Thanks to Trump, insurance premiums will jump for many in 2018

Apologies for two posts in a row about this (with a gap of time between them; I've been a bit ill), but it appears that Trump's efforts to undermine the Affordable Care Act are leading to a large jump in insurance costs next year in several states, though the great majority of people won't see their rates increase at all. The difference will be covered by taxpayers and by families making over 400 percent of the poverty line.

Briefly, here's what's going on:

Under the Affordable Care Act (Obamacare), lower-income working people who get individual or family policies through the exchanges can qualify for reduced co-insurance and copays, provided they pay for at least a Silver-level insurance policy. Under the law, insurance companies have to give these discounts, and in return the law requires the federal government to reimburse the companies. These reimbursements are called "cost-sharing reduction payments."

The Trump administration has been threatening to stop making these payments, justifying that by saying the ACA doesn't explicitly allocate funds for them. That is, it requires that the payments be made, but it doesn't contain additional, separate language saying the payments can be made. This is an arcane legal argument and at worse may represent a wording error, but the intent of Congress to authorize and require the payments is clear. Moreover, members of both parties, including Republican critics of Obamacare, have made clear they want to payments to continue, but so far Congress hasn't acted to make clear that the administration must keep making the payments.

If the administration does follow through on its threats, then the insurance companies will still be required to make the payments, but the money will have to come from somewhere. In order to have enough funds, companies in several states are sharply raising premiums next year, and they've made it clear that this is the reason.

About 80 percent of people with individual policies get subsidies to help pay the premiums. The amount of the subsidy is computed by subtracting a percentage of their income from the cost of the second-least-expensive Silver insurance policy available in their area. If the premium for that policy rises, the subsidy rises along with it so their cost for the policy never exceeds that percentage of their income.

But if they make more than 400 percent of the poverty line, they get no subsidy at all. (In my opinion this is dumb and ought to be changed to a tapering of the subsidy, not a sharp cutoff.)

So roughly 20 percent of people buying policies on the individual market will see a major price increase next year caused by the Trump administration. Of course, the administration hopes the public won't realize this and will believe twaddle about how Obamacare is supposedly "imploding." In fact, the administration and its allies in Congress are flat out lying about this.

For more on this see Ed Kilgore's piece here. See also these two earlier posts from this blog:

Trump is still undermining Obamacare (October 3)

How the Trump administration is still trying to sabotage Obamacare (September 2)

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Trump is still undermining Obamacare

I'm sorry to keep harping on this, but the Trump administration is still doing what it can to damage the Affordable Care Act at a major cost to people who need health insurance, and so far the news media have said little about that in comparison with the wall-to-wall coverage of (fortunately unsuccessful) Republican efforts in Congress to "repeal and replace."

Editor emeritus Charlie Peters at The Washington Monthly has often complained that the Washington media focus on Congress and the White House and ignore what's actually going on in the great bulk of government, which probably helps explain the relative lack of attention to the administration's Obamacare sabotage.

In fairness, there has been coverage, just not as much as we might hope. Back in July, for example The New York Times published an article (updated last week) entitled "4 Ways Trump Is Weakening Obamacare, Even After Repeal Plan's Failure."

The annual enrollment period to sign up for individual coverage is being cut in half this year, and the already modest budget for letting people know about this and other matters is being slashed by 90 percent. There's still a chance Trump may follow through on his threat to withhold legally required "cost sharing reduction" payments, creating uncertainty in the insurance industry and forcing them to raise rates, though even conservative members of Congress have opposed him on this.

This morning Kevin Drum asked in a blog post, "Why Is Trump’s Scorched-Earth Campaign to Destroy Obamacare Getting So Little Attention?" and referencing a blog post yesterday by Andrew Sprung. Sprung points out in passing that the administration is also hurting Medicaid. But as Sprung says, things could still be much worse.

CBO's updated projections for the ACA marketplace are reduced from past years, but CBO forecasts a stable marketplace at more-or-less current levels. Net, CBO forecasts 3 million more uninsured by 2026 than it forecast last year, pre-Trump, pre-sabotage The individual market core is insulated by the subsidy structure, though sabotage with its attendant rate hikes and curtailed participation by insurers hurts upwards of ten million subsidy-ineligible people. Trump's threatened executive order could further intensify adverse selection in the marketplace -- but again, roughly ten million subsidy-eligible enrollees would be insulated.

That justifies hope but not ignoring what's going on. As I mentioned a month ago, a Kaiser Family Foundation survey found that by 78 to 17 percent, people want the administration to do what they can to make the Affordable Care Act work rather than try to make it fail. Even among Trump supporters, 51 to 39 want them to try to make it work. A lot of people would presumably be disturbed to learn what's going on but aren't hearing enough about it. There's more about this in my post from August 14.

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Bully simulator

The clip below is six minutes of highlights from a "Bully simulator" video game as played by Fafa and Mario. Fafa is a groundhog puppet, Mario is a red puppet, and they are the lead characters on the Globe and Boots and Glove and Boots Gaming YouTube channels. I think they're pretty funny, but of course your mileage may vary.


If you want to see the full hour+ of gameplay from which the bits above were extracted, here's the whole thing. By the way, the opening screen last 45 seconds, so feel free to skip past it.)


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Colbert on the mad pooper of Colorado Springs

The funniest thing about this is the reaction of band leader Jon Batiste. (This may not be entirely safe for work, depending on where you work.)


(An aside: While this is a comically bizarre story, there's also likely some underlying human tragedy. A couple of videos -- since deleted -- were posted on YouTube by an anonymous man claiming to speak for the woman's family and apologizing for her behavior, attributing it to abdominal surgery and to a separate traumatic brain injury. A brain injury would be a plausible explanation, but it's unclear whether the man in question has an actual connection with the woman or her family. The police continue to search for the woman in question.)

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How much more might people with pre-existing conditions pay for health insurance?

Even though it currently appears that the Cassidy-Graham bill won't pass, it seems to me that there's a point worth making about how putting people with pre-existing conditions into a separate risk pool might affect their insurance premiums.

Not long ago House Speaker Paul Ryan gave a speech in which he suggested it's not fair for healthy people to pay for the medical needs of sick people. But sharing risks and costs is, of course, the whole point of insurance.

I can see some argument in favor of charging people more if they foolishly put themselves in danger by taking stupid risks. But there are practical problems with that, and except for charging smokers more, there are few proposals to base health insurance premiums on behavior. Instead, insurance companies have raised rates or denied coverage to those with pre-existing conditions.

The Cassidy-Graham bill would allow states to put people with pre-existing conditions into one or more separate risk pools from those who are currently healthy, resulting in higher health insurance premiums.

How much higher? Sam Berger and Emily Gee at the Center for American Progress recently did the computations. You can find their report here and a summary here.

Persons with asthma or diabetes without complications would expect to pay around $4000 to $6000 more per year above the premiums for healthy people. Those with serious types of cancer would be charged more like $28,000 to $140,000 more, and heart disease would cost $18,000 to to $58,000 more annually.

An obvious response is that it's unlikely people would be assigned to separate risk pools based on their specific current or past illness. But why not? If it's unfair to put healthy people in the same group as those who are or have been seriously sick, why isn't it just as unfair to put, say, asthma patients with those who have metastatic cancer? And even if there were just two pools, with those having pre-exising conditions paying a weighted average of those higher rates, the result would still be unaffordable for most people, leaving uninsured everybody but the well-off and those in Medicare, Medicaid, or other government programs.

That just isn't realistic. As it apparently still needs mentioning, the rest of the developed world has figured this out and has comparable or better outcomes with lower costs. Some employ a single-payer system (Canada, Taiwan, the UK, Italy, et al) and others use a tax-subsidized system with sensibly regulated independent insurance companies (as in Germany, Japan, Israel and elsewhere). The Netherlands and Switzerland have had pretty good results with programs not all that different from Obamacare.

As Senator McCain points out, there's no reason the United States can't do as well or better than other countries. But people from across the political spectrum will have to come together to do it in a way that's based on what works rather than rigid ideology. Most Democrats and some Republicans seem willing. Opposition comes mainly from a subset of the extreme right and the GOP leadership, and a few far-left Democrats who won't settle for anything but single payer. (I personally think Medicare for all isn't a bad idea, but insisting on that or nothing risks leaving us with nothing.)

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An injured wild hawk rides out Hurricane Harvey with a Houston cab driver

It wasn't just pets that needed help during Hurricane Harvey. An injured hawk took refuge in a Houston taxi as Hurricane Harvey approached, apparently having been scared by a cat as well as the approaching storm. The hawk showed no fear of cab driver William Bruso (who thought the hawk was merely afraid and didn't realize she was also injured) and wound up spending the hurricane in his house. (In fact, Bruso apparently let the hawk ride around on the dashboard while he continued to pick up fares and supplies before the hurricane arrived.)

Eventually Bruso turned the bird over to a wildlife rescue group, which treated the impact injuries and released the hawk back into the wild. All these clips are quite short, and I've trimmed them down to the ones I thought most interesting. You can find updates 1 and 4-7 on Mr Bruso's YouTube channel. Or just click the first link below to go to the clip's YouTube page and you should see links to the rest in the related-videos section (except possibly for the next-to-last one, which is from the rescue center's channel).

(Incidentally, as the hawk recovered she began acting more hawk-like and a good deal less tame. This is one reason you should let experienced people handle wildlife rescue and not try to do too much on your own.)

Hawk in taxi:


Update #2: Discussing what to do.


Update #3: Deciding to let the hawk ride out the storm at home.


Update #8: Snack time.


Update #9: Texas Wildlife Rescue takes custody.


Someone from Texas Wildlife Rescue talks about releasing the rehabilitated hawk back into the wild on their own channel.


Finally, here's a more detailed news report from Harvey the Hawk's release, with discussion of other animals needing help as a result of the hurricane and wildlife rescue in general. A little under seven minutes in William Bruso, who seems like a pretty decent guy, gives his own account of how Harvey came to get into his cab and the experience riding out the storm with her. He also talks about what happened to people in the Houston area and the devastation he saw doing volunteer work in the aftermath, and he even gets in a passing joke about Uber. He then helps release Harvey back into the wild.


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On taking knees

There's currently a debate going on about some NFL team members kneeling during the national anthem to protest widely reported instances of police violence toward minority groups. President Trump has called the players in question "sons of bitches" while team owners, even those who donated lots of money to Trump's campaign, have mainly supported the players.

Interestingly, only about a half-dozen players were joining in the protest at the time President Trump started to complain, and subsequently the number has greatly increased.

Yesterday's New York Times published an op-ed by Eric Reid headlined "Why Colin Kaepernick and I Decided to Take a Knee." Please read the whole thing. He begins

In early 2016, I began paying attention to reports about the incredible number of unarmed black people being killed by the police. The posts on social media deeply disturbed me, but one in particular brought me to tears: the killing of Alton Sterling in my hometown Baton Rouge, La. This could have happened to any of my family members who still live in the area. I felt furious, hurt and hopeless. I wanted to do something, but didn’t know what or how to do it. All I knew for sure is that I wanted it to be as respectful as possible.

When his teammate Colin Kaepernick stopped standing for the national anthem during the preseason Reid decided to join him, and they started discussing what to do.

After hours of careful consideration, and even a visit from Nate Boyer, a retired Green Beret and former N.F.L. player, we came to the conclusion that we should kneel, rather than sit, the next day during the anthem as a peaceful protest. We chose to kneel because it’s a respectful gesture. I remember thinking our posture was like a flag flown at half-mast to mark a tragedy.

It baffles me that our protest is still being misconstrued as disrespectful to the country, flag and military personnel. We chose it because it’s exactly the opposite. It has always been my understanding that the brave men and women who fought and died for our country did so to ensure that we could live in a fair and free society, which includes the right to speak out in protest.

Again, the whole piece is worth reading. But I have to say that I thought that what Reid says above should be completely obvious. Who in the history of the world has ever knelt to show disrespect?

Clearly not everyone thinks that a gesture of protest on a football field or during the national anthem is appropriate. I can see arguments on both sides. A lot of people disagree with the views of Kaepernick and Reid and not just their way of expressing it. (For the record, I happen to think they have an entirely valid point.)

But to suggest that players kneeling during the national anthem is showing disrespect to the flag or the country strikes me as absolutely ridiculous. In some cases it's dishonest, and effort to stir people up for political reasons by misrepresenting something. That's far, far worse than kneeling respectfully during the national anthem.

Personally this aging Navy veteran plans to continue to stand and salute the flag during the national anthem. (For one thing, if I did kneel, I might need help getting up.) But I respect Kaepernick and Reid and their colleagues, while Trump's tirades against them lower my respect for him yet another notch.

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The latest on U.S. crime rates

While overall crime in the United States has continued to fall, violent crime, notably murder, rose in the last two calendar years after a long period of decline. That increase turns out to have been entirely in metropolitan areas, especially Chicago. In the rest of the country (even in some large cities such as New York) the murder rate is still going down. Preliminary data from major cities so far this year suggests that 2017 will likely follow the long-term trend of falling crime rates, which are down by nearly half since 1990.

Now for the details, prompted largely by the FBI's release of full U.S. crime statistics for 2016 earlier today:

Josh Marshall at the Talking Points Memo website wrote a summary focusing specifically on the murder rate that features this graph:

USA murder rate 1987-2016

As Marshall notes, this is an important number to track because murder is the most serious of crimes, and the murder rate is a pretty solid indicator since murders rarely go unreported. I would add that it's also a relatively small fraction of violent crime and of crime in general, and it's statistically noisy and subject to distortion by a surge of murders in a few cities or regions. That said, the U.S. murder rate rose from a low of 4.4 per 100,000 persons in 2014 to 4.9 in 2015 and 5.3 in 2016. That's obviously not good.

But it's also a bit misleading. A more detailed breakdown of the FBI report by the Brennan Center for Justice at the New York University School of Law points out that the overall crime rate fell by 1.4 percent last year. In fact, crime has gone down for every one of the past 15 years (and there's reason to expect it to decline in 2017 as well; see below).

Moreover, the increase in the murder rate during 2016 was concentrated mainly in large cities. According to an earlier Brennan Center report, Chicago alone accounted for more than 55 percent of the increase across the 30 largest U.S. cities. In contrast, as mentioned in a blog post a few weeks ago, the murder rate in New York City was down again last year.

Also, outside of metropolitan areas, the U.S. murder rate in 2016 fell by 6.7 percent. That is, the rise in murders in 2015 and 2016 took place mainly a few cities and regions, not the country as a whole.

In addition, so far this year the combined murder rate for the 30 largest U.S. cities has been declining. The Brennan Center's preliminary projections for 2017 show the U.S. murder rate falling by 2.5 percent, largely because of declines observed in Detroit (down by 25.6 percent), Houston (down 20.5 percent), and New York City (down 19.1 percent). Even Chicago is likely to end the year with a slightly lower murder rate than in 2016. (Not every city has been so fortunate, however. For example, Charlotte's murder rate doubled in the first half of 2017.)

To be clear, I'm not suggesting that there's no cause for concern. The rise in violent crime in 2015 and 2016 isn't good. At the same time, a two-year increase doesn't prove the existence of a longer-run trend (especially since the data for 2017 so far point in the opposite direction). The United States is not in the grip of a skyrocketing crime wave, as some would like us to believe for reasons of politics or ratings. The overall crime rate for violent and property crimes combined is still down by nearly half since the start of the 1990s to levels typical of 50 or 60 years ago.

The reasons for the long-term fall are unclear, but one possible factor is, perhaps surprisingly, the phaseout of leaded gasoline decades ago. Even very low levels of lead poisoning in children can lead to behavioral problems in adolescence and adulthood, and measures of declining atmospheric lead concentrations track closely with the fall in crime rates years a couple of decades later, as journalist Kevin Drum has frequently written. Another possible influence is an increase in the number of police in the 1990s. (The likelihood of being caught has a greater deterrent effect than such measures as the duration of prison terms.) On the other hand, intensive policing that alienates people, such as New York City's stop-and-frisk policy of a few years ago, doesn't appear to help, since crime continued to fall after the policy was ended.

To summarize, the short-term rise in violent crime statistics in 2015 and 2016 shouldn't be ignored but neither does it suggest a crisis. Even despite that increase, both violent and property crime remain at historically low rates and there's reason to think the murder rate in 2017 will be lower. And while it's not entirely clear why crime rates have fallen of the past quarter-century, the fact that they have suggests it's a problem that can be dealt with.

(Updated 2017 September 30 and October 5 and 9 to add a few points and as usual try to improve my clumsy wording.)

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The facts on Cassidy-Graham and pre-existing conditions

Update: The just-released revised version of the Cassidy-Graham bill makes it even easier for states to do away with protections for people with pre-existing conditions, apparently in a vain effort to get support from Rand Paul and Ted Cruz.

Just a few years ago, many Americans with pre-existing medical conditions could not obtain health insurance at all, and many more could not purchase it at a price they could possibly afford. The Affordable Care Act -- Obamacare -- changed that. Insurance companies can no longer deny insurance to people just because they're sick or might get sick.

It has been widely reported that the proposed Cassidy-Graham healthcare bill (also known as Graham-Cassidy and Graham-Cassidy-Heller-Johnson) no longer has that requirement. Senator Bill Cassidy (R-Louisiana) has gone on news programs to deny this. He says the bill does protect people with pre-existing conditions. So which is it?

As far as I can tell, here's the story, but it's a bit complicated, and almost everything is followed by the word "But"...

The bill does require insurance companies to sell policies to people with pre-existing conditions. But...

It lets states opt out of the requirement that people with pre-existing conditions don't get charged more. It does this by letting states allow insurers to create more than one "risk pool," so people with pre-existing conditions would end up in a higher-risk pool with higher premiums. But...

It says that before they do this, states must seek approval from the federal government and provide a plan to insure people with pre-existing conditions at an affordable price. But...

It doesn't require states to actually implement such a plan, just to describe one, and as long as they produce a plan, the federal government would be required to grant a waiver to the states requesting one. (And the latest version of the bill seems to do away with the requirement to seek a waiver at all.) But...

You might say, surely states wouldn't leave people with pre-existing conditions unable to buy insurance. But...

The fact is that prior to the Affordable Care Act, almost every state did exactly that. In fact, a lot of them still do at least for some. That is, a number of states that used to restrict Medicaid to just a subset of poor people continue to do so. The Affordable Care Act required them to expand Medicaid and ensured that almost all of the additional cost would be covered by the federal government. However, the Supreme Court discovered something supposedly in the Constitution that made this optional (though it's a little unclear where in the Constitution they found this -- perhaps Nicolas Cage ran across it on the back, presumably in a deleted scene from National Treasure). People whose income puts them in the Medicaid expansion group often can't get insurance on the exchanges if they live in one of the states that refused to expand Medicaid, so their states force them to go uninsured, pre-existing conditions or not.

There's a reason (besides sheer meanness) states would want to make coverage for pre-existing conditions expensive or unaffordable: To force people to buy and maintain health insurance coverage without explicitly doing so. Right now the Affordable Care Act encourages people to get health insurance by charging them an extra income tax if they don't have it and don't belong to one of the exempt categories (such as those with a religious objection to health insurance). A lot of people want to do away with this so-called "individual mandate." The problem is that if they did so, a lot of people would just go without insurance until they got seriously injured or ill. And that would obviously raise the price of insurance sky-high, just as homeowners insurance would be horrendously expensive if you could wait until your house burned down to buy it. If you do away with the ACA's individual mandate and you still want people to buy insurance, the only alternative is to scare them into buying it by letting them know it will cost a lot more if they wait. The problem is that experience shows lots and lots of people just don't think ahead or assume that because they're pretty healthy now they can't possibly get sick or hurt.

The bottom line is that we can be close to certain, based on experience and on what a lot of Obamacare opponents stay publicly, that a lot of states would opt out of protection for people with pre-exisiting conditions. The bill's supposed "protection" is either poorly thought out or else a deliberately cynical con job to give political cover to people voting for it. Either way, it's one of the things that makes it a bad bill. But...

It's far from the only problem. The bill also deeply slashes funding (though the latest revises version dumps more money into it) and converts much of the Medicaid expansion and premium assistance money to block grants to states, with few regulations on how the funds are used.

Not one major medical or consumer organization supports the bill, and odds are any of those organizations whose name you've heard actively opposes the bill.

The latest news reports suggest that the bill is probably dead and likely won't even come up for a vote. That's not a certainty, however. So if you want to do something in the limited time available, here from Time magazine is a list of direct contact numbers.

Especially if you live in a state with a Republican senator you should give them a call. You'll wind up talking to a staffer, who no doubt has a script to read telling you that Obamacare is collapsing and something must be done. That's not actually true, but don't waste time arguing with them. Make sure they know you're from their state. Tell them what city or county you live it. Say you agree that Obamacare has flaws (which is true) but that the Graham-Cassidy bill is even worse and has never had open hearings or debate. Say that you support Senator John McCain's call for a bipartisan solution. (See what McCain says here.) It's OK to let them know you're passionate about it, but avoid yelling and the poor staffer answering the phone. If they're stubborn, just say you disagree with them and you'd like them to pass on your views to the senator.

Even senators who won't change their minds still keep track of how the call volume goes and pass on the information to their colleagues.

What if your senators are both Democrats? It's still good to call and let them know you don't want to Graham-Cassidy bill to pass. Ask them what you can do to make sure that doesn't happen.

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