Call your Senator

Right now the word is that the Senate is voting on something healthcare related tomorrow.

Does anyone know what the bill will be?

Is it the BCRA with a half dozen Byrd droppings?

Is it the BCRA with half a dozen Byrd droppings and the Cruz amendment?

Is it the AHCA?

Is it the 2015 show-me reconcilitaion bill that got vetoed by President Obama?

Is it complete repeal and delay ORRA?

No one knows.

That is not normal.

That is not healthy.

That is not safe.

But it is the reality that we are facing.

So call your Senator and tell them what you think about the wisdom of voting without knowing a goddamn thing about the subject.

Late Night Open Thread: A Little Silhouette-o of A Man


Archetypical celebrity clown figure for a clownshow “administration”. Buzzfeed:

Trump “wanted to give Scaramucci something to do because he likes him on TV,” a source close to the White House’s press operation told BuzzFeed News.

“Ivanka has been pushing this for some time. Since the communications job was open, Trump thought it would be a nice fit. But the president doesn’t understand what kind of responsibilities come with that job, and Sean did. Sean would have been expected to serve as press secretary, and do the comms job while Scaramucci held the ceremonial title, and he would have reported to him. It was the straw that broke the camel’s back,” the source said.

“And Trump did it over the objection of several senior staff who know Scaramucci in that job is a joke,” the source added…

At his first White House daily press briefing on Friday, Scaramucci named Sarah Huckabee Sanders the new press secretary. She read a statement from Trump about Spicer’s resignation, complete with an odd line about television ratings at the end: “I am grateful for Sean’s work on behalf of my administration and the American people. I wish him continued success as he moves on to pursue new opportunities. Just look at his great television ratings. Sean will continue to serve the administration through August.”

Scaramucci then took over, calling Spicer — a Navy reservist — a “true American patriot” and said he hoped he would go on “to make a tremendous amount of money.”…

Scaramucci was calm, chatty, and easily engaged reporters — something Spicer was never quite able to master at the White House — and repeatedly said how much he loves people in the White House and how much he loves the president.

Though his presentation was sleek, the substance from previous news conferences wasn’t that different: When asked about Trump’s baseless claim that about 3 million people illegally in the election, he said, “There’s probably some level of truth to that.”…

Those close to the administration who have remained skeptical of Priebus and Spicer because they don’t consider them Trump loyalists see the shakeup positively. This is “all good! Trump needs more people around him he can trust,” one of them wrote to BuzzFeed News…

Scaramucci, who recently sold his stake in his hedge fund, was originally under consideration for the Office of Public Engagement and Intergovernmental Affairs, a post held by Valerie Jarrett under President Barack Obama. But White House Chief of Staff Reince Priebus tried to get Scaramucci to pull out, claiming that his ethics review was taking too long. Priebus, according to reports at that time, did not want someone as close to the president in that position as Scaramucci is and sees him as a possible threat to his own power…

“Commutations” Director.

Notes from the CBO score of the BCRA

The Congressional Budget Office released their score of the Senate’s Better Care Reconciliation Act (BCRA). It does not include the Cruz amendment. There is not a whole lot of difference since the last score as there are not many large changes on the coverage side.

I just want to pull out a few things. The most important thing to pull out is Table 3 regarding Medicaid:

The largest savings would come from a reduction in total federal spending for Medicaid resulting both from provisions affecting health insurance coverage and from other provisions. By 2026, spending for that program would be reduced by 26 percent (see Table 3, at the end of this document).3

It is a $575 billion dollar cut to Medicaid. Throwing inadequate opioid specific money or allowing for a $200 billion dollar back door CSR funding stream won’t do anything remotely sufficient to address the people who lose coverage because of these cuts.

THe next nugget is a repetition of the basic point that the value proposition of super high deductibles is absolutely atrocious for lower income individuals:

Because this legislation would change the benchmark plan (in part, by repealing the current-law federal subsidies to reduce cost-sharing payments), the average share of the cost of medical services paid by the plan would fall—for the 40-year-old with income at 175 percent of the FPL in 2026, from 87 percent to 58 percent—and his or her
payments in the form of cost sharing would rise. And the person’s net premiums would be higher under the legislation than under current law for plans of comparable actuarial value. Those changes, CBO and JCT estimate, would contribute significantly to a decrease in the number of lower-income people with coverage through the nongroup market under this legislation, compared with the number under current law.

The baseline deductible in 2026 is a mind busting $13,000. This matters a lot for the people who are losing Medicaid. The deductibles are an absurdist joke.

a single policyholder purchasing an illustrative benchmark plan (with an actuarial value of 58 percent) in 2026, the deductible for medical and drug expenses combined would be roughly $13,000, the agencies estimate… Under this legislation, in 2026, that deductible would exceed the annual income of $11,400 for someone with income at 75 percent of the FPL. For people whose income was at 175 percent of the FPL ($26,500) and 375 percent of the FPL ($56,800), the deductible would constitute about a half and a quarter of their income, respectively.

Finally, the CBO notes a clear mechanical problem that can not be fixed without 60 votes:

The limit on out-of-pocket spending in 2026 is projected to be $10,900. (Under current regulations, the limit on out-of-pocket spending is defined by a formula based on projections of national health expenditures.) Therefore, plans with an actuarial value of 58 percent and a deductible of $13,000 would exceed that limit and would not comply with the law unless the formula used to calculate the limit was adjusted. CBO and JCT estimate that a plan with a deductible equal to the limit on out-of-pocket spending in 2026 would have an actuarial value of 62 percent. A person enrolled in such a plan would pay for all health care costs (except for preventive care) until the deductible was met and none thereafter until the end of the year.

The benchmark plan can’t be built.


Sunday Evening Open Thread: Can’t Take The Man Anywhere

You must be soooo proud, Repubs.

Apart from [facepalm]-ing, what’s on the agenda as we wrap up the weekend?

Care costs money

The most important concept in health finance is simple; sick people are expensive to cover. Let’s keep that in mind for the rest of the post.

The Independent Journalism Review captures the reaction of Rep. Mark Meadows (R-NC), head of the House Freedom Caucus, to the CBO score.

When reporters pointed out the portion of the CBO report saying individuals with preexisting conditions in waiver states would be charged higher premiums and could even be priced out of the insurance market — destabilizing markets in those states — under AHCA, Meadows seemed surprised.

“Well, that’s not what I read,” Meadows said, putting on his reading glasses and peering at the paragraph on the phone of a nearby reporter.

The CBO predicted:

“…the waivers in those states would have another effect: Community-rated premiums would rise over time, and people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive non-group health insurance at premiums comparable to those under current law, if they could purchase it at all — despite the additional funding that would be available under H.R. 1628 to help reduce premiums.”

The CBO analysis was likewise adamant that AHCA’s current high-risk pool funding isn’t enough to cover sick people if states use the mandate waivers.

After reading the paragraph, Meadows told reporters he would go through the CBO analysis more thoroughly and run the numbers, adding he would work to make sure the high-risk pools are properly funded.

Meadows, suddenly emotional, choked back tears and said, “Listen, I lost my sister to breast cancer. I lost my dad to lung cancer. If anybody is sensitive to preexisting conditions, it’s me. I’m not going to make a political decision today that affects somebody’s sister or father because I wouldn’t do it to myself.”

He continued:

“In the end, we’ve got to make sure there’s enough funding there to handle preexisting conditions and drive down premiums. And if we can’t do those three things, then we will have failed.”

There is a plausible high cost risk pool design that could theoretically work. It just costs a lot of money. The Urban Institute provides an updated floor to that type of design.

Government costs for the coverage and assistance typical of traditional high-risk pools would range from $25 billion to $30 billion in 2020 and from $359 to $427 billion over 10 years. (Figure 2)

I think this is a decent lower bound as they don’t look at very high cost but uncommon conditions like hematological defects, cystic fibrosis, major gastro-intestinal conditions, slow progressing cancers or hundreds of other things. But Urban’s estimates points us in the right direction. Taking care of sick people costs somewhere between expensive and very expensive.

This is not new knowledge. Anyone of any ideological stripe who is actively trying to be a good faith broker of information on health care finance has been shouting this basic insight for months. And yet, the Senate just invited actuaries to talk with them for the first time this week. And yet, the House voted on this bill without waiting for expert opinion. The bill was written without a public hearing. The product is a consequence of a process that deliberately excluded even friendly experts who were having a nervous breakdown when they looked at the cash flows much less incorporating the criticism of unfriendly but knowledgeable experts.

Healthcare for people with high needs is expensive.

How the CBO projects market failure

The Congressional Budget Office projects that the AHCA will lead to 15 % of the population living in destablized insurance markets because of the MacArthur/Upton amendments.

he agencies estimate that about one-sixth of the population resides in areas inwhich the nongroup market would start to become unstable beginning in 2020. That instability would result from market responses to decisions by some states to waive two provisions of federal law, as would be permitted under H.R. 1628. One type of waiver would allow states to modify the requirements governing essential health benefits (EHBs), which set minimum standards for the benefits that insurance in the nongroup and small-group markets must cover. A second type of waiver would allow insurers to set premiums on the basis of an individual’s health status if the person had not demonstrated continuous coverage; that is, the waiver would eliminate the requirement for what is termed community rating for premiums charged to such people. CBO and JCT anticipate that most healthy people applying for insurance in the nongroup market in those states would be able to choose between premiums based on their own expected health care costs (medically underwritten premiums) and premiums based on the average health care costs for people who share the same age and smoking status and who reside in the same geographic area (community-rated premiums)

What does that mean and how does that happen? Let’s work through an simple model of a state with 1,000 people in its individual market.
Read more

Open Thread: We’ll Always Have Paris Snark

Absolutely *not* fleeing the Titanic, per fellow WH cronies:

The decision for Priebus to return to the US was pre-planned, not spur-of-the-moment, White House spokeswoman Sarah Huckabee Sanders and a second Trump adviser said.

“He was planning to come for the first stop and then head back for the budget roll out,” Sanders said.

The chaotic nature of this White House has prevented Trump’s team from doing much strategic planning, the second Trump adviser said. Leaving the trip early would give Priebus time to plan for the President’s return, the adviser said.

Some major issues are awaiting Trump back home, including the possible hiring of outside legal counsel in the Russia probe, the selection of a new FBI director, and the effort to pivot back to the President’s domestic agenda…

Yeah, like that’s any different than when Priebus was on the plane.

Reince’s job is to (try to) ram the oligarchs’ agenda through Congress, voters be damned. Trump’s agenda is to loot everything not nailed down, or that his thieving spawn can pry loose. No point in the GOP’s hand-chosen ‘Chief of Staff’ trying to keep them in line, as the Saudi portion of the trip has made abundantly clear.