Tuesday, December 31, 2013

Good news: HealthCare.gov's shop-only feature is now all you could wish

In the darkest days of HealthCare.gov's dysfunction, I was preoccupied for a time by the partial workarounds enabled by third-party informational sites like ValuePenguin and HealthSherpa. ValuePenguin in particular offered (and still offers) a near-complete and accurate substitute for the informational functions of HealthCare.gov: it will calculate your subsidy and show you all available plans, accurately priced, with plan summaries.

HealthCare.gov at first, famously, had no pre sign-in informational feature allowing users to scope out options if they could not register, as most couldn't. When that feature was hurriedly added, it at first referred people to the Kaiser subsidy calculator, rather than incorporating its own subsidy calculation. It also gave out misinformation, at least for me in New Jersey: failing to query about age, the site quoted prices at a middle-range age without disclosing that it was doing so. In my case, the quoted prices were half to two-thirds of the actual prices, which I found on ValuePenguin and confirmed with the insurers.

Monday, December 30, 2013

The Wall Street Journal's narrow view of narrow networks

I have see-sawed back and forth between respect for the Wall Street Journal's healthcare reporters and intimations that WSJ coverage of the Affordable Care Act has been skewed toward the negative.

Today's front-page story by Timothy Martin on the prevalence of "narrow networks" in plans offered on the ACA exchanges certainly emphasizes the negative -- without adequate context, in my view.

First, consider the broader context. News this weekend was full of "ACA signup surge" headlines: 1.1 million people have enrolled in plans via HealthCare.gov, and about 2 million overall have enrolled in ACA plans when state exchange totals (not yet fully tallied for the pre-Christmas surge) are added in.  That's well off original projections but signals a significant recovery and acceleration. Today's front-page Journal story is the first since these numbers came in, and mentions them only in passing.

Fair enough, perhaps. The story is about "narrow networks" -- ACA plans that exclude access to many doctors and hospitals within the coverage area. The narrative is built on a McKinsey study finding that 70% of silver plans offered on the ACA exchanges are "narrow" or "ultranarrow" as defined by the study: offering access to fewer than 14 hospitals.

Saturday, December 28, 2013

The ACA is killing off a college plague: junk student insurance

One type of junk health insurance that the ACA is doing away with is the kind of crappy policy that many colleges used to push on their students. (There is one loophole extended to Jan. 1, 2015, explained below.)  BusinessWeek exposed this scam in 2008:
More than half of the insurance plans recommended by colleges offer benefits of $30,000 or less, according to a survey published in March by the General Accounting Office, an arm of Congress. Many plans have further limits that prevent payout of even modest maximums. While two-thirds of the country's more than 17 million college students have coverage from a parent's employer or their own job, many of the rest may be vulnerable if they suffer a serious illness or accident. With premiums and restrictions increasing under employer-provided plans, a growing number of parents are shifting children to college-sponsored coverage. But "when a student gets gravely sick, $30,000 in benefits is unrealistically low," says Alan Sager, a professor at Boston University's School of Public Health.

Thursday, December 26, 2013

Free market visionary foresees healthcare apocalypse

Free market fundamentalist John H. Cochrane gave himself a Christmas gift on the Wall Street Journal op-ed page on Dec.25, allowing himself to anticipate the Affordable Care Act's certain imminent demise. Then, like a Left Behind acolyte imagining the apocalypse, he moved on to a vision of the new healthcare heaven and earth (liberally adorned with those free market halos, stock tickers):
We need to permit the Southwest Airlines, LUV -0.18% Wal-Mart, WMT +0.42% Amazon.com AMZN +0.95% and Apples of the world to bring to health care the same dramatic improvements in price, quality, variety, technology and efficiency that they brought to air travel, retail and electronics. We'll know we are there when prices are on hospital websites, cash customers get discounts, and new hospitals and insurers swamp your inbox with attractive offers and great service. 

The Affordable Care Act bets instead that more regulation, price controls, effectiveness panels, and "accountable care" organizations will force efficiency, innovation, quality and service from the top down. Has this ever worked? Did we get smartphones by government pressure on the 1960s AT&T T +0.30% phone monopoly? Did effectiveness panels force United Airlines and American Airlines to cut costs, and push TWA and Pan Am out of business? Did the post office invent FedEx, FDX +1.01% UPS and email? How about public schools or the last 20 or more health-care "cost control" ideas? 

Tuesday, December 24, 2013

An all-too-hidden benefit in ACA insurance

Eugene R. Anderson, a pioneer in insurance coverage litigation for policyholders for whose firm I've long worked, was fond of saying that insurance is a unique product. You pay up front, and you get what you pay for much later, if ever.

That's less true of health insurance than of most other forms of insurance, since we all need some healthcare in most years. But it's true of high-deductible health insurance.  And that may prove a problem for public perception of the Affordable Care Act.

Monday, December 23, 2013

What subsidy cliff? Jared Bernstein and Dean Baker defend the Affordable Care Act

I spent my last post peering over the edge at various points of the Affordable Care Act's subsidy cliff -- the income cutoff beyond which shoppers for health insurance are ineligible for subsidies.  I was prompted by a New York Times article spotlighting  who stand to lose most by this cutoff: middle aged and older, with incomes just over the line. In brief: if you're 27 and single, premium subsidies fade out gradually. If you earn one dollar more than the subsidizable limit, it may cost you $100 per year. If you're 55 and looking to cover a family of four, however, that extra dollar may cost you almost $9000 in subsidies.

While I had a couple of quibbles with the Times article, I thought it was fair.  The subsidy cliff is a real design flaw. A pair of 55 year-olds covering a 23 year-old son or daughter in New Jersey with an income of $79k shouldn't have to pay $1300/month for rather crappy insurance, which is what they would pay in Essex County, NJ.

I was somewhat taken aback, then, to discover that the fiery Dean Baker and the more mild-mannered Jared Bernstein both took rather furious issue with the Times article (by Katie Thomas, Reed Abelson, and Jo Craven McGinty). Baker's rhetoric is harsher than Bernstein's, but I think he does have a point. Bernstein's rebuttal strikes me as more of a reflex partisan pushback.* Take his opening salvo:

Sunday, December 22, 2013

The ACA's subsidy cliff for older buyers

The New York Times quite rightly highlights* the plight of older ACA exchange shoppers who fall over the "subsidy cliff"  -- that is, earn just enough to be ineligible for premium subsides but are subject to high premium prices because they're older.

The article's poster family is in the worst possible situation as far as the ACA is concerned: 50-something couple, two kids, no employer-based insurance, and an income just over the subsidy line. You could say they're not representative, because they're worst-placed -- but that, in a way, was the point. Winners and losers should not be separated by $1000 in annual income.

There is a serious flaw in the ACA subsidy formula. If you're young and single, subsidies taper gradually. If you're 50something, they fall to zero abruptly.  If you're fiftysomething with kids, they fall very abruptly. That's because premium prices (and thus subsidies) are higher for older adults, and subsidies (if you qualify) rise with each additional person covered by the plan. If there's three or four or five of you, and you don't qualify, you lose effectively three or four or five subsidies. It's primarily age that carves the cliff, though -- especially for two older adults.

Friday, December 20, 2013

Self-employed? That pre-ACA health insurance deduction is still there...

Self-employed and seeking health insurance? Call an accountant.

Everyone who's paying attention knows that shoppers on the ACA exchanges are eligible for premium subsidies if their income is under 400% of the Federal Poverty Level  (FPL) and the benchmark silver plan in their area would cost them more than 9.5% of their income (for young people in states with low premiums, subsidies may fade out somewhere under 300% FPL).

Equally important for those who qualify are additional subsidies to reduce deductibles and maximum yearly out-of-pocket costs. As I pointed out in a prior post, these subsidies have hard break points: they bump up at income levels of $17,235 and $22,980 and phase out at $28,775. Since self-employed "profit from business" is notably malleable, and since retirement contributions come off the Modified Adjusted Gross Income (MAGI) used to calculate subsidy eligibility, the low income self-employed are well advised to keep an eye on those break points.

There is in fact a third dip for the low-income self-employed -- and a longstanding major benefit for those with higher incomes. It's the self-employment health insurance deduction. If you're self-employed and buying insurance for yourself and/or your family on the individual market, you can deduct the full cost of the insurance from your MAGI. That is, if your self-employment income exceeds the cost of insurance after various other deductions:

Tuesday, December 17, 2013

If only Obama would say what he's never stopped saying. If only he would do what he's done.

Perhaps inevitably, at every political stress point liberals knock themselves out urging Obama to say precisely the things he's been saying nonstop since he first appeared on our horizon. The latest to succumb to the temptation is Michael Tomasky:
...politically I don’t think fairness is enough. Average Americans care about fairness, but not really all that much. People who have incomes comfortably above the median but who still aren’t rich are going to suspect that fairness means something is coming out of their hide. What they do care about, though, is growth. Everybody from Bill Gates to his janitor wants the economy to grow. So the case for these programs that Obama needs to make consistently going forward is not the case for their fairness, but the case that these policies, and not tax cuts for the wealthy or more draconian domestic budget cuts or less regulation, will promote growth.
Yup, if only Obama would say something like "in America, our prosperity has always risen from the bottom-up" and make the case that prosperity is not sustainable when inequality is rising. As he did in Raleigh, NH in June 2008:
We've done this because in America, our prosperity has always risen from the bottom-up. From the earliest days of our founding, it has been the hard work and ingenuity of our people that's served as the wellspring of our economic strength. That's why we built a system of free public high schools when we transitioned from a nation of farms to a nation of factories. That's why we sent my grandfather's generation to college, and declared a minimum wage for our workers, and promised to live in dignity after they retire through the creation of Social Security. That's why we've invested in the science and research that have led to new discoveries and entire new industries. And that's what this country will do again when I am President of the United States.
 And in Georgetown in April 2009:

Monday, December 16, 2013

The long and the short of income inequality

Ezra Klein made a splash a few days ago by arguing that Obama is wrong to call rising inequality the defining challenge of our time, asserting that jobs should take precedence: "Growth simply isn't producing enough jobs. This is a more severe and more urgent problem than inequality.

Today, Paul Krugman counters that inequality that the president was right -- first because stagnant incomes may have contributed to the debt crisis and are now depressing consumer demand, but more fundamentally, because the wealthiest have converted their disproportionate economic power into disproportionate political power, corrupting the country's ability to address its policy challenges.  The  the super-0rich, Krugman charges, triggered the financial meltdown by building a bipartisan consensus for financial regulation -- and have crippled the recovery by demanding austerity.

Klein's binary choice between addressing unemployment or austerity seems fundamentally mistaken to me, I would supplement Krugman's analysis with research by Peter Turchin (thanks, T. Greer), who has identified very long-term cycles of expanding and contracting inequality, and tied them chiefly to the supply of labor:

Saturday, December 14, 2013

Young, self-employed and seeking health insurance via the ACA exchanges? See an accountant

A good number of Americans who will be shopping for health insurance on the ACA exchanges are self-employed.  A 2007 Commonwealth Fund study found that 34% of buyers on the individual market for health insurance were self-employed (p.3). In 2012, about 15 million Americans were self-employed.

Doubtless many of the younger Americans subject to "rate shock" on the ACA exchanges are self-employed and earning enough to qualify for only small subsidies or none at all. For those who have not learned to max out on allowable deductions to reduce their taxable income -- e.g., everything from paper clips to home office space to computers, auto expenses and retirement fund contributions  -- the ACA adds new incentives -- in some cases powerful ones.

The ACA offers subsidies not only for premiums but for deductibles and maximum out-of-pocket (OOP) expenses. While the premium subsidies shrink at a steady rate per $1000 of income (and fade gradually to zero for a single young person), the break points for deductibles and OOP are sharper.  At some break points, a $1000 difference in reported income can mean a difference of thousands in medical expenses covered in a given year.

Friday, December 13, 2013

In which Ezra Klein shorts Avik Roy

ACA supporters are naturally ticked off that conservatives are now carping at the high deductibles and out-of-pocket maximums in many ACA insurance plans, most notably the bronze ones. Ditto for "narrow networks" -- a limited choice among doctors and hospitals.  The Dish has a precis of complaints from Jonathan Chait, Jonathan Cohn, Kevin Drum and Ezra Klein. Here's Ezra:
What's confusing about this line of attack is that high-deductible health-care plans -- more commonly known as "health savings accounts" -- were, before Obamacare, a core tenet of Republican health-care policy thinking. In fact, one of the major criticisms of Obamacare was that it would somehow kill those plans off. "Obamacare may be fatal for your HSA," warned the Heritage Foundation on 2010. "Health Savings Accounts Under Attack" blared Red State....

Obama's pledge that "if you like your doctor, you can keep your doctor" is also under fire. The issue here is that insurers entering the competitive health marketplaces are tightening their networks in order to cut costs and improve quality. It's worked: Premiums in the marketplaces are far lower than was expected when Obamacare passed.

 This, too, is a success for a longtime conservative health-policy idea..."Narrow networks are not some cruel attempt to limit patient choice foisted upon us by the insurance industry," write economists David Dranove and Craig Garthwaite. "Instead, these plans may provide our best opportunity for harnessing market forces to lower prices."
Fair enough. However, when Klein asks his old healthcare sparring partner Avik Roy to explain the apparent hypocrisy, he lampoons Roy's response without engaging its substance, which is perfectly consistent with Roy's longstanding attack line against the ACA. There are, I believe, internal contradictions in that attack line, and Klein has dealt with them elsewhere. But not here:

Thursday, December 12, 2013

The End of the End of History?

In The Origins of Political Order, Francis Fukuyama casts the history of the state as the history of the sovereign power's struggle to neutralize powerful subjects' (or citizens') biological imperative to pass their advantages on to their children  -- that is, the sovereign's attempts to neutralize the force of kinship ties, which are the means of building rival power centers. Sovereigns have come up with various ingenious means of checking the encroaching power of hereditary local elites, such as an exam-based civil service (China) or an imported elite slave class (Mamluk and Ottoman empires). The most successful and enduring of such means has been democracy, enabled by (and evolving from) rule of law and a strong state, wherein the majority retains the power to periodically trim or slap back back entrenched privilege.  Hence Fukuyama's faith, famously professed in The End of History, that a kind of Darwinian pressure of global competition would lead all states to embrace liberal democratic capitalism.

Recent years have dented that faith, however, as Fukuyama has come to fear that that other Darwinian pull -- of elites to pass their privilege to their offspring -- might batter down the walls of commonwealth.  Here's how he puts it in an article previewing his next book, Political Order and Political Decay, due out in September 2014:

Tuesday, December 10, 2013

Obama's Mandela: man of interior action

Some time ago, after James Fallows wrote that Obama's speeches are often memorable at the ideas level, but rarely at the phrase level, I responded:
Re that strange absence of memorable phrases: it's not just balanced by one strength, it's book-ended between two: conceptual complexity/coherence on the macro side, and cadence on the sub-micro. At least in 2007/2008, less so now, Obama's speeches were musical, hinging on repeat phrases (yes we can) and on the simplest of rhetorical devices, various forms of parallel structure, e.g. anaphora, the repetition of beginning words (also a lot of parallel phrasings in series -- "A man touched down on the moon, a wall came down in Berlin" etc.).  It was no accident that Will.i.am was able to set one of his speeches to music to some effect.
I heard this kind of music in Obama's eulogy for Mandela. It was a speech of strong cadences that gave shape to the speaker's thought. At his best, Obama is a prose poet, and today he was Mandela's poet.

Poet, not novelist. At the outset, Obama set himself a problem:

Monday, December 09, 2013

WSJ hits ACA from the left

Good reporters at the Wall Street Journal continue to bust the ACA's chops.  The likes of Louise Radnofsky, Amy Schatz, Timothy Martin and now Leslie Scism, who's been covering insurance for at least 15 years (and is also a news editor), are not going to get their facts wrong. But it remains fair to wonder whether the Murdoch-era news editorial regime is shaping the stories' emphasis [UPDATE: I have spoken to someone at the Journal, whose word I trust, who assures me that editors area not imposing a political agenda on reporters. I regret speculating about motive without information.]

Today, Scism and Martin spotlight something that has in truth troubled me as I explore offerings on HealthCare.gov and ValuePenguin:  the prevalence of high deductibles, particularly in bronze plans:
As enrollment picks up on the HealthCare.gov website, many people with modest incomes are encountering a troubling element of the federal health law: deductibles so steep they may not be able to afford the portion of medical expenses that insurance doesn't cover.
The average individual deductible for what is called a bronze plan on the exchange—the lowest-priced coverage—is $5,081 a year, according to a new report on insurance offerings in 34 of the 36 states that rely on the federally run online marketplace.

Friday, December 06, 2013

An early proponent of leading from behind

was Nelson Mandela, according to the New York Times obit (by Bill Keller):
In his autobiography, Mr. Mandela recalled eavesdropping on the endless consensus-seeking deliberations of the tribal council and noticing that the chief worked “like a shepherd.” 

“He stays behind the flock,” he continued, “letting the most nimble go out ahead, whereupon the others follow, not realizing that all along they are being directed from behind.” 

That would often be his own style as leader and president.
[Update via Smartypants, citing Mandela's biographer Richard Stengel: Mandela used the term directly:
Mandela loved to reminisce about his boyhood and his lazy afternoons herding cattle. "You know," he would say, "you can only lead them from behind." He would then raise his eyebrows to make sure I got the analogy.
[Update 2: Note that the original association of Obama with "leading from behind," in Ryan Lizza's New Yorker analysis of his foreign policy, incorporates the shepherding metaphor (and in Mandela's case, experience):
Nonetheless, Obama may be moving toward something resembling a doctrine. One of his advisers described the President’s actions in Libya as “leading from behind.” That’s not a slogan designed for signs at the 2012 Democratic Convention, but it does accurately describe the balance that Obama now seems to be finding. It’s a different definition of leadership than America is known for, and it comes from two unspoken beliefs: that the relative power of the U.S. is declining, as rivals like China rise, and that the U.S. is reviled in many parts of the world. Pursuing our interests and spreading our ideals thus requires stealth and modesty as well as military strength. “It’s so at odds with the John Wayne expectation for what America is in the world,” the adviser said. “But it’s necessary for shepherding us through this phase.”

The Times obit also stresses Mandela's supreme self-confidence:

Wednesday, December 04, 2013

Obama portrays a nation at risk in bid to reset national agenda

Obama gave a great speech today, focused on reversing rising income inequality, which he called "the defining challenge of our time." It's been a dispiriting autumn, and as Obama's returned to the bully pulpit in recent days I've thought that maybe I'm past getting keyed up as he cranks up the rhetoric.  But he didn't do that. He offered new thinking and reframed our political discourse. He expanded and refocused the narrative he's been developing throughout his political career.

The outlines of that narrative were familiar. Throughout its history, the United States has thrived because it's periodically widened the circles of opportunity, extended the means to pursue happiness to previously excluded groups, made new investments in shared prosperity. Around 1980, though, the country took a wrong turn, and the American dream is fraying.  As president, he will channel popularly willed recommitment to shared prosperity.

This time around, though, there were several differences. The stylized, compressed precis of U.S. history that's an Obama speech staple was focused more sharply on economic turning points.  The wrong turn of the last 30-plus years was ascribed in large part to global economic forces, in a sense depoliticized. The faith that political action will right the ship was tempered by a warning that rising inequality, unchecked, could take us to a point of no return.

Finally, an economic argument that sustainable prosperity depends on reversing the widening wealth gap was more fleshed out than ever before. I have never read a presidential speech that cited as many economic studies.  Those studies and a battery of stats were deployed to make several key points: that inequality is at an historic high point; that the U.S. lags other wealthy countries in economic mobility; that those born in poverty in the U.S. today are likely to remain locked in; that poverty is not just a "minority" problem but touches more than half of Americans at some point in their lives; and that rising inequality is a drag on growth.

About that "toothless" Dodd-Frank reform...

Dodd-Frank is widely written off as meek, weak and watered down by relentless bank lobbying.  Perhaps it is in many respects. But the long-unfinalized and tortuously complex Volcker Rule, largely eliminating the banks' proprietary trading and in-house hedge and private equity funds, has already had significant effect, as the WSJ's Scott Patterson recounts:

Regulators aren't expected to start strictly enforcing the Volcker rule until 2015, giving banks some breathing room. Because the rule was widely anticipated, most banks already have done away with operations focused on proprietary trading, or making bets with their own money.

For example, Goldman shut down in 2010 its Principal Strategies in-house trading unit, partly as a response to the looming Volcker rule. Last month, Goldman Chairman and Chief Executive Lloyd C. Blankfein outlined other steps being taken by the New York company to comply with the Volcker rule, including "winding down our hedge-fund investments."
Moreover, the relative hawks in the contentious five-agency rule-writing process, most notably outgoing CFTC Chair Gary Gensler, seem to have in large part prevailed on key issues in the rule's pending finalization next week:

Friday, November 29, 2013

Against gratitude

[repost]

Okay, not really. But I am personally uncomfortable with overt expressions of gratitude, and while I think this is mainly an emotional limitation on my part, there may be at least the ghost of a reasonable caveat in it.

As a teenager, I took a slightly unsavory pleasure in the science fiction of Robert Heinlein.  He not only entertained but also influenced and repelled me. He once wrote (through a character) that there was something sick at the heart of German civilization, and whether that's true or not, I think that the sickness he condemned clings to him, in a kind of gleeful authoritarianism. At the same time, some fragments of his cracker barrel wisdom stayed with me. One of his quirks, voiced by various favored characters, is an aversion to gratitude. As I recall at this distance, he cast it as a power play of the weak, a form of toadying, or guilt masquerading as love.  I think he's wrong to reduce gratitude to those impulses, though gratitude is certainly alloyed with them.  In a similar vein, though, he ridiculed worship, asking why an omniscient, omnibenevolent  God would require the saccharine praise of human beings. That was the question that really stuck with me. It gets at the heart of gratitude, since worship is mainly an expression of gratitude to God.

Such gratitude is -- should be -- a spontaneous expression of love. That's how those who voice it understand it.  But why does it express itself in "saccharine" praise?  In a Thanksgiving post, Andrew Sullivan's Dish suggested an answer:

A caveat for Ezra Klein

[updated, with a rather large caveat to the caveat...]

..who has a cogent set of questions about how well HealthCare.gov will be working as of Dec. 1 and going forward.  On one key question I think there's a moderating factor:
9. Where the Dec.1 deadline really matters is for people who've already had their plans canceled and who need to be able to sign up for a new one in time for it to start on Jan.  1. If the Web site isn't working smoothly for these people in the next week or so it'll be an utter disaster when 2014 comes and many of these people find themselves uninsured and some get sick.
Most people subject to policy cancellations in the individual market are probably not eligible for subsidies, since they've already found insurance affordable. That means they don't really need HealthCare.gov.  They can easily get complete information about their options on ValuePenguin and then sign up directly with an insurer. [UPDATE: I'm afraid my premise here is severely compromised; William Ocasio reminds me that a recent Families USA study found that 71% of those currently in the individual market are below 400% of the Federal Poverty Level, and thus potentially eligible for subsidies. In practice, though, many people above about 270% FPL are not subsidy-eligible -- you only get a subsidy if the full cost of the benchmark silver plan exeeds a benchmark percentage of your income, and plan prices vary pretty widely from market to market. Still, probably more than half of those subject to cancellation are in fact eligible for at least some subsidy.]

Those who have received policy cancellations and are eligible for subsidies will need to get a subsidy application processed by hook or crook (that is, by online, phone or print application to the federal government) by Jan. 1. If they can't, I would imagine that some kind of retroactive subsidy payment will have to be worked out, after a lot of angst. For what it's worth, the subsidy-eligible probably won't be subject to rate shock, unless they're at the very top end of the scale, where the subsidy can shrink to near nothing.

Related:
Bypassing HealthCare.gov, cont.
Who needs HealthCare.gov?

Thursday, November 28, 2013

"People analytics" should lead to better pay in all jobs

Anyone who reads Don Peck's deep dive into new advances in "the algorithmic assessment of workers' potential might be in varying degrees excited and disturbed by new means of predicting, assessing and improving performance. My chief reaction went in a different direction. The tests potentially highlight the huge performance differential in any type of work -- and hence, the value of good performance:
Teri Morse, the vice president for recruiting at Xerox Services, oversees hiring for the company’s 150 U.S. call and customer-care centers, which employ about 45,000 workers. When I spoke with her in July, she told me that as recently as 2010, Xerox had filled these positions through interviews and a few basic assessments conducted in the office—a typing test, for instance. Hiring managers would typically look for work experience in a similar role, but otherwise would just use their best judgment in evaluating candidates. In 2010, however, Xerox switched to an online evaluation that incorporates personality testing, cognitive-skill assessment,

Tuesday, November 26, 2013

Just what is the United States retreating from?

I have a problem with the way Mark Landler frames recent Obama administration diplomatic activity -- the scheduling of a Syrian peace conference as well as the interim agreeement with Iran:
At one level, the flurry of diplomatic activity reflects the definitive end of the post-Sept. 11 world, dominated by two major wars and a battle against Islamic terrorism that drew the United States into Afghanistan and still keeps its Predator drones flying over Pakistan and Yemen. 

But it also reflects a broader scaling-back of the use of American muscle, not least in the Middle East, as well as a willingness to deal with foreign governments as they are rather than to push for new leaders that better embody American values. “Regime change,” in Iran or even Syria, is out; cutting deals with former adversaries is in.
To call these initiatives "a broader scaling-back of the use of American muscle" seems to me a distortion of historical US foreign policy norms. Regarding Iran: when has the U.S. ever imposed military muscle to halt another country's (professedly peaceful) nuclear program?  It is only the bluster of the neocons -- the crew who blundered into Baghdad -- and of a Congress always eager to show fealty to Netanyahu that makes a preemptive strike at Iran seem like a kind of default response to that country's nuclear program.

Monday, November 25, 2013

Bypassing HealthCare.gov, cont

In prior posts, most recently here, I have explored the possibility that shoppers for health insurance on the ACA exchanges might bypass the still-balky HealthCare.gov with the help of information-only comparison sites ValuePenguin and HealthSherpa. Customers ineligible for a federal subsidy can already easily get all the information they need on these sites and then enroll directly with an insurer. For those whose incomes entitle them to subsidies, however, the subsidy application has been the roadblock, as it must be submitted directly to the federal government, either through HealthCare.gov or via phone or print application.

That may be about to change. Kaiser Health News' Julie Appleby reports, "Insurers and the Obama administration are testing fixes to healthcare.gov designed to allow insurers and web-based brokers to directly enroll consumers who qualify for subsidies under the health law."  It appears, though that the fixes require insurers themselves to route the customer's application through HealthCare.gov -- that is, in the 36 states that have forced the federal government to run their exchanges.  Direct insurer processing of the subsidy application is still only an ask:

Sunday, November 24, 2013

C.S. Lewis: Joymongerer, democrat by default, less repressive than many of his critics, amateur philosopher

In honor of the 50th anniversary of C.S. Lewis' death on November 22, anappreciation that I agree with in toto:
I think Lewis was so compelling because, first, he was incomparable at evoking "joy" as he defined it. Whatever idea and yearning for "heaven" I ever had came from Narnia. Second, I think he had an intuitive -- not theoretical -- grasp of psychology -- he was one of those people who reads his own mind so well, he knows a good deal about how all human minds (and wills and emotions) work.The bickering of the children in The Magician's Nephew, Eustace's redemption in Dawn Treader, the seeds of human hatred elucidated by Screwtape -- and above all, the parental love turned to jealous gall in Till We Have Faces -- his greatest imaginative leap and rendition of the romance of the soul --have a kind of easy, intimate verity that give his spiritual dramas life.

At the same time, when it came to doctrine and apologetics, I think he was an unwitting sophist -- an honest sophist, if that makes any sense, because he fooled himself first...

Thursday, November 21, 2013

Red states' ACA exchanges: lab or slab?

Austin Frakt has launched a multi-post-and-tweet campaign arguing that the Affordable Care Act is an essentially conservative chassis amenable to conservative reform, and that conservative healthcare wonks should be aiming to mend it, not end it. (Subtext: they'd be doing just that  if they were not playing for Team GOP.)

The penultimate post in the series dangles conservative wonk-bait via a list of potential reforms in ascending order of disruptiveness to the current ACA structure, e.g., paring back essential benefits and allowing more catastrophic plans on the exchanges (not so disruptive) and creating high risk pools or universal zero- or low-premium catastrophic insurance (very disruptive).  But how to move GOP lawmakers and their think tank supporters off their "repeal and replace" schtick and onto a "revise and reform" track?

Frakt's most recent post suggests an answer by misdirection:
My conclusion is that the ACA is far more amenable to more conservative reforms than to more liberal ones. Of course, this could change. A public option could be added, for example. But, having had that political fight recently, I doubt it will. The most likely pathway leftward (in the sense of toward single payer) would be if the ACA failed in a sense that could be interpreted as market failure.

In fact, I do expect the ACA to fail in some states, but not in the ones that are most likely to adopt a state-level single payer program. Exchanges may fail where support for and enrollment into them is discouraged by political leaders and other institutions. Ironically, this is more likely to happen in states whose leaders are more ideologically supportive of market-based approaches.
If some state exchanges fail, and Republicans do not at that time control presidency, Senate and House, then what? Looking back at GOP state governments' refusal to run their own ACA exchanges, Jonathan Bernstein offers a might-have-been that's also, it seems to me, a may-be-yet:
Imagine if, right now, there were only a handful of states in the federal exchange, and some of the more aggressive and innovative conservative governors were running their own exchanges...suppose that several Republican governors had pushed for a deal in which they would implement Obamacare, including setting up exchanges in their states, if and only if they were given waivers and allowed to try some conservative policy ideas. The pressure would have been intense on the administration to allow at least some of them. After all, the administration never wanted to build all those different state exchanges in the first place. And certainly the president didn’t want obstruction verging on sabotage from Republicans across the board, as is de rigueur now. In order to get some Republican buy-in, there’s a very good chance Obama would have been extremely willing to cut deals, even if liberals would have been appalled at the results for the affected states.
Recall also that back in 2011 Obama supported legislation that would have moved the starting line for state waivers enabling alternative means of reaching near-universal coverage from 2017 to 2014 -- and further, that the administration has proven receptive to rather radical, privatized variations of the Medicaid expansion.

In short, O'Barkis is willing.  Too bad Republican governors and legislatures are more interested in sabotage than in genuine conservative policy innovation.  If and when, however, they're stuck with the corpse of a state exchange (or one on life support), and the ACA is still the law of the land, Republican governors may cook up some fetching Frankenstein monsters of their own. 

Wednesday, November 20, 2013

Who needs HealthCare.gov?

[updated and corrected 11/22, per notes at bottom]

HealthCare.gov may be obsolete before it's fixed.

Purely informational comparison shop sites ValuePenguin and HealthSherpa provide all the information that's supposed to be available on HealthCare.gov: price quotes incorporating the user's location, income,  age and family composition for all insurers available to that user on the exchange. ValuePenguin provides plan details.  (Shopping without a login or completed application is also possible on HealthCare.gov, but there are limitations and inaccuracies.*)

The missing link has been the subsidy application. That has had to be done through HealthCare.gov, or through phone or print applications, both of which can be started by calling the number posted on HealthCare.gov.  That application is the black box from which it's unclear how soon a completed application will emerge. As I've noted before, some insurers at least will take an application for a specific plan from a user who's started a subsidy application with the government, but that's a two-track and perhaps unsettling process

Now, though, the government is poised to let the insurers -- and online brokers, which also enable some comparison shopping -- take the subsidy application, according to HuffPost's Jeffrey Young:
Now these insurance issuers and brokers are about to get what they want. The Centers for Medicare and Medicaid Services is close to providing insurers with the technological capability to also take subsidy applications, as well as sell plans to customers, spokeswoman Julie Bataille said during a conference call with reporters Tuesday. ..

Online brokers eHealth, Go Health and about 30 others also will soon have this capability, Bataille said. "We believe that they are on track to begin their transactions as soon as possible. This is something that, obviously, they will make determinations about individually as they see how their system is interacting with ours, and they make their own assessments about the fixes necessary for them to begin their work." 
[Update: fixes currently being tested  have the insurers route their customers' subsidy applications through healthcare.gov.  It remains unlikely that insurers will gain direct access to the federal data hub that enables subsidy determinations.] 

The brokers could be a useful intermediary for some. eHealth  offers comparison shopping, with plan details for each posted choice, though in many locations it's far from covering all options on the exchanges. Within its own universe, however, eHealth will make your subsidy estimate, give you price quotes incorporating that estimate, hold information for any plan you select and notify you when enrollment is available on eHealth -- that is, when the site can initiate the subsidy application. A user should check their choices against ValuePenguin or HealthSherpa, however (I have found ValuePenguin's price quotes to be more accurate than HealthSherpa's in New Jersey).

If you want to eliminate the middleman, once the government allows third parties to process the subsidy application, you can use a non-transactional comparison site like ValuePenguin and then apply directly through the insurer offering the plan you choose. Many (I suspect most) insurers on the exchanges provide plan summaries online and enable online applications.

Once the government does outsource the subsidy application process, who needs HealthCare.gov? Its front end, that is. All that really matters is the back end: whether an application can be processed accurately in reasonable time. That of course is the rub, and allowing third parties to initiate subsidy applications won't make the technological challenge* go away. But perhaps the insurers and brokers will be able to expedite the process on behalf of their prospective customers -- and enable a smooth shopping process. If insurers and brokers can take the complete application, all the government needs to do on the front end is refer users to functioning online brokers and the informational sites.

At present, those who are not eligible for subsidies can easily make an informed choice from among policies available on the exchanges and complete the transaction through the insurer or an online broker.

One caveat: "informed" choice is a relative term. Online (and print brochure) plan summaries are not insurance contracts, which are complex, though less prone to booby-trapping than before ACA coverage rules took effect. If I were buying on the exchanges (as I might, next year), I might still seek the advice of a real live human broker to scope out how the co-pays, deductibles etc. might play out.

* You can comparison shop on HealthCare.gov without filling out an application. But subsidy information won't be incorporated in the price quote (they refer you to the Kaiser calculator for that). And the price quotes I got for my wife and I in New Jersey did not take our age into account and so were way off.

** Not to mention the yet-unbuilt systems to process subsidy payments to insurers.

Update, 11/21: just recalled that eHealth has been somewhat notorious for poor customer service:  it gets two out of five stars on epinions.com, and Rick Ungar spotlighted some customer horror stories when Avik Roy used the site to spotlight rate shock. Among the complaints: signing up at one price, getting enrolled at another. That should not be possible under the ACA. But the experiences do highlight possible pitfalls to using a middleman. Of course HealthCare.gov and the state websites should function at the least, in William Ocasio's  phrasing, as "public options to private marketplaces."   The point here is that complete effective workarounds while HealthCare.gov is still balky may soon be imminent, and that private online gateways may remain an important part of the landscape.

Update 2, 11/22: An earlier version of this post assumed that one could effectively ACA shop on eHealth. Prompted by the Anon comment below, I further tested eHealth and found that in many locations it does not include most of the plans available on the exchanges. I have amended the post accordingly. For the record, here is the original lead paragraph:
Online health insurance brokers like eHealth and purely informational comparison shop sites ValuePenguin and HealthSherpa provide all the information that's supposed to be available on HealthCare.gov: price quotes incorporating the user's location, income,  age and family composition for all insurers available to that user on the exchange. eHealth and ValuePenguin provide plan details. eHealth will make your subsidy estimate, give you price quotes incorporating that estimate, and, for now, hold the the plans you select in a kind of provisional shopping cart. [Update: management/healthcare scholar William Ocasio of Northwestern tweets that eHealth omits some insurers. So results should be checked against ValuePenguin or other brokers.] 

Tuesday, November 19, 2013

Low-tech glitches on HealthCare.gov

I get that fixing HealthCare.gov dysfunction is a massively complex tech project.  But there are informational flaws on the site -- sins of omission and commission -- that would be easy to fix. I've encountered two.

For the first, call me stupid. There's a hole either in my tech savvy or my reading about ACA implementation -- or both.  But stupidity is rarely rare, and the designers of heatlhcare.gov should have anticipated my need for one really basic piece of information.

From October 1 to November 15, I tried to create a login at healthcare.gov at least 40 times.  For perhaps too long, I assumed that my failure was just the core failure of the site. Gradually, recently, it dawned that whatever the site's functional failures, most people by now could at least log in -- and were encountering further glitches when they tried to complete applications (see comments on this HHS posting). So I went on live chat and quickly learned the cause of failure: if you've blocked access to pop-ups, you have to turn off the pop-up blocker. I did so, and lo, my login is created.

Sunday, November 17, 2013

Status quo Sunday at the New York Times

I had the oddest sense of deja vu while reading Ross Douthat's column about the Affordable Care Act today immediately after reading Tom Friedman's column about Israel. 

Both were sleight-of-hand defenses of a status quo: an Israel continuously extended on theft of land and a welfare state in statsis that Douthat would not have adapt to mitigate new problems of wealth distribution and risk transfer.

Friedman's column is a mealy-mouthed plug for a book by Haaretz columnist Ari Shavit, which may well be better than Friedman's characterization.  It begins with an even-handedness trope: a plea to view "the real Israel, not the fantasy, do-no-wrong Israel peddled by its most besotted supporters or the do-no-right colonial monster portrayed by its most savage critics." Fair enough. But the column sanitizes the colonial reality, flashing briefly on a bloodless freeze-frame of expelled refugees in 1948 rather than engaging with the continuing and accelerating gobbling of the West Bank.  It then devolves into que sera piety: Palestinians should suck it up and get on with their lives. And by the way, the failure of two-state negotiations is all their fault:

Saturday, November 16, 2013

"Urged on by Netanyahu..."

During the Cold War, in the course of pursuing perhaps the most successful long-term foreign policy strategy in human history -- containment of the Soviet Union -- the United States did a lot of stupid, cruel, counterproductive things -- overthrow elected governments, prop up corrupt autocrats, support quasi-fascist insurgencies. It did all of them, though, in the perceived national interest, however short-sighted or ruthless the calculus of the decision-makers -- even when, in the case of Nixon, that perceived national interest was avowedly a matter of national prestige.

Imposing new sanctions on Iran now would be in a different category of foreign policy malfeasance. The Times editorial board's wording casually captures what's cockeyed:
A rare opportunity for a diplomatic resolution to the dispute over Iran’s nuclear program is at risk because many lawmakers, urged on by Prime Minister Benjamin Netanyahu of Israel, are insisting that Congress impose tougher economic sanctions, perhaps next week as an amendment to the defense bill. 

Wednesday, November 13, 2013

Working around healthcare.gov: summary

To distill the takeaway from my last two posts (1, 2): anyone with computer access seeking to buy insurance on the ACA exchanges can easily get all the information they need to select a plan while bypassing healthcare.gov by visiting window-shopping sites ValuePenguin and HealthSherpa, as well as the individual insurers' sites once one has honed in on a single plan or a handful of top contenders.

Both sites prompt you for your location (zip code or state/county), the number and ages of people in your household, and your household income, and then give you specific quotes for all the exchange plans in your area. These quotes incorporate your subsidy if you qualify for one.  ValuePenguin provides plan details, and HealthSherpa provides contact information for each plan, including the identifying name of the plan in question. I appear to have gotten inaccurate price information in one location (Essex County, NJ) from HealthSherpa, but not from ValuePenguin, and the two provide identical price info at other locations I tested. The information on the two aggregator sites can in any case easily by checked against the insurers' own sites. The big insurers, if not all exchange participants, also offer subsidy calculators on their websites.

The catch is that as of now, the actual subsidy application has to be processed by the federal government, and the application process through the healthcare.gov website has proved broken for many if not most users (I have not been able to establish a login myself). You can, however, apply over the phone by calling the number listed at healthcare.gov and providing information orally, or you can ask the phone rep for a print application, which they'll mail. I reached a live person quickly, and he was ready to take a subsidy application from me, or so he said. Once you have an application case number, which can be sent by email if you apply over the phone, an insurer will let you apply for a specific plan, but you cannot seal the deal until the subsidy application comes through. 

The great unknown, I believe, is whether the federal government can process a phone or print application in reasonable time.  If so, the process need not be particularly onerous even if you cannot apply through the healthcare.gov site.

P.S. Healthcare.gov should be able to perform the ValuePenguin/HealthSherpa function even if you can't log in.  It does not provide age-specific price information, however -- at least, it hasn't in my three attempts. And it sends you to the Kaiser Family Foundation  for a subsidy calculator.  The Kaiser calculator is a great tool, and has been around for a while, but it doesn't provide plan-specific information.

Monday, November 11, 2013

Working around HealthCare.gov, cont.

[updated]

On Nov. 10 I spotlighted two public service websites, ValuePenguin and HealthSherpa, that appear to offer workarounds to the dysfunctional healthcare.gov for people hoping to buy health insurance on the ACA exchanges.

Both sites take your location (zip code or state/county), the number and ages of people in your household, and household income, and give you specific quotes for all the exchange plans in your area.  ValuePenguin links to plan details, and HealthSherpa provides contact information.

To what extent do these tools provide a workaround the broken Healthcare.gov website? They provide all the information needed to make an informed choice, at least when checked against the insurers' sites.  One still has to go through the federal government to apply for a subsidy, but that can be done by phone or snail mail. The main question, for those eligible for subsidies, is how long the subsidy determination will take.

A shopper who is not eligible for subsidies can buy a plan directly from the insurer of her choice, with all the information that should have been available on healthcare.gov easily obtained elsewhere. Below the jump, my experience initiating the shopping process.  I presented myself on the phone as someone planning to apply for a subsidy.

Sunday, November 10, 2013

A private-market patch for the ACA?

About ten years ago, I used LendingTree.com to refinance my house. On the website, I punched in various vital statistics -- perhaps more than I'd be comfortable submitting today -- and, as advertised, received four bids from mortgagers.  Each sent offer details, I believe all by email.  Parsing the offers -- points, fees, etc. -- took some time, as with any comparison shopping for a financial product.  The small bank I went with gave me some heartburn by not approving the loan within the rate lock period, but they did extend that period, and I did get the loan at the advertised rate, within the estimated costs. It wasn't as easy as buying a camera on Amazon, but it was within reasonable expectation.

About seven years ago, I helped my older son, then 23, buy health insurance on New Jersey's bare-bones individual market exchange. There were basically three choices. AmeriHealth looked best, and they sent us a plan summary  -- I think three options at different price points.  We settled on not-terrible coverage -- at least, not terrible on paper, to my reasonably informed eye -- for about $180 a month.

Months ago, the Kaiser Family Foundation put up a provisional ACA cost calculator: punch in the number of people in your household, their ages, family income, and zip code, and get an estimate of the price of a silver or bronze plan, with and without the subsidy you qualify for, if any. It does not provide information for specific plans,however.

Now, it seems, there's a private-market, state-specific improvement, with pricing for actual plans and contact info for the insurers offering them:
I gave this a whirl, putting in my zip code, ages for my wife and me, and various income estimates. It works. There are no plan details (other than plan type -- HMO or EPO or POS), and I haven't called the insurers whose plans are quoted [update - see next post], but I would assume that they will send plan details if asked. [Update: per below, another site, ValuePenguin, appears to give more accurate price quotes, at least in New Jersey -- as well as plan details. Most insurers' websites do, too.]

Friday, November 08, 2013

The ACA as a framework for (further) conservative healthcare reform

Austin Frakt does AEI's James Capretta the honor of seriously considering* elements of Capretta's attempt (with Douglas Holtz-Eakin) to fill in the long-empty "replace" blank in Republicans' purported "repeal and replace" program for the Affordable Care Act. After spotlighting various lacunae as well as potentially workable elements in Capretta's "decentralized, market-diven alternative to the PPACA," Frakt comes to a core point, implicitly questioning whether conservative healthcare wonks are acting in good faith:
6...Democrats are well aware of the limitations and problems with the Affordable Care Act. Some are so troubling that the administration is considering some interesting proposals that would require Congress to act. Point being, there is leverage for some negotiation on some aspects of the law. And, crucially, some of the things Capretta has proposed fit within the structure of the ACA, such as allowing Medicaid enrollees to buy exchange plans (see Arkansas), capping the employer-sponsored insurance tax subsidy (see the Cadillac tax), or making exchange plans more catastrophic. But that brings me to …

Thursday, November 07, 2013

More than just a website: state efforts to make the ACA work (and the lack thereof)

We've all read by now that the ACA websites in states that are running their own exchanges (14, plus D.C.) are working much better than the federal site. What most of us may not have fully recognized -- though it's no doubt obvious to health and insurance professionals and people who have run social service programs -- is that establishing, running and marketing a functioning insurance marketplace requires a wholehearted commitment from state government.

Enticing insurers, policing insurers, and, above all, educating and wooing the uininsured public require expertise, commitment, money and accountability. Putting the program across in mostly low-income and low-information populations is a lot like delivering chronic care to those in need: it requires a lot of patient, informed, sensitive one-on-one contact.

Kentucky and California are two states that are going all out to make the Affordable Care Act a success.  The Huffington Post's Jason Cherkis recently did some great reporting in Kentucky, where Governor Steve Besheare, a Democrat,
is using all the powers of his administration to sell Obamacare, marshaling millions of dollars for branding and market research, heartwarming television spots and eye-catching bus ads. A hired army of true believers have held meetings across the state, spreading the word and rebutting misconceptions.

Monday, November 04, 2013

Joy eludes the Archbishop (Lewisian joy, that is)

Rowan Williams, a former Archbishop of Canterbury who's written a book about C.S. Lewis, seems, on the basis of this interview, to appreciate CSL for what I regard as the right reasons: his understanding of human frailty based on personal humility, his capacious and sympathetic grasp of literature, and, above all, his imaginative evocation of spiritual desire and experience.  I was pleasantly surprised, too (probably shouldn't have been; I'm not up on current theological currents) that he pretty much dismisses Lewis's agitprop-thin "rational" arguments for Christianity's literal truth.

All that said, Williams seems to misunderstand the keystone of Lewis's imaginative theology, the experience Lewis called "joy." Williams conflates that joy with more prosaic spiritual phenomena -- the psychomachia of everyday life --  that Lewis also evokes.  

Here's Williams' take on Lewisian joy:

Sunday, November 03, 2013

Subtext to the WaPo healthcare.gov disaster narrative: Sabotage works

The Washington Post's tick-tock by Amy Goldstein and Juliet Eilperin on the decisions leading to the dysfunctional launch of healthcare.gov is cast in a familiar genre: an anatomy of politicized administrative incompetence. And the piece does capture some likely bad decisions.

But the narrative documents a more basic fact, not hidden but acknowledged only secondarily: sabotage works. More specifically: in a two-party system, if one party gives itself over with fanatic single-mindedness to sabotaging the enactment of a major reform, it will succeed in some degree.

Thursday, October 31, 2013

No, 93 million Americans will not lose their health plans under Obamacare

Avik Roy is within his conservative pundit rights in spotlighting the grievances of the estimated 3 percent of the population who may be subject to higher health insurance premiums when the ACA takes full effect in 2014 than they currently pay for plans in the existing individual market.  He descends into partisan hackery, however, in suggesting that tens of millions more will "lose" their coverage as employers' "grandfathered" plans fall by the wayside, as they are bound to do -- and that therefore, "93 million Americans will be unable to keep their health plans under Obamacare."

Roy purports to find a nuclear bomb in interim final regulations for group health plans issued in the Federal Register in 2010:
Contrary to the reporting of NBC, the administration’s commentary in the Federal Register did not only refer to the individual market, but also the market for employer-sponsored health insurance.

Wednesday, October 30, 2013

Will red states stonewalling the ACA pay for self-inflicted punishment?

The long-term effects of the Affordable Care Act that everyone should ardently wish for are 1) access for all Americans to affordable, adequate health insurance and 2) reduced or reversed health care inflation.

Republican governors and/or state legislatures determined to sabotage the law are causing needless suffering, by denying millions the access to Medicaid the law was designed to provide, and by refusing to run the private insurance marketplaces, forcing the federal government to operate them in 34 states, with so-far disastrous results. State-level stonewalling goes beyond refusal to build a website: it also means abjuring the responsibility both to entice insurers into the exchanges and to impose discipline on those that participate, via state adaptation of the federal coverage guidelines, and by working to prevent adverse selection in the exchanges through state regulation of the individual market outside them.

No real good can come of deliberate misgovernance. But its consequences may trigger self-correction over time. States that try to make the law work may emerge as better places to live than states that don't -- offering Medicaid to the lowest-income adults, and a competitive, well-regulated and subsidized market to those with modest incomes. That creates a range of economic freedoms -- to leave a full-time job to start a business or go to school, to go from full- to part-time to do either, or undertake the kind of de facto apprenticeships that a career change often requires, or care for a sick parent.

On the most basic level, Donald Taylor points out that the states refusing Medicaid expansion are effecting a wealth transfer to states that embrace it:

Sunday, October 27, 2013

"What if Obamacare works?" -- What Ross Douthat leaves out

Ross Douthat "fairly fairly" describes the differences between the cheapest health insurance plans available on the ACA exchanges and the cheapest plans currently available on the individual market, most of which will be phased out because they don't comply with ACA minimum coverage requirements.  But he leaves some important facts out.

Douthat acknowledges that the ACA's premium subsidies will offset the price increase for many who buy on the exchanges, and he fairly if too briefly presents the limitations of a cheap plan currently available on the individual market ("a $5,000 deductible, an annual out-of-pocket limit of $12,500, and all kinds of copays and coverage restrictions"). He then frames the ACA's political prospects like this:
With some grandfathered exceptions, Obamacare makes those kinds of plans illegal. The out-of-pocket limit for individuals is capped at $6,500 a year, preventive services are fully covered, and various “essential benefits” as well. 

If we ever get beyond the follies of HealthCare.gov, the politics of the rollout will probably be defined by how (and how vocally) middle-class Americans just above the subsidy threshold react to this “pay more, get more, subsidize other people” deal.
True, perhaps -- though the politics will also be defined by the reactions of those eligible for the subsidies, and those shut out of the current market by preexisting conditions or age (the ACA limits age-related price differentials to 3-to-1; currently they're as high as 6-to-1), or, to a lesser extent, by those newly eligible for Medicaid (who are less likely to be politically vocal and perhaps less likely to recognize that their new benefits are a product of the ACA).

It's Douthat's presentation of the likely long-term consequences of a successful ACA rollout that tilts our view of past and future playing fields:

Friday, October 25, 2013

A companion list to The Atlantic's "50 Greatest Inventions"

The Atlantic has a panel-generated list of the 50 greatest inventions since the wheel, which is entertaining, and an accompanying James Fallows meditation on what the exercise can teach us about innovation's impact, value and future prospects, which is humane, urbane and deeply informed, as you'd expect from Fallows.

Fallows also provides a "taxonomy" of the 50 chosen items. I had read the listicle first, and when I came to the lead-in to the taxonomy, it immediately made me sense a category missing from the list:
One of our panelists, Leslie Berlin, a historian of business at Stanford, organized her nominations not as an overall list but grouped into functional categories. From our panelists’ nominations, a similar but slightly broader set of categories emerges. Here is my adaptation of Berlin’s useful scheme.
Fallows' categories are as follows: innovations that 1) expand the human intellect; 2) are integral to the infrastructure of the modern world; 3) enabled the industrial revolution; 4) extend life; 5) allow real-time communication out of voice range; 6) enhance transportation; 7) enable organizational breakthroughs (clocks, calendars, alphabetization); and 7) facilitate killing.

I shouldn't say that what I want to add was "missing" -- arguably it didn't belong. Let's call mine a companion list. But it occurred to me a while back that the U.S. Constitution was a kind of enabling technology of the modern world, and that makes me want to think more about what you might call social technologies, from those traceable to the dawn of recorded history to the present (excluding an earlier strata including language, worship and prayer, marriage and tribal organization). Here's a first pass at a list of key "inventions" of this kind. It's neither chronological nor ranked in order of "importance," but rather loosely grouped according to type: legal, political, economic, pedagogical.

Thursday, October 24, 2013

John G. Taft's evasive honesty

What a peculiar exercise in moral exhortation. John G. Taft rather bravely excoriates the recklessness and cruelty of the current Cruzified GOP in the name of the party's grand old traditions of responsible governance and fiscal probity-- presumably embodied in "Five generations of Tafts [who] have served our nation as unwaveringly stalwart Republicans." And yet he does so by invoking the party's -- and his family's -- past shame: its collusion with Joe McCarthy's communist witch hunt. Taft manages to be refreshingly honest and subtly evasive all at once.

Taft levels his attack against Ted Cruz & co. in the name of his grandfather:
As I write, a photograph of my grandfather, Senator Robert Alphonso Taft, looks across at me from the wall of my office. He led the Republican Party in the United States Senate in the 1940s and early 1950s, ran for the Republican nomination for president three times and was known as “Mr. Republican.” If he were alive today, I can assure you he wouldn’t even recognize the modern Republican Party, which has repeatedly brought the United States of America to the edge of a fiscal cliff — seemingly with every intention of pushing us off the edge.

Throughout my family’s more than 170-year legacy of public service, Republicans have represented the voice of fiscal conservatism. Republicans have been the adults in the room. Yet somehow the current generation of party activists has managed to do what no previous Republicans have been able to do — position the Democratic Party as the agents of fiscal responsibility.
"The adults in the room" -- except with respect to one little issue that is the focus of Taft's historical analogy:

Tuesday, October 22, 2013

The Obamaquester according to Harry

Harry Reid's view of the sequester -- and how we got saddled with it -- has been seeping into the national political narrative in recent weeks. Notwithstanding his alleged renewed bonds and recent successful teamwork with Obama, his view is not a pretty picture for the president.

In Twitter exchanges with Greg Sargent and others -- I think Jonathan Bernstein and Brian Beutler -- I have sought a convincing account and analysis and possibly justification of the Obama administration's thinking at the fiscal cliff -- why Biden, with Obama's backing, cut in on Reid's negotiations with McConnell and settled for half a revenue loaf and only a short-term sequester postponement. I haven't found one. And today's somewhat triumphal narrative by Sam Stein and Ryan Grim of the Democrats' short-term shutdown victory -- a purported tale of renewed harmony and mutual trust -- also provides the opposite of what I've sought: Reid's indictment of Obama's fiscal cliff conduct.
 He complained that Vice President Joe Biden had undercut fiscal cliff negotiations at the end of 2012, when Senate Minority Leader Mitch McConnell (R-Ky.) was offered a more generous deal on tax revenue and sequester spending than Reid felt he could have crafted.
It didn't escape his notice, Reid said, that the deal Biden made conveniently postponed the budget cuts two months, or just long enough to allow the Inauguration and the State of the Union address to pass without the sequester's shadow. Senate Democrats had been pushing for a two-year delay and had been prepared to settle for just one.

Monday, October 21, 2013

Okay, so our problem is GOP extremism -- but what's driving that?


Jonathan Bernstein advances a kind of Bad Man theory of contemporary American politics -- the bad man being Newt Gingrich, the GOP's Faust. The problem with U.S. politics, he argues, isn't structural, and it's not political polarization per se:
No, the problem is the Republican Party, which has developed a weird and dysfunctional set of incentives along with the legacy of a handful of role models they would be better off without. There’s the race to be the True Conservative, which requires staking out ever-more-crazy positions in order to differentiate from RINOs and squishes – and the reaction by mainstream conservatives who are terrified at losing their conservative credentials and therefore cling as close as possible to the nuttiest radicals out there. There’s the lucrative conservative marketplace, which thrives on incivility and conflict – that’s one set of perverse incentives – and which also thrives when Democrats are in office, which is another set of perverse incentives. There’s the conservative closed information feedback loop, with Republican Party actors and politicians failing to see the U.S. that the rest of the nation sees.

Sunday, October 20, 2013

We're still in the sequester's grip

George Packer zooms out from the latest fiscal skirmish to assess the state of budgetary warfare in the Obama era:
President Obama and the Democrats in Congress appear strong for refusing to give in to blackmail.

But in a larger sense the Republicans are winning, and have been for the past three years, if not the past thirty. They’re just too blinkered by fantasies of total victory to see it. The shutdown caused havoc for federal workers and the citizens they serve across the country. Parks and museums closed, new cancer patients were locked out of clinical trials, loans to small businesses and rural areas froze, time ran down on implementation of the Dodd-Frank financial-regulation law, trade talks had to be postponed. All this chaos only brings the government into greater disrepute, and, as Jenny Brown’s colleagues dig their way out of the backlog, they’ll be fielding calls from many more enraged taxpayers. It would be naïve to think that intransigent Republicans don’t regard these consequences of their actions with indifference, if not outright pleasure. Ever since Ronald Reagan, in his first inaugural, pronounced government to be the problem, elected Republicans have been doing everything possible to make it true.

Saturday, October 19, 2013

Forever young in the New World

I can't remember what triggered it, but at dinner tonight I pulled out a copy of Death Comes for the Archbishop and read to my wife one of my favorite passages in American literature. It gives me a craving for something of which I've had intimation but never fully experienced -- except in reading this:
All his relatives at home, and his friends in New Mexico, had expected that the old Archbishop would spend his closing years in France, probably in Clermont, where he could occupy a chair in his old college. That seemed the natural thing to do, and he had given it grave consideration. He had half expected to make some such arrangement the last time he was in Auvergne, just before his retirement from his duties as Archbishop. But in the Old World he found himself homesick for the New. It was a feeling he could not explain; a feeling that old age did not weigh so heavily upon a man in New Mexico as in the Puy-de-Dôme.

He loved the towering peaks of his native mountains, the comeliness of the villages, the cleanness of the country-side, the beautiful lines and cloisters of his own college. Clermont was beautiful,-- but he found himself sad there; his heart lay like a stone in his breast. There was too much past, perhaps. . . . When the summer wind stirred the lilacs in the old gardens and shook down the blooms of the horse-chestnuts, he sometimes closed his eyes and thought of the high song the wind was singing in the straight, striped pine trees up in the Navajo forests.

Thursday, October 17, 2013

Twas the Night Before Shutdown (complete)

Twas the night before shutdown: the House changed its rules
To hold us all hostage to vain spiteful fools.

Poison pills had been stuffed in the CR with care
To deprive shiftless "others" of Obamacare.

A Senate CR, disinfected and clean,
Was blocked from a vote by the rightwing machine.

And Boehner with his baritone, and Cruz with his glower,
Took to podiums to prove gu'mmint could not sink lower.

So workers were furloughed and services shuttered.
The president was grounded, th'economy sputtered...

And all of a sudden the government mattered!
And Cruz and his crew with their own spite were spattered.

Twas the night be shutdown...Twas the night before default, cont.

The exciting conclusion...full epic after the jump.

     The leadership, stunned, called the vote off and soon
     The air fizzled out of the Tea Party balloon.

     The Senate bill, simplified, once more was tendered,
     As Boehner, Paul, Cruz in swift sequence surrendered.

     "We just didn't win. But we fought the good fight."
     Quite so -- if "good" equals "pumped full of spite."

     Thus did the caucus put on a brave face,
     Raised one more chorus of Ah-mazing Grace,

     Checked on their vitals and took a deep breath,
     Prepped to defend the sequester to death,

     Chanted their catechisms, glowing with pride --
     Beguiled, reviled and self-Cruzified.

Wednesday, October 16, 2013

Twas the Night Before Shutdown...Twas the Night Before Default

The epic continues...

Then Collins cooked up something Murray could swallow,
Five queens signed on, and the old bulls clicked "follow":

Senate-House conference on terms uncoercive,
Tweaks to Obamacare none too subversive,

Debt ceiling bump-up and short CR, clean,
Sequester not locked in for 2014.

Markets exhaled and the indexes soared,
Till Boehner rolled one more grenade of discord:

"Don't touch that hostage! A price must be paid --
Even if only by us and our aides...

National default is a bridge none too far
To uphold our values -- whatever they are."

Thus Boehner spooled his caucus one last yard of rope
To twine round their necks, as the nation's last hope.

Lo, Heritage Action gave one mighty yank,
The diehards jumped ship, and the House CR sank.

    To be continued (if the world does...)

Twas the Night Before Shutdown, Canto I
UPDATE: Here's the whole thing

Monday, October 14, 2013

Twas the Night Before Shutdown

Yesterday, Kurt Eichenwald tweeted:
Night before shutdown, House changed its rules so that ONLY GOP leadership could bring budget to floor. But it's the "Obama shutdown." Sigh. [Details here] .
The language sounded familiar, and seemed to gallop of its own accord as below -- with an assist from Matt Glassman as noted (MG):

Twas the night before shutdown: the House changed its rules
To hold us all hostage to vain spiteful fools.

Poison pills had been stuffed in the CR with care
To deprive shiftless "others" of Obamacare.

A Senate CR, disinfected and clean,
Was now blocked from a vote by the rightwing machine.

And Boehner with his baritone, and Cruz with his glower,
Took to podiums to prove gu'mmint could not sink lower.

Sunday, October 13, 2013

What McConnell could cook up with Reid

Well, the rumors are flying thick and fast this Sunday, and this post probably won't be worth the pixels it's printed on. But based on Mitch McConnell's past dealmaking history, his acknowledged relative lack of leverage this time, and the drop-dead taboos against raising spending levels or taxes that a primary challenge imposes on him, I can't resist a bit of speculation as to what he may be cooking up with Reid (Dick Durbin called the talks between them a "breakthrough" today, though Reid himself has sounded far less sanguine).

Recall that the Budget Control Act negotiated by McConnell in the last days of July 2011 created a mechanism whereby the executive branch could raise the debt ceiling and Congress could register a vote of disapproval -- or override the hike with a two-thirds majority in both houses. That deal was end-stopped by the amount required to raise the debt ceiling high enough to get past the 2012 election; it ran out in March of this year.

Recall too that progressive éminence grise Norm Ornstein has floated an acceptable exception to the Dems' current no-concessions-for-debt-limit-hike stance: trade a single concession to end debt ceiling terrorism forever:

Friday, October 11, 2013

The party that loses by winning

On July 4, 2011, when the Republicans were in the process of nailing Obama to the debt ceiling, David Brooks wrote:
If the Republican Party were a normal party, it would take advantage of this amazing moment. It is being offered the deal of the century: trillions of dollars in spending cuts in exchange for a few hundred billion dollars of revenue increases.
With about $4 trillion in deficit reduction over ten years the agreed target, Obama was ready to settle for just $800 billion in new revenue, a roughly 4-to-1 ratio of spending cuts to revenue . But the GOP passed up Brooks' 'deal of the century.' A four-fifths win for the no-new-taxes-ever crowd wasn't good enough for them.

They did "win," though, by forcing Obama to swallow, under threat of national default, the Budget Control Act, which purported to match every dollar of debt ceiling increase with a dollar of deficit reduction, with no concession on the Republicans' part that any of that reduction would come through tax increases. Nor has it, now that Republicans have learned to love the sequester, or professed to. The BCA imposed over $900+ billion in cuts to discretionary spending over ten years, and then another $1.2 trillion through sequestration if a Congressional supercommittee could not agree on a plan to replace that second tranche with a deficit reduction package of equal value. Since Republicans would not agree to any sequester replacement including new revenue, it is still with us, and the DBA's deficit reduction mix remains (approximately, counting interest savings), spending cuts $2.5 trillion, revenue 0.

Wednesday, October 09, 2013

Reading Oryx and Crake in the time of debt ceiling brinksmanship


I'm not quite sure when my long-held optimism about the human race took shape, but my read of history for some time has been that human life is steadily improving, that our progress, notwithstanding major setbacks, has been moral as well as material, and that we are adaptive enough to continue to increase wealth, freedom and peace. There's always been the caveat that global warming or some as-yet-unimagined disaster could undo all -- or that we would bioengineer or own evolution or replacement. But I've felt reasonably confident that the progress of the last few hundred years -- long lives, better health, less subjection to violence, more scope for more people to exercise their faculties -- would continue.

Margaret Atwood's Oryx and Crake trilogy, which I've read in the last couple of weeks, has dinged this optimism.  It's a double dystopia, with two narrative presents:  an anarchic world of balkanized corporate dominance and environmental degradation prior to the near-extinction of humanity by an engineered superbug, and a remnant community's life in the ruins - and interaction with a community of genetically engineered human mutants designed to be more pacific-- after the "waterless flood."

Tuesday, October 08, 2013

Maybe it doesn't matter, but...

I wish Obama would clarify, when laying out his current position on budget negotiations (as in today's press conference), that 1) he and Democrats in Congress have already agreed to the funding levels stipulated in the House GOP's bill funding the government for the next two months, and 2) what he's willing to negotiate is a bill funding the government on new terms for the rest of FY 2014 and the years beyond. In statements like this...
At the beginning of this year Speaker Boehner said, what we want is regular order and a serious budget process. So the Senate should pass a bill and the House should pass a bill, and then a committee comes together and they hash out their differences and they send the bill to the president. Well, that's exactly what Democrats did.

Except somewhere along the way, House Republicans decided they wouldn't appoint people to the committee to try to negotiate, and 19 times they've rejected that. So even after all that, the Democrats in the Senate still passed a budget that effectively reflects Republican priorities at Republican budget levels just to keep the government open, and the House Republicans couldn't do that either.
...it remains unclear what Democrats agreed to (Republican spending levels in a 6-10 week continuing resolution), what they've balked at (a litany and sequence of demands extraneous to that short-term funding), and what Obama is willing to negotiate if/when the threats of government shutdown and debt default are removed (funding for the remaining 9-10 months of FY 2014 and a long-term replacement of the sequester with a mix of more targeted spending cuts, including to entitlements, and revenue-yielding reductions in tax loopholes).

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