Come for the politics, stay for the snark.

“Perhaps I should have considered other options.” (head-desk)

“The defense has a certain level of trust in defendant that the government does not.”

The Giant Orange Man Baby is having a bad day.

Republicans do not trust women.

It’s pointless to bring up problems that can only be solved with a time machine.

They spent the last eight months firing professionals and replacing them with ideologues.

“A king is only a king if we bow down.” – Rev. William Barber

The real work of an opposition party is to oppose.

We do not need to pander to people who do not like what we stand for.

Authoritarian republicans are opposed to freedom for the rest of us.

A norm that restrains only one side really is not a norm – it is a trap.

Dear legacy media: you are not here to influence outcomes and policies you find desirable.

You are either for trump or for democracy. Pick one.

The media handbook says “controversial” is the most negative description that can be used for a Republican.

Dear Washington Post, you are the darkness now.

Republicans in disarray!

… gradually, and then suddenly.

Rupert, come get your orange boy, you petrified old dinosaur turd.

Let’s bury these fuckers at the polls 2 years from now.

These are not very smart people, and things got out of hand.

Optimism opens the door to great things.

Petty moves from a petty man.

Narcissists are always shocked to discover other people have agency.

Speaking of republicans, is there a way for a political party to declare intellectual bankruptcy?

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Still a Big Biden Deal

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The ACA turns five today, and it is still a big Biden deal.  The uninsurance rate has cratered, the growth rate of medical costs are now down to the level of general economic growth, and quality in the system is improving as Medicare has successfully begun to attach penalties for being ineffective.  These are all BBDs.

Right now, HHS estimates roughly 16.4 million more people have health insurance today than they did on on 3/23/2010.  This is an undercount as it neglects trend changes.  Before PPACA was signed, the trend was for more people to become uninsured every year.  If PPACa was not passed, we’re probably looking at 18 to 20 million more people without health insurance in that counterfactual universe compared to ours.

Is PPACA perfect? Hell no.  Is it a whole lot better than the pre-exisiting condition?  Hell yes.  Is it vastly superior to the Republican alternative of nothing but high income tax credits and race to the bottom deregulation, hell yes.

So our job is to understand why PPACA matters, defend it from the neo-feudalists and reactionaries, and figure out how to make it better.  But is still is a  Big Biden Deal.

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Wyden waivers and the CBO scores

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The Wyden Waiver (Section 1332 of PPACA) is an extremely interesting dare built into the Affordable Care Act that if the Republican Party was interested in policy, we should be hearing a lot about early prep work.  The dare is simple:

If a state can do as well or better in providing as good coverage to as many people at the same or lower cost as provided through the Exchanges but can do so in a different model, they can build out an Obamacare alternative effective 1/1/17.

The feds would kick in the entire expected sum of premium subsidies, cost sharing assistance subsidies and small business subsidies to the state.  The state could tweak benefit packages, get rid of the mandates, change essential health benefits and pay for those changes with the federal block grant.  Vermont had planned on a Wyden Waiver for its single payer plan that fell apart on the issue of transition costs.

The big constraints on a Wyden Waiver is that it had to be deficit neutral for the federal government and it had to be as good or better than the current Exchange model.

When PPACA was first scored by the CBO (March 20, 2010 report, Table 3), the CBO expected the Exchange and small business tax credits to cost $78 billion dollars in 2017.  That estimate has been steadily decreasing.  Now, the March 2015 baseline has an estimate of $73 billion dollars for direct coverage expansion costs on the Exchange.  Premium costs are still growing slower than expected and the CBO is starting to model that there has been a real and sustained slow down in medical inflation that is somewhat disconected from general economic conditions.

Innovating programs that can do the better with the same level of resources are far easier to pull off when the budget is fat.  My question is what does the declining net cost of coverage expansion through both lower unit cost and higher employer sponsored insurance uptake do to the feasibility of states that want to go the Wyden Waiver route?  A cheaper PPACA means the success zone’s lower boundary got higher and the entire zone got narrower.

 

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Good news everybody

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Via Think Progress:

For the first time in a decade, the number of people struggling to pay their medical bills has started to decline, according to a new survey released on Thursday by the Commonwealth Fund. …

Between 2012 and 2014 — as Obamacare’s main coverage expansion took effect — the Commonwealth researchers found that the number of people who had issues paying for health treatment dropped from 41 percent to 35 percent. Over the same time period, the people who skipped out on health services because they couldn’t afford them declined from 43 percent to 36 percent

Both of those numbers, in ideal societies, should be zero, but I’ll take a significant improvement and a massive break in negative trend to positive trend as a win.  This type of data is why I have very little patience for people who wanted to kill the bill in 2009/2010 in order to heighten contradictions for something better.  The people who wanted to kill the bill as they are either sociopaths, empathy stunted assholes or people figuring that they’ll come out on top so using scarcity and fear as a means of social coercian and control are who they are, but the heighten the contradictions folks wanted to inflict more pain when pain alleviation was achievable.

 

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Convergence

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The important thing to remember is that 2014 was a beta test year for Obamacare.  Some insurers went into the market with loss leader membership build strategies, others went in with a reasonable price sustainability model, others went in with a hyper cautious approach.  Some insurers had optimistic pricing models, others projected a much sicker enrolled population than they actually got. 

2015 is the first significant readjustment and the market is acting pretty much as we should expect markets for minimally differentiated products.  Plans that were underpriced are seeing their pricing go up, plans that are overpriced are seeing cost reductions.  It is almost like the market structure could work.

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Good news everybody

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From the Kaiser Family Foundation on employer sponsored health insurance:

　

The key findings from the survey, conducted from January through May 2014, include a modest increase in the average premiums for family coverage (3%). Single coverage premiums are 2% higher than in 2013, but the difference is not statistically significant. Covered workers generally face similar premium contributions and cost-sharing requirements in 2014 as they did in 2013. …

This is the private, off-Exchange market.  The big news here is that there is minimal change.  That is massive news after the disruption of 2014 coming into play with new community underwriting guidelines, and new requirements for benefits.  Not much of a change is a massive change.  Not much of that lack of change is directly attributable to PPACA in my mind unless you want to make an argument that there are some very nice positive spillover benefits from Medicare starting to pay for quality instead of quantity. 

More importantly, most of the total premium cost growth minimization is not coming through increasing cost-sharing.  Deductibles barely went up at the rate of nominal economic growth, and cost sharing is not too much more prevalent.  Instead, networks are getting narrower and very high cost providers are starting to be excluded. 

I know that Mayhew Insurance has been getting bombarded in the past 18 months from large self-insured employers for us to design and build custom networks for their employees.  We’ve always done that (our best selling commercial plan is a custom narrow network), but the amount of interets has perked up beyond that of just hospitals who wanted to build their own home host networks.  Big employers who sponsor bowl games and have hockey arenas named after them are in on narrower networks (these networks are 90% of the broad network) where the goal is to mainly dodge two and three standard deviations above regional pricing providers. 

IF these types of trends keep up for a couple of years, this is very good long term news.

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Friends Don’t Let Friends Vote Republican: Economic Stewardship edition

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From Forbes (sic!) this analysis of President Obama’s economic record as compared with Saint Ronaldus of Reagan:

Economically, President Obama’s administration has outperformed President Reagan’s in all commonly watched categories.

Preston_Dickinson_-_Factory_(c._1920)

Simultaneously the current administration has reduced the deficit, which skyrocketed under Reagan.  Additionally, Obama has reduced federal employment, which grew under Reagan (especially when including military personnel,) and truly delivered a “smaller government.”  Additionally, the current administration has kept inflation low, even during extreme international upheaval, failure of foreign economies (Greece) and a dramatic slowdown in the European economy.

That’s from Forbes contributor Adam Hartung, a business development and consultant kind of guy — i.e., no raging, card-carrying taker.  The whole piece is worth a look.

When you’ve lost Forbes…*

*which they haven’t, really — one drive by piece doth not an editorial campaign make.

Preston Dickinson, Factory, c. 1920

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Shocking news — people able to pay, pay

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More shocking news.  Obamacare is gutting another quintessential American industry that is a world leader without peer — medical debt collection.

Via Bloomberg:

HCA Holdings Inc. (HCA), the largest for-profit hospital chain, yesterday raised its forecast and reported a 6.6 percent drop in uninsured patients at its 165 hospitals, a reduction that grows to 48 percent in four states that expanded Medicaid, a top initiative of the Patient Protection and Affordable Care Act….

The law contributed as much as $13 million to LifePoint’s earnings in the second quarter, about 40 percent more than the company had expected, he said. People paying bills themselves, a proxy for the uninsured, represented just 4.8 percent of admissions, down from 7.1 percent a year earlier….

Shocking how making sure people have the ability to pay for medical care leads to them paying for medical care on time and close to the contracted rate.  The old system of haphazard payments stretched out over years leading to medical debt stress had to be superior because it created jobs for credit collection agencies to hound people for ridiculous fees, for hospital financial analysts to figure out how to smooth cash flow from good months to bad months, and for social workers to be busy as a medical emergency led to their clients entering a life emergency as every other thing that depended on decent health and pre-committed cash flows just got blown up.  Predictibability is a bad thing for all of these jobs.  We can’t have that as the extra couple of points of GDP spent on waste and passing the buck in healthcare means JOBS (TM) that will never be replaced by higher and better uses of people’s times.

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