ACA Open Enrollment Starts

Open enrollment through the Affordable Care Act starts tomorrow (November 15, 2014) and runs through February 15, 2015.  Here is a map updated in October for which states are providing their own health insurance exchanges and which are relying on the Federal www.healthcare.gov.  For the initial 2013-2014 enrollment period, the state exchanges outperformed the Federal exchange generally with Kentucky's KYNect being the star of the show.

What If: The Missouri and Crittenden Compromises

One of the more fascinating theories in modern physics is the concept of the multiverse where each decision made creates multiple universes. So, in one universe you chose strawberry ice cream today. In another you chose chocolate. In another you chose vanilla. It opens the door to wondering what if such-and-such has happened differently in another universe.


My partner is taking an American history class this semester and on a long car trip we read American history to each other. Of interest to me was the Missouri Compromise. For the past 15 years I have lived two blocks from the former home of Henry Clay, the early 19th century Kentucky master politician who guided the passage of the Missouri Compromise through Congress. I was intrigued about the geopolitical implications of this law if it had continued into later American history.


For those of you -like myself- a little hazy about the Missouri Compromise, it was a law passed in 1820 to keep the peace between the Southern and Northern states. Forty-four years after the Declaration of Independence, the North and South were quickly becoming very different Americas. Both regions economies were primarily based on agriculture, but the North was rapidly industrializing and desired a stronger Federal government that would invest tax dollars in industrial and transportation infrastructure and place higher tariffs on foreign imports. Slavery was also largely illegal in the North. The South on the other hand was politically ran by the plantation-based, export-oriented planters making up 1% of the South's population. While most Southerners were small farmers of modest means, racism, pride, and political manipulation by the very wealthy still led the white male Southern voter to support the slave economies pushed by the wealthy planters. In the South industrialization was far less advanced. Instead the Southern planters exported much of their cotton, indigo, sugar, and tobacco crops overseas to Great Britain and other European buyers. They then bought manufactured goods -and tea- from the British and other Europeans. Thus, Southerners developed a taste for sweet tea and a distaste for tariffs on foreign imports which raised their costs. Southern planters and their local allies opposed a strong Federal government which was suspected of wanting to abolish slavery.


The number of Southern Slave states and Northern Free states were about even by the early 1800s. A crisis ensued when Missouri and Maine applied for statehood. Slavery already existed in Missouri but there was a move to ban slavery in the Louisiana Purchase. After various political tussling, Henry Clay was able to broker and pass the Missouri Compromise that banned slavery in the former Louisiana Purchase north of 36 degrees 30 minutes of latitude (Missouri's southern boundary) except for Missouri. So, Missouri was admitted as a slave state and Maine as a free state. By 1837 there were an even 13 free states in the North and 13 slave states in the South. This uneasy peace lasted until 1854 when the Nebraska-Kansas Act replaced the Missouri Compromise with a system to let Nebraska and Kansas vote individually on whether to be a slave or free state.


When Abraham Lincoln's election in 1860 precipitated South Carolina and other Southern states to secede, another Kentucky politician, John Crittenden, offered a new compromise: extend the 36° 30′ Missouri Compromise line all the way to the Pacific. The so-called Crittenden Compromise failed to pass, and the Civil War ensued.


This map asks what could have happened if the Crittenden Compromise had passed and the South then not seceded. Instead, what if the same uneasy peace of the 1820-1854 had become an entrenched system. Without the South's secession to provoke Federal military action, would the horror of slavery been abolished by 2014? Would the system of admitting two states -one slave and one free- to keep the balance have continued? This map explores this scenario and is based on historical facts:


a. In the US of the Missouri and Critten Compromises, slavery is abolished largely north of the 36° 30′ parallel.


b. Without the Civil War to initiate its breakaway from Virginia, the counties that now constitute West Virginia remain part of the Virginia.


c. To even the free and slave state balance, the Dakota Territory and the Oregon Territory are admitted as single states rather than as North Dakota, South Dakota, Oregon, and Washington. And the once larger Deseret dreamed of by Mormon settlers has come into existence as the state of Deseret, the combination of Utah and Nevada. Keep in mind that some of the first white settlers of Nevada were Mormon farmers who established towns such as Las Vegas.


d. California on the other hand has been split into the free North California and slave South California roughly along 36° 30′ but actually along the Kern-Tulare County boundary.


e. Alaska has been admitted as a free state, but Hawaii and its sugar plantations have legalized human bondage.


f. Arizona, New Mexico, and Oklahoma have been admitted as slave states.


g. When the US annexed the former Mexican province of Texas (by then the independent Republic of Texas), the terms of annexation allow Texas to split into 5 states. This has happened to create North, South, East, West, and Central Texas.


h. Finally, even with 5 mini-Texases and other states, the South is still shy 3 states to have parity with the North. History, however, shows that Southern planters advocated annexing or buying Cuba and other Caribbean islands with a long history of slavery and plantation agriculture. In this scenario Cuba is now a state along with Puerto Rico and the combined US and British Virgin Islands.


The result is a nation of 54 states: 27 free states and 27 where the abomination of slavery still remains legal.

Updated Marriage Map

After the rush of court rulings in the first three months of 2014, April has been relatively a slow news period. The new Federal court rulings on same-sex marriage have created even greater complexity.  Judges in Tennessee and Indiana have ruled those states must recognize civil marriages performed out-of-state...but only for the plaintiffs in the lawsuits involving those cases.  So, this means Indiana must recognize the marriage of a lesbian couple in Evansville where one of the spouses is dying.  In Tennessee the judge ordered the state to recognize the three couples suing the state for recognition of their marriages.

Today an Ohio judge ordered that state to recognize marriages legally performed out-of-state.  He will decide tomorrow whether to stay his decision or not.

As for the number of states with and without a lawsuit seeking recognition of same-sex marriage, it is a challenge knowing which states have such lawsuits.  Lambda Legal put out a press release that to expect a lawsuit in Georgia this week, but there is no news there yet.  So stay tuned.

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.  

Religious Freedom Statutes

This week 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 also do not appear to have successfully exempted the defendant from legal consequences.

The recent rise of conservatives filing bills around religious freedoms 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) to ban such discrimination nationally.

21 states and DC, however, have state laws banning sexual orientation discrimination.  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 are currently performed have 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 again filed a complaint against 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.  On the political front, however, religious freedom bills appear to be more about making a political statement against gay people and same-sex marriage.

UPDATE: Marriage Map

This week there have been a number of changes affecting civil marriage laws in the United States.  So, it is time for another map update:

a. Yet another Federal judge -the 6th I think- has ruled that a state's ban on offering civil marriage and its benefits and responsibilities to same-sex couples violates the US Constitution.  This week a judge in Texas ruled that the Texas ban was unconstitutional.  The ruling has a stay on it while the case can be appealed by the state government.

b. In Kentucky another Federal judge today lifted his stay on an earlier ruling that the Bluegrass State must recognize marriages legally performed in other states.  The state's Democratic Attorney General has asked for a 90 day stay so that the state can decide to either appeal or prepare.  For KY's couples married out of state, confusion abounds about how to complete their taxes.  Currently they can file jointly their Federal returns as married but must submit state returns separately as single.  No word yet on how today's decision will affect tax filings.

c. The increasingly legal complexities are making my little map also more complex.  I've now added Ohio to the states recognizing out-of-state marriages because the Federal court ruling there orders the state to recognize such marriages on death certificates.  This ruling, however, if on appeal too.

UPDATE: Civil Marriage Laws Map

The new lawsuits and court rulings are making this map increasingly complex.  I've added a new category for states such as Oregon and Kentucky that currently do not allow same-sex marriages but which recognize them -or may.  At the time of this update there still is not official word from KY state government regarding how they will enact or respond to this week's ruling.

UPDATED MAP: Kentucky!!!! and Same-Sex Marriage Lawsuits

The legal situation involving the push to legalize same-sex marriage in most of the states is rapidly changing. As of today new lawsuits in Wisconsin, Missouri, and Louisiana are expanding the states with legal challenges to same-sex marriage bans.  A previous lawsuit in Louisiana was dismissed in December over legal standing issues.

Also, a new lawsuit in Ohio does not seek the legalization of same-sex marriages at the state level there. Instead it seeks to have the names of both parents listed on birth certificates when an Ohio or out-of-state adopting couple are legally married elsewhere.  This Ohio case would expand on an earlier Federal judge's ruling that Ohio must list same-sex spouses legally married elsewhere on Ohio death certificates.  That case is being appealed.

And today a Federal judge in Texas is hearing a challenge to that state's same-sex marriage ban.  Nevada's Attorney General also announced she will not defend Nevada's same-sex marriage ban from a legal challenge there because of the ban's likely unconstitutionality.

UPDATE:  Even as I posted this map over lunch, a Federal judge in Louisville, KY, ruled that my home state of Kentucky must recognize same-sex couples legally married in other states.  This particular lawsuit did not address whether same-sex couples could marry in Kentucky.  So now Kentucky will either join Oregon in recognizing same-sex couples married elsewhere or join Utah and Oklahoma in appealing this ruling.

UPDATE: The Typical American, English Language

Last night's Super Bowl commercial by Coca Cola featured various Americans singing America the Beautiful in different languages.  Strangely to me this commercial has triggered a backlash by the more xenophobic elements in American society.  Here's the commercial on YouTube and some statistics on the 1 in 5 Americans whose first language is not English.  America, c'est belle, no?

This backlash reminds me of a story floating around the web about two people waiting in line at the supermarket.  One person, a woman, is talking to a family member on the phone.  When she hangs up, the man behind her tells her that this is America and that if she wants to speak 'Mexican' she needs to go back to Mexico.  She looks him in the eye and informs him she was speaking Navajo and that if he wants to speak English he can go back to England. ;)

From its earliest days, the US has been a melting pot of languages from around the world.  The Founding Fathers almost voted to make German the language of government back in the 1700s!  In the 13 British colonies which became the original states, English was the most widespread language.

According to data from the 2012 American Community Survey, English still dominates with 4 out of 5 Americans speaking only English at home.  Yet, a sizeable number of Americans -1 in 5- do speak other languages at home.

Case in point:  A few years ago I looked into having a survey of Kentucky high school children translated into other languages.  When I checked, I found out that Kentucky schools -yes, Kentucky, not the most diverse state by any means- taught children whose primary languages included over 70 different languages! While English is the most common language in Kentucky schools and Spanish is the second most common, I was surprised that the third most common was Bosnian.  Kentucky has a rather sizeable Bosnian immigrant population who came to the area as war refugees.

Culture and Health

In my years of working in public health, I've come to see how culture plays an important part in the health behaviors we choose.  So today's post tells one of stories I've collected over the years about health choices:

I used to share an office suite with a retired dentist.  Jim is a great guy and would tell me stories from his decades of experience in oral health care in Kentucky.  One day he told me about a time a mother brought in her 16 year old daughter to his office.  The mother had false teeth, and Jim figured that this may have driven her to be concerned about her own daughter's oral health.  Jim checked the daughter's teeth and was happy to tell the mother than the daughter's teeth were in good condition.  He asked if there was any special problems beyond a routine cleaning and checkup that may have brought the pair to the dentist.  The mother quickly spoke up and said:  "Oh yes.  She's 16, so it's time."  

Jim:  "Oh?  Time?"

Mother:  "Yes.  For you to pull her teeth so she can get her false teeth."

Jim (shocked):  "What?"

Mother:  "I had my teeth out when I was 16 and got my false teeth.  So it's time."

Jim explained that the daughter had perfectly healthy teeth and did not need to have them extracted.  The mother strongly disagreed and demanded Jim pull her daughter's teeth and replace them with false teeth.  Jim refused, and the mother left in a huff.  He heard she eventually found a dentist who did pull her daughter's teeth and replace them with false teeth.  

I found this story rather bizarre.  I have no idea how long ago this scene took place or how this rural family became convinced that good oral health meant getting false teeth at the age of 16.  It certainly isn't the norm today among rural or urban Kentucky families.

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.

Where Have Smoking Cessation Programs Had the Biggest Impact?

In this continuing series on health data, let's look today at smoking.

The CDC lists smoking as the #1 preventable cause of early death.  Around 40% of people who smoke will eventually develop some type of health problem related to smoking.  Thus, smoking cessation and prevention programs for decades have -successfully I might add- greatly reduced the number of Americans to smoke.

In looking at data from the CDC's Behavioral Risk Factor Surveillance Survey (BRFSS) of adult health behaviors, I was curious if there were any regional differences showing where smoking cessation programs have had the biggest impact.  And it appears the answer is YES! -specifically in New England and Arizona which so the biggest percentages of people who have quit smoking.  

Let's look at the maps individually:

In every state except two, most adults have never smoked.  Only in Kentucky and West Virginia do the number of current or former smoker exceed 50% (52% each actually).  I have kept the legend values the same on these 4 maps, however, for comparison purposes.

By 2010 the number of adults who smoke daily in every state is below 1 in 5 -except in West Virginia where daily smokers exceed 20% of the population.





Interestingly, most American adults who smoke also smoke daily.  Less than 10% of American adults report they smoke but only a few days a week.

This last map shows the key differences.  People in Utah are the least likely to ever smoke.  Thus, Utah also has the lowest percentage of former smokers -because fewer people ever started smoking.  In most of the rest of the country, the percentage of former smokers is somewhere between 20-30% of the adult population.  The key exceptions are VT, NH, ME, and AZ where a larger percentage of the population has stopped smoking.  All four of these states actually had higher percentages of adults who have smoked or currently smoke but have had more success in adults quitting.

Kentucky Lung Cancer Death Rates By County

Kentucky leads the country in the number of adults who smoke -a leading cause of lung and bronchus cancer.  Sadly, Kentucky also leads the country in lung and bronchus cancer deaths.  Within the state, however, there are big regional differences with the blue counties in southeastern Kentucky having the highest death rates from lung cancer.