Respite Open Thread: Turbo Takes On The World

Sweet puppy video h/t geg6

And from JeffreyW, a sweet pairing, Gabe and Homer:

And here, the ducks are back to normal after a hawk (most likely an overly confident Cooper’s Hawk) was hanging out on the edge of the duck pool. I sent the dogs out to take care of things, but I’ll be keeping a watchful eye for a while. The ducks were smart enough to hide out under the bushes.

We have battened down the hatches here, expecting a stormy night. What’s up with everyone tonight?

Respite open thread.

GOP Venality Open Thread: If Only There Was Some Agency!...

… Or if Leader McConnell allowed us any!…

Romney of the Uncanny Valley, peak functionality.

Weak Man, Tough Talk

As you’ve no doubt heard, the Short-Fingered Vulgarian announced a plan to round up “millions” of undocumented immigrants via tweet last night:

This was news to ICE, according to The Post:

U.S. officials with knowledge of the preparations have said in recent days that the operation was not imminent, and ICE officials said late Monday night that they were not aware that the president planned to divulge their enforcement plans on Twitter.

I’d rather gouge out my eyes with a melon baller than watch Trump’s klan rally/2020 campaign launch from Orlando tonight, but I’d bet my next paycheck that anti-immigrant demagoguery will feature prominently in the evening’s bellowing. We’ve seen this movie before. Trump will make stupid accordion gestures with his tiny mitts and leer, snarl, strut and lie in an attempt to sound tough. The rage-fart huffers of Cult45 will stomp and hoot in approval.

But whenever Trump cranks up the bigotry, it’s a sign of weakness. Greg Sargent at The Post has it exactly right:

It has never been clear whether Trump acknowledges any political downside to his immigration cruelties and all around border-related impulsiveness. He appears to refuse to accept that they helped Democrats win a large national majority in the 2018 House races. He appears certain — outwardly, at least — that in 2020, this focus will energize his core supporters by enough to tip the electoral college, due to disproportionate numbers of blue-collar whites in the Rust Belt.

But the backdrop to all this is that the Trump campaign is firing several pollsters, because internal data leaked revealing Trump as deeply vulnerable to losing reelection — including trailing in Rust Belt states.

Trump still enjoys the advantages of incumbency and the good economy. But if his immigration agenda in particular is helping boost his reelection chances in those places, there’s no sign of it yet. Until that changes, this threat of mass arrests looks more than anything else like doubling down on a failing strategy — both substantively and politically.

In addition to firing up racist, xenophobic base voters, mean-spirited immigrant bashing frightens squishy Republican Never Trumpers like Andrew Sullivan and David Frum, who are urging Democrats to take a harder line on immigration — despite being immigrants themselves. Remind me again why we should listen to those assholes? Oh right, we shouldn’t — fuck them.

Candidates Julián Castro and Beto O’Rourke have compassionate, comprehensive immigration proposals. Even if neither man makes it to the ticket, it’s my hope that their proposals gain support in the primary, just as I hope many of Warren’s economic policies become part of the Democratic Party platform in 2020, even if she’s not the nominee.

Outside of Trump’s rabid, dwindling base, cruelty doesn’t play well. But Trump is going to double, triple, and quadruple down on immigrant-bashing from tonight on through election day — not because he’s strong, but because he’s weak.

That means we’ll have to stay strong, because friends, shit’s about to get even uglier. This may be a good time to reach out to immigrants in your life who are understandably anxious about the climate in this country and let them know you stand with them.

Tuesday Afternoon Open Thread

Think I need a bigger dog bed:

The Trump Effect on enrollment

The Journal of Health Politics, Policy and Law (JHPPL) just published my first peer-reviewed original research article. I worked with Dr. Paul Shafer on this article as he had requested and received through Freedom of Information Act (FOIA) week by week county level application counts for 2014-2017.

We asked a simple question that Balloon-Juice readers already sort of knew:

What happened to ACA enrollment during the 2017 Open Enrollment Period when the messaging and implementation regime switched from being very supportive to very opposed?

There had been several analysis that suggested a 4% to 5% decline in total open enrollment. The problem with these analysis is that the counterfactual (2017 trend would have looked like 2016 if the Obama HHS had run the entire open enrollment) was lightly tested.

We ran a descriptive analysis that basically was a repeat of the previous analysis. It suggested that something big happened.

We then ran two, more rigorous models. The first was a difference in difference design which found that the last two weeks of the 2017 Open Enrollment Period had a 30% reduction in applications for insurance. An event study design found a 24% reduction in applications in the last two weeks of 2017 compared to the pre-inauguration trend.

So what does this mean?

Folks who know that they are likely to incur a $100,000 or more in claims are very likely to sign up for health insurance that is community rated, guarantee issued and heavily subsidized no matter what the messaging regime is. It is highly salient and highly important that they get their healthcare covered. They will crawl through glass for coverage. We can also assume (but did not prove as our data was not that granular) that the vast majority of this population had signed up during the time period the Obama administration ran as the coverage that could be bought in the last two weeks of the Open Enrollment Period did not start until March 1st. I think it is reasonable to assume that folks who know that they have a $100,000 claim year would want coverage that started on January 1st instead of running naked to save a few thousand dollars in premiums while spending $10,000 or more in medical expenses.

However, folks who think it is likely that they will be in the bottom 50% of the US healthcare spending distribution ($0-$1,000 in total spend) tend to enroll late. They are the ones who need strong encouragement to go onto the Exchanges and buy. This cohort is where the drop-off is likely to have happened. And once they are not in the 2017 pool, they can’t auto-enroll for 2018 or benefit from Silver Loading as it is unlikely in a low outreach/negative messaging environment that they would have the same probability of looking at the Exchanges for 2018 as unenrolled individuals than if they had been enrolled in January 2017. This is a continual drop in enrollment over several years.

Messaging matters, operationalization matters, but we can’t say a ton more. We can’t say if the executive order drove X percentage of the drop, or if the cancellation of advertising was all of the drop and then some more, or if the general elite political messaging that Obamacare sucked and it would be replaced with something better real soon now did anything. We have hints of a story in the data but nothing strong enough to write on. Further research is needed on these factors (and I’m on a great team doing some of that work) but messaging and political support matters for enrollment in public programs.

OOPS and MLR rebates

Michigan’s insurers have asked for a net, blended 2% rate decrease for the 2020 individual market year. 2018 and 2019 were major actuarial OOPSIES as revealed in the rate filings.

I am grabbing two screen shots that show the oopsies in rate filings. First is from Blue Care Network, the largest single individual market insurer in the state:

The second is from the other Blue Cross and Blue Shield of Michigan product line as it is even more explicit:

Exhibit 2.2 in both filings is where all of the action is.  The short version is that the actuaries were way too pessimistic about 2018 and 2019.  The original projection for 2018 and 2019 expected the federal policy actions to be the equivalent of the market getting knee capped with a  tire iron.  The combination of uncertainty in 2017 leading into the 2018 policy year, reduced outreach and continual negative messaging against the exchanges were expected to lead to only the super sick/expensive buying plans for 2018.  The actuaries also expected the policy intervention of no individual mandate to matter a lot more in 2019.

I think both of those things matter (I have a paper on messaging regime changes that I just edited the proofs for over the weekend and our findings show it matters) but the impact on these two counts were counter-balanced by the incredible pricing discounts that the Silver Load strategy created for non-CSR buying individuals.

The actuaries thought that 2018 and 2019 were supposed to be a Category 4 Hurricane when reality had the storm come ashore as a big, messy Tropical Storm or a weak Category 1 that just went over a pool of cool water.  This makes sense, actuaries as a profession are biased against making pricing recommendations that have “lose the company” risks.  If they can’t predict something well based on past experience, the recommendations are to either assume a high rate or run like hell.  In these two insurers’ cases, they assumed a high rate.

So why does this matter?

Medical Loss Ratio (MLR) rebate regulations is why it matters.  Michigan insurers are indicating that they really guessed wrong in 2018 and 2019 on final rates.  We know that 2018 has ridiculously low MLR.  I’ve been using a 7% increase as my rule of thumb to determine if a state had priced 2019 close to “right” where right is defined as insurers thinking they are profitable and being in a non-refund position for 2019.

Blue Cross and Blue Shield of Michigan (the second filing) is stating that they think they overpriced 2019 by at least 10%.  This means they should be expecting to pay a very large MLR rebate next year as they will be dealing with a “normal” 2017, a very low 2018 and a low 2019 MLR.  Those checks will be arriving in the mailboxes of enrollees five weeks before the election cycle.  The MLR checks are effectively “magic” money as they are treated as post-tax refunds and not as income for purposes of taxes and income restricted social service programs.

Large 2019 rebate checks will not be universal but they will be fairly common.  Michigan will see quite a few next year.

Tuesday Morning Open Thread: Graphically Terrible

(Rubes via

Hey, the worst we have to worry about is Handsy Uncle Joe, an ‘independent’ who’s leaking support, and approximately a bakers dozen of disgruntled white dudes who can’t get traction. The Repubs are stuck with the Squatter-in-Chief, the half-bright diehards at the core of his personality cult, and the uncertain mercies of foreign oligarchs…

As President Trump prepares to formally launch his reelection bid Tuesday, his allies are trying to tamp down headlines that depict his campaign as trailing top Democrats, beset by withering leaks and unable to keep internal tensions from spilling into public view.

The 2020 drama intensified over the weekend, as Trump’s campaign abruptly fired three of its pollsters, including one polling firm formerly owned by Kellyanne Conway, the president’s adviser and former campaign manager.

Privately and publicly, campaign advisers fumed over the leak of internal polling data that showed Trump far behind former vice president Joe Biden in key states — a pattern that has touched a nerve with the president…

While an economy with low unemployment and steady growth would normally be a solid tail wind for an incumbent president, the Trump campaign is facing signs of a tough path to reelection.

The 17-state poll conducted by the campaign in March, for example, showed Trump trailing Biden by double digits in Wisconsin, Pennsylvania, Florida and Michigan, ABC reported Friday. Trump’s approval rating has also been stuck around the 40 percent mark throughout his term…

(Walt Handelsman via

Read more

On the Road and In Your Backyard

Good Morning All,

On The Road and In Your Backyard is a weekday feature spotlighting reader submissions. From the exotic to the familiar, please share your part of the world, whether you’re traveling or just in your locality. Share some photos and a narrative, let us see through your pictures and words. We’re so lucky each and every day to see and appreciate the world around us!

Submissions from commenters are welcome at

Have a wonderful day, and enjoy the pictures!

Have a wonderful day, and enjoy the pictures!

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Late Night Open Thread: Picking the GOP Nominee

Speaking of survivors from a distant past…

Instead of arena rallies, most of Weld’s weeks are filled with little-noticed trips to New Hampshire, the first-in-the-nation primary state, where he stops by diners and living rooms to meet with voters who might remember him from when he was a neighboring governor in the 1990s.

Other weeks are dotted with meetings and television appearances — he was on MSNBC on Sunday morning — where he has won occasional attention for his scathing criticism of Trump, but little else…

The president’s backers have ignored or mocked Weld since he announced his campaign in April, calling the Harvard lawyer — who can trace his family’s roots to the Pilgrims — “nothing more than a delusional elitist.” That view is shared in the West Wing, according to several Trump advisers, with Weld dismissed as a speck of lint on a black-tie tuxedo.

Weld is a particular type of Republican: a New England moderate who once had stable footing in the GOP but has all but disappeared in the party’s upper ranks. He is measured in temperament, advocates for strong ties with traditional U.S. allies, and is socially liberal. Weld supports abortion rights, and he was elected governor in 1990 and 1994 with the support of Republicans like President George H.W. Bush…

Despite the daunting odds and dynamics, Weld nonetheless remains cheery about his cause. At age 73 — and after a long and winding political career that has included a stint as the Libertarian Party’s vice-presidential nominee in 2016 — he is happy these days to provide like-minded Republicans with an option.

And he is hopeful that, perhaps later this year, he’ll somehow find himself in the political spotlight and be given a chance to lift his campaign’s status from quixotic to competitive, at least in New Hampshire, which has given a boost to past challengers of incumbent presidents — and has an open primary where independent voters can vote in party contests.

“When I go around New Hampshire and mention Mr. Trump’s name to people, I get frowns and thumbs down in response, these long faces,” Weld said, calling such exchanges encouraging. “But I know it’s going to be a long haul.”…

Election 2020 Open Thread: Reverend Barber’s PPC Moral Congress

Kara Vogt reports for Mother Jones; Chelsea Janes (and Dave Weigel) for the Washington Post:

The Poor People’s Campaign is a clergy-led effort to revive the Rev. Martin Luther King Jr.’s push to focus attention and resources on poverty. At the group’s forum in Washington, about 10 of the Democratic presidential candidates showed up to make their case on fighting poverty.

The Rev. William Barber II, a founder of the campaign, asked attendees not to cheer or hiss, but rather to greet all the candidates with polite applause. Even in this subdued setting, however, the response to Biden was noticeably muted, and he left the stage to applause that was less enthusiastic than that which greeted him…

Joy-Ann Reid, an MSNBC host who moderated the session, asked Biden how he would pass his plans through a stubborn Congress — in particular, how he would work with Senate Majority Leader Mitch McConnell (R-Ky.), who makes little secret of his satisfaction at blocking Democratic initiatives.

Biden bristled at the suggestion that his approach was misguided. As he wound through his response, Biden moved nearer to Reid, who was seated, and leaned over her.

“Joy-Ann, I know you’re one of the ones who thinks it’s naive to think we have to work together,” Biden said. “The fact of the matter is, if we can’t get a consensus, nothing happens except the abuse of power by the executive branch. Zero.” He added that “you can shame people into doing the right thing.”

Biden’s suggestion that he could persuade McConnell to cooperate prompted skepticism from those who have interacted with McConnell…

Read more

Kansas City and St. Louis Meet Ups With the Opie Jeannes!

For those in the Kansas City and/or St. Louis areas interested in a meet up, I bring glad tidings from commenter Opie Jeane!

We are traveling on Sunday the 23rd to Kansas City and will be there until the next morning, when we head down to the Ozarks to visit cousins. We will be in St Louis on the 27th and wonder if jackals in either city would like to meet with us for supper.

So that’s a possible Kansas City meet up on June 23, 2019 and a possible St. Louis meet up on June 27, 2019.

If you’re interested, sound off in the comments!

Open thread!

Well, Isn’t That Special

Alex Jone, asshole extraordinaire, might be in trouble with the law for something else:

Conspiracy theorist and InfoWars host Alex Jones sent child pornography to the lawyers for the families of the Sandy Hook tragedy, their lawyers said.

The law firm representing the families of the 2012 mass shooting, stated in court documents filed Monday they have contacted the FBI after discovering child porn in electronic files Jones recently turned over to the Sandy Hook families as a result of their lawsuit against him for calling the tragedy a hoax.

Jones publicly responded on a broadcast of his show that he is being framed by Chris Mattei, the lawyer for the Sandy Hook families and went on making what Mattei and his law firm, Koskoff, Koskoff and Bieder claim are threats against them.

“You’re trying to set me up with child porn, I’ll get your ass,” Jones states on the broadcast. “One million dollars, you little gang members. One million dollars to put your head on a pike.” Jones then pounds a photograph of Mattei and goes into a rant at one point stating, “I’m gonna kill…”

So he accidentally turns over his stash of kiddie porn to the lawyers in discovery for the lawsuit against him (possession and distribution of which is multiple felonies), and then threatens the lawyers, which, as you may be aware, is another round of felonies. We may just live long enough to see Alex Jones broke, without custody of his kids, and in jail. I’d say disgraced, but the man has no shame.

Flop Sweat (Open Thread)

They should have given it a different name. Who the fuck would watch an interview called “President Trump: 30 Hours”? Just reading those words makes me want to reverse-engineer a shop-vac so I can shotgun a quart of bourbon. [Oliver Willis at ShareBlue]

Americans would rather watch ‘Family Feud’ than Trump’s unhinged interview

ABC’s primetime special featuring Trump was a ratings flop.

“President Donald Trump’s much-teased interview with ABC was not the ratings bonanza the numbers-obsessed president likely would have wanted,” Politico noted on Monday.

The program, which featured ABC News anchor George Stephanopoulos following Trump for 30 hours, came in third place during it’s time slot on Sunday night, behind the U.S. Open on Fox and “60 Minutes” on CBS…

Trump’s special attracted 3.91 million viewers, far below the 6 million viewers ABC attracted in the same time slot a week ago with “Celebrity Family Feud,” hosted by comedian Steve Harvey.

A friend once produced a local news show that got lower ratings on Christmas than the public access version of the Yule log (a program featuring a single camera on a log in a fireplace with Christmas music playing in the background). This is worse.

Maybe Trump could try the kitty cat filter. (H/T: valued commenter Trollhattan.)

Open thread!

Insulin Insanity

These stories are becoming more and more frequent:

As their minivan rolled north, they felt their nerves kick in — but they kept on driving.

At the wheel: Lija Greenseid, a rule-abiding Minnesota mom steering her Mazda5 on a cross-border drug run.

Her daughter, who is 13, has Type 1 diabetes and needs insulin. In the United States, it can cost hundreds of dollars per vial. In Canada, you can buy it without a prescription for a tenth of that price.

So, Greenseid led a small caravan last month to the town of Fort Frances, Ontario, where she and five other Americans paid about $1,200 for drugs that would have cost them $12,000 in the United States.

For profit medicine is a fucking disaster. The “profit” of a good medical system is a healthy and productive populace, a society where people can allocate their resources to productive things rather than being gouged for medicine and medical procedures, and where people are not miserable and stressed out about medical bills.

I am not god emperor, but if I were, the very first fucking thing I would do is mandate single payer, nationalize the production of critical drugs in which there is no research and development being done to improve the drugs but just straight up price gouging, and ban health insurance for anything but elective procedures. Because it’s been my experience that a large and vocal portion of the medical community are entitled whiny ass titty babies who think they deserve millions of dollars per year and will do anything to preserve their wealth and status, a belief in part created by the ridiculous costs of medical school and the absolutely insane practice of grueling residencies, I would nationalize medical school, too, and then cap salaries. I’d also expand the number of nurses and technicians who do the actual bulk of the work in the medical industry.

This will displace a bunch of people in the insurance industry and medical admistration and elsewhere, and that’s just fucking fine- we will need a robust regulatory community to keep an eye out for fraud and abuse. That should create a few jobs. And the flunky pretty boy douchebags and their cheerleader counterparts who flocked to pharmaceutical sales will just have to find honest work somewhere.

And don’t come at me bashing the VA saying this would be no better- veterans love the VA. A few fucking loudmouths don’t.

The end. There’s your fucking marching orders. Make it happen.

Physician practice patterns and network design

Walid Gelad and many others have a recent article in the Journal  of General Internal Medicine** that looked at the different rate of emergency department physicians prescribing opioids in the Veterans Administration.  This is a replication of Barnett’s excellent work from 2017## that examined emergency department prescribing patterns to Medicare beneficiaries who were opioid naive.##

Walid highlights this graph as a key take-away.  There is huge variation in physician behavioral patterns when faced with similar patients.

I want to go in a slightly different direction than an opioid analysis with this graph. I want to go into network design. The Veterans Administration is a singular entity under, theoretically, singular management control. They have a good to excellent electronic medical record system. The opportunities for integrated care are fairly high. They have a much longer shadow of the future than most health financing entities. There are numerous opportunities present in the VA that most other systems in the United States don’t have. And they still have tremendous variation.

Insurers build narrow networks based on two primary objectives: price per unit control and total cost control. Some insurers will leverage reasonable competitive local clinician and hospital markets to get a dirt cheap rate per unit. The objective is to minimize price per unit without caring too much about how many units are paid for.

The other system is not as sensitive to the price per unit. Instead, the network is designed around variation in provider practice patterns on similar patients. The network if it was optimizing on minimizing opioid exposure in the ER would be built around the docs in the first quartile or at least built to avoid the docs in the most frequently prescribing quartile. This takes advantage of the fact that medicine for common conditions is still a folk art. There can be tremendous variation within the same office much less the same town on following evidence based recommendations. Building networks around providers who practice in a particular way that could conceivably lead to higher quality and lower total costs is a viable strategy.

Communicating the value proposition of a higher per unit cost but lower net cost is a challenge in the ACA domain given the subsidy structures. I think this type of network design choice could work far better in Medicare Advantage and large employer self-insured groups.
Variation in practice is widespread and common and it can be targeted.

** Barnett, M.L., Zhao, X., Fine, M.J. et al. J GEN INTERN MED (2019).

## N Engl J Med 2017; 376:663-673 DOI: 10.1056/NEJMsa1610524