Two rising sea stories from today (a reprise from four years ago)

I wrote the following post four years ago, but these stories still warrant attention. If your family has property on the coast, make sure you read this. The footnote is of interest as well.

In my newspaper today, two articles caught my eye about the impact of rising seas. The first is an editorial entitled “Rising seas eroding coastal property values,” written by Orrin Pilkey, the co-author of a study of this subject.

The other is an article called “Highest tide in 50 years swamps Venice,” by Elisabetta Povoledo of The New York Times. Beginning with the sensational, per Povoledo, “The Mayor of Venice, who said that the city ‘was on its knees’ has called for a state of emergency and the closing of all schools after the Italian city was submerged under…an exceptionally high tide – the highest in 50 years.”

At six-feet, the rising sea level in Venice was the most since 1966. Yet, per the article, “Last year, as severe weather in Italy killed 11 people, ferocious winds drove the high tide in Venice to more than five feet above average sea level.”

In Pilkey’s editorial, the study was reported in his book with Keith Pilkey called “Sea level rise: a slow Tsunami on America’s shores.” “The First Foundation, a non-profit research group with flood risk, analyzed 13.3 million real estate transactions, and compared the results to 25.6 million properties along the east coast and Gulf coast of the US. They concluded that there was a $15.8 billion loss in home value appreciation between Maine and Texas from 2015 to 2017.”

Pilkey made reference to increasing “sunny day flooding.” They note the sunny day flooding will increase even more until it becomes more permanent. In essence the sea water comes up through the storm drains in the street leaving standing water. A key quote toward the end of the article is a warning. “I know that if my family were living in or near a sunny day flooding area, I would urge them to sell and leave.”

Low lying coastal cities are at great risk. Global climate scientists have long said the City of Miami is the most at risk city in the world. Miami Beach is already seeing many more days of sunny day flooding. The state that had the most property loss in value is Florida. I would hope the leaders of that state would be banging the drum the loudest. As for Venice, they rely so much on tourism. Yet, that future looks to be at grave risk given its low sea level status.

Note: Below are two links to these articles:

https://www.newsobserver.com/opinion/article237245139.html

https://www.nytimes.com/svc/oembed/html/?url=https%3A%2F%2Fwww.nytimes.com%2F2019%2F11%2F13%2Fworld%2Feurope%2Fvenice-flood.html

Note further: A famous climate change “denier” in words does not match his rhetoric with his actions. Per a Politico article in May, 2016 entitled “Trump acknowledges climate change — at his golf course:”

“The New York billionaire is applying for permission to erect a coastal protection works to prevent erosion at his seaside golf resort, Trump International Golf Links and Hotel Ireland, in County Clare. A permit application for the wall, filed by Trump International Golf Links Ireland and reviewed by POLITICO, explicitly cites global warming and its consequences — increased erosion due to rising sea levels and extreme weather this century — as a chief justification for building the structure.” These actions support the concerns of the Pilkey study of property values being at risk due to sea level rise.

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Medicaid expansion – letter to the editor

When the Affordable Care Act was passed in 2010, a key element was for people who made less than 133% of the poverty limit based on their family size. This group would pay no premiums through a state-by-state expansion of Medicaid. The federal government said it would reimburse each state for 90% of that cost.

At this point in 2022, there are twelve holdout states that have not expanded Medicaid. That leaves 2 million Americans with access to no healthcare coverage. The holdout states include my home state of North Carolina and big states like Texas, Florida and Georgia (see link below to a NPR article).

North Carolina was close to passing Medicaid expansion, but the effort stalled once again. Here is a letter I sent to my newspaper that they graciously printed this morning.

NC and Medicaid

“As a retired benefits consultant and former benefits manager for a Fortune 500 company, I was hopeful that the N.C. General Assembly would at long last pass an expansion of Medicaid to fully comply with the Affordable Care Act. Failing to do this has harmed N.C. residents. Our economy has been impacted and some rural hospitals have either closed or are in financial trouble, according to the Commonwealth Fund, a nonpartisan healthcare advisor.

As former GOP presidential candidate and Ohio governor John Kasich noted when Ohio expanded Medicaid years ago, it was a no-brainer with the federal funding the state has realized for years now. Please move forward on Medicaid expansion.“

We have heard of food deserts in largely rural states which impact people in need more than others. But, we also have healthcare deserts as well. Taking only one data point, it is not a surprise to learn that maternal mortality rates in these states are worse than in other states and first-world countries. Note, this is mother’s dying in childbirth. That is a sad state of affairs, especially for a country who claims exceptionalism.

https://www.npr.org/sections/health-shots/2021/07/01/1011502538/12-holdout-states-havent-expanded-medicaid-leaving-2-million-people-in-limbo

US is the only developed nation where rate of pregnant mother deaths is rising (a reprise from 2015)

The rise in maternal mortality in the United States has been hitting the headlines, especially as it relates to Louisiana leading the way. Senator Bill Cassidy is getting flak, rightfully so, for trying to minimize the problem focusing on taking the African-American mothers out of the equation. Their deaths are an important part of this, but they are only a part, but deserve due diligence as to why just like every other race, income group, ethnic group, etc. We should look to things like – lack of healthcare access, fewer rural hospitals, food deserts and poverty as several of the causes. Yet, this is not a new problem, as I wrote this post seven years ago.

Recently, a very powerful article was written by Danielle Paquette in The Washington Post entitled “Why pregnant women in Mississippi keep dying.” A link to the article follows: http://www.washingtonpost.com/blogs/wonkblog/wp/2015/04/24/why-pregnant-women-in-mississippi-keep-dying/. While the article focuses its title on Mississippi, that is a metaphor for a national problem. The US is now the only developed nation where the rate of pregnant mother deaths is increasing. In 1987 only 7.2 pregnant women were dying per 100,000 births. That rate has more than doubled in 2013 to 18.5 deaths per 100,000 births. Our maternal death rate in childbirth is 3x the rate in Saudi Arabia and 2x the rate in the UK.

In Mississippi, it is far worse with 54.7 black mothers dying in childbirth out of 100,000 births and 29.3 white mothers dying per 100,000. There a number of reasons cited, but one of the key reasons is that Mississippi has not expanded Medicaid and have over 107,000 people who do not have access to healthcare coverage. Note, other reasons are cited, but not having health care coverage limits access to preventive visits that expectant mothers with care get.

As many know, I have been a broken record for the need to continue and improve the Affordable Care Act, which is working pretty well by a number of studies and has dampened cost increases with the Congressional Budget Office lowering health care projections three times due in part to the ACA. In fact, just yesterday at Congress’ request, the CBO and Joint Committee on Taxation noted that repealing the ACA would increase the deficit by $353 Billion (or $137 Billion when a new dynamic scoring approach is used). This seems to run counter to rhetoric of how harmful the law is. Here is a link to the article: http://www.msn.com/en-us/news/politics/obamacare-repeal-would-boost-10-year-deficit-by-dollar353b-cbo/ar-AAbQa2S?ocid=DELLDHP

But, we need to finish the job and completely implement the ACA in about twenty states, such as North Carolina, that have not expanded Medicaid to cover a key tranche of people under the ACA. It is not surprising, these predominantly southern states are seeing the worst child and mother health results. Several reputable health-related foundations (The Commonwealth Fund, Kaiser Family Foundation) and economic think tanks (RAND and Economic Policy Institute) have noted that not expanding Medicaid is actually harmful to people and this is more evidence of that assertion.

Please read these articles and, if you concur these are problems worth doing something about, reach out to your state legislators and US representatives and senators. Ask them to support the continuation of the ACA as the majority of Americans wish to happen. Ask the states who have not expanded Medicaid to do so as they are hurting people, rural hospitals and their own economies in not so doing. These issues are that important as people are the pawns in these political chess games and they bear the brunt of these decisions with their health and lives.

The real replacement practices

This concept of replacement theory where white workers are subject to a planned replacement by black and brown workers has been around for decades. In fact, the fascists in England were using this replacement theory in the early 1960s, of course, blaming Jews for its orchestration. In essence, the theory says white workers’ jobs are being systematically replaced by immigrants and those other people who don’t belong here. Sound familiar? Yet, this replacement theory well preceded the 1960s.

It is all subterfuge to create fear and blame others for your problems. Fear has been used to sell ideas and manipulate people for a long time. Overstating an inflammable cause is one way to do that. The fear of the other overlooks the deeper problems for loss of jobs and disenfranchisement. The key reasons for disenfranchisement are the actual replacement practices that we need to address. These are not some theory, but deployed routinely and recurringly in practice.

There are two key reasons, which impact all workers of all colors:

– technology improvements which reduce the number of workers needed, and

– CEOs chasing cheaper labor to lower the cost of production

The latter cause manifests itself in offshoring, outsourcing, or migration of factories. For example, the textile industry has left a trail of closed plants as the industry moved from England to the United States first in New England and then to southern states. Then in the 1980s, the heavy migration occurred to China and Mexico and eventually to Vietnam and Bangladesh searching for cheaper labor. One company that comes to mind went from 86,000 US employees in 1980 to about 4,000 today, with the rest abroad. That is not an isolated example and it is not just manufacturing work. It is call center, IT, analysis, etc. The US based insurance industry has been shipping claim forms for review to Ireland as the Irish were, on average, more literate than Americans, even before technology made it easier to get the Irish to review them.

The former cause has been occurring routinely as well, but has accelerated once again with the advancement in Artificial Intelligence (AI). Yet, a robot need not look like a humanoid to be effective. Computer driven machines and robotic appendages have evolved over time. I watched a “60 Minutes” episode about ten years ago, which demonstrated a programmable robotic machine that went for the price of a car to be used by small businesses. The tasks need not be complex to improve efficiency, so these cheaper machines could replace a half-dozen workers.

So, when you hear immigration is a problem, that does not address the main issues. Of course, the immigration system could be improved and opportunities to do so were not voted on after some agreement even by some of the most vocal critics. But, there are some industries and municipalities that need more workers. Those workers need to be trained or trainable, so some may come from abroad and some from here.

Where we need to focus our attention is working with new and old industries in transition and community colleges to train new workers. The coal industry has been on the demise for a dozen years, but some politicians have been clinging on to its protection. I have said several times, whether or not you like Senator Bernie Sanders, he was the only presidential candidate in 2016 to stand up in front of coal miners and tell them the truth – your jobs are going away, but here is what I plan to do about it.

In this vein, some towns are dilapidated by closed factories that moved. The forward thinking towns invested in bringing new workers from whereever they could. They developed initiatives to reinvest in the area using the brainpower of the new and old blood mixed together. They developed incentives to draw younger adults to their towns. And, it worked.

The issue of workers needing more opportunity and investment is where we need to focus our attention. This is a good example of a group of PR people coming up with an issue, blowing it way out of proportion as the problem, and putting it on a bumper sticker. “Build a wall” some might say as the panacea. Ironically, when the major proponent of that comment accepted a deal to get $25 billion for this wall in exchange for making DACA law, he was talked out of it. This was his number one issue, but he said no after saying yes. Why? He knew it would not solve the problems and his bluff had been called.

Our problems are complex and have multiple factors. One of the tenets of the book “Built to Last” by Thomas Friedman and Michael Mandelbaum is most of America’s major problems over time were solved in concert between some combination of government (federal, state and/ or local), venture capital, and private industry or philanthropy investment. We won’t solve our problems unless we identify them and their many causes. We won’t solve them by listening to opinion hosts and candidates who are trying to scare, who really don’t want to solve anything other than getting someone elected.

We will solve them by looking at the facts, coming up with a plan, getting buy-in and funding and making it happen. That is hard to put on a bumper sticker or define in a two-minute sound byte by an opinion host.

Are US hospitals in trouble?

Many hospitals, especially more rural ones, have been in trouble for some time. More on the rural hospitals later.

“More than 33% of all hospitals are operating on negative margins, according to the American Hospital Association,” per Michael Popke of Benefits Pro in a piece called “America’s hospitals facing ‘massive growth in expenses’.” Here are two select paragraphs from the piece that tell the gist of the story.

“Hospital employment is down approximately 100,000 from pre-pandemic levels, while hospital labor expenses per patient through 2021 were more than 19% higher than pre-pandemic levels. A new report from the American Hospital Association highlights the financial and operational toll the pandemic and inflation has taken on hospitals — concluding that more than one-third are operating on negative margins.

‘Hospitals and health systems have been nimble in responding to surges in COVID-19 cases throughout the pandemic by expanding treatment capacity, hiring staff to meet demand, acquiring and maintaining adequate supplies and personal protective equipment to protect patients and staff, and ensuring that critical services and programs remain available to the patients and communities they serve,’ notes the nine-page report released this month. ‘However, these and other factors have led to billions of dollars in losses over the last two years for hospitals.’”

Per an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

“Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

The rural hospital concerns predate the advent of the Affordable Care Act. Too many hospitals had high percentages of indigent health care costs, meaning people without insurance. If they were not funded by a county, the hospital was at severe risk of closing. Since fourteen states have still not expanded Medicaid under the ACA, the opportunity for getting paid did not increase and many have closed. And, the patients, employees and communities suffer.

Yet, a major part of this cost dilemma existed before COVID-19. The US has the most expensive health care system in the world, but we rank around 38th in health care quality. That is a pretty poor rate of return on one’s spend. Hospitals spent too much on technologies that need to be used. There exists a correlation between the ownership of a technology and its higher frequency of use. Yet, with COVID-19 and its aftermath, fewer elective procedures and tests were done in hospitals.

These issues need to be evaluated outside of the political lens and with data. Yet, that is not bound to happen. It would at least be helpful to see more people covered with full Medicaid expansion, but that has been politicized for zero-sum game reasons, not to actually help people. It would be helpful to see Medicare expanded, at least down to age 62 from 65. As Medicare works reasonably well, I would like to see it go lower, but whatever we do, it should be evaluated on its results, not a politician’s beliefs.

If people think I am unfairly picking on politicians, it would not be a stretch to say most politicians do not know a whole lot about health care. We saw this with the atrocious “throw stuff against the wall” repeal and replace discussion in 2017 by the thirteen Republicans, which came within one vote from passing the Senate. That would have screwed about 20 million Americans. Senator John McCain gave it a thumbs down vote for its lack of veracity and its poor protocols on evaluation.

And, we saw it with the discussions and passing of the ACA, which Republicans refused to vote for which is strange since it has several Republican ideas in it from Romneycare in Massachusetts, when Mitt Romney was governor there. The ACA is not perfect, but at least we should fully implement it and shore up its deficiencies. It is only people’s lives.

Medical debt impacts 23 million Americans per Kaiser study

In an article called “The burden of medical debt in the United States” by Matthew Rae, Gary Claxton, Emma Wager, Cynthia Clark, Jared Ortaliza, and Krutika Amin, the results of a Kaiser Family Foundation (KFF) are noted. Per the article, a link to which is below, the following conclusion can be drawn:

“We find that 23 million people (nearly 1 in 10 adults) owe significant medical debt. The SIPP survey suggests people in the United States owe at least $195 billion in medical debt. Approximately 16 million people (6% of adults) in the U.S. owe over $1,000 in medical debt and 3 million people (1% of adults) owe medical debt of more than $10,000. Medical debt occurs across demographic groups. But, people with disabilities, those in worse health, and poor or near-poor adults are more likely to owe significant medical debt. We also find that Black Americans, and people living in the South or in Medicaid non-expansion states were more likely to have significant medical debt.”

Several years ago, I cited a study that noted medical debt was the number one reason for bankruptcy by individuals, so the above result is not a surprise. The groups that are most exposed are non-Hispanic Blacks at 16% and people in the age 50 to 64 demographic at 12%. Some of the reasons for this age group being higher is Medicare does not kick in until age 65, people are getting downsized in that group and employer retiree medical benefits have largely gone away.

I posted a piece from Politico the other day about rural health care suffering. An important reason is the fourteen states who have not expanded Medicaid to those below a certain poverty level. This has led to more rural hospitals closing and exposed people who do not have coverage to higher medical debt or forsaking care all together. The debt comes with people waiting until they are a train wreck before going to the ER, a more expensive place to get care.

One of the things I have found in my consulting experience as well as patient and care taking experience, access to health care is critical to a person’s health. The ability to get preventive care before the train wrecks also lowers the cost while improving one’s health. In the US, one of our warts is we are the most obese country in the world per the World Health Organization. We have supersized ourselves to earn that mantel. We must get ourselves on a better path before it becomes too late.

Access to care is key to getting on that better path, but making it a more affordable journey. When people say we have the best health care system in the world, that simply is not borne out by the data – we have the most expensive health care in the world; we rank in the low thirties in health care outcomes. We must use the system more wisely. All of us.

The burden of medical debt in the United States

The emu and the gold mine

When my in-laws were alive, their family property included an old dried-up gold mine that never did amount to much. From what I gather, it was an expensive hobby for my mother-in-law’s father. One day, I was out walking their trails and came upon the large opening to the mine, which in essence is now a large pit about twenty meters in diameter and that much in depth.

As I looked at the bottom of the pit, I saw the skeleton of a very large bird. It looked like an ostrich, which would be very uncommon for this neck of the woods. When I got back to the house, I had to inquire.

My father-in-law laughed and said that was an emu skeleton, which would also be rare. It turns out, one of his neighbors was raising emus and one had passed on. So, he asked my father-in-law if he could toss it into the pit. Although it sounds like a person who just did not want to dig a hole, my father-in-law appeased him and said it was OK.

Currently, there are series of themed TV commercials for Liberty Mutual (who some call Limu or Lee-Moo) insurance, where the mascot is Limu the Emu. Note: some ad agency is making money off this idea. I guess they are combatting the Geiko Gekko (who is a CGI mascot), with an Australian man mimicking a Cockney accent – go figure.

Yet, as I watch these commercials, my mind drift backs to looking down into that pit and seeing the now known emu skeleton. Since I was alone on the trails, it was actually an out of body experience. As I was thinking WTF, I felt like someone was watching me see this skeleton in a Rod Serling sort of way. A spaceship had crashed, created this crater and its bird like pilot died as he crawled out.

Then, reality set in and the acknowledgment it was some kind of large bird came to light. The story of the throwing an emu carcass into the hole did not cross my mind, My saner version of the ET story is a large bird was running and did not know the hole was there and fell in. I like that story better than it just being used as a lazy person’s burial ground. It makes me feel the emu died what he liked doing best – running.

So, while Limu the Emu (and his buddy Doug) are peddling insurance, I am thinking of my ET-like emu skeleton. Since there was no cell service this deep in the woods, I could not “phone home” for this ET. It was truly a very weird day. Almost Twilight Zone-like. Cue Mr. Serling and the eerie music.

Mental Health is presenting unprecedented challenges

In a recent article in Benefits Pro, a piece on the rising mental health challenges caught my eye. An excerpt from the article follows:

“A new report from consulting firm McKinsey finds ‘unprecedented’ behavioral health challenges among Gen Z Americans. The age group, which ranges from middle-school students to younger members of the workforce, has significantly more issues with behavioral health than other age groups, the study found. Their conclusions are not unique: the U.S. Surgeon General recently issued a public advisory describing a ‘youth mental health crisis,’ which has been exacerbated by the COVID-19 pandemic.

The report pointed to consumer surveys that found Gen Z members more likely to report behavioral health issues, more likely to be diagnosed with mental health conditions, and more likely to contemplate suicide than other generations.”

Unfortunately, there remains a stigma attached to mental health that prevents too many from getting the needed help. With that said, a possible reason for the uptick is more younger folks are realizing the need than in previous demographic generations. Nonetheless, getting help is something that should be easily enabled. And, it is not just medicine that should be prescribed. Therapy paired with medicine is essential to getting the most productive level of help.

Before I retired as consultant, I used to travel with a behavioral psychologist who helped large companies set up mental health programs for its employees, including depression and obesity management ones. She would tell our clients that 1 in 5 people will have some level of mental health issue in their lifetime. She would add that if she looked at any prescription drug claims report, she would see 10% of the prescriptions be for mental health issues. What she was looking for is who prescribed the Rx, as she would prefer to see a psychiatrist rather a general practitioner.

I have a number of friends and relatives who have had mental health challenges, often multiple diagnoses – anxiety and paranoia are often paired together, eg. Therapy is the key. Having someone to help work through the problems is essential to managing them. The word management is critical as many of these problems don’t go away, so having tools to deal with them on a daily basis is utile.

Rather offer advice that I am not qualified to give, let me just say this simply. If you, a loved one or friend are having mental health issues, get or encourage them to get help from a therapist. Often, the therapy will come from a licensed clinical social worker LCSW. Your health plan or other networks will have several therapists to offer, so go through their bios and typical clients. They will suggest a psychiatrist if medicine is in order. Yet, if you or your relative or friend are having suicidal thoughts, call 911 or a suicide hotline (see below) and don’t wait on a therapist.

Life can be beautiful, but it is also hard. Sometimes it is harder than it needs to be. Just because you need help is nothing, I repeat nothing, to feel bad about whether you are the one in need or if it is your child. Get help. And, manage those challenges.

Imperfect American hero dies at age 98 – Bob Dole

In an article in Yahoo! Finance called “Bob Dole dies at 98, leaving lasting legacies on Social Security and food assistance,” by Bob Werschkul, the following brief obituary can be found:

“Bob Dole, a former Senate majority leader who unsuccessfully ran for president against Bill Clinton, died Sunday. He was 98 years old. He is survived by his wife Elizabeth Dole, who was also a U.S. senator, and a daughter, Robin, from a previous marriage.

One of the giants of American politics in the 20th century, Dole will be remembered for his heroism in World War II, his time as Senate Majority Leader, his 1996 run for president, and even his unlikely turn in a commercial for the maker of Viagra.

But perhaps two of his most enduring legacies on American life came earlier in his nearly 50-year-long career in public office. As a U.S. Senator, Dole was at the center of deals on the Social Security program and on food stamps (now known as SNAP) that have left lasting imprints on how Americans interact with these two programs.

In his memoir, “One Soldier’s Story,” Dole wrote that when he is asked about the accomplishments in the Senate he is most proud of, his ‘answer sometimes surprises people’ — he listed Social Security as his top answer alongside passing the Americans with Disabilities act, a civil rights law that prevents discrimination based on disability.”

I recognize fully that some folks may not appreciate Dole for some of his other stances, but even progressives should note his pride and help in getting three major pieces of legislation enacted that impact so many lives. Even without his legislative accomplishments, Dole served in the Army and survived World War II when many thought he would not. He was awarded a Bronze Star and two Purple Hearts for his courage and physical punishment that lasted the rest of his 98 years.

I was telling a retired neurosurgeon yesterday about Dole’s push for better access to healthcare. This neurosurgeon is among a national group of doctors pushing for Medicare for All. As we discussed the Affordable Care Act, I mentioned there are elements therein of Dole’s healthcare plans he was pushing in his 1996 presidential campaign. Some of these elements also found their way into Romneycare in Massachusetts, to which the ACA has similarities.

So, think about this legacy. Social Security, SNAP, the Americans with Disabilities Act and some elements of the ACA. But, of course, today we have more strident tribal politics, which flavor way too many things. What many folks need to better understand today is there is not one politician who will say and do things you agree with 100%. Nor should it be. This is a lot like all relationships.

We need to avoid taking people’s head off when they don’t agree with you. There is an old line that applies to any organization – be diplomatic when people disagree with you, as they may have supported your idea in the past and may very well in the future. Dole was imperfect, but he knew this. We should as well.

Our children deserve better – a repeated pre-pandemic clarion call

The following post was written a couple of years ago. Although the pandemic has rightfully gotten our attention, this story bears repeating.

Two time Pulitzer Prize winner Nicholas Kristof wrote an editorial earlier this week in The New York Times called “Our children deserve better.” It is a clarion call to our nation showing the plight of kids in America.

Here are a few quotes to frame the issue:

“UNICEF says America ranks No. 37 among countries in well-being of children, and Save the Children puts the United States at No. 36. European countries dominate the top places.

American infants at last count were 76 percent more likely to die in their first year than children in other advanced countries, according to an article last year in the journal Health Affairs. We would save the lives of 20,000 American children each year if we could just achieve the same child mortality rates as the rest of the rich world.”

“Half a million American kids also suffer lead poisoning each year, and the youth suicide rate is at its highest level on record….The Census Bureau reported this week that the number of uninsured children increased by 425,000 last year.”

These are different views and sources of the threats to US children that note we have a problem. Another source I read a couple of years ago noted America has a much higher maternal mortality rate at child birth than other civilized countries, which further endangers children as well as the mothers.

Yet, these issues are not being discussed in the halls of government. We have a poverty problem in our country with too many living in or just above poverty levels. We have not expanded Medicaid in fifteen states* whose numbers are worse than these national numbers per capita. We have not addressed our national water crisis which has a Flint, MI like exposure to lead in too many cities and a volume of available fresh water issue in other places. We have not invested as we should to diminish crime and provide more opportunities for jobs in disenfranchised areas. There are several pockets of success that can be emulated in more cities.

We also need to address better gun governance, especially with the number one gun death cause by far being suicide and a non-inconsequential accidental gun death rate. And, we have not dealt with the continuing and rising exposure to technology and artificial intelligence which have taken and will take even more jobs in the future. Finally, there is that climate change thing we need to deal with.

These are real problems. And, they will get worse. Data driven analysis of causes and solutions are needed. They are both multi-faceted. Investing more now, will save huge amounts later. This is not just an urban issue, it is rural one as well. The opioid crisis is rampant in these impoverished rural areas, for example.

None of the solutions will fit on a bumper sticker. And, political attempts to oversimplify issues should be questioned. Here is an easy contradiction to spot – if people believe gun deaths are a mental health issue, then why the effort to eliminate or not expand mental health benefits?

Please make your legislators aware of these issues and ask pointed questions. These questions deserve answers, not bumper sticker slogans. These concerns deserve to be talked about, studied and acted upon.

*Note: The number of states who have not expanded Medicaid is now twelve. Here is a link to a tracking of the states who have and have not. What puzzles me is this change would help people in rural areas, which tend to vote more conservatively. So, not expanding Medicaid hurts health access, but also rural hospitals and economies, with the federal government funding 90% of the cost. As former Republican governor of Ohio and presidential candidate John Kasich said, Medicaid expansion is a “no brainer.”

https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/