Healthcare down by the river

The Washington Post had a great article on how Idaho has tried to do something on Medicaid expansion eligible populations without actually accepting the federal money to just expand Medicaid eligibility to 138% of the Federal Poverty Line.  I have some sympathy for Idaho policy makers who actually want to do something in a state that is controlled by fantasists and Tea Party Republicans.  I’ve always though that health policy and working poverty policy  is tough work with lots of interacting factors.

Silly me, I could never have come up with this proposal that would have solved all economic and health policy problems:

One senator lobbed the idea of offering the working poor tax incentives if they use a life coach to motivate them to get higher-paying jobs. None of the proposals caught on.

Chris Farley down by the river is not a systemic solution.

Health policy is tough and there are few easy wins.

Open Thread

Aetna and cynicism confirmed

The anti-trust case where the government has been seeking to block the Aetna-Humana from merging has a ruling. The District Court judge has sided with the FTC and blocked the merger. I would be shocked if the ruling is not appealed.

There is a bit in here that made me smile as it gives some context to some of my more cynical writing over the summer. Aetna was profitable on the QHP market in Pennsylvania. However it pulled out of the entire state despite making a good deal of money.

Aetna was profitable in 2015 in the individual market in Pennsylvania. It is projecting to be profitable in 2017. The filing memo was drafted in late May and submitted to the Pennsylvania regulators in early June. Conditions have not changed enough to make Pennsylvania a money loser in under two months.

My wee bit of cynicism bears fruit. Aetna is trying to logroll an anti-competetive merger with on-Exchange political consequences.

The judge seems to be a cynical bastard as well:

I’ll have more on this including a policy perspective when I have time to write, but cynicism was completely justified.

Government, Meet Bathtub

It’s easy to run a government that does (next to) nothing.

Here’s where Trumpism — or really Pence-ism, or really, exactly what the GOP has been promising (threatening) will have its most immediate, and quite possibly its most damaging impact:

Staffers for the Trump transition team have been meeting with career staff at the White House ahead of Friday’s presidential inauguration to outline their plans for shrinking the federal bureaucracy, The Hill has learned.

The departments of Commerce and Energy would see major reductions in funding, with programs under their jurisdiction either being eliminated or transferred to other agencies. The departments of Transportation, Justice and State would see significant cuts and program eliminations.

The Corporation for Public Broadcasting would be privatized, while the National Endowment for the Arts and National Endowment for the Humanities would be eliminated entirely.

Overall, the blueprint being used by Trump’s team would reduce federal spending by $10.5 trillion over 10 years.

The NEH and NEA cuts are at once symbolic — the GOP is killing stuff liberals like, which is reward enough in those quarters — and, I think, intended to distract from other hugely reckless choices:

The Heritage blueprint used as a basis for Trump’s proposed cuts calls for eliminating several programs that conservatives label corporate welfare programs: the Minority Business Development Agency, the Economic Development Administration, the International Trade Administration and the Manufacturing Extension Partnership. The total savings from cutting these four programs would amount to nearly $900 million in 2017.

At the Department of Justice, the blueprint calls for eliminating the Office of Community Oriented Policing Services, Violence Against Women Grants and the Legal Services Corporation and for reducing funding for its Civil Rights and its Environment and Natural Resources divisions.

At the Department of Energy, it would roll back funding for nuclear physics and advanced scientific computing research to 2008 levels, eliminate the Office of Electricity, eliminate the Office of Energy Efficiency and Renewable Energy and scrap the Office of Fossil Energy, which focuses on technologies to reduce carbon dioxide emissions.

Under the State Department’s jurisdiction, funding for the Overseas Private Investment Corporation, the Paris Climate Change Agreement and the United Nations’ Intergovernmental Panel on Climate Change are candidates for elimination.

The single most important point I can make is that this is the Kansas-ification of America.  This isn’t a Trump policy choice.  This is Mike Pence shepherding plans the Republican Party has been trying to implement for years, decades even.  I doubt it will all get through, but much of it will, I’d guess, and when it does we will need to hang every shitty outcome and terrible choice around the neck of every Republican officeholder.

This is what they want. This is what they told us they wanted. They’re likely going to get it, to some approximation.  And they’re going to have to own it, so that once again, Democrats can come in and fix the serial catastrophes we’re going to witness very damn soon.

Also, too — who wants to bet all the pieties about the deficit and restoring balance to the budget will fall to the tax cuts to come?

Fuck it.  I’m heading back to the seventeenth century.

Image: Francesco de Rossi, Bathesheba at her Bath1552-1554.

Evidence based care in Medicaid

We want to do evidence based care.  We want to do things that work and avoid things that don’t work.  This sounds simple.  Let’s look at two very good natural experiments on unintended pregnancy rates:


    Since 2008, Colorado has successfully increased access to family planning services throughout the state, particularly for the most effective contraceptive methods, such as intrauterine devices (IUDs) and implants.

  • The Colorado Family Planning Initiative has increased health care provider education and training and reduced costs for more expensive contraceptive options, enabling more than 30,000 women in the state to choose long-acting reversible contraception….
  • When contraception, particularly the long-acting methods, became more readily available in Colorado between 2009 and 2013, the abortion rate fell 42 percent among all women ages 15 to 19 and 18 percent among women ages 20 to 24.
  • Colorado is a national leader in the use of long-acting reversible contraception, and reducing teen pregnancy and repeat pregnancies.

    • Teen birth rates in our state have declined more rapidly than in any other state or the nation as a whole.
  • The birth rate for Medicaid-eligible women ages 15 to 24 dropped sharply from 2010 to 2012, resulting in an estimated $49 million to $111 million avoided expenses in Medicaid birth-related costs alone.

More reliable and effective contraception was made available to Colorado women who had the choice to elect Long Acting Reverisble Contraception (LARC) or do something else.  A significant number of women elected to use LARC and the increased autonomy and reliability produced amazingly good results.



Reducing contraceptive availability led to higher abortion rates and higher unplanned pregnancies. Earlier live births have massively negative multi-generational repercussions for both the parents and kids.

The evidence strong suggests that significant improvements in quality of life can be made and significant expenditures reduced if contraception is made readily available.

And guess what Congress will consider to be a high priority:

House Speaker Paul Ryan announced Thursday that Republicans will move to strip all federal funding for Planned Parenthood as part of the process they are using early this year to dismantle Obamacare.

Wahoo… the evidence will strongly support the hypothesis that this policy will lead to more unintended pregnancies, more abortions and far worse outcomes for far more Americans.

Evidence based policy making — Hoo Yaa

The Republican Study Committee and Blue state experimentation

The Republican Study Committee is the policy group of the most conservative Republicans in Congress.  They have a health insurance bill out and there is a lot to say.  I only want to highlight one item though in Section 401:

‘‘(a) IN GENERAL.—Subject to section 601(d) of the American Health Care Reform Act of 2017, the covered laws of the primary State shall apply to individual health insurance coverage offered by a health insurance issuer
in the primary State and in any secondary State, but only if the coverage and issuer comply with the conditions of this section with respect to the offering of coverage in any secondary State.
‘‘(b) EXEMPTIONS FROM COVERED LAWS IN A SECONDARY STATE.—Except as provided in this section, a health insurance issuer with respect to its offer, sale, rating (including medical underwriting), renewal, and issuance of individual health insurance coverage in any secondary State is exempt from any covered laws of the secondary State (and any rules, regulations, agreements, or orders sought or issued by such State under or related to such covered laws) to the extent that such laws would— (My emphasis)

‘‘(1) make unlawful, or regulate, directly or in directly, the operation of the health insurance issuer
operating in the secondary State, except that any secondary State may require such an issuer—

That one sentence effectively forecloses any Blue state solution that relies at all on the individual market.  It blows up the Massachusetts model for if an insurer can register in New Hampshire as its primary state, it can sell across the border into Massachusetts where it offers medically underwritten policies with significant benefit carve-outs such as no maternity coverage.  The Massachusetts risk pool will become extremely sick or extremely likely to be pregnant.  That will significantly raise premiums and death spiral the non-subsidized and lightly subsidized portions of the three legged stool market.

Blue states can experiment under this law only in ways in which they will allow themselves to be subject to regulatory capture and race to the bottom of standards.


Death for fun and profits

538 has a good write up on the changing patterns of causes of death in the United States. There is one part I want to pull out:

Mortality due to substance abuse has increased in Appalachia by more than 1,000 percent since 1980….

The linked study has a great set of customizable maps. For substance abuse, it shows the southern most counties of West Virginia being one of the epicenters of substance abuse deaths in the country.

And now I want to focus on the specific from the West Virginia Gazette:

Rural and poor, Mingo County has the fourth-highest prescription opioid death rate of any county in the United States.

The trail also weaves through Wyoming County, where shipments of OxyContin have doubled, and the county’s overdose death rate leads the nation. One mom-and-pop pharmacy in Oceana received 600 times as many oxycodone pills as the Rite Aid drugstore just eight blocks away…

Cardinal Health saw its hydrocodone shipments to Logan County increase six-fold over three years. AmerisourceBergen’s oxycodone sales to Greenbrier County soared from 292,000 pills to 1.2 million pills a year. And McKesson saturated Mingo County with more hydrocodone pills in one year — 3.3 million — than it supplied over five other consecutive years combined…
At the height of pill shipments to West Virginia, there were other warning signs the prescription opioid epidemic was growing.

Drug wholesalers were shipping a declining number of oxycodone pills in 5 milligram doses — the drug’s lowest and most common strength — and more of the painkillers in stronger formulations….Between 2007 and 2012, the number of 30-milligram OxyContin tablets increased six-fold, the supply of 15-milligram pills tripled and 10-milligram oxycodone nearly doubled, the DEA records sent to Morrisey’s office show.

This is a complete system failure. There were good actors. It seems like WalMart from the story was doing a good job of actually telling abusers and addicts “no” as they were not filling high dosage prescriptions nor passing out an inordinate number of pills. But there are enough cracks in the system for unscrupulous prescribers, unscrupulous distributors who were solely responsible to pump up next quarters’ stock price, and usually small and locally owned pharamcies to pass a quasi-legal product out in droves without concern about how many people it was killing and how many lives it was disrupting and ruining.

I don’t know how to fix this problem. I just know it is a problem and it needs to be fixed.

A few notes on Replace

This tweet tree is an interesting indicator of the behind the scenes Replace state of play:

The first thing in health policy is to always follow the money.  Covering sick people means spending money.  The question is always how much money and who is spending that money.  We’ll know very quickly if there is an actual replacement plan that is way too heavily focused on HSAs but actually tries to provide some useful coverage to a reasonable number of Americans or if it is a Potemkin plan by looking at the top line CBO scoring of the expense of the coverage provisions.  This runs into a potential Norquist problem but the money is the big thing to review.

This piece from the Washington Examiner is interesting regarding the Norquist problem:

Republicans are searching for a way to capture savings from repealing Obamacare in a piggybank they could later use to fund a replacement.

It’s not clear how or if such a maneuver would work, but if Republicans are successful, it could overcome the tricky political problem of paying for whatever health reform they try to put in the Affordable Care Act’s place….

If Republicans find a way to set that money aside, in a bank account of sorts, they could use it to pay for measures that are more palatable to conservatives but still expensive, such as the age-based tax credits House Speaker Paul Ryan has proposed to help Americans buy health insurance.

 If this is a convoluted work-around of a self-imposed constraint, then there is a chance in hell that there could be a vaguely adequately funded bill.  I am not betting the house on it, but I might bet one soccer game referee fee on it.

There have been numerous wonks tearing their hair out about the mechanics of implementation.  My estimate derived from my time spent as a low level plumber :

Any big bill will have major rule making. Any big bill will require insurers to reconfigure and retweak their systems. I worked 70 hour weeks from roughly July 2012 to October 2013 to get my little part of the QHP Exchanges to a point where the user facing chunk was minimally functional. I then spent another six months getting all of the back-end mechanics of directory and network information working cleanly in an operational, no human intervention sense.  (I was up 53 of the 60 hours before October 1, 2013 launch date getting the final network directory ready to launch).

The ACA had roughly a 45 month ramp up period from signature to going live on the major components….

If the Replace Bill is anything more than a rebranding of the law and a dropping of subsidies, required actuarial value and essential health benefits, insurers need at least eighteen months from the signature to get something together and preferably 18 months from when CMS issues the big rules to get a good launch

IF the discussion is now on a four year transition period, some semblemance of reality may be at least temporarily be injected into the conversation.  Three years after a signature on the Replace Bill is a bare minimum and four years is a reasonable build-out time.