Thursday, July 24, 2014

Could the ACA exchanges go the way of the Medicaid expansion?

If the D.C. Circuit panel ruling in Halbig stands, and the state exchanges currently run by the federal government are deemed unable to grant subsidies to health plan buyers who qualify for them under the ACA's criteria, Nicholas Bagley posits that "the states with federally established exchanges will come under enormous pressure to establish their own exchanges." The federal government could make it easy for them, Bagley suggests, essentially allowing them to decree that they've "established" exchanges while letting continue to run them.  Thus the ACA would likely prove indelible after all:
True, not every state would accept the invitation to establish its own exchange, even if doing so were more or less a formality. But lots of states would, especially as voters started to howl about losing their tax credits. If so, even a bad outcome in Halbig might not matter that much in the end.
That quasi-forecast recalls the argument that all states will ultimately come round to accepting the ACA Medicaid expansion, albeit in their own sweet time (Arizona, the last state to implement Medicaid itself, did so 17 years after Congress established the program).

While this thought might be expected to soothe ACA proponents, for me it had the opposite effect. The Medicaid scenario might provide cover for the Supreme Court to uphold the D.C. Circuit panel in Halbig.

When Chief Justice John Roberts held in June 2012 that the ACA's individual mandate exceeded Congress's power under the Commerce Clause but was a legitimate exercise of Congress's taxing power, he justified the recourse to "the Government's alternative argument" by citing SCOTUS precedent that “every reasonable construction must be resorted to, in order to save a statute from unconstitutionality.” He would not thwart Congress's intent by destroying the law's ability to function if he could avoid it.

He showed no such reluctance, however, with regard to the ACA's requirement that states expand Medicaid eligibility to a new class of beneficiaries or else stand to lose federal funding for their existing Medicaid programs. He deemed that requirement coercive, and was joined by six other justices in striking the requirement down and making the Medicaid expansion voluntary for the states.

Wednesday, July 16, 2014

Let them all in? Laying a thought experiment on top of a thought experiment

Jeff Spross of ThinkProgress thinks we should give all kids who arrive on our borders immediate legal status. Josiah Neeley of the Texas Public Policy Foundation responds (on Twitter) by dangling a bit of bait: "why not let in anyone who wants come? Spross suggests that the U.S. could handle the influx if it had to or wanted to. Neeley then asks, "How many do you think would come if we accepted anyone who wanted to come?"

This recalled me to a thought experiment that seems apropos, though I'm not sure why -- maybe because it suggests, indirectly, how much running room we have. Courtesy of James Fallows:
I mentioned yesterday that Thomas Barnett had given a realistic brief appraisal of China's strengths and weaknesses in an NPR interview. A point I particularly liked was this tip for comparing American and Chinese scale:

If Americans wanted to imagine what it would take to be "strong" in the way China currently is, he said, all we'd have to do is think of moving the entire population of the Western Hemisphere into our existing borders. Every single Mexican. (Rather than enforcing the southern border, we'd require everyone to cross it, headed north.) Every Haitian, Cuban, and Jamaican. Everyone from Central America. All 190 million from Brazil. And so on. Even the Canadians. China, by the way, is just about the same size as the United States, though a larger share of its land area is desert, mountain, or otherwise nonarable.

Monday, July 14, 2014

Winning asylum in the U.S.: imminent danger of death is not enough

Reading about the flood of children now arriving on U.S. shores from Guatemala, Honduras and El Salvador, those of us not well versed in immigration law might assume that children who can demonstrate that they will be in imminent danger of death from gangs terrorizing their home towns if deported will be granted asylum. That is probably not so.

Determinations of refugee status or asylum in the U.S. are governed by the Refugee Act of 1980, which derives its criteria from the Convention Relating to the Status of Refugees approved by the U.N. in 1951. To be granted asylum, an applicant
"must prove that he or she would be persecuted on account of one of five protected grounds: race, religion, nationality, political opinion, and social group."  
If the gangs in question are equal opportunity terrorizers, it's hard to see at first glance how those criteria would be met.

Sunday, July 13, 2014

The U.S. healthcare system, up my nostrils

If you'll bear with a brief personal medical narrative, I think it holds some lessons about overutlization and economic incentives in our healthcare system, though I'm not entirely sure what they are yet.

I've been plagued with nasal allergies all my life, and almost twenty years ago I also developed nasal polyps. The worst of the allergy symptoms moderated at about the same time, except when the polyps flared up, which would happen when I had a cold. On three separate occasions, I took steps to have the polyps removed surgically, which entailed taking the steroid spray Nasonex for a few weeks and the scheduling an operation. On each occasion I backed out of the operation. On each occasion, too, the Nasonex vastly improved my breathing, but I always went off it because I was under the impression it's bad to inhale a steroid indefinitely.

The last time I put this process in motion, in February 2012, I got some straight talk from the ENT doctor. Polyps and allergies require constant maintenance, he said. If I got the polyps removed, I'd have to stay on the steroid, and the polyps would likely grow back and have to be removed again. He convinced me that using Nasonex indefinitely would not be dangerous.

"Every time I go on Nasonex the polyps disappear," I said. "If I need to stay on the drug after I get the operation, what do I need the operation for?" He allowed that I had a point at wrote me a prescription refillable for a year.

Thursday, July 10, 2014

Bypassing, revisited

Just a brief teaser here, as I work to finish a reported story about different approaches to improving the shopping experience at and getting essential information to users.

I have caught up again with HealthSherpa, which began life as one of the first ACA comparison shopping sites to spring up while was dysfunctional last fall, then went on to become a licensed broker and go live last February as one of the first third-party sites to start enrolling people in subsidized ACA plans. As I reported at the time (or rather, added some explanation to an initial report by the Washington Post's Brian Fung), HHS licensed a number of brokers to develop "web-based entities" -- that is, their own dedicated interfaces on the government site -- and HealthSherpa did so.

Now, co-founder Ning Liang tells me that the company has completed almost 2,000 applications and  continues to streamline the process. Liang claims that a solo applicant can now complete an application in 3-5 minutes --  and a family plan applicant in 10-15 minutes.  HealthSherpa has made this possible partly by reducing the lag time following each completed question, and partly by eliminating redundancies. One key streamlining is that a user goes directly from the shop-around process, where one enters personal info and gets price quotes with plan summaries, to the application process, rather than starting over as on The info entered in the shop-around process is ported into the application process.

Tuesday, July 08, 2014

Whaddaya mean, you didn't know about the subsidy? --Improving

Once stopped crashing, how successful was it in transmitting the most basic information to most users -- how much they'd be likely to pay in monthly premiums, and how much in out-of-pocket costs they'd be on the hook for?

My sense from late December on was that the website's shop-around feature, enabling a user to get that basic information without registering or applying, worked reasonably well. I used it all the time to check premiums, deductibles and maximum out-of-pocket (OOP) costs for different ages, income levels and locations. You need to enter about eight pieces of information, including state and county, household size, household members' ages, and household income, to get a listing of available plans, ranked lowest premium to highest, and sortable by metal tier. Each plan summary clearly lists what you'll pay in premium, deductible and OOP max (if your income estimate is accurate). Cost Sharing Reduction (CSR) subsidies lowering deductibles and OOP, available to those earning under 250% of the Federal Poverty Level, are figured in.

And yet, many people who tried to use the site came away with no idea how much they would need to pay -- that is, how big a premium subsidy they eligible for, let alone CSR, or even that they were eligible for subsidies at all. A McKinsey study found that 72% of the respondents who reported that they shopped but did not buy were subsidy-eligible, and that 66% of subsidy-eligible respondents who cited perceived affordability as the reason they stopped shopping were aware of neither their eligibility nor the amount for which they were eligible. Their plight is illustrated by the tale of a newly retired Philadelphia cop who went online and concluded that insurance would cost her $800 per month, -- missing the subsidy that reduced the premium to $135.

Monday, July 07, 2014

One more Jewish Voice for Peace

Update 7/7: Haaretz, voice of what's left of the Israeli left, published an astonishing indictment of Israeli society and culture in a staff editorial today:

No less responsible for the murder are those who did not halt, with an iron hand, violence by Israeli soldiers against Palestinian civilians, and who failed to investigate complaints “due to lack of public interest.” The term “Jewish extremists” actually seems more appropriate for the small Jewish minority that is still horrified by these acts of violence and murder. But they too recognize, unfortunately, that they belong to a vengeful, vindictive Jewish tribe whose license to perpetrate horrors is based on the horrors that were done to it.

Prosecuting the murderers is no longer sufficient. There must be a cultural revolution in Israel. Its political leaders and military officers must recognize this injustice and right it. They must begin raising the next generation, at least, on humanist values, and foster a tolerant public discourse. Without these, the Jewish tribe will not be worthy of its own state.
That makes me feel moderate in my little manifesto, originally posted on July 4, below.
A personal note here that I have joined Jewish Voice for Peace, which "seeks an end to the Israeli occupation of the West Bank, Gaza Strip, and East Jerusalem; security and self-determination for Israelis and Palestinians; a just solution for Palestinian refugees based on principles established in international law; an end to violence against civilians; and peace and justice for all peoples of the Middle East."  JVP campaigns to induce organizations and investors to divest from companies that profit from the Israeli occupation of the West Bank.

As a Jew, I feel a vital chord is struck by the JVP assertion that "we are among the many American Jews who say to the U.S. and Israeli governments: 'Not in our names!'" Not in my name the land theft, the caging of people in cantons via roads to which they're barred access, the legal codification of second class citizenship, the rampant housing discrimination, the mass arrests and consequence-free killings, the disproportionate assaults and bombardments, and the enablement of all of the above by obscene amounts of military aid showered on a first-world country by a U.S. Congress and executive branch forever in the pocket of a toxic combination of Jewish and Evangelical Christian lobbies.

I note that JVP is noncommittal as to the form of a just resolution of the conflict between Israelis and Palestinians, and that's as it should be. If conditions change to a degree almost unimaginable at the moment, and an Oslo-type two-state solution becomes acceptable to both sides, who would gainsay it?  I have come to believe, though, that a just state in which citizenship is defined by religion and ethnicity is impossible. Ultimately, by course of nonviolent evolution -- perhaps in a hundred years -- I would hope that a single democratic state with no special status accorded to any religion or ethnicity might emerge in present day Israel-Palestine.

Nostalgic bullying

Andrew Sullivan relays complaints from three writers, Leon Wieseltier, Molly Worthen and Rod Dreher, who are uncomfortable with the DIY approaches to religion adopted by many Americans. Worthen expresses the nub of their common complaint. "An institution" such as the Catholic church
forces you to have, for at least part of your life, a respect for authority that inculcates the sense that you have something to learn, that you’re not reinventing the wheel, but that millennia have come before you.
The loss of such authority is in my view a good riddance. On the plane of dogma, it means that those who confuse their close analysis of the fantasies derived from ancient fables with actual knowledge are not fooling anyone but atavists like themselves. On an institutional level, we've learned, or should have learned, that those credited an authority alleged to derive from God are likely to abuse it.