Site Maintenance Update

Just a quick update and test. This post will appear and then disappear, and then reappear again. Kind of like the health care travesty in the Senate.

Last night, our hosting company updated a lot of the back-end server stuff and that was why the site was a bit twitchy. It should be fine now.

I’m testing this theory by posting a picture to see if it errors out.

And the errors didn’t happen!

This was on a Reservation, forget which one  thanks to Adam, I’ve determined that it’s from my visit to the Taos Pueblo – thanks! I’ve visited a few out West over the years, but never stepped foot into a casino. Should you ever have the chance, visit a Reservation, tour and ask questions, and spend some money in non-casino settings, they can use it.

Open Thread








Hello Juicers

Been busy with real life stuff for the last 48 hours so I haven’t been able to check the news, and the amazing thing is that I have exactly the same amount of information about what the Senate will be voting on today in regards to health care as do the members of the Senate. What a way to run a country!

Drove down from CT with ABC and the kids on Sunday, got in around midnight, and yesterday a colleague came up for a couple day visit with her three kids, so it has been a flurry of energy and activity. We went to the Good Zoo at Oglebay yesterday, and apparently Mondays are as hard on the animals as they are on the adults:

After that, there was swimming, then spaghetti and meatballs and garlic bread, not one but TWO Men in Black movies, and then brownies and ice cream. I was in bed at 9:45. I don’t know about the kids.

Made some waffles and am now checking up on the news before unstickifying the downstairs and then we are all headed to heaven on earth, aka Barn With Inn for some quality time at the pool and pond and with the animals. We were supposed to go fishing but there has been a lot of flash flooding so I don’t want to take the risk- the creek is high and angry looking and it’s not worth it.

Also, fuck John McCain.








Rotten PEARS

Consumerism and patient directed insurance design is predicated on the assumption that pricing is transparent enough and choices are clear enough that patients can make reasonable decisions about cost effective treatment. There are a number of problems with that assumption, but I want to look at one today regarding the Pathology, Emergency Medicine, Anesthesiology and Radiology specialties.

These PEAR specialties are known as “invisible” providers. Invisible providers are seldom chosen by the patient. Invisible providers were intermittently listed in provider directories when I maintained the provider directory at UPMC. Invisible providers are part of the care team but they may not be employed by the same group that employs the visible providers.

Visible providers are the doctors that a patient can choose. My primary care provider is a visible provider. My wife’s Ob-Gyn is a visible provider. My former orthopedist is a visible provider. My mom’s neurologist is a visible provider. The hospital down the street with an ER is a visible provider. These are the providers where clear in and out of network designations occur.

The New York Times had a great article a study that examined the deliberate business strategy of a PEAR staffing agency to increase the number of out of network ER bills:

the new Yale research, released by the National Bureau of Economic Research, found those bills aren’t randomly sprinkled throughout the nation’s hospitals. They come mostly from a select group of E.R. doctors at particular hospitals. At about 15 percent of the hospitals, out-of-network rates were over 80 percent, the study found. Many of the emergency rooms in that fraction of hospitals were run by EmCare.

It is a deliberate business strategy to exploit the rottenness of the PEAR billing arrangements for profitability. Patients don’t know that the hospital is in network and most of the docs who work there are in network but the ER doctors or anethesologists are not.

The thing that leaped out at me was the deliberateness of the business strategy:

n addition to its work in emergency rooms, EmCare has been buying up groups of anesthesiologists and radiologists.

This is an exploit of the inability of people to make informed decisions in order to jack up rates.

What is a solution?

There are two common solutions. The first is to have states adapt out of network pricing limitations and dispute resolution systems. If out of network charges are capped at a multiplier of Medicare or a multiplier of usual and customary, the incentive to exploit a crack like this goes down dramatically. The other solution is to adapt a general contractor model for all emergency room services where the hospitals’ contractual obligations cover all service providers working under that roof. If someone presents to the emergency room with a broken arm, anyone who treats that patient, under this model, is assumed to be in-network if the hospital is in network.

As we move to a shopping model of health care, we need to get rid of the amazingly and glaringly obvious exploits and hacks to the system that do nothing for patient care but add significant expense and frustration.








You know what to do

And that is call the Senate.

I don’t know if it will help beyond not not doing nothing.



Tuesday Morning Open Thread: Banana Republicans

(Tom Toles via GoComics.com)
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Oh, how I would love to see Catherine Rampell’s Washington Post suggestion in action! “Jared Kushner ‘forgets’ to disclose his assets? Seize them.:

For the 39th time, top presidential adviser (and son-in-law) Jared Kushner has revised his financial disclosure forms. Kushner disclosed 77 additional assets, collectively worth millions of dollars. These items were “inadvertently omitted” from previous versions of his federal forms, according to a document the White House released Friday…

Maybe Kushner really did forget all those assets, including a stake in a start-up valued at $5 million to $25 million. Just as maybe he really did accidentally submit a security-clearance form that left off more than 100 contacts with foreign nationals…

It’s true that willfully omitting an asset on one’s federal financial disclosure form comes with the risk of criminal action. But how motivating can a threat of prison possibly be if Kushner knows he can just go back and add anything that the press happens to dig up?

That’s exactly why we need the banana republic rule (named for the lawless state, not the store).

Above a certain value — let’s say $1 million — any assets that are “forgotten” on federal disclosures can be seized by Uncle Sam. If they weren’t memorable enough for these forms, then clearly you’re rich enough that you don’t really need them.

Treasury gets to take them, without compensating you.

“That’s socialism!” you might protest. But really, it’s not so different from another policy that the definitely-not-socialist Trump administration already backs enthusiastically: civil asset forfeiture.

This is when law enforcement seizes private property without proving the owner is guilty of a crime, often without even charging the owner with a crime. Just last week, Attorney General Jeff Sessions announced he was restarting a federal forfeiture program the Obama administration had shut down.

“Civil asset forfeiture takes the material support of the criminals and instead makes it the material support of law enforcement,” Sessions explained, even though the stuff being seized is not necessarily providing “material support” for any crime or any criminal.

With such tenuous logic, why shouldn’t Sessions support appropriating possibly-innocent-but-still-kinda-suspicious financial disclosure omissions, too?…

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Apart from (gleefully) imagining a more just world, what’s on the agenda for the day?



On The Road and In Your Backyard

Good Morning All,

So far, this feature has been about travel, with the occasional “local” picture or two. I think limiting this to just travel is just that – limiting. So I’m changing this up a bit to include neat, colorful, funny, interesting, poignant, etc. pictures that don’t require travel.

As always, if you’re on a trip or have a story to share, you can just pitch in below.

I’m pleased to announce the release of the new picture submission tool for this feature. Using this tool will ensure I don’t mess things up, will make it much less time-consuming for me, and will make for a much easier process all the way around.  This would not be possible without the efforts of valued commenter Major Major Major Major. His help has been invaluable in this feature, not to mention in the pie filter and rotating quote.

The form is here and has a few simple rules:

  1. You have to have made at least one comment that’s been approved/published.
  2. It’s a picture and not too big (you can include up to 7 pictures in a single submission)
  3. You must include your commenter screenname and email (kept private) to verify you, just like making a comment. Only your nym is published.
  4. No more than 10 form entries per hour.
  5. You can include an overall description, per-picture descriptions, dates, locations, etc.

If you are a lurker and thus not a commenter, or should you wish to submit a video, archive of multiple pictures, links to pictures hosted online, or want to include more text or pictures than the form allows, send an email.

Travel safely everyone, even if it’s just down the hall for that second cup of coffee!

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Late Night Waste of Skin Pixels Open Thread: At the Boy Scout Jamboree

When I was a teenager, my slightly younger brothers were Boy Scouts. Worst thing I knew of the BSA was that, lacking adequate supervision, even reasonably intelligent and not-otherwise-sociopathic boys between the ages of 11 and {number to be determined} tend to rile each other up to do stupid & dangerous things. And the dumber the individual, the more dangerous “ideas” he’d come up with. Seems like the GOP has turned into a boys’ club with the same issues…


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Russiagate Open Thread: Trump Is Really Angry At “His” Government

Yeah, he’d be just about as terrible to everyone-not-a-rich-Republican as the Malevolent Leprechaun, but I’m not sure Cruz could even get confirmed, given how much his colleagues do not love him.

And it could be argued that, while his intentions are equally horrible, Cruz doesn’t have Jefferson Beauregard Session III’s lifelong bone-deep Confederate indoctrination to help him disguise his deep-seated racism.

Props to the CBC, though:

I wanna do a Jared ‘Simple Tootsie from the Country’ Kushner post, but there’s TOO MUCH BREAKING NEWS. How do the paid professionals keep up? (answer: they’re paid to do so!)



Monday Evening Open Thread: Gathering the Ghouls

They really don’t care. If they can’t be arsed to provide a halfway plausible cover story for whatever pile of manure they’ll present as a bill tomorrow, why should they worry about coming across as second-time-as-farce?

[9 July 2008] – The cancer-stricken Democratic senator Edward Kennedy made a dramatic return to Congress today, providing the boost needed to pass a bill securing healthcare coverage for senior citizens.

Kennedy, 76, was diagnosed with a malignant brain tumour in May after suffering a seizure at his home on Cape Cod, Massachusetts. The youngest brother of John and Robert F Kennedy, a revered figure in US politics, was not expected to return to Washington until September.

But Kennedy made an unexpected appearance on Capitol Hill as Democrats prepared to vote on a plan that shores up Medicare, the country’s government-run programme for senior citizens’ healthcare…

Apart from [facepalm]-ing, what’s on the agenda for the evening?
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EAT EAT EAT!


Here’s some exclusive video of Mitch McConnell and John Cornyn working over the Republican caucus in a closed door meeting. Must credit Balloon Juice.








Trump Screams “Death”

Remember Trump’s bizarre “Democrats scream death” tweet 500 years ago? Actually, it was only five days ago. Well, now HE’S the one screaming “death,” in a speech this afternoon. Via NBCNews:

Trump: ‘Obamacare is Death’

WASHINGTON — President Donald Trump declared the Affordable Care Act a “meaningless promise” Monday, using his presidential bully pulpit to amplify his calls for action on stalled Republican attempts to repeal and replace Obamacare — which he called “death” at one point.

“Obamacare has wreaked havoc on the lives of innocent, hard-working Americans,” Trump said at the White House, joined by families whom he said had suffered under the ACA.

The president hammered Democrats for their lack of bipartisanship and decried their criticism of Republican efforts to reform health care.

“They say death, death, death. Well, Obamacare is death,” Trump said. “That’s the one that’s death.”

Trump’s remarks come amid failed GOP pushes so far to repeal and replace Obamacare, with the White House urging Republicans to act this week.

Of course, he doesn’t have a fucking clue what Obamacare is or what provisions are in his own party’s bill. All he sees is a big, fat goose egg on the scoreboard under his name, and if Republicans don’t get in line, he’ll turn his fire on them. Yesterday, Trump threatened Republicans as follows:

I think he’s right about that — the infighting will consume this rancid pustule of an administration and rip that putrid turd of a party apart if this bill goes down. So yeah, keep calling!



First, we kill all the facts…

The Congressional Budget Office has been an obstacle to Republicans bent on stripping access to healthcare from tens of millions of Americans. Every time Zombie Trumpcare rises from the grave and totters toward the finish line, the CBO score provides one of the stakes that brings the monster down, albeit temporarily. It would be so much easier to shovel money from working people to plutocrats if Republicans could substitute figures pulled out of a Koch Brother’s ass for CBO estimates. Via The Hill:

Rep. Morgan Griffith (R-Va.), a member of the conservative House Freedom Caucus, plans on offering an amendment to spending legislation this week that would cut the nonpartisan Congressional Budget Office’s staff by 89 people.

The proposed cuts come after a series of CBO reports predicted that tens of millions of people would become uninsured under various Republican plans to repeal and replace ObamaCare.

Freedom Caucus Chairman Mark Meadows (R-N.C.) said Monday that, instead of relying on the CBO’s expertise to assess how much congressional bills would cost, the office should aggregate estimates produced by various think tanks like the Brookings Institution and the Heritage Foundation.

The Republican president and his minions tell bald-faced lies at such an unprecedented clip that statements that would have triggered months-long scandals in a normal presidency pass with barely a ripple. The GOP has its own propaganda network in Fox News (and lesser imps and demons) to lie to the American people about the dangers we face and make rational discussion of political or cultural issues with its brainwashed viewers impossible. And now Republicans want to drown the federal agency that provides budget and economic information to lawmakers. Makes sense.



Chuck Schumer’s “Better Deal” Op-Ed

So, Chuck Schumer wrote a NYT op-ed that’s drawing a lot of fire: “A Better Deal for American Workers.” Here are a few excerpts:

Americans are clamoring for bold changes to our politics and our economy. They feel, rightfully, that both systems are rigged against them, and they made that clear in last year’s election. American families deserve a better deal so that this country works for everyone again, not just the elites and special interests. Today, Democrats will start presenting that better deal to the American people…

And for far too long, government has gone along, tilting the economic playing field in favor of the wealthy and powerful while putting new burdens on the backs of hard-working Americans.

Democrats have too often hesitated from taking on those misguided policies directly and unflinchingly — so much so that many Americans don’t know what we stand for. Not after today. Democrats will show the country that we’re the party on the side of working people — and that we stand for three simple things.

First, we’re going to increase people’s pay. Second, we’re going to reduce their everyday expenses. And third, we’re going to provide workers with the tools they need for the 21st-century economy.

Americans from every corner of this country know that the economy isn’t working for them the way that it should, and they wonder if it ever will again. One party says the answer is that special interests should continue to write the rules and that government ought to make things easier for an already-favored few.

Democrats will offer a better deal.

The reactions I’ve seen fall into two groups: Pissed off Democrats who say Schumer validates Trump talking points and unfairly maligns his own party and, implicitly, Hillary Clinton, by claiming that the Dems didn’t put forth a progressive platform in 2016. I think there’s some truth to that. But there’s also some truth to the notion that certain Democrats seem captured by special interests themselves; until recently, I would have put Schumer into that category.

Left of center Democrats and non-affiliateds are adding to the jeers, criticizing Schumer for proposing yet another business tax cut-funded jobs training band-aid instead of more directly addressing wealth inequality by calling for massive tax hikes on the rich. I think there’s some truth in that too.

I’m trying not to read too much into this op-ed. It’s not necessarily a harbinger of Democratic Party strategy going forward. But I will note that it fails to mention Trump, and only mentions Republicans once. I think that’s a mistake. What say you?



50% of income is a wonderful choice

I was laid off from a program evaluation job in September 2009. I had been working at a grant funded pediatric behavioral and mental health care coordination demonstration project. It was a service that was more expensive up front but usually saved Medicaid money in a few years and social services/criminal justice costs very quickly. We had good results that had been backed up by an external program evaluation.

Our funding when I was on this project was overwhelmingly federal grant pilot funding with a small local match. We needed to transition to regular program funding. That meant we needed a Medicaid waiver for the service that we offered. There was absolutely no discretionary local money in 2009 so we did not receive a waiver. The nerds were let go in order to stretch operational funding. We wanted the kids to be served for as long as possible until a smooth hand-off could be arranged.

Thankfully I lived in Pennsylvania so I had a decent unemployment check. I was eligible for about $1,600 a month. My wife was working part time at the time and earning $1,000 a month and my daughter was nine months old and being very silly and adorable. I received an offer to COBRA our health coverage. We had a $2,500 high deductible health plan for $1,275 a month premium as the risk pool at my former employer was sick as hell. Half of our income would have had to go to just the premium. We were lucky, as part of the stimulus, there was a program that paid for 65% of the COBRA premium. That meant our premium was “only” 16% of our income.

We tried to make that work and we did until January when we switched my daughter to CHIP for $25 a month. CHIP was the best insurance I have ever had. My wife and I got a cheap underwritten policy that offered $500,000 in benefits after a $7,500 deductible with severe coverage limitations. We were getting it to give us some protection if the other person got hit by a bus.

Half of our income for a policy with a deductible equal to our entire monthly income is not an actual choice for insurance. We were trying to stay current on the mortgage, keep diapers on our daughter, and not fall too far behind. And we mostly were able to manage. Once we were both working full time, it took us two years to dig out of the hole that my lay-off placed us in. And that was only because we got lucky. We got lucky that we stayed healthy. We got lucky that we both could find decent enough jobs with decent pay and better advancement opportunities. We got lucky in that we were going to be okay if nothing else happened and nothing else actually happened.

Your money or your life is not a choice.



I’ve tried and I’ve tried and I’m still mystified

It blows me away that, as Dave points out, McConnell won’t even tell the GOP Senators what the fuck he wants them to vote for this week. This piece by former GOP Senator David Durenberger is very good. He details how little is known about the bill and concludes:

A vote in these circumstances will rightly provoke anger and distrust unlikely to abate. Take it from me: A no vote on the Motion to Proceed this week is the only one that will be defensible in the years to come.

I have had my arm twisted by the best of them — presidents and Senate leaders and party whips alike. I know how uncomfortable it can be. Usually, they were able to attempt a convincing argument about what is good about the bill for the country or my state. But I never would have voted for something so far reaching without knowing the answer to all the questions above.