Friday, September 4, 2015

Unsolicited Advice for Portland Mayoral Candidates

I took a poll the other day which asked a number of questions about Portland and the mayoral race.  My assumption is those questions are on behalf of a potential candidate, and they're testing the waters.

The poll focused on economic matters:  how is the economy doing, how important are jobs, should Portland try to entice businesses from out of state to move here or focus on growing our own, etc.  They're all good questions on their own, but if that's the focus of a mayoral candidate I think they're all wrong.  In my view Portland's economy is doing pretty well, and when the economy does well people take it for granted.  It won't get votes.

What will get votes is articulating a response to Portland's population growth and housing shortage.  Portland desperately needs not just a direction or a set of actions that will happen ("we'll build more housing, we'll stop demolitions") but a reconciliation with our commitment to sustainability and livable neighborhoods that have long defined the city.  To paraphrase a wise person who's name escapes me, out of
  • affordable housing, 
  • a tight UGB, and
  • our current neighborhood densities,
we can only have two out of three.  One way or another we have to compromise on one of those, and we ought to explicitly decide which.  If we don't, we'll lose affordable housing by default.  That's a shitty thing to do to people with lower income.  If we're pushing them out, the least we can do is tell them so and tell them why.  And if we're embarrassed to say such things out loud then maybe we should look at a different compromise.

I think (I hope) the next mayor will be someone who presents that call, who can answer it out loud, and convince us that they are right.

Thursday, August 27, 2015

Equity without Measurement is Impossible

This is a popular image demonstrating the difference between equality and equity (with equity implicitly the more desirable outcome).  Think about something though.  What does equity mean without measurement?  It's easy in the picture because we can see it, height is easily gauged by visual inspection.  But what happens if we don't know anything about height, either of the kids or the fence they all want to see over?  

To get a sense of the problem, imagine if we could only see the kids from above:

Without height, all we see are the tops of three heads and the fence in front of them.  How do we know who needs more resources and who needs less?  How do we know who can see over the fence?  Without the ability to measure height we can't answer any of those questions.  We could make some kind of guess and move resources based on that, but we wouldn't know if we were improving equity or diminishing it.  In the absence of measurement equity is impossible, even if we got lucky and lined up everything perfectly no one would know it.

I bring this up because measurement in at least one area, education, is a highly contentious issue.  Opposition to testing is a mainstream movement in Portland, even promoted by School Board members.  Not infrequently, those people also claim to be concerned with equity.

Any test can be improved, and any process informed by tests can be improved.  But categorically rejecting testing, which seems to me the heart of the anti-testing movement, simply isn't compatible with a commitment to equity.  Without testing policy is necessarily blind, and equity nothing more than a good but meaningless intention.

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.