For Hillary, a siren song from the right

Conservative pundits Ramesh Ponnuru and Ross Douthat argue cogently in today's NYT that Hillary Clinton is yielding nothing on policy grounds to Republican-leaning voters who might consider voting for her because they're appalled by Trump.

That's true. On abortion, on crime, on federal spending and taxes, Clinton is leading, and speaking for, a Democratic party moved well to the left. Nonetheless, there are good reasons why Clinton is not, and arguably cannot, "run to the center" for the general election, as nominees in normal elections do.

1. All other things being equal, Clinton does not need to win over more ideological conservatives than Obama did. Enough habitual Republican voters will likely be disturbed enough by Trump to stay home to put her ahead of Obama on that front. And Obama, temperamental moderate and pragmatist though he is, was cast as radically liberal by conservative media.

2. Trump has revealed that an awful lot of Republican voters have no allegiance to core Republican economic policies like massive tax cuts and social spending cuts.  Clinton is to his right on trade, more willing to acknowledge that "fair" trade deals have value.

3. In this moment of ideological fluidity, well-articulated left-side populism might win more white working class voters than centrism.  See Trump's siren song to Sanders supporters. In my view, Elizabeth Warren has a more compelling economic narrative than Sanders'.  It's this: since the 80s, monied interests, via the Republican party, have knocked out three pillars of postwar middle-class prosperity: union and employee leverage, tax fairness, and effective regulation. Hence the 1% has grabbed all the growth. As I've suggested in prior posts, Clinton could reverse-engineer this story to explain how she'll boost middle class incomes and security, with policies designed to 1) increase workers' share of profits, 2) invest new tax revenue to increase shared prosperity via investments in education, healthcare, infrastructure, etc., and 3) rein in banks and the shadow banking system, reduce greenhouse gas emissions, protect employee rights, etc. Clinton name-checks a host of specific policies that fit this agenda but, to my ear, does not explain how they all fit together.

Donald Trump, can you hear Ghazala Khan now?

"I'd like to hear his wife say something."

That was Donald Trump's vile response (snippetted by Maureen Dowd)  to the riveting on-stage appearance at the Democratic convention of Khizr and Ghazala Khan, parents of an army captain, Humayun Khan, who sacrificed his life in 2004 to protect his men and Iraqi civilians from a car bomb.  Mrs. Khan stood silently beside her husband while he questioned Trump's understanding of the Constitution and fitness to be president.

Trump elaborated in an interview on ABC this morning: "If you look at his wife, she was standing there. She had nothing to say. She probably, maybe she wasn't allowed to have anything to say. You tell me."

Well, it turns out that Mrs. Khan did say something -- last night, on Lawrence O'Donnell. Twelve years after her son's death, she expressed unbearable grief with an extraordinary eloquence that seems born of long years of endless interior replay.  James Fallows provides the segment (and the appropriate denunciation of Trump's barbarity) here.  Mrs. Khan speaks first at 2:35.*

Here is a transcription of the crux, but you have to hear it. Her short narrative hinges on two words, hero and son, in point/counterpoint:

Hillary, tell us a story

In a deep dive into Clinton's economic policies and messaging, Jim Tankersley makes two main points: 1) her package of proposals is detailed, nuanced and backed by mounds of think-tank research, and 2) hard to grasp.

On the first point:

Clinton's presidential policy apparatus began with a small group of formal and informal advisers conducting what amounted to a research project on what is wrong with the American economy — and how to fix it. They interviewed about 200 experts.

What she has released so far is the distilled product of that effort.

Hillary Clinton good enough

Hillary Clinton's convention speech was more about demonstrating that she was the person multiple convention speakers said she was -- caring, committed, tenacious, tough, smart (or, in Michael Bloomberg's oddly effective down-shift, "sane, competent") -- than setting off fireworks. She succeeded in that. She spoke deliberately and with conviction about her agenda, her experience, her commitment, and the danger manifest in Trump.

The idea was to have the cumulative effect of many congruent messages culminate in her person. For me, previous testimonies that moved my personal needle converged in one part of her speech.

Through the convention's four days, I had been most impressed by private citizens and local officials who testified to Clinton's caring and persistence. They included 9/11 survivor Loren Manning, who suffered burns across most of her body:

In which Republican pundits hear Obama for the first time

A hard-baking meme in the commentary following the Democratic convention is that the Democrats stole traditional Republican thunder  -- projecting American exceptionalism, support of the military, economic optimism.

Granting that the speaker selection and crowd chants may have been a bit more rah-rah than the Democratic norm, this meme has its root in Republican reaction to Obama's speech on Wednesday night that says more about them than him.  The Times' Nick Confessore cites this example:

“What is Obama talking about? He’s talking about the Constitution. He’s talking about personal freedom,” said Craig Shirley, a conservative author and Reagan biographer, referring to the Wednesday speech in which President Obama invoked his Scotch-Irish roots and the homespun values of humility and hard work.

“Moving out several paragraphs, Reagan could have given that speech,” Mr. Shirley added. “This might be part of a dialectical change in American politics.”

Twitter abounded* with similar sentiments:

When a democracy offers "one choice": Obama's haunted celebration

One of the enduring themes in  Obama's rhetoric is to embrace the messiness of democracy: to remind listeners that 'the other side may sometimes have a point,' to urge the necessity of compromise, to affirm that people on opposite ends of the ideological spectrum share some core values.  

It was all the more striking, then, that in his convention speech last night he placed Donald Trump outside the pale of this consensus allegedly underpinning all our battles over policy. In his 2008 convention speech, Obama praised John McCain's service to country and personal decency effusively while lambasting his polices; in fact the whole convention was structured to kill McCain with kindness. With Romney he was more caustic, suggesting in his 2012 convention speech that to vote Republican was to choose oligarchy. But oligarchy is on the democratic spectrum. The U.S. has always been an oligarchy to greater or less extent.

In this his valedictory paean to democracy, in contrast,, Obama asserted that there was only one choice. He ultimately placed the Republican nominee in the company of the destroyers of democracy, the nation's worst enemies: fascists, communists, jihadists. And the context in which he made that shocking but wholly appropriate charge is fascinating.

He began by evoking the "real America" as portrayed by Trump's precursor, Sarah Palin: the small town Bible belt heartland -- where ironically he, in a very real sense, came from. He then carried that "heartland" through space and time, to Hawaii and working class black Chicago and to the present -- and then to the entire world from which the U.S. draws its immigrants.

In which Bill fleshes out Hillary's boilerplate

After Bill Clinton's long narrative tribute to his wife last night, Republican operative Nicole Wallace allowed that while the second half of the speech was effective, the first 25 minutes "meandered."

Nope. The speech was long, it was narrative, it was discursive...you may or may not have been engaged or sympathetic. But it was the opposite of meandering. It was methodically building a case, fleshing out a set of claims Hillary Clinton has been reiterating over and over so that they feel like boilerplate.

The claims: She 's been committed to children's welfare specifically and improving people's lives in concrete ways generally all her life. She is practical and analytical and gets things done. She is a joiner, a leader and  a changemaker.

Toward the end, contrasting "the real Hillary" with the imaginary one created by her enemies Bill said, "The real one had done more positive change-making before she was 30 than many public officials do in a lifetime in office." In those "meandering" first 25 minutes, he had made that case in detail, so it was hard not to agree. Leaving out the humanizing, sanitized, personal remembrances, here are the resume points:

Michelle Obama took the high road to lay Donald Trump in the dust

Michelle Obama pulled off a Houdini trick in her magnificently distilled framing of the choice in this election in her convention speech last night.

On the one hand, she articulated a humane, inclusive vision of what America is and of what's required to lead America. At the same time, she framed the choice in this election as absolutely Manichean.

She managed at once to take the high road -- "our motto is, when they go low, we go high"--  while
leveling the most devastating attack on Trump yet articulated.  It was devastating because she didn't deign to name him. She refrained not out of delicacy, but to demonstrate that she didn't have to. He was so instantly recognizable -- as were his dual alter egos, Obama and Clinton. as she had earlier portrayed them:

By Trump's edits shall you know him

Josh Marshall details various ways that Trump's current business is dependent on funding from Russian oligarchs and operatives dependent on Putin, then notes Putin's hand in the GOP platform:

The Trump Camp was totally indifferent to the platform. So party activists were able to write one of the most conservative platforms in history. Not with Trump's backing but because he simply didn't care. With one big exception: Trump's team mobilized the nominee's traditional mix of cajoling and strong-arming on one point: changing the party platform on assistance to Ukraine against Russian military operations in eastern Ukraine. For what it's worth (and it's not worth much) I am quite skeptical of most Republicans call for aggressively arming Ukraine to resist Russian aggression. But the single-mindedness of this focus on this one issue - in the context of total indifference to everything else in the platform - speaks volumes.

This sparked a recent memory.  Tony Schwartz, Trump's "co-author" of The Art of the Deal (actually its sole author, as the publisher verifies), recounts the sum of Trump's input:

Brookings bombshell: ACA lowered premiums, subsidies aside. Some caveats....

In a rigorous study of health insurance premiums in the individual market pre- and post-ACA, the Brookings Institution's Loren Adler and Paul Ginsburg come to a startling conclusion: in 2014, the year the ACA marketplace launched, average premiums were 10-21% lower than in 2013 -- leaving aside the subsidies accessed by over 80% of marketplace enrollees. Further: even accounting for the steep increases coming into effect in 2017, premiums will remain lower than they would have been if the ACA had not become law.

Based on CBO estimates and  projections of premiums from 2009 and later years, and data from the Medical Expenditure Panel Survey (MEPS), Adler and Ginsburg conclude:

According to our analysis, average premiums for the second-lowest cost silver-level (SLS) marketplace plan in 2014, which serves as a benchmark for ACA subsidies, were between 10 and 21 percent lower than average individual market premiums in 2013, before the ACA, even while providing enrollees with significantly richer coverage and a broader set of benefits. Silver-level ACA plans cover roughly 17 percent more of an enrollee’s health expenses than pre-ACA plans did, on average. In essence, then, consumers received more coverage at a lower price.

In Covered California, deductibles get steeper and narrower

As deductibles have risen steadily in health plans sold in the ACA marketplace, plans are offering more services that are not subject to the deductible. HHS has embraced this trend and incorporated it in the standardized benefit designs launching in the 2017 (which are optional for insurers).

California, which has had mandatory standard plan designs since the launch of the marketplace in 2014, has always included benefits not subject to the deductible in those designs -- and they have expanded outside-the-deductible services periodically, as deductibles and copays have also risen steadily.

In 2014, bronze plans offered on Covered California had a $5,000 deductible, with no separate deductible for drugs. Three primary care doctor visits were not subject to the deductible, as were three urgent care, outpatient mental health or substance abuse visits. In 2016, when the medical deductible was raised to $6,000, a $500 pharmacy deductible was added, and laboratory tests were put outside the deductible.

Whither the 70,000 Louisiana marketplace enrollees who are newly Medicaid eligible?

Louisiana's Medicaid expansion continues apace, with a bit over 250,000 state residents gaining coverage since the program went live on July 1. As I noted in a prior post, most of those enrollees, about 190,000, were transferred from existing public limited-benefit plans. At present, about 2,500 people per day are enrolling. The state is aiming for about 375,000 new enrollees overall.

According to Andrew Tuozzolo, Chief of Staff at the Louisiana Department of Health, that target does not include enrollees in ACA marketplace plans rendered newly eligible for Medicaid. (In states that refused to implement the ACA Medicaid expansion, which included Louisiana until this year, eligibility for private plan subsidies begins at 100% of the Federal Poverty Level. In expansion states, residents with incomes up to 138% FPL are eligible for Medicaid, and not for private plan subsidies.)

Thanks to enrollment data released by CMS early this month, we now know that almost 85,000 Louisianans who had enrolled in private plans in the ACA marketplace as of the end of Open Season on Jan. 31 -- 40% of all enrollees -- reported incomes in the 100-138% FPL range. Most of those 85,000, though not all, should now be eligible for Medicaid, the chief exceptions being legally present noncitizens subject to the federal "five-year" bar to Medicaid eligibility.  About 15% of the state's marketplace enrollees had dropped out (or in most cases, probably, never paid a premium) as of March 31.  Most likely, then, about 70,000 current private plan enrollees are now Medicaid eligible (as well as perhaps 10-15,000 dropouts).

In Dallas, Obama returns to Gettysburg

Is suffering redemptive? Obama thinks it is.

Do violent upheavals lead Americans to recommit to and advance the nation's founding ideals? Obama professes faith that they do, and will.

The ideas, as Obama has absorbed them, come from Lincoln above all others. At moments of crisis, he reverts to Lincoln's rhetoric. And so, in Dallas this week, he closed his funeral oration for the five murdered police officers by reprising (not for the first time) the Gettysburg Address:

And that’s what I take away from the lives of these outstanding men.  The pain we feel may not soon pass, but my faith tells me that they did not die in vain.  I believe our sorrow can make us a better country.  I believe our righteous anger can be transformed into more justice and more peace.  Weeping may endure for a night, but I’m convinced joy comes in the morning.   We cannot match the sacrifices made by Officers Zamarripa and Ahrens, Krol, Smith, and Thompson, but surely we can try to match their sense of service.  We cannot match their courage, but we can strive to match their devotion.

The public option is inside out

The public option is back in the ether, though it's hard to see a path by which it may walk this earth. Hillary Clinton has reiterated her verbal support for it as part of her package of Bernie mollifications. Obama has also floated a kind of public option ghost, to haunt only those ACA markets where competition is scarce. Democratic yearning is in high gear.

The public option is designed to mitigate the fact that a private, subsidized insurance marketplace expands the very sector of our healthcare system that pays healthcare providers the highest rates. While a "strong" public option would pay Medicare rates, private insurers typically pay probably more than 150% of that, at least in the employer-sponsored market (many do pay less, some much less, in the ACA marketplace).

Insurers understandably don't like a public option because it would put them up against a competitor that pays less for the care they retail than they typically do. That would seem, in many ACA markets, an impossible task. Competition can't force insurers to charge lower premiums when premium revenue is less than medical payments, as it is in some ACA markets.  Competition is great if it pushes insurers' medical loss ratios from 80% to 85%; it's futile if it pushes them from 87% to 92% or 102% or 120%.

Thus a public option is pushing on a string -- or at best, pushing insurers toward ever narrower networks.

Perhaps what's needed is for the government to set affordable rates, or take bids within a given rate range, and invite the insurers to compete on that basis. That's how Medicare Advantage works, and also how Medicaid managed care programs work, with some important differences in how bidding is structured.

About one in five ACA marketplace enrollees should be in Medicaid

In March 2015, I calculated that about 2 million enrollees in the  ACA private plan marketplace  had incomes that would have qualified almost all of them for Medicaid if they did not live in states that had refused to implement the ACA Medicaid expansion. I estimated that these enrollees with incomes between 100% and 138% of the Federal Poverty Level (FPL)  represented about a third of all enrollees in nonexpansion states and about 22% of all marketplace enrollees.

It was necessary to estimate because until yesterday, HHS's income breakouts for marketplace enrollees used a range of 100-150% FPL. Those in the 139-150% FPL range are eligible for private plan subsidies in all states; almost all of those from 100-138% FPL are subsidy-eligible only in nonexpansion states (the exception is legally present noncitizens time-barred from Medicaid, who are subsidy eligible at any income level below 400% FPL). Based on the percentage of enrollees from 100-150% in the expansion states, almost all of whom would be over 138% FPL, I estimated that 68% of those in the 100-150% FPL band in nonexpansion states were under 139% FPL, and so mostly "should have been" in Medicaid.

Yesterday, in a new data release of ACA enrollment by county in the 38 states using HealthCare.gov, HHS provided a 100-138% FPL band for the first time. And it turns out I way underestimated the percentage of 100-150% FPLers who were in fact under 139% FPL. Charles Gaba has done the math (with a proportionate estimate for Idaho, the only nonexpansion state not using HealthCare.gov and so not included in the HHS income breakout). 85% of those previously shown in the 100-150% FPL range are under 139% FPL.  36.4% of all enrollees in the nonexpansion states are in the 100-138% FPL band.

Clinton avoids hard questions on healthcare reform in Ezra Klein convo (and Klein lets her)

Ezra Klein sat down with Hillary Clinton for an in-depth policy discussion. I find many of her responses frustratingly circumlocutory and vague. Let's take the exchange over healthcare reform, piece by piece.

Ezra Klein To ask about another interesting fissure from the primary: You often said that your preference was that we built on Obamacare to get to true universal coverage. And I’ve read your plan around Obamacare, and it doesn’t do that yet. So what would be your approach for taking that program from the roughly 90 percent covered that it’s at now to 100 percent?

Hillary Clinton Well, let’s celebrate that we’re at 90 percent coverage. And I think that is one of the differences: I see the glass at 90 percent full, not empty. And [I believe in not] starting over again — either by repealing it, as the Republicans advocate, or by coming up with a whole new plan.

Well yes, there's some cause for celebration. But given the starting point pre-ACA, the glass is far from 90% full.  According to Gallup's latest survey results, the uninsured rate has been cut from 17.1% since late 2013 to 11% now -- that is, reduced by about 35%.

Clinton continues:

Selling health insurance to young adults is inherently hard

Among the troubling aspects of the performance of the ACA private plan marketplace to date, the age distribution looms large. HHS officials hoped that 40% of enrollees would be in the 18-34 age range; they got 28%. The overall enrollee population in the marketplace is sicker than anticipated, leading to losses for most insurers and a sharp upward adjustment in premiums.

Some observers have argued that the ACA's subsidy structure is to blame. Jed Graham, for example, in his e-book Obamacare is a Great Mess, asserts:

While bronze plans are generally more appropriate for younger adults than older ones, the ACA pricing distortions likely account for part of the reason that enrollment has been so much more robust among older adults. For moderate-income, healthy young adults who get little to no subsidies, ACA age-rating rules have made health care significantly less affordable (Locations 656-658).

A multi-part argument is embedded above. First, reducing age-rating from the former industry standard of 5-to-1 to the ACA's 3-to-1 means higher premiums for unsubsidized young buyers. Second, the fact that unsubsidized premiums are much higher for older buyers, coupled with the pegging of income-adjusted subsidies to a silver-level plan, means that the subsidy often all but wipes out the premium for a bronze plan for an older buyer, but not for a younger one. Third, for those with low income and few or no assets, bronze plans are often close to worthless in any case.

That's all true. It's also true, though, that young adults are inherently less likely to fork out for health insurance than older adults, no matter how attractive the terms.  A recent report on employer-sponsored health insurance by the ADP Research Institute highlights this fact:

Commonwealth: Lower income ACA marketplace buyers get a tolerable substitute for employer-sponsored insurance

The Commonwealth Fund writeup* of its 2016 survey of adults under age 65 with health insurance stresses that lower income marketplace enrollees (under 250% FPL) pay premiums and deductibles comparable on average to those paid by enrollees in employer-sponsored plans.

Overall, survey results suggested, 57% of marketplace enrollees spend less than $125 per adult per month on premiums, compared to 60% in employer-sponsored plans. And among the 59% of marketplace enrollees with incomes under 250% FPL, 30% have per-person deductibles over $1,000, versus 26% at that income level in employer plans. At higher incomes, the discrepancy is sharper: 68% of marketplace enrollees over 250% FPL have deductibles over $1,000, compared to 42% of those in employer plans.

These survey findings track roughly with my own calculation that the weighted average actuarial value of a marketplace plan in the 38 states using HealthCare.gov  is 81.4%** -- quite close to various estimates of average AV in employer-sponsored plans, I also found, though, that the weighed average AV for Hc.gov enrollees with incomes under 200% FPL (not 250%)  was 86.3%. For those over 200% FPL, it was just 69.3%.

In my view, 200% FPL is a more useful dividing line for marketplace enrollees than 250% FPL -- because Cost Sharing Reduction (CSR) subsidies, while available up to 250% FPL, fall off a cliff at 201% FPL. CSR raises the actuarial value of a silver plan from a baseline of 70% to 94% for those up to 150% FPL, to 87% for those up to 200% FPL, but to just 73% for those in the 201-250% FPL range. To relate this to the Commonwealth survey: the average deductible for a silver plan at the weakest CSR level (200-250% FPL) is $2491.

He who buys bronze absconds

In the spring of 2014 my son, knowing he'd enter a graduate program that September, switched his health insurance from COBRA to a bronze marketplace plan. Healthy, he gambled the premium difference between bronze and silver (or bronze and COBRA) against the deductible difference, essentially settling for catastrophic protection for a limited period.

Yesterday I noted that attrition in the ACA marketplace, which is sharpest in the months immediately following open enrollment since 10 percent or more of those who select plans never pay the first premium, is highest among those who enroll in bronze plans.   As of March 31 of this year, while bronze enrollment dropped 15.5%, from 2,873,422 to 2,427,337, silver dropped just 9.3%, from 8,520,787 to 7,721,983. A similar discrepancy was recorded in the spring of 2015.

It turns out that the same pattern held throughout the year in 2015. By December 31, total enrollment was down from 11,688,074 as of  Feb. 22, 2015 (not all of it "effectuated," or paid for in the first month) to 8,780,545, a 24.8% drop. Among bronze plan holders, the drop was 30.5%, versus 23.2% for silver, 18.8% for gold and 18.6% for platinum. Those with gold, hold -- relatively speaking.  And he who buys bronze... absconds.

As bronze plans typically carry deductibles over $6,000, many enrollees may decide that they're not worth the money. But I think it's also likely that those who know they have a short-term need for insurance, like my son, may lean toward bronze, basically holding their breath until employer insurance, or school-based insurance, or a spouse's insurance kicks in.