Kevin Drum

Adding a Private Option to VA Health Care Is Going to Cost a Bundle. We Should Study Whether It Works.

| Fri Jun. 13, 2014 1:00 PM EDT

As part of the deal to fund new VA facilities in underserved areas, Democrats agreed to a Republican proposal that would allow veterans to seek private health care if they live more than 40 miles from a VA facility or if they have been waiting more than 30 days for an appointment. Here's what the CBO has to say about that:

Maybe this is a good thing. Better access to health care means more people will sign up for health care, and they'll do it via private providers. That's the basic idea behind Obamacare, after all. Of course, it's also possible that this might be a bad thing. As Phil Longman points out, outsourced care lacks the very thing that makes VA care so effective: "an integrated, evidence-based, health care delivery system platform that is aligned with the interests of its patients."

Because the VA truly is a system, it can coordinate among all the different specialists and other health care providers who are necessarily involved in patient care these days. And because it operates as a system, the VA can also make sure that all these medical professionals are working from a common electronic medical record and adhering to established, evidence-based protocols of care—not inadvertently ordering up dangerous combinations of drugs, or performing unnecessary surgeries and tests just to make a buck.

So which is it? Beats me. That's why I sure hope someone is authorizing some money to study this from the start. It's a great opportunity to compare public and private health care on metrics of both quality and cost. It's not a perfect RCT, but it's fairly close, since the people who qualify for private care are a fairly random subsegment of the entire VA population. If we study their outcomes over the next few years, we could learn a lot.

And that's important, because this isn't cheap. As CRFB points out, if this policy is extended beyond its initial pilot period it will cost more than we saved from the entire defense sequester and more than Medicare Part D. This is an opportunity that shouldn't be passed up.

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The Latest From California: Obamacare is Working

| Fri Jun. 13, 2014 11:17 AM EDT

California's biggest health insurer says there won't be any Obamacare rate shock next year:

In the strongest indication yet where Obamacare rates are headed, industry giant Anthem Blue Cross said its California premiums for individual coverage will increase less than 10% on average next year....[Anthem Blue Cross President Mark Morgan] said the age and projected medical costs of new enrollees are in line with the company's expectations thus far.

California is a big state that had a successful Obamacare rollout, and there's no telling if we'll see the same kinds of rate hikes in other states. But it's telling that Morgan said the demographic profile of its new Obamacare enrollees was about what they were expecting. Presumably, they're also seeing new enrollees pay their first premiums at about the rate they expected.

Note that these are no longer just vague predictions. Anthem and other insurers filed their rate increase applications with the state last week, and final rates will be set a few weeks from now.

Obamacare got off to a rough start. But despite endless hysterics from an endless stream of conservative talking heads—enrollment numbers are low, there aren't enough young people, nobody is paying their premiums, blah blah blah—Obamacare is working. It's not perfect, and it could be better if Republicans were willing to allow improvements. But it's working.

Eric Cantor's Surprise Defeat Means Virtually Nothing

| Fri Jun. 13, 2014 10:50 AM EDT

Brian Beutler emerged from his cave to get some lunch after 48 hours of covering Cantormania and discovered that....the rest of the world doesn't care:

When I arrived, the people in line were as bored and diet-conscious as they always are. Most of them were looking down into their smartphones. A few chatted with colleagues or fellow tourists about trivia like the weather (it was hot). Nobody seemed to realize that something extraordinary had just happened.

The profound contrast to the humming worlds of political Twitter, the U.S. Capitol, K Street, and Web Traffic™ now strikes me as incredibly apt symbolism. Three days later, Cantor's defeat still the biggest story in American electoral politics. But its legacy is shaping up to be a lot more humdrum than the buzz and and excitement surrounding it imply.

I'd go even further. Cantor's loss was a shock because no one predicted it. And of course, Cantor was a big wheel. But all the talk about the rise of right-wing populism or a civil war with the GOP or the victory of the tea party is just nonsense. It's just flatly not there.

Look. Cantor fucked up and something weird happened in Virginia's 7th district. But guess what? There have been lots of other primaries too this year. In some of them a tea-party conservative has won. In most of them, the incumbent won. When you look at the broad picture, you can't pretend that Cantor's loss overwhelms everything else. It doesn't. It's one primary, and it counts as one primary. And that means the broad picture is about the same as everyone thought a week ago: the Republican Party is becoming more conservative; the tea party largely controls the party's agenda in Congress; and occasionally there are going to be some primary upsets. As near as I can tell, there haven't been any more this year than in 2010 or 2012.

So don't let the shock of Cantor's defeat get to you. It's shocking mainly because all the pollsters got it wrong. But the fact that some pollsters screwed up means that....some pollsters screwed up. It doesn't mean there's an upheaval in the GOP that's changed the face of American politics. That upheaval is four years old, and we already know all about it.

We Hate Each Other, We Really Hate Each Other

| Fri Jun. 13, 2014 12:37 AM EDT

Pew has released a gigantic survey report on political polarization in America, and everyone will find fascinating nuggets throughout. The most consistent takeaways are these:

  • Polarization has increased considerably over the past few decades.
  • Both sides have moved away from the center, but conservatives have moved further.
  • Both sides tend to be more cocooned than in the past, but more conservatives live in a bubble than liberals.
  • Conservatives vote a helluva lot more than liberals. But you already knew that.

Here are three of my favorite charts from the report, picked semi-randomly. First up is one that I choose to interpret as supporting my view of Fox News as the primary source of the most toxic Gingrichian tendencies in the Republican Party. Take a look at the right side of this chart. Among consistent liberals, their dislike of the Republican Party goes down in the late 90s, then up in the aughts, then down again after 2010. This seems reasonably explainable by a growing antipathy whenever a Republican is president.

Now look at the left side. There's no such trend. Among consistent conservatives, dislike of the Democratic Party just goes up and up and up. These are the most rabid Fox watchers, and I'd submit that this is the most likely explanation for their skyrocketing hatred of Democrats.

Second, here's what people do and don't like. As every liberal has insisted forever, and as every conservative has vociferously denied just as long, conservatives are much more likely to be open racists. The more conservative you are, the more likely you are to be unhappy if a family member marries someone of another race. This is in the year 2014.

In the spirit of equal time, you see exactly the same dismay among liberals at the prospect of a family member marrying a gun owner. In fairness, however, gun ownership is an active personal choice that informs a person's character, so this is more defensible.

Third, here's yet more confirmation that atheists are still the most distrusted people in the country. An astounding 73 percent of consistent conservatives would be unhappy if a family member married an atheist. Hell, even 24 percent of consistent liberals would be unhappy at the prospect. Jeebus.

Missing the Point With Statistics

| Thu Jun. 12, 2014 5:52 PM EDT

I just caught a few minutes of the Brazil-Croatia World Cup opener ("patient possession football" said the announcer, which apparently means kinda slow and humdrum), and before I knew it, it was halftime. So I switched over to CNN to see if anything was going on, and caught a pretty good example of how to miss the point with statistics. The chart at issue is on the right. According to James Alan Fox of Northeastern University, mass shootings aren't on the rise, even though it might seem that they are. But there's something missing from this analysis, and regular readers who know my hobbyhorses should be able to guess what it is.

Is it the fact that the yellow line does, in fact, seem to be rising steadily? No. An eyeball analysis suggests that it is, but it's not a big rise, and anyway, it's probably accounted for by population growth.

Nope, it's this: Since 1993, the rate of violent crime in America has plummeted by half. That's the background to measure this against. In general, America has become a much safer, much less lethal place, and yet mass shootings have remained steady. Compared to the background rate of violent crime, mass shootings have doubled. Why?

And here's an equally interesting question: between 1976 and 1993, violent crime increased by a significant amount, but mass shootings remained steady. Again, why?

Raw numbers are a starting point, but they don't tell the whole story. If Americans, on average, are considerably less violent than they were 20 years ago, shouldn't mass shootings be down? The answer presumably, is that mass shootings are actually up when you measure them correctly, or else that mass shootings have nothing to do with violent tendencies in general. My guess is the latter, and it would be genuinely interesting to hear from experts about why this is.

Iraq's Problems Are Not Ones That America Can Solve

| Thu Jun. 12, 2014 2:56 PM EDT

One of the things that liberals chattered about endlessly in the latter stages of the Iraq War—and which seemed to annoy conservatives just as endlessly—was the simple claim that Iraq's problems were fundamentally political, not military. There would be no lasting peace in Iraq unless and until there was a political accommodation between the Kurds, the Shia, and the Sunni—especially the latter two. Unfortunately, Prime Minister Nouri al-Maliki seemed completely uninterested in reaching any sort of genuine power-sharing agreement with the Sunni minority that had ruled Iraq in Saddam's day, and no amount of cajoling from Americans swayed him even a little. Without that, any kind of durable peace in Iraq was out of reach, so it made sense for us to leave in 2011. Why remain when there was little we could do that would truly make a difference?

This is why our withdrawal from Iraq is no more than a tiny peripheral factor in the growing jihadist Sunni rebellion that's overwhelming Iraq right now. Ditto for our reluctance to arm "moderates" in the Syrian civil war. Laying the blame there is mostly just a tired but convenient talking point for the Fox News set and the dwindling but noisy band of unrepentant neocons. Marc Lynch takes up the story from there:

The more interesting questions are about Iraq itself. Why are these cities falling virtually without a fight? Why are so many Iraqi Sunnis seemingly pleased to welcome the takeover from the Iraqi government by a truly extremist group with which they have a long, violent history?

....The most important answers lie inside Iraqi politics. Maliki lost Sunni Iraq through his sectarian and authoritarian policies. His repeated refusal over long years to strike an urgently needed political accord with the Sunni minority, his construction of corrupt, ineffective and sectarian state institutions, and his heavy-handed military repression in those areas are the key factors in the long-developing disintegration of Iraq. In late 2012, protests had swelled across Sunni areas of Iraq, driven by genuine popular anger but backed by many of the political forces now reportedly cooperating with ISIS’s advance (essential background here). The vicious assault on the Huwija protest camp by Iraqi security forces, in the midst of political negotiations, galvanized hostility to the Iraqi state and paved the way for growing popular support for a returning insurgency. Maliki’s heavy-handed security response to the escalating insurgency across Anbar, including the bombardment of Fallujah, has predictably driven more and more Sunnis into their ranks. Maliki’s purges of the Sunni leadership discredited or removed Sunni leaders willing to play the inside game, and pushed some of them toward supporting insurgency. His exclusionary policies, attempts to monopolize power and rough security practices radicalized a Sunni community that might have been brought into the system following the civil war. Iraq’s political class as a whole has done little better.

Lynch offers a few additional thoughts on whether Maliki is likely to change course in the face of the threat from ISIS insurgents. So far, it doesn't seem likely. And as long as that's true, there's little reason that America should get involved in Iraq's ongoing sectarian war yet again.

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Living in the World That Fox News Built

| Thu Jun. 12, 2014 12:32 PM EDT

Andrew Sullivan made the mistake of spending an evening watching Fox News:

Here’s the gist: the president is a lawless dictator, abetting America’s Islamist foes around the world, releasing Taliban prisoners to aid in his own jihad on America, fomenting a new caliphate in Iraq, and encouraging children to rush the Mexican border to up his vote-count, while effectively leaving those borders open to achieve his “fundamental transformation of America.”

I watched Megyn Kelly, who is regarded as more centrist than Sean Hannity. You could have fooled me. The guests were Brent Bozell, far right veteran, and Andy McCarthy, pro-torture activist touting his book calling for Obama’s impeachment. The only pushback Kelly provided to a relentless stream of hysteria was to ask whether the president sincerely wanted another terror attack on America — since it would hurt his approval ratings. And that provided the only qualification to the picture of a Jihadist in the White House determined to destroy the America he loathes.

That's classic. Hey guys. We all know Obama's an empty suit who only cares about his poll standings. Amirite? So maybe he's opposed to terror attacks on America after all. You know, just to keep his approval ratings up.

I wish I had something really insightful to say about this, because for all the attention it gets, it still deserves more. Over the years, the more that I've thought about the evolution of conservative politics over the past few decades, the more I become convinced that Fox News is really at the center of it. Sure, it all started with a base of Reagan and the Christian Right and talk radio and the Republican takeover of the South. But Newt Gingrich was the game changer. He's the one who brought conservative politics to a truly new, truly unprecedented level of toxic rancor.

Here's the thing, though: As critical as Gingrich was, he lasted only a few years before flaming out and becoming a historical footnote. It was Fox News that became the ongoing, institutional expression of Gingrichism. The Republican Party would have turned right in any case, but without Fox I'm just not sure Gingrichism would ever have developed a critical mass. Without Fox, our politics never would have gotten so astonishingly toxic that a significant fraction of the nation—not just a fringe—honestly believes that we have a lawless, America-hating tyrant in the White House who's literally committed himself to destroying the country from both within and without.

Yes, the tea party has won. But it won because of support from Fox News. In reality, it's Fox News that won. And for all that Fox gets a lot of attention, I still wonder how many non-conservatives really watch it. Not just the occasional clip on Jon Stewart or Media Matters that's good for a laugh or an eye roll. How many really sit down occasionally and take in a full evening? Or a whole day? Because that's the only way you'll really understand.

Immigration Reform Is Dead, and That's Still a Big Problem for the Republican Party

| Thu Jun. 12, 2014 11:34 AM EDT

I got into an email argument with Greg Sargent yesterday over my belief that immigration reform has been "dead" for months and remains dead following Eric Cantor's primary defeat. His view is a little more nuanced: it could pass anytime John Boehner allows it to come up for a vote, so it's not really right to simply call it dead. As it happens, that strikes me as a distinction with barely a difference. The bulk of the Republican Party is dead set against immigration reform, and no party leader is going to buck that. In every practical, political sense, then, it's dead. And since this is my blog, I get the last word.

However, one of the fundamental issues here is the size and intensity of the pro-immigration wing of the GOP. This includes business interests, law enforcement, evangelicals, etc., and my take is that they have neither size nor, especially, intensity on this issue. That's why immigration reform has gone nowhere. But there is one other pro-immigration faction that matters: the party establishment, which believes that unless they do something to win back a share of the Latino vote, they're doomed forever in presidential contests. But how scared are they of this? And how scared should they be?

A new report from the Center for American Progress suggests they're pretty justified in being scared. Immigration reform is an especially salient voting topic for first- and second-generation immigrants, and that group has two important characteristics: (a) it's growing as a share of the Latino population, and (b) it's turning out to vote in ever higher numbers:

Republicans may be able to hold onto Congress for a while longer in the face of numbers like these, but winning the presidency is going to get harder and harder. Not impossible. But that's a mighty big headwind, and it's getting stronger every year.

The System Worked

| Thu Jun. 12, 2014 10:38 AM EDT

Dan Drezner says the system worked:

The initial shock of the 2008 financial crisis was worse than what happened in 1929, and yet we didn't experience another Great Depression. Outside the developed world, the global economy has actually done remarkably well. That's the interesting story, as far as I'm concerned.

This is true. It didn't work perfectly, or even as well as it should have. But it worked. What's more, you can make a pretty good case that the United States did a better job—or, at a minimum, as good a job—as any other major region in the world. We could have done a lot better if we had been plagued by fewer of what Keynes famously called "slaves of some defunct economist," but still. It's worth celebrating that for all the mistakes we made, we really have learned a lot, and we really are able to handle global economic meltdowns a lot better than in the past.

Can You Guess When Violent Crime in Our Schools Peaked?

| Wed Jun. 11, 2014 8:52 PM EDT

Via Tim Lee, here's a pretty interesting chart from a newly released report on crime in schools. It shows the rate of violent crime committed on campus: rape, robbery, assault, and sexual assault.1 And it sure looks pretty familiar, doesn't it? It peaks in 1993, about 18 years after leaded gasoline started being phased out in 1975, then turned down and continued declining for the next 20 years.

Since the oldest students in our schools are 18 years old, the crime rate should start to flatten out approximately 18 years after the final elimination of leaded gasoline in 1995. That would be 2013. And so far, it looks like that's about what's happening.

All the usual caveats apply. This isn't proof, it's just a data point. But it's a pretty compelling data point, isn't it?

1Homicide isn't included, but the homicide rate in schools is so low that it doesn't affect these figures noticeably.