In defense of the ending of La La Land

 

The ending of La La Land reinvigorated my faith in humanity and helped me recover from the election.

 

With the Academy Awards this weekend you really have no excuses not to have seen La La Land yet. The presumptive best picture award winner captivated many viewers with the simple fact that in the face of all of the news and reality the country has been facing– it was fun.

 

I should note that I have seen almost all of the nominated pictures and preferred Lion and Hidden Figures but also appreciated the beauty of Moonlight. However, I credit La La Land with impacting my life more than many movies I’ve seen in recent years.

 

Like many, the election made me sad. I love our country and watching it go in a direction that I don’t agree with is sad.

 

November and December was one of the worst periods for my mental health, not only because of the election, but because of financial, personal, existential, and romantic downturns. It was in that state of mind that I went to see La La Land with my parents for our annual Christmas Day movie.

 

Spoilers

In the ending of La La Land, the two main characters break up and end up achieving all of their dreams, he to open a music club and she to become a famous actress. At the end of the film, there is a brief flashback that almost makes you feel like it is an alternative ending, completely changing much of the plot of the movie. In the flashback simply the meet-cute was slightly altered and the rest was history as the two stayed together. The flashback ends and we are brought back to the reality that they were not together and their lives continued.

 

Walking out of the movie theater I overheard many people commenting that it was a good movie “but the ending! They should have ended up together.” No, they shouldn’t have. That’s not the way life works.

 

Sometimes life is sad. Sometimes what you thought would be happy and perfect doesn’t work out. Actually, that’s what usually happens. While the characters may have been perfect for each other because they were both played by talented actors and we were meant to be cheering on their romance for the previous two hours, life is complicated and flawed. While two people can want the best for each other, they may not always be best for each other. Heartache and failure are necessary for rebuilding one’s life and building character and resilience.

 

In a world where I seem to constantly be surrounded by people and thinking that we cannot admit we are sometimes wrong (example a: American contemporary politics) and an artistic medium where life always needs to end up wrapped in a tidy bow, it was refreshing to watch the movie continue to show the “what could be” scene. Life is full of the “what could be’s” and while it is important to take time at jazz clubs to reflect on how your future could have changed, even more, important it is paramount to reflect on the success you’ve achieved alone as a result of the experience that is life.

 

This is why I loved La La Land, not from the dancing and singing (I loved that too) but from the reminder of resilience.

The problem with the NBER paper on Medicaid reducing divorce

This week David Slusky and Donna Ginther released an NBER working paper which strongly suggested that Medicaid expansion reduced the prevalence of divorce by 5.6% among those aged 50-64. Their thinking is this- prior to the passage of the Affordable Care Act, the only way that many middle-income adults could qualify for Medicaid coverage was to spend down their assets to become eligible for one of Medicaid’s eligibility groups. Many people engaged in what is known as “medical divorce” when one spouse would become ill and need Medicaid services (particularly for long-term care services that Medicare does not cover). The couple would divorce so that the assets of the sick spouse would qualify them for the Medicaid asset test (often around $2,000 for an individual and $3,000 for a couple). Medicaid expansion allows all people regardless of assets apply for Medicaid coverage so long as their income is below 138 percent of poverty. Using a difference-in-difference approach comparing states that expanded Medicaid eligibility to 138% of the poverty level to states that did not expand, the authors found that divorce rates were lower in expansion states.

The problem with this paper is that Medicaid expansion did not entirely get rid of the asset test.

Medicaid is not one program. There are many avenues that a person can get Medicaid and the benefits and structure of that program look different for each eligibility group. Broadly speaking we can qualify Medicaid eligibility into MAGI and non-MAGI eligibility. The Affordable Care Act requires all states to use the Modified Adjusted Gross Income (MAGI) to calculate the eligibility for certain types of applicants (pregnant women, children, and the newly eligible Medicaid expansion adult population). These populations receive benefits that similar to private health insurance – hospital services, doctor services, and pharmaceutical drugs. They do not receive Medicaid long-term care services. There are certain groups that are exempt from MAGI eligibility (referred to as non-MAGI). These are Medicaid programs for the blind, disabled, and those over 65. These groups receive long-term care services. This is the population that typically engaging in medical divorces because private insurance and Medicare does not cover long-term care and Medicaid is the primary payer for long-term care services. Without Medicaid, people often pay up to $60,000-$80,000 annually for long-term care services which could impoverish families.

Yes, there could be some people that are early retirees or elderly couples that might need cancer care or other expensive hospital procedures and would qualify for Medicaid expansion rather than private insurance without the asset tests, but these are rare cases of people forgoing private insurance for the Medicaid medical safety net. Although high deductibles can be unaffordable for many, it is rarely the cause for divorce.

The paper does not look at divorce rates for populations over the age of 65 in states that have expanded versus those that did not expand. This might provide a more complete picture since the population over 65 is often the people who would divorce because of Medicaid asset test eligibility. If the rates similarly have gone down, perhaps there are other factors other than Medicaid expansion causing rates to fall.

Asset tests are prominent in Medicaid long-term care programs. In California, the asset test for a couple to qualify for Medicaid disability coverage was $3,000. California has not increased that amount in nearly 30 years. The value of that asset has halved since it was put into place in 1989. We haven’t eliminated asset testing and by believing they aren’t a problem we have made them worse because they have reduced in value. I wrote a longer explanation of the problem here.

The financial security that Medicaid provides does have large scale effects. Financial insecurity is a leading cause of divorce in the US and it is conceivable that more financially secure people because of the safety net of Medicaid expansion are less likely to divorce. However, reduced medical divorce to avoid asset tests is not happening because asset tests are alive and well in this country. I suggest that this may be the mechanism for the reduced divorce rates in those states. Alternatively there are many other causal factors that could be reducing divorce but asset limits are unrelated.

Where I am right now.

A few days ago I ran into a friend who I have had two conversations with prior to seeing her again on the street. She told me, “I’ve been thinking a lot about you over the last few days. All of the feelings of sadness that I have, I just envision that you are experiencing them 10 fold.”

Ladies, get out of spin class and on a bike

I ride two bicycles, one for commuting and one for happiness (going fast). Sometimes when I’m on my bike I get sad. I know, I said I have a bike for happiness, and trust me it makes me unbelievably happy.

But when I’m out riding the trails and going fast, I rarely see women on bikes. On a typical day I’ll pass dozens of  men with fancy bikes and riding gear “going fast” (let’s face it, I leave all of them in my dust). But I rarely see women out riding. In fact, I often get looks of confusion or maybe pride from men out riding. One time, when I passed a group of male riders, one said “oh hell no, we can’t let a girl beat us.” It’s so rare to see women on the trail that it seems foreign, even in Massachusetts.

Cycling requires some high up front costs and yes, it can be dangerous. I’ve gotten hit 3 times and have the scars and bruises to prove it. But I also have tripped running a dozen times and have the scars to prove that as well. My knees are basically scar tissue.

When I go to spin classes they are usually 60-80% female. So I know women know and enjoy riding.

There is something magical about the wind in your hair and the sun shining down on your face. Boston has some beautiful trails and it takes about 5 minutes to get from the bustling city to nature.

I’m really only writing this to remind myself how much I love cycling and how much of a badass it makes me feel like for the next time I’m lying on my bed too lazy to hit the trails.

Presidents’ Day

Every year I take the Federal Presidents’ Day holiday seriously and observe a President by learning about them and their lives. This year was a biggie- #16.

Here are the things I learned about our greatest President:

1. Mary Todd Lincoln, has often been called bipolar. I’m partial to think that the crazy label was a lot of pre-feminism, pre-suffrage understanding of her. She had a rough life (as if life in the mid-19th century wasn’t rough enough already) and was scrutinized in the public eye more than any other woman of her time. She was very well educated, getting a graduate degree and had dimples (like me!). When Lincoln met her he said “I want to dance with you in the worst way.” and she told her cousin “he certainly did.”
     -Bonus fact! Mary was originally courted by Stephan A. Douglas but she went for Lincoln instead. Yeah, that’s right. The Douglas of Lincoln-Douglas debates. No wonder it was so fiery!
2. On to another romantic angle to Lincoln, he was ghosted! For those of you not familiar with the term, read this. Lincoln was originally courting a woman named Mary Owens for about a year, even getting her to move for him. He proposed to her in probably the least romantic way possible. This seemed to cause problems in their relationship and he sent her a letter saying that it would be fine if she ended things. And she never wrote back!! Melodramatic Lincoln said he’d never find love again after that failed attempt. Very soon after, he danced with Mary Todd. Marys, amiright?
3.  It’s been noted that Lincoln initially never wanted to embrace the slavery issue, but he had a record of fighting for justice. Long time readers will remember 2011 when we learned about James Knox Polk. During this time Lincoln was serving in the House and was opposed to the Mexican American war. He drafted the Spots Resolutions that demanded to know the exact spots where blood fell in the war. Polk had said that we were attacked on American soil; good old Abraham didn’t believe him. Of course, no one really cared about Lincoln and his first and only term he promised to his district ended.

Medicaid at 50: Catch up day 12: Autism

The CDC estimates that nearly 1 in 68 children are diagnosed with Autism Spectrum Disorder (ASD). Children with autism require special services beyond the regular medical system– social services and supports. Last year, CMS, recognizing this special need, released guidance to states about how to provide services for these children under their Medicaid and CHIP programs. Check it out! 

This week People are gathering from across the country to talk about Medicaid coverage of ASD in Iowa.

One major topic of that conversation will be how to improve medication management for children with ASD and other mental impairments. 2/3rds of children with ASD are prescribed antipsychotic medication, many more than one. One problem is that little is known about how long to keep kids on these medications or what effect they have on children when combined.

Medicaid covers about 1/3 of children with behavioral health disorders. It is increasingly important to the treatment and coverage of mental disorders and the directions that states take in this area can have broad impacts on the private market.

Catch up – Day 12 – Medicaid at 50: State Highlight: Colorado

Basics: Colorado Medicaid covers: 1,244,031 lives

Colorado has been on the vanguard of accountable care in Medicaid. They started their Accountable Care Collaboratives in 2011 (the Affordable Care Act was just 1 year old!) with the goal of improving outcomes and saving money by using a medical home model embedded in a regional coordination strategy supported by strong data. Colorado Medicaid has produced this exciting YouTube video to teach us more!

As we look for evidence on how different models of ‘accountable care’ work, Colorado is great because they are a couple of years in and so are starting to produce some results. Plus, they’ve built strong data and analytics into their work to facilitate both patient care and evaluation. According to their 2014 Annual Report, last year the ACC overall (there are regional care organizations) generated $98-102 million in medical savings, and spent $69 million on administrative costs, for a net savings of $29-33 million.