who were or believed to be not working.
“I really think Medicaid is good, but I’m really having a problem with the people that don’t want to work,” she said. “Us middle-class people are really, really upset about having to work constantly, and then these people are not responsible.”
This has long been the basis for (often GOP-stoked) opposition to government support in the US, the resentment that others are getting more, a resentment that often gets racialized via stereotypes about welfare queens.
Importantly, Kliff also dismisses those who complain these rube voters should have known the stakes of voting in Donald Trump, because she didn’t know either.
I spent election night frantically reporting and calling sources, trying to understand what parts of Obamacare Republicans could and couldn’t dismantle. I didn’t know at the time, nor had I devoted the necessary time to learn, until election night.
Mills was wrong about what Republicans would do to Obamacare. But then again, I write about it for a living. And I was wrong too.
In any case, it was a sobering, humanizing report. I hope Kliff follows up on as Governor Matt Bevin makes KY’s ACA worse this year.
Democrats need to learn this lesson because, even if they can’t impose a penalty on Bevin and other KY Republicans for taking away benefits that people currently have, the same process is bound to roll out in states across the country. That is, liberals need to understand this dynamic if they want to reverse the policy changes the GOP are about to roll out.
Unsurprisingly, Democrats are taking away the wrong lesson about ObamaCare from the election. Markos Moulitsas rather notoriously offered this lesson (though not in the context of Kliff’s report).
But even Kevin Drum, after reading Kliff’s report, seems to have come up with the wrong lesson.
Obamacare has several smallish problems, but its only big problem is that it’s underfunded. The subsidies should be bigger, the policies should be more generous, and the individual mandate penalty should be heftier. Done right, maybe it would cost $2 trillion over ten years instead of $1 trillion.
Republicans wouldn’t have cared. If this were a real goal—like, say, cutting taxes on the rich—they’d just go ahead and do it. If the taxes didn’t pay for it all, they’d make up a story about how it would pay for itself. And if you’re Donald Trump, you just loudly insist that,somehow, you’re going to cover everybody and it’s going to be great.
But Democrats didn’t do that. They didn’t oversell Obamacare and they didn’t bust the budget with it. They could have. It would have added to the deficit, but that wouldn’t have hurt them much. Politically, the far better option was to go ahead and run up the deficit in order to create a program of truly affordable care that people really liked.
Even setting side whether the problem of providers exiting the marketplace is “smallish” or actually quite big, the one takeaway Drum takes from this article about how a technocratic solution sows hatred for that technocratic solution is just to wonk harder. That is, he wants to keep the existing program, and just throw more money at the providers via subsidies and more penalties at people who are literally choosing between paying for insurance they won’t use or making other choices with limited disposable income.
He ignores entirely how the two-tier system of benefits feeds resentments (not to mention all the unnecessary complexity it entails).
Luckily, being completely out of power, Democrats have another alternative besides just “wonk harder.” Since Republicans will already in in the difficult position of taking away benefits, Democrats can make that much harder — and play to what we’ve learned from the roll out of ObamaCare — by calling for what they should have called for in the first place: something that moves us towards true universal care, rather than just aspirationally universal insurance coverage. Not only is that what KY voters appear to want, but it is a more efficient way of providing health care. Implement it via subsidized Medicare (well-loved because it is universal) buy-in, I don’t care. But this is the opportunity for Democrats to turn the Republicans’ attacks on ObamaCare on their head, and make the policy much smarter at the same time.
Just after the election I did two posts considering the relative impact of the Jim Comey letter announcing FBI was reviewing the Anthony Weiner derived emails and the announcement of a huge ObamaCare premium spike.
I still think we don’t have enough data about the relative effect of the two events.
But a number of people are pointing to this post from Sam Wang, which ends,
In the above graph of the Comey effect, each point shows the median margin for polls that were in the field on that day. As you can see, the immediate effect of Comey’s letter was a swing toward Trump of 4 percentage points, about half of which stuck. This was enough to swing Michigan, Pennsylvania, Florida, and Wisconsin. It seems likely that Comey’s letter was a critical factor in the election outcome.
Nowhere in the post does Wang note what date Comey sent his letter, though. It was October 28.
Unless Wang’s chart is totally mislabeled (Update: In an “explanation” added to his post, Wang effectively says his graph is off by three — though not four — days due to the way he presents multi-day polls; he has, at least, now told his readers when the actual letter came out) but what it shows seems to be consistent with what I showed in this post, which shows a Hillary dip and a Trump spike moving in concert on before October 28), then his chart show doesn’t support a Comey effect at all — it shows the opposite. The differential started narrowing after October 24. By October 28, when the letter was released, the differential had plateaued before it turned up again.
As it turns out, the ObamaCare spike was announced on October 24 (and reported heavily starting October 25).
That’s precisely when we see the differential moving.
If we’re assuming an immediate response in polls in response to an event, then the ObamaCare premium spike would be a far better explanation than the Comey letter, which took place later.
Frankly, I suspect both had an impact, and further suspect there may have been something else driving the differential late turn to Trump in the Rust Belt. And I suspect we still don’t have the data to explain what made a bunch of Rust Belt voters move to Trump right before the election.
As I noted in my piece assessing the claims that the two letters Jim Comey wrote on the Hillary email investigation cost Hillary the election, the correlation between the October 28 Comey letter and what Trump’s camp reports as a surge is not exact. According to them (and they seem to have seen in real time far more clearly than the Hillary camp), the surge started before the letter.
Trump’s analysts had detected this upsurge in the electorate even beforeFBI Director James Comey delivered his Oct. 28 letter to Congress announcing that he was reopening his investigation into Clinton’s e-mails. But the news of the investigation accelerated the shift of a largely hidden rural mass of voters toward Trump.
So something else (which I posited could be nothing more than Gary Johnson voters deciding to vote Trump) has to have happened as well.
In comments, rollotomasi offered another suggestion, one I think may be significant: ObamaCare premium increases.
The press started reporting that increases would happen before they were announced. To prepare for that, on October 20, Obama, in what was treated by some as a campaign stop in Miami but what was technically a policy speech on the increases, had this to say (after having delivered a long explanation that ObamaCare was working just as planned).
Now, the second issue has to do with the marketplaces. Although the marketplaces are working well in most of the states, there are some states where there’s still not enough competition between insurers. So if you only have one insurer, they may decide we’re going to jack up rates because we can, because nobody else is offering a better price.
In those states where the governor or legislature is hostile to the ACA, it makes it harder to enroll people because the state is not actively participating in outreach. And so, as a consequence, in those states enrollment in the plan — especially enrollment of young people — has lagged.
And what that means is that the insurance pool is smaller and it gets a higher percentage of older and sicker people who are signing up — because if you’re sick or you’re old, you’re more likely to say, well, I’m going to sign up, no matter what, because I know I’m going to need it; if you’re young and healthy like you guys, you say, eh, I’m fine, life is good — so you have more older and sicker people signing up, fewer younger and healthier people signing up, and that drives rates up, because the people who use health care most end up being in the insurance pool; people who use it least are not.
And then, in some cases, insurers just set their prices too low at the outset because they didn’t know what the insurance pool was going to look like, and then they started losing money. And so now they’ve decided to significantly increase premiums in some states.
Now, it’s these premium increases in some of the states in the marketplace that sometimes attracts negative headlines. Remember, these premium increases won’t impact most of the people who are buying insurance through the marketplace, because even when premiums go up, the tax credits go up to offset the increases. So people who qualify for tax credits, they may not even notice their premiums went up because the tax credit is covered.
And keep in mind that these premium increases that some of you may have read about have no effect at all if you’re getting health insurance on the job, or through Medicaid or Medicare. So for the 80 [percent]-plus people who already had health insurance, if your premium is going up, it’s not because of Obamacare. It’s because of your employer or your insurer — even though sometimes they try to blame Obamacare for why the rates go up. It’s not because of any policy of the Affordable Care Act that the rates are going up.
But if you are one of the people who doesn’t get health care on the job, doesn’t qualify for Medicaid, doesn’t qualify for Medicare — doesn’t qualify for a tax credit to help you buy insurance, because maybe you made just a little bit too much money under the law — these premium increases do make insurance less affordable. And in some states, the premium increases are manageable. Some are 2 percent or 8 percent, some 20 percent. But we know there are some states that may see premiums go up by 50 percent or more.
One of the problems with ObamaCare is its complexity. If it takes 7 paragraphs to try to make a big rate hike sound better, it’s not going to work.
The actual rates for ObamaCare plan increases — with an average increase of 22% — came out October 24. There was a great deal of chatter between then and the election, especially around the November 1 start of sign-ups, as the Administration scrambled to get users to shop for a more affordable plan. Significantly, PA was one of the worst affected states.
According to a Kaiser Family Foundation, the ObamaCare hikes should not have mattered. It released a poll showing even among Republican voters, just 5% thought heath insurance was the most important issue. Except the poll, which was released on October 27, right in the middle of the discussion about spiking rates, was actually conducted from October 12 to 18, before the rate increases were announced (which to my mind makes it a largely useless but politically timed poll release). Moreover, the poll sampled far more self-identified Democrats than self-identified Republicans (408 to 285), meaning the margins of error would be far higher for Trump-leaning voters.
But in polls of voters taken after the election, repealing ObamaCare was the top priority among Republicans. 74% of those polled wanted to repeal ObamaCare, versus 30% who wanted to build Trump’s wall.
Admittedly, this isn’t a good measure of the importance of premium hikes (though it does seem somewhat inconsistent with the Kaiser poll). It may be a measure of 7 years of relentless opposition to ObamaCare, compounded by Trump’s repeated description of the program as a disaster.
Moreover, while the October 24 premium hike may explain why Trump started surging before the Comey letter, it wouldn’t explain what Hillary’s camp describes as energizing of Trump’s base when the second letter revealed nothing had been in the emails after all.
All that said, the premium hikes were probably the most significant policy discussion that happened between the last debate and the election. And for the small segment of the electorate that actually uses the exchanges, that policy change may have been felt very viscerally as they started the tedious process of shopping for an affordable plan.
By ‘bodies’ I mean sharing here pictures of cells you see in the embedded photos from a peer-reviewed study published this May.
In these images you’ll see the damage done to human tissue in lab conditions.
No pyriproxyfen was present.
How Researchers Studied Zika
This is the methodology researchers used:
1) The researchers used human stem cells to create neurospheres — the kind of cells which turns into nerve and brain tissue in an actual embryo.
2) They set aside control samples of neurospheres which were not infected.
3) They infected test samples neurospheres with Brazilian Zika virus.
4) They observed the changes in the infected neurospheres.
5) They compared them to the uninfected control samples.
6) They wrote and published a report on their findings.
The image above is the best example from their report of the difference between Zika-infected cells and the uninfected test samples.
What Researchers Found in this Study
In short, Zika inhibits, damages, and kills infected neurospheres.
This is what we can expect to happen to a fetus’ brain or nerve tissues when infected by Zika under the right conditions during early pregnancy.What Else Researchers Found in this Study
The researchers also conducted a very similar test on human brain organoids. These are not single neurospheres but neuro-tissue grown from stem cells so that they form a model like a tiny brain. Not a brain, a tissue-based model of a brain.
They used the same six steps above using a mock-infected model, a Zika-infected model, and a dengue virus-infected model. (Dengue fever is caused by a flavivirus — the same family of viruses to which Zika and yellow fever belong.) Researchers found Zika virus caused similar destructive damage on these larger models while limiting their growth; they did not find the same damage or destruction in the dengue-infected models and none in the mock-infected control models. Zika alone damaged neurological tissue models.
Researchers also studied neural stem cells (NSCs) — the simplest neuro tissue model — and found similar results in which the Zika virus killed off NSCs. Studying NSCs, neurospheres, and organoids, the researchers observed Zika’s actions on different stages of neuro tissue maturity. In each of these models, from the simplest (NSCs) to the most complex (organoids), Zika was destructive.Other Research on Zika Using Mouse Tissue
Three other studies published in May this year using mice or mouse tissues likewise showed evidences of neurological tissue and brain damage or growth suppression when infected by Zika virus. The studies came from research facilities in Brazil, China, and the U.S. — and in each study, pyriproxyfen was not included. The Zika-infected specimens showed damage and the control specimens did not.
The study from Brazil at the University of São Paulo also included research using human stem cells, comparing a Brazilian strain of Zika against an African strain:
Beltrão-Braga, Muotri, and their colleagues also grew brain organoids from human stem cells and infected these in vitro models with the Brazilian and African strains of the virus. In the human mini brains, both strains of the virus caused cell death, but the Brazilian strain appeared to also interfere with the formation of cortical layers. The virus didn’t replicate in the brain organoids grown from chimpanzee stem cells, suggesting it may have adapted to human tissue, the researchers noted in their paper.
Emphasis mine. Research published earlier showed Zika has already mutated rapidly after arriving in Brazil, with at least nine variants found inside the last two years.
What’s Next in Zika Research
What researchers don’t yet know, for starters: How Zika works — how does it damage or kill cells? When exactly does the virus do the most damage? What mechanisms interfere with Zika’s operations and can they be used in vaccines or drug therapy? What makes Zika different from dengue or other flavivirus? What does Zika do to adult neuro tissue to cause Guillain-Barre Syndrome? Which adults are most at risk? Will the different mutations in Brazil respond differently to vaccines? How long can humans carry live Zika virus? Has the virus mutated and become transmissible by bodily fluids or aerosol? These are just a few of the questions we still have about Zika.
There are some good guesses about Zika’s mechanisms — like this hypothesis focusing on vitamin A storage in the liver, which also suggests Zika may negatively affect liver cells (yet another avenue of research needed). But will a vaccine targeting this activity work for other flavivirus, too? What if this guess is wrong; are there other approaches we’ve yet to hear about?
We won’t have any of these answers in a reasonable period of time if we don’t have adequate funding.
It’s not just birth defects we are talking about here, either. Look at the damage in those images again; this virus not only damages fetal nerve and brain tissue, it kills fetuses. Infants born with Zika-related defects may be blind and may lead short, painful lives. And it may kill and maim adults, too, if they develop a serious case of Zika-related Guillain-Barre Syndrome.
Let’s not bring out any more Zika dead.
(Note: Forgive me for the simplistic terms used in this post if you have a background in science. I had to make this as brief and succinct as possible for those who don’t have that background.)
Zika virus impairs growth in human neurospheres and brain organoids
BY PATRICIA P. GARCEZ, ERICK CORREIA LOIOLA, RODRIGO MADEIRO DA COSTA, LUIZA M. HIGA, PABLO TRINDADE, RODRIGO DELVECCHIO, JULIANA MINARDI NASCIMENTO, RODRIGO BRINDEIRO, AMILCAR TANURI, STEVENS K. REHEN
SCIENCE13 MAY 2016 : 816-818
Zika virus infection in cell culture models damages human neural stem cells to limit growth and cause cell death.
Zika Studies Using Mice:
F. Cugola et al., “The Brazilian Zika virus strain causes birth defects in experimental models,” Nature, doi:10.1038/nature18296, 2016.
C. Li et al., “Zika virus disrupts neural progenitor development and leads to microcephaly in mice,” Cell Stem Cell, doi:10.1016/j.stem.2016.04.017, 2016.
J. Miner et al., “Zika virus infection during pregnancy in mice causes placental damage and fetal demise,” Cell, doi:10.1016/j.cell.2016.05.008, 2016.
Let me start this critique (what may be the first of two parts) of Jonathan Cohn’s scolding of Bernie Sanders on health insurance by looking at this passage, from the end of his piece:
[Bernie] might not get his plan through Congress, sure, but he could use his promise to extract other useful legislation from Congress. Maybe he could win approval for the “public option” insurance plan that was originally part of Obamacare, or for allowing the non-elderly to buy into Medicare.
These are legitimate arguments. But liberal policy wonks remember the struggle to enact and then implement Obamacare. They also also remember that universal health care was a progressive dream for nearly a century, one that proved impossible for presidents with names like Roosevelt and Truman (and Clinton!) to realize.
One reason reform took so long is that, for most of that period, activists and the wonks were pulling in different directions, with the activists pursuing single-payer and the wonks looking for compromises. The (mostly) unified front they showed in 2009 and 2010 was a big reason Obamacare became law. Now that unity is fading, creating a key divide in the Democratic campaign.
In this passage, Cohn talks about the things that Bernie Sanders might do as President that fall short of his goal of “single payer” health care (I put that in quotes because what we’re really talking about is government paid health insurance — as providers pull out of exchanges in Obamacare we’re actually moving closer to a much more alarming sort of single payer model).
He suggests that President Bernie, brought to earth by a reality of which, his critics suggest, he is woefully unaware right now, might set up the government as a competitor to private insurers within the Obamacare structure. Cohn then moves from that possibility (which I would suggest would be remote except for some realities about Obamacare as enacted) to saying “liberal policy wonks” know that Obamacare was a struggle and they know how hard it was to get even what we got (Bernie, who was in the Senate fighting to make Obamacare better at the time, apparently is too senile to remember all this, I guess).
As a reminder, one reason both the public option and Medicare buy-in were opposed by some Democratic Senators (and especially insurance state Independent Joe Lieberman, whom Bill Clinton had a big hand in getting reelected in 2006), meaning we couldn’t even pass it with a supermajority, is because they would make it too easy to move towards single payer. The idea was private companies could not compete, and so would slowly lose most exchange business to the government.
Now, if I were someone pushing for the improvement of healthcare delivery in this country, I’d say, “wow, if Bernie could pull off Medicare buy-in, that’d get us closer to single payer! That’d be a huge win!” I also might consider ways that true Medicare buy-in (rather than just gradually lowering the age at which you could buy in) might address some of the problems with cost sustainability with Medicare. I’d further applaud that getting more people into Medicare would expose more people to the innovations in delivery tied to it (one of the two best things about Obamacare), and therefore would move delivery as a whole down that path.
In short, I’d be applauding.
But Cohn doesn’t do that.
Instead, he decries what he calls a split between “wonks” and “activists.”
Can someone please define what those words mean for me? Can you explain how a man who has spent a decade writing about ways to improve health insurance and even sometimes healthcare, as Cohn has, is not an activist of sorts? Has he just been writing for a paycheck all these years?
Don’t get me wrong. I consider Cohn an expert in the subject, unlike some other people who get included in Paul Krugman’s club of wonks. I respect much of what he writes. And I have no doubt that he has become an expert on this topic because he’d like to improve a shitty system.
But setting up a dichotomy between “wonks” (“yes, I am one of those wonks,” Cohn says elsewhere) and “activists” is an insidious way of saying “some of the people who work on this issue are not as smart as me.” Would anyone suggest such a thing about insurance company lobbyists, who are themselves “activists”? Nope. They’re just experts who use different methods to press for their desired outcome. But somehow people who lobby and organize on the other side are presumed to be unicorn sniffing half-wits.
Calling oneself a wonk is also an easy way absolve oneself of examining what function wonk-scolding plays — a way to pretend one is delivering just unmediated rationality and not an argument designed to bring about some outcome. Here, the desired outcome seems to be the restoration of unity between those deemed “activists” and those deemed “wonks.” But not just to restore unity, mind you, but to restore unity by getting “activists” to be satisfied with what “wonks” tell them is realistic.
In other words, it’s a plea from one kind of activist for another kind of activist to fall back in line behind the policies the first kind of activist espouses, and, especially, to stop suggesting Obamacare (and, frankly, a whole bunch of other policies enacted by Obama and defended by Hillary Clinton, as well as some foreign policy ones that go beyond what Obama has done) isn’t an adequate solution.
So let’s go back to what else Cohn says. First, he explains why (unnamed) “liberals sympathetic” to government insurance consider it unrealistic by warning that even trying to move towards government insurance will “produce a major public backlash.”
Even many liberals sympathetic to the idea have said that Sanders’ scheme is simply not realistic. They worry that trying to push through another comprehensive health care package so soon after the Affordable Care Act’s tumultuous enactment would produce a major public backlash.
Note what Cohn has done here (besides putting his own argument in the mouths of unnamed anonymous liberals). In the rest of his piece, Cohn suggests that achieving government insurance is unrealistic. Fair enough — in a four year term it may well be. But here, he somehow ties what might fairly be considered the impossibility of actually achieving it with the specter of “major public backlash” if someone even tries.
I’m not sure if Cohn has noticed, but there is an ongoing major public backlash already. It was so bad in 2010 that it made predictable off year congressional losses far worse than they might have been. Much of that backlash is just Republican posturing. But not all of it. Some of the backlash comes from legitimate complaints about Obamacare: the government botched the original sign up, people actually weren’t able to keep their insurance plans, their selection of doctors has gone down, people are being forced to buy shitty insurance they can’t afford that won’t even make care affordable. Some of the backlash is unjustified, but some of it actually is justified.
But Cohn says we can’t talk about moving to government insurance because if so it will … cause what is already happening to continue happening? Or perhaps because it will legitimize some of the legitimate critiques of the Obamacare that activists like Cohn pushed back in 2009? Is that it? We can’t even talk about government insurance because doing so would bring people like Cohn in for some criticism?
Finally, here’s the line from the debate that Cohn frames this entire discussion around, where Hillary attacked Bernie’s plan because it would impose a $2,300 tax on the working poor.
But during the debate she also made another claim: That under the Sanders plan, some low-income people now on Medicaid would be much worse off. “A working woman on Medicaid who already has health insurance would be expected to pay about $2,300,” Clinton said.
Here’s why. If the federal government is going to provide everybody with health insurance, then it must raise enough money to pay for those benefits. To do this, Sanders has said, he’d create a new payroll tax, equal to 8.9 percent of wages. In theory, employees would pay only a portion of that, with employers covering the majority. In reality, economists say, the employer share also comes out of workers’ paychecks, if not right away then over time.
An 8.9 percent payroll tax would work out to a new payroll tax burden of $2,314 — just as Clinton said.
Today, by contrast, you’d be getting Medicaid without having to pay any new taxes. The money for the program comes out of general revenue and if you’re one of the newly eligible folks, then the money is coming almost entirely from taxes that fall on the wealthy and on corporations in the health care industry.
Now, “wonks” love to criticize Bernie for promising things he can’t deliver. But note what Cohn has done in this last paragraph: under Obamacare this working poor mother of two gets health insurance “without having to pay any new taxes.” Her health insurance “comes out of general revenue” which comes from “taxes that fall on the wealthy and on corporations in the health care industry.”
I think Cohn means to suggest that the revenue passed under Obamacare fall on the wealthy and corporations. He surely doesn’t mean that general revenue funds generally come from taxes that fall on the wealthy and corporations, because many rich people and corporations actually don’t pay income taxes. Indeed, it’s all that we can manage to keep corporations — some of them the health care ones Cohn says pay for all this — paying any taxes at all. What he really means is the taxes that pay for Medicaid come largely from the affluent and middle class taxes and even borrowing. That single mom likely still isn’t paying for her own Medicaid, but it’s not actually rich corporations that are doing so.
But even if Cohn meant only to refer to the planned funding method for Obamacare, his claim is problematic. That’s because one of the taxes targeting the industry, on medical devices, has already been suspended. Another tax that Obamacare boosters liked to pretend will only affect the wealthy, the Cadillac tax, will actually affect more people than that, including unions (which is why Hillary has promised to scrap it, as has Bernie). Plus, the Cadillac tax boosters sold it with a claim that workers wages would go up after their companies cut their health insurance. Those claims always seemed like fantasy — at least to me and actual experts like Larry Mishel, the latter of whom was pretty much ignored by the “wonks” during the debate. In the last six years that has become even more clear.
This is important: In a key fight about funding during Obamacare, the “wonks” promised workers (especially union workers) a wage increase, but evidence now strongly suggests it would lead instead to a wage cut. Read more
CDC director Dr. Tom Frieden confirmed Wednesday that the flavivirus known as Zika is a cause of microcephaly and other severe fetal brain defects.
The confirmation is based on an evaluation of available data for potential teratogenic effects. Using both Shepard criteria and Bradford Hill criteria, researchers proved prenatal Zika virus infection has a causal relationship with microcephaly and other serious brain anomalies.
The first set of seven criteria used in the assessment were developed by Dr. Thomas Shepard to assess an agent’s teratogenicity — the ability to cause birth defects. The criteria of proof are:
1. Proven exposure to agent at critical time(s) in prenatal development
2. Consistent findings by two or more epidemiologic studies of high quality
a. control of confounding factors
b. sufficient numbers
c. exclusion of positive and negative bias factors
d. prospective studies, if possible, and
e. relative risk of six or more
3. Careful delineation of the clinical cases. A specific defect or syndrome, if present, is very helpful.
4. Rare environmental exposure associated with rare defect. Probably three or more cases.
5. Teratogenicity in experimental animals important but not essential.
6. The association should make biological sense.
7. Proof in an experimental system that the agent acts in an unaltered state. Important for prevention.
Items 1~3 or 1, 3, and 4 are essential criteria.
Items 5~7 are helpful but not essential.
Shepard criteria summary:
1. The microcephaly and other brain defects observed in infants and fetuses were consistent with maternal Zika infection during first and second trimester of pregnancy. Mothers exhibited symptoms, and/or had infections confirmed by labs, and/or had traveled to areas where Zika was endemic. This criterion was met.
2. Data documenting the location of Zika virus infections and the subsequent incidence of microcephaly in those areas was supported by two epidemiologic studies. But as sample sizes were too small and controls were lacking, this criterion has not yet been met.
3. Cases manifesting with a very specific defect (an atypical microcephaly) or syndrome (a narrow range of neurological defects in tandem with microcephaly) satisfied this third criterion. With Zika infection, microcephalic cases displayed adequate bone tissue and scalp skin production, but ‘collapsed’ due to the disrupted development of fetal brain tissue. This is not common in other microcephalies.
4. An adequate number of cases fulfilled the criteria of rare exposure and rare defect — one example cited was that of a pregnant woman who traveled for a week to areas where Zika was not endemic. She tested positive for Zika during her second trimester, and the fetus displayed brain defects associated with Zika after the infection.
5. Studies for this criteria — teratogenicity in animal models — are still under way. This criterion is not yet satisfied.
6. This criterion is met as the causal relationship makes biologic sense.
7. This criterion does not apply to infectious agents.
The essential Shepard criteria have been met for proof of teratogenicity.
Bradford Hill criteria summary
Of the nine criterion — the strength of association, consistency, specificity, temporality, biologic gradient, plausibility, coherence, experiment (on animal models), and analogy — only two criterion are not applicable or not available. The remaining seven criterion were met in much the same manner as the Shepard criteria 1, 3, 4 were met.
A spectrum of additional fetal abnormalities has not yet been fully identified in association with Zika infection. This will become clear once some pregnancies being monitored reach term.
We don’t yet know if Zika virus affects adult neurological tissues; some cases of Guillain-Barre Syndrome (GBS) have been reported in areas where Zika is endemic. GBS has occurred in patients after viral infections where neurological tissues have been affected; it would make biologic sense for there to be a causal relationship between Zika and GBS. However, GBS has occurred in patients long after an initial infection, making it difficult to see obvious relationships without further screening and testing.
A Zika vaccine may be some time off; of the flavivirus family, only yellow fever and a couple of encephalitis viruses have vaccines while others like West Nile and dengue do not.
Mosquito control varies widely from state to state, let alone by county or municipality. We do not know if it is adequate to ensure Zika’s spread via Aedes aegypti and Aedes albopictus mosquito species is limited. U.S. experience with the spread of West Nile Virus may be informative.
Funding for additional research, education, training, vaccine development and mosquito control, as well as funding increases for birth control are much needed, But the GOP-led Congress will likely avoid this issue during the remaining days it is in session this election year.
In the meantime, if you’re around mosquitoes in warmer areas of the U.S., are pregnant, plan to be pregnant, or might get someone pregnant, check the CDC’s guidelines on Zika.
Still on spring break around here. If I was legit on a road trip some place warm right now, you’d find me lounging in the sun, sipping fruity cocktails at all hours, listening to some cheesy exotica like this Arthur Lyman piece I’ve shared here.
Though horribly appropriative and colonialist, it’s hard not to like exotica for its in-your-face corniness. I think my favorite remains Martin Denny’s Quiet Village. It brings back memories from the early 1960s, when life was pretty simple.
Let’s have a mai tai for breakfast and get on with our day.
Urgent: Increasing number of hospitals held ransom
Last month it was just one hospital — Hollywood Presbyterian Medical Center paid out bitcoin ransom.
Last week it was three — two Prime Healthcare Management hospitals in California and a Methodist Hospital in Kentucky held hostage.
Now, an entire chain of hospitals has been attacked by ransomware, this time affecting the servers of 10 related facilities in Maryland and Washington DC. The FBI is involved in the case. Is this simple extortion or terrorism? The patients diverted from the facilities to other hospitals’ emergency rooms probably don’t care which it is — this latest attack interfered with getting care as quickly as possible. Let’s hope none of the diverted patients, or those already admitted into the MedStar Union Memorial Hospital chain, have been directly injured by ransomware’s impact on the system.
The MedStar cases spawns many questions:
- Was any patient’s physical health care negatively affected by the ransomware attack?
- Given the risks to human health, why aren’t hospitals better prepared against ransomware?
- Have hospitals across the country treated ransomware as a potential HIPAA violation?
- Was MedStar targeted because of its proximity to Washington DC?
- Was Hollywood Presbyterian Medical Center targeted because its owner, CHA Medical Center, is South Korean?
- Were any patients being treated at MedStar also affected by the OPM data breach, or other health insurance data breaches?
- How much will ransomware affect U.S. healthcare costs this year and next?
Bet you can think of a couple more questions, too, maybe more than a couple after reading this:
Hospitals are considered critical infrastructure, but unless patient data is impacted there is no requirement to disclose such hackings even if operations are disrupted.
Computer security of the hospital industry is generally regarded as poor, and the federal Health and Human Services Department regularly publishes a list of health care providers that have been hacked with patient information stolen. The agency said Monday it was aware of the MedStar incident.
Apple iPhone cases emerge
After the San Bernardino #AppleVsFBI case, more law enforcement investigations relying on iPhones are surfacing in the media.
- L.A. police crack open iPhone with fingerprints obtained under warrant (Forbes);
- FBI will assist county prosecutor in Arkansas with iPhone belonging to alleged teen killer (Los Angeles Times); the method may be the same hack used on the San Bernardino phone, which was supposed to be a one-off (Network World);
- ACLU found 63 other cases in which FBI used All Writs Act to obtain iPhone/Android smartphone data from Apple and Google (The Register).
- In spite of screwing up not once but twice by releasing its racist, obnoxious Tay AI chatbot, Microsoft tripled down on a future full of chatbots you can build yourself with their tools. (Ars Technica) — Ugh. The stupid…
- UK’s Ministry of Defense awarded funding to Massive Analytics for work on “Artificial precognition and decision-making support for persistent surveillance-based tactical support” (Gov.UK) — OMG Precog in warfare. Human-free drone attacks. What could go wrong?
- Rich white guys queue up outside Tesla dealerships for days waiting to pre-order the new Tesla 3 (Vancity Buzz) — Vancouver, Sydney, probably other places I’m too arsed to bother with, because rich white guys.
That’s quite enough. Back to pretending I’m lying under a cerulean sky, baking my tuchis, cold drink in hand.