Why did Aetna decide to exit a state where it was making money?

Recently the health insurance company Aetna announced that starting in 2017 it would no longer be selling policies through the Affordable Care Act exchanges in several states because it was losing too much money. Curiously, though, one of those states is Pennsylvania, where (according to Aetna itself, as Richard Mayhew pointed out) it made a healthy profit there in the individual market for at least the past two years, and it had expected to do the same next year. So why would Aetna want to withdraw from Pennsylvania?

The explanation might be politics. Aetna had been planning to merge with Humana, another large health insurer, but the Department of Justice Antitrust Division was concerned that the merger would be anticompetitive, and Aetna didn't like that.

In a July 5 letter to the Department of Justice (PDF here), Aetna's chairman, Mark Bertolini, issued a warning: "Specifically, if the DOJ sues to enjoin the transaction, we will immediately take action to reduce our 2017 exchange footprint. ... In other words, instead of expanding to 20 states next year, we would reduce our presence to no more than 10 states."

The DOJ did decide to object to the merger, and Aetna did as it had warned. To be clear, Aetna presented this as a business necessity, not a threat. But it is curious that the company would pull out of a state where it was making money and employing and insuring a fair number of people. For more on this see Jonathan Cohn's Huffington Post article.

Incidentally, Aetna and other health insurance companies actually have been losing money selling individual policies some other places, mainly because not enough currently healthy people are signing up for coverage. Younger and healthier people are not signing up because extra tax imposed on those who go uninsured isn't all that big, they may not realize that coverage for silver plans (and you generally do want to get at least a silver plan) is affordable when you take into account the tax credit around 80 percent of people get, and a lot of them think that they can just wait and sign up if and when they get sick, which is only partly true, since open enrollment is limited to a few months a year and coverage doesn't start immediately and isn't retroactive.

So the most popular part of the law (the one that says insurance companies aren't allowed to cancel your policy, refuse to sell you one, or charge you more because you're sick or were in the past) depends on the least popular part (the so-called "individual mandate") in order to be economically feasible, because math. More on this in future posts.

(Updated 2016 August 27 to add the last to paragraphs.)

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U.S. infant mortality problem 1 to 12 months after birth

Pediatrician and medical school professor Aaron Carroll discusses the causes of high infant mortality in the United States relative to other developed countries. Some proposed explanations don't appear to be supported by research. For example, it doesn't seem to be a lack of prenatal care, and neonatal mortality -- deaths of infants during the first month after birth -- isn't notably worse in the U.S. than in other developed countries. The problem is for infants between one month and one year of age, particularly in low-income families.

Link: https://youtu.be/5ToJbhLEbdM

(A number of questions occur to me: Does the problem peak at some point and then decline? Does it extend past the first year of life?)

A number of countries send a trained helper (e.g. a kraamzorg in the Netherlands) to assist new mothers, both to do things for them (child care and some housework and making sure the mother's health is OK) and to teach them how to take care of their baby. This might partly explain the difference. The United Kingdom does not have such routine care, and it would be interesting to see how its outcomes compare with those of the Netherlands, France, etc.

For more, see Dr Carroll's article in The New York Times (link).

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Should primaries be open?

To many people it seems self-evident that the purpose of a primary election (or caucus) is to let the members of a political party choose their party’s nominees. If so, it pretty directly follows that primaries ought to be closed to voters who aren’t registered party members. But if the case for closed primaries is that straightforward and obvious, why are so few of our primaries closed?

For more on that see this post from yesterday. In brief, the majority of party primaries in the U.S. allow at least independents to vote alongside party members, and in many cases voters can pick which party's primary to vote in when they cast a ballot. (They can't legally vote in more than one party's primary in a given election cycle, however.) A few states have non-partisan primaries for state-level offices.

Primary elections were introduced in the early 1900s with the intent of making elections more democratic by taking the choice of candidates away from political party organizations and turning it over to the public. One reason is that our system of government leads to a two-party duopoly (we’ve never had more than two viable major parties in our history), and as with similar concentrations of power in business, it makes sense to regulate matters in the public interest.

Primaries are paid for, regulated, and run by the states as part of our multistage process of choosing elected officials. (Presidential nominating caucuses, however, are generally paid for by the parties.) In the minority of states with closed primaries, unaffiliated voters are effectively disenfranchised in the first round of voting, even though their taxes pay for the primary elections they’re not allowed to vote in.

A pragmatic argument against closed primaries is that primary turnout is often low and tilted toward voters with the most partisan views. Semi-closed or open primaries can bring in a somewhat broader spectrum of people, potentially increasing the likelihood of nominating candidates with broader appeal and electability. (Of course, whether that’s good or bad is a matter of opinion. There’s currently a movement in the Republican Party in favor of closed primaries in the hope of nominating more solid conservatives as opposed to so-called RINOs -- Republicans In Name Only.)

The fact that the not-very-moderate Bernie Sanders did rather better in open primaries than closed ones is an obvious exception, but it no more disproves the general tendency than a snowstorm disproves global warming. (And Sanders also did better in caucuses, which as a rule have even lower and more partisan turnouts.)

A concern with open primaries is the risk of “party crashing” -- adherents of one party crossing over to vote in the other party's primary in a strategic effort to damage the other party’s general election chances. The most famous example of that was Rush Limbaugh's "Operation Chaos" in the spring of 2008, in which the right-wing talk-radio host urged his listeners to vote for Hillary Clinton in the later primaries in an effort to prolong the Democratic nomination battle. But available data indicate that only a small percentage of Republicans crossed over to vote in Democratic primaries, and it's not clear that very many of them were motivated by Limbaugh. McCain had become the presumptive GOP nominee by March 4, so they might simply have wanted to cast a presidential primary vote that had some effect on the outcome, and those who did vote for Clinton had other reasons besides shenanigans for doing so, including an impression that she was more moderate than Obama. The effect of Operation Chaos was probably greater than zero, but not much greater. In any case, Limbaugh called it off after the May 6 primaries, saying he wanted Obama, whom he viewed as less electable, to win the nomination. Of course, by then Obama has a large delegate lead and was generally expected to take the nomination anyway. Perhaps for an encore Limbaugh could ask his listeners to throw ice cubes into their yards at the start of winter and then take credit falling temperatures.

Other real-world examples of attempted party crashing are hard to find, one likely reason being that voting in the other party’s primary means giving up a chance to vote in one’s own.

What about non-partisan primaries? A lot of people would like expand the use of non-partisan top-two jungle primaries like those in California, Washington, Louisiana, and Nebraska (at least for electing members of the legislature). There’s a problem with two-two primaries:

Suppose the great majority of voters in a district prefer Party A and hate Party B. A lot of good Party A candidates enter the primary while much-less-popular Party B draws only two. If Party A voters divide their support across their large field, Party B’s two candidate might well finish at the top, even if their combined vote percentage is small, leaving voters in the general election to choose between two candidates they hate.

There’s fortunately a simple solution that’s trivial to implement: Use what’s called approval voting in the primary, meaning voters can vote for every candidates they deem acceptable, however many that might be. The winners of the primary would be the candidates deemed acceptable by the greatest number of voters. Oddly, the only place I’ve ever seen a proposal to use approval voting in a top-two primary is a previous post on this blog. I don't mean to suggest I'm the first person to think of it, only that I've never encountered a discussion of it. There's more on approval voting in general here. For more on top-two voting from advocates of the system see http://www.openprimaries.org.

Anyway, I support the right of voters to change their political affiliation at any time, including just before they cast a ballot, so my inclination is to prefer open primaries until I see some reason to think that they are harmful to democracy or lead to a worse choice of candidates in the general election.

I do sympathize with the notion a party’s members should be able to choose their party’s nominees without outside interference, and in a multiparty democracy I think that’s probably how things ought to work. But in our two-party duopoly, I think other concerns are of greater importance. And in practice, the small number of closed-primary states suggests that even the parties themselves don’t demand closed primaries.

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Open versus closed primaries in the United States

This election season there has been some discussion of open versus closed primary elections, with a movement among conservative Republicans in favor of closed primaries and among progressive Democrats (notably Sanders supporters) for open ones. This got me curious about just who is allowed to vote in primaries in various states.

It turns out that there are basically four kinds of party primaries in the U.S.:

Closed: Only those who have registered in advance as affiliated with the party in question are allowed to vote in the party's primary.

Semi-closed: Unaffiliated voters as well as registered party members can vote.

Open: Voters can vote in any party's primary.

Non-partisan: All candidates for a given office are listed on a single ballot regardless of party, and the top two go on to compete in the general election, regardless of party. These are often called "top-two" or "jungle" primaries.

In no state are voters legally allowed to participate in more than one party's primary election in a given election cycle. If you vote in the Democratic primary, for example, then you're not allowed to vote in the Republican one.

To complicate matters, presidential primaries are often handled differently with respect to whether primaries are open, semi-closed, or closed, and some states use caucuses and state-level conventions rather than primaries to select delegates for the national presidential nominating conventions. This year the state of Washington had both caucuses and a presidential primary, and the results of the presidential primary had no effect.

Caucuses are paid for and run by the parties according to their own rules. Primaries (presidential and otherwise) are paid for and regulated by the states.

Here's how the numbers break down for state-level offices in 2016:

  • 9 states and Washington DC have closed primaries
  • 9 states have semi-closed primaries
  • 7 states allow parties to choose to make the primaries closed or semi-closed
  • 21 states have open primaries
  • 3 states (Washington, California, and Louisiana) have non-partisan primaries
  • 1 state (Nebraska) uses a mix of primary types for different offices

Presidential primaries and caucuses vary by party. On the Democratic side they are closed in 14 states, semi-closed in 12, and open in 24. For the Republicans, they are closed in 19 states, semi-closed in 9, and open in 22. Both parties' primaries are closed in DC.

For a complete breakdown, see http://www.fairvote.org/primaries.

Incidentally, FairVote, like many other references, distinguishes two types of open primaries, "open" and "partly open." In the former, states don't register voters' party affiliations and let voters pick a party when they vote. The other states do register voters by party but allow them to change party affiliation at any time, including when voting. Since in both cases voters can choose which primary to vote in at the last minute, I'm counting both types as "open."

In fact, it's worth noting that the only thing that distinguishes open primaries from closed and semi-closed ones is the deadline for picking a party. In New York's closed-primary system, already registered voters who want to change their existing party affiliation must do so at least 25 days before the date of the previous year’s general election. No other state comes close to that, and only five states besides New York require voters to change their party affiliation more than two months before election day for the primary. In effect, open primaries simply reduce the advance notice requirement to zero.

A separate question is whether primaries ought to be open, semi-closed, or closed. I'll get around to my thoughts on that, for whatever they're worth, in another post.

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Guardian columnist laments fossil fuel influence on climate change coverage

George Manbiot's succinct August 3 piece in The Guardian takes note of how well-to-do fossil fuel interests continue to promote misinformation about global warming in news coverage. As most of us are well aware, last year was the warmest ever recorded, beating the previous record set the year before, and this year is on track to be warmer still. Indirect measurements of warming, such as the declining extent of Arctic sea ice and the rise in sea levels, continue to point in the same direction. Despite that, we still hear people insist that global warming stopped more than ten years ago. And as Manbiot is far from alone in pointing out, past scientific predictions about warming of have actually tended to understate the problems we're now experiencing.

Not all that many years ago most Republican as well as Democratic leaders acknowledged the science and differed only on how to address the problem. Both Presidents Bush spoke of the need to do something, as did Republican presidential candidates Bob Dole and John McCain. Mitt Romney was largely dismissive of climate change when he ran in 2012, but last year he made it clear he recognizes the reality and importance of the problem (see e.g. this piece in The Atlantic).

Unfortunately, the recent sharp rightward shift of the GOP and its base seems to have led to a growing degree of science denial. Most Republican presidential contenders this year reject the scientific consensus, and the eventual nominee, Donald Trump, has called climate change a "hoax" invented by the Chinese. (That at least has the virtue of novelty. There are still some who credit Al Gore with the idea.) On the other hand, as Manbiot points out, Trump's golf course in Ireland "is seeking permission to build a wall – not to keep out Mexicans, but to defend his business from rising sea levels, erosion and storm surges caused, the application says, by global warming."

The candidate who finished second behind Trump and well ahead of the rest of the field, Ted Cruz, has said things just as nonsensical, for example repeating the myth that the term "global warming" was replaced by "climate change" two or three years ago when scientists supposedly realized the warming wasn't happening. In reality, of course, both terms for the same set of phenomena have been in use for decades.

For just one obvious example, the Intergovernmental Panel on Climate Change was created to study global warming during the Reagan administration. A previous post on this blog linked to a scientific paper published 60 years ago that referred to human-caused global warming as "climate change" in its title. The same post featured an amusing video someone created to contrast Cruz's claim with clips going back to the 1980s of Republican as well as Democratic presidents (as well as British PM Margaret Thatcher) speaking about "climate change" in a fashion that makes it clear they're talking about global warming.

For more about Cruz's multiple false assertions about global warming (errors that are by no means limited to Cruz), see also this post.

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The useful but abused verb "comprise"

The parts compose the whole. The whole comprises its parts. That's a useful pair of words, but unfortunately "comprise" has come to be used as a sort of redundant synonym for "compose."

In fact, nowadays one probably encounters the verb comprise most often in the nonsensical expression "is comprised of." A few months ago on some NPR program or other I heard someone argue that "is comprised of" has become such a commonplace phrase that it is now acceptable simply as a matter of established usage.

I admit I'm often sympathetic to such arguments. For example, I've never been a fan of the AP Style Guide's advice (at least in editions of years past) that it's incorrect to say "she graduated" or "she graduated from" college or high school on the ground that schools graduate students rather than the other way around. It was necessary, the AP said, to say, "she was graduated from" the institution in question. In fact, "She graduated college" is long-established and unambiguous and I see no reason to insist on "was graduated."

On the other hand, preserving the useful separate meanings of comprise and compose strikes me as a battle worth fighting, uphill though it might be. For one thing, most of the time when people say "is comprised of" they could simply say "comprises." Or if they for some reason wanted a wordier construction they could say "is composed of" or "is made up of." They could also say "constitutes." There's no shortage of ways to say the same thing, what does adding "is comprised of" to the set of possibilities get you?

OK, I suppose there's the fact that saying "is comprised of" annoys pedants like me, which may be fun...

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I'm still dealing with a family illness

It doesn't seem that it's been as long as it has since I last posted here. As I mentioned some time ago I'm dealing with a serious illness in my family, and that's taking up a lot of my time. It also takes a lot of emotional energy. I think it might help me deal with it to write about other things, so I'm going to try to do more of that here.

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"Between you and I" and related weird errors

A lot of people don't especially care about grammar, usage, and style as long as they get their message across. If you're one of them, just ignore me when I go off on the subject. A lot of this stuff is a matter of opinion anyway. But here I want to say a little about a common grammar mistake that's routinely made by experienced English speaker, and there's pretty much no informed disagreement that it is a mistake.

Except for children and cavemen, very few speakers of English are likely to say "Me went to the beach" or "Her went to the beach." But some will still say "Me and her went to the beach."

Worse, my not-very-careful observations suggest that an even larger number of English-speakers, even well-educated native speakers, will say "They invited she and I" and think it's good English grammar.

There appears to be at least a subconscious notion that the word "and" has something to do with pronoun case in English, even though it doen't. "I," "we," "he," "she," and "they" are all in the nominative case, while "me," "us," "him," "her," and "them" are all in the objective case. But you don't need to worry about grammatical terminology or technical detail. All you need to do is remember that using "and" doesn't change anything.

If you say or write, "They invited her" and "they invited me," it makes sense to combine them into "They invited her and me." Likewise "It came from me" and "it came from him" together become "It came from me and him."

I can think of one place this rule of thumb doesn't help: the space following the preposition "between." If you remember that "me," "us," "him," "her," and "them" are all in the objective case, then it should be obvious that just as we say "between us" we should say "between him and me." Or if you don't care about grammatical cases, just remember by brute force to say "between you and me" and the like.

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John Oliver's exposé and advice on retirement plans

A few weeks a couple of friends of mine asked me for some investment advice about their retirement savings, and if I'd known about this video I would have just told them to watch it. I highly recommend it.

Link: https://youtu.be/gvZSpET11ZY

I'm glad to say that what I told my friends is in keeping with the advice in this video. My only area of disagreement has to do with whether it's all that good an idea to invest in bonds. Bonds are less volatile than other investments, but they are a good deal harder to understand, and not only are interest rates are currently very low, any bonds you own will fall in market value should interest rates rise. (That's because the bonds you own aren't paying the higher interest rates.)

For many people the simplest option is to invest in a very low-cost fund associated with a target retirement year. These are available from all the large mutual fund companies, but I personally use Vanguard because their fees are very low, and Vanguard investors actually collectively own Vanguard. If there's not actually a fund for the specific year you plan to retire, choose one for a nearby year. I would lean toward a later year rather than an earlier one, in part because people often retire later than the originally intended to.

Other free advice: If you're single and don't need the money to live on, postpone taking Social Security retirement benefits until you reach 70. That's because monthly benefits are greater the more you delay starting them. Of course, by delaying you're also forgoing all the monthly payments you could have been collecting, and it takes years for the higher payment levels to catch up with that. But life is uncertain, and living a long time carries a risk of needing more money to deal with personal needs late in life. It's best to spend down other retirement assets and save Social Security for last.

If you're married, divorced, or widowed, things are more complicated, and you might want to check out the Maximize My Social Security service that for $40 will do the calculations for you. Full disclosure: I used to know Laurence Kotlikoff, the owner of the company in question, very slightly, but my recommendation isn't based on that, and I don't get anything in return for mentioning it. There are similar services out there but I think his is the best of the ones I've looked at.

(By the way, Social Security is not about to go bankrupt and the problem it does have are pretty easy to fix. Even if Congress were to do nothing at all and the Trust Fund runs completely empty in the mid-2030s, the worst case -- absent an asteroid strike, nuclear war, or a Donald Trump presidency -- would be an across-the-board reduction in benefits of twenty-some percent. If you don't see how that's possible it's probably because you don't realize that the Trust Fund exists to make up the difference if Social Security taxes aren't enough by themselves to pay for scheduled benefits. Contrary to popular misconceptions, Social Security has always been as pay-as-you-go system whose Trust Fund is invested in U.S. government bonds; there was no nefarious congressional "raid" on the Trust Fund. For more on myths about Social Security see these other posts on this blog.)

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Young people in a refugee camp

In the following very short video American writer John Green shows a little of what life is like for young people in the Zaatri refugee camp on an arid plain in northern Jordan near the Syrian border.

The camp was established 2012 July 28 (barely over 4 years ago as I write this) to shelter refugees from the civil war in Syria. It was supposed to be temporary, but because the war shows no sign of ending, Zaatri is developing into a permanent city with its own government and a population of around 80,000, most of them children and adolescents. The Wikipedia article on the camp (link) has a photo that shows the immense scale of the place.

Link: https://youtu.be/n2178SPJCKw

There are reasons besides simple decency to help educate young people like the ones John Green interviews in the video. Adolescents in camps like this can lose hope and become vulnerable to the influence of everything from criminal gangs and drug dealers to political and religious extremists and terrorist organizations.

For whatever they're worth, my other posts on the refugee crisis can be found at this link.

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