Thursday Morning Open Thread: The Common Clay of the New… Administration

(Drew Sheneman via GoComics.com)
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Old Republican voters: Why should we care if the world comes to an end? The only fun we can still enjoy is seeing young healthy people suffer!
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What’s on the agenda, as we count down towards the end of this supremely effed-up year?
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ZIKA, Medicaid and Risk Adjustment under block grants

And now for something really depressing:

The toll that Zika virus takes on pregnancies appears to be even higher than was previously estimated, with a newly updated study from Brazil suggesting that 42 percent of infants infected in the womb may have significant birth defects.

When the authors factored in stillbirths and miscarriages suffered by women who had been infected with Zika, 46 percent of pregnancies were affected. Microcephaly — a condition in which babies are born with smaller than normal heads — was seen in only about 3 percent of babies in the study.

“Microcephaly is just the tip of the iceberg. It’s definitely not where the focus should be,” said Dr. Karin Nielsen-Saines, the paper’s senior author. “For every case of microcephaly you’re probably going to have 10 cases of other problems that haven’t been recognized.”

In the United States, roughly half of all births are covered by Medicaid. Medicaid and CHIP cover a good number of kids and these two programs cover a disproportionate number of children with significant, expensive life long conditions. 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.

We know that treating and caring for an individual with microcephaly will have a lifetime cost of $10 million dollars. Other neurological and cognitive conditions will have lower lifetime incremental costs but these individuals will cost more than their non-Zika effected peers. We know that state Medicaid budgets will cover a high proportion of these individuals. If Zika is not quickly isolated and reduced to a random outbreak here and there and instead is endemic, we have a serious Medicaid financing crisis at hand if the federal funding is transformed into a block grant.

The Medicaid block grant procedures would give states a fixed head payment for each enrollee. It could vary by category of assistance and a few other criteria but the fee would be flat within subgroups by the number of enrollees. From here, the states could have the choice to top-up the Federal match or spend state supplied money in other manners. This is different from the current system where the Feds give the states an open ended funding stream that is a state specific multiple of the state contribution. The block grant removes the variability of the federal spending commitment. In the Ryan plans, it also shrinks in terms of real purchasing power over time so states either spend more money to maintain current level of enrollment and services or cuts to enrollment and services have to occur.

And here is where there is a problem. The capitated payments would be based on average expected costs in year 1 and then get weaker. States with disproportionate clustering of high cost conditions will be significantly worse off. Long run Zika neurological impairments will hit warmer states’ Medicaid budgets much harder and more disproportionally than Zika will hit cold weather states’ Medicaid budgets. This could be adjusted for by having a Zika bump in the block grant calculation much like there could be a diabetes bump or a maternity bump or any other number of risk adjusted bumps to capitation payments. But what happens when there is a new high cost and very concentrated disease that will have major impact on a few states’ Medicaid budgets? The block grant system fails unless there is a side payment of new federal funds. And given the political fights over natural disaster relief bills and the Zika bill, I have a hard time seeing Congress routinely providing multi-billion dollar cash infusions to a few states for new diseases or threatening epidemics.








Death spirals all around

We’re going to see how the Republican Party can create a death spiral in the individual market in sixty days or less. They have a few choices:

US Individual Market Policies

First Philip Klein in the Washington Examiner wants to create one the old fashion way:

In contrast, Republicans could immediately freeze enrollment — allowing those who already have insurance through Obamacare to continue receiving subsidies, but preventing new enrollees from receiving any (though they’d still be free to purchase insurance on their own if they aren’t seeking subsidies). The current open enrollment period for privately-administered insurance ends on Jan. 31, so that would be a natural cutoff point.

Do you know who is extremely likely to buy community rated, guaranteed issue insurance with a subsidy? People who are very sick.
Do you know who is extremely unlikely to buy community rated, guaranteed issue insurance without a subsidy? People who have reason to believe they are very healthy.

This proposal will get the individual insurance market to look like the individual markets from the mid-90s in the non-subsidized, non-mandated guarantee issue states. Super high premiums and very sick risk pools. And since insurers set their 2017 rates with the assumption that subsidies are available for Special Enrollment Members, they will lose a lot of money.

Means #2 is just pulling the Cost Sharing Reduction subsidies. Insurers will flee the market. The American Academy of Actuaries have their hair on fire as they look at the impact of Congress not funding Cost Sharing Reduction subsidies after January 20th.

Eliminating CSR reimbursements could also cause insurers to withdraw from the market Premiums for 2017 have been finalized, and they assume that CSR reimbursements will be made. Without those reimbursements, premiums would have been higher for all individual market enrollees. Regardless of whether CSR reimbursements are made to insurers, the ACA requires insurers to provide cost-sharing subsidies. If those reimbursements are not made, premiums will be too low to cover the costs of care. This creates the potential for insurer losses and solvency concerns. Due to contract provisions, insurers would be permitted to withdraw from the market if CSR reimbursements are not made.

Splitting the a Replacement Bill into discrete and seperate chunks will also death spiral the market:

The issue is the popular stuff (guarantee issue, no pre-existing conditions, community rating etc) will get 85 votes in the Senate and 400 in the House. The unpopular stuff (participation enforcement mechanism, definitions, subsidy attachment formulas) won’t get a majority as no one really wants to vote for either a mandate tax OR continuous enrollment criteria without being able to point to a lot of other good stuff enabled by the bad stuff.

So again we’ll get the mid-90s markets of guarantee issue, community rating for only very sick people.

The Urban Institute models out the impact of Repeal without immediate replacmement and it is ugly:

It is mostly a cost shift with massive extraneous suffering.

And that is where I think we’re heading.

So if you have an Exchange plan, I would try to get any problems that I was putting off on taking care of taken care of by January 31, 2017. After that the insurance markets will most likely be extremely chaotic and volatile with a decent tail risk of all carriers pulling all products in a number of states by early spring.








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.)



Listen To Someone Who Knows Something About The Shitgibbon’s Mentor

Masha Gessen knows from vicious fascist dictators.  Here’s what she has to say under the headline “Autocracy: Rules for Survival“:

I have lived in autocracies most of my life, and have spent much of my career writing about Vladimir Putin’s Russia. I have learned a few rules for surviving in an autocracy and salvaging your sanity and self-respect. It might be worth considering them now:

Rule #1: Believe the autocrat. He means what he says….

Rule #2: Do not be taken in by small signs of normality.

[See Betty’s post below]

Rule #3: Institutions will not save you….

Rule #4: Be outraged

Rule #5: Don’t make compromises

Rule #6: Remember the future….

ozymandias_collossus-_ramesseum_luxor_egypt

This is one of those read-the-whole-thing deals.  Masha has lived what she’s talking about here.  I have had the good fortune to spend some evenings talking with her, and she is at once one of the sharpest, most un-bull-shit-able political thinkers I know and among the most courageous people I’ve ever met.

If you don’t have time, or, like me, have only a finite tolerance for looking straight at the beast looking back at us, here’s the short form, as stated in Rule 4:

If you follow Rule #1 and believe what the autocrat-elect is saying, you will not be surprised. But in the face of the impulse to normalize, it is essential to maintain one’s capacity for shock. This will lead people to call you unreasonable and hysterical, and to accuse you of overreacting. It is no fun to be the only hysterical person in the room. Prepare yourself.

That leads to the logic of Rule 6:

Nothing lasts forever. Donald Trump certainly will not, and Trumpism, to the extent that it is centered on Trump’s persona, will not either. Failure to imagine the future may have lost the Democrats this election. They offered no vision of the future to counterbalance Trump’s all-too-familiar white-populist vision of an imaginary past. They had also long ignored the strange and outdated institutions of American democracy that call out for reform—like the electoral college, which has now cost the Democratic Party two elections in which Republicans won with the minority of the popular vote. That should not be normal. But resistance—stubborn, uncompromising, outraged—should be.

I expect we will lose most battles for years to come. Perhaps all of them.  ETA: Fuck that noise.  The comments below decrying defeatism are right.  We’re going to win a bunch.  Not everything, and people will get hurt, badly.  But Republicans are already over reaching.  They’re fuck-ups and we’ll be able to take advantage of the openings they provide.  See this from David Cole for a little hope.  Which is why I keep coming back to Masha’s conclusion — say no, and keep on saying it — and see it as a pocket-guide-for-the-perplexed.

I’ve more to say, as I think towards what specific forms my resistance may take, but none of that’s really formed yet, beyond giving some money to some of the most obvious targets.  More later.  In the meantime, what Gessen says:  Trump will not last forever, and resistance is many things — but not futile.

Image: the Ozymandias Colossus — Raames II, mistakenly identified as the mythical king Ozymandias.  This ruin inspired Percy Bysshe Shelly to write this.