Wednesday Night Open Thread

I just read some of the comments from the post below and I would like to state that you all suck and I never liked any of you.

Open Thread


Late Night ‘If Only It Physically Hurt to Be So Willfully Stupid’ Open Thread: Tucker Carlson, Nativist Poster Child

Shorter T-Carls: Why hasn’t the trailer trash security detail evicted all these scary strangers yet?????

Let me point out: Tucker Swanson McNear Carlson was born in 1969. He does not personally remember the 1950s, and he’s more than old enough to have figured out that change is a human constant, not a personal affront.

I encourage you to click over & read all of Michael Harriot’s hilarious excoriation of the “sentient celery stalk” at The Root:

Here we should point out that Hispanic immigrants have not pushed out Hazelton’s white population. There are just as many, or more white people in Hazelton as there have always been. There are just more Hispanics now. Hazelton just grew. Hazelton’s white residents are free to have as many white friends as they always had. For them, absolutely nothing has changed except they are now outnumbered. There’s a name for people who want to hold on to that kind of society:

White supremacists

Carlson’s entire argument is based on the fact that he doesn’t want to live around brown people. More pointedly, he doesn’t want to be a minority. But if—like Tucker often claims—he’s not a bigot and racism is overblown, why would he have any problem being a minority? After all, he’d still be white…

But he’d never know what those “Hispanics” were saying to each other, in their weird inscrutable furrin languages. They might even be laughing at him!

(Spoiler, Mr. Carlson: Even us monolingual White people are perfectly capable of laughing at you… )

Kids these days

The kids will be alright.


My first presidential vote was for Al Gore.

My first presidential donation was for Howard Dean.

My first presidential win was for Obama.

I’ve been pretty happy with my choices and my votes.  And the losses have been clusterfucks.

I don’t think that I am too unusual for the people of my generation and the generation that is younger than me.


Everyone my age and younger has seen Republican presidents lead us into dumb wars, insult, bully and harass our friends and family members  of color and/or non-hetero-cis gender identity and loot our futures while exacerbating large, long term climate problems.  We’ve seen that.  We’ve also seen the opposite.

Kids who are entering high school will have their political memories formed by the contrast of Trump and Obama.  Just think about that for a while.

The kids are all right; it is our job as old and not so old fogies to give them the time and space to grow.

A day in my life (health care thoughts)

Yesterday was a sick day. I needed a root canal.

I’ve always thought dental insurance is better visualized as a buyer’s discount club with some minimal insurance features instead of an insurance product with some buyer’s discount club features.  I estimate that my dental insurance has an actuarial value of about 50%.  The rest is out of pocket.

My endodontist started the procedure and about twenty minutes after I had been numbed up and the drill started to go through the crown of my tooth, she stopped and we had the following conversation:

“This is a little different than what’s on the X-ray”

“Is it a problem?”

“No, but I would like to do a scan to confirm the diagnosis, you okay with that?”

“How much would the scan cost and what does it get me?”

“$300 after your insurance pays, and it slightly decreases the chance you are in pain on Saturday”

“What are my baseline odds of pain?”

“Pretty low, I’m good at what I do…”

“Then no scan”


Twenty minutes later, the temporary crown was on and I was walking out the door.  As a health policy researcher and insurance geek, I was impressed with the radical price transparency and the discussion of value as my mouth was being worked on.  As a patient, this is something that I appreciated that I was not surprised with an unexpected $300 charge for minimal gain but it is not a decision that I was particularly able to make well.  I was operating at massive information asymmetry.  I had no way to evaluate whether or not my dentist was telling me the truth on how good she was and whether or not the baseline odds were accurate.

Once I got home, I checked the mail. And joy of joys, I received a revised bill from my son’s pediatrician.  We had taken him for his annual well child/vaccination update visit last July to an in-network provider.  The doctor’s office did not believe he was insured that day.  OOPS!

The HR office made an error on the special enrollment period membership file to the insurer.  He was initially deemed not covered so we got billed for the entire charged amount.  I fought and it took four rounds of phone calls to get everything straightened out.  Now we owe the standard co-pay and I dropped that check in the mail this morning on the way to the kids’ bus stop.

On one side there is radical price transparency fueled by low actuarial value coverage.  On the other hand, high actuarial value coverage required the paper work to work right.  One system worked as designed, I was a hyper informed consumer who decided to not get marginal care and the other took over six months to resolve to everyone’s satisfaction.  This is where we are probably going for health coverage where the insurer is more of a buyer’s discount club but the moment of decision felt like I was still operating under intense informational asymmetry and a power imbalance.  Getting the billing right for my son was a pain in the ass but I had allies from the insurer who do this multiple times a day so information and power were closer to symmetrical.


John, the ER and the prudent man standard

Cole illustrates why emergency room visits should not be adjudicated based on final diagnosis instead of presenting symptoms.

John had a bit of a scare earlier in the week:

Just got back from a relaxing seven hour visit to the ER. For the past couple of days I’ve had a little pain in my chest, but it felt like the pain I had when I had an ulcer a decade ago, so I dismissed it. Today it got worse and I could feel it in my shoulder and back, so I decided to go check my blood pressure. Checked my BP, and it was through the roof (200/100 normally about 135/75) and my heart rate was 84 bpm and it is normally about 55-65… so I decided I should probably go seek medical attention….

What do we know about Cole? We know he is a klutz. We know that he is middle aged. We know that he is carrying a couple extra pounds. We also know that he lives in the middle of nowhere and the closest hospital in Wheeling or Weirton is probably 30 minutes away once the vehicle leaves his driveway.

And we also know that he is having chest pains that were spreading and unusual cardiac measurements.

That to me sounds like a damn good reason to get checked out even if the eventual diagnosis is that there is not much happening. It sounds like a damn good reason because Cole is not a doctor but he knows his body and knows that something strange may be happening. It is prudent for someone with his demographics and chest pains to get a doctor to say “Okay” or “Oh Shit”. The cost of thinking he would be okay while he was actually going into an Oh Shit scenario is higher than the opposite way of being wrong.

The ACA requires insurers to use the prudent layperson standard to determine whether an ER visit a priori is an emergency. Using post-facto diagnosis codes imposes a knowledge requirement on the prudent layperson that they can’t meet.

Seth Trueger, an ER physician explains:

The ACA made the prudent layperson standard federal law (ACEP piece). The prudent layperson standard is exactly what it sounds like: the definition of a medical emergency is that a normal person with an average knowledge of medicine thinks is an emergency -– the patient’s symptoms make it an emergency, not the final diagnosis. So severe abdominal pain that turns out to be “just” an ovarian cyst is, by definition, an emergency….
If the patient is acting like a “prudent layperson” and thinks they are having an emergency, then it is an emergency and the insurer has to cover the ER visit. Full stop.

This is really important because there is a huge overlap in symptoms between simple benign problems (ovarian cyst) and serious life threatening problems (appendicitis) — see this fantastic paper by Maria Raven et al….

Tons of patients end up with final diagnoses like “acute viral bronchitis” which sound simple. Except when the patient is 80 and has CHF and COPD and it could easily be flu or pneumonia or a serious COPD or CHF exacerbation any or all of which could kill them.

We’re not medical experts. We know what does not feel right in our own body, that is a hyper valuable expertise but the layperson can’t self diagnose themselves and only go to the hospital when the chest pains are an actual heart attack instead of something else.

Look What You Done to Me

Just got back from a relaxing seven hour visit to the ER. For the past couple of days I’ve had a little pain in my chest, but it felt like the pain I had when I had an ulcer a decade ago, so I dismissed it. Today it got worse and I could feel it in my shoulder and back, so I decided to go check my blood pressure. Checked my BP, and it was through the roof (200/100 normally about 135/75) and my heart rate was 84 bpm and it is normally about 55-65 unless fucking Trump is on the god damned television, so I decided I should probably go seek medical attention. Went home, fed the dogs, packed up my laptop and sleep machine because if you go in and say heart at the ER those fuckers lock you up like Alcatraz.

Long story short, ekg and heart enzyme tests and chest x-rays were fine, but my lipase levels were elevated (but not double, so they could not give a diagnosis of pancreatitis), and my blood sugar was slightly elevated but they could not say if that was caused by the shit going down with my pancreas, but I am not dying and they let me go home and on monday I go to the doctor to get an upper gi and pancreatic tests done.

My blood pressure and heart rate are back to normal, and spiked because once again the #1 FUCKING DRAMA QUEEN IN WEST VIRGINA worked himself into a tizzy. I am absolutely the worst. I can handle physical pain no problem. I’m pretty sure I could have an arm amputated and I would wrap a towel around it (but not one of the good ones fer fucks sake I’m not a monster) and drive myself to the hospital. But if I cough funny twice I’ll be convinced I have fucking lung cancer and then work myself into an epic lather.

At any rate, I live to see another day. And for the love of everything holy, no remote diagnoses in the comments as I am already on a self imposed WebMD ban that has lasted close to 6 years.