Friday, August 29, 2014

"We don't have a strategy yet" is a strategy


Regardless of whether Obama's assertion that "we don't have a strategy yet" for confronting ISIS in Syria and potentially beyond (as opposed to in Iraq) was well advised, it was not a gaffe in the sense of an inconvenient truth that slipped out.

It couldn't have just slipped out, because Obama reiterated the point and elaborated it at length. His reasons for describing the strategy as in progress and TBA were multiple: 1) to reassure that he was not beginning a large-scale military operation without consulting Congress; 2) to pressure prospective coalition partners to play their parts and emphasize that US action depends in large part on their cooperation; and 3) to differentiate between immediate, limited military action and a more sustained, multilateral, slower-building and Congressionally authorized effort.  That's all in his second iteration of the strategy-to-be:

Gideon Levy, Jeremiah

I want to stay near silent in paying tribute, via this 2010 profile by Johann Hari, to Gideon Levy, Israel's most hated Jewish Israeli reporter and one of its bravest. Just a couple of excerpts below (okay, four)..

Levy’s father never saw any parallels between the fact he was turned into a refugee, and the 800,000 Palestinians who were turned into refugees by the creation of the state of Israel. “Never! People didn’t think like that. We never discussed it, ever.” Yet in the territories, Levy began to see flickers of his father everywhere – in the broken men and women never able to settle, dreaming forever of going home.

and

Thursday, August 28, 2014

Inching toward immortality

Kaiser Health News reports on medical research -- funded, albeit minisculey, by the ACA -- that taps into longstanding dreams:
Imagine if scientists could recreate you---or at least part of you---on a chip.

That might help doctors identify drugs that would help you heal faster, bypassing the sometimes painful trial-and-error process and hefty health care costs that accompany arriving at the right treatment.

Right now, at the University of California, Berkeley, researchers in bioengineer Kevin Healy's lab are working to make that happen. Funded under a provision of the health law, they're trying to grow human organ tissue, like heart and liver, on tiny chips.
Science fiction writers  have long envisioned variations on this theme-- e.g.. organ banks, rejuvenation via replacement of body parts. transfer of a individual consciousness into a spare body.  Back in the disk drive era, I put a less physical imagining into a children's poem:

A Good Dream

I dreamed I saved my sister on disk--
brother, was I relieved.
If any harm should come to her
she could be retrieved.

Wednesday, August 27, 2014

Will the ACA reduce the disability rolls?

Two years ago, I was riveted by TNR reporter Alec MacGillis' chat with a woman on line for a free REM medical clinic in rural Tennessee. Notwithstanding that she knew nothing about the ACA, she offered a stunning instant analysis, once the basics were described to her, of one likely economic effect:
..it it was hard to find visitors to the clinic who would not benefit directly from the law. Barbara Hickey, 54, is a diabetic who lost her insurance five years ago when her husband was injured at his job making fiberglass pipes. She gets discounted diabetic medication from a charity, but came to the clinic to ask a doctor about blood in her urine.

Under the law, she would qualify for Medicaid. Her eyebrows shot up as the law was described to her. "If they put that law into effect, a lot of people won't need disability," she said. "A lot of people go onto disability because they can't afford health insurance."
Lo, Ms. Hickey was a prophet (perhaps). In Arkansas, which has sliced its uninsured rate almost in half since ACA enactment, mainly by enrolling nearly 200,000 Arkansans in the state's "private option" Medicaid alternative, disability claims seem to be dropping.* Modern Healthcare's Paul Demko reports:**

Monday, August 18, 2014

In which Clinton slams Obama by articulating his "organizing principle"


A typical account of Hillary Clinton's assessment of Obama's foreign policy in the Goldberg interview ran like this one in the New York Times:
Her blunt public criticism of the president’s foreign policy in The Atlantic this week touched off frustration among Mr. Obama’s advisers and supporters, especially her suggestion that under Mr. Obama, the United States lacked an “organizing principle” in its approach to international relations. “ ‘Don’t do stupid stuff’ is not an organizing principle,” Mrs. Clinton said.
Three things to note about this takeaway:

1. Clinton didn't say that "don't do stupid stuff" is Obama's organizing principle, or that he lacks one. In fact she said the opposite.

2.  The "organizing principle" that Clinton articulated, when pressed, is indistinguishable from Obama's, and, just like Obama's, incorporates "don't do stupid shit" but doesn't end there  (though the particulars of her favored policies on specific issues may quite different, in disturbing ways -- more on this at bottom).

3. Obama has articulated that principle continually since his first year in office.

Sunday, August 17, 2014

A stealth modernist's divine lamppost

Lev Grossman, a fantasy writer whose works I have not yet been privileged to read, has a wonderful, wonderful, wonderful tribute to C. S. Lewis, who brought him into the worlds of reading and of fantasy. He focuses first on a passage that I used to xerox for students, also trying to capture its magic:
Even more than that, it’s the way he uses language—which is nothing like the way fantasists used language before him. There’s no sense of nostalgia. There’s no medieval floridness. There’s no fairy tale condescension to the child reader. It’s very straight, and very clean—there’s no Vaseline on the lens. You see everything clearly, not with sparkles or a flowery sense of wonderment, but with very specific physical details. Look at the attention to detail as you watch Lucy going through the wardrobe:
This must be a simply enormous wardrobe!" thought Lucy, going still further in and pushing the soft folds of the coats aside to make room for her. Then she noticed that there was something crunching under her feet. "I wonder is that more mothballs?" she thought, stooping down to feel it with her hand. But instead of feeling the hard, smooth wood of the floor of the wardrobe, she felt something soft and powdery and extremely cold. "This is very queer," she said, and went on a step or two further.

Friday, August 15, 2014

"What's a subsidy?" -- It's hard to reach the uninsured

Back in May, I noted a remarkable finding in a McKinsey survey of those who bought or sought health insurance in the individual market during the ACA's first open season:  Most of those who failed to obtain coverage were eligible for subsidies but did not know they were eligible. Two thirds of subsidy-eligible respondents who visited healthcare.gov but did not enroll were not aware of their eligibility -- and so had no idea how much health insurance would actually cost them.

Those findings are corroborated in a survey conducted at about the same time (April 10-28), commissioned by EnrollAmerica and conducted by PerryUndem Research/Communication. I just happened on this because HuffPost's Jeffrey Young cited the results in a story about the challenges of meeting signup targets in ACA year 2. Ignorance among the uninsured remains perhaps the greatest barrier (excepting the refusal of about half the states to accept the law's Medicaid expansion).

The EnrollAmerica survey drew responses from 671 new enrollees and 853 people who remained uninsured. 60% of those who remained uninsured said they wanted insurance. Only 21% of those who did not try to enroll knew that financial help was available to low-to-moderate income buyers -- and only 38% of those tried but failed to enroll were aware of this basic fact.

Perhaps even more remarkably, only 56% of those who did enroll in coverage knew that the law gives financial help to low- and moderate-income buyers. At the same time, 75% of enrollees, including 69% of those who enrolled online, said that the signup process was easy. Perhaps in this one regard it was a bit too easy, i.e., it was not hammered home that your friendly federal government was subsidizing your purchase.

Wednesday, August 13, 2014

Hillary Clinton was not so hawkish on Iraq

Jonathan Ladd sensibly questions the premise that  Hillary Clinton would act like a hawk as president, as opposed to talking a little like one now. As evidence that she would not, he cites the foreign policy continuity between the (Bill) Clinton and Obama administrations (of which she is of course a lynchpin), and the fact that the only hawkish action she's ever taken was her vote in October 2002 to authorize the use of force in Iraq.

I would complicate somewhat Ladd's contention that in her tenure as Obama's Secretary of State Clinton's "actions supported President Obama's less confrontational, less militaristic policies rather than the neoconservative policies advanced by the Bush administration." She supported the generals' plans for a surge in Afghanistan (the modifications were all Obama's own), urged the Libyan intervention, supported early intervention in support of "moderate" rebels in Syria, and claims that she always worked either to deny or reduce to a token Iran's "right to enrichment."  That doesn't mean that she wasn't a loyal administration member, but it does indicate that her relative hawkishness is more than talk. I find her stance with regard to Iran particularly disturbing, in that it bespeaks not just "hawkishness" per se but also near-complete deference to Netanyahu and AIPAC -- a deference to which her Goldberg interview pays really stunning and disturbing tribute.

To switch gears, though, I'd like to offer collateral support to Ladd's contention that Clinton's Senate vote to authorize the use of military force in Iraq does not necessarily indicate a predisposition to use military force generally.  Ladd concentrates on the strong political incentives to support the resolution. I'd add that Clinton cast her vote as a vote for diplomacy and a chance to avoid war. On several occasions following, she urged Bush not to rush to war. She was hardly a profile in courage in this regard: those urgings devolved into meek peeps as war approached in March 2003. But they do indicate that if she held the reins, she may have been content to force invasive inspections -- arguably a tool of the kind of "smart power" she claims to advocate.

If you're dropping ACA coverage for any reason, I'd like to hear from you

[moving this forward per request for input at bottom...]

Charles Gaba, ACA signups tracker extraordinaire, dives into a scary-sounding claim about attrition among people who signed up for private health plans on ACA exchanges -- Aetna enrollments to drop 30%! -- and provides some clarity: attrition for private insurers generally is likely coming in at about 2.5% per month, as expected.

That attrition -- offset, to an unclear degree*, by off-season "special enrollment period signups -- is expected and normal. A Kaiser study found that only 62% of people who had individual market coverage in January 2010 still had in July 2010.  According to an older study by Mathematica Policy Research,  while, 5.3 percent of the non-elderly population had non-group [individual market] coverage  in any given month, only 2.1 percent held non-group coverage for the entire year, and 9.7 percent had non-group coverage at some point during the year.

Of the four people I know personally who obtained insurance on ACA exchanges, none will stay pat for more than fourteen months, and two will be off their plans within six months of signup. One is a woman recently divorced who found a job in July and was covered by her employer as of August 1; another is entering a graduate program that provides free (or at least premium-free) health insurance, effective Sept. 1. A third is switching from a high-deductible ACA plan to insurance provided by his wife's employer. Another qualified for Medicaid, then found a job (without insurance) in June, notified the authorities and was allowed to remain on Medicaid for a year, dated from the point when he reported change of status. If his income doesn't change, he'll qualify for a subsidized private plan with Cost Sharing Reduction when his Medicaid eligibility ends.

Tuesday, August 12, 2014

Hedges, lies and pablum: Clinton to Goldberg

In a prior post, I may have overemphasized the hedge element in Hillary Clinton's interview with Jeffrey Goldberg, published Sunday. Hedging her criticisms of current policy and her interventionist impulses was definitely a part of the performance. But that performance was equal parts hedges, bald-faced lies and pablum in support of an implied general propensity toward more aggressive action that itself may prove illusory.

For the lies, see Peter Beinart. Everything Clinton said about Netanyahu and his dealings with the Palestinians in his two spells as prime minister was untrue. He didn't "move toward a Palestinian state" in the mid-nineties, he didn't agree to a meaningful settlement freeze in 2009, he didn't engage with Assad in 2009-2010, he didn't offer the Palestinians "Barak-like options"--or any concrete proposals -- in the last round of negotiations that collapsed this spring, and he either never relinquished or has recently reaffirmed a determination never to give up security control of the West Bank. As for the assault on Gaza, Clinton simply parroted IDF talking points.

With regard to the hedging, as I argued in the prior post, Clinton did not suggest that jihadism is a threat on the scale of communism, only that containment was an overall strategy that might be adapted to any toxic ideology that poses a threat to global order. Containment-as-framework was further hedged by allusions to the many mistakes the U.S. made in the Cold War, to be improved by "smart power" and "after-action reviews." Clinton's invocations of "smart power" sound a lot like Obama's oft-stated preferences for deploying nonmilitary tools of U.S. influence, as does her acknowledgement of "the limits of our power to spread freedom and democracy."

Sunday, August 10, 2014

Read Goldberg's interview with Hillary Clinton before you read Goldberg's account of that interview

I've seen more than one tweet this morning to the effect that Hillary Clinton "threw Obama under an ISIS-driven Humvee" in a long, probing, interview with Jeffrey Goldberg.  I think that's a wrong impression created by Goldberg's introductory overview, which overstates her actual and implied criticisms of Obama.

It's no secret that Clinton advocated for early U.S. support of allegedly moderate factions in the Syrian opposition. And it's necessary and prudent for Hillary to distance herself from Obama, or position herself to do so, in that a) she genuinely is more interventionist, and b) the world could blow up on Obama and doom her chances if she's seen as a continuation. But it's also in Hillary's DNA to hedge, both from a desire to cover both sides and an ability to see complexity (except with regard to Israel, to which she pandered without inhibition). And in at least three instances, Goldberg emphasized just one side of her equation.

First, with regard to the Syrian intervention. Here's Goldberg:
In an interview with me earlier this week, she used her sharpest language yet to describe the "failure" that resulted from the decision to keep the U.S. on the sidelines during the first phase of the Syrian uprising.

“The failure to help build up a credible fighting force of the people who were the originators of the protests against Assad—there were Islamists, there were secularists, there was everything in the middle—the failure to do that left a big vacuum, which the jihadists have now filled,” Clinton said.
And here's Hillary, in the interview:

Barbarians at the gate

From Robin Wright in the New Yorker, a warning about the Islamic State that concentrates the mind:
There is a broader danger. The direct American presence may galvanize more jihadis to the Islamic State. There was no Al Qaeda presence in Iraq until after the United States deployed troops in 2003, an act that fuelled Al Qaeda’s local appeal, on territorial, political, and religious grounds. In Iraq and Syria, ISIS is now estimated to have between ten thousand and twenty thousand fighters, including a couple of thousand with Western passports and a hundred or so from the United States.

As the United States confronts ISIS, the dangers that Americans will be targeted at home grow. Last month, the F.B.I.’s director, James B. Comey, said that the domestic threat emanating from ISIS “keeps me up at night,” that ISISwas a potential “launching ground” for attacks of the kind that occurred on September 11, 2001. The Attorney General, Eric H. Holder, Jr., told ABC News that ISIS, particularly its American jihadis, “gives us really extreme, extreme concern. . . . In some ways, it’s more frightening than anything I think I’ve seen as Attorney General.”

Thursday, August 07, 2014

If you like your ACA plan, you very likely won't be renewing anyway

Sam Baker and  Jonathan Cohn have both spotlighted a Milliman briefing paper warning of an important potential glitch looming as the ACA's second Open Season approaches. It's this: while the government is encouraging current customers to renew their current plans via auto-enrollment, many customers may see significant price spikes if the plan they selected last year loses its status as a "benchmark" plan.

Subsidies are keyed to the second cheapest silver plan in each market, deemed the benchmark; subsidized customers who buy a plan more expensive than the benchmark have to pay the whole difference. Thus, if the ACA affordability formula decrees that you should pay $30 per month for a benchmark plan with a base premium of $300, and that plan's premium spikes to $350 and it cedes its benchmark status, you'll now be on the hook for $80 per month rather than $30 if you stick with it. To stay at roughly the $30 level, you'll have to switch to one of the two cheapest silver plans on offer this year. (Additionally, if the benchmark plan price goes up, customers' advanced premiums may also go up if they re-apply rather than auto-enroll.)

I wouldn't dream of downplaying this very important potential glitch. But I think it's worth noting an often-unnoticed market factor that will mitigate its impact somewhat: there's tremendous churn in the individual market, and it's likely that half or more of those who enrolled in private plans in 2014 will be looking to renew. Many will have found jobs that offer insurance; some will become eligible for Medicaid; some will marry or move and need to select a new plan in any case. In November 2013, healthcare scholars Rick Curtis and John Graves estimated (with some caveats) that just 42 percent of Americans eligible for subsidized exchange coverage at end of 2014 (i.e., the upcoming open enrollment season) were eligible in the prior year. That doesn't quite tell us what percentage of those currently enrolled in subsidized exchange plans will not be seeking coverage for 2015, but it gives an idea of the degree of turnover.

Wednesday, August 06, 2014

The ACA preserved state regulation of health insurance

Yesterday I noted that the state-vs.-federal exchange debate within the Democratic party in early 2010 was focused primarily on which level of government would regulate insurance -- and not, as Halbig proponents are suggesting, on whether the "backstop" federal exchange created by the Senate bill would be enabled to issue tax credits.

Both before and after the Scott Brown earthquake, the question was how the Senate and House bills would be reconciled. The House bill created a federal exchange, with an opt-out for states that wanted to create their own. The Senate bill stipulated that states would establish their own exchanges, with an opt-out for those that chose to cede the function to the federal government.

As it turned out, the reconciliation bill that tacked House modifications on the Senate bill did not substantially alter the Senate bill's state exchange structure -- though it did, by the way, include a tax reporting provision that referred directly to tax credits allocated by the federal exchange, a provision that should lay to rest the Halbig contention that ACA tax provisions preclude the federal exchange allocating tax credits.  And although the federal government did end up running most of the state exchanges, in the sense of running the website processing citizens' applications, regulation of insurance, within the broad coverage parameters set by the ACA, remained mainly in state hands.*

Evidence of that retained state control can be found in the varying steepness of 2015 health insurance premium increases in different states. Overall, the rate hikes are in line with or slightly below the increases of previous years. A heat map by PriceWaterhouseCooper indicates that states that ran their own exchanges, and so more actively oversaw the offerings approved for sale, were on balance subject to more moderate increases (Vermont is an exception). From the data that's come in so far (only about half of the states have so far reported wholly or partly on 2015 rates), Jonathan Cohn extracts an illustrative tale of two states:

Tuesday, August 05, 2014

No, Ben Nelson didn't scuttle the ACA's federal exchange

[Update, 1/29/15: As Jonathan Cohn reports, Nelson has just precisely confirmed the reading below of his position re federal and state exchanges.]

The latest bit of sophistry deployed by Halbig supporters to convince the world that the Senate Democrats who drafted the ACA deliberately barred subsidies from flowing through any exchange set up by the federal government is a claim that "Ben Nelson made them do it," Here's David Catron in The American Spectator (retailed without value-add by the Wall Street Journal's James Taranto):
Jonathan Cohn advises his New Republic readers, “Like other journalists who were following the process closely, I never heard any of them suggest subsidies would not be available in states where officials decided not to operate their own marketplaces.”

This is an odd statement indeed considering that high-profile publications were reporting a lively debate over this very issue. And Ben Nelson’s name was frequently mentioned. In January of 2010, for example, Politico reported that he regarded federal control of Obamacare’s exchanges as “a dealbreaker.” Nelson said that too much federal involvement would inevitably lead to government-run health care: “I wouldn’t support something that would start us down the road of federal regulation of insurance and a single-payer plan.”

He reiterated his objection to federal exchanges in this 2010 video, wherein Greta Van Susteran presses him to provide a legitimate motive for ultimately voting in favor of health care “reform.” Nelson vehemently insists that no one bought his vote: “I had requirements… no government-run plan, no federal exchange… and adequate language to deal with abortion. Those were requirements, but no one was buying any vote.” Nelson clearly implies that these conditions had been met and this is why he flip-flopped and voted for the bill.
These statements prove nothing, and indicate nothing.There was precisely zero public debate over whether the Senate bill allowed a federal exchange to credit subsidies. Catron strips the context out of the Politico article, which in fact indicates the opposite of what Catron and Taranto imply.

Friday, August 01, 2014

Michael Cannon gives the game away, cont.*

The Halbig plaintiffs and their allies would have you believe that the titanic struggle in the Supreme Court in 2012 over the constitutionality of the ACA's individual mandate was a fight over nothing. Or, alternatively, that the government had a bulletproof defense of the law's constitutionality that it inexplicably left on the table.

According to the Halbig plaintiffs, the ACA's framers deliberately barred any exchange established by the federal government from crediting subsidies to qualified buyers of health plans offered on the exchanges. Only an exchange "established by a state can do that. Thus, the ACA could only function in a state that established its own exchange.  The law's creators and proponents have been protesting for three years that this claim is preposterous on its face, as a federal exchange would be worthless without the ability to credit subsidies, but that is the suit's  contention.

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