Justice Elena Kagan deserves part of the blame for this dreadful state of affairs. She is the Obama appointee, supposedly part of the "liberal" voting block on the Supreme Court, who voted with the conservatives to allow the states to decide whether to adopt the Medicaid portion of the A.C.A., thus allowing the ideological zealots of the hold-out red states to withhold healthcare from millions of poor people in this country.
66
@Joe Langford, just to clarify, it was Governor Rick Perry who refused to expand Medicaid in Texas because he didn't want any "handouts" from the federal government [with Obama as President] while he pandered to the secessionists. Passing on billions of dollars that would have prevented the closing of rural hospitals, but happily taking the post 9/11 economic stimulus funds and eventually using those numbers to proclaim a balanced budget when campaigning for re-election. Go figure.
90
@Joe Langford
That was a 7-2 SCOTUS decision, changing her vote would have had no effect
61
Wow. You really had to dig deep for that one. Let’s place the blame 6 degrees away from the makers in your state.
90
Yes, it is true that over the last 40 years the "GOP" (Greedy Old People) has become essentially the party of sociopaths, so they really could not care less about what happens to their own people as long as the politicians stay true to their delusional dogma that everyone is responsible for themselves and should not expect any help from anyone for any reason. That is pretty much their core "value."
Also, it is true that the Repubs have made it a core policy to destroy all government assistance that could help anyone in a ploy to convince people that the "guv'mint" is "bad." So they put the most incompetent and corrupt people they can find in charge of agencies and hire only party loyalists with no experience and then work very hard to destroy their own agencies.
The question is, why haven't the Republican voters figured this out yet? Because all they watch or listen to is the Repub channels? Because they are easy marks for con-men like the "president?" It seems a rational person would look at what their politicians have done or not done, and wonder what their motivation is. It is certainly not to represent the needs of the American People. So, gee, what could it be? What COULD it be?
38
You blame a minority for what the majority imposes on them. Your logical powers and ability to make a good argument are diminishing.
4
They VOTED for misery!
All to save the unbelievablely rich from a 5% tax on part of their income.
27
So tell me does Knoxville as anything to do with Fort Knox and the gold reserve?
1
Who would choose to live like this?
3
This article is just propaganda. Paul has never spoken to any of these people. They have vehicles to travel to the city to see doctors. It’s not a problem. I’ve spent time living in rural areas as well as the cities. Let me tell you something rural areas don’t suffer from – homelessness. I’ve been to New York City and L.A. many times. I’ve never seen so much homelessness in my life. It’s so sad.
4
And yet they will still vote Trump 2020
14
If the Republicans in the 14 states without Medicaid expansion allowed their uneducated masses to have it, these people would like it and wish for it to continue. And they would blame the Republicans if the Republicans finally succeeded in destroying it.
So the Republican governments in these states have decided that these people are better off full of Fox News and sick.
26
The saddest thing in democracy is that these people keep electing the same politicians who are out to hurt them, not represent them...
do you call this, stupidity, or ignorance, or just don't bother me with the truth?
22
Yes, but Trump is going to save the White Race. That's the important thing, not his constituents' misery....isn't it?
10
Stop voting Republican. You are killing yourselves and your neighbors by doing so, in some cases quite literally.
14
The idea of our government was always people working together for the common good. People working together take away power from the privileged few who rather run everything. Note how the majority of poor States are Red and the majority of rich States are Blue. Yet conservatives like to beat the same old GOP horse thinking somehow their fortunes will change, some are literally dying and that is somehow a better fate than to vote for Democrats.
7
Prof. K, no reason to apologize for accusing the GOP of embracing cruelty as a core principle. "[G]ratuitous political cruelty" is right on the money.
Make them own it.
14
We socialized the defense industry and according to the President we have the best military in the world.
6
It's awfully hard to feel sympathy for people who continue to vote against their own interests, because they would rather focus on hurting people of color.
24
This reminds me of the stories we always here about despotic countries where, because all information is state-controlled, the citizens don't know that the primary cause of their misery is not so much exterior forces (economic sanctions, natural disasters) as their own government.
What's our excuse? Our state-sponsored media outlet, Fox News, isn't going to report the truth about what's happening, or let these people know what they can do about it. And folks in rural Tennessee aren't going to read the New York Times, which they have been told to mistrust, like the rest of the "MSM." How do we reach them with the facts?
I'm reminded of that infamous Goebbels quote: “If you tell a lie big enough and keep repeating it, people will eventually come to believe it. The lie can be maintained only for such time as the State can shield the people from the political, economic and/or military consequences of the lie. It thus becomes vitally important for the State to use all of its powers to repress dissent, for the truth is the mortal enemy of the lie, and thus by extension, the truth is the greatest enemy of the State.”
15
It takes a ton of hatred towards liberals to maintain deprivation of healthcare leading to sickness and death.
Reinstate literacy tests!
For those who perceive words as values, facts, goals...etc etc, language provides a precious capacity for humans to evaluate complexity, Of course such literacy test must be what the word says. Rather than the misuse during the KKK years.
As of now those unfortunate enough to have a severe mental disability, either of birth or long life, still get to cast a vote that is decided on the most simplistic of emotions. It took the current president to normalize what had been known as a byproduct of mental disease "word salad" meaning the use of words incoherently that leave the impression of a rational message.
My proposed literacy test would be at the level of passing a high school course in civics. (I happen to have such a text book approved by Texas, that is not the propaganda accused off) Universal suffrage is a noble concept, but getting an entire state to vote down free health care demonstrates i's adverse possibilities.
3
I am a physician residing in Tennessee. Sad to say but the only way to be elected/re elected in this state is to promise NO NEW TAXES (local, state or Federal). This mindset runs deep. The problem of healthcare for rural America is complicated but Medicaid expansion would be a definite step in the right direction. For years I have been puzzled by the appeal of Republican policies that directly adversely affect those who vote Republican.
42
I live in NC.
Here is a statement from the local TV station web site in Raleigh, WRAL:
"While Senate President Pro Tem Phil Berger has long been blunt in his opposition to Medicaid expansion, House Speaker Tim Moore has generally taken a more nuanced approach. But this week, in his strongest language to date, Moore said the joint House and Senate budget deal due next week will not expand Medicaid."
Horrible. If you live in NC and want to help hundreds of thousands of people get health care, you should contact the above gentlemen. Scary that medical care coverage is so weak in this country -- one of the richest in the world. Is America in decline?
19
The GOP war against more compassionate, fairer, and MORE COST EFFECTIVE health care access and funding is metaphoric of the cruel, arrogant, selfish, and dogmatic theocratic plutocracy the GOP WILL impose on this great Nation if we do not stop them in their tracks with our votes come 2020.
I do not think the Ds are right about everything. I do not think Rs are wrong about everything. I do not think Rs are all bad nor Ds all good.
But I dunno - I guess I am just to close the WWII and what happened in Germany and Italy. When good people did not think of existential consequences and went with the most shiny PR object or with what satisfied their own pet issue or peeve.
It can happen here - it is happening here! Conservatives, Progressives, and in between - this is now existential. If you don't want to live- better yet if you don't want your kids/grand-kids to live - in a theocratic plutocracy then you must vote D.
D will not bring us to ruin existentially - they are malleable. They may be a bit more Progressive than you are but it is not like the system won't naturally center them - even via their own ranks - they are not monolithic like the GOP is now - they are not of one mind (and that is good!).
If you care unselfishly about what makes a MODERN Nation great - what really humanity needs to survive peacefully as a species - then you must vote D NOW. Sort out into 2 good Parties later when the existential danger is thoroughly vanquished.
13
I wonder what Darwin would have made of this.
10
I read this article in conjunction with the many articles about the "humanitarian" crisis at the border, and the current funding bill of 4 billion dollars to address that "crisis", and I am totally disgusted. First, this country is not spending "our tax dollars"....we are spending money borrowed from other countries, including China. Our national debt is frightening. Our own citizens don't have adequate health care and schools. Mitch McConnell seems to control the government even though he is just a senator from a small state. His wife helps fund his campaigns with foreign money. Out president is credibly accused of rape and is spending millions on his golf junkets. While our government squabbles about abortion and gender issues, the major problems of the country are ignored. No wonder people re overwhelmed and distrustful of all politicians.
24
A big part of the american people have been brain washed to think socialized medicine is evil and medicine could be a consumer good. THe result is the corrupt, cruel, unequal health (hell) care system we suffer from.
8
I am a rural family doctor, in practice for 29+ years.
Krugman is right. Lack of insurance, even bare-bones insurance like Medicaid, keeps people from getting care and exposes them to both physical and financial risk. When Obamacare came in, poor people in Washington State got Apple Health. Apple Health is not Cadillac insurance. A lot of specialists won't see these patients, we family docs don't make much money on them (and have to make up the difference with private insurance), but it's better than nothing. People get hypertension treated for the first time in their lives. They wind up in the ER less often for simple things like otitis externa. They get the dignity of going into a doctor's office and being treated just like everyone else. And make no mistake about it, most poor people in this country get damn little respect in their day-to-day lives.
Most important is that people don't face severe deprivation if, through no fault of their own, they get appendicitis or a bad case of pneumonia.
Not expanding insurance, even bare-bones insurance, for poor people is the height of cruelty. It disgusts me and makes me ashamed of my country. I love my country and don't want to be ashamed of it. Raise my damn taxes but do the right thing.
How many poor people will realize what is going on and vote for the Democrats in the next election?
44
Mean-spirited, selfish leaders looking for the glory of leadership without the burdens that come with a changing world.
7
Self inflicted misery shows up in many forms today.
In July 1967 residents of my near east side Detroit neighborhood saw fit to loot both of the thriving national chain supermarkets located there - Kroger and A&P. One was burned. Only a second tier supermarket reopened.
Shouts of "Redlining!" filled the air.
Today one of the two buildings remains.
It was used a few years ago as a backdrop for scenes in a Transformers movie. So there's that.
There are numerous other examples of how the destruction of neighborhoods can be seen as self-inflicted. I doubt Krugman or the NYT will ever write about them.
1
@Jp Thanks for the "whataboutism" from 1967. When someone points out destructive Republican policies, the fair thing to do it to try to change the subject.
11
One other reason why Republican elites in states like Tennessee do what they do: they don't pay a political price for their meanness. Republicans have made a science of nudging their poor and lower-middle-class supporters to vote against their own self-interest for the last fifty years.
14
The only really good news I’ve read lately is that something like only 29% of under 35’s identify as Republicans, so maybe their is hope for a future devoid of the next generation of Mitch McConnell’s.
7
How sad. We need a charity of Billionaires to donate one percent of the money they saved from income taxation. Medical assistance would be an ideal goal.
Surely they can bait each other as if they were a giant size Kiwanis or Rotary organization. Yes, Roy, Al, Justin, whoever, it’s pony up the pennies time.
Most of our billionaires are good ol' conservative Republicans so this would be a partial tax write off. So, it's a crazy idea. Some of the best ideas in our country started off as crazy ideas.
I disagree. Most of the blame does not lie with Republican state governments. It lies with the people who vote for these Republicans. Since the majority of rural Americans vote Republican, they are getting exactly what they deserve.
6
I believe that keeping people poor and struggling is part of the strategy for maintaining the status quo.
The majority of citizens are too busy and tired, or even too sick, to campaign against the excesses of capitalism.
6
Let's remember that it was Tennessee, home of decades of Senator Gores, that failed to support son Al's run for the Presidency, thus costing him the election and bringing to power, well .... the memory is too painful to go on.
10
“Of course, if the U.S. were like every other wealthy nation,
and provided some kind of universal health care, there would be no uninsured at all. “ This Dr. Krugman.
Looking from outside of America phenomenon, I feel for suffering of those without universal health care, the right of citizen among all civilized nations, I know.
Social backwardness of my cousins is beyond my understanding, unless “we” do not want to share our conspicuous “wealth” with the descendants of slaves.
Who knows?
This shameful mantra about the richest country in the world, is out of place, too. We in Canada, still remember “one million dollars” baby; that much was the asking price for delivery in this “Land of Brave and Free”.
My humanitarian instinct is sensing calamity; please help me before we all sink into incoherence…
4
Just like Trump and the Republicans want only white immigrants, they also want health insurance to be for whites, primarily. Because the percentage of people of color who are on Medicaid is higher than the percentage of whites who receive it, and because Medicaid is a federal program and colorblind, they are willing to abandon those whites who qualify for and need federally subsidized health care in order to continue to deny those of color the care they need. In the warped values system of the Republican Party, this is racial equality: See! We treat all the poor equally!
Back slaps all around, guys.
8
Not most - ALL of the blame for the lack of health-care lies with what is now the so-called Republican party. As your know Dr. Krugman, a variant of the ACA was first proposed by Nixon in the early 70's - but whatever remains of the majority in the Republican party that thought that up is long gone. And, when President Obama reached across the isle with an olive branch with the ACA proposal, the current crop of racist, morally bankrupt, corrupt clowns that make up the majority of the current version of the Republican party refused to consider it or participate in creating it because they were not the party in power and would not get enough credit - they were too busy making a pact to do WHATEVER IT TOOK to regain power and stop any effort to accomplish anything by the Obama administration. In so doing, they sold their souls to a person who lacks most of the qualities to qualify as a human being, let alone President of the United States.
8
Decisions are made by the people who show up. We all get the gov't we deserve.
1
This is another example of false class consciousness. When I learned about it when a took a controversial class on Marxism in high school, I did not believe the concept was real. How could you vote in a manner to hurt yourself? Now, I believe the concept because I observe it everyday.
5
You will have many rural people vote against their best interest for several reasons. They think that poor people in the cities are getting everything for free, while they work hard. So they believe cutting access to medicare is about those lazy Black and Brown people who don't want to work. They don't understand that they are also cutting off their family members and their neighbors from needed help as well. They think that everything is controlled by the big coastal cities and that the coastal cities get much of the tax money. They don't understand that most of the money going into taxes come from the large coastal cities. But, must of all they are people who feel the U.S. is moving in direction they don't like away from being a Patriotic, White and Christian Nation.
11
"Democracy is the theory that the common people know what they want, and deserve to get it good and hard."
H. L. Mencken
4
Great piece, thank you, sir.
5
It is hard to have much sympathy for Republican voters now their children that is another story.
2
Maybe poor American dying early is the conservative solution to shore up Medicare and Social Security shortcomings they talk about?
2
Throwing one's constituents under the bus should be the recipe for political oblivion. Too bad the Democrats are unable to focus and make the GOP pay for its mistakes. Maybe there are too many causes. It's a veritable "Tower of Babel" out there. What next, taxpayer funded health care for the undocumented? How about guaranteed health care for the hard working people who are paying taxes?
Let's call it Medicaid/Work.
1
@Caveman 007
Obamacare insures 20 million more Americans (documented, that is - it doesn't insure undocumented people).
It saves an additional half a million "hard working people who are paying taxes"'s lives a decade.
ALL of the Democratic candidates propose to build on that, by proposing healthcare plans that have already proven to work - and none of those plans includes undocumented people.
It will only happen, though, once ordinary citizens start to finally inform themselves and then vote, instead of standing at the sidelines yelling "not enough!" to those who are preparing the next step forward, all while allowing a cruel and incompetent GOP win election after election ...
5
Please keep in mind that many (!) of these rural residents including the elderly in nursing homes and in small towns where hospitals have closed reliably vote Republican. They won't be persuaded to vote otherwise. So if they choose guns and abortion issue representatives over daily pocket book and health responsibility I have zero (!) sympathy for them.
6
Here's an answer...
Place a short message on billboards throughout these No Medicare States, which clearly states why there is no health coverage for rural and low income residents!
Develop a short question for citizens to ask their Republican State politicians as to why they voted to refuse Medicare.
My God, can't the Democrats come up with a short concise program to inform these misguided voters?
7
@Wilson Woods -- Very very true. Democrats are awful at messaging. You and I could think of a dozen ways to crisply communicate the realities of right wing policies, but democratic pundits would think it's unfair and not nuanced enough. The right has no such squeamishness.
2
Anything that spurs the movement of Americans to the cities is fine by me.
Living in the countryside seems to be very bad for Americans' education, cognitive faculties, and mental health. And we all pay for that.
1
So Kentucky made a serious effort to implement Obamacare in a competent way, and expanded Medicaid. As a result, it's much better off than Tennessee.
But it ALSO sent McConnell to the Senate, who absolutely wants to replace it with Ryancare, and failed only because of John McCain.
So what is it that Kentucky wants? Decent healthcare, or a healthcare system that only works for health insurers and the wealthiest doctors and citizens ... ?
4
Thank you, Mr. Krugman, for addressing the issue of Republican cruelty. I have been disturbed by this since the Reagan administration when he started the derogatory term "welfare queen," a term which is still used today. My mother is gone now but she was never interested in politics. She voted but that was as far as her interest went. I remember watching the news with her in the early '90's when Newt Gingrich got to Congress and became Speaker. After he finished speaking, my mother said, "He seems so mean." I almost fell off of my chair. She had pinpointed exactly what I always thought of Gingrich and Republicans in general. Its only gotten worse since those days, culminating in the Republicans' refusal to expand Medicaid, as you so succinctly outline in this article. Could it be that the underserved in these states just don't know how the expansion would work? Have the Dems in those states not done a good job of explaining it? Is that why they keep voting Republican? Food for thought. Great article, Mr. Krugman---you always summarize issues so well!
10
Maybe some of these Tennessee legislators are faithfully reflecting the views of their constituents ---- those constituents who resent seeing their tax money, state or federal, spent on health care for the undeserving poor, those poor people who in their view are responsible for their own health problems because of drug or alcohol use, or crimes, or just the inability to hold down a job. Maybe there are people who think: I worked hard for what I have, and now the government will tax me to pay for the health care of folks who have done nothing to contribute to society. Maybe some of them are practicing Christians who are unclear on the concept.
Good article, and good for Krugman to bring more attention to that heartbreaking story.
1
I think much of this has to do with DACA. PA has to pass a fiscal budget by the 30th of June. As you know Larry Summers and the Obama Administration has had a big influence on current fiscal policies. Every state's demographics are different, as are the policies. What is universal is an aging population with the exception of India.
I am against human trafficking and good policies protect our most vulnerable.
1
"While rural Americans often tell reporters that they feel neglected and ignored by big-city coastal elites, the people preventing them from getting health care aren’t in New York or D.C., they’re in their own state capitals."
This is the major point. Whipped up resentment of supposed "coastal elites" is as demagogic as whipped up resentment of immigrants, minorities, and women in the workforce. There is no good solution to that other than people turning to their common sense rather than to the unrelenting propaganda spew out of right-wing media and too often from the pulpit. Eventually, it does happen or happen enough. People wise up to how they are being used and abused by those pretending to defend them from the Other. It just always takes far too long, with a great deal of lasting damage done in the meantime.
6
Everything in the public realm is worse in the old southern tier of states...and the voters say consistently they want to keep it that way.
Health care is often unavailable, education levels are lower, wages are lower, too. Draconian laws, such as "non-judicial foreclosure" are common. Punishment for minor crimes, even failing to pay a misdemeanor fine, often means jail time. Anyone accused of a more serious crime can be represented by a public defender who sleeps through the trial with no chance to appeal and then spend two to three times longer in jail. On credit reports, in one recent year almost 50% of the adult population in southern states had at least one item out for collection.
Kentucky? When Obamacare was being implemented, people signing citizens up for the program said they were forced to lie because the resistance to the effort was so drastically negative. They told people it wasn't Obamacare. Even a few people who said they had their lives saved by the program said they wanted it ended.
Yet, if it were left directly up to the voters, the expansion of Medicare would likely be passed. The people say they want it, the politicians don't.
Republicans in these and other states constantly tout low taxes as their calling card. Wait. Higher taxes are usually then forced on the bottom 1/2 to 1/3 income level of the population in the form of sales taxes, car license fees, etc. Low taxes means poorer people pay more of their income, richer pay less. What a deal.
7
@Doug Terry
Yes, democratic governor in Kentucky had to mislead people that their healthcare is something different (Kynect I believe) and as a result many people in Kentucky really believed it had nothing to do with Obamacare.
That one has to lie to overcome other lies is the sign of our times. A country devoid of moral core.
4
@CarolinaJoe
One of the lies that was spread about Obamacare is that it required that a microchip be implanted in everyone who signed up for insurance coverage. This was scary stuff. Why do people believe these lies and how do they spread so widely? (Facebook is an obvious answer to spreading the lies, of course.) "Fear of government" is something that has been preached by the far right in America for decades when, in fact, we are moving rapidly toward rule by corporations and, in health care, random circumstances.
1
One of the very great mysteries, one that will probably never yield to science is this: Why do so many rural Americans vote against their own self-interest? "Fly-over country" is 'Trump' country... and a person could count on one hand the things Trump has done that benefit those people, and have several fingers left over. Trump's Tariffs? Sure not benefiting rural farmers. Trump's immigration 'policy'? Again, not benefiting farmers needing workers to pick crops seasonally. Trump's signature "Tax Reform" directed 85% of the benefits to wealthy corporations and individuals. Trump's environmental policies sure aren't doing any good for the country, rural or urban. So why are rural Americans over-represented as Trump voters, and Republicans in general, when for decades Republican policies have done little or nothing to improve their lives? A long study by science would struggle to find any logical reason - perhaps the appeals to emotion and prejudice by Republicans in every election offer an insight. Rural Americans seem to tell Republicans "OK, treat us bad, but give us someone else to hate, tell us we're right to hate them, and we'll be yours forever." So sad.
6
Why is the Democratic Party not running issue ads every day in these states, emphasizing what Republican elected officials are doing to hurt their citizens?
Even as the Dems determine who their candidate is, they should be engaging on issues that all Democrats agree with.
The information needs to get out.
8
@KindaCold: Drug companies have made ads on media prohibitively expensive. Who can compete with them?
Rural america votes largely red, so it is a real surprise that the GOP has picked their own voters to deny healthcare. I sincerely hope that many of these folks come to their senses and vote for their own benefit. Religion and guns aren't going to provide you any medicine or healthcare.
4
Important to remember that "red" states and "blue" states are not monolithic. Tennessee, for example, is 48% Republican to 36% Democrat according to Pew Research Center. Although Republicans hold a consistent majority, there are quite a few Democrats. If you're welling up with schadenfreude, remember that not everyone imposed this on themselves.
5
@EPI: The US operates largely on a "winner take all" system that shuts down negotiations between competing interests.
6
I read the WaPo article about the woman who had to decide whether to have her eyes checked or her lungs and breasts scanned for cancer. Since the latter were too expensive for her to have treated should the results be grim, she went for the eyes.
I can't fathom politicians who'd be OK with someone having to make that choice rather than expand Medicaid so that all could be treated.
I hope one day they get to walk in that woman's shoes.
10
When ACA was crafted, one thing they wisely incorporated was the Medicaid Expansion with liberal federal subsidy in the initial years so that the States regardless of their political dominance domestically, would choose to accept the big federal subsidy to expand Medicaid.
Thus several states such as Ohio & West Va. expanded while MO & others didn't. There the animosity towards president Obama was so intense that they couldn't care less about the welfare of their residents.
Then the US Supreme Court helped a bit though Chief Justice Roberts didn't want to kill ACA.
All of these together resulted in the current calamity. Nevertheless, ACA, which was unpopular because of the initial technical & other problems became phenomenally popular now.
4
A friend of mine is a Brooklyn dentist who volunteers in Appalachian pop-up clinics. Once he showed me a photo of a quart glass jar three quarter filled with human teeth. "This is my morning at the pop-up clinic" was his comment.
6
Thank you for this article.
NC is one of the states that has not expanded Medicaid.
They are rushing toward a deadline for the budget bill.
This week, leaders in the house and senate, all said the budget deal due next week will not expand Medicaid. We still could have our governor veto this budget bill and see if this thing plays out to help the poorer people of my state.
Such a shame that health care continues to be difficult for so many in this wealthy country of ours.
These horrid kind of policies are what calls for a modern, National Health Care program. Most wealthy, advanced countries of the world have such program. What is wrong with America?
5
Let's see, Democrats want to spend public funds to help the poor ("Socialists!"), so they are no good. The Republicans want people to take responsibility for themselves and cut taxes ("Good Guys!"). Now, if only someone can help me get through these hard times, till the trickle down economy will finally gets to me. I know it's just around the corner.
6
How can you take responsibility for yourself when there are no doctors or hospitals in your community?
1
The Kaiser Foundation estimated about 4 million people would gain coverage if these self-destructive states adopted Medicaid expansion.
Add that to the CDC estimate of 2 million more uninsured since Trump took office, due primarily to ACA sabotage, and you've got an awful lot of people. Further, in 2017, we had the first increase in uninsured since 2010.
Democrats should have these statistics ready when they campaign.
And Republicans should question if Making America White Again is a more important goal than healthcare coverage.
7
There is a particular point Mr. Krugman failed to address while commenting on the 14 states refusing to expand Medicaid. All 14 of these governors, mostly comprising a solid block of southern states, are unwilling to do ANYTHING which will add to President Obama’s legacy, even though he is no longer in office.
I live in Florida. To the best of my knowledge, original pre-expansion Medicaid was only funded 70% by the federal government and it was the state’s responsibility to fund the other 30%. The Medicaid expansion was originally funded 100% by the federal government, decreasing to 90% over time.
Our then governor, now senator Rick Scott seized on that 10%, and refused the expansion, using the specious argument that the 10% was a “tax increase,” which he had sworn would never happen on his watch.
Given the geographic location of the dissenting states, I find it hard to believe that this continuing willingness to cause harm and suffering to their own constituents, rather than accept ANYTHING sponsored by President Obama, can only be a racist reaction to the very idea of a black president, who also just happens to be a Democrat.
10
Hospitals close in Kentucky and Tennessee because of the "business" decisions of the profit seeking private companies that own and operate the hospitals. The town of my grandparents in rural Kentucky, the county seat, no longer has a hospital because the motivation is to make a profit and there is no profit where people don't have jobs. The hospitals that depend on medicaid aren't making a profit. They are barely surviving. Medicaid doesn't pay as much as private insurance for a given procedure or office visit. Doctors would rather not accept medicaid patients because they make less money per patient. Thirty patients a day with "good" private insurance bring in much more money than thirty patients a day on Medicaid.
The cost of medical care in America is astronomical. It's the most expensive medical system in the world, and the least effective for the money. Old structures don't work. Kentucky and Tennessee was tobacco farming county. Farmers could make a decent living on tobacco and afford medical care. Not any more. Even if they had the money from tobacco they still couldn't afford the medical care. Trump and McConnell legalized hemp. Now they have a chance to make a living again. Kentucky was once the nation's leader in hemp production before it was classed as a dangerous drug, never mind that hemp and marijuana are not the same and are distinctly different plants in regard to the evil THC.
6
"Is it conceivable that conservative politicians have that much contempt for their base? Yes."
Yes, yes, yes. Just listen to your conservative acquaintances (friends, family or otherwise) in private conversation. Their cruelty towards others less financially secure than themselves is rather astounding.
16
Maybe some of these folks just don't see the connection between their vote and then what happens after that.
8
I feel for these people. My father who grew up as the son of immigrants in an East Coast city during the Great Depression used to say that being poor was easier in the city than in the country. I always took that to mean that greater access to transportation, education, and jobs meant that you could survive more easily. Simply put, there was more going on and you could depend on others to help at times. And, this was before Social Security and access to health insurance for most people.
4
Some of my friends in Appalachia are the conservative counterparts to Florence Fein, the protagonist in Sana Krasikov's novel, 'The Patriots'.
Florence emigrates to the Soviet Union in the 1930's, lured by the egalitarian promise of communism. Many decades later, the promise wholly unrealised, and having barely survived unspeakable hardships and criminal acts perpetrated upon her, she still believes.
Some people would rather die than admit that the central narrative of their lives is a lie.
8
It is a mistaken assumption that people vote in their own self-interest on any given issue. Several different patterns operate without regard to self interest: (1) Many people delegate their thinking to their pastor, Rush Limbaugh, or their spouse and behave as they are told. (2) Others consider it a betrayal to cooperate with someone or a party they detest. (3) Still others simply distrust the Federal government overall and trust their state government. In all of these patterns, thoughtful consideration of 'what is good for me' is missing. It could well be that the majority in Tennessee is an amalgam of all three and therefore unreachable with messages involving logic. It is a conundrum how to affect change.
9
This was a fine and needed column until Krugman got into the question of motives. As usual, he got them wrong, or perhaps more accurately, not quite right.
To understand motives, we have to look at both ends of the political spectrum. The far right are hostile to government, period! They fervently believe in free-market or laissez-faire capitalism, without government interference of any kind. It is true economic Darwinism: the cream floats to the top—as it should!
The far left, by contrast, talk a good game about government regulation to spread the wealth, support the middle class, or help the poor. When push comes to shove, however, they show their true colors. They are ideologues, moral absolutists, more concerned about virtue-signaling to their fellows or their constituents than helping those in need. (By the way, this is readily understood by voters for what it is: hypocrisy. That is why Democrats lose elections, and why they may lose, once again, to an historically unpopular president.)
The bottom line? Calling out the far right for their mean-spiritedness is fair game, and much needed. But honesty demands that an equally harsh light be thrown on the far left for their equally heartless lack of concern.
8
@Ron Cohen The voters in the rural areas have a say. One conclusion could be that the poor should not accept any charity. This hearkens back to the "Great Chain of Being," embodied in the Protestant Ethic. They view their presidents as autocrats chosen by God unanswerable to the law or to the majority. Look at how the religious right views Reagan, GWB and Trump
Add this to the the socialism equals communism equals atheism belief dynamic gets to the rejection of any government program that can save their lives.
@Ron Cohen: All this is nonsense to me. Private sectors are capitalistic, and public sectors are socialistic. Under communism, the government ostensibly owns everything. The US is now and always has been a mixed economy.
@Ron Cohen
Thanks. This was very well put.
1
i live in rural northern california, where we have a healthcare shortage simply due to a lack of doctors and nurses. we need to develop programs to recruit people into medical school and distribute them where they are needed, rather than where they can make the most money.
5
@slightlycrazy
The bottleneck is the residency system, which is funded by Medicaid. Medical schools cannot prepare more students than can be placed (allowing some over-run for attrition). The whole process is extremely expensive and competitive. Most students go into the higher-paying specialties rather than family practice, primarily in order to pay their loans down. The whole
medical system hierarchy is archaic. We need doctors and specialists, but we need a whole lot more nurse practitioners and public health nurses, who should
be able to operate more independently than at present. I would like to see public health clinics at local elementary schools, staffed 24-7, and equipped with vans for home visits (what a concept !)
We have been so at the mercy of how medical care is provided, for so long, that it is difficult to even consider viable -- and affordable -- alternatives. But they do exist.
Sure, maybe state-level politicians are being deliberately cruel to their constituents, but I think it's also possible that both they and their constituents have been persuaded by decades of conservative media telling them that government is the problem, so they honestly believe, despite all evidence to the contrary, that the best solution to their problems is refusing all help offered by the government.
3
In my opinion, this sort of mindset is uniquely American and specific to poorer, uneducated whites who vote Republican: they see themselves as "inconvenienced millionaires" who could one day be rich and benefitting from the policies the Republican party enacts to protect the interests of the 1%. But these poor, uneducated whites never seem to realize that these very policies are the policies that are keeping them poor and uneducated. The Republicans use issues like abortion, gay marriage, feminism, immigration, etc as wedge issues to keep the votes of the poorer whites while enacting policies that will ultimately destroy them. Racism, fundamentalist religion, homophobia, xenophobia and misogyny are all tools used by the Republican party to motivate poor whites to believe that "those people" are getting something the aren't and that "those people" are stealing their tax dollars. Due to the fundamentalist Christian and "prosperity gospel" bent of the Republican party, they have managed to convince a large portion of the American people that the poor (and anyone who is struggling) deserve to be that way and stay that way, and that no help should be given.
6
@Liz: NBC broadcasts Joel O'Steen's "Prosperity Gospel" service right after its Sunday news shows. God wants everyone to win the lottery. Hooray!
1
If they approved their own health care, next thing you know, "those people" would get something too.
This has become a matter of identity. They take pride in it.
6
South Carolina also failed to expand Medicaid. Libertarians here seem to think that people should take care of their own, despite the fact that they have neither the money nor the expertise to do provide care to their families. They have blocked expansion here and I suspect played a part in Tennessee as well.
Republican state governments are responsible for much harm to their citizens, not only lack of health care. SC also blocked a rise in gasoline taxes, though we had the lowest in the nation at the time and despite the fact that many millions of tourists passing through buy gasoline here, and thus could pay for infrastructure improvements to highways that claim the lives of almost 13,000 people every year, one of the highest rates in the country.
Yet people continue to vote against their own interests here, in Kentucky and elsewhere, allowing this scourge to continue.
8
Here in Florida the Republican legislature and governor blocked Medicare expansion because it was a program supported by Barak Obama and they saw political advantage in showing they would block anything he supported. The widespread misery of my patients does not matter to them and they do not want their tax dollars spent helping others. The people who are hurt are either disenfranchised (over a million ex-felons in Florida may never be allowed to vote) or are Democrats. The Governor and the majority party make no pretense of concern for anyone who did not vote for them.
9
@Dan Woodard MD
You meant "blocked Medicaid expansion", not Medicare.
Part of the 'justification' to the resistance of Medicaid expansion is that many providers are unwilling to accept Medicaid patients because the reimbursement rates are so low, but that certainly doesn't affect lawmakers.
In fact, many citizens may not realize that the expansion would actually have reduced what states currently pay for non-Obamacare Medicaid recipients from 25% to 10% and the rest comes from federal funding, not state funding. Sure it would have increased the current Medicaid population to include the 'working poor', but at less of a cost to the State.
2
What would have made this article more interesting would have been comparing actual health statistics between Kentucky and Tennessee.
It's one thing to point fingers regarding lack of coverage due to politics but it is more tangible if it is seen from an actual difference in the level of infant mortality, preventable deaths, longevity rather than comparing just the number of insured.
I also wonder if the Medicaid population is 'more healthy' than the insured population with high deductibles rendering this group unable to seek care despite coverage.
1
I'm starting to think that the real solution is to stop trying to work together as a country to improve our healthcare system. The problem is too large and working on the federal level just gives local politicians too much cover to blame the feds for their inaction. If folks in Tennessee don't want a functioning health care system, so be it. Why should that stop folks in Minnesota or New York from having one? the trump era has really pointed out me, an uber-liberal, that maybe the republicans are right to think the federal government has too much power. What was I hearing about a constitutional convention?? Sign me up!
4
@tim m: I wouldn’t bother signing up for a Constitutional Convention. There is no chance that anything more controversial than an amendment declaring that”henceforth all puppies, kittens and babies shall be referred to as cute” would have any chance of passage and ratification by sufficient states!
Agreed. Ruthlessness, once thought of has a Russian novel maintain has become part of the Republican Parties platform.
2
Keep 'em "Ignorant and miserable" and you can harvest the votes of their resentment year after year --- has been Republican policy for as long as I can remember, and I'm 77.
13
Amen Brother!!!!
Short lifespans are perfectly fine- for republikans.
4
It'd be interesting to track and report on coal miners' occupational black lung cases--or incidence of--and treatment available, in US states that embraced or accepted expansion of health insurance, compared with miners and health services available in states like Tennessee, that didn't. Pres. D. Trump loves coal mine owners [and, for some reason, coal mines]. But I never heard nor read that he'll fund treatment, let alone lung ailment & other illness prevention, in the miners that he adores sending back to the coal fields. I'd like to see NYTimes take a look at this. And also within states: do coal mining regions of Kentucky have occupational health facilities? Because, the men, and few women, who blast & dig the coal--again--will show symptoms sooner rather than later. Has Kentucky's Senator Mitch McConnell made promises about this? Will he pay for care for lung-disabled Miners?
2
I read the WP story yesterday as well. Indeed, invoking unnecessary suffering and killing your own people to make a mean-spirited point that the programs and money come from things you don't support does not justify such cruelty. The democrats need to hammer this disgusting example home. Also, to the hard-working folks who volunteered their medical expertise to serve these unfortunate people from Tennessee, well done. You are heroes.
6
This is what bugs me the most: We have firebrands such as Bernie Sanders and Elizabeth Warren, as well as panderers such as Kamala Harris, trying to run their campaigns partially on a promise of Medicare-for-All. Which as I know, and as most realistic, sensible people know, doesn't have a chance as long as there are enough Republicans in the Senate to block it, as well as many regular citizens wary of a $30 trillion 10-year price tag.
Why not try something that has already been passed into law? It's called the Patient Protection and Affordable Care Act, and it has never been enacted as it was intended, due to Republican resistance. Medicaid expansion was supposed to be universal, until the Supreme Court decided in a suit brought by the Republicans that it couldn't be mandated. And the penalty for being uninsured needed to be much higher than it was, and now Trump got rid of it entirely.
There is no need to reinvent the wheel, and disrupt people's private plans that they like and don't want to lose. Try something that has never been tried before. It's called, colloquially, Obamacare, named for our last honorable, non-criminal, non-rapist President.
9
"The federal government would have paid for Medicaid expansion." Yes, but for how long! The people in the "show me" state are pretty weary of 'pay later' arrangements and Trojan Horses. It is a judgement call whether in the long run it's a good thing. (I think it would be.) But insisting it's a black and white matter, with the informed on one side and fools on the other is a foolish strategy, IMO. It's clear that our state legislature would not get reelected by those living in participating states. But they remain where they are because they represent their constituents, rather than non-residents or the mainstream media.
5
The huge advantage that Republicans in general, and southern state administrations in particular have, is that they can be entirely divorced from rationality and facts. Their base vote is in the bag regardless of self-interest and logic. All they need to do is occasionally press one or more of the following hate buttons: abortion, socialism, elitism, etc. etc. Meanwhile, Democrats, intellectuals like Prof. Krugman, and rational suckers like us who read the NYT are left having to explain facts and reason calmly. Unequal contest.
3
We may need Doctors Without Borders to set up their clinics in these "non-expansion" states.
4
Republicans and rural Americans - often much the same group- do not like to be told what to do or how to do it, especially by those evil revenooers in Washington that took their stills and their slaves. but more than that, they are more religious than most, and know in their hearts that sickness and injury are the wages of their sins, and prayer and repentence the best remedies after all. there is no reasoning. dear Professor, no facts nor calculations that can effectively reach this segment any time before the Rapture. and they wonder why China is eating our lunch!
4
In Trumpian vernacular, Republican politicians are not
"good people".
2
It is definitely a case of rural self-inflicted medical misery, which is piled on top of economic misery. The same poor white folks who are sitting in the occasional pop-up medical clinics who do not have medicaid available to them are the self-same rural folks, nationwide, who elect GOP politicians who are the self-same politicians who refuse to expand Medicaid for the poor in their state. These folk vote GOP to protect themselves from the policies of "liberal elites" - aka, Democrats.
3
This is a good argument for Government Sponsorship of Health Care. Remove the profit motive and all citizen will be better served.
1
As a Canadian with relatives in the U.S. I sympathize with those in red states whose legislatures cause the kind of suffering described in this article. The lawmakers are covered, and they insist that the purity of their ideology is what their constituents really need ("market driven health care" rather than a system motivated by a desire for a healthy population). In turn, their constituents are too often profoundly ignorant of the truth: their healthcare problem would be solved if they'd wake up to their own reality compared to that of other jurisdictions like the one that I'm in, in which I get the same coverage as provided to the wealthy and to the politicians.
5
Great article Dr. Krugman. It's great to see someone pointing out how toxic Republican policies and politics truly are and the repercussions.
3
I'm almost tempted to say "let them suffer." Goal of a human life should be more than mere existence, something more than sustenance and TV tuned to Fox News. There has to be some effort to understand what goes around you and in the society that you belong. Clearly ignorance isn't always bliss.
4
I live in S.C. I was in line for a Kamala Harris rally, having spent two hours standing in line in 90 degree heat, when I realized I was going to pass out. A paramedic found I was cold and clammy, my heartbeat was thready and my BP was low. She called the ambulance.
I didn’t want to go to the ER, though I have insurance, because we already owe our public hospital $5000 after my husband was hospitalized last year when he almost died of flu. I allowed myself to be talked into it, and found I was suffering from an infection and anemia.
Other family members are also carrying medical debt from a ruptured appendix, a hernia, etc. It’s a constant worry even for those with insurance because the health care industry is intent on unlimited profits.
Its only responsibility is to investors, not patients. If greed wasn’t the system’s engine, society would be better off.
But life is cheap. Health care isn’t.
6
You could be forgiven from thinking, from this article, that the voters of Tennessee had no say in the makeup of their state government.
But, of course, they do - it's hard to feel very sorry for these people, whose poor (stupid) voting choices, among other things, gave us Donald Trump.
Happy schadenfreude.
3
Yet, the ruralites continue to vote republication. You reap what you sow, Paul.
2
Reading all the comments below, I don't know how we can get through to these rural voters that they are voting against their own best interests. It is so frustrating. It is more than frustrating; it is a tragedy. They listen only to each other, and to fox news...and their peers, families, and fox news tells them that Democrats are evil, Democrats are Socialists and Communists, Democrats want to see the country overrun with illegal aliens, Democrats hate white people, etc. And the right wing propaganda machine tells them that ONLY republicans will save their health care, and bring back everything to them. These Fascist republicans chortle in glee as they lie to these poor people, knowing that they have no intention of helping them, but that they desire to strip them of even the little that they do have. It is cruel, abhorrent, and criminal to deliberately lie to these people, knowing that the intention is to harm and disenfranchise them...to marginalize them even more than they already are. Although it seems not be illegal to lie to the American people, it SHOULD BE.
2
Almost seems like there is an inverse correlation between how racist a state is and average health outcomes. Racist states on average less healthier.
2
If rural voters are that dumb, I am not going to waste time offering sympathy for their suffering.
5
When you are poor, yet vote for the Republican party which is based upon racism and redistribution of wealth from the poor to the wealthy, you get what you deserve. Sorry to say it but you are ignorant and self-defeating.
3
Yet, the people from Kentucky keep electing the most powerful Senator, Mitch McConnell to the U. S. Senate. Ron Paul has less power, but he's also a threat to their well being.
5
@Shaheen: believe you mean Rand Paul, Ron is his father and not in KY elected office.
Sorry, but the dumbest people usually suffer more than everyone else. These people are too dumb to live apparently. Their leaders must be even stupider. Why rural has to mean ignorant and living under miserable conditions has never been fully explained but there it is. What this all has to do with "Americanism", fighting back Socialism, or for that matter Christianity is a total mystery. Nobody deserves this situation but the ones who bring it on themselves will have trouble even getting sympathy considering their choices.
10
yes Dr K we know its true. simple (partial) solution; advertise.
some horrible, bad, twisted meanie lefty like Soros ought to buy every last empty billboard space from Clarksville to Jesus.
Sick? Need a doctor?? Demand your REPUBLICAN state legislators quit blocking your access to free healthcare!
(not 100% true but if they can I can too)
DONT BE THEIR CHUMP!
DEMAND they restore it NOW or demand they leave!
call 1 800 I HATE BUMS.
(I know probably too high a reading level but could use fewer/shorter words if I tried)
3
God will look after them. Ha!
2
Why not just say it?
“...America is not, ‘an advanced nation...’” [my caption]
4
I believe Mitch McConnell is up for re-election in 2020. Can you imagine the stories he will weave and the lies he will spout. He's a shoe-in for retaining his seat. Some things never change.
It's "Hillbilly Elegy" all over again.
5
@PaulB67
He's gonna "retire".
1
@brogeorge If he believes he will lose his life-and-death power over the country, he will retire, just like Ryan did. McConnell isn't worth a long comment. Don't let the door hit you on the way out, Mitch.
2
My sympathy for these people lies with the fact that they have little access to factual news coverage... Fox and local radio stations from Sinclair ...are feeding them Republican propaganda and talking points.
3
and they have been primed by their churches to gobble it all up.
1
"Let's move to Texas," he said. "We won't have to pay state income tax!"
Uh, no.
1
Now if you can only find a way for this too be aired/viewed on FOX fake news then the people the article actually addresses might be enlightened.
4
It is “about the money” according to Nancy McLean’s book, Democracy in Chains. Based on the papers of James Buchanan, rich GOP donors looked for ways to convince voters to vote against all government programs with the aim of eliminating the “burden” of taxation of the very, very wealthy. Ultimately, Buchanan realized that repeal of the benefit state was too unpopular to set aside by democratic means. He died before recommending how to set aside this obstacle.
My impression is that being cognizant of the cruelty of their goals would be an “upgrade.” They couldn’t care less about that.
5
As a New Yorker, I guess I'm a coastal elite. I did go to college and earned my BA from Rutgers. But after returning to Westchester County eventually I became a Police Officer and later a Sergeant in the Yonkers Police Department.
So I'm scorned and hated by those in flyover states. But my like, my work, was more like theirs than the town I now live in which is highly populated by hedge funders and others in the financial field or successful doctors, lawyers etc.
I'm also a liberal Democrat, so one more bit of quirkiness in the puzzle.
What Republicans have been doing for the last 5-6 decades has truly been only in their own monetary power driven interests. Yet they convince people to vote for them and against their own interests and now survival.
So not only do they blame it all on me, the coastal elite, I'm now heavily subsidizing them with my taxes. Red states receive more money from the federal government than they pay.
I'm supporting Tennessee and other Red states and they have the gall to dislike me?
For that matter, the same is happening in NY. Every so often the Republicans in Upstate NY threaten to secede from NYC and Westchester County. Go ahead I say, then see how poor you'll be without my taxpayer dollars subsidizing your life.
It's abhorrent what Republicans are doing to their fellow citizens and perhaps articles like this will help educate people. But it's Fox News that needs to tell them this and that will never happen.
562
so, you are unhappy the red states are being subsidized by those on the coast and yet you want them to take more Federal money? Or perhaps you think then the red States will like you because you are paying them enough money. and it also seems to me that when the recent tax law went into effect limiting deductions for state income tax and mortgage interest it was those on the coast who complained. Perhaps subsidies are going both ways albeit in different forms. Maybe we need a coherent tax policy in this country and a coherent Health Care system in this country. And legitimate Health Care reform, which would involve a fair measure of personal responsibility and actually reform how we care for the health of people not just who pays for that care.
2
@Matthew The health care solution is actually very simple. We currently pay a 1.45% payroll tax to cover Medicare and to some extent Medicaid. Employers also pay 1.45% for a total of 2.9%. Medicare/Medicaid enrollees number about one third of the population. So if this tax were tripled to 4.35% (8.7% total) we could provide Basic coverage for everyone. Keep co-pays to help keep unnecessary trips down and maybe even have a deductible.
Workers currently covered would likely find it a wash since they no longer would pay for their current plans. And with the addition of ALL young (generally healthier) people, the program might even run a surplus since they would not use the service as much.
Private insurers could sell supplemental coverage to anyone who wishes it.
33
@Matthew
It's not the fact that we're subsidizing them. That's how taxes work - wealthier areas pay more so that poorer areas don't have to.
It's the fact that they then turn around and claim that THEY are subsidizing US.
56
It's not that "Republican state-level politicians {are} so determined to punish their own base." It's that the Republican "base" are those people just a bit better off than the people who need that medical care who resent the people who need that medical care (and other government services). And they're the ones who actually vote. The poorer people don't.
2
And yet most of these same people keep sending GOP reps to their state and federal legislatures -- the same GOP reps that vote against expanding medicaid, obamacare or raising taxes to pay for hospitals, etc. They keep shooting themselves in the foot election after election, and then claim they are ignored and nobody feels their pain.
271
@charles sparks It's fear of liberals that keeps them voting against their own interests. Fear that is constantly reinforced by right wing propaganda.
12
@charles sparks It's all about abortion, gays and guns. They get their marching orders from Fox, Rush, and their preachers. Period.
18
@charles sparks EXACTLY !
7
I'm a Tennessean and am disgusted by what our Republican State Legislature has done to hurt poor people. If I were the state chair of the Democratic Party, I would run a democrat against every republican who voted not to except the $100bb over ten years to fund Medicaid with this campaign slogan "Because of this person, your hospital closed."
330
@RLE123
Red state Democrats would like to run in every race, believe me. It is very difficult to find people to run for local office, given the cost in time and money and the likelihood that they would have to run over and over again before they had a chance of being elected. Locally, we've had at least three Republicans in recent years run as Democrats in our primaries, then switch back to Republican afterward, to ensure that a Republican holds the office. It is not as easy it sounds.
18
@RLE123
The campaign slogans should be put on billboards around every state that did not fund expansion of Medicaid. The name of the Republican candidate, the slogan, the number of closed hospitals and jobs lost, and the name of the Democrat running against him. Start now, go to the local Democratic campaign offices and get the presidential candidates to kick in.
21
@RLE123
Then do it. Get off your duff and speak out. You don't have to run for office to make your voice heard. Find a way. Just find a way.
6
Telling it like it is 24:7. Of course it is possible that it’s not merely cruelty but ideological blindness together with an inability to connect effect with cause. God Bless America—the Greatest Country in God’s Green Earth!
4
While I have tremendous respect and admiration for Paul Krugman, the title is so wrong: "Self Inflicted" Medical Misery. Why not be realistic and title it Republican inflicted Medical Misery? Sir, what do you mean, self-inflicted? Are you implying that as they voted Republican, they brought this upon themselves? White lower middle class Americans are fiercely independent and usually vow not to reach for government "handouts" which is why they continue to vote Republican; and why they refuse to protest lack of Medicaid expansion. Talk about shooting themselves in the foot.
1
It’s been said that civilization is a race between education and catastrophe: Looks like catastrophe is winning...
4
Ever since Donald Trump took over the Republican Party, it's become nothing more than an arm of the Russian government whose aim is to weaken American society. This is simply one more facet of their nefarious plan.
3
I have lived in rural America for most of my adult life. While I find the politics out here maddening, I have come to the conclusion that the answer to the masochistic voting tendencies of rural America is not contempt from the left but compassion. Admittedly, that's a hard thing to muster in the face of some really awful attitudes, but I believe it's the only solution.
Ruralites already accept a lower standard of living and many inconveniences in order to live out here, and now their kids are having to move away and they are losing everything they love. They are scared and bitter, and, while a criminal might garner sympathy from liberals because of police brutality, they get made fun of and told they deserve their living conditions.
Republicans lie to these people all the time, but they tell them they are the true Americans as they do. Democrats do offer some job-training programs, for instance, but those good things are overshadowed by the contempt with which so many liberals view rural Americans.
Politics aside, rural America actually has some very good values to offer this country. I would rather break down out here than any city because I know people would help me here. As a nation, we should commit to saving rural America because it's part of who we are. Democrats would peel off enough political support to send the Republicans packing if they could understand this. Paul Krugman's heart is in the right place. I hope other liberals can find his compassion.
2
I am surprised PK missed a valid reason that Republicans in Tennessee might not support Medicaid expansion : the number of uninsured voters are vastly outnumbered by the number of working class poor with employer provided medical plans with high premiums and co-pays who all got no benefits from Obamacare and don't like having the lazy unemployed get better medical benefits for free.
From the point of view of the working poor it isn't the Republicans who are being mean to the unemployed (who deserved their fate for not getting a job), but Obama who was being mean to the working poor by not only excluding them from any subsidies or benefits in Obamacare, but in some cases even had their benefits taxed ("Cadillac tax") all because Obama drank the conservative Cool-Aid about ACA having to pay for itself and not expand the budget deficit.
2
It is indeed strange that the neglect of rural health care in anti Medicaid expansion states has almost total representation by the GOP. The neglect of elites that seem more interested in immigrants and poor blacks. That's the sales pitch. Big gov't always serves the opponents of the GOP. Trump made a big splash. His bigoted ignorant rant. Big gov't wants take away your guns, open abortion clinics. The nanny state. The GOPs fondest hope is take Medicaid out of the argument. Defund it turn and it into a state program. They claim that it is the same as welfare.
While we've heard much about the opioid crisis, there is another drug that has afflicted many Republican voters. That is, FOX News and related right wing media. The adrenaline rush that viewers get from the deluge of outrage and apocalyptic narratives is indeed addictive to many people. Steeped in the toxic rhetoric that liberals are destroying our way of life, they willingly vote for the alternative.
9
This column is informative and strongly argued. The Republican party's agenda is based on callous indifference to the needs of their constituents. It is evident in policies like their opposition to a woman's right to abortion, opposition to the Affordable Act, and unwillingness to fund state colleges and public transit. Hopefully people in rural states will vote this party out of power during 2020.
only the very rich and fictitious persons with free speech rights who also cannot die are the GOP's constituents. money, in short, is the Republican constituency. , all those poor and working class suckers they hoodwink into voting Republican are their victims, only they do not wish to see it. have a blessed day.
I think simple cruelty is a bit of a stretch in trying to understand why state lawmakers would vote against the Medicaid expansion. I suspect it is more a tribal belief that we are republicans and we are against that. This combined w/ an electorate that does not really understand the personal impact of these beliefs. Remember how many people did not realize that Obamacare was the ACA. It's a case of all jumping on the bandwagon w/o realizing where that wagon is going.
2
Rather than Paul Krugman's question:
"But why are Republican state-level politicians so determined to punish their own base?"
Maybe better to ask:
"But why is the Republican base allowing Republican state-level politicians to punish them?"
4
Rather than Paul Krugman's question:
"But why are Republican state-level politicians so determined to punish their own base?"
Maybe better to ask:
"But why is the Republican base allowing Republican state-level politicians to punish them?"
While the 2020 candidates are campaigning, they need to "sell the truth" on this matter to the rural folks. It's sad that they have to be sold on the truth, but they're sure not hearing it from the GOP or conservative news. And judging from the success of the 2018 candidates, the Dems are gaining ground on health care in general. But the demise of rural hospitals and clinics due to their state's choice on medicaid expansion is a wrinkle they probably haven't heard before. And the Tennessee / Kentucky comparison is an easy example.
These GOP state governments are getting away with murder! And we need to use every opportunity to call them out.
1
ACA is a 2nd rate system. Even the insured are burdened and exploited. Yet we're so thankful for it, and protect it from GOP destruction.
Let's get real. Americans deserve better. Just bashing the conservatives, GOP, and Trump on and on is fine, but it is also a distraction from the real problems at the heart of our lack of HC for all.
It's big money in politics, with corporate donors setting our norms and dominating law making. This is equated with "American Freedom".
Krugman never connects cause and effect. So he's fine being anti GOP, but doesn't want to look too 'anti corporate'. Too left wing for our centrist liberals? Yes, in our distorted political culture.
The blatant, ignored fact is our whole HC system is inferior to that of dozens of countries---and they're also capitalist democracies. But their govts have more respect for their citizens than our elected govt has for Americans.
Krugman as an economist, concerned with inequality, would be the perfect expert to explain how we differ from positive role models around the world. But as years of columns have show, he doesn't want to deal with that.
So much easier to look good as the arch critic of our extremist rw party and the worst president in our history. For this, we need a Nobel economist?
As the book “What’s the Matter with Kansas” has shown, rural Americans have bought the GOP line based on religious issues against their own economic well-being. One can hardly, rationally feel sorry for them, employing the old adage, “You made your bed, now sleep in it.” Even though the lack of solutions to many of their problems finds a direct line to their own, brutal Republican state politicians, these people also possess an outsized influence in federal elections due to numerical inequities protected by the Electoral College. So this Progressive finds it difficult to muster much sympathy for Tennessee and Ohio voters with no health care. There’s just been too much damage done to this country due to the way they vote.
7
"...we’re talking about whether there are doctors and hospitals available to provide care. True, rural hospitals have been closing in many states as the nonmetropolitan population declines." -P. Krugman
I don't think so. The reason why capitalist corporations, which I assume these rural hospitals are, close is because they can't produce and sell a commodity, in this case health care, at a price that covers costs and yields at least a normal profit.
Therefore, they close and people go without any alternative for healthcare.
These consequences stem from the normal, profitable operation of capitalism. If you don't like these results, then you don't like capitalism.
1
2016 election results for Bradley County, of which Cleveland is a part:
Trump 77.5%
Clinton 18.4%
7
@RRBurgh
Right wingers love to blame the victim, so in this case one can almost hear them saying, "This is your choice. You deserve the consequences."
If the Democrats united for a long enough period of time rather than attempting to showcase their differences it might be possible to show the Trump supporters exactly how indifferent the GOP is to their suffering. This is not about the "elites" in any way. This about the rights of all Americans to receive decent affordable health care when and where they need it, to be able to live in decent affordable housing that doesn't eat half their net pay, to be able to pursue happiness for themselves and their families.
I've known too many people who have not been able to provide for themselves, not because they don't want to but because the economy/political atmosphere has made it impossible. Liberals, conservatives, old and young, we all deserve to have decent lives particularly when we do work hard to earn a living. What we don't deserve is the likes of McConnell, the Kochs and their ilk, and yes, Trump, telling us the lies about immigrants, health care, etc.
4
"Some of it may reflect the general meanspiritedness, the embrace of cruelty, that was already infecting the G.O.P. even before Donald Trump, and has now become one of the party’s defining traits."
That was certainly the case in Maine during the 8 years of the Le Page (R) reign. He blocked expansion 4 or 5 times and tried, unsuccessfully, to have Maine miss a Feb. 2019 expansion deadline.
Gov. Mills (D) took office on 2 Jan. 2019 and on 3 Jan. issued an executive order for the bureaucrats to work with the Feds to meet the deadline. On 1 Feb. she issued another order expanding coverage.
7
If Democratic Party candidates would stand up in Tennessee and repeat the message that you just delivered, Paul Krugman, I believe seats could be flipped. I wonder if lack of voter registration drives in some of these red states are also a major contributing factor to this third world scene.
2
"There’s also, I suspect, an element of cynical calculation. As I said, rural voters often complain that national elites don’t care about their needs. Well, one way to make people feel hostile toward those elites is to block their access to federal benefits, and hope they don’t realize who’s actually causing their misery."
This succinctly summarizes what historian Timothy Snyder has termed "Sado-Populism."
https://www.salon.com/2018/05/09/timothy-snyder-on-trumps-campaign-against-democracy-he-is-deliberately-hurting-white-people/
It's true that people become numbed & desensitized, even media can't deal with torrent of scandals around this administration.
This is our biggest peril.
3
How do we get this message to these people if all they ever view is Fox News. They wouldn't read this piece, having been brainwashed into believing anything they hear on their favorite radio stations and from the right wing media. Perhaps we need to start dropping leaflets in rural communities to tell them the truth. It is hard to feel sympathy for people who vote against both their own best interests but against the interests of the country.
3
I am done feeling sorry for people who vote against their own interests. Sow the wind, reap the whirlwind.
5
Kentucky expanded its insured and McConnell still wants to kill the ACA. How does he keep getting reelected?
3
I think the column by Dr. Krugman is mostly correct except when I got to the end where he said "most of the blame lies with Republican state governments".
Blame it one gerrymandering or whatever, but as Dr. Krugman pointed out in an earlier paragraph: "And these state politicians hold power in large part thanks to the strong Republican leaning of rural voters."
So who is to blame? The politicians (yes but only to the extent that they are the ones who sold the voters a bill of goods) or the voters themselves who are so willing to buy, and repeatedly at that, their bill of goods? It is, after all, supply and demand.
As they say: be careful what you wish for because you may get it. Vote GOP and you cut your own throat. Here again, as they say: election has consequences.
1
Mary McCleans's book " Democracy in Chains" details how the arch-conservative strategy to delegitimize government is to provide evidence of politicians incompetence and self-serving behavior. Republicans say that government is the enemy then set out to prove it by their actions.The stressed, ill-informed voters who go along with that characterization are oblivious to the fact that it is those politicians, not the system that needs to be changed.
Though ACA is a vast improvement over the previous HC situation that was a human rights violation by intl standards of modern countries, it's still a 2nd rate system.
Compare ACA to generations of truly universal systems in other capitalist democracies. We have the world's most expensive, and most profitable HC. Profit is 1st priority.
Repubs aim to destroy what progress we have made. But Krugman should be pushing for a truly universal system, in line with late 20th Century standards.
Compare the 2020 candidates proposals, and put them up against other countries. We're so thankful for ACA, but it shouldn't be idealized---it's an inferior system for a modern democracy.
The cause is our dependence on big corporations to subsidize our election campaigns. The politicians we line up to vote for can't free themselves from big donors, so they can give We the People better representation for our taxation.
The 2010 Citizens United decision by the S. Court, removing limits on corporate mega donor money, is a huge blockage to progress. Most voters and many politicians want to reverse it.
Our health care operates within norms set by big insurance/pharma. so true health care for all is still labeled 'left wing, radical, big govt' interfering with our 'freedoms'.
States can opt out. We need a national system, so that people don't lack this essential human right, becoming 2nd class citizens, depending on their zip code.
Bashing the GOP is easy, but is hardly enough.
I have enough compassion that if we ever get rid of Republicans in office I will support having tax dollars go to help these people in their need.
But I hold them entirely responsible for their votes. Maybe that is not fair as they have also given up on educating themselves, and maybe it's not productive since we are beholden to their "decision making" during presidential elections. But I am out of sympathy for people who vote for their own suffering just to prevent others from being helped.
7
Maybe hosting free clinics is not the way to go. Maybe letting those states handle their own problems will finally make them wake up to their own reality/mortality.
I am getting tired of raising money to fix what some regions wanted and subsequently voted for. Why should the rest of us be covering their costs?
Maybe that's heartless, but the voters of Tennessee made a deliberate choice. If they don't want to pay for health care, maybe they shouldn't have it. If they vote in a government that denies them access to health care, who are the rest of We, the People to tell them this is a poor choice?
These are the same people who said ACA "death panels" would kill them. Well, they rejected ACA and now they have no access to healthcare, affordable or not. Maybe it's time to let them pay their own piper.
Mom always said you elect the government you deserve. 2020 isn't that far away.
8
Why do you think that making EXACTLY the same argument right-wingers make—I don’t care about those people, they’re far away, they made their beds—helps a blessed thing?
@Robert
But does enabling those decision help either? So far, no. Do we continue to pick up the tab for their refusal to expand Medicare or any sort to accessible health care, or do we say, "this is your choice?" It is a harsh thing, but what is your plan to get the regional population to understand they are shooting themselves?
4
The hardest part of the problem is how to message to the voters in these states about the base feature of the problem, Republican-Reptilian disinterest in providing health care or any kind of government service.
Unless it involves pumping money uphill into their Donor Class pockets.
Republicans are big on DENYING service to the unworthy, which is pretty much all minority groups and poor people. See the Arkansas plain for a work requirement for Medicaid recipients, which in the (Arkansas) legislature was all about how much money they (The state) would save.
The actual voters around here are convinced the people who are being denied care(In populations unlikely to vote) are all moochers who have made poor life choices; the Propaganda Organs told them so, and they (the moochers) deserve their fate. You can't tell them any different.
5
As long as these cruel republicans have one third or more of the House or the Senate, there is no chance that we will not have medical bankruptcy as an ongoing problem.
The rural republicans have a false sense of self-sufficiency that the elite royalty in the party take advantage of. As long as the royal republicans can convince the serfs of the party that the brown and black people are responsible for the serfs plight, the parasitic royals will command their theocracy.
Educate, march, vote. Throw the parasitic royal republicans out of office in 2020 and improve your life.
3
Republicans are numb unless an issue directly effects them.
Health unless their child has a preexisting condition.
Abortion unless their daughter is raped.
War unless their child can be drafted.
Sexual assault unless it is Democratic president.
And the list goes on and on.
7
Self-made Americans believing the Marlboro Man will rescue them...
Some rural Tennesseans who have ailments and no access to health care should consider moving to Kentucky.
1
If your party gets votes by telling people that the ACA or similar programs are socialist, and We Hate Socialists! what do you expect?
1
Send a copy of this article to Texas Governor Abbott, Lt. Gov Patrick, Speaker Bonner and all Legislators so they can begin to understand the real pain and dehumanization they inflict on fellow Texans who are by far the most uninsured in the nation.
WWJD
1
these people aren’t mean, they’re racist. They can’t have benefits, or else the government would have to give them to black and brown people too. Fox News just perpetuates the myth and lines the pockets of the billionaire overlords.
2
Embracing ignorance as a qualification for being elected in Tennessee appears to be working
What part of "promote the general welfare" (in the Constitution below) don't voters and politicians understand? Seems to me like "general welfare" encompasses healthcare. Not so for members of the republic party and their loyal voters I guess.
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.
"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defense, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."
3
I've lived in the Deep South.
All government interference is bad, unless there's a check dangling at the end of a hook.
I have friends nearing 70 who thought they really pulled one over on the "guv'ment" because they were always paid under the table.
Now they want a Social Security check, but they never paid in so they are poverty stricken.
We reap what we sow.
4
The saddest thing is that the people most affected are also among those most likely to vote for politicians who hate them and whose motto is "Die Already." Their close cousins show their schednfreude by continual complaining that people need to have "skin in the game." You can't have skin in the game if you are barely surviving.
2
As one reader said on here, marketing is repetition. Exactly, exactly, exactly. Why in the heck haven't democrats figured out this simple trick?
2
Seems many vote to sacrifice their health educational and economic interests as other issues are for them a greater priority.if not the case they are just acting stupid
These poor people will vote for Trump anyway.. It's his base.
2
Two thoughts/facts.
At the time Medicaid expansion went into effect in Kentucky, Kentuckians were lucky (unlike now) they had a Democratic Governor with the authority to make it happen.
Of course Medicaid expansion was part of Obamacare passed by Congress until Justice John Roberts decided it was up to the individual states and overturned that particular piece of the legislation. So much for calling "balls and strikes" Mr Umpire.
We are seeing the effects of 40 years of AM talk radio, which has flourished, particularly in rural areas, without any significant challenge from the left.
People who live in rural areas and either have no reason or refuse to travel outside their area are served a hellish vision of masses of dark-skinned urban criminals living high on welfare while reproducing like rabbits, Democrats who hate white people and want to flood the country with even more dark-skinned people who will force them to speak Spanish and convert to Islam, Democrats who delight in murdering the unborn, and Democrats who want to introduce "socialized medicine," the latter point illustrated with every horror story from British and Canadian tabloids, and conniving gay people who will "recruit their children." In this fantasy world, Trump is the only one who can save "fine, upstanding [white] Americans" from marauding hordes of the Other.
These propagandists, evil as they are, can run circles around left propagandists with their knowledge of how to scare low-information voters.
I don't know what can be done about this except to have a firm Democratic majority in both houses of Congress and an FDR-like president who is willing to be as bold in implementing helpful measures as Trump is in implementing harmful ones.
If 50-year-old unemployed miners find that they can see a doctor at no cost or a low cost, without living a Daily Mail horror story, they may start to doubt the radio ranters.
7
This seeming paradox demonstrates why Trump loves the “poorly educated.”
1
This is a country with lost civility. I step over stinky, mentally unwell people in the streets of NYC every day. I wish they cleared them from the Subways, too.
This country has made a conscious decision to step over those folks, and to let those die who don't have the money for care. This is America. This is the society we chose to be. This has been going on for decades. Now let's stop pretending we care with articles like these!
let's not forget at least 40 years of cutting/neglecting education budgets. you can't vote for your best interests if you are too ignorant to know what they are.
3
We can't let the Democrats have a victory. Better to let the needy die. I often wonder why Republicans are so against helping their fellow Americans
1
Republicans mean spirited? Nah, just blind and deaf. Republicans can’t see beyond the Second Amendment and can’t hear any of their constituents’ pleas for help. Like a broken record the only utterances are “Undo everything that’s associated with Mr. Obama” and “We’ll get back to you when we have a solution of our own”. Sad.
2
It is sad. This is what happens when you’re ignorant enough to vote for the wrong candidate, or worse yet neglect your right to vote by abstaining.
1
Before I read the article about the pop up clinics, just seeing the article and picture, I though it was about good works in medicine, in some third world country.
I was astonished that this was happening in the United States!
Stories like this should be run on the nightly news and cable stations daily, until all voters understand the horrors inflicted on Americans by the heartless people they elected to office to represent them.
4
I, too, read the Post story and nearly wept, but a feeling of outrage won out. I am appalled and embarrassed that I can be so old, just over 80, and not have really known just how cruel and dysfunctional the so-called "healthcare system" has become. And I am a news junkie, so it's not for lack of paying attention.
The reality that hundreds of people in just one state had to line up before dawn, as if for a rock concert or an Apple product release, just to get any kind of medical help from minor to the major situation described in the story, stunned me. In America? Never as bad as that. Until now. Until the Trump and Republican vendetta against anything Obama tried to accomplish.
I couldn't believe the amazing scale of the medical help that arrived -- huge numbers of doctors and nurses and technicians swooped in and then had to leave to do what little they could in yet another medically deprived state.
Like the terrible border conditions, these assaults on American decency and kindness just keep coming. I am glad the media are doing a better job of reporting about these situations, but many of the victims don't see or hear it. In Tennessee is it just the FOX/Trump view of the country and the world that the citizens see, if any news at all?
Trump, McConnell, Stephen Miller and the rest of the non-caring Republicans responsible for these things are people with warped minds who should not be in positions of responsibility. I have never felt so helpless or discouraged.
13
@bse
Compassionate Conservativism in action!
What kind of future will the U.S. have when so many lives are so callously discarded?
So the rich can get a tax break upgrade to "filthy rich!"
Well, now, are we suggesting that money in politics is toxic for the public? Yes.
What else explains that Trump tax cut? It favored the donor class even at the expense of the great American working class.
We need mandatory public campaign financing so government works not for the money but for the people.
Where is the political support for that? Don't look in the Times.
1
@Occupy Government: The US obviously continues to operate as a state-level scheme to maintain liberty to enslave, with no national equal protection of the law in sight. The states really scrape the barrel for their representatives in Washington.
I worked with the medical community during the TennCare expansion of Medicaid. The State begged the Federal Government for the rights to verify eligibility and more control for the program to no avail. New residents moved to TN and immediately became easily eligible. Out of State patients signed up with no way to verify their eligibility or remove them without Federal approval. We were overrun. Even with the State matching funds, it eventually grew so big the costs were beginning to overwhelm the state budget. Doctors were swamped with more patients than they could handle and many retired early due to the stress. They were paid so little that many quit accepting Tenn Care patients. It was projected that it would eventually eat up 3/4 of the entire State budget. It had to be cut back to where it is today. The only way TN can afford to expand Medicaid would be to add a State tax which residents of all income levels will not vote for. They were burned once by Medicaid (TennCare) and have not forgotten.
1
It would have been really helpful if the ObamaCare/ACA had raised tobacco taxes and taxes on sugar-sweetened drinks such as Coke and Gatorade, the later a major contributor to obesity.
In NYC, the tobacco tax is $5.85 per pack (city and state) with a minimum cigarette pack price of $13 and the age for purchasing tobacco is 21. The Tennessee tobacco tax is 62 cents.
Raising the cost of tobacco contributes more than half the effect of getting people to quit smoking or to never start according to MPOWER, a plan used in NYC and for which NYC Mike Bloomberg has contributed nearly $1 billion to combat tobacco in poorer countries.
Countries that offer universal care such as Canada, UK, and France all have tobacco taxes ranging in the $5 or more per pack which compares to the US federal rate of $1.01.
Tennessee has about 22% adult smokers compared with a rate of about 15% nationwide. The state ranks 15 in the nation for obesity.
By raising the tobacco taxes by $3 per pack in Tennessee there would be much more money available to provide for community health centers.
The Obama administration with a Democratic majority had the opportunity to pass nationwide health measures such as taxing tobacco and sugar-sweetened beverages.
I wish Nobelist Krugman or other columnists would speak with officials at the Mailman or Bloomberg Schools of Public Health and then recommend Tennessee and nationwide plans for limiting their tobacco use and obesity.
1
What baffles me is why these people continue to vote against their own interest time after time. Since the election of Reagan the GOP has consistently served the rich at the expense of the working class and yet it seems that the working class is the backbone of GOP successes.
2
Not to be unkind, or anything, but one cannot help but notice the looks of despair and anxiety in the faces of those at the lifeline clinic, open only on a temporary basis. All are white—at least those who are visible—and not a few appear to be overweight.
I would be shocked beyond measure to learn if any of these sufferers weren’t dead-set against the Affordable Care Act after it became law in 2012, a civil war of sorts that is being waged between mostly red and blue states. Perhaps the deeper anxiety lies with the ethnicity of the president who labored to bring the national albatross into being. It would seem to these Tennesseans on the edge that their elected representatives have forgotten them—if they ever cared about them beyond Election Day.
Perhaps they believed the propaganda that flows so smoothly from the lips of the bought; the well-heeled; the robotic doers of all things Koch and ALEC. These frightened citizens may now be discovering that a promise made by their Republican party won’t go very far at all in checking grandpa’s rheumatism; or mama’s worrisome cough; and why does little brother or sister continue to suck a thumb at ten? Oh; and dad’s back pains recur and he still has to work.
“The rent is due. Healthcare premiums are beyond our means. But we can’t accept anything from the government; our elected representatives tell us that’s Democratic socialism. We’re proud Americans and we want Washington out of our lives.”
An undertaker’s bill isn’t cheap.
5
I live in a relatively prosperous area and in a nice home. At the same time, I worked at a RAM clinic about a month ago just a few miles away and saw the same crushing need as depicted in the feature article you cited.
Of course, Virginia only passed Medicaid expansion about one month ago to take effect next year, so unmet needs should surprise no one.
As a retired family doctor, I am bothered by those I could not help and those who still need access to care much less care itself.
Grinding poverty is a solvable problem if we have the will to address it. What is really lacking as we go about our lives in our nice homes, trendy restaurants and with few troubles is an increasing absence of empathy, an absence modeled by Mr. Trump and his minions. "I got mine and to hell with you" is no way to demonstrate leadership or run a country.
As the RAM clinic showed me again, there is need around every corner and under every rock if we could only see it for ourselves.
Why do we so hate our fellow citizens so much as to harm them without reason?
4
It's all part of the plan by the investment class too buy up all the high ground before the ice melts. The rich people in this country are buying land for their descendants and they don't want the poor white trash around. Don't educate them, don't provide healthcare. Keep them poor, stupid and sick. They'll die off quicker or move away and the hills will be cheaper for the rich.
2
Excellent points below, the schadenfreude needle has been pegged. When the Democrats are back in power, and they will be, the suffering will really begin then. "You want a rugged-individualist frontier fantasy world? Here you go!" Women will die in childbirth, 30% of children won't live past 3 (damn those vaxers, doncha know). That Remote Area Clinic program should be cancelled right now, it's only holding those good, hard-working Americans back from reaching their potential for greatness!.
LBJ observed "If you can convince the lowest white man he's better than the best colored man, he won't notice you're picking his pocket. Hell, give him somebody to look down on, and he'll empty his pockets for you."
Republicans have embraced this cynicism and have been very successful: "You may not have health care, but at least 'those people' don't have it either."
3
HL Mencken had it right when he said no one ever went broke underestimating the intelligence of the American People. The people who most solidly vote republican constantly shoot themselves in the foot; they vote for the very politicians who give huge tax breaks to the well off while increasing taxes on others, they vote for politicians who think that sending jobs overseas to cheap labor markets so Walmart can sell cheap, shoddy crap is 'good for Americans" while causing them to lose good paying jobs, they constantly refuse to do anything about a health care system they claim "is the best in the world", which it is if you are rich, but they still vote for them. Why? Because the GOP tells them it is the fault of lazy people on welfare glomming up benefits, that if we just elect conservatives we will get rid of all those freeloaders and they, the good working people, will get their cheap, comprehensive health care, and they believe it despite all the evidence to the contrary.
2
Dr. K: I am happy to see you approach the issue of the contempt the GOP has for everyone. Base included, maybe even base, targeted.
The nastiness they display is unfathomable. Why? What is their goal? Who is directing this intent?
About Medicaid, Ohio almost passed on the money. Kasich was fully against it until the deadline nearly passed. He pulled a Trump and at the last second figured out it was idiotic to pass up the federal money. Somebody must have gotten past his "we don't want government help in Ohio" crap with the news that Ohio would have to fund the shortfall if he didn't get it.
I am sick to death of Reagan's glib quip that the GOP loves so much about the government being here to help. The GOP is using the Dirty Harry approach to policy. "Do you feel lucky, punk? Go ahead make my day, etc." Stupid.
I was a Marine and I used my federal benefits to get an MBA and forge a career. I'm happy to pay my taxes. The Government did great things for me. I am grateful.
5
Amen.
2
What IF every democratic contender for President visited Knoxville TN and asked the people.."who's your health care?"
Until and unless the democrats get down into the trenches with the people who continue to drink the republican "kool-aid" they will continue to vote republican.
Democrats have an enormous opportunity to educated the voters but it should not be from a grandstand.
Go to "heart of the beast" the reddest of the red and ask:
1. Happy with the health care...for you and your family?
2. Satisfied with the education opportunities for your children?
3. What are the local employment opportunities for you and your children?
4. Got internet, clean air and water?
5.How have YOU benefitted from voting republican?
We vote we win
3
When I'm feeling especially anti-GOP, like now, I say, Let them all suffer in the Red States, especially the Republicans.
At some point, these people need to wake up and realize that the GOP helps only the rich.
3
It is kind of amazing that people would rather let their local hospital close than accept healthcare provided to them by an African American President and the Speaker of the House who is from San Francisco.
1
Fox news lies all the time. These people at the pop up clinics either don't vote or vote their fears. I just got off the phone with an intelligent co-worker who told me he read that millennials were all in for Trump -now where do you think he read that?
2
My sympathy for rural America is long long long gone. Let them have their “pick yourselves up from your bootstraps” Shangri-la. Cancel all public assistance. Close every abortion clinic. Resume mandatory prayer in schools. I don’t care about any of it any more.
Monsanto or Cargill or some other agricultural multinational will soon figure out how to farm robotically, and that will be the end of whatever few jobs remain (they can fly in the robot repair people).
3
If the sick and underserved die from lack of coverage, Tennessee saves money. As one who is Blue in a Red state, I remain appalled at the continuing cavalier attitude extended to those living in rural communities in Tennessee.
1
Paul is right there: there Must be some sadism if republican pro-lifers condemn an unborn child to a life without health care - and care at all (a tooth brush and a piece of soap are not necessary anymore for a child to stay healthy (almost 2 centuries after Semmelweis) - as they let us all know before the court last week)
1
Real Americans don’t need health care cause real Americans don’t get sick.
3
It's been obvious for years that the Republican elite just don't care about poor people. The Republicans want to destroy the ACA and withhold Medicaid while knowing that it will undoubtedly cost many people their lives. These Republicans are often the same people who claim to abide by Christian values. They are fake Christians.
An underlying tragedy in all this is that many of the victims of Republican cruelty are too ignorant to know it and actually vote to empower the party that despises them.
2
Implicit hatred for President Obama. Pure and simple racism.
6
Paul,
Here's an example of the problem: I was listening to local talk radio yesterday and the head of a local, crusading, clean government group was railing against many of the corrupt politicians here in South Carolina. Called them out by name. All were Republicans.
His solutions included, calling the politicians' office, demanding a change in the rules, and protest, protest, protest because you're "mad as hell and you're not going to take anymore!"
But the one solution he didn't mention was to vote for their Democratic opponent.
Whenever I mention this to "mad as hell" Republicans, they come up with every excuse in the book to not go outside their party. The most prominent one is, 'the Democrats will be even worse'. My reply: How do you know? and What do you have to lose? Afterall, you can always vote THEM out next election. But if you continue let the Republicans know they have a lock on the job, then they will never change. It's called competition; ever heard of it?
3
You conclude "This isn’t a problem of policy, it’s a problem of politics — and most of the blame lies with Republican state governments." But you point out that those governments are Republican because rural voters are conservative. Rural voters are getting the medical services they voted for.
2
Slaves could be beaten; contemporary workers can only be threatened with loss of health care and the other hardships of poverty from unemployment.
From a certain perspective, the working poor are doing pretty well.
True, that perspective comes from the first half of the 19th century, or from the contemporary elites of the Republican Party.
But it's still a perspective.
These pop up clinics in rural America put me in mind of the clinics Doctors Without Borders fund and staff in 3rd world countries. And that's a truly shameful thing. We are one of the richest countries, yet we can't / won't provide for the least of our own citizens.
The only answer is for those of us who can to try to educate the masses as to the true source of their pain. It's not the persons of color / migrants / coastal elites who are making their lives miserable. It's the Koch's, McConnell's, Trump's, and their ilk who are responsible. Voting them and theirs out is a good first step.
1
I never knew Paul Krugman didn't believe in democracy. Tenneseeans voted for people who repeatedly campaigned against providing healthcare. Please honor their votes and don't feel sorry for them.
4
Krugman’s not against democracy. His point is that Tennessee’s Republican politicians and conservative supporters should stop, either cynically or ignorantly, blaming Obama and Democrats for their self-inflicted health care crisis.
It's kind of a matter of choice isn't it? If voting decisions are made based on easy access to firearms, eliminating all abortion, burning coal, and contempt for others not in your socio-economic state, then you're at the mercy of what you're handlers do.
For me, even though I've never had any government assistance other than student loans, I got the heck out of a red state as soon as I was able. The oppression that has been lifted is fantastic.
4
I think that the people will just have to suffer and suffer and suffer until it finally begins to dawn on them that the Republican Party means them harm. All in the name of the great god of profit.
But the GOP will not go quietly into the night. Voters will be purged, districts will be gerrymandered, elections stolen, laws subverted, regulatory agencies captured, conspiracy theories invented, all the while billboards pop up all across America reminding the faithful that Democrats kill babies.
There is a lot of money riding on the GOP - billions and billions in tax revenue that the wealthiest people will get to keep. Remember, it's not personal, it's business.
4
Enough is MORE THAN enough! We need to get rid of Trump, and the Republican party. Mitch is not quite human, and loves to prove it.
Susan Collins is past her expiration date, and should go without a whimper, knowing she is no longer relevant. The Republicans in the senate should be forced to wear head horns, to properly show how much they hate their constituents. I'm very surprised they haven't already passed a bill to require all women to wear chastity belts.
1
Great article. If only we could tell them this. I doubt this analysis will be covered by fox news. Dropping leaflets from a plane would likely violate littering laws. Maybe a banner pulled behind a plane.
>This isn’t a problem of policy, it’s a problem of politics — and most of the blame lies with Republican state governments.<
No, we live in a democracy and the people elected those Republican state governments. In Kentucky, they rewarded the expansion of Medicaid by Democrats by electing a right wing Republican governor and Legislature. This has been the story across rural America, actually across all of America outside of college towns, the Northeast, and the West Coast.
In fact, the policy is the problem. The working poor are not stupid, nor have they been fooled by the GOP. They have been voting the Dems out of office since 2008 for a reason and part of that reason is Obamacare. The refusal of liberal Intellectuals and of academic economists in particular to accept these facts implies a disconnect with reality equal to any right wing fantasy.
2
@kbaa
In other words they chose the politicians who voted to deny them healthcare. Let them live with the choice.
3
I just don't know why Obama didn't go all out, no one agreed with him anyway.....sure wish it would of happened. I work in healthcare and the issues are out of control.
1
President Obama was so despised that if he offered nearly free health care to these folks they would turn it down. He did and they did. Dysfunction of the highest order.
2
Worse, the people of Tennessee do not know that their Governor and Legislature are refusing to take the Federal monies they need for health care. Ignorance has a price.
1
I have no sympathy for these people. Republicans control Washington and the local government in these states. They have no one to blame but themselves.
5
This is a tragic state of affairs. In his book, Dying of Whiteness, Jonathan M. Metzl chronicles precisely this phenomenon of rural whites who are often in desperate need of health care but who are perfectly willing to vote for politicians who promise they won't expand Medicaid. Why? Because these voters believe such expansions will benefit black people, Mexicans, and welfare queens among others. They are perfectly willing to forego medical attention if it means fulfilling some sort of ideological goal. Until we counter the ideology of cruelty, we will never reach these people. I'd like to believe that they've made their own bed, but that would be surrendering to the politics of cruelty. I want to care but that qualifies me as a much-hated "liberal." Human decency is no longer a value in this country.
5
I love the smell of schadenfreude in the morning. If there is one thing that brings me joy during this miserable political administration, it's knowing that the people who keep voting the GOP into office are suffering.
3
Another outstanding article! Thank you, Dr. Krugman!
2
The mean-spirited evilness seems to infect more and more of our country now. And it is not government. It is the personal creed of conservative politicians.
4
As long as red-staters keep voting for Republicans who keep telling them anything provided by the government is bad -- be it health care, a decent education or a social safety net for those in need -- this sorry state of affairs will continue. A tax graph interestingly labeled "Red State Socialism" says it all. Of 32 states which receive more federal tax dollars than they contribute, 27 are Republican. And of the 18 states which contribute more than they receive, 14 are Democratic.
http://democraticactionteam.org/redstatesocialism/
3
This report reminds me of famine. Famine, they say, is rarely the result of environmental factors alone, it is the result of politics. It sounds like we have a medical famine in our own country. And we thought we were first-world! Next, we will learn that catastrophes such as "widow-makers" and massive strokes are killing people who could not see a doctor because they couldn't afford the gas to drive to the nearest clinic. Where is John Steinbeck when you need him?
I love it!! This people are punishing themselves for poor choices. Keep voting GOP!
3
If people want to vote against their own self-interest and that of their friends, families and neighbors, so be it...they are the ones who suffer...
I'm personally tiring of their "fake suffering being pushed in our faces...we want them to have insurance and frankly, it's the bluest states like NY, Massachusetts and California that will pay for it, with their excess contributions to the federal treasury.
And spare me the "less government in our lives" story line and attempts at controlling our personal/social issues with their no abortion, no gay rights, no immigrants and no minority stances.
If they think this is what makes America great, let them have it...but only in their localized and rural lands of pretend.
They want to know why people don't respect them? This is just part of it.
3
This makes me think of the of the invisible fence shock collar for Mother’s dog to keep him in the yard. The little dog loves the collar. He whines when we take it off and wags his tail when we put it back on.
I wonder if the Republicans feel as bad about their tactics as I feel about that collar.
1
STATES THAT HAVE REFUSED TO EXPAND MEDICAID Are inflicting needless suffering on their residents. Politicians who support such cynical, sinister, regressive policies are like mother rats who eat their own babies. Still, those residents tend to blame the people in Washington for cutting their programs. Clearly they misunderstand that they would have qualified for Medicaid at no cost to them or their states. Rural medical facilities would not have closed and providers would have remained in the community, expanding their services. How is it that year after year, the GOPpers manage to mislead their constituents? They show little if any capacity for empathy or remorse. The GOPper politicians are guilty of dereliction of duty to their constituents. The nasty truth is that they would rather refuse a healthcare plan initiated by Barack Obama, the first black president of the US, than to attend to the medical needs of their constituents. So the healthcare plan of a black man means that rural citizens get thrown under the bus? That's how it looks to me! The whole premise is twisted. That rejecting Obama's successful healthcare plan is somehow better for their states? The negligence and hypocrisy are as overwhelming as they are destructive of the health of the constituents deprived of adequate medical care due to political and ideology at their worst.
1
Disgust is one of those universal things that even babies exhibit (others are fear, anger, happiness, etc.). The common reaction to disgust is to retreat into a kind of symbolic purity, where one’s own self and soul can be protected from that which is disgusting.
All religions encapsulate this reaction, some, like Christianity, tend to see the external world itself as disgusting, placing enormous relevance on self-reliance and independence. Republicans have long relied on this insight to manipulate voters, with claims that programs intended to alleviate pain and problems are simply disgusting. Medicaid becomes, not a solution to problems, but a threat to symbolic purity—a threat to independence and self-reliance.
The psychology of disgust is as much at the core of contemporary politics as the practical problem-solving that is sometimes called policy. And the Republicans are masters at it. They even find their own supporters disgusting.
And what does it say about the ineffectiveness of the Democratic Party in Tennessee ?
If Al Gore had carried the state, his very own, he would have defeated Bush.
Pelosi refuses to start an impeachment inquiry and Trump only gets stronger.
At what point do we say that the Democrats are as feckless as the Republicans are cruel?
1
It is easy, the people there believe all their problems are caused by 'those people', that they don't have health care because 'liberals' make sure people on welfare in the big cities have gold plated medical care, or are caused by liberal elites who insist on paying for sex change operations and that is what makes insurance non affordable (and I am not kidding, I have heard that). They are told by Fox News that if the Democrats would just allow competition in health care, if it was allowed to operate like Walmart, they would have cheap health care where they could pay 10 bucks and get full coverage. As long as the GOP can do that, blame 'liberals', these people will sit and suffer.
Put it this way, when asked red state/rural voters said they were looking for affordable care that covered what they needed and didn't have large deductibles and out of pocket costs, Trump promised them health care so brilliant they wouldn't believe it....yet Red state voters seem to be all fired up about abortion and make nary a peep about Trump's failure to do anything.
1
Let's talk about the other "self-inflicted medical misery" in rural America (since I avoid cities, I can't speak about them).
I've happily lived in small, hick towns my entire life. As much as I appreciate my wonderful neighbors, the fact is that many (most?) of them lead lifestyles that seem to be specifically designed to make them medical disasters.
They are obese, have terrible diets, smoke tobacco and meth, drink too much alcohol, soda pop is their beverage of choice, they get little to no exercise other than walking to their pickup/atv/snowmobile, they take multiple, often non-compatible meds to mask the symptoms of their poor life decisions, yada, yada…
I repeat, these are wonderful folks and I love 'em to pieces, but when I observe my neighbors, it's no surprise to me that our healthcare system costs gazillions of dollars yet compares poorly to other "advanced" countries.
2
I read the original article in the Post, and the plight of these people is indeed heartbreaking, as it is in all the articles that speak of the growing crisis in rural healthcare. Yet none of the reporters in this article ask these people about their politics or whether they vote. Perhaps that should be part of it - bringing sympathy and awareness to their plight, but also trying to understand if they have any insight at all into how their vote could influence that plight.
It reminds me of the farmers who voted for Trump, and are now being crushed by his tariffs. So many of them say in these articles that they know the president will come through for them once he realizes how desperate things are. I really don't know how you can get through to people that his party has had control of the entire legislative branch for two entire years, and still has control of the Senate. If he hasn't done anything by now, how can you honestly think he will?
And I truly agree with Alan J. Shaw - the only way for the Democrats to win is to unite and run on Reagan's old platform - Are you better off now than you were 4 years ago? And follow it up with specific questions
Do you have health insurance and access to a good doctor?
Does your job feel secure?
Do you worry about being able to retire?
Do you worry about your children's future?
Ask questions that will hit to the heart of what affects people, and give them a plan. Maybe then they'll listen.
3
The GOP epitomizes "Kiss Up/Kick Down" in their ideology, their policy, and their economics. Their health care plan is "if you can't afford it, don't get sick." Sadly, it's true.
The Democrats needs to hammer home health care reform (true reform, not insurance industry-brokered faux reform), because the GOP cannot and will not be able to go there.
Until rural voters wake up, they're going to keep getting kicked down by the GOP politicians they are propping up.
2
Certainly it is true, as Dr. K. points out, that Republicans have done great damage to our healthcare system by blocking their states from medicare expansion. Kentucky is as sad case. That state's expansion was one of the best, but its beneficiaries voted their Democratic governor out of office. But the turmoil in the health care system, the lack of transparency in prices, and a host of other issues were things that responsible parties could have prevented or fixed if, instead of doing everything they could to poison anything that President Obama did, they were instead Republican, Party of Fox, and did everything they could to demolish the ACA from the inside out. A smug and self-satisfied Marco Rubio comes to mind. The utterly nihilistic Mitch McConnell, of course, also comes to mind. With the tremendous damage the Republican party has done to the health care system, you'd think that people would be (not literally) dying to get rid of them. They're not. It just shows how much a northeastern liberal doesn't get the country he grew up in.
3
The photo shows a group of people who appear to need basic medical assistance. They are on their feet and appear not to need a costly organ transplant. Just assistance that a reasonable universal health care clinic could provide.
Medicaid is a targeted need-based program, and its low payout pushes doctors and hospitals to ignore people who just require basic medical treatment. Stopping the flu before it goes into pneumonia is usually just handing out a z-pack.
A universal medical treatment system, similar to medicare for old people with chronic health issues, would provide an acceptable payout scheme and most likely could replace the popup clinic with a permanent clinic open to everyone including those with good insurance.
4
Medicare, or Medicaid for all would focus our attention on the extortionary and wasteful practices of the medical industrial complex, especially Big Pharma. As it stands the system is too complex. It is tailor made for abuse. It's why pickpockets like crowds.
4
“While rural Americans often tell reporters that they feel neglected and ignored by big-city coastal elites, the people preventing them from getting health care aren’t in New York or D.C., they’re in their own state capitals.”
Rural Americans pride themselves on their rugged individualism. They can take care of themselves. They don’t need government or anybody else to look out after them. Or, at least that is what they tell us.
So, when coastal elites adopt this attitude for themselves and act on their economics interests, e.g. globalization, and ignore the impact on Red Staters, why do those rural, individualistic folk complain? The elites are playing by their rules.
And, as for the Republican state legislatures, maybe they are guilty not of mean spiritedness. Perhaps they are simply taking their constituents at their word.
1
I suggest that Republican state legislatures should be looking out for all their constituents, not just the ‘rugged individualists.’ As for the latter, no one is forced to participate in Medicaid; the rugged individualists would be perfectly free to follow their principles.
1
Mr. Krugman, this was a great editorial. However, you forgot a major reason why Republican politicians shunned the ACA because the President who signed it was Black! Please, let's be honest about that fact. There was an underlying racial issue here, hence the Republicans branded the name Obamacare. That was enough for red state GOP voters to vote NO for the ACA, even if it impacted their health.
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Even ACA is too expensive for most middle class families as deductibles and out-of-pocket limits are too high. PK forgot to mention that the free clinic next destination was Kentucky. We need Medicare for all and guarantee health care as a right.
3
I think the contempt for President Obama is why these states refused to expand Medicaid. They didn't want to see the Affordable Care Act work. The article about the desperately ill rural residents showing up at the pop up clinics (Washington Post) was shocking. It is all the more terrible that this is happening in our country today.
1
Sadly, many folks in rural America are addicted to voting against their own best interests. Or, they don’t vote at all.
2
Even more rarely mentioned is the fact that even when one is fortunate enough to have full coverage, healthcare doesn't provide good health. MDs receive scant minutes on nutrition. Even if they did, they get 15-minutes at most to speak to patients. And their favorite remedies are pills as opposed to adding exercise and moderating caloric intake. I write it as "caloric intake" because most food means only that to most people, as evidenced by what they eat.
Most foods found in supermarkets are covered and saturated with poison (pesticides, plastics and GMOs). They contain additives that are known health risks and worse.
We need so much more than insurance coverage. We need the whole system overhauled. The system isn't broken. It's basic design and implementation is flawed.
I am certain the Republicans will only make matters far worse. And many Democrat candidates will do a little better. I want a Democrat who will actually make healthcare better, which means making hard choices and BIG changes in how America thinks about health and healthcare. I think it means more laws, not less. More laws that force corporations onto the path of good health for ALL citizens.
4
its not just the government that chose to deprive people of health care in TN, its the majority of people there themselves that voted for such a government, presumably because they valued putting down gays, immigrants, minorities, forcing women to bear unwanted children, and/or unlimited rights for carrying weapons was more important than their health care. Perhaps its cosmic justice that they got what they voted for.
2
Who would choose to live in a rural area these days? Unemployment is high, resources are low, drug abuse and disability are at higher rates.
Often these areas are home to an aging population. It's not so much that people choose to move to these areas but that those who stay have roots there. The communities are collapsing around them. And why? Though it is complicated the answer is the same as that for why many African-American children grow up in poverty. We--as a society--do not care about these populations.
Rural America is home to those who made the nation great in the last century. They grew the food, mined the ore, and fought in wars. Though fewer in number than our urban neighbors, they are citizens and should have our support and an equitable share of resources. I'm not sure if either party truly cares, but I know that Republicans do a better job of pandering to these folks. It would be nice if someone actually provided undeniable leadership on these issues so that rural America could survive and its people could have the care they need.
2
Bear in mind the Democratic Party gave up on rural Kentucky after the Al Gore defeat. This means zero Party dollars spent in four of six House Districts last year. The price of this neglect is that Democrats have virtually no voice in Kentucky politics, and it partially explains why Democrats were *shocked* by Trump's victory. They hadn't been part of the conversation for 16 years, they had no idea how rural Kentucky felt. Perhaps you remember that HRC barely won the 2016 Kentucky primary - progressive Bernie Sanders won my District, the 2nd.
National stage Democrats don't visit rural Kentucky. They come to Louisville or Lexington, maybe cross the bridge from Cincinnati into Covington. I haven't seen many Times pundits in Kentucky either.
So consider this an invitation. Come to Kentucky's 2nd District, I'll happily take you around so you can see firsthand the people the DCCC chooses to ignore. We will both learn something I am sure. And for what it's worth, I will be asking you for a contribution - I was the Democratic nominee for Congress in the 2nd and I am planning on running again. The future of the Nation is at stake, not in California or New York, but in rural America. It's time for you to get reacquainted.
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@Hank Linderman
No--just no. The voters in rural KY made their choices--stop blaming dem politicians or those of us who live on the coast. The future is certainly not in sick and population-losing rural America. This is harsh but true---what happens in CA will always affect the country as a whole more than what happens in rural KY.
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Red state health care and red state farm communities. Why should we care about either when their problems are their own and they confirm their wish to have the problems every election?
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@Als I hope the answer to your question is obvious - its that we are all ultimately in the same boat. Democrats gave up on rural Kentucky almost 20 years ago, no wonder they don't pay much attention to Times op/eds or comments from the coasts. You have to be there to be heard.
I believe the battle for the soul of the country is no longer in California or New York, it is in places like Kentucky's 2nd District. I was the Democratic nominee there last year and I am planning on running again. Come out for a visit - and be part of finding a way forward for our Nation and our world.
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@Hank Linderman Thank you for your service in the military and in your district! I will be contributing via your website later this week. GO HANK!
@Hank Linderman
"You have to be there to be heard"
Hank,
Why should "Democrats" be the problem in your district - quit blaming "others" - your problem is the local voters and they get what they vote for.
1
It's truly remarkable lower income American's in particular would support a political party so obviously dedicated to increasing the misery and hopelessness in their daily lives.
The Trump administration has been spending most of it's time trying to destroy healthcare for tens of millions, lowering consumer protections across a broad spectrum of American life and giving massive tax breaks to the wealthy, resulting in mammoth budget deficits which will eventually be paid for by middle and lower class voters.
Yet Republican's are hero's to many of their victims.
That's salesmanship!!!
2
And in 2018, in a statewide election, the good folks in Tennessee decided that Marsha Blackburn was who they needed as a U.S. Senator.
3
Continued violence in our cities. Continuing neglect of our public school systems. And now, hard to obtain healthcare in our rural communities. All this as the United States slides ever more closer to Third World status in “Health, Education, and Welfare.”
5
This is all part of the GOP plan to blame all our ills on immigrants and the poor. These are exactly the people who need these services.
Cruelty is the point of the Trump administration.
Trump and his supporters bond by rejoicing in the suffering of those they hate and fear.
3
Paul, how do you convince voters who equate the mere word Republican with their concept of 'conservative' — god-loving, financially careful, honest, family oriented — that their party has gone from the ideals of Abraham Lincoln to the gimme game of the Donald Trump machine?
You'd have to open a lot of minds that were nailed shut decades ago by carefully orchestrated political propaganda and shenanigans.
4
@KJ You have to be there on the ground, rural America doesn't care one bit about the NYT firing op/ed missiles from Manhattan. I have invited Professor Krugman to come to Kentucky's 2nd District to see firsthand what he is writing about. I was the Democratic nominee in 2018 and I am planning on running again. This is where the fight for the heart and soul of the Nation will be fought, not in California.
I spoke with many Republicans during my run, more than half I spoke with agreed to vote for me, but it is tough to get to 240,000 voters in person without lots of money.
There is a way forward, but it means getting involved.
3
The superpower of the Republican party is its ability to get supporters to vote against their own self interest. Its response to the ACA is only an example and it happens time and time again. And some of these are not selfless acts, some are acts of spite. I am simply dumbfounded by these behaviors.
3
You may be too nice to lay out the tax argument all the way to the ground. Medicaid costs money, which comes from taxes. Even if the cost benefit balance favors the people in rural Tennessee, taxes are bad and - this is the not nice part - especially if they benefit Those People (most of whom, in your picture, are white). Without insurance, what will happen: trips to ERs - oh, they are closing - or go home and die prematurely, relying on God knows - that is another rant - what. The ultimate test of this scenario is being tested, perhaps, along the border between Texas and Mexico.
1
The self-inflicted misery maybe largely inherited from historical curse of racial hatred in US. But similar political pivot has taken place in Great Britain as well since Thatcher revolution. At about the same time a similar pivot was also initiated by Reagan administration . Now this anti-social phenomena is spreading in the large parts of Europe.
I am wondering what drives this antisocial trend. Is it because the wealthy has inherently strong political power? Is it because weakening of Christian social value?
I wonder why?
Recall the strident declaration from a sick, uninsured TN man, unable to pay for his medical care and prescription drugs. When pointed out to him that if he just lived one State over he would be covered, he said: "I would rather die than go on Obamacare".
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@Lrobby99 Yikes. Rugged individualist, indeed. Sad.
1
How did we arrive at this particular point in time? People believed the sound byte or filtered information, to arrive at space that they are unable to know or understand how the punitive policies actually harm them, their families, and friends.
They are constantly bombarded with everything is the fault of those evil "Democrats", this along with the constant lies and only "I" can protect you. Information and News are fake, we have indeed arrived at the end game. The unwashed masses, simply pawns, obeying the will of their masters.
I'm concerned about using patient photos in this article. You don't want to be embarrassing people who show up at these clinics. It's their last line of healthcare defense.
Great editorial....you mention next door neighbor KY with Medicaid expansion---true, but KY is now experimenting with a work requirement which will surely impact coverage. In addition, recent analysis (Geiger Gibson/RHCN Community Health Foundation Research Collaborative policy brief #59) of seven states where work requirements are approved (AZ, IN,OH,MI,AR,KY NH) also shows that these work requirements will, in the first year, generate almost $125 million revenue losses to health centers that serve the most underserved communities. This means jobs lost to the community and less access to care for the poor and underserved.
1
As I mentioned before and repeat again, you Americans should look North to Canada and its UNIVERSAL healthcare. Not only it takes care of all people regardless of income but it cost about half per person than the American one.
3
I rarely defend our health care industrial complex (it’s no integrated business model or delivery “system”) but the fact is business flees risky, unpredictable markets. Which is what you have when red-state politics actively fight national policies, and funding, that seeks to enlarge and stabilize, or encourage, expansion and innovation in health care. And yes, the blame ultimately falls to voters too clueless to vote out Republicans.
What has happened to the US, the wealthiest country in the world, in its care for its citizenry and for democracy? Both parties have participated in a gradual whittling-away of benefits and priorities that every people deserves. Since 1970 the income of the top 1% in this country has gone up 250% while that of the majority has declined.
One of the principal criteria for a nation to call itself a democracy is the welfare of ALL of its citizenry.
The coming presidential election will be the most important since 1932. Choose wisely if you don't wish to see the interests of the people decline in all things, including freedom of speech and association as well as economically.
This will continue as long as people vote Republican and the Republican party stays as it is. I guess the former are free to vote as they wish and the latter is free to be cynical.
I wonder how many of these people who would benefit from Medicaid expansion do not support it because they are delusional about small government and misunderstand suffering as resilience.
1
Remember that the ACA's original mandate that states expand Medicaid to serve all poor adults was thrown out by a Republican Supreme Court. So maybe in their distrust of Ivy League elites, rural Republicans aren't entirely wrong.
People need health care, not health insurance, there is a big difference. Subsidized health insurance drives up the costs for everyone. My "insured"prescription was $280 with a 50% co-pay.
Then I found out the same prescription was $20 OTC.
Think about it! And comment how I'm wrong.
4
So many questions...
What would it take for states like Tennessee to get Obamacare? In a situation where they are magenta or purple, how much would voting have to shift to deliver the relevant politicians? Do you need to flip both the legislature and the governor?
What does the process of starting a rural hospital look like? Who would step in to do so? Could it be grassroots, or is it more likely to be run by one of the big players? Will doctors have to earn less than their nurses to make it work? Is there still a building in good enough repair to house it in many areas? Would you have to build one from scratch? Does telemedicine do much to enable different models of care, or is a full-scale hospital required for it to be operationally viable? How many excess deaths occur every year that a hospital is not present in a community?
This passage says it all, " While rural Americans often tell reporters that they feel neglected and ignored by big-city coastal elites, the people preventing them from getting health care aren’t in New York or D.C., they’re in their own state capitals..."
Democrats try to pass programs to help people, but the rural people who need help, and can be helped, keep voting for the real culprits - Republicans.
3
Where there is an absence of education in civics and critical thinking, when people aren't curious enough to learn about life in other countries, they leave themselves open to manipulation. The line from voting for Republicans to losing their health insurance? From point A to point B! At some point they must be responsible for opening their eyes and educating themselves. Library cards are free.
3
When I read that article on the Post about the third-worldly conditions in so many red states, I had to ask my, how many MAGEs were at that clinic for treatment?
I'm wagering a lot.
4
My elderly parents in rural Kansas, which did not expand Medicaid, insured by Medicare had to move away when the only hospital in their county recently closed. The hospital closed not because there were not enough patients, but because they did not have enough patients with insurance. Hospitals, clinics and doctors cannot operate unless their patients have insurance. This out migration from rural areas caused by lack of hospitals and clinics is devastating the rural economies. After all why would anyone with health insurance choose to live in an area with little or no hospital, clinic or medical facilities. Not expanding Medicaid is killing rural economies, not just the remaining few people that live there.
3
One of the issues that I see with health “insurance” is that it’s used for all healthcare - even routine stuff - in a way that no other insurance is. So of course, it’s unsustainable.
Imagine if we used our auto insurance every time we needed a routine oil change or a new set of tires or to fix a little scratch on the fender.... The cost of auto insurance would become similarly astronomical.
I think routine health care ( I.e. yearly physical, basic yearly bloodwork, needing a few stitches after a cut) should always be out-of-pocket and should be affordable. Health insurance kicks in - like auto insurance does - when something unexpected and terrible occurs and then it covers everything.
1
@GBR It's not that simple. Routine healthcare may be that basic for you, today. What about the tens of millions of people with unexpected and terrible chronic conditions? Also, when preventative healthcare isn't covered, as it is in every civilized country, the result is the sick population America has today.
1
@Kathy
No it's not that simple, but it's also disingenuous in the extreme to conflate 'health insurance' with 'health care'. And the ACA is far from a panacea.
Ask anyone in the 'medicare gap' (late fifties - early sixties) and (barely) over the ACA 'income cliff'. The know it alls say, 'oh, just get a job with insurance benefits'. But we've spent thirty years building up a modestly successful small business and are not giving it up now. What we did give up was our health 'insurance', because we couldn't afford $39,000 / year in premiums (plus a $13,000 deductible) for the most 'affordable' Bronze ACA plan available in our admittedly expensive state.
I can see, for statistical purposes, comparing health care outcomes for two adjoining states such as Kentucky and Tennessee. However, don't forget, after a successful roll out of Medicaid expansion in Kentucky under a Democratic governor, Kentuckians turned around and elected a Republican who actually campaigned on taking the expansion away. A classic example of voting against your own interests.
6
Krugman seems to be saying that every local politician should ask for federal government aid because it doesn't cost them anything. Only honest local politicians realize that if everybody did that, nobody would be better off.
1
@Blair A Miller Actually, that's not what he's saying. And even if it were, since medical revenues under the ACA are produced on a progressive basis, it's not true either.
3
"So if rural America is suffering, a large part of the explanation is gratuitous political cruelty."
This is the perfect articulation of what is going on. What is so aggravating is that this comes from the very politicians who claim to be pro life.
6
@Paul in NJ They've shown their true colors for years now. When will people move beyond being aggravated, understand they're being lied to, and stop rewarding the liars with their votes?
1
@Paul in NJ They only care about you if still in the womb. Once out, their attitude is hurry up and die.
1
This is a good overview of a neglected aspect of reality. As a nurse for over a third of a century serving over a dozen Indiana counties, I would like to add emphasis to one aspect of this editorial. Specifically, the rural areas of states that have limited Medicare expansion don't just lack health insurance, they lack doctors and nurses and hospitals and clinics. Before Obamacare passed, a lot of rural hospitals were within five to eight years of going out of business, The ACA even in its reduced form has kept many such facilities afloat.
8
You mean expansion of “Medicaid,” not Medicare.
Proliferation of privately-owned, for-profit medical facilities seems to have driven community hospitals into ruin. When a local hospital stops making profits, the corporation shuts it down. It's not personal, just business. Add in conservative opposition to public healthcare and you have entire regions of the country slowly committing suicide.
7
Great article, these people deserve medical care that can depend on. I am looking forward to voting in 2020 on behalf of the entire country.
5
Your comparison of Tennessee to Kentucky after ACA passage is accurate only for that time period. Unfortunately, after Kentuckians voted in our current governor, Mr. Bevin, he gutted the very successful program. We no longer have the robust ACA that we began with because Mr. Bevin claims KY can't afford it. Such short-sightedness and mean spirit toward poor Kentuckians is that pattern you drive home here. It's maddening that the very people who needed these programs voted this man in. Hopefully we can vote him out this Fall.
13
@SGraves I remember after Bevin was elected, a woman who voted for Bevin was asked: 'Why did you vote for him when he said during his campaign he was going to reverse the Medicaid expansion?' She replied: "I know, but I didn't think he'd actually do it"
Kind like the 2016 era joke: The woman, sobbing, said: 'Yes I voted for the Leopards Who Eat People's Faces Party--but I didn't think they'd eat MY face!"
3
The other factor in the dearth of healthcare providers in rural areas is the invisible hand of the Free Market. The Free Market goes where the demand (i.e. revenue) and profits are. It generally makes no financial sense for a hospital or physician to locate in a rural area with limited demand and poor and limited sources of payment.
The inexorable conservative beliefs of "keeping the government out of my healthcare" combined with relatively unfettered "Free Market Capitalism" have yielded a predictable outcome. In other words, it's Obamacare's fault.
3
@JS
Did you understand the opinion piece?
I lived (for a few years) in a rural area and the fear of anything different and Government Agencies Programs was palpable. I found that shocking as I grew up in urban and suburban areas where getting help was not considered a weakness but the smart thing to do.
At one point when living in the rural area I lost my job and had to go on Unemployment I religiously looked for work I was on my last week of Unemployment Benefits and realized I needed help. So I went to Welfare to get help as I had a family and a house. I felt that I had never been unemployed since I graduated School there should be no major problem. During the interview in the Welfare Office I was asked if I had ever had a VD if I was sure I had a family and could we move in with my parents. I was very insulated but completed the paperwork and left feeling like I was a piece of trash. The next day I was doing follow up calls to the places I had applied for to get employment and found I was hired to start the next week at a decent salary.
I returned to the Welfare Office told off the person who interviewed me and retracted my application.
Not everyone has luck such as I did and when my better half became ill we moved back to an urban area so medical care was easily available.
Since then I have never left an Urban area.
Just a little thought from an old white man.
3
@Alecfinn
I agree with you. I was sarcastically stating that somehow Obamacare will be blamed.
The discussion has to be re-framed. Government is not composed of a bunch of bureaucrats in Washington or elsewhere. Government is simply a collective term for citizens banding together for the collective good. The adage, 'It takes a village to raise a child' is apt. Just substitute government for village. Same thing. Unfortunately, working against this truth, are some employed in government who are only interested in helping themselves, not others. Those individuals should be shooed out the door.
7
@Jeff P
And when they band together and gain political power they help only themselves and those they believe to be in their camp. Everyone else is less than they are and they tell scary stories to those who they believe are less than themselves but support them anyway.
I find that strange.
2
Karl Marx wrote that Capitalism cannot function without an industrial reserve army, a portion of the population so desperate and demoralized that they will take any job at any wage. Withholding health care from this population is just another tool to engender desperation and achieve this end.
15
Maybe it would work out better for rural America if Republicans in Congress were required to get all their own and their family's medical care in rural states controlled by Republicans? Oh, they have special medical plans where they don't to worry about such mundane matters???
4
There is one reason to promote single payer healthcare that I rarely see mentioned. It is unusual for the truth to be simple enough to be easily stated, to be something that can be put in a stump speech and be both understood and accurate.
If we had only one source of healthcare, we would all know what we it covered. The cruelty of the right depends, as Mr. Krugman points out, on their being able to blow smoke and confuse people about reality. No one really knows what their health insurance covers and doesn't cover. If we had single payer coverage we could talk seriously about whether that coverage was sufficient. As it is, Republicans can suggest that catastrophic coverage is cheaper than comprehensive coverage, as though there were any meaningful grounds for comparison. Of course it's cheaper. A bicycle is cheaper than a car, but other than being forms of transportation they serve entirely different purposes.
9
@Michael Dorsey
When the ACA was being discussed I clearly remember the GOP telling folk there would be death committees that would take medical care from families and would decide who would die.
I was amazed by the folk who believed that as well as the folk who believed that they were to be made to pay for anyone else's healthcare if the ACA passed. Usually the folk who believed that were making a decent wage and young.
The longer you live the more that happens and much is very challenging physically and financially.
2
The lack of medical resources in many rural areas boils down to control, those in power want to control the situation and control it for many different reasons. Some want to maintain dire situations to keep people from being able to focus on options that would reverse these dire situations. Education is one of the options, probably the best, to make it possible for people in dire situations to solve their own problems. Medicare for all's greatest achievement is it's ability to advance preventative medicine. Education for all could have the same benefit. There are too many places (states) where providing education is on the same level as providing health care, as little as possible. Then there is the Religious control, which goes back to the middle ages. The Church decides what education is healthy and if there health problem then it will be addressed by miracles. I find it amazing that in the 21st century we still have enclaves with the power to enslave the people to such dogma.
7
The reason things are like this is because of the governmental laws and regulations which promoted and continues to promote aquistions and mergers creating large “healthcare” systems. This consolidation is about money not medical care.
4
Yes, the WaPo article was heart-breaking to read and Mr. Krugman provides a cogent analysis of the situation. However I suspect the vast majority of the rural population in the 14 states that have rejected the Medicaid expansion under the ACA would never read either of these articles because the WaPo and NYT are part of the hated Main Stream Media that promotes Fake News.
The message about the need to expand Medicaid at the state level needs to be carried by the local rural news media. All state office Democratic candidates need to make it a central part of their campaign. The message needs to reach those voters most affected so they hopefully can make more informed decisions when they vote for their State representatives.
13
@Bob What local/rural news media? Small town media are disappearing along with health care services.
@Bob
Unfortunately many people in the south can't read, and if they can they just don't read.
Obscurantists?
@Aging Hippie I agree that for print media that is certainly the case as 171 counties have no local paper (https://www.dailyyonder.com/one-fifth-u-s-newspapers-close-last-14-years/2018/10/22/28144/). However the Public Broadcasting Network for radio and TV still covers 95% of the US population with over-the-air signals (https://www.cpb.org/aboutpb/rural).
"But why are Republican state-level politicians so determined to punish their own base?"
I suspect one reason is the strong association that Republicans have been able to make in the minds of many between Medicaid and "welfare."
Even in the bluest of blue states, I imagine most would consider Medicaid some form of welfare. Until they are looking at putting their parents in some sort of nursing or long-term care, where due to exorbitant costs Medicaid ends up payings the majority of the "average" person's costs.
8
I suspect you are absolutely correct on this point which has been made to me by numerous people. You would think that they personally are receiving a bill for another individual’s medicaid coverage. It is all part of the libertarian fraud that is being perpetrated by the Republican Party and especially by its billionaire funders. The truth is that just as no individual can build a Boing 737 or an electrical utility or the equipment needed on a modern farm, no individual as such can survive in our society. We need each other to get our basic subsistence of life. Medicaid, Medicare, social security are “social” insurance to protect individuals from the unknown chance events in life.
6
Donald Trump "loves the uneducated" and so do Republican governors. Under Paul Lepage, Maine residents suffered eight years of modern GOP policies that deprive needy people of access to healthcare, education, housing and nutrition. Even after a successful referendum vote to expand Medicaid, Lepage dragged his feet until his second term was up. Democrat Janet Mills expanded the program on Day 1 of her administration.
7
And Kentucky then elected a republican as governor who wants to to get rid of medicare and take them back to be equal to Tennessee. Eventually he will succeed and they will continue to vote republican.
7
Thank you Paul Krugman. This is the way to win the 2020 Presidential and Congressional elections. Not by attacking Trump, but pointing out the dereliction of the Republican party and its leaders, particularly McConnell.
928
@Alan J. Shaw
The great irony buried within the comments here is that all this self love and certainty about the evil of the "Republicans" is exactly what you'd read - just in reverse - if you went to a foxnews comments section espousing the evils of "Socialist Democrats". As a Registered Independent I can only shake my head, since this type of zero-sum, my-way-or-the-highway, I'm-right-and-you-are-wrong politics is exactly what we don't need and should guard against. Perhaps if both sides allowed - just for a moment - that the other side may be right about a few things we could make some actual progress that would be embraced by a majority.
16
@John
Okay, I'm game. What, exactly, is right about Tennessee (and 13 other states) from refusing to expand Medicaid?
102
I'm afraid this argument sounds hollow without at least one example of Fox getting it right. On THIS issue, at least, there's no conceivable way of arguing that Republicans are right to deny their constituents affordable health care. What would Tennessee's legislators say in rebuttal? They might point fingers at Obama's plan, and say that it would unbalance their state's budget. Well, 36 other states have solved that problem, including impecunious Kentucky. Or they might trot out the "creeping socialism" smear, to which the answer is "So what?" Or, like Donald Trump, they might claim that the problem doesn't exist, and that Krugman is peddling "false facts." Well, then, let's hear some true facts in rebuttal, and see whose facts hold up.
Not everything the President does is bad, sure - he DIDN'T use the downing of a U.S. drone as a pretext to start a war - but on the subject of health insurance (and on many other issues) he and his party's policies and actions are simply indefensible - except by lies and bluster - and, on THIS issue, at least, there is no "truth on both sides" claim possible. If @John thinks otherwise, let him cite evidence, not just play the victim card - "boo-hoo, nobody understands my point of view." This is what you say when no other defense is possible.
75
There are two kinds of people who are affected by the lack of health care described in this article. One is the group who don't know that their government has put them in this situation deliberately. The others are those who know this but are willing to pay a high personal price to promote a right wing ideology over all else. May they be happy in their choice.
628
@Stevenz
No, they should not be happy in their choice!
4
@Stevenz States denying Medicaid do it with the willingness and approval of their base. I live in Texas, another of the 14 non-Medicaid states, and on a regular basis I hear about the freeloaders, especially the druggies and minorities who want a free ride from the government, people who don't deserve it. The base does not want any of their tax money going to help out anyone with less than what they have. Then, when one of their own without insurance has a medical emergency, they put up a gofundme page on facebook to help out poor ol' whoever. The fund drive raises about $200 or $300, which may or may not pay a tenth of what the medical bill is. Sigh.
20
@Edwin Duncan
Where I live the focus is on the second amendment and abortion. They vote R and lack of health care goes with that. We had 8 yrs of LePage(R), no Medicaid expansion, closed hospitals etc
We also now have the highest food insecurity of any state from here to NC.
A Dem. Governor, Senate and House were elected in Nov.
We are hopeful.
18
People need to reflect on what it means not to have health care . If not for my employer health insurance I would either be miserable or dead. I have had two common procedures at the cost of over 300 k. Without the operations I probably would not be able to walk and would be at severe risk of stroke or heart attack. Maybe the purpose of the republican plans is to let anyone over 55 die but it seems to me that our wealth should be shared . People seem to think that the luck of great wealth, either inherited or earned in a system that supports, bestows a privilege that permits them to hold their heel to necks of those less fortunate . Level the playing field -- become a first world country give everyone health care !!
5
@Peter, $300K for two procedures is NOT sustainable. Why cost is never discussed is beyond me. My healthy teenage son's appendectomy 5 years ago cost over $35K. A similar procedure in Germany at the time was quoted at $1K.
Also not discussed is outcome. Here in CA we have had a robust implementation of the ACA. A visit to a hardware store in an adjacent mostly low-income community this weekend was eye-opening: the morbid obesity of over 50% of the shoppers was scary, the number in scooters shocking, people lighting up their cigarettes once outside was disheartening. There are lots of healthy people in even blue states like mine who wonder why we should pay for the treatment of unhealthy people with really bad habits and no inclination to change. I do so mind you, but I do question the sanity.
2
@Peter Republicans do not think wealth "should be shared." On the contrary, they believe that paying taxes is the same as "theft" and that if you didn't save enough money to pay for your health care procedures, well, that's on you. Maybe you shouldn't have spent so much money on lattes.
There's no doubt that rural and impoverished areas are sorely lacking in equal access to health insurance/ health care. However, this is but one piece of the barely-functioning system of "healthcare" in the US. Even people who have "healthcare" through their employers have seen their access to healthcare limited and blocked more and more over the last 5-10 years, no thanks to sky-high deductibles and employers shifting costs of premiums and insurance onto employees. When even people with insurance have to think twice about going to the doctor when they're sick, the entire system is screaming for a radical change.
508
@Tres Leches
So true. I don't know how people think they have health insurance when their deductibles are so high they can’t even use it. To me it looks like their insurance companies are just getting free huge amounts of money from them without having to reimburse any but catastrophic medical expenses.
57
@Concerned Citizen You can get policies with lower deductibles.
44
@Concerned Citizen A plan with a $9K deductible is cheap. A plan with a $1K deductible costs more, but saves when you need it most. It was always that way.
36
You can bet that the majority of those rural residents voted Republican. From what I have seen, it is those in those rural areas that believe the Democrats want make this a Socialist country, they equate Socialism with Communism. The see themselves as rugged individuals true Americans just like those who settled there in the first place.
For instance they do not like zoning laws there, it infringes on their right to use their property as the see fit. That many of them lined fur a free medical clinic does not mean they will reflect on their need for a health care program, they do not want to pay for others health care. Even in a rich state like California here, we have people just like them in some of out northern counties, Shasta County for instance.
Even if they have such low incomes they do not have to pay for government paid care, they treat it like welfare, and that is anathema to them. Take a look at their demographics, income, religious beliefs, educational level, and I think you can get a good idea as to why they vote against their own interests. You might think it is the HMOs that lobby against expanding Medicare there, but those people can not afford any of those plans, from my point of view it has to be the culture.
417
Agreed. They’re getting exactly what they voted for.
85
@Scott D:
but they didn't vote specifically for this and didn't expect it to have the effect on them and their families that it has had.
7
@David Underwood We can’t forget that Tennesseans also made a US Senator out of Marsha Blackburn, certainly the dimmest of all senators. So these people vote against their own interests, they shouldn’t be surprised that they get what they voted for.
86
I live in a rural state -- New Hampshire -- that is struggling mightily with health care costs and availability in remote areas despite participating in the expansion of Medicaid. The same problems exist in Vermont.
The problem is simple enough -- the ACA was based on a model fostering competition between hospitals and provider networks. But that could only work in mega-metros with large populations and high population densities.
In rural areas, the only option is consolidation, because economies of scale make medical care a natural monopoly in places with small populations and lower densities.
Vermont tried like heck to implement single-payer. But they couldn't make it work because the ACA was not designed to support a single-payer system.
5
The Tennessee economy is booming. Tennessee's population is growing more than twice as fast as Kentucky's. It's even growing at a faster rate than California and New York. Same thing with Texas. The decision not to expand Medicaid isn't about mean-spiritedness. It's about economics.
@Mark...hmmm. Resident of 5th largest economy in the world here. We have implemented the ACA and we have expanded Medical. So please explain your point about economics.
2
@Mark not sure where you come down on providing sick poor people with healthcare? sounds to me like your philosophy is let the devil take the hindmost. by the way, CA is not a model for what to do with a booming economy and those left out of the prosperity and TX is turning purple as people from booming/expensive CA move there and expect the government to provide services for the least among us.
@karen
My point is, if you split California into 2 states, you'll no longer be a resident of the 5th largest economy, but you're city's homelessness crisis will still be there.
When I was still working as a Surgeon, I had an outreach clinic at a small rural hospital twice a month. The picture at the top of the article reminds me of those days. A crowded waiting room, men with huge bellies, the fit looking health care provider. It can't show another part of the scene - the thick odor of tobacco smoke.
The people were mostly very appreciative and well mannered, but I eventually learned that they were in a different world from me. Advanced education was not important, or was not possible. They loved rural life and their trucks, but had a different kind of conservatism than I heard from some of my urban friends. Most of them did not like democrats, and viewed them as the minority race party. Many were very angry, and did not hesitate to express their opinions, often shocking. I was not surprised at all when Trump dominated those areas in 2016. It will be the same in 2020.
15
The rural uninsured vote in Republicans to represent them. They vote in Republicans to repeal Obama Care. They do this to themselves as they wave the flag and yell Make America Great Again.
9
I think that while Krugman's article does touch on valid points, it's not the whole story. There have been other, large-scale economic forces besides politics at work for decades in health care. Growing up the son of a physician in the Cleveland area, I remember my father visiting a large number of independent hospitals to make his rounds: Hillcrest, Huron Road, Highland View. Not all were for-profit. He had his own independent practice in a small office.
Fast forward 30 years and the hospital landscape in Cleveland and many other places looks very different. Now there are two behemoths: the Cleveland Clinic, and University Hospitals. Between them, they own practically all the hospitals, including the far-flung rural ones. In Southern Oregon where I now reside, the situation is similar: two large hospitals own everything, and if you're a physician your practice is part of one or the other.
The consolidation and profit motive of these mega-hospital corporations has decided that there is little profit to be made in rural areas. Rural communities have lost not only health care, but transportation in the form of planes and trains. Airlines have pulled out of small markets like Klamath Falls or Chico, CA. In aviation, we know what deregulation has produced--crowded seating, short connections, poor service, etc.
Short of a mandate that these large hospital corporations keep rural hospitals open, I don't see the trend changing.
13
What liberals do not get is that the Red States actively want and vote for their situation. It does not matter what they give up or how their families suffer, anything is preferable as long as it not a "liberal" solution. Sticking it to liberals is much more important than their own health. The proof is in their votes. And the conservative SCOTUS backs their decision.
15
Dr. Krugman of course is right. To add a point that he and other people have made explicitly elsewhere, Republican politicians tend to be beholden to donors who want to make it seem that government can never do anything good for people who aren't wealthy. If Medicaid were extended, well, ordinary people might get the wrong idea.
6
Re "But why are Republican state-level politicians so determined to punish their own base?" Wrong question. Should be, 'But why is the Republican base so determined not to punish their state-level Republican politicians?' Some folks, especially rural folks, keep voting for Republicans. That's the mystery.
9
Due to certain circumstances, a few yeas ago I received Medicaid In New York City. It was excellent. I was able to get preventative care (tests for free). I had nothing major during this time but a respiratory infection needing medication. Everyone should have this.
6
In addition to the expansion of Medicaid, these rural communities need to attract and keep doctors. Perhaps forgiveness of medical school loans for a two year commitment for service to a rural community?
5
The picture in the article is powerful. It is why we need voter registration outside of clinics. Or just maybe, the Democrats should hold campaign rallies outside of clinics. They can run on Medical Care, and what better place to do so?
Time to bring out the graph of the number of bankruptcies in the US before and after the Affordable Care Act (and please, call it that).
And please, win the war on language. These people aren't interested in white papers; they want their child or themselves to see somebody--soon-- for medical care.
4
After reading articles like this I am often left wondering if denying healthcare is part of a broader approach of intentionally limiting lifespan in order to reduce future liabilities in the form of social security, Medicare, and so forth.
6
@Brian O’Leary, as is increasing the age of eligibility for SS. It is purposeful.
2
At an earlier point in my life, I would have cared about these people. At this point, I don't.
89
@Jason Shapiro. Good heavens! Why would you want the world to read those words? What happened to you?
1
Hopefully that means you will vote for representatives who want to make health care available to everyone. Democrats want universal health care. Republicans want to say we can’t afford it while giving tax cuts to the rich. Please vote in your own best interest. It will be better for you and for all of us.
9
@Ambroisine 1.Check the entire list of comments, as I am hardly alone. 2. 73 people apparently agree with me.
1
Ah , yes. Republican “pro-lifers” are like this ...
7
There is a video on the NYT website, "I'm a Republican. I Never Thought I'd Fight for Medicaid." This is another iteration of the same issue, Republicans denying health insurance coverage to the most vulnerable populations. I watched the video, and North Carolina Senator Phil Berger (R) is LYING when he implies that the State would have to pay for the expansion of Medicaid, because the federal government would pay for 90 percent of it. He also trotted out that old trope, that people who want Medicaid are lazy, and giving them health insurance "disincentivizes" those people to work. He needs to be called out on his LIES by voters of North Carolina. Show Senator Berger that you are not the dummies he believes you to be!
BTW, J.K. Rowling was on public assistance when the first of the Harry Potter books was published; she is now richer than the Queen.
7
If Phil Berger‘s argument was accurate, the flourishing economies of Western Europe are based on pure laziness given the universal access to health care which would be fine. But unfortunately people have to and do work for their living, but what they don‘t have to is worrying about being ruined as soon there is a serious health issue. Nobody is missing those worries there ...
4
Earth to media. Without Medicaid moolah rural hosptials
will fold.
Refusal to take Medicaid Expansion Money means
death and iillness to millions.
4
Sadly the people who most need to hear (read) this will not because, well "FAKE NEWS!"
14
PUBLIC Health
PUBLIC Education
PUBLIC Infrastructure
Republicans dare not say
Democrats don't have a clue
1
All those rural "farmers", who probably gain most of their income through other work are hard-core, pull yourself up by your boot-straps, hardest worker in the world, CHRISTIAN, Republicans who don't want big gubmit SOCIALIZM in THEIR COUNTRY!!! But, when their farm was flooded, the government had to bail them out, and subsidize their insurance..because, well, that's different. See BIG GUBMIT REGULATIONS!!!, don't as which ones, are the reason that premiums were so high, so government had to subsidize that insurance. Oh, and they need healthcare, see BIG GUBMIT, caused the old clinic to close. So now, gubmit needs to use all that free money they have to reopen the clinic for me and the other 15 farmers that live within the 200 sq mi county we have. No, I haven't paid taxes in 10 years...taxes are theft! My family has been farming this land for 150 years, I was never given anything, and big gubmit isn't stealing from me!!!
6
This fine piece is entirely wasted on NYT readers. I'm pretty sure not a single person from Cleveland Tennessee (or any other rural town in Tennessee or any rural town anywhere) is going to read this piece of fake news written by "the enemy of the people".
What exactly is the GOP planning on doing when they kill off their constituency? Gerrymandering works wonders, but it can't raise the dead.
15
I wonder when any of us will ever learn that the GOP
doesn't care about us in any way....we're merely
canon fodder ....simple minded fools thinking that
they wouldn't lie to us...
5
Why aren't you on CNN and MSNBC? You deserve a larger audience!
2
@Rumpelstiltskin He should be on Fox and tell people who don't watch those news programs what they need to hear. And certainly what they will never hear on Faux News. You think anyone in these rural areas watch MSNBC and CNN? Seriously? Educate the ones who keep voting for people who fight against their interests.
1
@Rumpelstiltskin Perhaps FOX, CBS.ABC.NBC
& TELEMUNDO would be better choices...
1
First thing you know you’re expanding people’s healthcare, next thing you know you’re just embracing socialism entirely.
You’ve gotta watch out for anyone that’s trying to help to improve your quality of life. That’s how they get you hooked.
7
Republicons know that there are only two reasons for poverty: personal sloth or God’s will. They make policy accordingly.
7
Descriptions such as "the general meanspiritedness, the embrace of cruelty,[...] infecting the G.O.P." should go a long way in alleviating the unfortunate bi-partisanship that tugs incessantly on USA political shorthairs. We be good; they be bad. It's great to have the Evil Empire back! "But you know that it's true."
@Dan, there are just so many instances of ACTUAL cruelty, it's hard to believe you folks still don't have enough dots to connect. I know you consider all criticism of trump to be horrifying insult, but trump's actual demeaning insults and playground nicknames? He's the partisan in chief, don't you think?
Dan, what do you think of the Grim Reaper, the NOT Democrat who quashes even bipartisan legislation? What do you think of the one Republican who objected to bipartisan border funding for no reason that anyone could figure? TWICE? Are thoseNazis openly marching to trump rallies, with their actual swastikas, fascist hand signals, those Proud Boys Democratic voters? They have a simple pacifist message of "Jews will not replace us!", so bipartisan!
We could go on and on, but the point is, people like Dan are obviously unable to serve on a jury! A dumptruck load of evidence, the words of the defendant, the testimony of the entire town,his long history of crime, all fail to convince them that the prosecution isn't just as much at fault.
Seriously, that's how demented it is to claim that bothsides are chaining children in cages! And you folks wonder why grownups don't respect your 'fake news!' defense.
You get what you vote for.
Until Tennesseans learn that and start to put Democrats in office, this is what they get and no one to blame but themselves.
6
@Carl Zeitz
Exactly. They could vote them out. But they don't. So the question is why don't they?
we all have our own theories, but mine is that its based on religion, racism and meanness.
These are the same people who applaud a president for putting children in concentration camps and denying them basic humanity. I have little compassion for the people of Tennessee. Sorry but they voted for people who only care about power. Now live or die with it.
8
Yes, Paul, but more Tennesseans are going to Heaven.
3
Tragic and criminal. But unless you are a billionaire, fools who vote Republican get what’s coming to them.
4
.
Class War kills
.
http://www.pbs.org/newshour/making-sense/america-inequality-begins-womb/ -inequality-begins-in the womb/
.
“The accident of birth is the greatest source of inequality in America today.” :
.
Nobel Laureate James Heckman’s recent book, “Giving Kids a Fair Chance.”
.
“Children born into disadvantage are, by the time they start kindergarten, already at higher risk of dropping out of school, teen pregnancy, crime, and a lifetime of low-wage work.”
.
2
So how do you wake these people up?
3
@John You can't. Look at the repeated comments from "Concerned Citizen" in this thread. As best I can tell, she is most concerned about "sticking it" to liberals. Other than that, she really doesn't have a plan.
3
@Rena
I did work for a top guy in a large corporation once who had theory that the peasants as he called lower level employees liked being abused (he used more scatological terms) so perhaps he was right. His was a version of Stockholm syndrome.
The governors of any American State, which does not provide basic healthcare clinics to their own people should be hung from an oak tree until they expire.
I guess in Tennessee, they figure a suffering 'capitalist' is worth more than a well 'socialist.'
1
Here are the 14 cruel Christian Republican states that refuse to expand Medicaid.
Alabama
Florida
Georgia
Kansas
Mississippi
Missouri
North Carolina
Oklahoma
South Carolina
South Dakota
Tennessee
Texas
Wisconsin
Wyoming
They are all Bible Belt and 'heartland' states.... owned, operated and masses carefully duped by the heartless Republican Party.
(NOTE: Wisconsin has a Democratic Governor, but its corrupt, gerrymandered GOP legislature and its former Koch-puppet Governor Scott Walker refused to help poor Wisconsin citizens survive)
Grand Old Phonies claim that Medicaid expansion would be 'too expensive' for states even though the federal government pays for 90% to 100% of expanded Medicaid.
At the same time, these Grand Old Phonies voted for a party that dedicates its life to 0.1% welfare and blowing up state and federal debt to paint the toenails of the rich in the finest gold.
Other Republican states that do have Medicaid - such as Arkansas - for example, have passed work requirements for Medicaid recipients.
The result in Arkansas was kicking 17,000 poor people off of Medicaid with no positive impact in state employment.
The Arkansas result was pure right-wing Republican cruelty.
Republican voters are a bunch of religious sadomasochists, clueless cult members and cruel Christians who seem to enjoy the perennial Republican shaft.
"Sure my family and I may suffer and die from lack of basic healthcare...but at least I didn't vote for a Democrat"
Nice GOPeople
17
@Socrates
nailed it!
2
These are Marsha Blackburn’s people. They should call her office tomorrow.
4
They vote republican while they stand in line at the medical pop up clinic to refill their meds. These people would rather hold on to their fears than realize they are being used.
11
One important additional point is that by not covering the poor or those unable to work, premiums rose for everyone else just to cover those uninsured. That is why insurance rates escalated especially in those states where Medicaid was not expanded. The Federal government would have covered the gap and thus prevented the majority of premium increase. The Right has lied again by claiming is was the ACA that caused the rise. No it was primarily 3 right wing decisions, the first was eliminating the “public option”, the second was to not force everyone to participate and third to opt out of Medicaid expansion. Unfortunately, too many people don’t want the truth despite the damage that they are inflicting on themselves.
4
Look at the photo of the obviously ill young man by Spencer Platt. That is a picture that says you can be afflicted at any age, even young, and that everyone needs health care coverage.
1
You simply cannot repair multiple decades of damage done to education by Republican state governments. All of the southern tier states collectively lead the nation in poverty. They contain the highest rates of public assisted poor and uneducated residents. They lead the nation in rates of abortion and infant mortality. They have the highest rates of hospital closures in the nation. They have the poorest schools in this nation. They suffer from the highest rates of addictions, from alcoholism to opioids and all manner of illicit drugs. They have the highest unemployment rates in all of the nation. They are all Republican led states. Understanding what motivates people to vote for the destruction of their incomes and infrastructure is not hard to do. Take no education, mix in massive doses of religion, add a full measure of Republican, add two full cups of racism and one overflowing cup of hatred for everyone. Now you bake that in a Fox News oven and the outcome is a bunch of folks getting exactly what they wanted from life. Now they're serving that same recipe to their children. It's hard to feel sorry for them. Good luck rural America. You're gonna need it. You threw everything else away.
9
@wsinsel
You nailed it. Word.
1
Again, we learn that the Christianity of conservatives is false.
4
We need new thinking revolving the truth to stop the march of lies. Let's consider why the Republican voter base actually voted for their leaders against their own health and life. They were lied to. The voters were convinced the ACA was an attack on their freedom because of the mandatory enrollment mandate. The voters actually voted in several elections to take away their own health care. The dog whistle is when Congressional Republicans called the ACA, "Obamacare" in an obvious attempt to manipulate voters tribal instincts and underlying bigotry.
The suffering in Tennessee isn't self inflicted. The population was psychologically abused into voting against health care. Now they will know better. You can't blame our people, yeah, that's right, our fellow Americans, regardless of party, for being lied to and brainwashed through the TV's in their homes. The Congressional Republicans precipitated the Tennessee suffering and the States leaders carried on the dog whistling. Imagine that Senate Majority leader McConnell hails from neighboring Kentucky.
@SHAKINSPEAR The information available to all of us is also available to these people. And yes, you can blame them when, as your comment admits, one of the primary reasons that the Republicans are able to manipulate them is their "underlying bigotry."
Trump's base (for it is his party now) votes for these inhumane "health care policies". And they aren't "hoodwinked". They know exactly what they're doing. Because affordable health care, like affordable higher education and job retraining, is extremely far down on their list of priorities.
So what is their main priority? Punishing brown-skinned people. For this, Trump voters will gladly see their children die of illnesses because they cannot afford the treatment. Because they are the ultimate identity voters.
Trump voters wanted a president who told them that as whites, they were the "real Americans" and the rest of us should be content with second-class citizenship. This is their main interest. And they'll gladly trade away their homes, their jobs, and their children's very future to have this.
So I cannot find it within myself to have any empathy or compassion for any Trump voter who is going without health care in a Red state. The citizens of these states spoke, and they clearly wanted someone who would tell them that the KKK and neo-Nazis are some very fine people -- not that Medicaid could be expanded.
I do have compassion with anyone in Red state America who did not vote for Trump. You are in the minority in your jurisdiction, and unfortunately you must suffer because of your neighbors' bigotry.
But what columns like this cannot continue to do is say that the Republican party treats its base with disdain -- it has given its voters exactly what they asked for.
5
These rural republicans who elect republicans to govern them and then whine about not having health care are like the fellow who murders his parents and then asks for mercy from the court because he is an orphan.
Until they wake up they will suffer from self inflicted misery.
And coal isn't coming back either.
Vietnam Vet
5
Democrats running for office need to use the information in this column loudly and often.
1
keep hammering Paul, every little bit helps.
2
@will
Except he's preaching ot the choir, do you think for one minute that those living in the red states read the Times or watch MSNBC? Seriously?
They are ignorant in their beliefs and care more for their guns and hatred of all people who don't look like themselves, they continue to vote the same ineffectual repubs into office and wonder why they rank the lowest in education, jobs and healthcare. I feel very little sympathy for these people. They have themselves to blame.
Many of these voters are willing to sacrifice their healthcare in order to outlaw abortion and fight illegal immigrants.
2
Conservative compassion, that’s what makes America great.
1
This article describes GOP genocide by malign neglect. Remember Romney's fund-raising speech in Boca Raton where he claimed that 47% of Americans are "takers" (some 150 million people), who should somehow "vanish" at little or no cost? This is how it's done.
1
There is an easy, and well documented, answer for why these states and rural communities refuse to expand access to healthcare and “vote against their own interests.” Racism. Jonathan M. Metzl’s recent book, “Dying of Whiteness” is a comprehensive yet highly readable study of this phenomenon. One section looks at Kentucky and Tennessee, before and after the ACA. He quotes white Tennesseans, reliant on government assistance to survive with their myriad life-style induced health problems, as declaring they would rather die than have Medicare expansion in their state because then black and brown people might benefit. If you want to understand Trump voters, or still believe that (white) Americans cannot possibly be this racist, read this book.
4
The amazing thing is that the hard right has done such a great job of propaganda over the last 40 or 50 years that Krugman and most of the commenters here are still talking in terms of providing health insurance coverage instead of talking about providing actual health care.
The private insurance companies siphon hundreds of billions out of the system in obscene profits while providing no value whatsoever in return. They confound the system with their own independent rules that drive medical bookkeepers crazy and lead to hundreds of thousands of people doing essentially useless duplicative work. Then insurance companies make life miserable or unaffordable with deductibles, co-pays, exclusions, needless paperwork, and endless disputes. They even combine with medical providers and big pharma to drive up prices and premiums.
Private insurance is not part of the answer; private insurance is the problem. The US private insurance based system is harmful to your health.
7
Even more than cruelty, the worries of places like Tennessee come from religiousity. Not the religion that says there is a god that created the universe, the religion that says that government action is always bad, that the liberal/coastal elites hate you, and that guns are mankind best invention. Like religion, this is unfalsifiable and totally waterproof against any factual evidence. You could show them black on white that they are suffering from the non-extension of Medicaid, they would still claim it's not possible because Medicaid is government and government is bad. And then they will vote for the guy saying the same thing.
3
"Get the government out of my Medicare," the voter from South Carolina supposedly said a few years ago.
...and Marsha Blackburn (R) was recently elected to the US Senate...from TN.
We're in trouble here in the USA. Real trouble.
4
Slow on the uptake, if not stubborn.
1
It's too easy to pawn if off as racism, racism against whites. Why doesn't rural, white America not have health care? Is it the nasty Republicans serving their donors interests? Or is it the Democratic elites giving away all the money to minorities and foreigners? Selling the second is what right-wing media is paid to do. Politicians just follow that wind.
4
It is 300 years since Swift wrote his Modest Proposal. It is not about eating babies it is about economics and morality . It is the darkest satire that anticipated the Irish economic genocide by 125 years and Swift's essay couldn't be more germane to America 2019.
It is time to talk about Whiggism which I guess in America is called conservatism or sometimes neoliberalism.
https://andromeda.rutgers.edu/~jlynch/Texts/modest.html
1
Here is the big question: Why don't we have a stream of Psychologist & Psychiatrist experts on our screens with their studies on how trump's administration affects our general population's mental health, the dire damage and horrific consequences of this present nightmare.
https://www.salon.com/2019/02/22/yale-psych-prof-if-trump-werent-president-he-would-be-contained-and-evaluated/
https://psmag.com/news/research-suggests-trumps-election-has-been-detrimental-to-many-americans-mental-health
RESEARCH SUGGESTS TRUMP'S ELECTION HAS BEEN DETRIMENTAL TO MANY AMERICANS' MENTAL HEALTH
There's also a bestseller on this subject...The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President
https://www.amazon.com/Dangerous-Case-Donald-Trump-Psychiatrists/dp/1250179459/ref=sr_1_1?keywords=%22The+Dangerous+Case+of+Donald+Trump%3A+27+Psychiatrists+and+Mental+Health+Experts+Assess+a+President.%22&qid=1561455352&s=books&sr=1-1
So while the Congress deliberates on Impeachment process, considering all political outcomes & repercussions, I would suggest they take time to examine the potential, irreparable brain damage for their future voters.
How long do you think humans can exist in this dystopian environment without having serious brain damage.
Call for Mental Health Professionals to reveal their research and grave concerns openly to the general public.
1
As a non-U.S. physician, I can't tell you how nauseated I feel reading stories about how underprivileged US citizens and immigrants are being treated. What a sick, sick group of people you have running your country...
12
@GP The GOP is really a criminal organization, they w/o exceptions write the laws to make unregulated predatory capitalism possible.
1
You can blame the Republican politicians, but who voted them in?
2
Depressingly sad state of politics in America. Republicans are denying Americans in their states healthcare, purely out of spite and greed. 'Life, liberty and the pursuit of happiness' is all but impossible if you are sick.
1
These people don't want socialism - they would be helping pay for other peoples' healthcare, but they flock for free healthcare for themselves? How hypocritical/dumb can someone be!?
5
This is what runs through my mind when reading a tragic article like this. Republicans are indirectly killing off their constituents by keeping available healthcare from them. Most are white, the same folks that vote for these politicians. So in a matter of a decade or so, the white population in these states will have diminished to such a degree that states like Tennessee will be clamoring to have immigrants, legal or illegal, populate their states. Just insane.
Republicans are their own worst enemy, all of them.
“Dying of Whiteness” by Metal has a section devoted to this problem in Tennessee. It also addresses guns in Missouri and Brownbeck’s farce in Kansas.
l?I have a feeling that this "mean-spiritedness" alluded to in this article could be racism and its derivatives: xenophobia and privilege.
It’s the same narrative of blaming the victim and pushing them for not having the common sense of being born rich.
1
From a European viewpoint, all this is stating the obvious. Even Britain, long a bastion of the Conservative Party, far-seeing politicians have realised that universal health care is good for everybody. And despite some desperate chipping away of the health edifice, all countries in what might be called "Old Europe" see things the same way. Cynically speaking, the owners of labour-intensive factories and other sources of income stand to lose money when their employees are off sick (for these days there are hardly any jobs for which no training or experience is needed.)
2
Unfortunately, I am becoming increasingly unfazed by these articles. I hate to say it, but my first thought was...who did the people going to the clinic vote for? Elections have consequences. Maybe I'm just having a bad day and my empathy will be back. I hope so.
5
Why assume that voters who repetitively elect Republicans who consistently reject Medicaid are not fully cognizant of what they are voting for? Perhaps these voters are simply willing to suffer for their principles. Maybe for them, Medicaid is welfare, and they would rather suffer than accept welfare. In other situations, we call people who suffer for their principles, heroic. As an American, I am reluctant to say that my fellow Americans are so dumb they do not know what they are voting for.
3
@Ernesto Oh, please. These people are willing to give up their health because they think Medicaid is welfare? Do you not think any of these people receive food stamps? Do you not think any of these people receive Social Security disability payments? Do you not think any of these people receive any form of government assistance? Sorry to say that there are tens of millions of Americans who have no clue of the consequences when it comes to voting.
3
So who show up at a pop-up clinic if your principles reject welfare?
1
I hope Dem's in those states are saturating the media about Rep.'s choice to make their constituents suffer.
As for Kentucky, Dem's should be saturating the media with how their own self-described "Grim Reaper" would love to follow suit.
1
A "public option" should be made available to everyone who works and pays taxes. American workers need a dog in this fight.
1
What kind of a fool would vote a GOP into office knowing that taking away medical benefits for low income people is the goal of the GOP. Shameful that people receiving medical benefits has turned into a purely political decision. For those who have forgotten, it is a GOP policy point. But also someone else should be blamed Mr. PK: and that would be Democrats. Why don't we read how much effort is being spent, and money too, educating the GOP voter it is their GOP politicians that are taking away medical benefits. Unfortunately, the past is still present today, and that is those in power control the information going to the public. And as we know the GOP is no longer in the 21st Century known as the Good Old Party, but is now clearly known as the POL (Party of Lies).
1
Mr. Krugman, of course, partially lets the citizens of Tennessee off the hook, by blaming it on the Republican politicians. Of course, the subtext is that those scallywag politicians were voted into office by those very same citizens. In Democracy, you get what you vote for.
2
People have principles, and many honorable people are willing to go to extremes - even die - for their principles. Mr, Krugman does not seem to understand that “rural people” are not necessarily ignorant of what is going on. They may very well know that they don’t have Medicaid because of what their elected state officials have decided. But they choose to live by their Republican principles and refuse to accept what they regard as welfare. As an American, I am very hesitant to label any fellow American as stupid, and I would advise Mr. Krugman to do the same.
1
@Ernesto
Not stupidity, necessarily, but ignorance. Everyone has chosen to be ignorant about something at some point in their lives.
I wondered why grassroots 'conservatives' hate Obamacare and want to block expansion of Medicare and then I had a conversation with a couple who proudly proclaim they are Teapartiers. This couple and their adult children have healthcare through their employers – so they're fine and they're not afraid of losing it.
What concerns them is that they don't want others to gain a benefit and get on par with them. The mindset seems to be 'I've got mine, and if you get it too, you'll be as good as me.' It's cruel and miserly
5
@Peter
It's an example of the divide-and-conquer strategy of the Republica Party.
Many people in line for that clinic in Tenessee probably fervently believe they're are getting this shaft because of Obamacare.
The triumph of the modern Republican party has been to persuade voters to cast ballots that run directly counter to their own interests. In this case it's fatal. Those voters seem largely oblivious to the ruse.
6
Interesting that Mitch McConnell’s state expanded Medicaid while he actively works to destroy the ACA. Why do the people of Kentucky keep electing the greatest threat to democracy? Yes, worse than Trump who is clueless while McConnell display a Machiavellian evil.
5
"Is it conceivable that conservative politicians have that much contempt for their base? Yes."
Surely that is not true. There must be some other reason(s) why they refuse to expand Medicaid. No large group of Americans could be that cruel and financially stupid.
Some Republican, please jump in here and explain the thinking behind this position (rejecting Medicaid expansion).
[If they are really that bad, we are lost, defeated, done for; civilization can't exist with such Ebenezer Scrooges, which only works if we all pull together.]
But I'm sure there must good reasons for Republicans' reluctance. They aren't misanthropes.
You can lead a sick person to insurance coverage but you can't make them vote out the politicians that are keeping it from them. The politicians that have kept medicaid expansion from their constituents have their pride. Proud to the death.
Let me say it again -- Trump is only the tip of the iceberg, the iceberg is the Republican voters. These voters repeatedly vote for the Republican state government and Republican Congress that deny them healthcare, clean air and water, and god knows what else. It's therefore not accurate to say blame lies with the Republican state government.
Since the passage of ACA, the Tennessee rural voters had several chances to vote for those who would look out for them, but they didn't. Instead they choose to let Fox News tell them what to think. They choose to blindly believe all liberals and government programs are devils incarnate. They choose to hate those different from them, then cry victims. They choose to stay ignorant of their own reality.
So I blame not the politicians, but their constituents.
5
Did not Alan Grayson state on the floor of Congress thatthe Republican idea for health Care was don’t get sick. But if you do, then die?
Voters from Tennessee are just getting what they voted for. They have the power to change their current (lack of)system. If they don’t, then they are getting all the health care they deserve.
1
Yes, its about racism, and demonizing far off elites. But don't forget the role of greed. Republican politicians knew that Medicaid expansion would ultimately result in higher taxes on the state's wealthiest, and the care and comfort of the wealthy is their raison d'etre.
3
Earlier, @Matthew Carnicelli (Brooklyn, NY) commented:
"When I was watching the HBO Chernobyl series, I couldn't help noticing the similarities between the modern GOP and those Soviet apparatchiks. When ideology is all you got, promoting that ideology is all you focus on, no matter how many innocent people get hurt as a result along the way."
Back in the 1970s, a gig I had put me into contact with apparatchiks from several Communist countries. They very effectively convinced us LatAmericans that Communism was a crock and not something we wanted in our countries.
Much more recently, a similar sort of gig has put me into contact with pro-tRump GOP activists/promoters. Although unwittingly, they loudly recite the old Marxist/Communist liturgy about the dictatorship of the people -- i.e. one of many excuses for brutally repressive regimes.
What horrifies me is that they frequently quote their religious leaders, not GOP-related politicians. Some seem to think they're part of the "crusade" the Cheney-Bush regime started in Iraq. Where is the US headed?
The indifference of these state Republican leaders to suffering of their constituents is despicable.
Ultimately, however, the responsibility belongs to the state voters who repeatedly reelect them.
4
“and most of the blame lies with Republican state governments“. Maybe it’s just me but, why are these awful Republicans holding power? Not that the US is a perfect democracy but it isn’t really a totalitarian state. People can vote and generally elect representatives of their liking to run their towns, states and country. What am I missing? Education, that’s what.
2
Great article. Never underestimate the stupidity of voters.
Trump won Tennessee by more than 650,000 votes! It's voters, particularly the poor, continue to suffer as a direct result of Republican policies, yet will continue to vote Republican. I would guess that the percentage of poor voters who do so is even greater than the state's wealthier individuals. As long as Republicans continue to preach fundamentalism, racism, sexism, homophobia and anti-Muslim rhetoric voters will continue to vote against their self-interest. They believe their immortal souls are more important than their pocketbooks.
4
Not mentioned is the strong undercurrent provided by Evangelical thinking in Bible belt country. Calvinists, and proponents such as Mr Osteen, tell us that poor people are poor because they're not blessed. God rewards good people with riches. so the poor get what they deserve. So evangelical assumptions link with greed-based plutocrats to oppress the weak and unfortunate.
So many opportunities for new candidates to run against glaring themes of incompetence and corruption.
2
Trump's nasty, cynical attitude is catching. It has outed the true nature of the Republican Party. Yes, the conservatives really are that contemptuous. Once I was discussing healthcare with a Republican zealot. I'll never forget the look of disdain on his face as he told me that "health care is a PRIVILEGE, not a right!!" And this guy is a healthcare worker!
2
You get the government you vote for. It's on the voters regardless of the why.
2
I would not give Kentucky too much credit as they went out and elected a governor who campaigned on getting rid of Obamacare. Gov. Bevin has done much damage to KY healthcare and the poor folks who depend on KYNECT their state exchange.
1
Let's make them pay big time at the ballot box for their mean spiritedness and cruelty. It is absolutely true! Thanks for saying so Mr. Krugman. This Republican party needs to feel the pain of being crushed into becoming a third party status. A blight on our decency as human being's. An embarrassment around the globe in advanced country's. Miserable lying low life's.
2
I've said it before and I'll say it now: watch the red states is like watching somebody deliberately drive off a cliff. I get the same helpless feeling of the bystander who can't stop the horror of what is happening right in front of her eyes. And the worst of all? Both the car and the state are full of helpless passengers.
4
A democracy is only as good as its voters.
2
I highly recommend the new book “Dying of Whiteness: How the Politics of Racial Resentment is Killing America’s Heartland,” by Jonathan Metzl. One-third of the book is an analysis of how Tennesseans have been harmed by their state’s refusal of Medicaid expansion. But many of the White folks he talks to insist that they’d rather do without government-supported health care than see their tax dollars go to fund the health needs of strangers, especially immigrants and people of color.
Very compelling analysis.
2
Ultimately, it's a problem of education. Uneducated voters who are convinced by fallacious Republican arguments will continue to hurt themselves because of some misguided allegiance to their ignorant representatives.
1
I'll bet that most of the people in that clinic voted Republican. This is going to sound heartless, but they're getting what they deserve. Vote Blue, no matter who!
2
Under Obama’s commiecare these poor people lost their health insurance and were left with an unaffordable high premium high deductible garbage government product. Government can’t run the DMV, why should we trust them to run a healthcare system? We need to get to a system where the patient is the customer and actually pays the bills. The cheapest and best products are create when the consumer is king (not the insurance or government bureaucrat).
@Registered Repub - Millions of Americans are very happy with their Medicare. The CBO says it would cost $20,500 a year for seniors to purchase a Medicare-equivalent policy on the private market. But then there are some Americans, apparently like you, who say, "Yeah, I'd like to put a profit-taking middleman between me and my access to healthcare, driving up the costs and denying care."
1
Back in 2011, some people thought that we should let people, who lacked health insurance, die.
There’s a CNN video clip, uploaded September 13, 2011, onto YouTube, showing a Republican presidential debate where some audience members shouted “Yeah!” in response to whether society should just let a person without health insurance die.
The CNN video is less than 2 minutes long, but it’s worth revisiting that moment to bring the present into focus. Also, Remote Area Medical (RAM) has been operating mobile health clinics in less-developed countries since the 1985, and started mobile clinics in rural USA in the 1990s. I remember watching a video where RAM set up their clinic in a large barn on a county’s fairgrounds, but I don’t remember which state that was.
@Donna Nieckula - I live in an relatively upscale community in KS. When a dental clinic down the street started, once a year, setting up a gigantic tent on their lawn to provide free dental care, I was shocked that so many people in this community needed it. I was even more shocked the next year to see that people started lining up before dawn to stand in 6" of snow to wait to see a dentist. There were people out there all day in bitter winter weather.
1
Recall the Republican debates in 2011... the one where Rep. Ron Paul was given a hypothetical situation about a seriously ill person without health insurance. Rep. Paul was asked if we should just let that person die. Before Rep. Paul could answer, some people in the audience shouted, “Yeah!” While Rep. Paul visibly gasped, several audience members applauded the “Yeah” let him die.
That was the Tea Party mentality, which has worsened under the Trump Party (formerly Republican Party) mentality.
They say that people have to hit bottom (suffer enough) before they address their character defects, and everyone’s bottom has a different depth. How low will Republican voters go, before turning around and voting their real interests, is anyone’s guess.
2
My mom always that there are some people you can't confuse with the facts.... During the Trump years these include poor and middle class Republican voters in Red STATES. Very sad.
I'm a Canadian who finds the GOP attitude towards health care incredibly cruel. What does it make GOP voters? Incredibly stupid.
1
Dr. Krugman, as others have said below, perhaps not individually but collectively, these folks do not want help. They do not trust the government and since the civil war ended they never have. There is no crisis here except in the minds of east/west coasters who fail to understand this. Live in North Carolina if you don't care about your children, your parents or your teeth.
What you Americans need is something like our NHS.
We are very proud of it.
1
Tennessee should give back the “New York values” federal tax ..
1
Idaho is in the middle of this fight right now, and it is possible that sanity will prevail, in spite of the worst efforts of the Republican legislature and the cowardice of the Republican governor. It is baffling that they could be so in contempt of their own voters.
The GOP wants to keep the poor and the minorities "in their place" and they do that by denying these people decent healthcare and education opportunities. It's worked for them for generations so why change now?
Too bad none of those who Dr Krugman writes about will read this column. No doubt, all will vote for Trump in 2020.
1
It's simple really. The current republican ethos is that government should not be in the business of transferring wealth. Period. Unless of course their donors need welfare and subsidies for large corporations. Situational ethics. It's what repubs do.
As for the voters.....there's a sharp stick in the eye for continuing to vote against their own interests. Land of the free, home of the brave blah blah blah. Just don't expect to get that stick extracted out of your eye at a local hospital in Tennessee. They are all closed.
2
This is ugly. Being a big city resident, I always thought that we have more healthcare capability than necessary. We can pick and chose what we think is necessary to cover our health risks. But I can never image the cruelty of inhuman and calculated motive to hurt ordinary people that actually happened in rural America. I wonder can the Tennessee governor sleep soundly every night. Can't he or she hear the desperate cry for help? Where is the Christian value? Where is the American spirit helping the needed in this case? I hope that the election candidates will address this issue in the campaign.
The hardest hit areas are the ones who generally identify with and vote Republican, especially in the southern states. Yet it is the GOP that continually move to decrease Medicaid, Food Stamps, and Welfare. The people that vote these Republicans into office do not seem to understand this. I guess you could say they have made their bed now it is time to lie in it...but it is still tragic.
The GOP is the real death panel! Humans don’t mean anything to them. Perks, power, graft and, of course, controlling women are just a few of the GOP’s favorite things.
Tax breaks for billionaires, making sure they can buy that second or their private jet. That is what matters to the GOP. Rural residents don’t make big donations and as Lindsey Graham has told us if the big donors want it he doesn’t even have to read it he’s going to do it!
1
Krugman overlooked two elements:
1) Democrats, who supposedly represent the alternative to the miserable Tennessee medical status quo, did not use the health repair event/assemblage to spread their message and register voters.
2) Those seeking care may be too dim to ever understand the political game in Tennessee tilts against them.
Time and again the poor-pitiful articles omit the voting question as they tell the misery stories. If one effectively chooses government medical care benefits for the wealthy only, then expect its consequences. Mean spirited Republicans are they? No, they follow the will of the voters.
1
If only I could feel sorry for rural residents in red states, but I can't. These same people are unaware there is no difference between Obamacare and the ACA, but listen to the republican lies being fed to them. Will the willfully ignorant ever face the fact that republicans are not their friends? I seriously doubt it!
Are you sure these are all people who would be eligible for expanded Medicaid? A lot of people with insurance just cannot afford to use it..premium and oop are just too high.
You've got to do the math.
1
"Gratuitous political cruelty." Let' dedicate this column to that.
The cure? Could it be that electing Democrats in these various states that are being shortchanged? Or could it be that the existing Republican leadership needs to grow a heart?
There is no excuse for this in any state.
1
Many of the doctors now in rural America are the rejects, the wannabe retirees and the pawns of rural "hospital associations."
If you are over 65, your health plan is nil. Everyone is waiting for you to die. You are expected to take meds which require meds to offset the side effects of the first meds, but no one can afford them! Only if you are rich and/or can afford supplemental insurance will you receive "good" care. And the nursing homes? I have had 2 friends opt in favor of suicide rather than end up in one. I plan to follow their lead. That should make all the agists happy.
No, America does NOT have the best medical care in the world. It has the most exclusive medical care, but that does not mean "the best."
1
Cruelty is a feature not a bug of Republican state policies. Republican orthodoxy states that it is better to have people suffer and die prematurely rather than live under socialism. So as long as local residents keep supporting republicans they are getting what they voted for.
1
As an American expat living in Italy (hardly a perfect place) the citizens of this country have a system that offers medical care to virtually everyone. We pay for it and, for the most part, it works. Just look at the outcomes. Reading this article convinces me that there's a nastiness and mean-spiritedness that permeates American society. Today, you Americans tolerate squalid conditions for the children of immigrants, streets in your largest (wealthiest) cities are filled with homeless and when you get sick, you must worry about bill collectors, attorneys and bankruptcy. When it comes to health care, you tolerate the mercenary attitudes of the hospitals, the insurance companies, the doctors and big pharma and all of the leeches who feed off your over-priced system. Americans have a deeply held resentment against "the other," that is, you all believe in a zero-sum game and worry that someone else isn't working hard enough or will get something for nothing. I think it's high time you take a good hard look at yourselves. From over here in Europe, it's not a pretty picture.
10
@mrfreeze6 You are so right. As an expat, you know how really brutal this predatory capitalist society is, even the words social and public service have been denigrated for political propaganda, they see a socialist under every bed and that scares them to death.
1
I have difficulty accepting "The GOP is mean-spirited and intentionally cruel" as the foundational cause of this health care crisis. Is Paul really saying that cruelty, for cruelty's sake, is the goal? With so many of the comments agreeing, what am I missing?
I AM NOT DISMISSING THE HORRORS of this or so many of the GOP's actions. But even with our president's "kids in cages", where he IS intentionally cruel, he is doing it because he thinks it is a strategy for deterrence or re-election.
Sociopaths exist, of course. But at the scale of an entire political party?
Yes, the GOP's actions are mean-spirited, cruel, and inhumane. But I can't believe they are doing it just for kicks and giggles.
I'd like to know WHY they are cruel. What is their actual goal?
2
@ImagineMoments - If you live among Republicans, as I do, or spend any time on message boards, you'll see that the prevailing fear seems to be that the "undeserving" will get help. Or "those people," meaning anyone unlike them. I know rabid Republicans who are on assorted safety net programs (and not working) who insist that THEY paid taxes for everything they get, while those OTHER people are just freeloading.
@ImagineMoments They are greedy and out for the money, what else is there, yes, more power to make more money. Lobbyists get paid very well. See Trump, he needed a golden toilet, he really likes things gaudy and kitschy and made of gold, it must feed his big ego.
The photograph is a nice group of Trump supporters.
It is still astonishing that there are people who will vote against their own interests. Ignorance.
1
What it comes down to is this; The people in Tennessee would much rather move toward a health care system like they have in West Virginia than the one they have in Massachusetts. They also need to remember that the Republicans next move is to get rid of social programs. The ones that help minorities. They don't recognize they are in the minority. They shot themselves in the foot. Now they will blow the whole foot off. I got bad news for them.....the health care system in Massachusetts is humming right along. Now, don't you feel better.
@Walking Man
The words public and social are really taboo. Greed is good is the real republican slogan.
I try to formulate an explanation for this "inflicting of misery" by Republicans and all I can come up with is "cruelty fetish." You see it plainly with Trump, McConnell, et. al. The concept of empathy is absent. This is a full-fledged serious psychological disorder.
1
I wonder how Mitch McConnell explains Kentucky’s decision to expand Medicaid to himself.
Nobody but Trump hates Obama more than Mitch. He hates him with a perfect hate. Yet somehow his state went in a different direction on Medicaid expansion. That tells me Senator McConnell can be defeated
in 2020. Get rid of him, Kentucky!
4
Why should I care if rural people vote over and over, for politicians who make their lives miserable?
2
What I liked in that article was one couple drinking Gatorade and eating chips while they waited.
1
Very early on, I actually emailed President Obama and told him that he was doing a very poor job of explaining the ACA to the nation. I suggested that he use public service announcements to explain key parts of the law. I never saw any of this. However, he also shot himself in the foot with the "you can keep your doctor if you want to" mantra. The fact is, most people with health insurance before the ACA and afterwards were limited to the physicians in their health plan's network. This is something that was in place long before the ACA. So even then, you had no guarantee you could keep your doctor from policy year to policy year or if you changed health plans. This was a big gaff that played into Republican hands.
3
Do they watch Fox News in Tennessee? That is why all of the blame does not fall on Republican government; if the voters only new the truth things would be different.
Bring back the Fairness Doctrine.
6
Jonathan Metzl's wonderful book, Dying of Whiteness, tells the same story, and explains it. Rural white folks have been told by their leaders (correctly) that minorities benefit from the Affordable Care Act and Medicaid expansion in particular, and that, all by itself, is why they don't want any of it for anyone.
1
Rural republican voters don't read the Times or Dr. Krugman. Hannity and Fox probably aren't providing this information.
Got any ideas how to get through to them?
2
This is a naive column: This is precisely what red states want. If the people there wanted effective, affordable healthcare that was readily available, they would vote for it. This silly blue states paternalism that the people in red states "don't get it" and are misinformed or that corruption keeps them from voting has to end. It's high time blue states stop treating red states like toothless yahoos and respect that not having proper healthcare is the people's will. They want it, they voted (or didn't) for it, and they got it. The bleeding hearts should worry about their own states or move to states that are more in line with their values. This would solve the abortion issue too.
1
Shouldn't this be an easy win for local democrats?
Cruelty and pain is being inflicted to more and more people, more and more severely at time goes on. Read "Squeezed" by Alissa Quart for a wide-angle view based on real-life examples. And, while it is true that individuals are ultimately responsible for their own mess and their own progress, it is strange that the Dems are unable to communicate with and convince these dead-beats who keep voting R
1
Bravo!
Thanks for this article on the cruelty of Republican policies.
As a former Goldwater Republican who came to Washington to work in the Public Health Service on controlling air pollution in 1966, I learned how wrong I had been. See
https://www.legalreader.com/republican-racketeers-violent-policies/
2
Facepalm, headshake...
Paul, you said universal health care isn't going to work here in the US. Even though you have twice (at least) admitted that it is the only way to cover all and reduce costs.
Good thing you haven't started looking for a way to make it work. I'd hate for an award winning economist to waste time on the issue effecting most of America.
Lets just shoot the messengers and the politicians attempting to right the wrongs. It's soo much easier.
Right Paul?!
1
retired federal attorney F/70
Spot on until the last sentence. Accurate and complete story would replace "most" with "all." "All of the blame lies with Republican governors."
Strikingly comparable faces of emaciated young people at the start of this story and the separated-from-families immigrant children found this week: living in filth, sleeping on a concrete floor in cages, and starving in OUR border warehouse in Clint TX. Built to hold 135 adult men for processing, there were about 300 kids from five months to 17 years old.
Months of warehousing in secrecy until Court-appointed attorneys heard a rumor and refused to leave until they got inside. Kids found within hours of OUR attorney from DOJ arguing with federal court judges about whether soap or tooth brushes or a way to wash clothes not cleaned for weeks since they arrived was required by long-settled immigration law (Flores case).
Stephen Miller is puppeteer for the man in The White house whose cruelty this week again reaches war crimes levels of inhumanity. My job before I leave this earth will be to get these equally cruel Governors tried for the same crimes since TennCare was jettisoned.
1
it's a pretty safe bet that if the people lining up for health care get their 'news' from Fox, they're being fed a line about how Obamacare is a disaster. talk about cynical.
1
But they bring the misery onto themselves, so who cares? They are masters of their own fate believe it or not, and this is what they want.
Paying taxes willingly that go towards another's healthcare suggests that the taxpayer believes there is a social responsibility and a sense of collective good. Those receiving such care know that others are subventing their needs. The "Christian" culture of these rural Americans reminds them at every turn that the government is evil and, more importantly, that recipients are not worthy of such aid. If you can't afford it, it's clearly because God has not blessed you. If you weren't such a sinner neither poverty nor malady would befall you. If you are compelled to pay for collective healthcare---through taxes---then you serve the evil state. The problem is complex and so includes elements of racism, cruelty, spitefulness and the rest, but at the heart of it is an ignorance nurtured by religious pathology.
2
Yes Obamacare will solve all our problems. Instead of using this example to ask for Single Payer or Medicare for All or even argue for a Public Option, what does Krugman do? Yes, shill for legislation written for and by the Medical Industry complex, i.e. Obamacare.
How feckless must Democratic politicians be, that they can not take advantage of this situation to get voters to support them in places like Tennessee?
1
"Is it conceivable that conservative politicians have that much contempt for their base? Yes." Not just their base however, all of us. Worse yet, they have convinced a whole bunch of other well-to-do people to view us with contempt. We don't deserve decent health care. We don't deserve decent affordable housing. Unemployment benefits are a form of pampering. (It's better if unemployed people take any job they can find and if they can't find a job, oh well.)
What's inconceivable is how unnecessary all this suffering is and that our country, alone among the developed countries of the world, still refuses to improve its social safety net. Our politicians do not view health care as a right. If it's not listed in the Constitution it's not a right. They consider the latter part of the Second Amendment "the right of the people to keep and bear Arms, shall not be infringed.” to be more important than any other rights implied or explicit.
Notice however, that they are not adverse to changing things or funding things that work to the advantage of their largest donors. There's more than enough good will for corporate welfare and rich welfare. It's only average Americans who are unworthy of any sort of consideration except when it comes to picking our collective wallets bare. Bush coined the oxymoron compassionate conservatism. It wasn't compassionate when he coined it and it's not now. We can change it if we want to. Vote in 2020.
6/24/2019 11:01pm
1
If those rural voters knew how much higher the living standards are in civilized countries they would never vote for Republicans.
3
When you care more about what’s happening on the Batchelor, or your ‘team’, or whatever show is streaming instead of how the people you put in Office are controlling your life, well, you get the government you deserve.
1
I’m sorry but these people will vote for Trump in 2020 without the blinking of an eye. And if one tries to confront them with the contradiction, they will say there is none because ABORTION. ( And I’m being kind and not bringing up racism et al ). So, you get what you pay for. Can’t have it both ways. These hospitals and clinics really started closing with the last vote cast for Trump on November, 2016. He was never keeping ANY of his promises, least of all, his “...better health plan....” than the Affordable Care Act. They’ve chosen their poison pill and now they have to live with the bitter consequences. Sad.
1
Scapegoats are always appropriate in this situation to get re-elected in Tennessee. Hence ,cuz I live in Ct. then it’s my fault.
Real ignorant of their constitution and their representatives reason for existing.
"So I’m not sure how many readers grasped the reality that America’s rural health care crisis is largely — not entirely, but largely — a direct result of political decisions."
Correct!
AND it's not just the rural health care crisis Billy Tauzin's history and the drug industry, CLIMATE CHANGE, schools and other mass shootings, immigration, collapsing bridges and crumbling roads...the list seems endless.
Unless and until there's REAL political accountability.....yeah, right.
1
Underlying all this, of course, is race. Obamacare is a codeword for black. These rural voters have been told since the 70's that Medicare is a code word for black too.
Nothing will change in this country until we confront this truth.
1
As long as Fox 'news' is on the air, low-information voters will get republican propaganda instead of real information. And they will continue to endure their torment willingly.
2
@markymark Sorry but not all "low information" voters voted for the beast, I know business owners, some very successful and college educated people who voted for him. That adage doesn't work anymore.
But why do the rural voters keep falling for it? Why do they elect their persecutors by wide margins? I'll tell you why. Because the people have been bought off. The currency used to buy their votes are guns.
The Republicans have leveraged guns as the ultimate pathway to freedom. Guns are liberty. No they are not. Guns just let people kill other people.
Guns are the ticket to manhood. I've talked to people from these areas and when hold that rifle, when they strap on that pistol, the are a somebody, they are a man. They can fight. They can defend their family.
The lure of holding that rifle, of firing that pistol is so great that it supersedes all other needs. The gun is the baseline. So much so that these people will continue to vote for those who will deny them health care. All the Republicans have to do is scream socialism and the these people think, well if we go socialist, next, they will take my guns from me.
My advice to the people of Tennessee: Fool me once shame on you. Fool me twice shame on me.
2
Yes it would cost money.
Federal money is money is taxpayer money.
Good guys don’t fudge.
3
Public policy DEFINES personal experience. VOTE BLUE!
2
In the Deep South, many white voters oppose Medicaid expansion because they think their tax dollars would support a government program that (they think) mostly benefits African-Americans.
3
Hard to feel sorry for these people since they gave us people like mcconnell and bone spurs. I live in a Blue state and most of our money props up states like this, if the repubs were so good at governing you'd think they'd have better healthcare, oh wait they don't believe in healthcare for all just for themselves. Keep voting the same repubs in and this is the end result. I shed not a tear for them this is their own doing. And as we speak they plan to take away healthcare entirely. So thanks to all of you who keep giving us the same tired old white men who care more for their wallets and power than their actual constituents.
1
In an NPR interview an older woman, a nurse who lost her medical insurance and job during a recent red state election was asked why she voted for the candidate who undid Medicare expansion, she replied he candidate she supported is against gay marriage and abortion and that's more important than my own personal circumstances. If voters put their moral beliefs ahead of personal welfare, politicians will continue to act with impunity.
3
I have had experience in all aspects of healthcare coverage, from none to exchanges to COBRA to employee sponsored, the underlying problem with each of these kinds of coverage is the additional costs involved to access it. High deductibles, how did we end up with this? How did we go from paying our premiums to also having to pay high deductibles, cost sharing, and copayments? You are right, when people complain about their insurance it is always to lay the blame for everything bad in healthcare on Obamacare. I confront this head on, making them acknowledge that what we had before wasn’t working. People really have no concept of how much they are paying for insurance because their employer picks up a portion of that cost but more of that is being foisted off on to employees. Then I ask them to imagine what their incomes could be if we didn’t have employee sponsored insurance, it is part of a benefit package. I want my benefit package to benefit me not used as an excuse to pay me less because they offer health insurance. When you get your insurance coverage through another means (spouse, etc.) you reap NO benefit from that package but to subsidize other employees. Insurance companies are paying CEO’s millions from my deductibles, copays, cost sharing etc, they literally live high off our misery with healthcare and whine about socialism for the masses ignoring their own socialism to reap millions off of poor people dying without care. Universal healthcare terrifies them.
1
@tjcenter - The average employer who offers health insurance spends $12,000 per year per employee. They take that amount right off the top of what the employee would otherwise be paid. Most people don't realize that.
Without Fox News (now the propaganda arm of an anti-democratic party), and the myth that all criticism of Trump is Fake News, would Republicans have been so successful selling the myth that “big government is evil” to poor people who could most use the help?
You have to give Republicans credit for the depth of their convictions, and their devotion to their ideals: no amount of suffering, no amount of pollution, no amount of corruption or cynical twisting of the gospel is too much if it puts more money in their corporate supporters’ pockets.
That The Base continues to swallow the line that Republicans are protecting their “freedoms” (to starve, to die of preventable causes, to live in balkanized fear of “them” while clutching an assault rifle), and that Democrats want to ruin everything is a testament to Republican marketing prowess. Just imagine if they put their mighty energy into governing on behalf of their constituents.
1
How much of the reluctance to support Medicaid, or universal healthcare in general, stems from the bleating attributed to a long-failed politician about "death panels".
How much of the reluctance can be attributed to "socialism" and "socialist-communist proposals of the Democrats" as these same politicians and supporters seek or apply for government-provided healthcare-Medicaid, Medicare, VA-those very socialist programs they decry.
In time their opposition to the ACA or universal healthcare will wane as those who are in need realize their politicians and their hero Trump care little about their plight. And those same people may realize they have been conned.
6
@Dan
“In time their opposition to the ACA or universal healthcare will wane as those who are in need realize their politicians and their hero Trump care little about their plight. And those same people may realize they have been conned.”
If they’re not dead first.
While you are , most likely, correct that Medicaid expansion would have decreased the uninsured numbers. It would have done little to prevent the closure of rural hospitals. Based on current levels of Medicaid reimbursement for inpatient and emergency care, giving people the illusion that they were "covered" would have increase hospital utilization in this population with re-imbursements that do not even come close to the cost of care.
The reality is that in a free market economy, (debate the merits some other time) rural hopsitals are forced to pay higher costs for staff, equipment, etc, so they link up with the largest hospital system they can, out of desperation. This still doesn't change the reality that for many, nothing short of a huge subsidy, will keep the lights on. One potential solution; primary care clinics and free standing ERs with subsidies in the underserved area and a WELL ORGANIZED EMS regional system, to get the real patients to an Urban referral center. Government sponsored loan forgiveness to Docs who move to rural areas would help, but hey, there are flights to Palm Beach that need to be paid out first.
2
Political leaders tend to be pathologically driven in that they put their own career interests ahead of the welfare of millions. Military officers revel in wars because they provide opportunities for advancement of one's career. Politicians worry about offending rich donors and losing the next election. Professional investors often enjoy a good economic crisis as an opportunity to scope the leftovers as others lose their jobs, houses, and health.
If a few million die, what's the problem? A policy that advances one's own interests is a good policy, independent of how many suffer and die. This attitude is as true of politicians on one side of the spectrum as on the other side.
If you were asked to identify a psychopath or a sociopath, a good place to look would be to the ranks of those in political leadership. The Republican Senators who protect Mr. Trump do so because they are afraid not to, as they would lose in a coming primary. The Democrats who are against impeachment hearings are driven by the fear that it will damage their re-election in a general election. Political leadership, for a great part, equals a pathological level of self-interest.
Let the constituents suffer so long as I advance my own interests.
2
@Che Beauchard
You said "This attitude is as true of politicians on one side of the spectrum as on the other side." I see no evidence of that.
What happens slowly does not garner the attention of a public preoccupied with the challenges of day to day survival. Even when the slow occurring action is the most devastating event in their lives.
Every American was traumatized by 9/11 and mobilized to prevent another such attack. On the other hand, much of the country is impervious to the Republican Party's devastation of America's standard of living, democracy and values which has been taking place over the past 5 decades.
Put in perspective, the Republican Party has done and continues to do more harm to America than 9/11 ever did. Sadly, the Republican attack on our nation goes unnoticed by Fox viewers and right wing radio adherents. Even though they are the ultimate victims.
5
Serious question: do Red States deserve Healthcare?
If the people, through their elected leaders, try incessantly to demolish the Affordable Care Act, Medicare, Medicaid and every other subsidized health solution, do they deserve any type of healthcare that’s not subsidized?
I say no.
For the same token, do these States deserve to be reimbursed with Federal funds regarding climate change?
I say no.
We live by our actions.
6
@PC
One problem with your argument is that the large minority who didn't vote for the idiots suffer along with those who did.
Eventhose who voted against their own self interest deserve health care. It is a moral right, not a reward for voting intelligently.
1
This is of course not the only case of the cynical calculation described at the end. We should not forget that the Republican Party deliberately shut down the government under Obama so as to inflict maximum pain from the 2008 recession. In return their rich donors were rewarded with tax cuts so monumental they could only have dreamed.
Now that the “balanced budget amendment scam has been so amply exposed, you’d think this would be common knowledge. But somehow whatever makes for public dialog has passed it by. Just as in the cases mentioned in the article.
As long as they keep getting away with it this will continue.
2
Rural hospitals are closing throughout the united states , the very hospitals that are in the front lines of treating the poor, the uninsured, immigrants and those caught in the opiate crisis. Part of the reason in many states is that they did not opt for the medicaid expansion...but that is not the sole reason. A major contributor has also been the medicare program that has penalized rural hospitals with reimbursement rates that do not cover their true costs of care.
Urban hospitals have not seen a wave of closures mostly because they have been at the forefront of concentrating on procedures that are profitably reimbursed by medicare and private insurers, such as hip surgery, cardiac transplants and exotic cancer therapies. The cost of mandated computerization of medical records and billing, cost hospitals millions of dollars that must come out of patient care reimbursements . In a setting such as this medicaid alone alone is not the answer.
The coming elections will be very much about health care, and the closing of rural hospitals and loss of access to medical care can not be addressed by slogans alone. The fact is that the current medical system has failed in much of america and a realistic system must take its place accepting that costs in a rural hospital can be just as great as in a major urban center!
3
While some who call themselves "conservatives" might prefer that sick and disabled citizens who can't fully pay their way just vanish to pay for the tax cut of the Republican Party financiers, that is not what will happen. Without good health insurance, ill and injured working Americans often become poor and unemployed Americans. They stop paying taxes, families lose breadwinners and society picks up the cost of both healthcare and welfare for them and their dependents. . There is no doubt that giving all Americans good healthcare, would extend their ability to work; make them more productive; Keep families together; Avoid bankruptcies, and actually do more to make America great than slogans on hats. The ACA, (Obamacare), should have been named the keep Americans Working Act, because that is exactly what it would have accomplished in the long run, if not for the efficacy of the GOP propaganda machine.
8
My favorite example is Representative "entitlement reform" Paul Ryan retiring with lifetime health & pension benefits that make the average social security stipend seem sarcastic.
13
And while it's good that yesterday in Manhattan, Hollywood actors read the Mueller report for everyone to hear, I would rather they start it in a Rust Belt where his base resides, it won't be as glamorous as NYC, but it's much more needed in these particular counties, where people are still stubbornly vow to re-elect him, no matter what.
Rural and other areas could benefit the most, when people can finally meet their screen heroes on their own turf...
Don't you think it could start real meaningful discussion and change ordinary people's mind on so called Costal Elite.
That's where all this talented actors belong right now, away from their bubble, and establishing honest connection with people not on screen but in their day-to-day real life.
4
My heart breaks as I read this article. As a CRNA for 40 years now and an RN for 3 prior to that, I know how the poor are overlooked in healthcare. Ever notice how the majority of People who have died over the age of 90 had great health care due to jobs, government and private. But now this insurance is becoming less and less and we will see a decline in the average age span.
No doctor can survive in a rural setting. She has been saddled with large school loans and malpractice insurance and collection has become more and more difficult with the convoluted coding system in place now. Just setting up a practice is a large expense. Plus, doctors want to send their kids to good schools which the rural areas are having difficulty funding as well.
All in all, as the emphasis has gone from rural to urban living, poor folks who can not afford to move on are left to take care of everything themselves. Not so easy when you have so little to start with.
14
Medicaid coverage is a means to an end. Healthier citizens is the end.
Rather than focus on Medicaid coverage in the states that have refused to expand the program, we should focus on what is the overall health of the people living in those states.
If the "problem" were couched as "people are sicker and dying younger" (due to lack of Medicaid and rural medical infrastructure closures) rather than "Medicaid coverage rates are lower in state X than in state Y" (and that may or may not lead to better/worse health outcomes) it might motivate people to vote for politicians who actually care about their constituents.
3
Dear Paul, As a longtime addiction counselor living in Beckley, West Virginia I couldn't agree with you more. I want to add that I suspect a lot of the displacement of blame from those responsible for the hardships - Republican politicians especially hailing from rural states - to the designated scapegoats - "urban elites" - has been fostered by Fox News and also, tragically, by no small number of fundamentalist pulpits that distract their congregations by repeatedly harping on abortion, abortion, and abortion. Sincerely, Scott Thompson, MA, LPC, ADC.
17
The real question is how to get rural voters to act in their own self-interest. No matter how on target Paul Krugman's assessment, these people aren't reading his column in the NYT. They trap themselves in a self-made bubble of the misinformation put out by the likes of Fox News or, even more likely, specious sources on Facebook and Twitter. It's hard to think of a way to help folks who seem so determined to enable the politicians and policies that harm them.
20
I think we need to step back and parse people differently to see why this works for Republicans. Rural vs urban is not the divide here. Social class is. The poor that are being denied health care here are not voters. The people of means, say in KY, do vote and see their poor neighbors as unworthy. The estrangement of the poor is not just a national, abstract phenomenon, it is also strong locally, in THEIR backyard.
8
About 40 years ago, I shared a breakfast table with some Americans who had come to Stratford Ontario for plays: Shakespeare and such. From them I heard what I could never have imagined: they would rather have a fund of tens of thousands of dollars in their bank for eventual medical bills rather than have a health care regime that financed people who could not pay for their own care.
It was much like readers of A Modest Proposal must have felt had they not realized it was satire. In America, the reflex to not take care of others who have not had the ( what would they call it?) to take care of themselves is the very ugly underbelly of all the resistance to Medicare for all.
Irony of all of that is that the whole population pays more, gets less quality care, but they do get to feel smug.
29
I'm sorry to say this, but I don't care. The people who live in these states deserve what they get. This is what they get for electing Republicans. elections have consequences.
8
In essence then, this problem is a failure of education and a federal democracy’s failure to adequately support the learning needed to participate adequately in a people’s democracy.
4
Dr. Krugman states that other nations have universal coverage for disease care (he uses the synonym “health”) and we could also.
I agree.
The benefits of those system approaches are so obvious, that I remain amazed that it is considered an “issue”.
Then, I read an analysis in the N.Y. Times several years ago, about the “best” health care system in the world and it concluded that there was no best one.
The republican voters are not the only ones who can’t see the forest for the trees.
Stephen Rinsler, MD
(Retired pediatrician, current volunteer physician in a free clinic.)
3
Once again, I must swim against the tide of the comments about the effect of the Affordable Care Act. I do wish that Paul Krugman would yet read the actual contracts of people in the independent market who, by small margins, are not eligible for subsidies.
My premiums tripled (yes, THREE times) in the first several years after the ACA became effective. This blew a hole in the tightly planned finances of my early partial retirement. My actual coverage declined to the point that I do not go to the doctor short of an emergency. Ultimately, I ended up with NO coverage under the ACA when out of state except for the ambulance, emergency room, and urgent care. God forbid I should admitted to a hospital in Florida, where I spend part of the year for reasons both personal and for business. I would be bankrupt in a week. Really!
Talk about "junk insurance!"
Krugman seems unable to confront the political effect of a Rube Goldberg program born of "politics is the art of the possible." Barack Obama and Nancy Pelosi pushed legislation through a temporarily amenable congress that was so typical of the Democratic Party: well-intended but massively complicated (think Elizabeth Warren's policy papers) and which created yet new layers of bureaucracy (read: more power for the administrative state and more jobs for self-righteous, power-mad do-gooders).
After all this, progressives like Krugman sniff at the unwashed who "don't understand their own interests," and wonder how Trump was elected!
2
@D I Shaw
The Republicans have sabotaged the ACA so the effect would be precisely as you describe. This includes both the original compromises made to win their support, which they then withheld, as well as later efforts to dilute requirements that would have spread costs over a greater number of people.
So then Republicans can complain again of problems they created.
9
@D I Shaw I"m old enough to be fully retired and on Medicare. Your position does expose one of the weaknesses of the ACA, though I cannot testify to the accuracy of what you experienced or how wide-spread the problem might be. Still, the next question to ask is--"how do we fix it"? And then I'd ask you--"which party do you think will try?" Have you heard of GOP fixes? Personally I would prefer extending Medicare to anyone willing to chose it. Those with good policies provided through work or those with enough money to buy good private policies could keep what they have;
you could chose Medicare. It's good, and you could add a supplement, if you wished.
6
@Richard Miner
A public option just like the Germans have had for a very long time. Check the healthy-nations data from the World Health Organization and Kaiser Foundation to see what a small change could do for a huge percentage of our children and working age citizens.
retired federal attorney F/70
1
Yes, yes and yes.
And they will continue to vote for Trump.
5
Simon Sez: Your comment and the attitudes that seem to underlie it make a point opposite to the one I think you are trying to make. Trumpism is the savior of nothing and no one other than Dear Leader himself, associated acolytes, and the ‘movement’. How anyone can support Trump, Republicans, and other like-minded cultists as “the party of healthcare” (Dear Leader’s words, not mine) defies imagination. Don’t forget that the Trump ‘Justice’ Department has thrown its support behind purveyors of a lawsuit currently wending its way to SCOTUS that would completely dismantle the ACA nationwide!
The ACA was never intended to be a cure-all for the travesty of healthcare availability in the USA prior to ACA. It was designed to be a credible first step in the direction of providing access to healthcare for the broadest swath of the our national population not otherwise having open access to the human right that is simply being able to see a doctor when sick and on the way to becoming sicker.
Large, trail-blazing, social programs like Social Security, Medicare, Medicaid, and now the ACA require ongoing maintenance & evolutionary tweaking to achieve full effectiveness so as to remain so. That type of functional maintenance has been steadfastly opposed by a truly cruel Republican Party and its operatives at every turn. Do the right thing and drop resistance to a national system of healthcare availability for all—including but not limited to those who currently feel ‘ignored’.
The problem with state legislators making life miserable for their downscale constituents isn't a matter of the heart, but the head.
To varying degrees, Republicans have embraced the small-government conservative model. This leads to insanity such as Rep. Justin Amash (R-MI) pointing with pride to the fact that he has voted to spend less than any of his colleagues. It sounds crazy unless you can back up your stance by a belief in starving the beast when in actuality you're starving your constituents.
News flash: that which doesn't kill you doesn't automatically make you stronger. That's certainly true of health care, especially for the aged. But try telling that to a post-Reagan Republican.
5
I used to take some comfort in the pithy description of the trump administration as, “Malevolence tempered by incompetence.” I hoped that the incompetence would bungle or at least slow the malevolence.
I can’t really say they’ve become more competent, but they’re certainly more entrenched. I shudder to envision what damage and cruelty they could inflict in four more years.
VOTE as if your life depended on it - it does.
13
.
@Nancy,
.
I doubt Trump will be mentally & physically fit to run in '20
.
I was in Tennessee recently and was appalled by what I saw - morbidly obese people dominated everywhere I looked. I did a random check at one point of the next 50 people I came across. 27 were so large and unhealthy they couldn't walk very far without stopping. A few of them too. up an entire sidewalk by themselves, and these were people in their 30s, 40s and 50s. Every one of them was white. Did they do this to themselves? Yes, but poor healthcare availability makes the problem worse. And they still vote against their own interests, time after time, beaten down by fear and ignorance foisted on them for years by the GOP. What are we to do with people like this?
9
Is it the GOPs plan to keep poor rural Americans marginalized and angry so that they can be used to bolster their base? Is withholding Medicaid expansion the tool sowing the seeds of resentment about illegal immigration in rural populations?
If the poor, and disenfranchised have “someone other” to blame for their pain, why would the GOP not exploit it?
Keep the rural poor mad, and they will buy any hokum the GOP wishes to sell them. It is the only possible reason why states like Tennessee would not jump at the chance to expand Medicaid. They want a poor base disgruntled base to exploit.
4
The mindset among too many Republican voters is that I am a perpetual victim. It is especially promoted by Fox. Elites own big government. While elites are a problem, the genius of the right is to only make the ubiquitous "them" a problem when they operate through government. This is while the GOP is doing just that to government: putting the foxes in the henhouse.
Part of all victims is the huge potential to be a bully. It is a system of power. That is why Trump is revered. The rest of America is appalled by his personalized verbal abuse and attacks on women in particular. The scary part is millions who wallow in helplessness actually see the bully they cannot be as their hero on a power struggle they otherwise feel they cannot win.
The other Tea Party aspect of this is that if I am in a victim class then I will look for people who have less than me to punish so I feel some worth. So the poor, immigrants and women will bear the brunt of my anger. One must vote against Medicaid because it belongs to the despised poor and I will never be one of them. I would rather die.
Be careful what you wish for.
7
@Tom. This is so true. Republicans campaign against bad government. When elected, they make bad government a reality.
One thing Democrats can do is to stop joining in the deafening chorus of complaints against government. Every time we criticize a legislator, the Republicans smile.
3
@K. Corbin. Thank you K. FDR recognized that government could lead populist policy. Otherwise, angry populism often moves rightward toward fascism.
Government needs to be cleaned up. For instance Trump has blatantly abused government trust to turn it over to lobbyists. So why aren't the Dems calling him swamp thing? My fear is the general political MO makes everyone a bit of a hypocrite when it comes to protecting democracy when private money means power. The difference is that the GOP has no scruples when making accusations. Hypocrisy doesn't bother them in the least.
How many of the people suffering poor health care, waiting in line all night for the pop up medical clinic services, voted GOP? I am sorry to see any living being suffer, but I also believe it's time that people are held responsible for the consequences of their foolish choices. Why all the hand wringing? If these states insist on voting GOP, they are getting what they are voting for.
2
@Suzanne In all probability they did not vote.
1
@Suzanne
How many of them voted at all?
1
People who are in need of federal benefits are usually not in a situation where they can vote, or even gain the knowledge to understand where the problem lies. It is all they can do to get by, day by day. The suffering poor are not the ones supporting Trump in a literal sense. It is only the hateful and hating that support Trump. The rich who support Trump have as much regard for the working poor as they do for the refugees at the border--not their people, not their problem, just use them for their own gain.
8
Until these Red State, rural & conservative voters wake up and pay attention to who's actually hurting them, is tough to help them from the outside. In fact, it might just be a fool's errand.
2
America needs to wake up. Part of me thinks that people are just getting the consequences of how they vote. Are you really expecting any help from the politicians you voted for, that literally say "don't count on us, the government for anything"? I know that's not an appropriate comment when talking about people's health, but for sure elections have consequences. But we will keep going treating elections like popularity contests, and voting mindlessly based on absurd information.
4
Krugman's points are persuasive. In IN we have opioid crisis but many legislators are spending more time keeping wages low or trying to end Roe.
4
This story breaks my heart. Each and every one of us has had a relative or dear friend with the "emperor of all maladies", cancer, or a similar health condition. What it must be like to leave a condition untreated--I can't imagine.
Aside from winning the presidency, Democrats must take control of the Senate. Legislation to expand the ACA is a critical condition.
9
You might wonder whether the Republicans have contempt for their base, but actually the people that are hurt a) don't vote and b) might vote Democrat and c) they are "moochers" anyway. Those just above these poor people are those that have a bit better life and maybe a state employed secretary or janitorial worker in the family with health benefits and they are convinced that those "moochers" are taking from them. Great marketing by the McConnell the traitor's of the world.
5
A large part of the problem seems to be "in large part thanks to the strong Republican leaning of rural voters."
Maybe theses rural voters would finally get it if you put it in terms they understand better:
"And as ye sow, so shall ye reap."
7
Here in Maine, our former guv, Paul LePage (Trump Jr.) refused to expand Medicaid for the all of the 8 years he was in office. He used every excuse in the GOP playbook, which eventually backfired in this state made up primarily of kind, generous people. He was replaced in November by Janet Mills, Democrat, who promptly accepted Medicaid expansion, as well as a number of reasonable, humane policies. Hopefully, the GOP is doomed as people wake up and see the results of their cruel, inhumane policies. Can't happen soon enough...
15
Contrary to Mr. Krugman's beliefs, universal healthcare is not the solution to every problem. In typical fashion, he makes sweeping statements about how moving the entire country to a single government sponsored plan would be beneficial to all (it wouldn't) and embraced by all (it wouldn't). Of course, he skips completely over the cost of paying for such an endeavor (a favored approach among the far left) and pushes aside criticism of the idea by either stating (1) that disbelievers are inherently evil, or (2) that disbelievers are misinformed and just don't understand. This creates a nifty shell for Krugman to hide under when legitimate counter arguments are made, such as the fact that support for the IDEA of universal healthcare is between 55-70% but DROPS to about 37% when people learn that they would have to give up their employer sponsored insurance (source: CNN) to fund it. But hey, lets blame the Republicans and the billionaires for the fact that 150+ million Americans want to keep their current insurance....that line always seems to work with this crowd.
4
I think you need to actually read the article. He was pointing out states that didn't expand health coverage under our existing insurance plan the ACA that is paid by the federal government because Republicans are just mean and would prefer to have people suffer and actually cost us more to have suffering than to have expanded the ACA.
16
@John " the IDEA of universal healthcare is between 55-70% but DROPS to about 37% when people learn that they would have to give up their employer sponsored insurance (source: CNN) to fund it." What you fail to mention, as does the MSM is no one bothers to explain to people that overall, when you add it all up and weigh it against the existing mess we have, it is beneficial. But because the MSM are slaves to the clock and advertising dollars, you can't reduce this to a bumper sticker sized explanation.
7
What John says Mr. Krugman claims - universal healthcare is the solution to every problem.
I searched the piece and found one mention of universal healthcare: "if the U.S. were like every other wealthy nation, and provided some kind of universal health care, there would be no uninsured at all."
It seems that would be true. Nor does it state that is solves every problem. It would mean that there would be no uninsured. Hard to argue with that conclusion.
It is John who spins off into all sorts of characterizations of that simple fact.
In terms of paying we pay one way or the other. What gets me is those who refuse to have insurance can show up at the hospital and expect to be treated - i.e., the rest of us pay higher bills as result. This is what the ACA was designed to change (a Republican idea!).
Until Republicans include a provision to allow hospitals to turn leave people outside their steps to die for lack of insurance I will continue to view their stand against the ACA with cynicism.
12
Sadly the rural poor in so many red states is not enough of a voting block to cause Republican politicians to pay any attention to them. The denial of medicaid expansion in many of the red states denied adequate medical care to this unseen minority.
In Nebraska, even with a referendum that was to finally provide for expansion, the Republican governor and Republican majority in the one house legislature dragged its feet and set the implementation as a non-priority.
4
I have been baffled for years why so many in our poorest states vote Republican. This is the party that does not want to increase the minimum wage. Wants to take away government help like food stamps. Does not want healthcare for all. Does not want quality education for all. Pushed for tax cuts for the wealthy. Why do they vote Republican?
17
Because they would rather suffer than think they are being told to do something from "the coastal elites".
@Sue Thompson: Good question. The Vandal in Chief provided the answer during the 2016 campaign:
"I love uneducated people".
2
This column should be posted in every gathering place in Tennessee, read to those who attend services, participate in any activities and given out with what medicine is available to give.
Don't blame the victims, except for their votes for a Republican party which views them as collateral damage in a war of ideologies fought in state capitals and the halls of Congress.
In times of war, votes for who will lead are critical. In states like the few Republican controlled states who refuse health care access to the neediest among their voters, this war is a matter of life and death.
Cuba has done a better job than the US in reaching their rural poor. Third world countries across the globe are being funded by US foundations to get access to the very type of health care the Republican party is obstructing in the US for political reasons.
I have long time friends and many acquaintances who do still vote Republican without actually looking at the new GOP agenda. Caught up in my grandfather's view of the GOP, they cheerfully volunteer at food banks and drive people to libraries (but no longer doctor appts because the doctors have moved, died or retired).
To people with transportation, the extra time and miles are only a slight inconvenience. To the rural poor the miles are another Trump wall defining the border between life and death.
Vote Democratic Women in 2020
28
I live in TN and have watched hospitals wither and die courtesy of decisions made by our state government. Good luck if you get in a wreck on I40 between Memphis and Nashville, or your tractor flips and your kid is pinned underneath or your disabled parent needs to get to a doctor’s appointment. West TN is as much a medical desert as east TN. Why? Because people like Delores Gresham (State senator, devout Catholic, and die-hard “right-to-lifer”) and David Kustoff (Congressman) don’t care. Period. People can drop at their feet and all that matters to them is their next NRA handout and an unquestioned party line. It’s sad and frustrating, hypocritical, cruel, and immoral. Yet my neighbors keep electing the people who punish them.
3
It's an "us" versus "them" phenomenon which causes some to cut off their noses to spite themselves. Whether it's city vs village or rich vs poor or black vs white or church vs temple people in more rural areas are insular and view with suspicion things that are new or different. A demagogue can easily influence them.
11
@R. Anderson - When my husband-to-be and I became engaged over 50 years ago, I met his rural and small-town relatives, and was shocked to realize that they HATED city people with a virulent hatred. At least that's how they appeared to me. The fact that my husband and I were working toward our PhDs sealed the deal - we were so "other" they could barely speak to us. What I'm saying is that this rural/urban split apparently isn't anything new. It may be worse now, but it has been there for decades, at least.
1
When the word 'hospital' comes up, people tend to think of the seriously ill and injured. But general maintenance and vaccinations are critical for good health, and many sports activities require a cursory examination for things like heart defects or skin diseases. Then there's the problem of self-medicating with illegal drugs or quack remedies when no help is available.
Commenter John Harkey mentioned our governor in his fine post. Bill Lee is a nice guy, but he's turning out to be a wishy-washy sort who looks to the heavens to decide who should lead him by the nose. In other words, he's useless. Except to wealthy Republicans.
7
@KJ
If Gov. Lee is "useful" only to the wealthy and not to the majority of Tennessee residents, then he is NOT a nice guy.
6
@Michael Richter
By "nice" I meant affable in the usual smiling, praise-the-lord Southern way. He shakes a lot of hands and takes good pictures. That seems to be what counts around here.
2
And the funniest thing is that the Republicans leave the charge by suggesting that Democrats play “identity politics.“
A main difference between Republicans and Democrats is that Republicans are willing to allow people to suffer to make a point. Democrats bail out the country from countless Republican examples of mis-guided policies. Democrats are punished rather than rewarded as proponents of the evil government.
12
@K. Corbin
A main difference between Republicans and Democrats is that Republicans intentionally cause people to suffer to make a point. It's not a bug, it's a feature.
"He's not hurting the ones he is supposed to be hurting."
4
I'm sincerely trying to feel badly about so many of these rural people going without medical help. And I do.
However, after seeing how many of them supported their own representatives in state and congressional positions attempts to destroy ACA, I am having a difficult time overall.
If offered the opportunity to have Medicaid expansion and at the same time being told by their representatives that this is "socialism" how would they respond? If they are like a family member, they would be against it in spite of everything that would be helpful to them.
8
Everyone knows a kindhearted Republican, a person who volunteers at a church or temple, who cares for family and community members. A good person who nonetheless chooses politicians who inflict pain and misery on others.
How can this be? I can only explain it as a Venn diagram, in which the circles in which Democrats live overlap other circles that are populated by others of whichever party. The empathy circle is not tiny, nor is it exclusive.
I see the GOP circle as homogeneous, including only those nearby, either physically or spiritually (same town, same religion).
Secondarily, there seems to be an element of control inherent in these decisions: To allow people in need to find succor without kowtowing to community elders or embracing the community faith. When governments provide aid, churches lose a selling point.
Recently, my state, exhausted by Paul LePage, who I consider Trump's John the Baptist, voted the GOP out of not only the Governor's mansion but also both the state Senate and House.
At some point, voters just might get it and sneer rather than cheer when Fox and Friends tell them that they are so special that they should vote to let their roads crumble, their healthcare fail, and their environment degrade so that GOP campaign contributors can save a few bucks that can then be used to buy more ads to convince people that all will be well as long as they have their guns.
Or maybe not.
22
The ACA is a joke. I am speaking from personal experience. The only choice I had for insurance as a healthy 26 year old (employed) was an HMO plan with an 8000 deductible! Do you know what an HMO is? You must go to specific physicians, labs, hospitals, etc. You have NO CHOICE. Did you see my deductible? This is catastrophic insurance, nothing else. Does it encourage me to see my physician for wellness checks? NO. It's a joke. I am healthy, I am employed. My employer does not offer insurance and this is considered insurance? As for Medicaid? Ohio MEDICAID is a joke now that they have outsourced it to other companies such as CARESOURCE, etc. They PAY NOTHING to healthcare providers and not all healthcare providers take the newer "MEDICAID" expansion plans (what a joke). The reason the providers DO NOT take all of the Medicaid plans is because these new Medicaid companies only take a specific number of providers in a geographic area. If you are a cleveland clinic provider you are automatically in! And going to the cleveland clinic is great if you can wait 6 months for an appointment (after being on hold for 25 minutes trying to make an appointment)
2
@Piper Meona - Does it encourage me to see my physician for wellness checks?
Than that is not an HMO, not matter what they call it.
I had an HMO plan for years with my employers. And I loved it. I didn't feel restricted (I also had out of plan coverage) because the wealth of doctors in the plan.
It was my employer who took that option away and now we have more costly regular insurance. It wasn't the ACA or government.
6
@Piper Meona
So many jokes! What a great sense of humor.
A quick search at Healthcare.gov reveals that in Cuyahoga County, Ohio, there are 39 ACA plans offered with individual deductibles as low as $1000.
8
@Piper Meona
Such anger and frustration. My family and I have been on ACA for 4 to 5 years. with a high deductible. Essentially same as I had with my past private insurance (a choice I made as for a higher fee I could have had a lower deductible). I even have the same insurance company as before. Before ACA I could never have risked starting my own business because of the weak and expensive insurance available for small businesses. ACA made it possible for me to protect my family and reduce some of the risk of starting a small business.
Put the anger aside, do some homework and make a different choice.
4
While I totally agree with the conclusion of your article, I think we are making a mistake labeling lawmakers who do not adopt progressive programs as “mean spirited”. I have several friends who truly believe that government programs are the root of all evil and if those programs were gone the invisible hand would right the economy. Of course to reach that goal does require some extraordinary thoughtlessness to the suffering required to backtrack to a Hoverian economy. My question is: how do we talk? Where is the middle ground on these life destroying issues and can we listen or do we just continue fighting? Thank you Dr. Krugman for your accurate insight.
7
Valerie, as a fellow Michigander living on the conservative west coast of the state, I have also heard friends express the heartfelt thought that government-provided anything must be inherently bad, and that “big government “ is inherently evil. I gently, and persistently, challenge this sentiment at every opportunity. We must *respectfully* continually present the rest of the story, and not let the lie that government has no value continue to circulate, unchallenged.
Calling people who believe that way “evil” and “mean” is probably not the most productive way to get them to think differently and hear what you’re saying.
1
Bunk! They may believe in the invisible hand but it does not make it true. The market would favor the strong as it should and always does.
His point is about ignorance. Not about “ free marketeers “.
1
@Valerie Anderson
You make a good point but after watching our last congressmen Bishop it is hard to see him anyway but "Mean Spirited" To talk to him or his staff was beyond frustration. I can certainly have discussion with those who have contrarian opinions but Bishop and his party for the most part could not do the same.
Is Medicaid expansion under Obamacare even still available? I can’t imagine the Trump regime allowing a state to expand government health service without a brutal and prolonged court battle — a Trumpian tactic just to delay things.
The refusal by red states to take advantage of Medicaid expansion is short-sighted and selfish. The folks in those states have been had by their state legislatures and their own blind obedience to a political Party that has no interest in their welfare.
4
A healthier society is a happier and more equal one, and a comprehensive state funded health system pays back many times to society what it costs, even if some of those benefits are not quantifiable. But it has to be connected with a progressive taxation system, with the tax revenue clearly linked to health expenditure so that on healthcare clearly indicated. In this way people, especially low earners, can see and what goes on healthcare, and so can balance that with how much more they benefit. The well off can go on using private health care if they wish, of course, so long as they have contributed their taxes.
5
Why aren't the Democrats heralding the wonders of the Affordable Care Act all these years while allowing the Republican messaging machine to mold alternate realities in the nation's minds? Why can't Democrats go beyond defending their ACA and condemn the Republicans for taking away their supporters health care psychologically with lies?
Speaker Pelosi; you know I admire you, but you are not up to the masculine fight needed to promote the ACA under the onslaught of the Bears. I wouldn't write it unless I thought it had to be said to save American lives. Please give way to a Democrat Alpha Male the likes of Kennedy to fulfill the dream he began. He was a fighter, and a tough one. Thank you for being so smart all these years but remain as the Majority Whip and share your knowledge and wisdom, but this is a man's fight and no time for boutique dignity to look good. The Republicans started a fight, and a fight they should get.
2
@SHAKINSPEAR not sure where you got the idea that any fight involving non-physical combat is a 'masculine' fight and Pelosi should abdicate her power to a man. Everyone knows men have brawn and women have brains. Brains are needed to articulate the practices employed to deprive these people of base human needs to influence political outcomes. Men as lawmakers created this situation, now you want to call them in to solve it? Heck no, let the women handle this.
@SHAKINSPEAR
I can’t believe there is only one reply to this comment about the masculine superiority in a fight. Is it sarcasm I’m just not getting?
As to the fighting strength of women, perhaps you have forgotten Hilary Clinton taking on the entire foreign relations committee for ten plus hours and making them look like fools. And Nancy Pelosi, whose fighting abilities you disparage, has repeatedly taken on trump and most of the republicans.
1
How have physician groups contributed to the problems of health care in rural America? Not enough attention has been given to the personal and moral responsibilities of physicians, and the groups (like the AMA) to which they belong. True, health care is a mess in places like rural Tennessee, but is this only the fault of insurance companies or is it only Republicans? Doctors vote, and someone elected those who now block health care. Look at urban areas. There is better access in cities, but what about quality? In cities, it is all "quantity" over quality, where as many patients as possible are packed into a few short hours. It is about money. Rural patients have less money. Rural states have less to spend on health care. Patients are product. Who wants to practice in a small town where there are few opportunities to attain true medical wealth? The medical obsession with money poses dangers for patients. Physicians block access to other health care providers, too. Physicians hardly support the roles of well educated and experienced NP's and PA's. Suppose enough imaginative, moral physicians ran for office in places like Tennessee? There are doctors in Congress and the Senate, but look at there voting records on health care. It says a lot about the medical profession, why the health care of people in rural areas is so poor.
2
@et.al.nyc - It's not all about the money for physicians. Why would most of them want to live in a rural backwater? Small towns and rural areas are losing population every year because even the people born and raised there don't want to live there, and get out as soon as they have a chance.
Thanks, Dr. Krugman! Next you might want to do a column on energy companies trying to convince legislatures and voters that people trying to use less fossil fuel are gaming the system and stealing from their neighbors. Here in Illinois (a blue state) it now costs $100 more per year to register an electric vehicle than a non-electric one. The reason is that the owners pay no gas tax. The gas tax is used to pay for infrastructure upkeep (roads). Thus EV owners are getting a free ride over infrastructure paid for by people who pay gas tax. EV users are freeloaders, it is argued. The purpose is to discourage purchase of EVs. Meanwhile, in Iowa, the legislature is busy trying to pass legislation sponsored by Midamerican Energy (Huge conglomerate owned by Berkshire Hathaway pushed by Warren Buffet) which would make it more expensive for individuals and groups (including churches) to install their own solar panels or wind turbines. The argument is that by doing so, they are "stealing" from their poorer neighbors who must pay higher electric bills. Buffet's solution is that Midamerican should own the solar and wind farms so that everyone can benefit equally from the utility's monopoly. So now you know, people who want to use less fossil fuels are a bunch of freeloaders!
7
@M. Johnson
while i understand the gut feeling of unfairness about this, infrastructure must be paid for by all who use it. whether driving your prius down the road or selling your excess electricity back to your local provider , the infrastructure that allows you to do this must be supported.
5
@M. Johnson We installed solar panels on our roof a few years ago. It cost a little more than $20,000, which is not a casual expense. But we got a 30% federal tax credit on the installation and a $1,000 state tax credit. In addition to using the power we generate, we get paid for all of it (not just excess) in the form of SRECs, which we will get for 10 years. Overall, the system will probably pay for itself in about 8 years. Then the system will provide mostly free electricity for another 20-30 years.
It's a sweet deal, but the truth is we didn't need all those incentives. The utilities have a point.
There is another Republican mantra floating about which I've heard parroted by a former friend - Healthcare is not a right.
I countered with well we have a right to expect affordable healthcare but said friend was too far gone in Trumpworld for this to register.
9
@Michelle Teas
I am deeply distressed by family members who voted for Trump and feel that health care is the problem of the person and is not a government responsibility in any way.
They lovingly speak of the parable of the Good Samaritan, as if health care should be up to neighbors to offer help.
5
@Michelle Teas - "Republican mantra floating about"
First line of the Constitution.
We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.
The general welfare of the people was a primary purpose for establishing the Constitution. I'd say our general welfare and our posterity depends on our health.
What that means exactly can be debated, but the government has a stake in our welfare - our health, our being. If it doesn't it is dereliction of duty in my opinion.
And there is also Amendment IX: The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.
For Republicans the Constitution is only a weapon to get what they want or to deny others their rights and protections.
2
I hope there are people in Tennessee who will read and interpret this article into political action. As soon as I saw the WaPo piece when it ran, my first thought was, "but they didn't expand Medicaid in TN." Their article should have begun, "As one of the consequences of the choice not to expand Medicaid...." and gone on from there.
I'm tired of hearing about impact of policy on the poor beleaguered "red states" that keep making ignorant decisions for themselves. Their populations need to wake up and elect people who will act in their interests.
18
Mr. Trump's evisceration of anything-Obama has resulted in the hollowing out of options offered through the ACA. We should begin by decoupling health insurance from employment, and since it seems to be politically impossible to produce a nationalized healthcare system, we could invigorate the private sector by allowing companies to pay, to their employees, health insurance stipends, which could then be used on a (reinvigorated) national healthcare platform. So, health insurance would become part of taxable wages, and coverage would need to be mandatory. This would have the additional salutary effect of making everyone understand just how expensive health insurance truly is. Right now, coverage costs are opaque, because employers cover most of them. Only the self-employed (and CFOs) understand the costs right now, and companies do a poor job of educating their employees about just how many dollars get spent on coverage. This is a pro-business policy change which Republicans should support wholeheartedly.
Since rural areas have particular problems attracting and retaining doctors, the best policy, to remedy this, is for the federal government to pay for medical school training, with the stipulation that, after graduation (and residency and fellowship...), the newly minted doctors would "pay back" their training costs by being deployed for several years to the rural and inner city areas that have the hardest time keeping medical professionals.
5
Democratic presidential candidates should hammer away at these facts at every campaign stop. This is a good concrete topic to show the difference between right and left. For Democrats, its speaking the truth and therefore should be an easy way to score points. Its maybe the most clear issue the Democrats have besides college costs. Tone down the immigration talk and bring this topic up, please.
2
A newly minted doctor is likely to graduate with about $300,000 dollars of debt. That doctor needs to be paid, even is she is altruistic, even if he wants to help in undeserved communities. A new minted doctor cannot afford to practice in an area in which people do not have insurance to pay the bills.
They will remain underserved.
How did we address this? We walked away from the reimbursements to hospitals under the old system and walked away from the ACA as well, leaving a gaping hole in funding for people, and no money to pay those new doctors. AND we made graduate loans more expensive, assuring that doctors cannot choose to work in rural America.
Of course it is policy killing these people. But whether they have understood the genesis of that policy and demanded their own representatives to fix it is another story.
3
And let’s not forget that Trump has also reduced opportunities for loan forgiveness through service in the National Health Service Corps, which could supply junior staff to those hospitals and clinics that do remain.
4
Once again Krugman is barking at a straw man. It is clear he didn't read the full article. The people featured did not have local care options available and it was that lack of local care that tipped the scale to what led to the free clinic. Also insurance does not equal care you can afford and nor does expanded Medicaid ensure you will get the needed care. Medicare for all is not a viable answer either.
Krugman needs to get out into the real world and drive 100 miles to see his GP or wait 3 months to see them when they are in town. He needs to do a Gwyneth Paltrow and go on Medicaid for three months. He can learn how hard it can be to find a doctor that accepts Medicaid then he can learn how disinterested they are in treating him because Medicaid reimbursements are next to nothing.
1
@skramsv - The reason there aren't local care options available is because in these states that refused to expand Medicaid, the rural and small town patient mix is so heavily poor and uninsured that hospitals and doctors can't stay solvent. If these people had access to expanded medicaid, their hospitals and doctors could afford to stay in business. In my state, 15 small town or rural hospitals closed in 2018 alone, and that's following several years of previous hospital closures. I didn't see stats for closed clinics or doctors' offices, but they'd be about the same.
Just one example of how the cruel wing of the Republican party have managed to cynically deceive their base into believing that government programs that support those in need are "entitlements" and "socialism". Meanwhile, income discrepancy increases and one drone being shot down scrambles the military, the bill for which would probably support medical care for those without in Tennessee for months.
8
It is important for everyone to realize that a new "payer system", whether it is single payer or not, will not solve the problem of doctor distribution. Unequal distribution of physician care is the result of poor reimbursement and the excessive work requirement of certain payer populations. The economic realities of how many patients you need to support certain services will not change with Democratic proposals which all reduce payments to physicians by substituting more government run plans with lower reimbursements rates for doctors and hospitals.
You do not have obstetricians in the Mississippi delta because of the inability to pay one's malpractice insurance let alone make a living with reasonable work hours. Having the government pay for everyone's health care doesn't change anything.
180 million Americans purchase health insurance which covers 240 million people. According to WaPo, 80% of them want to keep their coverage. This industry employs 3 million people and 65% of Americans with an investment portfolio have stock in one of these companies. Exactly how can you justify getting rid of a pillar of our economy that people pay for and want? And in the name of what? The uninsured? Last time I checked they can purchase insurance, subsidized if necessary, on an exchange.
Every misappropriation, unequal distribution, and inequality can not and should not be solved with government intrusion. It leads often leads to graft and makes the problem worse.
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@jkemp - You know nothing about the ACA. It's for working people who earn at least 138% of poverty. Those below that income were supposed to be covered by expanded Medicaid. In the 14 states that still refuse to expand Medicaid, there are hundreds of thousands of people who have no access to affordable insurance at all. It's the poor and uninsured who have strained doctors' and hospitals' finances so much that they're facing or undergoing bankruptcy and closing their doors at a rapid rate.
I frequently agree with and often quote Paul Krugman after reading his columns. However, I completely disagree with the conclusions of this article. It is NOT Republican State politicians that caused the destruction of Government subsidized health care for poor citizens in the South, but rather the CITIZENS themselves who hated Mr. Obama and anything Obama, that they were willing to suffer dire personal consequences by voting Republican. It is "The People" and not their representatives who are completely responsible for their lack of availability to medical care. This is Jonesville all over again. When people are willing to die for their philosophical beliefs, they will, indeed, die for lack of health care.
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But those people are misled by decades of deeply deceptive coverage on Fox. It is the job of leaders to lead, and so I think Krugman is right.
The through line of the last forty years can best be understood by reading “What’s the Matter with Kansas”, by Thomas Frank. In it, he lays out a similiar thesis. Republican voters are tricked into voting against their best interests by politicians who use social issues and fear to persuade. Once elected, these politicians ignore the social issues they campaigned on, and vote for tax cuts and other preferential treatment for the wealthy and the interests of corporate America. Then the voters, increasingly being pressured by a system that ignores them, their resentment building, can be appealed to on fear again. Wash and repeat for forty years, and eventually the system coughs up Donald Trump.
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@Evan Benjamin - I live in KS. I've said for decades that Republican government hurts the average person, causing them to feel aggrieved and resentful. And then along comes the Republican party to provide handy scapegoats for their plight, stoking fear and resentment of those "others" and causing them to cling more strongly to the Republican party. The worse things get, the more strongly some people cling to the GOP. (In other words, I guess I was saying just what you're saying).
@Evan Benjamin if it is the job of leaders to lead, why are the Dems MIA? Calling the voters "deplorables" wont help you convince them to your POV
All we can do as people who believe that health care - as well as a full and complete education - is a basic human right in a civilized society that has the ridiculous amount wealth that we do possess - well, we just have to keep saying:
Health care is a basic human right of every American, and as long as any American is deprived of reasonable health care, that is every bit as wrong as depriving them of their property or their family members.
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