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4 Obamacare’s class problem

Maybe this is obvious! Here’s my crude, relatively unwonky framework for thinking about the ongoing troubles of Obamacare (specifically, of the Obamacare exchanges): It’s a class problem. The exchanges are attractive to lots of heavily subsidized near-poor Americans, but distinctly less attractive to middle class Americans with incomes above 4-times-poverty, about $48,000 for a single person. (That’s the point at which subsidies disappear and the exchanges become a much-less-good deal).  Most of the middle class doesn’t have to use Obamacare, of course, to their immense relief — they get coverage from their employers. (Some, like freelance writers, have no choice. They have been known to complain.)

Why is this lack of a middle class participants a problem? Not because “programs for the poor are poor programs.” (Some are, some aren’t). Two other reasons:

1) We’re all human beings with the same health problems — but poorer Americans tend to be less healthy, so premiums that cover a poor-heavy risk pool will be higher than the “one true price” that would cover a risk pool made up of everybody. Middle class people thrown into this unhealthy risk pool wind up paying higher prices than they should have to pay. **

2) Different tastes. If you haven’t had health insurance because you can’t afford it, you might rationally be happy with any access to a regular doctor at all. If you’re middle or upper class you probably want access to the best doctors and the best hospitals. Not surprisingly, with a huge near-poor presence and no big middle class presence Obamacare is evolving to serve the former group: Medicaid-like packages with low prices and short lists of maybe-not-quite-as-top-tier docs (sorry, make that “narrow … networks that are especially adapted to the needs of lower income consumers”) have driven higher-end plans off the playing field. In some places, it’s hard to get a plan with top doctors and top hospitals on the exchanges even if you are willing to pay extra for it.  More reasons for the (healthy) middle class to look at Obamacare the way a traveler views a seedy hotel — something to be avoided if possible. ***

It’s not easy to see how this core problem can solved without somehow getting more middle class people off their employer plans and into the Obamacare pool, something they won’t want to do as long as — well, as long as there aren’t more middle class people like them in the Obamacare pool, which won’t happen as long as the plans are too expensive and too Medicaid-like,  which won’t change unless there are more middle class people in the pool ….

— Tinkering with the subsidy structure, a la the just-defeated Ryancare, might improve the mix a bit at the cost of leaving many poor Americans insufficiently subsidized and uncovered.

— Lowering the cost of the policies (by limiting “essential benefits,” for example) would also ease but not eliminate the underlying tension.

— Making the insurance mandate really coercive– with stiff penalties — is likely to be highly unpopular (who wants to be forced to check into a seedy hotel?) while failing to solve the problem, simply because there are too few middle class people to coerce. They’re squirreled away on their employers’ plans, and they ain’t comin’ out if they can help it.

Note that Medicare does not have this problem. Americans of all classes are in the Medicare system and good doctors are still (as of this writing) available. But even extending Medicare down to age 55 (from the current 65) or offering a public option (i.e. to effectively “buy into” Medicare) wouldn’t be a cure for Obamacare’s class problem: Those moves should again make  Obamacare policies much cheaper — in this case by removing the higher risk patients from the pool. That alleviates the symptoms.  But the insurance offered to whatever age group is left on the exchanges will still be overpriced for higher income people.

I suppose with enough money, anything can be fixed: You could slather the exchanges with such rich subsidies that they’d be a good deal for the semi-affluent as well as the semi-poor. That sounds awfully expensive, though. Would it be any cheaper than Bernie Sanders’ famously costly Medicare-for-all?

Or you could figure out some politically palatable way to knock millions of middle class people off their employer plans. Good luck with that.

Any help with this dilemma appreciated. …

__________

** — They do get at least one benefit they may not have had before: Insurance companies can’t kick them off if they get sick. Not enough to make the exchanges appealing apparently.

***-  Alternate analogy: When I was in Cleveland for the GOP convention, I needed some groceries late at night. The only open store was in a nearby, very poor neighborhood. The shelves were filled with highly suspect off brands —  Count Chocula would have been a welcome, healthy choice. The stuff wasn’t even that cheap. A valued local institution, maybe — but I would never voluntarily shop there again if a more Gelson’s-like alternative was available. Let’s say Obamacare is not the Gelson’s of health insurance.

7 One Way Trump Can Win on Health Care

Here’s an idea-so-crazy for a big, Trump-like move on health care of the sort Peggy Noonan seems to call for:  Lower the Medicare eligibility age to 55 (from 65) as part of the deal. Why?

1) This would remove the costliest, highest risk cohort (older people) from the Obamacare risk pool, allowing Obamacare insurerers to lower prices. The near-poor who are served by the program would find it easier to afford. Ditto the healthy young. The unsubsidized middle class would feel less ripped off.

2) The deal could still include many things Republicans want:--e.g.  replacing the individual mandate with some other incentive, offering tax credits instead of subsidies,  paring down the list of “essential benefits” (that anyone who buys an Obamacare policy must purchase–including substance abuse treatment), eliminating the rightly controversial Independent Payment Advisory Board.  Or bolder: Make selling Obamacare insurance a nationwide market (rather than in 50 state markets),

3) Medicare-at-55 wouldn’t just be a halfway house on the way to Bernie-style Medicare-for-everybody.  It’d be a way to give the competitive Romneycare/Obamacare model a chance to work. It’s not working now. We could decide later whether to apply it to Medicare or expand Medicare to absorb it. Let the best model win.

4) It would add to the federal budget. (Medicare isn’t cheap.) Since when has Trump been Dr. Cut-the-Deficit-Now?

5) How would it pass? Straight down the middle. Medicare-at-55 will be very popular with voters, including Trump supporters. That’s a big engine to power any deal through (just as voter hostility to welfare powered the 1996 welfare reform through, in another down-the middle play).  Democrats (and many Republicans) would have a hard time voting against a deal that included Medicare-at-55.  In the 1996 welfare debate,  President Clinton was a passive triangulator, oppposing, but not actively denouncing, the pro-welfare views of his own party in Congress. You’d expect Trump to be far less passive dealing with recalcitrant GOPs who don’t get on board.  Arguably that’s what voters expected when they elected him.

Just a thought!

3

Policy, the last resort of  … : Ryan Lizza on the allegedly suspiciously-friendly-with-Russians Trump players (Flynn, Manafort, Page):

To some extent, they all share Kislyak’s view that America, through NATO and its eastern expansion, has been needlessly hostile to Russia, that Ukrainian democracy and sovereignty is a nuisance issue, and that the U.S. and Russia could be united by the common threat from ISIS. [E.A.]

Yikes. That is so … um, reasonable. It would be easier to join the press’ near-unanimous scorn for the Trump advisers if it weren’t. …  (I wouldn’t say Ukrainian sovereignty is a “nuisance issue” — just not our cause, and not a cause we should be willing to go to war over.) …

0

David Frum on Trump and autocracy:

If the story ends without too much harm to the republic, it won’t be because the dangers were imagined, but because citizens resisted.

This is anti-Trumpism as a closed system, no? It leaves no possibility that events can ever convince Frum he was wrong (e.g., that the dangers maybe weren’t imagined but were just never close to materializing). Nice work if you can get it. …

4 No “merit,” please! We’re American.

A small complaint about Tuesday’s speech: President Trump seems to think the most appealing way to frame his proposed immigration reform — shifting immigration from low-skilled to higher-skilled — is as “adopting a merit-based system.”

Why use that word? If I were going to crudely describe the roots of the Trump movement, it would be as a rebellion against the idea that people without degrees or high SAT scores or complicated training are the rational and inevitable losers in the global economy.  Trade sends their jobs overseas, unskilled immigrants take their jobs at home, automation may permanently remove their jobs from the face of the Earth. That’s why you got Trump!

Calling this  de-selection of the unskilled “meritocracy” only adds an invidious layer of judgment, as if the winners are superior to the losers — they have the smarts, or some other virtue (but usually smarts) and can justifiably look down their noses at unemployed ex-steelworkers in small Pennsylvania towns. That’s really why you got Trump. 2016 was a revolt for social equality.

It’s especially discordant for Trump to appeal to “merit,” in other words.  Let’s call people with skills people with skills. They may have “merit,” they may not!  In the case of immigrants, we don’t even know how they’ll perform in their new U.S. jobs — so even if you equate career success with “merit,” the judgment is premature.  Yes, there’s an argument for preferring them over the unskilled . As Trump argues, they’ll pay more taxes and consume less in various benefit programs. More important, skilled immigrants will compete with — i.e. lower the wages — of  well-trained Americans rather than unemployed ex-steelworkers.  But they aren’t better, any more than liberal Hollywood movie stars are better than Chris Arnade’s photo subjects.

“We are all equal in the eyes of God. But as Americans, that is not enough, we must be equal in the eyes of each other.”

9 The 1934ists: Ron Rosenbaum Edition

Godwin Is Dead: Ron Rosenbaum, one of the great magazine writers of our time, has written a widely-hailed L.A. Review of Books piece that he insists does not argue that “Trump=Hitler.”  He’s explicit on this point!

While Trump’s crusade had at times been malign, as had his vociferous supporters, he and they did not seem bent on genocide. He did not seem bent on anything but hideous, hurtful simplemindedness — a childishly vindictive buffoon trailing racist followers whose existence he had mainstreamed. … [G]enocide is almost by definition beyond comparison with “normal” politics and everyday thuggish behavior, and to compare Trump’s feckless racism and compulsive lying was inevitably to trivialize Hitler’s crime and the victims of genocide.

“I posit similarities and differences, not identity” between Hitler and Trump, Rosenbaum later declared. All very careful and nuanced. And yet, by the end of his piece, Rosenbaum seamlessly deploys the stock 1934ist template when discussing how the media should react to Trump: they should shun “compliance,” condemn “normalization,” emulate the “defiance that was heroic and inspirational” by the anti-Hitler journalists of the Munich Post. Obviously, Rosenbaum thinks the similarities are strong indeed– strong enough, anyway, to justify cranking up the full machinery of the pre-war anti-fascist struggle, strong enough to justify invoking the martyrs of Munich.

How strong, exactly? Rosenbaum says, “Trump and his minions are … attempting to pose as respectable participants in American politics, when their views come out of a playbook written in German.” [Emphasis added]

And they’re not joking. If you’d received the threatening words and pictures I did during the campaign (one Tweet simply read “I gas Jews”), as did so many Jewish reporters and people of color, the sick bloodthirsty lust to terrify is unmistakably sincere. The playbook is Mein Kampf. [E.A.]

Sounds pretty bad. ** And if Trump really is that much like Hitler — Not identical! Not equal — no sirree! But with bloodthirsty views out of Mein Kampf! — then we really don’t want to normalize him the way so many Germans foolishly normalized Hitler. The trouble is, Rosenbaum’s own piece, with its riveting, punctilious descriptions of Hitler’s rise to power, makes a perhaps-unintended but near-overwhelming case that Trump is really not much like Hitler at all.

I’m talking here of any indications that Trump, like Hitler, will , if “normalized,” pursue an evil, autocratic course of action.  It’s not enough if both men are “mountebanks,”*** con men who don’t believe their cons, whose outrageous acts and contradictory statements distract, lull and befuddle opponents, so that

you can’t take a stand against Trump because you don’t know where Trump is standing. You can’t find him guilty of evil, you can’t find him at all.

What we need is the evidence, amid all the confusion, that Trump actually is driven to autocracy, as Hitler was — not that he, like Hitler, conned and clowned his way into office, but that he’ll use the office so acquired to further some horrifying, megalomaniacal, perhaps “bloodthirsty” anti-democratic scheme. That’s the key question, isn’t it? The Munich Post journalists knew that underneath it all Hitler was Hitler — and he needed to be fought, not normalized. How does the evidence they had compare with the evidence offered by Rosenbaum regarding Trump?

Here’s my crude catalog of HItler’s Hitleresque sins — as known (often uncovered) by Munich Post journalists — compared with Trump’s:

HITLER

— Had attempted to violently overthrow the government (the Beer Hall Putsch of 1923)

— Had “a death squad (“cell G”) that murdered political opponents”

— Sent his private militia (precursor of the SS) to physically ransack the newsroom of the paper that opposed him

Planned a “‘final solution’ for Munich’s Jews.”

TRUMP

— Supported by some racist and anti-Semitic tweeters

— Proposed, and then abandoned, a hold on travel to the US by Muslims.

— Allegedly had a copy of Mein Kampf by his bed

— Once ducked an invitation to “unequivocally condemn” David Duke.

You get the idea. The two lists are orders of magnitude apart. Are there things about Trump — seeds, if you will**** — that make reasonable people worry about future developments? Sure, just as there were with a dozen other national politicians (including Nixon and even FDR). But those are seeds, not the tree, and there are seeds of a lot of things in Trump, including many good things.  Hitler, you had more than seeds.

And don’t say (as Rosenbaum did when we argued on Twitter) that “[H]itler was in office 12 years Trump 2 weeks.” The list above is a list of things Hitler did before he took office in 1933 — the equivalent of Trump before January 20 of this year. Was boycotting the Iowa debate Trump’s Beer Hall Putsch?

Maybe Trump will try to acquire autocratic power. But, in Rosenbaum’s piece, that seems to be more an assumption than a conclusion.

This became clearer after the piece was published,  when Rosenbaum vigorously defended it on Twitter — because a funny thing began to happen. In argument, Rosenbaum tried to supply some of the evidence the piece he was defending lacked — evidence that Trump, if “normalized,” really would try to become an autocrat.  Hadn’t Trump aide Steve Bannon told the “press to ‘shut it’s mouth.'”?  That was “an example of autorratic [autocratic] impulse he shares with many dictators not just AH.”

Rosenbaum’s right: Telling the media to “shut up” [actually, saying it should “be embarrassed” and “keep its mouth shut and just listen for a while”] does represent an autocratic impulse.***  It’s an impulse shared by half the politicians in America — but if followed blindly to its ultimate conclusion it would be bad news for the First Amendment. So why didn’t Rosenbaum include it in his piece, which cries out for actual examples of the dictatorial drive that only Munich Postische anti-normalist resistance can block?

Answer: Because it would look pathetic. Hitler sent his militia to physically destroy newsrooms.  Trump has an aide who said a hostile press should put attacks on hold! See the paralllel? We do … and we don’t.

Likewise, Rosenbaum, who mentions the “Muslim ban” in passing in his piece, refers on Twitter to Trump ” banning an entire religion.”   When a Twitter adversary notes Trump’s actual executive order affected only 7 out of  “40 or so Muslim countries,” Rosenbaum responds “the order can be extended w/o to all Muslim nations.”  Why yes, it can! But that would be a transformative change, and Trump has been heading in the opposite direction. Normalization works sometimes.

If comparing Politican X to Hitler makes you spend most of your time explaining that you aren’t equating the two, and mainly succeeds in making your legitimate complaints about X seem small in comparison to Hitler’s monstrousness, maybe it’s not such a useful comparison. Godwin had a point! If Trump’s only a 2% Hitler then maybe the media attitude we need is 2% no-business-as-usual anti-normalization–or, in any case, not 100% heroic***** dedicated resistance. All Rosenbaum’s words spent in stirring description of the Munich Post tend to obscure this point. They become a distraction, much as even Trump’s more righteous tweets are often distractions.

Why strain to make the comparison? Why not find an autocrat who better fits the subject? (Berlusconi seems an obvious choice.) [Because then Trump’s opponents couldn’t cloak themselves in the glory of the German resistance?–ed You said that.]

**************

** — The antecedent of “they” — who are “not joking” — seems to be Trump, or maybe “Trump and his minions.” Not merely the minions.

*** –Rosenbaum notes that historian Alan Bullock, proponent of the “mountebank” theory, “would later change his mind” and acknowledge that Hitler was heavily invested in his anti-Semitism.

**** — Attacking judges represents another potentially troubling impulse, a “seed”– one Rosenbaum doesn’t mention in his piece. So far, Trump has engaged in name calling while he obediently complies with judges’ orders.  The author of the “Mein Kampf playbook” went a little further (at one point setting up an alternative court system until the judges “knuckled under”).

*****– Does it take heroism to oppose Trump? Not that I can see. In most places resistance (like resistance to the Vietnam War, or to Nixon) is more likely to get you laid.  Former N.Y. Judge Robert Smith wrote recently that “Not many federal judges travel in circles where being an enemy of Donald Trump is anything but a badge of honor.” Same for journalists.

2

Luckily, in the future there will be no irony:  “There is no walk of life that is not going to require computational understanding,” says Microsoft CEO Satya Nadella, describing his notion of a future oriented around Artificial Intelligence. But he’s optimistic!

“The most exciting thing to me is beyond what we are doing ourselves, which is to take the same AI capability we have and make it available so everybody can use it,” he says. Take the state I was born in [Andhra Pradesh] and the state I live in [Washington]. Both are using essentially the same machine-learning algorithms to make high school dropout predictions.” [E.A.]

Exciting! But is the algorithm sophisticated enough to realize that, since pretty clearly there’s no role for non-smart people in Nadella’s vision of the future, high school students in both countries may be saying “F*ck it, might as well drop out now”?

3

The massive Kausfiles Rebuild Project is in theory complete. The unheated Venice warehouse, once filled with surly millennial coders,** lies silent, its floor littered with empty bottles of $12 juice. ….

The purpose of the rebuild is to (again) mix tweets with blog items, a rebellion against the disastrous early Word Press era in which blog posts became discrete, pompous hey-link-to-me declarations. Ben Smith may think this was the golden age of blogging. To me it was the beginning of the end. …

I’m sure I’ll screw things up for a while. There will still be many more tweets than blog items, though a) I’ll try to write more of the latter especially since b) it should now be possible to easily expand tweets into short (or long) blog entries.  Will escaping the 140 character limitation make them better or worse? I actually don’t know. Could be worse! It’s awfully easy to kill a tweet with improvements.

** — The tech work was actually performed by John Keegan of Rackshare. I recommend him. …