Late Night Horrorshow Open Thread: Murderers’ Balls

This high-five might’ve gotten more attention if GHWB hadn’t done his beloved GOP one last fortuitous favor, but don’t worry, we’ll hear more about the Russia-Saudi bro-fest as its implications multiply. Both Putin and MBS are kleptocrats in control of third-world shitholes entirely dependent on fossil fuels for their continued survival… but to date, as far as I know, the Saudis haven’t been able to get their hands on the kind of nuclear arsenal that keeps Russia ‘relevant’. Maybe MuhammedBoneSaw’s new BFF can help him with that, now!

And to think we might’ve had an actual President in the Oval Office, instead of the current Squatter-in-Chief…

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Thoughts on the new 1332 waiver concepts

The Center for Medicare and Medicaid Services (CMS) released four Section 1332 waiver concepts yesterday. One is non-problematic, the other three are likely to result in a lot of lawyers billing a lot of time as soon as a waiver similar to these concepts is filed or approved. We’ll start with the non-problematic concept first.

  • Split Risk Pool for tail cost smoothing

CMS is encouraging states to split their risk pools. Most people will stay in the general pool while some likely to be high cost people are split off to the side. This sounds nefarious but it is not. This is how reinsurance actually works on the already approved 1332 reinsurance waivers. There are a dozen different flavors on how the actual details can be implemented: visible or invisible risk pools, claims cost triggers, diagnosis triggers, or hybrid triggers.  All of those details can then vary at attachment points. But those are fundamentally minor details.

I think a waiver that is just a reinsurance program of whatever flavor will and should go through the approval process with only actuarial challenges and not legal challenges.

That is the simple and straightforward concept.  It does not have legal risk.

The next three concepts are ambitious and legally suspect on rule making administrative procedure grounds as outlined by Christen Linke Young of the Brookings Institute. These concepts all split the market and shift significant resources away from highly likely to be high cost to likely to be low cost populations.

The three concepts can be short-handed as:

  • Defined Contribution
  • Subsidy re-allocation (Iowa Stopgap Measure Version 1.0)
  • Subsidize anything

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Open Thread: Beware of GOP Lame Ducks

A reminder from historian Eric Rauchway, in Time, that the GOP has been untrustworthy about its deepest alliance (to money, not voters) since at least the First Great Depression:

After this November’s blue wave crashed on the electoral shore, Congress returned to Washington in the all-American oddity of the lame-duck session, when lawmakers who have lost their posts but retain office go to work on Capitol Hill. But the lame-duck session is more than just strange: it’s dangerous for incoming majorities hoping to keep their campaign promises.

As one political scientist observed in 1933, “defeated Congressmen have frequently been found trouble-makers and mischief-mongers” while they remain in Washington. He had reason to know, having just watched president Herbert Hoover and other defeated Republicans spend their last weeks in office trying to deny Franklin Roosevelt and the new Democratic majority the ability to enact their promised New Deal — and nearly succeeding.

Hoover understood quite well what the New Deal would mean because, as he grumbled, “there is constant promise” from the Democrats of their new policies. Once in office they would borrow money to build dams, roads, bridges and whatever else they could to put Americans to work. They would increase the debt and cause inflation. (Although Roosevelt had declared himself in favor of a balanced budget, he admitted he would do nothing in that direction that would inhibit Depression relief.) During the campaign Hoover warned these policies would “destroy the very foundations of the American system of life,” and said they smelled of the same “fumes of the witch’s caldron which boiled over in Russia.”…

Hoover tried several strategies. First, he worked hard if quietly with his Congressional allies to stop any substantial lawmaking. Democrats drafted a farm relief bill to ease the Depression’s effects on agriculture, and also a bill to permit the sale of beer (which would have been a first step in ending Prohibition). If they passed, it would prove Hoover could have acted sooner on both counts. He opposed them, telling an aide their passage would “mean the destruction of the Republican Party.… Our game is to prevent the cloture … and encourage all filibustering.” He succeeded. Observers credited his actions with stopping both bills.

The repudiated president also launched a project to protect his legacy, commissioning aides to write favorable assessments of his presidency and seeking a satisfactorily conservative buyer for the financially troubled Washington Post. (Ultimately, Hoover’s Federal Reserve chief, Eugene Meyer, would purchase the paper.) One of Hoover’s aides wrote a pseudonymous article declaring that “younger Republicans” recognized Hoover as the party’s future. (The aide was almost 50 years old at the time.)

Most importantly, in his last weeks in office Hoover refused to do anything to address the worsening banking crisis. Waves of bank failures had occurred throughout his presidency. This last one began just before the election. Federal Reserve officials and lawyers advised the president that he had the power to close the banks temporarily, providing time for officials to inspect their books and guarantee their safety, thus restoring financial confidence. They pleaded with him to do it. He would not. “I certainly hope the crash won’t come until we go out,” he told an aide. But he had no intention of stopping it for an ungrateful citizenry. “They are dissatisfied with what has been done and turn to other leaders,” he said…

At least we don’t have to worry about the current Oval Office Squatter badmouthing the Russians, for what that’s worth.

Silvergapping 2019 just released their public use files.

I am running my annual Silver Gap analysis. Silver gapping is the measure of the spread between the least expensive Silver plan in a county and the benchmark Silver plan. The bigger the spread, the better the deal that subsidized folks may be able to get. The smaller the spread, the worse (comparative) deal subsidized buyers get. Silver Gapping varies year over year by insurer strategy choices, market entry and exit and regional pricing changes. Silver gapping is only about the relative differences in price and not about the absolute price levels. This information does nothing to inform people about the market premiums if they don’t qualify for subsidies.

I am using premiums for a single 40 year old non-smoker for all analysis.

Major Points:

  • As always, if you buy your insurance on the Exchanges SHOP AROUND as the relative and absolute prices in your county will change every year so a great deal this year may become a stinker next year
  • Way more Gold Gapping in 2019 than 2018 (at least in counties, I have not population weighed)
    • 2018: 595 counties had at least 1 Gold plan less expensive than Benchmark
    • 2019: 1,136 counties had at least 1 gold plan less expensive than Benchmark
  • More really big Silver Gaps (Counties with at least a $100 Silver gap between benchmark and least expensive Silver)
    • 2018: 174
    • 2019: 198
    • Population benefiting probably declined as Philadelphia and inner ring suburbs lost their huge Silver discounts as Centene entered the market and compressed the spread.
  • North Carolina is seeing some Silver Gapping outside of the Triangle
  • Something odd is happening in Oklahoma
    • $500+ Gold Gap in Grant County



Just a reminder of the stakes

Go vote early if your state allows you to do so.

Open thread

Cash for CART

CAR-T therapies are a type of innovative cancer therapy that tweaks a patient’s immune system cells to attack cancer.  The National Cancer Institute explains:

A type of treatment in which a patient’s T cells (a type of immune system cell) are changed in the laboratory so they will attack cancer cells. T cells are taken from a patient’s blood. Then the gene for a special receptor that binds to a certain protein on the patient’s cancer cells is added in the laboratory. The special receptor is called a chimeric antigen receptor (CAR). Large numbers of the CAR T cells are grown in the laboratory and given to the patient by infusion.

This treatment regime has good clinical results and the attack path is expanding to more diseases.  However it is (to use a technical term) wicked expensive.  Novartis charges a list price of $475,000 for their CAR-T regime.  This is one more example of something that we’ve looked at with Hep-C last March.   Hep-C cures generate two true statements with a significant tension.

1) They are really freaking expensive on both a per-patient basis and total spending basis
2) They are really effective and thus high value

JAMA Pediatrics just published a cost-effectiveness study on CAR-T for a particular type of childhood cancer .**  This paper raises the same points as the Hep-C cures:

In this decision-analytic modeling study using deidentified data, cost-effectiveness analysis generated an incremental cost-effectiveness ratio between $37 000 and $78 000 per quality-adjusted life-year gained over a patient lifetime horizon, with more than 40% of those initiating tisagenlecleucel treatment becoming long-term survivors.

Currently, the next best alternative to CAR-T treatment has a survival rate of 5% to 10%.  So there are huge survival gains.  Secondarily, those survival gains are cost effective gains.  Most health policy analysts in the United States assume that a quality adjusted life year price of under $100,00 is a reasonable deal.  Very few analysts will argue that a treatment with an upper bound price per QALY well below $100,000 is unreasonably priced.

A policy problem is that these are huge cash outlays for an insurer that has to assume that a patient won’t be covered by them for the rest of their life.  The insurer will pay for the treatment and won’t get any of the gains of the new, high cash outlay treatment.  If there is perfect risk adjustment with a technological innovation plus-up, this could remove some incentives for insurers to either not cover CAR-T facilities at in-network rates or to try to drown a patient and their family in paperwork and pre-authorization purgatory.

We need to figure out ways to pay for treatments that are both incredibly expensive and incredibly cost-effective within the insurance model that we are committed to.



** Whittington M et al, “Long-term Survival and Value of Chimeric Antigen Receptor T-Cell Therapy for Pediatric Patients With Relapsed or Refractory Leukemia”, JAMA Pediatrics, October 8, 2018


Work requirements working as intended

Arkansas has instituted Medicaid work requirements.  A subset of Medicaid beneficiaries have to report monthly online their work or work-search or community engagement activities.

September 5th was the end of the third reporting period.

They are working as their advocates have intended.


The work requirements are paper work and administrative hassle requirements.  They are roadblocks to coverage which is leading to a 50% attrition rate in a good, high employment economy.