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Senate AHCA Version – Premium Increases and Subsidy Reductions

CBPP has this pictorial analysis of the increased premiums resulting from the Senate version of the AHCA for a 60 year old at 350% FPL with an ACA Silver plan. “For a 60-year-old with income of 350 percent of the poverty level (about $42 ,000 today) facing the average premium on HealthCare.gov, out-of-pocket premiums would jump by an estimated $4,994. Premiums would rise by $ 2,022 for a 45-year-old at this income level, and fall by $75 for a 30-year-old. Premiums would rise by $2,694 for a 60-year old with income of 300 percent of the poverty line, and by $1,903 for a 60-year old with income of 150 percent of the poverty line.”

Premium Increase The Senate AHCA Bill increases Premium Costs .

A sixty year old slightly above 350% FPL would face the loss of thousands of dollars in tax credits. Presently, the ACA covers up to 400% FPL and limits how much can be charged for age to 300%. The AHCA goes to 500% and reduces the subsidy coverage to 350% FPL.

Losses in Tax Credits Senate AHCA also eliminates subsidies for those between 350% and 400% FPL resulting in $thousand of dollars in cost for those in the Individuals Market.

Senate Bill Still Cuts Tax Credits, Increases Premiums and Deductibles for Marketplace Consumers CBPP, Aviva Aron-Dine and Tara Straw, June 25, 2017

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Chait vs Roy on Baicker not really vs Baicker

Jon Chait has a brilliantly ruthless takedown of the absurd defences of the AHCA (house obamacare replacement) and BCRA (Senate version) . His main point is that Republicans are lying claimiing the huge cuts to Medicaid aren’t cuts to Medicaid and that the huge increase in the number of uninsured will actually be zero.

He also criticizes Avik Roy. This quarrel has become very interesting. Roy praised the BRCA. He refused to answer when Chait asked if he had also written it. Roy will not say if he is commenting on his own work without noting the conflict of interest.

Jonathan Chait‏Verified account @jonathanchait
Update: @avik tells me his policy is to not disclose his role in crafting legislation.

Chait notes that Roy praises the bill for increasing deductibles and also notes that Republicans denounced the Obamacare deductibles — for being too high. This just shows hypocrisy ( ok psychopathic dishonesty) or GOP politiicians. I’m sure Roy believes dedcutibles should be high, and Republicans in Congress have revealed a preference for high deductibles.

Chait also objects to Roy’s claim that Medicaid doesn’t cause improved health. Interestingly I had the same debate with someone on twitter yesterday. In both debates, the case against Medicaid is based on a citation of Baicker et al (2013) the report on the Oregon Medicaid experiment.

Chait (and I) responded by citing Somers Gawande and Baicker (2017) who wrote

Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply
inconsistent with the evidence.

and

One head-to-head quasi-experimental study of Medicaid versus private insurance, based on Arkansas’s decision to use ACA dollars
to buy private coverage for low-income adults, found minimal differences.11

So is it Chait’s experts against Roy’s experts ?

Not at all. Roy bases his argument on Baicker et al and Chait on al et Baicker. Katherine Baicker PhD (who should know) does not think that Baicker et al (2013) showed that Medicaid doesn’t work.

Indeed she concedes much less than Chait does. He wrote “The study was unable to detect better physical health outcomes.” This is false. The study found better physical health outcomes in the treatment group than in the control group. What Chait should have written was “the study was unable to detect statistically signficicantly better physical health outcomes”.

Treating a statistically insignificant evidence improvement as evidence that there was no improvement is a gross error. It is also almost universal (I have doubts only about the “almost”). In fact Baicker et al found statistically significant effects on access to health care, diagnosis of diabetes, and treatment of diabetes. They did not find new proof that standard treatment of diabetes is better than no treatement. In every other context, this is not treated as an open question. The study did not find statistically signficant evidence that the benefit was smaller than predicted based on other studies either.

But the motto of the New England Journal (and all serious scientific journals) is first make no claims which go beyond the data.

Statistically insignificant is not an assertion. It doesn’t mean zero. It doesn’t mean small. So it is always favored. Then it is read as meaning small or zero.

Chait understands this. He argues that the Baicker et al (2013) study had low power so the fact that “The study was unable to detect better physical health outcomes.” [failed to reject the null of zero effect on physical health] doesn’t tell us much. But even in the context of a discussion of power, he refuses to distinguish zero from statistically insignificantly different from zero. I think there is some rule that people writing for general audiences must not use technical terms like “statistically insignificant”. The result is that they write falsehoods.

Tens of thousands of people a year may die partly because people just will not accept that the Neyman Pierson framework is what it is.

In any case, Roy is reduced to arguing that he understand Baicker et al (2013) and Baicker doesn’t. He is not in great shape totally aside from the question about unreported conflicts of interest.

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BCRA CBO Score

WASHINGTON (AP) — Congressional Budget Office sees 22 million more uninsured by 2026 under Senate health bill.

Toher Spiro appears to be snipping and tweeting the key bits of the CBO report

Premiums for a 64-year old with middle income go from $6,800 under ACA to $20,500 under BCRA

Deductibles for plans eligible for tax credits go from $3,600 under ACA to $6,000 under BCRA

death spiral

open thread.

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Welfare Reform Kills ?

This is an update of this post in which I expressed immense confidence that welfare reform killed people in Florida .

The post is based on

https://www.ncbi.nlm.nih.gov/pubmed/23733981

Muennig P1, Rosen Z, Wilde ET. (2013) “Welfare programs that target workforce participation may negatively affect mortality.”

Abstract

During the 1990s reforms to the US welfare system introduced new time limits on people’s eligibility to receive public assistance. These limits were developed to encourage welfare recipients to seek employment. Little is known about how such social policy programs may have affected participants’ health. We explored whether the Florida Family Transition Program randomized trial, a welfare reform experiment, led to long-term changes in mortality among participants. The Florida program included a 24-36-month time limit for welfare participation, intensive job training, and placement assistance. We linked 3,224 participants from the experiment to 17-18 years of prospective mortality follow-up data and found that participants in the program experienced a 16 percent higher mortality rate than recipients of traditional welfare. If our results are generalizable to national welfare reform efforts, they raise questions about whether the cost savings associated with welfare reform justify the additional loss of life.

It’s not in the abstract, but they also analysed a larger data set and got a larger point estimate of 26% higher deaths due to participation in welfare reform.

The authors have since conceded that they unreasonably underesimated the standard errors of their point estimate. They used cluster robust standard errors with only 2 clusters (2 counties). This is not valid (the estimate of the variance of the point estimate of 16% more deaths is biased down). A reader noticed (as I should have) that the large difference between 16% and 26% would be extremely unlikely if the analysis had been correct.

using a reasonable fixed effects estimator (without the cluster robust consistent but biased down standard errors) they get

In the article we also presented combined results including participants in both Escambia and Alachua Counties, again controlling for year of birth, year of assignment, and site location and clustering the standard errors on location. The point estimate for that analysis is 1.26 (95 percent CI: 1.10, 1.45). Without clustering the standard errors around location, while controlling for location fixed effects as well as the other covariates, the new point estimate is 1.26 (95 percent CI: 0.96, 1.66).

So the more reasonably estimated stardard errors are roughly twice as large as the biased down ones. This means that the null of no effect (ratio of mortality rates =1) isn’t rejected at the 5% level. It is close. But the p-level of a t-statistic of a bit less than 4 is tiny (hugely significant).

The corrected standard errors imply evidence that welfare reform killed people, but not strong evidence. Hence the question mark in the updated title.

Like the authors, I apologize. I should have read the paper more carefully.

I thank Douglas Hess @douglasrhess for pointing out the published correction

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Did Conway Con Herself

This is remarkable even for the Trump administration. Kellyanne Conway claimed that the Medicaid slashing BCRA proposed by the gang of 13 doesn’t include “cuts to Medicaid”.

The Trump administration position appears to be that Trump could sign it in to law and keep his promise to protect Medicaid from cuts. Wow.

I am not President of the USA, but this doesn’t seem to be good strategy to me. It makes it clearer than ever that Trump will throw representatives and senators who vote yes under the bus if the horrible bill becomes even more unpopular as a horrible law causing horrible suffering. It also makes it clear that they will have to deal with the debate about whether $ 800 billion is zero. They could choose to repeatedly say that Trump is a liar (which will hurt them as much as voting no) repeatedly tell blatant lies about the suffering they caused, or they can avoid that debate by voting the bill down. To me the third option looks very attractive.

Already Susan Collins has had to say that she “disagrees” with Conway. She should understand that a yes vote will only be the beginning of dignity wraithdom.

It’s a small thing compared to tens of thousands of deaths a year, but Senators don’t like to be humiliated at all. I hope this makes some difference.

Update: Also Price

“HHS Secretary Tom Price making a bold delararion to @DanaBashCNN: “We would not have individuals lose coverage.” “

We know he’s shameless, but how many seantors representatives are willing to stand up for such absurd lies.

Also I don’t think insulting the CBO is optimal strategy right now. For one thing they are working very hard over the weekend to get a report which the Senate needs in order to consier the BRCRA. If someone treated me as Price treats them, I would be very very lazy (trivially true as I am, have always been and will always be very lazy). Also they can calculate effects on coverage outside the 10 year window first (they are doing this) and work backwards.

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McConnell’s AHCA Kabuki

he McConnell Obamacare repeal and replace “discussion draft” is worse than I imagined possible even taking into account that it would be worse than I imagined possible. I fear he made sure it was horrible so moderate Senators could win staged battles and claim they had saved people (needless to say I am not the first to write of this possibility).

I guess a vox explainer is always useful and Sarah Kliff is very smart thorough and reliable.

The bill is surprisingly aweful in two ways. First it doesn’t slow the phasing out of the ACA Medicaid expansion over 7 years but rather does it in 3 (from 2021 through 2024). Several relatively non reactionary Republican senators stressed how important of 7 year phaseout was to them. Also the bill contains no additional funding to deal with the opioid addiction crisis. Many of those senators specifically proposed this increased funding.

I fear that this is all theater. That the so called moderates will get their 7 years and their opioid treatment funding and then vote yes. Not including them in the “discussion draf” will make this more dramatic, allow the self described moderates to claim credit, and give them cover.

The Senators in question are almost saying this is their price.
I will include phone numbers in case any reader is interested in calling to say he or she is not falling for it. All are from the very useful

https://www.trumpcaretoolkit.org/

The Senators include
Robert Portman of Ohio (202-224-3353) who wrote
portman

This almost explicitly says his price is an extended Medicaid phaseout and, especially, money for treatment of opioid addiction.

Shelley Moore Capito of West Virginia (202-224-6472 called senator Capito with the accent on the a not on the i as in the Italian word for understood)
She has a very strong position on increased opioid treatment funding. West Virginia (like Ohio) is hard hit by the epidemic.

Her web page includes

Earlier today, I posted a link to the health care discussion draft on my website for all West Virginians to read. Over the course of the next several days, I will review the draft legislation released this morning, using several factors to evaluate whether it provides access to affordable health care for West Virginians, including those on the Medicaid expansion and those struggling with drug addiction.

Which, again, is very clear. I want to mention that I guessed there was a press release similar to Portman’s before checking, and why, lo and behold, there is (it’s almost as if they coordinated).

Dean Heller of Nevada (202-224-6244 is another self described moderate (and up for election in 2018 and very vulnerable)

His web page has

“Throughout the health care debate, I have made clear that I want to make sure the rug is not pulled out from under Nevada or the more than 200,000 Nevadans who received insurance for the first time under Medicaid expansion. At first glance, I have serious concerns about the bill’s impact on the Nevadans who depend on Medicaid. I will read it, share it with Governor Sandoval, and continue to listen to Nevadans to determine the bill’s impact on our state. I will also post it to my website so that any Nevadans who wish to review it can do so. As I have consistently stated, if the bill is good for Nevada, I’ll vote for it and if it’s not – I won’t.”

Again quite clear. The phrase “the rug is not pulled” is almost explicit that slowly sliding it out from under them would be OK. The reference to Sandoval is important, as Sandoval is very popular in Nevada and signed a letter opposing the House AHCA and generally arguing for bipartisan compromise (so did Gov. Kasich of Ohio whom Portman didn’t mention).

update 3: This is interesting. John Ralston is a very highly respected expert on Nevadan politics. He tweeted

“I don’t think so. And will say he [Heller] votes No after consulting with @GovSandoval.”
replying to another top reporter, Ronald Brownstein, who tweeted “#AHCA reduces # covered by Medicaid in NV by 45%. #SenateHealthCareBill proposes > l/t cuts. Can @SenDeanHeller vote Y? @RalstonReports”
end update:

OK how about Lisa Murkowski (202-224-6665 only interested in voice mail from Alaskans) ?
Nothing yet. I actually find this promising. She might not have decided on the price of her vote.

Finally (for moderates for now) Susan Collins of Maine (202-224-2523) Nothing on the McConnell discussion draft yet. A lot on the Opioid crisis (very bad in Maine too). Also “bipartisan” is her favorite word. Actually the web page section on health looks OK. Her voting record doesn’t. Collins and Murkowski strongly support funding for Planned Parenthood. Neither have said they will vote no if the elimination of that funding stays in the bill (most likely they propose an amendment and it goes down 50-51 including Pence). I do not want to count on Senator Collins growing a spine.

update: Collins spoke with the press instead of having a staffer write a press release. Her comments as reported by Tierney Sneed are mildly interesting

Sen. Susan Collins (R-ME) gave the Senate health care bill released Thursday a mixed review, but zeroed in on its major cuts to Medicaid as a potential problem for her.

She took issue with how the Senate bill, starting in 2025, used a rate of growth for federal funding for Medicaid that is significantly slower than the typical increases of costs for the program.

“I’m very concerned about the inflator that would be used in the out years for the Medicaid program,” she told reporters in the Capitol a few hours after the bill was released. “It’s lower than the cost of medical inflation and would translate into literally billions of dollars of cuts.”

She added that she was concerned about how the cuts would negatively affect rural hospitals or prompt states to restrict Medicaid eligibility.

This might amount to something. Unlike “pulling the rug out” Heller, Collins is talking about the long term and a huge amount of money. The ceiling on Medicaid spending amounts to a huge cut over 10 years. It is they key measure used to finance the bill’s tax cuts for the rich. Unlike the 3 year Medicaid extension phase out it can’t be fudged. The case for Heller, Capito, Portman Kabuki is strongly supported by the fact that they don’t specifically address the ceiling.

It is vital that people who had no problem before the ACA understand that they will have huge problems if the AHCA passes, because of the huge cuts of legacy (pre-ACA-expansion) Medicaid spending. The fact that Collins discusses this would be a hint that she might actually vote no (if she weren’t actually Senator Susan Collins (R-Maine) who always always caves).

end update:

update 2: Collins is stealing the stage. I think she is torturing us. She said she can’t vote for a bill which deprives tens of millions of health insurance (I’ll believe she can’t if she votes no and not before)

ehd update 2:

Separately 4 right wing Senators said the McConnell draft is too close to the ACA: Ted Cruz, Mike Lee, Ron Johnson (Wisconsin) and Rand Paul (Kentucky).

I think Paul might really mean it. He is extreme and resistent to party discipline. Also the ACA has benefited Kentucky enormously. Blocking the repeal bill would be good for Rand Paul (and Mitch McConnell). Blocking it for not being extreme enough could be crazy like a fox 11- dimensional Aqua Buddha chess.

Ron Johnson has been hinting a no for a long time. He was just re-elected. Here I think that senators with 6 safe years might be more likely to vote no. Failure to pass a bill with hurt Republicans in the short run. Passing a horrible bill will hurt them in the long run.

I’m pretty sure Cruz and Lee are play acting. My guess is that they said no to establish a bargaining position — if McConnell is the right most position, the bill will move further left than if they pretend they might vote no. I read somewhere thatCruz had an individual statement in which he made it almost clear he was going to get to yes.

Summing up, I have no prediction for how this will end. But I do very strongly suspect that Heller, Capito and Portman will win two (staged) battles and get 7 year phaseout and some opioid money, declare victory and vote yes.

update 4: My prediction was wrong (as usual). Heller denounced the bill. He described many of its horrible aspects, definitely including the long term cuts to legacy Medicaid. This is not an issue which can be fudged, because the amount of money involved is huge. He still might cave, but it would be an authentic cave not a staged victory. This is very good news. Also there is even better news reported by The Washington Post

Sen. Dean Heller (R-Nev.) announced that he could not vote for the legislation without revisions, singling out the measure’s long-term spending cuts to Medicaid as the reason for his opposition. The announcement caught some Republicans in Senate Majority Leader Mitch McConnell’s orbit by surprise.

If McConnell had been counting on Heller, his count could be off. In particular, he might have counted to 49 and assumed he could get one more from a senator unwilling to decide the victory for the Democrats. Heller’s announcement takes pressure off of her (she is named Lisa or Susan).

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McConnell’s AHCA Bill Text and WP Interpretation

I have not had a chance to read through this; but, I thought I would put this out here for all of us to read, Senate Version AHCA McConnell

Updated this post with the changes proposed in the McConnell Senate Bill as taken from today’s Washington Post.

Washington Post Version

ACA1
ACA2
ACA3
ACA4
ACA5
ACA6
ACA7
ACA8
ACA9

How Senate Republicans Plan to Dismantle Obamacare; Washington Post; Haeyoun Park and Margot Sanger – Katz; June 22, 2017

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Many places in America are essentially devoid of doctors

Via Kevin MD Dr. Kenneth Lin writes another article on disappearing rural medical care.  this is part of the article…

I recently attended a conference in Savannah, Georgia sponsored by the Association for Prevention Teaching and Research.

Since I haven’t spent much time in Georgia outside of Savannah and Atlanta, the welcoming plenary on improving health outcomes for the state’s rural and underserved populations was eye-opening. According to Dr. Keisha Callins, Chair of the Department of Community Medicine at Mercer University, Georgia ranked 39th out of 50 states in primary care physician supply in 2013 and is projected to be last by 2020. 90 percent of Georgia’s counties are medically underserved. Mercer supports several pipeline programs that actively recruit students from rural areas, expose all students early to rural practice and community health, and provide financial incentives for graduates who choose to work in underserved areas of the state. But it’s an uphill battle. Even replicated in many medical schools across the country, these kinds of programs likely won’t attract enough doctors to rural areas where they are most needed.

When people talk about places where doctors won’t go, they tend to focus on international destinations, such as war zones in Syria or sparsely populated areas of sub-Saharan Africa. It’s hard to believe that many places in America are essentially devoid of doctors, and access to medical care is as limited as in countries where average income is a tiny fraction of that in the U.S. Providing health care coverage for everyone, while important, won’t automatically ensure the availability of health professionals and resources in rural communities. In a recent JAMA Forum piece, Diana Mason discussed the financial struggles of rural hospitals that support community health alongside primary care clinicians, which may become more acute if budget cuts to rural health programs and grants occur as proposed in President Trump’s budget.

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Rethinking rural hospitals

Via Journel of American Medical Association (JAMA) is an invitation us to keep looking at the plight of rural hospitals in light of decreasing rural population. Dr. Diana Mason writes:

But other rural communities, home to nearly 20% of the US population, are not so fortunate. Since 2010, 78 of the more than 2150 rural nonspecialty US hospitals have closed. While the closure rate has recently declined, the proportion of financially struggling rural hospitals has increased. When a rural hospital closes, the economic losses can devastate an already stressed community through loss of health care workers, emergency services, and primary care capacity, as well as higher unemployment and lower per-capita income, a drop in housing values, poorer health, and increasing health disparities.

Why are rural hospitals at higher risk of closure than urban hospitals? George Pink, PhD, Deputy Director of the North Carolina Rural Health Research Program, sees 3 main contributors:

  • Market factors. Rural areas tend to have poorer population health, higher unemployment rates, and stiffer competition from other hospitals
  • Hospital factors. These include low occupancy rates, lack of physician coverage, deteriorating facilities, and patient safety concerns
  • Financial factors. From 2012 to 2014, for example, rural hospitals averaged a 2% operating margin, compared with 5.9% for urban hospitals

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Mitch McConnell, Healthcare, and the ACA

I am always curious about why certain people make it a mission to get rid of things. I think it truly is about Addison Mitchell McConnell trying to erase the accomplishments of what the first black President Barack Obama did as the president. I did some rather easy digging and pulled up Wikipedia. here is what they said about Mitch.

As a youth, Addison (Mitch) McConnell overcame polio. He received “government-provided healthcare” in Warm Springs saving him from being disabled for the rest of his life.” Addison Mitchell McConnell

Given that you Senator McConnell received government-provided healthcare during your youth which saved you from being disabled, why do you feel the need to strip 24 million people of their healthcare? This healthcare may save their lives also.

Paul Ryan benefited from government survivor benefits which allowed him to go to college.

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