The ACA: Health Rankings and Health Exchanges

Most of the least healthiest states' governors opted to not pursue a state-level health exchange.

Of the 12 unhealthiest states in 2012, only one -Kentucky- opted to set up its own state health exchange under the Affordable Care Act.  Arkansas and West Virginia chose to set up joint Federal-state exchanges. All three states had Democratic governors in 2012.  

One other state in the bottom quarter of health rankings also had Democratic governor in 2012.  Missouri voters in 2012, however, passed a law blocking their governor from setting up a state health exchange. 

The other 8 unhealthiest states currently have Republican governors.

These maps underscore the political element involved in decisions to expand health insurance to the states with the most serious health challenges.

Ranking America's Health

The Southern states rank as America's least healthy.

As a Southerner, I'm somewhat used to rankings that often find the Southern states where I live, work, and visit family as among the worst on a host of social indicators:  poverty, low education, and disease.  The University of Wisconsin recently received funding from the Robert Wood Johnson Foundation (RWJ) to synthesize a large number of health indicators and rank the states and counties for health.  America's Health Rankings (for states) and its sister site, County Health Rankings, generated considerable news coverage and controversy as you would expect anytime you rank places.  Below is a map of the health rankings for the year the ACA was enacted by Congress:  

As you can see, the least healthy states tend to be in the southern tier of the country.  Of the former Confederate states, only Virginia ranks among the healthiest half of states.

The ACA: Medicaid Expansion

Medicaid expansion leaves out the majority of America's uninsured.

Via: The Advisory Board Company

One of the primary mechanisms to insure low income Americans under the ACA is the expansion of Medicaid.  Currently households earning up to 100% of the Federal poverty limit can enroll in Medicaid, the public health insurance program jointly administered by the individual states and the Federal government.  The ACA seeks to expand Medicaid to cover households earning up to 134% of the Federal poverty limit (FPL).

When the US Supreme Court upheld the constitutionality of the ACA as a tax, the Court's decision ruled that expanding Medicaid was optional for the states.  As a result, most of the states with Republican governors have chosen to not expand Medicaid -citing fears of the program busting state budgets.  The Federal government pays 100% of the costs of expansion for the first several years and then pays 90% of the costs after the first several years.

The results create a number of consequences.  More than half of America's uninsured live in the red states opting not to expand Medicaid.  Texas and Florida especially contain large numbers of uninsured Americans. Consequences:

a. Many or even most of the uninsured poor will not be covered by Medicaid as planned.

b. In 2014 all Americans -with a handful of exceptions- must show they have health insurance coverage.  For households earning 101-134% or so of the Federal poverty limit and who live in one of these non-expansion states, they currently will not get Medicaid or the subsidies designed for households earning 135% or higher of the FPL.  So unless this "insurance donut" is fixed, these working poor will have the additional burden of non-subsidized health premiums or a fine for not having health insurance.  Or they will have to move to a state that has expanded Medicaid.

c. Hospitals -especially those rural and inner city ones treating large numbers of uninsured- currently can dip into a Federal fund to offset the costs of treating uninsured patients.  The ACA expected the vast majority of these uninsured patients to be covered by Medicaid or another type of private insurance by 2014 and moved half of this fund to paying for the ACA.  Now the Federal government is delaying the reductions in this hospital pool.  Starting in 2016, however, the pool for offsetting the costs of treating the uninsured will be halved.  For those hospitals in non-expansion states, they must still treat or stabilize any patient entering their doors -at least if the hospital receives any government funding such as Medicare or Medicaid patients.  Without the expansion they have only one way to offset their costs:  raising premiums on insured patients.  Thus, the choice to not expand Medicaid may lead to higher premiums for the insured in these states or the closure/bankruptcy of hospitals.

The ACA: Health Exchanges

Whether your state has its own health exchange or relies on the troubled Federal exchange, healthcare.gov, depends largely on whether you have a Democrat or Republican as governor.

History is full of ironies.  

Most Americans get their medical insurance from their employers.  This system is largely a fluke of history.  1930s Depression Era laws limited the ability of American employers to give raises.  So when the economy began to boom during and after World War II, employers turned to offering benefits as a way to recruit and retain workers.  In other countries, health insurance coverage usually evolved in the post-war, mid-20th century as a government service like the military, police, schools, and fire departments.  

For the US, 1965 was a crucial year.  It was in this year that Medicaid and Medicare started as programs to help certain groups of uninsured Americans.  By 2010 the public health insurance landscape in the US had become a patchwork of programs:

• Medicare for seniors
• Medicaid for low income Americans -mostly seniors and children
• VA (Veterans Administration) for military veterans
• TRICARE for active duty military and their families
• CHIP (Child Health Insurance Program) for low income children
• IHS (Indian Health Service) for Native Americans living on reservations

Ideas for how to cover the big group -the working poor- left out by these programs goes all the way back to the Nixon administration.  Ironically, largely Republican think tanks and policy experts created a system of funneling the uninsured into private health insurance programs using subsidies for the poor and individual mandates to require younger, healthier, uninsured people to buy private health insurance.  It was this basic program which Republican Governor Mitt Romney installed in Massachusetts.  And it is this system of using private health insurers and government subsidies which is the same model making up Obamacare.

Even more irony:  More liberal Democrats wanted to simply expand Medicaid to cover the uninsured and have a tax withdrawn from people's checks in the way we pay for Medicare.  Some political commentators argue the use of the Romneycare model -plus the adoption of more than a 100 Republican amendments to the ACA- largely was a failed carrot to entice Republican legislators to vote for the ACA.  So, while the ACA is largely a Republican idea filled with Republican amendments, the ACA passed with zero Republican votes in 2010.  

Thus, it comes as no surprise that most Republican governors have opted to not set up a health exchange for their state and instead let the Federal exchange fill the void.

The Affordable Care Act (ACA): Obamacare Comes to America

Congress enacted the Affordable Care Act -AKA Obamacare- in 2010.  Various elements of the new healthcare law have been rolling out in the past several years, but the key health exchanges opened this month.  My next series of maps and data will focus on the ACA.

If you are interested in my own personal odyssey enrolling for coverage, check out one of my other blogs, My ACA Experience.

Just How Many Americans Are...

The typical American overestimates the percentage of the population which is Black, Hispanic, or gay.

For me as a demographer, it sometimes seems strange that others don't pour over the latest Census figures and polling data with the glee others dive into a new Harry Potter book.  But, people are strange <wink>.

So perhaps it is not unsurprising that the typical American wildly overestimates the percentage of the population consisting of minority groups.  I believe many people probably base their perceptions on TV programs and the frequency of media coverage involving Americans from various minority groups.  

As I discussed earlier this week, the typical American in a recent Gallup poll estimated a quarter of the US population is gay -rather than the likely more accurate 3.5%.

An older poll from 2001 finds a similar misperception regarding Black and Hispanic Americans.  The average percentages of the population offered by respondents argues that 33% of Americans are Black and 29% of Americans are Hispanic!  The correct percentages from the 2000 US Census are 12.3% Black and 12.5% Hispanic.

Now keep in mind that you can mark Black for your race on the Census, mark Hispanic as your ethnicity, and be gay -a characteristic the Census doesn't ask about individually.  Still, it is fun to ponder that -barring overlap- our poor, hapless typical American may think 87% of the US population is Black, Hispanic, or gay!

Some of My Best Friends Are...

Majority:  The majority of Americans report they know someone who is gay/lesbian.

Various studies and polls find that people who reporting knowing someone who is gay or lesbian are also more likely to support gay rights.  A 2009 Gallup poll finds most Americans (58%) say they personally know someone who is gay or lesbian.  Among self-identified liberals, that percentage shoots up to 71%.

It might be easy to conclude that knowing someone who is gay makes you more sympathetics to gay people and gay civil rights issues.  On the other hand, perhaps the higher percentage of liberals -a group generally supportive of gay rights- reporting they know someone who is gay may well also express the reverse:  gay Americans may be more likely to come out to heterosexuals known to be supportive of gay rights.

While such questions are interesting, they also leave a bit of a bad taste for me because they other gay people.  Imagine how strange it would be to ask the same Gallup sample "Do you personally know someone who is heterosexual?" 

Gay Marriage: The Next States to Walk Down the Aisle?

Polling from last summer finds majorities or pluralities of Americans in these states support legalization of civil marriage for same-sex couples:

Statistical guru -and openly gay man- Nate Silver calculates that by 2016 a majority of American voters will support legalization of same-sex marriage nationally.  By 2020 he predicts a majority of voters in all but six Deep South states (LA, AR, MS, AL, GA, and SC) will support legalization.  Read it here.

Just How Many Gay People Are There?

The majority of Americans -incorrectly- believes 1 in 5 Americans are gay.

An interesting 2011 Gallup poll finds that 52% of Americans believe 20% or more of the US population is gay.  Indeed, this poll shows respondents on average believe 1 in 4 Americans are gay.  A hodgepodge of demographic groups report the highest -and likely most incorrect- answers:

• women
• lower income respondents
• Southerners
• individuals with a high school degree or less
• Democrats
• social liberals
• people who oppose legalization of gay/lesbian relations

The poll has a margin of error of +/-4 %.

The cold fact is that any estimation of the number of gay, lesbian, and bisexual Americans relies on sampling data.  Why?  Because our numbers for Americans based on race, Hispanic ethnicity, sex, and age all come from the US Census.  For other categorizations of the American population -such as by sexual orientation or by religious affiliation- we have to turn to other research techniques such as sampling, compilation of church registries, etc.  

UCLA's Williams Institute, however, does considerable work in the area of LGBT demographics.  Gary Gates' paper does an admirable meta-analysis of various studies seeking to determine the number of gay Americans.  He concludes that 3.5% of the population are likely to identify as gay, lesbian or bisexual.

Gay Marriage: Opponents

While the national majority of Americans now say they support legalizing same-sex civil marriage, majorities in some states oppose such legalization.

From Outlaws to In-Laws: Sodomy Laws to Marriage

Majority:  In a reversal from before 2001, most Americans do not support criminalizing private, consensual sexual relations between members of the same sex...and probably also do not support criminalizing private, consensual oral and anal sex for the heterosexual majority either.

With the quick succession of states legalizing civil marriage between same-sex couples, it is easy to forget that private, consensual sexual relations between same-sex couples -as well as certain sex acts between opposite-sex couples in some states- were criminalized up until a decade ago.  Under various names such as crimes against nature laws or sodomy laws, such laws made it a crime for a gay or lesbian couple to be intimate in the privacy of their own home.

The American Bar Association's model penal code revisions in the 1960s began to urge state legislatures to remove victimless moral crimes including consensual sodomy.  Keep in mind that such laws often banned oral and anal sex for heterosexuals too -and breaking these laws could lead to a felony conviction, listing on a sex offender registry, years in prison, and fines.  While the laws were rarely used against heterosexual couples, they were frequently cited in custody cases involving a lesbian mother and the heterosexual father of her children from a former relationship.  They were also cited as rationale for denying domestic partner benefits and allowing gay student organizations under the premise that such actions would support criminalized relationships.

My home state of Kentucky provides an interesting case study via Wikipedia:

At that time, Kentucky law criminalized consensual sexual relations between people of the same sex, even if conducted in private. Specifically, the law criminalized genital-oral (oral sex), genital-anal (anal sex), and anal-oral (rimming) sex -but only between partners of the same sex. Such sexual activities between mixed-sex (male-female) couples were legal. Such conduct was a misdemeanor punishable by up to 12 months in jail and a fine of up to $500. Solicitation of same was also a misdemeanor, punishable by up to 90 days in jail and a fine of up to $250. Historically, Kentucky's sodomy statutes had changed over time. The 1860 sodomy statute criminalized anal penetration by a penis and applied to both male-female couples and male-male couples. Because the law focused exclusively on penile-anal penetration, consensual sex between women was technically legal in Kentucky until 1974. In fact, in 1909 the Kentucky Supreme Court issued a ruling in Commonwealth v. Poindexter involving two African-American men arrested for consensual oral sex. In this decision the court upheld that the then current sodomy law did not criminalize oral sex but only anal sex.

In 1974 Kentucky revised its statutes as part of a penal code reform advocated by the American Law Institute. While the American Law Institute urged states to decriminalize consensual sodomy and other victimless crimes, the Kentucky legislature chose to decriminalize anal sex involving male-female couples but to broaden the new statute to criminalize anal-genital, oral-genital, and oral-anal sexual contact involving same-sex couples (both male-male and female-female couples). Thus, the 1974 revised statute decriminalized consensual anal sex for mixed-sex couples but expanded criminalization of sexual acts to include both male and female same-sex couples.

Morrison, Matthew (2001). "Currents in the Stream: The Evolving Legal Status of Gay and Lesbian Persons in Kentucky". Kentucky Law Journal 89 (4).

Jones, Jeffery (2001). Hidden Histories, Proud Communities: Multiple Narratives in the Queer Geographies of Lexington, Kentucky, 1930-1999. Lexington, KY: University of Kentucky (dissertation).

Illinois became the first state to decriminalize sodomy in 1968.  Various states dropped their sodomy laws until the movement stalled with the advent of AIDS in the early 1980s.  It was not until 1992 when Kentucky's Supreme Court overturned the state's same-sex only sodomy law on state constitutional grounds that decriminalization proceeded.  Using similar arguments made in the Kentucky case, a lawsuit involving a gay couple arrested in one man's bedroom by Texas police serving him for traffic violations came before the US Supreme Court.  In a close 5-4 decision in Lawrence v. Texas, the US Supreme Court overturned the last remaining sodomy laws in 2003.

Interestingly, conservative Republican Virginia Attorney General, Ken Cuccinelli is running for Governor of Virginia.  He has argued Virginia's consensual sodomy law is still in force and applies to all Virginians:

Virginia Is for Retro Anti-Sodomy Law Campaigns

But regardless of the US Supreme Court's ruling, does our Average American want anal -maybe even oral- sex between consenting adults criminalized?

Well, considering that one study looking at sexually transmitted infections finds that one-third of a sample of over 12,000 heterosexuals report having anal sex, and three-quarters say they have had oral sex, enforcement of such criminalization would be challenging to say the least.

But what about only criminalizing homosexual sodomy?  It turns out that Gallup polls from 1977 to 2011 show a steady increase in Americans stating they believe gay or lesbian relations -sexual relations and relationships- should be legal.  In 1977 Gallup found support at 43%.  By 2011 this had risen to almost two-thirds of Americans (64%).  Most Americans (56%) also now say they find homosexuality to be morally acceptable -an increase from 40% in 1977.

So, no, according to polling most Americans would not be in favor of criminalizing sexual relations between members of the same sex.

ENDA: The Employment Non-Discrimination Act

Majority:  Most registered American voters support a Federal law banning employment discrimination because of a person's sexual orientation.

While recent media attention focuses on same-sex civil marriage, it remains legal to discriminate against a person because of her or his sexual orientation in most states.  Ironically, earlier and a recent poll find most Americans believe such discrimination is already illegal.  Thus, some Americans believe attempts at a gay rights law banning employment discrimination is instead some attempt at 'special rights'.  Such laws fall within the system of civil rights laws already existing in the US and thus cover heterosexuals as well as homosexuals and bisexual orientations.

A September 2013 national poll by Republican pollster Alex Lundry with TargetPoint Consulting finds that 80% of Americans incorrectly believe it is already illegal to fire, refuse to hire, demote, or otherwise discriminate in employment against a person because of her/his sexual orientation. A law to ban such discrimination currently is gaining steam before Congress.  ENDA, the Employment Non-Discrimination Act, would ban discrimination based on an individual's sexual orientation and gender identity in the area of private and public employment.  The bill exempts religious organizations and private clubs as well as only applies to businesses with 15 or more employees.(1)

Supporters have tried to get ENDA passed since 1994.  A similar bill had been introduced to Congress for decades starting in 1974.(1)

Lundry's polling finds 68% of his sample of registered voters support a Federal law protecting against sexual orientation discrimination in employment.  3 out of 5 registered voters believe sexual orientation discrimination is a problem in the US -with 31% believing such bias is a major problem.

Lundry also calculated that a majority of voters in all 50 states support such legislation.

Gay Marriage

Majority:  Most Americans now support legalizing civil marriage for same-sex couples.

Starting around 2011-2012 various national US polls began finding the scales had tipped on legalizing civil marriage for same-sex couples.  Polling now consistently finds a slim majority of Americans support same-sex marriage.  With New Jersey becoming the 14th state -plus DC- to allow same-sex marriages, 30% of Americans now live in a state where both same-sex and opposite-sex couples may legally marry.  Another 13% live in states allowing opposite-sex couples to marry and allowing same-sex couples to enter into civil unions.  As of last week, Oregon also recognizes same-sex marriages performed out-of-state.  Eight counties in New Mexico are also issuing marriage licenses.  Six tribal jurisdictions in the US also offer legal same-sex marriages.  And there are pending lawsuits seeking to legalize marriage for same-sex couples in more than half a dozen states.

This blog is dedicated to exploring data on the "Average American's" views on social and political trends.

This week I'm going to start with gay rights issues,  along with abortion one of the two big political social "hot button" issues in recent elections.