Saturday, November 8, 2014

King v. Burwell, or life sucks under Republican governance

The Supreme Court announced it would hear King v. Burwell.  In short this case is a challenge to the ACA, protesting the subsidies granted to people buying policies through a federally managed exchange.  Those people live in the 36 states that didn't create their own exchange, states that did set up an exchange wouldn't be impacted.

I've seen a lot of teeth gnashing about what would happen if the courts upheld this challenge.  People argue that it would undo the ACA because without subsidies people wouldn't be able to afford policies, and the resulting adverse selection would kill the market.  I think those arguments are entirely correct.  I also think that's not something worth spending a lot of time worrying about.

If the challenge is upheld, states have an obvious and easy remedy.  They can create an exchange.  It doesn't need to be a big complicated web site, it just needs to meet whatever certification threshold the feds set.  And so long as the President is a Democrat that threshold will likely be low.  

States may opt not to do this, they might prefer having more uninsureds and less access to health care.  That sucks if you live in such a state, but I don't feel sorry for you.  Collectively, the people in your state empowered asshole Republicans to run it.  That has consequences, and those consequences aren't any secret.  An earlier Supreme Court ruling (by  Republicans) gave states the right to turn away free money and keep a large segment of their adult population uninsured.  About half the states, overwhelmingly red ones, took the court up on the offer.  So it's known that Republicans would rather shit on a poor family than help them.  Republicans who reject exchange subsidies are merely extending that treatment to the middle class.  

That sucks for people on the receiving end, but it sucks no worse than for the low income population.  Why should the middle class be treated better?  Why is it a bigger problem that people with incomes between 1.33 and 4 times federal poverty level can't get insurance than people with lower income?  Is cancer worse if you make 40 grand a year instead of 15?  Does heart disease care what's in your wallet?

I just don't see it.  King v. Burwell isn't a problem for the ACA, it's a problem for the people living under Republican governance.  Sorry, but you shouldn't order a turd sandwich if you don't want to eat one.

Sunday, September 28, 2014

An Open Letter to Portland Public School Board on Boundary Review

Portland Public School Board Members,

I'm writing to urge you to complete the District Wide Boundary Review Process as soon as possible.  At [my neighborhood school] overcrowding is materially degrading educational quality and school leadership is not adequate to deal with the problem on its own.  Boundary Review offers immediate relief for enrollment disparities.  But it isn't enough.

Within PPS there are currently high reputation or "good" schools that are overcrowded, and low reputation or "bad" schools that suffer from under-enrollment.  Merely increasing the catchment area of "bad" schools and shrinking the catchment of "good" schools won't work in the long term.  The reputations still exist and families will react by finding a way to enroll in the "good" school such as by moving or maintaining an address in the new catchment area, or they'll switch to a charter school or out of PPS entirely.  I don't think you'll ever convince parents with means to go to a "bad" school.  Enrollment balancing in the long term requires addressing the reputations that make schools "good" or "bad" in the first place.

Reputation in my view is primarily a function of parents.  Reputation doesn't matter to kids, they don't care about financial hierarchy or relative privilege.  Nor are they in a position to make decisions based on reputation, they go where their parents send them.  It is parents who create and react to school reputation.  Breaking down the process that creates "good" schools and "bad" schools requires changing the way parents interact with schools. 

From my experience the two institutions that most involve parents are the PTA and Foundations.  Generally speaking, the former is a mechanism by which parents can improve their schools through donations of time and skills, the latter is a way to improve schools through donations of money.  Both resources materially impact the student experience, providing some factual basis for differences in reputation.  Disparity is reinforced psychologically; participants in parent groups commit to "their" school, they make sacrifices for "their" school.  People are proud of their sacrifices and attribute to them value and distinction, which contributes to a negative view of schools lacking that distinction.  And disparity is reinforced socially, because parents who are passionate enough about schools to make sacrifices on their behalf want to be with other parents similarly engaged.  Those dynamics create a positive feedback loop, particularly when applied to a backdrop of economic segregation in which some neighborhoods have much greater resources to donate to schools than others.  The end result is schools with disparate reputations, often wildly out of sync with the underlying reality.

I think the solution to this problem is to loosen the connection between parent organizations and specific schools.  Instead of silos defined by school, PTAs and Foundations should be organized over a wider area with a mission to promote the welfare of all schools within that area equally.  Dividing the district into four or five areas, each would be broad enough to incorporate an economically diverse population and to retain that diversity over the long term. 

Resources would be spread more evenly, rather than being concentrated in the neighborhoods where those with money or the ability to have a stay at home parent happen to live.  It would allow those who are passionate about schools to find community and support regardless of where they live.  And it would retain a degree of autonomy and local connection.  Parents wouldn't be donating to an anonymous, monolithic "PPS" but to the local area schools that that their children or friends of their children attended.  If boundary rebalancing were broken down by area, they would also be the schools parents' children might attend in the future as a result of enrollment balancing.  I think this would create a culture of investment in schools, directed not just where people with resources live but where investment is needed. 

With regards to boundary changes, it would make the switch to a different school far less intimidating.  The new school would be familiar and less likely to carry stigma.  At the same time there would be less social loss, parents would maintain connections with those at the old school through the broader parent organizations and have the same access to their resources.  Families subject to boundary change would be grounded and supported by community, instead of feeling like they're being voted off the island like they are now.

It could be argued that this approach is geared too much towards the subset of parents that are active in PTA and Foundations.  But I'd argue it is exactly that group that is most influential in determining school reputation.  They are the ones who care enough about educational quality to act on it.  They're the ones least likely to accept going to a "bad" school and who will not only pursue alternatives, but promote them to all their friends reinforcing disparities in reputation.  People seek community one way or another.

So in summary, please complete the boundary changes as quickly as possible.  But don't stop there, because it won't be enough.  Look at the dynamics that make rebalancing such a traumatic process and find ways to ameliorate them.  I think doing that will create a stronger, more equitable school system positioned to thrive rather than merely survive.  For the 21st century, Portland needs no less.

Saturday, September 13, 2014

Consumer choices vs. Community choices

I came across this quote in Ravitch's book.  It's part of a discussion of school choice, but I think it applies to Oregon measure 90 as well.  Emphasis mine:
The market undermines traditional values and traditional ties;  it undermines morals, which rest on community consensus.  If there is no community consensus, then one person's sense of morals is as good as the next, and neither takes precedence.  This may be great for the entertainment industry, but it is not healthy for children, who need to grow up surrounded by the mores and values of their community.  As consumers, we should be free to choose.  As citizens, we should have connections to the place we live and be prepared to work together with our neighbors on common problems.  When neighbors have no common meeting ground, it is difficult for them to organize on behalf of their own self-interest and their community.
What is the top-two concept but an attack on political parties?  And what are political parties but the vehicle by which residents organize and collaborate for political activity?  I think parties are exactly the common ground Ravitch references above.  Without that common ground, we're just a bunch of individuals screaming in the wind.

Sunday, September 7, 2014

Elected Officials are not Cheeseburgers

I think there are multiple reasons to dislike this Oregon's ballot Measure 90, which would create a top two primary.  It essentially discards our current system by doing away with primaries as we know them, moving the real election to May, and relegating November to a mandatory runoff.  It tosses out a century of work at opening party primaries, replacing them with an amorphous endorsement process whose value is unclear.  If current party primaries are bad because of limited participation, how much worse will an endorsement process be which has no rules or customs?  If most people don't vote in the pre-election now how many will vote in the pre-pre-election?  And for what?  To tread water on overall voter participation?

But I want to focus on one particular aspect of arguments for Measure 90, the idea that it increases competition and that this is unambiguously good. A recent Oregonian editorial was dedicated to the concept, and it's a common element in arguments for the measure.  But is it right?  Is an uncompetitive election necessarily bad?

We have good reason to take the idea for granted.  For most consumer decisions it holds true, having more choices allows a more specific decision that better aligns with our preferences.  The more restaurants that serve cheeseburger, the more likely it is that one of them serves the exact combination of product and price that you want.  But are elected officials like cheeseburgers?  Not really.
  • The decision to buy a cheeseburger is individual, one person makes the choice and immediately gets what they asked for.  Elections are a community decision.  Votes are cast by individuals, but they are cast for one office and only one individual wins.  In the end everyone will be served the same thing.
  • The timing of the decision to buy a cheeseburger is entirely at individual discretion.  One can buy cheeseburgers as often as one wants, it can be centennial or hourly or anywhere in between.  Elections are on fixed schedules and the decision generally lasts for a fixed term.
  • Cheeseburgers have a price constraint.  That constraint overrides any other preference, one cannot buy what one cannot afford.  The price constraint doesn't apply to voting, there is no cost to choosing one candidate over another.
Put those elements together and think about what a cheeseburger decision would look like if it had the same properties as an election.  Communities would decide by majority rule what cheeseburger everyone would have to eat, over a term of years.  They would have to make this decision without a cost constraint, so any topping, ingredient, style, or quality level would be allowed.

That would be a miserable decision even for just a married couple.  It would be miserable because in effect the only reason one couldn't get their "dream burger", one that matched exactly to what they wanted, would be the constraint of getting their spouse's agreement.  And the spouse would have the exact same problem.  Now expand the voting pool to an entire community and you can see why elections are contentious, even violent, things.  Unlike the individual's decision to buy a cheeseburger, I think communities need some structure to effectively reach a decision.  That's where parties and primaries come in.  They facilitate coalitions and compromises, they provide organization to what would otherwise be a war of all against all.

As an example of how this plays out consider approval ratings.  Who would you guess has higher ratings, an incumbent running unchallenged or a newly minted freshman who won a narrow victory?  Which election did the public feel better about, George W Bush's ultra-narrow victory in 2000 or the dominant wins by Reagan in 1980 or Obama in 2008?  The closer an election, the more competitive it is, the more people necessarily are unhappy with the outcome.

When measure 90 supporters uncritically support competition they are using the wrong model.  Elections aren't consumption decisions, elected officials aren't cheeseburgers.  An election is much more like a hiring decision, the community is hiring someone to do a job.  Competition isn't totally irrelevant to making a good hire, but it's significance depends on the circumstances:  is it an open position or already filled?  If the latter is the person competent?  Are they so incompetent that it warrants firing them in favor of an unknown?

Looking at it that way it's easy to see why many elected offices aren't always competitive, it's because voters are reasonably good at filling them.  What's wrong with that?

Thursday, March 27, 2014

Do you know your doctor's expiration date?

CMS is considering new rules to protect seniors if their Medicare Advantage Plan drops their physician.  I think that's a great idea, and wish everyone had such protection from network changes.  I was pretty sure I'd written something about that, but couldn't find it posted.  After digging through old files, here it is.

January, 2012

Imagine going to buy milk at the store, only to find that none of the cartons are marked with an expiration date.  You ask a clerk about it, only to be told that the dates exist, the store knows what they are, but that they are a trade secret and they can't disclose them to you.  All they will tell you is that the milk is not expired as of today.  "How," you ask, "will I know if it is safe to drink tomorrow?" 

"Check back tomorrow", is the answer.  "All we can ever tell you is whether your milk is expired as of the day you ask."


Such an arrangement would be absurd on its face, and if a store attempted to impose such conditions a regulatory or legislative remedy would surely not be far behind.  But in one industry such absurdity is the norm.  Do you know your doctor's expiration date?


Most private health insurance plans are circumscribed by networks.  Go outside the network and you face a steep increase in out of pocket expense through  copays or deductibles. In some plans the out of network coverage is so restricted that patients are functionally uninsured.  Most people know this and quickly learn to identify in-network providers.  But those networks change over time, depending on whether or not doctors and insurers continue agreeing to terms.  And included in those agreements are expiration dates.  If no renewal agreement is reached the contract expires and the provider drops out of network.


What notice do patients get when that happens?  Whatever their doctor feels like giving them.  Maybe they'll tell you when you make your next appointment, or maybe not.  As the paperwork repeats ad infinitum, patients are solely responsible for managing their insurance, and patients are solely responsible for payment.  Even if you've seen a doctor a hundred times and checked your insurer's web site to verify their network status yesterday, nothing guarantees that they are in network on the day of your appointment save checking with your insurer on that day.  Realistically, you probably won't find out until you get an Explanation of Benefits statement from your insurer stamped "Out of Network" followed by a hefty out of pocket medical bill.


What makes such circumstances frustrating is how unnecessary they are.  By simply disclosing the expiration date of the provider-insurer agreement, people would know when they needed to check to see if it renewed.  Not only could they avoid hundreds or even thousands of dollars in out of pocket expenses by being better able to avoid out-of-network physicians, they could improve the continuity of care.  Knowing at once if a provider had dropped out of network would allow more time for selecting and transferring records to a new provider, it could be done ahead of time rather than starting the process on the day you realize you need treatment and go to make an appointment.  All that, just from disclosing a date.


The only argument I've seen against such disclosure is that contracts between insurers and providers are trade secrets.  According to that logic, the contracts must remain secret to prevent collusion on prices.  I won't argue for or against that point, but I'd observe that the contract expiration date has no bearing on it.  What is the harm in disclosing an expiration date?  Is the market for milk screwed up because people know ahead of time when a particular carton will go bad? 


It's worth thinking about, because paying medical bills out of pocket because a physician's office didn't disclose they dropped your insurance  stinks worse than rotten milk.

Thursday, February 6, 2014

Why are we still talking about the CRC?


Generally speaking, you don't loan out money you're banking on getting paid back without collateral.  That's because people who don't put up collateral, who don't have any disincentive against walking away from their debt tend to walk away from their debt.

Applied to the CRC, if we think we need Washington support to build the CRC than we must have collateral to ensure their support.  That can come in the form of direct funding up front or it can be irrevocable collection rights against Washington citizens to the same effect, whatever.  What matters is that it's skin in the game, a reason for Washington to not walk away when the bridge is built but the bonds are only half paid off leaving Oregon holding the bag.

With that in mind it's hard to understand what Governor Kitzhaber is thinking.  How likely is Washington to put up collateral if they think Oregon can be suckered into going it alone?  Every step Oregon takes toward building the bridge without Washington support validates their inaction and makes their support on the next step less likely.  The path Kitzhaber is following  doesn't lead to a bridge supported on both ends.

If we really want Washington support we ought to give them a reason to give it.  The screamingly obvious one is to walk away from the CRC.  If the Feds are as loose with money as Kitzhaber's plan requires, a year isn't going to matter.  The only risk is that Washington might judge the benefit of a new bridge not worth its cost.  If that's the case aren't we better off finding that out now rather than 10 years and hundreds of millions of dollars in unsecured debt later?

Saturday, December 28, 2013

How We Do Harm

It's one thing to read a statistical assessment of overtreatment, and how some "cures" are either ineffective or worse.  It's quite another to read the personal stories of people who underwent such treatment. 

A woman suffered brutal side effects getting HDC-ABMT, only to discover that studies show the treatment doesn't prolong survival.  A few years later she finds the cancer has come back, and at almost the same time she loses her insurance for having blown the life time benefit max.

A 70 year old man gets free prostate cancer screening at the mall, finds an abnormality and gets "treated."  He spends his remaining years incontinent and with a colostomy bag before dying of a UTI.

Even as we spend vast sums on overtreatment we have people suffering from undertreatment, such as an uninsured woman who walked into an ER with a body part in a bag after suffering auto-mastectomy from advanced, untreated breast cancer.

Health care reform is going to have its ups and downs.  But if you ever need a reminder about why the pre-ACA system was unacceptable, why it was a gross moral failure, check out How We Do Harm by Otis Webb Brawley and Paul Goldberg.  In their words, incidents of failure weren't aberrations from the system, failure was the system.