Some notes on the RAND survey

RAND has released its latest survey results on the health insurance status of American adults aged 18-64, spotlighting changes in health insurance enrollment since 2013. The results are based on survey responses from 2,425 people -- and since RAND surveys its panel monthly, it is able to track changes in health insurance status, pegging sometimes quite wide margins of error for each finding. The top line is that an estimated 9.3 million more people had health care coverage in March 2014 than in September 2013 (albeit plus or minus 3.5 million). That is, as Adrianna McIntyre frames it, "the uninsured rate among 18-64 year old adults in the United States fell by 23 percent—from 20.5 percent to 15.8 percent."

Adrianna also spotlights the report's biggest surprise: that the bulk of the increase comes from an estimated 8.2 million people gaining employer-sponsored insurance (ESI). RAND speculates that "some" of these people "may have taken up an employer plan as a result of the individual mandate; others may have newly found a job."  RAND found that only about 1.4 million people gained coverage from the new exchanges, as only about a third of the 3.9 million they found gaining coverage through the exchanges were previously uninsured.

A few thoughts and questions in response to the RAND findings are outlined below. My own confirmation bias may be at work, but I suspect that more than one third of ACA private plan signups were previously uninsured, for reasons outlined mainly in point #5.

Leonhardt seconds Gawande: put doctors on salary

David Leonhardt has joined Atul Gawande in pointing toward what should be the central front in the war on health care costs:

put doctors on salary.

Leonhardt prices four ways of treating prostate cancer: watchful waiting ("a few thousand dollars"), prostate removal ($23,000), I.M.R.T. radiation ($50,000), and the latest, proton radiation (often over $100,000).

Which one works best? “No therapy has been shown superior to another,” an analysis by the RAND Corporation found. Which treatments are growing fastest? "Use of I.M.R.T. rose tenfold from 2002 to 2006, according to unpublished RAND data." Proton radiation is newer, but treatment centers, which require "a proton accelerator that can be as big as a football field," are springing up left and right.

Why do the most expensive treatments always gain traction, whether or not there's any evidence that they're effective, or more effective than cheaper treatments? Insurers -- all insurers, including Medicare -- pay per procedure. At the center of the skewed incentive system, as Gawande showed, are doctors -- who are not only paid by the procedure, but in too many cases own all or part of the treatment facilities such as medical imaging centers.

OMB Director Peter Orzag, in his drive to shape health care reform, has tried on a couple of mantras since taking office. The first was "healthcare reform is entitlement reform" -- because problems with the social security trust fund are miniscule compared with the problem of runaway health care costs. Another was "the Mayos, not the McAllens" -- framing Gawande's contrast of a county where the doctors have "gone entrepreneurial" with the Mayo Clinic, where doctors are on salary. And when ticking off the administration's proposed reforms, Orzag generally tucks in "changes in provider incentives."

The nub of incentive reform is pretty simple: put doctors on salary. Good salaries. High salaries. Sweeten the pill with tort reform, reducing the defensive medicine imperative. But remove the incentive for prescribing the most expensive care.

New York Times seconds Obama's "central front in the war on terror"

What's the chief reason Obama wants to extricate U.S. troops from Iraq? He wants to concentrate more troops and money and energy on the fight against al Qaeda in Pakistan and Afghanistan.

Compare the New York Times' front page June 30 account of the renewed danger we face from a reinvigorated al Qaeda, grown strong in the tribal badlands of Pakistan, with Obama's diagnosis of our chief strategic priority on March 19. Laid side by side, the two documents offer a powerful case in support of Obama's claim that judgment and analytical power -- the ability to gather and process facts -- are more important than experience in a given field.

According to the Times exposé, U.S. efforts against al Qaeda's revival in Pakistan have failed because of failure to put meaningful pressure on Musharref, diversion of trained CIA operatives to Iraq, and continuous infighting within U.S. intelligence agencies. The upshot:

The story of how Al Qaeda, Arabic for “the base,” has gained a new haven is in part a story of American accommodation to President Pervez Musharraf of Pakistan, whose advisers played down the terrorist threat. It is also a story of how the White House shifted its sights, beginning in 2002, from counterterrorism efforts in Afghanistan and Pakistan to preparations for the war in Iraq.

Just as it had on the day before 9/11, Al Qaeda now has a band of terror camps from which to plan and train for attacks against Western targets, including the United States. Officials say the new camps are smaller than the ones the group used prior to 2001. However, despite dozens of American missile strikes in Pakistan since 2002, one retired C.I.A. officer estimated that the makeshift training compounds now have as many as 2,000 local and foreign militants, up from several hundred three years ago....

Current and former military and intelligence officials said that the war in Iraq consistently diverted resources and high-level attention from the tribal areas. When American military and intelligence officials requested additional Predator drones to survey the tribal areas, they were told no drones were available because they had been sent to Iraq....

“The United States faces a threat from Al Qaeda today that is comparable to what it faced on Sept. 11, 2001,” said Seth Jones, a Pentagon consultant and a terrorism expert at the RAND Corporation.

“The base of operations has moved only a short distance, roughly the difference from New York to Philadelphia.”

Here's Obama in Fayetteville, NC on March 19:

Above all, the war in Iraq has emboldened al Qaeda, whose recruitment has jumped and whose leadership enjoys a safe-haven in Pakistan – a thousand miles from Iraq.

The central front in the war against terror is not Iraq, and it never was. What more could America's enemies ask for than an endless war where they recruit new followers and try out new tactics on a battlefield so far from their base of operations? That is why my presidency will shift our focus. Rather than fight a war that does not need to be fought, we need to start fighting the battles that need to be won on the central front of the war against al Qaeda in Afghanistan and Pakistan.

This is the area where the 9/11 attacks were planned. This is where Osama bin Laden and his top lieutenants still hide. This is where extremism poses its greatest threat. Yet in both Afghanistan and Pakistan, we have pursued flawed strategies that are too distant from the needs of the people, and too timid in pursuit of our common enemies.

It may not dominate the evening news, but in Afghanistan, last year was the most deadly since 2001. Suicide attacks are up. Casualties are up. Corruption and drug trafficking are rampant. Neither the government nor the legal economy can meet the needs of the Afghan people.

It is not too late to prevail in Afghanistan. But we cannot prevail until we reduce our commitment in Iraq, which will allow us to do what I called for last August – providing at least two additional combat brigades to support our efforts in Afghanistan. This increased commitment in turn can be used to leverage greater assistance – with fewer restrictions – from our NATO allies. It will also allow us to invest more in training Afghan security forces, including more joint NATO operations with the Afghan Army, and a national police training plan that is effectively coordinated and resourced.

A stepped up military commitment must be backed by a long-term investment in the Afghan people. We will start with an additional $1 billion in non military assistance each year – aid that is focused on reaching ordinary Afghans. We need to improve daily life by supporting education, basic infrastructure and human services. We have to counter the opium trade by supporting alternative livelihoods for Afghan farmers. And we must call on more support from friends and allies, and better coordination under a strong international coordinator.

To succeed in Afghanistan, we also need to fundamentally rethink our Pakistan policy. For years, we have supported stability over democracy in Pakistan, and gotten neither. The core leadership of al Qaeda has a safe-haven in Pakistan. The Taliban are able to strike inside Afghanistan and then return to the mountains of the Pakistani border. Throughout Pakistan, domestic unrest has been rising. The full democratic aspirations of the Pakistani people have been too long denied. A child growing up in Pakistan, more often than not, is taught to see America as a source of hate – not hope.

This is why I stood up last summer and said we cannot base our entire Pakistan policy on President Musharraf. Pakistan is our ally, but we do our own security and our ally no favors by supporting its President while we are seen to be ignoring the interests of the people. Our counter-terrorism assistance must be conditioned on Pakistani action to root out the al Qaeda sanctuary. And any U.S. aid not directly needed for the fight against al Qaeda or to invest in the Pakistani people should be conditioned on the full restoration of Pakistan's democracy and rule of law.

The choice is not between Musharraf and Islamic extremists. As the recent legislative elections showed, there is a moderate majority of Pakistanis, and they are the people we need on our side to win the war against al Qaeda. That is why we should dramatically increase our support for the Pakistani people – for education, economic development, and democratic institutions. That child in Pakistan must know that we want a better life for him, that America is on his side, and that his interest in opportunity is our interest as well. That's the promise that America must stand for.

And for his sake and ours, we cannot tolerate a sanctuary for terrorists who threaten America's homeland and Pakistan's stability. If we have actionable intelligence about high-level al Qaeda targets in Pakistan's border region, we must act if Pakistan will not or cannot. Senator Clinton, Senator McCain, and President Bush have all distorted and derided this position, suggesting that I would invade or bomb Pakistan. This is politics, pure and simple. My position, in fact, is the same pragmatic policy that all three of them have belatedly – if tacitly – acknowledged is one we should pursue. Indeed, it was months after I called for this policy that a top al Qaeda leader was taken out in Pakistan by an American aircraft. And remember that the same three individuals who now criticize me for supporting a targeted strike on the terrorists who carried out the 9/11 attacks, are the same three individuals that supported an invasion of Iraq – a country that had nothing to do with 9/11.

Can Obama execute the multi-level campaign in two countries described above? That remains to be seen. Has he accurately identified the central danger facing the U.S. and its allies in the struggle with Islamic extremism -- and the military, political and social tasks we need to undertake? As well as can be done in a political campaign.

Related post:
Breaking the Commander-in-Chief Chokehold: Obama maps a strategy