Late Night Horrorshow: Zika Is Coming, Ready or Not

I’m probably gonna get dinged for chicken-littling, because hey, no Ebola outbreak happened in America, right? And yet… “White House Ebola response coordinator from 2014 to 2015” Klain’s Washington Post article:

The good news is that both the House and Senate have finally passed bills that would provide some funding to combat the Zika virus. The bad news is that this action comes more than three months after President Obama requested the aid. Moreover, the House bill provides only one-third of the response needed; pays for this limited, ineffective response by diverting money allocated to fight other infectious diseases; and necessitates a conference committee to resolve differences with the Senate bill, meaning we still do not know when any money will finally get through Congress to fund the response…

As befuddling as Congress’ refusal to approve funds for the Zika response is, perhaps even more of a mystery is why such approval is needed in the first place. If nature was threatening us with serious injury and evacuations via fire, flood or hurricane, the president could use his authority under the Stafford Disaster Relief and Emergency Assistance Act to provide immediate aid without waiting for Congress to act. The fact that epidemic “natural disasters” are the result of disease and not an earthquake or tornado should not constrain the federal government’s ability to provide a timely, comprehensive response…

Speaking of those damaged babies? Once the Zika virus gets established in “our” mosquitos, microcephaly is going to become yet another standard prenatal test for women in the afflicted areas. Or who’ve visited those areas. Or whose male partners were exposed to Zika, even months before the pregnancy. And by the time microcephaly can be diagnosed, it’s too late for a quiet ‘medical abortion‘ — women will need full surgical services, and most will have been visibly pregnant. It’s not going to be easy for ‘fundamentalist’ anti-choicers to find reasons to blame good married Christian white ladies in the Sunbelt for having been bitten by the wrong mosquito… but I’m sure they’re gonna try their damndest.
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Monday Morning Open Thread: Positive Thoughts

I’m sure Richard Mayhew will be along to tell us about this in much more detail, but this is good news. Per the NYTimes, “Immigrants, the Poor and Minorities Gain Sharply Under Health Act”

LOS ANGELES — The first full year of the Affordable Care Act brought historic increases in coverage for low-wage workers and others who have long been left out of the health care system, a New York Times analysis has found. Immigrants of all backgrounds — including more than a million legal residents who are not citizens — had the sharpest rise in coverage rates.

Hispanics, a coveted group of voters this election year, accounted for nearly a third of the increase in adults with insurance. That was the single largest share of any racial or ethnic group, far greater than their 17 percent share of the population. Low-wage workers, who did not have enough clout in the labor market to demand insurance, saw sharp increases. Coverage rates jumped for cooks, dishwashers, waiters, as well as for hairdressers and cashiers. Minorities, who disproportionately worked in low-wage jobs, had large gains…

Until now, the impact of the law has been measured mostly in broad numbers of newly insured people — about 20 million by the administration’s most recent account. But the Times’s analysis of census data from 2014, the first year the heart of the law was in full effect, provides a finely detailed look at who the newly insured actually are — by race, education, occupation, immigration status, and family structure…

“From the vantage point of the poor and working poor, Obamacare has been profound,” said Jim Mangia, president of the St. John’s Well Child and Family Center, a federally funded health clinic in South Los Angeles that has enrolled 18,000 new patients under the law, nearly all of them Hispanic or black and the vast majority in Medicaid. The clinic reported a 44 percent increase in cervical cancer screenings, a 25 percent increase in tobacco cessation therapy, and a 22 percent increase in the share of patients with controlled hypertension since 2014, the result, he said, of more patients having insurance.

Having insurance does not necessarily mean better health, but experts hope it could start to ease some of the worst disparities that have kept the United States close to the bottom of health rankings of rich countries…

Apart from cheering improvement, what’s on the agenda as we start another week?

Horror Movie Open Thread: Teach Screen the Controversy!

Zombie lies, they’re not just for economics any more! Per the NYTimes:

In a decision that has dredged up the widely debunked link between vaccines and autism, the Tribeca Film Festival plans to screen a film by a discredited former doctor whose research caused widespread alarm about the issue.

The film, “Vaxxed: From Cover-Up to Catastrophe,” is directed and co-written by Andrew Wakefield, an anti-vaccination activist and an author of a study — published in the British medical journal The Lancet, in 1998 — that was retracted in 2010. In addition to the retraction of the study, which involved 12 children, Britain’s General Medical Council, citing ethical violations and a failure to disclose financial conflicts of interest, revoked Mr. Wakefield’s medical license…

On Friday, Robert De Niro, one of the festival’s founders, said in a statement issued through the festival’s publicists that he supported the plan to show the movie next month, although he said he was “not personally endorsing the film,” nor was he against vaccination.

Mr. De Niro’s statement seemed to suggest that this was the first time he has expressed a preference that a particular film be shown at the festival.

“Grace and I have a child with autism,” he wrote, referring to his wife, Grace Hightower De Niro, “and we believe it is critical that all of the issues surrounding the causes of autism be openly discussed and examined. In the 15 years since the Tribeca Film Festival was founded, I have never asked for a film to be screened or gotten involved in the programming. However this is very personal to me and my family and I want there to be a discussion, which is why we will be screening VAXXED.”…

The plan to show the film has unnerved and angered doctors, infectious disease experts and even other filmmakers…

According to the festival’s website, “Vaxxed” will be screened only once, on April 24, the festival’s closing day. A talk with the director and the film’s subjects will follow.

An earlier version of this article suggested that perhaps Mr. de Niro intended to rebut the film during his talk, but that doesn’t seem to be what he’s planning, per Deadline:

[T]he TFF promotional material could easily be taken to endorse Wakefield’s cause. “Digging into the long-debated link between autism and vaccines, Vaxxed: From Cover-Up to Catastrophe features revealing and emotional interviews with pharmaceutical insiders, doctors, politicians, parents, and one whistleblower to understand what’s behind the skyrocketing increase of autism diagnoses today.” Also this: “The most vitriolic debate in medical history takes a dramatic turn when senior-scientist-turned-whistleblower Dr. William Thompson of the Centers for Disease Control turns over secret documents, data and internal emails confirming what millions of devastated parents and ‘discredited’ doctors have long-suspected.”…

One happy effect of De Niro’s statement, according to the LA Times: “The De Niro news does quell reports that actor Leonardo DiCaprio was involved in backing the film — as Wakefield apparently told reporters on a promotional cruise — and even may have been orchestrating its Tribeca screening.”

Bernie Sanders vs. the Magical Math Asterick

I know that every Repub candidate gets a free pass on “then a miracle happens” budget proposals, but that’s strictly IOKIYAR in my experience. From the NYTimes article:

With his expansive plans to increase the size and role of government, Senator Bernie Sanders has provoked a debate not only with his Democratic rival for president, Hillary Clinton, but also with liberal-leaning economists who share his goals but question his numbers and political realism.

The reviews of some of these economists, especially on Mr. Sanders’s health care plans, suggest that Mrs. Clinton could have been too conservative in their debate last week when she said that his agenda in total would increase the size of the federal government by 40 percent. That level would surpass any government expansion since the buildup in World War II.

The increase could exceed 50 percent, some experts suggest, based on an analysis by a respected health economist that Mr. Sanders’s single-payer health plan could cost twice what the senator, who represents Vermont, asserts, and on critics’ belief that his economic assumptions are overly optimistic.

His campaign strongly contests both critiques, defending its numbers and attacking prominent critics as Clinton sympathizers and industry consultants…

“The numbers don’t remotely add up,” said Austan Goolsbee, formerly chairman of President Obama’s Council of Economic Advisers, now at the University of Chicago.

Alluding to one progressive analyst’s early criticism of the Sanders agenda as “puppies and rainbows,” Mr. Goolsbee said that after his and others’ further study, “They’ve evolved into magic flying puppies with winning Lotto tickets tied to their collars.”

Adding $20 trillion to projected federal spending would mean about a 37 percent increase in spending through fiscal year 2026 — close to the 40 percent that Mrs. Clinton suggested. But Kenneth E. Thorpe, a prominent health policy economist at Emory University who advised the Clintons in the 1990s, recently concluded that Mr. Sanders’s health plan would actually cost $27 trillion, not $14 trillion, which would put total spending for all of Mr. Sanders’s initiatives above $30 trillion through 2026…

Mr. Thorpe in recent years helped Gov. Peter E. Shumlin in Mr. Sanders’s home state of Vermont to design a single-payer plan there. It was unsuccessful.

“The problem was that the price tag and the amount of disruption and redistribution was just so enormous,” Mr. Thorpe said of Mr. Shumlin’s efforts, “that he just had to drop it.”

More detail at the link. Again, I don’t have the math skills to argue that Sanders’ plan wouldn’t work — but, given the importance of this election, I don’t want to put the entire Democratic ticket at risk by giving the Media Village Idiots a bonus EvenTheLiberalEconomists! card, either…

Open Thread: Who Says Debates Don’t Get Results?

This seems significant, if only for the record books:

Officials at Concerned Veterans of America are lashing back at the two Democratic presidential frontrunners a day after both panned the group’s proposals in a national debate…

CVA has advocated restructuring the Veterans Health Administration as an independent entity and giving veterans more access to private care options with federal dollars, both radical shifts from the current system. But they reject the accusation that the plans amount to “privatization” of the department…

CVA officials have repeatedly declined to discuss funding sources and trustee information for the group, but numerous news reports have linked the group to the Koch brothers network of conservative activist organizations.

Both Sanders and Clinton — along with numerous mainstream veterans groups — have promised to fight privatization of VA services. CVA officials have said privatization and offering more health care choices are distinctly different things.

In a statement Friday afternoon, Democratic National Committee officials supported Sanders and Clinton.

“The jig is up,” said Eric Walker, spokesman for the DNC. “Vets shouldn’t be fooled by a right-wing front group whose main objective is not helping veterans, but electing Republicans like Marco Rubio, Jeb Bush, and others who support privatizing the VA.”

In recent months, CVA officials have held a series of town halls to discuss their reform proposals, which have sometimes doubled as campaign events for Republican presidential hopefuls…

Am I over-optimistic?

Another Democratic “Town Hall” Just Announced

Be careful what you wish for. Per CNN:

The Democratic presidential hopefuls will face voters in a CNN town hall on Monday in Des Moines — one week before the highly anticipated Iowa caucuses.

Former Secretary of State Hillary Clinton, former Maryland Gov. Martin O’Malley and Vermont Sen. Bernie Sanders will field questions from Iowa Democrats in this prime-time event hosted by the Iowa Democratic Party and Drake University…

The town hall, which will be moderated by CNN anchor Chris Cuomo, will air from 9 p.m.-11 p.m. ET, the network announced. A CNN spokesperson added that it will make the town hall available to its Iowa affiliates to air live.

Some of the enticing new-candidate aura may be leaking away from Senator Sanders, as it is. Ta-Nehisi Coates asks “Why Precisely Is Bernie Sanders Against Reparations?”

… For those of us interested in how the left prioritizes its various radicalisms, Sanders’s answer is illuminating. The spectacle of a socialist candidate opposing reparations as “divisive” (there are few political labels more divisive in the minds of Americans than socialist) is only rivaled by the implausibility of Sanders posing as a pragmatist. Sanders says the chance of getting reparations through Congress is “nil,” a correct observation which could just as well apply to much of the Vermont senator’s own platform. The chances of a President Sanders coaxing a Republican Congress to pass a $1 trillion jobs and infrastructure bill are also nil. Considering Sanders’s proposal for single-payer health-care, Paul Krugman asks, “Is there any realistic prospect that a drastic overhaul could be enacted any time soon—say, in the next eight years? No.”…

Speaking of Professor Krugman’s judgement…

[H]ere’s the thing: we now have a clear view of Sanders’ positions on two crucial issues, financial reform and health care. And in both cases his positioning is disturbing — not just because it’s politically unrealistic to imagine that we can get the kind of radical overhaul he’s proposing, but also because he takes his own version of cheap shots. Not at people — he really is a fundamentally decent guy — but by going for easy slogans and punting when the going gets tough.

On finance: Sanders has made restoring Glass-Steagal and breaking up the big banks the be-all and end-all of his program. That sounds good, but it’s nowhere near solving the real problems. The core of what went wrong in 2008 was the rise of shadow banking; too big to fail was at best marginal, and as Mike Konczal notes, pushing the big banks out of shadow banking, on its own, could make the problem worse by causing the risky stuff to “migrate elsewhere, often to places where there is less regulatory infrastructure.”

On health care: leave on one side the virtual impossibility of achieving single-payer. Beyond the politics, the Sanders “plan” isn’t just lacking in detail; as Ezra Klein notes, it both promises more comprehensive coverage than Medicare or for that matter single-payer systems in other countries, and assumes huge cost savings that are at best unlikely given that kind of generosity. This lets Sanders claim that he could make it work with much lower middle-class taxes than would probably be needed in practice.

To be harsh but accurate: the Sanders health plan looks a little bit like a standard Republican tax-cut plan, which relies on fantasies about huge supply-side effects to make the numbers supposedly add up. Only a little bit: after all, this is a plan seeking to provide health care, not lavish windfalls on the rich — and single-payer really does save money, whereas there’s no evidence that tax cuts deliver growth. Still, it’s not the kind of brave truth-telling the Sanders campaign pitch might have led you to expect…

Looks like Monday will be another long evening of liveblogging.

(Already up past my bedtime, so I won’t be here for you to argue with until this evening.)

The next Arkansas 1115 waiver

Arkansas is submitting another round of waivers for their private option Medicaid expansion.  There is one thing I don’t see CMS granting, and a couple of fights but the waiver as a whole is fairly straightforward.  The biggest problem with the waiver is that it is unnecessarily expensive.  Straight up Medicaid expansion would have been cheaper than paying providers Exchange rates but that has never been on the table.  As Arkansas needs to pay 5% and then 10% of the total expansion costs, switching back to a straight expansion would get increasingly attractive as a means of reducing the state government cost exposure.

So let’s look at the details:

    • Requiring individuals eligible for Medicaid to enroll in employer-sponsored insurance where available, with Medicaid covering employees’ costs that would exceed Medicaid levels

This is straight forward. Medicaid should be the payer of last resort, so if ESI coverage is available, it should be the primary payer. Medicaid will be used as secondary coverage to reduce cost sharing to no more than 5% of total income. Coordination of Benefits is an administrative pain in the ass, but this happens everywhere.

    • Requiring premium payments for beneficiaries with incomes above 100% of the federal poverty level, with a consideration of contributions for those with incomes above 50%.

CMS has approved 2% premium requirements for people making more than 100% FPL. This will get approved. Premiums for people making under 100% FPL are solely designed to force people out of the program as the administrative cost of collecting a $3 per person per month premium means there is no net payment by the individual for actual medical care.

    • The state would offer enhanced coverage and other incentives for those who comply and meet goals set in Healthy, Active Arkansas, a Hutchinson initiative encouraging wellness.

This is not a big deal, it is a wellness program that CMS has approved in other states. I don’t think it moves the needle all that much on cost or quality outcomes, but it does not hurt as long as participation is not mandatory.

    • Care coordination for medically frail individuals

This is a good thing in and of itself.

    • Verifying beneficiaries’ incomes through enhanced data matches.

This is an administrative back-end plumbing tweak. It will most likely be used to force marginal cases out of Expansion and onto the Exchanges. The state wants to look at more databases to build an income profile (food stamps, tax records, lottery winnings etc)

Here are some of the areas where I think fights will occur:

    • Eliminating the current retroactive eligibility that allows new beneficiaries to be covered for expenses incurred 90 days before they were enrolled.

Medicaid is assumed to be the payer of last resort and there is a presumption of eligibility. Medicaid in most states is not concerned about adverse selection problems as they assume that they are the dumping ground for adverse selection. Medicaid has a bad risk pool. The problem is Arkansas is trying to use an at risk insurance model for Medicaid where presumptive eligibility creates massive adverse selection problems. I could see CMS agree to a 30 day walkback from the date of application but not the elimination of presumptive eligibility.

    • Restricting coverage or requiring greater cost sharing by individuals with substantial assets.

Medicaid expansion’s only eligiblity requirements are citizenship (or 5 years of legal residency) and income. There are no asset tests in PPACA. I am having a hard time seeing CMS approving a waiver that institutes asset testing even if the threshold is a million dollars (ie the lottery winner who now does not work and is on Medicaid). If the goal of Expansion is to help the working poor, creating asset tests traps people in a narrow income range as they can’t afford a newer car, or they can not afford to save against expected but unknown shocks.

This is the area of straight up disapproval in my eyes:

    • Implementing work training referral requirements with a continued discussion with President Obama’s administration on specific work requirements.

CMS has been vehement against tying eligibility to work requirements. At the most, CMS has told states that they are free to set up and offer voluntary work training programs that are targeted at Medicaid Expansion populations with state money but eligibility is independent of work status.