About last night…

What does last night mean for PPACA?

These are initial, pre-coffee thoughts and not all of the data is in.  I’m also venturing away from technical comments and towards general political punditry which is not my strength, so please apply an appropriate discount to everything.

  • Medicaid expansion is dead for at least the next two years.  Utah and Wyoming will probably get waivers and that will be it. (90% confidence)

Not expanding Medicaid inflicted absolutely no cost on the veto players in any state that I can see.  Larger Teabagging majorities are opposed to Medicaid expansion for Those People.  The invisible portion of the Republican primary process is coming to an end sometime in the next hour or two, so no one who thinks they have a shot in 2016 can thread a needle for expansion.

  • Arkansas may stop the private option expansion (60% confidence)

From my understanding, Arkansas needs 75% reauthorization and the governor’s signature every year for the private option.  I don’t think either condition is in place for next year.  This will destroy the financial stability of hundreds of thousands of people AND destroy the financial base of the Arkansas rural hospital system as those hospitals were replacing charity care and uncompensated care DSH payments with Exchange payments.

  • At least 1 week of government shutdown will happen by next October (85% confidence)
  • Employer mandate will go down (80% confidence) as well as medical device tax (97% confidence)

From a policy point of view, the Employer mandate is probably the least important pound of flesh for Republicans to claim.  It does not do much for coverage, and it produces bad business level incentives as well as locking people into really crappy insurance that their job provides when they would be better off on the Exchange.  This is a probably a good piece of policy.  The Medical device tax has bipartisan opposition because medical device makers sit in too many districts and are raising a big stink.  The only question is whether the revenue losses are offset.  I would hope that as part of the negoatitations, the rest of PPACA is Halbig proofed.  If it is, then Don Taylor would be right in that there is a window to talk health policy on both sides of the aisle.  I don’t think that will be the case.

  • PPACA will work in states where the states want it to work.  It will be a clusterfuck in Republican base states.
  • At least one Republican base state will start preparing Wyden Waivers for 1/1/17 which makes everything on Exchange an HSA style system with no EHBs.  (60% confidence)
  • Risk adjustments are at risk as they need appropriations

PPACA has three risk transfer mechanisms. Reinsurance and Risk Corridors are temporary stabilizers, and risk adjustment is a permanent program. The goal is to help insurers figure out what a stable market risk pool looks like by transferring money from low risk/healthier than average plans to high risk/high disease burden plans. The problem is that the way PPACA is written, money can come into the Federal government, and it can go out for 2014 payments, but it is questionable if it can go out in 2015 and 2016 without an appropriation.

  • My hangover will subside by late afternoon (98% confidence, 100% hope)

Not Even Trying To Hide It

Via TPM — Lindsay Graham (R-Who Can We Bomb Today) tells the one true beating heart of the GOP exactly what it wants to hear.  Speaking to the all-male, seemingly all-pale Hibernian Society fo Charleston SC, the Senator forgot a fundamental truth of modern politics:  there is no such thing as a private speech anymore.  Or maybe he just doesn’t care.  Whatever, here’s Lindsay, letting his freak flag fly:

“If I get to be president, white men who are in male-only clubs are going to do great in my presidency,” Graham says …as the audience laughs. (h/t Twitteratus @GrooveSDC)


Leave aside the cosmic delusion there — is there any geographical location outside the confines of his head in which any sentient being thinks Graham could be elected president? — the glory and horror of this confirmed-by-audio (head over to TPM for a listen) lies with its utter, transparent, total honesty.  Graham speaks the core Republican truth.  The people they server are rich white men.  Full stop.

Please proceed, senator:

“I’ve tried to help you with your tax status,” the senator says in another recording. “I’m sorry the government’s so f*cked up.”

Because, of course, the only thing that the United States government really exists to do is to make sure rich white guys  capture more money.

Friends don’t let friends vote Republican.


Oh — and one more thing:  if there is any last deluded teahadist out there who thought until now that the movement really had a chance to reclaim the GOP for the values of some mythic better America, you can apologize to the rest of us anytime.

Image:  Rembrandt van Rijn, Syndics of the Drapers’ Guild, 1661.

The Bush Crime Family Is Never Going Away

Barring a moral awakening or some other improbable event, it looks like we’re gonna be forced to witness the Bush clan attempting to shoehorn yet another family member into the White House. Per CNN:

… The Des Moines Register reports Tuesday that GOP Iowans recently received mailers from the former Floridian governor that sounded more like a campaign pitch than a donation plea for his social fundraising group, Excellence in Education National…

In recent days speculation about a potential bid has increased following several comments made by his family members. On Sunday, both of Bush’s sons hinted that their father is seriously considering running. In an interview with the New York Times, Jeb Bush Jr. said that people and donors are “getting fired up” about the idea of his father running for president.

“I think it’s more than likely that…he’ll run. The family will be behind him 100 percent if he decides to do it,” George P. Bush, the governor’s youngest son, told Jon Karl on ABC’s “This Week.”

Jeb also, per the AP, criticized President Obama’s crisis management as “incompetent” and called his Middle East strategy “an unmitigated disaster”, because his target GOP voters have had six whole years to forget everything about the Dubya/Cheney administration.

So I’m happy to see that Mother Jones has published an early primer of “23 Reasons Why Jeb Bush Should Think Twice About Running for President“, including helpful links to some of the many shady characters in Jeb’s business background:

The fraudster: In 1986, Camilo Padreda, who had been a counterintelligence officer for Cuban dictator Fulgencio Batista in the 1950s, hired Bush to find tenants for office buildings financed with US Department of Housing and Urban Development-backed loans. Bush took the gig, despite the fact that four years earlier Padreda had been indicted for embezzling $500,000 from a Texas savings and loan. Those charges were dropped, but in 1989 Padreda pleaded guilty to defrauding HUD of millions…

The international fugitive: In 1986, Miguel Recarey, who’d done 30 days in jail for income tax evasion in the 1970s, paid Bush $75,000 to help him find a new headquarters for his health care company. The company never moved, but while Bush’s father was serving as vice president, Bush lobbied the US Department of Health and Human Services to help Recarey access millions in Medicare funds…

The fortunate son: Cuban American real estate developer Armando Codina was the Florida chair of George H.W. Bush’s unsuccessful 1980 bid for the GOP presidential nomination. He loved the Bush family so much that when Jeb first moved to Miami in the early 1980s, he made Bush a partner in his real estate company and gave him 40 percent of the profits—even though Jeb had no real estate experience or money to invest. In 1985, Bush and Codina bought an office building partially financed by a savings and loan that later failed. The $4.56 million loan went into default, but federal regulators gave Bush and his partner a pass. Instead of foreclosing, they merely asked them to repay $500,000 of the loan. Taxpayers picked up the rest. In 1991, Bush and Codina sold the building for $8 million.

The shady company: In 2007, Bush joined the board of InnoVida, a building materials-manufacturing startup founded by a businessman whose previous company had gone bankrupt under suspicious circumstances. Bush and his fellow board members subsequently failed to notice that InnoVida officials had used forged documents to fake solvency, hidden the company’s financial problems, and misappropriated $40 million. The company’s Maserati-driving founder eventually went to jail for money laundering, and investors lost their shirts when the company went bankrupt in 2011. Last year, Bush agreed to repay the $270,000 he was paid by the company as a consultant to reimburse defrauded investors….

Fables of the Restoration

As Election Day nears, the battle for King Shit of Turd Mountain, i.e., the contest between Charlie Crist and Rick Scott for governor of Florida, has produced a shit-storm of negative advertising. Commercial after commercial projects images of the combatants in sinister poses and evil lighting, accompanied by strained voiceover accounts of their misdeeds in office.

Obviously, the Crist Photoshop team has the cushier job: I don’t think there’s a photo in existence of Rick Scott where he doesn’t look like an alien creature from a reptile off-world come to foreclose an orphanage and grind the inhabitants into feed-paste.


But yesterday, there was an ad I hadn’t seen before featuring former Governor Jeb Bush excoriating former ally Charlie Crist as a career politician only interested in personal aggrandizement. The stones. The fucking stones on those Bushes.

Bush 2016: The Restoration is apparently a thing. Here’s a puke-inducing paragraph from a NYT article published yesterday about the alleged upswing in Jeb Bush’s political prospects:

Just six years ago, at the end of the last tumultuous Bush presidency, this would have been all but unthinkable. But President Obama’s troubles, the internal divisions of the Republican Party, a newfound nostalgia for the first Bush presidency and a modest softening of views about the second have changed the dynamics enough to make plausible another Bush candidacy. And while Jeb Bush wants to run as his own man, invariably this is a family with something to prove.

Unpacking that paragraph is like opening a rancid diaper pail, but let’s brace ourselves and give it a go: “President Obama’s troubles?” Yes, he has them, mostly traceable to Stately Bush Manor and exacerbated by the Bush-aligned vandals in Congress.

“Internal divisions of the Republican Party?” Oh, you mean that GOP rebranding campaign gone awry in which the Republican Party nominated scads of pekoe-huffing troglodytes who lost winnable races and turned the GOP presidential primary into a crackpot bake-off?

“Newfound nostalgia for the first Bush presidency and a modest softening of views about the second?” Bush I is a doddering old fart who occasionally weeps with shame in public over his fuck-up namesake. He will be forever overshadowed by the half-wit he served as VP, and his son empowered a cabal of sociopaths to complete the cycle of destruction Poppy’s boss set into motion.

And now we’re seriously being asked to countenance another Bush run at 1600 Pennsylvania? Just shoot me now. (You can get away with it here in Florida — thanks to Jeb’s partnership with the NRA.) I can’t be objective because I utterly despise them all. But is there really a Bush restoration movement afoot outside of the Bushies, their minions and political columnists? Y’all help me out here: I haven’t seen any evidence of it.

God, that article. “This is a family with something to prove?” Fuck them. “The Bushes, Led by W., Rally to Make Jeb ’45’?” From the current generation until the sun goes supernova and vaporizes this planet, fuck the Bushes, and fuck the putrid media hacks who enable them by framing the ambitions of that clan of psychotic leeches as if writing a human interest piece on a sports dynasty.

When the Obama administration decided not to pursue its vile predecessors for their ghastly war crimes and corruption, I understood the rationale, even if I didn’t agree with it entirely. It would have paralyzed the government in the midst of a cascading global crisis.

But the question of justice denied aside, this spectacle of the Bush family rehab alone is evidence that the dirty fucking hippies were right: We should have driven a stake through the fat black heart of that bunch when we had the chance.

Calling the consolidation efficiency bluff

Last week, a major specialty practice in the east suburbs of my central city announced that they had agreed to be bought out by Big City Medical Group.  BCMG will now control 85% of the orthopedists, 100% of the dermatologists, 90% of the nephrologists, 75% of the oral surgeons and 50% of the cardiologists who practice in three well populated counties east of the Big City.  The press releases claim that BCMG will realize significant efficiencies and cost savings.  The buy-out price only makes sense if BCMG either sees 30% efficiencies or 25% above trend reimbursement increases.   The latter is far more likely than the former.

Aaron Carroll at the Incidental Economist passes along some further confirmatory research on the effects of provider consolidation on pricing in healthcare.  As expected, consolidated providers get paid more:

The authors looked at more than 1050 counties in the US to see if changes in physician competition were associated with prices between 2003 and 2010. They used the HHI …

Variation existed in competition by counties. The 90th percentile HHIs were 3-4 times higher than in the 10th percentile. They also found that prices were $5.85 – $11.67 higher in the counties with the highest decile of HHI versus the lowest decile. Price indexes in the same deciles were 8%-16% higher as well. Over seven years of the study, prices went up more in areas of less competition than in areas of more competition.

One of the great weaknesses of PPACA is that it encouraged provider consolidation while fragmenting the insurance market.   The power imbalance which had already led to very high pricing compared to other industrial countries was not corrected, nor improved upon but it was exacerbated.  Provider consolidation has been encouraged by the significant push towards adapting electronic medical records which is a massive capital investment for two and three doc practices and the move towards population health management in the ACO model.  ACOs require big populations and significant back-end administrative support to target the right patients with the right care.  Small practices can’t do that well.

So far, pricing has been moderated primarily through the aggressive use of narrow networks that are excluding high cost providers, and some quality improvements through the Medicare re-admission reduction program among others.  But these are marginal changes within a dysfunctional quasi-competitive market.

Assuming that a full National Health Service style take-over of all providers is off this table (and I’ve not had enough shrooms to keep that option on the table) what are the policy options to increase competiveness in the provider market?

Read more

Thoughts on Arkansas

As open enrollment is creeping up on us, I’ll be spending some time doing retrospectives on interesting policy experiments. The Arkansas model of premium support for most of their Medicaid population is a fascinating experiment. The basis of the experiment was for the Democrats to find someway to get more than half of the Republican caucus onboard for a Medicaid expansion. So they did not do expansion, they did premium support for private insurance on the Exchanges with supersized subsidies for the Medicaid eligibile population. The first year results are mixed. Access to care, utilization and enrollment are great. The problem will be cost, and that problem is an underlying issue with the Arkansas 1115 waiver.

First, the good news:

A decline in uninsured ED usage would have met everyone’s expectations as the population of the uninsured plummetted.  A smaller population, means, all else being equal, less utilization even if the declining population cohort is cherry picked as low utilizers.  I can’t say anything about the characteristics of the newly covered population.  The same logic applies to uninsured hospital visits, fewer uninsured individuals should lead to fewer uninsured hospital admissions.  These were expected results.

Now the total decline in emergency room visits was unexpected.  Massachusetts saw ER usage increase after insurance expansion.  This is utterly fascinating and meaningful as a 2% decline on a population of a couple million people is statistically significant and more importantly financially significant.  It may mean that there is successful diversion of acute care cases to lower, more appropriate levels of care such as urgent care clinics or primary care provider office visits.  More research is needed for that set of claims to be made.  If Arkansas can replicate the ER diversion and minimization for next year and figure out why it is working, this is something that should be taken to other states for replication.

Enrollment is good as well. Slightly more than 200,000 people are in the program. The net uninsured rate in Arkansas has been cut in half

Access to care is pretty good as well as Arkansas is using full commercial reimbursement (more on this later) for broad commercial networks.  Any doc who wants in is probably in.

And that is where there are problems lie.  Read more

Late Night Open Thread: Who Lost China the WMDs?

Eli Lake, accredited Wingnut Wurlitzer puke funnel, wrote the article:

In an interview with The Daily Beast, former Senator Rick Santorum said he and his staff began receiving photographs of discarded Sarin and Mustard shells from U.S. soldiers in 2004. Two years later, when he was up for re-election, Santorum even went public with some of this information in a press conference disclosing a Pentagon report that found 500 chemical weapons shells had been found in Iraq…

But at least in 2005 and 2006 the Bush White House wasn’t interested. “We don’t want to look back,” Santorum recalled Rove as saying (though Santorum stressed he was not quoting verbatim conversations he had more than eight years ago). “I will say that the gist of the comments from the president’s senior people was ‘we don’t want to look back, we want to look forward.’”…

Santorum on Thursday stood by that claim. “There was no active chemical weapons operation in Iraq, that doesn’t mean there were no chemical weapons,” he said. “That was the point we were making. It’s clear from the New York Times article that the military as well as the administration didn’t want to have that conversation because they missed it.”…

… including a special guest appearance by our old friend Pete Hoekstra (see: Hoekstroika):

In an interview Thursday, Hoekstra declined to name Bush administration officials with whom he spoke. But he said he felt stonewalled during his own investigation in 2005 and 2006 into the issue. “This was an active investigation by the intelligence committee and they chose not to answer our questions truthfully and fully,” Hoekstra said….

Tell me again how “nobody” takes Luzer Rih Sanctorum seriously. I’m just barely old enough to remember when RWNJs used the magical phrase Matsu and Quemoy un-ironically, and I seriously think Santorum is his generation’s Dick Nixon. Sure, he’s a twisted little sociopath that you wouldn’t want as a neighbor (much less an in-law), but there’s a negotiable bloc of American voters who want to be represented by a twisted little sociopath “they can count on” (to punish all the happy, successful, smiling folk who are not like them — and Rick Santorum).