Brad DeLong links today to his wife, Ann Marie Marciarille, who in turn links to a New York Times article from a few days ago about small companies who choose to self-insure for health coverage. Here's the basic drill:

  1. Regulations are looser for companies that self-insure, so more small companies are doing it.
  2. Obamacare is (probably) accelerating this process.
  3. But small companies that self-insure need "stop loss" coverage, just in case one employee has a gigantic health disaster that could bankrupt them.
  4. Stop loss insurers are loosely regulated too, which means they can choose to insure only companies with young, healthy workforces.
  5. And they do.

The Times explains what happens next:

As a result, companies with less healthy work forces may find self-insuring more difficult....Insurance regulators worry that commercial insurers — and the insurance exchanges being set up in every state to offer a range of plan options to consumers — will be left with disproportionate numbers of older, sicker people who are more expensive to insure.

That, in turn, could drive up premiums for uninsured people seeking coverage in the exchanges. Since the federal government will subsidize that coverage, it, too, could face higher costs, as would some employees and employers in the traditional insurance market.

And Marciarille picks up the story from there:

The moral of the story? Wherever 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.

This is the problem with private insurers: they only have three basic ways of making more money: (a) charging higher premiums, (b) operating more efficiently, or (c) reducing payouts. Option A is limited by competition. Option B is nice to think about, but pretty hard to implement consistently. And Option C....

Well, Option C means either denying coverage to iffy customers in the first place, or else denying treatment to sick people who you have the misfortune to cover despite your best efforts. In a free market the incentives to do these things are very strong, which means the only way to stop them from spiraling out of control is with heavy-handed regulation, of the kind they have in Switzerland. But Obamacare doesn't quite have regulations that heavy-handed, and that's going to cause some growing pains. Eventually we'll get there.

Megan McArdle writes today about our elite class and its growing lack of connection to the working class world:

Since I moved to Washington, I have had series of extraordinary conversations with Washington journalists and policy analysts, in which I remark upon some perfectly ordinary facet of working class, or even business class life, only to have this revelation met with amazement.

....Then there was the time I responded to the now-standard lament that graduates of elite schools tend to gravitate to banking and consulting by pointing out that traditional management rotation programs frequently involve less-than-glamorous stints in line jobs; one of my friends from business school ended up running a call center for a telecoms firm. Another very smart, very wonky person who I deeply respect argued that this was an idiotic misuse of an elite MBA, for both the company and the MBA. Which is just 100% wrong. It is not a waste to have a smart, well-educated person in telecoms  management. And senior executives at a telecom should have run a call center, or done something very similar: that's where you learn to understand your customers, and the core challenges of your business.

But many of the mandarins have never worked for a business at all, except for a think tank, the government, a media organization, or a school—places that more or less deliberately shield their content producers from the money side of things....In fact, I think that to some extent, the current political wars are a culture war not between social liberals and social conservatives, but between the values of the mandarin system, and the values of those who compete in the very different culture of ordinary businesses—ones outside glamor industries like tech or design.

Without endorsing every word in this essay, I can say that I've certainly felt a bit of this myself, even though (like Megan) I'm not exactly some sort of hardscrabble coal-miner's son who overcame a life of poverty to get to my current exalted position as a blogger for a lefty magazine. Still, I spent a couple of decades in the business world before I became a pseudo-journalist, and it does seem to make a difference in my outlook sometimes.

(Not enough of a difference, I'm sure my conservative readers would say. Nonetheless, a difference.)

As it happens, I don't have a lot to add to this. I just thought it was worth linking to. In a way, it's an ancient complaint—book learning vs. street smarts—and the big question I have is whether anything about today's elites is really very different from yesterday's. It's the same question I had after reading Chris Hayes' Twilight of the Elites.

However, there's certainly one profession that I think elitism has changed a lot, and probably not for the better: mine. Reporters of the past were a mix of everything from Walter Lippman to the working class strivers from The Front Page. But there aren't many Hildy Johnsons left today. That may not be an unalloyed bad thing, but on balance it's a loss. No matter how hard you try, it's tough to really empathize with the common problems of half the population if you don't have, and have never had, any real connection to them. I suspect that our modern trivia-centric, narrative-obsessed style of DC journalism owes a lot to this.

Trust salmon, maybe red snapper, but not tuna. These are the lessons a nervous seafood eater could glean from a new study by the marine-life advocacy group Oceana. A whopping 87 percent of red snapper and 84 percent of "white" tuna tested was found to be mislabeled, the study found.*

But only seven percent of salmon—one of the most commonly consumed fish in the USwas mislabeled, making it a somewhat bright spot in a sketchy fish market.

More than 300 volunteers served as food detectives for the study, purchasing more than 1,200 samples of seafood from 674 restaurants, sushi bars, and grocery stores in in major cities between 2010 and 2012. Oceana then DNA-tested the fish to catch imposters.

So what are you eating, really? For example: The report found a hodgepodge of fish masquerading as snapper, some more palatable than others:

Chart of mislabeled snapper

The best chances of finding actual red snapper were in Miami, New York, and in Boston, where several samples of red snapper ironically turned up in a grocery store mislabeled as a different fish. In samples from out west, including San Francisco, Portland, Seattle and Los Angeles, all of the red snapper was mislabeled, according to USDA standards.

The good news for Democrats in today's new Pew/USA Today poll is that if Congress and the president fail to reach an agreement on the sequester, 49 percent of the public say they'll blame Republicans. Only 31 percent say they'll blame Obama. He's obviously winning the PR battle here.

But not all the news is so cheery. In a separate question, 70 percent said it was "essential" to pass major legislation this year to reduce the budget deficit. What's worse, there was very little support for doing this primarily through tax increases. A whopping 73 percent of the public want to address the deficit either entirely or mostly via spending cuts. Only 19 percent want to do it entirely or mostly via tax increases. It's true that most of the public prefers a deal that includes some new revenues, but that preference is small enough that it's not likely to produce any movement on taxes from Republicans.

In other news, the public is enormously in favor of raising the minimum wage; Obama's approval rating is up a bit and Republicans' approval ratings are at record lows; immigration is on a knife-edge; and nobody cares about climate change.

The Obama administration has taken plenty of heat in the past couple of years for its record number of deportations. A new report by the Transactional Records Access Clearinghouse (TRAC) at Syracuse University, though, highlights a different (albeit related) problem: US citizens are getting snagged in the Immigration and Customs Enforcement dragnet, too.

Of the nearly 1 million people for whom ICE issued detainers (a.k.a. immigration holds) from fiscal year 2008 to FY 2012, 834 were US citizens. As the above chart shows, that's right on par with the number of Korean, Belizean, Iranian, and Thai citizens that the government asked local law enforcement to hold after arrests. Those numbers are nowhere near those of, say, Mexican citizens (No. 1 at more than 690,000 detainers), but, as the TRAC report noted: "It is illegal for DHS to detain US citizens, and to do so is a significant violation of their constitutional rights."

Given the administration's stated focus on criminal offenders (PDF), it seems odd that only 23 percent of those who received ICE holds had a criminal record, and that just 9 percent had committed what the agency calls Level 1 crimes—a definition broad enough to include "serious" offenses like traffic violations and marijuana possession.

ICE holds by crime

ICE did change its policy (PDF) in December, restricting the use of detainers on people arrested for small-time misdemeanors, and the White House's draft immigration bill proposes to give judges more discretion when it comes to deporting such offenders. Still, for an unpopular agency already dealing with its union members' acrimonious lawsuit against the federal government and with a recent USA Today story that detailed desperate ICE efforts to reach deportation quotas, detaining Americans isn't helping its image.

In a recent column about the limitations of data, David Brooks wrote this about the debate over how effective economic stimulus has been: "As far as I know not a single major player in this debate has been persuaded by data to switch sides." This got Bob Somerby's attention. Had he ever changed his mind based on data? He says yes: the first time he actually looked for himself at NAEP testing data on schoolchildren and discovered what it actually showed:

We were stunned by what we saw there. We saw that, according to this gold standard program, black kids had been making large progress in reading and math down through the years. (Hispanic kids too.)

Like everyone else who reads newspapers, we had never heard this. Like everyone else who reads newspapers, we had endlessly heard that our schools were awful and getting worse—that absolutely nothing was working.

....That progress, if real, is astounding. But thanks to the mountain of liberal indifference, the public has never been told. Very few people have ever heard that our low-income and minority kids seem to be doing much better in school.

This is one of the reasons why Obama will face great odds if he tries to sell universal preschool. To this day, the public is constantly told that nothing works. Why would they want to pay for universal preschool if nothing else ever has worked?

I guess I sort of plead guilty to this. Like Bob, I was also surprised the first time I really started to dig into test score data: it showed pretty clearly that we've made consistent progress over the past three decades, especially at the elementary school level. It turns out that American schools aren't in terminal decline. At the same time, years of dipping into the ed reform literature has made me very cynical about faddish interventions. Virtually none of them really seem to hold up when you test them with bigger sample sizes, longer time series, or better studies.

I feel differently about pre-K interventions for a couple of reasons. First, we aren't talking about marginal improvements to an existing system. In many cases, we're talking about replacing nothing with something. The returns are much more likely to be large when you're starting from zero.

Second, the evidence in favor of pre-K seems to be stronger, even though it suffers from some of the same limitations of K-12 programs. It's true that we won't know for sure what (if anything) works until we perform rigorous testing on large-scale programs that have been run for years, but the evidence we have so far suggests to me that we're likely to see measurable benefits. It also, frankly, just seems like the right thing to do. Rich and middle-class parents already provide this kind of thing for their kids, and in a country as wealthy as ours, I see no excuse for not giving poorer parents at least the same opportunities for their kids.

So yes: I suppose that cynicism about K-12 interventions doesn't help to gain public support for pre-K programs. Mea culpa. But the answer isn't to lower our evidentiary standards. The answer is to make sure we do rigorous analysis of K-12 and pre-K programs. In the end, the public will never be willing to consistently fund these programs unless we do.

There's a growing interest among enviros these days in combating climate change with direct offensives against the fossil fuel industry, sights locked on its bottom line. The idea is that while we scramble to invent more efficient light bulbs and throw up solar panels, we also chip away at the mountain of money that gives the industry its power, by turning shareholders on to the idea that unwise investments can make them accomplices in global warming.

Activist investment is nothing new, of course, the best-known case being the massive movement to divest from apartheid South Africa in the 1980s. But it's gaining traction in the realm of climate change: Bill McKibben in particular has campaigned recently for colleges and universities to divest their endowments from fossil fuels, and Al Gore this month backed the efforts of Harvard students to do so.

Shareholders at a host of corporations nationwide—including Exxon Mobil, fracking giant Nabors, and, incongruously, Dunkin' Donuts—have climate-related resolutions on the table this year that aim to require companies to account to shareholders on everything from mountaintop removal to greenhouse gas emissions to renewable energy use. This week, an unexpected institution became the first major bank to join their ranks and have its climate impact interrogated by shareholders. From the LA Times:

The resolution, which follows years of protests over banks financing certain coal operations, is to be included in proxy material being sent to shareholders of PNC Financial Services Group of Pittsburgh before the bank's April 23 annual meeting.

It asks PNC to assess and report back to shareholders on how its lending results in greenhouse gas emissions that can alter the climate, posing financial risks for its corporate borrowers and risks to its own reputation.

PNC is the only major bank based in Appalachia, a region where coal and gas extraction is a major business. It has long lent to mining companies, including those engaged in mountaintop removal, which involves blowing up peaks to reach coal seams below and has been blamed for degrading landscapes, destroying habitat and polluting streams.

You might not expect a bank smack dab in the heart of coal country to have the most environmentally progressive shareholders, but then again PNC, heavily entwined with the coal industry but not as unbreakably massive as, say, Bank of America, could be fertile ground for climate leadership. The bank has in recent years tried to give itself a green makeover, but apparently not enough to satisfy the shareholders behind the resolution, including a Roman Catholic group and Walden Asset Management. The case PNC ultimately makes to its investors should be an interesting study in the practical power of wielding shares as a weapon against climate change.

So what's in my morning copy of the LA Times today? Let's take a look.

Page A1: Stomach stapling is a crock. "A new study has found that the surgery does not reduce patients' medical costs over the six years after they are wheeled out of the operating room." Actually, it's worse than that: according to the accompanying chart, medical costs were higher for patients who got bariatric surgery.

Page A7: A group of doctors has made a list of nearly 100 medical procedures that are overused in the United States. "The medical interventions — including early caesarean deliveries, CT scans for head injuries in children and annual Pap tests for middle-aged women — may be necessary in some cases, the physician groups said. But often they are not beneficial and may even cause harm."

Page A17: Bullying women into getting routine, annual mammograms is a bad idea. "There's no question that diagnostic mammograms should be performed on women who have discovered a lump. But a growing number of primary-care physicians, surgeons, epidemiologists and women affected by the process have begun to question the value of telling all women they need to be checked regularly with screening mammograms." And just so you don't think we're picking on women here, the same is true for PSA tests for prostate cancer.

Maybe I can get better news elsewhere? Nope. My email this morning has a link to a recent article in Harvard Magazine, in which David Jones tells us that nearly all angioplasties and heart bypass surgeries are useless. "As Jones painstakingly explains, it took years to show whether the procedures prolonged lives; in both cases, subsequent research deflated those early hopes. The interventions—major procedures, with potentially significant side effects—provided little or no improvement in survival rates over standard medical and lifestyle treatment except in the very sickest patients."

As near as I can tell, aspirin works. Blood pressure meds work. Beyond that, I'm beginning to wonder.

Charles (left) and David Koch.

Charles and David Koch—yes, those Koch brothers—are two of the most influential figures in American politics in the last 30 years. The future of their political/policy juggernaut has implications for us all. Which is why you should read Ken Vogel's latest story on the Kochs at Politico, a peek behind the curtain at the big shake-up underway in Kochland. 

The Kochs fared poorly in 2012. Their flagship organization, Americans for Prosperity, spent $140 million last year, tens of millions of which went toward ousting President Obama and flipping control of the US Senate back to the GOP. We know how that turned out. AFP did solidify Republican gains at the state level—in Arkansas, AFP helped Republicans take full control of the legislature for the first time since Reconstruction—but for the most part, the Kochs and their allies were left empty-handed in 2012.

And so, as Vogel reports, the Kochs are studying what went wrong and shaking things up to avoid future flops. Out went Tracy Henke, AFP's chief operating officer, as well as more than 100 AFP field organizers. The president of Generation Opportunity, a Koch-backed group targeting young voters, also left post-election. More importantly, the Kochs are choking off the cash flow to certain groups that didn't live up to the hype.

A big question looking over the Koch "reboot," Vogel points out, is what happens to the Kochs' mighty donor network, which reportedly steered some $400 million to GOP and conservative causes during the 2012 cycle:

Maybe the biggest question looming over Koch World, though, is whether it can still count on the support of the dozens of wealthy supporters in its network, who—as much as the brothers' own personal fortunes (estimated at $31 billion each) from their family owned industrial conglomerate Koch Industries—give the Kochs their political muscle.

The 2013 installments of the secretive twice-a-year Koch seminars at which donors often pledge seven-figure contributions have been delayed to allow for completion of the audit, which is being conducted by independent contractors and overseen by Koch operative Marc Short. The results will be presented at a seminar in April—a change from the typical late January or early February winter seminar in Southern California. The summer conference has also been pushed back but is still being planned, POLITICO has learned.

If donors are either not satisfied that Koch World has learned the lessons of 2012 or are anxious that their anonymity is at risk from heightened scrutiny of the Kochs' operation, they might be reluctant to give at the unprecedented level that they did in 2012, when the Kochs aimed to steer as much as $400 million into conservative causes.

"Nobody expected that people were going to continue to give at the level that they were giving leading up to that election and that cycle," said Jeremy Jensen, one of the dozens of field organizers laid off by Americans for Prosperity this year.

"I don't think they're going anywhere," Jensen added of the Kochs and AFP. "No, I think it will only come back bigger. I believe [2012] was a trial run for what things will look like in the future for some really big money plans."

Vogel's article also raises the question of what happens to AFP, the powerful advocacy group started by David Koch. In my own reporting, I've heard about all the grumbling among conservative donors about what AFP did—or didn't do—in 2012. Charles Koch apparently shares their concern: He was overheard at a holiday party questioning AFP's work in the last election cycle.

Could AFP be in for a major overhaul? Could it be broken up into a bunch of state-specific groups? No one knows at this point. But Vogel's story is the best glimpse we have at the inner workings of Kochland. It's worth the read.

It took December's Newtown massacre to renew the debate around mental health policy in America. In the wake of the shooting, President Obama took close to two dozen executive actions on gun control, several of which deal with providing better services to the mentally ill, and recent Congressional hearings have focused on the issue. This week, the Obama administration issued a long-awaited set of Obamacare regulations that will require health insurers to cover mental health services for tens of millions of people for the first time.