Mister Richard Smoker

So much going on with the Senate Health Care Bill Tax Cut Bill that I don’t want you all to miss this:

The framed copy of Time Magazine was hung up in at least five of President Trump’s clubs, from South Florida to Scotland. Filling the entire cover was a photo of Donald Trump.

“Donald Trump: The ‘Apprentice’ is a television smash!” the big headline said. Above the Time nameplate, there was another headline in all caps: “TRUMP IS HITTING ON ALL FRONTS . . . EVEN TV!”

This cover — dated March 1, 2009 — looks like an impressive memento from Trump’s pre-presidential career. To club members eating lunch, or golfers waiting for a pro-shop purchase, it seemed to be a signal that Trump had always been a man who mattered. Even when he was just a reality-TV star, Trump was the kind of star who got a cover story in Time.

But that wasn’t true.

The Time cover is a fake.

There was no March 1, 2009, issue of Time Magazine. And there was no issue at all in 2009 that had Trump on the cover.

In fact,the cover on display at Trump’s clubs, observed recently by a reporter visiting one of the properties, contains several small but telling mistakes. Its red border is skinnier than that of a genuine Time cover, and, unlike the real thing, there is no thin white border next to the red. The Trump cover’s secondary headlines are stacked on the right side — on a real Time cover, they would go across the top.

And it has two exclamation points. Time headlines don’t yell.

“I can confirm that this is not a real TIME cover,” Kerri Chyka, a spokeswoman for Time Inc., wrote in an email to The Washington Post.

Time has responded:

This fucking guy.

In Re: Calls

Following up Doug’s post, and Doug’s post, and David’s post, and…you get the idea…

Keep calling, and don’t restrict yourself to your senators’ DC offices.  Each and every senator has several in-state offices. They’re populated mostly by actual staffers, not interns.  Real people answer the phones — and if the one nearest you doesn’t pick up, you can call on down the line till you find someone at home.  They’re often less crazed and more ready to listen, even to opposing views.

My own experience:  my wife’s family has a place in the Bath-Boothbay stretch of the Maine coast, and several family members who live up around the Penobscot Bay area.  So I used that as the base from which I called Senator Collins’ Portland office, the one she lists as serving the county in which my in-laws hang.  I told the nice lady who answered that I was grateful to the senator for coming out in opposition to the bill, that I agreed with her that it was bad for Maine, and that I was calling both to thank her and to emphasize that cosmetic changes to the bill won’t alter its underlying effects, which will still be bad for Maine.  We talked about this for five or ten minutes and it was an actual conversation.

How much effect will it have? Not that much. She knew I was only partly attached to Maine, so that’s a discount right there.  But at least it lets that office and perhaps the senator know that we’re paying attention, and that we will continue to do so.  And the fact that this was a conversation, an actual accumulation of reasons to worry about the bill matters quite a bit, I think.

So the moral of the story:  you don’t have to bash down the front door to reach someone who can reach closer to power.  There are back doors, listed (with phone numbers) on every senators’ web page.

Use them.

Image:  Gerrit Beneker Telephone Operator (A Weaver of Public Thought), 1921.

Communication, a telephonic invasion

Keep calling, it’s working:

Republican senators’ offices say they’re getting a flood of calls from voters worried about the GOP Obamacare repeal bill, potentially further complicating Senate Majority Leader Mitch McConnell’s attempt to muscle the legislation through this week.


“Since last Thursday, the Cochran offices have received approximately 224 constituent calls against and two in favor of discussion draft of the healthcare bill,” Gallegos wrote in an email Monday.

Pardon Our Motherfucking Dust

Since I grew up in the shadow of The Mouse, I’m familiar with Disney’s hokey-ass Hall of Presidents exhibit. In case you aren’t, I’ll summarize: It’s like a jingoistic “It’s a Small World” ride, only with robots fashioned to look like U.S. presidents instead of multicultural animatronic dolls in traditional garb, and it features a mostly warts-free voice-over account of U.S. history in place of the painful ear-worm song. Lincoln and whoever is the current president have the only speaking roles.

Bush 2 was president last time I actually sat through it, but Obama’s people worked out a short speech with the Disney folks, which President Obama himself recorded in time to ensure a transition between robot presidents as seamless as the real transfer of power. Just as Bush 2 had done when Robot Bush 2 took over for Robot Bill Clinton.

You’ll be shocked to learn that Robot Donald Trump is just as big a pain in the ass as his bloated, orange, fleshy counterpart. Via VICE’s Motherboard:

“When Disney tried to get this process started earlier this year,” said the source in an email to Motherboard, “Trump’s people said, ‘We’ll be writing the speech that the President’s Audio-Animatronic figure will be saying.'”

“The Imagineers [the researchers and developers behind Disney’s theme park attractions] tried to point out that they’re typically involved with this process,” continued the source. “That they directly collaborated with Clinton, Bush, and Obama’s people when it came to figuring out what the President’s Audio-Animatronic figure would say. Trump’s people said, ‘No. We’re writing this speech. You guys have no input on this.'”

So that’s been the holdup. Disney has always collaborated with the president on the final speech. Disney, apparently, has finally reached an agreement with the Trump team, though we still don’t know yet how much involvement Disney will have in the crafting of the speech (if any).

“There are those at Imagineering who hope that if they hold off on doing anything with this attraction until the fall, Trump may have done something so egregious that the general public won’t have an issue with putting a non-talking version of [Trump] in The Hall of Presidents,” said the source.

And now, a simple speech recording—something that should have been small, perfunctory, and ceremonial—has snowballed into a political issue.

The Imagineers will be waiting a long time if they think Trump will ever do something egregious enough to put off his cult followers. Those morons will line up to kiss Trump’s ass as he’s disconnecting their disabled children’s ventilators due to Medicaid cuts.

But yeah, a non-talking Trump would be the least embarrassing option. Or just scrap the whole goddamned thing — send animatronic presidents 1-44 to their respective libraries, demolish the Hall of Presidents building and erect a circus tent in its place to honor the current clown. The US presidency has jumped the fucking shark.

BlogCon 1: Global Ransomware Attack in Progress

Time to batten down the cyber hatches!

Companies across the globe are reporting that they have been struck by a major ransomware cyber-attack.

British advertising agency WPP is among those to say its IT systems have been disrupted as a consequence.

Ukrainian firms, including the state power company and Kiev’s main airport, were among the first to report issues.

The Chernobyl nuclear power plant has also had to monitor radiation levels manually after its Windows-based sensors were shut down.

The international police organisation Interpol has said it is “closely monitoring” the situation and liaising with its member countries.

Experts suggest the malware is taking advantage of the same weaknesses used by the Wannacry attack last month.

“It initially appeared to be a variant of a piece of ransomware that emerged last year,” said computer scientist Prof Alan Woodward.

The NY Times has a break down of what is and is not known.


• Cybersecurity researchers first said that the new ransomware appeared to be a variation of a well-known ransomware strain called Petya. One researcher from the Moscow-based cybersecurity firm Kaspersky Lab reported the new ransomware was a strain of Petya first identified in March 2016. Kaspersky found evidence that the latest strain had been created on June 18, suggesting it has been hitting victims for more than a week. But Kaspersky also said it was still investigating the attack and that it could be a new type of ransomware that has never been seen before.

• Kaspersky reported that approximately 2,000 computer systems had been affected by the new ransomware so far.

• Symantec, a Silicon Valley cybersecurity firm, confirmed that the ransomware was infecting computers through at least one exploit, or vulnerability to computer systems, known as Eternal Blue.


• Who is behind the ransomware attack. The original Petya ransomware was developed and used by cybercriminals, and variations have been sold through dark web trading sites, which are accessible only by using browsers that mask a user’s identity, making it difficult for cybersecurity researchers to track.

• Why it is spreading as quickly as it is. Cybersecurity researchers believe that like WannaCry, the ransomware infects computers using vulnerabilities in the central nerve of a computer, called a kernel, making it difficult for antivirus firms to detect. It is not yet known if the new ransomware uses any new vulnerabilities, or variants of the vulnerabilities, made public by the group known as the Shadow Brokers.

• It’s unclear if systems protected against WannaCry can still be affected by the new ransomware attack.

Let’s not start sucking each others’ dicks quite yet

Delaying the Trumpcare vote til after recess is a big fucking deal. Why? Because Republican Senators are going to take a lot of shit about how crappy the bill is when they are home over recess. So don’t just keep calling, start going to protests and townhalls if you can, especially if you’re from a state with a Senator who is on the fence. Pretty please with sugar on top. It’s not over yet.

Let us know about any protests that you’re hearing about in the comments.

Keep on Calling

Good news

Now keep on calling

Commercial and Medicare Rates

Bob Herman of Axios was paying attention to the other important healthcare related CBO report yesterday:

This is an important report as it illustrates the spread between Medicare and Commercial rates. Unfortunately it does not have Medicaid managed care rates. With that limitation, this still provides a very good heuristic of thinking through the mechanics of how we pay for health care services.

There are a few things to notice here. The first is that there is a wide variation of variance by type of procedure. The second is that of the five procedures that have the smallest median bump over Medicare rates, four of them are overwhelmingly procedure codes used by primary care physicians. We should want to use more primary care which means we probably should want to pay more for primary care.

The third point is that the heuristic that commercial payers pay about 50% more per service than Medicare is loosely supported by this chart. The details aren’t quite fine enough for that statement to be 100% certain, but it is a solid heuristic.

Finally, the most interesting thing to me are the trimmed ranges. The gray dots are the 10th percentile commercial payments and 90% percentile commercial payments. The 90th percentile for every procedure is very expensive. That is known knowledge and not particularly interesting to me.

More importantly, take a look at the 10th percentile. I am eyeballing the spread across 21 categories as being from about 70% Medicare rates for some PCP services to maybe 110% Medicare rates for imaging and orthopedic procedures. This is the business case for tiered networks, it is the business case for narrow networks, it is the business case for reference pricing. There are providers who are willing to take Medicare-like rates for common services. Engaging in any of the restrictive network or payment practices looks to exclude as many providers in the 90th percentile as possible while steering as much work as possible to providers who are willing to take near Medicare rates.

This is where money can be squeezed from commercial insurance where we currently pay way too much per unit of service. The downside of that squeezing is this means hospitals and doctors with local market power will be excluded from networks and services unless they drop their rates.

Cyber Strategy – Different From A Shooting War

Big hack of pretty much everything in Ukraine this morning: internet, power plants, government. I wrote this post before that happened, but it applies.

The Obama administration was in an extremely difficult position after learning about Russian hacking of last year’s election. Several factors came into play: the difficulty of dealing with international cyber attacks, intransigent Republican partisanship, and the decaying relationship with Russia. I’m going to break down those factors into at least two posts.

Cyber attacks present a national security problem different from any encountered before. Lumping them into a designation of “cyberwar” projects assumptions of conventional war onto them and distorts the difficulties and possibilities. I haven’t seen much analysis of these differences and how they affect strategy. Please point me to them, if they exist. Most punditry assumes that cyber attacks can be equated to war, and numerous opinion articles have referred to the Russian hacks as a form of war. In this post, I will consider only that part of last fall’s situation. A later post will consider the political ramifications. Read more

A scheme in a no MLR world

Part of the Senate bill invites states to file waivers that basically would allow a state to do whatever it wanted. One of the elements of the ACA that can be waived is the requirement that insurers spend at least 80% of the premium dollars on claims. That is known as the Medical Loss Ratio (MLR). Waiving MLR is an invitation to loot in single insurer states.

Here is how it would work in a single insurer state.

The insurer would split their business into two filing entities. The first one would be off-Exchange only. They would file normal rates for this entity. The second one is the vehicle designed to extract cash from the federal government as it offers on-Exchange policies. These policies will be extremely pricey. The benchmark plan could be a nation wide network PPO for instance. The insurer could offer a low cost local network Bronze and Silver plan priced under benchmark. The subsidized buyers are protected from the price increases as they pay a percentage of income and the federal government picks up the rest.

The insurer runs a 70% MLR while keeping core administrative costs relatively low. This produces a new pot of money that can be split three ways. The first stream is a small stream. It is a public benefit stream where the insurer sponsors more Little League teams or sponsors a neighborhood vaccination clinic or some other combination of public facing entities that makes the community smile. The second stream goes to campaign contributions and other legal financial and political cover to friendly regulators who can help keep the region a single insurer region. The last pool of money is internalized for senior company stakeholders or distributed back as profits.

This scheme is straightforward. It is legal. It is against the interests of a region with only a single insurer but the costs are diffuse and the benefits are tightly concentrated. It fails in multi-insurer regions unless there is illegal collusion. MLR requirements are usually superfluous in competitive markets. Insurers can be profitable with MLRs in the high 80s and low 90s. I worked at one that was. MLR requirements are a constraint on looting in non-competitive markets.

Tuesday Morning Open Thread

Because I am not a naturally nice person myself, I fear a lot of the “If Trumpcare passes, here’s a person who will suffer and probably die” narratives simply don’t work on Republican voters. Too many people, even the people you know and sometimes love, look at those sad tales and think: Here’s a worthless meatbag gobbling up my tax dollars, and I’ll never get so much as a THANKS SUCKER in return. Yes, that’s a terrible and selfish response, but spoiler: A great many people are terrible and selfish, when they’re sure nobody’s watching!

On the other hand, those sad narratives are for sure energizing for the rest of us, those who possess the basics of human empathy (even if it took us years of grim practice to learn). Just be sure you know your audience. Some people want to save the baby ducks. Others just want not to lose their own personal jobs / relatives / lives — and if they can be convinced saving the baby ducks is what it takes, they’ll be out there collecting armloads of fluffy little peepers…

Mr. Charles P. Pierce:

Unless there’s a procedural snag of which I’m not aware, I don’t know why the Senate majority wouldn’t punt this until August, and do so at the last minute. The accelerated schedule is insane; even Republican senators are complaining about it. It would give them more time to sabotage the Affordable Care Act, which Sean Spicer threatened to do in today’s audio-only daily briefing. (Jesus, people. Just turn the cameras on and see what happens.) It would give them another month to make the cosmetic changes necessary for the “dissenters” to come around. It would give them the fig leaf of a “process” they could cite.

Of course, it also would give the opposition a month to increase its already formidable momentum. Tough call for McConnell, but that’s why he gets the big money.

McConnell needs to ram this monster through while he can, before enough sheep GOP senators get spooked at the thought of having to defend their vote to their voters.

Apart from facing down the haters, what’s on the agenda for the day?

BCRA creates even more confused markets

The Senate’s Better Care Reconciliation Act (BCRA)[1] is a significant modification to the current Patient Protection and Affordable Care Act (PPACA)[2] exchange structure in a variety of ways.  One major change is the designation of the benchmark plan which determines the level of subsidy that the federal government provides to individual buyers on a health insurance marketplace.  There are two elements of note.  The first is that the benchmark plan is now a plan with a calculated actuarial value of 58%.  This is a significant change from the current benchmark plan with a calculated actuarial value target of 70%.  More importantly for this post is the benchmark plan in the BCRA is the median qualified plan.

Research has shown that consumers can be overwhelmed by too much choice[3].  Dominated choices can and often will be selected.[4]  Buyers have frequently confused the value proposition of Gold and Bronze plans based on prioritizing either more out of pocket maximum protections or lower monthly premiums. [5] Buying and using insurance is a complex task with significant uncertainty and cognitive demands.  The BCRA subsidy attachment system creates incentives for insurers to further increase complexity.

Within PPACA the incentive for insurers to clone plans with minimal meaningful differences between them only applies to the insurer which controls the least expensive Silver plan in a county.  This single, low cost, insurer faces a decision as to whether or not to design a second plan with the same actuarial value in a slightly different cost sharing structure in order to guarantee that this single carrier controls both the least expensive and the benchmark Silver point.  All other insurers plan offering decisions are made independent of subsidy attachment point manipulation purposes.

The BCRA creates a broader and more complex strategic design problem for carriers.  Every entry in the benchmark category influences the benchmark price.  Once an insurer has built a network and performed the basic actuarial calculations, modifying a basic plan design by altering co-insurance slightly or decreasing deductibles while increasing co-pays to achieve a constant actuarial value is a fairly low cost action.  A high cost carrier can introduce an isomorphic plan design to increase the benchmark and asymmetrically decrease the relative post subsidy price of its preferred offerings.  Low cost carriers have an incentive to offer one more plan to lower the benchmark and make its offerings more attractive compared to higher cost peers.

Counties with multiple insurers will face an unstable equilibrium.  Every insurer will have an incentive to add a marginal, incremental plan to be offered on the BCRA exchanges in order to move the subsidy attachment point closer to their preferred position.  Once this arms race begins, consumers will be asked to differentiate miniscule differences between dozens of plans offered by two or more insurers.  Common heuristics such as evaluating a plan first on the inclusion of a specific doctor or hospital in network and then examining a subset of plans based on maximally acceptable premium with the final decision step based on minimizing deductible will be corrupted.  Plans can be offered with low deductibles but higher maximum out of pocket exposure with a cost structure that significantly advantages or disadvantages certain types of consumers.  Insurance buyers will face decision fatigue and be overwhelmed with almost meaningless choice.

There are two possible solutions.  The first is for the Department of Health and Human Services to update stringent meaningful difference regulation.  Current regulation[6] allows carriers to offer multiple plans built on the same network ID and same plan type (HMO, POS, EPO, PPO) with fairly minor differences in cost sharing.  Stronger meaningful difference regulation would restrict carriers to offer only a single cost sharing design per network ID and plan type dyad.  The second is for the Senate to modify the benchmark.  Every participating carrier would place their lowest cost plan in the benchmark set and the median plan from the benchmark set would be the benchmark plan for the county.

These design modifications lower consumer confusion and will minimize strategic manipulations of the subsidy formula which will lead to more effective and efficient markets.

Read more

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 picstopost@balloon-juice.com or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

That’s what it’s all about.

Read more

Late Night Open Thread: The Wrath of Cat

Steve, a couple days ago, completely happy and content:

Steve, tonight, after I finished that box of cd’s and closed it, giving me straight up stinkeye, seething with contempt and plotting my demise:

Looks like I need to go get a box for Steve tomorrow.

This is Going to be Amazing

Allow me a three part joke. First, this:

FBI agents have repeatedly questioned former Trump campaign adviser Carter Page about his contacts with Russians and his interactions with the Trump campaign, according to people familiar with the investigation.

Over a series of five meetings in March, totaling about 10 hours of questioning, Page repeatedly denied wrongdoing when asked about allegations that he may have acted as a kind of ­go-between for Russia and the Trump campaign, according to a person familiar with Page’s account.

The interviews with the FBI are the most extensive known questioning of a potential suspect in the probe of possible Russian connections to associates of President Trump. The questioning of Page came more than a month before the Russian investigation was put under the direction of Special Counsel Robert S. Mueller III.

Page confirmed Monday that the interviews occurred, calling them “extensive discussions.” He declined to say if he has spoken to investigators since the March interviews.

He said the FBI agents “acknowledged that I’m a loyal American veteran but indicated that their management was concerned that I did not believe the conclusions” of a Jan 6. U.S. intelligence report describing Russian government interference in the U.S. election. “Our frank and open conversations gave me confidence that there are still logical, honest individuals at the bureau who respect civil rights and the Constitution,’’ he said.

Next, here’s Carter Page just having a conversation:

Sorry for the long setup, but trust me, this is worth it. And now, the punchline:

Because it is against the law for an individual to lie to FBI agents about a material issue under investigation, many lawyers recommend that their clients not sit for interviews with the bureau without an attorney present. Page said he spoke without an attorney and wasn’t concerned about the risks because he told the truth.

I say again, the firmest evidence I have seen that there is no Russian involvement in the 2016 election is that Carter Page hasn’t taken a nose dive out of a hotel window.