Brad DeLong

Understanding the Roberts Court's Health-Care Decision: Monday DeLong Smackdown by Jonathan Adler

The extremely smart Jonathan Adler delivers the smackdown:

For some reason I just saw this now. The Eldred point is interesting, but it’s missing important context. Lessig abandoned the Lopez-style argument against the CTEA. A conservative group had filed an amicus brief in the D.C. Circuit making a Lopez-influenced textual argument, Lessig failed to adopt it as an alternative argument, and the D.C. Circuit held that the argument was waived (a point on which the judge for whom I was clerking at the time – David Sentelle – dissented). As a consequence, the textualist argument against Eldred was never really in play in the Supreme Court.

As for your hippie-punching theory, that does more to explain the voting pattern of Justice Kennedy – who joined the majority In Raich, and tends to vote against criminal defendants in close drug cases – than Scalia or Thomas. See, e,g., Kyllo v. U.S.

The Oregon Medicaid Lottery New England Journal of Medicine Baicker et. al Study Power Calculations

Austin Frakt has done the heavy lifting, and presents the power calculations that, in an ideal world, should have been done and archived ex ante as part of the experimental design of Baicker et al.: The Oregon Experiment — Effects of Medicaid on Clinical Outcomes. Needless to say, he may have made an error: this is the moral equivalent of rocket science. But with enough eyes all bugs are shallow, hopefully…

Until somebody improve and refines his calculations, I believe that the right bottom line is his:

Updated power calculation: Thestudy was underpowered for the change in proportion with elevated glycated hemoglobin (GH) by a factor of 23. Yes, twenty-three…. Let me now state where we are. With respect to the statistically insignificant physical health measures in the study… the sample was too small even for much larger effects. This renders them… uninformative about whether or how much Medicaid improves physical health. Uninformative means just that. No new information. No resetting of priors is justified… We also know, from the authors’ discussion and from Aaron’s posts, that the results include [point estimate] changes in blood sugar and blood pressure that are not unreasonable to have expected clinically [if Medicaid were effective]…. Again, no resetting of priors is warranted.

Given this, for the physical health measures only, I don’t understand the rush I’ve noticed in people updating what they expected Medicaid could do…. I think it is time for people to take another look at what this study is saying…. What I think we’re seeing is a re-expression of everyone’s priors. This study is an opportunity to do that, but it doesn’t and shouldn’t change what [priors] are. The claims that people should be changing sides from pro- to/from anti-Medicaid expansion just make no sense based on the physical health measures in this study.

On the other hand, it is perfectly acceptable--in fact, I think it is morally and scientifically required--to update your priors and shift them in a pro-Medicaid direction from the findings on emotional health and financial stress.

Mary Carson and Jordan Rau: A Patient’s View on the Oregon Medicaid Experiment

A patient’s view on the Oregon Medicaid experiment:

Jordan Rau, KHN:

A study of Oregonians who won Medicaid benefits in a 2008 state lottery has sparked an intense debate about the value of expanding health care to the poor — and the value of health benefits in general. Mary Carson is, in a way, at the center of that debate. The 55-year-old Oregon woman was accepted into the Oregon Health Plan, the state Medicaid program, in 2011. She and her partner live with her three children. They earn about $1,000 a month by making and selling replicas of historic battle knives used in the Civil War and the two World Wars, doing odd jobs and providing respite care for people with cancer.

Austin Frakt: Power Calculations for Diabetes in the NEJM Oregon Medicaid Study

Austin Frakt:

Power calculations for the Oregon Medicaid study: Kevin Drum:

Let’s do the math. In the Oregon study, 5.1 percent of the people in the control group had elevated GH [glycated hemoglobin, aka A1C, or colloquially, blood sugar] levels. Now let’s take a look at the treatment group. It started out with about 6,000 people who were offered Medicaid. Of that, 1,500 actually signed up. If you figure that 5.1 percent of them started out with elevated GH levels, that’s about 80 people. A 20 percent reduction would be 16 people.

Doug Holtz-Eakin Turns to the Dark Side

One correspondent asks if perhaps Douglas Holtz-Eakin isn't an honest Republican worth engaging with--those whom Clive Crook claims are so thick on the ground and that Paul Krugman is so remiss in not engaging, but he can't remember any of their names.

But another correspondent writes, and I agree:

He was an honest and effective CBO director. After he left CBO… he was invited to set up what he called a 'conservative think tank'. That that was the way he decided to go. And then he went downhill: occasionally now he says something informative and interesting, but most of the time he is saying what he calculates all please his right-wing political masters. It's quite sad…

This Is Brad Being Stupid and Slow... And, in Email, Robert Waldmann Delivers the Smackdown!

OK. The Baicker et al. (2013) NEJM Oregon Medicaid Lottery study…

Aaron Carroll: Additional Thoughts on the New Oregon Medicaid Results

Aaron Carroll: Additional thoughts on the new Oregon Medicaid results:

1) This was a HUGE study. How can you say otherwise?

According to the paper, 12,229 people responded to the surveys and were analyzed. So, yes, for outcomes that effected everyone (think financial hardship), it’s likely they were super-powered. But for many of the outcomes that were more murky, that’s not the case. Take A1C for instance. Only 5.1% of the control group had an A1C>=6.5. Let’s assume that the starting prevalence was the same in the intervention group. That means that only 624 people (312 in each group) actually had a high A1C in the study. That’s not anywhere near as big. Especially when you’re talking about an indirect intervention like insurance as opposed to actual health care.

MCarson on the Oregon Medicaid Expansion

Robert Waldmann hoists this from my comments: mcarson:

I am one of the winners in the Oregon lottery [winners could get Medicaid]. Going from no insurance to insurance is very confusing. When you have no money every health question starts with "would I rather live with this problem and have electricity, or treat this problem and keep my milk in a cooler for a month or so?" Stepping back into healthcare was like hopping on a merry-go-round. The doctor wanted to do test after test to come up with baselines for me, and I had a hard time showing up at the lab.

Josh Barro: What to Make of the Oregon Health Study

I would say that we already knew that the Medicaid model is not a terribly productive way to create chronic conditions like high blood pressure and diabetes, and that we need to find better condition-management models pronto. But I would also say that the depression and financial security findings are better news than I expected. About what I would have expected (but worse than I might have hoped) on some welfare indicators, better than expected (and as good as I might have hoped) on others--net-net, goods news for the efficacy of Medicaid expansion.

And people who say otherwise aren't reading the study…

Oregon Medicaid Lottery Says: "Medicaid Expansion Definitely Worth It": Hoisted from Incidental Economist Comments Weblogging

Matt:

Two thoughts:

1. On your point #1 on sample sizes, note that the study is effectively even smaller than you’re saying. Thinking of the high A1C sub-sample as containing 624 people is correct for the intent-to-treat analysis (i.e. for estimating the effect of offering insurance). But (net) take-up was only about 25 percent. Thus, for the IV analysis (which provide the estimates of the effect of insurance per se), the point estimates and variance are scaled up by a factor of 4=1/0.25. This means that the “RCT-equivalent” sample size is only 156=624/4. That’s really, really small, even before you get to the fact that insuring people does not automatically get them the appropriate care (your point about direct versus indirect interventions).

DeLong, Neyman, Pearson, and Many Others Smackdown Watch: Medicaid Expansion Hoisted from Comments Weblogging

Robert Waldmann:

Heh, indeed.

I actually haven't read the whole [Baicker et al. NEJM Oregon Medicaid Lottery] paper, but I have read the abstract and a key table cut-and-pasted by Kevin Drum. It shows a more than four-fold increase in diabetes diagnosis due to Medicaid availability. This does not correspond to statistically significant decrease in the fraction of people with high hemoglobin glycosylation. So the paper does not contain proof that current therapy for diabetes is better than nothing.

I Am More Confident This Morning That Medicaid Expansion Is a Good Idea

Having read Katherine Baicker et al. (2013), "The Oregon Experiment — Effects of Medicaid on Clinical Outcomes", New England Journal of Medicine, I conclude that the study was--as natural experiments are--significantly underpowered, that the jury is still out on most of the effects, but that the success of the Medicaid expansion in reducing depression and improving financial security are rock-solid and nailed benefits, by themselves worth more than the net cost of the expansion.

Therefore I wish to withdraw my tweet from last night:

@tylercowen @petersuderman the case for Medicaid expansion is *marginally* less strong than I had thought...

— J. Bradford DeLong (@delong) May 1, 2013

And substitute for it, instead, the correct:

.@tylercowen @petersuderman CORRECTION: I have read the paper and evaluated its power, the case for Medicaid is stronger than I had thought

— J. Bradford DeLong (@delong) May 2, 2013

What Austin Frakt is doing instead of coming to my weblogging conference this week...

http://theincidentaleconomist.com/wordpress/the-price-is-not-right-often-its-not-even-observable/

Buce on the Terrifying Map of Increasing Female Mortality in Red America

Underbelly: Red Counties: More on How the Poor Live:

[T]he Wichita Bureau updates on life in the trackless void that is Western Kansas:

KS counties in red are mostly what you’d expect – the odd part is NW Ks – where the main industry is I-70 (hotels, fleecing hunters and the only Starbucks in that corner of KS; we stayed in a motel out there on the way back from a trip to Denver – and each room has a sign warning against cleaning pheasants in the bathroom sink – they point out that there is a special area behind the motel for THAT). There are three little towns out there that are holding their own – but apparently not in healthcare. The two red counties in SE KS are quite familiar: Greenwood where we had a second home for years and Elk, the poorest county in the state, supposedly. Both are dominated by big land owners – ranchers and oil guys. the Koch family owns at least 5000 acres of prime grass land. I suspect they own the commission. Greenwood has a small county hospital (that mainly packages people up for the helicopter ride to Wichita) with a decent number of doctors – mostly DO’s and foreigners. There is absolutely no industry – and damn few restaurants. About the only significant employers are the county, school system and a cluster of nursing homes supported by Medicaire/Kancare…

Why People Think I Am So Smart: Medicaid Expansion Edition

People think I am smart and know a lot about health care reform because I can ask Ann Marie Marciarille questions about health care finance, regulation, quality, and liability 24/7. I can.

Here she is last June explaining what has been happening for the last nine months with Medicaid...

Ezra Klein: Is Texas Governor Rick Perry Going to Shoot Texas in the Head to Prove That ObamaCare Is a Failure?

Ezra Klein thinks he just might…

Will the GOP’s plan to fight Obamacare in the states backfire?: The question, though, is whether governors who purposefully do a very bad job implementing Obamacare will hurt the law, or just themselves and their states. Call it the California v. Texas question. In 2010, Governor Arnold Schwarzenegger of California signed into law two bills to establish the online insurance marketplace — “exchanges” — that are at the center of President Obama’s health-care reform…. California promptly accepted the law’s Medicaid expansion. By this time next year… it’s possible that the portion of the state’s uninsured population will have declined from 20 percent to less than five percent.

In Texas… the Lone Star State isn’t lifting a finger to create an exchange, instead leaving the work to the federal government. Texas is refusing Obamacare’s Medicaid expansion, too. “The idea that we would expand and put more money and more people into a broken system is not unlike putting another 1,000 people on the Titanic,” Republican Gov. Rick Perry told Forbes. “You know how this is going to turn out. And it’s going to be a disaster.” One might observe that the health-care system in Texas, which, has the nation’s highest rate of uninsured residents — 24 percent, or more than six million people — is already a disaster. But the recalcitrance of Perry and Republican state lawmakers has the potential to make it much worse.

Ann Marie Marciarille's Missouri State of Mind...

https://www.rebelmouse.com/annmariemarciarille/

The Arkansas Medicaid Budget-Buster

Austin Frakt:

So efficient you can’t afford not to buy it: Medicaid private option edition: David Ramsey of the Arkansas Times has done a ton of great reporting on the private option. His latest post begins:

The strangest part of the “private option” is that the plan grew out of pressure from local Republican lawmakers, the very same folks who had the loudest concerns about costs of the original Medicaid expansion. That’s strange because the new “private option” is going to cost more (not necessarily for the state — see here and here — but almost certainly for the feds)…. There are a number of reasons that offering coverage via private insurance is costlier than offering it via Medicaid but the main one ain’t rocket science: private insurers reimburse at higher rates. Even conservatives that like the “private option” better agree that it will cost more. Well here’s the thing. Despite a broad consensus about cost, Republicans at the forefront of advocating for a “private option” as a possible alternative to Medicaid expansion do not agree. They think that the “private option” might not be any more expensive for the feds, and could even cost less.

He gives those Republican views a generous airing in the rest of his piece. Go read it! I didn’t see anything in it that I didn’t touch on in my “prebuttal.” (I should be clear. I’m not against expanding the scope of exchanges. I just think it will cost more and we should not be deluding ourselves that it won’t.) It’s crucial to separate two propositions: (1) Competition can be efficiency increasing; (2) Competition on a state insurance exchange of the type permitted under the ACA can bring spending below that of Medicaid. The former can be true even if the latter isn’t. That’s a reasonable expectation if Arkansas or any other state goes forward with the private option, as we currently know it (which is not very well).

The Onion Is America's Finest News Source

GOP Senator Flips On Gay Marriage After Son Comes Out:

Sen. Rob Portman (R-OH), a leading conservative who was on Mitt Romney’s shortlist for vice president, announced the reversal of his longstanding position against same-sex marriage, saying he had a change of heart after his son came out to him two years ago. What do you think?

“Let’s hope his kid has a tough time finding affordable health care.”

Lee Swart – Wharf Worker

I Am Guest-Moderating Health Law II at UMKC on Friday Morning at 9 AM...

ONLINE Readings for Friday, March 1, 2013

Read Steven Brill’s 2/10/13 TIME cover story: “Bitter Pill: Why Medical Bills Are Killing Us” available at: http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/

Douglas Holtz-Eakin and Avik Roy: "You Know All That Stuff We Have Been Saying for Four Years? Nevermind!"

Via Andrew Sullivan, Don Taylor notices Doug Holtz-Eakin and Avik Roy effectively saying "we've been misleading you about ObamaCare for the past four years":

Obamacare Obstruction Begins To Crack II « The Dish: Holtz-Eakin and Roy’s piece was and is primarily political, and doesn’t really have much to do with any facts or policy. They both (and many others) have overstated the case against the ACA for quite a while in my mind; that doesn’t mean I don’t read their stuff. And Holtz-Eakin was Senator McCain’s chief health policy advisor and Avik was an advisor to Gov. Romney. Given all this, the main content of the piece was reform of Obamacare v. strident ideological language arguing against something without offering an alternative that has been the norm for most opponents of the law for the past 34 months. So, even though my first thought was “Switzerland! I thought you guys hated mandates” I am personally glad to welcome them down from the ledge.

Ann Marie Marciarille: Self-Insurance by Small Employers and the Possible Breakdown of Community Rating Under the ACA

Ann Marie Marciarille:

Missouri State of Mind: Self-Insurance by Small Employers Under the ACA: [S]elf-insurance in employer-sponsored health insurance is a riddle wrapped in a mystery inside an enigma… the explosive growth in self-insurance by employer sponsored health insurance plans is… under-discussed… the New York Times took it on…. explains… 59% of private sector workers with health coverage are enrolled in self-insured plans (up from 41% in 1998)… the exemption of self-insured plan from state health insurance regulation is not premised on any genuine absence from all insurance markets, the article explains about self-insured plans' participation in the stop-loss insurance market…. The stop-loss market responds by cherry picking among the new refugees on the basis of -- you guess it -- health status of the employee group, reintroducing underwriting by small group to places where it had been eliminated for individuals by the Affordable Care Act. 

The moral of the story? Whereever and whenever we have competing insurance products whose profitability is determined by calculating every health care payout as a loss, the insurance markets will respond accordingly -- ever inventing more methods, even if once or twice removed, to screen those who need health insurance out of the health insurance marketplace.

Maintaining the pooling equilibrium as health care costs increase is going to be really hard. If it turns out to be impossible--well, then, the ACA system will lurch toward pay-or-play and then single-payer.

Ann Marie Marciarille: California's Health Insurance Exchange Web Presence is Up and Running

Ann Marie Marciarille:

Missouri State of Mind: California's Health Insurance Exchange Web Presence is Up and Running: Lots of people ask me what a health insurance exchange will look like.  I've been telling them that they may visit the Massachusetts connector for one example and that California's site will be up soon.  Now I have to amend that: Covered California may be visited here: http://www.coveredca.com/

Now the harder question still remains unanswered: what will it be like to actually use the health insurance exchange to try to acquire health insurance? The conventional response seems to be that the exchanges will be modeled on Travelocity. I guess it all depends on your most recent experience with Travelocity and whether you think the kind of sophisticated value-driven computer-savvy consumers that use a site like Travelocity were the ones I am most worried about in the Exchanges.

I would add a worry: Travelocity needs to attract customers or its people will lose their jobs, the Director of Human Resources at a large company needs to have an HR website that does not get the CEO mad enough to fire them. The exchanges, by contrast, will work according to a less consumer-is-always-right more political-horse-trading logic. How will that work?

Ann Marie Marciarille: Health-Care Implications of Wal-Mart's Always Low Wages (and Prices)

Ann Marie Marciarille:

Missouri State of Mind: Attention Wal-Mart Shoppers: Wal-Mart Shops for Value: Wal-Mart… is a brilliant illustration of our larger ambivalence over employer-sponsored health insurance…. Wal-Mart gained notoriety… in 2005 with the release of internal documents discussing the need to drive down employee health care costs… [by] hir[ing] younger presumably healthier and perhaps childless individuals…. Wal-Mart and every large employer of low-wage and low-skilled employees had and has every incentive to seek the employment turnover necessary to keep health care costs low and demand for employer-sponsored health insurance lower…. Wal-Mart's interest… in advance screening job applicants… by requiring lifting, carrying, and walking in every job description….

Attention: Republicans: Your Governor Is an Innumerate Dork Who Is Trying to Bankrupt You!: Medicaid Expansion Weblogging

Aaron Carroll:

The Medicaid expansion is a really great deal: I wrote the following last summer, when discussing why it will be hard for states to turn down the Medicaid expansion:

1. This is a pretty good deal for states. They’re getting most of the tab picked up by the feds.
2. It’s one thing to turn down high speed rail. It’s another to tell your constituents that they can’t have insurance entirely paid for by the federal government in 2014.
3. As more and more states take the money, those that don’t will be more easily marginalized.
4. History. States threatened not to join Medicaid the first time as well. All did, eventually. Now the program is so American that threatening to remove it is “coercive”.
5. There will be enormous pressure from doctors, hospitals,pharma, etc. who potentially will lose a lot of money in uncompensated care. They have pretty good lobbying groups.

Recently, Gov. Brewer of Arizona decided to accept the expansion, citing a number of the reasons above. Yesterday, Gov. Kasich of Ohio did the same:

Ohio Governor John Kasich: Even Though I Pretended to Be an Innumerate Dork When I Ran the House Budget Committee, Now That I Am a Governor I Can Reveal I Am Actually Not an innumerate Dork

John Kasich accepts the Medicaid expansion:

Sahil Kapur: Ohio’s GOP Governor Embraces Key Part Of Obamacare: Ohio Gov. John Kasich announced Monday that he will accept the Medicaid expansion under the Affordable Care Act, becoming the fifth Republican governor to embrace the provision of the health care reform law that the Supreme Court made optional….

We are going to extend Medicaid for the working poor and for those who are jobless trying to find work. It makes great sense for the state of Ohio because it will allow us to provide greater care with our own dollars.

The four other Republican governors to back the Medicaid expansion are Brian Sandoval of Nevada, Susana Martinez of New Mexico, Jack Dalrymple of North Dakota and Jan Brewer of Arizona. About a dozen GOP governors from red states have rejected the expansion; others from mostly blue and purple states have yet to decide. Democratic governors have broadly embraced it.

It’s an enticing deal: the expansion would extend Medicaid eligibility to their residents up to roughly 133 percent of the poverty line. The federal government would cover the full cost of the new beneficiaries in the early years and 90 percent after 2020. “The net effect is 270,000 Ohioans coming into the [Medicaid] program,” said Greg Moody, the director of Ohio’s Office of Health Transformation. “Over two years the state of Ohio will have saved $235 million as a result of the decision to extend coverage.”

The Governors who are innumerate dorks are, so far: Indiana Governor Mike Pence, Michigan Governor Rick Snyder, Nebraska Governor Dave Heineman, Florida Governor Rick Scott, Oklahoma Governor Mary Fallin, South Dakota Governor Dennis Daugaard, Louisiana Governor Bobby Jindal, Texas Governor Rick Perry, Alabama Governor Robert Bentley, Georgia Governor Nathan Deal, Idaho Governor C.L. Otter, Maine Governor Paul LePage, Mississippi Governor Phil Bryant, South Carolina Governor Nikki Hale, and Wyoming Governor Matt Mead.

The ACA's IPAB Exists to Dismantle the RUC: Health Cost and Finance Acronym Overload Weblogging

Austin Frakt writes:

It’s (past) time to dismantle the RUC: If you’re an evidence-based thinker or an advocate of transparency you’ll practically be moved to tears by Brian Klepper’s account of the latest chapter in the life of a relatively obscure committee. It and our near-slavish deference to it explain much of what is wrong with the U.S. health system…. Too few know how much power the Relative Value Scale Update Committee (RUC) has and what it’s done with it. Though I’ve known about it for ages, I am guilty of rarely posting about it. Brian Klepper has been beating the drum for years. Give him and this issue a little time. His latest is on the Health Affairs blog and he blogs regularly at Care and Cost.

I would also recommend Marciarille and DeLong (2011): the ACA has already launched a missile aimed at the RUC, and it is called the IPAB--the Independent Payment Advisory Board.

John Brown's Body Is a'Turnin in His Grave: Medicaid Expansion Weblogging

Tara Culp-Ressler:

If Oklahoma Governor Expands Medicaid, Her Aunt's Free Health Clinic Won't Be So Overcrowded: Oklahoma Gov. Marry Fallin (R) has refused to accept Obamacare’s optional expansion of the Medicaid program… the direct impact of the GOP governor’s decision is evident even within her own extended family. Fallin’s aunt, 85-year-old Dorthea Copeland, runs a free health clinic in Pottawatomie County, an area of Oklahoma that has an 18 percent poverty rate and a 28 percent uninsurance rate…. [T]he clinic is currently overloaded with low-income patients who don’t currently qualify for government assistance. As Tulsa World reports, Copeland’s volunteer staff — who served over 850 patients last year — are now struggling to keep up with the increasing demand for health services:

Ann Marie Marciarille: Riddle: How Many Doctors Will It Take to Implement One Affordable Care Act?

Missouri State of Mind: Riddle: How Many Doctors Will It Take to Implement One Affordable Care Act?:

If you saw the recent Wall Street Journal article on the development of Smartphone apps to detect skin cancer, you may already be wondering about specialty physician over-supply…. [T]he fourth app… the one with the astonishingly accurate results that used a system that forwarded data and images to board-certified dermatologists for remote review at a cost of $5 per mole -- you could tell Christopher Weaver at the Wall Street Journal was intrigued. I am as well. Teledermatology is not particularly well developed in the United States but is fairly advanced in Australia…. [D]ermatological care for some Australians is provided, in part, remotely.

There are many other health care related apps out there but not as many as you might think…. (If you have one in mind, here's a forum for you to seek fame and fortune: http://rwjf.org/en/about-rwjf/newsroom/newsroom-content/2012/12/foundation-announces--200-000-developer-challenge.html?cid=Xtw_qualequal. No worries if you miss today's deadline, this is an ongoing series of competitions.)… [I]t is not difficult to imagine a trend line on dermatology: fewer dermatologists practicing remotely in ever larger specialized practice settings… we can already notice [this] in some parts of radiology… the specialization of the visual exam reader may also improve accuracy -- both in screening function and in elimination of expensive-in-every-way (financially, clinically, emotionally) false positives. I think of this as the paradox of learning to have clinical confidence in the doctor you never meet: the super specialized mammogram reader, for example, you hope you never meet.

Alan Blinder: How to Worry About the Deficit: (1) Don't; (2) Wait a Few Years; (3) Then Worry About Healthcare Costs

I would say:

1. We should start worrying about health-care costs now--i.e., actually staff up the IPAB, encourage private insurers to start cutting specialists' reimbursement rates, and aggressively assault scope-of-practice restrictions.

2. Right now we should worry that our current deficit this year and next year and even the year after is too small.

But, otherwise, Alan Blinder is 100% correct:

How to Worry About the Deficit: (1) Don't; (2) Wait a Few Years; (3) Then Worry About Healthcare Costs.

The Curse of Richard Nixon: Republican Primary Electorate Edition

Paul Krugman:

Seneca, Selma, and Stonewall: "What many people may not realize is how recent those changes are. Gay rights may be relatively obvious — it’s just 8 years since opposition to gay marriage arguably played a significant role in Bush’s victory. But the big changes on the racial front are also more recent than widely imagined…. Republicans pine for the glory days of Ronald Reagan — but that was a different country, a county with a lot more raw racism, a country in which only a minority of Americans found interracial marriage acceptable. And yes, that had a lot to do with GOP political strength. And I don’t think the right has a clue how to operate in the better nation we’ve become.

I suspect that some 6% disapprove of interracial marriage but won't tell the Gallup interviewer because they want to save their face--that 20% of Americans today disapprove of interracial marriage. That means that 40% of Republicans disapprove of interracial marriage, and thus that perhaps 60% of Republican primary voters really do not think as the rest of us Americans do.

That poses a huge problem for the Republican Party today. And we can see that problem reflected in--among other things--the tragedy of Mitt Romney.

Ann Marie Marciarille: The Pediatric Dentistry Market Is About to Get a Big Shock

Ann Marie Marciarille:

PrawfsBlawg: Just Open Your Mouth Wide and Say: "Dental Therapist": Pediatric dental services are included in the essential health benefits standard of the Affordable Care Act… individual and small-group plans sold in the exchanges and outside the exchanges [must] offer pediatric dental services, as of January of 2014…. And dental services already are part of the benefit package for children who are enrolled in Medicaid. 

Demand for pediatric dental services is about to increase. But no one knows by how much….

Remember, the Dormouse Says Medicare Is the Best-Working Part of Our Health Care Financing System: Not the Jefferson Airplane Weblogging

Ann Marie Marciarille:

Missouri State of Mind: Go Ask Alice: Alice… a friend… octogenarian… had fallen outside her home, broken her hip, had surgery, and was now in rehab for her Medicare-sanctioned 21 day stay… during Medicare’s open enrollment this past fall, financial exigencies had pressed her to abandon fee-for-service Medicare for a Medicare Managed Care plan. And, you guessed it, the Medicare Managed Care plan kicked in mid-treatment on January 1, 2013….

Disenrolled from fee for service Medicare – and unable to keep the surgical follow-up appointment from a surgeon who takes Medicare assignment but does not participate in Medicare Managed Care – and moved to a Medicare Managed Care rehab funded facility, Alice was advised that this was her problem to unravel. Her new Medicare Managed Care insurance plan vacillated between advising her she was not an enrollee in their plan and advising that, even were she an enrollee, no follow up post-surgical appointment was necessary….

Bear in mind that Medicare is that portion of our health care system that ranks highest in patient satisfaction data.

Ann Marie Marciarille: Up In Smoke: ObamaCare's Tobacco Surcharge

Ann Marie Marciarille:

PrawfsBlawg: Up In Smoke: [T]he ACA's much vaunted promise to end both pre-existing condition exclusions and individual underwriting of insurance risk…. There are some exceptions… use of tobacco products…. The ACA permits premiums to vary based on tobacco use by a factor of 1.5.  And the premium supports available to low income individuals are not available for the tobacco use premium band bump. 

What does this really mean for older low income tobacco users?… [I]nsurers could apply a different -- and considerably lower -- surcharge for tobacco use on younger smokers than on older smokers… could knock a substantial number of older smokers into a very familiar kind of uninsurability known as unaffordability… an un-subsidized tobacco premium surcharge of perhaps $4,000 a year…. (Of course, were you an older low income citizen intent on evading the individual mandate you could take up smoking and game yourself into the exceeds 8% of houshold income exemption for the individual mandate.)

All of this makes some actuarial sense…. All of this may not make the most public health sense, however.  If higher unsubsidized premiums are designed to discourage tobacco use, there is little doubt that shorter term tobacco users have a higher success rate at quitting. Older smokers -- say a 57 year old male -- tend to be those with a pretty hard core addiction to nicotine, an addiction intensity not evenly distributed among the smoking population.

Austin Frakt: The epidemic of low-value care

Austin Frakt:

The epidemic of low-value care | The Incidental Economist: Craig A. Umscheid, MD, MSCE. Being a physician does not confer immunity from clinical capture disease:

The ophthalmologist was underwhelmed by my findings. But “just in case,” he wanted a brain MRI scan, eye ultrasonography, and a visual field test to rule out multiple sclerosis (MS), subclinical neurovascular disease, masses compressing my fourth cranial nerve, and thyroid disease causing ocular muscle hypertrophy. We agreed that these diagnoses were extremely unlikely because I had no symptoms and no changes in examination findings over 2 years. But he “wanted to make sure.”

I tried to understand and put myself in his place. But it was difficult, because he seemed so unimpressed. Even if I had MS or vascular disease, I wouldn’t do anything differently. I was already getting blood pressure checks and was taking a statin for a family history of early heart disease. An intracranial mass also seemed unlikely given the duration and asymptomatic nature of my findings. But despite my own medical and epidemiologic training, it was difficult to resist his advice. As my physician, his decision making was important to me. I trusted his instincts and experience.

Medicaid Expansion

Kevin Outterson:

Reality: Red State Option Edition: Yesterday, Arizona’s Governor [Jan Brewer] stopped pointing her finger and joined the Medicaid expansion. Pundits expressed shock, but no one should be surprised. Most of the plaintiff states will ultimately follow suit, for two reasons: politics & money. First, in most counties, the local hospital is one of the largest employers and these hospitals want the Medicaid expansion. The political pressure will be intense, well-connected, and local. Second, the federal match rate is indeed generous. It is hard to justify turning down such largess. But as the plaintiff states jump on ship voluntarily, it undermines their prior claims of unconstitutional coercion.

Meanwhile, in Oklahoma, the Governor is sticking to her guns.  200,000 Oklahomans will lose (or fail to obtain) coverage as a result. The state authorized $500,000 for a consultant to study options to cover these people. Will the report recommend the expansion?

Boehner Breaks the Money-Saving Part of the ACA

Sam Baker:

House Republicans signaled Thursday they will not follow rules in President Obama's healthcare law that were designed to speed Medicare cuts through Congress…. The rules package says the House won't comply with fast-track procedures for the Independent Payment Advisory Board (IPAB)…. House Republicans have tried unsuccessfully to repeal the IPAB, the central cost-cutting feature in the Affordable Care Act. The IPAB was designed to take Medicare payments largely out of Congress's hands, similar to the independent panel that recommends closing military bases, because lawmakers would rarely sign off on such politically risky moves….

The healthcare law says the House must begin taking up the IPAB's recommendations as soon as they're made… requires House committees to pass them quickly… can only change the IPAB's recommendations if it comes up with the same level of savings elsewhere in the budget.

But the 113th Congress won't abide by those procedures…

Aaron Carroll: Raising the Medicare Qualifying Age Is Really, Really, Really, Really Bad Policy

Aaron Carroll:

Raising the eligibility age will likely hurt seniors’ health: [P]eople wait to get care until their Medicare kicks in.  This is bad both for health and for the federal government’s bottom line…. Medicare improved the health of the uninsured; delaying Medicare would delay that help. The argument for why things would be different this time around is that Obamacare will prevent 65 and 66 year olds from becoming uninsured. Through the Medicaid expansion, or through the exchanges, everyone would get coverage. Therefore, there would be no jump in quality once people get Medicare.

This might be true if everyone was sure the Medicaid expansion was going to happen everywhere. This might be true if we believed that 65 year olds would all be able to afford insurance in the exchanges. Both of those things are far from assured.

Raising the Medicare Eligibility Age Would Harm Seniors and Increase Health Care Spending

Maura Calsyn and Lindsay Rosenthal: Raising the Medicare Eligibility Age Would Harm Seniors and Increase Health Care Spending

The Political Medicaid Expansion Wars Begin…

If you want to know what's going on, you need to start by reading my wife's "50 Flowers" paper. Ann Marie Marciarille:

Let Fifty Flowers Bloom: Health Care Federalism after National Federation of Independent Business V. Sebelius by Ann Marie Marciarille :: SSRN: Conventional wisdom is that the American public does not want to think too long or too hard about Medicaid. Medicaid’s reputation has long been big, complicated, and widely misunderstood…. Medicaid is the budget-buster of government funded health insurance. Its budget busting propensities are most pronounced at the intersection of Medicaid and the government-funded health insurance program we do love to discuss: Medicare…. [E]verything possible will happen: if somebody can imagine it, some state will try it. This paper first looks at the pre-ACA past… considers the past role of Medicaid… and how the Supreme Court has understood that role. It next considers the roles that Medicaid is likely to play in our health care system post-implementation of the Medicaid opt-in in 2014…. It finally considers the implications of transformed health care federalism for the implementation of the ACA….

The ACA’s individual mandate is Constitutional, as is the Medicaid expansion, in large part. The states have been re-enforced in their historic roles as Medicaid makers or experimenters. A close reading of the statute and the NFIB opinion with an understanding of the background of health care markets is in order to provide a counterweight to the tendency of Americans to use the ACA as 'something of a blank slate onto which Americans … [impose] their own hopes, fear and concerns.'

Republicans as the Pointless Misery Caucus Yet Again

Ezra Klein:

Over the last few days, I’ve reported that raising the age for Medicare eligibility is very much on the table in the fiscal cliff talks. That has led some to believe that I support the idea as part of a deal. I don’t.

Yes. Congressional Republicans Are Insane. Why Do You Ask?: "Grand Bargain" "Austerity Bomb" Weblogging

The Obama Administration has a moral responsibility to block any and all spending cuts that are not good policy. And whatever raising the Medicare qualification age is, it is not good policy--nobody who hasn't been bought by the Republican Party thinks it's good policy, and many of those who have been bought draw the line at claiming that it is.

James Heckman: Yes, Charles, Poverty Can Be Fought Via Early Childhood Programs

http://www.bostonreview.net/BR37.5/ndf_james_heckman_reply_social_mobility.php

Charles Murray mischaracterizes the quality of the evidence on the effectiveness of early childhood programs. In doing so he suggests that my evidence is highly selective. The effects reported for the programs I discuss survive batteries of rigorous testing procedures. They are conducted by independent analysts who did not perform or design the original experiments. The fact that samples are small works against finding any effects for the programs, much less the statistically significant and substantial effects that have been found.

Murray questions whether any early childhood interventions can be effective because while some have worked, others have failed. His methodological stance is peculiar. In evaluating drugs to control blood pressure, we do not dwell on the failures except to learn from them. We should implement the successes. That is common sense and sound science. Perry and Abecedarian are rigorously evaluated, subjected to long-term follow-up scrutiny, and have shown high economic rates of return. Neal McCluskey’s claim that Perry is costly and has few benefits does not hold up. Perry’s high rate of return takes account of the program’s costs.

Murray misrepresents the evidence from the Infant Health and Development Program (IHDP) in an attempt to bolster his argument. IHDP was not a replication of Abecedarian, but rather an application of the Abecedarian model to a low–birth weight population—not the target population of Abecedarian. The designers of IHDP recognized in advance of collecting the data that severely low-weight children had medical needs not likely to be addressed by the Abecedarian curriculum. IHDP had substantial benefits for high–birth weight babies at ages of eight and eighteen. It was particularly effective for children from low-income families, and it promoted maternal employment.

The right interventions empower people to be what they want to be without forcing them to adopt one way of life over another.

In addition, the evaluations of IHDP (discussed by Murray) and Head Start (discussed by Almagor and McCluskey), do not account for David Deming’s point that many members of the control groups of those (and other) studies were enrolled in other early childhood programs, biasing downward simple treatment-control comparisons. (This is called “substitution bias” in the literature.) For these and other programs, there is the additional problem that treatment intensity varies among subjects. Adjusting for these biases boosts estimated program treatment effects. Also, Head Start is a very heterogeneous program and has not had any long-term follow-up, so evaluations of it are not comparable to those of Abecedarian and Perry...

 

Raising the Medicare Eligibility Age Is Not Good Politics

Duncan Black:

Jeebus It's Not High School: raising the Medicare eligibility age will cost money, not save money, and also kill people.

Aaron Carroll: Raising the Medicare Eligibility Age Is Really, Really, Really, Really Bad Policy

Aaron Carroll:

Whenever a debate begins on how to cut Medicare spending, someone "sensibly" suggests raising the eligibility age to 67 from 65….

It's a bad idea because it's a regressive way to cut Medicare. Life expectancy at age 65 has gone up over the past four decades, but it hasn't gone up equally. A 2007 study showed that while earners in the top half of incomes saw life expectancy at 65 increase more than five years since 1977, earners in the bottom half saw an increase of barely more than a year. So raising the eligibility age likely will result in a significant number of people receiving less years of Medicare overall than people did when the program was enacted. We're punishing the poor, not correcting for improved health and longevity.

Raising the Medicare Qualifying Age Is Really Bad Policy!

Especially in a system with community rating for the non-Medicare population.

That is all.

Robert Greenstein of the Center for Budget and Policy Priorities on the "Austerity Bomb" Negotiations

STATEMENT OF ROBERT GREENSTEIN… IN RESPONSE TO REPUBLICAN BUDGET OFFER:

House Republican leaders portray the deficit-reduction offer that they issued yesterday as a fair middle ground. It isn’t…. [T]he new Republican offer proposes $800 billion over ten years…. Erskine Bowles, Alan Simpson, and some members of their commission… proposed tax changes that would raise $2.6 trillion in revenues over 2013-2022…. Republicans… proposed substantially deeper cuts in… Medicare and Medicaid than Bowles-Simpson…. How… does the new Republican plan get to $600 billion? Republicans do not say. When the well-being of millions of Americans is at stake — as it is with major changes in Medicare and Medicaid — that shouldn’t be acceptable. If… [they] propose $600 billion in health care entitlement savings, as they have every right to do, they should show us the specific changes they would make…. (Some news accounts report the House Republican leaders would raise the Medicare eligibility age to 67 and increase Medicare premiums for more affluent beneficiaries… those measures would raise only about one quarter of the $600 billion and raise questions as to whether House Republicans have an answer for what would happen to many 65 and 66 year olds.)…

TThe good news is that Republican leaders have made an offer, non-specific as it is in virtually all key areas…. The bad news is the guts of the offer itself — and its attempt to lock in a requirement for deep cuts in programs on which tens of millions of Americans of modest means rely, without coming clean on the nature and severity of the cuts that would be required.

Can't Any Republicans Play This Game?

Ezra Klein looks at the dirigible explosion in bemusement:

The GOP’s Medicare confusion: The austerity crisis talks have hit a peculiar impasse. The problem isn’t, as most analysts expected, taxes…. And the particular Medicare problem isn’t that Democrats are refusing the GOP’s proposed Medicare cuts. It’s that Republicans are refusing to name their Medicare cuts.

Ezra Klein Pleads with Republicans to Be Not-Insane

Heather:

Ezra Klein: Presidential campaigns… usually focus on… hope and change. The candidates promise big grand new policies and how everything's going to be different and then they get elected and they go to Congress, and Congress usually just says no. This time… is different. Candidate Obama in 2008 promised universal health care. And shockingly, unlike the many, many presidents who had run for office and been elected promising that before him, President Obama was pretty much able to get it passed into law. But though the Affordable Care Act became law in 2010, it wasn't scheduled to actually begin until 2014…. You might have heard the old saw that elections have consequences. This election had real, completely life changing consequences for the 30 million uninsured people and maybe millions more who will get health care coverage because President Obama [has been] re-elected and… the Affordable Care Act will take effect. That is not just change you can believe in, or change you can hope for. It is change that is actually happening. It is happening even as we speak right now. It doesn't need another vote in Congress or to clear another challenge before the Supreme Court. It is law and even John Boehner knows it.

DeLong Smackdown Watch: Health Care Diplomat Says That Demand for Treatment Is Supply-Driven

Health Diplomat:

Health Diplomat: Will the ACA increase waiting lines for patients?: Brad DeLong has a question on ACA implementation:

What is your guess as to what will happen if the ACA works for access, works for quality, works for coverage--but the extra health-care workforce needed isn't there, and the lines start to get longer?…

[T]o answer the question directly: looking at the issue from a market-based standpoint, if his scenario comes true, I think the obvious answer would be that we need to graduate more doctors… there are loads of people who would like to be doctors, but can't get into medical school because there are not enough spots. The problem, in my opinion, is that a lot of healthcare seems supply-sensitive… the more available doctors or hospital beds, the more doctors will prescribe more treatment, despite the fact that a lot of this treatment has very little effect…. It's possible that lines will start to get longer as a result of the ACA's provisions on access, quality and coverage, but it's possible that demand-side is a less significant factor than we believe it will be….

A better solution, as my doctor friend Dylan notes, is to expand the Nurse Practitioner workforce: "Non-urgent medical screening can be handled by NPs, and physicians can see sicker patients. Many clinics already do this. There's no reason a doctor has to perform a screening pap-smear for example."