Come for the politics, stay for the snark.

Come for the politics, stay for the snark.

My right to basic bodily autonomy is not on the table. that’s the new deal.

They’re not red states to be hated; they are voter suppression states to be fixed.

It’s a new day. Light all those Biden polls of young people on fire and throw away the ashes.

Tide comes in. Tide goes out. You can’t explain that.

They think we are photo bombing their nice little lives.

You can’t attract Republican voters. You can only out organize them.

The fundamental promise of conservatism all over the world is a return to an idealized past that never existed.

It’s not hopeless, and we’re not helpless.

Polls are now a reliable indicator of what corporate Republicans want us to think.

You can’t love your country only when you win.

Republicans don’t lie to be believed, they lie to be repeated.

I know this must be bad for Joe Biden, I just don’t know how.

Republicans can’t even be trusted with their own money.

Jack be nimble, jack be quick, hurry up and indict this prick.

In after Baud. Damn.

A snarling mass of vitriolic jackals

Chutkan laughs. Lauro sits back down.

You don’t get rid of your umbrella while it’s still raining.

Sitting here in limbo waiting for the dice to roll

My years-long effort to drive family and friends away has really paid off this year.

If you tweet it in all caps, that makes it true!

Is it irresponsible to speculate? It is irresponsible not to.

Whoever he was, that guy was nuts.

You are here: Home / Archives for David Anderson

I am a student in the doctoral program at the Duke University Department of Population Health Sciences. I am working towards my my doctorate in Health Services Research with a policy focus. I am fundamentally fascinated by insurance markets, consumer choice and the navigation of complex choice environments. I'm currently RA-ing at the Duke Margolis Center for Health Policy.

I used to be Richard Mayhew, a mid-level bureaucrat at UPMC Health Plan. I started writing here and have not found a reason to stop.

Conflicts of interest: Previously employed at UPMC Health Plan until 12/31/16. I also worked full time as a research associate at the Duke University Margolis Center for Health Policy. I have received direct funding from the National Institute for Healthcare Management, and I have been on projects funded by the Rockefeller Foundation, Kate B. Reynolds Charitable Trust, Gordan and Betty Moore Foundation, Duke University Health System, CMMI, and various value based payment consortiums. I serve as a consultant on a grant from the Commonwealth Fund and have acted as a consultant to several ACA insurers.

Research Production is here: https://scholar.google.com/citations?user=zof9b4IAAAAJ&hl=en

David Anderson has been a Balloon Juice writer since 2013.

David Anderson

Preach it

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Commenter Emerald:

HaHaHaHa! I’ve been without coverage for nearly 13 years. (Took care of my Dad for 10 of those).

I qualify for the “Enhanced Silver” plan in California. Cheapest for me would be $3 per month for an HMO. Most expensive would be $159 for the Anthem Blue Cross HMO.

But unless my doctor is in that $3 plan (he might be–he takes more insurance than most), I’ll be deciding between the $94 Anthem EMO or Blue Cross PPO at $122.

Without the subsidies these all would be from $679 to well over $700 per month.

And I’m turning 63 in Dec and have been diagnosed with gallstones.

Commenter MomSense:

Just went to ObamaCare and filled in the information and I am going to get insurance much cheaper. Was paying 1,600 a month for years because I have a pre-existing condition and then because of some life changes I couldn’t afford it anymore so have been waiting and praying to be healthy until I could sign up. Starts at $243 a month so now I am going to decide on the plan! I can manage this!!!

Commenter BotSplainer:

I looked at Kentucky’s exchange. I can insure 4 of us (eldest daughter living away undoubtedly qualifies for enough subsidy to bring her a separate policy under $100) for somewhere between $850 and $950. Even if I get no tax credit at all,…. we’ll get a plan that has a $1500 deductible for the same price as our current tub of shit with a $15000 deductible.

This kind of plan has never been available to me at rates like this. Also, it ensures that my youngest daughter is insurable (she would never pass underwriting on the individual market – a biopsy…

Preach itPost + Comments (86)

Wave around the Waiver

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In the previous post, there were a couple of good questions about the Arkansas Medicaid “private option” waiver.  The big one is would the Bronze plans on the Exchange be effectively useless to someone making 75% of FPL as they could not even look at the co-insurance and deductible as plausible payments.

Here is a bit more news on the Arkansas waiver (amazing what happens when one read’s the application!)

Arkansas will be submitting a SPA in addition to the submission of waiver requests for this Demonstration which includes eligibility limits for the newly covered population, updated cost-sharing requirements and the state’s selection of an ABP. Consumer cost-sharing obligations under the Demonstration will be identical to those under the State Plan for all individuals receiving the ABP. The SPA describing the ABP will include the cost-sharing design for all individuals receiving the ABP. As will be described in the SPA, Private Option beneficiaries with incomes below 100% FPL will not have cost-sharing obligations in year one of the Demonstration; Arkansas plans to submit amendments to the waiver to implement cost-sharing for Demonstration participants with incomes from 50-100% FPL to be effective in years two and three of the Demonstration. Individuals with incomes of 100-138% FPL will be responsible for cost-sharing in amounts consistent with both the State Plan and with the cost-sharing rules applicable to individuals with comparable incomes in the Marketplace. . For individuals with income between 100-138% FPL, aggregate annual cost-sharing will be capped at 5% of 100% FPL ($604 for 2014). Providers will collect all applicable co-payments at the point of care. QHPs will monitor Private Option beneficiaries’ aggregate amount of co-payments to ensure that they do not exceed the annual limit.

Let’s break it down.

  • Year 1, people under poverty line won’t have any cost-sharing.
  • Year 2 and 3 people under poverty line will have some cost sharing.
  • People over poverty line but MA eligible will have cost sharing up to 5% of federal poverty line. 

§ 1902(a)(17): To permit the State to provide different delivery systems for different populations of Medicaid beneficiaries. The State is not requesting a waiver of comparability with respect to benefits, eligibility, or cost-sharing.

Earlier in the waiver, Arkansas is making a big deal about dealing with churn as its justification for the “private option:”

Continuity of coverage – For households with members eligible for coverage under Title XIX and Marketplace coverage as well as those who have income fluctuations that cause their eligibility to change year-to-year, the Demonstration will create continuity of health plans and provider networks. Households can stay enrolled in the same plan regardless of whether their coverage is subsidized through Medicaid, CHIP (after year one), or Advanced Premium Tax Credits.

I think this is a good policy justification for this option.  We know that income variance is high at the bottom of the economic scale.  Some people could have a good couple weeks of overtime at working that knock them out of one program to another, or someone who had just missed qualifying by $22 a week now qualifies after they lost the Thursday morning shift.  People shifting between dissimilar plans and dissimilar networks and different providers are a problem because the continuity of their care (to use a highly technical term) sucks. 

 

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Arkansas waiver news

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CMS approved a waiver for Arkansas for Medicaid expansion. Instead of doing the mechanically simple thing of just expanding Arkansas Medicaid for individuals up to 133% of poverty line, Arkansas will engage in premium support. Individuals who are newly qualified for Medicaid in Arkansas will get a voucher to buy a policy on the Exchange.

The Hill blog:

Under the waiver, Arkansas will expand Medicaid to cover individuals whose income is less than 133 percent of the federal poverty line — the expansion contained in the Affordable Care Act.

But rather than placing those newly eligible residents on traditional Medicaid, Arkansas will offer them private coverage. Residents will be able to buy the private healthcare plans offered in the state’s insurance exchange — the other half of ObamaCare’s coverage expansion.

Iowa, following Arkansas’s lead, has already proposed a similar waiver, and state officials have said Arkansas’s plan could serve as a broader model.

This is big news with a couple of levels if implications:

Arkansas waiver newsPost + Comments (35)

First, as a purely technocratic wonk, this is asinine.  It is reinventing the wheel and adding some right angles to the second prototype for the hell of it.  Medicaid has a system for enrollment that is scaleable and a set of providers who are willing to take it.  Premium support will lead to the ineffecient use of a couple billion federal dollars over the next ten years.  It will also lead to the waste of a few hundred million Arkansas dollars.
However, screw that.  This is a political exercise that will make sure that tens of thousands of people who otherwise would not have gotten coverage will get coverage.  A 8% or 10% inefficiency tax that allows people to benefit from Obamacare without calling it Obamacare is a net societal win.  Furthermore, since it now builds in a layer of middle men that have minimal real value, there is a rentier class in Arkansas that will now be interested in keeping their income stream.  A new advocate for Medicaid will be created which will make Medicaid sustainable in Arkansas.
Furthermore, several other states (Indiana and Iowa) have applied for very similar waivers from CMS.  I think they will get the same waiver in the next couple of weeks.  Pennsylvania’s expansion request will not be going through the same expedited approval.  Pennsylvania wants to do a premium support model, but Gov. Corbett also wants to do some serious poverty shaming and lifetime limitations on both expansion and current Medicaid populations.  I don’t think that waiver request has been filed yet, nor do I think that we can draw any conclusions from the Arkansas waiver to the Pennsylvania plan.

To think, to drink and to waste some ink

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An ode to quarterbacks as well as an analysis as how great process does not always lead to great results…

Change and counters to changes

The structure of language and concepts dictating physical realities

Interesting piece on reference pricing and its impacts in California…

When too many choices are bad

To the extent that better decisions do lead to problematic risk selection other interventions, like additional subsidization, could address the problem. Nevertheless, it isvaluable to recognize that some degree of confusion can be harmful to consumers while playing a market stabilizing role.

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Premium bullshit

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The bullshitter ignores these demands altogether. He does not reject the authority of the truth, as the liar does, and oppose himself to it. He pays no attention to it at all. By virtue of this, bullshit is a greater enemy of the truth than lies are.

Harry G Frankfurt On Bullshit

 

Avik Roy is a premium bullshitter when he ‘analyzes’ the premium changes that an unregulated, underwritten market will produce and Obamacare.  Let me describe his ‘methodology’:

Our map compares the five cheapest plans available on the market today to the five cheapest plans available on Obamacare’s exchanges.

Let me give you some examples of the policies that he is using to argue rate shock:

Arkansas: $26 per month for a $25,000 deductible 23% applicants denied. 28% uprated.

Ohio:  $25,000 deductible, 19% denied, 17% uprated.

Yep, when the comparison is between get hit by a bus and then have the bus back up and run you over again  insurance and even Obamacare catastrophic coverage, the get hit twice by a bus insurance that significant number of applicants can’t get actual coverage, looks good. It is a product that does absolutely nothing for the few people that qualify for it.  Most will look at $25,000 deductibles and laugh as that is a bankruptcy just as a $250,000 medical bill is a bankruptcy.  Oh yeah, it also assumes the applicant is male as women will get higher rates.

 

 

 

 

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I aint got no Satisficing

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Satisficing is one of my favorite concepts and words. Yes, my name is Richard Mayhew and I am a nerd of unusual size.

And in a just world, satisficing and the related concept of bounded rationality would have made Milton Friedman a very smart, very interesting thinker who had some excellent things to say about the world around us and not the economic intellectual father of the current socio-political superstructure that is around us today.

Wikipedia has a good definition and example:

Satisficing, a portmanteau of satisfy and suffice,[1] is a decision-making strategy that attempts to meet an acceptability threshold. This is contrasted with optimal decision-making, an approach that specifically attempts to find the best option available. A satisficing strategy may often be (near) optimal if the costs of the decision-making process itself, such as the cost of obtaining complete information, are considered in the outcome calculation.

The word satisfice was given its current meaning by Herbert A. Simon in 1956,[2] although the idea “was first posited in Administrative Behavior, published in 1947.”[3][4] He pointed out that human beings lack the cognitive resources to optimize: we usually do not know the relevant probabilities of outcomes, we can rarely evaluate all outcomes with sufficient precision, and our memories are weak and unreliable. A more realistic approach to rationality takes into account these limitations: This is called bounded rationality.

And here is a good example:

Example: A task is to sew a patch onto a pair of jeans. The best needle to do the threading is a 4 inch long needle with a 3 millimeter eye. This needle is hidden in a haystack along with 1000 other needles varying in size from 1 inch to 6 inches. Satisficing claims that the first needle that can sew on the patch is the one that should be used. Spending time searching for that one specific needle in the haystack is a waste of energy and resources.
 

Another useful example is thinking about picking up an attractive person to hook up with as graphed against time at the bar.  Early in the night, individuals may be attempting to optimize the matching process and hook-up with the most attractive person who is willing to say yes to them.  As the night goes on and failure to score with the 10, the decision process changes until at last call, the decision is to hook up with whomever is willing to say yes.  This is slightly different than the decision process described in A Beautiful Mind bar scene, although all of the men in that scene were engaged in satisficing decision making.   

 

I aint got no SatisficingPost + Comments (46)