Travel: The Canadian Maritime Provinces

Going to the Canadian Maritime Provinces?  Don't miss these less well known facts about the area.

Georgia's MUPs

In looking at areas without sufficient medical providers, HRSA designates areas as HPSAs, MUAs, or MUPs (see previous posts on HPSAs and MUAs).  This final map shows Georgia's Medically Underserved Populations (MUPs).  MUPs and MUAs use the same criteria, but an MUP designation evaluates a specific sub-population rather than an entire county.

Georgia's HPSAs

HRSA also designates areas as HPSAs, Health Professional Shortage Areas, based on a formula.

Georgia's Medically Underserved Areas

HRSA, the Health Resources and Services Administration, categorizes areas as MUAs (Medically Underserved Areas) if they score 62 or less on an Index of Medical Underservice.  This score is based on an area's ratio of physicians per 1000 population, infant mortality rate, percentage of residents living below poverty, and the percentage of the population aged 65 or older.  Here is a map of Georgia's MUAs showing that most of the state is medically underserved.

Religious Freedom Restoration Act (RFRA) Statutes

One of the hot news items this week has been Indiana Governor Steve Pence's signature into law of a Religious Freedom Restoration Act (RFRA) statute for the Hoosier State.  Asa Hutchinson, Pence's fellow Republican governor of Arkansas, has vowed to sign a similar law passed in Arkansas this week.

This allows me to revisit earlier posts about these laws and their impact.

As you may recall, back in 2014 Arizona Governor Jan Brewer (R) vetoed a bill passed by the Republican-controlled Arizona legislature.  Dubbed a "religious freedom" statute, the law would have exempted both individuals and companies from legal penalties if they violated the civil rights of customers, patients, etc. because of the perpetrator's sincerely held religious beliefs.  The backlash from major employers, citizens, and potential tourist events to Arizona led to various initial supporters and even the state's two Republican US Senators to oppose the bill.

Similar bills are not new.  A study by Wayne State law professor Christopher Lund identifies 16 states that added such laws between 1993 and 2009:

Interestingly, it appears Arizona has a law very similar to the one Gov. Brewer vetoed already on the books. Lund's article finds very few cases have arisen involving these laws.  Most lawsuits stemming from these laws also do not appear to have successfully exempted the defendant from legal consequences.

Connecticut passed the first of these RFRA statutes back in 1993 in reaction a Federal court case that had nothing to do with LGBT Americans.  The recent rise of conservatives filing these bills around religious freedoms, however, comes largely as a backlash to the rapid expansion of same-sex marriage legalization.  Here is a brief primer on the issue:

First, dear readers, you must understand that existing civil rights on the national Federal level cover very specific classes of people (race, religion, ethnicity, disability, etc.)  Age is covered but only for people 40 and above.  In turn, not all classes of people are covered equally in the areas of employment, housing, and public accommodations.  For instance, sex discrimination is illegal in employment and housing.  Sex discrimination is also illegal in terms of some public accommodations (hotels, etc.) but generally not restaurants and many other venues.  So, you can offer special Ladies Night deals not offered equally to men, have gay male leather bars that exclude women, women-only music festivals, and women-only gyms.  Similarly, discrimination because of one's familial status is illegal in housing but not employment or public accommodations.

And when it comes to sexual orientation, there simply is no existing Federal law banning discrimination based on a person's homosexual, bisexual, or heterosexual orientation.  For years supporters have been trying to pass the Employment Non-Discrimination Act (ENDA) or similar bills to ban such discrimination nationally.

22 states and DC, however, have state laws banning sexual orientation discrimination.  Utah just passed such a law covering employment and housing but excluding public accommodations.  11 other states ban sexual orientation discrimination involving public (state) employees.  Additionally, scores of cities, universities, and businesses have ordinances and policies banning sexual orientation bias.

So, now we have a number of states legalizing same-sex marriages.  In fact, all of the states where same-sex marriages were initially performed had civil rights statutes banning sexual orientation.  In New Mexico, a gay couple planned their wedding and contacted a public photography business to photograph their ceremony.  The business' owner, a devout conservative Christian, refused claiming performing this service for this couple would violate his religious beliefs.  The couple filed a civil rights complaint against the business and ultimately won.  Conservatives howled this application of existing civil rights laws against this business violated the owner's personal religion.

In Oregon, there was a similar case involving a lesbian couple planning a ceremony to bless their union. Again, a public business -in this case a bakery- refused to serve them.  The couple filed a complaint against the bakery, Sweet Cakes by Melissa.  Writers for the Portland Willamette Weekly wrote an interesting article exploring just how devout the Christian owners of this business were.  They write that the bakery was willing to make cakes celebrating a divorce party, a pagan solstice party, an out-of-wedlock baby shower, a non-kosher BBQ, and a party celebrating a researcher who had just received a grant to clone human cells.

This selective application of 'sincerely held religious beliefs' is also what led to a Lexington, KY, t-shirt printing company's loss over a complaint filed when it refused to print an innocuous Pride festival t-shirt but showed a history of printing a variety of sexually suggestive and crude t-shirts for other customers.

Yet, -and this point is key- the Oregon and New Mexico couples and the Kentucky gay organization would have been out-of-luck legally if they had lived in other jurisdictions.  Kentucky for instance has no civil rights law banning sexual orientation.  GLSO, the gay organization, and the offending printer both happened to be in Lexington, a city that passed a non-discrimination ordinance covering sexual orientation in 1999.

So, a gay couple that marries in Iowa and then goes home to rural Kansas and is refused a wedding cake by a local bakery has no civil rights protection and no way to legally fight the refusal.  So on the legal front, it is not marriage that is the driving force behind the civil rights cases but the enforcement of existing civil rights laws.

Let us ponder the impact of a RFRA on the cases in New Mexico, Oregon, and Kentucky.  These RFRA laws set a higher bar for the government to enforce regulations that defendants claim infringe on their sincerely held religious beliefs.  Professor Lund's article finds that such claims under a RFRA rarely if ever stand up because the state can respond by saying that it has a compelling reason to ban discrimination in employment, housing, and public accommodations against people based on characteristics with a history of discrimination.

So, in Indiana before the passage of this RFRA, it was not illegal to walk in and say to an employee, "Ellen, you're a lesbian.  You're fired.  Get out."  ...except in Marion County (Indianapolis) which has a local non-discrimination ordinance.  It was perfectly legal for Ellen's homophobic boss to fire her in most of Indiana.  Maybe the boss fired her because he just hates lesbians and is an atheist.  Maybe he is a conservative Christian who doesn't want to employ a lesbian.  It doesn't matter:  Ellen is out the door without a legal remedy to being discriminated against because she is a lesbian.

Indiana's new RFRA does not change that except possibly in Marion County.  Let's say the Christian boss and Ellen work in Marion County.  Ellen can now file a discrimination complaint with the local government.  The boss man can claim being forced to employ a lesbian in his public business infringes on his private religious views ...a la Hobby Lobby.  But the city can come back and say this burden on his religious views is trumped by a compelling interest in protecting citizens of Marion County from discrimination.  It now also opens the boss' actions to scrutiny about just how Christian is he?  What if he is openly employing bacon-eating divorcees with tattoos?  adulterers?  women who have previously had an abortion?  former convicted murderers? or a host of people whose lifestyles could be claimed to be in conflict with some interpretation of Christian values?

It also raises the question of whether a member of the erstwhile Christian-identifying Ku Klux Klan could fire an African American and claim via the RFRA that non-discrimination laws barring race discrimination infringe on his or her religious beliefs.

These RFRA laws and the media coverage they generate involve a lot of theoretical situations.  Lund's analysis finds these laws do not have much legal impact.

On the political front, however, religious freedom bills appear to be more about making a political statement against LGBT people and same-sex marriage.  It is analogous to the wave of post-Reconstruction Southern states that added the Confederate battle flag to their state flags in the 1890s once control of Southern state legislatures returned to local control.  So yes, blue states like Connecticut, Illinois, Rhode Island, etc. pass their own RFRAs in the 1990s, but they did so for different rationales.  The public record among supporters of the current wave of RFRAs is clear that these statutes are meant to send the message that conservative Christian values should trump Federal and state expansions of LGBT civil rights.  And thus that creates a difference between the intent of these laws in the 1990s and their new counterparts being passed this week.

Here is an updated civil marriage map.  As you can see, most of the country now allows same-sex couples to marry.  The map though has a lot of legal quirks that are not shown.  For example, a Federal judge ruled Alabama's marriage ban was a violation of the US Constitution.

Marriage licenses were issued and then stopped by a contravening order of the Alabama Supreme Court.  Any basic understanding of American law knows that Federal law trumps state statutes that in turn trump local ordinances.  So, the AL Supreme Court ruling is likely illegal.  (Note:  Arkansas just passed a law limiting civil rights to the state's statutes.  It effectively overturns a local ordinance in Eureka Springs that banned sexual orientation discrimination.)

Marriage has been legal in Idaho since last year, but this month the Idaho House passed a resolution that any judge ruling the state's marriage ban is unconstitutional should be impeached.  Idaho is giving Alabama a run in terms of swimming against the tide of history...and the law.

Only a handful of counties in Missouri issue marriage licenses but the state recognizes such marriages.

Across the border in Kansas, clerks issue marriage licenses but the state does not recognize these marriages.

And Oklahoma is trying to pass a law that would get rid of marriage licenses altogether.  Instead couples would get a certificate of marriage from a minister, priest or rabbi and file it with their county clerk.  Thus clerks would not have to issue marriage licenses.  If you are an atheist or do not want a religious marriage, you would get an affidavit of a common law marriage (which some states do not recognize).  If passed, it is likely to create huge headaches for Oklahoma couples and end up in the courts.

Court cases in the 8th, 5th, 11th and 1st circuits (Puerto Rico is in the 1st circuit) continue to slowly wind their way through the courts.  These lawsuits may be moot, however, since the US Supreme Court is expected to rule on this issue in June.

Utah Passes Non-Discrimination Law

This month the Utah legislature -with the blessings of the Church of Latter-Day Saints- passed a law banning discrimination on the basis of sexual orientation.  It also covers gender identity.  Unlike most such statutes, however, Utah's law does not cover public accommodations.  Thus, bias in employment and housing is now illegal, but Utah businesses can still deny services to individuals or couples based on their sexual orientation.

Georgia and the ACA

In 2014 Georgia had the dubious honor of being the only state with 2 of the 10 most expensive health insurance markets in the country.  Southwest Georgia ranks as the second most expensive market in the country after an affluent area of western Colorado (#1).  Centered around Albany, GA, this area has a number of factors likely playing into the expensive premiums there.  Neighboring southern GA has many of the same issues:

*These two markets are fairly rural.

*Georgia's legislature chose not to expand Medicaid to residents making 101-138% of the Federal Poverty Limit even though the Federal government pays 100% of the expansion costs for the first couple of years and 90% of the costs after that.  Rural hospitals in GA thus continue to have to treat uninsured poor patients and pass along the costs in higher costs to their insured patients and these insured residents' insurance companies.  Compounding this scenario is the fact that southwestern Georgia is served by a single hospital system.  In terms of seeking medical care, there is no other game in town.

*Southwestern and southern Georgia are fairly poor, rural areas with relatively high levels of chronic disease.  In other words, the populations of these areas are sicker and poorer than other parts of the state.  

The differences in average premiums between relatively affluent north Georgia/Atlanta and southern, rural Georgia earned Georgia the distinction of having the greatest disparities of any state in terms of insurance premiums.  

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.

Collegiate Recovery Programs

Collegiate recovery programs are a new concept for me.  I discovered of their existence in 2014. Only about 50 U.S. colleges and universities offer these programs to support college students who are recovering from alcoholism and drug abuse.

If you consider the usual images of college social life, they often focus on heavy drinking and experimentation with illicit drugs.  College can be a tough place for a student in recovery.  Collegiate recovery programs help provide a range of services to assist students in recovery.  Most require a student to have been in recovery for a minimum of 6 months.  Some provide counseling.  Almost all seek to provide social gatherings and academic advising that take the special needs of students in recovery into account.

Georgia offers such programs at Georgia Southern University (with students from East Georgia College also served) and Kennesaw State University with a new effort/program at the University of Georgia.

Updated Marriage Map

Today civil marriages for same-sex couples became legal in Florida.  If we add in Missouri and Kansas (see below), 37 states and the District of Columbia now offer civil marriage licenses to both same-sex and opposite-sex couples.  Basically the number of states where same-sex civil marriages are legal doubled in 2014 after a string of court rulings based on the Windsor case.  One article I read stated that 4 out of 5 Americans now live in a state where same-sex couples can legally wed.  Using 2010 Census data, I came to the figure of 73% of the population living in a state with marriage but those data are 5 years old now.

There are many complications to this story however:

*The US Supreme Court avoided taking up the constitutionality of same-sex marriage bans in 2014.  After a split in appellate court rulings developed after a 2-1 ruling by the 6th Circuit in Cincinnati upheld the bans, the US Supreme Court has agreed to discuss whether to address the question of same-sex marriage bans and the US Constitution.  The Court will decide whether to take a case or pass again on the issue in January.

*Same-sex couples can only marry in a handful of jurisdictions in Missouri, but the state government recognizes these marriages.  Other jurisdictions continue to refuse licenses to couples pending more litigation.

*Neighboring Kansas is also a strange case.  A handful of jurisdictions there issue licenses but the state continues to refuse to recognize these marriages in spite of a ruling striking down marriage bans by the 10th Circuit.  

*Idaho's governor and attorney general are also appealing the striking down of that state's ban.

*Couples were briefly allowed to marry in Arkansas and Michigan.  After the 6th Circuit's ruling upholding Michigan's ban, Michigan's governor rushed to announce the marriages that had already occurred there using legally issued licenses at that time never happened and were void.  Even if that state's ban is upheld in appeal, the retroactive voiding of these marriages is likely to be more litigation.

*All this litigation by state officials seeking to uphold marriage bans is proving costly to states.  As state officials are losing more than 27 cases in 2014 over the unconstitutionality of these laws, they must by law pay the court costs of the citizens challenging these bans.  

I feel that it is likely the US Supreme Court will take up the constitutionality of same-sex marriage bans in 2015 and issue a ruling.  The number of states with and without marriage now closely resembles the lineup of states before major court decisions on interracial marriages and school desegregation.  Most of the states have already adopted the new policies with the usual holdouts in the former Confederacy as well as the 6th Circuit states and the sparsely populated Dakotas and Nebraska remaining.  I should add that Puerto Rico and other US territories are also holdouts.  I predict that by January 2016 civil marriages will be open to both opposite-sex and same-sex couples alike with future generations wondering what all the fuss was about.