Sandinista!

The big thing in American politics is a generational divide where older Americans vote like racist, xenophobic idiots and kids vote like socialists. How did it happen? Well, old people have always been stupid. Trust me, when I was seventeen I was a sharp as a tack and now, well, you read my posts. And I’m not even a fully fledged old yet. I don’t care how much hot teen blood Peter Thiel drinks, he’s going to struggle with the daily jumble when he’s a 120. But olds weren’t always this right-wing and the kids weren’t always commies.

I was reading once that the CIA had a theory about blowback, that they knew there was a pattern where they whacked countries with propaganda/coups/right-wing strongmen and ended up with strong socialist movements (or Islamic fundamentalist movements in the case of Iran) coming to dominate the country.

Do you think that’s what happened, or is happening, here? That the American right, with an assist from corporations, an Aussie media mogul and Russia, has whacked us with an endless stream of propaganda (that works brilliantly on the old) and two near-coups (2000 election and 2016 election), and that the end result is a sort of Sandinista generation?








Wednesday Afternoon Open Thread

My sister is a HUGE fan of Pink (the singer, not the color) and went to a concert last night even though it was a school night. She sent breathless fan girl dispatches throughout the evening and was thrilled to report that Pink flew over her:

Yep, Pink got into a harness thingy and flew around the venue. (In my day, we had to make do with acid and lame-ass laser shows.) It didn’t make my sister’s night; it made her YEAR. Open thread!



Least Expensive plan spreads

I want to dig a bit deeper into Gold uptake on Healthcare.gov as there was wild variability this year.  Some counties saw 50% of the on-Exchange market share go Gold while other counties barely saw any Gold sold.  One of the first metrics that I’ve used is the gap between the Benchmark Silver and the the least expensive plans of any other metal.  My logic has been that the marginal buyers are reasonably healthy and they are mainly shopping on prices.

Andrew Sprung did a deeper dive into the Philadelphia regional Gold purchasing pattern as he had noticed that Philly looked odd compared to the rest of Pennsylvania.  He goes into benefit design but he begins his search for knowledge by looking at the least expensive plan in each metal band.

Gold plan enrollment north of 30% in populous counties such as Allegheny (e.g., Pittsburgh), Lancaster and York made sense, as the cheapest gold plans in these counties, offered by dominant insurers UPMC (in Allegheny) and Geisinger (in York and Lancaster) were cheaper than cheapest silver. I was somewhat mystified, however, by high gold takeup compared to prior years in Philadelphia, Montgomery and Bucks counties, ranging from 9%-14%. In these regions,the cheapest silver plan offered by sole insurer Independence Blue Cross was considerably cheaper than the cheapest gold. In Philadelphia, gold selection was 9% — compared to 3% in 2017.

This is a really good idea and I think it provides a bit more illumination.  I cleaned up the data and looking at only the counties where there was non-suppressed Gold data, I ran a simple regression that sought to predict Gold market share by the size of the gap between the least expensive Silver and the least expensive Gold.

Gold MS = .000966(Price Gap) +.1769
R^2 = .48 P<.001 f=1099

This is way too quick and dirty to do anything beyond go “Umm… this is interesting” but it is very interesting and confirms the prior that as Gold gets comparatively cheaper, more people buy Gold.

A visualization of the relative prices of the cheapest plans is below the fold:
Read more








IOKIYAR Open Thread: Mick Mulvaney, All-Too-Honest Grifter

Yesterday:

 
Also yesterday:

In any other modern administration, Mulvaney would be gone by the time this post pops up (I’m writing it just after finishing the early-morning open thread). In *this* one, he’ll probably be given some special Trump-branded award for public service.

Mr. Mulvaney, who also runs the White House budget office, is a longtime critic of the Obama-era consumer bureau, including while serving in Congress. He was tapped by President Trump in November to temporarily run the bureau, in part because of his promise to sharply curtail it.

Since then, he has frozen all new investigations and slowed down existing inquiries by requiring employees to produce detailed justifications. He also sharply restricted the bureau’s access to bank data, arguing that its investigations created online security risks. And he has scaled back efforts to go after payday lenders, auto lenders and other financial services companies accused of preying on the vulnerable.

But he wants Congress to go further and has urged it to wrest funding of the independent watchdog from the Federal Reserve, a move that would give lawmakers — and those with access to them — more influence on the bureau’s actions. On Tuesday, he implored the financial services industry to help support the legislative changes he has requested…

The association, which invited Mr. Mulvaney to give the keynote address at its conference, strongly backs his efforts to consider the financial burdens on banks imposed by the bureau’s actions…


Read more



Wednesday Morning Open Thread: That State Dinner — Early Reviews

I guess the good news is that Donny Dollhands didn’t try to return Louisiana to France, in hopes of pocketing the refund for himself…

From the Washington Post‘s style page:

On an already symbolic evenin that carried the added pressure of being the Trumps’ foray into official diplomatic branding, the first couple managed to pull off the glitzy party in honor of French President Emmanuel Macron and his wife, Brigitte, without any major glitches. There were the bigwigs gussied up in black tie, the fine china decorated in gold, the long red carpet, the thoughtful toasts. All in all it was a state dinner, but in and of itself that is something.

Remember back on the campaign trail when then-candidate Trump denounced state dinners altogether? Speaking about “China and others” who allegedly “ripped off” the United States, Trump said that the White House should “forget the state dinners that cost, by the way, a fortune.” Hamburgers, which POTUS unabashedly enjoys, and a conference table were all the pomp and circumstance he needed, so the campaign bombast went, to iron things out.

My, how things have changed…
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Your Nightly Lily

Starring Lily, with musical guest Steve:

I guess I will get around to talking about politics again tomorrow.








It’s a long way for Tipirneni

Holy shit, this one’s close for a district that a Republican should normally win by 26 points:

Relative to the district, this is as impressive as Conor Lamb’s showing. Let’s finish off the Balloon Juice fund that is split equally among all Democratic nominees in districts currently held by Republicans.

Goal Thermometer








IOKIYAR Open Thread: Insecure Man Communicates Insecurely

Don’t worry, it’ll be a VERY SERIOUS IMPEACHABLE OFFENSE again once there’s a Democrat in the Oval Office! (Assuming we all live through the current occupancy, that is… )



Only in America Open Thread: The Waffle House Killings


 
Needless to say, this drew a ton of questions (you can click on the tweet to see some of them). Even from those of us who oppose the death penalty, because if walking into a restaurant wearing only your bullets-holder and shooting down multiple strangers in cold blood doesn’t qualify for the death penalty, what does?

(Yeah, I know: Being wilfully not-white in a public — or, if the wrong ‘authority figures’ get involved, private — space.)

And I’ve seen tweets saying Reinking’s father has been charged as an accessory for giving those guns back to his obviously incompetent-to-handle-them-safely son, but I haven’t found a proper news report.

Be that as it may, here’s a genuinely positive response to the tragedy:

Reporter Yashar Ali is raising money for the man who pried the gun away from a shooter at a Waffle House.

James Shaw Jr. wrestled the weapon away from the gunman during a mass shooting on Sunday in the Nashville restaurant. On Monday, Shaw started a GoFundMe account raising money for the families of the shooting victims…

Ali said that the money will be given directly to James and that the funds could be used for his daughter’s education.

“But I’d be just as happy if James used some of this money to take his family on a nice vacation,” he added.

More than $61,000 had been given to the GoFundMe as of Tuesday afternoon, more than the goal of $60,000.

Shaw has been hailed as a hero after fighting back against the shooter. His GoFundMe for the victims’ families had raised more than $98,000 as of Tuesday afternoon.

Shaw suffered a gunshot wound and burns from grabbing the assault-style rifle from the gunman. Four people were killed and at least three others were injured in the shooting…

Direct links to the GoFundMe pages:

Victims Of Waffle House Shooting

Help The Waffle House Hero



Y’all Weren’t Kidding

I had to leave for about five hours, and when I got back I was going to give Lily a snack. But because I am giving Lily a snack, I had to give Thurston and Rosie a snack as a distraction. I had a half a can of cooked chicken in the fridge from yesterday (the vets say they buy it by the ton at costco and give it to the dogs in recovery), and I opened another. The plan was to split the open can for Rosie and Thurston, and take the other can upstairs for Lily so she would not be pushed around (in bowls obviously, we’re not fucking animals).

I went to put the bowls down, which requires some precision- “Rosie, here is your bowl,” and then walk a few feet and say “Thurston here is yours” and then take Lily upstairs to feed her unmolested. No sooner did I have Rosie’s bowl on the ground when the new boss bitch Lily elbowed her way past Rosie and basically inhaled the bowl in two gulps.

I still don’t think Rosie knows what happened. I just stood there for a second thinking “Well, that was different.” I picked up Lily, gave Rosie some more, then took Lily upstairs, gave her the entire can, and she ate every last drop and then drank the chicken juice out of the bowl.

So yeah, the steroids are giving her a good appetite.








She hates him as much as we do.

Damn, Melania hates the loud-mouthed fatberg she married for money and a green card! Check out how she avoids holding his tiny, damp hand as they’re lined up to meet the Macrons at the White House:

The facial expression — or lack thereof — tells the story too. Still, no pity. She chose the rotten bastard. We didn’t.



Hop on Pop (Open Thread)

We’ve got a family of purple house finches in the yard with three fledglings. The fledglings are still a bit awkward in flight but do well enough; they can land on our feeders and gorge themselves, as they do pretty much all day.

But they still harass their parents for food. Here’s Father Finch being importuned by a baby, which is flapping its wings and screeching to demand that food be stuffed directly into its maw — just a few feet from a 24/7 all-you-can-eat buffet:

So, Papa feeds the little screecher:

But that just makes the little bird flap harder and screech more loudly:

So he feeds it some more:

It STILL won’t shut up, so Dad says, “Fuck it, I’m out.”

But another hungry chick awaits him on the next branch. Poor Papa Purple.

Open thread!








I Know, Let’s Jail Teachers!

Rep. Paul Lundeen (R) and state Sen. Bob Gardner (R) introduced a bill to throw striking teachers in jail. Let that sink in.

Despite a booming economy, Colorado’s school funding lags well below national average

DENVER –  As hundreds of educators from across the state plan to walkout Monday to fight for increased school funding and teacher pay at the state capitol, data shows that despite Colorado’s booming economy, our public schools are still struggling.

Colorado’s economy is red hot. The unemployment rate is just 3 percent. New skyscrapers and apartments are going up everywhere as more and more people throw cash at downtown bars and restaurants, but no one invited Colorado’s public schools to the party.

The National Education Association’s (NEA) annual report found Colorado ranks 46th in the country for teacher pay, with an average annual salary of $46,155; seven-thousand below the national average. Wyoming teachers, which ranks 16th for teacher pay, earned an average annual salary of $58,140.

I suspect this will not age well come election time…

Open thread



Morning Pupdate

She got a solid seven hours sleep, had breakfast, her morning meds, and I actually lost sight of her for about twenty minutes and when I realized she was not in the same room with me, I looked out the window and she was in the backyard pooping, peeing, sniffing, with her tail up and just prancing about. Being a dog, basically.

When I see her just lying there, being relaxed and comfortable, I can just feel my blood pressure dropping.








Risk adjustment and practice changes

There are three major styles of claims based risk adjustment systems. Some systems use only diagnosis information to slot a claim into a risk group. Most systems use diagnosis information. If a specific code is on a claim, the person is placed into the risk group. Some systems only use pharmacy claims where specific National Drug Code (NDC) number corresponds to a risk group. If a person picks up a prescription of a specific NDC, they get slotted into a risk group. Finally there are hybrid systems that use both diagnosis and prescription data.

Milliman looks at the challenge of pharmacy based risk adjustment in the context of the shift of opioid addiction harm mitigation and minimization efforts for the CDPS Dx/Rx risk adjustment model. They raise a very astute point about how risk adjustment lags clinical practice changes.

Diagnosis based systems suffer from severe lag from when a service was performed and when the claim could be processed. Claims are not settled for at least six to nine months after the date of service. Diagnosis is specific. A diagnosis will indicate Type 2 diabetes with or without complications which will drive their own score that drives a monetary transfer.

Pharmacy based systems are fast. Almost all pharmacy is point of sale claims processing. The big challenge with pharmacy based risk adjustment is that very few drugs have only a single use. For instance, oral hormonal contraception have a predominant use of preventing pregnancies but they are also used for a number of other medically valid reasons.

Hybrid systems like the CDPS MRx use both diagnosis and pharmacy data to drive a risk score. I optimized the UPMC Medicaid risk adjustment process for this model. It tended to award higher scores for diagnosis while a pharmacy claim slotted someone in as low as possible in a general category as pharmacy claims covered a much wider array of conditions than a specific diagnosis.

Over the past several years, physicians, hospital systems and insurers have all been trying to reduce opioid prescribing through a variety of means in order to minimize the number of additional people who will become addicted to an opioid. This means people who previously would have been prescribed an opioid are getting prescribed either non-pharmaceutical treatments or alternative non-opioid prescription drugs.

Some of the drugs in the model are used to trigger a multiple schelerosis diagnosis. That is an expensive disease so it is a significant increase in scored morbidity. There are a few important policy considerations that arise from this problem in the model’s data lag.

First, most Medicaid programs use revenue neutral risk adjustment, just like the ACA uses revenue risk adjustment. If everyone’s score increases by the same margin, no one gains or loses money. If there is a differential change in the risk scores that are solely driven by the opioid alternatives driving up MS scores, then some insurers will gain money that they really did not earn and some insurers would lose money that they “should” get.

The incentive in this situation is for a red queen race. Every insurer in revenue neutral risk adjustment where opioid alternatives can score increased risk adjustment payments should seek to maximize the number of people receiving opioid alternatives that score highly in other risk adjusted categories. If one insurer is doing this and no one else in the state/risk adjustment group, that insurer will get a lot of “free” risk adjustment money.

The second policy consideration is whether or not we want to intentionally use the fact that risk adjustment lags clinical reality as a fairly strong incentive for insurers to aggressively move people off of opioids and towards the prescribed alternatives? If the state uses revenue neutral risk adjustment, this policy had no direct monetary impact on the state but may lead to fewer people newly addicted to opioids.

Finally, a broader point needs to be raised. Most health insurance systems that require some type of guarantee issue and community rating needs risk adjustment to counter-act the cherry picking incentives every insurer faces. Every risk adjustment system is flawed. Diagnosis based systems have a significant lag between the event and data generation while pharmacy based systems have wider error bands due to the multiple indications most drugs can be used. The critical question is how much error should we tolerate, in what direction and to what purposes? And from there, how often do we need to update models to account for changes in clinical practice?

Milliman’s deep dive on the CDPS MRx model showed a critical exploit that aggressive insurers using that model can use to generate millions of dollars of additional revenue that is not supported by the underlying claims. They also lead to several critical questions that we need to think about.