Boehner's not retreating, he's doubling down

Robert Costa has a funny little narrative today in which John Boehner and Eric Cantor, moderate old hands who know how Washington works, talk the GOP's young Turks off the ledge of a government shutdown when this year's funding runs out at the end of September.  We don't have the votes, we'll be blamed, etc. etc.  But then there's this kicker, which gave me hot flashbacks:

Members were also buzzing about the leadership’s emerging strategy for the autumn talks. Sources tell me the House GOP will probably avoid using a shutdown as leverage and instead use the debt limit and sequester fights as areas for potential legislative trades. Negotiations over increasing the debt limit have frequently been used to wring concessions out of the administration, so there may be movement in that direction: Delay Obamacare in exchange for an increased debt limit. As members huddled and talked through scenarios, leadership aides reminded them that since the House GOP retreat in Williamsburg, Va., earlier this year, the plan has been to end the year with a debt-limit chess game, and not a messy continuing-resolution impasse (my emphasis).

What this flashed me back to was not debt ceiling summer 2011, but early this year, when Boehner made rather a big show of not forcing a debt ceiling showdown, instead suggesting that his caucus would take its stand at the end of March, when the sequester kicked in. Progressive observers reacted with some incredulity that Boehner would let the sequestration cuts, which include massive defense cuts, happen. At the time, McConnell and Boehner's victory at the fiscal cliff  (Obama forced to settle for just half of his reduced December revenue demand, sequester set to spring in two months) was being viewed as a defeat. But it was Obama and the Democrats who folded when it came time to fund the government for the remainder of this fiscal year, quietly acceding to full uncut sequestration.

Detroit's destruction began in its heyday

Thomas J. Sugrue's The Origins of the Urban Crisis: Race and Inequality in Postwar Detroit (1997) is a great book -- and in some ways a simple one.  It provides extensive, fine-grained documentation of two or three (depending on how you count) relentless forces that destroyed Detroit.

The first was the hemorrhaging of manufacturing jobs that was in full flow by the early fifties, and could only have been stemmed by national industrial policies unthinkable in the United States: a rollback of Taft-Hartley's enablement of state right-to-work laws; a German-style role for labor in corporate management; legal restrictions on companies' right to lay off workers or move manufacturing operations as they saw fit.

The second was the vicious, rooted, legally codified and government-sanctioned racism that kept African Americans at the bottom of the labor totem pole, consigning them to the hardiest, dirtiest, poorest-paying and least secure factory jobs and excluding them skilled crafts, retail service and a host of other occupations.

Obama's drinking gourd ain't no Holy Grail

(reposted from 8/10/13)

Was I too dark a prophet when I said
To those who went upon the Holy Quest,
That most of them would follow wandering fires,
Lost in the quagmire? -- lost to me and gone,
And left me gazing at a barren board.

-- King Arthur to his knights, in Tennyson's Idylls of the King, The Holy Grail

Now, I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number-one priority. The one unifying principle in the Republican Party at the moment is making sure that 30 million people don't have health care and, presumably, repealing all those benefits I just mentioned -- kids staying on their parents' plan; seniors getting discounts on their prescription drugs; I guess a return to lifetime limits on insurance; people with preexisting conditions continuing to be blocked from being able to get health insurance.

-- President Obama, press conference, 8/9/13

Obama has more than once tagged his Republican opposition with a fundamentalist mindset on economic issues. In his mind, they do indeed follow wandering fires -- mirages of a "holy quest." He has used the metaphor before to denote their worship of false economic gods.

Snowden, patriot; Obama, in denial

This is just to say, for the record, that I think Obama was shamefully disingenuous or self-deluded in declaring in his press conference yesterday that Edward Snowden is not a patriot and suggesting that he himself would have triggered the kind of inquiry into current surveillance practices that Snowden has unleashed if not pushed by Snowden's disclosures.

This, in particular, is a logical elision:

So the fact is, is that Mr. Snowden has been charged with three felonies. If, in fact, he believes that what he did was right, then, like every American citizen, he can come here, appear before the court with a lawyer and make his case

Obama's drinking gourd ain't no holy grail

Was I too dark a prophet when I said
To those who went upon the Holy Quest,
That most of them would follow wandering fires,
Lost in the quagmire? -- lost to me and gone,
And left me gazing at a barren board

-- King Arthur to his knights, in Tennyson's Idylls of the King, The Holy Grail

Now, I think the really interesting question is why it is that my friends in the other party have made the idea of preventing these people from getting health care their holy grail, their number-one priority. The one unifying principle in the Republican Party at the moment is making sure that 30 million people don't have health care and, presumably, repealing all those benefits I just mentioned -- kids staying on their parents' plan; seniors getting discounts on their prescription drugs; I guess a return to lifetime limits on insurance; people with preexisting conditions continuing to be blocked from being able to get health insurance.

-- President Obama, press conference, 8/9/13

Obama has more than once tagged his Republican opposition with a fundamentalist mindset on economic issues. In his mind, they do indeed follow wandering fires -- mirages of a "holy quest." He has used the metaphor before to denote their worship of false economic gods.

For state GOP officials, a manual for undermining Obamacare

In 2011, the National Association of Insurance Commissioners (NAIC) produced a report cataloging risks of adverse selection in the ACA state insurance exchanges and provisions in the ACA designed to avoid or mitigate those risks. (Adverse selection occurs in plans that chiefly attract less health and more expensive customers, e.g. when younger, healthier customers have other options more attractive to them, including remaining uninsured.)

One key ACA measure to mitigate adverse selection is as follows. Those who offer insurance on the exchanges must treat all their customers in that state as one risk pool and must offer silver and gold plans -- the middle options in a spectrum that runs from bronze to platinum. If "young invincibles" choose bronze plans, their choices won't affect pricing in more expensive plans, which may be more attractive to older and sicker customers.

A continued risk is posed, however, by the ongoing existence of an individual market outside the exchanges, where insurers may still sell cheap high-deductible plans that appeal to healthy young people, albeit subject to many if not all of the same rules governing plans offered in the exchanges. In yesterday's New York Times, Eduardo Porter outlined that risk:

Are "burn your Obamacare card" proponents incurring potential liability?

Progressives have been first dumbfounded, and then enraged, by the right-wing campaign to convince the uninsured not to purchase health insurance on the exchanges established by the Affordable Care Act.. The young, healthy uninsured whom the exchanges need to sign up in order to thrive are being urged to "burn your Obamacare draft card," as the Koch-funded Freedomworks puts it.  Here's Kevin Drum's reaction:

Nice. I wonder if FreedomWorks plans to help out the first person who takes them up on this and then contracts leukemia? I'm guessing probably not.

What's next? A campaign to get people to skip wearing seat belts? To skip using baby seats in cars? To skip vaccinations for their kids? It's times like this that words fail those of us with a few remaining vestiges of human decency.

There may be legal ramifications to Drum's question.  Might those who gratuitously offer a kind of malign financial advice to the general public -- in particular, to a disproportionately young and poor segment of the public -- incur liability?

Read that NYT exposé of price gouging in joint replacements? Here's an antidote

For those angered by the recent New York Times exposé of price-gouging in joint replacement devices and operations in the U.S. (total hip replacement tabs topping out at $112k, vs. $13k in Belgium), a CalPERS health insurance initiative offers a partial antidote. Melanie Evans explains in Modern Healthcare:

Joint replacement prices at the most costly California hospitals plunged by one-third after the state required its workers and retirees to pay out of pocket all costs above a “reference price” of $30,000 for orthopedic surgery, a new study said.

The average cost of joint replacement among high-priced hospitals dropped to $28,465 after the California Public Employees' Retirement System made the change in 2011, wrote University of California researchers James Robinson and Timothy Brown in the journal Health Affairs. That's down from $43,308 the prior year.

Using patient incentives to control costs is usually branded as "conservative" in the U.S. And indeed, "consumer-driven healthcare" is just a misleading euphemism unless crucial elements -- price transparency and genuine choice -- are part of the mix. In this case, they are:

Reminder: chained-CPI means new revenue

Chuck Todd, attempting to flesh out  some talk show chatter from Eric Cantor about budget compromise (GOP-style, i..e., with no new revenue), floats a GOP trial balloon:

Left unsaid by Cantor is what entitlement reform has to look like. There’s been some chatter in GOP circles that it’s about simply taking the president’s offer on chained CPI.  The argument by some Republicans on this strategy is that Republicans would be able to claim victory on stopping the sequester and getting an opening to begin entitlement reform without capitulating to the president’s demand that chained CPI (which would change Social Security benefits among other things) come with some new tax increases. But would the president be open to this? Chained CPI in exchange for turning off sequester? Seems reasonable now… but who knows.

The happiest wrong I could ever be

I am on vacation from from vacation so to speak, in the Catskills in the rain, inspired by the legislative news and willing to brave this horrific Samsung phone keyboard to get a brief thought down [couldn't do it - finishing the half-baked thought at home, 8/4]. What if the narrative I've invested myself in all year is wrong? That is, that Obama blew his point of maximum leverage at the fiscal cliff and locked us into the sequester, gravely hindering his long-term agenda? Could it be that Republicans will this year choke over sequestration and wriggle out by one means or another?

Obama girds for nuclear budget war, cont.

So Obama has repackaged and linked two old proposals -- revenue-neutral corporate tax reform and a package of jobs stimulus measures. The tax reform would be revenue neutral over the long term, cutting rates and reducing loopholes, but would yield a one-shot revenue boost as the loopholes are closed, paying for teh short-term jobs measures.

This mini "grand bargain" is part of Obama's announced series of economic speeches and proposals.  The purpose, as I see it, is twofold. First, to shift the national agenda in the upcoming budget battles from deficit reduction to jobs (short-term stimulus and long-term investments). Second, to present Republicans with a series of manifestly reasonable programs and compromises to reject. That way, when they shut down the government or threaten national default because Obama won't agree to obscenely large spending cuts, he can say, "I offered to compromise six ways to Friday, but my opponents won't agree to anything but more spending cuts and more tax cuts." 

Long-suffering Lincoln

[Updated, with illustration!]
Vandalism at Lincoln Memorial recalls a precursor in Buffalo some 15-plus years ago:

                                                                        On a statue in Delaware Park,
                                                                        almost as old as Noah's ark,
                                                                        some disrespectful, disreputable fellow
                                                                        sprayed Abraham Lincoln's hair bright yellow.

                                                                        It's despicable. It's deplorable.
                                                                        Sunny-side up
                                                                        he looks adorable.

In which "strategic advisor" Howard Dean attacks IPAB

Why would Howard Dean -- physician, former governor, former meteoric presidential candidate and current "strategic advisor" to healthcare clients at a lobbying firm, stick a knife in IPAB, the Independent Payment Advisory Board created by the Affordable Care Act to rein in the federal government's Medicare spending?

In a Wall Street Journal op-ed published this morning, Dean first pays lip service to core aspects of the ACA before launching into a perfunctory, mail-it-in attack on  IPAB:

By reframing national agenda, Obama hopes to "force a different result" in budget negotiations

When Obama came his speech urging a national refocus on jobs and the foundations of long-term economic growth last Wednesday, the first in a series on the economy, I suggested that he was positioning himself to win a budget showdown should the Republicans shut down the government or seriously threaten a debt ceiling default if he does not agree to radical new spending cuts or the defunding of Obamacare. He is trying preemptively to reframe the argument, to convince the public that jobs and investments that foster long-term economic growth should be the national priority -- not spending cuts,.

In a long interview with the Times' Jackie Calmes and Michael Shear, conducted while he was at Knox College in Galesburg, IL to deliver that speech, Obama continued his bid to shift the agenda:

NYT: [House Republicans] are still embracing sequestration and who are still willing to use the debt limit to go to the mat. 

MR. OBAMA: Well, this is what they say. On the other hand, we also have a number of very thoughtful and sensible Republicans over in the Senate who have said that we should not play brinksmanship, that we should come up with a long-term plan. I met with a couple of House Republicans over the last several weeks who would like to see that happen. They’re not the loudest voices in the room at the moment. 

And part of what I’d like to see over the next several weeks is, if we’re having a conversation that’s framed as how are we growing the economy, how are we strengthening the middle class, how are we putting people back to work, how are we making college more affordable, how are we bringing manufacturing back -- the answer to those questions I think force a different result than if we are constantly asking ourselves how can we cut the deficit more, faster, sooner.

My fantasy flashes in the news, flickers, fades

I have fantasized from time to time that Obama would pull a Jan Brewer and refuse to sign any appropriations bills that don't shut off the sequester. Or the (earlier) Chris Christie variant: that he will sit back, crack open a beer, and wait for Congress to send him a budget he can sign.

Therefore, this peek at alleged White House deliberations by the Washington Post's Zachary Goldfarb and Paul Kane set my heart a bit aflutter:

White House officials also are discussing a potential strategy to try to stop the sequestration cuts from continuing, the lawmakers and Democrats said. Under this scenario, the president might refuse to sign a new funding measure that did not roll back the sequester.

But reality came back quick:

No decision has been made.

And this sounds more like Obama:

Is Obama preparing for nuclear budgetary war?

It's a foundation built upon five pillars that will grow our economy and make this new century another American century: new rules for Wall Street that will reward drive and innovation; new investments in education that will make our workforce more skilled and competitive; new investments in renewable energy and technology that will create new jobs and industries; new investments in health care that will cut costs for families and businesses; and new savings in our federal budget that will bring down the debt for future generations. That is the new foundation we must build. That must be our future – and my Administration's policies are designed to achieve that future.

That's Obama laying out his broader economic vision -- in April 2009. Three of the five pillars match the five cornerstones he laid down in yesterday/s speech on long term economic growth -- or rather two and a half, as his "jobs" cornerstone yesterday centered in large part on renewable energy.

As many pointed out, there were no new proposals in Obama's speech yesterday, and not much detail -- it was a framework, with details to be supplied in an upcoming series of speeches. And that's okay. As the political storms of autumn approach, dullness is good. Repetition is good. Reminder of what Obama is about -- how he thinks, how he carries himself, what he wants -- is useful, even if it doesn't excite anyone now. It's an impression scheduled for timed release.

Could a "doc fix" have a bigger impact on U.S. healthcare than the ACA?

Two interrelated features of the U.S. healthcare system are probably the primary causes for the uniquely high cost of healthcare in the U.S.: weak government control over pricing, and the fee-for-service payment model.

These interrelated weaknesses are exacerbated, as a weekend Washington Post exposé showed, in that Medicare pretty much lets doctors determine the rates at which they paid, by leaving it to the AMA to produce estimates of how long each procedure takes. Surprise! The doctors' chief trade group massively pads the estimated times required for most procedures. 

Even if procedure prices were based on accurate time estimates, free-for-service incentivizes providers to perform a high volume of the most expensive procedures. Nonetheless, countries in which the government imposes monopsony price control -- i.e., every other wealthy country in the world -- generally manage to deliver universal healthcare at two thirds to half the cost per capita of healthcare in the U.S.  Government control over pricing, as Ezra Klein recently forced healthcare free market evangelist Avik Roy to admit, is the sine qua non of effective heathcare cost control.  And we in the U.S. don't have it, as a study published in Health Affairs ("It's the Prices, Stupid...", Gerard F. Anderson et al., 2003) explains:

Why is McCain suddenly John So-New-New?

I have no insight into the latest cut-back in the double reverse that is John McCain's long career. I just want naming rights.

Update: Dana Milbank interviewed McCain 4.0.  The reborn maverick's explanations for his serial transformations make no sense, but as long as this is the final somersault, Democrats won't complain.

Party of Spite

There is no word for this but sick:

"ObamaCare is bad for America," Boehner told CBS's "Face the Nation." "We're going to do everything we can to make sure it never happens." 

Republicans have already acted to deny Medicaid to millions of uninsured Americans. It's their stated goal to wreck the ACA's insurance exchanges and so prevent millions more uninsured -- a projected 15-17 million over time -- from buying affordable health insurance. They jawed for years about "repeal and replace" but have offered no replacement.  They profess to believe it "good for America" to leave tens of millions uninsured and prone, as they now are, to bankruptcy, lack of regular healthcare, and haphazard, incomplete, unsustained care if they get seriously ill.

Sugarcoat it as they will, the GOP has devolved to nothing other than the Party of Spite.  The party is unworthy of sharing the governance of a village, let alone a nation of 300 million.

"Trayvon Martin could have been me"

ICYMI, America, you elected a black president. Twice. Obama reminded us forcefully of that rather miraculous fact today, while addressing the impact and meaning of the Trayvon Martin affair.

It is always expensive for Obama to affirm his identity as an African American, and so his representation of African American experience and perspective on the Zimmerman trial today to Americans at large came couched in qualifiers. The jury has spoken, but.  Young African American men are more likely to involved in violence, but. Criminal law is mostly a matter for state and local government but. Stand your ground law was not used by the defense but. Politician-initiated conversations about race end up being stilted and politicized, but.

It was straight talk wrapped in apophasis -- "saying by not saying," or saying what I say I shouldn't say: That African Americans still encounter reflexive prejudice in their daily lives, that American justice is still far from colorblind, that we are still collectively failing African American inner city youth.

Why I'm glad that Democrats didn't change the Senate rules

Almost since Obama took office, almost every writer on politics whom I enjoy reading most, driven mad by GOP obstruction in the Senate, has urged filibuster reform.  Let Harry Reid's latest complaint stand in for a long statistical litany of GOP obstruction: he has had to deal with over 400 Republican filibusters, compared to Lyndon Johnson's one. 

Without doubt, Senate rules could use some rational tweaking. But I have argued since 2009 that the problem is not so much with the Senate rules as with the GOP destruction of governing norms. Instead of a loyal opposition we have had a nihilist one, unwilling to let the majority govern (with a rational level of resistance and negotiation to shape laws more to the minority's liking) and abide the electoral consequences of the laws they pass, unwilling to let the executive branch be staffed so it can perform its constitutional functions, unwilling to allow the lengthy enactment process to work for laws already passed and signed.

The problem is not so much the rules as the GOP; such nihilist opposition is dangerous, and bespeaks graver danger should the extremist party gain control of the presidency and both houses of Congress. Against that very real possibility the filibuster stands as a bulwark: I would rather let the GOP inhibit the Democrats' ability to pass legislation and fill vacancies than enable the GOP to wreak legislative havoc unrestrained if it has not moderated before the next time it gains power.

Nonsense question of the day: "Does Obama have a second-term strategy?"

Sometimes it's hard not to suspect that Politico reporters don't believe their own bullshit when they spin out narratives about who's up, who's down, how A perceives B, what C's prospects are, etc.

Today's nonsense question, posed by Glenn Thrush, is Does President Obama have a second-term strategy? Of course the implied answer is no. But the argument is self-cancelling from the get-go.

The implicit premise is that because Obama said during the campaign that his victory might break the GOP's fever of no-compromise opposition, and that fever has not in fact broken, the president is at loose ends. But that premise must be hedged, because of an inconvenient truth that Thrush acknowledges at the outset: Obam never expected that his reelection would end partisan gridlock:

The WSJ on the ACA, cont.

Early this month, I looked at a couple of Wall Street Journal stories that emphasized the negative in the Affordable Care Act rollout and wondered whether the WSJ healthcare coverage wasn't Foxifying a bit. One emphasized the premium hike for a relatively small subset of people subject to the individual mandate (and without employer-provided insurance), and one aggregated and exaggerated a series of "blows" to the law, most of which were old news.

Healthcare reporter Louise Radnofsky was on both bylines. She's a good reporter. Her coverage over time has been balanced.*

But as the rollout of the ACA exchanges looms, I wonder whether WSJ news editing is tilting the emphasis on ACA coverage generally [ [UPDATE: I have spoken to someone at the Journal, whose word I trust, who assures me that editors area not imposing a political agenda on reporters. I regret speculating about motive without information.].

Today, Project Millennial blogger Mike Miesen flags another questionable WSJ framing of ACA news that had also registered with me this morning:

A Pooh guide to blogging

While I usually avoid talking or even thinking entirely consciously about this, it often strikes me (usually when I don't find anything to blog about) how strange it is that for five-plus years I've managed, FWIW, to come up with a post idea about six days out of seven.  More often than not, this just happens while I'm reading something (something doesn't add up, or reminds me of something else that doesn't seem entirely arbitrary), but sometimes it's a matter of mood, or caffeine: it feels like something is about to catch.

When it's the latter, my repetitive mind -- not so much a lizard brain as a perpetual child brain -- usually throws up a line from Winnie-the-Pooh "he felt singy." Here is that jewel in its setting (House at Pooh Corner, Ch. 6):

One day, when Pooh was walking towards this bridge, he was trying to make up a piece of poetry about fir-cones, because there they were, lying about on each side of him, and he felt singy.

Poem for a hot summer Sunday

In high Buddleia season:

                                                                  Butterflies (a truth to utter)
                                                                  don't look much like flying butter.
                                                                  Why do we say "butterfly"?
                                                                  Babies can't say "flutter by."

"Government-run healthcare," Singapore style

In his long rhetorical war against the Affordable Care Act, Avik Roy likes to hold up Singapore's healthcare system as a shining counter-example. He quite rightly points out that Singapore spends far less on healthcare than the U.S. (4% of GDP vs. 18% for the U.S.), and with better outcomes. How do they do it? Roy -- while acknowledging one aspect of the government's heavy hand --  credits free-market magic:

The key to the Singapore system is mandatory health savings accounts: again, something that libertarians and many conservatives wouldn't like. Matt Miller of the Center for American Progress describes Singapore as "further to the left and further to the right" than the American system--something that could also be said of Switzerland.

Pulping the bully approach to presidential politics, VI

Ezra Klein is replaying that whole paradox of power thing: When Obama comes out for a policy, the GOP will demonize it -- so if Obama wants to get anything done with a GOP House, how can he jump off his shadow?  This time, Klein brings Jon Favreau to bear, affirming the White House's not-at-all-surprising hyper-awareness of this conundrum:

Jonathan Favreau, who in February stepped down as Obama’s chief speechwriter, said that dealing with the Republican Party’s reflexive opposition is a pervasive reality in the White House. “People take a very realistic approach to it,” he said. “They’re not frustrated or upset. It’s more, ‘This is just the way things are and this is how we’ll deal with it.’ The strategy always comes to ‘What gives us the best chance to get something passed?’”

Since you're here, read this

I don't usually post excerpts without comment, but...I feel like Jon Favreau has told basically the whole story of U.S. politics of the last five years with his piece, The GOP is Terrified Obamacare Could be a Success. It lays bare the bad faith, the all-in commitment to misinformation, the callousness and cruelty of today's GOP.  It makes my heart sing, so I'm going to carry my bucket of water to the ocean of Favreau's readership and say: read it:

But here’s my question: if Republicans are so confident Obamacare will end badly, why not just shut up about it? It’s not like they have the votes to repeal the law—a math problem they still haven’t solved after 37 different tries. Their appeal to the Supreme Court ended in defeat at the hands of a conservative chief justice. And now the bulk of the plan will begin to take effect in just a few months.

At this point, why not sit back and wait for this crazy experiment to self-destruct? Why not let President Obama and the Democrats reckon with the millions of angry Americans who will undoubtedly hate their new insurance or their new insurance protections?

Because Republicans are terrified that Obamacare could actually work.

Mistrust among the poor

I am reading Doing the Best I Can: Fatherhood in the Inner City by Kathryn Edin and Timothy J. Nelson, a compulsively readable in-depth account of how poor inner city men view and attempt to fulfill their responsibilities as fathers. The authors lived in Camden, NJ, one of the country's poorest cities, and spoke in depth to some 110 unmarried fathers in Camden and poor black and white neighborhoods of Philadelphia.

The title aptly captures the core idea: the men have shining ideals of fatherhood and marriage but hold themselves to much lower standards in keeping with their earning power and lack of strong ties to their children's mothers. Most beget children as the result of brief and haphazard relationships with women and are much more invested in their relationships with the children than with the children's mothers. Repeatedly, these mostly none-too-trustworthy men express a lack of trust in women.  And one expression of that lack of trust reminded me of a different all-too-common suspicion. Below, a father of three speaks:

Who'll stop the hospital billing machine when you're "covered"?

My family gets its health insurance through my wife's employer, a multi-hospital system. Until this year, we have had in-network coverage only. Last fall, somewhat to my surprise, the hospital-insurer agreed to cover in full an operation out-of-network on grounds that no one in-network was qualified to do it. This was a wake-up call for me, and I insisted that this year we pay more for a plan that provides limited out-of-network coverage.While out-of-network coverage has substantial deductibles and limited co-pays, out-of-pocket expenses are capped at about $11,000 per individual. That strikes me as worthwhile catastrophic insurance if one of us gets seriously ill and needs to tap a top specialist outside the network. But our experience with the covered out-of-network operation we already had raises a question in mind about that out-of-pocket maximum -- for myself and for insured patients in general, particularly those buying on the new healthcare exchanges.

Here's the rub: while our insurer informed us that the operation would be covered in full, they were slow to pay some bills and paid some only in part. We then became targets of "balance billing" -- practices affiliated with the hospital where the operation occurred as well as the hospital itself dunning us for unpaid balances, often under threat of siccing a collections agency on us.

An "introvert" in the White House

Richard Neustadt, author of Presidential Power and Modern Presidents, seems to have been rather a Kennedy worshipper, judging from a chapter on Kennedy written for a later edition of his signature work.  All the more reason that this minor caveat to a portrait of near presidential perfection caught my eye:

.., he was not a "mixer" socially, not, anyway, with most members of Congress and their wives. His manners were impeccable, his charm impelling, but he kept his social life distinct from his official life and congressmen were rarely in his social circle. To know how Congress works but to disdain its joys is an acquired taste for most ex-congressmen downtown, produced by hard experience. Kennedy, however, brought it with him. Many of the difficulties he was to encounter in his day-to-day congressional relations stemmed from that disdain (p. 174, 1990 edition).

How does Roger Cohen know what Egyptians want?

With all due respect to Roger Cohen's long experience as a reporter, how does he know what the Egyptian revolution has been "about"?

He addresses the question with apparent confidence:

The uprising that ended decades of dictatorship and led to Egypt’s first free and fair presidential election last year was about the right to that vote. But at a deeper level it was about personal empowerment, a demand to join the modern world, and live in an open society under the rule of law rather than the rule of despotic whim.

In a Muslim nation, where close to 25 percent of Arabs live, it also demanded of political Islam that it reject religious authoritarianism, respect differences and uphold citizenship based on equal rights for all.

Cohen's sources? Heba Morayef, head of Human Rights Watch in Cairo, and Mohamed ElBaradei, the world famous "liberal modernizer" (Cohen's phrase) who signed onto the generals' coup. That's it -- the sum total of his cited sources for telling us what 80-plus million Egyptians want.

OK, Krugman: How will hypocrisy help us?

Paul Krugman, Jeremiah of galloping income inequality in the United States, today manages a rather half-hearted tribute to the nation's long-term fidelity to its founding ideals. Half-hearted, because seeing those ideals subverted by encroaching oligarchy, he takes rueful solace only in our national hypocrisy:

Of course, our democratic ideal has always been accompanied by enormous hypocrisy, starting with the many founding fathers who espoused the rights of man, then went back to enjoying the fruits of slave labor. Today’s America is a place where everyone claims to support equality of opportunity, yet we are, objectively, the most class-ridden nation in the Western world — the country where children of the wealthy are most likely to inherit their parents’ status. It’s also a place where everyone celebrates the right to vote, yet many politicians work hard to disenfranchise the poor and nonwhite. 

But that very hypocrisy is, in a way, a good sign. The wealthy may defend their privileges, but given the temper of America, they have to pretend that they’re doing no such thing. The block-the-vote people know what they’re doing, but they also know that they mustn’t say it in so many words. In effect, both groups know that the nation will view them as un-American unless they pay at least lip service to democratic ideals — and in that fact lies the hope of redemption. 

So, yes, we are still, in a deep sense, the nation that declared independence and, more important, declared that all men have rights. Let’s all raise our hot dogs in salute.

Left unspoken here is how hypocrisy helps. It's said that hypocrisy is the tribute that vice pays to virtue -- bad conscience with a cover. The question is, how productive will our ethical unease prove? Now that our income distribution (and opportunity distribution) has reverted to roughly where it was before the Great Depression and the New Deal, will this retrogression prove, to borrow a bit of econ-speak, 'secular or cyclical'?  That is, will we readjust, as Obama in '08 argued we must, from a 30-year Reaganite right turn turbo-charging pressure on wages powered by automation and globalization? Will we find means to train our youth to create and fill "good-paying jobs of the future"? Or was the relatively weak American version of the welfare state merely a one-time strategic retreat by elites that have more recently tightened a now unshakable proprietary grip on the means to prosperity?

The "I want the best" quality measure in healthcare

On The Incidental Economist, Bill Gardner rather wearily brushes off claims, based on personal experience, that the U.S. has "the best healthcare in the world." He outsources to Aaron Carroll the marshaling of evidence that "on most important measures, the US has poorer quality of care than comparable countries" and concentrates on a prior question: what do we mean by quality of care? He then offers a breakdown of quality measures which, for policy purposes, may be comprehensive, but which I think misses a dimension that may be in the minds of many who claim "best" status for the U.S. Here are Gardner's "dimensions of health quality*":

• The hotel experience. Some hospitals are nicer places to stay than others. This may seem trivial in the context of life and death, but any hospital manager will tell you that ‘hotel quality’ matters to patients.
• The relationship experience. Did the health care providers treat you with respect? Were they considerate of your religious beliefs? The well-educated readers of this blog may have difficulty imagining that they would not be well-treated by health care providers. But disrespect may be a primary consideration if you are poor, speak a language other than English, live outside the mainstream culture, or are mentally ill.
• The rightness of treatments. By the ‘right’ treatment, I mean the one that was most likely to benefit you.
• Safety. Were you harmed through error or neglect while you were in care?

In response, I posted this comment:

For Egypt, a warning from Aesop

Not to pretend to any expertise about Egypt, but as soon as I read about the military's ultimatum to Morsi, this fable of Aesop's came to mind:

There was once a Horse who used to graze in a meadow which he had all to himself. But one day a Stag came into the meadow, and said he had as good a right to feed there as the Horse, and moreover chose all the best places for himself. The Horse, wishing to be revenged upon his unwelcome visitor, went to a man and asked if he would help him to turn out the Stag. "Yes," said the man, "I will by all means; but I can only do so if you let me put a bridle in your mouth and mount on your back." The Horse agreed to this, and the two together very soon turned the Stag out of the pasture: but when that was done, the Horse found to his dismay that in the man he had got a master for good.

Until Mubarak's deposing, Egypt had been under military rule since 1952.  Do Egyptians really want to toss out their first elected leader, in power for just a year, and take the bit again?

In which Ezra Klein makes Avik Roy acknowledge why U.S. healthcare costs are so high

Avik Roy and Ezra Klein had a long --very long -- conversation about Roy's beefs with the Affordable Care Act. They covered "rate shock,"  minimum coverage standards, and Roy's dreams of a more fundamental system overhaul that would push everyone onto healthcare exchanges by privatizing Medicaid and Medicare and ending the employer tax deduction for health care benefit provision. 

Roy has been a relentless critic of the ACA. Having read some of his writings about it but by no means all, I was surprised to learn, as Klein probed his reaction to feature after feature, that he "do[esn't] have* a problem with standardizing benefits" and that "guaranteed issue [no refusals or cost bumps for preexisting conditions]is fine." His objections really boiled down to three: 1) he objects strenuously to "community rating," i.e., the ACA's limiting of the price differential between the youngest and oldest age cohorts to 3-to-1, as opposed to the roughly 6-to-1 ratio that Roy says the market would dictate.  2) He would like the exchanges to offer plans that cover even less than the lowest cost plans in the current design -- plans covering, say, 40% of a member's average yearly costs rather than the 60% that the exchange's lowest-run "bronze" plans are designed to cover. 3) As mentioned above, he would like more radical reform -- health exchanges for everyone.

As Klein eventually made Roy implicitly acknowledge, though, none of his favored solutions get at the root of the United States' disproportionate healthcare inflation.

WSJ leans into the "rate shock" narrative for Obamacare

[Updated 7/13, per "Blows to Obama's Health-Care Law Pile Up"...]

The WSJ's Louise Radnofsky is an experienced healthcare reporter, and her front-page story today about pending "rate shock" for healthy singles when the ACA takes effect is factually accurate. Since the focus is on the risk that the healthy uninsured will stay out of the ACA's healthcare exchanges, it's arguably fair to focus on the subset -- a minority of those who don't get insurance from an employer or the government -- whose premiums may go up. But nonetheless I find the emphasis and framing misleading in some particulars (e.g., the online home page teaser, "Insurance Rates Could Soar Under New Law"). .

The lede goes for maximum shock effect, setting reader perceptions before multiple caveats qualify the picture:

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.

Take two: Employers want to provide health insurance

Perhaps I buried my lede a bit yesterday in a post about the ACA's employer mandate. So let me try a carve-out.

Josh Barro, taking at face value some bitching about the requirement that employers with more than 50 full-time employees offer health insurance to their employees, recently charged that the mandate is a mistake and that health reform should have pushed health insurance away from the employer-employee relationship.

Defensible as that diagnosis may be in the abstract, voters at large were not the only constituency resistant to weakening the employer-healthcare bond.  Big businesses, and a not inconsiderable number of small businesses, values their role as health insurer, seeing that role as an important part of their bond with employees, as a competitive advantage, and increasingly, as an opportunity to make their workforce more productive  -- not to mention as font of a tax-free form of compensation.

Call them crazy, as Matt Miller did in October 2009 when the National Coalition on Benefits, an association purporting to represent the interests of employers covering 130 million Americans in the health reform process, helped to shoot down Senator Ron Wyden's Free Choice Amendment, which would have enabled all employees to opt out of their employer's health care plan and buy insurance on the insurance exchanges established by what later became the Affordable Care Act. The group's motto: Don't Erode What Works to Fix What's Broken. *

U.S. employers want to provide health insurance

The Wall Street Journal has a good article today, by small business reporters Emily Maltby and Sarah Needleman, about three smallish businesses grappling with the the Affordable Care Act's employer mandate, which charges employers with more than 50 employees $2,000 per employee (excluding the first 30) if they don't offer coverage.  None of the business owners opt not to offer coverage. Here's the head of a small pizza chain with 90 hourly workers:

Next year, Mr. Stark intends to offer a health-insurance plan for the first time to comply with the law. "At the end of the day, if we take care of our team members, they will take care of the guests," he says. "I philosophically believe people having health care, regardless of age, is positive."

A consultant with 93 employees adds:

Love the sin, hate the sinner or whatever

Forty five-odd years ago, a popular poster, sweatshirt etc. showed the Peanuts character Linus (blanket in tow), protesting loudly, "I love mankind -- it's people I can't stand."

That flashed back to me last week when I read Marco Rubio's justification for a fresh round of budget terrorism:

“I have tremendous respect for this institution,” Mr. Rubio said in an interview on Friday. “But I’m not all that interested in the way things have always been done around here.” 

"The way things have always been done" in this case means reconciling House and Senate budgets without tying those negotiations to a threat of national default.

The Times editorial board reminded me of that flashback this morning. Their take on Rubio's comment: it exemplifies the mindset of the latest crop of high profile Republicans, who "want to dismantle government, using whatever crowbar happens to be handy, and they don’t particularly care what traditions of mutual respect get smashed at the same time."

As Peanuts characters used to say from time to time: I'd be foolish to deny it.

Hobson's choices in Syria

Re Syria, the FT's Gideon Rachman is at his best -- teasing out the geopolitical crosscurrents tugging at those countries that fancy themselves able or compelled to try to influence events, and noting the extent to which appearances may be deceptive:

As the world edges towards a peace conference on Syria, three ideas about the west’s role in the conflict are widely accepted. First, that the longer the conflict goes on, the greater the chances of direct or indirect western military intervention. Second, that there is a deep and bitter division between the US and Russia that is making progress much harder. Third, that the Syrian civil war is dominating western thinking on the Middle East. Few people publicly dispute these propositions. And yet they are all distinctly questionable (my emphasis).

Western inhibitions about intervention are driven not just by the debacle in Iraq but by the "success" in Libya: