Saturday, June 20, 2015

A letter to my state legislators on Clean Fuels Standards

I'm writing to urge you to reject pressure to repeal Oregon's Clean Fuels law, particularly as part of some larger package involving transportation and land use.  Oregon is already feeling the impact of climate change with widespread drought and ocean warming, those impacts will only accelerate.  Clean Fuels is a small step towards a practical and inevitable response, shifting away from fossil fuels.  As compelling as Clean Fuels is, so are reasons to oppose the proposed repeal package.

The repeal package is at every level an abuse of process and an insult to democracy.  Where in the state constitution is there a "Gang of 8"?  Where does it say that Republican and Democratic interests must be given equal weight regardless of election results?  This isn't the first time we've seen a "Grand Bargain" that sacrificed process in the name of political expediency.  The result speaks for itself.

Please, look to the future.  Don't repeat mistakes of the past.

Thanks for your consideration,

Sunday, June 7, 2015

California Network Regulation Musings

Good doings in California on network regulation.  Two quotes jumped out at me. 
The problem this leaves is who's going to eat the excess charge? That's the core of the medical association's problem with the bill. It's asking that the measure be amended to "require an efficient, equitable dispute resolution mechanism that guides parties towards a reasonable rate for services," in the words of an Assembly staff analysis. The California Medical Assn. says it favors the approach of a 2014 New York law, which requires arbitration between providers and insurers, leaving the patient out of it. 
Arbitration in this context sounds like a polite word for "crappy rate setting process with limited input, limited consistency and limited accountability."  Why would anyone want that?  If we know physicians will do these services for these patients why not deal with it upfront by establishing what they will be paid?  That allows the possibility of opening the process and incorporating more of the interests involved.  Someone could argue, "why make a big deal about this when there's essentially no process around in network contracting?" but the difference is control.  If an insurance plan has a too-expensive or too-cheap network one can switch plans.  There's no equivalent remedy with out of network providers, whatever process the state comes up with is what everyone in the state lives with.  It ought to be held to a higher standard.
Here's the background. in the good old days, doctors in those three key specialties[radiology, pathology, and anesthesiology] were employees of hospitals, so if your hospital was in your insurer's network, they were too. Over time, many hospitals have outsourced these specialties to independent doctor groups, which may or may not be in the same network as the hospitals themselves. If they're not in yours, you could suddenly get a bill with an astronomical number at the bottom line.
Organizational structure matters.  Shock bills are stemming in part from hospitals arbitrarily and without any public discussion deciding that radiology, pathology, and anesthesiology are no longer their problem, instead it's the patient's responsibility.  That's a huge change that I don't think we'd accept uncritically in any other industry.  Airlines are getting pushback about baggage fees, imagine the outcry if one day they decided that ticket prices no longer paid for pilots and passengers had to pay that on their own.  Part of the solution here might well be stricter controls on what hospitals are allowed to outsource and what they're required to bundle within their own services.

Food for thought as I look forward to Oregon jumping into network regulation.

Monday, February 23, 2015

Why Governor Brown is going to fire someone

Here's a challenge for anyone who is not self employed.  I want you to share with me every email coming into or going out of your organization.  Not just yours, but those of everyone who works there.  I promise to keep the emails confidential, unless I decide that something's wrong.  In that case I'll release whatever I want to a newspaper reporter, with however much or however little supporting material I see fit.  I'll also do it anonymously, so you'll have no recourse against me and no way of preventing me from doing it again.

Who's up for it?

I don't think any responsible organization would accept such terms.  Why would they trust my judgment of what is right or wrong?  Even if they trusted my judgment how would they know I wouldn't misinterpret something or misunderstand the context?  And how would they know I'd safeguard sensitive personal or confidential information?

I pose this challenge because that's basically where Oregon's state government is.  A culture of leaking has set in, in which employees are deciding on their own what belongs in public.  Bright red lines have been crossed, such as attorney client privilege.  I don't think any organization could function long under such circumstances.  How do you work in a place where anything you said could be used against you, not in a court of law but in tomorrow's smear piece?

Given that, it shouldn't surprise anyone that one of the first things to happen under Governor Brown is a crackdown on leaking.  If she wants to be in charge, leakers and newspaper reporters can't be.

Saturday, February 14, 2015

Another angle to the Kitzhaber scandal

Here is a 2012 TED talk by Dan Carol, a prominent figure in the ongoing Kitzhaber corruption scandal.  He's worked for the state of Oregon since 2011, after he allegedly lined up consulting work for Kitzhaber's fiancee.  Two things jump out at me in this presentation.

One is the reversal of power relationships and a general contempt for workers.  Librarians, sewer workers and DMV employees are "warlords" because they take their roles and responsibilities seriously.  For them to do anything other than instantly comply with whatever is asked of them is "power hoarding."

The other is a disdain for process.  The normal public solutions to public problems,  legislation and regulation, are in his view corrupt and ineffective.  Carol seems to think handshake deals ("less process, more decisions") are preferable.

These themes come together when he considers the construction of the Hoover Dam.  After noting the project was super fast by modern standards (done in two and half years) and also super reckless (130 workers killed in the process), Carol suggests we're too safe now and too regulated.  He doesn't specify how many deaths he thinks are acceptable.

I can see some good things inspired by these ideas, such as the CCO effort.  I can also see how they might lead someone toward cronyism and corruption in a big way.

I don't think the Kitzhaber story is just about Cylvia Hayes.

Saturday, January 3, 2015

What Oregon legislators were (and were not) thinking when they passed the insurance exchange

The Oregonian recently ran a story on Michael Cannon and his crusade to screw over the middle class in states that didn't set up their own health insurance exchange.  His challenge to the tax credits people receive now relies on the premise that his understanding of the law is the only possible rational interpretation.  If the law is only ambiguous then he has no case

Given that, I wanted to see what Oregon legislators were thinking when they enacted SB99 which created Oregon's exchange.  Did they understand that they were enabling Oregonians to receive tax credits?  The following quotes from Senators and Representatives are from discussions preceding the votes.  Transcriptions and any errors are mine, as is the emphasis.
Senate vote on 4/25/11 (SB99 discussion starts at 17:00 mark). 

Senator Morse
… as we all know, the federal patient protection and affordable care act was passed in 2010, which mandates the implementation of state based insurance exchanges by January 1, 2014.  In the event states do not implement an exchange the federal government will do it for them.

Senator Monnes Anderson 
if Oregon does not develop its own health exchange, insurance exchange, the federal government will create one.  This legislation is our own plan that takes our states' specific needs into account with a consumer driven mission and local control. The health insurance exchange will give Oregonians more health care options, a greater number of affordable plans, and more information about which one will best meet their needs.

Senator Kruse
When we went at this proposal, we made it very clear on the front end that regardless of what happened at the federal level we wanted to create something that would work for Oregon, and that has been our intent all the way through on this is to make something that works for Oregon.  Now knowing full well that at some point in time the feds are gonna define a few things like what an exchange actually looks like from their perspective, what a basic benefit plan actually looks like from their perspective, but colleagues those are things that are undefined at this point in time.  It was incumbent on us to do something Oregon specific because quite honestly I don't want the federal government coming in and running things in the state of Oregon.  So this was our option.

Senator Bates
This act says that starting in 2014 every state has to have an exchange.  If the state doesn't do it the federal government will do it.  And we have some very special things in this state that other states don't have.  Managed care plans in Medicaid.  Different kinds of DCBS systems.  And if we don't have our own actual exchange put together we're going to have trouble making the federal one work and it's going to cost us a lot of money to make it work.  So we need to do this ourselves and we need to do it for Oregon and we need to do it fairly quickly...
...My biggest worry is this goes to the house and dies and we are stuck in 18 months to 24 months from now with a federal exchange that we can't make work in this state without us spending huge amounts of money, to put an IT program together, and to make it wedge into a system we have here in this state that's so unusual and actually more effective.

House vote on 6/17/11 (SB99 discussion starts at 2:43:50 mark).

Representative Thompson
Congress provided funds for early adopters, and indicated that if no action was taken by a state to create the exchange, the federal government would create and operate the exchange on behalf of the state.

Representative Cannon
The choice we have today is whether to allow the bureaucrats in the Hubert Humphrey building in Washington to design a health insurance exchange or to put Oregonians to work designing a health insurance exchange that works for Oregonians.  That's the issue.  By adopting SB99, we don't know precisely what this exchange will look like, it's several years from being operational, but at least we'll give ourselves the chance to move forward with an Oregon solution to the national problem of health care and affordability and accessibility.

Representative Thompson (speaking a second time)
...We also know that in January of 2013 the feds are going to move in and do an exchange.  This is not a question of whether or not we have an exchange, whether you like it or not.  It's in the federal law that that's what's going to happen.  They have the right to do that in January and we don't even meet in our long session until February to do anything additionally about this.  So the stakes are relatively high.  The issues of tax credits and navigators and what not are not really germane to this discussion.  That's in the federal legislation.  We're going to get all of that when the feds come in and do their plan for us.  I wish I could wave the magic wand and give a tax credit to anybody who buys insurance anywhere for their employees.  We can't do that.  But the feds did do it.  And they set it up with rules.  We can tuck those rules into our bill and use them, in our plan, or not.  But it's in the federal legislation and your vote today doesn't affect whether or not certain individuals will get tax credits for using an exchange or not.  They're going to get the tax credit because the federal will take precedence over ours if we don't do anything.

A total of 13 Senators and Representatives spoke before the votes.  None of them suggested they thought this would impact tax credits.  Two supporters of the law, one a Democrat and the other a Republican, talked explicitly about what would happen if Oregon didn't build an exchange.  If anyone was going to talk about the impact on tax credits, they would.  What they said speaks for itself.

I think this proves that as a factual matter, neither Republicans nor Democrats in the Oregon legislature held Michael Cannon's interpretation of the ACA.  And to accept Cannon's case, it isn't enough to say they just had different interpretations.  One has to say that the Oregon legislature, both Republicans and Democrats, held to an irrational interpretation of the ACA.

In a comment under the Oregonian story, Steve Buckstein describes a meeting months after these votes where Cannon tried to get Oregon legislators to reject building their own exchange even though this would deprive residents of tax credits.  There are some problems with that story (the timing makes no sense), but if it's even half right I think it says a lot about Michael Cannon.  He sought to strip Oregonians of tax credits, and as a consequence access to health care, in order to score political points for the Republican Party.  Think about that for a second.

The Oregon legislature was wrong about a lot of things when it came to Cover Oregon.  But as wrong as they were, I trust them a hell of a lot more than I trust someone like Michael Cannon.

Saturday, December 27, 2014

2014 Wrap up

Facebook suggests reviewing 2014 through photos, I'm going to take a stab at reviewing the year in terms of reading and writing.

Looking back at my notes, one theme jumps out.  I spent a lot of time reading about late nineteenth century America.  How did we go from ending slavery to starting Jim Crow?  From Radical Republicans to Imperialism?  What role did industrialization and technology development play? 

I wouldn't attempt to answer those questions here, but I'd offer some quotes I found meaningful.

C Van Woodward describes the agreement giving Rutherford Hayes the presidency as a watershed moment comparable with the development of the constitution.  To Woodward, both acts were to some extent betrayals of the revolutions that preceded them, and that wasn't a bad thing:
… the year 1877 was not attuned to the revolutionary fervors of the years 1861 and 1866.  The Men of 1877 were rather like the Men of 1787.  They were of smaller stature than the great Federalists, to be sure, and their work was less celebrated and certainly less known.  But if the Men of 1787 made the Thermidor of the First American Revolution, the Men of 1877 fulfilled a corresponding part in the Second American Revolution.  They were the men who come at the end of periods of revolutionary upheaval, when the great hopes and soaring ideals have lagged and failed, and the fervors have burned themselves out.  They come to say that disorder has gone too far and the extremists must be got in hand, that order and peace must be established at any price.  And in their deliberations they generally have been more concerned with preserving the pragmatic and practical gains and ends of revolutions than the more idealistic aims.  In this respect the Men of 1877 were not unlike those who had been cast in the same historical role before them.
Woodward cites 1787 approvingly, as a means of legitimizing politicians a century later.  Lawrence Goldstone inverts that relationship, blaming the founding fathers for creating an arbitrary and unaccountable Supreme Court.  The court's perverted interpretation of the 14th amendment in those years had horrific consequences for African Americans, and still troubles us today:
If the Court's complicity in the subversion of equal rights had been due to rogue justices, or was an aberration of jurisprudence, Americans of the current day might merely shake their heads, deplore a shameful episode in their history, and congratulate themselves that the United States was no longer that nation.  If, however, the Court's actions were not aberrant at all, but simply examples of ongoing practice, in which justices subordinate the role that Hamilton espoused for them to the exigencies of popular politics- or worse, their own personal beliefs and prejudices- the equal rights decisions of the latter decades of the nineteenth century become expressions of issues deeper, more disturbing.  For then the United States Supreme Court would have, in a very real sense, eschewed the dispassion that the Founders thought so vital and become merely a third political arm of government.  The long-maligned and discredited Brutus then becomes the more effective prognosticator of the pitfalls inherent in Article III, which allows Supreme Court justices to serve for life, virtually without oversight or supervision.  Lack of accountability does not, as Hamilton insisted, constitute a bedrock of liberty, but rather a profound defect in our constitutional fabric.
If politically the nation was ossifying, culturally (for whites) it was liquefying under the influence of industrialization.  Cities offered an alternative to the farm or home town, factories offered work that didn't depend on skill, technology and mass production provided a new world of consumer goods.  TJ Jackson Lears describes it in terms of money:
The alchemical promise of sudden self-transformation gave money a centrifugal force and a corrosive edge.  It could dissolve settled communities and social bonds, send young men spinning off from ancestral seats in search of fresh possibilities, clothe reprobates and rakes in raiments of respectability.  A universal standard of value, money was also a universal solvent of other standards of value.  Custom, tradition, morality - all dissolved, as Karl Marx and Friedrich Engels said, "in the icy waters of egotistical calculation."
What lead me to look at this era?  I'm not sure.  Maybe it's because inequality is rising to levels not seen since the gilded age.  Maybe it's because I think information technology can alter society as radically as industrialization did before it.  And maybe it's because I'm looking for reassurance that as messed up as the nation seems these days, it's not the first time this has been so and it's possible for things to get better.  We'll see what we see in 2015.

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.