Kevin Drum

Is This the Most Astonishing Obamacare Result Ever?

| Thu Mar. 31, 2016 1:11 AM EDT

Phil Price points us today to an intriguing chart from the Department of Health and Human Services. It shows readmission rates within 30 days of a hospital stay for Medicare patients—including both "official" readmissions and short-term "observations"—and it's pretty stunning. When Obamacare passed, readmission rates started to fall dramatically almost instantly. They fell most sharply for a subset of conditions specifically targeted by Obamacare, and by a smaller amount for other conditions. If this is accurate, it means that hospitals could have done something about readmission rates all along, but they just hadn't bothered. Only after Obamacare provided an incentive to get their readmission rates down did they do anything about it.

So how should we think about this? I'll confess to some skepticism because the chart is almost too perfect. For four years the readmission rate is dead stable. Then, in a single month between December 2010 and January 2011 it suddenly drops by a full percentage point, and continues dropping for two years. This decline started about eight months after the passage of Obamacare, and it's hard to believe that hospitals could react that quickly.

Then, the very instant that penalties begin for high readmission rates, everything stabilizes again. Apparently America's hospitals unanimously decided that once they'd hit a certain level, that was good enough and they wouldn't bother trying to improve even more.

Maybe. But even for those of us who believe in incentives, this is the damnedest response to a new incentive I've ever seen. I guess my advice is to treat this with cautious optimism. It looks like a great result, but as with most Obamacare outcomes, it's too early to tell for sure how things are going to work out. When we have five or ten years of experience, we'll start to be able to draw some concrete conclusions. Until then, we can say how things seem to be going so far, but not much more.

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Yet More Obama Tyranny Turns Out to Be Pretty Non-Tyrannical

| Wed Mar. 30, 2016 9:08 PM EDT

Stanley Kurtz is yet again in a lather about a HUD program called Affirmatively Furthering Fair Housing, the centerpiece of President Obama's plan to fight housing discrimination:

Federal Tyranny Gags GOP in Hillary’s Backyard

The Obama administration’s AFFH policy has morphed from “mere” massive regulatory overreach into a bald attempt to quash the freedom of speech of its political opponents. The new federal effort to muzzle Westchester County Executive Robert Astorino’s attacks on the Obama administration’s housing policy is very arguably designed to silence public opposition to AFFH, and to remove a potential political time-bomb from Hillary Clinton’s presidential campaign.

Hillary Clinton’s hometown of Chappaqua, in Westchester County, New York is ground zero in the national controversy over AFFH....And now it just so happens that the “Federal Monitor” appointed to oversee the settlement of a court case compelling Westchester to “affirmatively further fair housing” has asked a court to muzzle Astorino.

But here's a funny thing: Westchester's problems were caused by a private lawsuit filed in 2006, which it lost in February 2009. It hardly seems likely that Obama had much to do with that. And it seems doubly unlikely that AFFH, which was announced a mere nine months ago, could possibly be "ground zero" for a fight that's been ongoing for over a decade.

Still, I suppose those are nits. Regardless of when it all started, it's certainly outrageous for the feds to try to gag an opponent of their policies. This is the kind of thing that—

What's that? Maybe I should take a look at the federal monitor's actual court filing? How tiresome. But we're professionals around here. Let's see now...ah, here it is on page 55: "Recommended Remedies." This is what the monitor wants:

  • a Court declaration reemphasizing the essential terms of the Settlement and issuing findings making clear that none of the terms have been changed and the County’s statements analyzed in Section II of this report are false;
  • distribution by the County, voluntarily or by order, of the declaration and findings described above to the leadership of all of the eligible communities;
  • posting the declaration and findings described above prominently on the County website and the removal of press releases inconsistent with the declaration and findings;
  • unsealing the videotapes of the depositions of, at the least, the County Executive, the Commissioner of Planning, and the Director of Communications, inasmuch as each made or reviewed unsupported public statements that were inconsistent with both the terms of the Settlement and their own sworn testimony; and
  • hiring, within 30 days of the issuance of this report, a public communications consultant that will craft a message and implement a strategy sufficiently robust to provide information broadly to the public that describes the benefits of integration, as required by Paragraph 33(c)....

Basically, Westchester is under court order to do certain things. They haven't done them. In fact, county leaders have been loudly and habitually lying about both the consent decree and HUD's affordable housing requirements for years. So now the monitor wants (a) the actual terms of the settlement to be widely distributed, (b) depositions to be unsealed so everyone can see what county leaders have been saying under oath, and (c) a third-party consultant to craft the court-ordered PR plan, since the county plainly has no intention of obeying the consent decree on its own.

But nobody is being muzzled. As near as I can tell, Astorino can continue saying anything he wants. However, the county, in its official capacity as an arm of the government, is required to carry out the consent decree. In the face of repeated intransigence, the federal monitor is asking the court to force it to do just that.

I like reading The Corner. It's a good place to get a lot of different conservative opinions on the headlines of the day. But there are a few bylines I routinely skip because the authors are basically unhinged. Kurtz is one of them. Among other things, he was part of the crowd that went bananas about Bill Ayers during the 2008 campaign, and he's been flogging Obama's "war on the suburbs" for years. Today's post is just the latest installment.

Anyway: No muzzling. No gagging. No tyranny. Just a county that refuses to obey a court order and a federal monitor who wants a judge to push harder on them. It's hard to think of anything more routine.

Donald Trump Wants to Punish Women Who Have Abortions

| Wed Mar. 30, 2016 2:47 PM EDT

Sigh. Yet another news cycle for Donald Trump:

Donald Trump Is Galactically, Deliberately Ignorant

| Wed Mar. 30, 2016 1:07 PM EDT

The depth of Donald Trump's ignorance is inexplicable. Seriously. How is it that after nine months of campaigning he still knows less about most subjects than your average guy in a bar working on his fourth beer?

At the CNN town hall last night, an audience member asked Trump, "In your opinion, what are the top three functions of the United States government?" That's not a bad question. I think that pretty much every presidential candidate will say that national security is No. 1, but there are plenty of good choices for the next two. Protecting the environment. Keeping taxes low. The social safety net. Protecting religious liberty. Climate change. Gun rights. Creating jobs. Etc.

But watching last night, it was obvious that Trump had no idea what to say. So after mentioning national security, he paused a bit and then decided on health care and education. This produced incredulity from Anderson Cooper:

COOPER: Aren't you against the federal government's involvement in education? Don't you want it to devolve to states?

TRUMP: I want it to go to states, yes. Absolutely. I want—right now…

COOPER: So that's not part of what the federal government's…

TRUMP: The federal government, but the concept of the country is the concept that we have to have education within the country, and we have to get rid of Common Core, and it should be brought to the state level.

COOPER: And federal health care run by the federal government?

TRUMP: Health care—we need health care for our people. We need a good—Obamacare is a disaster. It's proven to be…

COOPER: But is that something the federal government should be doing?

TRUMP: The government can lead it, but it should be privately done. It should be privately done. So that health care—in my opinion, we should probably have—we have to have private health care. We don't have competition in health care.

In his panic to pick two subjects—any two subjects—Trump managed to light on precisely the two that every conservative in the country thinks the federal government shouldn't have a role in. So then Trump fumbles around and starts talking about "the concept of the country" that we have to have education. Brilliant! And Common Core has to be "brought to the state level," because apparently Trump has no idea that Common Core has been a state program from the very start.

Then we get to health care. "We need health care for our people," but it should be privately supplied even if the government leads it. This, of course, is precisely what Obamacare is: a program that coordinates and regulates health care provided by private suppliers. But apparently Trump doesn't know that either.

I know that mocking Trump for his policy ignorance is sort of boring. I mean, what else is new? But is it possible that he's actually getting dumber over time? Out of every possibility available to him, he managed to pick possibly the worst two for any conservative.

It's obvious that Trump not only resists the idea of being briefed about anything, but actively tries to avoid learning anything about the government. Just by accident you'd learn more than this just by running for president. What's the deal here?

Crime in St. Louis: It's Lead, Baby, Lead

| Wed Mar. 30, 2016 11:59 AM EDT

A team of researchers has released a new study investigating the association between childhood lead exposure and later crime rates in St. Louis. Unlike most previous studies, it uses census tracts in order to get the most detailed possible look at subpopulations within the city. Their conclusion: "We uncovered a relatively strong effect of lead on behavior, especially violent behavior." This was true even after controlling for other variables that affect crime rates:

It is important to recognize that for the current analyses, the effect of lead remained a robust predictor of crime using methods capable of accounting for spatial correlations, and above and beyond the possible confounding influence of concentrated disadvantage.

....Because sociologists (as well as other macro-level scholars) have continued to highlight the primacy of concentrated disadvantage (as well as other macro-level variables) in predicting societal adversities (including crime), other relevant predictors such as lead often receive short shrift in the literature as well as less consideration when the topic shifts to policy initiatives. This is less than ideal because lead has emerged consistently, both in the current sample as well as others, and at the macro- and individual-level, as an apparent potent predictor of adverse behavior. Continuing to myopically focus on traditional forms of “social” adversity such as poverty runs the risk of downplaying more important behavioral predictors.

The authors are appropriately cautious about interpreting their findings. This is yet another ecological study, which compares populations across time, and that means it's hard to assess causality. That said, there are now a lot of ecological studies at different levels (census tract, city, state, nation) showing the same result, as well as a smaller number of prospective and medical studies showing the same thing. There are still some unanswered questions about the lead-crime hypothesis—mostly because we lack the data to clearly demonstrate an age cohort effect—but the evidence sure seems to be piling up. There are lots of causes of crime, and lots of ways of reducing crime. But the biggest bang for the buck might be the simplest: get rid of the damn lead. If we start today, we'll be glad we did it 20 years from now.

Blue Cross Blue Shield Report Suggests That Obamacare Is Doing Its Job

| Wed Mar. 30, 2016 10:24 AM EDT

Blue Cross Blue Shield has a new report out that examines Obamacare enrollees in 2014 and 2015:

Health insurers gained a sicker, more expensive patient population after the Affordable Care Act expanded coverage in 2014, according to an early look at medical claims from the Blue Cross Blue Shield Association, which represents the most common brand of insurance. Newer customers had higher rates of diabetes, depression and high blood pressure, among other conditions, the association said in a report released Wednesday.

Technically, there's nothing incorrect in that paragraph. But take a look at the actual data from the report:

It's true that Obamacare enrollees tended to be sicker than pre-Obamacare individual enrollees. But that's not because Obamacare enrollees are especially sick. In fact, they're nearly identical to people enrolled through employer plans, which take all comers and therefore come pretty close to representing the average patient in America.

But if the Obamacare enrollees are about average, what does this say about the pre-Obamacare enrollees? That's pretty obvious: they were considerably healthier than average. Why? Because insurance companies routinely refused to offer individual coverage to anyone who showed even a glimmer of poor health. Obamacare put an end to that, and that's good news.

Oddly, the BCBS report concludes that Obamacare enrollees used more medical services and ran up higher bills compared to those in employer plans. That's a little hard to make sense of, since Obamacare enrollees are no sicker than average and generally have higher deductibles and copays than people in employer plans, which should motivate them to use fewer medical services. One possibility is that this is related to heart disease, the one area where Obamacare enrollees really do seem to be sicker than average. Another possibility is that this is a one-time thing: lots of people had been putting off medical care, and when Obamacare kicked in they spent the next year or two making up for it.

Overall, I'd say the bottom line from this report is two things. First, Obamacare enrollees look fairly average compared to everyone else. Second, it's still early days. It's hard to draw conclusions based just on the startup period. We'll know a lot more after five or ten years have passed.

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Correction of the Day

| Wed Mar. 30, 2016 9:32 AM EDT

From the Washington Post:

CORRECTION: An earlier version of this article incorrectly said that Clinton used two different email addresses, sometimes interchangeably, as secretary of state. She used only hdr22@clintonemail.com as secretary of state.  Also, an earlier version of this article reported that 147 FBI agents had been detailed to the investigation, according to a lawmaker briefed by FBI Director James B. Comey. Two U.S. law enforcement officials have since told The Washington Post that figure is too high. The FBI will not provide an exact figure, but the officials say the number of FBI personnel involved is fewer than 50.

Oh well. Close enough for government work, I guess. One of these days, journalists will learn not to rely on Republican sources when they write about the Clintons. One of these days.

Here's the Frame-by-Frame Footage of Trump's Campaign Manager Grabbing Michelle Fields

| Tue Mar. 29, 2016 3:49 PM EDT

In case you're curious, here's a frame-by-frame breakdown of security camera footage from the Donald Trump rally in Jupiter, Florida, on March 8. It shows Trump campaign manager Corey Lewandowski grabbing Breitbart reporter Michelle Fields in order to get her away from Trump:

A few things are obvious here. First, Fields didn't hallucinate anything, as both Lewandowski and Trump have implied. Second, Lewandowski did indeed grab Fields by the arm, just as she says. Third, Trump was already walking away from her at the time. Fourth, it doesn't really look very serious. Fields is obviously a little nonplussed, but otherwise fairly unscathed.

The whole thing is crazy. It's a minor incident, and all Lewandowski had to do was give Fields a quick call to apologize for grabbing her in his haste to catch up with his boss. Incident over. But apparently that was out of the question. Team Trump never apologizes. Instead they went on the warpath and publicly accused Fields of being nothing but an attention-seeking fantasist.

Yeah, this is definitely the team we need in the White House.

It Looks Like the Supreme Court Is Getting Ready to Rule Against Religious Objections to Contraceptive Coverage

| Tue Mar. 29, 2016 2:33 PM EDT

I might be missing something here, but the latest Supreme Court order in the Little Sisters of the Poor case seems kind of odd. As you'll recall, the Sisters object to the idea of having to submit a form saying that they don't want their health insurance coverage to include contraceptives. Their reasoning is that filling out a form is an affirmative act that will eventually lead to employees getting contraceptives, which they consider a sin.

What to do? Today the Supreme Court noted the Sisters' objections and asked both sides to submit briefs with alternative ideas:

For example, the parties should consider a situation in which [the Sisters] would contract to provide health insurance for their employees, and in the course of obtaining such insurance, inform their insurance company that they do not want their health plan to include contraceptive coverage of the type to which they object on religious grounds. [The Sisters] would have no legal obligation to provide such contraceptive coverage, would not pay for such coverage, and would not be required to submit any separate notice to their insurer, to the Federal Government, or to their employees.

At the same time, [the Sisters'] insurance company—aware that [the Sisters] are not providing certain contraceptive coverage on religious grounds—would separately notify [the Sisters'] employees that the insurance company will provide cost-free contraceptive coverage, and that such coverage is not paid for by [the Sisters] and is not provided through [the Sisters’] health plan. The parties may address other proposals along similar lines, avoiding repetition of discussion in prior briefing.

The briefs are limited to 25 pages, but it sure sounds as if the government could submit a one-page brief that copies this language exactly and agrees that it sounds just peachy. For all intents and purposes, it seems like the Supreme Court is telling them to do exactly that and they'll get a ruling in their favor. End of case.

That's a little unusual, isn't it? That is, for the court to basically tell one of the parties, "say this and you win the case." But that's what it looks like, unless the Sisters manage to manufacture some kind of credible objection even to this.

American Amnesia: Three Cheers For the Mixed Economy!

| Tue Mar. 29, 2016 1:15 PM EDT

In American Amnesia, Jacob Hacker and Paul Pierson defend the mixed economy from the conservative apostles of pure market forces. One of the problems they identify with unchecked markets is externalities, the effects of private actions on others. The problems associated with externalities, they say, become greater as population increases and countries become more urbanized. For example:

Consider one of the great health scourges of the mid-twentieth-century: lead. Exposure to lead was far greater in inner-city neighborhoods—less because of the prevalence of lead paint than because lead additives in gasoline accumulated in automobile-dense urban areas. The consequences were terrible. At the level experienced by kids in urban communities from the 1950s through the 1970s (the decade that saw the phaseout of leaded fuel), lead exposure causes substantial drops in IQ. It also diminishes impulse control. Substantial evidence now suggests that these effects may have played an important role in driving the epidemic of violent crime that began in the 1960s, as well as rising rates of teen pregnancy.

Did they toss that in there just for me? I'd like to think so.

Of course, it's also a very good example of their thesis. Private actors had no particular reason to remove lead from gasoline, and market forces alone probably would never have eliminated it. It was government regulation, in response to research results that were largely government-funded, that got rid of lead in gasoline. That's the mixed economy at work: private buyers and sellers created the basic market, with the government stepping in to regulate it for the common good. The result is better than a pure free market (which produces lead-poisoned kids) and better than socialism (which likely produces shortages of gasoline). For most of the 20th century, the mixed economy was a pillar of all advanced economies, including ours.

But beginning in the 1980s, American conservatism took a turn away from paying even lip service to the mixed economy. Government regulation was bad, full stop. The free market was good. The less that government was involved in the economy, the faster the country would grow, benefiting everyone.

Everyone who gets rich from an untrammeled economy, anyway. The rest of us get lead in our gasoline, pathogens in our food, the most expensive health care in the world, and a financial system so imperious that it can produce an economic collapse and then demand that it get bailed out. How did this happen? Hacker and Pierson follow the trajectory of the Republican Party since its radicalization began during the Reagan administration, and conclude that the GOP's fealty to wealthy and powerful rent-seekers has been pretty successful:

Those whose job it is to serve the public have more to do and less with which to do it. The same is not true of the private industries they are regulating....The typical public worker lives in a world of scarcity. The typical lobbyist lives in a world of abundance: lavish salaries, PR wizards, mercenary experts who can provide just the favorable finding or legislative language needed. No wonder the federal government has hemorrhaged talent.

....The root of the problem is simple: a growing mismatch between the enormous outside pressures on government—more and more organizations in Washington spending more and more to shape policy—and the weakened capacity of government to channel and check those pressures. "More than three decades of disinvesting in government's capacity to keep up with skyrocketing numbers of lobbyists and policy institutes, well-organized partisans, and an increasingly complex social and legal context," argue the political scientists Lee Drutman and Steven Teles, have created "a power asymmetry crisis."

Unregulated markets aren't generally a big problem in small economies. In the United States, it wasn't until the Robber Baron era of the late 19th century that underregulation became a serious issue. The backlash against the Morgans and the Rockefellers eventually produced the modern mixed economy, which served the country well for the rest of the century. But now, as Hacker and Pierson say, we've developed a sort of historical amnesia. A lot of Americans have forgotten both the bad old days and the government actions that made them better. All that's left is a seething anger—stoked by a modern GOP dedicated to corporations and the rich—toward jack-booted government bureaucrats who prevent the economy from taking flight. Get rid of the regulators, and all will be well again.

That might be true if we could also return to the America of the 1830s. But we can't. The United States is bigger, more complex, and far more technologically advanced than it was two centuries ago, and there's simply no plausible counterweight to powerful corporate rent-seekers other than government regulation. Like it or not, the mixed economy is the only way to run a modern country.

Hacker and Pierson do a good job of telling both the history of the mixed economy as well as its more recent breakdown. If you're already familiar with this story, there might not be much new here for you. For the rest of us, it's as good an introduction as you're likely to find.