Tag Archives: health insurance exchanges

Undue Burdens: Heartbeats vs. Health Care

Anti-abortion activists almost salivated in saying that “it all comes down to Alito,” as they hoped the Court might affirm the recent restriction of women’s access to abortion in the state. Right to Life groups were particularly ardent about Alito’s willingness to allow the Texas Heartbeat Act, which was up for review from the court, as if their efforts were getting national attention and could tip national law. John Seago, as legislative director of Texas Right to Life, trusted the Justice to represent their own interests: “We are [just] hopeful that Justice Alito will examine why the [request to stop the law being enacted on constitutional grounds] should ultimately be dismissed,” as if hoping to find a like-minded member of the court to recognize Texas’ right as a state to define wrongs against a public good that would trump personal rights. We are, post-Trump, perhaps only beginning to come to terms with the effects of the cases about abortion rights invited by the new stamp that Trump put on the justices of the United States Supreme Court. If we have tried to map this as a Texan peculiarity, although there are good reasons to see the authoritarian nature of the dramatically receding windows at which women can seek abortion in Texas as a reflection of long-term restrictions on access to abortion as a serious problem of health care and a state in which constitutional rights are under attack. While access to abortion had been “settled law,” on the federal level, the insistence Roe v. Wade or later decisions entitling women to seek abortions as a matter of constitutionally protected rights to privacy has been revealed to be a vulnerable protection of civil rights by the current attempts of town councils or state legislators to push back on precedent.

To be sure, the on-the-ground picture in Texas of access to abortion has revealed disturbing trends for some time–disturbing trends on a national level as well–that may not have fully been appreciated in those blue state residents often insulated in levels of existential panic, if not filter bubbles, as a stratagem to recast national laws about access to health care by a regressive and retrograde platform of anti-abortion activism, dressed in the terms of modern science. The hope to use the increased technologization of pregnancy as a standard for curtailing abortion would create a dangerously discrepancies in levels of public health access in the nation–a terrain of extremes in health care tantamount to translating increased extremes of climate change to legal terms, masquerading in a language of medical objectivity in its rigor, in order to conceal its authoritarian ends. While the Senate Bill 8 asserted abortion was a criminal act of a doctor, a crime no District Attorney would prosecute, the promising of a minimum compensation–better seen as an effective bounty–of $10,000 guaranteed to all citizens, neighbors, family and friends willing to report any attempts to terminate pregnancy by abortion six weeks after conception allowed them to reclaim the status of a longstanding crime in Texas law no District Attorney would deem to prosecute. By entitling all Texans to bring civil suits on their own, however, as agents of the state, they created a geography of local precedent that trumped a woman’s Constitutional right to privacy.The network of obstruction seeks to actualize a new geography of health care in the country, with passage of SB 8, by making Texas a model of enacting restrictions on abortion impervious to judicial review, by appealing to retrograde principles of moral purity in the guise of “heartbeat laws” to affirm fetal personhood.

The shifting groundmap of access on women’s health care in Texas as been watched for decades in the state, as much as from afar, closing clinics to effect a decrease in abortions, even after the U.S. Supreme Court had queried several of its provisions as “undue burdens” on pregnant women. Even after the suit brought against the State by an abortion provider, Whole Women’s Health, aware and fearful of the dangers that closing abortion providers in South and West on women’s health care, the decrease in state-wide abortions by a third as providers shifted after fifty miles away seems in retrospect a successful ground-game for curtailing access to abortion, and one that encouraged several municipalities to adopt restrictive local measures on abortion access. In ways that seem to have emerged in reaction to the America Cares Act, or Obamacare, the new law suggests how the state became a battleground for finding practices for restricting abortion rights, turbocharged by making restrictions amenable to the new composition of a Supreme Court increasingly eager to letting state law stand, with an eye to reviewing not state policy but Roe.

Number of Clinics Providing Abortions in Texas, 2012-2016

The new legal strategy rests on the determination of cardiac activity in embryos–termed a “heartbeat” to invest it with a sense of personhood–but casts abortion as a crime that goes against the public good it might be considered medical malpractice. By creatively adapting whistleblowers’ right to sue any entity committing wrongdoing in an organization to abortion providers, promoting civil suits for assisting abortion in the name of government distributed the agency of legal enforcement in the state as a moral economy of personal judgement and justice, dispensing with the office of a District Attorney to prosecute it as a crime that was dispersed among all who helped the pregnant seek an abortion–all but abolishing her legal agency of redress, and striking fear into abortion providers for opening themselves to civil suits. The paradoxes of invoking the “heartbeat” as a persuasive standard to manufacture alleged dangers of abortion beyond six weeks–when over 92% of abortions are performed nationwide within thirteen weeks, and most women are not cognizant of pregnancy at six weeks–elevates the ultrasounds now legally mandated for all seeking or requesting an abortion from a tool serving maternal and fetal health to a mode of legal surveillance of the womb.

In the decade since the Supreme Court found that restrictions on admittance to abortion clinics an “undue burden” on all women, the recent enactment of State Bill 8 shifts the onus of prosecuting abortions from state regulations, sanctioning all citizens–rather than state officials–by affirming the civil rights of any citizen to sue all abetting–or providing–an abortion, implicitly holding that this does not constitute an “undue burden” on a woman’s right to seek an abortion before fetal viability. As Legislative Director of Texas Right to Life, Seago had boasted of his place in this new geography of medical constraints as he framed local ordinances prohibiting abortion in some thirty Texan towns progress toward formulation on a state-wide level: with the assistance of a skilled litigator who had brought many cases of medical malpractice, Texas’ former Solicitor General Jonathan F. Mitchell seem to have framed a local law shielded from judicial review: in allowing citizens arrests for all “abetting” abortion in the state, State Bill 8 restored criminality to abortion, removing abortion from health care to return to a landscape of an era when the extraction of a fetus was illegal, far beyond the thirty Texan city councils that now self-identify as “sanctuary cities for the unborn,” inviting legal action against involving themselves in any strategy that “aids and abets an abortion.” In ways that rather ingeniously appropriate the near forgotten geographical divide of contested “sanctuary cities” that refused to dedicate local resources to enforce federal immigration laws, that provoked the wrath of Texas’ Attorney General, the new sanctuary cities seeking to curtail abortion may provoke a new national divide, hoping to reach a newly balanced Supreme Court to provoke the removal of abortion from the constitutional protections of a pregnant woman’s rights to privacy.

The division of this national landscape has clear precedent as a form of polarization, and polarization is something Texas does well. Immigration laws were pushed back on in the Trump Era even in the “red” state by Dallas, Austin, and Houston, who, siding with families of immigrant populations, had proudly declared themselves to be sanctuary cities by refusing federal executive orders on immigration that were hardly democratic laws with legal precedent, taking municipal funds off the table for their enforcement. The newly declared largely rural “sanctuary cities for the unborn” reveal a counter-geography of sorts, echoing the state legislature’s banning of any city to comply with federal immigration law, not assuming they would not face legal challenges, but almost inviting them.

RIGHT TO LIFE: 'Sanctuary Cities for the Unborn' could face legal  challenges | KXAN Austin
Rural Sanctuary Cities Affirming Right-to-Life/KXAN Austin

But although It is tempting to see SB 8 as an issue of red states like Texas–or the south–perhaps because the rift in standards of health care are so extreme–but we would do well to regard those “red” states are grounds for battle lines for staging a struggle against abortion nationwide. For in 2021, eleven states adopted ninety laws meant to restrict access abortion — the most in a single year since the 1973 Roe v. Wade established fetal “viability” outside the womb as a threshold for women’s right to abortion.  “Heartbeat” laws in nine states posit a “fetal heartbeat” as the index that would mandate ultrasounds for abortions, no matter at what stage of gestation, to determine “according to standard medical practice, whether the fetus has a detectable heartbeat,” even if the putative beat is a legal creation more than a medical one, and the “flutter” perceived in sonograms suggest the first cardiac cells in an embryo firing electrical signals, more than they map onto an individual, and has no bearing on the viability of the heart, the embryo, or the pregnancy. Yet the legal fiction of a “heartbeat” is presented as a technologically modern registration, able to reframe constitutional rights and health laws–an attempt to seize the legal high ground, even as abortion rates had in fact dramatically fallen nationwide.

The shifting landscape of reproductive health care is not without a clear echo of the way states “stood their ground” in local refusal to accept federal health care funds, akin to separatism–leading a full twenty-six of the lower forty-eight states to outright exclude insurance coverage for abortion in medical marketplaces.

Circumscribed Insurance Coverage of Abortion in ACA Marketplaces, 2020/Kaiser Family Foundation

The ban on insurance coverage for abortion seem draconian. The recent radical reduction of access to clinics–and criminalization of abortion–in Texas dramatically reduced access to abortion clinics beyond insurance coverage. Determined not by medical grounds, but by state legislators, Texas is poised to redraw the constitutional right by an illusion of direct democracy. The result of SB 8 is to undermined the geography of health care in terms of the preservations of freedoms–the unvocalized or expressed freedoms of the unborn–to challenge the nation’s legal landscape by local resistance to longstanding constitutional rights. The devious legal stratagem of denying precedent outright was spread by the diffusion of local laws on online templates that were announced to be able to withstand court challenge or judicial review, leading many to seek to affirm the.local purity of places that imagined themselves as contemporary Cities of God. The drive to preserve the purity of their domains, spread by many preachers in Texas, grew as an imperative, as Gov. Abbot put it, or to show the nation that ˆ”no freedom is more precious than life itself” in Texas, although the assumption of life or freedom as what an embryo enjoys seems to debase freedom as a term. Abbott embraced this rather tautological precept of anti-abortion activists of fetal personhood, as he took pleasure in celebrating the day the act banning abortion for those in their sixth week of pregnancy–when it is hardly perceived–in full knowledge the preponderance of medical procedures are performed in the first thirteen weeks of pregnancy, and that the state law would create chaos in health plans across the state. Over the strong objections of Texan lawyers who feared it would also undermine principles of the state’s the legal system, by categorizing the procedure of abortion of an undeveloped embryo as a crime against the state and reconstruing personal injury, and personal freedoms, the potential clogging of local courts was less the intent than to paralyze health networks by fear.

As Justice Antonin Scalia first opined that abortion was to be understood not as a constitutional right, but only as determined by voting on local laws, city councils in Lubbock and Waskom, both in Texas, and soon twenty-five other municipalities in Texas, Nebraska, and Ohio revealed a legal strategy from 2019–the date when a former clerk to Justice Antonin Scalia, former Texas Solicitor General Jonathan Mitchell, framed a unique strategy of legislating limits on access to abortion at a local level. Having offering legal assistance to frame local statues to circumvent the reluctance of Attorneys General to criminalize early abortion, and promised imperviousness to judicial review, the new edict in SB8 effectively financially compensates private citizens who bring successful civil suits on behalf of the state, not openly denying women’s constitutional right but ensuring women live in fear. Texas Right to Life offered online legal boilerplate for setting up “Ordinances Abolishing Abortion” from August, 2019, using a language of self-governance to urge Texans “take matters into your own hands by petitioning your local government to protect unborn children.” The specious “direct democracy” about abortion promised an absence of shared consensus, in a call to legal separatism seeking to commandeer national legal discourse, even as rates of abortion have declined, elevating abortion rights to fighting words of moral purity, hoping from attention from eager ears of the newly balanced US Supreme Court. The hope to reframe the law of the land is dressed in deeply coercive strategies, however, both surveilling women’s wombs by mandated sonograms and a community and family surveillance, boosted by the promise of $10,000 bounty per abortion would encourage surveillance of family members, among generations, or at workplaces.

The geography of restrictions on abortion is telling, and is a landscape that is confusingly changing, in ways that many will be both disoriented and confused, as it lacks uniformity. If Texas has long been seen as a “red” state, it is less “red” than on the cutting edge of promoting sonograms as a threshold limiting access to abortion–already limited beyond six weeks gestation in Idaho, Oklahoma, South Carolina, and Texas, as if preparing to send cases to a Supreme Court dominated by justices appointed by Donald Trump. Although other state legislatures and Governors have signed draconian laws into effect–as Alabama, where abortion at any stage is called a punishable felony–the “heartbeat” laws openly pit local legislations against constitutional rights, promoting technological determination over women’s rights. As increasing states constrain access to abortion, omen’s constitutional access to reproductive health is pressed between the technologization of pregnancy and an authoritarian legal culture. Many states adopted the “heartbeat laws” before Texas devised its vigilante policy of rewarding civil suits on behalf of the state for facilitating abortions six weeks since conception–

–eighteen have prohibited abortion after twenty weeks, as had Texas, a year before SB8 narrowed the window.

The broad shift in curtailing access to clinics predicted if Roe was overturned suggested the impact of the new state regulations if local ordinances took precedent over constitutional rights, cleaving the health topography of the nation–suggesting a nation so bruised beyond recognition deep scars lay on access to public health care.

An ultrasound of an embryo at 6 weeks.
Human Embryo at Six Weeks

Yet the mandates set the a to expand “heartbeat laws” on a national level–even if heartbeats are not beats, or in fact in evidence at six months, or signs of embryonic development or fetal life. Hopes vested in Justice Alito grew as Texas Right to Life promoted “Sanctuary Cities for the Unborn” movement, hoping a blossoming of local laws might rewrite national laws on abortion, redefining not the U.S. Constitution, but the “freedoms of the unborn” to promote “citizens arrests” of any facilitation of abortion after cardiac activity–that “detectable heartbeat”–irregardless of the mother’s condition or desire. Texas Right to Life crafted skilled legal advice for implementing local restrictions against abortion growth in Texas created a geography of resistance built to withstand judicial review, even if continued constitutional rights to abortion for women still hold in theory across fifty states. “There is a place in the United States where [unborn] children with beating hearts are legally protected right now,” anti-abortion activists crowed to frame a national call for eroding access to abortion. The day that SB8 went into effect, on September 1, 2021, Governor Greg Abbot took to social media to affirm rights of the unborn–crafting ‘rights’ from whole cloth out of “heartbeats,” casting coercion to perform an ultrasound as form of protection, in a slick sleight of hand,–even if the “heartbeat” hardly registered save as a squiggle in Abbott’s own tweet, far from a familiar sinus rhythm of cardiac contraction.

@GregAbbotTX, September 1, 2021

By identifying Justice Alito as a judicial savior, able to prevent an injunction on SB 8 and protecting what Texan legislators had defined as freedoms for the unborn, it seemed the state law would remain on the books. Alito gained the role as a custodian of American jurisprudence of state rights that the late Justice Antonin Scalia, no friend of abortion, who argued abortion was a state’s option, but that the United States Constitution neither “require[s] them to do so,” but that its permissibility is to be understood not as resting in the law, but by encouraging debates about and “voting on local state laws,” while long seeking five votes to strike down Roe v. Wade. He denied the precedent demanded any respect or judicial restrain, describing removal and extraction of the fetus from the womb as a “method of killing a human child . . . that . . . evokes a shudder of revulsion”–even if “Dilation and Extraction” remains among the safest for the pregnant woman. The fear of similar edicts, playing more on empathy to the unborn more than medical science or medicine, has already sent many fleeing state lines for better health care, and we have yet to gain compelling maps of the out-of-state flight or traffic beyond state boundaries to seek abortions, as we lack a better map of crossing state boundaries for seeking better health care for coronavirus infections in states where mandates for unmasking have elevated local case loads–or the flooding of urban clinics with requests for abortion procedures from those living in rural areas, already suggested in this national map. YEt in much of the nation, we can already see

Distances Required to Travel for Abortion Services, Guttmacher Institute, 2018/Public Health Post

The more logical distribution of abortion clinics north of the border will presumably soon be reflected south of it.

Travel Patterns to Abortion Clinics from Rural Areas in Canada, 2012

Right to Lifers’ optimistic confidence that “it all depends on Alito” was unwarranted: Alito summoned a divisive 5-4 split of extreme bitterness, overturning the hopes of the Chief Justice for judicial review, if hope may remain that one of the conservative justices will join the Chief Justice Roberts to give further scrutiny to so restrictive a law. We will probably lack anything like pro-choice legislation for some time in our deeply divided union. The Texas legislature’s passage of SB 8 criminalized abortion at a local level, but with eyes on the change of national law. For it generalizes a movement rooted in the creation of “local” ordinances in small towns, most all of which lack abortion providers but have a strong feeling that they also “really don’t want a business that murders innocent children,” as an East Texas pastor put it. The same pastor played a large part in proselytizing that small towns work to adopt similar ordinances since 2019, whose template was available online, as a way of preventing abortion within their jurisdictions, by delegating enforcement to local citizens, including disapproving relatives. The expansion of local enforcement of these laws contest a woman’s constitutional rights, but are agued to uphold the standards and moral purity of a city–and the legal advice that Texas Right to Life offered to frame local restrictions against abortion growth in Texas created a geography of resistance to the continued constitutional rights to abortion for women that still hold in theory across all fifty states. The promotion that “there is a place in the United States where [unborn] children with beating hearts are legally protected right now” has become a national call for eroding constitutional rights, by affirming rights of the unborn.

With Texas having long reduce funding to abortion providers that erode community health, SB 8 escalates the curtailment of health services on new logic of the law–under the pretense of medical objectivity–that spread among thirty-odd towns to declare themselves “sanctuary cities,” appropriating the term used by those cities that were attacked by Texas’ Attorney General Kenneth Paxton for their refusal to cooperate with federal immigration policies laws, and refusal to cooperate with federal immigration authorities. By denying validity of the Supreme Court to overturn the criminality of abortion by Texan law that defined murder as the death of “an unborn child at every stage of gestation from fertilization,” offering a legal stratagem to make “your town the next ‘Sanctuary City for the Unborn’ in Texas!” independent of constitutional law.

–as if the cities had the right to assert constitutional duties, terrifying residents about their own legal rights.

The “Heartbeat Act” classified abortion as a moral a wrong, but by recognizing the criminal act of terminating a fetal life of over six weeks of gestation–as if witnessing the mandated observation of a heartbeat qualified as a crime, and considering abortion a crime that opens all who “aid and abet” its practice, if a physician has already detected the heartbeat, as already mandated by Texas law. Linking the threshold at which a woman can receive a legal abortion to the time of the first ultrasound–about eight weeks, even if the heartbeat of the fetal pole can be sensed earlier, as early as five and a half weeks, this is the first time that the heartbeat can be mapped onto a visible fetal form by trans-vaginal ultrasound, and the heart beating at a rate of ninety to one hundred and ten beats a minute. Governor Greg Abbott of Texas, acting as if he was the state sheriff, proclaimed with the satisfaction of the convert that “every unborn child with a heartbeat will be protected” from September 1, 2021, asserting “no freedom is more precious than life itself,” as he relished reduced freedom of access to abortions if they clashed, as was apparent, from the protection due to the unborn beating heart of the unborn from “the ravages of abortion.” Abbot’s rousing social media post declaring Texas’ protection of fetal rights used the word heartbeat to register of “the steady and repetitive rhythmic contraction” or cardiac activity–

@GregAbbotTX, Sept. 1 2021

–but finished with an odd squiggle, as much as a sinus rhythm. The scientific argument was not as important as the rhetorical parsing of personhood, offering the assurance of registering a separate life by mapping onto a notion of personhood. The “cardiac activity” detected at six weeks might imply a life needing protection, but was just the “flickering of a portion of the fetal tissue that will become the heart,” as we are reminded by the American College of Obstetricians and Gynecologist, and more than indicative of a stage of fetal development, mapped onto an imaginary of personhood and maternal love, rather than modern medical understanding.



But the “Heartbeat Laws” enacted at some forty East Texas towns, and from Ohio to Kentucky to Texas, seem to take advantage of the gaps between expert medical knowledge and presuppositions of fetal health, able to incentivize the possibility of civil suits against not women seeking abortion, or abortion providers, but anyone assisting in the illegal activity of terminating the alleged “heartbeat” that is posited as an index of vitality. At all of six weeks, a heart has not actually formed in the fetus, but the signals registered on the ultrasound are impressive–and graphically demonstrable–as a life line of sorts that the woman bearing the fetus is forced to face, as if she were suppressing her emotional attachment to the fetus she is carrying, but might reconsider her plans or own health needs before a line registering the presence of some electrical activity approximating a sinus rhythm–or, as the lawyers who parsed the new law put it in tortured prose, “cardiac activity” that involved the “steady and repetitive rhythmic contraction of the fetal heart within the gestational sac”–not an actual heartbeat but a surrogate form of personhood.

If just over half of the women who sought abortions in the state did so after six weeks, the new Texas law would allow penalties to be assessed and collected against anyone who “aids and abets” the shifting goalposts that now define the “end” of a pregnancy, beyond a six-week timeframe, sanctioning all Texans to become both consider themselves experts in embryology and district attorneys as well. For by deputizing anyone to view their liberties as infringed, and file civil lawsuits against anyone who “aids or abets” an abortion, equally liable as the perpetrator, to situate the procedure in recognized language of criminal liability. Access to abortion is intwined in both a criminal and pseudo-medical contexts to be removed from a woman’s health or choice.

The index of the heartbeat in a recognizably human form is an odd proxy to deem abortion a crime, but a rhetorically powerful one for fetal personhood–as well as a dramatically retrograde legal criteria, and a means to deny women a constitutional right to which they are entitled. But it is politically powerful, as an early canon shot in the territory of the circumscription of access to abortion, and the sanctioning of what amounts to “bounty” to charge all who help any woman seek access to abortion past the six weeks threshold. The bill entitles citizens of Texas to bring suit against any deemed “abortion providers,” by imputing personhood to that heartbeat, or “cardiac activity,” allowing them to recover a minimum of $10,000–a guaranteed a payback of legal expenses irrespective of individual health or personal reasons, or the rights that women are constitutionally entitled. Based on the logic, tweeted by Governor Abbott with evident self-satisfaction, that “no freedom is more precious than life itself,” a weird inversion of the claim of the 1320 Declaration of Abroath refusing that Scottish lords will submit to English lordship, and that freedom is something “no honest man gives up but with life itself.” If the evocation of “freedom” is a slightly less antiquated but more terrifying polarity of “Live Free or Die,” the end is intended to terrify: the bounties offered on notification per potential abortion of $10,000 per unborn, the state legislators placed value placed on fetal life in the state by consensus as well as incentivizing apprehension.

If Texas was the state where the deputization of all state residents as vigilantes for all “aiding and abetting” abortion after the detection of that “cardiac activity”–a reduction of the established threshold of twenty weeks, now reduced by almost two thirds. The law treats the performance of an abortion past this set threshold as a criminal activity by alerting widespread vigilance against something contrary to the common good. Indeed, the “life-saving Heartbeat Act” that the legislative director of Texas “Right to Life” described is a legal maneuver designed to entrap those seeking to terminate a pregnancy past even six weeks, by the specter of loosening vigilantes to compel women seeking abortifacients to live in fear, depriving any sense of a constitutional right to access abortion. And the concerted strategy was to introduce a virtual onslaught of similar cases passed by states with republican legislatures, undermining the durability of Roe v. Wade and Planned Parenthood v. Casey, which prevented states from imposing “undue burden” on the right to abortion, by framing a mandate on those assisting in the abortion–not directly on those seeking it. The disconnect between the reduction of health care services and palpable sense of excitement of anticipatory groupthink at the possibility to “be the first state in the nation to successfully enforce a ban on abortions when the preborn child’s heartbeat is detectable.” The contradictions of implicating a form of medical judgement to enforce forced public compliance of the most reactionary ban on abortion in the nation’s history. (A parallel movement in Mississippi seeks to push the threshold to fifteen weeks, as arbitrary a benchmark, not pegged to cardiac activity but fetal movement that as a sign of personal agency.)

The decree is local, but the dramatically different local determination of how late abortion is permitted is a removal of constitutional freedoms that has huge consequences for health care, and individual liberties. Local legislative bills have exploited a “states rights” rhetoric, with eery echoes of Secession, to curtail the window at which state laws permit abortion in ways that have already eroded what is the “Law of the Land”–but the “six weeks” threshold shortens the window to below when a woman is even likely to know she is bearing a fetus. But the medicalized logic which SB8 presented to the public as its rationale for such a constriction of the threshold at which Texas residents were granted “rights” to an abortion conceals the strategic gambit to undermine longstanding consensus about “settled law” since Roe v. Wade, taking “weeks past fertilization” as the metric, rather than the viability of the fetus outside the womb, or twenty-four to twenty-eight weeks. The analogies for this Solomonic decision were very Old Testament, with abortion doctors reach back to the Book of Esther, seizing upon a premodern image of female agency of begging for mercy to elevate their legal fight against the extinction of the unborn: the OB/GYN assumed the archetype of the female plaintiff who masquerades to avert Jewish genocide to represent himself as advocate for the unborn, while touring nationally before anti-abortion legal groups as if to hint at a legal stratagem that trumped his responsibility to counsel female patients.

The map of circumscribing abortion rights suggest that the crusade he led is hoped to eventually end up before the U.S. Supreme Court, however, hoping to rewrite the law that nominally keeps abortion legal in all fifty states.

Although the issue has been foregrounded in an attempt to erode legal consensus, if not redraw the political landscape of the United States, as abortion emerges as a touch-button issue for local relation to federal law, is “cardiac activity” a true index of freedom, or of circumscribing constitutional rights?

It is far more easily seen as a loss. It is important to map the legal attempts to curtail abortion not only in a “states rights” optic that would be a frontal assault to current statistics on how many women of reproductive age who have sought abortions. A map, made roughly as the judicial solution was formulated for legislative restrictions on those seeking abortions, responded to the a contested terrain, viewed by women’s county of residence, that places Texas, Mississippi, and South and North Carolina as a contested battlegrounds of legislative attack–areas to seek a new Civil War, and where Republicans were in the legislative majority, to frame a law deemed likely to survive challenge.

Onto this topography of fear, an increasing number of states have sought to circumvent national law, with twenty-nine mandating a form of counseling before abortion, and nineteen banning outright abortions that involve dilation or fetal extraction, creating a legal morass for any woman seeking an abortion in many states, in a relatively recent whittling away of Roe, designed to substantively alter the meaning of the decision.

Image may contain Plot Diagram and Map

An earlier Texas state law designed to challenge the constitutionality of abortion providers in Texas in 2014 by shifting the geography of access to abortion during the Obama administration, before the specter of making abortion part of a national health insurance program. The expanded access to abortion shocked activists, who were determined to create new restrictions for how abortion was part of health care at a local level, using state law to restrict the expansion of medical services. But the result has shocked medical organizations by shifting the grounds of access to health care in a direction unlike the rest of the nation–curtailing the place of abortion in plans for expanding public health care. The current legal battle in Texas’ legislature passing of SB 8 returns to familiar grounds: in pernicious ways, it erases the framework for evaluating a woman’s decision to terminate pregnancy according as a constitutional protection, elevating the detection of the heartbeat above the principle of health care to interfere with what was long settled law. That attempt to institute a restrictive law, indeed, led to the passage of proactive laws from 2017-18 defending rights of abortion in the northeast, northwest, and Illionois, setting the stakes to a redrawing of the place of access to abortion on purely legal grounds.

By advocating the standard of the “heartbeat” as a basis to eliminate health care for pregnant women, it poses as a modern recognition of the start of life in the womb that uses the now standard coin of the sonography as a basis to register fetal health as a grounds for affirming a tie to fetal individuality, in ways that will only be destined to sharpen the stark medical divides long existing in the land. The increasingly existential relation to policies that allow access to abortion is so terrifying that Planned Parenthood has created a dashboard of abortion access in updated form, whose shift in local policies suggest a terrifying unequal scenario of access to abortion in the future–a future when the legalization of abortion in Mexico may well increase the specter of women’s travels across the southern border to find the access to abortion that their own states’ legislators have decided was in their interest to deny.

While the question of access to abortion threatens to be existential for many women in the United States to a degree that would turn back the clock on what had long been guaranteed to be the accepted “law of the land,” the increased space that was given to legislatures of individual states to determine access to what they have called the termination of pregnancy : the heartbeat has gained currency as the new symbol of the shifting of the grounds of debate, as the heartbeat serves to provide a semantic shift from abortion to “termination,” and the ending of what is now construed as “fetal life,” as the heartbeat first seen in the fetus at about eight weeks has provided the new threshold for allowing abortion in Texas–and perhaps soon in other states–a rhetorical shift in the logic of shifting the threshold from “viability”–the ability of the fetus to live outside of the womb–to the first registration of this totem of life in the womb. Although the fetal heartbeat is able to perceived in its lub-dub rhythm at just three weeks, when a tiny 40,000 cell embryonic heart works in synchrony with the mother’s heart, as if learning its rhythm, beating the vital rhythm that Goethe elevated to a macrocosmic vibration “an eternal movement of systole and diastole of the heartbeat, the inhalation and exhalation of the world in which we live, act, and exist.” Anti-abortion activists legislated that harmony at a remove from the world, in the womb.

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Is Health Care a Democratic Right?

The bulbous, bloated cartogram meant to render the prospective withdrawal of insurers from individual health-care exchanges under the Affordable Care Act in its deepest colors foregrounded the concentration of a reduced insurance market in rural areas.  The image of a nation seething over, and the ground boiling over as if with discontent, cartogram, distorted “red” and “blue” states alike, but seemed evidence of the ways that the Affordable Care Act warped the even playing field in the United States–as if that ever existed, and could be expected to exist today.  But it might be taken as an emblem of the deep anger and resentment that many areas of the United States felt toward what was labeled “Obamacare,” and the regional markets left with but one insurer–and an inevitable feared rise in their insurance premiums–in the health insurance markets that the Affordable Care Act would create.

The designers of the cartogram warped to counties’ population almost aptly if inevitably rendered the country as boiling over with anger:  it seemed to render a powerful emblem to justify if not inspire broad indignancy about the apparently uneven consequences of mandated insurance exchanges which it argued the less populated–and poorer–areas of the country would be stuck with, as a distillation of social injustice.  For the cartogram captured what its designers argued was the distorted market for health insurance which people on the coasts had designed as destined to shut out large areas of the country shaded in lighter colors–and prevalently light pink.  But the prediction of a contraction of providers that undergirds this ominous scenario, as we now know, didn’t come about at all,–even if the strong passions provoked by the fight over health care did leave the country boiling over with anger and indignancy widely felt to be objectively justified.


map2_20170725Warped Map on Insurers Red v Blue Goves

It can be quite forcefully argued that health care deserves to be regarded as a  democratic right–democratic with a “small ‘d,'” in the sense of an egalitarian right, even though debates about access to health insurance are increasingly cast in politically partisan terms.  Although access to insurance exchanges are increasingly treated as a question less of a right than the reflection of a political position, the proposition of guaranteeing health coverage is rejected by champions of the marketplace and its benefits, who argue that its falsity undermines a free market.  As a result, in part, health-care exchanges are increasingly mapped in terms that might well be mistaken for political partisan divisions within the fabric of the nation.  Indeed, the sharp, flat blues, reds, and deep carmine of different regions suggest the hopes and difficulties of providing a uniform insurance plan for a nation of radically different numbers of insured, facing the hope to provide more with coverage in a way that may seem to tilt against the open nature of the marketplace.


Us Marketplaces.png


But democratic rights include not only political participation but due rights to certain benefits that accord undeniable liberties.  And although liberties which were not defined as including health care in the eighteenth century, leading many strict constructionists to view health insurance as an excessive presence of the state in individual lives, the range of liberties have expanded to-liberties to education, or to health, or protect against race-based, ethnic, or sex-based discrimination–revealing the broadening scope of understanding liberties, and might be  mapped into the fabric of the nation as an individual rights, and a basis for ensuring greater egalitarianism–and social equality–as a right.


Obama-healthcareBlack Enterprise


Back in 2013, of course, the institution of health-care exchanges set up a new landscape of the Patient Protection and Affordable Care Act–the Affordable Care Act or simply ACA–allowing most Americans to buy insurance on  government-run exchanges (or marketplaces) to have access to health care that they were often lacking in all fifty states, creating the reign of designing data vis of Obamacare exchanges often subsidized by the government for those eligible, to make it available to all, in ways that created some thirty-six exchanges run with the federal government, as states ran the others alone–creating the odd scenario that more enrollees came from red states, where they were run largely by the federal government.




But this was not widely accepted, and the rejection of the promise of what is now widely labeled Obamacare reflect the deep divides that its opponents argue the government mandate for buying insurance policies will impose on the nation.  The online popularity of recent projections of a constriction of health insurance options for most counties of the nation that were proposed as recently as the spring of 2017 seemed to reveal the deep dishonesty in the proposals of the Affordable Care Act to level the playing field.  And although the capital of health care as a good to the nation demands to be mapped, the difficulty of parsing the ACA independently of the name of Barack Obama reflect the unfortunate polemic level of debate about seeing adequate health insurance as a right of all–even as fear of losing health insurance dramatically rose across the nation, and the fears of rising premiums posed by its mandates were widely stoked by data visualizations suggesting widespread abandonment of insurance exchanges.


Changes in Providers.pngUS Health Policy Gateway


The data visualization–which almost amounts to a tool of outright propaganda–uses flat carmine to blanket the real improvements in numbers of the uninsured.  The presentation of an apparent distortion of the market is confirmed by declining insurance policies available on Obamacare exchanges, as its accompanying text assures readers that the real people to benefit from “marketplace enrollment” was the “private health insurance industry” who gained $90 billion in premiums, greatly profiting “publicly traded insurance companies”–distorting meanings of “public” and “private” as if to imply the dystopian nature of health exchanges that benefit coastal states alone.  The map of possible changes in rates of premiums were even more striking, and was presented as evidence of poor policy planning, as well as signs of a grim “slow motion death spiral”–a strategic choice of term suggesting the poor level of health-care it provided, and organically faulty nature of its establishment, but alienating the numbers of premium growth from individuals covered.





The familiar series of sequential images forecasting the mass exit of insurers from exchanges over a period of four years of the adoption of Obamacare stand at odds with the fears of losing health care and the defense of health care as a right, as well as a national system of insurance.  And despite an onslaught of maps  ostensibly demonstrating the ever-narrowing options for individuals as available insurers in state-based exchanges  dry up; they convey an imaginary future in which few counties with “active markets” of four or more alternatives–apparently compromising the rights of many Americans.


nssustaniable decline

Bloomberg Graphics/2017 Health Insurer Exits (projected)


Indeed, the image of rapidly dwindling options faced by Americans that such data visualizations claim to be based on data from HealthCare.gov. seem to suggest a focus on individuals.  But the broad brush strokes leave little to the imagination and present an ominous emptying of choice that seems designed to induce panic.  The images are executed with great dramatic effect, but little sense of cartographic skill–they presented a dire picture in which four options would be only available to residents of eight to ten states by 2017, calling into question the ability of much of rural America to remain insured.  The images of rural abandonment by health care exchanges were particularly powerful,  so absolute in their predictions as if to afford little room for interpretation

Yet the projections, for all their power, stand at variance with reality.  There will be, we now know, in fact no Obamacare marketplaces that remain at risk of being without insurers in 2018, as of August 24, 2017–


w:o insurers in echange

–and but a smattering of counties that were at risk for being without any insurers:


at risk of no insurer

Kaiser Family Foundation Interactive Version/Open Street Maps:  Counties at Risk of Having No Insurer on the Marketplace in 2018 as of August 24, 2017


In short, the disruption of the narrative of a dwindling of insurance options has been, after the failure to repeal the ACA, dramatically disrupted.  Even while acknowledging that there was a record low of uninsured in America after the American Care Act was adopted in “Obamacare marketplaces”–a coded term if there ever was one, loaded with disparagement–data visualization were crafted to predict deteriorating coverage options deteriorated in the months ahead in many rural states of apparent objectivity; hastily created maps, at an odd angle to reality, suggested that as much as over a fifth of all federally run marketplaces–predominantly in rural areas–were with only one insurer.

The alleged “bolting” of insurers from such marketplaces were predicted to leave areas like eastern Tennessee without any insurers, like, perhaps, southern Georgia, much of Colorado, almost all of Iowa, many counties in Ohio,  and large numbers of Virginians, as Aetna, Wellmark, and Anthem were predicted to “bolt” from the exchanges, leaving those Obamacare “customers” high and dry.  The argument of the abandonment of rural America was particularly grim.  But as the projections of the “bolting” of insurers fail to acknowledge the sparsely populated nature of many rural areas, the story that they tell of magnifies the poorly managed nature of the marketplace, obscuring the benefits or rights to health care–and the reduction of the number of uninsured across America– that the ACA has managed to create.  By privileging the size of largely unihabited regions of the midwest, maps of uninsured counties presented a decidedly skewed picture of enrollment, where the square miles covered by insurers projected to participate in health exchanges  seemed to outweigh those where insurers participated, irrespective of the sizes of inhabitants.  It is perhaps no surprise that support for Trump’s candidacy did not correlate with support for the ACA–





We focus on individuals to measure popularity for the support for health care reforms across the country.  Although many have recently entertained sustained interactive levels of introspection about where Americans supported  the Affordable Care Act in the months that preceded the election, pouring over the support for the ACA through county-by-county lenses that made sense pretty much only in how they might translate into votes.

While moving toward the acknowledgement of health care as a right is independent from such measurement of support for the ACA, the  low support for the act in sparsely populated areas intensifies as one moved to less populated areas, by and large, to suggest poor penetration of exchanges into much of the nation–and the distance of health care from what seemed in square miles a quite considerable geographic area.  Resistance to the ACA however reflects a rejection of the broad classification of health care as a right–or to even start to affirm it as one nation.   The division of the country, while reflecting the red state/blue state map in many ways, suggest pockets of counties with strong support for the ACA in a surprising range of the south, southwest, and other regions–across the divide between red states and blue.  Haystack’s micro targeting models estimated just under 98,943,000 ACA supporters nationwide–wondering how the electorate would parse on such a push-button issue.  And, indeed, the Senate Republicans were quick to issue a somber grey data visualization that affirmed a clearcut divide suggestive of the status of yellow- or red-alert in areas “abandoned” by Obamacare– in an openly partisan moment, undoubtedly funded by tax dollars.

Senate Republican Party flawed policies 2018U.S. Senate Republican Policy Committee


If over a third of the nation, colored an arresting yellow, seem to flounder in facing monopolies of insurance in the image that the Republican Policy Committee in the United States Senate designed for public consumption, who seem to have sought to raise a yellow- or red-alert for subscribers of Obamacare being abandoned, the map foreground  a divide in deeply partisan ways, failing to note persistently steep inequalities among  uninsured across the states, and the difficulties to attract insurers to markets in equal numbers, particularly in regions where up to a fifth remained uninsured in 2001-3.


% Uninsured 2002-3.png



Despite some questions of whether Republicans would be “alienating their own voters” didn’t affect the results of 2016 congressional elections.  But the power of the continued threat of a coming “implosion” of exchanges that upset the level playing field as an inevitable occurrence was successfully manufactured in projections of insurance markets that peddled groundless prognostications as if they were objective fact:  they successfully mobilized fears of the ability to avoid or precipitate a coming crisis by making it concretely manifest for viewers, pushing many to question the benefits that the extension of the ACA would actually bring–and to see it as a promise that would not be able to guarantee continued coverage or familiar premiums, and indeed to be engineered by the coastal elites and insurance companies that so much of the country has already come to distrust.   For the data visualizations that projected the uneven playing field that exchanges would create cast a divided commonwealth as a result of the limited choices restrictive options of health insurance many Americans would face.  These visualizations raised significant alarms bout the fate of Obamacare–and the specter of its undemocratic nature raised questions of what it provided to the country, or what future it might bright–that were deployed in particularly effective ways.

Flat colors of a data visualization communicate as many falsehoods about its actual relation to people as Trump’s favored declamation of Obamacare “very, very bad insurance.”  They obscure satisfaction ratse of over 75% among those enrolled in plans, and of almost 90% in public Medicaid programs for the poor.  Rather, the picture of an implosion of insurance markets garnered ungrounded trust, and became demonized as but “a first step” toward what he presented as the apocalyptic scenario in which the “government basically rules everything”–a fear of the implosion of a free market–ignoring that the American Care Act is premised on encouraging competition among medical insurers.  Yet the image of such an implosion or collapse perpetuated in data visualizations of crude colors was something that was manufactured in projections that masqueraded as objectively designed maps.  In charting decreasing insurer participation in exchanges as actualities, data visualizations seem designed to stoke uncertainty about the future viability of health insurance markets in America.  Yet the uninhabited nature of this landscape of counties–a metric that makes sense only really as a convention of electoral politics, rather than health care or even of individuals residing in different parts of the country, is starkly removed from health care save in terms of how it might translate into a political choice.

The rhetoric of these “maps” uses projections cover the individuals who benefit from medical care.  They encourage voters to feel slighted in new medical marketplaces, and ask them to chose a future–without considering metrics of coverage or the relative quality of medical care.  They serve to map a landscape of fear, encouraging fears of growing premiums and less choice among voters in what is painted as a compromised medical marketplace.


1.  Construing health-care as part of a democratic system has been understood in surprisingly partisan terms.  Some would restrict liberties to participation a marketplace, by adopting and privileging the market as a primary metaphor if not end of civil society:  the success of such a distinction has lead to a broad and striking demonization of its mandate, rather than the policies of the health care law signed in 2010–the Affordable Care Act–which as a law has consistently received far less opposition than the change in health insurance provision that mentions President Obama’s name.  The divide in perceptions seems to have been broadened considerably by recent visualizations that project the future market for health care, or project the numbers of insurance carriers available in exchanges, the colors of the availability of carriers overwhelms the presence of individuals, and reveal the new markets that the Affordable Care Act (or ACA) created as if it were an uneven playing field for all Americans.

Indeed, as recently as June 2017 and during the Trump-Clinton campaign, media outlets and websites trumpeted “maps” or “a map” as evidence of the uneven playing fields that the ACA would bring in the country and the restrictive options that were increasingly identified with “Obamacare,” as if it were something different from the health policies that increasing numbers of Americans had enrolled in, but rather a specter of higher premiums, fewer rights, and new restrictions on providers if not health policies that could not be trusted, in ways that continued a drumbeat of visualizations predicting coming imbalances for those enrolled in Obamacare to insurance carriers or to a competitive marketplace–if not rob them of access to insurers–concretizing what Donald Trump cannily called “the broken promise” of Obamacare, as some 2.4 million “customers of Obamacare” would be with but one insurer to select in the coming year.   Health officials in the Trump administration issued a “new map showing in full color how many counties in the United States could have zero or just one insurer selling Obamacare health plans in 2018” as if to provide confirmation of the poor deal that was offered the nation; the data vis produced by the folks at the Heritage Foundation was accompanied by an announcement that, in case any one missed the point, insurance exchanges in 2017 would feature ” a major decrease in competition and choice” (italics added) that exposed the deep failure of the ACA to promote competition as promised:


IB-exchange-competition-2017-map-1-825.gifHeritage Foundation (January 30, 2017)


The absence of competition left some state, the not unsubtle point was made, that were neglected by the insurance companies that had promoted the ACA:


ACA Header?.png


The stark contrasts of the data visualization were a rallying cry for a public campaign for the repeal of the Affordable Care Act, designed to activate the red states that were shown to be the largest losers of the insurance exchanges Obamacare created.  The map released shortly after the inauguration in a push to confirm the repeal of Obamacare, showed almost all counties in the southern United States with but one insurer–as almost a third of the counties in the nation–but not the population by any means.  In the rhetoric of an earlier map that described how “large of swaths of yellow cover a number of Southern and Midwestern states, all of Alaska, and elsewhere indicating counties . . .  are projected as of now to have just one insurer selling individual plans next year,” the images of a restriction of opportunities to buy health insurance was alerted, with areas with but one insurer appropriately colored red, as if to convey danger.

The slightly different visualization from June that accompanied this projected danger suggested that some counties–colored red again–would strip residents enrolled in Obamacare from any insurer for those enrolled in Obamacare–this time in “a new map showing in full color how many counties in the United States could have zero or just one insurer selling Obamacare health plans in 2018“:


Conties Analysis ObamacareMSNBC (June 13, 2017)


The fear that such maps stoked of an imbalance that cut into the insurance options of many as far as health goes suggested a lack of care and a lack of coverage that suggested a deep disinterest of almost a third of the nation, but did so with little actual grounds.  Those sparsely populated regions loose out in the new marketplace that Obamacare seemed to threaten to impose–even if the Affordable Care Act was created to extend health insurance across the nation:


Obamacare 2016_0

McKinsey Center for U.S. Health System Reform (August 26, 2017)


Such deep divides within the United States that cut against equal access to health insurance was of course what Obamacare was introduced to prevent, but the exchanges in the less populated states were indeed slow to attract insurers.  However, the terrifying fear of a subtraction of any guarantees of well-being and a level playing field that these projections promote–they are hardly really data visualizations, if they resemble maps–seem as good a definition and a metaphor of undemocratic policies, and a metaphor for the restricted roles people are given a crucial say in the policies and decisions that most affect their lives.  Although the sentiments for including health care as a right has become to a deep divide in the nation, the disadvantages that the initial introduction of the exchanges were cautioned to bring to peoples’ lives and policies were immediately striking.

And the recent success of mapping the actual resurgence of insurers’ involvement in many exchanges in counties nationwide reminds us of–and asks us to reconsider–the deceptive nature of their claims.  Indeed, as recently as June, 2017, media sources presented “a map” or a set of maps as evidence of the imbalances that the previous administration had failed to foresee, or willfully imposed on the nation.


1.  The negative benefits to all of health-care being a restrictive good are pretty clearly evident:  healthcare should not be seen as a commodity alone, existing on an open marketplace.  Given the clear negative pressures of lowering access to health care to society, the gleeful prediction by President Trump that Obamacare–as Trump calls the Affordable Care Act (ACA)-, as if it were just not American to promise health care to all–would be implode because of e lack of plans available on exchanges in much of the country thankfully seems untrue.  Indeed, the failure to repeal the ACA by the United States Senate–a failure that seems to have sent a shudder of initial convulsions within the Trump administration, and within Donald J. Trump’s sense of his hold on the Presidency, has led insurers to return to the many counties where they had in previous months left, provided all but one of the counties that seemed to have no clear options in the Obamacare exchanges–and that now-President Trump’s declarations of Obamacare’s demise were quite premature.  Although the graphics of health insurance providers that were available to residents in local exchanges under the Affordable Care Act seemed truly badly served in much of the nation by early 2017–when many of the counties not on the coasts or in coastal states seemed to suffer from a gap in options, as was true even shortly before the 2016 Presidential election in surprisingly effective ways.

As soon as the future markets for insurance were mapped and the maps were released, the revelation of apparent gaps and “dwindling in surname choices” and egregious absences in covering the nation’s populations seemed to show up the falsity of past promises.  The maps gained a polemic authority of their own, confirming lingering suspicions about the poor fit of “Obamacare” to the nation, and providing fodder for raising alarms about the inequitable nature of the exchanges that emerged in different states and counties.  For they seemed to reveal an apparent abandonment of the majority of the country by the coastal elites of California Massachusetts, New York, Chicago and Washington D.C.:  indeed, it triggered a sense of the abandonment of the nation by coastal elites.  The very story that was told about Hillary Clinton and the Democrats in many circles were being repeated in the Presidential campaign were used to lace increasing suspicion about the emergence of fair marketplaces in future years.



County-Level Data on Insurance Providers under ACA/AP  (October, 2016)


The deep brown nature of the map didn’t reveal the restrictive choices of insurers, but muddied the picture of the nation, as if throwing into relief a plurality of counties that existed on a higher plateaux of health care, and left behind the rest.  The visualization suggests that a sombre picture of health-care had emerged before the Senate failed to dismantle Obamacare, light tans suggesting the greatest gaps in low-lying lands of few insurance options, and markets where sufficient variability would not bring lower costs.  In those regions, the widespread “lack of choice” appeared so evident in dismaying gaps across the nation, where the departure of insurers from a market seemed that had been seen to rise in 2015 and 2016 had started to fall precipitously, raising the fears of rising premiums.  Several entire states–deep red states, as it happens, like Alabama, South Carolina, Oklahoma, and Wyoming–had only one participating insurer across the entire state, suggesting gaps in the health plan that claimed to be engineered to offer choice.

The mapping of these projections seemed to make manifest the deepest fears of inequality and an unloved playing field, which data visualizations like the above seemed to expose–while dying the projected nature of its claim that insurers’ “departure” had already occurred.  Yet the residents of all counties in the United States but one will be able to purchase an Obamacare plan in the coming year in actuality–the fifth year and enrollment cycle of Obamacare insurance markets, has brought successful expansion, with increasing coverage is provided by insurers across the United States may be even effect a new acceptance of health care as a right.  For despite widely stoked fears of drying out health insurance markets projected in deceptive data visualizations with such particularly alarming effects.

Just a mere two months ago, it was predicted that forty-seven counties would have absolutely no insurers by 2018, and that residents of greater than a thousand counties–and up to 1,200– would be left “bare”–hight and dry–with access to but one insurer in their exchanges.  The alleged analysis of the impending “collapse” of insurer participation nationwide showed an image of “projected insurer participation” as if they described an actuality of declining participation that had effectively fractured the nation–lending currency to pronouncements that struck fear into many voters.


County by County analysis.pngExchnage Carrier.pngCNBC, June 13, 2017


Despite the manipulative nature of these data visualizations, the recent resilience of markets after election, and specifically the failure to repeal Obamacare, has responded in ways that stand to change.


2.  But the picture was indelible when it was framed, forged in the sharp colors of data visualizations which arrived with regularity at the same time as maps of projections of the Presidential election dominated social media and the press.  They created a terrifying image of a divided nation, destroyed by the all but inevitable impending “collapse of Obamacare ‘coverage’ in 2017” as revealed in “stunning maps” released in the late summer during the Presidential election, as if they were the hidden understory of national divisions that some candidates just didn’t get.  These visualizations allegedly revealed divisions of the nation in ways that must have spooked many, weren’t being addressed by the White House or health care officials, and seemed to signal an era’s end–touting “Higher Costs and Fewer Choices for Obamacare Customers in 2017.”  The below-the-radar war of data visualization for national attention suggested nothing less than the erosion of the union that was tied to the encouragement of insurance exchanges.

Such data visualization worked their magic, triggering narratives of abandonment and appearing to reveal an isolation of several of the poorer parts of the nation that set of alarms about the increased division of a nation and an uneven playing field that the Affordable Care Act–now demonized by the name “Obamacare” to distance itself from the actual legislation–that revealed the apparent absence of competition in “stunning” ways.  For by depicting the “epic collapse” of a system that in fact seemed to be give greater stability to a projection and make it manifest as reality.  The magic of the data visualization was that they purported to reveal an actuality the Obama administration seemed to deny as if it were an actuality that denied options to many Americans.   And although the spread of the one-carrier-ounties across much of the “heartland” seemed confirmation, for many Republicans, of an abandonment of the mythic heartland of Trump voters, which pulled from Iowa to New Mexico to West Virginia for Appalachia for Trump–the complexion of where insurance is available.

The alleged objectivity of the visualization left many with breath held, as “stunning maps” released during the heat of the Presidential election in late summer prophesied an impending “collapse of Obamacare ‘coverage’ in 2017” as an all but inevitable reality.


Obamacare 2016_0McKinsey Center for U.S. Health System Reform


Data visualizations of jarring color selections suggest the discontinuity in a system of health care, using the not necessarily clear metric of the existence of a range of carriers.  The notion of the medical marketplace that such competition was supposed to create however realized clear gaps with the counties in violet, whose disarming continuities suggested pockets of the nation that were unfairly left behind, and others in pink that seemed to be similarly compromised in the notion of options or choice their inhabitants were offered.  But the alarmist cartographies were extremely effective in tellign of a story of those regions that were left out–not only Kansas, but Wyoming, West Virginia, and stretches of North Carolina, South Dakota  and Michigan. The maps spoke to many.

The deeper debate about health care as a right demand to be examined in far greater detail than the polemic nature of such visualizations allowed.  And the recent resurgence of insurers in almost all counties of the nation provides a good occasion to do so.   It’s not a secret that the difficulty of construing health-care as a democratic right has also been rejected by many,–who would  restrict liberties to participation a marketplace.  In doing so, they adopt the market as a primary metaphor if not end of civil society–and view any tampering with the health care market as undue governmental meddling.  Yet the guarantees of well-being and a level playing field seem as good a definition of what is democratic as any, as it affords a needed means to allow people to have greater say in policies and decisions that most affect their lives.  And sentiments for including health care as a right has however come to be one of the deeper divides in the nation.  And the recent success of mapping the real resurgence of insurers’ involvement in many exchanges in counties nationwide reminds us of–and asks us to reconsider–the deceptive nature of their claims about the narrative of the impending collapse of Obamacare that many data visualizations of the nation relentlessly advanced, with minimal questioning or interrogation, and the how the image of the nation they suggest may explain public understandings of health care as a democratic right.

But since the negative benefits to all of health-care being a restrictive good are pretty clearly evident, healthcare should not be seen as a commodity alone, existing on an open marketplace alone.  Given the clear negative pressures of lowering access to health care to society, the gleeful prediction by President Trump that Obamacare–as Trump calls the Affordable Care Act (ACA), as if it were just not American to promise health care to all–would be implode because of e lack of plans available on exchanges in much of the country thankfully seems untrue.  Indeed, the failure to repeal the ACA by the United States Senate–a failure that seems to have sent a shudder of poor guidance and convulsions within the Trump administration, and within Donald J. Trump’s sense of his hold on the Presidency, has led insurers to <em>return</em> to the many counties where they had in previous months left, provided all but one of the counties that seemed to have no clear options in the Obamacare exchanges have gained them.


3.  Trump’s declarations of Obamacare’s demise were indeed quite premature.  Although the graphics of health insurance providers that were available to residents in local exchanges under the Affordable Care Act seemed truly badly served in much of the nation by early 2017–when many of the counties not on the coasts or in coastal states seemed to suffer from a gap in available options, as was true even shortly before the 2016 Presidential election in surprisingly effective ways.  The sentiment of a curtailing of options–and of choice, that elusive and so malleable term–became something of a battle-cry against the ACA, which redefined how it was portrayed and cast as an imposition that failed to meet health needs, but whose premiums were substantially more.

If one might say, with poet Elizabeth Bishop, that “more delicate than the historians’ are the mapmaker’s colors,” unlike the color-choices by which cartographers define land and sea as areas viewers can inhabit and read, the stark colors of the data visualization suggest clearcut differences and decisive results–too often just to stark to be lent the credibility that they seek.  Bishop linked the art and science of the cartographer and the art of poetry, in her first published poem, written when staring at a framed map of the North Atlantic that lay under glass as she was ill.  In tracing the mapped waters, and the land that lies beneath the water in maps, shadowed in green, she admired the transformative nature of the cartographer’s art and the expressive license of defining land and sea, and the edges of sandy shelves, as allowing the cartographer to create an aesthetic object able to engage the viewer’s fantasy, through the delicacy of color choices:  the stark, flat tones of the above data visualization–whose colors are all too strict and edges overly severe–work best to create oppositions and manufacture absolutes that offer little distance on the world, or clear purchase on it.

The colors chosen by the cartographer, if at odds with the actuality of the ordering of the land, cannot compare to how the translation of the edges of insured and uninsured are erased in the clear contrasts that compress the actual contours of health care.  If Bishop contrasted the reality claims of the historian to the artifice of the map-maker, whose creations appear arbitrary, but reveal actual complexities, as allowing possibilities for the contemplation of the world.  But rather than presenting an authoritative version of the world, the human measure of a carefully made map, and the invention it offered as an angle at which to examine the world absent from many visualizations, which privilege a single actuality as sufficiently authoritative to orient viewers to the world along a single narrative–and not preserving a human scale to do so.  The deceptive nature with which data visualizations foretold collapsing insurance choices in the Affordable Care Act presented a false reality. about health insurance exchanges, in short, by creating alarming contrasts between sharp colors in maps that offered no opening for interpretation. In contrast, maps of the actual numbers of those without health insurance reveals a landscape of much more complex edges and shadows, as well as deep divides, demanding to be moused over in detail for their interactive experience, if only to come to terms with the changed life experiences of those in many states, as from 2013-16, as the constantly shrinking number of uninsured grew nation wide in ways that attest to the increasing health of the nation–if with considerable numbers of uninsured remaining in may exchanges:


shrinkin uninsured.png


percentage uninsured.png

New York Times


In contrast, the almost uninhabited landscapes bereft of insurers that data visualizations depict to suggest a narrowing marketplaces and dwindling options of Americans offers an image less about “health”–our about our health as a nation–than the problems of creating continuity among the insurance exchanges that underwrite the insurance marketplace.  The lack of perspective that they offer on the residents of each county and of our country–and the forced viewing of “health” in terms of insurance companies which participate in exchanges, suggest what more contemporary poet, Claudia Rankine, called the particularly contentious meaning of “health” today in the United States:  at a time when “Affordable Care Act” is seen as something different from “Obamacare” by most Americans, who want the affordability of health care but suspect the inequality of “Obamacare”–whose repeal Trump declared his first order of business as President.  “We heard health care and we thought public option/we thought reaching across the street across the lines,/ across the aisle was the manifestation of not a red state/ not a blue state but these united states we thought,” Rankine wrote with assurance of a new landscape of health insurance, “we could be sure of ourselves in this one way sure/of our human element our basic decency.”

But the increased decency of providing more Americans with adequate health care, “a kind of human kind of union we were ready to check-up,” as Rankine wrote, in the belief that “in this one way we were ready/to care for each other we were ready to see/our range of possibilities as a precious commodity,” was distorted in a map that focussed on the marketplaces of insurance options that Obamacare–the Affordable Care Act–sought to create.  If in this nation “despite being founded on genocide and sustained by slavery/in God’s country we thought we were ready/to see sanity inside the humanity,” the humanity of health care seems sadly obscured in the exclusive focus of data visualizations that focus on providers absent from the marketplace.


4.  It is rather terrifying that the alleged objectivity and authority of such data visualizations were arrogated to make a point that disguised their nature as projections and roles as arguments.  While doing so is tantamount to disinformation, claiming predictive value as declarative statements which has since proved to be without any merit.  For not only did they distort the question of coverage by ignoring that the areas where three or more carriers would be options were most populated–where the best job had been done informing patients of their options to enroll in policies, and also where far better medical coverage existed for Americans in previous years–but the alarms that they sounded were ungrounded, although the image of two coasts and a well-off midwest that suddenly left large parts of the nation in the lurch effectively tapped into deep suspicions and uncertainty.

Rankine persuasively hypothesized–and elsewhere actively protested–the deeply ingrained racism that motivated a nation ready to distinguish between “Obamacare” and the “Affordable Care Act”–valuing the affordability of health insurance, but suspicious of the insurance labeled by the name of Trump’s predecessor.  The motivations for suspicions about “Obamacare” as a tampering with the free market of health providers is unclear, but it undermines the interest in our understanding of the preciousness of health care as a right.  Yet the humanity of health care seems sadly forgotten by the shift from a topography of individuals insured to a topography of the marketplace.  Although Trump seemed to think he had fired Obamacare from the country by declaring it “dead,” and just destined to implode, the markets revealed themselves to have been set up with considerable resilience, despite deeply troubling glitches in its roll out; if more than eighty counties earlier risked offering no options to enrollees, insurers returned overwhelmingly, where they were able, especially when already strongly present in the marketplaces, despite the threat from President Trump to pull federal subsidies.

The presence of mapping future markets for insurance were released with claims to show of apparent gaps, “dwindling insurance choices,” and egregious absences in covering the nation’s populations.  They seemed to show up the past promises of the President to preserve choices for Americans to adopt a health plan that suit them best, and portray them as undue impositions on the marketplace.  The projections acquired a polemic authority, as if confirming lingering suspicions about the poor fit of “Obamacare” to the nation, by providing fodder for raising alarms about the inequitable nature of exchanges in different counties and even in different states.  They seemed to confirm a feared narrative of the abandonment of the much of the country:  indeed, many popular data visualizations triggered a sense of the abandonment of the nation by coastal elites in New York, California, and Washington DC, in particular in Arizona, Oklahoma, Texas, Colorado, Missouri and the Deep South, as well as parts of Michigan.  They confirmed the very story told about Hillary Clinton and the Democrats repeated in the Presidential campaign as if to lace suspicion about the emergence of fair marketplaces in future years.



County-Level Data on Insurance Providers under ACA/AP  (October, 2016)

The particularly grim picture that they offered came in for little criticism or rebuttal.  But the data visualizations describe landscapes that are curiously depopulated, even as they present a sobering picture to suggest the withdrawal of insurers from medical exchanges.   The map implies an absence of interest in much of America by the very insurers who claimed to have sponsored the new marketplaces–but had only concentrated on the most profitable regions.  Its implications one of the abandonment of many of the rural areas of the country–the less densely populated–although the greatest success of such exchanges in densely populated urban areas that were liberal-leaning is no secret, they imply an absence of interest in less populated areas of the nation.  The implicit message that little attention was paid to the rural areas was underlined through the strategic colors of the data visualization, which seems to suggest a relief map of areas that would suffer higher premiums:   audiences in much of the country were convinced that they just had it worse in the projections all too often portrayed as eventualities that the nation would stand to suffer.  The tan colors that suggest diminished choices of medical insurance muddied the picture of the nation, throwing into relief a plurality of counties that existed on a higher plateaux of health care, and left behind the rest.

The visualization suggests that a sombre picture of health-care had emerged before the Senate failed to dismantle Obamacare, light tans suggesting the greatest gaps in low-lying lands of few insurance options, and markets where sufficient variability would not bring lower costs.  In those regions, the widespread “lack of choice” that appeared evident in dismaying gaps across the nation, where the departure of insurers from a market seemed that had been seen to rise in 2015 and 2016 had started to fall precipitously, raising the fears of rising premiums.  Several entire states–deep red states, as it happens, like Alabama, South Carolina, Oklahoma, and Wyoming–had only one participating insurer across the entire state, suggesting gaps in the health plan that claimed to be engineered to offer choice.

Such premature projections seemed to make manifest the deepest fears of inequality and an unloved playing field, and invested themselves with an objective authority of exposing an uneven system that was indeed rigged–denying the projected nature of its claim that insurers’ “departure” had already occurred.  Yet residents of all counties in the United States but one will in fact be able to purchase an Obamacare plan in the coming year in actuality–the fifth year and enrollment cycle of Obamacare insurance markets, has brought successful expansion, with increasing coverage is provided by insurers across the United States may be even effect acceptance of health care as a right.  For despite widely stoked fears of drying out health insurance markets projected in deceptive data visualizations with such particularly alarming effects.


2.  To better grapple with the readiness of insurers to fill the health-care marketplace, the stunning maps of the presence of insurers who have made health-care policies available demands to be examined through a red state-blue state optic.  For eve if the aversion of Republican-leaning regions in the United States to providing alternatives to health care insurers creates a deep divide concentrated in much of the south, prairie, and southwest, where only 1-2 insurers exist, and despite uneven nature of conditions conducive to access to health services that guarantee well-being–and presumably happiness–the markets have grown.


HEalth Care Insureres:Red v Blue Govs.png



If the divide looks harsh anyway for many rural areas, the red/blue divides cannot reflect the actual availability of health providers to Americans.  Since the notion of the division of the distribution of insurance markets by counties seemed suspect anyway, given the sparser population of many of these states, a more accurate picture of national coverage is offered by a simple proportional warping of the odd division of the electorate by the “county”–an outdated geographical unit if there ever was one.  The mapped that warped counties by their relative populations reveals  an even sharper picture of the actually improving state of availability of insurers–the fewer residents of many of the just-one-insurer regions of the south and indeed midwest shrink, to confirm the growing success of the selection of insurance providers by the ACA, despite some obviously problematic and important to address gaps in coverage.


Warped Map on Insurers Red v Blue Goves.png


It is striking that these very gaps mirror with a terrifyingly clear correlation both dial-up speeds and broadband technology, as well as intractable bottom-line problems like gaps in the availability of health-care services in rural areas.





Rural Health Information Hub, December 2016



5.  Abandoning the red/blue divisions, which are taken by the elected governor, we see an even healthier division of the nation, at least in terms of the regions that provide their residents with something like a reasonable variety of possible health care insurers, with large areas of the most populated areas having three potential insurers, rather than insurance markets imploding at all, despite the clear gaps that it reveals in what seem more underpopulated areas–and, quite strikingly, the absence of broadband that would make it easier to enroll for insurance online.


5995cec01400001f002c3494Harold Pollack and Todd Stubble


Broadband 2014.pngNational Broadband Map, June 2014 (not updated since)


These gaps reveal a division of much of America into two regions–no doubt conducive between two expectations of health care or medical provision.  Most southern states indeed had far fewer insurers–left “bare” with but one provider, despite the low populations of such rural regions being just less conducive to insurance markets, and revealing an uneven playing field long preceding the passage of the Affordable Care Act–


SOUTHERN states health care insurers 2017-18Harold Pollack/HealthInsurance.org


One Provider South Rural.pngHarold Pollack and Todd Schuble


The area is not only medically underserved, but suggests a “Southern Problem” having far less to do with Obamacare than with the disproportionate topography of medicine and indeed of those without health-care, but creating many counties including large stretches of chronic undeserved populations.


RAC 2014



Such maps and data visualizations only suggest a need to appreciate and fathom the deeply compromised liberties in areas with few health insurance providers, where insurers haven’t reached clear markets, that not only overlap with many of the more chronically uninsured areas and populations, but with areas of the a terrifying number of uninsured–folks who have decided or been forced to do without health insurance, and where going without health insurance becomes an accepted acceptable alternative, unlike in many regions of the country,





which often echoed the very regions of greatest vulnerability in the nation–counties that to be sure often reached out to Trump as a savior for their deep discontent.


Rural Assistance Center Underserved.png


RAC 2014.png



2.  The increasing variety of insurance options for much of the nation raises questions about the persistence of a deep inequality–undemocratic for many–in those pockets coinciding with denser votes for Trump, in a normalized choropleth, and more hospitable to an argument of revising current options of health care–and viewing the Affordable Care Act as an imposition of the federal government.


Trump votes normalized choropleth


There are interesting overlaps on those areas where Trump out-performed previous Republican candidates, notably in Florida’s panhandle and less densely populous counties in the deep south; southern Texas; and Appalachia.





The odd reluctance of these areas to attract anything like a range of possible insurers in lower income areas of low-density where Republicans have recently performed well.



New York Times



They reflect the difficult problem of distinct notions of liberty and rights in the country, corresponding to areas where the civilian population was long underinsured, often by upwards of 15%, and where shortages of health-providers–even if not as readily available in county-level data–are strikingly revealed in a state-by-state survey:  states like Georgia, Mississippi, Arkansas, New Mexico, Nevada and Texas remained significantly below the national average for primary care physicians in 2012, suggesting regions where there were less developed expectations for attaining health care coverage.





Increased numbers of uninsured exist in many of the same states are, to recap, unsurprisingly located in some of the same regions–which are less likely to vote for representatives who advocate the belief in health care as a right, and perhaps seeing it as able to be outweighed in importance by an argument of states’ “rights,” even if this discourse is designed to deny health insurance.




It seems a cruel irony in an era of globalization that the majority of those doctors or members of the healthcare force serving areas of the United States that were most in need, and who see some 14 millions patients every year, were from Iran, Libya, Somalia, Sudan, Syria, or Yemen–citizens of countries included in Trump’s Muslim Ban.  (In other words, these immigrant doctors are filling the increasingly pronounced gap that exists among medical providers in the United States–and getting the job done.)  If medically underserved areas occur in almost every state in the country, the preponderance of medically underserved populations concentrated in less populated areas–as the southwest, southern states, and parts of the Midwest seems to have attracted foreign doctors–and had already led bills to be sponsored to allow Medicare to reimburse pharmacists directly in those communities, to acknowledge the absence of medical services needed by Medicare beneficiaries, to allow clinical pharmacists to work in medical care settings as a health provider.


Doctors from coutnries in Muslim Ban.pngSee interactive version of this map here, at the Immigrant Doctors Project


The map has some striking overlaps with those regions of rural America that are losing population, although it should be kept tin mind that the above map, which used data from Doximity to suggest the commenting zones for the number of doctors in the United States may distort by expanding the zones of providing services beyond that which physicians actually serve most actively:


map-loss.pngRural Communities Losing Populations, United States of America


The elevation of the pharmacist to a medical provider may raise ethical questions.  But the existence of hight concentrations of medical physicians from the very countries that were targeted by the so-called “Muslim Ban” that Trump championed had the effect of allowing a crucial degree of medical assistance to reach Americans–although the apparent intent of Trump’s legislation would have been to restrict their abilities to return home freely to visit their families, and compromise the proportion of doctors on call in the cities where they are most concentrated–in Toledo, Cleveland, and Dayton, Ohio as well as Detroit MI.


Medical Assistance.pngImmigrant Doctors Project


Such pronounced concentrations of physicians which were mapped online in readily seaarchable formats by the Immigrant Doctors Project provide powerful tools to view how the markets for physicians’ skills meets the needs of a marketplace, to be sure, if one recalls the huge numbers of medically underserved counties.  But this is not a marketplace that would be easily filled by our current medical system, or the health-care industries that service more rural or poorer areas.


RAC 2014.png


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Filed under Affordable Care Act, data visualization, health care, health insurance, Obamacare