Tuesday, November 24, 2015

How do we use bikeshare in the Sun Belt?

The Kinder Institute at Rice University has an interesting report out comparing four Bike-Share Systems in four "Sun Belt" cities.  Three are in Texas (Austin, Houston, Fort Worth), while the other is in Colorado (Denver).  The report's central idea is to get a snapshot of bike share in newer cities with lower density and planning optimized for the automobile -- in contrast to the old urban areas in the Northeast with high density.

The study, which covers the first five months of 2015, notes that most kiosks and most trips are still of the two-way weekday variety (i.e. from one-Kiosk to another), indicating that most users use the system for work trips.  However, there is a greater percentage of users in Houston and Fort Worth -- especially Houston -- who use the systems for round trips (i.e. they start and end at the same Kiosk). I'd be interested to see how this compares with bike share systems in older, denser cities.

The study is a good first stab and thinking about how we use bike share in newer cities, but I do have several additional points to make here, including a criticism or two. 

First it's interesting to note that the broad pattern of trips in these Sunbelt cities still is two-way weekday trips, which indicates that many residents here use the program for similar purposes to those in older cities -- though the report doesn't explicitly compare the two.

Second, I think that the report misses a rather obvious explanation for the differences in trip types between the cities. The authors do suggest several useful variables to explain the differences in usage across kiosks and cities. For example, they note that cities with greater numbers of kiosks have more two-way work trips. Also, the kiosks with more round-trips tend to be located near bike paths or in large parks. Also, Houston allows for a full hour of use before additional surcharges kick in, unlike the traditional pay system which gives a free half hour to the first members.

However, the report misses the idea of density.  Denver's and Austin's systems seem at first glance to be more closely spaced in a tight network, facilitating two-way commuter or errand trips. In contrast Houston and Fort Worth's systems are more spread out, limiting the utility of the system and leading to people treating it like a bike rental than bike share. They don't have any measurements on density, which would be interesting to see as well (maybe a median distance between adjacent kiosks, or a distribution of distances would be a good measure here....)

Density of the network is also rather valuable to total usage, as a National Association of City Transportation Professionals study has noted. So as Houston looks to expand this year, while I hope officials expand the scope of the bike share (please, please come to Rice Village!), I also hope they reinforce its density in its existing footprint (more stations in the Museum District!). This will expand its utility as a short-distance commuting tool.

And it goes without saying that expanding the bicycle infrastructure on the ground (more and better bicycle lanes please...) will help bring more cyclists on to the roads and keep cars moving at more reasonable (and safer) speeds.

But with this gripe aside, the report is a nice initial foray into how bike share works, and has nice nuts-and-bolts data on the use of each kiosk in all the cities and some good basic visualizations of usage in each city's network.

The invaluable Charles Kuffner, as always, has a summary and extensive analysis of a Houston Chronicle article on the subject.  He also makes the trenchant point that while knowing how people use bike share is useful, the fact that they are using it widely is the most important point.

Amen to that.

Union contracts, what are they good for?

Last week, Erik Loomis posted a summary of an article about the ongoing pilots' union negotiations with Southwest.  Loomis' point (and the excellent article he links to) are that union negotiations are about more than money -- they are also about the conditions under which employees work.  In this case, pilots voted down a proposed contract that offered them a large raise in part because Southwest demanded far more flexibility on duty hours to match other airlines  (which had managed to force those concessions from bankruptcy judges).

With the constant refrain we hear about unions being all about grabbing money, this idea of the employment environment is extremely important. I would also add that rules about firing and hiring are very important as well. My old union at the University of Michigan just settled (and essentially won) a grievance filed by a Graduate Student Instructor named Alex Chen who was offered and accepted a job in the bargaining unit, before having that offer yanked by her supervisor for spurious reasons. 

Of course, Chen lost her health insurance and tuition waiver in addition to her salary. This situation is deadly to a graduate student, who probably would have to drop out of school facing a tuition bill of more than $10,000. I've known several students in situations like this; and the psychological stress they face is extreme.

Chen reached out to the union and found out that not only did contract language back her position, but that she also scores of fellow members willing to protest on her behalf.  That article, which details what happened in the meeting, contains several fabulous anecdotes about a department program chair behaving like a stubborn child who has been caught lying about doing her homework.

An interview with Chen outlining her particular situation is here.

Anyhow, I highly recommend Loomis' post -- and the excellent comment thread, which features a really good discussion of the nuts and bolts of work rules in a contract led by a freight pilot (Major Kong) who is often found in the comment threads of progressive blogs. The thread is doubly worthwhile because it brings in information from the union and not just from Southwest, as well as discussing how issues like codeshare and subcontracts with regional airlines can undercut airline unions.

And remember -- work rules and hiring practices are just as important as wages.

Monday, November 23, 2015

With Bel Edwards win, Louisiana set to expand Medicaid

A quiet legislative maneuver from last Spring combined with an unexpected triumph of Democrat John Bel Edwards in the governor's race makes it nearly certain the Louisiana will become the 31st state -- and second in the former confederacy --  to expand Medicaid.

On Saturday, Edwards, who strongly favors expansion, easily defeated sitting U.S Sen. David Vitter in Louisiana's gubernatorial run-off election (after throwing this haymaker on the airwaves). Edwards' replacement of Bobby Jindal in itself removes a massive obstacle to the Medicaid expansion, as Jindal is an implacable (and inexplicable) foe of covering 242,000 uninsured Louisianans.

However, the state legislative majorities remain firmly in GOP hands in Louisiana. This phenomenon has stalled governors who have wanted to accept the expansion: just ask Jay Nixon in Missouri, Terry McAuliffe in Virginia and (until recently) Steve Bullock in Montana.

But the good news is that the legislature in Louisiana already has acted. Well, sort of. The legislature has rejected multiple bills expanding Medicaid in 2013, 2014 and 2015. However, in 2015 both houses passed a joint resolution laying out circumstances under which the state can expand Medicaid. The resolution creates a mechanism under which -- if a new governor assents -- the department of health and hospitals will set a fee on hospital systems to fund any state portion of the Medicaid expansion. Hospitals will likely be fine with this, as the bill exempts the smallest providers and in any case accepting federal Medicaid dollars will pump a much greater amount of funding back into the system.

In short, the legislature isn't exactly pushing for an expansion, but it is devolving its power to set up a mechanism under which a governor can chose to take it. That's exactly the opposite of what Texas did in 2013, when it took away the governor's power to accept the expansion in order to make it less likely that the state would take it.

So in any case, at least we're stumbling forward toward doing the right thing -- after we've tried everything else, of course, but I'll take it.  

Finally, note that this happening is further evidence of two important points.

First, Republican resistance to the Obamacare remains strong and widespread, but continues to slowly erode at the state level.

Second, quite simply is that elections still matter. Each of the four major contenders in the Louisiana gubernatorial race, including the three Republicans, expressed openness to expanding Medicaid. However, Edwards was the most consistent and strident supporter of expansion and is the least likely to impose conditions on expansion that would hurt recipients.

Wednesday, August 26, 2015

How much would expanding Medicaid help in states that haven’t accepted the expansion?

Perhaps the single biggest story about the implementation of the Affordable Care Act has been the battle in states deciding whether to accept the Medicaid Expansion. The expansion is perhaps the single most important tool in the ACA’s coverage expansion tool kit. It takes 50 state-based single payer systems and drastically expands eligibility for them, which is the single largest progressive victory in politics since the Great Society. Other important Medicaid reforms drastically streamline the application procedures and eliminated asset tests to draw out formerly eligible people who might have gotten tangled up in the system or not bothered applying because the state made you apply in person on Tuesday between the hours of 2:30 p.m. and 3:04 p.m.

However, the expansion is not some magical talisman that instantly enrolls all eligible individuals. Some people will remain ignorant of the program despite the best outreach efforts, while other will not enroll for any variety of reasons. And more to the point, 24 states hadn’t fully taken advantage of the Medicaid expansion by the beginning of 2015. Pennsylvania, Indiana, Montana and Alaska have all signed on this year, leaving 20 holdouts (half of whom were in the former Confederacy – but I digress).

The cool thing that we have some real data of how ACA has actually performed on the ground over the last two years, we make some some interesting dynamic projections of what would have happened had some states accepted the Medicaid, instead of simply discussing the number of people who would be eligible for help under the expansion.

I mean, heck, this Charles Gaba fellow has been counting the people who actually signed up for coverage for two years, I might as well take one shot at figuring out who would have signed up if they could have. 

To accomplish that, follow me below the fold, where I build a simple interactive regression model to project the reduction in the uninsured population in states that haven’t expanded Medicaid. Don’t worry; I’ll label the scary part where I work through the model so you can skip the simple summary where I discuss the results in plain English (but you really should read the model section, it’s rather of important and it makes fun of Bobby Jindal).  

Monday, August 24, 2015

Some follow-up technical notes on State-based exchanges

When I reposted the last post as a DailyKos diary, a commentator engaged me a bit on a few ideas to improve the basic concept. He suggested for controlling for partisan control of the state government as a binary variable (cooperative == full Democratic control=1; non-cooperative==full Republican control=0). I thought a tertiary variable (0=GOP 1=split 2=Dem) might be a bit better.

Having an independent variable for partisan control might soak up some of the variation for cooperation with implementing the ACA, but the problem is that any partisan control variable would be extremely highly correlated with State-based exchanges. There were very few complete Democratic states without at least a shared exchange (West Virginia and Illinois jump to mind), and only one GOP controlled state (Idaho) with an exchange. I'm not sure how useful it would be in practice at sorting out variation not associated with exchanges since the two are so strongly correlated.

In any case, it was a thoughtful piece of feedback and definitely worth the brief conversation we had.

Another idea I thought of was to take quarterly data for each state to increase the number of observations for each state from one to six to track changes from the end of 2013 through the second quarter of 2015. Taking the data from cross sectional data to cross-sectional-time series in this manner would create 300 observations (vs. 50) and increase leverage dramatically, while allowing us to track over-time change in states setting up and taking down exchanges and or expanding Medicaid at different points.  Of course, as my old methods prof John Jackson used to stay "No good deed goes unpunished" and we'd have to control for the serial correlation in the states with either a fixed or random-effects model.  At least we wouldn't have to worry about panel-corrected standard errors, seeing that we're dealing with the universe of states, not a subsample.  And there would also be the problem of increase error within states for each quarter, since the Gallup sample would slip to alarmingly low levels for some states, increasing the margin of error around the uninsured rate for a given quarter.

And that's assuming that I could even get the more specific data out of Gallup.

I don't really have the time to try out either of these ideas right at the moment, but anyone in Internet land can feel free to try and report back. I'm rather interested.

Sunday, August 23, 2015

Does having a state-run exchange improve health insurance access under the ACA?

With the ruling in King vs. Burwell behind us, focus on the differences between state sponsored health exchanges vs. the federal exchange has fallen away. But as state-based data has been rolling in from Gallup, the CDC, and the Urban Institute on declines in people without health insurance, I began wondering whether providing a state-based exchange has any advantages over a the federal marketplace. Gallup’s comments and tables in particular seem to push the idea that states with state-based exchanges seem to have had more success with reducing the uninsured rate.

Of course, the real reason that state-based exchanges exist is political. The original House of Representatives bill had a national marketplace, while the Senate Bill incorporated state-based marketplaces. This particular breakdown shouldn’t surprise anyone, since Senators represent entire states, and all states are equally represented. The general state-based structure of the Senate bill won out. The final ACA incorporated a mechanism that defaulted to a federal backstop, but the markets themselves were still based on state boundaries.

However, despite that structural political reason, there might be some practical reasons why state exchanges might have superior performance to a unified federal exchange. First, commentators often refer to states as “laboratories of democracies” that can innovate and try numerous different ideas. Over time, the theory goes, good ideas from some states will diffuse across other states naturally and more quickly than if the federal government had installed and tried to improve a clunky national idea. Second, there’s the idea that differing conditions and preferences across states mean that state-based exchanges will allow individual states to customize their exchanges to best fit the needs of their state.

We would have to hold these potential advantages against some very real drawbacks. First, there’s administrative complexity and cost of constructing and running an exchange for a state-level. With federal grants to construct exchanges running out, several smaller states are already transitioning back to the federal marketplace, while others are having trouble paying the upkeep costs. Also note that there’s a question of whether several states even have enough potential subscribers to form a healthy individual insurance market to begin with.

With these ideas in mind, I used Gallup’s state-based data to build an extremely simple statistical model to predict the effects of a state-based exchange on improvements in health insurance coverage.  Follow me below the fold for more details.

Saturday, August 22, 2015

Medicaid Expansion gets entrenched in Arkansas -- even with a conservative GOP government

The latest news out of Arkansas offers more evidence that the Medicaid expansion will durable even in the most conservative states once it gets entrenched.  

I argued this point tentatively in March when new Republican Governor Asa Hutchinson and large GOP majorities in the state legislature reauthorized the expansion, which had been put in place under Democrat Mike Beebe’s administration, for the current fiscal year while putting together a task force to examine long-term tweaks in the system.

Arkansas has an unusual expansion: instead of simply enrolling everyone eligible in traditional Medicaid, the expansion provides subsidies to fully pay for private health insurance sold on the exchanges. As Richard Mayhew notes, commercial policies have higher costs than Medicaid, so the plan is a more expensive piece of “performance art,” albeit one that still accomplishes the primary goal of getting people covered.

The Arkansas Times picks up the story from there. As the federal match starts dropping in 2017 (and Arkansas enters new negotiations for a waiver with the Feds), the state found its was going to be on the hook for an extra $50-60 million, and Hutchinson implored the task force to cut costs.

Last week he met with the Task Force and made a speech with three major parts.

First, he engaged in the usual right-wing Kabuki ritual of complaining about how horrible Obamacare was and that it was taking away health insurance and….

(insert Charlie Brown trombone sounds here).

Oh, sorry, nodded off there. 

Second, he offered several of the usual conservative pet rocks to cut costs: notably requiring  more premium cost sharing for people above the poverty line (Iowa does this and the Feds would likely approve it in a waiver), requiring some sort of job search requirement for people on Medicaid that wouldn’t require a new waiver (this Feds won’t tolerate much here, and most of the people on expanded Medicaid work anyway) and making sure that working people with access to health insurance take that rather than enrolling in Medicaid (this will affect almost no one).

Finally, after emphasizing his anti-Obama bona-fides, he got to the real point: The Medicaid expansion had covered more than 220,000 of “our friends, our neighbors and our families,” and that rejecting it would cut them off of health care and drain more than $1.4 billion from the state economy. He also made the biggest policy proposal, which would be to shift everyone below the poverty line from private plans to the cheaper (and just as comprehensive) traditional Medicaid.

So the big conservative plan to tweak the “private option” Medicaid expansion in Arkansas and be fiscally responsible is to …. move more people into traditional Medicaid, just like Obamacare originally envisioned. I swear HHS Secretary Sylvia Burwell and President Obama just exchanged knowing glances and an extremely restrained fist bump in the Oval Office.