Time to call Congress

You know what to do.

Call Congress. If your Senator is a firm No vote to Puzder, thank them and their staff.

If they are a firm Yes vote, tell them they are wrong.

If they are mushy, encourage them to vote no.

Burn those phone lines up.

And let’s see if we can get another minor win.

UPDATE 1

UPDATE 1

Puzder is withdrawing.

 



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.



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:

Colorado:

    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.

Texas

 

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



Andrew Cuomo is Vile Scum and His Political Future Must be Destroyed

Asshole:

Gov. Cuomo vetoed a bill late Saturday that would have required the state to fund legal services for the poor in each county.

Cuomo’s office in a New Year’s Eve statement released just over an hour before the bill was required to be signed or vetoed said last-minute negotiations with the Legislature to address the governor’s concerns failed to yield a deal.

“Until the last possible moment, we attempted to reach an agreement with the Legislature that would have achieved the stated goal of this legislation, been fiscally responsible, and had additional safeguards to ensure accountability and transparency,” Cuomo spokesman Richard Azzopardi said. “Unfortunately, an agreement was unable to be reached and the Legislature was committed to a flawed bill that placed an $800 million burden on taxpayers — $600 million of which was unnecessary — with no way to pay for it and no plan to make one.”

***

Jonathan Gradess, executive director of the New York State Defenders Association, called Cuomo’s decision to veto the bill “stunning.”

“We are all shocked that the Governor vetoed a bill that would have reduced racial disparities in the criminal justice system, helped ensure equal access to justice for all New Yorkers, provided improved public defense programs for those who cannot afford an attorney, and much-needed mandate relief for counties, Gradess said. “The governor refused to accept an independent oversight mechanism on state quality standards, and now, sadly tens of thousands of low-income defendants will pay the price.”

I know this upsets tax cut jeebus, but taxpayers are supposed to foot the bill for this, you fucking douchenozzle. Geneticists should study Cuomo, as we appear to be seeing a gene pool decline in real time.



HSAs, tax deductions and help for those who don’t need it

Health Savings Accounts (HSA) are going to be a big component of whatever passes as Republican health policy over the next couple of years. An HSA is a tax advantaged savings account that can be used to pay for out of pocket expenses and premiums. They are initiated and contribution eligible when the owner is covered under a high deductible health plan (HDHP). One of the primary tax advantages for an HSA is that contributions are tax free. Growth (as long as it is used for qualified medical expenses) is also tax free. I want to focus on the first part though.

My wife was notified of her bonus yesterday. Her firm also gave her a cost of living and merit based pay bump. She’ll see her bonus in the first check in January. I was sitting in a meeting where I barely needed to pay attention so I started sketching out my family’s 2017 budget. 2017 is looking good for us. I figure that I’ll still do some soccer but the four year plan to trade quantity for quality will continue as I value my family time more than soccer time as I no longer need it to pay the mortgage. My son will be out of daycare this summer so we are seeing a major expense drop and our incomes are going up. As my son leaves daycare, we’ll lose the value of the tax free benefit of the flexible spending account and that thought made me angry. Not angry at losing a tax benefit but angry at getting a lot of help when my family really does not need a lot of help.

We are able to contribute tax free a significant chunk of his day care costs. In 2016, we are doing well for ourselves so our marginal income is taxed at a fairly high marginal rate. I’m okay with paying a high marginal rate as I like civilization and the public sphere. I thought back to 2009 and 2010. Those years were lean. I was either out of work or consulting and my wife was working but unable to find full time work. We were tight and paying the mortgage was an adventure some months. If we were able to afford to put money away, we would have seen a tax benefit that is significantly less than what we are getting now. And those were the years when we really needed help as we had an infant daughter and a fraction of total income in 2016 or projected for 2017.

I’m angry about this because the tax deduction racket shovels most of the benefits towards people who don’t need the additional help. Someone who is in the top bracket this year will see the federal government subsidize their $1,000 contribution with a $400 tax break. Someone who is making $10,000 a year will not be able to afford to make a $1,000 contribution and in the odd case that they could, the federal subsidy administered through the tax code is only worth $100. That is wrong on a moral basis. More help goes to people who really don’t need it as the marginal value of their last dollar is fairly low.

One of the policies I want to see advanced is a flipping of tax deductiblity towards an open ended credit so it is more of a sliding scale based on either income or contribution. Here is how I think it could work:

The first $200 of a contribution to an HSA or an FSA would have credit equal to the size of the contribution times the top income tax marginal rate.
The next $500 contributed would have a credit equal to the size of the contribution times the second highest income tax marginal rate
The next $500 would have a credit equal to the increment times the third highest marginal rate

This would continue until a threshold is reached where any contributions to a tax advantaged account receive a federal subsidy equal to the lowest marginal rate. It still encourages savings but it gives more help to people who need it and less help the the people who are in pretty good to really good shape.



Geographic disparities and HR2300

HR2300 is the incoming Secretary of Health and Human Services, Rep. Price (R-GA), PPACA replacement bill. It does lots of things. One of those things is it replaces income based subsidies with age based subsidies.

Sec. 101. Refundable Tax Credit for Health Insurance Coverage
 Provides for refundable, age adjusted tax credits with amounts tied to average insurance on individual
market adjusted for inflation.1
o $1,200 for those between 18 to 35 years of age
o $2,100 for those between 35 and 50 years of age
o $3,000 for those who are 50 years and older
o $900 per child up to age 18

Besides being grossly inadequate in size, there is another problem with these subsidies. These subsidies will have massive geographic disparities. Individuals who live in low cost medical markets with large and healthy risk pools will see their subsidy cover a far higher percentage of their premium costs for a given actuarial value. Individuals who live in high cost medical markets will pay a lot more out of pocket for their premiums. Below is a map of every county on Healthcare.gov excluding Alaska. The pricing is the least expensive Silver plan with no subsidies for a forty year non-smoker. The range is significant. The least expensive Silver in the data set is thirteen counties in Texas at $199.28 per month. The most expensive non-Alaska coverage is three counties in Arizona at $754.74.

least-expensive-silver-2017

The subsidy in the price plan will let the Texas 40 year olds buy 70% AV coverage for less than $20 a month out of pocket. Given quite a few other moving parts in HR0-2300 I can’t get a firm estimate but this is a good ballpark estimate. However the subsidy for the three Arizona counties for a forty year old would be sufficient to buy 25% AV coverage and the individual is paying $500 out of pocket every month.

We’ve talked about county level inequities within PPACA through Silver Gapping and Silver Hacking

More importantly, people in Perry County who are getting subsidized will see the ACA working really well. They have good, cheap health insurance. However their cousins across the state are getting a raw deal compared to the great deal that they get in Perry County. This is especially true as we move up the income scale which means moving up the likely voter scale and influence scale.

The people in the cheap Texas counties will see the Price plan as a great deal, especially higher up the income scale as the current subsidies fade out and then fall off a cliff. The people who make under 400% FPL in Arizona will be getting a raw deal.