Happy 25th Anniversary, ADA

Twenty-five years ago today, July 26, 1990, President George HW Bush signed the Americans with Disabilities Act into law.

The fact that this anniversary is boring and uncontroversial underscores the depth of social changes that ADA exemplified, ratified, and advanced.  Aspects of the ADA are costly.  The required changes to American physical structures–buildings, sidewalks, roadways, and more–have been significant. (If you wonder how significant, travel to any great old European city and imagine how you would get around if you were mobility-impaired.) No serious politicians speak of repealing and replace ADA. They would be universally condemned if they tried.

So much of American social policy has proven mediocre or mean-spirited. Much remains to be done to help people with physical, intellectual, or psychiatric limitations and disabilities achieve full and equal citizenship in American society. Yet today deserves celebration. Americans across the political spectrum have opened their hearts and their wallets to make a better country. In this important area, much was accomplished.

Another false alarm on the costs of Medicaid expansion

The universe of people obsessed with my Twitter debates with Michael Cannon presumably went ecstatic over our weekend exchange, which centered on Cannon’s short Friday column: “Your Friday afternoon news dump: Obama admin. Admits Medicaid expansion costs more than projected.” Michael and I disagree on everything. He is the Cato Institute firebrand who has apparently dedicated his life to destroying the Affordable Care Act. But he is a smart guy. I often learn from what he writes even as I disagree with it.  Cannon quotes from a recently-released Medicaid actuary report, which bears careful reading.

Michael’s first sentence made my heart sink: “It appears that Medicaid-expansion enrollees are going to cost the states a lot more than they thought.” Given the current knife fight over getting states to expand their Medicaid programs, this would be quite damaging. We know, for for example, that behavioral health costs are significant in a subset of new enrollees. There are also complicated interactions with other state and federal assistance programs. It’s certainly plausible that Medicaid expansion will turn out to be more costly than originally thought.

Because he is such a firebrand happy warrior, I have learned to follow up on his hotlinks to see what else might be going on. So I hunted down the report and ran the numbers. The actuaries did indeed predict higher costs—but almost all in the first year when states wouldn’t have to pay any of these costs. (The higher costs seem to reflect pent-up demand and perhaps more pregnant women than predicted in this particular Medicaid pool. I would like to learn more about what’s happening as states gain experience in the expansion population.)

I also ran the actual numbers from this year and last-year’s reports. The increase in predicted annual* costs per enrollee are shown below, broken down between the states and the federal government. The increased cost to the states averages that Michael warns us about are…. about $5/enrollee per year between 2014 and 2022. If you’re having trouble finding it, its the blue line visually indistinguishable from zero. To Michael’s credit, he’s told me he will modify the post. He certainly should.

2013-14 differences in actuarial prediction

The increased costs to the federal government are shown in red. The difference here is about $881 in the first year as the Medicaid expansion gets rolling, and then plunges in subsequent years, averaging out at about $95/enrollee per year.  That’s something like 2.2% of average non-disabled adult Medicaid costs. Despite the initial upward bump, things are quite manageable. It’s certainly not the sort of bad news one must conceal in a Friday news dump.

The main good news  about the overall Medicaid program is below the fold. Continue Reading…

Just a couple of stammering professors discuss gay marriage, Confederate flags, and more

Glenn Loury and I discuss a pile of Supreme Court cases, social marginalization of people who don’t believe in gay marriage, Bowers v. Hardwick, the Confederate flag issue, and more.

A harm reduction approach to gang violence: The Pass 36 campaign

This Cure Violence campaign is pretty interesting. “Give a pass. And kiss your kids when you get a pass.”


Expert predictions of the outcome in King vs. Burwell

The week before King v. Burwell was announced, I confidentially polled an elite group of health policy and legal experts to get their personally-assessed prior probability that the King plaintiffs challenging ACA subsidies would actually win this case. The somewhat-arbitrary group included leading health economists, political scientists, journalists covering the case. It also included several legal antagonists who had written briefs on the various sides.

I received more than forty responses. Not surprisingly, given my own liberal views, about three-quarters of the responses were from Democrats. Although Democrats and Republicans had wildly different views of who should win, the distribution of predicted probabilities of a plaintiff victory was surprisingly similar between the two groups. Amazingly, Cato’s Michael Cannon and I offered identical prior predictions—20% probability of plaintiff victory.

Among Democrats, the median predicted probability of plaintiff victory was 40%. Among Republicans, the median was 37.5%. The means showed a bit more of a difference between the two groups: 46% among Republicans, 37.5% among Democrats. Yet five of the six highest predicted probabilities of a plaintiff victory came from Democratic experts; two were 70% or higher.
The overall distribution is shown below.

clunky expert poll results

Judging by my admittedly- clunky informal poll, the Obama administration’s emphatic victory surprised many close observers on both sides. Many Democrats reported that the plaintiffs had more than 0.5 probability of winning. Otherwise, why would the Supreme Court have jumped to take the case? We may never know the answer to that question.

We don’t merely know this from polls. Hospital Corporation of America stock rose 8% at the decision’s announcement. (See below from WSJ.com.) That is an amazing jump, which reflects hospitals’ strong stake in ACA’s effective national implementation.

HCA stock price (WSJ.com)

Many states went to considerable trouble devising contingency plans, suggesting that they, too, took this case very seriously indeed.

After the ruling was announced, I tweeted that conservatives magnified their political and legal losses by tethering themselves to a preposterous legal case. I stand by that deep, 140-character argument. Yet it is definitely an ex post argument. The smart money believed that the plaintiffs might well have won.

We’re likely to see a huge amount of hindsight bias applied to this case. From the plaintiff’s perspective, this seems ex post like a more doomed tactical gambit than it actually was, when properly viewed from an ex ante perspective. From my opposing perspective, this is sobering. Fortunately, the same insights make the government’s emphatic victory appear more exhilarating and important than it would otherwise seem to be.

Philip Roth as Founding Father

The greatest trolling exercise in the history of health policy is now over.

My short take for Politico on the King case.

The Supreme Court has finally spoken. It never really needed to speak at all. The Court’s 6-3 decision to uphold federal subsidies under the Affordable Care Act was simple and emphatic, written by Chief Justice Roberts, no less. Justice Antonin Scalia’s dyspeptic dissent indicates the extent of the administration’s legal victory. Stock prices for the Hospital Corporation of America jumped approximately 8 percent with this decision, providing some sense of the economic havoc that might otherwise have ensued.

I’m gratified by the outcome. But I remain saddened by the full history of this case….

More here.

It’s a shame that the best health policy minds in both parties spent many months battling over this preposterous thing. We could have been trying to make better policy. IBy tethering themselves to King and then suffering a comprehensive legal defeat, conservatives ironically set back their own efforts while further embedding ACA within the fabric of American life.

There are many ways to comfort the grieving in this life

This isn’t a bad one.

Not a bad bit of speech-writing, either.

As a nation, out of this terrible tragedy, God has visited grace upon us, for he has allowed us to see where we’ve been blind. He has given us the chance, where we’ve been lost, to find our best selves. We may not have earned it, this grace, with our rancor and complacency, and short-sightedness and fear of each other — but we got it all the same. He gave it to us anyway. He’s once more given us grace. But it is up to us now to make the most of it, to receive it with gratitude, and to prove ourselves worthy of this gift.

Weekend interlude: Just a closer walk with thee

The setting and circumstances of Charleston’s atrocity remind me of the many times that I’ve visited various African-American churches. As a white non-Christian, I’ve always been embraced as a valued guest. That Dylann Roof was accorded similar hospitality, and yet apparently went on to murder the very people who graciously welcomed him adds yet another incomprehensibly depraved element to this attack.

We could all use some joyful noise to salve the wound just a little bit. Below are Mahalia Jackson and Louis Armstrong, at the Newport Jazz Festival 1970.

Wealth journalism and the self-regard of the “single-digit” millionaire

I am a love-hate reader of the New York Times’ “Wealth Matters” series. I find such articles embarrassingly addicting. Less focused on straight real estate porn than the Wall Street Journal’s “Mansion” section, Wealth Matters provides an interesting sociological window into the world of wealth. The section often reveals more than it intends, about both its subjects and its comfortable reading audience.

$2500 analog model (Also available in rust).

My own conspicuous non-consumption item

Consider one recent column by Paul Sullivan: Millionaires Who Are Frugal When They Don’t Have to Be. Continue Reading…