Block grants and shock events

Politico reported late last week that the Center for Medicare and Medicaid Services (CMS) wants to block grant Medicaid through the 1115 waiver process.

A block grant transfers all shock risk to the state while potentially allowing the state wider flexibility to cut services and not cover certain, current mandatory populations.

I want to look at the risk transfer component first. Right now if a state has a significant expense shock to its Medicaid population, the federal government absorbs at least half of the expense and in some states, up to three quarters of the incremental expense will be paid for by the federal government through the normal FMAP process. For the expansion population, an expense shock will have the state only bear up to 10% of the incremental and unexpected shock. Conversely a state that manages to save money will only see a small portion of the effort show up on the state budget.

What could an expense shock look like?

I spent some time a few years ago freaking out about Zika.

We also know that locally transmitted Zika infections will not be uniformly distributed. Alaska will have far fewer proportional Zika infections than Florida. We also know that one of the major policy planks of the Republican trifecta will be to block grant Medicaid on a per capita basis…. States with disproportionate clustering of high cost conditions will be significantly worse off….

There could be other emerging, infectious diseases that have expensive long run prognosis that are not uniformly and randomly distributed.

Technological shocks are also a major concern within block grant schemes. The Hep-C anti-viral cures are a massive technological shock. They are very cost effective for the improvement in the quality and quantity of life but they are very expensive as they bring forward significant future costs to a three month treatment window. They are a cash flow problem for Medicaid entities even with high federal matches. They would be a cash flow disaster for states with block-granted federal funds as the technological/financial shock of a state being required to pay for effective, efficient but expensive cures would be entirely on the state’s marginal costs.

Enrollment shocks are another major issue. Enrollment eligibility goes up when the economy goes down. A state has the least capacity to take on new enrollment during the time of the highest demand in the middle of recession. It would be worsened under a block grant schema unless Congress relaxes funding in a counter-cyclical manner. Right now, the funding shock of 51 mini-Hoovers is at least partially counter-acted by the automatic stabilizer of the federal matching component.

The most notable shock is the natural disaster shock. Puerto Rico was walloped by Hurricane Maria. Population health declined significantly after the hurricane. Puerto Rico’s Medicaid program is running out of resources and funding for treatment. Puerto Rico is currently on a block granted Medicaid program and it can not handle the after-effects of a massive external shock event.

The US Federal government is the globe’s biggest, deepest, and most experienced risk bearing and risk sharing entity. It can engage in massive counter-cyclical debt financed spending. It can shift resources between disparitely impacted geographies. It can spread risk over a hundred year time frame without too much effort. States can’t absorb those shocks anywhere nearly as well as the pools are far shallower and the ability to access financing in excess of immediate tax revenue is far more constrained.



Late Night Eugenics Open Thread: Why Are There So Many Skunks At Every ‘Conservative Intellectual’ Garden Party?

It took just 80 minutes after racially incendiary emails started flying for the Claremont Institute, a conservative think tank, to shut down an email Listserv connecting hundreds of high-profile conservatives.

The emails that sparked the controversy began ricocheting midday Tuesday, in response to a plea from Darren Beattie, a recently fired speechwriter for President Donald Trump, for “those on this list with media influence” to come to his defense. The White House over the weekend dismissed Beattie after CNN revealed that he had spoken at a conference alongside a racial provocateur.

Charles Johnson, an alt-right provocateur and Trump loyalist, was first to respond.

“Beattie’s offense is that he spoke at an event where — gasp! — there were white nationalists afoot!” Johnson wrote the group. “Heaven forbid that some thinkers — like the American founders who favored our country be majority white — think that the U.S. of A should stay majority white! Perish the thought. Can’t have that.”

A little more than an hour later, as senior administration officials and white-shoe lawyers asked to be removed from the list, the Claremont Institute had scuttled it entirely.
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The Conservatives’ Nightmare: ‘Respectful Disagreement’, But Between Social Equals

The NYTimes recently hired the “provocative” Bari Weiss (as far as I can tell, because Bret Stephens was getting screechy about being the punchline to every ‘reactionary FTFNYT columnist shows his arse in public again’ joke). Earlier this week, Weiss produced her longest, most provocative piece so far, and boy did it get the hate-clicks!

Lots of the responses are funnier, and far better thought out, than the original piece. I’ve been collecting links to share, but it was a twitter side-spat that sparked my chain of thought…

Andrew Sullivan, once again being cruelly repressed with a highly-compensated platform at a widely-read center-liberal print/media publication:

I remember a different time — and it wasn’t so long ago. A friend reminded me of this bloggy exchange Ta-Nehisi and I had in 2009, on the very subject of identity politics and its claims. We clearly disagreed, deeply. But there was a civility about it, an actual generosity of spirit, that transcended the boundaries of race and background. We both come from extremely different places, countries, life experiences, loyalties. But a conversation in the same pages was still possible, writer to writer, human to human, as part of the same American idea. It was a debate in which I think we both listened to each other, in which I changed my mind a bit, and where neither of us denied each other’s good faith or human worth.
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FBI- Fapping Bunch of Insufferables

Apparently the entire FBI is filled with moralizing blowhards patterned after Michael Shannon’s character in Boardwalk Empire, Agent Nelson van Alden:

Deputy Attorney General Rod Rosenstein has struck a stoic and righteous tone in private conversations he has had this week about the fate of his job as President Donald Trump has launched public criticism against him and considered firing him, according to three sources who have spoken to Rosenstein.

In those conversations, he has repeated the phrase, “Here I stand,” a reference to Martin Luther’s famous quote, “Here I stand, I can do no other.” Coincidentally, former FBI Director James Comey, whom Rosenstein fired, repeated the same phrase to President George W. Bush in a conversation that has been widely reported and that Comey describes in his forthcoming book.

That’s right on the heels of this portion of a NY Times mutual masturbation society meeting:

What books over the years have most influenced your thinking?

Reinhold Niebuhr’s “Moral Man and Immoral Society” and “The Nature and Destiny of Man” had a huge impact on me, as did Strunk and White’s “The Elements of Style,” which was one of 12 books in my college course “Significant Books in Western Religion.” The professor believed that all ideas are wasted that can’t be clearly expressed. King’s “Letter From Birmingham Jail” was also one of the 12 books and is the only book I’ve read repeatedly as an adult. More recently, I was really struck by Jonathan Haidt’s “The Righteous Mind: Why Good People Are Divided by Politics and Religion.”

You’re organizing a literary dinner party. Which three writers, dead or alive, do you invite?

I read “Lean In,” by Sheryl Sandberg, when I was the F.B.I. director and recommended it to the workforce, so Ms. Sandberg would be invited. And if she doesn’t mind eating with dead people, I’d also have Reinhold Niebuhr and Martin Luther King Jr. Both were remarkable observers of human nature and America. It would be really interesting to pick their brains about current events.

The bonus of it all is he didn’t need to fucking think about whether or not to go give that speech tanking Clinton. It didn’t require any Niebuhresque judgment, it just required he follow the fucking DOJ guidelines that were already in place:

The day before the F.B.I. director, James B. Comey, sent a letter to Congress announcing that new evidence had been discovered that might be related to the completed Hillary Clinton email investigation, the Justice Department strongly discouraged the step and told him that he would be breaking with longstanding policy, three law enforcement officials said on Saturday.

Senior Justice Department officials did not move to stop him from sending the letter, officials said, but they did everything short of it, pointing to policies against talking about current criminal investigations or being seen as meddling in elections.

That Mr. Comey moved ahead despite those protestations underscores the unusual nature of Friday’s revelations, which added a dramatic twist to the final days of the presidential campaign. His action reignited a firestorm that Mrs. Clinton believed she had put behind her when the F.B.I. decided in July not to charge anyone in the investigation into the handling of classified information on her private email server.

Remember, that was after he had already created new Clinton rules in July and decided to speechify about Clinton when they decided not to prosecute the nothingburger of an email case. He called Clinton “careless,” when in fact it was he who was being careless and reckless.

For the record, it’s entirely possible to, as I do, think that Comey and company are a bunch of insufferable pricks while also thinking they are telling the truth about Orange Julius Caesar. I also maintain that Comey was convinced Clinton was going to win and was trying to shore up GOP losses in the House and Senate and also sending a shot across the incoming President’s bow about who the boss in town was, as well as settling an old score with the Clenis on the Mark Rich pardon.

In closing, fuck these guys. They make you long for the days of FBI agents who were merely vindictive monsters who secretly liked women’s clothing but kept their mouths shut in public. Additionally, we need to stop allowing college students to read Niebuhr, Luther, Oakeshotte, etc., unless they sign a NDA stating they will not issue any public mention of them without first having their statement approved by their old professor or someone with standing in the field who actually understood what they read.



Just When You Thought They Couldn’t Get Skeevier…

My son, for reasons known best to himself, has taken to watching old Jon Stewart clips, and this morning he was watching a long one, a sit down between Steward and Bill O’Reilly.

Stewart comes off as the smarter, more moral one in the particular bit I saw, but I told my kid I still hated the whole premise.  Stewart was normalizing a monster — even giving him a little bit of his own thoughtfulness as cover.  It wasn’t news back then that O’Reilly was a stone racist and a grotesque boss, a harassing womanizer dragging a tail of NDAs behind him.

But while I watched a true PGO came to me: the GOP obviously has no monopoly on men who are assholes to women, but it does seem to have more than its share, or rather the share you’d expect, given both specific ideology* , and the broader authoritarianism that both depends on and breeds the certainty that to be white and male is to have the right to f**k — and f**k with — the women who are their due.

Hence Porter and Farenthold and Moore and a magazine writer who thinks mere lethal injection is too good for the wanton harlots who choose to have an abortion — and the male-led magazine that thought such views were “provocative” — until it became clear just how provoked the intended gallows-bound (and their friends) had become.  And of course, hence the omphalos of modern Republican moral degeneracy, the Shitgibbon himself.

But I have to say, the latest entrant into the GOP-Sleazebag sweepstakes actually managed to surprise even my jaded self.  Meet Mr. Benjamin Sparks:

A Las Vegas political adviser who worked on national campaigns and high-profile Nevada races sexually enslaved and battered his ex-fiancée before police responded to a domestic dispute, the woman told the Review-Journal.

The 46-year-old woman provided copies of emails, text messages and a signed contract laying out her duties as a “slave in training” to Benjamin Sparks.

Sparks isn’t some small-time local operative.  He was a 2012 Romney spokesperson, and worked for Goggle-Eyed Homunculus Scott Walker during the recall campaign.  And he really, really doesn’t like the idea of female autonomy:

According to emails, documents and text messages obtained by the Review-Journal, Sparks and his ex-fiancée signed a five-page contract stating that she would be his “slave and property.”…

Her specified duties were what you might expect, given that starting point and then escalated to the point of rupture. (Go to the link if you want the details.)

“Slave and property.” Dwell on that phrase.  I’ll wait.

Not All Republicans would be a true statement.  But too much Republican rhetoric, policy and conviction rests on a view of women that taken to pathological extremes, ends with Benjamin Sparks putting down on paper his belief that a woman could be chattel.

There are all kinds of reasons these shandes and goniffs need to get their asses handed to them this November. This is one. A big one.

Open this thread can be.

ETA: Several commenters have pointed out that consensual relations between adults aren’t the problem, and they’re right (as always, IMHO). The issue here for me is the way Sparks took what appears to have been one stage of initial consent and translated that into a one-off permission that gave him the right actually to treat his partner as property.

*Anti-abortion, anti-contraception, anti-non-discriminatory-treatment in work and society politics that are all underpinned by the conviction that women can’t be allowed to have full agency over their own bodies and their own decisions.

Image: J. Collier, Three grotesque old men with awful teeth pointing and grimacing at each other, 1810. (Via Wellcome Images.)