If there's anything that you take away from reading my blog, I hope that the importance of persisting underinsurance in America is one of them. Chelsea Clinton recently spoke out about this, raising the possibility that Hillary Clinton might use the tool of executive order to help curb healthcare costs for those who are unable to afford to use their health care, specifically working to reduce out-of-pocket maximums: "And, kind of figuring out whether she could do that through executive action, or she would need to do that through tax credits working with Congress. She thinks either of those will help slove the challenge of kind of the crushing costs that still exist for too many people, who even are part of the Affordable Care Act and buying insurance." This was consistent with Clinton's health reform plan in the 1990s, though that we know to have been unsuccessful.  

This raises an important question: What is the best way for a president to achieve this end consistent with the party platform and campaign goals (not to mention many public preferences)? There are a number of options. One is to work with Congress to push for amendments to the Affordable Care Act (ACA) in ways that reduce healthcare costs. The challenge here is that both chambers of Congress are controlled by the Republican Party. It is unlikely that the partisan control of the House of Representatives will change with the November elections. The Democrats have a chance at reclaiming the Senate, but it's a toss-up -- the Democrats may take the Senate, but it may only see a leftward lean in the Senate median with a de facto need for supermajoritarian support in order to pass legislation of any significance. And amendments to the Affordable Care Act would absolutely fit the bill. The result is that there will be a political environment not ripe for major policy change, with potentially only incremental progress to be expected given tendencies toward obstructionism. In fact, partisan voting extends even to non-political but also to procedural votes. In short, Congress isn't likely to move much unless the Democrats take the Senate, and even then there will be marked potential for opposition obstruction. 

Another option is to work with states to incentivize improving upon the federal plan. For example, we find marked variation in air and water quality standards in the states, with California standards being particularly higher. We might envision states opting into add-on plans that cap out-of-pocket maximums and deductibles, two of the plan costs that constitute massive barriers to individuals being able to use the plans by which they nominally are covered. 

Which then brings us to changing health policy by way of executive order, which are legally binding orders given by the President of the United States. The challenge is that the public's view of executive orders tend to low, as Reeves and Rogowski (2015) show. They find that support for the use of executive orders tracks the public's evaluation of the president and the their beliefs in the rule of law (e.g., ensuring civil rights, civil liberties, mechanisms of accountability, etc.). 

So there is a real risk in pursuing policy through this means. When the president works with Congress to achieve progress toward healthcare progress, in the face of obstruction, it becomes relatively easy to point to Congress (in particular, congressional Republicans) as the culprit in precluding movement from the status quo. We are seeing this in the context of the current battle to fill the Supreme Court vacancy held by the late Justice Antonin Scalia. That said, it is easy also for Republicans to say, "You elected Clinton, and what has she accomplished? Vote for us in 2020 and we'll let you decide how you spend your money." But amid a polarized setting, pursuing policy change by way of executive order may be smart, but it would have to work given that there would, in that case, be only one person to blame, using a tool not revered by the American public on principal (a trend that is consistent over time, though with public support for unilateral action higher in those contexts in which Congress fails to act). How Clinton continues this discussion with respect to executive orders (in this context and others) will give us valuable information as to how we can expect her to work with Congress and to what extent she will work toward a stronger presidency, albeit toward responsiveness to public needs by way of unilateral action. 

​Auden’s “Funeral Blues” characterization of funeral perhaps most aptly describes the sense of loss that one feels upon the passing of a loved one: “He was my North, my South, my East and West, My working week and my Sunday rest, My noon, my midnight, my talk, my song; I thought that love would last for ever: I was wrong.” While Auden shows us the devastation of funeral mourning, he does not there address the grappling with the permanence of that person’s passing, the transition to addressing the person forever in the past tense. That was something that hit home markedly at the memorial concert for a friend who tragically died in January at the young age of 30. We heard two hours of people delivering hauntingly beautiful performances of Amy’s music because she couldn’t. There was so much love, so much loss in that room, but so much finality about her never to return to the stage with that “extra dose of awesome,” guitar in hand and mic stand in front of her petite figure as she sang her songs of love and loss. Her music lives on now only through recordings and others’ renditions, which beautiful though they are, still echo her absence, her missingness. And none of us quite know how to grapple with accepting that loss. 

Unabashedly opportunistic though it is, the tragic attacks in Brussels gives Clinton an opportunity for her foreign policy experience to shine, showing herself the most competent candidate from among both fields to navigate the complexities of this international attack and helping nations to coalesce toward a solution. This is not a traditional "women's issue," which is to Clinton's advantage in a sense because she cannot be marginalized as caring primarily about such issues as women's rights and social programs (areas in which she also shines politically), but also national defense and security, which are issues in which the Republican Party tends to dominate more and which have been more "owned" by the Republican Party. 

Accounts of unfavorables on both sides of the political aisle have been documented, and part of the dissatisfaction that the Democratic voters have had with Clinton is her more moderate approaches to policymaking. In truth, her policies vary only marginally from those of Sanders, but she has the more pragmatic and admittedly less "sexy" approaches to these political problems -- wear and tear in the Senate and other offices have given her realistic expectations -- which Sanders supporters have ben keen to characterize as being less progressive.

There are a few realities with which they must both contend and one that only Clinton must  contend. First, making radical changes at the national level may founder, leaving the Democratic Party highly vulnerable in taking the fall in the 2018 midterm elections. But that would be an unlikely scenario to arise because it is contingent upon even getting to the implementation stage. Which brings us to the second problem. Having a likely still divided government  scenario (the Democrats will assuredly move the Senate median to the left, but not necessarily enough to gain control) requires some measure of compromise and conciliation which is hampered by designation as a self-described socialist, and by the stubborn promotion of positions too far to the left and too uncompromising to garner needed moderate Republicans' support. 

The Clinton-specific challenge is that of being a woman operating in a man's world, and thus needing to appear stronger, tougher, more in command, and let's face it, deal with slanders that our culture rightly abhors in the racial context and yet somehow accepts in the analogous cases where gender is concerned. Such is consistent with years of American history, with African Americans gaining suffrage far earlier than did women of any color. And concessions to emotion by women immediately confirm biases that women "may not have what it takes" to be the leader of the free world. There is no question that if Nancy Pelosi cried publicly as much a did John Boehner, we would not have heard the end of it. Boehner got a free pass, except for his name of course. 

Part of what we are seeing in Hillary is her effort to play this man's game, but until we change the gender dynamics of the United States, it will be a necessary evil, and a necessary condition for winning elected office not to mention prevailing in bargaining conditions upon electoral success. In a wonderful "West Wing" episode titled "Let Bartlett Be Bartlett," in which the main players choose to set loose the progressive Jed Bartlett with whom they had all fallen in love in the primary campaign. Hopefully one day we will be able to "Let Hillary be Hillary," but as long as she and her staff know well, you have to play the rules of the game in order to get in the door and begin to win the real fights. In the meantime, I hope that the Democratic voters have the patience to let her show her true colors as a bona fide progressive and champion of rights as Madame President. We just need to elect her first. 

In the interest of full disclosure, my (strong) personal preference is for Hillary Clinton to be the next President of the United States (#ImWIthHer). But even absent this personal preference, at this point in the campaign there are innumerable reasons for Sanders to concede to Clinton in the race to the White House and not merely in the individual states in which she outshines him (sometimes very modestly as in Missouri, other places much more dominantly such as in Virginia). 

Whether or not you like superdelegates (definition: an unelected delegate free to support any candidate for the presidential nomination at the party's national convention), they change the delegate math in a way that makes the nomination virtually unattainable for Sanders. While one needs 2,382 of the 4,763 delegates in order to win the Democratic nomination, Clinton currently has 1,119 to Sanders' 813. But among superdelegates, Clinton currently has 467 to Sanders' 27, making the delegate gap much larger. To be clear, this is not a case in which the superdelegates are going against the preferences of the rest of the delegate population. Clinton leads in both subgroups. But the superdelegate differential reinforces the upward climb that Sanders would face, an upward climb that is moving steadily from challenging to futile. 

And yet he still has ample support, and there are arguments of representation in American politics that can be made in support of his continuing to represent those preferences (which admittedly from a policy standpoint differ only minimally from the preferences of Clinton, who emphasizes experience and pragmatism in implementation of a similar core agenda). There are also cases in which candidates can serve important roles to put on the agenda issue items that mainstream candidates will not, but maybe should at least think more critically about, or promote some dialogue in the media and among the voters themselves. Kucinich's campaign in 2004 serves as a salient recent example. And despite apparent determination to take the nomination battle to the convention, we have seen some rhetoric from Sanders that echoes the inclination to put issues on the agenda, to force discussion of issues, as opposed to battling for those ideas to be put into practice. 

The problem is, when treating the race as hotly contested (and it is being hotly contested in a number of states, though keep in mind that New York has not yet voted), Sanders is -- as does any candidate -- making a number of attacks on Clinton. It has been argued that his becoming an "attack dog" is the only winning strategy he would have left in order to succeed. And that is certainly his right given that she is his opponent. But given the high probability that she will indeed win the nomination, battles on the nuances of policy and personal attacks leveraged among Democrats become ammunition come the general election. Sanders is in effect writing attack ads for the Republicans or shortening the amount of time they need to do on opposition research. And that isn't for the good of the Democratic Party. (Indeed, it has not gone unnoticed that some are attracted to both Sanders and Trump given their anti-establishment rhetoric, in addition to going after Hillary on the issues on which the GOP will be focusing going into the November general election). What it shows is that, like any human and particularly like any politician, he has self-interest and is acting on it, even to the detriment of the policies that he so vigorously defends. 

Sanders has come much farther than many (even he) thought possible, and it was going to be a difficult road no matter what (not aided by his being a self-proclaimed Socialist, which is a label unlikely to play well among Blue Dog Democrats, independents, and moderate Republicans feeling that their party's candidates are out of step... also not aided by his failure to garner support among key Democratic constituencies such as the African American community, or the fact that he does not hail from a key state). He should feel proud of what he has accomplished, both in delegate counts and in promoting discussion of a progressive vision of what America can and should be. But that is where is should end, lest he help facilitate a change in presidential partisan control and in turn the (potentially far) rightward direction of American social, economic, and foreign policy.

We all know the phrase. It isn't easy being green. Kermit was a wise frog. But maybe it's not so hard after all. Don't lose hope, Kermit (and other similarly-woed frogs of the world).

When we talk about the environment, we often create for ourselves a dichotomy between economics and environmental protection. And there is some merit in that. We impose oil taxes to increase the cleanliness (such as it is) and to incentivize reduced consumption. Green alternatives for products can be more expensive. Not everyone can afford a Prius as opposed to an older, less fuel-efficient model.

But there is also so much opportunity for job creation and innovation when we fully commit ourselves to environmental protection in ways that go beyond images of polar bears in melting ice or taking the bus instead of driving (if your city of residence has such infrastructure in place). And even as other nations have outpaced us on health care and education and certain technologies, Americans pride themselves on their innovation, tenacity, finding pathbreaking alternatives to the status quo.

There are few policies as ripe for innovation as environmental policy. From wind and solar technologies to finding new sources of alternative energy that we have not even yet considered, there are innumerable opportunities for those with scientific skills and craftsmanship to think outside the box, or better yet, beyond the box. Finding affordable ways to manufacture products sustainably provides other such opportunities to bring new ideas and visions to the table, some of which may well fail, but some of which may allow us some meaningful breakthroughs so that we can collectively work to leave the planet better than how we found it (or at least not considerably worse).

There inevitably are costs of compliance with environmental regulations, and some small businesses may feel the pinch. But if possible, it would behoove us all, especially amid the policy rhetoric of the coming months of the presidential election to set aside the false dichotomy of economic security versus environmental protection. Without a planet with breathable air and drinkable water, the economic impacts may begin to pale in comparison. With economic investment in hiring smart people to develop ways to limit our environmental impact, we can have both. The ball is in our court.

​On March 12, 2016, Hillary Clinton said of Sanders at a campaign rally in Saint Louis, “I always get a little chuckle when I hear my opponent talking about doing it. Well, I don’t know where he was when I was trying to get health care in ’93 and ’94, standing up against the insurance companies, standing up against the drug companies.” Thanks to the depth and breadth of political records, we know that Sanders was not with Clinton during this battle, but rather ​was continuing to advocate for a single-payer, universal health care system.
 
To be clear, this was not to say that Sanders was standing back on the health care fight, but rather fighting a different fight. In this case, neither won particularly. Hillary’s Health Security Act garnered 103 cosponsors (Sanders not among then), but Sanders’ fight here represents his continued disconnect from the pragmatic realities that one faces when taking policies from a small state like Vermont to a national context.
 
The fact is, most of liberal Democrats would be thrilled to see the passage of a single-payer, universal health care system that is more emblematic of what we see in parts of Europe. Of course, the advantage of many European countries is their size: granting greater benefits with greater efficiency is easier with a more finite population than the United States has. And at the end of the day, pragmatism isn’t just an advantage at the negotiation table – it’s a necessity of governance (not to mention election to get in the door in the first place).  
 
Were it not for the candidates both fighting for the Democratic nomination, they would be on the same team. They share a commitment to expanding health coverage for more Americans and making it easier to draw on the coverage that they have, with one candidate espousing the more realistic vision in a conflictual partisan environment and the other putting forth more liberal ideals whose implementation are less realistic. The problem is that if you ask for too much, you may get nothing. If you make a realistic request, you’ll probably get something. And that something will make the difference in who is able to see their doctor about a suspicious lump that could be malignant, for an endoscopy to rule out gastric cancers, for therapy that can help one to manage depression before it leads to suicidality and medical disability.
 
What we also know is that pragmatism isn’t sexy in an election season. There are times when Hillary comes off like the parent constantly having to tell her children “no” to their lofty goals, even though she is most often right. Her plan is the stuff of one who has weathered many storms and knows what can (and must) be done: expand the Affordable Care Act, reduce rising out-of-pocket costs for obtaining medical treatment, crack down on rising prescription drug costs, and protect reproductive choice. These are not game-changers, but they are necessities, and her battle scars come with the evidence of her ability to weather this storm.
 
There is something to be said for aspiring to greatness, and in the absence of those aspirations to greatness it becomes unlikely to achieve it. Indeed, one of the great political inspirations of the Democratic Party, Bobby Kennedy, held famously, “Some people see things as they are and say, ‘Why?’ I dream of things that never were and say, ‘Why not?’” Indeed, we should with more frequency be asking ourselves “why not?” and to Sanders’ credit, he is pushing for more of that discussion. The problem is when it interferes with the ability to achieve good governance in the face of a party working to undo all of the progress on which Clinton and Sanders both hope to build. Clinton has both the tools and the wisdom to deliver when we most need it. 

​I had placed my bets on Sri Srinivasan. I was not the only one. I swear. I don’t remember whether I put money on said bet, but I hope that I didn’t, or that the affected persons have since contracted amnesia of at least some selective form. Actually, sometimes I wouldn’t mind amnesia. When my grandmother developed dementia in her last years, the doctors tested her lucidity with a number of questions. (Relevant background information: She worked in politics, had been sharp and savvy, and had a major crush on Bill Clinton. But didn’t we all?).
 
“What is your name?”
“Betty Elliott.”
“What year is it?”
“2003.”
“Who’s the President of the United States.”
As a coquettish grin swept across her cheeks, she scrunched up her shoulders bashfully and said wistfully, “Bill Clinton.”
 
Yeah, we wanted dementia that day. We all did.
 
But back to Garland. Senator Mitch McConnell has made it abundantly clear since Justice Scalia’s death that he intends for the next president to choose Scalia’s successor, despite the fact that Obama’s term in office does not end in January and a number of pending cases will be impacted markedly by the absence of a pivotal justice, leaving many decisions likely to fall 4-4. To have such a long vacancy would be unprecedented. While it is true that the last person to be nominated and confirmed during a presidential election year was Benjamin Cardozo in 1932,  so 84 years ago, the longest wait for a nominee, from the time of nomination to the time that there was a Senate vote was 125 for Louis Brandeis in 1916. Thus, to fail to confirm Scalia’s replacement would set a major precedent. And while there was little doubt that President Obama would nominate someone to the bench, it came to some (myself included) as a surprise who that nominee ultimately was.
 
Srinivasan was in many ways the perfect candidate. Young, check, Minority, check. DC Circuit Court of Appeals, check. Experienced in other capacities, check. Clerked for a Republican-appointed justice and thus able to potentially garner GOP support in the Senate, check. Unanimously confirmed, check.
 
Now, Srinivasan would not have been the dream justice for a liberal Democrat hoping for a game-changer, but that was never in the cards given the current partisan climate. We are in a “move the median” game, not a “change the game” setting, and either way, regardless of Obama’s nominee, the Democrats can only win with an Obama appointee given that they are replacing a staunch conservative justice. So in a sense, feather ruffling isn’t so much called for except with respect to the issue of obstruction for the sake of obstruction.
 
Which brings us to Merrick Garland, Chief Judge of the DC Circuit Court of Appeals (and who for the record I told my mother and friends would be a good choice but for his age), Obama’s nominee to fill Scalia’s vacancy. In the coming days and weeks, we will learn a great deal about his biography and positions, and with 19 years on the Court of Appeals there is a lengthy record to scour, no doubt bringing to light important positions on issues of privacy, speech, the constitutionality of the Affordable Care Act, and jurisprudential doctrine (the kinds of things that tickle my fancy but rarely make for good cocktail conversation unless I change my invite list).
 
Partisanship aside, there is no question of this man’s credentials to be appointed to America’s highest court. He was summa cum laude from Harvard College, magna cum laude from Harvard Law School, a member of the coveted Harvard Law Review, clerked for judge Henry Friendly on the 2nd Circuit Court of Appeals and for Justice William Brennan, served as a successful attorney, received bipartisan support in his confirmation to the DC Circuit Court of Appeals in 1997 (the circuit from which Supreme Court nominees draw heavily), and became chief judge in 2013. He is a centrist judge, and thus is not ideologically likely to alienate either party, with some liberal leanings but more pro-prosecution in criminal cases. We know that he has taken some broad views of First Amendment Rights, has defended some environmental regulation cases, but also held (and had reversed by the Supreme Court) the view that the DC Circuit lacked standing to consider Guantanamo cases. With continued challenges to EPA regulations, to the constitutionality of the Affordable Care Act, to antitrust, and other issues, who fills this vacancy is of monumental import.
 
An additional challenge in gauging the preferences of appellate judges is the fact that appellate judges rule in three-judge panels with high norms of unanimity, low rates of dissent, and even fairly low rates of concurrences. Characterized as “panel effects,” judges votes can be shaped importantly by the (purportedly) randomly assigned panel of judges with whom they sit in a given case, making individual preferences difficult to gauge (that is, a man sitting disproportionately frequently with other female judges may have a more pro-plaintiff view on sex discrimination cases, independent of his expressed preference on an all-male panel), and Senate hearings all the more important avenues for probing his positions on core matters of policy likely to come before the Court in the coming years. And while the Supreme Court does not reach the level of the economy or security in voters' Gallup polls of "most important issue," (in February 2016 the top economic issues were the economy in general, jobs/unemployment, and the deficit, and the top non-economic issues were dissatisfaction with government, immigration, and national security), and it is also true that most legal matters are resolved at the lower levels of the judiciary (the district and appellate courts) given the Supreme Court's limited and highly discretionary docket, it is undeniable that a change in the partisan balance of the Court has the immense potential to impact issues ranging from civil liberties to abortion to campaign finance to health care to business regulation, many of these issues touching at the core of our values as citizens if not in our everyday lives.
 
Garland will not prove an easy case for McConnell and others to make against holding a hearing, given his noted credentials and the problems posed by the ongoing vacancy on the Court. It is a true gamble whether to hold true to that determination and resolve going into the November elections given that the Senate Republicans are likely to suffer at least a few losses even if they do not lose control of the chamber (though that itself is unclear), and given the uncertainty as to the presidential election. In this case, Obama opted for a risk averse strategy of a known quantity with a solid record with bipartisan support. McConnell may do well to adopt the risk averse strategy of granting a hearing rather than accepting the uncertainty of a nomination with potentially very different political players.  

On Monday, March 14, I woke up in the ICU after having been intubated for reasons that I won’t go into. The presenting problem had more to do with my chronic depression, but the subsequent lab work revealed massive electrolyte imbalances that could easily have induced seizures or a coma in someone not as chronically predisposed to them as I. Because of a history of depression that was the “main event” in the conversation, I was discharged with worse levels than I’d had in years (and for that matter, worse electrolytes than in previous hospitalizations for this issue... personally, I don't think the treatment effect of being surrounded by crucifixes helped).
 
It is not news that many Americans go to their primary care doctors first in seeking treatment for depression and other mental illness, whether because of persistent stigma attached to receiving mental health treatment or because of the greater difficulty access to services given relatively low numbers of providers and a markedly lower rate of providers accepting insurance relative to other medical practitioners.
 
In a sense, it’s all well and good to get that care from anyone – they have gone to medical school, done psychiatry rotations, encountered both medical and psychiatric cases in internal medicine residencies, and presumably continue to be competent physicians addressing a host of different issues (which is not to say that a physician friend in Westchester County doesn’t spent three fourths of his time addressing diabetes and high blood pressure, to which I respond in probabilistic terms given disease rates in the United States).
 
Deemed the “common cold of mental health,” depression leads to approximately 8 million doctors’ appointments a year, again whether because of comfort level or availability or insurance. The catch is that primary care doctors emphasize breadth over depth, whereas specialists are best equipped to address the nuances of more particular care. Thus, there are limitations in the care that even the most well-meaning practitioners can provide.
 
But there is a greater problem here, spanning all physicians and not just those in primary care (PCPs). What those experiencing mental illness – whether depression or anxiety – may well experience psychosomatic symptoms with which many even just having a stressful week can relate (heart palpitations, indigestion, perspiration, headache). The challenge is when we preemptively write off such symptoms in a patient who also happens to have a history of depression, especially considering that a number of those with depression also have medical illnesses as well (sometimes depression triggering worse self-care and thus issues such as type II diabetes, other times chronic illness and pain understandably contributing to depression or its worsening, and still other medical issues such as thyroid problems notoriously having the potential to induce depression in otherwise non-depressed patients. So in short, there are a lot of moving parts that make things both clinically interesting and diagnostically challenging.
 
And that is not necessarily doctors’ fault. Indeed, most are very well-meaning. I for one have been blessed by my doctors at New York Presbyterian. But it is not uncommon to find accounts – some anecdotal, others more systematic – of those with mental illnesses getting short shrift from physicians to whom patients are going for non-psychiatric conditions (whether reluctance to write prescriptions, being suspicious of whether it's "all in their head," etc). And again, there are reasons for those concerns, especially if there are risks of overdose in a depressed patient, even if the particular prescription is indeed valid.

The good news is that there are resources in place to facilitate productive discussions with doctors (of all specialties) about depression and its management. The bad news is that as depression spirals downhill, it becomes more and more difficult to advocate for oneself, and it’s easy to find oneself on the losing end of the battle. When at the lowest point, getting dressed can feel like a challenge in itself. Researching physician quality and medications and scheduling appointments goes beyond arduousness. (And given the noted high rates of depression and suicide among doctors themselves, this is not likely unnoticed by any parties). Having a good mental health provider is imperative if this is something with which you struggle or might be predisposed to struggle (whether from physical illness, a family history, a stressful job, such that a single trigger might be devastating). But having a good primary care provider to advocate when you cannot do so is at least as important, and it’s worth searching for one who doesn’t stigmatize reaching out, and who’s invested in treatment and feels like a safe person to go to if only in the interim until other resources are in place. We have already seen medical recommendations about depression screenings for all patients, which hopefully will reduce the stigma of acknowledging some of the symptoms on that list (that is, you’re not being singled out and asked, “You look tired today. Do you mind filling out this survey about your loss of interest and pleasure?”) and raise greater awareness to doctors of the prevalence of these symptoms in their patient populations, whether or not they meet DSM diagnostic criteria for depression (because as we can draw from pain management, it's easier to manage when caught earlier at a 6 as opposed to an all-consuming 9 or 10 ("but it goes to 11").
 
While doctors are – admittedly with much reason – told that when they hear hoofbeats, they shouldn’t assume zebras. That is, many ordinary diseases are in fact ordinary. But given the complexity and interconnectedness of the mind and the body, and the ways in which they can exacerbate ailments in the other, it is at least important to have more of a “zebra prevention strategy” in place (yes, I come from the San Francisco Bay Area, I have experienced one major earthquake in 1989, and you bet my bookshelves were bolted and I had an earthquake supply kit) so that doctors will  be less likely to write of symptoms as physiological manifestations of depression when there could be something more at work (or to undergo expensive tests instead of making a referral to a therapist). So is the solution to run expensive batteries of tests on a mere hypochondriac? Surely not. But would it hurt is to make more open the discussion across the country (and not just major metropolitan areas where services are more available and information more easily acquired) discussions to disentangle the medical from the psychological, and their potentially numerous interactions? Surely not. 

I am an academic. We are constantly learning. Doctors are constantly learning. The more that we can remind ourselves that yes we have our expertise, but we can also grow and evolve and improve (and that shortcomings in a patient case present opportunities to learn for future reference), the better off both doctors and patients will be. 

​With the 2010 passage of the Affordable Care Act (“Obamacare”), we saw the vast expansion in the number of people who were able to be covered by a health insurance plan. In fact, while the US Census Bureau found that in 2009 (before the enactment of the ACA) the rate of uninsured Americans was 15.7%, compared with 9.2% in 2015, the lowest uninsured rate in 50 years.
 
The problem is, this isn’t enough. Indeed, what we continue to face in large number in the United States is the problem of underinsurance, with people unable to utilize the health insurance benefits covered under their plan. Underinsurance can be defined as having out-of-pocket health care costs excluding premiums over the last year that are at least 10% of one’s household income, or a deductible of at least 5% of income. The Kaiser Family Foundation found that health care deductibles have risen to degrees outpacing wage increases, making clear the strain on working-class individuals and families. In fact, 31 million Americans were underinsured in 2014. This shakes out to being 23% of 19-64 year-old adults covered by an insurance policy. For perspective, 31 million individuals is the equivalent of the entire tri-state area’s population.
 
Consider some basic facts:

• 11% of privately insured adults had a deductible of $3,000 or more in 2014. (This rate was 10% in 2003). 20% have deductibles of $2,000 or more. The average deductible is approximately $1,100 (67% increase over 5 years ago). Thus, the average person will still need to spend approximately $1,100 before their policy will cover care. That alone is over 2% of the average American’s pre-tax income (not including copays and coinsurance).
• 51% of underinsured individuals reported problems with medical bills. 44% reported that costs prevented them from getting needed care.
• While premiums went up 4% between 2014-15, workers’ wages increased only 1.9% during that same period. Premiums for family coverage increased 27% between 2011-2015.
• 1 in 4 adults surveyed by Families USA did not seek needed health care because of cost. Among those with deductibles of $1,500 or more, nearly 30% could not afford needed health care.

 
There are important steps in place to make health care more affordable for those who have limited income. The federal poverty level (FPL) for a single-person household was $11,770/year in 2015, with Medicaid or CHIP available to those making less than 138% of the federal poverty level (up to $16,243/year), out-of-pocket assistance to those making 100-250% of the federal poverty level (up to $29.425/year), and premium tax credits available to those making between 100-400% of the poverty level – that is, up to $47,080/year (however, note that this is in reference to the federal and not the state poverty level, with some regions such as New York City and San Francisco having especially high cost of living).
 
The question then becomes, what if you make $50,000 per year in New York City, where the median apartment rent is $3,100, or in San Francisco, where the median apartment rent is $3,500? Absent an income high enough to shoulder the load of deductibles and medical bills, or low enough to garner greater (or perhaps any) government support, middle class families find themselves caught between a rock and a hard place, often finding themselves skimping on needed health care, and thus potentially making themselves more vulnerable to more serious (and subsequently more expensive) medical conditions down the line. Such reduction in the use of health care policies is particularly poignant when considering that nearly 40% of mortality cases in the United States are estimated to have been from preventable causes of death.
 
It should not come as a surprise that delaying treatment (or even an initial doctor’s appointment) can lead to more costs down the line. A trip to urgent care for an X-ray and splint for a fractured foot may not be cheap, but it’s more economical than surgery if made necessary by further wear and tear. The cost of cancer treatment goes up significantly from stage II to stage III (in the case of breast cancer, going from $17,400 to $32,600), with earlier testing potentially aiding with diagnosis and earlier intervention and better survival rates. If an artery blockage is detected early, angioplasty may be a reasonable intervention, with costs ranging from $44,000-145,000, compared with heart bypass surgery, which can range from $70,000-200,000 or more in cost.
 
Also not surprisingly, given this reduction in medical treatment by those unable to afford it, America has marked income inequality in life expectancy. The rampant income inequality in the United States has been well-documented, with the 2015 Global Wealth Report holding that America is the richest and most unequal country, with the United States having by far the highest share of the total global personal wealth (41.6%) but also the highest concentration of overall wealth in the hands of the few (with a Gini coefficient of 80.56 on a scale of 0-100). What’s more, America’s middle class has been shrinking over the years, with more people moving into lower-income and upper-income groups, and reports have shown that paying rent has been an increasingly difficult challenge for the middle class and not just the poor. In 2010, the average upper-income 50 year-old man would be expected to live to be 89, but if lower-income would be expected to live to 76 (that is, a 13-year differential based on income alone. The same inequality can be seen among women, with a life expectancy of 92 if at the wealthiest end of the spectrum versus 78 on the lowest end of the spectrum. While some of these disparities can be attributed to other factors such as eating (and relatedly, obesity) and smoking habits, it is not difficult to imagine how the reluctance to invest in diagnostic procedures given high deductibles and coinsurance would factor in here in a non-trivial way.     
 
The notion of “the American dream,” has permeated much of our society’s discourse, in particular in presidential election seasons as we hear the candidates’ journeys to their running for office (some from humble beginnings, others less so), and as candidates offer their policy solutions to help individuals to rise up the income ladder through hard work and seizing opportunity, achieving successes of which previous generations only dreamed. The problem is that this dream appears to be more alive and well in nations other than America, while every day working families are expected to pull themselves up by their bootstraps.
 
The 2016 presidential campaign provides an opportunity for underinsurance to be addressed squarely by the candidates. Sanders raised during the March 9, 2016 debate these challenges of affordability in using health insurance and obtaining prescription drugs. Clinton has called attention to the advancements made by the Affordable Care Act and her intention to build upon its successes and expand coverage. The Republican candidates have expressed a determination to dismantle the Affordable Care Act and offer alternatives to curb prices, such as Trump’s proposal to use imported prescription drugs and Rubio’s plan to invest in market-driven alternatives and tax credits.
 
While the realities of governance, particularly amid divided government, are such that the ideals espoused during the campaign season typically ultimately find themselves tempered through partisan compromise with Congress, the months ahead provide a crucial opportunity for citizens to press the candidates on how they will work to close the gap in health care affordability moving forward.  

​While the fight for the Democratic nomination is not over, Hillary Clinton’s commanding victories in South Carolina and on Super Tuesday solidified her support with a number of key Democratic constituencies, and notably winning with those reporting in South Carolina exit polls that they cared most about health care and among those reportedly caring most about income inequality.
 
Battles for party nominations – especially long and protracted battles as in 2008 and 2016 – are often characterized by rhetoric aimed at setting candidates apart from one another in policy substance, experience, and/or ability to execute the given policy vision. Yet there are questions as to how different candidates ultimately are on the issues.
 
In many cases, the answer is that there are far more similarities than not. Indeed, at the heart of much of the Clinton versus Sanders debate is the issue of experience: supporters largely fight for the same issues, but Sanders supporters think in terms of expected benefits, while Clinton supporters think in terms of expected values (that is, both expected benefit and the probability of obtaining that benefit, which in a conflictual partisan environment requires some measure of pragmatism). The Washington Post reported that Senators Clinton and Sanders voted alike 93.1% of the time, with Clinton overall more aligned with the Democratic majority.
 
However, there is a key vote on which they disagreed, which strikes at the heart of the campaigns’ core messages: while Senator Clinton joined 73 other Senators to vote in favor of the Paul Wellstone Mental Health and Addiction Equity Act of 2007, Senator Sanders joined 9 Democrats and 15 Republicans to vote against it.  
 
Hillary Clinton’s emphasis on health care issues has been long-recognized, from her work with the Children’s Defense Fund to her less-than-successful efforts to revamp health care in the 1990s to her advocacy in favor of protecting and expanding on the Affordable Care Act. Sanders likewise has spoken vociferously in favor of expanding the right to health care, advocating for Medicare for all Americans. Both candidates have welcomed the opportunity to talk on the campaign trail about mental health, an issue that affects an estimated 1 in 5 Americans in a given year. So what is this vote that divided them?
 
The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is aimed centrally at preventing health insurance companies from giving lower benefits for mental health and substance use disorders than for medical or surgical benefits. The issue was raised at a Portsmouth, New Hampshire town hall, with a woman addressing the challenges of navigating insurance coverage for her son’s mental health treatment, to which Clinton asserted her determination to ensure that parity laws are properly enforced.
 
To be sure, Senator Sanders has spoken in favor of protecting coverage to mental health services, though his discussion of mental health only in the context of gun violence in the October 2015 Democratic debate met with mixed responses. Yet when we rely in no small part on candidates’ records in office as evidence in support of the policies that they profess to support as president, this nay vote on the parity legislation is important not just to mental health policy but also to broader issues of underinsurance and income inequality, which has been central to the Sanders message.
 
While parity laws provide that physical health and mental health issues be treated equally by state insurance providers, the laws are inadequately enforced and insurance denials for mental health care remain high amid challenges to “medical necessity.” Despite ample attention to expanding the number of people who are covered by an insurance plan, a pervasive remaining problem is that of underinsurance, which according to the Commonwealth Fund in May 2015 had risen to 31 million Americans, a figure doubled from estimates in 2003. Such individuals, given exceedingly high deductibles, copayments, and coinsurance, are either unable to use their health insurance at all (leading to complications from potentially otherwise treatable conditions) or who face financial despair because of their medical costs. This is all the more prevalent in the context of mental health care, with over 50% of respondents in a 2013 survey citing cost as the reason for not obtaining mental health treatment, even if they had health insurance.
 
There are at least two reasons why this issue of underinsurance is particularly relevant to mental health coverage. First, a recent report found that 72% of American adults feel stressed about money, and that financial stress is among the main issues people cite as a source of stress and depression. Thus, limiting the feasibility of utilizing health services perpetuates the need for drawing on those services, both medical and mental health, with many interactive effects between the two.
 
Second, underinsurance is perhaps most acute within the domain of mental health, with many insurance plans limiting the number of therapy sessions that may be covered for certain conditions, and fewer and fewer psychiatrists seen taking Medicare and private insurance as in-network providers (an estimated 55% in 2015, compared with 93% in other medical specialties). This leaves patients, if they can obtain an appointment, to face potentially arduous reimbursement processes for low reimbursement rates in many cases.  Thus, there is an inextricable link here to the pervasive income inequality of the American economic system, with many most in need of these medical and mental health services unable to obtain them, even irrespective of their having obtained some level of health insurance.
 
For all of the idealistic rhetoric that typically accompanies presidential campaigns, improving the American health care system will not happen overnight. Important first steps toward progress will include tackling the problems of underinsurance in medical and mental health care, and ensuring the enforcement of existing parity legislation, on which the Democratic candidates’ voting records have in at least one key instance diverged. The Sanders campaign would do well to reconcile the inconsistency between this vote and its rhetoric on the trail.