Health insurance coverage is in a way better place than it was in 2004. My state's healthcare system is falling apart and it's nearly impossible to get a primary care doctor unless you have money to go concierge. Just broken post COVID and the long developing primary care shortage is getting worse as boomers retire.
Good point. The shortage of healthcare is separate from the coverage.
The shortage of so many things - housing, healthcare, transit, college slots, etc - each has their own story, but they all are an abdication of responsibility by the folks in charge. Nationally because of Republicans, but statewide and locally for different reasons.
But getting home care or a bed in a SNF is nearly impossible. Our Emergency Departments are overwhelmed, boarding in EDs for people who need a mental health bed is at an all-time high. Length of Stay in hospitals has gone up, so even people who need to be admitted from the ED can't be.
And we got RomneyCare in 2006. The subsidies were a lot less generous but it was something, so we had pretty high rates of insurance. In fact, now ai would argue that we have higher rates of under-insurance as companies switch to high deductible plans and more people report that they deferred care due to cost.
Length of stay going up is probably a good thing, as a counterbalance to when you used to get ejected due to insurance caps. The problem is that we need more doctors, hospitals, and health care staff, but no one is willing to do anything besides leave it to the free market.
Early 2000s Dan Savage was really instrumental on my journey to liberalism.
5: they're saying LOS is going up because the patients are sicker. Hospitals don't like it. I'm not sure how doctors bill but hospitals get paid based on something called DRGs. So , you coukd have pneumonia or complex pneumonia or something and then you get a certain amount of money, but you aren't paid by the day, so if a patient stays a really long time, the hospital will lose money. Flow into skilled nursing is halted, because they can't staff up. Nursing homes can't hire staff, because CNA work is hard and right now McDonald's and Target pay better.
There's work right now on home hospital. I just worry that's dumping the work onto families.
I actually think we may get some action at the state level, because everybody knows that we can't rely on Washington with Trump in power.
"The DRG system was first introduced in 1982 as part of the Medicare Prospective Payment System (PPS). The PPS was designed to control healthcare costs by reimbursing hospitals a fixed amount for each patient based on their DRG. This system incentivizes hospitals to provide efficient and cost-effective care."
We can blame Reagan.
I'm generally always comfortable blaming Reagan.
I'm guessing Dan Savage has come around on trans people in the past 20 years? My memory is that that was the flashpoint here, regarding him, 20 years ago.
I think the controversy around Dan Savage and Trans activists falls pretty squarely in the grey area of where I don't know what exactly the rules are on what you are and aren't allowed to say here, and would prefer not to discuss it here. That is, I agree with your policy decision to ban certain viewpoints on Trans issues on the blog and think it has improved the discussion, but I do think it just means we should avoid topics where it's really unclear what exactly would run afoul of that. At any rate, the early 2000s that I'm talking about was long before this controversy really erupted.
Yeah, I imagine it's not worth rehashing.
FWIW my understanding is that Savage has, indeed, more or less come around. There were slurs lots of people used in the 00s (including on this blog!) that he doesn't use now, and I wouldn't worry about him being on the wrong side of major battle lines as they're now being drawn in the US. (Honestly, if I were Sarah McBride I wouldn't want to share a bathroom with MTG either.)
I'm just a simple incompletely urbanized farmer, but living in cities is nice because there's jobs that pay much more money any rural job that isn't doctor or lawyer.
I mean, I can do all the urban things but I can't parallel park.
Savage here is endorsing the Big Sort, which I can sympathize with because I've been sorted into Blue America myself and didn't like living among the troglodytes when I was in Tennessee. But this is not the path to political power.
The best we can hope for is that the blue states can minimize the damage. Plus (as Savage suggests) we can take some grim satisfaction in the fact that the red state rubes are destroying themselves. But even in a pandemic, not enough of them died to make a difference, and they took a lot of us with them.
8: This is one of the things Reagan administration did but that I don't blame on his politics. Medicare paid hospitals at literally their costs starting in the 60s; as a result their costs were skyrocketing, to the point that federal costs were growing by double-digit percentages every year in the late 70's. Incentivizing hospitals to get LOS down has negative side effects, sure, but there was bound to be some kind of control out of pure fiscal responsibility. DRG is actually seen as a pretty well-thought-out policy overall compared to hack-and-slash style cuts - they carefully analyzed what types of hospital stay should result in what costs, then held hospitals to that average, with adjustments for various factors, and then for really long stays they go back to costs. I think some of Europe may have even borrowed from it.
Underlying issues of scarcity make it worse of course. Our hospitals shouldn't cost thousands a day total.
Really, we just need to follow the Big Sort to its natural conclusion and mutually break into a few smaller countries. The reds want this too.
(And this way Gavin could finally be president of something! Although I think CA has soured on him.)
President Barbara Lee (ceremonial), Prime Minister Robert Rivas
I don't understand the assignment.
Geddy Lee can be elected President per the 22nd Amendment, but he can't be President per Article II, Section 1. This is another possible mechanism for a third Trump term.
17: Yeah, I know it's more complicated. I didn't want to get too into the weeds though. I do believe Medicaid pays behavioral health providers a flat rate by the day, but I'm not sure. Inpatient Medicaid is always a money loser, outpatient not so much.
During my research trip to Florida, I've learned that it is getting hard to find a doctor that takes Medicare.
I wish the big sort got us a Republican party that actually did concrete things for rural and small town America. Like some kind of tax on companies that only have retail in the biggest cities (I'm looking at you Apple!!), or big subsidies to rural medicine, etc. But the actual Republican party doesn't give one shit about rural America.
Did you know Apple has 9 locations in metro Chicago and zero in the rest of Illinois? It makes me angry.
I do believe Medicaid pays behavioral health providers a flat rate by the day, but I'm not sure.
Yes, Medicaid is different from Medicare and how it's different will vary widely state-by-state, although where I am it has slowly moved toward a comparable DRG system. Behavioral health remains one of the most primitively designed.
25: My godmother was an only child and inherited her parents' house in Northern Florida. She and her husband see some specialists there. They have an apartment in MA that they keep because they have ties here, but also because they have primary care doctors at the University Health Services where she worked.
Around here, it's just hard to get a doctor or other provider no matter what insurance you have unless you can go concierge.
28: we have a small number of people in the Primary Care Clinician Plan. Most have been put into Accontable Care Organization run by a health system or a health system paired with an insurer. There are some managed care plans plus integrated plans for dual eligible. Many quality metrics in the ACOs,but mostly it's full assumption of risk with bonuses for quality and a primary care sub-capitation. Steward had an ACO,
I'm not a fan. I think the problem with FFS is what's covered and how much various providers are paid, and there's too much room for gaming and scrimping on care in an ACO as well as too much incentive to refer in network even if a patient has other preferences.
Do we have any current-ish commenters who live in counties that went for Trump? Have we all been sorted?
big subsidies to rural medicine
Hello Medicaid expansion! Part of the ACA, passed with zero Republican votes. John Roberts invented some constitutional jiggery-pokery to let states opt out, and nine of the ten that are still opted out are solidly Republican states, all but two in the old Confederacy. Louisiana has it thanks to a Democratic governor, and I think Arkansas got it by referendum or something else that went around a Republican establishment. (Wisconsin is the weird holdout, but I think that has to do with whatshisface the R governor people thought would be president and a ton of gerrymandering that's led to minority R rule in the legislature.)
Part of the expansion was a reworking of federal financing for rural hospitals, and by turning down the expansion Republicans ensured that their rural hospitals would lose a ton of free federal money. Good job guys!
All of which is a long way to repeat 26.last: But the actual Republican party doesn't give one shit about rural America.
Rural Texas is so hard pressed that they have turned the local grain silo into a lifestyle marketing center.
How's Waco? You could do worse than going to see some old mammoth bones here.
But we're not in Nebraska, now are we. Go watch the stupid bones.
It does sound better team than the Dr Pepper Museum.
33: No, Anchorage went for Harris (and Biden in 2020).
Mooseking's county, if I have it right, narrowly went Trump/Vance.
It's a weird conversation, because the most salient fact of the election to me is Democrats losing a large numbers of urban working class votes. And what DS says about it is, I think, wrong:
Cities are still our stronghold. We need to shore those strongholds up. That's the lesson of 2024. I think, culturally, in the cities, you know, this is when I'm gonna get in trouble. Because I am a part -- this is not me criticizing the left. I am of the left. And I am part of, I think, at times, the insufferable left as well. But cities are the places where people had the most interactions with the insufferable left, with the scolds, with the people who are policing language, with the people who are elevating.
I don't think the rightward shift in cities is primarily about people reacting to liberal rhetoric. It's a feeling that the Democratic governing class doesn't care about, or doesn't have solutions for, the material realities that matter to them: (1) cost of housing and food and (2) the perception of increasing public disorder during the pandemic and migrant crisis.
My South Brooklyn state assembly seat flipped on this stuff (and the niche NYC issue of exam school politics, because of the large Asian population).
https://www.thecity.nyc/2024/11/06/steve-chan-iwen-chu-red-wave-southern-brooklyn/
I think it's definitely true that if Democrats are going to increasingly be the party of cities, and they are, they need to get a lot better at urban governance.
RFK Jr has the best mammoth bones
31: I see you stayed sorted. (Shift from 2016.) But boy is Comal a sort the other way.
31, 40: Yes, my county turned pink this election, after a couple on the right side.
41: You're right; our loudest battles are mostly about how to handle homeless encampments, which is very much a (2) public disorder issue. My mildly blue city aligned with the redder county on moving homeless ordinances this year, in the wake of the supreme court decision and green light from the state.
Making a serious effort to address housing costs and homelessness (which are the same problem although people don't usually see it that way) would go a long way to improve city governance. It's a solvable problem but most municipal elected officials seem to be too beholden to NIMBYs to do what it takes.
Cala is in a Republican county, right?
41: I have not had a chance to read it in detail, but here is a pretty comprehensive look at a lot of different trends in the election by a numbers guy in New York City.
He covers a lot, but with some special attention to NYC. One thing he shows is that for the most part the move away from Biden is similar to the move away from Ds with Hochul. (some further erosion in places like South Bronx.)
In cities there was both some change to R and a lot lower D turnout.
47: If she is in Salt Lake County itself, no. But everything else there except Summit (Park City) was R.
A small county on Colorado border also D.
the large Asian population
I think they go by "Samoan."
But boy is Comal a sort the other way.
Oh yeah. True nest of Nazis and wealthy people there. It's wild how balkanized this area is.
I'd happily live in plenty of red counties, but it'd be a blue city (eg Lancaster PA). My county just has too few people to swing the county against the county seat.
Our county has turned blue as Austin has spilled south. The city has been blue for a long time, but wasn't enough to swing the county.
Franklin and Marshall didn't give us any aid, so no Lancaster.
31: Me. We are mostly white, and relatively less educated compared to the rest of New Jersey, with the largest employers being oil refineries, a container port, and Amazon warehouses. A fair number work in the Philadelphia Navy Yard, building ships, and a few work in the Atlantic City casinos. My congressman is a longshoreman, and displays a local community college certificate above his desk, where most Congressmen have their law school diplomas (he's a union guy and a democrat). The other half of the county is represented by Jeff VanHorn, the only Democrat who voted against the first Trump impeachment, after which he changed parties and keeps winning. We're sorting in the wrong direction.
My pet peeve (not that I expect anything to be done about it) is that we pretend this is not an urbanized country by classifying the suburbs as non-cities, when they're part and parcel of cities. I think the Census is right that no more than 20% of the population is rural and the rest is urban.
Not that people are wrong to do analysis splitting "cities" and "suburbs". The distinction is understood by all as it's intended. I just don't like how it's wormed its way into our thinking.
58: In MA, we have very small amount of rural areas, a few small-ish cities and lots of suburbs. There is a real divide on a lot of issues between the suburbs and cities even though both vote for Democratic candidates at the Federal level.
Well now you made me look up the results just for the fun of it.
City: 86% Harris, 8.2% Trump, 2.0% Harris. This was an improvement for Trump, I think last time was 94% Biden.
County: 67.8% Harris, 29.1 Trump
WRT to healthcare costs, the huge disconnect between list prices and insurance paid rates is beyond anything that makes sense. Sure they want to have price discrimination networks and such, but why not just say the list price is a billion dollars if everything (including payment plans for uninsured) is a negotiation. My large interaction with the system a couple years ago revealed that the operating room was something like $6k per 15 minutes, 8 hour surgery was $192k but insurance paid about $20k. I don't think they negotiate from the perspective of a 90% discount (if list had been $1M insurance would still have paid about 20k not 100k) so where do the list prices come from? Some historical baseline adjusted annually over decades?
31: me, too. Trumpy around here.
To BG: What does "go concierge" mean? I mean, from context it obviously means pay more than others can afford for medical care, but why "concierge?"
From last week:
https://www.bostonglobe.com/2024/11/15/business/concierge-medicine-doctors-primary-care-yearly-membership-fee/
First few paragraphs:
Money can buy lots of stuff. But one of its greatest perks is the ability to make life more frictionless: A first-class airline ticket will expedite you through the airport and onto the plane. An upgraded theme park ticket will allow you to cut to the front of the line.
But if you have a few thousand dollars to make your trip to Disney World more enjoyable, why not use that money for something far more consequential? Like skipping the incredibly long line at your doctor's office.
"If you look at it from the perspective of people who have high income, or relatively high income," says Asaf Bitton, a primary care doctor and associate professor of medicine and health care policy at Harvard Medical School and the T.H. Chan School of Public Health, "$2,000 or $5,000 a year is something you'd spend on a vacation. So I've heard people say: 'Why wouldn't I spend that on my health?'"
Over the last two decades, that's exactly what has happened, as more and more doctors and patients have turned to "concierge medicine," which provides enhanced medical services for a yearly membership fee. Often, that fee falls between $2,000 to $10,000 a year, but it can run as high as $30,000 or $50,000, in addition to typical insurance reimbursements.
The fee generally gets you more time with your doctor, quick access to appointments, better connections with a network of specialists, and a simple way to contact your doctor when you need advice. But the rise of concierge medicine puts pressure on an already-strained primary care system -- a system that's not attracting enough physicians and has become increasingly reliant on nurse practitioners, nurses, and physician assistants.
SP beat me to it. It started out as somethingg incredibly expensive $40k in today's equivalent dollars that only he most entitled executives paid for instant access to the doctor any hou of te day or night. Doctors would have panels of 100 patients or less for full time practice. Now, there are versions that are much less and get you longer appointments and easier access but they still have NPs. It's a little bit nicer than the average experience in the 80's, but not by a ton.
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"It's not a full reopening. While some activities are occurring, they are mainly limited to the transportation of bananas."|>
Anyway, I'm running in a fancier milieu than is my usual wont. I just paid $40 for two mixed drinks and the bitters were artisanal or something.
I also learned that my extremely anti-abortion cousin is trying to find a lawyer to argue that her grandson shouldn't have to pay child support for a child he conceived at 18. Because of religious freedom. (They either weren't invited or didn't come, so people can gossip.)
The bitters were very good though.
Moby is but a simple soy farmer, at the mercy of the sophisticated urban hipsters of Waco.
her grandson shouldn't have to pay child support for a child he conceived at 18. Because of religious freedom
Do they worship money?
I don't think so. My least-reliable aunt told the story. The argument was that the child was not conceived in a wedded relationship and therefore in violation of his Catholic beliefs, so it's against Catholicism to make him pay child support.
74 The answer to 73 is clearly yes.
I think it's more "we get to do what we want" than money. At least, they don't have much money, so if they worship it, they did poorly.
I only know the grandparents of the father of the kid. The father of the kid is probably a minor as he just started college and the age of majority in Nebraska is 19. I've never met his father and have never seen his mother except when she was a child.
The grandmother was a named plaintiff in lawsuits about the abortion initiatives on th ballot earlier this month.
Anybody have any touristy recommendations for my family when we visit Boston to see son #2 next week? We have an airbnb in Roxbury and I was so looking forward to a duck tour Friday but the forecast high is 44 degrees, winds 10-20 and good chance of showers so probably we won't. Apparently there's a little tiny museum in a park 1/2 mile from the house so we'll walk over there, and we'll also probably sightsee a bit over by BU where son #2's room is. 87 year old grandma will be with us and long walks (more than a mile or two) are also a problem for another one of our decrepit family. But otherwise - ? Aquarium? Other fun stuff?
NMM Alice Brock, the Alice of Alice's Restaurant,
80: dang, under a week till her big day.
As this has become a random thread, I'll add that I just got home from spending 7.5 straight hours helping my TA put together her application for asylum and I am mentally and emotionally exhausted. I can only imagine how she's feeling. We've been working on the application for a few weeks now and--pending a document or two she should receive shortly--she's now ready to submit it. I'm a lot less worried about her individual case than I am about her family members that my friends and I are trying to bring to the US and Canada through private refugee sponsorships, but it's still A LOT. Our only consolation is that her personal situation puts her into one of the few groups of refugees for whom there's still substantial bipartisan support.
MFA is near Roxbury if you want a museum. Steal a painting while there, it's the thing to do.
Aquarium is good. Don't bother with Faneuil Hall and Quincy Market or the dumb Tea Party boats. ICA is fairly close if you prefer modern art.
Near BU... hmm, could do a tour of Fenway Park?
The patriarchy is really explicit here.
were there mason jars and a barn, and edison bulbs and string lighting?
Country Club with regular stemware and lights.
Did they sing Cross the Brazos in Waco at the reception?
As alluded to in the Bile thread:
Randy Newman's "Marriage in McLennan Cherokee County":
Today we will be married
And all the freaks that she knows will be there
And all the people from the village will be there
To congratulate us
I will carry her across the threshold
I will make dim the light
I will attempt to spend my love within her
Though I'll try with all my might
She'll laugh at my mighty sword
She'll laugh at my mighty sword
Why must everybody laugh at my mighty sword?
Lord, help me if you will
Maybe we're both crazy, I don't know
Maybe that's why I love her so
On the OP. That it seems almost transgressive in contrast to an absolute flood of pieces on Dem/Libs just don't get the rurals is telling.
The high-information, well-informed voters just aren't spending enough time overthinking the low-information vote-on-a-whim underthinkers.
Quick: I need a good road trip book. Good engaging story, nothing too gory/extremely sexual, since the 10 year old often listens in.
97: asking Labrys--
My Grandmother Asked Me To Tell You She's Sorry: https://elitistbookreviews.com/2017/04/25/my-grandmother-asked-me-to-tell-you-shes-sorry/
Mrs Polifax novels: https://en.m.wikipedia.org/wiki/Emily_Pollifax
The last time there was handwringing over how the Dems lost the rurals it turned out that what swung the election was upper middle class white dudes who identify with/cosplay as rurals. I don't want to get in the way of a circular firing squad but maybe the question is how to keep the suburbs bluer;;if the election is settled by 1/75 voters changing their mind, you can ignore actual rural counties because land doesn't vote.
Fun times at one of the Calabat's activities chatting casually about the red state/blue state being urban/rural. Yes, even Salt Lake County. No, you shouldn't take my word for it, you can totally look it up on your phone! Yes, it's the county North of Utah County. Yes, that blue one. Yeah, it's a nationwide thing. Probably is something about cities, yes. (To Other Mom's credit, she is remarkably intellectually curious in a way unusual for adults.)
97. Remarkably Bright Creatures? It's engaging, fairly light, and a 10 yr old might like it.
Whether or not it's the main thing that swung any particular election, it's absolutely true that rural areas are way way way more Republican now than they were 20 years ago.
These are great suggestions. We all loved one of Bachman's other books on a road trip, so I think I'll go for that one.
Remarkably Bright Creatures is a great suggestion - the ten year old is very into ocean creatures, even - but I've read it, and don't think I have the heart to read it again.
(I contemplated the Grossman book but then decided I wanted to enjoy the pleasure of reading it by myself.)
101: yes. When I first moved to Texas, I could listen to Texas and not be overwhelmed with seething rage at the hypocrisy and smarmy podunk fakeness. I lost the ability somewhere around the late 00's.
When I first went to Waco, I was overwhelmed with the number of stupid-big pickups.
Gotta have a big rig to cross the Brazos.
If You Ever Get to Waco Houston (Look me Down).
Texas is so this morning. Florida is the thing now.
Amanda...
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NNM to Alice (restaurant owner)
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Are the "pebbles" just bumpy, unpolished cement?
Anyway, the baggage claim was about as half-assed as I've ever seen.
103: I lost the ability somewhere around the late 00's.
Ann Richards died in 2006 and Molly Ivins died in 2007, so yeah, that tracks.
Wait. You're back in florida?! No, the pebbles are actually pebbles.
I'm afraid I can't help you from here.
But I'll be there tomorrow! But we're driving.
109: Saw that and was planning to e-mail heebie the l8nk from the article in the Globe.
117: I'll be in Bay City. Maybe even rolling.
There appears to be no bookstore in the Charlotte airport, despite it being huge.
97, probably too late: The Screaming Staircase.