Last Minute NY City Meet Up: RedDirtGirl Invites You to Her Self Thrown Surprise Birthday Party

I’m elevating this from comments to front page on behalf of RedDirtGirl (whether she likes it or not!):

New York City area Balloon Juicers: in observance of my birthday week I’m throwing myself a surprise party!
It’s at Sunny’s Bar in Redhook (link below). The weekly bluegrass jam starts at 9pm and it’s beautiful space. So…
You are invited to my
52nd Birthday
this Saturday,
the 24th

* I’ll be there for the weekly bluegrass jam that starts at 9pm. If you are in the tri-state area/general vicinity, please come by!

** bring a SMALL, shareable treat.

Now don’t spoil the surprise by RSVPing!

Yom hooledet sameach! Sanna halwah ya jameela!

(and that’s all the ways I know how to say happy birthday in Semitic languages)

Open thread!

Friday Night Open Thread- MOAR STEVE

Still importing cd’s, and I opened the next box and no sooner got started when this happened:

Nevertheless, I persisted:

At this point it’s a battle of wills, and we all know who is going to win that. Hint- it’s not the asshole who gets out of bed at 5 am every morning to feed Steve.

We’re trying to have a civilization here

Look, the politically savvy move for liberals is to let Republicans pass their shitty health care bill and use the backlash to take the House back. But fuck that, this is about people’s lives. So this is very good news:

Senator Dean Heller of Nevada, perhaps the most vulnerable Republican facing re-election in 2018, said Friday that he would not support the Senate health care overhaul as written, dealing a serious blow to his party’s attempt to repeal the Affordable Care Act just days before a showdown vote.

There’s no time like the present to get ready for 2018. Let’s raise some more money for the guy running against Paul Ryan

Goal Thermometer

Lazy Late Friday Open “Tech” Thread: Move Fast, Break the Wrong Stuff…

Shoved aside, amid all this week’s affray. It’s all about noisy displays of public dominance, innit? The NYTimes:

Timothy D. Cook of Apple, Jeff Bezos of Amazon, Satya Nadella of Microsoft and Eric Schmidt of Alphabet were among 18 tech executives and investors — many of whom have criticized the Trump administration — who attended the four-hour afternoon session to discuss cloud computing and procurement systems run by government agencies.

For many, it was the second group meeting with Mr. Trump since the election — and another demonstration of the administration’s ability to summon top business executives, even amid controversy.

“Government needs to catch up with the technology revolution,” said Mr. Trump, who strolled in at the end of the meeting to greet the tech titans. “We’re going to change that with the help of great American businesses like the people assembled.”

He later said, drawing laughter, “We have approximately $3.5 trillion of market value in this room — but that’s almost the exact number that we’ve created since my election.”

Few technology specialists from the White House attended. The administration has not filled several major science and technology positions. But the business and economics team closest to the president attended, including Gary D. Cohn, director of the National Economic Council, and Dina Powell, senior counselor for economic initiatives…

As described by NYMag‘s Select/All blog, “Tech Leaders Cucked by God-Emperor Trump”:

The White House is hosting leaders and CEOs from leading technology companies this week, hoping to get the best in the biz to figure out why the government sucks so bad at technology. The summit was the first meeting of the American Technology Council, which the administration established in May, led by Jared Kushner. Big boy Jared even made a speech, and presumably received an extra scoop of Cheez-Its at snack time for doing so…

Kushner suggested shifting government data to the cloud. “Federal agencies collectively operate 6,100 data centers,” he noted, “the vast majority of which can be consolidated and migrated to the cloud” (a little fun fact for you tech-heads out there: Remote data centers are what comprise “the cloud”). He also spoke about how the Department of Defense still uses floppy disks (not sure how that matters to the average American, but fair point), and that it takes months to update any government website (in part because the “move fast, break things” ethos doesn’t work for enormous populations of more than 300 million people).

The meeting appears to be fulfilling its implied purpose: making the president look good. Breitbart, to highlight one example, is celebrating how these feeble lefty tech CEOs are bowing before their new god, citing quotes like Eric Schmidt’s: “I’m absolutely convinced that during your administration there is going to be a huge explosion of new opportunities because of the platforms that are getting built in our industry.” (In January, Schmidt told an audience of Googlers that Trump would do “evil things,” citing the president’s stance on immigration.) Jeff Bezos said that Trump could be the “innovation administration,” while Tim Cook pressed the president on immigration and requiring coding classes in public schools…

What odds Trump vaguely assuming putting all this government stuff “in the cloud” would make it too heavy to hang over his head suspiciously any more?

In other news…


PCP availability for 58% AV

In 2020 and beyond, under the Senate’s BCRA, the working poor will have a very hard time finding primary care providers (PCP) who will schedule appointments with them.  Providers, rightly, fear bad debt from high deductible plans.  They will discriminate on the ability to pay upfront.

In the NEJM, Karin Rhodes,  Genevieve Kenney, and Ari Friedman looked at PCP appointment availability in the from the end of 2012 to Spring 2013.  They found that appointments were usually quickly available if the person had insurance and unavailable if they were cash paying patients who could not afford the median price of services.**

The overall rate of new patient appointments for the uninsured was 78.8% with full cash payment at the time of the appointment (Figure 2). The median cost of a new patient primary care visit was $120, but costs varied across the states, as indicated in the figure legend. Only 15.4% of uninsured callers received an appointment that required payment of $75 or less at the time of the visit, because few offices had low-cost appointments and only one-fifth of practices allowed flexible payment arrangements for uninsured patients.

Why does this matter in the BCRA environment?

The baseline plan will be a plan with a $7,500 deductible for a single person.  For people with means, paying $120 for a PCP visit is unpleasant but not onerous.  If I had to do that this afternoon, I would grumble as I pull out a credit card.  I would pay that credit card off tomorrow after I got the transaction points.  Not everyone can do that.

Craig Garthwaite raises a good point this morning:

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Dakota to Decatur

As I’ve said before, I worry that the Democratic party likes to spend millions of dollars backing non-ideological civility-bots in wealthy suburbs instead of competing everywhere. I’m not against backing candidates like Ossoff but I’m against not really backing candidates like Parnell.

The truth is that the returns from the specials look pretty good so far even if we haven’t won one yet.

So let’s raise more money for all 238 districts currently controlled by Republicans (note: I randomized the order now so that it will get spread out equally over all districts over time)

Goal Thermometer

The Smoking Gun: Putin’s Specific Instructions for Active Measures Against the United States During the 2016 Presidential Election

The Washington Post reports (emphasis mine):

The intelligence captured Putin’s specific instructions on the operation’s audacious objectives — defeat or at least damage the Democratic nominee, Hillary Clinton, and help elect her opponent, Donald Trump.


Early last August, an envelope with extraordinary handling restrictions arrived at the White House. Sent by courier from the CIA, it carried “eyes only” instructions that its contents be shown to just four people: President Barack Obama and three senior aides.

The White House debated various options to punish Russia, but facing obstacles and potential risks, it ultimately failed to exact a heavy toll on the Kremlin for its election interference.

But it went further. The intelligence captured Putin’s specific instructions on the operation’s audacious objectives — defeat or at least damage the Democratic nominee, Hillary Clinton, and help elect her opponent, Donald Trump.

At that point, the outlines of the Russian assault on the U.S. election were increasingly apparent. Hackers with ties to Russian intelligence services had been rummaging through Democratic Party computer networks, as well as some Republican systems, for more than a year. In July, the FBI had opened an investigation of contacts between Russian officials and Trump associates. And on July 22, nearly 20,000 emails stolen from the Democratic National Committee were dumped online by WikiLeaks.

Miller, Nakashima, and Entous’s excellent, detailed reporting now tells us exactly what Putin’s guidance to his subordinates was. It also tells us what his strategic objective was: to elect Donald Trump to the presidency of the United States. It is important to be very, very, very clear here about what this reporting tells us. It confirms that not only did Putin order active measures against the United States, specifically during the 2016 presidential election. He did so specifically to damage Secretary Clinton and elect President Trump.  As I wrote in July 2016 we are at (cyber) war. And again in March 2017 – we are at war. The only question now is what do we do about it?

ETA at 1:05 PM EDT

The US government has specific actionable intelligence, that is assessed to be of high confidence, that a hostile foreign power has attacked and continues to attack the United States for its own ends. This is a national security problem. And every part of the solution, including election system reforms, need to be understood within the discussion national security responses and solutions to the threat we face.

Elect a Clown, Expect a Circus

Trump’s exchange this morning with Fox News “reporter” Ainsley Earhardt (approximately one minute in) is fascinating, in the sense that the visual effects of the aerodynamic heating of an asteroid hurtling toward the planet would be briefly interesting:

Not gonna click? I don’t blame you. I wish I hadn’t seen it. To summarize, Trump brags that he tweeted about non-existent tapes to intimidate a witness, James Comey. As we know, Comey subsequently cited that incident as the reason he arranged the release of memos in a successful bid to get a special counselor involved in the investigation of Russian election meddling.

We know this investigation, which grew exponentially more serious once a special counselor became involved, is eating Trump up. It has prompted White House aides to take extraordinary measures to keep Trump from exploding, including morning play-dates to distract Trump from cable news coverage and keep him from obstructing the investigation even more.

But in the clip above, Earhardt calls the witness intimation tweet “smart,” and Trump agrees that it “wasn’t very stupid.” Even though it blew up in his fucking face worse than any Acme product ever maimed Wile E. Coyote.

I guess Earhardt was this morning’s play-date. And really, you couldn’t have found a more likely specimen if you created an amalgam of every woman Trump ever hoped to grope.

I sincerely hope the folks who are orchestrating these charades are as rattled, anxious and enraged as their boss.

98 to 58

Andrew Sprung at Xpostfactoid notes one group of low income people who could be better off under the BCRA; poor people who would have been Medicaid expansion eligible if they lived in states that expanded Medicaid. The subsidy structure of the BCRA sells the baseline plan at 2% of income for people up to 100% of Federal Poverty Line. The Benchmark plan is 58% actuarial value.

The BCRA does toss a bone to the dis-insured poor by offering private-market subsidies to those who are shut out of Medicaid. Under the ACA, in the 31 states plus D.C. that accepted the law’s Medicaid expansion (rendered optional to states by the Supreme Court), anyone whose household income is below 139% of the Federal Poverty Level (FPL) qualifies for Medicaid, and so not for subsidies in the private plan marketplace (with one class of exceptions*). In states that refused the expansion — a possibility not envisioned by the law’s drafters — eligibility for Marketplace subsidies begins at 100% FPL, and those below that level are left out in the cold — because their state’s governors and legislatures wanted it that way. The BCRA allows people with incomes in 0-100% FPL range to buy a “benchmark” plan for 2% of income, and those in 100-133% FPL range** to buy one for no more than 2.5% of income…

For low income enrollees [ACA] – the majority of marketplace enrollees — silver plans are enhanced by Cost Sharing Reduction (CSR) subsidies that raise AV to 94% ….That usually means deductibles in the $0-250 range for people with incomes up to 150% FPL…
The Senate bills drops the AV of a benchmark plan to 58% — below that of the ACA Marketplace’s bottom-level bronze plans, which have an AV of 60%. Bronze plans generally have single-person deductibles over $6,000

Prof. John Graves from Vanderbilt has a great illustration of comparative actuarial value:

The value of these plans mainly accrue to providers and hospitals.

It is very hard to design a 58% AV plan given the lack of change in out of pocket maximum where there are any services excluded from cost sharing. Donut designs where a few PCP visits and low cost generic drugs are no cost sharing are plausible at 60% or 61% AV. Using the 2018 AV calculator, I could only get a 59% AV Bronze plan with a $7,150 deductible that applied to everything.

There is some money allocated to bring down out of pocket expenses. If it is used as a state based CSR, it is grossly insufficient compared to current funding. There is less money and a larger gap. Someone who makes 100% FPL today receives a 24 AV point bump to get to a 94% plan with a $100 deductible and $1000 out of pocket maximum. That same 24 point bump produces an 82% AV plan with an $1825 deductible that applied to everything. That person is still massively underinsured as the out of pocket exposure of 10% of their income.

So when someone who earns 100% of FPL or less has a catastrophic event, the benefits will be in the form of unpayable debt and care for them. The doctors and hospitals will have a fixed limit of unpayable debt. If there is matched CSR, it might be $1,825. If there is no CSR, it could be $7,500. For diagnoses that routinely generate $100,000 claims over the course of treatment in a year, this is an acceptable discount. For PCPs and low level specialists, this will be 100% bad debt.

This has an interesting risk pool aspect. Third party payment of premiums will be quite common for patients who are guaranteed to run up $50,000 or more claims. Paying a few hundred dollars to minimize the amount of bad debt an oncology practice incurs is a smart business decision. It will make the risk pool even uglier.

So yes, there will be some poor people who are better off because their states have refused to accept significant federal funds to provide 98% actuarial value insurance. Now they will be getting 58% actuarial value insurance for 2% of their income. But they won’t be able to use it for common care as they can’t come up with out of pocket first dollar cost sharing.

Open Thread: You Come At the Queen…

Cue the Somewhat Soiled Lady, a day late and a hot-take short — “Nancy Pelosi Tells Democratic Critics, ‘I Think I’m Worth the Trouble’”:

The House Democratic leader, Nancy Pelosi, strolled before the cameras on Thursday with defeat at her back once more, projecting a well-worn swagger — brash, defiant, more than a little off key — as she insisted that her moment had not passed…

With six words, Ms. Pelosi, 77, demonstrated the self-assurance that has powered her as one of the most successful congressional leaders in the modern era. Yet even as Democrats enjoy a surge of grass-roots energy that could resurrect their House majority, some members of Ms. Pelosi’s own party are impatient for her to give up her 15-year grip on power.

She is the Democrat most crucial to determining whether her party can take back the House and torpedo President Trump’s agenda — an avatar of the kind of coastal excess that Republicans abhor and that some progressives have come to view suspiciously in an age of ascendant populism.

“Everybody wants leaders,” she said in an interview in her office at the Capitol, during which she was often as dismissive of critics in her own party as she was of the Republican opposition. “Not a lot of people want to be led.”
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Why were insurers so hot and bothered for HIT

Dylan Scott in Vox yesterday looked at what the health insurance lobby got from not actively fighting against the BCRA/AHCA in the Senate:

The major health insurance companies made a tactical decision to work with Republicans on their plan to repeal and replace Obamacare rather than lobby to stop it….

For insurers, at least for now, there is a lot to like in the Senate plan. It repeals Obamacare’s tax on health plans, a $144 billion tax cut over 10 years, per an analysis of the House bill. It provides $50 billion in federal funding in the short term to shore up the private insurance market and $62 billion over the longer term for state programs that help stabilize their insurance markets.

I don’t grok this.

I’m looking at things through the lens of profitability not total revenue.

The individual market so far has been a break even at best business for most insurers. 2017 is looking better with very low MLR in quite a few states for a wide variety of providers. But it is not boringly profitable. Medicaid managed care is boringly profitable. A barely competent MCO should scrape out a consistent 1% or 2% per year. When I worked at UPMC Health Plan, we budgeted for 2% profits and as I was leaving we were looking at 5%+ profitability for FY17. Medicaid is getting whacked. One of the first things states will do to compensate for less federal funding is squeeze MCO profit margins by reducing rates while mandating a year to hold providers harmless. Medicaid anyways is a much bigger market than the individual market.

The thing that I really don’t get is the push to eliminate the health premium tax. It is a tax that all fully insured plans pay. This basically means small and medium group employer sponsored plans, individual policies, and Medicare Advantage plans pay. Large, self insured, employer groups don’t pay, traditional Medicare fee for Service does not pay. If we assume a perfectly elastic market, I could see the self-interested push to eliminate the tax as it would make going fully insured marginally less expensive than going to self-insured ASO contract arrangements for medium size employers or make Medicare Advantage bids slightly more attractive. But in the individual market all of the carriers in the 2018 rate filings indicate that the insurers assume it is a market with low elasticity of demand. The tax incidence is overwhelmingly borne by the buyer and does not eat into the operating margins of the insurer.

Most of the tax savings will accrue to the policy buyers not the insurers in competitive markets. In non-competitive markets like Alabama with a dominant Blue, more the tax savings can be captured by the insurer. But I am trying to figure out exactly how much more profitable this tax cut makes insurers. It will be billions but it will not be a hundred billion dollars of additional profitability.

I’m having a hard time grokking the actual incremental profitability that insurers got out of the BCRA compared to the assured losses they will be taking on Medicaid managed care cuts.

On The Road

Good Morning All,

This weekday feature is for Balloon Juicers who are on the road, travelling, etc. and wish to share notes, links, pictures, stories, etc. from their escapades. As the US mainland begins the end of the Earth day as we measure it, many of us rise to read about our friends and their transient locales.

So, please, speak up and share some of your adventures, observations, and sights as you explore, no matter where you are. By concentrating travel updates here, it’s easier for all to keep up-to-date on the adventures of our fellow Commentariat. And it makes finding some travel tips or ideas from 6 months ago so much easier to find…

Have at ’em, and have a safe day of travels!

Should you have any pictures (tasteful, relevant, etc….) you can email them to or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

Two Blue Damselflies

Two Blue Damselflies, Colorado

This was my pond, and these damselflies were born and raised in it. It was scary the first time I ran into the aquatic stage of this glorious creature – they look like mean-ass water bugs you shouldn’t mess with. I learned to carefully preserve them when I did major pond cleanings to ensure their lives weren’t snuffed out too soon.

And now, back to Italy….

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Quick Thoughts after Reading the GOP “Health Care” Bill

I can’t believe more people aren’t talking about the last page of the Senate bill:


Late Night Open Thread

Here’s a picture of Steve sitting in the dark at the top of the stairs bitching for food. He perches there so if I make any movement towards the stairs, he can race downstairs and be prepared for to inhale whatever I give him.

He’s not getting anything until tomorrow morning.

Only a fool would think someone could save you

I think that repealing Obamacare would be a disaster for Republicans. You could argue that the takeaway from GA-6 and the other specials is that, while things aren’t great for Republicans in 2018, they have a good chance to hold the House unless some crazy shit happens. Repealing Obamacare qualifies as crazy shit and then some.

So I can see reasons why McConnell, who’s a shifty one, might be happy if repeal fails. That said, all the Senators expressing “concerns” about the bill looks and smells like kabuki to me. Jim Newell is probably right:

If he’s sticking to the script, McConnell has a list of giveaways that he saved to offer members later so that they can argue they only voted for the bill after extracting concessions:

This bill could fail, but that would be an abrupt last-minute rewrite of a script from which none of the players, so far, have deviated. Conservatives are organized, coordinated, and eager to share with the press their early objections. They will move the bill further to the right. Moderates are disorganized and press-shy, keeping their objections within the family. They will get offered a few more bucks or state-specific carve-outs and then draw straws to determine who has to vote for it. The Senate sequel to the House bill process is playing out like the most disciplined scene-by-scene retread since Home Alone 2. Don’t expect a surprise ending.

The so-called moderates always cave. I’m not a fan of calling people cucks but if anyone deserves it, it’s so-called moderate Republicans in Congress.