Many people living in the 'Diabetes Belt' are plagued with medical debt(text.npr.org)
text.npr.org
Many people living in the 'Diabetes Belt' are plagued with medical debt
https://text.npr.org/1173439205
126 comments
Frontline did an episode a while back were dentists were performing unnecessary major dental work on poor people when the government had a program to pay the dentists for such work. Frontline was outraged at the dentists, but did not seem to recognize that this is the inevitable result of incentives the government set up.
Whoa whoa whoa, I'm the first one to call out perverse incentives in government programs, but even I would assume that dentists had meaningful ethics codes and enforcement that would largely mitigate this kind of abuse.
OTOH, if the "unnecessary" there just means "not satisfying the platonically correct cost/benefit analysis", and there's still some net benefit to the patient, and the government program didn't ask the dentists to use such CBA, then I wouldn't consider that abusive.
(I can imagine Frontline being equally outraged at dentists denying government-subsidized dental care on grounds of failing the platonic CBA too...)
OTOH, if the "unnecessary" there just means "not satisfying the platonically correct cost/benefit analysis", and there's still some net benefit to the patient, and the government program didn't ask the dentists to use such CBA, then I wouldn't consider that abusive.
(I can imagine Frontline being equally outraged at dentists denying government-subsidized dental care on grounds of failing the platonic CBA too...)
Dentists do have an ethical code, government payers do look for patterns of abuse, and state licensing boards do investigate complaints of unnecessary procedures (to some extent). But many of these cases really fall into gray areas. Dentistry is still more an art than a science, and different dentists treating the same patient in good faith will often come up with completely different treatment plans. It's tough to really prove abuse. Financial incentives absolutely do encourage healthcare providers to err on the side of doing more procedures.
Medicare pays based on how many tests are performed. Hence, medicare patients get lots and lots and lots of tests done.
When the government provides a vending machine that dispenses gold coins at the push of a button, how many of us could resist pushing that button as much as possible?
A society cannot be run on expecting people to resist the powerful incentives set up for them.
You can see this effect in every aspect of government operations.
A society cannot be run on expecting people to resist the powerful incentives set up for them.
You can see this effect in every aspect of government operations.
If too many of us would literally cut off the limbs of others unnecessarily to acquire said gold coins than we're done here. Let's just burn it all down and start over.
The best part about over-treating as a dentist is there's no evidence, and the patient might never know.
> Frontline did an episode a while back were dentists were performing unnecessary major dental work on poor people when the government had a program to pay the dentists for such work
I haven't seen this episode and so don't know what qualifies as "major dental work." However, as someone who has had government dental insurance, I wanted to chime in with a possibly irrelevant anecdote.
This dental insurance covered few things, one of which was having teeth pulled. When I was having major pain and other issues with a molar, the only covered treatment was to have the tooth pulled. Anything else would have to be paid 100% out of my own pocket. So the only viable option for most people in my situation would have been to have the tooth pulled, which certainly seems like "unnecessary major dental work on poor people", through no fault of the dentist.
I haven't seen this episode and so don't know what qualifies as "major dental work." However, as someone who has had government dental insurance, I wanted to chime in with a possibly irrelevant anecdote.
This dental insurance covered few things, one of which was having teeth pulled. When I was having major pain and other issues with a molar, the only covered treatment was to have the tooth pulled. Anything else would have to be paid 100% out of my own pocket. So the only viable option for most people in my situation would have been to have the tooth pulled, which certainly seems like "unnecessary major dental work on poor people", through no fault of the dentist.
Google:
Frontline Dollars and Dentists season 2012 episode 13
and see for yourself.
Frontline Dollars and Dentists season 2012 episode 13
and see for yourself.
[deleted]
And such incentives get amplified when healthcare is the only game in town in terms of economic activity.
Man.. It's Nazi Germany level of evil.
Hitler claimed to have taken inspiration from how America treats its undesireables.
A doctor who grew up in the heyday of eugenics could still be practicing medicine into the 70s. We literally gave black people syphilis behind their backs, and now we wonder why they are vaccine shy. We spent over two centuries with at least half the country openly espousing as policy that black people were a lesser race and the south screamed from the hills that it was God's intention that white people control black people.
The children of these people were still politically relevant recently.
A doctor who grew up in the heyday of eugenics could still be practicing medicine into the 70s. We literally gave black people syphilis behind their backs, and now we wonder why they are vaccine shy. We spent over two centuries with at least half the country openly espousing as policy that black people were a lesser race and the south screamed from the hills that it was God's intention that white people control black people.
The children of these people were still politically relevant recently.
We also set up concentration camps for Japanese-Americans.
"Seventy-nine out of the 100 counties with the highest levels of medical debt are in states that have not expanded Medicaid under the ACA"
Who benefits in these 10 states that have still failed to expand Medicaid? What is the upside, to either the populations of these states or the politicians who run these states and make those decisions? Because the downsides are obvious and seem to directly harm a lot of people.
Who benefits in these 10 states that have still failed to expand Medicaid? What is the upside, to either the populations of these states or the politicians who run these states and make those decisions? Because the downsides are obvious and seem to directly harm a lot of people.
The Federal Government covers 90% of the Medicaid expansion costs. Which means that there is a some cost in terms of state taxes.
But that's not the reason I usually see expressed. It usually comes expressed like this:
“The health care industrial complex made up of hospitals, medical device manufacturers and pharmaceutical companies are the great robber barons of our time,” Oliva said. “The term robber baron is defined by government manipulation, monopolizing industry and price gouging.”
“We must reform Medicaid and double down on pursuing common-sense policy reforms to unleash innovation and increase access that can all lead to lowering costs,” Zander said.
https://www.jacksonville.com/story/news/politics/state/2020/...
I'm afraid I don't entirely understand what that means.
But that's not the reason I usually see expressed. It usually comes expressed like this:
“The health care industrial complex made up of hospitals, medical device manufacturers and pharmaceutical companies are the great robber barons of our time,” Oliva said. “The term robber baron is defined by government manipulation, monopolizing industry and price gouging.”
“We must reform Medicaid and double down on pursuing common-sense policy reforms to unleash innovation and increase access that can all lead to lowering costs,” Zander said.
https://www.jacksonville.com/story/news/politics/state/2020/...
I'm afraid I don't entirely understand what that means.
A lot of these states have big problems with gerry-mandering and there tends to be huge wealth disparity between the few small wealth centers in the state and the rest of the state is extremely poor. The money just isn't being distributed with any sense of equity.
Income inequality is at least as big of a problem, if not bigger, in blue states than red states: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ.... New York is the most unequal state in the country.
I don’t know about gerrymandering. In the most recent Texas house election (Texas being one of the major ACA holdouts) republicans won a 12-point seat margin with a 7-point popular vote margin. The governor, which is elected by statewide popular vote, won by an 11 point margin. In the 2022 Tennessee House elections, meanwhile, republicans won 75% of seats with 70% of the popular vote, which is as lopsided as some heavily skewed states like California and New York. (At a certain point, winning more seats than popular votes isn’t due to gerrymandering but just normal population distribution effects.)
I suspect the real issue is that, in red states, the democrats tend to be low propensity and younger voters. In Tennessee, Trump beat Biden by 24 points. But the GOP beat democrats by almost 50 points in the popular vote in the 2022 Tennessee House elections.
I don’t know about gerrymandering. In the most recent Texas house election (Texas being one of the major ACA holdouts) republicans won a 12-point seat margin with a 7-point popular vote margin. The governor, which is elected by statewide popular vote, won by an 11 point margin. In the 2022 Tennessee House elections, meanwhile, republicans won 75% of seats with 70% of the popular vote, which is as lopsided as some heavily skewed states like California and New York. (At a certain point, winning more seats than popular votes isn’t due to gerrymandering but just normal population distribution effects.)
I suspect the real issue is that, in red states, the democrats tend to be low propensity and younger voters. In Tennessee, Trump beat Biden by 24 points. But the GOP beat democrats by almost 50 points in the popular vote in the 2022 Tennessee House elections.
Income inequality isn't an issue, wealth inequality is.
I find it perfectly fine to earn 8 time as much as my artist best friend does as long as we are in a market-based system. What bothers me is that I do not pay enough taxes, and could pay even less by declaring my donations.
I find it perfectly fine to earn 8 time as much as my artist best friend does as long as we are in a market-based system. What bothers me is that I do not pay enough taxes, and could pay even less by declaring my donations.
> Who benefits in these 10 states that have still failed to expand Medicaid?
The people who run on this as a component of their platform.
The people who run on this as a component of their platform.
It's not about who benefits. It's about fucked up cultural priorities. It's not just the politicians who are the problem. The voters who keep electing these people over and over are asking for this too.
https://www.bostonreview.net/articles/jonathan-m-metzl-dying...
> Debates raged in Tennessee around the same time about the state’s participation in the Affordable Care Act and the related expansion of Medicaid coverage. Had Trevor lived a thirty-nine-minute drive away in neighboring Kentucky, he might have topped the list of candidates for expensive medications called polymerase inhibitors, a lifesaving liver transplant, or other forms of treatment and support. Kentucky adopted the ACA and began the expansion in 2013, while Tennessee’s legislature repeatedly blocked Obama-era health care reforms.
> Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
> At the most basic level, Trevor died of the toxic effects of liver damage caused by hepatitis C. Yet Trevor’s deteriorating condition resulted also from the toxic effects of dogma. Dogma that told him that governmental assistance in any form was evil and not to be trusted, even when the assistance came in the form of federal contracts with private health insurance or pharmaceutical companies, or from expanded communal safety nets. Dogma that, as he made abundantly clear, aligned with beliefs about a racial hierarchy that overtly and implicitly aimed to keep white Americans hovering above Mexicans, welfare queens, and nonwhite others. Dogma suggesting to Trevor that minority groups received lavish benefits from the state, even though he himself lived and died on a low-income budget with state assistance. Trevor voiced a literal willingness to die for his place in this hierarchy, rather than participate in a system that might put him on the same plane as immigrants or racial minorities.
https://www.bostonreview.net/articles/jonathan-m-metzl-dying...
> Debates raged in Tennessee around the same time about the state’s participation in the Affordable Care Act and the related expansion of Medicaid coverage. Had Trevor lived a thirty-nine-minute drive away in neighboring Kentucky, he might have topped the list of candidates for expensive medications called polymerase inhibitors, a lifesaving liver transplant, or other forms of treatment and support. Kentucky adopted the ACA and began the expansion in 2013, while Tennessee’s legislature repeatedly blocked Obama-era health care reforms.
> Even on death’s doorstep, Trevor was not angry. In fact, he staunchly supported the stance promoted by his elected officials. “Ain’t no way I would ever support Obamacare or sign up for it,” he told me. “I would rather die.” When I asked him why he felt this way even as he faced severe illness, he explained: “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
> At the most basic level, Trevor died of the toxic effects of liver damage caused by hepatitis C. Yet Trevor’s deteriorating condition resulted also from the toxic effects of dogma. Dogma that told him that governmental assistance in any form was evil and not to be trusted, even when the assistance came in the form of federal contracts with private health insurance or pharmaceutical companies, or from expanded communal safety nets. Dogma that, as he made abundantly clear, aligned with beliefs about a racial hierarchy that overtly and implicitly aimed to keep white Americans hovering above Mexicans, welfare queens, and nonwhite others. Dogma suggesting to Trevor that minority groups received lavish benefits from the state, even though he himself lived and died on a low-income budget with state assistance. Trevor voiced a literal willingness to die for his place in this hierarchy, rather than participate in a system that might put him on the same plane as immigrants or racial minorities.
Some guesses:
- It benefits corporations and the wealthy (whom the government actually work for) in some way
- Politicians think running on "rugged individualism" works
- Same politicians truly believe in trickle-down economics and austerity.
The politicians benefit, and run on a platform of deflection. "Just imagine how much worse it would be if the government helped you."
Medicaid expansion under the ACA isn't "free" for state budgets. The Federal government only puts in part of the funding. So by forgoing expansion the state politicians can keep taxes low or continue funding other priorities. Some politicians also have ideological objections to expanding government control over the healthcare system.
(I am not endorsing these policies, just explaining some of the reasoning behind them.)
(I am not endorsing these policies, just explaining some of the reasoning behind them.)
I pointed this out earlier but its important to understand given what's going on in the US currently.
>>Federal government only puts in part of the funding
Via the issuance of debt.
>>Federal government only puts in part of the funding
Via the issuance of debt.
Spite.
Segregationists closed public pools and defunded public schools, rather than share with black people. Hurting poor whites as much as poor blacks.
Of course they'd also gut the social safety net.
Segregationists closed public pools and defunded public schools, rather than share with black people. Hurting poor whites as much as poor blacks.
Of course they'd also gut the social safety net.
Some Americans would gladly eat shit if a black person had to smell their breath after.
Given how often I see the argument that “blue states subsidize red states” I can see why folks who want to maintain their dignity wouldn’t want to expand their reliance on blue state largesse. That money comes with no strings attached.
Also, even if it’s true that blue states may bear the brunt of taxes, inflation hits everyone equally.
Also, even if it’s true that blue states may bear the brunt of taxes, inflation hits everyone equally.
Inflation literally doesn't hit everyone equally, prices are set in local markets, not fixed at a national scale.
Things like federal mortgage subsidies probably cause more inflation in less affluent regions where housing is less competitive than they do in affluent regions (where the competitors for housing aren't particularly pricing their offers to the largest payment they can afford).
Things like federal mortgage subsidies probably cause more inflation in less affluent regions where housing is less competitive than they do in affluent regions (where the competitors for housing aren't particularly pricing their offers to the largest payment they can afford).
I mean, medical debt collectors benefit, and they do have lobbyists.
In North Carolina, before Uber and stuff like that, there was this driver a few of us knew and would call to taxi us around. He was a skinny fellow but through the years we knew him, he'd tell us about how he keeps telling his brothers not to eat as much because they're going to get in trouble and how he was a fat dude but managed to lose weight.
No happy ending. One of the brothers died just before I moved away, of an obesity and diabetes related illness.
Interesting tale. Mostly a question of junk food and portion sizes.
No happy ending. One of the brothers died just before I moved away, of an obesity and diabetes related illness.
Interesting tale. Mostly a question of junk food and portion sizes.
This is as much a cultural problem as a financial one. Somehow we've convinced ourselves that in spite of the fact that we can afford to provide everyone with good food and access to medical care, that we'd rather give you bad food which causes health care issues and then treat those because it contributes to GDP.
> This is as much a cultural problem as a financial one.
I live in one of these Diabetes Belt counties. I'd like to add another aspect to the "cultural problem", which is that the median person here eats absolutely horrendously and doesn't exercise at all.
> we'd rather give you bad food
I'd like to believe that people have the agency of choosing what they eat.
I live in one of these Diabetes Belt counties. I'd like to add another aspect to the "cultural problem", which is that the median person here eats absolutely horrendously and doesn't exercise at all.
> we'd rather give you bad food
I'd like to believe that people have the agency of choosing what they eat.
> I'd like to believe that people have the agency of choosing what they eat.
They do, but they need to know how to eat a healthy diet. I don't know about you, but I've never once seen a commercial about eating whole foods with vegetables. I am however bombarded on a daily basis with adds for fried chicken and burgers. Some people just don't have the access and education.
They do, but they need to know how to eat a healthy diet. I don't know about you, but I've never once seen a commercial about eating whole foods with vegetables. I am however bombarded on a daily basis with adds for fried chicken and burgers. Some people just don't have the access and education.
I don't think it's an advertising thing though it could play into it.
- Eating a varied healthy diet is a lot more expensive than eating a varied unhealthy diet (if you can eat kale, rice, and beans all day then good for you but most can't)
- We're creatures of habit, if we grow up eating unhealthy we are more likely to continue to as adults. Eating healthy for most people requires cooking for yourself, many never learn this skill or see their parents putting daily effort into meals when they are children.
- Lack of public education around the topic, lack funding for free healthy lunches for school children
I had a friend when I was in school who had the most messed up disgusting teeth I'd ever seen. He had dental insurance, a decent job, decent pay. Turns out he never grew up learning that you're supposed to brush your teeth regularly so he just never made a habit out of it.
- Eating a varied healthy diet is a lot more expensive than eating a varied unhealthy diet (if you can eat kale, rice, and beans all day then good for you but most can't)
- We're creatures of habit, if we grow up eating unhealthy we are more likely to continue to as adults. Eating healthy for most people requires cooking for yourself, many never learn this skill or see their parents putting daily effort into meals when they are children.
- Lack of public education around the topic, lack funding for free healthy lunches for school children
I had a friend when I was in school who had the most messed up disgusting teeth I'd ever seen. He had dental insurance, a decent job, decent pay. Turns out he never grew up learning that you're supposed to brush your teeth regularly so he just never made a habit out of it.
> Eating a varied healthy diet is a lot more expensive than eating a varied unhealthy diet (if you can eat kale, rice, and beans all day then good for you but most can't)
Eating healthy is not more expensive. Potatoes, rice, beans, carrots, etc. are all inexpensive. I was in the store today, and a can of Nalley chili with meat and beans is $2.19. It's more than enough for a meal.
I also buy whatever's on sale, including the day older steak which is around half off. A half gallon of milk is $1.99.
Eating healthy is not more expensive. Potatoes, rice, beans, carrots, etc. are all inexpensive. I was in the store today, and a can of Nalley chili with meat and beans is $2.19. It's more than enough for a meal.
I also buy whatever's on sale, including the day older steak which is around half off. A half gallon of milk is $1.99.
Kale, rice, and beans are notoriously cheap! When I worked in a restaurant 20 years ago we put kale out as decoration because no one wanted to eat it. Times change, I suppose.
Fried chicken and burgers really aren't that bad from a diabetes standpoint. You will sustain more metabolic damage from drinking a regular Coca Cola with that fried chicken than from the fried chicken itself.
Broccoli, right now after reading this, I'm choosing broccoli.
That's 50 Calories in a serving. What are you having for the other (let's say) 1950 Calories?
Broccoli sauteed with garlic and black pepper is awesome. Then served over rice with a cheddar cheese sauce and I'm pretty sure you can get up there in calories if you want to.
You can have more than one serving of broccoli.
As someone who regularly eats several pounds of broccoli (I love it so much), I can only describe the outcome as a cleanse, of both the colon, and if you survive, the mind.
Is the median person there dumber than the median person in the rest of the world?
Or are they eating shit, because eating shit is the path of least resistance, and median person travels down the path of least resistance, and if you set up your society such that the path of least resistance results in horrible outcomes, you're going to get horrible outcomes?
Or are they eating shit, because eating shit is the path of least resistance, and median person travels down the path of least resistance, and if you set up your society such that the path of least resistance results in horrible outcomes, you're going to get horrible outcomes?
It’s not necessarily “dumber”—culture is a thing too. Attitudes towards food and what food to cook and how much to eat are deeply cultural.
> I'd like to believe that people have the agency of choosing what they eat.
Sometimes not:
* https://en.wikipedia.org/wiki/Food_desert
Sometimes not:
* https://en.wikipedia.org/wiki/Food_desert
Industry caters to consumer demand. If consumers wanted white meat, fruit and vegetables, they would have been provided as cheaply and abundantly as red meat and corn syrup.
Corn is heavily subsidized by the government.
I think that'd be true if chickens were the size of cows and it was easier to grow, say, tomatoes, than corn.
Chicken is already cheaper than beef. A lot cheaper.
I wonder how the broken window fallacy plays into this. I would assume a healthy population is more productive than a diseased one.
That effects healthcare profits though, so incentives aren't exactly aligned.
That effects healthcare profits though, so incentives aren't exactly aligned.
If you like this, you might enjoy The Price We Pay[0] by Marty Makary. It talks about the incentives in the US health system, and how they combine to create a system where even people with insurance can end up with unmanageable medical debt.
The book points out both genuinely bad actors (e.g. companies that pay kickbacks to medical staff for pushing patients into unnecessary helicopter rides) and also problems that happen due to the design of the system, despite the best intentions of individual actors.
[0] https://www.amazon.com/Price-We-Pay-American-Care/dp/1635574...
The book points out both genuinely bad actors (e.g. companies that pay kickbacks to medical staff for pushing patients into unnecessary helicopter rides) and also problems that happen due to the design of the system, despite the best intentions of individual actors.
[0] https://www.amazon.com/Price-We-Pay-American-Care/dp/1635574...
https://features.propublica.org/diabetes-amputations/black-a...
Another link if you are skeptical there is a racial issue: page 12 of https://data.dartmouthatlas.org/downloads/reports/Diabetes_r.... Among Medicare beneficiaries with diabetes, black people are still way more likely to have a leg amputated.