Virginia: Weighing Medicaid Expansion against Work Requirements

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Tuesday February 20, 2018 · 7:14 AM PST

2018/02/20 · 07:14

no image description available — Will Virginia be next in the Medicaid Expansion parade? And what price with legislative Republicans extract as a cost?

(Cross posted at the Makeshift Academic)

Good news came out of Virginia last week, as enough Republicans in the House of Delegates seemed to have caved in to popular demands and backed expanding Medicaid. It would make the state the 34th to expand Medicaid under the Affordable Care Act, and get 300,000 people health insurance.

Of course, there’s a catch: Republicans have conditioned acceptance of the Medicaid expansion on the imposition of work requirements for able-bodied Medicaid recipients.

It looks like Democrats in the legislature and Gov. Ralph Northam would be willing to play ball. The question is, as I asked with previous alternative Medicaid expansion attempts during the Obama administration, are the trade-offs worth it?

My answer is: it depends.

Follow me below the fold for details.

I'd lay down a few general markers to help Democrats determine when they should deal and when they should resist:

1. Less restrictive conditions (like requiring five hours a month on job related activities instead of 20 hours a week, not implementing co-pays for people under the poverty line etc) would nudge me toward a deal

2. Submitting fewer people to restrictions (exempting pregnant women, children, disabled, those over 50, people earning less than the poverty line, students etc. from requirements) nudges me toward a deal

3. Imposing access conditions like work requirements only on people who’d otherwise have no access to insurance at all would nudge me toward a deal

4. Imposing extra conditions on people who already receiving benefits, especially onerous ones, would nudge me away from dealing

5. Democratic control the executive branch of a state would nudge me toward a deal, seeing as it would be in charge of enforcing any agreed-upon provisions, and could do so in the most humane, reasonable fashion

Hypothetically in Virginia, based on what I know, I’d hold my nose and say yes.

Where Virginia stands on the above parameters is currently unclear, according to current reports because we don’t have a specific proposal or agreement to expand Medicaid – including the expansion in the House of Delegates budget proposal is only the first step.

Point 5 is satisfied – and Northam ran hard on expanding access to insurance, so his people at the State Health Department would likely enforce any sort of restrictive rules as loosely as possible.

Points 1-4 are murkier because we don’t know the deal. But we know that in all states attempting to work rules for Medicaid exempt most vulnerable populations (though the paperwork burden introduced by proving this status will likely cut off a considerable number of people from insurance.)

Initial discussions indicate that some adults – like parents currently on Medicaid, might end up subject to restrictions.

However, parents only are currently eligible for benefits if they make less than 38 percent of the poverty line ($7,760 for a family of 4), and many of those are likely disabled, students or already working part time.

In contrast, more than 300,000 adults would be eligible for help under the expansion. I’d have to see language, but I think it’s pretty likely that conditions 3 and 4 would satisfied.

That leaves conditions 1 and 2. And it’s unclear what’s in the plan.

Northam’s spokesman said the following to the Richmond Times-Dispatch:

“The governor supports the concept of expanding coverage to Virginians who need it and offering training and incentives to connect people with work opportunities.”

That language is a far cry from embracing work requirements and sounds more like Northam would like a Montana-style expansion, where adults on Medicaid get linked up with job search and support services from the state labor department, if they want it.

Republicans in the House majority, like Speaker Kirk Cox, want much stricter conditions. As he told the Times-Dispatch:

“Instead of fighting a losing battle against straightforward Medicaid expansion, I believe the House should lead by putting forward a responsible plan similar to what Vice President Mike Pence adopted as governor of Indiana,” said the speaker, referring to federal approval this month of a work requirement for the Indiana Medicaid program that Pence expanded with reforms in 2015.”

Bridging that gap is going to be a delicate and fraught discussion among Cox, his caucus, Northam and his legislative Democratic allies, but I think that any likely result would involve much more good than harm.

In contrast, Democrats should ferociously fight attempts to implement work requirements in states that have already expanded Medicaid or are trying to implement restrictions without expansion.

The ultimate lesson remains, as always, the following: Elections matter.

Imagine the conversation we’d be having if the Democrats had scraped up 200 more votes last fall and secured control of the House of Delegates?

(Or for that matter, imagine the depressing situation we’d be if the Dems only had picked up 2 or 3 seats instead of the 15 they ended up getting.)

The good guys will get another shot at the Virginia House in 2019, as well as an opportunity to flip the 21-19 GOP-controlled Senate. Flip 5-10 more seats across those two bodies, and the conversation about Medicaid expansion changes drastically again.

Good news on climate change: New Jersey and Virginia likely to join regional carbon trading plan

Fake Irishman

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Tuesday November 28, 2017 · 3:01 AM PST

2017/11/28 · 03:01

(Cross posted at The Makeshift Academic)

I’d like to break into the our regularly scheduled doom and gloom to note a small but important piece of good environmental news from last month that has poked green shoots up through the toxic sludge the Trump administration is trying to pass off as public policy.

The Regional Greenhouse Gas Initiative (RGGI) is about to add two new states.

RGGI is a consortium of nine New England and Mid-Atlantic states formed to reduce carbon emissions from large power plants through a cap-and-trade system. The program, which applies to power plants with a capacity of larger than 25 megawatts, establishes a region-wide cap on carbon emissions. Emitters bid in a competitive auction to purchase permits that allow the emission of one ton of CO2. They trade in permits when they pollute, or can save unused permits for future use, or sell them to other bidders. States invest the proceeds in energy efficiency or clean energy programs.

The annual cap, which was set originally at 165 million tons of CO2 equivalent in 2008, and adjusted to 91 megatons in 2014, declines by 2.5 percent each year through 2020. The stakeholders are currently negotiating an extension of the program through 2030, which will further reduce CO2.

The first new RGGI member, New Jersey, was an original member of the consortium, but Republican Governor Chris Christie withdrew in 2011, and has vetoed several bills since that would rejoin. The incoming governor, Democrat Phil Murphy, has pledged to rejoin.

In more exciting news, Virginia is also moving steadily toward joining the RGGI as well. Gov. Terry McAuliffe issued an executive directive in May directing the Virginia Department of Environmental Quality to develop a rule to limit carbon dioxide from existing power plant. The order emphasizes both designing the rule in such a way to allow Virginia to join a multistate emissions trading group – i.e. the RGGI – AND doing so in such a way that a legislative vote isn’t required.

The proposed rule was finished in October and received preliminary approval in November from the state air pollution board. Several hurdles remain, but it is on track for adoption by the end of 2018.

Bringing New Jersey back into the RGGI fold is good news and will reinforce the program’s stability and expand its footprint to cover more carbon emissions -- New Jersey will have the second-largest amount of emissions of any of the current members. However, getting Virginia into the program is extremely promising for several reasons.

Follow below the fold for why.

Fake Irishman

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Thursday July 21, 2016 · 7:00 AM PDT

2016/07/21 · 07:00

(Crossposted at The Makeshift Academic)

During the last several weeks, it’s been rather depressing recognizing (yet again) that racism (still) is widespread in the United States. We’ve had yet another set of killings highlighting the differences between how police treat whites and people of color. Then we had a sitting U.S. Congressman enthusiastically endorse white supremacy on national television.

And I’m a clueless white dude– if I feel depressed about this state of affairs, imagine how bad it really must be.

When it seems like the median opinion of the national debate is somewhere between “Black Lives Don’t Matter” and “Black Lives Might Sort of Matter Sometimes When We Feel Like It as Long as Black People Keep Quiet and Don’t Hurt White People’s Fee Fees”, feeling the urge to slip into despair is understandable.

But over the last several years one indicator of racial equality has quietly been rapidly improving – a lot more African Americans are getting access to health insurance under the Affordable Care Act.

Quarterly analysis from the office for the Assistant Secretary for Planning and Evaluation (ASPE) at the Federal Department of Health and Human Services (HHS) has been keeping track of changes in the uninsured rate. APSE (and other measures have noted massive across-the-board declines in the percentages of people without health insurance since the Medicaid Expansion and Insurance Exchanges went into effect in 2014.

What’s particularly notable, however, is how well African Americans seem to be doing under the ACA, however.

In the fourth quarter of 2013, 23.2 percent working-age African Americans lacked health insurance coverage, as did 14.3 percent of Whites. By 2016, the African American uninsured rate had fallen to 10.6 percent, while the White rate had declined to 7.0 percent. In total then, the gap between the uninsured rates between whites and blacks fell from 8.1 percentage points to 3.6 percentage points -- a reduction of 55.6 percent.

That’s not perfect, but it’s a heck of a lot of progress.

Getting several southern states with large African American populations to expand Medicaid will likely further cut into this gap (yes, ex-Confederate States not named Arkansas or Louisiana, I’m looking at you).

The other challenge is that, despite improvements, coverage of Hispanics still lag significantly behind both Whites and Blacks.

But these are struggles going forward. For now, two and a half cheers for Obamacare's contribution to racial equality.

ACA exchange plans cost near-poor more than Medicaid

Fake Irishman

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Tuesday June 28, 2016 · 3:46 PM PDT

2016/06/28 · 15:46

(Cross posted at The Makeshift Academic.)

The Commonwealth Fund just released an interesting brief regarding the effects of failing to expand Medicaid on the health care costs of people between 100 and 138 percent of the poverty line.

Yes, that sounds about as exciting as watching paint dry, loyal readers (both of you) but it’s important – so wake up, dammit!

Here’s the score: the Affordable Care Act expands Medicaid to cover everyone under 138 percent of the poverty line. The problem is that 19 states – generally dominated by Republicans – have refused to expand their Medicaid programs. This poor public policy has created a “Medicaid gap” consisting of people who are too rich to qualify for legacy Medicaid (in Texas, for example, parents earning more than 15 percent of the poverty line – about $2,400 a year for a family of 2 – don’t qualify) but too poor to qualify for subsidies on the health insurance exchanges, which are available to households earning between 100 and 400 percent of the poverty line.

The 3.2 million people in this gap have no functional access to insurance, since there’s no way a person making, say, $10,000 a year can afford several hundred dollars a month in health insurance premiums.

People earning between 100 and 138 percent of the poverty level in non-expansion states are considerably better off though, because they qualify for both premium subsidies and cost-sharing subsidies for exchange plans. The indispensable Charles Gaba has estimated this group at roughly 1.9 million people.

But do the exchange plans stack up favorably with the generosity of Medicaid for poor people?

The good scholars over at Commonwealth Fund set out to find out. And their general answer is “no.”

Follow me below for more details.

Fake Irishman

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Thursday April 28, 2016 · 5:04 PM PDT

2016/04/28 · 17:04

(Cross posted at The Makeshift Academic)

While we were all focused on the primary elections on Tuesday, something interesting happened on the Senate floor when Democrats made a conscious, polite and ultimately futile effort to get a few judges confirmed.

Hawaii Senator Mazie Hirono (D-Hawaii) asked for unanimous consent to vote on Obama's eleven district court nominees that have been approved by the Senate Judiciary Committee -- without objection -- and have been awaiting the action of the full Senate (see the full Senate Calendar here).

Sen. Majority leader Mitch McConnell (R-Kentucky) objected to the request.

Then Chuck Schumer (D- New York) asked for unanimous consent to vote on the seven that have been approved by Judiciary -- again without opposition -- and have been waiting on the floor since November 5.

McConnell again objected.

Then Ben Cardin (D - Maryland) said, OK, could we vote on the four that have been waiting on the floor since October 29 -- six months ago. Those are

Paula Xinis, District of Maryland,

Brian R. Martinotti, District of New Jersey,

Robert F. Rossiter, Jr., District of Nebraska,

Edward L. Stanton III, Western District of Tennessee

John Cornyn (R-Texas) objected.

Finally, Cardin said, could we maybe just vote on the Xinis nomination, since she was approved by Judiciary in September, no one has raised any opposition to her, and she has been awaiting floor action for seven months?

Cornyn objected again.

We all know about the near complete refusal of Senate Republicans to even meet with, let alone hold hearings for, vote on or even, gasp, approve President Obama's Supreme Court nominee Merrick Garland.

But we can't forget about the rest of these nominations either that are facing nearly a complete blockade by Republicans. In addition to the 11 awaiting floor action, 41 nominees are awaiting action in the Judiciary Committee.

In the 2015-2016 Congress to this point, the GOP-controlled Senate has only confirmed two circuit court appointments and 15 district court judges.

For comparison, in the 2007-2008 Congress through April 30, the Democratic-controlled Senate had confirmed seven of George W. Bush's circuit court nominees and 38 of his district court nominees.

And in 2013-2014, by April 30, the Democratic controlled Senate had confirmed 15 nominations to the circuit courts and 54 to the district courts.

It's reasonable that the GOP wants to scrutinize Obama's appointments a bit more (and even reject a few), but these 11 judges have had been scrutinized. They've been waiting for confirmation between seven and 14 months. They have all cleared a GOP-controlled Judiciary committee by voice vote. There is no opposition -- reasonable or otherwise -- to giving them their commissions. This is only about delay.

These are judges that are uncontroversial and needed to help the government perform their basic functions. Unlike Garland, they don't represent huge ideological stakes in themselves, so a bit of pressure might get the Republicans to let a few go.

Consider calling your state's Senators, especially if they are Republicans -- and especially if you're from Texas and have Cornyn as your Senator. (Don't e-mail, that's useless). Here's a list of numbers for their Washington offices. State your name, and give a brief, polite (don't be a jerk) message asking them to hold a vote on the 11 district court nominees that await floor action.

The 11, including their numbers on the executive calendar are:

#307 Paula Xinis, District of Maryland,

#357 Brian R. Martinotti, District of New Jersey,

#358 Robert F. Rossiter, Jr., District of Nebraska,

#359 Edward L. Stanton III, Western District of Tennessee

#362 Julien Xavier Neals, District of New Jersey

#363 Gary Richard Brown, Eastern District of New York

#364 Mark A. Young, Central District of California

#459 Marilyn Jean Horan, Western District of Pennsylvania,

#460 Susan Paradise Baxter, Western District of Pennsylvania,

#461 Mary S. McElroy, District of Rhode Island

#508 Clare E. Connors, District of Hawaii

Boring bureaucrats help save the world: climate change and energy efficiency edition

Fake Irishman

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Friday April 22, 2016 · 8:53 AM PDT

2016/04/22 · 08:53

vending machine, soda machine — Don't worry, the government is on it. (Really.)

(Cross-posted at the The Makeshift Academic)

When it comes to stopping global climate change, you probably don't think much about vending machines.

Fortunately for all us, a lot of non-descript civil servants do.

You’ve probably never heard of the Department of Energy's Appliance and Equipment Standards Program (AESP) either. I'm sure it's staffed by lovely, if slightly nerdy khaki-wearing personnel.

But it's one of the Obama administrations most effective secret weapons in the fight against global warming.

Let's start with the two million beverage vending machines in the United States. Rules issued by AESP in 2015, will lead to machines coming online in 2019 required to be 16 percent more energy efficient in 2019 than today's. Over 30 years, it will save 7 million metric tons of carbon dioxide emissions, an average 233,000 tons a year. That's the equivalent of shutting down Ohio's First Energy's Lakeshore Power Plant, which is a medium-sized coal plant in Ohio.

It will also save businesses at least $210 million in electrical bills over the same time.

Big deal, you say. The US emitted 6.8 billion tons of CO2 equivalent in 2014. Cutting 233,000 tons a year is a nice gesture, but hardly serious climate reduction.

We're just getting started. Read on to see efficiency standards really start to add up.

Residential air conditioners are notoriously inefficient. In January, the AESP worked out consensus standards with input from environmental activists, consumer advocates and manufacturers to increase efficiency standards for residential air conditioners. The resulting rule will save consumers $38 billion and cut carbon emissions by 175 million of CO2 over three decades. That's about 5.8 million tons a year, or the same as removing Kyger Creek, which is the coal plant with the seventh largest emissions in Ohio.

But there's more. Rooftop air conditioners cool large commercial buildings and suffer from many of the same inefficiencies as residential units. Manufacturers groups and DOE have been working together on improving specifications and performance since 2011. In 2015, the AESP took the results and codified improved performance into efficiency standards that phase in starting in 2018. By 2023, new commercial air conditioners will need to be at least 25 percent more efficient than today’s. The tougher standards will result in $50 billion in reduced utility bills for building owners and 885 million tons in reduced carbon emissions over 30 years. That works out to an average of 29 million tons in reduced emissions every year -- the same as mothballing the two largest coal power plants in Ohio.

And there's still more: televisions, dishwashers, ceiling fan lighting units, fluorescent lights, furnaces, industrial boilers, washing machines.... you get the idea. It starts adding up to significant savings.

How much? Since 2009, the AESP has issued 34 updated equipment standards, covering 40 common appliances, which will save 3 gigatons of carbon emissions by 2030. That accumulates to 150 million tons of emissions reduction a year -- about 2 percent of 2014's emissions.

In coal power plant terms, that reduction is the same as permanently shutting down every coal power plant in Ohio.... and most of the ones in Michigan too.

So when we talk about the solving global warming, remember that the struggle occurs on many fronts. Putting a price on carbon matters (and no it isn't important whether it's a Cap and Trade system or carbon tax), eliminating coal production is paramount, but the Obama administration's quiet focus on improving efficiency standards for the machines we use every day leverages an extremely effective and underrated tool we need to value a lot more.

If Dems get a chance to confirm Garland in the lame duck session, they should take it

Fake Irishman

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Sunday April 17, 2016 · 9:30 AM PDT

2016/04/17 · 09:30

(Cross posted at The Makeshift Academic)

At last Thursday's Democratic debate, moderators asked Democratic presidential candidates Hillary Clinton and Bernie Sanders a question from NY Daily News reader Hannah Green regarding Obama's nomination of Merrick Garland to the Supreme Court vacancy left by the death of Antonin Scalia: (debate transcript from CNN)

Hannah Green wants to know your position, Secretary Clinton, regarding President Obama's nomination of Merrick Gaarland to the Supreme m Court. President Obama said earlier this week that he would not withdraw the nomination, even after the presidential election. If elected, would you ask the president to withdraw the nomination?

Both Clinton and Sanders said that the currently support the nomination and strongly denounced Sen. Republicans for obstructing Garland's appointment. But they differed on whether they would ask Obama to withdraw the nomination if they were elected president:

Clinton indicated acceptance of Obama's pick:

I am not going to contradict the president's strategy on this. And I'm not going to engage in hypotheticals. I fully support the president.

Sanders said he would ask Obama to withdraw the nomination:

...obviously I will strongly support that nomination as a member of the Senate. But, if elected president, I would ask the president to withdraw that nomination because.... I think that we need a Supreme Court justice who will make it crystal clear, and this nominee has not yet done that, crystal clear that he or she will vote to overturn Citizens United and make sure that American democracy is not undermined.

I want to be careful about extrapolating inaccurate meanings from their words, but it seems that Clinton is indicating that she'd be open to having Garland confirmed to the court in a lame duck session if Democrats retain the presidency and retake the Senate. Sanders, on the other hand, would want to wait to get a better judge (meaning younger, more liberal and perhaps non-white or female.)

I agree with Clinton. I think the costs of passing up a chance to get Garland on the bench are greater than the gains of holding out for some one potentially better (in the admittedly extremely low chance that Garland ever actually gets a vote). Hit the jump for my reasoning.

Don't get me wrong: Sanders is taking a legitimate position and I understand the appeal. A Democratic Senate might be able to get at least a younger (see Jane Kelly or Sri Srinivasan), or and/or perhaps a more liberal (Cornelia Pillard, anyone?) justice on the bench. The idea would be to lock a surefire vote for progressives on the bench for 20-25 years instead of 10-15.

But there are two sets of costs to this strategy as well that I think likely outweigh the gains.

(Note that this analysis assumes an incoming Democratic president and Senate, which is the only circumstance under which Republicans would even consider confirming Garland)

First, a confirmed judge Garland on the bench immediately takes his commission and joins oral arguments in December or January, while a nominee in a Sanders administration would take some time to get confirmed. That's important, because there might be some important cases coming down the pike that will be heard that he can participate in. It took 87 days from her nomination to confirm Elena Kagan in 2010, and 65 days to seat Sonia Sotomayor in 2009. Considering that any incoming administration is going to be taking up precious Senate floor time getting more than a dozen cabinet officials and other personnel confirmed -- including the attorney general and deputies, which go through the judiciary committee -- a Supreme Court justice might take even longer.

Second, there's an opportunity cost for Democrats to not confirming Garland if they have a chance to do so. Supreme Court justices take massive amounts of resources in both the administration and the Senate to move through the confirmation process, even assuming that no one is trying to obstruct the process.

If Garland is on the bench, all of those resources can be spent on doing other productive things that need to be done....

.... like potentially vetting and approving another Supreme Court justice. Ruth Bader Ginsburg will turn 85 this year, and Stephen Breyer will turn 79. It's pretty likely that one or both might choose to step down in the first year of a Clinton or Sanders presidency, especially if the Democrats take a majority of the Senate. And Anthony Kennedy will be 81 in 2017. Replacing any or all of those seats helps solidify the progressive position on the court.

But Supreme Court justices aside, it'd still be great to spend time and resources pushing through other federal judges to fill the vast number of vacancies in the courts instead of re-litigating a potential Supreme Court nomination. Remember that the vast majority of cases are settled at the district level, and most of the rest An extra 15-20 district judges in the first two years of a new Democratic administration would fill unused seats, lower case loads and speed up justice in hundreds of routine civil cases that aren't routine to the victims of discrimination and theft that file them. An extra three or four appellate judges would nudge the balance of power on important appeals courts further toward the progressive edge and lower the potential for circuit splits. A Fifth Circuit with only a 10-7 or 9-8 Republican majority would provide three-judge panels that on the balance were much less scary for progressive litigants pressing claims on every thing from reproductive and labor issues to voting rights, civil liberties, immigration and the environment than the current 10-5 split does. Ditto for the Sixth, Seventh and Eighth circuits, all of which still sport large majorities of Republican-appointed judges.

And using this precious floor time wisely becomes doubly important, because the Democrats face an utterly brutal landscape in the 2018 Senate races: defending seats in dark red North Dakota, Missouri and Indiana and West Virginia, as well as in Montana, Ohio, Pennsylvania, Florida, Virginia and Wisconsin.

That ain't going to be easy, folks. Best make hay while the sun shines. Sending back a good Supreme Court pick to try to get an great one isn't the best use of an incoming president's or Senate's time when we're going to have a lot of open lower court positions to fill -- if not another Supreme Court vacancy.

Cost sharing blocks the poor's access to health care

Fake Irishman

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Thursday April 07, 2016 · 6:01 AM PDT

2016/04/07 · 06:01

(Cross Posted at The Makeshift Academic)

The notion that health cost containment requires people to put “skin in the game” has a long pedigree. Requiring people to pay something through premiums or co-pays for health care, the theory goes makes them more discerning consumers about health services and eliminates unnecessary health care.

The problem is that they also stop seeking care for things that require medical attention.

Follow me below the fold for a tour of the latest research and its policy implications for the Medicaid Expansion

A recent meta study in Pediatrics has reviewed the existing research on the impacts that cost-sharing through charging low-income people premiums for Medicaid and CHIP. Reviewing eight studies on the subject noted that all of them found that low-income recipients of Medicaid were more likely to cut out needed care than they would with no costs. Aaron Carroll of the must-read Incidental Economist blog breaks it all down succinctly and clearly here.

That meta study joins an National Bureau of Economic Research study from 2015 that showed employees insured under plans with high cost-sharing simply stopped seeking care rather than shopping around.

This outcome was actually pretty predictable. In the 1970s, the famous RAND healthcare study ran across similar findings as well. The result that always gets reported from that study is that people tend to consume more healthcare if they don’t pay for it, without regard to quality. Conversely cost-sharing in the form of co-pays, deductibles and coinsurance, decreased the amount of healthcare consumed.

What isn’t often reported, however, as Balloon-Juice’s resident Health Policy Richard Mayhew has noted, is that people subjected to cost-sharing in the RAND study (and follow-up studies) consumed less health care regardless of quality. That is, they didn’t become more discerning consumers that the “skin in the game” argument suggested they would be. Instead they cut back on needed care, likely with bad results for their own health, and public health.

The Pediatrics meta study shows that a reasonably large body of research since then on the same subject reaches the same conclusion – charging poor people for health care leads them to skip necessary care.

But many state Medicaid programs incorporate cost-sharing for enrollees in the higher end (above 100 percent) of the Poverty line, and Indiana’s expansion waiver makes everyone in its “Healthy Indiana” contribute something to a Health Savings Account on a monthly basis. To be clear here, these are generally low amounts -- $1 for co-pays or $5 a month into an Health Savings Account. Most people in the program pay them, but some still can’t, which makes the program controversial and less helpful than it otherwise would be, while contributing miniscule amounts to its bottom line.

The research implies that focusing on the supply-side (providers) is ultimately the most effective way to control costs. On some level this is intuitive. Only non-individual payers (like the government and, yes, even those evil insurance companies) have the expertise and financial power to uncover and force providers to provide cost-effective care. Reforms to payments like penalties for unnecessary hospital readmissions, cutting payments for Medicare Advantage programs, encouraging accountable care organizations and the still dormant Payment Advisory Board, ultimately will help providers push their expertise toward providing better care instead of more care.

So if cost-sharing doesn’t work, why does it keep finding its way into Medicaid expansion programs?

To put it bluntly: conservative ideology in the case of Republicans controlling numerous state governments, and the need to work around it on the part of the Obama administration and allies pushing to expand Medicaid.

The Obama administration’s basic strategy seems to use cost sharing as a bargaining chip in Medicaid expansion negotiations with GOP-controlled states. The administration willing to a give a bit on cost sharing in exchange for the goal of extending basic coverage to large swaths of previously uninsured individuals. Given the practical constraints of resistance in GOP-controlled states, it seems like a reasonable approach. It will allow states to expand Medicaid with a bit symbolic (though harmful) cost-sharing in a waiver. Even though the take-up would be lower than it would be with a no-premium no-cost-sharing structure, the compromise is worth it to get large numbers of people into a Medicaid expansion instead of holding out for a completely free Medicaid program while tens or hundreds of thousands of people twist in the wind. Indiana, Michigan, Iowa and Arkansas’s original waiver expansions fall under this rubric of expansion in return for a bit of cost sharing – especially Indiana’s plan which mandates contributions even from extremely poor people under 50 percent of the poverty line.

However, Obama’s HHS has drawn three fairly bright lines. First, it almost always rejects egregious cost sharing for the most vulnerable beneficiaries: extremely poor individuals (under 50 percent of the poverty line and medically frail recipients. Second, it rejects work requirements for Medicaid recipients out of hand.

Finally, Secretary Sylvia Burwell has strongly resisted attempts to introduce or increase cost-sharing for people enrolled in an expansion program already up and running. So Ohio, which wants to attach cost-sharing to its Medicaid expansion population and Kentucky Governor Matt Bevin, who wants to trade in the successful traditional expansion of Democratic Governor Steve Beshear for an Indiana-style model, will likely face stiff resistance from HHS as long as a Democrat occupies the White House.

Assuming a hypothetical Republican administration keeps the basic structure of Obamacare intact (still an extremely large assumption, though less big than it was in 2012), you can bet that President Cruz’s HHS secretary would eagerly approve lots more cost-sharing for poor people in the name of “personal responsibility,” regardless of the impact on access to care or overall health.

Yep, elections still matter.

Don't forget about Obama's other stalled federal court nominees

Fake Irishman

Community

Friday March 18, 2016 · 6:01 AM PDT

2016/03/18 · 06:01

Crying kid throws a tantrum. Toddler rage. — Republican Sen. Majority Leader Mitch McConnell calmly and rationally outlines his objections to President Obama's nomination of Merrick Garland to the Supreme Court and explains why he's stalling every other Obama judicial nominee.

Much of the coverage of the federal courts over the last several weeks has rightly focused on President Obama's nomination of D.C. Circuit Judge Merrick Garland to fill the Supreme Court vacancy, and the complete refusal of Republican senators to even pretend to consider him.

But we can't forget about the other court vacancies that exist. As of last month, there are 62 district court vacancies, and nine vacancies on the Courts of Appeals.

Obama currently has nominees waiting for 34 of those district court slots, and seven of the circuit court openings.

But Sen. Majority Leader Mitch McConnell and his fellow Republicans will likely drag those nominations out. In 2015, the Senate confirmed one circuit judge and 10 district court judges.

In 2007, under an incoming Democratic Senate, George W. Bush was able to get six circuit court justices and 34 district judges appointed.

And during 2014, the Democratic-controlled Senate confirmed 12 circuit court judges and 76 district nominees.

(Gee, holding the Senate in the 2014 elections would have been nice, huh?)

So far this year they have managed to confirm one circuit judge and four district judges—all of whom were ready for votes last November.

Now with the Garland nomination taking up a lot of bandwidth, it's possible the McConnell and Judiciary Committee Chairman Chuck Grassley can use it to claim that they don't have time to process any lower-level judges—even though they’re not actually, you know, doing any work on Garland.

Progressive activists can't let that happen. We should highlight the near total ongoing blockade in the Senate of Obama’s judicial appointees, alongside our demands for Garland.

Fake Irishman

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Saturday February 27, 2016 · 10:10 AM PST

2016/02/27 · 10:10

(Crossposted at The Makeshift Academic)

This graph shows US military spending by GDP. — Cutting a little military spending could give us a lot more room to fund domestic initiatives.

So with the usual amount of depressing news circulating through, I set myself a happier task, which nicely dovetails with this piece last Sunday by Meteor Blades on military spending:

How much could I cut the U.S defense budget and what would I spend the proceeds on?

The rules were designed to make this somewhat realistic. I'm not trying to eliminate the Pentagon's budget entirely, unilaterally disarm, or make the Air Force hold a bake sale to buy necessary equipment. The idea here is simply to identify some reasonable spending limits for the American military machine (kind of like the discussions we have for regulatory agencies, health care funding research and infrastructure spending), and then think about what sorts of programs (or tax cuts, or deficit reduction) we could implement with the savings.

Figure 1 shows U.S. military spending as a percentage of national GDP between 1962 and 2015, based on GDP figures from the Bureau of Economic Advisors and spending figures from the White House's Office for Management and Budget. This number represents military expenditures, but doesn't represent veteran services or health care (i.e. funding for activities under the Department for Veterans' Affairs.) Notice how the figure generally steadily declines, though it does ramp up during the Vietnam War, the 1980s Reagan build-up and the Iraq and Afghanistan wars. The 1990s peace dividend is clearly visible as well, reflecting the end of the Cold War.

In 2015, according to GDP figures, from military spending represented about 3.16 percent of GDP. In a world in which we made decisions that maintained a reasonable military investment, what might defense spending look like? I came up with plausible three candidates.

Scenario 1: We reduce military spending to the lowest level of spending (Fiscal Year 1999) in which we spent about 2.7 percent of GDP on military spending. This scenario would give us roughly $82 billion (all peace dividends will be rounded down) in funding to allocate elsewhere.

Scenario 2: We reduce military spending to levels of the Republic of Korea (South Korea), which is about 2.6 percent of GDP, according to the Stockholm Institute for Peace Research in 2014. I thought this seemed reasonable, since the ROK is an advanced industrialized democracy, participates at a reasonably high level in international operations and faces a clear and presents military danger from North Korea, both of which necessitate large investments in the armed forces. Cutting to this level leaves us with a annual peace dividend of about $101 billion.

Scenario 3: We could really give into the hippies and spend only the percentage of our GDP that an average country spends on the military: 2.3 percent of GDP. This would leave us with a cool $155 billion to spend.

Note that all three of these scenarios would leave use spending at least double any other country in the world in absolute amounts of defense spending.

Head below the fold to see what I came up with to spend my peace dividend under each scenario. Some funding proposals are fairly detailed, but most (e.g. the preschool and parental leave are rough back-of-the-envelope calculations at best) Let me know in the comments what you would do with your surplus.

Fake Irishman

Community (This content is not subject to review by Daily Kos staff prior to publication.)

Sunday February 07, 2016 · 10:16 AM PST

2016/02/07 · 10:16

(Cross posted at The Makeshift Academic)

It looks like West Virginia's new Republican majority is about ram through a Right-to-Work (for less) bill.

It's not a surprise, that's what GOP majorities always do with anti-labor legislation. (See Wisconsin, Michigan, Indiana, and Michigan, oh, and Michigan again.) Once these bills surface, they rocket through the ledge without a lot of the usual niceties of full debate and due consideration to stop opposition and minimize the public discomfort their backers have to face.

In West Virginia, they're drawing on Orwellian inspiration to call it the "Workplace Freedom Act" Guh. Like all (so-called) Right to Work laws, it would give employees the right to stop paying dues to the labor union that represents them, but forces those unions to continue to represent the workers. The goal is to defund the unions, leaving workers out in the cold.

I've always been of the belief that if workers don't want to work in a union shop, they should quit and find an employer without a union. I mean, that's what management tells employees when they demand healthcare or higher wages or better working conditions, right?

Anyhow, back to West Virginia.

Proponents, backed by the usual third-rate think tanks, push the usual bad arguments about RTW improving West Virginia's economic prospects (because gutting workers' rights always improves things for residents). And anti-labor legislation debates always come with a few gratuitous shots at pro-labor protesters .

It was only a matter of time. I thought the GOP would wait until they elected one of their own as governor, but the state's weak gubernatorial veto (simple majorities of the legislature can override as long as the legislature is in session) made it too tempting to not get done this year.

Kentucky is likely next up, with Missouri, New Mexico, Montana and Ohio potentially on the chopping block depending on how 2016 elections go.

Yes, I am depressed about this. I'm doubly so because the battles in West Virginia's coal fields rocketed the United National Mine Workers to prominence. But the group has lost more than 90 percent of its membership in the last half century as coal-mining has died and the remaining operators rely on cheap bankruptcy tricks to undercut the few union minors left.

John Cole over at Balloon Juice has more on this and the other predictable horribleness that results when you let vandals take over your state legislature (like apparently now $100 for a five-year gun permit is an unconstitutional infringement on your right to pack heat).

Also hat tips to Hillbillyfairy and Laura Clawson for their diaries on the issue.

Potential legislative ways to limit the damage of Friedrichs

Fake Irishman

Community (This content is not subject to review by Daily Kos staff prior to publication.)

Saturday January 30, 2016 · 10:11 AM PST

2016/01/30 · 10:11

(Cross posted at The Makeshift Academic)

Public sector labor unions across the country have been grimily preparing for the likely negative results from the Friedrichs vs. California Teachers Association case heard two weeks ago. The opinion in Friedrichs (likely 5-4, written by a super smug Samuel Alito, with a vicious dissent read from the bench by Elena Kagan) will likely ban union agency fees on the grounds of free speech.

Previously, I have outlined why this opinion shouldn’t be conflated with the end of public sector unionism. Below the fold, I outline a legislative step unions and workers might be able to lobby for to blunt some of the impact of yet another depressing Alito majority opinion.

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Virginia: Weighing Medicaid Expansion against Work Requirements

Good news on climate change: New Jersey and Virginia likely to join regional carbon trading plan

Good News Everybody! (on Racial Equality in Health Care)

ACA exchange plans cost near-poor more than Medicaid

GOP's near-total blockade on Obama's judicial appointments continues -- but you can help a bit

Boring bureaucrats help save the world: climate change and energy efficiency edition

If Dems get a chance to confirm Garland in the lame duck session, they should take it

Cost sharing blocks the poor's access to health care

Don't forget about Obama's other stalled federal court nominees

Beating swords into plowshares: If you could cut the Pentagon's budget, what would you spend it on?

West Virginia about to fall to "Right to Work"

Potential legislative ways to limit the damage of Friedrichs