Wednesday, July 01, 2015

The president's left hand

In response to those who paint Richard Nixon as a master of liberal domestic policy, Elizabeth Drew cites his approach to formation of the Environmental Protection Agency:
He’s given credit for signing into law several bills to improve the environment, including establishing the Environmental Protection Agency. But in fact, Nixon wasn’t very interested in the subject and he fobbed it off on his aides to handle, saying at one point: “Just keep me out of trouble on environmental issues.” He privately called the then-rising environmental movement “crap” for “clowns.” 
That jogged a memory.  according to Nick Kotz in Judgment Days: Lyndon Baines Johnson, Martin Luther King, Jr. and the Laws that Changed America, shortly after the Kennedy assassination, LBJ met with U.S. ambassador to Vietnam Henry Cabot Lodge and told him, "I am not going to lose Vietnam."  Afterward,

Last laugh for Republicans in the SCOTUS session that was

Democrats were still in their happy dance over Supreme Court decisions preserving ACA subsidies and legalizing gay marriage throughout the U.S. when, in its final orders of the year, the Court agreed to hear cases poised to gut pubic unions and affirmative action.

In Friedrichs v. California Teachers Association, ten California teachers are challenging a requirement that they pay fees to the teachers union for nonpolitical services, chiefly collective bargaining. That's the type of provision that Scott Walker killed in Wisconsin; without it, pubic sector unions wither. As Mark Joseph Stern at Slate points out, "there is virtually no chance" that the Supreme Court will rule against the teachers:

Monday, June 29, 2015

An add-on health benefit for same-sex couples who marry

Jay Hancock of Kaiser Health News notes that the Supreme Court decision granting same-sex couples the right to marry in any state is likely to boost employer coverage of same-sex couples:
The logic is simple. Fewer than half of employers that offer health benefits make the insurance available to same-sex partners who aren’t married. Virtually all of them offer coverage to spouses.

By marrying partners with employer health plans, people in same-sex relationships are likely to get coverage in states that banned gay marriage until now, as well as in those that welcomed it. Thanks to rapidly shifting legal ground, 37 states recognized gay marriage before last week’s ruling, up from nine in 2012.
Footnote: as-yet-unmarried gay employees whose employers do currently offer health insurance to partners will, if they marry, be able to get that coverage on a tax-free basis.

Saturday, June 27, 2015

Obama's eulogy for Clementa Pinckney was also autobiography

Obama's eulogy for Clementa Pinckney yesterday was, among many other things, a compressed autobiography -- or spiritual autobiography, a review of what life has taught him. It sent me back to the remarkable Chicago chapters of Dreams from My Father

When I first read that book, in maybe 2007, I wondered, could a man with this experience and orientation really be president of the United States? Six years into that presidency, it seems no less remarkable. Three strands of the experience recorded there struck me as being compressed into yesterday's speech.

First was Obama's ode to empathy, his tribute to the connection that comes from truly listening to people. Second, the extent to which in his engagement with people on Chicago's South Side he'd taken the full measure of the devastation wrought by institutional racism. Third, his discovery of the community of black churches as the most powerful resource for countering those ravages. In each of those themes there were echoes of his personal narrative.

Obama was in a sense speaking about himself, or rather, speaking from personal recognition and memory, in this tribute:

For my own scrapbook...

I swore off Scotusblog on Thursday morning, but a couple of minutes after 10 the time startled me and over I went just in time, and...

Thursday, June 25, 2015

My call on King

I hope I don't end up thrashing myself for wishful thinking, but I think the Supreme Court will rule for the government in King -- no odds on whether it's Chevron deference (the law is ambiguous, and the IRS interpretation is reasonable) or that the law's intent to provide subsidies to all states is unambiguous. I would hope that my bias -- I think the case is a fraud -- is balanced by superstition --an unwillingness to predict what I wish (overridden by being asked, as part of a list).

I can't wrap my mind around both Roberts and Kennedy agreeing to a) blow up the economy and b) credit the plaintiffs' bogus narrative that Congress intended a form of coercion that no one recognized and that the law does not spell out (a state only gets premium subsidies if it establishes its own exchange).  On both counts I take some reassurance from the dissent as well as the majority opinion in NFIB v. Sebelius, the challenge to the ACA's constitutionality ruled on in 2012.

The dissent in that case shows both thorough awareness of the interdependence of the ACA's core provisions and a wariness of causing massive economic disruption:

Wednesday, June 24, 2015

A quarter of those who stand to lose ACA subsidies should be in Medicaid

Greg Sargent and Charles Gaba have been pointing out repeatedly (after a prompt from Jonathan Cohn) that the majority of private plan buyers who stand to lose their subsidies if the Supreme Court rules in favor of the King plaintiffs are in Republican congressional districts. I have noted that most of them are low income -- 83% of private plan buyers have incomes below 250% of the Federal Poverty Line (FPL). That may affect the degree to which Republicans consider them constituents.

There's an irony in that low income profile. In states that refused to expand Medicaid, all but one of which rely on, private plan enrollments were swelled by those who would have been at the upper end of Medicaid eligibility if their states had accepted the expansion.  In expansion states, residents with incomes below 138% FPL are eligible for Medicaid, and eligibility for subsidized private plans begins at that threshold. In states that refused the expansion, eligibility for private plan subsidies begins at 100% FPL; all those with incomes below that level are left out in the cold.

In states using that expanded Medicaid, 34% of enrollees had income under 150% FPL.  In states that refused to expand Medicaid, 50% had incomes below 150% FPL. I have calculated that some two thirds of them would have been Medicaid-eligible had their states expanded. That estimate may be low: in Pennsylvania, which refused the Medicaid expansion in 2014 but implemented it in 2015, CMS determined about half of 2014 enrollees had incomes that would qualify them for Medicaid in 2015 (that is, incomes between 100 and 138% FPL).

Polling reflects the ACA's tough tradeoffs

A couple of thoughts* about Kaiser's recent analysis of its most recent survey of those who bought their insurance in the individual market in 2015, on exchange or off-exchange, ACA-compliant or not. To review some key points first (some from the original survey report, others from the analysis):

Tuesday, June 23, 2015

For ACA marketplaces, the near-poor have been the sweet spot

The just-released National Health Interview Survey for 2014 confirms that the chief beneficiaries of the ACA private plan marketplaces were those defined by the survey as "near-poor," with incomes between 100% and 200% of the Federal Poverty Level (FPL).

The NHIS found that among near-poor adults aged 18-64 (those with incomes from 100-200% FPL),
the percentage who were uninsured decreased from 38.5% to 30.9%, the percentage with public coverage increased from 26.6% to 29.6%, and the percentage with private coverage increased from 36.4% to 41.2% between 2013 and 2014. 
In states that expanded Medicaid, those with incomes up to 138% FPL became Medicaid-eligible -- hence the substantial rise in those in this income group with public insurance. But the jump in private insurance is really substantial, By comparison, private coverage for adults 18-64 with incomes over 200% FPL rose  from 81.2% in 2013 to 83.9%, and for the poor, from 19.0% to 21.9%* (while public coverage for the poor rose from 42.4% to 46.6%).

Monday, June 22, 2015

Why the ACA remains unpopular, cont.

Over at the Huffington Post, Jonathan Cohn has teamed up with pollster Mark Blumenthal for a deep dive into why the ACA's approval ratings remain underwater* and why more people continue to say that the law has personally harmed than helped them (though the gap had narrowed. to 22-19 when Kaiser last polled this question in March).

There are two main takeaways: 1) polling results are overwhelmingly partisan, and Republicans are more passionate in their hatred of the law than Democrats are in support of it, and 2) Americans tend to attribute any changes in their health plans -- usually price hikes or coverage cutbacks -- to the ACA. That's especially true of people with employer-sponsored insurance, a third of whom said they'd been hurt by the law.**

While those conclusions are spot-on, and Cohn and Blumenthal provide a nuanced overview of the ACA's effects on various groups, I'd like to throw one sidelight and add a couple of caveats.

First, the sidelight. Noting that the largest category of those who say the law hurt them say it drove their costs up, Cohn and Blumenthal suggest that the perception is not accurate: