Sunday, February 28, 2016

How the GOP can stop Trump

It's obvious by now that barring a sudden radical winnowing of the Republican field, the nomination is Trump's. Therefore....

Cruz, Rubio and Kasich should meet a hold a lightning round of paper-scissor-rock to settle three positions in a unity ticket: president, vice president and secretary of state.

Each will have a much better chance of being nominated than any of them has now. If we're charitable, and assume that a solo rival would have a 50-50 shot at beating Trump, the casting of lots gives each a one-in-six chance of being the nominee -- and a 50/50 shot at standing for one of the highest offices in the land (they can play for Treasury if they prefer. Plus, their unity ticket would be les likely to shed supporters to Trump than any one would have by besting the others in coming weeks.

It might be objected that Kasich does not deserve to compete on equal terms, and Cruz and Rubio probably each believe as much about the other. But each at present has an equal chance (as far as can be discerned) of ruining the others' chances. In fact, all together are virtually certain to ruin the chances of all.

There's still Carson to be dealt with. But all three could pledge to plump for his books.

P.S. If Cruz and Rubio want to band together and insist that Kasich shouldn't get even odds, he could be pushed into doing a qualifying round. That is, he shoots once with either Cruz or Rubio. If he wins, he competes in the round of three on equal terms. If he loses, he goes to SecState (or Treasury), and Cruz and Rubio go one-on-one for prez-veep.

What it looks like when mainstream leaders fall in behind a fascist

It's been terrifying enough to witness a large plurality of Republicans respond to Donald Trump's calls for mass deportations, a ban on Muslims, uninhibited use of torture and terror. It's about equally terrifying  that, "policies" aside, large numbers of Americans would respond to a man whose speech consists entirely of empty boasts and insults. 

It will be more terrifying to watch Republican party leadership fall in behind the blowhard. And Chris Christie -- the kind of garden variety authoritarian bully-boy who in his own right would be constrained by American political institutions -- has started what will probably become a stampede.

Here is how Christie introduced Trump at a rally in Oklahoma City on Friday. The message is simple and moronic: Trump is "strong." American needs a strongman.

Friday, February 26, 2016

Murmur of a prayer

Whenever I get sick, I think "what if this never ended?" I don't mean I'm afraid the particular illness will last -- but rather, that  some illness someday will, unless you die a violent death. And so, imagine a life where pain, or enervation, or distraction is there all the time, or half the time, or a third of the time, and you have to try to do your life's business around or through that straitjacket (as Kevin Drum is doing). Which is just to say, labor while it is day,

P.S. I've got a-bit-more-than-a-cold, which may make for light blogging for a bit. Or maybe not.

Wednesday, February 24, 2016

What would it cost a state to offer something like Medicaid to all its uninsured?

At, I look back at a state-wide proposal to create what I've called an "all-public option" for the ACA -- that is, an exchange in which all the insurers operate like Medicaid managed care companies, paid directly  by government. Here I want to outline a few factors involved in funding such a plan.

Here's the basics from the post:
In November 2009, before the ACA was passed, a New York nonprofit, Community Service Society, produced a plan for the state that would have done just that -- and then some, as it would have given employers the option of buying in. (In 2013, CSS produced a plan outline and cost estimate for the state's BHP that did a good job scoping out the costs and target population as it actually played out, )

Authored by  Elisabeth Benjamin, CSS's VP of health initiatives, and Arianna Garza, the Cornerstone for Coverage Plan  would have used New York Child Health Plus plan (CHP), which was the prototype for the national Children's Health Insurance Program, as the building block of a low-cost public program available not only to the uninsured but to the underinsured. Here is the core proposition:

Tuesday, February 23, 2016

Hillary Clinton "waives through" the public option

[Update: more on "BHP for all," with New York as model, on, here.]

Hillary Clinton has updated her package of proposals for "building on" the Affordable Care Act, finding incremental ways to make coverage more affordable. The new proposals include this:
Continue to support a “public option”—and work to build on the Affordable Care Act to make it possible. As she did in her 2008 campaign health plan, and consistently since then, Hillary supports a “public option” to reduce costs and broaden the choices of insurance coverage for every American. To make immediate progress toward that goal, Hillary will work with interested governors, using current flexibility under the Affordable Care Act, to empower states to establish a public option choice.
Clinton is here suggesting that her HHS will support state initiatives to form their own public options. In a vague way, she references the ACA's Section 1332 "innovation waivers" enabling states to propose alternative schemes to the core ACA structure that would meet the ACA's coverage and affordability standards. The great advantage of this proposal -- as with Clinton's promise to ramp up healthcare antitrust enforcement -- is that it would not require legislation.

As Kaiser's Larry Levitt has pointed out to me, "Nothing in the ACA stands in the way of a state creating a public option." He further noted that a state would not need an innovation waiver to form one. It would, however, need funding, and that's where the waiver might come in. If the state could find other means of savings, those measures might be integrated in a waiver proposal with a public option.

Sunday, February 21, 2016

Investment firms revive a home sale contract with a racist history

The Times has an exposé today, by Matthew Goldstein and Alexandra Peterson, of predatory investment firms that buy up foreclosed homes, mainly in midwest rust-belt cities as well as in the south, and sell them in uninhabitable condition at huge markups to unsophisticated buyers.

The chief vehicle for exploitation is a sub rosa mode of sale known as a "contract for deed" that leaves actual ownership of the property in the seller's hands while imposing onerous responsibilities on the buyer. Here is how the contract is structured by the largest buyer of foreclosed houses from Fannie Mae's bulk sale program from 2010-2014,  Dallas-based Harbour Portfolio Advisors:
More than a dozen Harbour contracts reviewed by The Times — including Ms. Howard’s — all ran for 30 years, carried a 9.9 percent interest rate and required buyers to bring their property into “habitable condition” within four months. The contracts also contained an arbitration clause to settle disputes between seller and buyer, a stipulation that consumer advocates contend strips buyers of the right to litigate onerous clauses in a courtroom.

Provisions in a contract for deed are enforceable as long as they do not conflict with state law. The home dweller has more limited protections than a person buying a house with a mortgage, and evictions are quicker than a foreclosure. The residents are typically responsible for repairs and paying all property taxes, but the legal title under a contract for deed does not transfer until the final payment is made — an end result that rarely happens.
Nationally, the Times cites an estimate that more than 3 million people have bought homes through a contract for deed.  And that exploitative vehicle has a racist history. Thomas Sugrue, in The Origins of the Urban CrisisRace and Inequality in Postwar Detroit (1997) details the many means by which Detroit's African American population was shut out of the housing market and shut into islands of concentrated poverty.  This kind of contract has pride of place in the narrative:

Thursday, February 18, 2016

Cheap and narrow Molina gains market share in Covered California

Yesterday, Covered California released some selected health insurers' sales data. The press release emphasized the fact that insurers that cut their prices in 2016 gained market share. 

As I've been tracking the offerings performance of Medicaid managed care providers (MCOs) that are selling on the ACA exchanges, I was interested in the snippets about Molina, an MCO that fields narrow networks on the exchanges and probably pays providers something close to Medicaid rates. Here's what CoveredCA had to say about Molina in CA in 2016:
Molina Healthcare lowered its rates for 2016 and ended up enrolling more than 50,000 new consumers during open enrollment, which, when added to the more than 37,000 who selected Molina in renewal, means it has more than 88,000 enrolled, the fifth-largest total statewide...

Monday, February 15, 2016

What if all the ACA "options" were "public"?

Consider these two facts about current U.S. health insurance markets.

First, as Bruce Japsen reports in Forbes:
Though the nation’s health insurance industry is having a tough time turning a profit selling individual policies on the public exchanges under the Affordable Care Act, the health law’s Medicaid expansion is churning big profits.

Saturday, February 13, 2016

How the ACA reversed two decades of insurance bleeding for the near-poor (and cut uninsurance for the poor too)

I've noted before that while the ACA works best for uninsured people with incomes under 200% of the Federal Poverty Level (FPL),* that's also where the uninsured are concentrated. While just about exactly one third of the U.S. population is below 200% FPL,  55% of the uninsured were below that level in 2013,  according to the Census Bureau's  Census' Current Population Survey 2015 Annual Social and Economic Supplement.**

A Health Affairs article by Nicole Huberfeld and Jessica Roberts spotlights one reason for the concentration of the uninsured at low income levels. While the availability (or affordability) of employer-sponsored insurance has dropped for all income levels since early this century,
The decreases in coverage were measurably greater for middle- to low-income workers; for example, those earning more than 400 percent of the federal poverty level (FPL) experienced a 2.8 percent drop in employer-sponsored coverage from 2000 to 2011, but people earning less than 200 percent of the FPL experienced a 10.1 percent drop in employer-sponsored coverage.
That snippet sent me to the most recent National Health Interview Survey  (NHIS) update, which indicates that the ACA has plugged this gap by making both private and public insurance available to lower income workers. (Stats for 1997-2010 are here.)

Thursday, February 11, 2016

Love in the time of Obamacare, 2016

#HealthPolicyValentines came early this year! Since the ACA's open enrollment ended on January 31, it's a bit post-coital this year (unlike 2015, when open enrollment was set to end on Feb. 15). But here we go with the third be updated at intervals.

Bonus this year: #GetInsuredShakespeareSonnets, toward the bottom.

My dearest ACA,
I feared you'd not endure well
till Roberts torpedoed
King versus Burwell.

     *     *     *

I've heard tell that health wonks
study best in pairs.
Cuddled on couches,
deep in Health Affairs.

     *     *     *

Uninsured and unmarried,
my troubles are myriad.
Let's get hitched and apply for
a Special Enrollment Period.

Will Clinton feel the Bern on Israel?

Very interesting little trial balloon-and-reaction reported in Haaretz (via Nathan Guttman Forward): 
“Hillary Clinton has been a very strong friend of Israel and that is something that should not be lost on the American Jewish community,” said Paul Hodes, a former New Hampshire congressman who came to rally for Clinton at her post-primary event. Hodes, who is Jewish and from New Hampshire, told the Forward: “Senator Sanders hasn’t showed himself to be the kind of friend of Israel that Secretary Clinton is.”

UPDATE: The Clinton campaign denied that it was considering this strategy. “We have no idea what this report is referring to. The notion that we’re planning to start attacking Sanders’ record on Israel is simply false,” Laura Rosenberger, foreign policy adviser, told the Forward.

Wednesday, February 10, 2016

Coming today: An Obama message "for" Hillary?

Obama just sent an email  to supporters announcing a speech to be delivered this afternoon. I imagine it will be a message "for" Clinton -- both to support her and to model a coherent pitch for incremental change. There are hints in the letter, highlighted below.
Nine years ago today, I stood on the steps of the Old State Capitol in Springfield, Illinois, to announce my candidacy for President of the United States.

I asked you to join me in taking up the unfinished business of perfecting our union -- to work together to build a better future.

Along the way, Americans like you have done that by playing the most important role in our democracy -- the role of citizen. You've taken on the painstaking work of progress. You've helped us find that middle ground where real change is won -- change like rescuing our economy from the brink of another Great Depression, protecting our planet, and helping millions of Americans gain health insurance.

Tuesday, February 09, 2016

Pussyfooting around torture

Last night, Twitter flared up in response to the latest Trump provocation. Taking up a cry of passion from an audience member, Trump had called Ted Cruz a pussy. He'd crossed another red line, one tweet proclaimed.  He could be the first New Hampshire primary winner to use the epithet, said another.

Taking a very back seat was what the taunt purported. Trump was mocking Cruz for hedging his support of waterboarding -- the war crime for which the U.S. had executed enemies, the simulated death experience that the Bush administration had sanctioned as official U.S. policy. Trump has promised to do "a hell of a lot worse" -- that is, put the U.S. in permanent, proudly proclaimed violation of the Geneva Conventions, the international Convention Against Torture signed by Ronald Reagan, and the U.S. Constitution's ban on cruel and unusual punishment.

Cruz, for his part, asserts that waterboarding isn't torture, taking as his authority the discredited and withdrawn "Bybee memo" from the Bush administration Justice Department that limited the definition of torture to punishment that induces pain equal to organ failure or death. He's also called for carpet bombing regions in which ISIS holds a civilian population hostage and relaxing efforts to minimize civilian casualties. He's evinced since his early manhood an unsavory passion for the death penalty. But he's not sadistic enough to meet Trump's standard of leadership.

It's not meaningless that Trump seized on a feminizing epithet to denigrate his rival, and one that associates femininity with vulnerability to being dominated. But the epithet was hardly the point. Lost in the grade-school reaction was the appalling fact that a presidential frontrunner was whipping up a crowd's enthusiasm for torture, and taunting a rival for expressing some ambivalence about it. And in fact, re-instituting torture as official U.S. policy is a near-consensus position among Republican candidates (Cruz says he opposes torture, but then defines a practice universally considered torture outside the GOP as not-torture).  Oppose it, and you're a pussy in the Foxosophere.

We are watching democracy degrade before our eyes. It's not done yet; the Democratic debates are an alternate universe, in which policy and political philosophy are debated civilly and with reference to facts. But one major party, primed for years by a sensationalist media that amplifies its worst impulses, is trafficking in dreams of mass deportation, mass murder (via carpet bombing), and institutionalized torture.

We are hanging by a thread.  And the dominant reaction, when the promise of Nazi policies is on most naked display, is "He said pussy!!"

Update: The Intercept's Dan Froomkin is one of the few to look past the name-calling itself and focus on the real story: GOP Candidates Compete Over Who Will Commit Most War Crimes if Elected

Monday, February 08, 2016

Look for America (at 3000 feet)

Ever since my teens, I've had a horror of American strip mall roads -- those endless routes lined with fast food joints, big box stores etc. etc. for mile after mile. As the years went by I told myself to get over it, don't be prissy, they loom large when you drive them but it's not like they're the whole landscape....

Enter James Fallows, previewing an Atlantic cover chronicling  his three-year small-plane tour of American towns that are either noteworthy successes or striving effectively, or at least intelligently, for a comeback.
A coast-to-coast drive across America has its tedious stretches, and the teeming interstate corridors, from I-95 in the east to I-5 in the west, can lead to the despairing conclusion that the country is made of gas stations, burger stands, and big-box malls. From only 2,500 feet higher up, the interstates look like ribbons that trace narrow paths across landscape that is mostly far beyond the reach of any road. From ground level, America is mainly road—after all, that’s where cars can take you. From the sky, America is mainly forest in the eastern third, farmland in the middle, then mountain and desert in the west, before the strip of intense development along the California coast...

Sunday, February 07, 2016

Rubio on Obama vs. Obama on Reagan

Greg Dworkin, who does the Daily Kos Daily Pundit Roundup, was kind enough to storify a tweetstorm of mine beginning like this:

Saturday, February 06, 2016

CMS Open Enrollment error in New York (updated, with CMS correction)

[Update 2/11/16: CMS has made  a correction -- see below.]

CMS's ACA enrollment snapshot for the final week of Open Enrollment 2016 contains an error, bolded below:
It is also worth noting that nearly 400,000 people signed up for New York’s new Basic Health Program, along with about 33,000 people who signed up for Minnesota’s Basic Health Program, during this Open Enrollment. Basic Health Programs are state based programs supported by the Affordable Care Act that provide health insurance coverage to low income individuals who would generally otherwise be eligible for qualified health plans [QHPs]. In fact, about 300,000 of the New York Basic Health Program enrollees for 2016 are people who enrolled in Marketplace coverage for 2015 and were included in last year’s Marketplace total plan selections.
Enrollees in New York's Essential Plan, the BHP formed under the auspices of  the ACA, come from two pools. The first is those who lack access to employer-sponsored plans and have incomes between 139% and 200% of the Federal Poverty Level (FPL). If the Essential Plan did not exist, these people would be eligible for subsidized QHPs in New York's private marketplace. Some of them were in fact enrolled in QHPs in 2015, but not 300,000.

Friday, February 05, 2016

Trump blames

Volumes have been written about what drives Trump or explains his appeal, but I think I've got it pared down to a verb.

Trump blames Tony Perkins for '2 Corinthians' - CNNPolitics ...
Jan 21, 2016 - Washington (CNN) Donald Trump says it's Tony Perkins' fault he said "two Corinthians" instead of "Second Corinthians" during a speech at ...

Trump Blames Obama for His Hair Problems | Mother Jones
Mother Jones
Dec 14, 2015 - Donald Trump's hair is not as clean as he would like, and he says it's the president's fault. At a campaign event in Aiken, South Carolina, the ...

Trump blames 'young intern' for retweet that riled up Iowans ...
USA Today
Oct 22, 2015 - Hours after the release of a Quinnipiac University poll showing rival Ben Carson leading Trump among Iowa caucusgoers, the businessman ...

Thursday, February 04, 2016

United Healthcare is a major MCO, but its large-market ACA plans don't reflect that

In the ACA marketplace, insurers whose core business has been Medicaid managed care, most notably Centene and Molina, have increasingly underpriced the competition in markets where they compete. These insurers field narrow networks and probably pay little more than Medicaid rates to providers.

United Healthcare, the nation's largest health insurer, has made waves by reporting large losses in the ACA marketplace and threatening to withdraw from it.  Yesterday Richard Mayhew posited that UHC's complaints mainly reflect the extent to which the giant has gotten its clock cleaned in the marketplace -- offering more extensive networks than competitors, charging much higher rates in many key markets, and thereby likely attracting sicker enrollees who place a premium on provider choices.

Mayhew's main source is an Urban Institute analysis of 2016 rates, mainly focused on 81 ACA rating regions that account for 47% of the country's population. Urban's John Holahan and Linda Blumberg found that in 2015, UHC sold plans in 36 of those 81 regions, but offered the cheapest or second-cheapest silver plan in only eight of them. In 2016, UHC is in 48 regions, and offers cheapest or second-cheapest (benchmark) silver in just 15 of them.

In marked contrast, Medicaid managed care providers, led by Centene (fielding the Ambetter brand) and Molina, are playing in 48 of the 81 regions this year and offering cheapest or second-cheapest silver in 44 of them. That up up from 36 out of 44 in 2015.

Tuesday, February 02, 2016

Clinton vs. Sanders: It's not really head vs. heart

In an Iowa post-mortem, Greg Sargent spoke to several top Democratic campaign operatives about how Bernie Sanders managed to fight Clinton to a virtual tie. Here's one diagnosis:
Her message has tended to focus on solutions and not really reflect back to people the feelings that they have,” Mark Mellman, a veteran Democratic pollster, tells me. “Bernie is reflecting back to people their feelings. She has to do a better job reflecting back to people what they feel and think. Forging an emotional connection is critically important. She’s not always done that very effectively.”
I think that's true to a point, but it leaves something out. Sanders doesn't appeal purely to emotion. He establishes a better head-to-heart pipeline than Clinton does. His read on our current situation and how we got there may be oversimplified, but it's coherent and easy to grasp. It's political cognitive therapy: you feel good because you feel you understand what's wrong and what to do about it.