​On January 26, 2016, the U.S. Preventive Services Task Force issued a report advising that primary care doctors screen all adults for depression. They advised that such screenings can raise awareness of the common and treatable nature of many mental illnesses. This is particularly important given the potentially fatal consequences of untreated depression (with 41,000 Americans committing suicide each year, 90% of which are associated with mental illness according to the Centers for Disease Control and Prevention) as well as the economic impact of costing the United States $210 billion per year (40% of which are related directly to depression specifically, as well as indirect costs such as losses of productivity).
 
Such advisement was in keeping with an already noted trend of primary care doctors – trained as internists – treating many patients for mental illness, with more than a third of patients relying solely on their PCPs for mental health treatment given limited accessibility of care in many regions as well as concerns about stigma.
 
Given both the prevalence of mental illness and the high degree to which physicians outside of psychiatry are treating mental illness directly or incidentally to other medical conditions, it is important to evaluate the ways in which non-psychiatrists treat patients with psychiatric histories. Do they treat medical conditions equally for patients with or without histories of mental illness, or are there intentional or inadvertent practices that discriminate in the management of health conditions?
 
A firsthand account of this was taken up in a 2013 New York Times op-ed, with the author Juliann Garey noting the numerous occasions in which her medical conditions were not treated seriously once the treating physicians noticed her history of bipolar disorder and her medications to treat it. From being given only Tylenol for an ear infection that soon resulted in a ruptured eardrum and permanent hearing loss, to being scolded by her gastroenterologist because of co-existing psychological and stomach problems, she found that the nature of treatment was noticeably poorer once it was revealed to her provider that bipolar disorder was in the mix, a phenomenon referred to as “diagnostic overshadowing.”
 
The term was coined in 1982 to characterize physicians’ potential propensity to attribute physical symptoms to mental disorders, yielding bias in diagnosis in treatment. Thus, if a patient with a depression history is having digestive symptoms, they might be more quickly attributed to stress as opposed to leading to a GI workup. Mild chest pain might be more quickly attributed to anxiety than a cardiac arrhythmia. While the initial instincts may well be accurate in the end, the disparity in treatment quality may be problematic.
 
By and large, I have been immensely fortunate in that despite a history of depression and a complex medical history, both have been treated seriously, with my physicians highly invested in my recovery in both domains and treating my health conditions with dignity and professionalism, often going above and beyond the call of duty. I cannot say enough good things about my primary care provider and the specialists I have had over the years. However, a recent and quite severe experience with this at SSM St. Mary’s Hospital in St. Louis, MO necessitates some further discussion on this matter of discrimination on the basis of mental health from those in whom we trust for our care.
 
Having entered their hospital care by ambulance after severe complications involving psychotropic medications, it was revealed that my previously diagnosed endocrine conditions were acting up at dangerous levels, with electrolyte abnormalities that were worse than in any of my medical workups to date and such electrolyte abnormalities associated with a significant potential for cardiac complications.
 
Despite my having had prior discharge paperwork from only three weeks earlier to attest to their knowledge of my medication list and dosages to manage chronic parathyroid and stomach conditions, they neglected to provide me with my normal medication regimen, even with the increasingly severe electrolyte abnormalities with which I had presented in their emergency department. Multiple conversations with multiple nurses and the attending physician failed to result in their correcting the numerous deficiencies in this regard: one medication would be approved but another not, another medication prescribed for four times daily (calcium carbonate, hardly carrying any addictive properties) authorized for only once daily. What’s more, the attending psychiatrist ordered the discontinuation of all psychotropic medication without ever once informing me of the decision, let alone explaining the rationale. (It is worth nothing that cold turkey discontinuation of one of these medications, Klonopin, is considered to be medically dangerous).
 
To fail to so much as inform a patient as to the medications that they are being prescribed, or from which they are now barred, is an act of unprofessionalism. To justify it on the grounds that the patient has a history of severe depression adds a further dimension to this maltreatment, which is discrimination on the grounds of mental illness (covered by the Americans with Disabilities Act of 1990) not only from primary care medicine but also from psychiatry, the very subspecialty of medicine designed to treat these illnesses. It should thus come as little surprise that I left the hospital with declining electrolytes and more noticeable symptoms given their lackadaisical mode of treatment and diagnostic overshadowing that, if in a patient more critical than I, could have resulted in much more significant complications.
 
While it is perhaps understandable to take with a grain of salt a medical report from a psychiatric patient, particularly one whose condition contains psychotic features or delusional thinking (neither of which typically applies to unipolar depression), prior medical records and prescription records from pharmacies, and the ability to consult with one’s primary care physician should assuage concerns in this regard and should not result in the failure to adequately treat the medical needs of those who have co-occurring medical and psychiatric disorders and move beyond these discriminatory treatment practices.
 
In a perfect world, such a change would be in the interest of all parties – certainly patients, but also for physicians seeking to do their best jobs in treating their patients, depressed or not (though such an approach may admittedly result in more insurance claims). More realistically, practices will be adjusted strategically on the basis of risk aversion with respect to medical malpractice litigation. With any luck, with more primary care physicians involving themselves to some degree in the mental health care of their patients through routine screenings and such, so too will there be increased understanding of mental health among PCPs whose work had not previously focused on such conditions, and with that greater knowledge in treatment, also greater compassion and thoroughness in treating other conditions in those same patients. 

Reported on April 9, 2016, the Commonwealth of Massachusetts ordered that 4 Arbour mental health facilities -- those in Pembroke, Quincy, Westwood and Jamaica Plain, with a combined 363 psychiatric beds -- all owned by Universal Health Services, “urgent patient care and life safety violations.” This is only further and growing evidence of the lack of care with which Universal Health Services continues to provide mental health treatment in its monopoly of care around the nation.  

The Massachusetts Department of Health and Safety is reportedly empowered to halt new admissions to these facilities on the grounds of these egregious safety violations revealed through recent inspections are corrected:

"The state agency did not specify the violations uncovered at the facilities, but Pembroke Hospital has come under fire by state and federal regulators since late August when a 20-year-old patient, Amber Mace, was found dead in her room at the hospital. Mace had been dead for at least two hours and her body was already in “full rigor mortis” before any staffer at the 120-bed hospital took action, according to state investigative reports obtained by The Patriot Ledger from the woman’s family. Pembroke Hospital staff was supposed to check on patients’ well-being and verify signs of life at 15-minute intervals through the night, but the safety checks were done improperly because staff did not actually enter Mace’s room and watch for signs of Mace breathing, according to state reports. The state determined that Pembroke Hospital created a 'dangerous and inhumane' condition for Mace and said the policy and treatment failures could have prevented the young woman from receiving meaningful treatment."

The pervasiveness of such substandard are provided by this organization is becoming increasingly clear, and should not be tolerated by state agencies or by the organization itself. 

​October is without question my favorite month of the year (postseason baseball and the peak of election season and Central Park at its most beautiful in hues of red and orange? Where can I sign up?). However, despite the disregard with which my favorite poet famously spoke of it (“April is the cruelest month…”), April is in fact a close second for one reason only: the resumption of regular season baseball.
 
Some who look at my profile – political science academic, classic movie buff, walker of the fine line between cat person and cat lady, music junkie, and all-around proud intellectual nerd and politico – may find surprising my almost unmatched affection, nay, deep passion and conviction, for this sport on which I grew up and have continued to watch vociferously. It is true that it will never measure up to music in my book. Nothing can. There are never words so quickly loneliness-inducing as “I’m sitting in a railway station, got a ticket for my destination…” as wistful and dreamy as “The screen door slams, Mary’s dress waves…” as romantic as “These arms of mine,” as rage-inducing as “London Calling,” as quick to leap to my feet and dance (badly) as “Start me up.” And there is something about the opening guitar chord to “A Hard Day’s Night,” the opening harmonica chord of “Thunder Road,” and the opening drumbeat of “Graceland” that fills me with unmatched joy, knowing that even in a world seemingly intent on breaking my heart six ways to Sunday, at least for the next three or so minutes, all is right with the world.
 
But there is also a similar sound that is comforting in a way less accessible to those not as well-acquainted with the sport, and lost entirely by those watching baseball on muted televisions in bars. The sound to which I am referring is the meeting of the ball and the bat when you can hear just from the sound that it is a home run. Second only to my cats’ purring, I do believe it is my favorite sound in the world, and yet it is not easy to explain to those whose knowledge of baseball does not extend beyond discussions of steroid usage and the magical and romantic (though not in the traditional sense of the word) film Field of Dreams.
 
But you see, baseball is in my view (and I say this with the caveat that Cal Berkeley football (go bears) is the only other sport that I follow) the most magical and most romantic sport, for while we are unlikely to ourselves witness the return of Shoeless Joe Jackson, at the bottom of the ninth inning with runners in scoring position, virtually anything is possible. The right swing of the bat, the right sound echoing through the stadium as the bat meets the ball, and you’re looking at extra innings (and it’s still early April, so potentially coldly so). And that is just with regular season.
 
Postseason baseball is its own peculiar set of triumphs and trials, with some of the statistics with which we evaluate players (batting average, home runs, RBI’s, ERA’s, strikeouts, etc.) seemingly conditional upon playing in regular versus postseason, with some large treatment effects among the players. Some psych themselves out of the games. Bonds, for example, was a phenomenal players who was far more valuable during the regular season and seemingly choked postseason. Others look October in the face and say “bring it on.” Those are my favorites. Buster Posey’s grand slam in a 2012 playoff game against the Reds, and Madison Bumgarner’s flawless pitching against the Royals in 2014 will be forever burned into my brain. And yet even without a personal stake (to the extent that one is personally invested absent stocks or financial bets), I still find myself biting my nails when a friend posts a clip from a 1990s game involving the Chicago White Sox (a team for which I have rooted when dating a White Sox fan but am other otherwise unaffiliated). The White Sox were losing by a couple of runs going into the bottom of the ninth inning, but had loaded the bases. (Conversations as to the proper conditions under which to take out pitchers in such conditions can go on and on – for every story of a pitcher collecting himself and squeaking by with runners stranded, others can recall the first pitch by a new pitcher yielding an RBI or worse, though there appears to be consensus in St. Louis that Mike Matheny is too slow to change pitchers). Ventura, now the team’s manager, stepped to the plate. Even on this older footage, one can here the CRACK! of Ventura’s grand slam that won this game that had previously seemed a lost cause. How can one not be romantic about baseball?
 
It is not without at least some measure of reservation that I profess my profound love for baseball, not least of them being the notoriously conservative nature of the game, standing in stark contrast with my left-of-center preferences. Polls have shown a Democrat-Republican divide between football and baseball, with my political and sport preferences misaligned, and there are countless accounts of the baseball management funds contributed largely to the Republican Party (the Chicago Cubs are the leader in this regard). My home team of the San Francisco Giants has been fairly apolitical, and the New York Mets (I lived in New York City during graduate school) took a stand against gun violence in New York, though my current local team of the St. Louis Cardinals unfortunately allowed its mascot Fredbird to be photographed at a police rally while holding the sign “police lives matter” after the riots over the Ferguson shooting of Mike Brown and the acquittal of the (white) officer involved. I felt betrayed by this sport that has given so much joy, though also anxiety over the many years (I feel as though I’m writing about a relationship).
 
And yet for all my deep-rooted animosity toward the establishment for which the New York Yankees stand, sitting in the upper deck with a close friend at the new Yankee Stadium (where I committed to rooting for the Yankees only because they were playing the Bush-affiliated Texas Rangers) during a two-hour rain delay and watching the pinstriped footage of the greats, so many of whom had been on the Yankees, it was in fact quite difficult not to develop at least some measure of admiration for this team that had fostered such talents as Mickey Mantle, Joe DiMaggio, and Babe Ruth.
 
One of my favorite screenwriters is the oh-so-delightfully-cynical David Mamet, who in his film State and Main has a cheeky exchange between Alec Baldwin’s character and a child getting his autograph:
 
            Baldwin: Chuckie, what’s your favorite sport?
            Chuckie: (yelling) Baseball!
            Baldwin: Baseball… Well, that’s the national sport.
 
Silly and contrived though this exchange is, and intentionally so mind you, there is some truth to it. Baseball is distinctly an American pastime, and has historically been associated with patriotic wartime efforts such as the introduction of a women’s league while the able-bodied men were overseas fighting in World War II (see A League of Their Own if you haven’t yet). And it is dominated by another great love of mine, statistics, over which modelers and followers alike obsess in aspiration of better predicting in this moneyball game that in many ways is special because it is dominated by the intangible hope and spirit. Though of course, statistics are fun to mull over, e.g., pr(Cardinals win| playing Cubs), which is for reasons inexplicable to those out of the loop, different than the probability of success against a comparably ranked team. Statistics seem to defy games involving arch rivals. Bit if I left my heart in San Francisco, my heart likewise will forever remain with the San Francisco Giants (Gigantes!), win or lose, October season or not.
 
And so as a non-romantic in life, I find myself romantically drawn in to baseball every April to October (and my whiskey consumption increasing correspondingly). The season is young and full of possibilities, and I for one am eagerly awaiting what it will bring as these players – strangers in most ways but old friends in some strange sense – continue to “go the distance.”

​I don’t make it a general quest to attack members of my own political party. Indeed, I am notably tight-lipped in most cases and in general elections need to know only whether a D or an R follows the name of the candidate, but Sanders supporters have officially put me to the test. Sanders does too, and I have written previously on his frustrating positions on guns and on mental health (which he unfortunately discusses often in conjunction with one another), but his followers seem even more extreme than he, with as many as one in four Sanders supporters now saying that they would not vote for Secretary Clinton in the general election should she get the Democratic nomination. Sanders’ recent attack on her lack of qualification is, however, a new blow, especially given Clinton’s status as “one of the most broadly and deeply qualified presidential candidates in in modern history” according to the New York Times.
 
I know the pain and frustration of losing in a primary race (dare I say, “I feel your pain”). In 2004, I spent much of November and December writing letters to Iowa voters on behalf of Howard Dean through coffeehouse meet-ups, telling them of the importance of caucus participation and why I believed that Dean’s progressive agenda was what the nation needed in that time of war and economic depravity. We all know how that ended. I loved Wes Clark’s expertise on the Republican-owned issue of national defense, though I knocked on California doors and made nation-wide calls on behalf of the most populist message of John Edwards. When John Kerry became the presumptive nominee, I was not my most satisfied, though I liked him and his strong environmental and foreign policy credentials (not to mention affection for Springsteen),and I worked anywhere from 15 to 30 hours per week on his campaign – making calls, knocking on doors, registering voters, putting up signs, helping with house parties and the coordination of events at which he or Edwards (or even Clinton himself) would speak, and turning out the vote tirelessly during GOTV (later dubbed GOTMFV) until the minute that the polls closed. I had my second drink ever while curled up in a ball on the floor crying that night, dismayed by the Ohio voter disenfranchisement at the hands of Ken Blackwell and devastated that our hard work and faith had not been rewarded but rather left us with a second Bush Administration that turned out to be worse than the first, which we had not at the time imagined possible.
 
In 2007 and 2008, I worked locally on behalf of Hillary Clinton, believing her to be the most electable and qualified candidate, with a policy agenda whose progressivism exceeded that of her husband. I made calls on her behalf and had booked a flight to Iowa for GOTV, though unfortunately had to forgo the opportunity on account of emergency wisdom tooth extraction. I twisted the arms of Nader 2000 voters who I claimed (rightly!)  that they owed me and owed the nation for their prior poor reckless judgment as to throwing away their votes. When Obama became the presumptive and then official nominee, I returned to house party organizing, door knocking, and phone banking, and took an overnight Greyhound bus from Washington, DC to Winston Salem, NC, where I mobilized voters in housing projects and other poor communities and ran Election Day Phone banks for over 50 precincts in a state that Obama won by a mere 25,000 votes. I did the same thing in State College, PA at Pennsylvania State University in the 2012 election cycle, which garnered a more substantial statewide victory, despite winning the county by only 100 votes. Do not let anyone tell you that your vote does not matter.
 
The point here is not to flaunt my campaign experience (which for the record I have vastly abbreviated), but rather to emphasize the valuable work that can be done for one’s own party even if not working for one’s candidate of choice. After all, despite my love for politics, my primary record is not the best as I have just shown you. The fact is, if we array candidates on an ideological spectrum from -1 to 1 in keeping with NOMINATE ideological space (McCarty, Poole, and Rosenthal), where -1 is the most liberal and 1 is the most conservative and our dream candidate is located at -.88, to sit out the election is in effect one less vote for a candidate who is at -.70 and who is being made electorally vulnerable and susceptible to letting the election go to a conservative candidate whose ideal point is at, say, .72, thus a radical rightward shift from the status quo policy location.
 
The reality in a separation of powers system is that presidents rarely obtain policies are actually at their actual ideal points. Politics is the product of compromise with Congress (currently controlled by the party opposing the president) as well as considerations about the courts and interest groups, and thus a president’s platform is rarely a 1 to 1 mapping with policies ultimately produced. Rather than holding uncompromisingly to the particulars of certain policies to which one holds dear, one should consider broad-based policies and values – pro-environment versus supporting environmental deregulation, pro-choice versus pro-life, pro- or anti-Affordable Care Act expansion, civil rights protection, business regulation, tax policy (especially with respect to the wealthy), etc. – and the political tenacity and bargaining power to accomplish the maximal degree of that policy agenda. The extremism espoused by Susan Sarandon and others epitomizes the narrow-mindedness of those on the far left (and to be sure, there are equivalents on the far right with respect to Trump) that leads to an unproductive campaign of misinformation and intra-party squabbling that can produce outcomes vastly contrary to the preferences of those spouting that very all-or-nothing ideology that is nothing short of immature (if not negligent). If people insist on being so vocal in their political convictions, they should consider more squarely the longer-term consequences of their public statements, so as not to mobilize ill-advised non-participation in politics or else participation contrary to the principles for which they purport to advocate. 

​I’m going to do something unusual now: I’m going to defend a Republican. Not on policy, mind you, but because of the personal nature of one of Trump’s recent attacks, in this case targeting Heidi Cruz for her history of depression.  
 
The gendered nature of this election cycle has not escaped anyone, from the obvious point that the leading Democratic contender is a woman, to Trump’s notoriety for sexist remarks on the campaign trail. Most recently, he tweeted to his opponent Ted Cruz regarding Cruz’s bout of depression approximately ten years ago.
 
Despite ongoing (and increasing) attention to mental health issues, along with discussion of the remarkable prevalence of mental illness (approximately 1 in 5), there remains persistent stigma attached to these diseases. Part of the reason is that it is difficult for those on the outside to understand. Though scientists are developing better diagnostic criteria, there is not an easy blood test, not everyone is responsive to medication, the symptoms are not as visibly physical (relative to, example, bleeding or breaking bones), and powering through the symptoms of depression is not nearly as easy a feat as one might believe. Celebrities’ “coming out” about their own struggles (or more sadly, their suicides) arguably promotes more open conversation about these challenges, and in turn facilitates people viewing it as more acceptable to seek out help. Patrick Kennedy and Tipper Gore notwithstanding, however, we see little firsthand discussion of this in the political sphere, making the Cruz case noteworthy.
 
Heidi Cruz said, “When I came out of Washington and the White House, I didn't feel that there was really a glass ceiling in the administration ... and Texas was very different,” with the “traditional culture” and social environment less hospitable and perpetuating her feelings of depression. She was reportedly found in 2005 by an Austin police officer, appearing to be a danger to herself. Her transparency on the matter is noteworthy. A Cruz advisor responded to the Trump attack by saying, “About a decade ago, when Mrs. Cruz returned from D.C. to Texas and faced a significant professional transition, she experienced a brief bout of depression. Like millions of Americans, she came through that struggle with prayer, Christian counseling, and the love and support of her husband and family.”
 
Apart from the question of whether candidates’ spouses should be fair game for attacks, in particular of such a personal nature, there is the fact that it frames the issue of depression as something to which one must “confess” and can be “accused of,” rather than a medical condition for which she appropriately sought treatment. Such a characterization of depression only further reinforces people’s sense of shame, reticence about symptoms, reluctance to reach out for help, which can be dangerous and even fatal depending on the severity of the condition.
 
There are many grounds on which to criticize the political extremism of Ted Cruz or even Heidi’s political influence in his campaigns. However, reinforcing the closeting of depression by attacking Heidi on these grounds is a major (and dangerous) setback in the treatment of mental health conditions. 

In 2008, I had the privilege of working on the presidential campaign staff in the oh-so-scenic terrain that is Winston Salem, NC, which at least at the time smelled exactly as it sounds like it would. Turning out the majority minority housing projects and over impoverished areas, I spoke with individuals who well into their thirties, forties, even fifties, had never voted, let alone had campaign workers on their doorsteps. After all, the perk of having such a well-resourced campaign is being able to touch the less reliable voters who would reliably be allies, and turn them out to the polls. By a margin of only approximately 25,000 votes, Obama won the state. 

In the 2012 campaign, I spent the home stretch in State College, Pennsylvania, a region notoriously low in turnout due to electoral institutions that systematically depress turnout (e.g., no early voting, excuse required for absentee voting). While the courts had put a stop on the photo ID  law, confusion was rampant, with signs throughout the region claiming that voters had to present photo ID (their response to challenges was that they were "preparing voters for the next election") and voters not being clear on the fact that while poll workers were entitled to request photo ID, they were not entitled to require it. Some erroneously walked away from their polling places due to photo ID confusion. Others, seeing long lines due to the absence of early voting and the like, opted out of the extensive wait time. Such conditions should be anomalous, but sadly are not.

Florida 2000 notwithstanding, the chances of one's own vote determining the election outcome is indeed infinitesimal. That said, with many reasonably narrow election outcomes we can see easily how shifts in the laws can powerfully impact the likelihood of one being able to vote (and certainly of being likely to vote), with constraints on voting rights disproportionately hurting the poor and minorities, demographic groups that typically vote Democratic. 

A number of tactics -- from felon disenfranchisement to constraining early voting to photo ID laws -- have been employed across the country to supposedly crack down on voter fraud, though in effect disenfranchising voters unlikely to be in the Republican camp. Only Maine and Vermont allow prisoners to retain their voting rights while incarcerated, with other states demonstrating a range of constraints. 19 states now require that one present photo ID in order to vote, with an additional 14 states requiring non-photo ID. Obtaining a photo ID is not costless. I, for one, do not have a driver's license. Obtaining my California state ID came with a fee, which if required to vote could constitute a poll tax. This does not even account for the time needed to obtain that ID during business hours, or the forms of other identification needed to obtain a state ID or driver's license (e.g., passport or birth certificate).

North Carolina is the latest controversy with respect to voting rights, with the implementation of a photo ID requirement and 218,000 registered voters, disproportionately African American, lacking the necessary government identification in order to cast their votes.  Such an effect is particularly stark when considering an investigation into voter fraud revealing only 31 credible instances out of one billion votes cast, calling into question the validity of the justifications for this legislation. 

The Nation detailed this recent struggle of a North Carolina voter: " In September 2012, Douglas’s niece, Clara Quick, took her to the DMV in Laurinburg, North Carolina, to get a state photo ID. Douglas was told she needed a copy of her birth certificate to get an ID. So they traveled across the state line to Dillon, South Carolina, where Douglas was born, to find her birth certificate. But the government office there said she needed a photo ID to get a birth certificate, and Douglas was caught in a seemingly unresolvable catch-22...  Her niece called the South Carolina’s Vital Records office, paid $17 for an expedited birth certificate, but still couldn’t get one. Instead, she was told to find her aunt’s marriage certificate, which was in Bennettsville, South Carolina. After getting that, they made a second trip to the North Carolina DMV, but were once again told Douglas couldn’t get a photo ID because she didn’t have a birth certificate.  They were so frustrated that they gave up trying for a time. In the fall of 2013, after North Carolina passed the voter ID law, they made a third trip to the DMV. An employee told Quick to get a census report to confirm her aunt’s identify, which she purchased for $69. Quick brought her aunt’s census report, marriage certificate, Social Security card, and utility bill during a fourth trip to the DMV in September 2014 and was finally able to get her the photo ID needed to vote." There is little ambiguity as to the motive, and the effect, of such laws being in place.

The Supreme Court's holding on the Voting Rights Act paved the way toward greater constraints on voting rights in southern states with histories of discriminatory practices. Moreover, the xenophobia by which some of the current primary debates (ahem...Trump) could aptly be characterized only further perpetuates the racial tensions underlying these voting constraints. Indeed, North Carolina's photo ID law (along with cuts to same-day registration and early voting, which can have the effect of producing long Election Day wait times and in turn suppressing turnout) was passed oh-so-subtly a mere month after the Supreme Court's VRA decision. Consider this statistic: in recent elections in North Carolina, African Americans were twice as likely as whites to utilize same-day registration, early voting, and vote out of their precinct. 

Rather than simply seeking to outperform their opponents, coalitions have turned increasingly to such suppressive tactics to limit the pool of eligible voters in ways that disadvantage minorities and the poor, thus being both anti-Democratic and undemocratic. In addition to calling attention to the pervasive racism that still remains in much of our nation, it highlights the striking impact of Supreme Court holdings on key civil rights (and other) issues. Clinton has begun to make the Court a central issue in her campaign as she addresses voters about the dangers of the extremism and racism promoted -- or at least motivated -- by Trump. We won't have long to wait to see whether the Senate is responsive to public support hearings for Garland, the prospective replacement for the late Justice Scalia and a game-changer with respect to Supreme Court politics and the preservation of basic voting rights for the American electorate. 

​Many commentators and scholars have called attention to the importance of filling the Supreme Court vacancy left by the death of Justice Antonin Scalia given the lack of precedent for Senate inaction on the Court within a certain time frame. On principle, President Obama is still the president and thus is entitled to nominate justices to the Supreme Court, as he did with his nomination of Judge Garland, and the nominee should be entitled to confirmation hearings.  
 
There are also pragmatic concerns. On Wednesday, the Supreme Court heard oral arguments for a case regarding religious accommodations to the contraceptive mandate under the Affordable Care Act (ACA). Justice Anthony Kennedy typically serves as the swing vote siding more often than not with the conservative wing of the Court. In oral arguments, Kennedy appeared sympathetic to the substantial burdens of those working to opt out of contraception coverage in health plans under the ACA, though he posed questions in both directions of the issue. If Kennedy votes with the liberal wing of the Court, Scalia’s death will not be consequential for the case, but if Kennedy aligns with conservatives, we will have a 4-4 split. In the event that the Supreme Court is indeed evenly split, as appears fairly likely the case, lower court rulings rejecting the Christian organizations’ challenges would stand.
 
Kennedy’s record on reproductive rights is mixed. He voted with the majority in Planned Parenthood v. Casey, which reaffirmed Roe v. Wade but nevertheless allowed states to impose a number of constraints on abortion access provided that such laws do not pose an “undue burden.”  However, he also authored the majority opinion in Gonzales v. Carhart, which upheld the Partial-Birth Abortion Ban Act of 2003. And in 2014, he authored a concurrence in Burwell v. Hobby Lobby, in which the Supreme Court held 5-4 that the Religious Freedom Restoration Act (RFRA) allows a for-profit company to deny employees contraceptive coverage given the religious objections of the company owners. So which Anthony Kennedy will we see in the resolution of this case? Time will tell… 

In  a recent visit to the emergency room (side note: one of its "frequent flyers" is a wanna-be singer, dabbling in opera it sounded like), it was brought to my attention that while most of the hospital was in-network, the particular division of doctors to which I needed access was not. It was a Saturday night. The insurance company was closed. And the dreaded phrase came up regarding transfer to another in-network hospital when it became clear that a hospital admission would be necessary: "insurance preauthorization required."

It turns out, despite the fact that peoples' propensity to get sick is not exclusive to insurance company business hours, insurance preauthorization often is required for the transfer to another hospital facility, or for certain procedures to take place. This can result in unnecessary delays in obtaining needed care, or being transferred to less reputable facilities that do not carry certain restrictions. 

The Department of Health and Human Services defines insurance preauthorization as follows: "A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost." Such requirements can in some cases lead to extensive persuasion by doctors to insurance companies (that is, those who are not medical professionals but on the business end of the deal) that certain procedures, tests, transfers, are medically necessary. Issues of preauthorizations absorbed in 2006 an average of 1.1 hours per week from primary care providers, 13.1 hours per week of primary care nursing staffs, and 5.6 hours per week of primary care clerical staff. While insurance companies are barred from imposing prior authorization rules in the context of emergency care, some issues regarding interfacility transfers still apply, and should it become clear that a battery of tests must be ordered in the near future, a patient nervous about an impending diagnosis and treatment may have a barrage of insurance inquiries awaiting them first. 

The fact is, this is just one of many ways in which we have nominally worked to expand health care insurance coverage while simultaneously making it profoundly difficult for people to actually utilize those benefits. Whether it is a large deductible that one must meet before benefits kick in, a large out-of-pocket maximum such that expenses can continue to aggregate, or a large coinsurance that can lead one to such conditions as asking their doctor to run fewer or less expensive tests, we often find ourselves crafting policies that perhaps work well enough for those wealthy enough to afford the out-of-pocket costs or poor enough to obtain government-sponsored insurance and credits, but with the middle class continuing to get squeezed. The matter of insurance preauthorization is in fact an equalizing force in that it is not about dollar amounts but rather red tape, navigating a complex system that is all the more challenging when medically compromised and potentially from a vulnerable population. And while parity laws are meant to ensure that medical and behavioral health are treated equally with respect to benefits, such laws are notoriously poorly enforced, with "medical necessity" looked upon with greater scrutiny in the behavioral health context, adding an additional barrier to a category of care already inaccessible to far too many Americans.   

There is little question who benefits from this bureaucratic maze: doctors and patients alike are frustrated if not maddened by the system, and insurance companies themselves are the lone stakeholders gaining from the system. In an election season filled already with so many surprises, one certainty is that health care will remain prominent on the agenda -- whether expanding but building more incrementally on the Affordable Care Act, moving to single-payer, or rolling back the ACA -- and one hope is that with this continued discussion, there should be greater emphasis on allowing questions of "medical necessity" and the timeliness with which those medical procedures be carried out be determined by those holding the medical credentials. 

 One takeaway from the last few election cycles is that the Republican Party has not done an effective job of reaching out to women voters, particularly salient given that they currently make up just over half the population and are more likely than men to turn out to vote. We can point to a number of explanations for this difficulty in reaching out to such a key demographic group, from pro-life stances that in some cases go as far as opposing family planning services and access to preventive care, and the politicization of more basic policies such as equal pay for equal work, largely supported by the Democrats and opposed by Republicans. From "binders full of women" to adding Palin to McCain's ticket in hopes that women's solidarity would trump policy preferences, the Republicans have made a number of moves that have not served them well. 

The so-called "war on women" is particularly salient this year given that the Democratic Party's presumptive nominee is Hillary Clinton, and Donald Trump has not been known for his sensitive comments toward women, quite notably in his battles with Fox News' Megyn Kelly, who may or may not have had "blood coming out of her wherever." Indeed, Huffington has even catalogued hard-to-believe things that Trump has said about women, from marginalizing the importance of sexual assault in the military, referring to breastfeeding as "disgusting," to characterizing women as a "manipulative" sex, to speaking often to the importance of looks in politics and entertainment. Trump's latest attack on Cruz's wife only adds not only to the GOP's struggle to garner the support of women, but also to the animosity between the two main remaining Republican presidential candidates. 

Trump's charge: his wife Melania (a retired model) is more attractive than Heidi Cruz (depicted unflatteringly), with the caption, "The images are worth a thousand words." This was in conjunction with allegations that Cruz had cheated on his wife. Admittedly, it is not uncommon for the families of presidential and vice presidential candidates to be "vetted" as well as the candidates themselves. 1992 saw numerous GOP attacks leveraged at Hillary Clinton and Tipper Gore, characterizing them as "radical feminists" with women not actually wanting to be liberated from their home/kitchen. Tipper Gore was challenged for her campaign against violent and sexually explicit lyrics on record albums. The Palin family came under extensive scrutiny as well in the 2008 election cycle, showing that it is not solely a partisan matter. 

Trump's comments may not be surprising to those who have followed him closely, and his transparency in the way of discussing the importance of image over substance (resulting in a 70% unfavorable rating of Trump among women, with even a 39% unfavorable rating among Republican women). They also allow Cruz an opportunity to defend women, because while women do vote more Democratic (52 vs. 36% according to a 2015 Pew study), Republicans cannot win the election without some women on their side. Cruz retorted that spouses and children should be off bounds with respect to partisan attacks. What remains to be seen is to what extent he will stick with that language moving forward. Will we see a resurgence of Bill Clinton's extramarital affair(s)? Will we see other personal attacks? Is it only personal when it is personal to them? 

While Trump's comments certainly underscore his continued assaults on women (and many others), for example, his characterization of Hillary Clinton as "very shrill," it would be hard to construe Cruz's defense as much more than defending his wife. Cruz, after all, has opposed abortion even in cases of rape and incest, and opposes the provision of plan B. And while abortion is only one of many issues of gender (in)equality at play, Cruz has also expressed that equal pay for equal work is already law, and voted against the Paycheck Fairness Act. That Cruz defended his wife as beautiful and a wonderful wife and mother should not be mistaken for a position in favor of women more generally. Whether Cruz stands by his charge that the families of candidates should be off grounds for personal attacks remains to be seen.