February 22, 2019 / by 

 

Three Things: Shocker, Badger, Vapor

Summer doldrums are hitting hard here; it’s too steamy today to do much but watch the garden grow and the ‘hot takes’ bloom. Let’s breeze through these.

~ 1 ~

Shocker: The White House had its ass handed to it last night, alongside a serving of vanilla ice cream and peach cobbler. While it was kissing up to some über conservative Senators, Utah’s Mike Lee and Kansas’ Jerry Moran announced they would not support the Motion to Proceed on the latest POS edition of AHCA.

Excellent work on the dual tweets dispatched simultaneously at 8:30 p.m., by the way (see this one and this one). Live by the tweets, die by the tweets, Littlehands.

What I find particularly interesting is the secrecy this announcement revealed. Not just the discreet collaboration between two senators from very red states, taking advantage of the additional time afforded them by John McCain’s personal health care challenge. Apparently Senate Majority Leader Mitch “Yertle” McConnell has had such a tight grip on the legislative process that even his wingman, John Cornyn, doesn’t know what’s going on until McConnell’s office emails his deputies.

Not exactly a way to win friends and influence enemies, that.

(For some reason McConnell’s super-secret hyper control makes me think of the compartments Washington Post wrote about with regard to the Russian election hacks and the subsequent investigation. Why is that?)

~ 2 ~

Badger: Russia is pissed off about its dachas-away-from-home, threatening retaliation if they’re not returned. Uh, right. Like the U.S. suddenly decided to boot Russian occupants out of the Long Island and Maryland digs for no good reason last year. Russian Foreign Ministry “reserves the right to retaliate based on the principle of reciprocity,” forgetting that Obama took a too-measured response to repeated incursions by Russia into U.S. information systems — including hacks of the White House and Defense Department in 2015 — not to mention the ‘Illegals Program‘ spy who worked at Microsoft circa 2010. (Let’s also not forget an ‘Illegals Program’ spy worked their way close to Hillary Clinton’s 2008 campaign co-chair.) The U.S. could and should have been far more aggressive in its response; Russia isn’t entitled to reciprocity.

This is a test for Congressional Republicans. Either cement sanctions against Russia including the ‘foreclosure’ on these two compounds, or admit complicity in the undermining of democratic process last year. The GOP needs to revisit a CRS report on U.S.-Russia relations and Executive Orders 13660, 13661, and 13662 before they give any ground. [EDIT: See also EO 13964, issued April 1, 2016 in response to “malicious cyberactivity” — this EO the GOP will probably ignore just as it has all signs of Team Trump collusion as well as Russian interference in the 2016 general election.]

If there are truly compelling reasons in the nation’s interest for conceding these compounds, give them back — but only after the buildings have been razed and permits for reconstruction are denied under sanctions. The Russian government can work out of trailers on the property, or on boats from the dock. They do not need to be any more comfortable than they have been.

~ 3 ~

Vapor: No longer a ghost — we  now know who the eighth attendee was at Donnie Junior’s June 9th meeting at Trump Tower last year. Lucky number seven is believed to be a translator — and wow, so is number eight!

Which seems kind of odd — in the information Junior dumped online, there was no mention that Veselnitskaya didn’t speak English and needed a translator, or who would be the translator. Doesn’t it seem strange that there would be no concerns about security clearance into Trump Tower or a meeting with a presidential candidate’s son and/or campaign team given the meeting requester was a foreign national?

Perhaps because there was little concern, Body Number Eight, Ike Kaveladze, purportedly showed up as Veselnitskaya’s translator only to learn she had brought her own, Body Number Seven, Anatoli Samochornov. It’s not clear from USA Today’s reporting who asked Kaveladze to attend; did Junior just let any Russian in the neighborhood attend the meeting? Aras Agalarov sent Kaveladze “just to make sure it happened and to serve as an interpreter if necessary,” Kaveladze’s lawyer told NYT. Why so many witnesses?

The room must have been a little crowded with Junior, Jared Kushner, Paul Manafort, Rob Goldstone, Veselnitskaya and two translators as well as Rinat Akhmetshin.

Given the two translators, Akhmetshin’s presence seems even more curious. Why was he there if there were two translators?

~ ~ ~

That’s that. I could go on but it’s too damned hot here. Refresh your iced tea and settle yourself in front of the fan. This is an open thread — behave.


AHCA: GOP and its Ugly Poke

One of the most immoral and unethical episodes of American government unfolds today as the House votes today on the American Health Care Bill (AHCA) H.R. 1628, a bill which violates the GOP’s promise to allow three days advance notice before a vote, the text of which had not been made publicly available before last night and will only receive an hour’s debate, and the economic impact of which has not been analyzed and scored by the Congressional Budget Office.

Today the GOP-led House votes blindly on a purported pig in an ugly poke.

Nothing about this GOP-spawned atrocity serves the public’s interests — not even the estimated 2% who will obtain tax cuts from this legislation if it clears the Senate. The financial benefits for these über-wealthy who, already owning more than most of the rest of the country combined, do not need them. These cuts will eventually be neutralized by degradation of the overall economy after consumer spending tanks. Short-sighted gains yielding long-term losses.

Utterly stupid. Highly unethical.

In B-school I was taught that an ethical business decision was one made for long-term shareholder value, with reasonable decency and distributive justice.

If this is the business of American government, AHCA fails to meet those criteria.

For the über-wealthy there is no long-term improvement in value.

For Congress, there is no reasonable decency in cutting benefits — even when demanded by a minority of voters — to those most vulnerable in order to hand over money to those who do not need it. They are literally taking money from babies and mortally ill to hand over to rich people who will never even feel the weight of the addition to their bank accounts, amounting to little more than a rounding error for billionaires.

There is no decency in voting for legislation which most certainly will result in American deaths in the thousands from cancer and other diseases. Nor is there decency in signing away lives in some unacknowledged Malthusian attempt to limit population growth — a great permanent amelioration of their condition — by increased mortality rates.

There is no decency in voting for a bill which treats women as disposable annoyances instead of the font of America’s future, treats sex crimes against them as excuses to hurt them further.

There is no decency in cutting funding necessary for students requiring health-related aids in special education.

And there is absolutely no decency whatsoever for Congress to place itself above shared suffering. They are exempting themselves from the worst effects of AHCA on those with pre-existing conditions by voting for Amendment to Public Health Services Act H.R. 2192 while slipping in threats to working American’s employer-based health care insurance.

There is no decency, only shame, in Congress’ scuttling off into the shadows at the end of the day to avoid dealing with the repercussions of these offenses against their constituents.

For the average American — and most average Americans will be directly affected by the AHCA — there is no justice.

Not until November 2018.


Freedom in the Health Care Debate

The failure of the American Health Care Act provides an insight that might be useful in combating neoliberalism. Paul Ryan centered his defense of ACHA around the notion of individual freedom. But there is a better view of freedom that the Democrats could offer: freedom from fear.

Ryan explained his view of freedom, the neoliberal view that freedom exists only in monetary transactions, in an appearance on Face The Nation March 12, 2017:

DICKERSON: How many people are going to lose coverage under this new —

RYAN: I can’t answer that question. It’s up to people. Here — here’s the premise of your question. Are you going to stop mandating people buy health insurance? People are going to do what they want to do with their lives because we believe in individual freedom in this country. So the question is, are we providing a system where people have access to health insurance if they choose to do so. …

The most important talking point in this whole interview is freedom; Here’s another example:

…[W}e’re not going to make an American do what they don’t want to do. You get it if you want it. That’s freedom.

What if you want it but do not have the money to get it? You are free not to get it. One of the problems with the ACA is that even with subsidies, people can’t afford a decent policy. A lot of people have a policy that doesn’t cover them sufficiently to prevent bankruptcy, or they have a policy but can’t afford to use it because of high deductibles and co-pays.

Ryan’s solution was to get rid of the Essential Health Benefits mandated by the ACA. These set the minimum coverage for any policy offered on the exchange. They include lab tests, drugs, maternity care, treatment for substance abuse and mental illness, and others. If insurance companies can issue policies that don’t cover these mandated benefits, they can offer cheaper policies. That doesn’t help anyone. It increases the number of people with policies that don’t cover treatment they suddenly need, and raises prices for others to buy fuller coverage.

Ryan and the Republicans think we only care about a few bucks we don’t have to pay an insurance company. They only value the freedom to buy and sell in unrestrained markets, as if anyone actually wanted to spend any part of their precious lives studying insurance contracts.

So there we have Ryan’s definition of freedom. You have the freedom to give money to an insurance company to buy any policy you can afford, and you can shop around for a policy that may or may not provide the coverage you eventually need, or you can take the risk of bankruptcy or denial of health care.

That’s a peculiar kind of freedom.

The Democrats have the possibility of offering a different kind of freedom: the freedom from fear that you and your family and your friends and neighbors and fellow citizens won’t be able to get health care when they need it. This kind of Freedom is the foundation of Franklin Roosevelt’s Second Bill of Rights, so it’s well within the historic tradition of the Democrats, at least before their neoliberal turn. The outpouring of public hostility to the ACHA proves that this definition of freedom is much more popular than Ryan’s.

Another way to phrase this idea is that what people want is the freedoom to pursue their own projects, projects that they choose for themselves and that give them a sense of satisfaction. John Maynard Keynes thought that as the age of work came to an end, people would pursue artistic, intellectual and cultural pursuits. Maybe. Maybe it’s going fishing, learning how to weld, or following the Cubs. For maximum freedom, there are areas where people would rather have the government protect them from the “market”, rather than wasting time coping with yet another market, or living in fear of the consequences of not handling the market. I think his is an idea with a lot of general appeal.

If we raise taxes fairly, or reorder our budget priorities favoring defense contractors, we can all get good health care at a price we can all pay. That’s the kind of freedom I want: freedom from fear and freedom from the endless consumerism we have to endure because of the other version of freedom. Not to mention freedom from profit-maximizing insurance companies.


The Lesson Trump Has (Thus Far) Not Taught Us: Civilian Casualties

I have a confession.

There’s something I like about the Trump Administration.

It’s the way that his unpopularity taints long-standing policies or practices or beliefs, making people aware of and opposed to them in a way they weren’t when the same policies or beliefs were widely held under George Bush or Barack Obama. Many, though not all, of these policies or beliefs were embraced unquestioningly by centrists or even avowed leftists.

I’ve been keeping a running list in my mind, which I’ll begin to lay out here (I guess I’ll update it as I remember more).

  • Expansive surveillance
  • The presumption of regularity, by which courts and the public assume the Executive Branch operates in good faith and from evidence
  • Denigration of immigrants
  • Denigration of Muslims
  • Denigration health insurance

As an example, Obama deported a huge number of people. But now that Trump has expanded that same practice, it has been made visible and delegitimized.

In short, Trump has made things that should always have been criticized are now being far more widely so.

But there’s one thing that Trump has escalated that has thus far — with the singular exception of the botched raid on Yemen — escaped widespread condemnation: the bombing of civilians. There was the Al Jineh mosque on March 16, a school sheltering families in Raqqa on March 21, and this strike last week in Mosul, not to mention continued Saudi attacks in Yemen that the US facilitates.

Again, I’m not saying such civilian strikes didn’t happen under Obama. And it’s not clear whether this spate of civilian bombings arises from a change in the rule of engagement put in place in December, the influence of James Mattis, or Trump’s announced review of rules of engagement. But civilians are dying.

And for the most part, unlike all the other horrible things happening under President Trump, they’re getting little notice and condemnation in the US.

Update: This NYT story on the Mosul strike says that the increased civilian casualties do reflect a change in rules of engagement put in place under Trump.


Which Came First, the Failed Ideology or the Spiking Mortality Rates?

One of the things that drives me nuts about the obsessive focus on Russia right now is the claim that Vladimir Putin is the biggest risk to America, to the EU, to western civilization. That claim ignores that — to the extent Putin is engaged in policies to maximize his advantage vis a vis American hegemony right now — the opportunity to do so has been created by the failure of American hegemony. The biggest threats to the EU, for example, stem from the idiotic policies “technocrats” enacted after America crashed the global economy and a refugee crisis caused, in part, by the chaos America has sown in the Middle East over the last 15 years (and to some degree manipulated by “allies” like Turkey). Sure, Putin is making the most of the American failures, but the underlying causes that make right wing populists popular, here and in Europe, can be significantly blamed on America. Significantly, that’s about a failure of the policies dictated by American ideology to deliver on what it promises — peace, democracy, prosperity.

Which brings me to this passage from a WSJ article on the latest installment of Anne Case and Angus Deaton’s documentation of a big spike in mortality among white people in America.

“For many Americans, America is starting to fail as a country,” said James Smith, chair in labor markets and demographic research at the Rand Corp., who wasn’t involved in the paper and said he was struck that mortality rates are rising for young working-class adults. “The bad things that are going on in America do not appear to be going on in Western European countries, and that’s a big deal.”

The spike in mortality, Case argues, is not about existing life conditions, but rather about “accumulating despair.”

The increase in mortality rate for working-class whites can’t be explained by declining income prospects alone. Blacks and Hispanics face many of the same income struggles but have experienced declines in mortality over the same period, the two economists argued, though their findings reveal more recent troubles for blacks, with gains stagnating the past couple of years amid an increase in drug overdoses and stalling progress against heart disease.

“This doesn’t seem to be about current income,” Ms. Case said in a call with reporters. “It seems to be about accumulating despair.”

The rising mortality of working-class white adults appears to be rooted both in worse job opportunities and increasing social dysfunction, following generations of relatively stable lives that involved job advancement and an expectation of living better than one’s parents, the researchers said.

As a number of people have noted, both today and after earlier releases of Case and Deaton’s data, one of the few precedents for such a spike is the rise in mortality in Russia leading up to and after the fall of the Soviet Union. Addiction and other despair-related health problems were significant in both.

Which got me wondering: to the extent this is driven by a failure in ideology — by the failure of the American dream — which comes first, the failed ideology or the rising mortality rates? That is, are people dying of despair in response to the recognition the American dream doesn’t deliver for people like them anymore (which, it should be said, has always involved white Americans benefitting from the unequal treatment of brown people both in the US and around the globe)? Or did a worsening lifestyle lead to a spike in mortality that has contributed to despair and the collapse of ideology?

I don’t know the answer — and admit it might be more closely tied to policy outcomes than ideology. But as we try to figure it out, we ought to be focusing at least as much on how to roll out life and meaning that can sustain Americans again as we are on blaming Putin for our recent failures to do that.


Democrats Can Do Better than “Wonk Harder” on ObamaCare Going Forward

Sarah Kliff has finally done what left wonk journalists should have done years ago: go interview people from Kentucky about their understanding of and feelings about ObamaCare. KY is, with WV, the state in which ACA achieved its best results, with the number of uninsured going from 25% to 10% of the state. And yet Democrats in KY have been utterly hammered since ACA passed.

Kliff spent a lot of time actually listening to voters to understand why they voted overwhelmingly for a guy who promises to scrap ACA in its existing form (though he always promised to replace it with something better).

Definitely go read the whole thing, because the degree to which Kliff let these voters speak for themselves (and the degree to which they appear like real and often thoughtful people) is admirable.

Here’s how she summarizes what she heard.

Many expressed frustration that Obamacare plans cost way too much, that premiums and deductibles had spiraled out of control. And part of their anger was wrapped up in the idea that other people were getting even better, even cheaper benefits — and those other people did not deserve the help

There was a persistent belief that Trump would fix these problems and make Obamacare work better. I kept hearing informed voters, who had watched the election closely, say they did hear the promise of repeal but simply felt Trump couldn’t repeal a law that had done so much good for them. In fact, some of the people I talked to hope that one of the more divisive pieces of the law — Medicaid expansion — might become even more robust, offering more of the working poor a chance at the same coverage the very poor receive.

Significantly, Kliff dispels one explanation always given for why Kentuckians hate ObamaCare so much: purportedly because the state had hidden that the state’s program was actually ObamaCare. All but one of the people she talked with knew they were getting ObamaCare.

All but one knew full well that the coverage was part of Obamacare. They voted for Trump because they were concerned about other issues — and just couldn’t fathom the idea that this new coverage would be taken away from them.

Which leaves the two major complaints with the law: expense and the divisiveness associated with two-tiered benefit programs.

We’ve known since before the bill passed that it was too expensive, such that middle class families would still go into debt even with fairly normal life medical care, including normal childbirth. At the time, the wonk boys were talking among themselves about how they needed to push back against such claims.

But Kliff puts a face to the consequences of that expense, where people use precious disposable income for insurance they know they won’t use.

The deductible left Atkins exasperated. “I am totally afraid to be sick,” she says. “I don’t have [that money] to pay upfront if I go to the hospital tomorrow.”

Atkins’s plan offers free preventive care, an Obamacare mandate. But she skips mammograms and colonoscopies because she doesn’t think she’d have the money to pay for any follow-up care if the doctors did detect something.

Atkins says she only buys insurance as financial protection — “to keep from losing my house if something major happened,” she says. “But I’m not using it to go to the doctor. I’ve not used anything.”

She also focuses on something that got discussed during passage, but not in as much detail: the degree to which the two-tiered method of expansion, with some getting Medicaid and some getting subsidized shitty insurance, would poison the perception of the law, because the working poor would get fewer benefits than people who were or believed to be not working.

“I really think Medicaid is good, but I’m really having a problem with the people that don’t want to work,” she said. “Us middle-class people are really, really upset about having to work constantly, and then these people are not responsible.”

This has long been the basis for (often GOP-stoked) opposition to government support in the US, the resentment that others are getting more, a resentment that often gets racialized via stereotypes about welfare queens.

Importantly, Kliff also dismisses those who complain these rube voters should have known the stakes of voting in Donald Trump, because she didn’t know either.

I spent election night frantically reporting and calling sources, trying to understand what parts of Obamacare Republicans could and couldn’t dismantle. I didn’t know at the time, nor had I devoted the necessary time to learn, until election night.

Mills was wrong about what Republicans would do to Obamacare. But then again, I write about it for a living. And I was wrong too.

In any case, it was a sobering, humanizing report. I hope Kliff follows up on as Governor Matt Bevin makes KY’s ACA worse this year.

Democrats need to learn this lesson because, even if they can’t impose a penalty on Bevin and other KY Republicans for taking away benefits that people currently have, the same process is bound to roll out in states across the country. That is, liberals need to understand this dynamic if they want to reverse the policy changes the GOP are about to roll out.

Unsurprisingly, Democrats are taking away the wrong lesson about ObamaCare from the election. Markos Moulitsas rather notoriously offered this lesson (though not in the context of Kliff’s report).

But even Kevin Drum, after reading Kliff’s report, seems to have come up with the wrong lesson.

Obamacare has several smallish problems, but its only big problem is that it’s underfunded. The subsidies should be bigger, the policies should be more generous, and the individual mandate penalty should be heftier. Done right, maybe it would cost $2 trillion over ten years instead of $1 trillion.

Republicans wouldn’t have cared. If this were a real goal—like, say, cutting taxes on the rich—they’d just go ahead and do it. If the taxes didn’t pay for it all, they’d make up a story about how it would pay for itself. And if you’re Donald Trump, you just loudly insist that,somehow, you’re going to cover everybody and it’s going to be great.

But Democrats didn’t do that. They didn’t oversell Obamacare and they didn’t bust the budget with it. They could have. It would have added to the deficit, but that wouldn’t have hurt them much. Politically, the far better option was to go ahead and run up the deficit in order to create a program of truly affordable care that people really liked.

Even setting side whether the problem of providers exiting the marketplace is “smallish” or actually quite big, the one takeaway Drum takes from this article about how a technocratic solution sows hatred for that technocratic solution is just to wonk harder. That is, he wants to keep the existing program, and just throw more money at the providers via subsidies and more penalties at people who are literally choosing between paying for insurance they won’t use or making other choices with limited disposable income.

He ignores entirely how the two-tier system of benefits feeds resentments (not to mention all the unnecessary complexity it entails).

Luckily, being completely out of power, Democrats have another alternative besides just “wonk harder.” Since Republicans will already in in the difficult position of taking away benefits, Democrats can make that much harder — and play to what we’ve learned from the roll out of ObamaCare — by calling for what they should have called for in the first place: something that moves us towards true universal care, rather than just aspirationally universal insurance coverage. Not only is that what KY voters appear to want, but it is a more efficient way of providing health care. Implement it via subsidized Medicare (well-loved because it is universal) buy-in, I don’t care. But this is the opportunity for Democrats to turn the Republicans’ attacks on ObamaCare on their head, and make the policy much smarter at the same time.


The ObamaCare Not Comey Effect

Just after the election I did two posts considering the relative impact of the Jim Comey letter announcing FBI was reviewing the Anthony Weiner derived emails and the announcement of a huge ObamaCare premium spike.

I still think we don’t have enough data about the relative effect of the two events.

But a number of people are pointing to this post from Sam Wang, which ends,

In the above graph of the Comey effect, each point shows the median margin for polls that were in the field on that day. As you can see, the immediate effect of Comey’s letter was a swing toward Trump of 4 percentage points, about half of which stuck. This was enough to swing Michigan, Pennsylvania, Florida, and Wisconsin. It seems likely that Comey’s letter was a critical factor in the election outcome.

Nowhere in the post does Wang note what date Comey sent his letter, though. It was October 28.

Unless Wang’s chart is totally mislabeled (Update: In an “explanation” added to his post, Wang effectively says his graph is off by three — though not four — days due to the way he presents multi-day polls; he has, at least, now told his readers when the actual letter came out) but what it shows seems to be consistent with what I showed in this post, which shows a Hillary dip and a Trump spike moving in concert on before October 28), then his chart show doesn’t support a Comey effect at all — it shows the opposite. The differential started narrowing after October 24. By October 28, when the letter was released, the differential had plateaued before it turned up again.

As it turns out, the ObamaCare spike was announced on October 24 (and reported heavily starting October 25).

That’s precisely when we see the differential moving.

If we’re assuming an immediate response in polls in response to an event, then the ObamaCare premium spike would be a far better explanation than the Comey letter, which took place later.

Frankly, I suspect both had an impact, and further suspect there may have been something else driving the differential late turn to Trump in the Rust Belt. And I suspect we still don’t have the data to explain what made a bunch of Rust Belt voters move to Trump right before the election.


What Was the Role of ObamaCare Premium Hikes in Trump’s Win?

As I noted in my piece assessing the claims that the two letters Jim Comey wrote on the Hillary email investigation cost Hillary the election, the correlation between the October 28 Comey letter and what Trump’s camp reports as a surge is not exact. According to them (and they seem to have seen in real time far more clearly than the Hillary camp), the surge started before the letter.

Trump’s analysts had detected this upsurge in the electorate even beforeFBI Director James Comey delivered his Oct. 28 letter to Congress announcing that he was reopening his investigation into Clinton’s e-mails. But the news of the investigation accelerated the shift of a largely hidden rural mass of voters toward Trump.

So something else (which I posited could be nothing more than Gary Johnson voters deciding to vote Trump) has to have happened as well.

In comments, rollotomasi offered another suggestion, one I think may be significant: ObamaCare premium increases.

The press started reporting that increases would happen before they were announced. To prepare for that, on October 20, Obama, in what was treated by some as a campaign stop in Miami but what was technically a policy speech on the increases, had this to say (after having delivered a long explanation that ObamaCare was working just as planned).

Now, the second issue has to do with the marketplaces.  Although the marketplaces are working well in most of the states, there are some states where there’s still not enough competition between insurers.  So if you only have one insurer, they may decide we’re going to jack up rates because we can, because nobody else is offering a better price.

In those states where the governor or legislature is hostile to the ACA, it makes it harder to enroll people because the state is not actively participating in outreach.  And so, as a consequence, in those states enrollment in the plan — especially enrollment of young people — has lagged.

And what that means is that the insurance pool is smaller and it gets a higher percentage of older and sicker people who are signing up — because if you’re sick or you’re old, you’re more likely to say, well, I’m going to sign up, no matter what, because I know I’m going to need it; if you’re young and healthy like you guys, you say, eh, I’m fine, life is good — so you have more older and sicker people signing up, fewer younger and healthier people signing up, and that drives rates up, because the people who use health care most end up being in the insurance pool; people who use it least are not.

And then, in some cases, insurers just set their prices too low at the outset because they didn’t know what the insurance pool was going to look like, and then they started losing money.  And so now they’ve decided to significantly increase premiums in some states.

Now, it’s these premium increases in some of the states in the marketplace that sometimes attracts negative headlines.  Remember, these premium increases won’t impact most of the people who are buying insurance through the marketplace, because even when premiums go up, the tax credits go up to offset the increases.  So people who qualify for tax credits, they may not even notice their premiums went up because the tax credit is covered.

And keep in mind that these premium increases that some of you may have read about have no effect at all if you’re getting health insurance on the job, or through Medicaid or Medicare.  So for the 80 [percent]-plus people who already had health insurance, if your premium is going up, it’s not because of Obamacare.  It’s because of your employer or your insurer — even though sometimes they try to blame Obamacare for why the rates go up.  It’s not because of any policy of the Affordable Care Act that the rates are going up.

But if you are one of the people who doesn’t get health care on the job, doesn’t qualify for Medicaid, doesn’t qualify for Medicare — doesn’t qualify for a tax credit to help you buy insurance,  because maybe you made just a little bit too much money under the law — these premium increases do make insurance less affordable.  And in some states, the premium increases are manageable.  Some are 2 percent or 8 percent, some 20 percent.  But we know there are some states that may see premiums go up by 50 percent or more.

One of the problems with ObamaCare is its complexity. If it takes 7 paragraphs to try to make a big rate hike sound better, it’s not going to work.

The actual rates for ObamaCare plan increases — with an average increase of 22% — came out October 24. There was a great deal of chatter between then and the election, especially around the November 1 start of sign-ups, as the Administration scrambled to get users to shop for a more affordable plan. Significantly, PA was one of the worst affected states.

According to a Kaiser Family Foundation, the ObamaCare hikes should not have mattered. It released a poll showing even among Republican voters, just 5% thought heath insurance was the most important issue. Except the poll, which was released on October 27, right in the middle of the discussion about spiking rates, was actually conducted from October 12 to 18, before the rate increases were announced (which to my mind makes it a largely useless but politically timed poll release). Moreover, the poll sampled far more self-identified Democrats than self-identified Republicans (408 to 285), meaning the margins of error would be far higher for Trump-leaning voters.

But in polls of voters taken after the election, repealing ObamaCare was the top priority among Republicans. 74% of those polled wanted to repeal ObamaCare, versus 30% who wanted to build Trump’s wall.

screen-shot-2016-11-13-at-8-06-11-am

Admittedly, this isn’t a good measure of the importance of premium hikes (though it does seem somewhat inconsistent with the Kaiser poll). It may be a measure of 7 years of relentless opposition to ObamaCare, compounded by Trump’s repeated description of the program as a disaster.

Moreover, while the October 24 premium hike may explain why Trump started surging before the Comey letter, it wouldn’t explain what Hillary’s camp describes as energizing of Trump’s base when the second letter revealed nothing had been in the emails after all.

All that said, the premium hikes were probably the most significant policy discussion that happened between the last debate and the election. And for the small segment of the electorate that actually uses the exchanges, that policy change may have been felt very viscerally as they started the tedious process of shopping for an affordable plan.


Bringing out the Dead: What We Know about Zika Virus Effect on Human Tissue

[(A) Control neurosphere (B) Zika-infected neurosphere Source: Science, 13MAY2016 http://science.sciencemag.org/content/352/6287/816.full]

[(A) Control neurosphere
(B) Zika-infected neurosphere
Source: Science, 13MAY2016
http://science.sciencemag.org/content/352/6287/816.full]

Because unproven claims persist that chemical exposure — specifically the pyridine-based pesticide pyriproxyfen — causes the birth defects seen in children born to women exposed to Zika virus, I am bringing out the dead, laying out the bodies.

By ‘bodies’ I mean sharing here pictures of cells you see in the embedded photos from a peer-reviewed study published this May.

In these images you’ll see the damage done to human tissue in lab conditions.

No pyriproxyfen was present.

How Researchers Studied Zika
This is the methodology researchers used:

1) The researchers used human stem cells to create neurospheres — the kind of cells which turns into nerve and brain tissue in an actual embryo.

2) They set aside control samples of neurospheres which were not infected.

3) They infected test samples neurospheres with Brazilian Zika virus.

4) They observed the changes in the infected neurospheres.

5) They compared them to the uninfected control samples.

6) They wrote and published a report on their findings.

The image above is the best example from their report of the difference between Zika-infected cells and the uninfected test samples.

What Researchers Found in this Study
In short, Zika inhibits, damages, and kills infected neurospheres.

This is what we can expect to happen to a fetus’ brain or nerve tissues when infected by Zika under the right conditions during early pregnancy.

[(A) Control mock-infected organoid (B) Zika-infected organoid (damage noted at arrows; growth was also inhibited)]

[(A) Control mock-infected organoid
(B) Zika-infected organoid (damage noted at arrows)]

What Else Researchers Found in this Study
The researchers also conducted a very similar test on human brain organoids. These are not single neurospheres but neuro-tissue grown from stem cells so that they form a model like a tiny brain. Not a brain, a tissue-based model of a brain.

They used the same six steps above using a mock-infected model, a Zika-infected model, and a dengue virus-infected model. (Dengue fever is caused by a flavivirus — the same family of viruses to which Zika and yellow fever belong.) Researchers found Zika virus caused similar destructive damage on these larger models while limiting their growth; they did not find the same damage or destruction in the dengue-infected models and none in the mock-infected control models. Zika alone damaged neurological tissue models.

Researchers also studied neural stem cells (NSCs) — the simplest neuro tissue model — and found similar results in which the Zika virus killed off NSCs. Studying NSCs, neurospheres, and organoids, the researchers observed Zika’s actions on different stages of neuro tissue maturity. In each of these models, from the simplest (NSCs) to the most complex (organoids), Zika was destructive.

[ZIKV (Zika virus) induces death in human neurospheres. These micrographs show the ultrastructure of mock- and ZIKV-infected neurospheres after 6 days in vitro. (A) Mock-infected neurosphere showing cell processes and organelles. (B) ZIKV-infected neurosphere showing a pyknotic nucleus, swollen mitochondria, smooth membrane structures, and viral envelopes (arrow). (C) Viral envelopes on the cell surface (arrows). (D) Swollen mitochondria. (E) Viral envelopes inside the endoplasmic reticulum (arrows). (F) Viral envelopes close to smooth membrane structures (arrows).]

[ZIKV (Zika virus) induces death in human neurospheres. These micrographs show the ultrastructure of mock- and ZIKV-infected neurospheres after 6 days in vitro.
(A) Mock-infected neurosphere showing cell processes and organelles.
(B) ZIKV-infected neurosphere showing a pyknotic nucleus, swollen mitochondria, smooth membrane structures, and viral envelopes (arrow).
(C) Viral envelopes on the cell surface (arrows).
(D) Swollen mitochondria.
(E) Viral envelopes inside the endoplasmic reticulum (arrows).
(F) Viral envelopes close to smooth membrane structures (arrows).]

Other Research on Zika Using Mouse Tissue
Three other studies published in May this year using mice or mouse tissues likewise showed evidences of neurological tissue and brain damage or growth suppression when infected by Zika virus. The studies came from research facilities in Brazil, China, and the U.S. — and in each study, pyriproxyfen was not included. The Zika-infected specimens showed damage and the control specimens did not.

The study from Brazil at the University of São Paulo also included research using human stem cells, comparing a Brazilian strain of Zika against an African strain:

Beltrão-Braga, Muotri, and their colleagues also grew brain organoids from human stem cells and infected these in vitro models with the Brazilian and African strains of the virus. In the human mini brains, both strains of the virus caused cell death, but the Brazilian strain appeared to also interfere with the formation of cortical layers. The virus didn’t replicate in the brain organoids grown from chimpanzee stem cells, suggesting it may have adapted to human tissue, the researchers noted in their paper.

Emphasis mine. Research published earlier showed Zika has already mutated rapidly after arriving in Brazil, with at least nine variants found inside the last two years.

What’s Next in Zika Research
What researchers don’t yet know, for starters: How Zika works — how does it damage or kill cells? When exactly does the virus do the most damage? What mechanisms interfere with Zika’s operations and can they be used in vaccines or drug therapy? What makes Zika different from dengue or other flavivirus? What does Zika do to adult neuro tissue to cause Guillain-Barre Syndrome? Which adults are most at risk? Will the different mutations in Brazil respond differently to vaccines? How long can humans carry live Zika virus? Has the virus mutated and become transmissible by bodily fluids or aerosol? These are just a few of the questions we still have about Zika.

There are some good guesses about Zika’s mechanisms — like this hypothesis focusing on vitamin A storage in the liver, which also suggests Zika may negatively affect liver cells (yet another avenue of research needed). But will a vaccine targeting this activity work for other flavivirus, too? What if this guess is wrong; are there other approaches we’ve yet to hear about?

We won’t have any of these answers in a reasonable period of time if we don’t have adequate funding.

It’s not just birth defects we are talking about here, either. Look at the damage in those images again; this virus not only damages fetal nerve and brain tissue, it kills fetuses. Infants born with Zika-related defects may be blind and may lead short, painful lives. And it may kill and maim adults, too, if they develop a serious case of Zika-related Guillain-Barre Syndrome.

Let’s not bring out any more Zika dead.

(Note: Forgive me for the simplistic terms used in this post if you have a background in science. I had to make this as brief and succinct as possible for those who don’t have that background.)
___________

Source:
Zika virus impairs growth in human neurospheres and brain organoids
BY PATRICIA P. GARCEZ, ERICK CORREIA LOIOLA, RODRIGO MADEIRO DA COSTA, LUIZA M. HIGA, PABLO TRINDADE, RODRIGO DELVECCHIO, JULIANA MINARDI NASCIMENTO, RODRIGO BRINDEIRO, AMILCAR TANURI, STEVENS K. REHEN
SCIENCE13 MAY 2016 : 816-818
Zika virus infection in cell culture models damages human neural stem cells to limit growth and cause cell death.
URL: http://science.sciencemag.org/content/352/6287/816.full

Zika Studies Using Mice:
F. Cugola et al., “The Brazilian Zika virus strain causes birth defects in experimental models,” Nature, doi:10.1038/nature18296, 2016.

C. Li et al., “Zika virus disrupts neural progenitor development and leads to microcephaly in mice,” Cell Stem Cell, doi:10.1016/j.stem.2016.04.017, 2016.

J. Miner et al., “Zika virus infection during pregnancy in mice causes placental damage and fetal demise,” Cell, doi:10.1016/j.cell.2016.05.008, 2016.


The Obamacare “Wonks” Are Awfully Selective about Which Taxes and Costs They See

Let me start this critique (what may be the first of two parts) of Jonathan Cohn’s scolding of Bernie Sanders on health insurance by looking at this passage, from the end of his piece:

[Bernie] might not get his plan through Congress, sure, but he could use his promise to extract other useful legislation from Congress. Maybe he could win approval for the “public option” insurance plan that was originally part of Obamacare, or for allowing the non-elderly to buy into Medicare.

These are legitimate arguments. But liberal policy wonks remember the struggle to enact and then implement Obamacare. They also also remember that universal health care was a progressive dream for nearly a century, one that proved impossible for presidents with names like Roosevelt and Truman (and Clinton!) to realize.

One reason reform took so long is that, for most of that period, activists and the wonks were pulling in different directions, with the activists pursuing single-payer and the wonks looking for compromises. The (mostly) unified front they showed in 2009 and 2010 was a big reason Obamacare became law. Now that unity is fading, creating a key divide in the Democratic campaign.

In this passage, Cohn talks about the things that Bernie Sanders might do as President that fall short of his goal of “single payer” health care (I put that in quotes because what we’re really talking about is government paid health insurance — as providers pull out of exchanges in Obamacare we’re actually moving closer to a much more alarming sort of single payer model).

He suggests that President Bernie, brought to earth by a reality of which, his critics suggest, he is woefully unaware right now, might set up the government as a competitor to private insurers within the Obamacare structure. Cohn then moves from that possibility (which I would suggest would be remote except for some realities about Obamacare as enacted) to saying “liberal policy wonks” know that Obamacare was a struggle and they know how hard it was to get even what we got (Bernie, who was in the Senate fighting to make Obamacare better at the time, apparently is too senile to remember all this, I guess).

As a reminder, one reason both the public option and Medicare buy-in were opposed by some Democratic Senators (and especially insurance state Independent Joe Lieberman, whom Bill Clinton had a big hand in getting reelected in 2006), meaning we couldn’t even pass it with a supermajority, is because they would make it too easy to move towards single payer. The idea was private companies could not compete, and so would slowly lose most exchange business to the government.

Now, if I were someone pushing for the improvement of healthcare delivery in this country, I’d say, “wow, if Bernie could pull off Medicare buy-in, that’d get us closer to single payer! That’d be a huge win!” I also might consider ways that true Medicare buy-in (rather than just gradually lowering the age at which you could buy in) might address some of the problems with cost sustainability with Medicare. I’d further applaud that getting more people into Medicare would expose more people to the innovations in delivery tied to it (one of the two best things about Obamacare), and therefore would move delivery as a whole down that path.

In short, I’d be applauding.

But Cohn doesn’t do that.

Instead, he decries what he calls a split between “wonks” and “activists.”

Can someone please define what those words mean for me? Can you explain how a man who has spent a decade writing about ways to improve health insurance and even sometimes healthcare, as Cohn has, is not an activist of sorts? Has he just been writing for a paycheck all these years?

Don’t get me wrong. I consider Cohn an expert in the subject, unlike some other people who get included in Paul Krugman’s club of wonks. I respect much of what he writes. And I have no doubt that he has become an expert on this topic because he’d like to improve a shitty system.

But setting up a dichotomy between “wonks” (“yes, I am one of those wonks,” Cohn says elsewhere) and “activists” is an insidious way of saying “some of the people who work on this issue are not as smart as me.” Would anyone suggest such a thing about insurance company lobbyists, who are themselves “activists”? Nope. They’re just experts who use different methods to press for their desired outcome. But somehow people who lobby and organize on the other side are presumed to be unicorn sniffing half-wits.

Calling oneself a wonk is also an easy way absolve oneself of examining what function wonk-scolding plays — a way to pretend one is delivering just unmediated rationality and not an argument designed to bring about some outcome. Here, the desired outcome seems to be the restoration of unity between those deemed “activists” and those deemed “wonks.” But not just to restore unity, mind you, but to restore unity by getting “activists” to be satisfied with what “wonks” tell them is realistic.

In other words, it’s a plea from one kind of activist for another kind of activist to fall back in line behind the policies the first kind of activist espouses, and, especially, to stop suggesting Obamacare (and, frankly, a whole bunch of other policies enacted by Obama and defended by Hillary Clinton, as well as some foreign policy ones that go beyond what Obama has done) isn’t an adequate solution.

So let’s go back to what else Cohn says. First, he explains why (unnamed) “liberals sympathetic” to government insurance consider it unrealistic by warning that even trying to move towards government insurance will “produce a major public backlash.”

Even many liberals sympathetic to the idea have said that Sanders’ scheme is simply not realistic. They worry that trying to push through another comprehensive health care package so soon after the Affordable Care Act’s tumultuous enactment would produce a major public backlash.

Note what Cohn has done here (besides putting his own argument in the mouths of unnamed anonymous liberals). In the rest of his piece, Cohn suggests that achieving government insurance is unrealistic. Fair enough — in a four year term it may well be. But here, he somehow ties what might fairly be considered the impossibility of actually achieving it with the specter of “major public backlash” if someone even tries.

I’m not sure if Cohn has noticed, but there is an ongoing major public backlash already. It was so bad in 2010 that it made predictable off year congressional losses far worse than they might have been. Much of that backlash is just Republican posturing. But not all of it. Some of the backlash comes from legitimate complaints about Obamacare: the government botched the original sign up, people actually weren’t able to keep their insurance plans, their selection of doctors has gone down, people are being forced to buy shitty insurance they can’t afford that won’t even make care affordable. Some of the backlash is unjustified, but some of it actually is justified.

But Cohn says we can’t talk about moving to government insurance because if so it will … cause what is already happening to continue happening? Or perhaps because it will legitimize some of the legitimate critiques of the Obamacare that activists like Cohn pushed back in 2009? Is that it? We can’t even talk about government insurance because doing so would bring people like Cohn in for some criticism?

Finally, here’s the line from the debate that Cohn frames this entire discussion around, where Hillary attacked Bernie’s plan because it would impose a $2,300 tax on the working poor.

But during the debate she also made another claim: That under the Sanders plan, some low-income people now on Medicaid would be much worse off. “A working woman on Medicaid who already has health insurance would be expected to pay about $2,300,” Clinton said.

[snip]

Here’s why. If the federal government is going to provide everybody with health insurance, then it must raise enough money to pay for those benefits. To do this, Sanders has said, he’d create a new payroll tax, equal to 8.9 percent of wages. In theory, employees would pay only a portion of that, with employers covering the majority. In reality, economists say, the employer share also comes out of workers’ paychecks, if not right away then over time.

[snip]

An 8.9 percent payroll tax would work out to a new payroll tax burden of $2,314 — just as Clinton said.

Today, by contrast, you’d be getting Medicaid without having to pay any new taxes. The money for the program comes out of general revenue and if you’re one of the newly eligible folks, then the money is coming almost entirely from taxes that fall on the wealthy and on corporations in the health care industry.

Now, “wonks” love to criticize Bernie for promising things he can’t deliver. But note what Cohn has done in this last paragraph: under Obamacare this working poor mother of two gets health insurance “without having to pay any new taxes.” Her health insurance “comes out of general revenue” which comes from “taxes that fall on the wealthy and on corporations in the health care industry.”

I think Cohn means to suggest that the revenue passed under Obamacare fall on the wealthy and corporations. He surely doesn’t mean that general revenue funds generally come from taxes that fall on the wealthy and corporations, because many rich people and corporations actually don’t pay income taxes. Indeed, it’s all that we can manage to keep corporations — some of them the health care ones Cohn says pay for all this — paying any taxes at all. What he really means is the taxes that pay for Medicaid come largely from the affluent and middle class taxes and even borrowing. That single mom likely still isn’t paying for her own Medicaid, but it’s not actually rich corporations that are doing so.

But even if Cohn meant only to refer to the planned funding method for Obamacare, his claim is problematic. That’s because one of the taxes targeting the industry, on medical devices, has already been suspended. Another tax that Obamacare boosters liked to pretend will only affect the wealthy, the Cadillac tax, will actually affect more people than that, including unions (which is why Hillary has promised to scrap it, as has Bernie). Plus, the Cadillac tax boosters sold it with a claim that workers wages would go up after their companies cut their health insurance. Those claims always seemed like fantasy — at least to me and actual experts like Larry Mishel, the latter of whom was pretty much ignored by the “wonks” during the debate. In the last six years that has become even more clear.

This is important: In a key fight about funding during Obamacare, the “wonks” promised workers (especially union workers) a wage increase, but evidence now strongly suggests it would lead instead to a wage cut. Yet those same “wonks” (though Cohn wasn’t one of the more obnoxious Cadillac tax defenders) are now scolding Bernie about the realism of his claims. Why should we listen to the “wonks” when they too promised illusory unicorns?

Finally, though, I want to look at the premise of Hillary’s attack, that Bernie’s plan would be bad because it would impose an 8.9% tax on a working poor woman. Cohn admits that’s surely something Bernie would fix before implementation, but he apparently finds the criticism legitimate because “doing so would require new trade-offs.” Trade-offs like those that continue to need to be made on Obamacare to make up for the medical device and Cadillac tax, I’d respond.

But here’s the other thing about that 8.9% tax. I absolutely agree that an 8.9% tax on the working poor in exchange for health insurance would be steep. But let’s consider what Obamacare is for a segment of the middle class that are forced to buy insurance — spending up to 13% of their income — that they can’t use. Sure, it will minimize but by no means eliminate the problem of medically related financial crisis in the case of a catastrophe. But the rest of the time, it functions as a tax, a payment necessitated under this scheme to make care accessible for others. One that — unlike that poor woman who’d pay $2,300 if Bernie’s implementation of single payer somehow didn’t fix things along the way — wouldn’t necessarily provide care in response. (Note, in reality, 22% of Medicaid recipients also can’t afford to use their insurance, though unlike the general number of underinsured, that’s a number that Obamacare has improved.)

Now, we knew this was going to be a problem, though the “wonks” generally didn’t like to talk about it during the debate (though Cohn is actually one who did admit it at least once in response to me raising it), because somewhere between 16 and 21% of people in Massachusetts couldn’t afford to use their RomneyCare. Hillary has suggested she’d throw more money at the problem (and, ultimately, insurers) to address the problem, but she hasn’t actually explained what trade-offs she’d make to achieve that. Again, it seems okay for Hillary to remain silent about the trade-offs she’d have to make whereas when Bernie does he’s a fantasist.

Partly, though, Obamacare is designed to underinsure people, because there’s a belief that unless people feel the sting of obtaining care, they’ll get too much of it. “Bending the cost curve” under Obamacare is largely driven by increasing the costs of actually using insurance to the end user as opposed to, say, eliminating the many layers of private profit that doesn’t actually improve health care but makes it expensive.

In truth, the people the “wonks” deem “activists” aren’t actually stupid, or naive, or unicorn herders. Some of them are actually experts of longer standing than those writing in favor of Obamacare. Rather, they disagree about what acceptable costs are, as well as about whether it makes sense to continue pointing out that the US has an unbelievably ineffective healthcare delivery system with terrible outcomes that not only is immoral, but saddles our economy with a burden that other developed countries don’t have, making us less competitive in any industry not driven by this exorbitant spending. Yes, there is also a difference of opinion about whether it is more effective “activism” to set the goal where everyone agrees it should be — providing actual health care — or to instead set more moderate goals that also have the effect of naturalizing a particular ideology. But ultimately there is a real debate about policy here, and rather than use “activists” to continue to set the bar on the most efficient way to provide the best health care, a lot of those close to Hillary would prefer they just shut up.

Update: First, Cohn has corrected his piece to note that the single mom he discusses would actually pay $1,600, and that it would actually come from her employer.

Dean Baker (another expert often ignored during these debates) not only reminds that if Bernie were able to pass both his single payer and his $15 minimum wage proposals, the single mom would be better off overall (and he used Cohn’s uncorrected number). He also provides the equivalent example to the one Cohn offers, to note (as I did) that Obamacare requires some people to pay for insurance they won’t use.

Let’s take the case of a young African American woman just out of college, with $30,000 in debt. Let’s suppose this woman has an income of $35,000 a year. Let’s say she is in excellent health and from a family of people enjoying excellent health. In the pre-Obamacare days she might have opted to either buy one of the low-cost catastrophic plans that is no longer available under the ACA, or go without insurance altogether.

Under the ACA, this young woman will be expected to pay roughly 8 percent of her income, or $2,800 a year, for health insurance that she does not want. Should we feel bad about this young woman struggling to meet a large debt burden, while working at a low-paying job and now being forced to buy insurance?

Well, that is a bad story and there are many like them. But many of the same policy wonks who have endlessly highlighted the plight of the Medicaid mother under the Sanders plan (I have seen it featured as a news article in the Washington Post and also as a topic of numerous columns and editorials), have been content to largely ignore the plight of young people struggling to pay their ACA premiums. At least they don’t see it as a basis for rejecting the Affordable Care Act.

Copyright © 2018 emptywheel. All rights reserved.
Originally Posted @ https://www.emptywheel.net/health-policy/page/2/