Can the electoral college revert to its original function to negate its original intent?

There's a knot in the logic of those urging the presidential electors to deny Trump an electoral college majority. It comes between these two propositions:

1. The founders (wisely?) established the electoral college as a potential veto of the popular choice* in case the people (or state legislatures) voted in a demagogue.

2. The popular choice in this election was not a dangerous demagogue, as Hilary Clinton will end up with about 2.5 million more votes than Trump.

Thus, the electoral college should use its veto function to un-veto the popular choice rather than to countermand it.

The disconnect is between the electoral college as designed versus the electoral college as evolved. It was designed to be a deliberative body (or set of bodies, as each state's electors meet separately). It evolved into an inexact and unreliable mirror and intended rubber stamp of the popular choice. Like a human appendix, it serves no practical function except to rupture occasionally.

Michelle Obama opens the doors of perception

For the second time* in this election season, Michelle Obama riveted the country and the world with moral clarity, in a speech delivered yesterday in New Hampshire. She named Donald Trump before the world. She detailed the effects of his sexual predation -- on herself, voice shaking a little, and on a series of concentric audiences -- the one before her, the nation's children, the world. As she did at the convention, she set Trump's manifest depravity against an idealized portrait of American values as she (or her husband) strives to embody them.

The denunciation was as carefully structured as it was deeply personal. She began, by way of contrast, with a norm as she experiences it, American values that she strives to advance, as expressed in an International Day of the Girl event at the White House  (part of her Let Girls Learn program). There she "had the pleasure of spending hours talking to some of the most amazing young women you will ever meet, young girls here in the U.S. and all around the world." That opened a window on the ravages of male dominance throughout human society - and the route out:

Bill Clinton's other "craziest thing in the world"

I have a post up at healthinsurance.org that looks at an apparent slip from Bill Clinton's political id regarding Obamacare. No, not that "craziest thing in the world" slip -- the one about allowing those who earn too much to qualify for subsidies in the ACA marketplace to buy into Medicaid.

To buy into what? Who suggested that? Certainly not Hillary. But it -- or something very like it  -- might not be such a bad idea. Please take a look.

My last several posts at healthinsurance.org explore outside-the-box ideas for strengthening and/or amending the ACA. They include a Medicare buy-in that Republicans might like and a way to get public option pricing into the ACA marketplace without the 'public' part. Also pointing possible alternate paths: a close look at the Basic Health Programs and proposals to expand them in Minnesota and New York.

Hillary, speak to service workers

In this aphorism by Binyamin Appelbaum lies latent, I think, the organizing principle, articulated or not (okay, not), of Hillary Clinton's economic agenda:

Soon, we will be living in the United States of Home Health Aides, yet the candidates keep talking about steelworkers. 

Let's back up for some context. While U.S. manufacturing output is at an all-time high,  80% of Americans work in the service sector, Appelbaum reports, Yet politicians of both parties keep romanticizing and prioritizing manufacturing jobs:

In which Obama feels the pain of the price tag he imposed on the ACA

In an interview with Jonathan Chait, President Obama rather casually ticked off his first priority for shoring up the ACA:

In my mind the [Affordable Care Act] has been a huge success, but it’s got real problems. They’re eminently fixable problems in terms of strengthening the marketplace, improving the subsidies so more folks can get it, making sure everybody has Medicaid who was qualified under the original legislation, doing more on the cost containment. But you hit a point where if Congress just is not willing to make any constructive modifications and it’s all political football, then you’re getting a suboptimal solution. 

By now, the imperative to enrich the marketplace subsidies is a matter of consensus among progressive healthcare scholars and officials. Out-of-pocket costs are just too high for prospective enrollees with incomes over 200% of the Federal Poverty Level (FPL)*, the cutoff for strong Cost Sharing Reduction (CSR) subsidies, and premium subsidies leave buyers paying too high a percentage of their income -- between 6.4% and 9.7% of income for those in the 200-400% FPL range. In August 2015, Urban Institute scholars Linda Blumberg and John Holahan put out a detailed proposal for subsidy enrichment that included raising the actuarial value of the benchmark plan to 80% from the current 70% , with richer CSR extending further up the income ladder, as well as capping premiums at 8.5% of income for all income levels. Hillary Clinton's rather vague proposal for subsidy enrichment is apparently based on Blumberg and Holahan's. ACA improvement proposals by Timothy Jost and Harold Pollack and Sabrina Corlette and Jack Hoadley also prominently feature subsidy boosts.

The inadequacy of marketplace subsidies was evident to progressives from the beginning. Complaints began when Max Baucus's Senate Finance Committee released its bill in fall 2009, with a subsidy schedule that was far skimpier than that of the House bill.** In his 2011 book about the battle to pass the ACA, Richard Kirsch, national campaign manager from 2008-12 for Health Care for America Now (HCAN), an  umbrella group formed by unions and progressive nonprofits to advocate for universal health care, pins responsibility for the skimpy subsidies primarily on Obama:

Scoping out a Medicare buy-in

Hillary Clinton's raft of healthcare policy proposals includes enabling 55-64 year-olds to "opt in" to Medicare. No detail is provided.

I have a piece in progress that looks at a variant of a Medicare buy-in. This is a scratch-pad post, to help me clarify for myself who might or might not benefit.

When Clinton first verbally expressed a willingness to consider a Medicare buy-in, Avalere Health scoped out the potential market, but they did it for a wider age group, 50-64, as Clinton first mentioned 50 or 55 as a threshold.  Avalere's Caroline Pearson and Chris Sloan were kind enough to provide me with a breakout of their calculations for 55-64 year-olds. As it's based on the 2014 American Community Survey, I have updated where possible, as explained in notes below.

Presumably the buy-in would not be offered to roughly 24 million people in the 55-64 age group who have access to employer-sponsored insurance -- including retirees with ESI, whom Kaiser estimated to number 5.3 million in 2012.  I doubt there's a single member of Congress, Senator or potential president other than Bernie Sanders with a more than theoretical interest in shaking up employer-sponsored insurance

The buy-in would be open to the uninsured in the 55-64 age band, who currently number about 3.4 million,* and to those who currently get their insurance in the individual market, of whom there are probably a bit over 5 million. That includes a shade under 3 million in the ACA marketplace, and probably another two million-plus buying off-exchange. About 2.4 million marketplace enrollees in the age group are subsidized, if. the marketplace income breakouts reported by CMS apply proportionately to this age group.**

Could the ACA help the Democrats take Florida?

The latest battleground state polls show Trump trailing Clinton by a narrow margin in Florida, a must-win state for him. One factor tilting the Florida field against Trump is surging voter registration among Latinos.  As flagged by Greg Sargent, Politico's Marc Caputo reports:

Since the 2012 presidential election, Florida’s voter rolls have grown by 436,000 — and only 24 percent of that increase is from non-Hispanic white voters while non-whites grew by 76 percent, according to new voter registration numbers released in advance of the Aug. 30 primary.

The number of Hispanic voters leaped by 242,000, which was 55 percent of the increase. Latinos are now 15.4 percent of the voter rolls, up from 13.9 percent overall in 2012, when President Barack Obama narrowly carried Florida thanks to the outsized backing of minority voters.

Recent Florida polls show Trump is losing the Hispanic vote by historic margins to Hillary Clinton after the Republican’s incendiary comments about illegal immigrants, which offended a broad array of Latino leaders, including many in his own party.

Latino voters have no shortage of reasons to reject Trump.  But what about positive motives to come out for Clinton and the Democrats generally? The Affordable Care Act -- generally a political loser for Democrats to date -- could be a factor. Latinos in particular, and minorities generally, have benefited hugely from the ACA in Florida. Here are the salient enrollment facts:

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.

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 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:

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:

Uh oh: Trump has a coherent narrative

Donald Trump is a kind of idiot savant of demagoguery. Too lazy, ego-driven and solipsistic to analyze the facts of any business deal, let alone policy question, he does have an acute radar for the kinds of scapegoating that large numbers of people will respond to.

So far, though, with the American public as a whole, his credibility has been undercut by his boasting, his schoolyard insults, his lack of impulse control, his whining. Policy aside, a disinterested six-year old should be able to see through him. as 70 percent of Americans have to some degree.

Now, however, in the wake of Britain's primal scream, someone has put together for him a more coherent narrative that I fear could be very powerful, delivered today in a speech in a steel and aluminum shredding plant outside Pittsburgh. Never mind that the narrative fundamentally false -- it has enough elements of truth in it to seem plausible.

Like Obama's speeches, this speech has a historical sweep from the country's founding through Obama's presidency (and Hillary Clinton's tenure as Secretary of State).  While it projects a duce-like can-doism, it eschews direct boasting, as well as racial or religious scapegoating. The enemies are American elites and foreign nations, with the Clintons as the chief avatars of the domestic despoiling class. Trump is always all about blame, but here the domestic betrayers overshadow the overseas cheaters and predatory migrants.

The speech begins with a stab-in-the-back narrative:

A Medicare buy-in? Harold Pollack discusses Clinton's trial balloon

Hillary Clinton recently made headlines by expressing openness to allowing not-quite-elderly Americans to buy into Medicare:

“I'm also in favor of what's called the public option, so that people can buy into Medicare at a certain age,” the Democratic presidential front-runner said during a roundtable with local residents at the Mug'N Muffin coffee shop. “Which will take a lot of pressure off the costs.”

That's...confusing, since the public option, as originally conceived and as debated when the Affordable Care Act was being drafted, was a publicly financed health plan that would be offered in the ACA marketplace to prospective enrollees of all ages, competing directly with private plans. It was connected to Medicare only insofar as "strong" versions mandated that the plan would pay healthcare providers at Medicare rates, which are generally lower than those paid by private insurers.

Clinton's ACA subsidy sweeteners: Something for everyone

Of the roughly 24 million people whose health insurance is currently subsidized as a result of the Affordable Care Act*, over 80% have incomes below 200% the Federal Poverty Level (FPL).

About 14 million more people are enrolled in Medicaid than would have been had there been no ACA. They live in households with incomes below 138% FPL.  Of approximately 9 million subsidized enrollees in private plans sold in the ACA marketplace**, about 60%, or 5.4 million, have incomes under 200% FPL.

If banks are where the money are, the poor and "near-poor," as The CDC's National Health Interview Survey (NHIS) defines people in the 100-200% FPL range, are where the uninsured are most concentrated. A third of the U.S. population lives in households with incomes under 200% FPL. In 2013, just prior to ACA implementation, 55% of the uninsured had incomes below that level, according the most recent update of the Census Bureau's Current Population Survey. As of the first three quarters of 2015, according to the NHIS, the uninsured rate among those under age 65 had been cut by 35% for the poor (under 100% FPL) and by 38% for the near-poor (100-200% FPL).

Those with incomes over 200% FPL were not that far behind: the uninsurance rate for those above that income level fell by 30% from 2013 to 2015, according to the NHIS (from 9.6% to 6.7%).  But that may be a result more of stick than carrot: the tax penalty for remaining uninsured is quite stiff for higher earners. Among those in the upper range of ACA subsidy eligibility, 200-400% FPL, takeup has been poor. Above 200% FPL, subsidies require enrollees to pay between 6.4% and 9.7% of their incomes for benchmark silver plans. Cost Sharing Reduction subsidies fade to insignificance above 200% FPL and phase out entirely at 251% FPL, leaving silver plan holders with high deductibles and out-of-pocket costs.

Here comes Aunt Hillary's cavalry 

The concentration of ACA benefits on the poor and near-poor probably underlies the law's low approval ratings.  Enter Hillary Clinton's wish list. Her proposed package of supplements and sweeteners to ACA subsidies has something for people at all points in the income distribution, very much including those at the top of it (my emphasis below):

Could a Clinton HHS entice more Medicaid expansions?

When I was 19, I spent a summer on an archaeological dig in New Mexico. Work groups were mainly led by grad students in archaeology, and I recall someone telling the tale of a Ph.D thesis (not hers) that devoted 600 pages to demonstrating that an artifact dating technique did not work. She said,
somewhat ruefully, something to the effect of, "that's supposed to be useful too."

Below, I want to devote 600 words to an ACA-strengthening proposal that probably won't work. Writing 500 words before realizing this probably has something to do with the decision. But maybe floating it is useful. Maybe it suggests some variation that might work.

The context: I was combing Hillary Clinton's raft of healthcare reform proposals for measures that might be enacted without legislation.  In a prior post, I looked at her proposal to help states form public options in their ACA marketplaces. Next up:

Entice states that have refused the Medicaid expansion to embrace it. Clinton's healthcare page reiterates an Obama administration proposal to "to allow any state that signs up for the Medicaid expansion to receive a 100 percent match for the first three years." That was the original plan, with the federal share dropping in stages to 90% thereafter. But that was beginning in 2014. By statute, at present, states that opt in late don't get the full three years of full reimbursement.Beginning in 2017, the federal contribution to the cost of the expansion starts phasing down to a mere 90%, regardless of when the state implemented (or will implement) the expansion. Altering that would require legislation.

Can Hillary Clinton strengthen the ACA without legislation?

Jonathan Cohn has a post urging Bernie Sanders to use his enhanced visibility in the Senate to push for incremental moves toward his long-term goal of a single-payer healthcare system. Shorter term goals within the realm of imagination include letting CMS negotiate drug prices (and, I would add, leave some drugs off the formulary); gradually opening Medicare to people under 65 (perhaps starting with a buy-in option at age 60); and pushing for the widely popular "public option" that didn't make it into the ACA.

So much for Bernie in the Senate. What about Hillary in the White House? Let's be optimistic for a few minutes and assume she gets there. What can she really do to improve healthcare access and affordability?

We don't have to speculate wildly. In typical Hillary Clinton fashion, she has posted a raft of proposals to supplement and strengthen the Affordable Care Act and rein healthcare cost growth. They're lightly sketched in, though, and it's hard to know where Clinton would place her emphasis

One obvious starting point is with those that can be effected by executive action and administrative focus rather than by legislation. Steps requiring legislation are for the most part unlikely to happen, except in the unlikely event that a Democratic blowout takes back the House as well as the Senate -- and legislative possibilities would probably be quite limited even with a narrow Democratic majority.

Optimism flash

Trump is scary for sure.* But after all the shit is shoveled in this shameful election season, the U.S. will probably have elected its first woman president, after twice electing its first black president. And both are arguably about the best choices a country could make. fit to govern the world's most powerful country.

"Arguably"...I have always had doubts and qualms about Clinton -- her judgment, her ties to powerful interests, her political communication skills. But she probably has as good a grasp of policy -- issue by issue, detail by detail -- as any elected official in the country. She could be a disappointment -- or even, if she gets pulled into a stupid war, a disaster. But she could be great, too. Obama, early in his presidency, defined his task as turning the battleship of state a few degrees on multiple fronts. He's done that, and Clinton would (or should) ensure that we stay the corrected course.

----
* I would have thought that Trump was too obviously fraudulent, infantile and incompetent to be scary in himself. What's scary is that a substantial chunk of the electorate finds him credible -- or, if those who respond to infantile rage are always with us, that our media and political system give such a buffoon oxygen.

In which Hillary Clinton is confronted by a likely ACA loser (UPDATED)

[Please see 3/16 and 3/17 updates at bottom]

In last night's Democratic town hall forum, an audience member, Teresa O'Donnell of Powell, Ohio, told Hillary Clinton that she voted for Obama, "but then my health insurance skyrocketed, from $490 a month to $1,081 a month, for a family of 4." Charles Gaba has the clip, his own transcription, and an analysis here.

The question's a toughie, because Clinton couldn't very interrogate Ms. O'Donnell to determine all the factors behind her claim.  She did ascertain that the family had previously bought their insurance in the individual market. She then faintly intimated that perhaps O'Donnell hadn't fully checked out her options; credited the ACA with getting costs down generally (though not for all); stressed that she wanted to work to better contain costs; and implicitly blamed the absence in many markets of nonprofit insurers for much of continued cost hikes.