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.

Keep on Calling

Good news

Now keep on calling

Jared Kushner’s Big Loan From Deutsche Bank

A month before election day, Deutsche Bank came through for Jared Kushner. If I am reading this right, the loan is to Jared’s corporation, for a property near Times Square, but Jared and his brother are guaranteeing it.

The corporate loan and Kushner’s personal guarantee are not mentioned on his financial disclosure form, filed with the Office of Government Ethics. Blake Roberts, a lawyer who represented Kushner on the matter, said in a statement to The Post that Kushner’s form “does not list the loan guarantee” because the disclosure relied on “published guidance” from OGE that he said “clearly states that filers do not have to disclose as a liability a loan on which they have made a guarantee unless they have a present obligation to repay the loan.”

The Post sent the language cited by Kushner’s lawyer to Don Fox, a former general counsel and acting OGE director. After reviewing the wording, he said in an interview that he would have advised Kushner to disclose the personal guarantee of the $285 million corporate loan because of its size and possible implications.

One more thing, like the meetings with Russians, that Jared forgot to tell us as he took his seat as the President’s special advisor. He and his mother also have a personal line of credit at Deutsche Bank up to $25 million.

Deutsche Bank has been in trouble, and so was Jared’s property. Sounds like a marriage made in heaven.

The value of insurance

Three researchers, Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., M.P.H., and Katherine Baicker, Ph.D. have reviewed the past ten years of research on the effect of insurance on mortality and financial stability in the New England Journal of Medicine.

Here are the highlights:

Overall, the study identified a “number needed to treat” of 830 adults gaining coverage to prevent one death a year. The comparable estimate in a more recent analysis of Medicaid’s mortality effects was one life saved for every 239 to 316 adults gaining coverage.29

Cost effectiveness

Are the benefits of publicly subsidized coverage worth the cost? An analysis of mortality changes after Medicaid expansion suggests that expanding Medicaid saves lives at a societal cost of $327,000 to $867,000 per life saved.29 By comparison, other public policies that reduce mortality have been found to average $7.6 million per life saved, suggesting that expanding health insurance is a more cost-effective investment than many others we currently make in areas such as workplace safety and environmental protections.29,54

It seems that Medicaid is extremely cost efficient in buying longer lives. I speculate that part of the resistance is that the cost of Medicaid is extremely explicit while regulations can be more easily hidden off budget. I also speculate that there is a sympathetic beneficiary differential.

Medicaid versus private payer

there is no large quasi-experimental or randomized trial demonstrating unique health benefits of private insurance. One head-to-head quasi-experimental study of Medicaid versus private insurance, based on Arkansas’s decision to use ACA dollars to buy private coverage for low-income adults, found minimal differences.11,19 Overall, the evidence indicates that having health insurance is quite beneficial, but from patients’ perspectives it does not seem to matter much whether it is public or private.47

This is telling me that if we are to expand cost efficiently, we should expand Medicaid as much as possible.

Go read this article. It is only eight, double columned, pages that is easily accessible and clearly written.

And then go call the Senate.

The incentive problem

As long as norm busting creates rewards, norms will be busted.

We can either engage in a race to the bottom of norm busting or change the incentive structure so that norm busting is not rewarded. Neither set of choices is easy or certain to succeed.

Open thread.

Medicaid is getting sliced even more in the Senate

What is going on here?

Medicaid which was scheduled to take a 27% federal cut in spending under the House version of the AHCA, is getting cut even more in the Senate.

Why is this?

It is a function of reconciliation rules. The Senate bill has to reduce the deficit by at least as much as the House passed bill. Any dollar that is spent on beefing up opioid addiction spending or creating a multi-billion fund for NICU babies so that Senators can claim it passes the Kimmel test or slowing down the Medicaid expansion phase out from three years to seven years or anything else has to be paid for elsewhere in the bill.

There are three major sets of pay-fors in the AHCA. The first is reducing or slowing down tax cuts that accrue overwhelmingly to upper income individuals. The second is to cut funding for the individual market/Exchanges. The third is Medicaid.

The Republican Party has a strong revealed preference for tax cuts for upper income individuals above almost all else. That is the one policy plank that holds that party together. So pushing back the Medicare tax increment on investment income is unpossible within the political realities of the Republican caucus.

The Senate bill has been focused on taking off some of the most pointy edges of the individual market problems in the House bill, or at least sanding them down to avoid some attack ads in October 2018. So taking money out of there does not make sense within the internal logic of the Senate bill.

That leaves Medicaid as the sole pay for that does not have either strong and broad consensus support or immediate political logic. And here the power of compound interest comes into play. Switching to CPI-U instead of CPI-M or CPI-M+1 is a massive cut. Below is the difference in the CPI-U and CPI-M since 1/1/2000 with spending index at 100 for 1984.

What does this mean? May 2017 CPI-M had 2.7% growth from May 2016. CPI-U only had 1.9% Applying that to the $344 billion the Federal Government spent on Mediciad in 2015 (from the NHE fact sheets Table 03 Line 11), that is a difference of $2.75 billion dollars in the first year. And then it compounds. Over a ten year budget window, it is a $150 billion dollar or more in cuts adding to the current $800 billion dollars already scheduled to be cut. The Senate rumor has the change in formula not start until the end of the budget window so the total in-window cut may only be $20 or $30 billion dollars incrementally but the long run growth curve is incredibly compressed. It further shrinks the federal role for Medicaid finance over time. It is a slower shrinkage than the FY-18 budget proposal where by the end of the budget window, federal funding for Medicaid would be cut in half compared to present baseline but it will get to that point fairly quickly outside of the budget window.

Grabbing money out of Medicaid by lowering the index growth rate is a massive cut of future growth. It is also fairly subtle as I know the number of people whose eyes have not glazed over by now in this brief explanation can fit into a large booth at the local Cracker Barrel. It kicks Medicaid harder while allowing for attack ad insulation and large tax cuts.

Monday Morning Open Thread

Ah, summer!…

Apart from #StillResisting, what’s on the agenda as we start another week?

You know the drill —

And finally, some useful advice: