Two Polls Give (Limited) Hope For A Democratic Upset In November

May 17, 2014 — Ron Chusid

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There are two recent poll findings which you might think should help the Democrats in November but most likely will not. Gallup found that the Democratic Party had a favorable rating of 44 percent while the Republicans have a with 34 percent favorable rating.

Unfortunately this type of lead has not necessarily translated into election victories in the past. It also doesn’t help the Democrats that, while leading the Republicans, they are still under 50 percent.

Republicans also have an advantage in House elections due to gerrymandering, and due to the concentration of Democrats in urban areas, leading to a larger margin of victory in a smaller number of districts. Democrats are defending several Senate seats in red states where they would not enjoy this lead over Republicans.

Brendan Nyhan looked at a recent Washington Post-ABC News poll which showed that more people agree with the Democrats on the issues:

More Americans say they trust Democrats than Republicans on the “main problems the nation faces over the next few years” as well as a number of key policy issues, including the economy, health care and immigration. Members of the public also typically indicate that Democrats are closer to their opinion than Republicans on specific issues like abortion, same-sex marriage and raising the minimum wage.

This apparent political advantage is less important than it might seem, however. For instance, Democrats had greater advantages on several major issues at comparable points in the 1994 and 2010 electoral cycles, which both resulted in Republican landslides…

Why haven’t these issue advantages translated into electoral success? First, the midterm electorate is not representative of the American public. The public’s preferences for Democrats on the issues may diminish or disappear once you look at registered voters or those who claim they are “absolutely certain” to vote, as Jaime Fuller of The Washington Post has noted. The Democrats’ edge on the issues is likely to dissipate further among the older, whiter group of Americans most likely to vote in November.

In addition, the importance of the issues in congressional elections is typically overstated. Structural factors like presidential approval, the state of the economy, the type of election (midterm or presidential year) and the composition of the seats that are up for election tend to matter more.

Most likely, based upon fundamentals in a midterm election the Republicans should do better than the Democrats. However, if the Democrats are seeking to significantly beat historical expectations, they sure have a better chance at the upset if they are the party which a majority support than if they did not have this support. How they do will depend a lot on whether the Democrats can get more of their supporters out to vote than is typical in midterm election years.

While the Democrats face a difficult task in holding onto Senate seats in the red states, there is an advantage to incumbency which should allow some to win. This might be enough to allow the Democrats to maintain control of the Senate until 2016 when the fundamentals are in their favor, including having an election year electorate and it is the Republicans who will be defending Senate seats in several blue states.

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The Republican War On Science: From Climate Change To Reproduction

May 16, 2014 — Ron Chusid

Fertilization and Implantation-MU

There is good reason that, going back to the Bush years, only six percent of scientists identify themselves as Republicans. For several years Republicans have promoted views contrary to facts as demonstrated by the scientific method, and commonly distort science to justify their positions. We have seen more examples of this with Marco Rubio’s denial that human action is responsible for climate change despite overwhelming evidence that this is the case.

Some on the right have come to Rubio’s defense. One of the more absurd defenses of Rubio came from James Taranto who questioned whether appeals to authority are fallacious. In scientific matters it only makes sense to rely on authorities in the field, and ninety-seven percent of climate scientists agree that human action is responsible for climate change. Taranto dismissed this by arguing that, “The trouble for global-warmist journalists like Marcus and Lapidos is that an appeal to the authority of a distrusted source undermines rather than strengthens one’s argument.” That is a rather circular argument that conservatives are apparently right in dismissing arguments based upon the views of  climate scientists because conservatives already distrust the source.

Rubio defended his earlier statements by pivoting to yet another area where conservatives promote pseudo-science to promote their views–reproduction. Rubio tried to portray liberals as not accepting settled science in an interview with Sean Hannity, but Rubio got the science wrong:

“All these people always wag their finger at me about ‘science’ and ‘settled science.’,” he told Hannity. “Let me give you a bit of settled science that they’ll never admit to. Science is settled, it’s not even a consensus, it is a unanimity, that human life begins at conception. So I hope the next time that someone wags their finger about science, they’ll ask one of these leaders on the left: ‘Do you agree with the consensus of scientists that say that human life begins at conception?’ I’d like to see someone ask that question.”

Philip Bump turned to the American College of Obstetricians and Gynecologists for their response to Rubio’s scientific claims. The response:

Government agencies and American medical organizations agree that the scientific definition of pregnancy and the legal definition of pregnancy are the same: pregnancy begins upon the implantation of a fertilized egg into the lining of a woman’s uterus. This typically takes place, if at all, between 5 and 9 days after fertilization of the egg – which itself can take place over the course of several days following sexual intercourse.

There are points in human reproduction which are defined scientifically, such as implantation and fertilization. Other points, including the time of intercourse and birth, have clear definitions. When life begins is not such a point:

There’s a blurry line between “pregnancy” and “life” in this discussion. When we asked ACOG if the two were interchangeable, we were told that the organization “approach[es] everything from a scientific perspective, and as such, our definition is for when pregnancy begins.” On the question of when life begins, then, the scientific experts we spoke with didn’t offer any consensus.

“Life” is something of a philosophical question, making Rubio’s dependence on a scientific argument — which, it hardly bears mentioning, is an argument about abortion — politically tricky. After all, if someone were to argue that life begins at implantation, it’s hard to find a moral argument against forms of birth control that prevent that from happening. If that someone were, say, running for president as a conservative Republican, that could be problematic.

Asking for the moment when life begins is a phony conservative frame which has no scientific validity, used to promote their viewpoint. The process of human reproduction is a continuum. The abortion issue involves matters beyond defining when life begins, such as the right of a woman to control her own body. The same is true with contraception, with some conservatives apparently choosing a point before the true onset of pregnancy as when life begins in order to justify opposition to forms of birth control which interfere with implantation.

Think Progress has more on conservative junk science being used to violate reproductive rights.

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Health Care Policy Briefs: Early Retirement, The Two Americas, Sabotaging Obamacare, Marijuana Not A Gateway Drug, And The Pentagon’s Plan For The Zombie Apocalypse

May 15, 2014 — Ron Chusid

zombies_01

Five  health care policy items today:

Goldman issued a report on how availability of health insurance allows people the option of retiring early (or as Republicans would put it, become takers) as opposed to waiting until they qualify for Medicare. The found that “the annual probability of retirement–i.e., what share of workers of a given age will retire within the next year–is on average between 2% and 8% higher when retiree health insurance is available.” Early retirement is seen more between the ages of 60 to 64, than in those who are age 55-59.

With Republicans blocking Medicaid expansion in twenty-four states, The Commonwealth Club looked at the healthcare differences in the two Americas:

The Commonwealth Fund’s recently released Scorecard on State Health System Performance, 2014, finds big differences between states on measures of health care access, quality, costs, and outcomes. What’s more, its authors warn that these differences could very well widen in the future. Many of the lowest-performing states are choosing not to expand their Medicaid programs under the Affordable Care Act (ACA). Some also are discouraging eligible uninsured citizens from purchasing subsidized coverage through new ACA marketplaces, though some uninsured are signing up nonetheless.

The fact that so many low-performing states are spurning the ACA’s benefits, while high-performing states are rushing to embrace them, raises profound questions for the future of our country. What would it mean if different parts of the United States find themselves on radically different health care trajectories, with some enjoying progressively better health and health care and others falling further and further behind? In other words, what would it mean if the two health care Americas grow further and further apart over time?

This is unexplored territory for health care researchers and policymakers, but we know enough to point to some possibilities.

To begin with, we know that when people have health coverage they live longer, healthier lives. Widening gaps in rates of insurance coverage between low- and high-performing states will almost certainly lead to growing differences in life expectancy and health status. This is worrisome and regrettable, but probably only part of the story.

An equally important—but much less explored—question is whether differing health care trajectories also will lead to differing economic and social trajectories. All else equal (of course, it never precisely is), will regions with poorer health care and health status suffer economically and socially as well? Will they have less productive workforces, less productive economies, and, as result, lower quality of life overall? Will they become less attractive places to live, work, and do business?

Several lines of evidence suggest that diverging regional health care systems could lead to diverging general welfare. First, untreated physical and mental health problems increase workers’ time off from work, reduce performance while at work, and lower rates of employment. In the early 20th century, infections such as yellow fever, malaria, and hookworm greatly hindered the economy of the American South. In his memoir, Jimmy Carter recalls that, while growing up in rural Georgia, “almost everyone was afflicted from time to time with hookworm,” a parasite that causes anemia, malaise, and fatigue. Eventually, public health measures and improved living conditions brought this and other health problems under control, contributing to a burst of economic growth.

A century later, chronic illness is the equivalent of the infectious illness that once disproportionately taxed the economy of the American South. In the United States, annual productivity losses from diabetes and depression alone exceed $100 billion nationally. And we know this burden can be lightened through good primary and preventive care that will be less available in regions with large uninsured populations.

Second, health insurance boosts economies by protecting people against catastrophic out-of-pocket health care expenses. These costs can lead to bankruptcy, which raises the cost of borrowing for the rest of society as lenders take into account the risk that they will not be repaid. Those avoiding bankruptcy often incur substantial medical debt, with far-reaching consequences. A 2012 Commonwealth Fund survey found that 61 percent of uninsured adults ages 19 to 64 reported problems paying their medical bills or said they were paying off medical debt over time. Among these individuals, more than half said they received a lower credit rating as a result of unpaid medical bills, 43 percent used all of their savings to pay their bills, and 29 percent delayed education or career plans. The 2006 Massachusetts health reform, which has led to nearly universal health coverage, has also led to fewer personal bankruptcies and bills past due and improved credit scores, particularly for those with limited access to credit before the reform…

The report continued to discuss further differences resulting from differing access to health insurance.

Besides blocking Medicaid expansion, conservatives are reducing the number of insured with misinformation campaigns and campaigns to outright dissuade people from obtaining coverage in the exchanges. This has led many uninsured people to fail to obtain coverage through the exchanges to based upon misconceptions spread by conservatives, such as that the cost would be much higher than it actually is. Jonathan Cohn wrote:

About half of the people who McKinsey surveyed did not end up buying insurance—either because they shopped and found nothing they liked, or because they didn’t shop at all. When asked to explain these decisions, the majority of these people said they thought coverage would cost too much. But two-thirds of these people said they didn’t know they could get financial assistance. In other words, they assumed they would have to pay the sticker price for coverage, even though federal tax credits would have lowered the price by hundreds or thousands of dollars a year.

With a little education and outreach, many of these people will discover that insurance costs less than they thought. When next year’s open enrollment period begins, they are more likely to get coverage. But the idea was to help more of those people this year. And if the administration deserves some blame for this shortfall, its adversaries deserve more. Republicans and their allies did their best to taint the law—and, where possible, to undermine efforts to promote it. Without such obstruction, even more uninsured people would probably be getting coverage right now. As Sprung quipped in his post, “Those who deliberately spread disinformation about the ACA and actively encouraged the uninsured to remain in that blessed state of freedom can be really proud of themselves.”

Or as I put it in a recent post: Fox Lied, People Die.

The National Bureau of Economic Research looked at the effects of legalization of medical marijuana on drug use:

21 states and the District of Columbia currently have laws that permit marijuana use for medical purposes, often termed medical marijuana laws (MMLs). We tested the effects of MMLs adopted in seven states between 2004 and 2011 on adolescent and adult marijuana, alcohol, and hard drug use. We employed a restricted-access version of the National Survey on Drug Use and Health (NSDUH) micro-level data with geographic identifiers. For those 21 and older, we found that MMLs led to a relative increase in the probability of marijuana use of 16 percent, an increase in marijuana use frequency of 12-17 percent, and an increase in the probability of marijuana abuse/dependence of 15-27 percent. For those 12-20 years old, we found a relative increase in marijuana use initiation of 5-6 percent. Among those aged 21 or above, MMLs increased the frequency of binge drinking by 6-9 percent, but MMLs did not affect drinking behavior among those 12-20 years old. MMLs had no discernible impact on hard drug use in either age group. Taken together, MML implementation increases marijuana use mainly among those over 21, where there is also a spillover effect of increased binge drinking, but there is no evidence of spillovers to other substance use.

If marijuana turns out not to be a gateway drug, this would be another reason to reevaluate current marijuana laws. Further discussion at Vox.

The Pentagon has contingency plans for any emergency, including the Zombie Apocalypse. It isn’t as ridiculous as it sounds as it is actually a model plan using a fictional situation, as reported by Foreign Policy:

“This plan fulfills fictional contingency planning guidance tasking for U.S. Strategic Command to develop a comprehensive [plan] to undertake military operations to preserve ‘non-zombie’ humans from the threats posed by a zombie horde,” CONOP 8888′s plan summary reads. “Because zombies pose a threat to all non-zombie human life, [Strategic Command] will be prepared to preserve the sanctity of human life and conduct operations in support of any human population — including traditional adversaries.”

CONOP 8888, otherwise known as “Counter-Zombie Dominance” and dated April 30, 2011, is no laughing matter, and yet of course it is. As its authors note in the document’s “disclaimer section,” “this plan was not actually designed as a joke.”

Military planners assigned to the U.S. Strategic Command in Omaha, Nebraska during 2009 and 2010 looked for a creative way to devise a planning document to protect citizens in the event of an attack of any kind. The officers used zombies as their muse. “Planners … realized that training examples for plans must accommodate the political fallout that occurs if the general public mistakenly believes that a fictional training scenario is actually a real plan,” the authors wrote, adding: “Rather than risk such an outcome by teaching our augmentees using the fictional ‘Tunisia’ or ‘Nigeria’ scenarios used at [Joint Combined Warfighting School], we elected to use a completely-impossible scenario that could never be mistaken for a real plan.”

But do they have plans in case of a Dalek invasion?

Posted in Drug Policy, Health Care, National Security, Republicans, Science Fiction. Tags: , , , , , , , . No Comments »

One Way Obamacare Is Lowering Insurance Premiums

May 14, 2014 — Ron Chusid

While insurance policies purchased through the exchanges and Medicaid expansion (or blocking it in many red states) have obtained the bulk of the publicity regarding the Affordable Care Act, there are many other aspects to the law. (No, Sarah Palin, establishment of death panels is not one of these). In the last post I looked at the benefits of enabling students to remain on their parents’ insurance plans. An even less discussed change is the regulations on medical loss ratios, which require that the bulk of premiums paid in be used for health benefits. Business Week explains that, “Expenses for marketing, fees to brokers, administrative costs, profits, and the like can’t take up more than 20¢ of each premium dollar (or 15¢ for large-group plans). Any amount collected above that threshold must be returned to customers.”

The Commonwealth Club looked at how this is working:

For the past two years, the Affordable Care Act has required health insurers to pay out a minimum percentage of premiums in the form of medical claims or quality improvement expenses—known as a medical loss ratio (MLR). Insurers with MLRs below the minimum must rebate the difference to consumers. This issue brief finds that total rebates for 2012 were $513 million, half the amount paid out in 2011, indicating greater compliance with the MLR rule. Spending on quality improvement remained low, at less than 1 percent of premiums. Insurers continued to reduce their administrative and sales costs, such as brokers’ fees, without increasing profit margins, for a total reduction in overhead of $1.4 billion. In the first two years under this regulation, total consumer benefits related to the medical loss ratio—both rebates and reduced overhead—amounted to more than $3 billion.

These rules are one of the reasons that the insurance industry is unhappy about the Affordable Care Act, even if they do profit from expanding sales to the currently uninsured. The rules do punish them if they set premiums too high while  there are no benefits to the insurance company from setting premiums below the expected medical-loss ratio. Insurance companies are responding by setting their rates as close to the medical-l0ss ratio as possible. This is beneficial for consumers, who benefit from lower insurance rate and from receiving rebates if the insurance premiums are set too high.

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Young Earning More Due To Obamacare Thanks To Remaining On Parents’ Insurance Plan & Conservatives Distort Report On Narrow Networks

May 13, 2014 — Ron Chusid

Two health care items today, one on a benefit of the Affordable Care Act and another on a news item which conservatives are distorting to attack Obamacare. First the positive news.

I have discussed the benefit of the Affordable Care Act freeing people from the “insurance trap” in which they take jobs they otherwise would not want to work at purely to obtain health insurance. Allowing people more options to obtain insurance coverage independent of large employers allows people to retire earlier if they desire, go to work for smaller companies, or even start their own companies. The Journal of Health Economics considered another group of people freed from the “insurance trap” by Obamacare–young people who are allowed to remain on their parents’ insurance policies until age 26. They found that those who lived in states with similar laws were able to go to school at an older age and this also resulted in higher wages.

Health Economist Austin Frakt looked at this study for The New York Times:

One of the earliest pieces of the health-care law to go into effect — and one of the easiest to understand — was the one that allowed adults under age 26 to remain on their parents’ insurance plan. It has long been clear that the policy has somewhat increased the insurance rate among young adults. Now a new study suggests the effects may be much broader, also leading to increases in educational attainment and the wages of young adults.

The findings suggest that the health law has given young adults more flexibility to make decisions they think are best for them financially, rather than making decisions simply to obtain health insurance. With coverage from their parents’ plans, they can remain in college or graduate school, rather than leaving to take a job that provides health insurance. The cost of college is also potentially lower for such students because some colleges require health insurance coverage, which raises the cost of attendance.

With coverage in place, once students leave school, they can consider a broader range of jobs, including some that do not offer good health insurance or any health insurance. This finding is consistent with the academic literature on “job lock,” which has consistently shown that people who do not need to take a job with employer-based coverage have more flexibility, resulting in better employment matches with higher wages on average.

The Affordable Care Act appears to have increased health-insurance coverage among people under 26 by about 3 to 7 percentage points, academic research has found. The new study, published in the Journal of Health Economics, does not directly examine the health-care law, though. (It’s too recent to know its long-term effects.)

The study instead examines the earlier state-based laws with similar requirements that adult children be able to remain on their parents’ plans. It found that for people who were at least 18 at the time a coverage law was passed, wages earned after age 22 increased by about 2 percent. An increase in education drove the wage boost for men.

No similar educational effect was found for women, yet their wages increased as well. Those wage gains may stem from the new employment flexibility the law gives young women, allowing them to avoid job lock.

If anything, the Affordable Care Act may have a bigger effect than the state-based laws, because it has a broader mandate. While the state laws don’t apply to all types of employers, the federal law does. The new study estimates that the law will lead to sustained wage increases for affected young adults closer to 4 percent.

The New York Times also has an article on the trend for insurance companies to use narrower panels of physicians to cut costs. While several conservative sites are quoting this article to attack Obamacare, the article points out that this trend actually started in the 1990′s and has become increasingly common in all forms of insurance, not just plans sold on the exchanges. The article specifically points out that  “Smaller networks are also becoming more common in health care coverage offered by employers and in private Medicare Advantage plans.”  It also notes that “In 2010, 24 percent of the largest employers offered smaller networks, chosen for their low costs or quality. Last year, 27 percent offered them and 44 percent said they were considering them…”

The Affordable Care Act preserves the dominant role of private insurance companies. As a result, it does not prevent private insurance companies from continuing the trend towards smaller networks, but this is also not something developed because of the Affordable Care Act. The difference is that there are new regulations on insurance companies requiring that they maintain an adequate network of physicians. There are also a variety of policies available on the exchanges. Many people chose the less expensive plans (often free to those who receive subsidies) with narrower networks, but also have a choice of other plans which would give them a greater choice of physicians and hospitals.

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Republican Scare Stories Of Doctor Shortages Under Obamacare Failing To Come True

May 12, 2014 — Ron Chusid

We are well into the year and none of the Republican horror stories about Obamacare have come true. There are no death panels. Enrollment through the exchanges has exceeded expectations. Over 80 percent of those purchasing insurance are paying premiums as the Obama administration predicted, and ultimately this might exceed 90 percent. Premiums are not expected to increase next year any more than is traditional on the individual market. The Hill even reports that Republicans are holding off on attacking the Affordable Care Act, although I wouldn’t count on that to continue.

Republicans have also predicted that the Affordable Care Act would lead to a shortage of doctors as more people obtain coverage, contradicting their claims that the uninsured were not signing up for coverage. Opposing health care reform because it might lead to shortages because of more people becoming covered is also a rather cruel answer to the millions who were uninsured. Some Republicans even predicted that doctors would not accept people in the new exchange plans, which is especially absurd considering that these private insurance plans pay doctors more than government plans such as Medicare and Medicaid.

Kaiser Health News reported today that there has not been a problem with shortages of doctors due to the Affordable Care Act:

The headlines were ominous: Good luck finding a doctor under Obamacare. Not enough doctors for newly insured. Obamacare, doctor shortage could crash health system.

Despite these dire predictions, the nation’s primary care system is handling the increased number of insured patients without major problems so far, according to interviews with community health centers, large physician practices and insurers nationwide.

Five months into the biggest expansion of health coverage in 50 years — with about 13 million people enrolled in private insurance and Medicaid under the Affordable Care Act — there are few reports of patients facing major delays getting care, say officials from more than two dozen health centers and multi-group practices, as well as insurers and physician groups in nine big states.

There are some exceptions, particularly in parts of Colorado, Kentucky and Washington state, which had some of the biggest gains in coverage…

Many of the concerns about people experiencing delays grew out the experience in Massachusetts after that state adopted near-universal coverage in 2006. Wait times for a doctor’s appointment rose to an average of 50 days with some as long as 100 days, according to a Massachusetts Medical Society report in 2008.

But Glied notes that Massachusetts’ residents historically had long waits for primary care visits so their experience is not a good indicator.

And unlike the Massachusetts law, the Affordable Care Act gave health providers more than three years to prepare. In that time, the federal government has spent billions expanding community health centers while private practices have added nurse practitioners and physician assistants and adopted electronic health records.

“Despite the widely publicized shortage of primary care physicians, primary care capacity does exist in each state,” said Karin Rhodes, director of the Center for Emergency Care Policy & Research at the University of Pennsylvania School of Medicine.

Rhodes was the lead author of a study published last month in JAMA Internal Medicine in which researchers posing as new patients called about 8,000 primary care practices in 10 states. The vast majority quickly secured appointments although those with Medicaid had a tougher time.

I also discussed that study in a post last month.

Some of the anecdotal reports of difficulty seeing a physician are probably erroneously being attributed to the Affordable Care Act, especially as an already existing shortage in some areas has been exacerbated by other problems recently. As a large number of the newly insured didn’t sign up until late March, I am quite skeptical of those claiming to have experienced problems due to shortages beginning in January. Before blaming the Affordable Care Act, keep in mind the fact that health care utilization began to rise in late 2013 due to factors such as improvements in the economy. People who had been putting off medical expenses were thought to have more money to spend while others obtained new jobs with health insurance.

In addition, new requirements for electronic medical records and the conversion to ICD-10 billing codes have been very time consuming for physicians over the past year, resulting in many doctors not being able to see as many patients as in previous years. Fortunately the conversion to ICD-10 has been postponed another year, but time-consuming transition programs are continuing. While computerization theoretically will increase efficiency, the conversion, with many onerous new requirements, initially results in a considerable drop in productivity.

While many of the Republican scare stories are easily dismissed as ridiculous, there is legitimate reason for concern that increasing the number of people with insurance will worsen already existing physician shortages in many areas, especially in the future when even more people are insured. That would certainly be the case if the Affordable Care Act didn’t also include measures to increase the number of primary care physicians to offset this. Some of the measures in the Affordable Care Act which will help increase the number of primary care physicians can be seen here.

Often people are unaware of how new physicians in an area are a result of the Affordable Care Act. While researching this post I stumbled across this press release for a new Family Medicine Residency Program in San Diego, which has been designated a health shortage area for several years. It reports that, “The training program was made possible by the Affordable Care Act, which created the new Teaching Health Center Graduate Medical Education Program (THCGME) to establish physician training programs in underserved community-based settings.” I was glad that the ACA received credit for the establishment of this program.

Those who studied the Affordable Care Act did not take the Republican scare stories of shortages seriously. In December, Scott Gottlieb, who advised George W. Bush, and  Ezekiel J. Emanuel, an adviser to Barack Obama on the Affordable Care Act, jointly wrote an op-ed in The New York Times entitled, No, There Won’t Be a Doctor Shortage. They explained how changes in health care delivery will offset the increased demand both from the newly insured and an aging population.

The physician shortage has been studied extensively and while increased demand due to newly insured is expected to play a role, other factors are expected to be far more important with regard to the physician shortage. For example, The Manhattan Institute concluded, “Ultimately, the impact of Obamacare on the primary-care physician shortage, rather than just the increase in demand for primary-care physicians, is relatively minor: the insurance expansion will require about 5,000 more doctors in 2025, compared with about 25,000 more physicians who will be required because of demographic changes and population growth.”

The National Center for Health Workforce Analysis found that the aging population is by far has the greatest influence on future projected shortages, accounting for 81 percent of increased demand. They also project that many of the shortages can be alleviated by increased use of nurse practitioners and PA’s, increasing from 23 percent of primary care services in 2010 to 28 percent in 2020. This would still leave physicians as the primary providers of care, decreasing from 77 percent of the primary care services in 2010 to 72 percent in 2020. I don’t think that there is any doubt that NP’s and PA’s can handle this amount of routine primary care. This would reduce their projected shortage of 20,400 physicians in 2020 to 6,400.

While the number of newly insured has already been accounted for in projections (often assuming full Medicaid expansion nation wide), the number of new programs to expand primary care, and other ways to transform health care to make it more efficient, can still be increased over time. Increased government involvement in health care can lead to additional solutions which would not occur if we continued the old, inefficient system. The Affordable Care Act also has provisions requiring insurance companies to maintain panels with an adequate number of physicians. While such requirements might be meaningless if there aren’t enough physicians available, they do protect consumers from problems such as insurance companies limiting the size of their physician panels too drastically in order to reduce costs.

We already have a shortage of primary care physicians in many areas and will face challenges in the future, but the Affordable Care Act should not be blamed for this problem. The impact will vary in different areas, but overall the result of the newly insured should not create major problems for the health care system.

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SciFi Weekend: Hannibal; Orphan Black; The Americans; Agents of SHIELD; Community; Arrow; Continuum

May 11, 2014 — Ron Chusid

Hannabal s02e11

Ko No Mono is the beginning of the end for Hannibal, now providing a clear path to the scene in the season premier with Jack and Hannibal fighting. Alana Bloom has been terribly under utilized this season but played a key role in this episode. She represented the audience, expressing the same questions I had from the perspective of a character on the show.

Last week’s episode left two possibilities. Either Will had killed Freddie Lounds and Hannibal has succeeded in turning him into a monster, or there is an elaborate scheme to expose and capture Hannibal. My view of the show would be forever changed if it turned out that Will has become like Hannibal and no longer a sympathetic protagonist.  Alana’s question was limited to wondering if Will had killed Freddie, and the answer to that would provide the viewer with the answer to what we were wondering.

It is a common axiom in reviewing genre shows that if there is no body the victim very well might still be alive. Bryan Fuller really played with the audience on that one.  We got funeral, and saw a burning body which could not be confirmed as Freddie’s visually by the audience, but which provided possible confirmation to those aware of her fate in the novels. Of course Fuller has displayed a tendency to take aspects from the novels but alter them or have them occur at different times to keep things interesting. Once Jack “verified” that the body was Freddie’s from dental records it became even more clear that Freddie was dead or there was a very elaborate scheme, which would have to include Jack along with Will, to fake Freddie’s death.

This question was answered with another question, with Freddie asking Alana, “How was my funeral?” Alena seemed so distraught over the situation that it was hard for Jack not to let her in on the secret, but this might be a big mistake. Even assuming that Alana doesn’t intentionally give away the secret, there is too great a risk that Hannibal will sense that something is wrong. Perhaps that is why the season ends in a fight as opposed to a more organized arrest.

The other theme of the episode was parenthood and surrogate parenthood. This included a look back at Abigail, Hannibal’s perception of fathering a new Will who has adopted his views on killing, and sadly Margot’s terminated pregnancy. Mason Verger is turning into the even bigger villain of the season.

Hannibal freddie-lounds1

Bryan Fuller discussed the revelation that Freddie was alive and Margot’s desire for children:

AVC: So the end of this episode reveals that Freddie’s alive. Jack is in on the plan somehow. How cognizant are you of not letting those story points stretch out too long?

BF: We had originally talked about, gosh, how long can we keep Freddie dead? Because we wanted to make sure that the audience felt that she was dead, and that’s why we used the flaming wheelchair. Those who are close to the material know that is how Freddie Lounds goes out, so we wanted to make sure that the audience felt that she was dead, and that the funeral was a real funeral. Also, telling the story through Alana’s eyes as she’s like, “What the hell is going on with everybody?! Everybody’s lost their minds!” and to really feel that kind of mounting panic and dread that she’s experiencing. We felt like to clear the path for episode 12 to really be the final episode with the arc between the triangle of Will, Mason, and Hannibal, we really needed to wrap that up by the end of 11 and put all of our cards on the table at that point. What I think is really fun about using the wheelchair death is it tells the audience that, oh gosh, Freddie very well may be dead, because they used the actual way that she dies. But in a fun way, I loved forecasting the moment between Hannibal Lecter and Francis Dolarhyde in the Red Dragon story where Hannibal Lecter is part of Freddie’s demise and says, “If you’re going to kill Freddie Lounds, this is exactly how she has to go out, because she faked it once and I’m not particularly happy with her for that.”

AVC: Why does Margot want to have a child with Will?

BF: That was a big element of the novel, was Margot’s desire to have a child and I thought, “Well, wouldn’t it be interesting if Will Graham became the device to achieve that goal?” That way, we had elements of the future story that we had recombined with other stories so they felt distinct from the novel but reflective of the novel at the same time. I think it goes back to that Thomas Harris mash-up DJ aesthetic that we have with this show, where we’re pulling elements that suit us for any given story and then mixing them in as needed. It also felt like a clever way for Margot to get back at her brother. We knew from the book that Margot had been cut out of her father’s will for being a lesbian and not being able to breed, and the stipulation had been put into the will that only an heir proven to be of the blood of the Verger clan would be deemed legitimate. So it set into motion a very crafty plan of Margot’s, “Well, I’ll get pregnant and once the baby is born I’ll kill my brother, and I will not have to deal with him anymore or his evil ways.” It felt like she was being very crafty, and she’s waving her uterus around like a loaded weapon. So that felt like it was part of the new Margot and part of her new agenda for dealing with her brother and also giving her a little bit more strength. Also, it puts her clearly on the chessboard as one of Hannibal Lecter’s pawns, and he is now influencing and moving her piece around to suit his greater agenda.

Fortunately Hannibal was renewed for another season. NBC sadly canceled Community, giving us the darkest timeline, with fans hoping someone else will pick up the show. SpoilerTV doesn’t think it is likely to happen. At least the show went out with an excellent season with Dan Harmon back. I think NBC did make the right move in deciding to permanently turn out the lights on Revolution. There is a lot of other news regarding cancellations, renewals, and new shows picked up, but being a holiday weekend I’ll hold off on most of the other news until a later post. I’ll also be brief in looking at the other shows this week.

ORPHAN-BLACK Helena

In other genre shows of the week, Orphan Black provided more information on Mrs. S. and Project Leda. Alison is in rehab, we learned whether Helena could have children, and there was a reunion of sisters. Orphan Black c0-creator Graeme Manson discussed the reunion scene:

ENTERTAINMENT WEEKLY: Let’s start with what has to be the creepiest sisterly reunion ever — one in a bloody white wedding dress and the other bleeding and in handcuffs in the bathroom. You’re a sicko, Graeme.
GRAEME MANSON: Homage to Carrie, all the way. The director did a great job with that scene and it’s right up the alley of what John Fawcett and I really like. It really slips into horror mode there and we like that the show has that elastic tone that we can do that. We expect a lot of Helenas in bloody wedding dresses at Comic-Con this year. It’s a truly freaky and wonderful scene, and just the fact that it has that horror and its broken by the sisterhood and by forgiveness is one of the great clone-on-clone scenes we’ve done, I think.

EW: You can feel and read the terror on Tatiana’s face as Sarah in that scene. Just an unbelievable job she does in that moment.
MANSON: It was. And it was a really hard scene for the crew to watch, because Tatiana really went there. It was scary. She was scaring the whole crew. And then you yell “Cut!” and everyone just has this ball in the pit of their stomach and Tatiana recovers immediately and is immediately smiling and laughing.

Americans Stealth

Larrick  has turned into the big bad for the season on The Americans, and is getting closer to Elizabeth and Phillip. With no progress finding out who murdered Emmet and Leanne, I wonder if Larrick’s earlier denial should be believed. Of course there are still two episodes in which to advance that storyline.

I was  sad to see Kate go, but she was clearly over her head. Now I wonder what the deal was with Jared, between Kate meeting him with no disguise and her encoded note to “Get Jared out.” I suspect he knows about his parents, and possibly realizes who Elizabeth is. Is he already working as a spy with Kate his handler?

Nina made the obvious move of turning to Stan for help in avoiding a forced return to Russia to stand trial. Will she take the next step in convincing him to get the information on Echo for her so that the two can remain together, as opposed to Nina going into hiding?

CLARK GREGG, MING-NA WEN

Agents of SHIELD presented Grant’s back story, and it was rather disappointing. Being left out in the woods was not the type of training I expected. Just because he spared the dog should not mean that he gets to be redeemed as a good guy in the end, but I suspect that that might be where the show is going. Sparing Fitz and Simmons is also not enough (and might be considered two points against him). Besides, evil Grant is a much more interesting character than the Grant we saw most of the season.

Skye has also improved as a character in recent episodes, actually showing that she has some skills. The story with Cybertek was also weak, but I suspect this was set up for the season finale, in which Nick Fury returns. After a run of excellent episodes I can forgive this one, although if they didn’t have a better back story for Grant it might have been better just to leave it out.

It looks like Arrow is getting ready for a comic book style big battle with Malcolm Merlin and the League of Assassins joining up with Team Arrow to take down Slade.

It also looks like Person of Interest and The Blacklist will have big season finales this week.

For those watching Continuum on Syfy, it might seem like things aren’t moving very fast this season, but big things happen on the next two episodes which have aired in Canada. No spoilers.

Posted in Entertainment & Leisure, Science Fiction. Tags: , , , , , , , , , , , , . No Comments »

Rand Paul Could Shake Up An Election Against Hillary Clinton

May 10, 2014 — Ron Chusid

Senators Gather To Caucus Over Hagel Nomination

While Ron Paul had a small devoted group of supporters, everyone knew he had no real chance of seriously competing for the Republican nomination. There’s something about being a new face, and being from the Senate instead of the House. People are looking far more seriously at the possibility of Rand Paul becoming the Republican nominee.

Not that long ago, most Republican leaders saw Rand Paul as the head of an important faction who, like his father, ultimately had no shot at becoming the party’s presidential nominee.

Now the question is no longer whether Paul can win the nomination, but whether he can win a general election.

The shift follows a year in which the Kentucky senator has barnstormed the country, trying to expand the party’s base beyond older, white voters and attract a following beyond than the libertarian devotees of his father, Ron Paul. Although the job is far from complete, Paul has made undeniable progress, judging from interviews with more than 30 Republican National Committee members meeting here this week.

That he has struck a chord with this crowd is all the more telling because it is heavy with GOP establishment-types who tend to prefer mainstream candidates.

“I don’t see how anyone could say it’s not possible he’d win the nomination,” Texas GOP chairman Steve Munisteri said. “His mission is to convince people of what his coalition would be in November” 2016…

At the moment it doesn’t really look likely that Rand Paul could win, but they said the same about Ronald Reagan.

Many of Paul’s views remain at odds with the Republican mainstream, but he now seems less of a pariah among Republicans than Mitt Romney was in many circles. It is possible Paul could win a primary battle with the vote divided between more conventional Republican candidates. He would also benefit from the first contests being a caucus in Iowa and a primary in New Hampshire. He could conceivable wind up in first place in both and quickly turn into the front runner.

If Paul does win the nomination, Democrats might need to rethink handing the nomination to Hillary Clinton. What happens when the Republican candidate starts attacking Hillary Clinton over her support for the Iraq war, drone strikes, NSA surveillance, the Patriot Act, and the drug war? Paul might also turn Clinton’s close ties to Wall Street into a serious liability. Many potential Democratic voters might find that they agree with Paul and disagree with Clinton on several issues.

Of course Rand Paul is also on the wrong side of many issues, but can we count on Clinton to take advantage of this? Republicans already have managed to put Democrats on the defensive on issues such as Medicare and health care–two issues where they have facts and principle firmly on their side.

Paul would face many obstacles. His opposition to abortion rights could limit his ability to win over female voters from the Democrats, perpetuating the gender gap between the parties. His anti-war views would be a negative in many red states, possibly even leading to upsets in some red states by a hawkish Democrat such as Clinton.

Looking at the electoral college, I don’t think Paul could win, a race between Clinton and Paul would shake up many of the current party-line divisions. I could see Paul taking some states such as New Hampshire from the Democrats, but not many with large amounts of electoral votes, with the possible exception of California. Still, with their current disadvantages in the electoral college this might be the best chance for Republicans, and a potential threat for Democrats, especially if looking at shaking up the current Democratic advantage among younger voters. I could see many young males being far more interested in Paul on the issues where he is more libertarian, while not being as concerned about issues such as preserving Medicare. This could destroy what now appears to be a long-term Democratic advantage, considering that people tend to stick with the party they chose when young. Democrats might still win the 2016 battle by running Clinton against Paul, but could suffer long term from such a match up.

Posted in Civil Liberties, Drug Policy, Health Care, Hillary Clinton, Republicans, Ron Paul, Social Issues. Tags: , , , , , , , , , , . No Comments »

Defending and Attacking Presidents In The New Media Age

May 9, 2014 — Ron Chusid

Obama media

There is some amazing tunnel vision from James Oliphant in an article on the progressive blogosphere. An article on the subject, or even  how it often helps Obama, might make sense. This does not make sense once you get to the second paragraph quoted below:

It’s been a familiar pattern since President Obama took office in 2009: When critics attack, the White House can count on a posse of progressive writers to ride to its rescue. Pick an issue, from the Affordable Care Act to Ukraine to the economy to controversies involving the Internal Revenue Service and Benghazi, and you’ll find the same voices again and again, on the Web and on Twitter, giving the president cover while savaging the opposition. And typically doing it with sharper tongues and tighter arguments than the White House itself.

While the bond between presidential administrations and friendly opinion-shapers goes back as far as the nation itself, no White House has ever enjoyed the luxury that this one has, in which its arguments and talking points can be advanced on a day-by-day, minute-by-minute basis. No longer must it await the evening news or the morning op-ed page to witness the fruits of its messaging efforts.

At least he recognized that sometimes Obama receives criticism from the left further in the column, even if the article does downplay how often this happens. Still, in general, I’ll accept that quite often “the White House can count on a posse of progressive writers to ride to its rescue.” What is wrong is the claim that no White House has ever enjoyed such a luxury.

There are plenty of conservative bloggers to counter liberal bloggers–both having defended Bush when he is in office and in intensifying the attacks on Obama. Obama might have more defenders thanks to the blogosphere, but he also has far more people attacking him, quite often with totally manufactured attacks.

Maybe the conservative blogosphere isn’t as potent a force as the progressive blogosphere. It doesn’t matter. Bush had Fox , which is essentially the unofficial propaganda arm of the Republican Party, actively defending and often lying for him.  Bush had the right wing noise machine defending him to a far greater effect than blogs are capable of defending Obama.

When there is not a Republican in the White House, Fox does a 180 degree switch in outlook, having been the biggest attacker of both Clinton and Obama. Fortunately Clinton had his own people to defend him as the liberal blogsophere was not yet a meaningful force back then. Fox provides far more assistance for the right than MSNBC is capable of doing for the left, and there is barely an equivalent to right wing talk radio on the left. On the other hand Obama does have Jon Stewart’s fake news show defending him from the attacks coming from the fake news shows on Fox, when Stewart is not criticizing him from the left.

These days both Democratic and Republican presidents are going to have far more defenders and attackers than was the case in the past, with the progressive blogosphere defending Obama (when not criticizing him from the left) not being anything unique to Obama.

Posted in Barack Obama, Bill Clinton, Blogs & Social Media, George Bush, News Media. Tags: , , , , , , , , . No Comments »

Vulnerable Democrat Takes Offensive On Obamacare

May 8, 2014 — Ron Chusid

I have been writing for a while that Democrats need to take the offensive on the Affordable Care Act. As long as they fail to promote its significant accomplishments, voters will only hear the Republican misinformation. If Democrats act scared, people will assume they have something to be afraid of. I was happy to see this example of a Democrat in a tight race using Medicaid expansion in the Affordable Care Act to her benefit:

In a flipping of the proverbial script, a Senate Democrat facing a tough re-election race used a confirmation hearing of Sylvia Mathews Burwell, nominated to head the Department of Health and Human Services, to advocate forcefully in favor of Obamacare.

While Republican senators mostly went through the motions with their anti-Obamacare talking points or outright endorsed Burwell as Kathleen Sebelius’s replacement, Sen. Kay Hagan (D-NC) used her time to trumpet the benefits of Medicaid expansion — and emphasize the downside of not expanding.

Left unsaid, but strongly implied, was that her opponent, North Carolina House Speaker Thom Tillis, who locked up the GOP nomination earlier this week, had been instrumental in stopping the state from expanding Medicaid under the law.

“Last year in North Carolina, our state legislature and governor decided against expanding the state’s Medicaid program,” Hagan said as she started her questioning, “and as a result, about 500,000 people who would have qualified for coverage through Medicaid are not now able to do so.”

“These are some of the most vulnerable in our society,” she said, “who will continue to seek care in emergency rooms and then will leave chronic conditions unmanaged, which we know is detrimental to their health and the economy.”

Hagan is one of the most vulnerable Senate Democrats, holding a slim 0.8 percent polling advantage over Tillis per Real Clear Politics. She has been one of the targets in the American for Prosperity’s air campaign, which has attacked her for her support of the law.

“We’ve already seen a decrease in the number of uninsured” in Medicaid-expanding states, Burwell said after Hagan asked to compare the experiences of states that had expanded and states, like North Carolina, that had not.

Hagan then gave the example of a 35-year-old single woman whose income is below the federal poverty level — therefore falling in the Medicaid expansion gap, which in non-expanding states means that those Americans will not have access to health coverage under Obamacare.

“So if a state had expanded it, she would have had access,” Hagan said, “where in the 24 states that haven’t expanded it, there is this huge number of people, in my state, 500,000, that are still without coverage.”

Burwell said those people would not be subject to the law’s individual mandate, but added: “It doesn’t address the fundamental issue that you’re talking about which is: Do they have health care coverage?”

Hagan completed her line of questioning by asking how much it would cost states to expand Medicaid in 2014, surely knowing that the federal government covers 100 percent of the costs through 2016.

“That would be zero,” Burwell said. “The state doesn’t pay.”

Posted in Democrats, Health Care. Tags: , , . No Comments »
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