Time to get into the weeds

I want to build on Tamara’s good post from this morning on how to organize and defend when forced to and advance when possible.

The federal bureaucracy will be our friend. Right now the Trump team is being staffed by incompetents, grifters and Brietbart comment section heroes in too many high level, high profile locations. That means the federal civil service bureaucracy will either be micromanaged to death or if the political appointees know that they don’t know anything, they’ll be given quite a bit of loose guidance and a lot of freedom of action. And this is an area where we can have some success.

In October, I submitted a long comment to CMS for the NBPP 2018 rule. The core of the comment is a call for greater meaningful difference:

This new rule solves the current problems that are created by the current Meaningful Difference rule. Buyers will have far clearer choices when they actively shop on Healthcare.gov. The number of plans that can be offered for a geographic region and metal band will most likely be reduced. The reduction in plans will come from the removal of plans that are extremely similar to plans that will still be offered on Exchange. Finally, the removal of isomorphic clones will lead to higher enrollment and improvement of the risk pools as more individuals will find the post-subsidy premiums to be a better deal than paying the individual responsibility fee (individual mandate) penalty.

CMS released the final rule last Friday. The only reference to this comment was on p.178 where CMS brushed the suggestion off.

So that was not a win for me.

However, it is a point of leverage and pressure. If we are going to see technical staff have some technical freedom because their management won’t know what they are looking at, we can minimize the dumb or spiteful while getting some wins in the rulemaking process.

I’m going to get on Tim F’s beat — if you see something that the Federal government is doing that either intrigues you, pisses you off or touches on an area of specialized knowledge that you have, comment on the rule making. This letter took me three or four hours to write and revise with the other signers. It will be read, and it will be remembered by CMS technical staff as it engages them and it is not a mindless screaming of rage (from what I’ve heard, the EPA gets the best rage-grams.) Thoughtful, relevant responses that point to possible ways of accomplishing the mission of the agency in question will be read and they will be remembered. So please, do so

PSA: Enroll tonight

Healthcare.gov extended their enrollment period by four days for January 1st coverage. That extension ends tonight at 11:59 Pacific Time. Time to get enrolled.

There are three damn good reasons to enroll.

1) You need coverage for yourself and your family
2) Most plausible Replace plans will rely on some type of continual coverage mandate so it is time to build up a history.
3) Let’s create facts on the ground for better attacks ads in 2018 and 2020 when #2 is failure.

So go enroll today.

ZIKA, Medicaid and Risk Adjustment under block grants

And now for something really depressing:

The toll that Zika virus takes on pregnancies appears to be even higher than was previously estimated, with a newly updated study from Brazil suggesting that 42 percent of infants infected in the womb may have significant birth defects.

When the authors factored in stillbirths and miscarriages suffered by women who had been infected with Zika, 46 percent of pregnancies were affected. Microcephaly — a condition in which babies are born with smaller than normal heads — was seen in only about 3 percent of babies in the study.

“Microcephaly is just the tip of the iceberg. It’s definitely not where the focus should be,” said Dr. Karin Nielsen-Saines, the paper’s senior author. “For every case of microcephaly you’re probably going to have 10 cases of other problems that haven’t been recognized.”

In the United States, roughly half of all births are covered by Medicaid. Medicaid and CHIP cover a good number of kids and these two programs cover a disproportionate number of children with significant, expensive life long conditions. We also know that locally transmitted Zika infections will not be uniformly distributed. Alaska will have far fewer proportional Zika infections than Florida. We also know that one of the major policy planks of the Republican trifecta will be to block grant Medicaid on a per capita basis.

We know that treating and caring for an individual with microcephaly will have a lifetime cost of $10 million dollars. Other neurological and cognitive conditions will have lower lifetime incremental costs but these individuals will cost more than their non-Zika effected peers. We know that state Medicaid budgets will cover a high proportion of thees individuals. If Zika is not quickly isolated and reduced to a random outbreak here and there and instead is endemic, we have a serious Medicaid financing crisis at hand if the federal funding is transformed into a block grant.

The Medicaid block grant procedures would give states a fixed head payment for each enrollee. It could vary by category of assistance and a few other criteria but the fee would be flat within subgroups by the number of enrollees. From here, the states could have the choice to top-up the Federal match or spend state supplied money in other manners. This is different from the current system where the Feds give the states an open ended funding stream that is a state specific multiple of the state contribution. The block grant removes the variability of the federal spending commitment. In the Ryan plans, it also shrinks in terms of real purchasing power over time so states either spend more money to maintain current level of enrollment and services or cuts to enrollment and services have to occur.

And here is where there is a problem. The capitated payments would be based on average expected costs in year 1 and then get weaker. States with disproportionate clustering of high cost conditions will be significantly worse off. Long run Zika neurological impairments will hit warmer states’ Medicaid budgets much harder and more disproportionally than Zika will hit cold weather states’ Medicaid budgets. This could be adjusted for by having a Zika bump in the block grant calculation much like there could be a diabetes bump or a maternity bump or any other number of risk adjusted bumps to capitation payments. But what happens when there is a new high cost and very concentrated disease that will have major impact on a few states’ Medicaid budgets? The block grant system fails unless there is a side payment of new federal funds. And given the political fights over natural disaster relief bills and the Zika bill, I have a hard time seeing Congress routinely providing multi-billion dollar cash infusions to a few states for new diseases or threatening epidemics.

PSA: Sign-up

Tonight Tomorrow night at midnight is the deadline on Healthcare.gov to sign up for coverage that starts January 1.

If you are already in a plan for 2016 and do nothing, you will be auto-assigned to a plan that (hopefully) is similar to what you have now.

If you are not covered, get covered tonight.

We don’t know what the Repeal bill will do that market as we have not seen enough of the language in it. We don’t know if there will be a Replace bill or what will be in it. If there is a Replace bill, it will most likely count on the idea of continuous coverage as its mandate analogue. So now is the time to build the history to survive Replacement.

Get covered tonight!

UPDATE: I missed a day

The Trickster God Is Toying With Us

There really can’t be any further doubt:

On Friday night, Mr. Trump’s transition team insulted the American intelligence community by saying that officers had misrepresented the threat of weapons of mass destruction ahead of the Iraq War, meaning that they should not be trusted with their conclusion of Russian meddling in the presidential election.

In a new twist, Mr. Trump will meet on Monday with Carly Fiorina, the former Hewlett-Packard chief executive, to discuss the job of director of national intelligence, a senior transition official said. [h/t TPM]

The sound you hear is every H-P veteran shrieking in shock and despair.  This is screaming-of-the-lambs scale horror, Ph’nglui mglw’nafh Cthulhu R’lyeh wgah’nagl fhtagn madness.


Fiorina’s picture is in the dictionary next to “Fail Upward.”

To speak the obvious: she has, as far as I know, exactly zero professional intelligence training, and nothing in her work (or, for the last several years, unemployment) record suggests she’s mastered what you’d want America’s eyes on the secret world to possess.  There’s no way to justify appointing Fiorina to this position unless you take Trump at his word and believe that he believes there’s simply no reason to bother with anything so frivolous as data, information, or knowledge of the world, our friends and adversaries alike.

Coyote is laughing…but at least this gives us all an excuse to revisit an old favorite:

ETA:  I’m just hoping our Adam isn’t drowning himself in a butt of sack right now.

Image: H. P. Lovecraft, Cthulu sketch1934

Death spirals all around

We’re going to see how the Republican Party can create a death spiral in the individual market in sixty days or less. They have a few choices:

US Individual Market Policies

First Philip Klein in the Washington Examiner wants to create one the old fashion way:

In contrast, Republicans could immediately freeze enrollment — allowing those who already have insurance through Obamacare to continue receiving subsidies, but preventing new enrollees from receiving any (though they’d still be free to purchase insurance on their own if they aren’t seeking subsidies). The current open enrollment period for privately-administered insurance ends on Jan. 31, so that would be a natural cutoff point.

Do you know who is extremely likely to buy community rated, guaranteed issue insurance with a subsidy? People who are very sick.
Do you know who is extremely unlikely to buy community rated, guaranteed issue insurance without a subsidy? People who have reason to believe they are very healthy.

This proposal will get the individual insurance market to look like the individual markets from the mid-90s in the non-subsidized, non-mandated guarantee issue states. Super high premiums and very sick risk pools. And since insurers set their 2017 rates with the assumption that subsidies are available for Special Enrollment Members, they will lose a lot of money.

Means #2 is just pulling the Cost Sharing Reduction subsidies. Insurers will flee the market. The American Academy of Actuaries have their hair on fire as they look at the impact of Congress not funding Cost Sharing Reduction subsidies after January 20th.

Eliminating CSR reimbursements could also cause insurers to withdraw from the market Premiums for 2017 have been finalized, and they assume that CSR reimbursements will be made. Without those reimbursements, premiums would have been higher for all individual market enrollees. Regardless of whether CSR reimbursements are made to insurers, the ACA requires insurers to provide cost-sharing subsidies. If those reimbursements are not made, premiums will be too low to cover the costs of care. This creates the potential for insurer losses and solvency concerns. Due to contract provisions, insurers would be permitted to withdraw from the market if CSR reimbursements are not made.

Splitting the a Replacement Bill into discrete and seperate chunks will also death spiral the market:

The issue is the popular stuff (guarantee issue, no pre-existing conditions, community rating etc) will get 85 votes in the Senate and 400 in the House. The unpopular stuff (participation enforcement mechanism, definitions, subsidy attachment formulas) won’t get a majority as no one really wants to vote for either a mandate tax OR continuous enrollment criteria without being able to point to a lot of other good stuff enabled by the bad stuff.

So again we’ll get the mid-90s markets of guarantee issue, community rating for only very sick people.

The Urban Institute models out the impact of Repeal without immediate replacmement and it is ugly:

It is mostly a cost shift with massive extraneous suffering.

And that is where I think we’re heading.

So if you have an Exchange plan, I would try to get any problems that I was putting off on taking care of taken care of by January 31, 2017. After that the insurance markets will most likely be extremely chaotic and volatile with a decent tail risk of all carriers pulling all products in a number of states by early spring.

Moral Action in Trump’s America

I’m way deep in a big project, and rather significantly behind on it too, so my blogging for the next few months is going to be quick-hit stuff rather than anything thought through.  I’ll try to make up for that by making it as regular a practice as I can to toss good reads your way.

Todays comes from Masha Gessen, someone y’all know I greatly admire.  About a week ago she posted a piece on The New York Review of Books site.  In it, she asks if the realist stance in politics can function in the context of Trump.  To find out, she looks to her own family history — including choices she made — to answer no.  She takes no prisoners:

In Bialystok ghetto, my great-grandfather’s responsibility in the Judenrat was to ensure that the ghetto was supplied with food. He ran the trucks that brought food in and took garbage out, he ran the canteen and supervised the community gardens that a group of young socialists planted. He also discouraged the young socialists from trying to organize a resistance movement: it would be of no use and would only jeopardize the ghetto’s inhabitants. It took him almost two years to change his mind about the resistance efforts, as he slowly lost hope that the Judenrat, by generally following the rules and keeping the ghetto inhabitants in line, would be able to save at least some of them.

As in other ghettos, the Judenrat was ultimately given the task of compiling the lists of Jews to be “liquidated.” The Bialystok Judenrat accepted the job, and there is every indication that my great-grandfather took part in the process. The arguments in defense of producing the list, in Bialystok and elsewhere, were pragmatic: the killing was going to occur anyway; by cooperating, the Judenrat could try to reduce the number of people the Nazis were planning to kill (in Bialystok, this worked, though in the end the ghetto, like all other ghettos, was “liquidated”); by compiling the lists, the Judenrat could prevent random killing, instead choosing to sacrifice those who were already near death from disease or starvation. These were strong arguments. There is always a strong argument.

But what if the Jews had refused to cooperate?


Was Arendt right that fewer people might have died? Was Trunk right that Judenrat activities had no effect on the final outcome? Or would mass murder of Jews have occurred earlier if Jews had refused to manage their own existence in the ghetto? We cannot know for certain, any more than we can know now whether a scorched-earth strategy or the strategy of compromise would more effectively mitigate Trumpism. But that does not mean that a choice—the right choice—is impossible. It only means that we are asking the wrong question.

The right question…or better, the right stance, the right scale on which to weigh any choice of action?

We cannot know what political strategy, if any, can be effective in containing, rather than abetting, the threat that a Trump administration now poses to some of our most fundamental democratic principles. But we can know what is right. What separates Americans in 2016 from Europeans in the 1940s and 1950s is a little bit of historical time but a whole lot of historical knowledge….

Armed with that knowledge, or burdened with that legacy, we have a slight chance of making better choices. As Trump torpedoes into the presidency, we need to shift from realist to moral reasoning. That would mean, at minimum, thinking about the right thing to do, now and in the imaginable future. It is also a good idea to have a trusted friend capable of reminding you when you are about to lose your sense of right and wrong.

I’m convinced Gessen is correct.  More, I believe her demand that we make the moral choice first, and then pursue whatever particular tactic seems most likely to embody that choice, will be the most effective, as well as the right thing to do.  A Democratic response to Trump that says we can make this work a little better enshrines Trumpism, and all the vicious GOP assumptions as the ground on which such matters get decided.  One that says “No. This is wrong.  Democrats will oppose, not mitigate…” is the one that creates a real choice going forward on the ground on which we want to fight.

Read the whole thing.

Image: Charles Le Brun, Horatius Cocles Defending the Bridgec. 1642/3 (I know it’s not dead on point, but it’s close, and I always loved the story, so there.)