Last year was the first year in which the Affordable Care Act's (ACA's) new health insurance exchanges were operating.  Starting in 2014, almost all Americans must now have health insurance or face a tax penalty.

Premiums varied widely.  Today's map shows the 10 most expensive health insurance markets for 2014.  Citizens can purchase a variety of plans from different private insurers.  The standard for comparison looks at Silver plans for a 40 year old non-smoker.  In 2014, the average monthly health insurance premium for a Silver plan for a non-smoking, 40 year old adult was $328/month.  Rates were lowest in 2014 in Minnesota and highest in western Colorado.

So, are there any patterns to markets with high or low premiums?  Yes.

*Some fairly wealthy areas such as western Connecticut and western Colorado have relatively healthy people but appear to be paying more.  Why?  I guess because insurers feel the markets in these areas can bear higher premiums.  That is just a guess.

*Other areas are a) remote with limited medical providers, b) are in areas where Americans are in fairly poor health, or c) both.  Georgia has the dubious honor of having 2 of the 10 most expensive markets in the country AND having the greatest disparities of any state between the high costs around Albany, GA, compared to the relatively lower costs in the Atlanta market.  Wyoming, northern Nevada, western Wisconsin, Alaska, and coastal Mississippi all have issues with few providers and/or sick populations.

*Vermont ranks in the 10 most expensive because of a policy in that state.  Unlike in other states which have opted to allow insurers to charge older residents more than younger people, Vermont law requires insurers to charge everyone regardless of age the same premium for the same plan.  As a result insurers increased premiums across the board in Vermont.

The new 2015 premiums came out in mid-November and there are relatively big fluctuations in premiums.  Minnesotans will be paying more.  Mississippians will pay less.  Overall prices nationally are either slightly down or steady after years of rapidly rising premiums.  The geography of premiums, however, continues to be sorted out as insurers and their actuaries figure out if they are charging enough to cover the health issues of their populations AND make a profit (since the Republican-invented ACA model relies on government subsidies and private insurance companies rather than the single-payer Democratic alternative).  It will likely be at least 3 years (circa 2017) before we can see more stable premium data as the system finds its groove.

Updated: Religious Freedom Laws

Mississippi Governor Phil Bryant (R) today signed into law the Mississippi Religious Freedom Restoration Act which allows Mississippians to sue or use as a legal defense the claim that any government policy, law, regulation, or ordinance places a burden on their free exercise of religion.  It also adds "In God We Trust" to the state seal.  The new law does not, however, allow employees to sue their employer by claiming the employer infringes on the employees' religious practices.

As I noted in my earlier post, at least 18 states (16 plus now KY and MS) already have these laws on the books.  A study by Wayne State law professor Christopher Lund also notes that these laws rarely lead to the successful defense of discriminatory acts.  For example, it is difficult to claim your deeply conservative Christian values force you to deny a wedding cake to a lesbian couple when you are willing to make cakes celebrating a Pagan solstice party, divorce, new grant to study cloning, etc. as recently was the case in Oregon.  Apparently to use these laws as a legal defense you would have to show you consistently apply your religious values in your dealings with customers.  Unfortunately, these laws also put the government in the position of differentiating consistent theological principles from discrimination seeking to hide behind religion.  Ironically, these 'religious freedom restoration' laws bring the courts into defining religion.

What is perhaps the true aim of these recent legislative attempts and new statutes is to make a political statement.  This isn't a new phenomenon.  Former Confederate states added the Confederate flag to their state flags to make a statement.  Mississippi amended its state flag in 1894, and in 2001 state residents voted down a proposal to remove the Confederate battle flag widely associated nationally with racists and rednecks.  Similarly, the Catholic organization Knights of Columbus spearheaded the addition in 1954 of the words "under God" into the US Pledge of Allegiance -a previously thoroughly secular pledge.  Symbols matter and are often appropriated by political agendas by groups across the political spectrum.  Take for example the recent debacle in South Carolina where a little girl's suggestion that the state adopt the wooly mammoth as the state fossil unleashed various amendments pushing a Creationist agenda.

These recent religious freedom laws underscore a symbolic resistance to advances in gay rights and a growing pushback to a politicized conservative Christianity.  Yet, as an observer from the South, it is interesting to note the massive media attention and pushback that states like Kansas and Arizona received over their religious freedom bills.  In Kentucky in 2013 and now in Mississippi in 2014 you don't see anything close to the pushback.  Perhaps the relative silence when the KY and MS legislatures beat their Bibles reflects a national attitude that much of the South is like a Confederate reservation where people can continue to live with 19th century values?  I've noticed when there is an anti-gay incident or attack in New York or another urban area, many commentators react against the perpetrators. When a similar anti-gay incident happens in the South, many commentators lash out at the entire state or the South as a whole.  Similarly, I see a number of my fellow Southerners view the diverse populations of cities and urban suburbs where the vast majority of Americans live as not the "real Americans" and erroneously paint Democrats and Democratic-voting areas as "welfare queens" and "takers".  In fact, data shows that most of America's economic production comes from its cities and urban states that in fact tend to vote Democratic.  Thus, the older, poorer, more rural red state areas are generally the "takers" who receive far more in Federal benefits than they pay in via taxes.  

My point here is that laws like the religious freedom bills are more about political theater than policy.  They enhance stereotypes that are not universal in these states, and they highlight the differential treatment and attention given to some states by the national media and social networks.  The Culture Wars continue and while same-sex marriage sweeps the country MS' conservatives can now proudly point to the "In God We Trust" on their state seal.  

An Updated Marriage Law Map

Middling America reader Vin alerted me to a divorce case in Mississippi involving a same-sex couple.  So, I've added a blue asterisk for Mississippi.  Also a Federal judge in Tennessee has ordered the Volunteer State to recognize the out-of-state marriages of three same-sex couples suing for recognition of their marriages.  The judge based her decision on the couples' suit likely being successful.

To recap:  To date Federal judges appointed by both Democratic and Republican presidents have ruled in favor of legalizing same-sex marriage in some aspect in:

• Utah
• Texas
• Oklahoma
• Ohio
• Kentucky
• Virginia
• Tennessee

(It seems I may be missing some decisions, but there have been 100% favorable decisions to date.)

Fat in America

Happy New Year!  The start of a new year is often also the start of a new diet or health plan for many Americans.  The holidays have come and gone and left many with a few extra pounds.  So I thought today would be a good day to look at what else -obesity data!

Measuring obesity is somewhat complicated.  Because it is a relatively easy measure to gather, most survey data -including the CDC's Behavioral Risk Factor Surveillance Survey (BRFSS) data- use people's height and weight to calculate their Body Mass Index (BMI).  It is far from a perfect measure.  If you really are "big boned" as the country saying goes or are muscular, you may have a higher BMI but not be overweight. Or, you might come from an ethnicity of smaller framed people and rate as underweight when you are actually a healthy weight.  Still, for most people, the BMI is a relatively accurate measure of obesity.

The CDC breaks overweight people into the categories of Overweight (see above) and Obese (see below). Overweight people have a BMI of 25 to 29.9.  Obese people have a BMI of 30 or higher.  Being overweight puts you at risk for a shorter life, heart disease, diabetes, knee problems, and even psychological issues related to stigma against the overweight.

You'll notice that some states have relatively high percentages of people who are overweight but not that high of percentages of people who are obese.  Arizona stands out with this pattern.  Mississippi -which leads the country in the highest percentage of overweight and obese adults- has a relatively low percentage of people who are overweight in part because so many adults have transitioned into the obese category.

Even while obesity has risen across the country, a general pattern has emerged where the western states and northern tier states are relatively thinner than the South.

Toothless in Tennessee

As part of my continuing series on health data from the 2010 Behavioral Risk Factor Surveillance Survey (BRFSS), I thought I'd look at seniors who are missing all their teeth.  While this may seem a humorous topic, having poor oral health can open the door for bacteria and shave around 7 years off your life.

This map breaks the data by standard deviations from the mean/average.  So the pale, gray/white states' seniors are average -for the USA- in the percentage who are toothless.  The purple states have higher percentages of toothless seniors with WV, TN, MS, and KY having the worst data on senior oral health.

My friend Lee B. from Clinton, CT, used to tell me that people in Connecticut had great teeth.  Apparently she is right because the Nutmeg State and Hawaii have the most older Americans with their choppers.