Thursday, July 21, 2016

Good News Everybody! (on Racial Equality in Health Care)

During the last several weeks, it’s been rather depressing recognizing (yet again) that racism (still) is widespread in the United States. We’ve had yet another set of killings highlighting the differences between how police treat whites and people of color. Then we had a sitting U.S. Congressman enthusiastically endorse white supremacy on national television.
And I’m a clueless white dude– if I feel depressed about this state of affairs, imagine how bad it really must be.

When it seems like the median opinion of the national debate is somewhere between “Black Lives Don’t Matter” and “Black Lives Might Sort of Matter Sometimes When We Feel Like It as Long as Black People Keep Quiet and Don’t Hurt White People’s Fee Fees”, feeling the urge to slip into despair is understandable.
But over the last several years one indicator of racial equality has quietly been rapidly improving – a lot more African Americans are getting access to health insurance under the Affordable Care Act.

Quarterly analysis from the office for the Assistant Secretary for Planning and Evaluation (ASPE) at the Federal Department of Health and Human Services (HHS) has been keeping track of changes in the uninsured rate. APSE (and other measures have noted massive across-the-board declines in the percentages of people without health insurance since the Medicaid Expansion and Insurance Exchanges went into effect in 2014.
What’s particularly notable, however, is how well African Americans seem to be doing under the ACA, however.
In the fourth quarter of 2013, 23.2 percent working-age African Americans lacked health insurance coverage, as against 14.3 percent of Whites.  By 2016, the African American uninsured rate had fallen to 10.6 percent, while the White rate had declined to 7.0 percent.  In total then, the gap between the uninsured rates between whites and blacks fell from 8.1 percentage points to 3.6 percentage points  -- a reduction of 55.6 percent.

That’s not perfect, but it’s a heck of a lot of progress.
Getting several southern states with large African American populations to expand Medicaid will likely further cut into this gap (yes, ex-Confederate States not named Arkansas or Louisiana, I’m looking at you).

The other challenge is that, despite improvements, coverage of Hispanics still lag significantly behind both Whites and Blacks.

But these are struggles going forward. For now, two and a half cheers for Obamacare's contribution to racial equality.

Tuesday, June 28, 2016

ACA exchange plans cost near-poor more than Medicaid

The Commonwealth Fund just released an interesting brief regarding the effects of failing to expand Medicaid on the health care costs of people between 100 and 138 percent of the poverty line.
Yes, that sounds about as exciting as watching paint dry, loyal readers (both of you) but it’s important – so wake up, dammit!
Here’s the score:  the Affordable Care Act expands Medicaid to cover everyone under 138 percent of the poverty line. The problem is that 19 states – generally dominated by Republicans – have
refused to expand their Medicaid programs. This poor public policy has created a “Medicaid gap” consisting of people who are too rich to qualify for legacy Medicaid (in Texas, for example, parents earning more than 15 percent of the poverty line – about $2,400 a year for a family of 2 – don’t qualify) but too poor to qualify for subsidies on the health insurance exchanges, which are available to households earning between 100 and 400 percent of the poverty line.

The 3.2 million people in this gap have no functional access to insurance, since there’s no way a person making, say, $10,000 a year can afford several hundred dollars a month in health insurance premiums.

People earning between 100 and 138 percent of the poverty level in non-expansion states are considerably better off though, because they qualify for both premium subsidies and cost-sharing subsidies for exchange plans. The indispensable Charles Gaba has estimated this group at roughly 1.9 million people.
But do the exchange plans stack up favorably with the generosity of Medicaid for poor people?

The good scholars over at Commonwealth Fund set out to find out. And their general answer is “no.”
Follow me below for more details.

Thursday, June 9, 2016

Transitional plans and insurance exchanges II

One day after my last post, the New York Times ran an article on Geisinger Health, an insurance company requesting a large rate increase on the PA exchange. One reason why? Because the transitional plans are keeping considerable numbers of healthy people out of the exchanges. It would have been nice if the article had mentioned it before three paragraphs from the end.

Wednesday, June 8, 2016

Are transitional insurance plans driving losses on state exchanges?

The ACA's insurance exchanges have generally been successful in helping to reduce the ranks of uninsured in the United States, while providing reasonable quality insurance to its policyholders.

However, several challenges still remain. Most notably, a good number of insurers have had problems with breaking even on the exchange products (though some are making money). That stems from several problems, notably Marco Rubio blowing up the risk corridor reinsurance program that undermined many insurer's business plans, especially non-profit co-ops trying to break into the market. Other insurers, like United Health, have just tended to be bad at competitively designing and pricing plans.

However, the risk pools for the exchanges have also proven to be somewhat older and sicker than predicted, which has also tended to drive up prices in 2016 and will likely do so more in 2017. I haven't seen a great explanation for this other than "predicting new risk pools is hard," -- which it undoubtedly is.

However, the New England Journal of Medicine last week featured a very interesting Perspectives piece (gated unfortunately) by John Hsu that fingers grandmothered plans as the culprit.

Tuesday, June 7, 2016

Two-tiered justice

On the recent Stanford rape case, I think Scott Lemieux makes a valuable point that helps clarify something I've been struggling with: does asking for a stronger sentence for a privileged person who has gotten off lightly undermine the broader push to make the U.S. criminal justice system less punitive?

Lemieux argues that it doesn't. Indeed, he suggests that the two are complementary goals: If you hold privileged (read: white and rich) defendants to the same standards the you hold underprivileged ones, people with power won't be able to ignore how draconian the system is and push to change it, instead of being able to close their eyes to it because those close to them escape its clutches. Think about the differences in the ways we've treated the opioid addiction problem and cocaine (abused broadly by middle and upper-class whites) in comparison to the way we treated the meth, heroin and crack problems (used disproportionately by the poor and/or minorities).

Finally, good on the survivor for her statement to the court and defendant during the sentencing. I have much respect for her.



Thursday, April 28, 2016

GOP's near-total blockade on Obama's appointments continues -- but you can help a bit

While we were all focused on the primary elections on Tuesday, something interesting happened on the Senate floor when Democrats made a conscious, polite and ultimately futile effort to get a few judges confirmed.

Hawaii Senator Mazie Hirono (D-Hawaii) asked for unanimous consent to vote on Obama's eleven district court nominees that have been approved by the Senate Judiciary Committee -- without objection -- and have been awaiting the action of the full Senate (see the full Senate Calendar here).

Sen. Majority leader Mitch McConnell (R-Kentucky)  objected to the request.

Then Chuck Schumer (D- New York) asked for unanimous consent to vote on the seven that have been approved by Judiciary -- again without opposition -- and have been waiting on the floor since November 5. 

McConnell again objected.

Then Ben Cardin (D - Maryland) said, OK, could we vote on the four that have been  waiting on the floor since  October 29 -- six months ago. Those are

Paula Xinis, District of Maryland,
Brian R. Martinotti, District of New Jersey, 
Robert F. Rossiter, Jr., District of Nebraska,
Edward L. Stanton III, Western District of Tennessee

John Cornyn (R-Texas) objected.

Finally,  Cardin said, could we maybe just vote on the Xinis nomination, since she was approved by Judiciary in September, no one has raised any opposition to her and she has been awaiting floor action for seven months?

Cornyn objected again.

We all know about the near complete refusal of Senate Republicans to even meet with, let alone hold hearings for, vote on or even, gasp, approve President Obama's Supreme Court nominee Merrick Garland. 

But we can't forget about the rest of these nominations either that are facing nearly a complete blockade by Republicans. In addition to the eleven awaiting floor action, 41 nominees are awaiting action in the Judiciary Committee.

In the 2015-2016 Congress to this point, the GOP-controlled Senate has only confirmed two circuit court appointments and fifteen district court judges.

For comparison, in the 2007-2008 Congress through April 30, the Democratic-controlled Senate had confirmed seven of George W. Bush's circuit court nominees and 38 of his district court nominees.

And in 2013-2014, by April 30, the Democratic controlled Senate had confirmed fifteen nominations to the circuit courts and 54 to the district courts.

It's reasonable that the GOP wants to scrutinize Obama's appointments a bit more (and even reject a few),  but these 11 judges have had been scrutinized. They've been waiting for confirmation between seven and 14 months.  They have all cleared a GOP-controlled Judiciary committee by voice vote. There is no opposition -- reasonable or otherwise -- to giving them their commissions. This is only about delay.

These are judges that are uncontroversial and needed to help the government perform their basic functions. Unlike Garland, they don't represent huge ideological stakes in themselves, so a bit of pressure might get the Republicans to let a few go.

Consider calling your state's Senators, especially if they are Republicans -- and especially if you're from Texas and have Cornyn as your Senator. (Don't e-mail, that's useless). Here's a list of numbers for their Washington offices. State your name, and give  a brief, polite (don't be a jerk) message asking them to hold a vote on the 11 district court nominees that await floor action.

The 11, including their numbers on the executive calendar are:

#307 Paula Xinis, District of Maryland,
#357 Brian R. Martinotti, District of New Jersey, 
#358 Robert F. Rossiter, Jr., District of Nebraska,
#359 Edward L. Stanton III, Western District of Tennessee
#362 Julien Xavier Neals, District of New Jersey
#363 Gary Richard Brown, Eastern District of New York
#364 Mark A. Young, Central District of California
#459 Marilyn Jean Horan, Western District of Pennsylvania,
#460 Susan Paradise Baxter, Western District of Pennsylvania,
#461 Mary S. McElroy, District of Rhode Island
#508 Clare E. Connors, District of Hawaii

Friday, April 22, 2016

Boring Bureaucrats help save the world: energy edition

When it comes to stopping global climate change, you probably don't think much about vending machines. Fortunately for all us, a lot of non-descript civil servants do.

Don't worry, the government is on it. (Really.)
Nor have you probably ever heard of the Department of Energy's Appliance and Equipment Standards Program (AESP). I'm sure it's staffed by lovely, if slightly nerdy khaki-wearing personnel.

But it's one of the Obama administrations most effective secret weapons in the fight against global warming.

Let's start with the two million beverage vending machines in the United States. Rules issued by AESP in 2015, will lead to machines coming online in 2019 required to be 16 percent more energy efficient in 2019 than today's. Over 30 years, it will save 7 million metric tons of carbon dioxide emissions, an average 233,000 tons a year. That's the equivalent of  shutting down Ohio's First Energy's Lakeshore Power Plant, which is a medium-sized coal plant in Ohio.

It will also save businesses at least $210 million in electrical bills over the same time.

Big deal, you say. The US emitted 6.8 billion tons of CO2 equivalent in 2014,  cutting 233,000 tons a year is a nice gesture, but hardly serious climate reduction.

We're just getting started. Read on to see efficiency standards really start to add up.