Understanding the Red State Death Trip

[boatsnguitars]

Understanding the Red State Death Trip
April 3, 2023

By Paul Krugman

Last Friday the Medicare trustees released their latest report on the system’s finances, and it contained some unexpected good news: Expenditures are running below projections, and the Hospital Insurance Trust Fund won’t be exhausted as soon as previously predicted.

But one important reason for this financial improvement was grisly: Covid killed a substantial number of Medicare beneficiaries. And the victims were disproportionately seniors already suffering from severe — and expensive — health problems. “As a result, the surviving population had spending that was lower than average.”

Now, Covid killed a lot of people around the world, so wasn’t this just an act of God? Not exactly. You see, America experienced a bigger decline in life expectancy when Covid struck than any other wealthy country. Furthermore, while life expectancy recovered in many countries in 2021, here it continued to fall.

And America’s dismal Covid performance was part of a larger story. I don’t know how many Americans are aware that over the past four decades, our life expectancy has been lagging ever further that of other advanced nations — even nations whose economic performance has been poor by conventional measures. Italy, for example, has experienced a generation of economic stagnation, with basically no growth in real G.D.P. per capita since 2000, compared with a 29 percent rise here. Yet Italians can expect to live about five years longer than Americans, a gap that has widened even as the Italian economy flounders.

What explains the American way of death? A large part of the answer seems to be political.

One important clue is that the problem of premature death isn’t evenly distributed across the country. Life expectancy is hugely unequal across U.S. regions, with major coastal cities not looking much worse than Europe but the South and the eastern heartland doing far worse.

But wasn’t it always thus? No. Geographic health disparities have surged in recent decades. According to the U.S. mortality database, as recently as 1990, Ohio had slightly higher life expectancy than New York. Since then, New York’s life expectancy has risen rapidly, nearly converging with that of other rich countries, while Ohio’s has hardly risen at all and is now four years less than New York’s.

There has been considerable research into the causes of these growing disparities. A 2021 paper published in The Journal of Economic Perspectives examined various possible causes, like the increasing concentration of highly educated Americans (who tend to be healthier than those with less education) in states that are already highly educated and the widening per capita income gaps among states. The authors found that these factors can’t explain more than a small fraction of the growing mortality gap.

Instead, they argued, the best explanation lay in policy: “The most promising explanation for our findings involve efforts by high-income states to adopt specific health-improving policies and behaviors since at least the early 1990s. Over time, these efforts reduced mortality in high-income states more rapidly than in low-income states, leading to widening spatial disparities in health.”

That sounds right. But did high-income states adopt health-improving policies because they were rich and could afford to? Or was it because in 21st-century America, high-income states tend to be politically progressive and politics, rather than money per se, account for the difference?

There is, in fact, a strong correlation between how much a state’s life expectancy rose from 1990 to 2019 and its political lean, as measured by Joe Biden’s margin over Donald Trump in the 2020 election — a correlation slightly stronger, by my estimates, than the correlation with income.

There are several reasons to believe that America’s death trip is largely political rather than economic. One is the comparison with European nations, which have had much better health trends even when, as in Italy, their economies have performed badly.

Another is the fact that some of the poorest states in America, with the lowest life expectancy, are still refusing to expand Medicaid, even though the federal government would cover the bulk of the cost (and the failure to expand Medicaid is killing many hospitals). This suggests that they’re failing to improve health because they don’t want to, not because they can’t afford to.

Finally, since Covid struck, residents of Republican-leaning counties have been far less likely to get vaccinated and far more likely to die of it than residents of Democratic-leaning counties — even though vaccines are free.

All of this seems relevant to our current era of culture war, with many Republican politicians praising rural and red-state values while denigrating those of coastal elites. Gov. Ron DeSantis of Florida, for example, claims that although he grew up around Tampa Bay, he’s culturally a product of western Pennsylvania and northeastern Ohio. It’s worth noting, then, that the culture these politicians want all of America to emulate seems to have a problem with one of society’s most important functions: keeping people from dying early.

Paul ends with a sentiment that I don't think the GOP shares. I don't think the GOP feels that the government has any role in "keeping people from dying early".

"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."

So says our founding document, but it's interpretation is up for...err, interpretation.

For example, we know Christians often take the position of 'tough love." For example, when arguing against homosexuality, they argue that they hate the sin - and they "just love the sinner so much that they want to save them from their evil ways, so that's why it should be illegal..." Or, they are fond of talking about how loving God was when he Flooded the world, massacred the Midianites, etc. It was Righteous Love!

They seem to continue this line of thought that says, "Hey, if you want to smoke and drink yourself to death. That's your Freedom!" And, "Hey, if you don't want to pay $2000 per month for Health Insurance, and you get cancer, that's on you! Tough love!"

Krugman's article is what has been fairly widely understood: The Right Wong doesn't care if people live or die, they just want to be left alone to make money any way they see fit - Caveat Emptor. They want deregulation to allow banks to take wild risks because "you should have done your homework, or kept your money under your mattress." They want freedom to sell supplements without having to tell people what's in them because "hey, you should have done your research". They don't want licenses for guns or child care workers because "hey, the reason you got shot, or your kid got raped is because you didn't do your research."

IMO, the Right is trying to remove themselves from any responsibility for anything in society - until it comes to religion. Then suddenly, they want everyone to comply. They want the Ten Commandments, Creation, the Bible, etc. taught in school, because they think that is how we will have a better society. They think if everyone becomes Christian, we'll have a wonderful society. It's a pipedream, and one of those pipedreams that because it has no chance of ever happening, and with no other plan in place, it becomes detrimental to society.
So, I understand they think it's about "individual responsibility", but what they don't see is that it is individual responsibility when those individuals come together to form a collective solution in the form of a corporation or government.

Delegating, for example, meat inspection to the government is wildly successful. We don't have people dying of bad meat, or disease because the USDA inspects meat packing plants and farms.
Delegating responsibility to the police, EMT's, schools, day care, health care, is, in fact, individuals taking responsibility by letting others focus on the problem, rather than thinking each individual can actually learn everything they need to know about those topics.

We've all known that Red States are poorer, more ignorant, more religious, die of Covid more, less scientifically literate, etc. This was all their choice. They wanted to vote for Right Wing policies because - like they think more guns will stop shootings - they think more freedom will al make them happy and rich.

Meanwhile, as they become poorer, sicker and sadder, they will blame it on the Libs. After all, these Southern States have had generations of Right Wing rule - so like the gun problem (when we have the most guns per capita already) - when do they expect their de-regulation, anti-government policies to start working for them?

They're (literally) dying to know.

1. What do you think is the main reason for the widening disparity in life expectancy between different regions in the US?
2. Is the Covid pandemic responsible for the decline in life expectancy in the US, or are there other underlying factors at play?
3. Should the government have a role in ensuring that people live longer, healthier lives? Why or why not?
4. What policies could be implemented to improve life expectancy and overall health in the US?
5. Why do you think some of the poorest states in the US are refusing to expand Medicaid?
6. Is there a political or cultural factor that explains the correlation between political leanings and life expectancy in the US?
7. Do you think that access to healthcare is a basic human right? Why or why not?
8.Should healthcare be a for-profit industry, or should it be provided by the government?
9. Are there any specific policies or practices in other countries that the US should adopt to improve its health outcomes?
10. Should the government take action to encourage people to get vaccinated? If so, what measures should be implemented?
11. Should healthcare professionals be required to get vaccinated against Covid?
12. What is the role of education in improving health outcomes?
13. Should the government be responsible for educating people about healthy lifestyles and disease prevention?
14. How can we address the underlying socioeconomic factors that contribute to poor health outcomes, such as poverty and lack of education?
15. What do you think is the most effective way to reduce health disparities between different regions and socioeconomic groups in the US?

[Athetotheist]

Understanding the Red State Death Trip
April 3, 2023

By Paul Krugman

Last Friday the Medicare trustees released their latest report on the system’s finances, and it contained some unexpected good news: Expenditures are running below projections, and the Hospital Insurance Trust Fund won’t be exhausted as soon as previously predicted.

But one important reason for this financial improvement was grisly: Covid killed a substantial number of Medicare beneficiaries. And the victims were disproportionately seniors already suffering from severe — and expensive — health problems. “As a result, the surviving population had spending that was lower than average.”

Now, Covid killed a lot of people around the world, so wasn’t this just an act of God? Not exactly. You see, America experienced a bigger decline in life expectancy when Covid struck than any other wealthy country. Furthermore, while life expectancy recovered in many countries in 2021, here it continued to fall.

And America’s dismal Covid performance was part of a larger story. I don’t know how many Americans are aware that over the past four decades, our life expectancy has been lagging ever further that of other advanced nations — even nations whose economic performance has been poor by conventional measures. Italy, for example, has experienced a generation of economic stagnation, with basically no growth in real G.D.P. per capita since 2000, compared with a 29 percent rise here. Yet Italians can expect to live about five years longer than Americans, a gap that has widened even as the Italian economy flounders.

What explains the American way of death? A large part of the answer seems to be political.

One important clue is that the problem of premature death isn’t evenly distributed across the country. Life expectancy is hugely unequal across U.S. regions, with major coastal cities not looking much worse than Europe but the South and the eastern heartland doing far worse.

But wasn’t it always thus? No. Geographic health disparities have surged in recent decades. According to the U.S. mortality database, as recently as 1990, Ohio had slightly higher life expectancy than New York. Since then, New York’s life expectancy has risen rapidly, nearly converging with that of other rich countries, while Ohio’s has hardly risen at all and is now four years less than New York’s.

There has been considerable research into the causes of these growing disparities. A 2021 paper published in The Journal of Economic Perspectives examined various possible causes, like the increasing concentration of highly educated Americans (who tend to be healthier than those with less education) in states that are already highly educated and the widening per capita income gaps among states. The authors found that these factors can’t explain more than a small fraction of the growing mortality gap.

Instead, they argued, the best explanation lay in policy: “The most promising explanation for our findings involve efforts by high-income states to adopt specific health-improving policies and behaviors since at least the early 1990s. Over time, these efforts reduced mortality in high-income states more rapidly than in low-income states, leading to widening spatial disparities in health.”

That sounds right. But did high-income states adopt health-improving policies because they were rich and could afford to? Or was it because in 21st-century America, high-income states tend to be politically progressive and politics, rather than money per se, account for the difference?

There is, in fact, a strong correlation between how much a state’s life expectancy rose from 1990 to 2019 and its political lean, as measured by Joe Biden’s margin over Donald Trump in the 2020 election — a correlation slightly stronger, by my estimates, than the correlation with income.

There are several reasons to believe that America’s death trip is largely political rather than economic. One is the comparison with European nations, which have had much better health trends even when, as in Italy, their economies have performed badly.

Another is the fact that some of the poorest states in America, with the lowest life expectancy, are still refusing to expand Medicaid, even though the federal government would cover the bulk of the cost (and the failure to expand Medicaid is killing many hospitals). This suggests that they’re failing to improve health because they don’t want to, not because they can’t afford to.

Finally, since Covid struck, residents of Republican-leaning counties have been far less likely to get vaccinated and far more likely to die of it than residents of Democratic-leaning counties — even though vaccines are free.

All of this seems relevant to our current era of culture war, with many Republican politicians praising rural and red-state values while denigrating those of coastal elites. Gov. Ron DeSantis of Florida, for example, claims that although he grew up around Tampa Bay, he’s culturally a product of western Pennsylvania and northeastern Ohio. It’s worth noting, then, that the culture these politicians want all of America to emulate seems to have a problem with one of society’s most important functions: keeping people from dying early.

Paul ends with a sentiment that I don't think the GOP shares. I don't think the GOP feels that the government has any role in "keeping people from dying early".

"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."

So says our founding document, but it's interpretation is up for...err, interpretation.

For example, we know Christians often take the position of 'tough love." For example, when arguing against homosexuality, they argue that they hate the sin - and they "just love the sinner so much that they want to save them from their evil ways, so that's why it should be illegal..." Or, they are fond of talking about how loving God was when he Flooded the world, massacred the Midianites, etc. It was Righteous Love!

They seem to continue this line of thought that says, "Hey, if you want to smoke and drink yourself to death. That's your Freedom!" And, "Hey, if you don't want to pay $2000 per month for Health Insurance, and you get cancer, that's on you! Tough love!"

Krugman's article is what has been fairly widely understood: The Right Wong doesn't care if people live or die, they just want to be left alone to make money any way they see fit - Caveat Emptor. They want deregulation to allow banks to take wild risks because "you should have done your homework, or kept your money under your mattress." They want freedom to sell supplements without having to tell people what's in them because "hey, you should have done your research". They don't want licenses for guns or child care workers because "hey, the reason you got shot, or your kid got raped is because you didn't do your research."

IMO, the Right is trying to remove themselves from any responsibility for anything in society - until it comes to religion. Then suddenly, they want everyone to comply. They want the Ten Commandments, Creation, the Bible, etc. taught in school, because they think that is how we will have a better society. They think if everyone becomes Christian, we'll have a wonderful society. It's a pipedream, and one of those pipedreams that because it has no chance of ever happening, and with no other plan in place, it becomes detrimental to society.
So, I understand they think it's about "individual responsibility", but what they don't see is that it is individual responsibility when those individuals come together to form a collective solution in the form of a corporation or government.

Delegating, for example, meat inspection to the government is wildly successful. We don't have people dying of bad meat, or disease because the USDA inspects meat packing plants and farms.
Delegating responsibility to the police, EMT's, schools, day care, health care, is, in fact, individuals taking responsibility by letting others focus on the problem, rather than thinking each individual can actually learn everything they need to know about those topics.

We've all known that Red States are poorer, more ignorant, more religious, die of Covid more, less scientifically literate, etc. This was all their choice. They wanted to vote for Right Wing policies because - like they think more guns will stop shootings - they think more freedom will al make them happy and rich.

Meanwhile, as they become poorer, sicker and sadder, they will blame it on the Libs. After all, these Southern States have had generations of Right Wing rule - so like the gun problem (when we have the most guns per capita already) - when do they expect their de-regulation, anti-government policies to start working for them?

They're (literally) dying to know.

1. What do you think is the main reason for the widening disparity in life expectancy between different regions in the US?
2. Is the Covid pandemic responsible for the decline in life expectancy in the US, or are there other underlying factors at play?
3. Should the government have a role in ensuring that people live longer, healthier lives? Why or why not?
4. What policies could be implemented to improve life expectancy and overall health in the US?
5. Why do you think some of the poorest states in the US are refusing to expand Medicaid?
6. Is there a political or cultural factor that explains the correlation between political leanings and life expectancy in the US?
7. Do you think that access to healthcare is a basic human right? Why or why not?
8.Should healthcare be a for-profit industry, or should it be provided by the government?
9. Are there any specific policies or practices in other countries that the US should adopt to improve its health outcomes?
10. Should the government take action to encourage people to get vaccinated? If so, what measures should be implemented?
11. Should healthcare professionals be required to get vaccinated against Covid?
12. What is the role of education in improving health outcomes?
13. Should the government be responsible for educating people about healthy lifestyles and disease prevention?
14. How can we address the underlying socioeconomic factors that contribute to poor health outcomes, such as poverty and lack of education?
15. What do you think is the most effective way to reduce health disparities between different regions and socioeconomic groups in the US?

16. Should those who pride themselves on being progressive have let their congressional majority get away with prioritizing "bipartisan consensus" over lifting a finger on its own to make anything better?

[Purple Knight]

Another is the fact that some of the poorest states in America, with the lowest life expectancy, are still refusing to expand Medicaid, even though the federal government would cover the bulk of the cost (and the failure to expand Medicaid is killing many hospitals). This suggests that they’re failing to improve health because they don’t want to, not because they can’t afford to.

Expanding Medicaid has effects beyond its initial cost. For example, even if the government bears the full dollar amount in cost, pumping money into the system like that has effects on that system. Hospitals are largely for-profit enterprises. So, when every poor person in need finds their costs all paid for, and will continue to have access to that government blank check, you can expect costs to rise. Why shouldn't the hospital charge $10,000 to treat a skinned knee? Black check. Government will pay it. The people who bear the brunt of that are the ones just barely outside the scope of Medicaid, wherever its scope happens to end.

As long as Medicaid exists and is not for everyone, there will be a class of working poor just outside its reach who could have easily paid for their procedures if not for Medicaid's existence, but thanks to it, are left totally unable to afford it.

Some people don't think that's fair and I agree with them.

[Athetotheist]

[Replying to Purple Knight in post #3

Why shouldn't the hospital charge $10,000 to treat a skinned knee?

Because it doesn't cost $10,000 to treat a skinned knee.

I'm skeptical of the assumption that people would be careless if their medical expenses were paid for. Even if you didn't have to worry about being able to afford a cast, you'd still be laid up with a broken leg instead of out having fun.

Look at politicians. Their health care is all paid for with their constituents' tax money, but they make sure that the Secret Service is with them wherever they go. They're not taking any chances.

[Purple Knight]

I'm skeptical of the assumption that people would be careless if their medical expenses were paid for. Even if you didn't have to worry about being able to afford a cast, you'd still be laid up with a broken leg instead of out having fun.

Look at politicians. Their health care is all paid for with their constituents' tax money, but they make sure that the Secret Service is with them wherever they go. They're not taking any chances.

That's not the kind of careless I'm saying they are. I'm not saying they run in front of trains or take extra chances, but that once they do have a skinned knee, they don't have to think about what it will cost or if they should go to the hospital; they just go. That has an effect on the market. It equals extra demand. Prices increase, and working people outside of Medicaid's reach can't afford to just get care if they need it. And it's not fair to them, and it's not right, and they have just as much right to be against Medicaid expansion for pushing the cost of medical care out of their reach, as anyone does to want Medicaid to expand because they will get care they could not get before.

Everyone has a right to support the policies that will allow them to have medical care. Nobody should be demonised for that. And if we live in a world where it's okay to charge some people and not others, because for the poor it's a need but for the working people it's, "It's a business buy the product if you like and and if not, tough," then you're just going to have to accept that those people will oppose it being free for more and more of anyone-but-them, and if you look at the world they're forced to fight to stay alive in, you wouldn't judge them so harshly.

[boatsnguitars]

Another is the fact that some of the poorest states in America, with the lowest life expectancy, are still refusing to expand Medicaid, even though the federal government would cover the bulk of the cost (and the failure to expand Medicaid is killing many hospitals). This suggests that they’re failing to improve health because they don’t want to, not because they can’t afford to.

Expanding Medicaid has effects beyond its initial cost. For example, even if the government bears the full dollar amount in cost, pumping money into the system like that has effects on that system. Hospitals are largely for-profit enterprises. So, when every poor person in need finds their costs all paid for, and will continue to have access to that government blank check, you can expect costs to rise. Why shouldn't the hospital charge $10,000 to treat a skinned knee? Black check. Government will pay it. The people who bear the brunt of that are the ones just barely outside the scope of Medicaid, wherever its scope happens to end.

As long as Medicaid exists and is not for everyone, there will be a class of working poor just outside its reach who could have easily paid for their procedures if not for Medicaid's existence, but thanks to it, are left totally unable to afford it.

Some people don't think that's fair and I agree with them.

Firstly, the idea that hospitals will charge exorbitant prices simply because Medicaid exists is not supported by evidence. In fact, research has shown that Medicaid expansion has not led to increased costs for those with private insurance or the uninsured.

Secondly, the argument that there will always be a class of people just outside the reach of Medicaid is not a reason to not expand the program. Instead, it is an argument for further expanding access to healthcare, such as through a universal healthcare system.

Finally, the argument that Medicaid is unfair because some people who are just above the income threshold may not be able to afford healthcare is not a strong argument against the program. While it is true that there may be some individuals who fall into this category, it is also true that many more individuals are able to access necessary healthcare because of Medicaid. In addition, the argument overlooks the fact that there are many other factors beyond Medicaid that contribute to healthcare affordability, such as the high cost of prescription drugs and medical procedures.

[boatsnguitars]

I'm skeptical of the assumption that people would be careless if their medical expenses were paid for. Even if you didn't have to worry about being able to afford a cast, you'd still be laid up with a broken leg instead of out having fun.

Look at politicians. Their health care is all paid for with their constituents' tax money, but they make sure that the Secret Service is with them wherever they go. They're not taking any chances.

That's not the kind of careless I'm saying they are. I'm not saying they run in front of trains or take extra chances, but that once they do have a skinned knee, they don't have to think about what it will cost or if they should go to the hospital; they just go. That has an effect on the market. It equals extra demand. Prices increase, and working people outside of Medicaid's reach can't afford to just get care if they need it. And it's not fair to them, and it's not right, and they have just as much right to be against Medicaid expansion for pushing the cost of medical care out of their reach, as anyone does to want Medicaid to expand because they will get care they could not get before.

Everyone has a right to support the policies that will allow them to have medical care. Nobody should be demonised for that. And if we live in a world where it's okay to charge some people and not others, because for the poor it's a need but for the working people it's, "It's a business buy the product if you like and and if not, tough," then you're just going to have to accept that those people will oppose it being free for more and more of anyone-but-them, and if you look at the world they're forced to fight to stay alive in, you wouldn't judge them so harshly.

It is understandable to be concerned about the potential negative effects of Medicaid expansion on the market and the possibility of rising costs. However, it is important to consider the benefits of expanding Medicaid to the working poor who are just outside its reach. The argument that they can simply pay for their own procedures if not for Medicaid's existence ignores the reality that many working people struggle to afford basic healthcare even without a major medical event.

Additionally, the argument that some people will oppose Medicaid expansion because it is being made free for anyone-but-them is a flawed one. The purpose of Medicaid is to provide healthcare access to those who cannot afford it, not to give free healthcare to everyone except a certain group. It is important to consider the greater good of expanding healthcare access to those who need it, rather than solely focusing on potential negative effects on the market.

Health Care, among some, is believed to be a Right, and worth whatever cost it takes. I expect this conversation to continue well past our little interaction here, and probably, will end in the same way as the rest of the civilized world.

As Churchill said, "You can always count on Americans to do the right thing - after they've tried everything else."

[Purple Knight]

Firstly, the idea that hospitals will charge exorbitant prices simply because Medicaid exists is not supported by evidence. In fact, research has shown that Medicaid expansion has not led to increased costs for those with private insurance or the uninsured.

I don't see how that's possible when two generations ago, paying out of pocket was normal and no one had the problem where they were insured and shelling out for the insurance and still can't go to the doctor because they can't afford their deductible.

Insurance has an effect on the market and so must Medicaid. It's basic supply and demand that if you create more demand (the new poor people suddenly able to pay because they got a government blank check) without creating more supply, costs will rise. People can tell when they're being gouged and it would be easy to package Medicaid expansion with regulations on cost to keep care affordable, but by saying it doesn't happen you're just going to make more people vote red.

This is what happens when you take red tape, government blank checks, and insurance out of the picture:
https://time.com/4649914/why-the-doctor ... only-cash/

Secondly, the argument that there will always be a class of people just outside the reach of Medicaid is not a reason to not expand the program. Instead, it is an argument for further expanding access to healthcare, such as through a universal healthcare system.

Finally, the argument that Medicaid is unfair because some people who are just above the income threshold may not be able to afford healthcare is not a strong argument against the program. While it is true that there may be some individuals who fall into this category, it is also true that many more individuals are able to access necessary healthcare because of Medicaid. In addition, the argument overlooks the fact that there are many other factors beyond Medicaid that contribute to healthcare affordability, such as the high cost of prescription drugs and medical procedures.

I didn't say it was. I said people have the right to oppose policies that will hurt them. Those people being demonised for opposing Medicaid expansion would probably be on board with universal healthcare. Nobody should vote for a policy that will hurt them even if it is some kind of brick in the road to some greater good. Just bring out that greater good.

Imagine if I were dictator and I said that to solve overpopulation, I'm going to kill all the minorities because they have more babies. Even if it would solve the problem, it's completely unfair to expect one segment of the population to just take a hit so everyone else can be better off later. If my policy hurts people, they have a right to oppose it. And in fact I shouldn't implement it. I should find a policy that will make everyone better off, not sacrifice some so I can help others.