The only ones without help

Bloomberg recently ran a great story on a family that is facing hard times affording health insurance because they don’t qualify for ACA subsidies and they don’t get coverage through work. The key take-away for me is that this population is one of the few insured groups that receives very little direct assistance.

David and Maribel Maldonado seem the very definition of making it in America….David’s annual salary reached about $113,000 by the time the children were in their teens. It was more than enough to live in a pretty suburban house outside Dallas, take family vacations, go to restaurants and splurge at the nearby mall. And to afford health insurance.

Then, in 2012, Maribel discovered she had breast cancer. “Your world comes crumbling down,” David says…
Health insurance offered through the company would soon be discontinued. It had simply become too expensive for the small company to provide it.

For David, the responsible head of a thriving middle-class family, having health insurance was non-negotiable. But the coverage he found to replace the company plan cost $1,375-a-month, up from the $260 a month he had been paying.

By the end of the story, a family of four has one person insured.

This family gets no explicit help. People who make between 100% and 400% Federal Poverty Level (FPL) are eligible for premium assistance subsidies. People who are insured through work have their insurance paid with pre-tax dollars. More importantly, those payments are mostly invisible so people only react to the employee contribution coming out of their paycheck. The elderly have their healthcare from Medicare while the poor or the disabled have Medicaid. People who buy on the individual market and who make more than 400% FPL get nothing. They are some of the few people who pay full freight.

The ACA has helped this family. In an underwritten system, the mother is uninsurable at any rate that looks vaguely affordable for an upper middle class family. It has not helped enough.

Solutions that allow for healthy people to pay lower premiums by splitting the risk pool might help cover the son with affordable coverage. The daughter and the father have medical history that could lead to uprates or rejections. Splitting the risk pool will significantly increase the premiums for the mother as she can only be covered through guaranteed issue policies. As healthy people leave, the ACA risk pool is more morbid and expensive on a per-capita basis. The family would absorb a dollar for dollar increase in premiums.

Medicaid buy-in proposals could be useful as Medicaid tends to pay doctors and hospitals significantly less than commercial plans. These lower provider payments lead to lower premiums but the trade-off tends to be narrower networks and less convienent access. The other solution that is plausible is a national cap on the percentage of family income that can be assumed to be reasonable and affordable to pay for a benchmark Silver plan. A cap of 10% would allow the family to buy Silver coverage for $11,300 a year which is still significant and presumably painful but far less painful than spending almost a fifth of their pre-tax income to pay for the entire family.

A cap and a split market are not neccessarily opposing policies. I argued last year that these policies could work in conjunction with each other:

Removing the cap on ACA subsidies so every family can access the ACA Silver plan for no more than 10 percent of its family income would provide immediate relief for Senator Cassidy’s constituents and others in similar situations. At the same time, the proliferation of underwritten plans will offer less expensive options for families without health challenges.

Patients and families will be able to choose the plans that will work for them. The ACA market will mostly cover the working poor who receive high subsidies and low deductibles, as well as the very sick who need to have comprehensive benefits and broad provider networks.

The underwritten market, which Republicans support and are seeking to expand, will consist of healthier individuals whose premiums no longer subsidize the care of the chronically ill in the individual market.

This type of solution is plausible if both parties want a healthcare ceasefire over the next couple of years.



On the 11th Hour of the 11th Day of the 11th Month of 1918 World War I Did Not Come to an End

(Satwinder Sehmi’s Calligraphy: In Flander’s Field)

As Veteran’s Day 2018 comes to a close, and with it the commemorations for the 100th anniversary of the end of World War I, it is important to remember that World War I did not actually end on the 11th hour of the 11th day of the 11th month of 1918. While it is true that the armistice was signed and peace talks would soon begin, World War I did not stop on November 11, 2018. Rather, and more accurately, it transformed into a series of low intensity conflicts that would simmer until reigniting into World War II. At the heart of those conflicts was a war of ideas. One of these ideas was national identity. Specifically, how ethno-national minorities that were left behind the lines, so to speak, when the armistice was signed would relate to the governments they now lived under, their ethno-national majority neighbors, and how those governments and those neighbors would relate to them. Out of these tense, taut, and often violent relationships between ethno-national majorities and minorities in post World War I Europe would grow other even more dangerous ideas such as fascism, in its corporatist, nationalist-syndicalist, and racist forms. Even, to a certain extent, Leninism, was unable to escape the nationalist tensions that resulted from the way World War I never really ended.

The great power competition that had led to World War I was changed by these clash of ideas – nationalism, fascism, communism – and, as a result, World War II and the Cold War were as much wars of ideas and ideology as they were wars of conquest and for territory. These ideas were about how to better organize state and society. And they placed the ideas of liberty and liberal democracy in all of its various types in direct conflict with the totalitarian ideas of fascism on the extreme right and communism on the extreme left. And just as different forms of liberal democracy would develop, so to would different variations of fascism and communism. These clash of ideas, of how states, societies, and even the global system should best be structured, would lead to both World War II, a long Cold War, the Korean and Vietnam Wars, and a number of conflicts fought by the proxies of the two post World War II superpowers. to a certain extent they are also an undercurrent in the US’s seeming forever war against terrorism in Afghanistan and Iraq.

As 2018 moves towards 2019, the world is once again faced with a war of ideas. The ideas of well ordered liberty and its expression in the different types of liberal democracy are once again facing off against totalitarian ideas from both state and non-state actors. Vladimir Putin challenges the US and its EU and NATO allies and partners with his promotion of managed democracy as a façade for the kleptocratic organized crime state he has created in Russia. Xi Xinping, recently declared as President for Life, promotes his fusion of Maoism, state controlled capitalism, and Chinese nationalism through his Belt and Road Initiative. ISIS continues to promote an extreme version of tawheed, the Islamic theological understanding of the unity of the Deity, which includes violently imposing its doctrine on believers and unbelievers alike. 

The War to End all Wars did not do so because it could not do so. Nor did World War II. Now has any other war. So while we recognize and commemorate the 100th anniversary of the armistice that ended World War I, we need to be realistic about what we face both within and without the United States. We need to remain vigilant in order to ensure that well ordered liberty prevails in this 21st century war of ideas.

Open thread.



726 Days of perspective

Yesterday, I posted something that would have been ridiculous to even think about 726 days ago.

Utah, Nebraska and Idaho all voted to expand Medicaid last night.

Funding Expansion via a tobacco tax in Montana is failing. The Montana legislature and governor will now need to figure out what they want to do next.

The next round of Medicaid Expansion stories is in the governors races in Kansas and Maine.

Five states can plausibly expand Medicaid at some point in mid-2019 or on January 1, 2020. Another state, Virginia, is currently enrolling people into Medicaid with a go-live date of January 1, 2019. The deals for subsidized individuals on the Exchange are, in some counties, ridiculously good (there is an op-ed I really need to write and shop around about this!)

I went silent for a week for my own health and to actually process and think. I’m glad I did that.  I had two reaction posts the week after the 2016 election.

First:

We’re going to lose a lot.

Let’s acknowledge that and then let’s figure out how to fight to prevent the losses that are preventable and get back into a position where we have at least one veto point if not the entire shebang.

This week, we got divided government again. It is not the whole shebang, but it is a veto point that is not reliant on marginal Republicans doing “not Republican” things.

Second:

  • the poor-shaming Medicaid waivers that tie Medicaid to work requirements will go through in thirty three seconds or less….
  • Cost control is out the door. So insurers and more notably, providers will be snorting the finest coke off the tight asses of the best hookers again.
  • Any Republican plan will include throwing more tax advantages at HSA’s (which are great for people who are truly insuring against hit by the meteor events AND have money) and telling everyone else to pay more for their own care

At least two of those things are true.

Work requirement waivers are slowly working their way through the courts and are being implemented and achieving their actual objectives of reducing enrollment in Arkansas. HSAs are continually promoted to solve any and all problems. Insurers and providers are profitable. I expect ACA insurers in 2018 to be Scrooge McDucking it at year-end. I am happily surprised and supportive of the efforts by CMS to eliminate some of the more perverse billing and organizational incentives.

We got here because we got to choose how to fight and probably lose in that fight which we happened to win. In May 2017, I wrote:

We aren’t going to win often but we get to choose how to lose. We can roll over without trying to defend our values and our morals or we can fight as hard as we can to either get a policy win or inflict significant political costs on Republicans to increase the probability of future policy wins by either putting the fear of losing their seats into them which constrains future opportunity space or flipping those seats in 2018.

More subtly, we tell stories to ourselves. I want those stories that I tell to myself about me to be true. Defending and improving the ACA is one of those stories that I tell myself. The ACA benefits 2009 me far more than it benefits the 2017 me. It is a gut check. Am I full of shit or do I actually believe in what I think I believe in.

In comments, TenguPhule asked:

Is this the modern version of come back with your shield or on it?

It was.

And we came back with our shields.

Representative MacArthur (R-NJ-03) was defeated last night as provisional ballots were counted.  He authored the work-around that barely got the AHCA out of the House last May.  After January 3rd, the ACA’s fundamental structure and ,more importantly, funding streams including Medicaid Expansion will be untouchable without Nancy Pelosi’s permission.

Far more importantly, some of the winning Republicans were running on their supposed support of covering pre-exisiting conditions.  The truth values of those statements are highly variable but the fact that Republicans who won needed to make these statements means the default assumption of the social contract is changing.  Preexisting conditions are now part of the social contract.  And this will be even more true in 2020 when there are another two years of embedding, another two years of people getting bad news from the doctor and they worry about many things but not reclassification risk, another two years of the default status quo becoming stronger and another two years of Millennials aging into their priming voting years.

Yes, there will be administrative actions.  The new proposed rules of requiring separate bills and envelopes for abortion coverage will decrease total coverage and specific abortion coverage riders.  That is important but it is chipping at the edges instead of taking a sledgehammer to the framework.

And if you told me 726 days ago that the arguments would be on administrative rule-making within the framework of the ACA, I would have thought that the time traveller went into the wrong time stream.

 

 



The Mueller Investigation: A Few Thoughts

 

I’ve been watching and reading the coverage of this all evening and here’s what I think is likely to happen:

  1. Whitaker will be read on to all or part of the Special Counsel’s investigation.
  2. Specifically either Rosenstein and/or Mueller will read him on to the material that shows his op-ed and remarks on CNN were pure fabrication because he has no actual idea what Mueller is doing, nor what the counterintelligence information is.
  3. They’ll also include in this whatever info they have on or got from Sam Clovis, who Whitaker used to work for and with.
  4. At that point:
    a) Whitaker will, himself, either seek a DOJ ethics section opinion on recusal and follow it or he’ll let things alone for the time being.
    b) Whitaker will do whatever he’s going to do to obstruct the Mueller investigation.

I think it is important for everyone to remember that Special Counsel Mueller has been planning for something like this to happen. As such he has contingency plans in place and for each contingency plan he has multiple sequels (to use DOD planning terminology). I would expect to see a bunch of indictments, either previously sealed ones or ones prepared and waiting to go, to be dropped in short order. I would also expect that whatever could be farmed out to the Federal prosecutorial districts, such as the Southern District of New York or the Eastern District of Virginia, as well as to the state level, such as NY state, Maryland, Virginia, and DC will be handed off to them. Whitaker will have limited ability to interfere with anything Mueller hands off or farms out to the Federal prosecutorial districts and no ability at all to interfere with state or DC prosecutions. I’m in agreement with Cheryl that the President’s response here isn’t strategic, rather it’s reflexive.

I also expect, just as we saw with Sessions, that a selected leak or two from the intel community will be quickly released as warning shots across Whitaker’s bow. You’ll recall that the intel community leaked very quickly to force Sessions to recuse himself. And it then leaked a second time regarding Sessions when it looked like he might be trying to, if not interfere with the Special Counsel’s investigation, then peer into it and see what was going on with the investigation. Both of these were warnings. Sessions recognized them as such and quickly adjusted his behavior accordingly. I expect that whatever there is on Whitaker, most likely from the fraudulent Miami patents company that he was involved with and that was fined by the US government, is being weaponized now and lined up for a quick release if a warning is needed to get Whitaker in line.

Finally, if Whitaker decides to seriously interfere with the Special Counsel’s investigation I expect that our allied and partner’s intelligence communities will start to strategically leak. A lot of them have provided the Special Counsel with the information he needs for the counterintelligence portion of his investigation, they are very, very, very worried about Putin, his intentions, his capabilities, and his behavior, as well as the apparent connections between Putin and the President’s businesses, his campaign, and his administration. They will do what they need to do to protect themselves.

So strap in, buckle up, and hold on as it’s going to be a crazy ride for the next few days. And remember that while things seem dire, every previous time it seems that the President and his catspaws were coming for Bob Mueller they failed to stop his investigation. That doesn’t mean it is safe this time, but it does mean that Special Counsel Mueller has been paying attention, has his plans in place, and will respond accordingly when he needs to do so. And, as with everything else the Special Counsel does, we won’t really know what those responses are until he makes them. He’s rigged for silent running, he has his targets selected, he’s got his firing solutions dialed in, and he will prosecute those targets on his schedule.

And if you don’t want to believe me, believe former Special Agent Asha Rangappa, who was a counterintelligence specialist at the FBI and is also an attorney.

Twelve more tweets after the jump.

Read more



Friday Morning Open Thread: Let Them Call It A Win, If It Stops the Argument…

Look, any Bernie supporters want to declare victory and get out, I am more than willing to give ’em a big hand on their way. Even better, should the more realistic ones choose to actually become Democrats, I’ll give ’em a second chance to show that they’re willing to do the hard work of winning voters, not just stanning a celebrity. From Politico (so: whole shaker of salt), “Bernie 2016 alums wary of 2020 sequel”:

With the Vermont senator kicking off a nine-state tour on Friday with stops in Iowa, South Carolina, Nevada and California, a sizable contingent of the people who helped build his insurgent 2016 campaign is ambivalent about a second run, according to interviews with more than a dozen former staffers. Many of them are looking for a different progressive champion to finish what Sanders started.

Sanders should just declare victory, they said, content in the knowledge that much of his 2016 platform has been adopted by other ambitious Democrats considering White House bids. Plus, he’s a white man who would turn 80 in his first year as president, who’d be trying to lead a diverse party fueled by the energy of young voters, women and people of color.

“I think that if a younger candidate can pick up the mantle and have Bernie’s support, I think that would be a better option for 2020. I feel like 60 to 70 percent of former staffers are looking around for another Bernie-esque candidate this time around, even if it’s not him,” said Daniel Deriso, a field organizer for Sanders’ 2016 campaign who went on to help run a successful insurgent mayoral campaign in Birmingham, Ala., last year. “But if Bernie called me to have me work on the campaign then I’d do it.”…

Enough fervent supporters — from the 2016 campaign’s top officials to field organizers — are wary of a 2020 run that it could be difficult to reignite the 2016 movement. Jeff Weaver, who managed the 2016 race, has been talking about the idea of a “Draft Bernie PAC” of sorts after the midterms. But many supporters have been noncommittal, according to two people with knowledge of the discussions…

A common frustration among former staffers is that they feel Sanders and his tight circle of aides have taken their support for granted and failed to keep their 2016 team cohesive, which would have been an inherent advantage in a second run.

Multiple former staffers said that the Clinton campaign alumni network is far more connected and active than Sanders’…

“He’s the grandpa of the movement,” said another campaign worker from 2016, “but that might not make him the best choice for 2020.”

So… People who want an actual career working in politics have accepted their loss and are calculating their next moves. Tad Devine is lying low, waiting for Robert Mueller to wrap up his various investigations. Jeff Weaver wants to get the band back together — but being the Media Village Idiot’s “More Virtuous Than Thou” Gadfly is pretty much a one-man enterprise. Just look at the latest performance reviews for its most famous modern exemplar:

(If Nader is hoping / expecting Bloomberg to throw him a bone, or a paid consultancy, he must really be desperate. Mayor Mike has been content to let the Horserace Pundits do his testing-the-candidacy-waters media for free, all these years; I seriously doubt pity, or excitement at Nader’s celebrity, will loosen his pursestrings at this point.)



Never Let Your Opponent Set The Terms Of Debate

Last night, I told a friend that Elizabeth Warren’s DNA test was a strategic mistake. I haven’t wanted to say much about it, because I didn’t want to add fuel to the fire. But Democrats and others opposing Donald Trump have to get strategically smarter.

Never let your opponent set the terms of debate.

Never let your opponent set the terms of debate.

Never let your opponent set the terms of debate.

Apparently the lie about Warren’s using Native American heritage started in an earlier race. But Trump added the “Pocahontas” part, an obvious racial slur. He also added a challenge that he would pay $1 million dollars to a charity of Warren’s choice if she would take a DNA test.

Probably the way Warren’s people thought about this was: Take the DNA test, demand the $1 million, show Trump to be a piker.

WRONG

 

History shows that Trump is a piker. The $1 million challenge gives him an opportunity to continue the smear. And there was no way he would stop the “Pocahontas” thing in response to a DNA test. Negative commentary from Native Americans gave him more ammunition. All that was predictable.

Trump gets some things right, and his idea of hitting back hard is one of them. Warren should have, the first time Trump said “Pocahontas,” hit back hard by calling that for what it was.  RACISM. Say that her heritage, like everyone else’s, has nothing to do with her eligibility for office. Give the story of Pocahontas and show how the wrongs against her are perpetrated by Trump’s bigotry.

I don’t want to make a big thing out of this – we have more important points to make as we move toward the election. But please, please, Democrats get smart about this.

Never let your opponent set the terms of debate.

 



Muhammad bin Salman’s Khashoggi Gambit: The Trump Doctrine in Action

The actual Trump Doctrine, which we’ve covered here at Balloon Juice extensively since the President gave his first campaign speech about national-security and foreign policy back in April 2016, is:

America’s allies are taking advantage of our treaty and other obligations in the national security space; America’s allies and peer competitors are ripping the US off through our trade agreements; the US should go it alone if it can’t renegotiate better deals; and only a President Trump could guarantee that the US would be treated fairly – or else. That only a President Trump could guarantee that the US would be treated fairly, whether in national security arrangements or global trade, was simply an extension of one of the major, if not the major theme of his campaign: Donald Trump would be treated fairly or else and only Donald Trump could guarantee that Americans, especially the forgotten men and women as he phrased it, would be treated fairly or else.

That the US will be treated fairly or else, and that only a President Trump could guarantee that happening became the central, unifying theme of his national security and foreign policy approach was actually a stroke of strategic communication genius. A significant amount of the President’s initial strategic communication approach was through tying his primary opponents, the Republican National Committee, and the broadcast and cable news networks in knots about treating him fairly. This included trying to get Megyn Kelly removed from debate moderation after he felt she treated him badly, as well as actually dropping out of a GOP primary debate on Fox News and holding a competing charity event for veterans because he did not like that Fox wouldn’t comply with his demands. And if they failed to do so he’d deal with them harshly. Then candidate Trump threatened his fellow primary opponents and the RNC by making it clear that if he didn’t feel he was being treated fairly by them, then the “or else” would be his running as an independent candidate, thereby splitting the Republican vote for president, and handing the election to the then presumed Democratic front runner Hillary Clinton.

By making this the dominant theme of his national security and foreign policy approach, he was able to make a singular through line for his campaign – “I, Donald Trump, will be treated fairly or else by the GOP, the RNC, and the news media; only I, Donald Trump, can guarantee that you the forgotten men and women of America are treated fairly in regards to both domestic politics and foreign policy; and only I, Donald Trump, can guarantee that the US will be treated fairly or else there will be serious and severe repercussions for the GOP, the RNC, the news media, elected and appointed officials, and America’s allies, partners, and peer competitors”. Here was the simple through line to connect Make America Great Again both domestically and internationally by placing America first. It is also the essence of the real Trump Doctrine: President Trump and by extension the forgotten men and women of America, as well as America itself, will be treated fairly or else.

Muhammad bin Salman’s strategy for the wetwork operation against Jamal Khashoggi is to leverage the Trump Doctrine in order to allow him to get away with having Khashoggi to be vanished by rendition, or as is now reported and most likely to have happened, extra-judicially executed at the Saudi Consulate in Istanbul. The Crown Prince, who is popularly known as MBS, like so many other authoritarian and autocratic foreign leaders, has figured out that the President makes his decisions on whether he feels he is being treated fairly. If he feels that he is, then one can pretty much do whatever they want. If he feels that he isn’t, then the President goes on the offensive to deliver the “or else”. MBS believes he can get away with this because the President has publicly made it clear that as long as the Saudis spend money purchasing his properties or at his properties, then he likes them because they are treating him fairly.

At one of his 2015 campaign rallies the President said:

Saudi Arabia, I get along with all of them. They buy apartments from me. They spend $40 million, $50 million. Am I supposed to dislike them? I like them very much.

The Permanent Saudi Mission to the UN is housed in Trump World Tower across the street from the UN. The Kingdom owns the entire 45th floor. The Trump Tower in Chicago is running a profit, as is the Trump International Hotel and Tower in New York, largely because of bookings from the Saudis. Even as almost all the other Trump branded properties posted significant losses, especially his beloved Scottish golf courses. Jared Kushner has also been seeking financing from the Saudis for his personal business interests. At this time it appears that funding stream did not come through. The lack of funding, however, has not kept the Crown Prince from bragging that he has Jared in his pocket, which, once reported, MBS denied.

Muhammad bin Salman is gambling that because the Saudis spend lavishly on the President’s private business interests, and that because the President doesn’t understand the terms of what the Saudis have negotiated in regard to their potential purchases of US military equipment, which are really just a bunch of letters of intent that have yet to be finalized., that the President will provide him with the plausible deniability he needs to get away with having Khashoggi vanished and mist likely extra-judicially executed. Despite the fact that MBS negotiated a huge discount from Jared “The Hidden Genius” Kushner and guarantees that approximately 50% of the weapons would be built in Saudi Arabia, which means that the sale, if it were actually finalized, would not significantly increase US manufacturing or jobs.

Right on schedule this morning the President announced that Saudi King Salman, who is actually just an infirm figure head, stated the Saudis didn’t do anything to Khashoggi, but it could have been rogue killers.

You know, rogue killers who just happened to be traveling on Saudi Arabian diplomatic passports, on Saudi Arabian government jets, one of whom was an autopsy specialist who happened to pack his bone saw, who just happened to be hanging out at the Saudi Consulate in Istanbul when Jamal Khashoggi walked in to get his official Saudi marriage documents signed, and who just so happened decided that Khashoggi looked like a good guy to practice a little recreational wetwork and improvisational autopsying on. Which would, I suppose, explain, why the Saudi Arabians had a professional cleaning team in their Istanbul consulate this morning, which left shortly before the Turkish police were allowed to enter the building.

As long as the President places being treated fairly, and specifically his subjective understanding of being personally treated fairly, as the central consideration of US policy, we will see more of this type of behavior from the authoritarians, autocrats, despots, tyrants, neo-nationalists, and neo-fascists that the President finds so admirable. During his 60 Minutes interview with Lesley Stahl, he all but gave Putin a green light, and anyone else who was paying attention and might have similar interests, to keep assassinating people – from political rivals to opposition figures to journalists to defectors from Russia’s intelligence services – as long as they’re not American citizens and the wet work doesn’t take place in the US.

While there is an old political science/international relations axiom that state’s don’t have friends, they have interests, the Trump Doctrine has turned the US into a transactional state. A transactional state being run by the head of an ongoing white collar criminal and organized criminal enterprise. It is no surprise that authoritarians and aspiring authoritarians like Muhammad bin Salman are developing strategies that leverage the treat the President fairly part of the Trump Doctrine to get away with whatever they want in order to avoid the “or else” response.

We are off the looking glass and through the map.

Open thread!