Map of life expectancy at birth from Global Education Project.

Wednesday, May 24, 2017

No, Obamacare is not collapsing (wonky)


The Republicans are justifying their effort to strip millions of people of health insurance in order to fund tax cuts for rich people by claiming that the Affordable Care Act is "unsustainable" or, in the words of Donald of Orange, "collapsing."  The Urban Institute has done a thorough analysis of the state of the ACA. Since people nowadays have short attention spans, I'll give you the pistachio shell version.

First, some background. As you can read in my banner, the U.S. spends far more on health care (which I would prefer to call medical services but that's a lost cause) than any other affluent country. Yet they all cover everybody, and they are healthier! How can this be? We're less healthy in part because we don't cover everybody, but also because we have greater inequality, gun violence, and other social determinants of health are generally worse here.

What is more, prior to the ACA, the situation was getting steadily worse. The growth in what the Urban Institute calls National Health Expenditures (again, they mean medical services) exceeded growth in GDP by about 2.5% a year, in other words health care was gobbling up more and more  of the economy. At the same time, the number of uninsured people was growing.

The ACA put a stop to that. Obviously, it extended coverage to millions of people; yet the growth in National Health Expenditures actually slowed way down. This was partly a result of the recession and slow recovery, but also because of the ACA. The Act included Medicare payment reforms that reduced overutilization; the managed competition structure of the exchanges; and yes, reductions in Medicare payments to providers.

So what about the claims that premiums on the exchanges are skyrocketing? Actually in most of the country they are fairly stable or even declining. They are going up in places where insurers may have set premiums too low initially, and where there is no competition between insurers. They are really spiking in Arizona where state law allows for the sale of policies that aren't compliant with the ACA, which draws healthy people out of the risk pool. These problems could be fixed by regulations that pull in more competition and by getting more people to enroll. It's most difficult in rural areas. But the bottom line is that Obamacare premiums in most states are similar to, or even lower, than premiums for employer-provided insurance.

Finally, what about growth in Medicaid spending? Medicaid enrollment grew not only because of the Medicaid expansion under the ACA, but also because of the aging population, which means more people who are eligible because they are over 65, and more disabled people under 65. (The rate of disability rises with age well before age 65.) But Medicaid is the most efficient insurance there is! It costs less per enrollee than private insurance or Medicare, even though it's good, comprehensive insurance. And the cost per enrollee is growing more slowly.

So the Republicans want to drastically slash Medicaid. Who are we talking about here? Welfare queens? No, mostly elderly people who need long term care. What they want to do is kill your grandmother, to pay for tax cuts for rich people. That's because they are good Christians.

Sunday, May 21, 2017

You don't need a weatherman . . .

To know which way the wind blows.

I often maintain that I am reticent to prognosticate. However, the excitement over the "when does the residency end" pool is just too great for me to resist.

So no, I don't think he can survive till the mid-term. One major reason for my conclusion is that he is too ignorant, stupid, and crazy. Actually the stupid and crazy are weirdly intertwined, so it's often hard to know which is really operative in a given brain fart.

The second variable in my equation is the nature of Trumpism. There in fact is no such thing. He managed to sell himself as the champion of disaffected white racists who knew they were mad about something but weren't sure exactly what it was. The only concrete promises he made are either impossible to keep or already totally abandoned. (Yes, we're fine with cutting Medicare, Medicaid and Social Security. No, you aren't getting a $35 and hour job in a steel mill.) There is no organization, no movement, and no ideology behind the "movement" Trump claims, but only a bombastic, vulgar and bullying pose. Which means there is no real base and nobody to save him.

Third, it is by now obvious that the campaign was a tool of a hostile foreign power. Some degree of this claim is already publicly established. Whether Cheeto Benito was really involved, or is just a dupe, is not entirely clear. I think he kind of knew what was going on, or was at least exposed to the information, wasn't really an active participant, but didn't think it was any sort of a problem. Oh, we're getting help from my friend Vlad? That's nice.

Whether the Republicans in congress would ever find the cojones to impeach him I don't know, but a totally ineffective presidency will not be helpful in advancing their incredibly unpopular legislative agenda. So yes, I think they'll find a way to push him out. But the wreckage from this catastrophe will endure for decades.

Thursday, May 18, 2017

A couple of press releases about the so-called American Health Care Act


A lot of stuff hits my in-box that I should probably share. This from Avalere is a finding that Trumpcare would cut Medicaid funding for non-disabled children by $43 billion over 10 years. Children are the largest group covered by Medicaid, although disabled people and elderly people in long-term care account for the majority of actual spending. The whole thing is long and wonky but the bottom line is:

Avalere also examined the impact of per capita caps at the state-level, and found that all 50 states and the District of Columbia would lose Medicaid funding for traditional children. The reductions ranged from $59 million in North Dakota to $5.1 billion in Texas.
 Meanwhile, the Robert Wood Johnson Foundation finds that Dumpcare would cause a sharp increase in premiums for lower income older adults, who currently receive much more generous subsidies under the ACA.

"Age-related tax credits, while easy to understand, do not target subsidies most efficiently,” said Katherine Hempstead, senior adviser at the Robert Wood Johnson Foundation. “Tax credits that don’t reflect differences in ability to pay and geographical variation in the cost of health care will lead to significant loss of coverage, as suggested by the most recent CBO score of the AHCA.”
The reason the Republicans want to do this is to provide a huge tax cut to wealthy people. That is the only reason. In every other way, it makes things far worse for the American people, and particularly the people who voted for the current Resident. Don't let you representatives in congress lie to you about this.

Oh yeah, and this just in: the "high risk pools" which are supposed to cover people with expensive pre-existing conditions are underfunded by 3-5 times. In other words, the Republican solution is indeed "let people die."

"Traditional high-risk pools are symptoms of poorly regulated and inadequately subsidized insurance markets," said Katherine Hempstead, senior adviser at the Robert Wood Johnson Foundation. "To properly finance them is extremely expensive, which is why they tend to be underfunded, resulting in inadequate access to coverage for those who need health care the most."

Wednesday, May 17, 2017

Idiot wind

Blowin' every time you move your teeth.

Two stories from Daily Kos, one about the upcoming world tour, the other on Republican attempts to defend Cheeto Benito in the Comey affair.

It turns out that our Resident has too short an attention span, and is too ignorant, to participate in a standard NATO meeting, so heads of state are being encouraged to limit their speeches to 2 to 4 minutes. Also, it seems he doesn't understand the Israel-Palestine conflict, even though he's about to visit both countries.

Meanwhile, the new talking point about the White House scandals is that he is too stupid to know what he's doing, so you can't blame him.

This has long been obvious. He evidently really thought that he could replace the Affordable Care Act with some policy that would cover everybody, be cheaper than the status quo for consumers, and come with a big tax cut. Then he discovered, much to his surprise, that health care is complicated. (Actually, it isn't all that complicated. It costs money so if you want everybody to have it, wealthier and healthier people have to subsidize poorer and sicker people. That's called arithmetic.)

Here's Tony Schwartz, official biographer, who has spent many a long hour with the man:

Trump was equally clear with me that he didn’t value — nor even necessarily recognize — the qualities that tend to emerge as people grow more secure, such as empathy, generosity, reflectiveness, the capacity to delay gratification or, above all, a conscience, an inner sense of right and wrong. Trump simply didn’t traffic in emotions or interest in others. The life he lived was all transactional, all the time. Having never expanded his emotional, intellectual or moral universe, he has his story down, and he’s sticking to it.
A key part of that story is that facts are whatever Trump deems them to be on any given day. When he is challenged, he instinctively doubles down — even when what he has just said is demonstrably false. I saw that countless times, whether it was as trivial as exaggerating the number of floors at Trump Tower or as consequential as telling me that his casinos were performing well when they were actually going bankrupt. In the same way, Trump sees no contradiction at all in changing his story about why he fired Comey and then undermining the explanatory statements of his aides, or in any other lie he tells. His aim is never accuracy; it’s domination.
That doesn't work when you are president of the United States. I think there is a limit to how long the congressional Republicans can play this game; one way or another he'll be gone before the midterm election. We just have to hope that World War III doesn't come first.

Monday, May 15, 2017

Do not consume the flesh of tetrapods

Well, maybe birds are okay, it isn't entirely clear. The horrific harm to the planet from human meat consumption doesn't seem to be motivating very many people to stop it, but maybe the risk of death will.

With a total of more than 7.5 million person years of observation, further analyses by Etemadi and colleagues (doi:10.1136/bmj.j1957) now show an association between high intakes of red and processed meat and elevated total mortality and mortality from most major causes: cardiovascular disease, diabetes, cancer, and hepatic, renal, and respiratory diseases.
As the BMJ editorialist goes on to remind you of what you already know or should know -- even though you have been carefully avoiding thinking about it -- 30% of the earth's land surface is now pasture, or devoted to growing animal feed, which means:

Damage to planetary health includes depletion of aquifers15 (producing 1 kg of meat protein requires more than 110 000 L of water22); production of 37% of anthropogenic methane (with 23 times the global warming potential of CO2) and 65% of anthropogenic nitrous oxide (almost 300 times the potential of CO2); groundwater pollution; and 64% of anthropogenic ammonia emissions, which contribute significantly to acid rain and acidification of ecosystems.15 The combination of rainforest destruction for livestock and the production of greenhouse gases by livestock contributes more to climate change than do fossil fuels used for transport.15
There is also antibiotic resistance, recombinant influenza (from pig farms), and human hunger -- 95% of soybean is fed to animals. Contrary to common belief, our hunter-gatherer ancestors prior to the last ice age consumed much less meat than we do. So did people in Europe right up until the 20th Century. Our meat based diet is unprecedented in human history. So just stop it.

Wednesday, May 10, 2017

What we already know . . .

is more than enough. Here's another tl;dr for you, from the editor of Foreign Policy, David Rothkopf. I'll just give you a few pull quotes:

On a daily basis, Republicans watch their leader violate not only the traditions and standards of the high office he occupies, but through inaction they enable him to personally profit from the presidency, promote policies that benefit his cronies and his class to the detriment of the majority of the American people, and serially attack the principles on which the country was founded — from freedom of religion to the separation of powers. . .

America looks like a country it has never been. Trump is a laughingstock in the best of circumstances, a disgrace based on his known behavior to date, and a threat to global order and security with each action he takes. He discredits the office he holds and the government he leads. . . . 


Only if an independent prosecutor is appointed will America be seen as being the nation of laws it has long represented itself to be. Only if a thorough investigation takes place that includes an examination of Trump family ties in Russia (and elsewhere) and how these may have compromised the United States will the message be sent that America is the nation that has for so long been seen as an example to the world.
Well sure. But the problem is really worse than that. The institutional failures that brought us to this point are so massive, so pervasive, that there may not be any way out. The Republicans in congress still show no convincing signs of the slightest interest in the truth. They know that their policy agenda will be catastrophic for the people who voted for them, and they need to ram it through now. The continual degradation of political discourse and democratic institutions is in their long-term interest, because it was necessary for them to come to power and will have to grow more profound in order for them to keep it. I do not foresee a single patriot emerging from the Republicans in the senate. 

Monday, May 08, 2017

Questions

Andrew Bacevich has 24 questions about U.S. military and foreign policy that seem pretty obvious once he mentions them. Yet for some reason they never seem to occur to people -- if by people one means politicians and reporters. Do read the whole thing, but here are a couple of free samples to get you to click on the link.

2. American military supremacy: The United States military is undoubtedly the world’s finest.  It’s also far and away the most generously funded, with policymakers offering U.S. troops no shortage of opportunities to practice their craft.  So why doesn’t this great military ever win anything?  Or put another way, why in recent decades have those forces been unable to accomplish Washington’s stated wartime objectives?  Why has the now 15-year-old war on terror failed to result in even a single real success anywhere in the Greater Middle East?  Could it be that we’ve taken the wrong approach?  What should we be doing differently?
I'll give you 10 and 11 as a package deal:

10. Hyping terrorism: Each year terrorist attacks kill far fewer Americans than do auto accidents, drug overdoses, or even lightning strikes.  Yet in the allocation of government resources, preventing terrorist attacks takes precedence over preventing all three of the others combined. Why is that?
11. Deaths that matter and deaths that don’t: Why do terrorist attacks that kill a handful of Europeans command infinitely more American attention than do terrorist attacks that kill far larger numbers of Arabs? A terrorist attack that kills citizens of France or Belgium elicits from the United States heartfelt expressions of sympathy and solidarity.  A terrorist attack that kills Egyptians or Iraqis elicits shrugs.  Why the difference?  To what extent does race provide the answer to that question?
You get the idea. These are questions designed to pry open minds. Maybe they''ll work for you.


Friday, May 05, 2017

Should Senator Menendez resign?

Just to make sure you know I'm not a blind partisan -- which I hope has been obvious -- Sen. Menendez of New Jersey is unworthy of his office. First let me back up a second to point out that conservative complaints about people defrauding public benefits programs are always about welfare queens in Cadillacs. In fact the main offenders are physicians.

This particular schtickdreck, ophthalmologist Salomon Melden, has been convicted of defrauding Medicare of $190 million. You read that correctly. Along the way, he became BFF with Sen. Menendez, to whose campaigns he contributed $1 million (pocket change to him) and to whom he gave rides on his private jet. Mendendez's spokesman says this all very sad, but it has nothing to do with the Senator. Right.

In fact Menendez interceded in the dispute between Melgen and Medicare. Melgen billed $57m for single use vials of Lucentis, a treatment for wet macular degeneration. Each vial had more than a single dose, and Melgen would use one vial to treat as many as four patients, billing Medicare each time. Medicare later clawed back $8.9m in a case that reached the Supreme Court.

Menendez tried to justify Melgen’s billing, leading to an audience with the then health secretary Kathleen Sebelius. But she told the senator: “The government is not going to pay for the same vial of medicine twice.” Melgen would later agree to pay back another $32m that he billed for Lucentis.
Menendez faces a bribery trial in August. No, I don't want Chris Christie appointing his replacement, and it wouldn't be just since Christie is extremely unpopular and a special election would almost certainly be won by a Democrat. New Jersey law is confusing, but it appears that Christie would not have to call a special election and could appoint someone to serve until the 2018 regular senatorial election. Obviously Menendez intends to hang in there until and unless he is convicted. With the usual legal maneuvering that could get us pretty close to November 2018. But it feels wrong.

Thursday, May 04, 2017

A political death wish?

I can't outdo Jonathan Chait in eloquence or informativeness regarding the grotesque House bill purporting to repeal and "replace" the affordable care act. The only purpose of the legislation is to cut taxes for rich people.

Republican efforts to repeal Obamacare without a replacement failed. But they are attempting the next closest thing: a bill the party leadership will try to rush into law without the barest elements of due diligence. There have been no hearings, no studies, no Congressional Budget Office analysis; not even the text of a bill circulated the day before Thursday’s vote.
Other than that, the bill will leave 24 million people without insurance, raise premiums for people in their 50s and 60s, cause people who become seriously ill to lose insurance just when they need it most, and, as Chait puts it succinctly, "Millions of Americans will lose access to medical care, and tens of thousands of them will die, and Congress is eager to hasten these results without knowing them more precisely. Their haste and secrecy are a way of distancing the House Republicans from the immorality of their actions."

The fact is that people will notice this when it happens to them. Whither the Republicans in congress then?

Update: It seems Jamelle Bouie agrees with me. The political strategy behind this is incomprehensible.