Kevin Drum

Medicaid Expansion Now an Even Better Deal For States

| Wed Apr. 23, 2014 9:10 AM PDT

Need some more good news on Obamacare? How about some mixed news instead? Here it is:

Congressional Budget Office (CBO) estimates released last week show that health reform’s Medicaid expansion, which many opponents wrongly claim will cripple state budgets, is an even better deal for states than previously thought....CBO now estimates that the federal government will, on average, pick up more than 95 percent of the total cost of the Medicaid expansion and other health reform-related costs in Medicaid and the Children’s Health Insurance Program (CHIP) over the next ten years (2015-2024).

The good news is obvious: the Medicaid expansion is an even better deal for states than we thought. The federal government will pick up nearly the entire cost of expansion, and when you account for money that states will save from reduced amounts of indigent care and greater help with mental health costs, the net cost of expansion gets very close to zero.

The mixed nature of this seemingly good news comes from the reason for CBO's more optimistic budget projection: it's because they think the program will cover fewer people than they previously projected. There had always been a fear among states that lots of people who were already eligible for Medicaid—but had never bothered applying for it—would hear the Obamacare hoopla and "come out of the woodwork" to claim benefits. Since these folks weren't technically part of the expansion, states would be on the hook to cover the bulk of their costs.

CBO now believes this fear was overblown. Apparently most people who didn't bother with Medicaid before Obamacare took effect aren't going to bother with it now either. That's good for state budgets, but obviously not so good for all the people who could be getting medical care but aren't.

For what it's worth, this is a tradeoff we're going to see a lot of. Unless the actual cost of medical care comes down, the budget impact of Obamacare is always going to depend on how many people benefit from it. If lots of people sign up, that's good for public health but costly for taxpayers. If fewer people sign up, then government spending goes down but fewer people receive medical care. There aren't very many ways around this iron law.

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Running Away From Obamacare Is a Fool's Errand

| Wed Apr. 23, 2014 8:24 AM PDT

Are red-state Democrat senators certain losers to Republican challengers in this year's midterm election? According to recent polling, no. The races are all pretty close. But Greg Sargent points out that these Democrats do indeed have an Obamacare problem:

In Arkansas, 52 percent would not vote for a candidate who disagrees on Obamacare, versus 35 percent who are open to doing that. In Louisiana: 58-28. In North Carolina: 53-35. It seems plausible the intensity remains on the side of those who oppose the law. This would again suggest that the real problem Dems face with Obamacare is that it revs up GOP partisans far more than Dem ones — exacerbating the Dems’ already existing “midterm dropoff” problem.

However, in Kentucky, the numbers are a bit different: 46 percent would not vote for a candidate who disagrees with them on the law, while 39 percent say the opposite — much closer than in other states. Meanwhile, Kentucky Governor Steve Beshear — the most outspoken defender of Obamacare in the south — has an approval rating of 56-29.

I'm keenly aware that I've never run for dogcatcher, let alone had any experience in a big-time Senate race. So my political advice is worth zero. And yet, polls like this make me more, not less, invested in the idea that running away from Obamacare is a losing proposition. Electorates in red states know that these Democrats voted for Obamacare. Their opponents are going to hammer away at it relentlessly. In practical terms, it's impossible for Dems to run away away from Obamacare, and doing so just makes them look craven and unprincipled.

The only way to turn this around is not to distance yourself from Obamacare, but to try and convince a piece of the electorate that Obamacare isn't such a bad deal after all. You won't convince everyone, but you don't need to. You just need to persuade the 5 or 10 percent who are mildly opposed to Obamacare that it's working better than they think. That might get the number of voters who would "never" vote for an Obamacare supporter down from the low 50s (Arkansas, Louisiana, North Carolina) to the mid 40s (Kentucky). And that might be enough to eke out a victory.

Needless to say, this works best if everyone is pitching in. And surely this is the time to start. The early website problems have been resolved and the initial signup period has been a success. Conservative kvetching has taken on something of a desperate truther tone, endlessly trying to "deskew" the facts and figures that increasingly make Obamacare look like a pretty effective program. There are lots of feel-good stories to tout, and there are going to be more as time goes by. What's more, the economy is improving a bit, which always makes people a little more sympathetic toward programs that help others.

Obamacare isn't likely to be a net positive in red states anytime soon. But it's not necessarily a deal breaker either. It just has to be sold—and the sellers need to show some real passion about it. After all, if they don't believe in it, why should anyone else?

Why Does Everyone Think Lolita Is a Teenager?

| Wed Apr. 23, 2014 7:20 AM PDT

This is way off my usual beaten path, but here is Hillary Kelly in the New Republic:

People have the wrong idea about Lolita, and Lolita. Today, the name is widely used as a synonym for a sexually precocious young girl. But the most important fact of the novel is that Lolita is a 12-year-old girl....This makes the oversexed, hyper-titillating cover art that has been repeatedly slapped on Lolita incredibly bizarre—not to mention disturbing. We aren't meant to find Lolita sexy. We shouldn't find Lolita sexy. Nabokov himself said that readers were "misled" by the book's repuation "into assuming this was going to be a lewd book." I'm not so naïve as to imagine book covers always faithfully replicate the literary intentions of their authors. But Lolita covers aren't simply exaggerated or oversimplified representations. They're downright creepy.

Huh. I didn't know that. But there's a good reason for this: I've never read the book. Like a lot of people, however, I have seen the movie. And in the movie, Sue Lyon plays a teenage Lolita. So I always figured Lolita was indeed a high-school age girl. I don't know if Stanley Kubrick made this decision for artistic reasons or—ah, wait. Sure enough, the ever-helpful Wikipedia informs me that "Lolita's age was raised from twelve to early teens in the film to meet the MPAA standards. As such, Sue Lyon was chosen for the title role partly due to her more mature appearance."

Anyway, I wonder if this is the wellspring of much of the common confusion? I'll bet a whole lot more people have seen the movie than ever read the book.

Most Independent Voters Aren't, Really

| Tue Apr. 22, 2014 5:31 PM PDT

I write from time to time about the myth of the independent voter, which goes something like this: there aren't any. Oh, lots of people say they're independent, but it turns out that most of them lean in one direction or another, and when Election Day rolls around the leaners vote just as reliably as stone partisans. True independents—the ones who switch between parties from election to election—make up only about 10 percent of the electorate.

Still, 10 percent is 10 percent. It's not quite nothing. But it turns out that it really is. Today, Lynne Vavreck breaks things down a bit further and explains just how these folks vote:

Only a small percentage of voters actually switched sides between 2008 and 2010. Moreover, there were almost as many John McCain voters who voted for a Democratic House candidate in 2010 as there were Obama voters who shifted the other way....On average, across districts, roughly 6 percent of Obama voters switched and just under 6 percent of McCain voters switched.

So, yes, there are some true switchers. But mostly they're going to cancel each other out. The net result from a huge push for swing voters is likely to be no more than 2 or 3 percentage points. In a few high-stakes states in a presidential election, that might make them worth going after. But in your average congressional election, it's a waste of time and money. So what does make the difference?

On turnout, the numbers were not evenly balanced for Democrats and Republicans. Only 65 percent of Obama’s 2008 supporters stuck with the party in 2010 and voted for a Democrat in the House. The remaining 28 percent of Mr. Obama’s voters took the midterm election off. By comparison, only 17 percent of McCain’s voters from 2008 sat out the midterms.

....It may seem hard to believe that the [2010] shellacking was more about who turned up than about who changed their minds between 2008 and 2010, but it lines up with a lot of other evidence about voters’ behavior. Most identify with the same political party their entire adult lives, even if they do not formally register with it. They almost always vote for the presidential candidate from that party, and they rarely vote for one party for president and the other one for Congress. And most voters are also much less likely to vote in midterm elections than in presidential contests.

The problem is that going after turnout is every bit as hard as picking up the crumbs of the swing voters. Traditional Democratic constituencies—minorities, low-income voters, and the young—simply don't turn out for midterm elections at high rates. They never have, despite Herculean party efforts and biannual promises that this time will be different. But it never is. They'll vote for president, but a big chunk of them just aren't interested in the broader party.

So what's the answer? Beats me.

Male Doctors Bill Medicare for More Services Than Female Doctors

| Tue Apr. 22, 2014 11:45 AM PDT

Via German Lopez, today brings us an interesting study from Andrew Fitch of NerdWallet. Long story short, he finds that male doctors get paid a lot more by Medicare than female doctors.

Obviously there are several reasons for this. Chief among them: Higher paid specialties tend to be dominated by men, and men see more Medicare patients than women. But here's the most interesting bit:

  • Male doctors perform more services per patient treated.  To explore this, NerdWallet Health devised a metric to calculate a physician’s average “service volume” per patient. We found that male doctors billed Medicare, on average, for one more procedure per patient than female physicians (5.7 services performed per patient by male doctors vs. 4.7 services per patient by female doctors).
  • This gap in service volume is true across specialties. Male doctors performed more services per patient than female doctors across nearly all specialties. In a specialty like pathology — where doctors infrequently provide services directly to patients — we found no variation in average service volume.

On average, male doctors bill 5.7 services per patient vs. 4.7 for women! That's a huge gap. And it's not just that cardiologists tend to bill for more services than, say, pulmonologists. Even within specialties, men bill for more services than women.

But why? Are they just generally more aggressive? Are they gaming the system? Do sicker patients prefer male doctors for some reason? If this analysis turns out to be true, it would sure be fascinating for someone to follow up and try to figure out what's going on.

Chart of the Day: Wind Turbines Don't Kill Very Many Birds

| Tue Apr. 22, 2014 9:22 AM PDT

Tom Randall is fed up with hysteria over wind turbines being responsible for bird genocide. The numbers just don't support it:

The estimates above are used in promotional videos by Vestas Wind Systems, the world's biggest turbine maker. However, they originally came from a study by the U.S. Forest Service and are similar to numbers used by the U.S. Fish and Wildlife Service and the Wildlife Society — earnest defenders of birds and bats.

....It’s nice for wind-farm planners to take migration patterns and endangered habitats into account. But even if wind turbines were to double in size and provide 100 percent of our energy needs (both of which defy the laws of physics as we currently understand them), they still wouldn’t compare to the modern scourges of high-tension power lines or buildings with glass windows. Not even close.

Wind turbines can be noisy and they periodically kill some birds. We should be careful with them. But the damage they do sure strikes me as routinely overblown. It's bad enough that we have to fight conservatives on this stuff, all of whom seem to believe that America is doomed to decay unless every toaster in the country is powered with virile, manly fossil fuels. But when environmentalists join the cause with trumped-up wildlife fears, it just makes things worse. Enough.

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America's Middle Class is Losing Out

| Tue Apr. 22, 2014 7:20 AM PDT

First, there was Wonkblog. Then came 538. Then Vox. And now we have The Upshot, a new venture from the New York Times that aims to present wonky subjects in more depth than you normally find them on the front page. Today, David Leonhardt and Kevin Quealy kick off the wonkiness with an interesting analysis of median income in several rich countries. Their aim is to estimate the gains of the middle class, and their conclusion is that America's middle class is losing out.

Their basic chart is below. As you can see, in many countries the US showed a sizeable gap in 1990. Our middle class was much richer than most. By 2010, however, that gap had closed completely compared to Canada, and become much smaller in most other countries. Their middle classes are becoming more prosperous, but lately ours hasn't been:

Germany and France show the same low-growth pattern for the middle class that we see in the United States, but countries like Norway, Ireland, the Netherlands, and Britain have shown much faster growth. What's going on?

[The data] suggest that most American families are paying a steep price for high and rising income inequality. Although economic growth in the United States continues to be as strong as in many other countries, or stronger, a small percentage of American households is fully benefiting from it.

....The struggles of the poor in the United States are even starker than those of the middle class. A family at the 20th percentile of the income distribution in this country makes significantly less money than a similar family in Canada, Sweden, Norway, Finland or the Netherlands. Thirty-five years ago, the reverse was true.

Note that these figures are for after-tax income. Since middle-income taxes have been flat or a bit down in the United States, this isn't likely to have had much effect on the numbers.

Quote of the Day: Here's How the GOP Shows Its Enviro Cred

| Tue Apr. 22, 2014 6:58 AM PDT

Jonah Goldberg says it's unfair that environmental groups are almost uniformly anti-Republican:

Contrary to what you may have heard, GOP politicians still care about the environment, but they take their cues from public opinion, not from the green lobby. This often means that when the green lobby denounces Republicans (or centrist Democrats) for supporting drilling or fracking, the greens are at odds with the majority of Americans.

So there you go. Conservatives care deeply about the environment, and they demonstrate this commitment by ignoring "global warming hysteria" and instead pandering to public opinion polls at every turn. I'm glad we got that straightened out.

In America, Spending Cuts Are Driven by the Rich

| Mon Apr. 21, 2014 1:15 PM PDT

Over at the Monkey Cage, Larry Bartels presents the remarkable chart on the right. Its message is simple: In most affluent countries, there's net support for government spending cuts, but it doesn't depend much on income. Not only is the level of support modest, but it's the same among rich and poor.

But not in America. Here, demand for spending cuts is driven almost entirely by the well-off:

What accounts for the remarkable enthusiasm for government budget-cutting among affluent Americans? Presumably not the sheer magnitude of redistribution in the United States, which is modest by world standards. And presumably not a traditional aversion to government in American political culture, since less affluent Americans are exposed to the same political culture as those who are more prosperous. A more likely suspect is the entanglement of class and race in America, which magnifies aversion to redistribution among many affluent white Americans.

....The U.S. tax system is also quite different from most affluent countries’ in its heavy reliance on progressive income taxes. The political implications of this difference are magnified by the remarkable salience of income taxes in Americans’ thinking about taxes and government....Income taxes seem to dominate public discussion of taxes and tax policy. For example, years of dramatic political confrontation culminated in a grudging agreement to shave a few percentage points off the Bush tax cuts for incomes over $400,000 per year; meanwhile, a major reduction in the payroll taxes paid by millions of ordinary working Americans expired with barely a whimper.

It's no surprise that spending cuts are popular in other countries: most of them spend a lot of money, and they fund it with high tax rates on just about everyone. But that's decidedly not the case in the United States. Our government spending is relatively low and so are our tax rates. But none of that matters. Rich Americans don't like paying taxes, and as we know from multiple lines of research—in addition to plain old common sense—the opinions of the rich are what drive public policy in America. Add in longstanding grievances against providing benefits to people with darker skins, and you've got a big chunk of the middle class on your side too. This works great for the rich. For the rest of us, not so much.

A Criminologist Takes On the Lead-Crime Hypothesis

| Mon Apr. 21, 2014 10:25 AM PDT

Dominic Casciani of the BBC has a good piece up today about the hypothesis linking lead exposure in small children to violent crime rates later in life. Here's my favorite part:

So why isn't this theory universally accepted?

Well, it remains a theory because nobody could ever deliberately poison thousands of children to see whether they became criminals later in life. Lead theorists says that doesn't matter because the big problem is mainstream criminologists and policymakers who can't think outside the box.

But Roger Matthews, professor of criminology at the University of Kent, rejects that. He says biological criminologists completely miss the point. "I don't see the link," he says. "If this causes some sort of effect, why should those effects be criminal?

"The things that push people into crime are very different kinds of phenomena, not in the nature of their brain tissue. The problem about the theory is that a lot of these [researchers] are not remotely interested or cued into the kinds of things in the mainstream.

"There has been a long history of people trying to link biology to crime — that some people have their eyes too close together, or an extra chromosome, or whatever. This stuff gets disproved and disproved. But it keeps popping up. It's like a bad penny."

If Matthews didn't exist, someone would have to invent him. He plays the role of closed-minded scientist to perfection here. He obviously hasn't read any of the literature about lead and crime; doesn't care about the evidence; and is interested only in sociological explanations of crime because he's ideologically committed to a particular sociological school of criminology. Beyond that, he apparently figures that because phrenology got debunked a century ago, there's no real point in reading up on anything more recent in the field of neuroscience. All this despite the fact that mainstream criminology is famously unable to reasonably account for either the epic crime wave of the 60s through the 80s or the equally epic decline since then.

In any case, if anyone really wants to know why the lead theory isn't universally accepted, the answer is easy: it's not universally accepted because it's new and unproven. Nor does it pretend to be a monocausal explanation for all crime. However, there's pretty good reason to think that neurology might indeed mediate violent behavior, and there's pretty good reason to think that massive postwar exposure to lead may have been a very particular neurological agent mediating a large rise in violent crime starting in the mid-60s. The evidence isn't bulletproof, but it's pretty strong. It deserves more than cavalier dismissal.