Floriduh Man: Presidential Campaign Rally Edition

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A BFD that passed amongst the chaos

In most strands of the multi-verse, the below would have sent the health wonk community ablaze. Instead in this strand, we spent all day yesterday talking about a proposed rule from CMS and generally shaking our head as our government continues to say “Hold my beer and watch this….”

But this is normally a BFD:

What does this mean?

Repeal and Replace or Repeal and Delay and Pray is dead. There is no coherent coalition of 218 and 51. The Republican Senate caucus can afford to lose two votes (assuming Democrats are healthy and have everyone show up). The 2016 ACA Repeal bill defunded Planned Parenthood and knocked out Medicaid Expansion. Either of those elements will cost the Republicans at least two votes. Combined, those two provisions probably cost the Republicans six to ten votes. That is a blocking coalition when combined with Democrats.

In the House, Speaker Ryan would like to pass anything with only Republican votes in order to not be hung out to dry like former Speaker Boehner (remember he has tough votes on the debt ceiling coming up). That means he needs 90% of his caucus on board with anything. The Republican House Freedom Caucus has enough members to deny Ryan a Republican only majority. The HFC is demanding a word for word replica of the 2016 bill.

This is a Big Biden Deal as the status quo bias works in our favor for the avalanche approach that I feared in November can’t get started. Long, boring committee meetings, calls to the CBO, wonks ripping apart a plan to help advocates find very sympathetic people to tell true stories with high emotional punch is where we’re going for anything more complicated than a technical correction bill or rebranding.

Is this lump out of my head? I think so

I don’t have any particular suggestions of activist things to do today, so I’ll let people leave suggestions.

In the interest of encouraging everyone to be more militant, I’ll relay a story. I was talking with a moderately totebaggerish friend of mine (he works in finance but has totebagger tendencies) and he was feeding me the line that, although he voted for Hillary, he hated having to do choose between a crook (Hillary) and a lunatic (Trump). I’m sure that he, and many people who think this way, get those kinds of ideas by reading MoDo and Bobo and Frank Bruni and the rest. There’s no other way to put it: centrist punditry rots your brain. I used to like to read that stuff to get a sense of how people were thinking, and I still do occasionally hate read it in limited doses. But it does represent a some kind of propaganda state that many people live in, no different from North Korea in its own way. It took me a while — probably a couple years — to get that crap out of my brain once and for all.

4.29% enrollment loss is the cost of Trump’s First Day EO

I’ve been playing a bit more with the 2016 and 2017 QHP data in an attempt to figure out the incremental cost of the Trump Executive order.  I think 4.25% is a good lower estimate.

My data is still here:

Data and Methods

I again excluded Kentucky and Louisiana.  Kentucky was switching from Kynect to Healthcare.gov while Louisiana had a mid-year Medicaid expansion.  I wanted to isolate the effect of the executive order from whatever the general trend in enrollment was.  I used the CMS enrollment snapshot for 2016 and 2017 that contained January 14th.  2016 was goes through January 16 while 2017 only goes through January 14th.  The 2016 report contains two extra days worth of data and more importantly, 2016 contains a deadline day as people who buy coverage by the 15th would see their policy start on February 1st.  We know deadlines spur enrollment.

CMS recognized this problem:

More than 8.8 million Americans were signed up for 2017 coverage through HealthCare.gov as of January 14, 2017. This compares to about 8.7 million sign-ups as of January 14 last year, as Americans continue to demonstrate strong demand for 2017 Marketplace coverage.

So on the 14th of each year, 2017 was running slightly ahead of 2016.  My data due to timing constraints will show 2016 running slightly ahead of 2017.   This is fine as the known flaw in the data favors the argument that the executive order had no impact.

So the question is what was the deviation from 1/15 to 1/31? If the Executive Order and the dropping of advertising and potentially elite knowledge networks disseminating anti-enrollment messaging or more likely fear, uncertainty and doubt about PPACA being a good play?

Analysis and Conclusion

2017 using my known flawed data was running .96% behind 2016 on the January 14th inclusive update.  2017 ended up running 5.25% behind 2016 on Healthcare.gov states.  The increment (using favorable to the null hypothesis data) slowdown in pace that can be attributed to Trump Administration actions is 5.25-.96 or 4.29% of enrollment was lost due to the executive order and other Trump administration actions such as shutting down some outreach and advertising in the last eleven days of enrollment.

4.29% is a minimal level of enrollment loss.  Using the January 14th pace, 2017 was running 1.1% ahead of 2016.  Charles Gaba is collecting data from the state based exchanges.  The state based exchanges ran their own marketing campaigns that did not get shut off on 1/20/17.  He is showing at least a 1.5% enrollment increase.  So more aggressive baselines can credibly argue that the Trump Administration actively discouraged 6% of the market from signing up.

Finally, here are some charts that I had fun creating as I worked through this problem.

You can be a hero in an age of none

I don’t want to keep fucking this chicken for too long, but Gillibrand really was smart to oppose all of Trump’s nominees. I’m sure Fred Hiatt doesn’t approve, but that’s the kind of the point.

We need to create a climate where Democratic toughness is incentivized. Politicians are calculating people by necessity. If they get a lot of positive attention by standing up to Trump, they’ll do that. If they get a lot of positive attention by acting very serious on the Charlie Rose show, they’ll do that instead.

Democrats in Congress should be competing to see who can be the most anti-Trump. So far, Kirsten Gillibrand seems to be winning. For that, I salute her.

Two more perspectives on Cassidy-Collins

From last night’s very long live blog of my first read through of Cassidy-Collins, there are two comments I really want to highlight:

First from Archteryx:

Admittedly, my view on this is strictly selfish, but it does have some larger utility.

“Does this kill me?” is pretty much how I judge any Potemkin Village “replacement”. If the answer is “no” then at least they acknowledge that leaving the ACA largely intact is the only viable way going forward. If the answer is “yes”, then a whole lot of other Medicaid and individual-insurance folks are going to die with me, and it means they still only care about ‘repeal’ with ‘replace’ being nothing more then a fig leaf to hide the mass graves.

For those who don’t know his story, Archteryx has a chronic condition which requires regular nursing and surgical care.  He moved from a non-Medicaid expansion state to a Medicaid expansion state as soon as he could in order to guarantee his access to care.  Under the 2009 status quo, the national health policy for him is “Be quiet and die quickly in the corner”.  Cassidy-Collins won’t kill him.

Secondly, from Barbara on picking fights:

Here is a lesson I learned over the many years I have been working on health care regulation: things that are tweaks or forward looking can be changed and improved. Things that dismantle or gut the structure of a program will be, for all intents and purposes, permanent. They certainly won’t be revisited for at least 15 years. The two cardinal examples of this during my career were prescription drug and long term care coverage for Medicare beneficiaries (passed in 1988 and repealed in a mindless fury a year later, with drug coverage not re-examined until 2003 and long term care still not covered); and health care reform (killed in 1994, not revisited until 2009). Based on that simple analysis here is my reaction to what I have seen so far:

Hills to die on: Medicaid block grants
Hills to keep fighting on: high deductibles that mostly leave the rest of the ACA structure in place.

Let’s keep these two evaluation lenses in mind when we look at what comes out of this Congress and whether or not Democrats decide to engage on policy.

Nothing but a G thing

I think maybe that the first woman to get elected president will have to be a political prodigy, just as the first African-American president is a political prodigy. Kirsten Gillibrand is sharp as a tack. She got into Congress running in a heavily Republican district, and had to take many conservative positions to win. The moment she was appointed to the Senate, she turned on a dime and became one of the more liberal members of Congress. That’s how you do it, you cut the tail off all at once, not one inch at a time. And, hate it or love it, voting against all the Trump nominees is the smart move (via) for future Democratic presidential primaries:

She is the only senator to vote against all three of Trump’s cabinet appointments. Yesterday, 15 Senate Democrats voted to confirm Mike Pompeo, a noted pro-torture Islamphobe. This is pathetic. Why? Why would Chuck Schumer vote for Pompeo? Why would Sheldon Whitehouse do this, of all people? What does anyone get out of this? Do they legitimately think these are good choices? Do they think that this will mean Republicans will take Democratic voices seriously? No, of course not. It’s that even Schumer doesn’t understand the rules of the game, even after 8 years of fireeating extremism.

On the other hand, Gillibrand is running for president in 2020 and she is going to have an excellent message for Democratic primary voters: “I voted against every single person Donald Trump nominated for his Cabinet.” And that’s a pretty compelling message. That no one else seems to understand what is going to play in 2018 and 2020 is more than a little dispiriting. But hey, I’m sure a few Democratic votes for Betsy DeVos and Tom Price will totally get Manchin and Heitkamp legit home state cred!

It’s also the *right* thing to do on Pompeo, that’s for damn sure.