Slim hope open thread

My only hope for the new year is that 2017 is not telling 2016 “hold my beer and watch this…..”

 

Open thread



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.



Reminder: The unpopular stuff was needed

Via TPM, Senator Corker (R-TN) is stating an impossibility:

“You really do have to have 60 votes to replace and you know reconciliation can create some hangover effects as we’ve seen with the health care bill itself and with the Bush tax cuts and all of that so are you better off going ahead and attempting to put something in place that will work that does away with all the negatives that exist in ACA, but builds on some of the positives?” Corker asked. “Again, President-elect Trump mentioned, I thought wisely during the campaign, that replacement and repeal should be done simultaneously.”

The negatives (mandates, reinsurance, risk adjustment, risk corridors) and the annoying (narrow networks, HMO’s, high cost sharing) were needed to make the popular stuff work (guarantee issue, community rating) work.  Definitions as to what counted as a qualified plan were needed.  Definitions as to what counts as an essential health benefit were needed.  All of the negatives were needed .  They can be tweaked and twisted.  The continual enrollment concept changes the form of a mandate but performs the same function of making going without coverage too expensive to be attractive.  The negative stuff was not put into the bill for shits and giggles.

About the only major things in the medical coverage expansion sections of the ACA that don’t need the negatives of the ACA are Medicaid expansion and the Under-26 coverage expansions.  Those are easy things that are severable from the core of the three legged stool.  One is state by state single payer and the other is an expansion of multi-payer community rated/guaranteed issue coverage.

We’ll see this refrain at least four times a week for the next four years.  Health policy is hard even if the objective is to present a patina of coverage in order to loot.  Actually providing a usable coverage expansion is harder.

 

Update 1: Victor in comments makes a very good point:

I think it is also fair to point out that most of the stuff on the revenue side was also unnecessary. The ACA can work without the employer mandate or the cadillac tax although the Cadillac tax is a good economic policy. The employer mandate was a fine rule from a fairness issue but can easily cause labor market distortions.



Overnight Open Thread: Shocking!

Here’s an actual Tesla coil rifle to shock you awake on this early Sunday morning/late Saturday evening. If you want to build your own, the details are here. I’m going to bed, amuse yourselves!



WASF, Part ∞

If we can’t see it, it won’t happen, climate change edition:

Donald Trump is poised to eliminate all climate change research conducted by Nasa as part of a crackdown on “politicized science”, his senior adviser on issues relating to the space agency has said.

Nasa’s Earth science division is set to be stripped of funding in favor of exploration of deep space.

After all, we can’t have any of that nasty left wing bias that reality imposes:

There is overwhelming and long-established evidence that burning fossil fuels and deforestation causes the release of heat-trapping gases, therefore causing the warming experienced in recent decades.

[Trump campaign advisor Bob] Walker, however, claimed that doubt over the role of human activity in climate change “is a view shared by half the climatologists in the world. We need good science to tell us what the reality is and science could do that if politicians didn’t interfere with it.”

Walker is, as one expects from Trumpistas, simply lying. Half of the world’s climatologists do not doubt the fact of human-driven climate change, unless you include those who got their advanced degrees at the University of Exxon’s Koch School of Science.  Ostriches and sand ain’t in it.

carl_eytel_and_george_wharton_james_in_a_horse-drawn_wagon_on_the_butterfield_stage_road_in_the_colorado_desert_ca-1903_chs-2280

This is a hugely consequential move.  There are two technologies that are essential to modern climate science: large scale numerical modelling made possible by the insane advances in computing power and associated computer science over the last several decades…and remote sensing, the ability to monitor earth systems on a planetary scale.  That’s what NASA — and for the forseeable future, no one else, brings with its earth science programs.  Kill that and we not only lose data going forward, we degrade a capability in an intellectual infrastructure that will take a long time indeed to restore:

Kevin Trenberth, senior scientist at the National Center for Atmospheric Research, said as Nasa provides the scientific community with new instruments and techniques, the elimination of Earth sciences would be “a major setback if not devastating”.

“It could put us back into the ‘dark ages’ of almost the pre-satellite era,” he said. “It would be extremely short sighted.

“We live on planet Earth and there is much to discover, and it is essential to track and monitor many things from space. Information on planet Earth and its atmosphere and oceans is essential for our way of life. Space research is a luxury, Earth observations are essential.”

This is a call your representative kind of issue.  It’s going to be difficult, certainly, if Trump really does go down this path, but NASA is enough of a pork barrel, and some GOP senators, at least, are not wholly clueless on this issue, so it might be possible to avoid the worst outcome.  It’s necessary to try.  If and as I hear of organized campaigns on this, I’ll bring the news (and feel free to email me with any info you might gather.)

Feh.

PS: that laser like media focus during the campaign on issues like climate change sure was impressive, wasn’t it?

C. C. Pierce, Carl Eytel and George Wharton James in a horse-drawn wagon on the Butterfield Stage Road in the Colorado Desert, c.1903. (Eytel was a painter associated with the “smoketree school” of artists working on desert subjects; James was a journalist and photographer.)



Amendment 69, single payer and plausible option space

Amendment 69 was the Colorado Care amendment.  Ballotpedia has the language the results:

A “yes” vote supported creating ColoradoCare, a healthcare payment system designed to finance universal healthcare for Colorado residents partly through an additional 10 percent payroll tax—two thirds paid by employers and one third by employees—providing approximately $25 billion per year in revenue.
A “no” vote opposed this proposal, leaving the Colorado healthcare system unchanged.

No won by more than 3:1 over Yes.

It was not just Trump supporters who voted no.  Mechanically well over half of Hillary Clinton’s vote in the state voted against Amendment 69.  I probably would have been one of the Clinton-No votes as I could never figure out the financing of the proposal.

So what are the lessons that need to be learned?

First, single payer has a concentrated and motivated group of supporters but they are not a majority of the Democratic party.  We have revealed preferences on this in the 2007-2008 health policy proposals.  In that election cycle there were three viable candidates offering healthcare plans (Obama, Clinton, Edwards) and none of them offered single payer.  We also have Amendment 69 failing with at least majority Democratic opposition.  We saw major Democratic influencers not come out for Amendment 69.

Secondly, this is the second major single payer failure in the past three years.  Vermont stopped their exploration process because they could never make the money work well enough to get a viable proposal to send out for approval.  Colorado resoundingly rejected their proposal.

Single payer, behind a Rawlsian veil of ignorance and starting fresh, makes a massive amount of sense.  We do not operate in that world.  The world that we live in has a healthcare system that produces winners and losers.  Providers and healthy people with good insurance through either work or Medicare are either actual winners or apparent winners.  Most of the losers of the current system are either amazingly diffuse (lower cash wages for most workers), already somewhat covered (disabled on Medicare or Medicaid) or politically powerless.  The challenge is how to get a policy that is disruptive as all get out that mainly benefits people with low political salience and power while either hurting or causing fear in people with high political salience and power through?  I don’t know how to do that.  This needle threading exercise is one of the many reasons why the ACA was designed as it was as it sought to keep the status quo as visibly entrenched as possible while improving things for low political power and salience groups.

Third, single payer is hard.  It is not something that can just be hand waved into existence.  It is something that needs a lot of high quality nerds and experts working through odd scenarios, looking at interactions and then presenting their thoughts to the general public for a long and hard listening to the concerns, questions and suggestions of the people that will actually have to use the system.  One of the major reasons why I was not gung-ho for Colorado Care is that I had not seen them do the actual financial math.  They assumed they could get a 1115 Medicaid waiver and a 1332 ACA waiver even as the waiver granting authorities were indicating reluctance to grant the needed expansive waivers.  They just assumed the money would be there instead of lining up cash commitments ahead of time.  They also assumed Hyde and current Colorado state law would not apply to abortion and other female reproductive health care procedures.  There were a lot of assumptions on the mechanics of implementation.

Single payer is hard work to implement.  Lazy work turns off potential allies that may not be sufficient to form a minimally viable winning coalition but definitely necessary to that coalition.

Given today’s politics, single payer advocates will have a decade to get the hard work done of designing a plan, figuring out implementation and persuading the public including people who are current winners that this plan is better than the status quo and the uncertainty is low.  That works needs to be done and Colorado is a source of good information for that work.



Putin’s Puppet and NFLG Harry Reid

Senator Harry Reid has just released a letter to FBI Director Comey that is utterly (and IMHO appropriately) brutal.

It contains two key elements.  The first is a direct assertion that Comey has engaged in partisan political action, and may (by implication, has) broken the law by violating the Hatch Act.

The second is this:

In my communications with you and other top officials in the national security community, it has become clear that you possess explosive information about close ties and coordination between Donald Trump, his top advisors, and the Russian government – a foreign interest openly hostile to the United States, which Trump praises at every opportunity. The public has a right to know this information. I wrote to you months ago calling for this information to be released to the public. There is no danger to American interests from releasing it. And yet, you continue to resist calls to inform the public of this critical information.

neuville_alphonse_de_-_the_spy_-_1880

Hillary Clinton’s aide’s husband sent dick picks from a computer that may or may not contain emails that may or may not add to our nation’s stock of risotto recipes.

Donald Trump, apparantly, has consequential entanglement with the former KGB thug-led Russian government and its klepto-thug circle of supporters.

We know hair-raising innuendo about the former.

About the latter, from the same institution?  Crickets.

Sauce for the goose damn well ought to be sauce for the gander.  And Comey’s a hack who needs to go at the earliest politick opportunity. (And yeah, that’s not a typo.  I like that old spelling.)

No BS here: if the FBI has pertinent information on Trump’s potential for conflict of interest due to his Russian encounters, we need to know this now.

Here is Reid’s letter in full:

Dear Director Comey:

Your actions in recent months have demonstrated a disturbing double standard for the treatment of sensitive information, with what appears to be a clear intent to aid one political party over another. I am writing to inform you that my office has determined that these actions may violate the Hatch Act, which bars FBI officials from using their official authority to influence an election. Through your partisan actions, you may have broken the law.

The double standard established by your actions is clear.

In my communications with you and other top officials in the national security community, it has become clear that you possess explosive information about close ties and coordination between Donald Trump, his top advisors, and the Russian government – a foreign interest openly hostile to the United States, which Trump praises at every opportunity. The public has a right to know this information. I wrote to you months ago calling for this information to be released to the public. There is no danger to American interests from releasing it. And yet, you continue to resist calls to inform the public of this critical information.

By contrast, as soon as you came into possession of the slightest innuendo related to Secretary Clinton, you rushed to publicize it in the most negative light possible.

Moreover, in tarring Secretary Clinton with thin innuendo, you overruled longstanding tradition and the explicit guidance of your own Department. You rushed to take this step eleven days before a presidential election, despite the fact that for all you know, the information you possess could be entirely duplicative of the information you already examined which exonerated Secretary Clinton.

As you know, a memo authored by Deputy Attorney General Sally Yates on March 10, 2016, makes clear that all Justice Department employees, including you, are subject to the Hatch Act. The memo defines the political activity prohibited under the Hatch Act as “activity directed towards the success or failure of a political party, candidate for partisan political office, or partisan political group.”

The clear double-standard established by your actions strongly suggests that your highly selective approach to publicizing information, along with your timing, was intended for the success or failure of a partisan candidate or political group.

Please keep in mind that I have been a supporter of yours in the past. When Republicans filibustered your nomination and delayed your confirmation longer than any previous nominee to your position, I led the fight to get you confirmed because I believed you to be a principled public servant.

With the deepest regret, I now see that I was wrong.

Sincerely,

Senator Harry Reid

Image: Alphonse de Neuville, The Spy1880.