Open Thread – When I make a word do a lot of work like that, I always pay it extra…

I love words, despite the indignities I enforce upon them, so I relish a little bit of grammar geekery.

Geoffrey K. Pullum has a wonderfully nasty post up at Lingua Franca and a wonderfully wonky post up at Language Log, both discussing an article by Washington Post blogger Alexandra Petri.

Petri piles on poor old Bill Keller (isn’t being married to Emma punishment enough for you jackals?), not only for being a concern troll and a horrible human being but, worse still, a blatant and premeditated user of “passive constructions” in his writing. As Petri puts it:

Concern trolls thrive on passive constructions the way vultures thrive on carcasses.

Pullum wonders whether Petri might be getting her “passive” confused with her “obscured agency”, and details his analysis in the Language Log post. There are tables and numbered lists. It’s great fun.

Pullum also links to his tutorial essay which provides a “clear and simple explanation of what a passive clause is” in English, and his forthcoming article Fear and Loathing of the English Passive (pdf):

No folk rhetorical property could yoke together this diverse array of constructions. What is going on is that people are simply tossing the term ‘passive’ around when they want to cast aspersions on pieces of writing that, for some ineffable reason, they don’t care for. They see a turn of phrase that strikes them as weak in some way, or lacks some sort of crispness or brightness that they cannot pin down, and they call it ‘passive’ without further thought. And such is the state of knowledge about grammar among the reading public that they get away with it.

If concealed passives dipped in a little bit of scorn are your thing, then that will keep you entertained for a while.

Meanwhile, in segues, music. Sunday is Australia Day, and one of Australia’s proudest traditions – besides pretending to have invented pavlova*; meat pies; footballers in tiny shorts; dispossessing indigenous peoples; and shipping coloured people back where they came from – is the Triple J Hottest 100. Voting on the best music releases for 2013 has ended, but if you feel like an Aussie weekend, tune in online at 12 noon Sunday Sydney time (Saturday evening for most of you).

You may have to crank up the thermostat and buy some Australian beer to get you in the mood. Think James Boag or Little Creatures. Please don’t buy Fosters, because it is watered-down mule piss.

Cheers, buckeroos. I’m off to bed, for there is to be much drinking today, so that we’ve got a headstart on Sunday. I’ll post a post at Hottest 100 kickoff time for anyone who wants to listen along.

ETA: * Edited for accuracy

EATA: Jesus, you’re going to turn me into Greenwald.

Petri probably was using the term “passive construction” in some rhetorical sense to mean “hiding behind the alleged views of others”, but that means she was being unclear, and exposing herself to the argument that she didn’t know what the term meant. I’m a writer who agonises over every word (and I still manage to fuck up half my posts). I try to use words in a way that avoids confusion, and Petri wasn’t doing that.

I agree, however, that that doesn’t mean she deserves to be called a nincompoop.

EOATA: It is, of course, entirely possible that Ms Petri is, in fact, a nincompoop.

At this stage, I’m just enjoying typing “nincompoop”.

On Target

The big news in the healthcare world was that Target Corporation would stop offering health insurance to part time workers effective 4/1/14.  Over the long run, this is good policy news. 

Here is the Minnesota Star Tribune:

The Minneapolis-based retailer will give each worker $500 to help buy health insurance, and has arranged for one-on-one consultations with benefits manager Towers Watson to help with the transition….In the article, Kozlak acknowledged the disruption to workers. But she said the exchanges might offer options that some workers will prefer, and noted that those who qualify for subsidies and tax credits could find insurance that is less expensive than their current plan offered by Target….

Target, the nation’s second-largest discount retail chain, said less than 10 percent of its workforce of about 361,000 participates in the health plan for part-time workers….

The change goes into effect April 1, the company’s normal open-enrollment period. It will affect those who average 20 to 31 hours a week.

Health policy wonks across the political spectrum have at least a shared common stated goal of decoupling employment from health insurance over the long run.  Companies don’t want to be health insurance purchasers and managers, people don’t want to be tied to a job because that is the only place they can get health insurance and the federal government does not want health insurance tied to employment for tax reasons.  It is a massive economic and societal distortion that should be facilitated away. 

Target’s plan to shift 35,000 people to the Exchanges is the first of many companies deciding that it does not want to be the health insurance point of contact when an adequate or better replacement is available.  This was part of the plan of PPACA as the Exchanges in 2014 were overwhelmingly built for individuals and very small companies, by 2017, they are able to be open to any employer group. 

And honestly speaking, most of the people who are no longer eligible to renew their plan at Target because Target is not offering it will be better off.  Assuming an average wage of $10 an hour and a full work year, the income ranges from $10,500 to $16,750.  In expansion states, that is the sweet spot of the Medicaid expansion so people will be getting very low co-pay insurance and a $500 bonus from Target.  In non-Expansion states, this a little messier.  If the person is single, the vast majority of people are subsidy eligible, and can get cost-sharing assistance Silver plans with a very significant subsidy.  If the person is trying to insure a family, they might be stuck due to fucking Chief Justice Roberts et al as their income (if this is a sole source of income for the family) is too high for legacy Medicaid but too low for subsidies.  I am hoping Target is thinking this through to make sure these people are no worse off. 

Over the long run, we should expect to see more employers put their employees on the Exchange either directly by no longer offering coverage and paying the employer mandate fee OR by giving their employees a subsidy to buy insurance on the SHOP exchanges in the next couple of years.  And from a policy perspective, this is a good to very good thing.

Good news everybody

Covered California is reporting some good enrollment numbers for coverage effective February 1st.

And the preliminary total of enrollments in Covered California health insurance plans from Oct. 1, 2013, through Jan. 15, 2014, has increased to more than 625,000….

Covered California™ and the California Department of Health Care Services (DHCS) announced today that 500,108 Californians enrolled for health insurance and selected plans through the end of 2013

 soaring past November’s enrollment of 78,377…

California added 125,000 individuals between January 1st and January 15th to Exchange plans.  These people will receive coverage starting February 1st. 

I want to pick out a couple of important notes.  First, enrollment is deadline driven so a significant drop-off between enrollment before Dec. 24th and Jan. 15th was expected.  Secondly, if I am reading the statement correctly, the 125,000 people signed up only signed up in January, so it is a monthly pace of a quarter million people or 8,000 people a day.  That is more than triple Covered California’s November pace.  Covered California did not have significant website issues suppressing the enrollment in November.

And now onto some extrapolations and suppositions:

1) Doing a linear population weighted extrapolation, the February 1st coverage national cohort could be a million or more people.

2) I’m betting the risk pool for Covered California got a little bit healthier and a little bit younger than the 4th quarter 2013 enrollment risk pool.

3) I’m also betting narrow networks were more frequently chosen.  This is a bet based on the assumption that people with the highest known healthcare needs have mostly already signed up.  These people had pre-established relationships with providers and they’re willing to pay extra to keep those relationships intact.  If the risk pool is younger and healthier, fewer people will have frequent contact with the medical care system, so more people will be shopping primarily on price instead of network.

4) February 20th to March 15th will be massive.

Narrow networks and price takers

A regular commenter asked me a good question via e-mail this morning:

This morning on my local NYC public radio station, there was a call in segment regarding  the cost of polices on the exchanges coming in lower than anticipated. A woman caller, claiming to be a physician, was stating that she would not buy her coverage on the exchange, because the payment rates to providers was less than what is paid, if she buys her insurance directly from the provider. (Blue Cross.) She also stated that a significant number of doctors will not accept the exchange coverage policies as a result of the lower levels of reimbursement. If this is true….

This is true.  This is the provider side of low cost narrow networks. 

Wonkblog has a good explainer on narrow networks from the patient point of view:

Narrow networks are health insurance plans that place limits on the doctors and hospitals available to their subscribers…

Less choice in a health plan typically means lower premiums. First, the insurance plan can decide to only sign contracts with the hospitals that charge lower prices…

Narrow network plans have become increasingly popular in recent years, growing from 15 percent of the insurance plans that employers offered in 2007 to 23 percent in 2012….

approximately 70 percent of the exchange plans are either narrow or ultra-narrow plans, according to a study by McKinsey and Co. The consulting firm defined “narrow” as having at least 30 percent of the 20 largest hospitals in the geographic region not participating

Pricing and indepdendent quality metrics are at best minimally correlated.  Narrow networks can be both cheap and effective at delivering high quality health care.  They can also be cluster-fucks, but that is not a function of narrowness per se. 

So how does a network go from being a broad network to a narrow network.  Let me take Mayhew Insurance as an example.  We offer two networks on the Exchange.  The first is our regular commercial network minus a few idiosyncratic opt-outs.  It is 99.8% of our regular network.  Since we are including everyone, we don’t have a ton of pricing leverage as the providers know we are the price-taker in this case.  We’ve offered our standard commercial rates which range from Medicare plus 20% to Medicare plus 125% depending on specialty, location and group size/clout. 

The other network is Mayhew Narrow.  This is a network that is 47% of the general network.  The way that the network was assembled was that we set a price that we would pay at Medicare plus a smidgen (highly technical term right there).  Company reps went out to the general network and asked if they wanted into the Exchange network at Medicare plus a smidgen.  This allowed us to be price-makers as a company.  The first round produce a network that was almost good enough to sell.  A second pass at a slightly better smidgen went to several selected specialty groups that filled out the network to a point where the sales people thought we could sell a broad enough network at a low enough price point. 

There are a lot of providers who aren’t in Mayhew Narrow but are in Mayhew Big.  Most of those providers are out for one of two reasons.  The first is that they were willing to take Medicare plus a smidgen but did not have admitting privileges to hospitals that were also willing to take Medicare plus a smidgen and were unwilling to get privilges at a Mayhew Narrow hospital.  The second is a provider or their finance manager looked at Medicare plus a smidgen and laughed at the number. 


Family composition and subsidies

I’m late to this as this weekend’s kerfluffle about marriage and poverty rates.  Let me start with the appropriate level of snarking from Lawyers, Guns and Money:

Speaking of conservatives who want to pretend to talk about inequality while not actually talking about it, Edroso finds this gem from Kathleen Parker:

Obviously, marriage won’t cure all ills. A single mother could marry tomorrow and she still wouldn’t have a job. But in the War on Poverty, rebuilding a culture that encourages marriage should be part of the arsenal.

See, if you want to make it to the real big leagues, it’s better to let snarky critics refute your smarm than just doing it yourself.  I’ll leave the rest to Roy:

There are strong arguments for actual long term gains from marriage in that two people and two close-tie support networks provide for a system of shock absorbers and support that one person can’t easily match, but a decent chunk of the “marriage” gain is a coding artifact of how poverty is federally defined.  This coding error does lead to some people having an incentive to not get married.  This is not unique to Obamacare, it is an artifact of any progam that relies on federal poverty guidelines and household size. The first person in a family unit has a federal poverty level of $11,490.  Each additional member of a family unit adds $4,020 in 2013.  This arrangement assumes Ozzie and Harriet nuclear families with signficant economies of scale.  It does not account for co-habitating long term relationships .

When I first moved in with my long term girlfriend and future wife, we filed separate tax returns.That year, we were both under the federal poverty level as individuals because we were grad students.  If we had married that year for love or health insurance we would have been significantly over the poverty level for a family unit of two.  Yet, there would have been no additional resources available to us.  We still would have been broke. 

My friends Annie and Beth  have been together for almost as long as my wife and I have been.  They’re not married as our state is governed by bigots. Last year,  Annie did not work too much as she was laid off at the start of the year, and then took time to take care of her mother.  Beth worked all year and did well for herself. Beth has insurance through work, and her work offers domestic partner benefits for employees who live in bigot states (SSM states benefits only extend to married couples for Somewhat Evil Medium Size Corp), so Annie was covered as well.  However, Annie went on the Exchange and since she had minimal income and is not married, she qualified for a very large subsidy and Silver cost-sharing assistance.  If the two of them were in a federally recognized marriage, she would not have qualified for any subsidies for two reasons.  First, one person in the marriage had access to affordable employer provided health insurance. Secondly, the combined income of the family would have been over 400% of federal poverty line.  These corner cases do exist, and it is an artifact of how poverty is defined in America. 

A marriage neutral poverty measure that somehow looked at household size and characteristics of the relationships between the people in the household so that two committed adults with significant ties between them (financial, longevity of relationship, cats etc) would be an improvement.  Such a marriage neutral poverty measure would treat Annie and Beth the same as my wife and I and it would remove some perverse incentives.  It would be an administrative bear to set-up as it would have to differentiate the roommate relationship I had with one of my best friends in college when I lived with her for two years.  We  split the bills and I argued ferociously against buying a bunny for anything other than dinner.  This must be differentiated from  a long term romantic relationship with my girlfriend, then fiancee and now my wife.  The simplest take might be a formula where Adult Value is a constant so the poverty level would be Adult Value+Adult Value + X(kids value) instead of the current Single Adult value+X(related others) formula where the Adult Value is someplace around the current Single Adult value.

Health outcomes over health outlays

The Hill reports on a proposal that is floating in Congress to change Medicare payment methodologies that has an unusual and perhaps effective set of sponsors behind it:

New legislation from Sens. Ron Wyden (D-Ore.) and Johnny Isakson (R-Ga.) and Reps. Erik Paulsen (R-Minn.) and Peter Welch (D-Vt.) would attempt to improve care for chronically ill seniors by revamping how their providers are paid.

Under the bill, voluntary “Better Care” plans and practices would specialize in treating patients with multiple chronic conditions. In return, they would receive specially tailored payments that reward good outcomes.

AARP backed the legislation in a statement, noting that 75 percent of healthcare dollars are spent on chronic disease.

“It is important to better coordinate and improve the quality of care for these individuals … rather than to just ask individuals to continue to pay more for their healthcare,” said AARP Legislative Policy Director David Certner in a statement.

The proposal seems to be a low strings attached capitation model with risk adjustments based on member age and pre-exisiting health conditions.  The AP has some more details: Read more

Pareto Principle and effectiveness, efficiency and equity

Most medium to large companies have some type of wellness program.  That wellness program is part of the major medical group health insurance.  It ranges from the annoying reminders to take the stairs and team weight loss events to significant disease and condition management.  The more aggressive wellness programs will often tie money to participation.  Some will charge smokers an extra $50 a month in premiums, others will offer a much lower deductible to individuals who have gone for a primacy care/obgyn well visit in the past year, and others will have a complex reward matrix. 

The evidence as to whether they work in either saving costs or improving health has been mixed.

Aaron Carroll at JAMA Forum has a nice article on wellness programs that highlights an important policy point:

Many companies believe that these programs have the potential to improve health and by doing so, reduce spending in such a way as to make them cost effective.

Whether they actually accomplish these goals is not well understood. A review of randomized controlled trials found that they had no significant effect on blood pressure, blood sugar, or cholesterol. Another such review found that lifestyle programs that seek to improve weight and activity saved little, if any, money. But this has not slowed enthusiasm for wellness programs in the private sector: they account for about $6 billion a year in spending….

The overall result, which will please proponents of wellness programs, is that the program reduced health care spending by $30 per member per month, or $360 per year. For every dollar spent, $1.46 was returned in savings. This, of course, sounds great. Who wouldn’t want such a program? But a further analysis showed that things were not so simple. The disease management component accounted for almost all of the savings. Those who participated in that part of the program saw a reduction in health care costs of about $136 a month, or more than $1600 a year. This was driven largely by a 29% decrease in hospital admissions.

In fact, for each dollar spent on disease management, the company saw a return of $3.78. For each dollar spent on lifestyle management, they only saw a return of $0.48. In other words, lifestyle management cost more than they saw in return. [bold and italics mine]

This is not surprising, it is the Pareto Principle or the 80/20 rule in action.  Most costs, and most benefits are attributed to a small portion of a population. 

Now let’s ask the interesting questions, can a targeted disease management program for employer sponsored health insurance be created that is effective, efficient and perceived to be equitable?

Read more