Tuesday, July 30, 2013

Obama girds for nuclear budget war, cont.

So Obama has repackaged and linked two old proposals -- revenue-neutral corporate tax reform and a package of jobs stimulus measures. The tax reform would be revenue neutral over the long term, cutting rates and reducing loopholes, but would yield a one-shot revenue boost as the loopholes are closed, paying for teh short-term jobs measures.

This mini "grand bargain" is part of Obama's announced series of economic speeches and proposals.  The purpose, as I see it, is twofold. First, to shift the national agenda in the upcoming budget battles from deficit reduction to jobs (short-term stimulus and long-term investments). Second, to present Republicans with a series of manifestly reasonable programs and compromises to reject. That way, when they shut down the government or threaten national default because Obama won't agree to obscenely large spending cuts, he can say, "I offered to compromise six ways to Friday, but my opponents won't agree to anything but more spending cuts and more tax cuts." 

Long-suffering Lincoln

[Updated, with illustration!]
Vandalism at Lincoln Memorial recalls a precursor in Buffalo some 15-plus years ago:



                                                                        On a statue in Delaware Park,
                                                                        almost as old as Noah's ark,
                                                                        some disrespectful, disreputable fellow
                                                                        sprayed Abraham Lincoln's hair bright yellow.

                                                                        It's despicable. It's deplorable.
                                                                        Sunny-side up
                                                                        he looks adorable.

Monday, July 29, 2013

In which "strategic advisor" Howard Dean attacks IPAB

Why would Howard Dean -- physician, former governor, former meteoric presidential candidate and current "strategic advisor" to healthcare clients at a lobbying firm, stick a knife in IPAB, the Independent Payment Advisory Board created by the Affordable Care Act to rein in the federal government's Medicare spending?

In a Wall Street Journal op-ed published this morning, Dean first pays lip service to core aspects of the ACA before launching into a perfunctory, mail-it-in attack on  IPAB:

Sunday, July 28, 2013

By reframing national agenda, Obama hopes to "force a different result" in budget negotiations

When Obama came his speech urging a national refocus on jobs and the foundations of long-term economic growth last Wednesday, the first in a series on the economy, I suggested that he was positioning himself to win a budget showdown should the Republicans shut down the government or seriously threaten a debt ceiling default if he does not agree to radical new spending cuts or the defunding of Obamacare. He is trying preemptively to reframe the argument, to convince the public that jobs and investments that foster long-term economic growth should be the national priority -- not spending cuts,.

In a long interview with the Times' Jackie Calmes and Michael Shear, conducted while he was at Knox College in Galesburg, IL to deliver that speech, Obama continued his bid to shift the agenda:
NYT: [House Republicans] are still embracing sequestration and who are still willing to use the debt limit to go to the mat. 

MR. OBAMA: Well, this is what they say. On the other hand, we also have a number of very thoughtful and sensible Republicans over in the Senate who have said that we should not play brinksmanship, that we should come up with a long-term plan. I met with a couple of House Republicans over the last several weeks who would like to see that happen. They’re not the loudest voices in the room at the moment. 

And part of what I’d like to see over the next several weeks is, if we’re having a conversation that’s framed as how are we growing the economy, how are we strengthening the middle class, how are we putting people back to work, how are we making college more affordable, how are we bringing manufacturing back -- the answer to those questions I think force a different result than if we are constantly asking ourselves how can we cut the deficit more, faster, sooner.

Friday, July 26, 2013

My fantasy flashes in the news, flickers, fades

I have fantasized from time to time that Obama would pull a Jan Brewer and refuse to sign any appropriations bills that don't shut off the sequester. Or the (earlier) Chris Christie variant: that he will sit back, crack open a beer, and wait for Congress to send him a budget he can sign.

Therefore, this peek at alleged White House deliberations by the Washington Post's Zachary Goldfarb and Paul Kane set my heart a bit aflutter:
White House officials also are discussing a potential strategy to try to stop the sequestration cuts from continuing, the lawmakers and Democrats said. Under this scenario, the president might refuse to sign a new funding measure that did not roll back the sequester.
But reality came back quick:
No decision has been made.
And this sounds more like Obama:

Thursday, July 25, 2013

Is Obama preparing for nuclear budgetary war?


It's a foundation built upon five pillars that will grow our economy and make this new century another American century: new rules for Wall Street that will reward drive and innovation; new investments in education that will make our workforce more skilled and competitive; new investments in renewable energy and technology that will create new jobs and industries; new investments in health care that will cut costs for families and businesses; and new savings in our federal budget that will bring down the debt for future generations. That is the new foundation we must build. That must be our future – and my Administration's policies are designed to achieve that future.
That's Obama laying out his broader economic vision -- in April 2009. Three of the five pillars match the five cornerstones he laid down in yesterday/s speech on long term economic growth -- or rather two and a half, as his "jobs" cornerstone yesterday centered in large part on renewable energy.

As many pointed out, there were no new proposals in Obama's speech yesterday, and not much detail -- it was a framework, with details to be supplied in an upcoming series of speeches. And that's okay. As the political storms of autumn approach, dullness is good. Repetition is good. Reminder of what Obama is about -- how he thinks, how he carries himself, what he wants -- is useful, even if it doesn't excite anyone now. It's an impression scheduled for timed release.

Wednesday, July 24, 2013

Could a "doc fix" have a bigger impact on U.S. healthcare than the ACA?

Two interrelated features of the U.S. healthcare system are probably the primary causes for the uniquely high cost of healthcare in the U.S.: weak government control over pricing, and the fee-for-service payment model.

These interrelated weaknesses are exacerbated, as a weekend Washington Post exposé showed, in that Medicare pretty much lets doctors determine the rates at which they paid, by leaving it to the AMA to produce estimates of how long each procedure takes. Surprise! The doctors' chief trade group massively pads the estimated times required for most procedures. 

Even if procedure prices were based on accurate time estimates, free-for-service incentivizes providers to perform a high volume of the most expensive procedures. Nonetheless, countries in which the government imposes monopsony price control -- i.e., every other wealthy country in the world -- generally manage to deliver universal healthcare at two thirds to half the cost per capita of healthcare in the U.S.  Government control over pricing, as Ezra Klein recently forced healthcare free market evangelist Avik Roy to admit, is the sine qua non of effective heathcare cost control.  And we in the U.S. don't have it, as a study published in Health Affairs ("It's the Prices, Stupid...", Gerard F. Anderson et al., 2003) explains:

Monday, July 22, 2013

Why is McCain suddenly John So-New-New?

I have no insight into the latest cut-back in the double reverse that is John McCain's long career. I just want naming rights.

Update: Dana Milbank interviewed McCain 4.0.  The reborn maverick's explanations for his serial transformations make no sense, but as long as this is the final somersault, Democrats won't complain.

Sunday, July 21, 2013

Party of Spite

There is no word for this but sick:
"ObamaCare is bad for America," Boehner told CBS's "Face the Nation." "We're going to do everything we can to make sure it never happens." 

Republicans have already acted to deny Medicaid to millions of uninsured Americans. It's their stated goal to wreck the ACA's insurance exchanges and so prevent millions more uninsured -- a projected 15-17 million over time -- from buying affordable health insurance. They jawed for years about "repeal and replace" but have offered no replacement.  They profess to believe it "good for America" to leave tens of millions uninsured and prone, as they now are, to bankruptcy, lack of regular healthcare, and haphazard, incomplete, unsustained care if they get seriously ill.

Sugarcoat it as they will, the GOP has devolved to nothing other than the Party of Spite.  The party is unworthy of sharing the governance of a village, let alone a nation of 300 million.

Friday, July 19, 2013

"Trayvon Martin could have been me"

ICYMI, America, you elected a black president. Twice. Obama reminded us forcefully of that rather miraculous fact today, while addressing the impact and meaning of the Trayvon Martin affair.

It is always expensive for Obama to affirm his identity as an African American, and so his representation of African American experience and perspective on the Zimmerman trial today to Americans at large came couched in qualifiers. The jury has spoken, but.  Young African American men are more likely to involved in violence, but. Criminal law is mostly a matter for state and local government but. Stand your ground law was not used by the defense but. Politician-initiated conversations about race end up being stilted and politicized, but.

It was straight talk wrapped in apophasis -- "saying by not saying," or saying what I say I shouldn't say: That African Americans still encounter reflexive prejudice in their daily lives, that American justice is still far from colorblind, that we are still collectively failing African American inner city youth.

Thursday, July 18, 2013

Why I'm glad that Democrats didn't change the Senate rules

Almost since Obama took office, almost every writer on politics whom I enjoy reading most, driven mad by GOP obstruction in the Senate, has urged filibuster reform.  Let Harry Reid's latest complaint stand in for a long statistical litany of GOP obstruction: he has had to deal with over 400 Republican filibusters, compared to Lyndon Johnson's one. 

Without doubt, Senate rules could use some rational tweaking. But I have argued since 2009 that the problem is not so much with the Senate rules as with the GOP destruction of governing norms. Instead of a loyal opposition we have had a nihilist one, unwilling to let the majority govern (with a rational level of resistance and negotiation to shape laws more to the minority's liking) and abide the electoral consequences of the laws they pass, unwilling to let the executive branch be staffed so it can perform its constitutional functions, unwilling to allow the lengthy enactment process to work for laws already passed and signed.

The problem is not so much the rules as the GOP; such nihilist opposition is dangerous, and bespeaks graver danger should the extremist party gain control of the presidency and both houses of Congress. Against that very real possibility the filibuster stands as a bulwark: I would rather let the GOP inhibit the Democrats' ability to pass legislation and fill vacancies than enable the GOP to wreak legislative havoc unrestrained if it has not moderated before the next time it gains power.

Wednesday, July 17, 2013

Nonsense question of the day: "Does Obama have a second-term strategy?"

Sometimes it's hard not to suspect that Politico reporters don't believe their own bullshit when they spin out narratives about who's up, who's down, how A perceives B, what C's prospects are, etc.

Today's nonsense question, posed by Glenn Thrush, is Does President Obama have a second-term strategy? Of course the implied answer is no. But the argument is self-cancelling from the get-go.

The implicit premise is that because Obama said during the campaign that his victory might break the GOP's fever of no-compromise opposition, and that fever has not in fact broken, the president is at loose ends. But that premise must be hedged, because of an inconvenient truth that Thrush acknowledges at the outset: Obam never expected that his reelection would end partisan gridlock:

Tuesday, July 16, 2013

The WSJ on the ACA, cont.

Early this month, I looked at a couple of Wall Street Journal stories that emphasized the negative in the Affordable Care Act rollout and wondered whether the WSJ healthcare coverage wasn't Foxifying a bit. One emphasized the premium hike for a relatively small subset of people subject to the individual mandate (and without employer-provided insurance), and one aggregated and exaggerated a series of "blows" to the law, most of which were old news.

Healthcare reporter Louise Radnofsky was on both bylines. She's a good reporter. Her coverage over time has been balanced.*

But as the rollout of the ACA exchanges looms, I wonder whether WSJ news editing is tilting the emphasis on ACA coverage generally [ [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, Project Millennial blogger Mike Miesen flags another questionable WSJ framing of ACA news that had also registered with me this morning:

Monday, July 15, 2013

A Pooh guide to blogging

While I usually avoid talking or even thinking entirely consciously about this, it often strikes me (usually when I don't find anything to blog about) how strange it is that for five-plus years I've managed, FWIW, to come up with a post idea about six days out of seven.  More often than not, this just happens while I'm reading something (something doesn't add up, or reminds me of something else that doesn't seem entirely arbitrary), but sometimes it's a matter of mood, or caffeine: it feels like something is about to catch.

When it's the latter, my repetitive mind -- not so much a lizard brain as a perpetual child brain -- usually throws up a line from Winnie-the-Pooh "he felt singy." Here is that jewel in its setting (House at Pooh Corner, Ch. 6):
One day, when Pooh was walking towards this bridge, he was trying to make up a piece of poetry about fir-cones, because there they were, lying about on each side of him, and he felt singy.

Sunday, July 14, 2013

Poem for a hot summer Sunday

In high Buddleia season:


                                                                  Butterflies (a truth to utter)
                                                                  don't look much like flying butter.
                                                                  Why do we say "butterfly"?
                                                                  Babies can't say "flutter by."

Saturday, July 13, 2013

"Government-run healthcare," Singapore style

In his long rhetorical war against the Affordable Care Act, Avik Roy likes to hold up Singapore's healthcare system as a shining counter-example. He quite rightly points out that Singapore spends far less on healthcare than the U.S. (4% of GDP vs. 18% for the U.S.), and with better outcomes. How do they do it? Roy -- while acknowledging one aspect of the government's heavy hand --  credits free-market magic:
The key to the Singapore system is mandatory health savings accounts: again, something that libertarians and many conservatives wouldn't like. Matt Miller of the Center for American Progress describes Singapore as "further to the left and further to the right" than the American system--something that could also be said of Switzerland.

Thursday, July 11, 2013

Pulping the bully approach to presidential politics, VI

Ezra Klein is replaying that whole paradox of power thing: When Obama comes out for a policy, the GOP will demonize it -- so if Obama wants to get anything done with a GOP House, how can he jump off his shadow?  This time, Klein brings Jon Favreau to bear, affirming the White House's not-at-all-surprising hyper-awareness of this conundrum:
Jonathan Favreau, who in February stepped down as Obama’s chief speechwriter, said that dealing with the Republican Party’s reflexive opposition is a pervasive reality in the White House. “People take a very realistic approach to it,” he said. “They’re not frustrated or upset. It’s more, ‘This is just the way things are and this is how we’ll deal with it.’ The strategy always comes to ‘What gives us the best chance to get something passed?’”

Since you're here, read this

I don't usually post excerpts without comment, but...I feel like Jon Favreau has told basically the whole story of U.S. politics of the last five years with his piece, The GOP is Terrified Obamacare Could be a Success. It lays bare the bad faith, the all-in commitment to misinformation, the callousness and cruelty of today's GOP.  It makes my heart sing, so I'm going to carry my bucket of water to the ocean of Favreau's readership and say: read it:
But here’s my question: if Republicans are so confident Obamacare will end badly, why not just shut up about it? It’s not like they have the votes to repeal the law—a math problem they still haven’t solved after 37 different tries. Their appeal to the Supreme Court ended in defeat at the hands of a conservative chief justice. And now the bulk of the plan will begin to take effect in just a few months.
At this point, why not sit back and wait for this crazy experiment to self-destruct? Why not let President Obama and the Democrats reckon with the millions of angry Americans who will undoubtedly hate their new insurance or their new insurance protections?
Because Republicans are terrified that Obamacare could actually work.

Tuesday, July 09, 2013

Mistrust among the poor

I am reading Doing the Best I Can: Fatherhood in the Inner City by Kathryn Edin and Timothy J. Nelson, a compulsively readable in-depth account of how poor inner city men view and attempt to fulfill their responsibilities as fathers. The authors lived in Camden, NJ, one of the country's poorest cities, and spoke in depth to some 110 unmarried fathers in Camden and poor black and white neighborhoods of Philadelphia.

The title aptly captures the core idea: the men have shining ideals of fatherhood and marriage but hold themselves to much lower standards in keeping with their earning power and lack of strong ties to their children's mothers. Most beget children as the result of brief and haphazard relationships with women and are much more invested in their relationships with the children than with the children's mothers. Repeatedly, these mostly none-too-trustworthy men express a lack of trust in women.  And one expression of that lack of trust reminded me of a different all-too-common suspicion. Below, a father of three speaks:

Monday, July 08, 2013

Who'll stop the hospital billing machine when you're "covered"?

My family gets its health insurance through my wife's employer, a multi-hospital system. Until this year, we have had in-network coverage only. Last fall, somewhat to my surprise, the hospital-insurer agreed to cover in full an operation out-of-network on grounds that no one in-network was qualified to do it. This was a wake-up call for me, and I insisted that this year we pay more for a plan that provides limited out-of-network coverage.While out-of-network coverage has substantial deductibles and limited co-pays, out-of-pocket expenses are capped at about $11,000 per individual. That strikes me as worthwhile catastrophic insurance if one of us gets seriously ill and needs to tap a top specialist outside the network. But our experience with the covered out-of-network operation we already had raises a question in mind about that out-of-pocket maximum -- for myself and for insured patients in general, particularly those buying on the new healthcare exchanges.

Here's the rub: while our insurer informed us that the operation would be covered in full, they were slow to pay some bills and paid some only in part. We then became targets of "balance billing" -- practices affiliated with the hospital where the operation occurred as well as the hospital itself dunning us for unpaid balances, often under threat of siccing a collections agency on us.

Saturday, July 06, 2013

An "introvert" in the White House

Richard Neustadt, author of Presidential Power and Modern Presidents, seems to have been rather a Kennedy worshipper, judging from a chapter on Kennedy written for a later edition of his signature work.  All the more reason that this minor caveat to a portrait of near presidential perfection caught my eye:
.., he was not a "mixer" socially, not, anyway, with most members of Congress and their wives. His manners were impeccable, his charm impelling, but he kept his social life distinct from his official life and congressmen were rarely in his social circle. To know how Congress works but to disdain its joys is an acquired taste for most ex-congressmen downtown, produced by hard experience. Kennedy, however, brought it with him. Many of the difficulties he was to encounter in his day-to-day congressional relations stemmed from that disdain (p. 174, 1990 edition).

Friday, July 05, 2013

How does Roger Cohen know what Egyptians want?

With all due respect to Roger Cohen's long experience as a reporter, how does he know what the Egyptian revolution has been "about"?

He addresses the question with apparent confidence:
The uprising that ended decades of dictatorship and led to Egypt’s first free and fair presidential election last year was about the right to that vote. But at a deeper level it was about personal empowerment, a demand to join the modern world, and live in an open society under the rule of law rather than the rule of despotic whim.

In a Muslim nation, where close to 25 percent of Arabs live, it also demanded of political Islam that it reject religious authoritarianism, respect differences and uphold citizenship based on equal rights for all.
Cohen's sources? Heba Morayef, head of Human Rights Watch in Cairo, and Mohamed ElBaradei, the world famous "liberal modernizer" (Cohen's phrase) who signed onto the generals' coup. That's it -- the sum total of his cited sources for telling us what 80-plus million Egyptians want.

OK, Krugman: How will hypocrisy help us?

Paul Krugman, Jeremiah of galloping income inequality in the United States, today manages a rather half-hearted tribute to the nation's long-term fidelity to its founding ideals. Half-hearted, because seeing those ideals subverted by encroaching oligarchy, he takes rueful solace only in our national hypocrisy:
Of course, our democratic ideal has always been accompanied by enormous hypocrisy, starting with the many founding fathers who espoused the rights of man, then went back to enjoying the fruits of slave labor. Today’s America is a place where everyone claims to support equality of opportunity, yet we are, objectively, the most class-ridden nation in the Western world — the country where children of the wealthy are most likely to inherit their parents’ status. It’s also a place where everyone celebrates the right to vote, yet many politicians work hard to disenfranchise the poor and nonwhite. 

But that very hypocrisy is, in a way, a good sign. The wealthy may defend their privileges, but given the temper of America, they have to pretend that they’re doing no such thing. The block-the-vote people know what they’re doing, but they also know that they mustn’t say it in so many words. In effect, both groups know that the nation will view them as un-American unless they pay at least lip service to democratic ideals — and in that fact lies the hope of redemption. 

So, yes, we are still, in a deep sense, the nation that declared independence and, more important, declared that all men have rights. Let’s all raise our hot dogs in salute.
Left unspoken here is how hypocrisy helps. It's said that hypocrisy is the tribute that vice pays to virtue -- bad conscience with a cover. The question is, how productive will our ethical unease prove? Now that our income distribution (and opportunity distribution) has reverted to roughly where it was before the Great Depression and the New Deal, will this retrogression prove, to borrow a bit of econ-speak, 'secular or cyclical'?  That is, will we readjust, as Obama in '08 argued we must, from a 30-year Reaganite right turn turbo-charging pressure on wages powered by automation and globalization? Will we find means to train our youth to create and fill "good-paying jobs of the future"? Or was the relatively weak American version of the welfare state merely a one-time strategic retreat by elites that have more recently tightened a now unshakable proprietary grip on the means to prosperity?

Thursday, July 04, 2013

The "I want the best" quality measure in healthcare

On The Incidental Economist, Bill Gardner rather wearily brushes off claims, based on personal experience, that the U.S. has "the best healthcare in the world." He outsources to Aaron Carroll the marshaling of evidence that "on most important measures, the US has poorer quality of care than comparable countries" and concentrates on a prior question: what do we mean by quality of care? He then offers a breakdown of quality measures which, for policy purposes, may be comprehensive, but which I think misses a dimension that may be in the minds of many who claim "best" status for the U.S. Here are Gardner's "dimensions of health quality*":
  • The hotel experience. Some hospitals are nicer places to stay than others. This may seem trivial in the context of life and death, but any hospital manager will tell you that ‘hotel quality’ matters to patients.
  • The relationship experience. Did the health care providers treat you with respect? Were they considerate of your religious beliefs? The well-educated readers of this blog may have difficulty imagining that they would not be well-treated by health care providers. But disrespect may be a primary consideration if you are poor, speak a language other than English, live outside the mainstream culture, or are mentally ill.
  • The rightness of treatments. By the ‘right’ treatment, I mean the one that was most likely to benefit you.
  • Safety. Were you harmed through error or neglect while you were in care?
In response, I posted this comment:

Tuesday, July 02, 2013

For Egypt, a warning from Aesop

Not to pretend to any expertise about Egypt, but as soon as I read about the military's ultimatum to Morsi, this fable of Aesop's came to mind:
There was once a Horse who used to graze in a meadow which he had all to himself. But one day a Stag came into the meadow, and said he had as good a right to feed there as the Horse, and moreover chose all the best places for himself. The Horse, wishing to be revenged upon his unwelcome visitor, went to a man and asked if he would help him to turn out the Stag. "Yes," said the man, "I will by all means; but I can only do so if you let me put a bridle in your mouth and mount on your back." The Horse agreed to this, and the two together very soon turned the Stag out of the pasture: but when that was done, the Horse found to his dismay that in the man he had got a master for good.
Until Mubarak's deposing, Egypt had been under military rule since 1952.  Do Egyptians really want to toss out their first elected leader, in power for just a year, and take the bit again?

In which Ezra Klein makes Avik Roy acknowledge why U.S. healthcare costs are so high

Avik Roy and Ezra Klein had a long --very long -- conversation about Roy's beefs with the Affordable Care Act. They covered "rate shock,"  minimum coverage standards, and Roy's dreams of a more fundamental system overhaul that would push everyone onto healthcare exchanges by privatizing Medicaid and Medicare and ending the employer tax deduction for health care benefit provision. 

Roy has been a relentless critic of the ACA. Having read some of his writings about it but by no means all, I was surprised to learn, as Klein probed his reaction to feature after feature, that he "do[esn't] have* a problem with standardizing benefits" and that "guaranteed issue [no refusals or cost bumps for preexisting conditions]is fine." His objections really boiled down to three: 1) he objects strenuously to "community rating," i.e., the ACA's limiting of the price differential between the youngest and oldest age cohorts to 3-to-1, as opposed to the roughly 6-to-1 ratio that Roy says the market would dictate.  2) He would like the exchanges to offer plans that cover even less than the lowest cost plans in the current design -- plans covering, say, 40% of a member's average yearly costs rather than the 60% that the exchange's lowest-run "bronze" plans are designed to cover. 3) As mentioned above, he would like more radical reform -- health exchanges for everyone.

As Klein eventually made Roy implicitly acknowledge, though, none of his favored solutions get at the root of the United States' disproportionate healthcare inflation.

Monday, July 01, 2013

WSJ leans into the "rate shock" narrative for Obamacare

[Updated 7/13, per "Blows to Obama's Health-Care Law Pile Up"...]

The WSJ's Louise Radnofsky is an experienced healthcare reporter, and her front-page story today about pending "rate shock" for healthy singles when the ACA takes effect is factually accurate. Since the focus is on the risk that the healthy uninsured will stay out of the ACA's healthcare exchanges, it's arguably fair to focus on the subset -- a minority of those who don't get insurance from an employer or the government -- whose premiums may go up. But nonetheless I find the emphasis and framing misleading in some particulars (e.g., the online home page teaser, "Insurance Rates Could Soar Under New Law"). .

The lede goes for maximum shock effect, setting reader perceptions before multiple caveats qualify the picture:

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