Children first in the acceptance of same-sex marriage

I may later thicken up this post, which has been stalled by a few reading blocks, but just to get the basic idea down...

When I read Justice Kennedy's reasoning on behalf of the children of gay parents in his opinion striking down section 3 of DOMA in U.S. v. Windsor...

This [federal non-recognition of marriages sanctioned by states] places same-sex couples in an unstable position of being in a second-tier marriage. The differentiation demeans the couple, whose moral and sexual choices the Constitution protects, see Lawrence, 539 U. S. 558, and whose relationship the State has sought to dignify. And it humiliates tens of thousands of children now being raised by same-sex couples. The law in question makes it even more difficult for the children to understand the integrity and closeness of their own family and its concord with other families in their community and in their daily lives...

...I flashed back to Jeffrey Toobin's profile of Ruth Bader Ginsburg, which thanks to dysfunction on the New Yorker website I have not been able to access, subscription notwithstanding. According to Toobin, Ginsburg is at least a bit ambivalent about Roe v. Wade, which she thinks may have brought too much change too quickly. Held up as a counter-example was the low profile manner in which gay would-be parents won adoption rights -- in relatively non-adversarial family court proceedings. I can't recall whether Ginsburg had a hand in this, or simply admired the steady under-the-radar progress.

Civil unions are not marriage "in all but name"

When I read the passage below in Justice Kennedy's decision striking down DOMA today, I thought of a gay friend of mine:

DOMA also brings financial harm to children of same-sex couples. It raises the cost of health care for families by taxing health benefits provided by employers to their workers’ same-sex spouses.

My friend was married to his husband in a New Jersey church a few years ago.  Legally, they are joined in a New Jersey civil union. My friend gets health insurance through his spouse, but thanks to DOMA, the employer does not get the federal tax exemption for providing his health insurance, and the employer passes on the cost to this couple.

When New Jersey passed its law establishing civil unions in 2006, it was billed as marriage in all but name. It was never that, and now its difference from marriage is all the more acute. An ACLU-NJ press release applauding today's decision and exhorting New Jerseyans to push for gay marriage spells this out:

Same-sex couples in civil unions will remain ineligible for the hundreds of benefits that now will be granted to same-sex married couples in other states under the court’s decision.

Will we hear Obama in retrospect?

Greg Sargent very sensibly notes that Obama, in his speech at Georgetown today announcing executive actions to reduce greenhouse gas emissions, "recast the call for climate action as the centrist, common-sense solution." Further developing that idea, he cites Chait:

As Jonathan Chait noted recently, the untold story of the Obama era is his vision of achieving liberal goals as a means for also achieving long-term economic growth:

Fashioning a long-term growth strategy is, and has always been, Obama’s deepest passion. He’s been caught up in an economic crisis and a culture war over the role of government that he wants badly to escape.

I must add that if Obama's vision of enacting liberal policies as a means for achieving long-term growth has been left untold by certain parties, those parties don't include Obama. He has never stopped telling that story: it is the very heart and soul of his pitch to America and always has been. That goes for casting those policies as "common-sense centrism," too. Throughout the 2008 campaign, tracking his speeches, I referred repeatedly to Obama's bid to move the center left. The argument has (and had) these components:

On Neustadt's gold standard for presidential power

I am nearing the end of the chapters comprising the original edition of Richard Neustadt's Presidential Power and the Modern Presidents (originally focused on the presidencies of Truman and Eisenhower, later much expanded).  The original edition is in large part a close study of two failures in presidential decision-making: Truman letting his policy in Korea be shaped by MacArthur's military overreach, and Eisenhower failing to resolve internal splits in his administration over budget policy, and therefore appearing several times over the course of a year to contradict his own prior policies and pronouncements.

The basic premise is that almost nothing happens simply because the president decrees that it should: presidential power depends on convincing a multitude of individuals and constituencies that the president has the ability to help or harm them.  There is a chicken-egg aspect to this: the president convinces people of his power when things that he says will or should happen do in fact happen, and when the results are in line with his stated goals or expectations.  That means being highly alert to the human, interpersonal factors that can undermine both policy decision-making and execution - for example, a rift between budget director and Treasury secretary, or military brass unwilling to cross a legendary general in the field. The requisite alertness can only come from a president developing his own back-channel information network: he (or someday she, as Neustadt enthusiastically adds in a latter-day preface) must constantly be gathering such intelligence from a multitude of sources.

This all seems solid information as far as it goes, derived from Neustadt's personal experience in government as well as by talking to a lot of people in government. And yet, toward the end of the original edition, the thesis is nailed down by means that make a bit wary on structural grounds.

Sweet spot for Obamacare exchanges: some competition, but not too much?

This exchange in a Modern Healthcare interview of Douglas Hough, author of Irrationality in Health Care: What Behavioral Economics Reveals About What We Do and Why, may have some implications for the design of the ACA insurance exchanges:

[Jason] Shafrin: People often perform better, in terms of choosing better when they have fewer choices. Why is that the case? Most economists think that more choice is better.

Hough: What behavioral psychologists and behavioral economists have discovered is that more choice is not necessarily better. The problem is regret bias. If they are shown five things and are asked to choose among them, they can probably choose well. But if they are offered 25 or 50, people end up not choosing at all. This is actually what happened at the beginning of Medicare Part D, when patients were given an extraordinary number of prescription drug plans choices, and a good number of the elderly were paralyzed by having to make that choice. My mother was an incredibly successful business woman, but when at the age of 85 she was faced with the choice of among 45 plans in Virginia for Part D, she just threw up her hands and said, “Well, I don't know which one to pick. Doug, you pick one for me.”

In which Bernstein's "anti-quagmire president" conforms to type

Last week, I noted that in the unfolding of the news that Obama was stepping up aid to the Syrian rebels, it was possible to glimpse Obama pushing back, or holding back, against those trying to promote a more extensive commitment.  There was less to the step-up than meets the eye, the administration seemed to signal.

Last night I watched the Syria segment in Obama's interview with Charlie Rose. And there he made it quite clear that notwithstanding the Sully's fears, Larison's expectations and Marc Lynch's anxieties, he is determined not to get sucked in to another middle east quagmire.  When Rose challenged him on the perception of timidity, this exchange followed:

How now, Politico?

A double dactyl in honor of Politico's  founders, who defiantly dished out their credo to TNR's Isaac Chotiner today:

Higgledy piggledy
Harris and VandeHei
rivet the Capitol:
"Who the day won?"

Beltway CW
retailed quite thrillingly,
gleaned as they willingly
get themselves spun.

Healthcare consolidation perverted by pricing power

Last week, I noted Eduardo Porter's warning that the ACA was spurring hospital consolidation, which increases the hospitals' pricing power. That's the downside of consolidation. Below, that post is updated with a snapshot of the upside of consolidation, realizable when the power to set prices lies elsewhere.
---
Eduardo Porter today spotlights a key factor in healthcare inflation: consolidation among hospitals and other healthcare providers:

What is missing from the stampede of policy innovation is something to tackle one of the best-known causes of high costs in the book: excessive market concentration. 

Two decades ago, there were on average about four rival hospital systems of roughly equal size in each metropolitan area, according to research by Martin S. Gaynor of Carnegie Mellon University and Robert J. Town of the University of Pennsylvania. By 2006, the number of competitors was down to three. 

The share of metropolitan areas with highly concentrated hospital markets, by the standards of antitrust enforcers at the Justice Department and the Federal Trade Commission, rose to 77 percent from 63 percent over the period. 

Did Obama just cross a Rubicreek in Syria?

Just how much of a game changer was the Obama administration's announcement yesterday that it would start providing lethal aid to selected Syrian rebels?  This was one case where the feints and false starts in the news-breaking process suggest that there may have been less of a departure from existing policy than meets the eye. At least, that's what my absorption of the news over an evening and morning suggested to me.

At around 4:45 ET yesterday, a short item in the WSJ Online reported rather ambiguously about a U.S. "proposal" to establish a no-fly zone in a strategic 25-mile sliver of Syria, at the Jordanian border.  The wording immediately raised the question, who was proposing to whom?

1. Daily Intelligencer ‏@intelligencer 19h

   WSJ: U.S. PROPOSES NO-FLY ZONE INSIDE SYRIA http://on.wsj.com/141Fcsv

   
   
2. xpostfactoid ‏@xpostfactoid1 19h

   @intelligencer @lrozen "proposes" to whom? Is this a plan/option or a decided-upon course of action?

   4:47 PM - 13 Jun 13 · Details 

As the WSJ story accrued new paragraphs a few minutes later, it was looking awfully like certain sources were trying to create a reality:

Do past abuses of personal data point toward future abuses of NSA metadata collection?

Stephen Walt spotlights why we worry about metadata collection:

The real risk to our democracy is what this situation does to potential dissenters, whistle-blowers, investigative journalists, and anyone else who thinks that some aspect of government policy might be boneheaded, unethical, or maybe even illegal. If you are one of those people -- even on just a single issue -- and you decide to go public with your concerns, there's a possibility that someone who doesn't like what you are doing will decide to see what they can find out about you. It doesn't have to be the attorney general either; it might just be some anonymous midlevel bureaucrat or overly zealous defense contractor. Or maybe it will be someone who wants to suck up to their superiors by taking down a critic or who wants to have their own 15 minutes of fame. It really doesn't matter: Unless you've lived an absolutely pristine online and cellular life, you might wake up to discover that some regrettable moment from your past is suddenly being plastered all over the blogosphere or discussed in the New York Times. 

 In a way, though, Walt's evidence that we should worry cuts two ways:

Healthcare competition is good. Uniform pricing is better

Eduardo Porter today spotlights a key factor in healthcare inflation: consolidation among hospitals and other healthcare providers:

What is missing from the stampede of policy innovation is something to tackle one of the best-known causes of high costs in the book: excessive market concentration. 

Two decades ago, there were on average about four rival hospital systems of roughly equal size in each metropolitan area, according to research by Martin S. Gaynor of Carnegie Mellon University and Robert J. Town of the University of Pennsylvania. By 2006, the number of competitors was down to three. 

The share of metropolitan areas with highly concentrated hospital markets, by the standards of antitrust enforcers at the Justice Department and the Federal Trade Commission, rose to 77 percent from 63 percent over the period. 

The moral carpet bombing of Edward Snowden has begun

David Brooks vents his prejudices and treats us to pop sociology in search of moral clarity this morning. Nice how some things don't change.

Brooks first reduces Edward Snowden to a social stereotype on flimsy evidence, then condemns him in high moral dudgeon, then undercuts the basis of his condemnation without noticing. For bonus points, he throws in a near-nonsense assertion about the founding fathers' original intent that, insofar as it has any meaning at all, is more false than true.

Brooks' lede intones, "From what we know so far, Edward Snowden appears to be the ultimate unmediated man." That's Brookspeak for 'not a good boy.'  He does not accept the authority and inherent benevolence of Institutions -- in Brooksworld, the repository of all moral value.

Condemning the world's anti-Boy Scouts does not exhaust Brooks' font of indignation. No, the charge must be generational and societal. We are All at Fault, for we are raising a generation of idiots (in the Greek sense of individuals isolated from society):

Intelligence's Heisenberg Principle

Two Times articles about the Edward Snowden leaks suggest variants of a kind of Heisenberg Principle of intelligence gathering. First: the better you share information, the more the information will be "shared" in unintended ways, perhaps affecting your ability to gather it:

Some outside experts said the push in recent years to break down barriers between spy agencies and share information across the government had greatly expanded the universe of government employees and outside contractors with access to highly classified intelligence. 

“In past years, someone like Snowden may not have had access to briefings detailing these collection programs,” said Cedric Leighton, a former deputy director of the National Security Agency, “but now with the push from a ‘need to know’ to a ‘need to share’ philosophy, it’s far more likely for an I.T. contractor like him to gain access to such documents.”

Snowden worked for the mega-intelligence services firm Booz Allen, which earns over a billion dollars a year in mostly intelligence-related work for the federal government.  Which suggests the second variant:

What Snowden sees, what Obama sees

Edward Snowden,the whistleblower on the NSA's surveillance programs, is brave, serious-minded, and capable, and was very selective in what he exposed, determined not to endanger individuals. I am glad he revealed what he did, to paraphrase James Fallows, though I'm not yet sure what I think the government ought to refrain from doing in its efforts to thwart terrorist plots. I just want to take a second to try to hold two ideas in the mind at once.

The first is this, from Snowden, in an exchange with Washington Post reporter Barton Gellman (Gellman's debriefing is a  remarkable read, as is a Q&A between Snowden and his contacts at the Guardian). Asked, "Did he impute evil motives to his former colleagues, or the White House?", Snowden responded:

“Analysts (and government in general) aren’t bad guys, and they don’t want to think of themselves as such,” he replied. But he said they labored under a false premise that “if a surveillance program produces information of value, it legitimizes it."

Why would the president say no?

In a ritual that's got to be 50 years old by now, journalists bemoan and ridicule poorly targeted pitches sent by PR people. You're a Bloomberg "healthcare" reporter covering, say, large hospital chains.  You get press releases urging you to inform your readers about a promising new skin cream. What cretin would send you such drek?

Good PR people do constantly hone, refine and update their media contact lists. But they winnow down only to a point.  Those lists are initially generated by media database screening software: you punch in, say, print publications with circulations over 200,000 and reporters covering "healthcare" and get a list of, say, 700 names. You might shrink that list to half its size, but probably not to a point of perfection, because a) the "negative" work of shrinking a list is time-consuming, and b) the cost (to your potential work result) of leaving out someone who might respond is higher than the cost of leaving in people who won't.  The costs to credibility of sending poorly targeted email are incremental and cumulative (unless you're featured in James Fallows "The Glamorous Life of a Journalist" series); the cost of striking someone off of a list who might have responded to your pitch is potentially high.

Dunkin Donuts, Starbucks, and Fish

On Boston.com, Andrew Ba Tran, Scott LaPierre and Alvin Chang interviewed and giffed (is that a verb?) customers of Dunkin Donuts and Starbucks, each about the other place, in search, it would seem, of an obvious class and cultural divide. Customers for the most part didn't disappoint (Starbucks' branding is extraordinary).  One anti-yuppie caught my year, both because she expressed a feeling of mine about Starbucks and because I'd heard her plaint before, in a very different voice. Paula Shay said of Starbucks:

...they're way too expensive, you gotta make it yourself -- it's very inconvenient. I love Dunkin Donuts, they always make it right -- you go to Starbucks, you gotta make it yourself. I feel like it's a yuppieville, urban, like -- it's just not for me. ANd I don't like the coffee, it's way too strong. It's just not for me, Hon.

In sync with Ms. Shay is one of the most erudite of academics, the always argumentative Stanley Fish, who complained in the Times in 2007 that Starbucks confronted the customer with a "coordination problem" akin to the challenges faced by a general deploying an armed force. The struggle climaxes in the combat of the condiments table:

Who might suffer "rate shock" under the Affordable Care Act?

Avik Roy's much-debated screed implying that the launching of the ACA exchanges will trigger widespread "rate shock" among legions of healthy young people who could previously by insurance more cheaply relies on misleading comparisons, as Ezra Klein, Jonathan Cohn and Rick Ungar charged. None deny, though, that the price of the most minimal available insurance will rise for a subset of healthy young adults

In an essay suggesting that rate shock is real, Will WIlkinson recounts that for a brief time a year or so ago he was paying about $100 a month for a catastrophic plan that he found through the Freelancer's Union (presumably a more honest broker than the scammy online broker Roy relied on).

I clicked through and tried the union's plan-finder with random zip codes in the northeast, south and west; it wasn't until  my fifth try that I found a zip code -- 27108, in Winston-Salem, NC -- in which a UnitedHealth quote was available. If I were my 22 year-old son, I could get a plan for $79 a month with a $10,000 deductible and 70% of expenses paid after that, with a total out-of-pocket expense cap of $15,000 (except that if I were my son I couldn't, because he had hip labral surgery this year, which would doubtless jack up his rate if he were searching now -- see Ezra Klein on this.) For $105 per month, I (or 22-me) can get the same deal with a $5,000 deductible and $10,000 annual cap on my out-of-pocket expenses. (Of course, that's a posted plan from just one provider in one market, and comparing ACA offerings to the current individual market is not just comparing apples to oranges, but 50 different fruits to hundreds of other different fruits. But the offering is roughly in line with what Roy found on eHealthInsurance.com)

Submerged state update: Obamacare's gift of the MAGI

[UPDATE, 10/24/13: Per "Freelancer" comment below, there are multiple definitions of MAGI in the tax code, and in the initial post I used the wrong one. Erroneous info marked below. If you got here by search and are simply looking for info about how to calculate MAGI in the ACA, go to Freelancer's post or to this summary sheet of what income to include/exclude]

[UPDATE 2, 12/23/13: Now that actual plans, prices and subsidies can be viewed, I have a series of posts exploring various income/subsidy scenarios. Last in series here. ]

Covered California, the state entity enthusiastically administering the state's health care exchanges, offers not only posted price estimates for the different plans offered in the exchanges, sorted by age and income, but also a personal cost calculator, in which you punch in the number of people in your household, their ages, and your family income to get an estimate of both the cost of a mid-level silver plan and your subsidy.

One fact worth mulling is that the income on which the subsidy is based is the Modified Adjusted Gross Income (MAGI) based on IRS filings. That's a reminder that the premium subsidy is another tax cut (offset in large part by increased taxes on the wealthy, employers, medical device makers and others). The ACA's premium support is one more benefit credited negatively, by lowering the tax bill, the social service mechanism of choice for a tax-averse polity.  Bowing to preferred conservative methods, we've added another subaqueous pillar to the Submerged State.

The "m" in MAGI is important, however, as it modifies the adjusted gross income (AGI) we're all familiar with on our tax forms by adding important deductions back into the total -- e.g., student loan interest, tuition, IRA contributions, and the deduction for half the self-employment tax. The "m" in some measure avoids piling subsidy on subsidy, or augmenting one incentive with another.

The use of MAGI rather than AGI is bad news for the self employed, who I assume make up a large proportion of those who make enough money to qualify for  premium subsidies but who lack access to employer-provided health insurance. But it could be worse.

Ben Bernanke's over-the-cliff notes

No one needs me to add my wonder to that of everyone encountering Ben Bernanke's remarkable commencement speech at Princeton debunking the concept of meritocracy as defined by nearly every politician in America who pays lip service to it. No one needs me either to highlight the implicit rebuke to a party fanatically devoted to preserving low taxes for the rich and benefit cuts for the poor. 

I will only gild the lily so far as to note how thoroughly Bernanke set up the climactic credo from the moment he opened his mouth.  With caustic good humor, he repeatedly struck notes that eventually merged in the climactic chord: Life is unpredictable; merit is a product of chance; you are collectively the luckiest of the lucky; and your only instrument of meaningful control is a determination to do well by others. To wit:

Poor infrastructure breeds its own etiquette

Lamenting the recent rash of pay-to-jump-the-line enticements pushed by amusement parks and ski resorts as well as airlines, "Matthew J.X. Malady" (that's a pseudonym, right?) writes an eloquent tribute to the eroding social achievement of the queue:

This process [of forming lines] may not be fun, but it’s fair. Curse lines all you like, but we would be doomed without them. Unless you’re simultaneously the strongest, smartest, fastest and most universally capable human being on the planet, you should be thankful that lines exist and that, for the most part, people use them in ways that make life less miserable, not more. Which is to say the line is not a persistent social nuisance. It’s one of our most noble collective achievements.

I came to this via Timothy Noah, Jeremiah of inequality, and was led in a Twitter exchange to think about a relative bright spot where the new classism has not yet penetrated: commuter trains. I ride New Jersey Transit into Penn Station in New York, a prime example of inadequate U.S. infrastructure which, on the plus side, has induced regular commuters to develop their own complex, site-specific queuing etiquette.