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We Survived Breitbartpocalypse!

I thought we were promised Infrastructure Week

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This blog will pay for itself.

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I personally stopped the public option…

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Cancel Culture Question

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I thought cancel culture meant trying to get people demonetized and deplatformed, which I am fine with, tbh, but this article has me confused:

A few weeks ago, Neelam, a high school senior, was sitting in class at her Catholic school in Chicago. After her teacher left the room, a classmate began playing “Bump N’ Grind,” an R. Kelly song.

Neelam, 17, had recently watched the documentary series “Surviving R. Kelly” with her mother. She said it had been “emotional to take in as a black woman.”

Neelam asked the boy and his cluster of friends to stop playing the track, but he shrugged off the request. “‘It’s just a song,’” she said he replied. “‘We understand he’s in jail and known for being a pedophile, but I still like his music.’”

She was appalled. They were in a class about social justice. They had spent the afternoon talking about Catholicism, the common good and morality. The song continued to play.

That classmate, who is white, had done things in the past that Neelam described as problematic, like casually using racist slurs — not name-calling — among friends. After class, she decided he was “canceled,” at least to her.

Her decision didn’t stay private; she told a friend that week that she had canceled him. She told her mother too. She said that this meant she would avoid speaking or engaging with him in the future, that she didn’t care to hear what he had to say, because he wouldn’t change his mind and was beyond reason.

“When it comes to cancel culture, it’s a way to take away someone’s power and call out the individual for being problematic in a situation,” Neelam said. “I don’t think it’s being sensitive. I think it’s just having a sense of being observant and aware of what’s going on around you.”

Isn’t this just ignoring someone who is a total dick and not subjecting yourself to deal with their bullshit? How is this any different from the number of people I have just written out of my life because they are useless trash, or any different from me avoiding NASCAR races like the plague?

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Registration tables vs. Mortality tables

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American politics right now is basically a race of the registration tables against the mortality  tables.

Charles Franklin has a great graph on Twitter looking at mid-term voter participation rates by age for 2010, 2014, and 2018.

There are a few take-aways here. First, the probability of voting by age pretty steadily increases as cohorts age until about age 75 or so and then it drops off. Secondly, the slopes are fairly similar over time; it is a matter of levels for the differences in turn-out.  Young voters increased their voting rates faster than almost any one else in 2018.

Age is a strong dividing line. Pew shows this nicely from a poll in January 2019:

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Doesn’t Mean That Much to Me to Mean That Much to You

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This twitter thread by Catherynne Valente gets it pretty much right:

Last night, Bill Maher went on a rant about comic books & those who love them & the generation (it rhymes with Schmelennials!) that uses words like #adulting & doesn’t want to give up the things they loved as kids or grow up

Well my name is Miss Valente & I got something to say

First of all, Mister Bill Maher, I’m not sure how smugly bloviating, smoking pot, and screwing people way too young for you is any more mature than reading comic books but okay buddy. Secondly, I’m not even going to get into the literary merit of comic books. Some are great art. Some are ridiculous trash. Kind of like every other genre & medium out there. It’s not worth discussing as it’s obvious on the face of it that adding pictures does not subtract value. I want to say this.

Do you know why millennials “refuse to grow up”?

Because we finally figured out that the whole idea is bullshit designed to suppress human joy enough to keep them grinding for an uncaring company for 50 years in unhappy marriages until death is a mercy. The reason my generation still plays in ball pits & reads comic books & plays dress up is that contemporary society has made most of the good parts of adult life financially unreachable: home, family, travel, even theater is $500 a ticket

All that’s left is the crushing despair! In the vacuum left by the loss of reachable life goals, we 80s kids kind of figured: fuck it.

Why the hell should we give up what is good & joyful & rich of the art & accoutrements of childhood in exchange for a yawning grey void? How was that ever considered a fair deal? What Maher and his peers cannot understand is that even their generation returned to the beautiful well of childhood—to share it with their own children.

The problem is, many in my generation cannot afford to have kids, or must wait until very late. You are not superior because you collect items from the Sharper Image catalogue rather than Comic Con. You have just allowed what others think of you to dictate a narrow range of joy you are allowed to experience.

Unless you really love $5000 massage chairs I guess. Adulthood has always been a trick played on the whole of humanity. Convincing us to give up magic & beauty & fun for their own sake in exchange for our labor & loyalty to whatever boss is going around

Only recently has society become decentralized enough to re-examine the terms

When complaining that millennials refuse to grow up, it might behoove the media to stop referring to 35 year olds as though they’re hapless children who don’t know what’s good for them. Companies will give us nothing but a company store. Governments sell out to each other and burn the planet. Markets offer no safety. There is almost nothing left of our parents’ world.

So read a fucking comic book if you want to, life is so heartbreakingly brief. Maybe, just maybe, consider the idea that the millennials got this one right.

It was always a bad deal that only benefitted the masters.

You get one life on this rock. Why in the hell would you give up something you love just because you got old enough to really appreciate it? Give us back the social contract, make the hallmarks of adulthood remotely reachable for us, and maybe we’ll consider putting down the comics.

Probably not, but we’ll have a house to read them in.

Boomers like Maher who reflexively dunk on the young, who have been fucked out of many of the social benefits that boomers take for granted, deserve this and more.

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Late Night Open Thread: Social Media Is A Bad Place for the Clueless

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Since I use this blogging platform largely to share online links and embed twitter posts, I can hardly condemn social media as a concept. But as the saying goes: Nothing can be made foolproof, because the fools are so ingenious.

Although I suppose it’s some kind of progress when, if a tween girl must be pimped out to support her family, it’s done through virtual reality. Allow me a ‘kids these days’ moment over a world where Buzzfeed and Netflix collaborate on a documentary series “Inside The World Of Teenagers With Millions Of Followers”…

Being an adolescent is inherently awful, but the best thing about it may be the complete lack of shame teenagers feel for the things they love. The breadth and depth of their fandom — say, for some online influencer with millions of underage fans — might be perplexing for those of us older than 18, but it makes perfect sense for teens who love whatever they love with their whole being…

Danielle Cohn is one of those teenage curiosities that most of us old enough to vote (have you registered yet?) don’t know much about despite her alarmingly potent online popularity. At the wee age of 14, she already has a startling 2.6 million Instagram followers and 11.2 million on an app called TikTok. (You might know TikTok better as Musical.ly, the app where the youth lip-synched and bopped around in front of their phones in 15-second video clips. It changed its name to TikTok in early August.) Cohn’s videos don’t exactly sound worthy of millions upon millions of followers: They’re largely just her, in full hair and makeup, lip-synching in front of her camera phone and a bright ring light, shaking her hips and smiling wide. And yet.

Cohn looms large online, but in person, she is teeny tiny. Her Instagram is, like a lot of young girls, seemingly curated to make her appear older, but in person she just looks like a pubescent girl with a remarkable amount of hair extensions. When I met her earlier this year, she was living in the Studio City neighborhood of Los Angeles with her mom, her brother, and a gray puppy named Silverpom who was suffering from an eye infection. She and her family are from Florida, but moved to LA so Cohn’s career as an influencer could really take off, and eventually be parlayed into a Hollywood career, as attempted by so many internet celebrities before her.

Cohn’s burden is twofold: Not only does she have a hungry and demanding fanbase to appease, but she’s a significant part of her family’s financial backbone. There’s online popularity to maintain, but also new clothes to buy, agents to compensate, and of course, the family rent to pay through her live events and sponsored posts…

Ultimately, there’s nothing explicitly sexual about Cohn’s act online, nor is there when she shows me how she makes one of her videos in person. She mostly mugs for the camera and flips her hair and points and cocks a hip and acts out sassiness. It’s a reminder that our anxiety about a girl like Cohn being sexualized comes only because we, as adults, are sexualizing a child. I believe her when she says her work is chaste…

And now I am, in my own small way, part of the problem (am I wrong to assume kids like Cohn attract as many older male followers as they do other young girls — or that the platforms monetizing them don’t really care?) Excuse me while I go find a new onion for my belt…

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Interesting Sunday Read: Something About Bob (Woodward)

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Olivia Nuzzi, professional journalist-assassin, sizes up Bob Woodward, professional journalist-legbreaker, in NYMag — “Bob Woodward on the ‘Best Obtainable Version of the Truth’ About Trump”.

IMO, she did a really good job of getting past the old man’s practiced patter and demonstrating just how cozy the Beltway Media Village expected to be with this season’s Temporary Oval Office Occupants, whether or not that warmth is reciprocated — or deserved:

… Entering the author’s home required walking past a stack of the books on the floor. It’s a warm and colorful place, full of eye-catching paintings and, at this particular moment, lots of people and one medium-size dog. Woodward introduced me to his wife, the journalist Elsa Walsh, and then ushered me into a dining room. Over the course of 50 minutes, we discussed his philosophy and methods. But first, my tape recorder malfunctioned in front of America’s most famous journalist…

Nuzzi: I am but a humble newbie, visiting the Great Master…

I wanted to talk to you about how you decide who is credible. It is difficult for me, sometimes, to determine who is credible, even at the most senior levels of the administration at this White House. Mostly at the most senior levels in some ways.
Particularly if it is on the record and public. It is kind of a press release.

I agree to a large extent. But I am curious how you decide who is credible. Because somebody like Rob Porter, he is obviously very present in this book. I won’t guess about your sourcing. There is a lot to suggest that his character is — there is a fundamental flaw there.
In what way?

Well, by some personal accounts he is a very flawed human being. He is allegedly abusive. There is a lot to call into question his honesty.
Say that again.

There is a lot to suggest that he may not be an honest individual, right? So why do you decide to trust somebody like that?
Well, I am not going into the sourcing but there are — you test it with other people and documents and notes and it makes a big difference when somebody tells you something and you get your hand on the document itself. So because I had the luxury of time, of essentially two years to work on this, not quite, even. Ever since Trump was elected you can cross-check and see…

Woodward: I review theatrical performances on the world’s most important stage. Why should anyone expect me to take an interest in the actors’ personal hobbies?

In a review, Isaac Chotiner at Slate asked if you were perhaps the last optimist.
Really? I have not seen this.

He had a lot of criticisms of the book and one of them is there is this sort of view, a bias towards the people who cooperated, and they are presented in an almost heroic way.
But see, he does not know that. No one knows that except for myself and my assistant Evelyn.

Do you think that is true?
I know it is true.

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Five years now

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Five years ago, I made a serious miscalculation.

I was a low level bureaucrat trying to get Exchange networks to work for UPMC Health Plan.

I was exhausted that first fall as we were scrambling with interim solutions for several months after the ACA individual market went live.  We then had to go crazy to ramp up HealthyPA, a convoluted Medicaid expansion waiver program in Pennsylvania.

I was in Pittsburgh living an anonymous life.

I thought I would only have a couple dozen health insurance related posts spanning twenty or thirty thousand words in me.

Now I’m in Durham.

I’m now at 1,550 + Mayhew on Insurance posts and several hundred other general purpose posts.  My health policy word count is closer to a million words than half a million words.  There is a mostly written book somewhere in these posts and I will sooner or later need to convince myself that I can write a book on health policy.

 

Then, I could never be quoted nor would anyone want to hear what I wanted to say besides a couple of co-workers as we slammed espresso shots before another analysis run cycle.  Now, I’m part of the usual quotable suspects when major ACA news breaks out.

Writing here at Balloon Juice has been and continues to be an amazing experience.  I get to play with ideas that fascinate me, and John gives me the keys to write to an audience.

One of the big changes since I’ve come to Duke, beyond saying good bye to the persona of Richard Mayhew, is that I’ve changed my writing targets.  When I was Richard Mayhew, I had to write at Balloon Juice.  I could and would poke a few people here and there that something big was coming down the pipe but I was limited.  Now, the audience is sometimes all jackals.  Other days, the intended audience is a few score of geeks and policy professionals who need to know about some esoteric corner case.  I apologize when I take over the blog for those purposes as I feel like I am hijacking your attention to pay the cost of entry into conversations that I want to be in.

As I have been drafting this post over several days, I’ve talked to reporters from local and national general interest press, I talked to a reporter from the trade press, I submitted a pair of long and very technical pieces to Health Affairs, and a revise and resubmit just went back to the editors of a good peer reviewed journal.  If you spend enough time reading Balloon Juice, you could figure out 85% of the article excluding some of the regression based analysis.

I feel guilty about this at times.

Last week, was a good example.  I wrote a Medicare shared savings post that I was aiming at a few dozen academics and several dozen think tankers, journalists and very targeted policy wonks. It is a very specific, nerdy, and incomplete idea.  It was not worth an op-ed as it it too geeky. It was not a Health Affairs blog or a journal perspective piece as the idea was not polished enough for that purpose, so I went Balloon Juice. And that post got three comments.  And I was fine with that as this was not a general purpose post but a very small part of a very different conversation that I participate in.

I’ve moved away from some general purpose health insurance and ACA blogging and at times over the past year, I’ve chased personal shiny objects down rabbit holes.  And you guys put up with that. And for that I am greatly appreciative as I love writing here at Balloon Juice.  I have a scratch pad and a place to get first drafts (seldom second drafts as you see my grammar and spelling) of reactions and thoughts.  I can dig into something that fascinates me on my own time and my own schedule until it makes sense to me.  I hope that this is not pointless intellectual public indecency as this entire creative process is extraordinarily valuable for me.

Balloon Juice is a very different form of writing than writing a journal article.  Under the best case scenario, a fast journal timeline from “umm, that is a cool question” to publication is a year or more.  It is very different writing than a multi-author Health Affairs blog where commas can become fighting marks while the critical point that I want to make might be the lead melody or become subsumed as a backing bass line.  It is a very different writing process than pumping out a New York Times op-ed where I first truly appreciated the value of a wonderful editor.  That process makes me sound a whole lot smarter by the end.  The final 750 words are a tight 750 words instead of a 5 post, 3,000 word series here.  But I was worn out both times I went through that process.  This is a fun place to write  and it allows me to get into awesome conversations of a variety of stripes.

But mainly, I just want to thank all of the jackals, the front-pagers and John for a community where I can nerd out on something that I find fascinating.  I’ll figure out what Year Six looks like, but the first five have been wonderful.

 

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

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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… )

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Kids these days

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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.

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A day in my life (health care thoughts)

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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”

“Okay”

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.

 

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John, the ER and the prudent man standard

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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.

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Look What You Done to Me

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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.

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