After Trumpcare, Medicare Part M

Here’s a thought: as soon as we defeat Trumpcare, Democrats in both houses introduce Medicare Part M (for Middle-Aged), covering people ages 50-64.

A. It’s good politics:

1. These are the people who were going to be hit the hardest by Trumpcare premium increases. Offer them a better deal and they’ll support us–and people this age vote!

2. It sounds more moderate than Medicare for All, while also making a solid step closer to single-payer, which the Republicans have managed to make sound like pie-in-the-sky socialism with a side order of end-of-the-world.

B. It’s good policy:

1. These are the sickest people in the Obamacare exchanges–move them out of the pools and premiums go down.

2. BUT they’re healthier than most people now on Medicare: put them into that risk pool and the premiums go down there, too.

DON’T believe Trump when he says Obamacare is collapsing.

DON’T believe pundits who say the Democrats have no platform/positions: this plus increased minimum wage plus let’s get out of Afghanistan is platform a-plenty.

Hey Weekly Standard: Could you correct that Obamacare tax thing?

Kimberly Pinter is a tax attorney in northern Virginia*. So her April 3 article in the Weekly Standard, “Obamacare Pinches the Poor,” on ACA’s tax requirements will understandably concern many low-income citizens.** She writes:

According to the web site, you can get an income-based exemption if “you don’t have to file a tax return because your income is below the level that requires you to file.”

Sounds simple enough, right? Until further investigation reveals that this exemption is claimed directly on the tax return. That’s right – the tax return you’re not required to file.

While the circular nature of this exemption is ludicrous on its face, its effects are far-reaching and incredibly regressive….

It’s a safe bet that many members of this population will not be cognizant of their need to file simply to avoid the Obamacare penalty for being uninsured.

[….]compliance with this behemoth law disproportionately burdens the poorest of the poor.  Like a shark silently stalking its unknowing prey, Obamacare lurks waiting to take a bite out of the unwary. And in this case, it’s the poor.

Yet another stupid Rube Goldberg application of the Nanny State, right?  Well no. actually. ACA has its share of glitches and complications. But this isn’t one of them. As ACA legal expert Timothy Jost notes over email, Pinter is wrong.

Indeed here is the government’s actual directions to low-income people. I found this through a quick Google search at a website called

If you are not required to file a tax return and don’t want to file a return, you do not need to file a return solely to report your coverage or to claim an exemption.

This isn’t Nanny State. It isn’t Rube Goldberg. Nothing behemoth. No shark is stalking or biting. It’s not particularly complicated, either.

The Weekly Standard should run a correction on this important point.

*A friend notes that my description of Ms. Pinter as a tax attorney conveys the impression that Ms. Pinter is someone whose main duties are assisting people with their taxes. Her byline says: “Kimberly Pinter is a tax policy lawyer and writer in Northern Virginia.” Her Twitter byline notes that she is a “Tax policy expert, lawyer, lobbyist, jewelry designer, and Zumba fitness instructor.”  Sounds kindof cool, actually.

**Update: I received a very professional email from the Weekly Standard. To their credit, they are now looking into this. I await a correction or amplification.

This weird-looking Medicaid expansion map would sadden Dr. King on his holiday

(This column is cross-posted at the Huffington Post.)

I wonder what Dr. King would think about the current health reform debate. OK I don’t really wonder. Here, for example, are his comments, apparently made here in Chicago:

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

Martin Luther King supported health care as a human right. He also knew how far we had to go as a nation in making that right a reality.

King was the energizing force behind the Southern Christian Leadership Conference (SCLC). I suspect he would be ashamed but unsurprised to see his home region so resistant to the basic expansion of health insurance coverage to Americans with incomes below the poverty line. To some extent, the extent of southern resistance is obscured by maps such as the one below, that display which states have rejected the Medicaid expansio­­­n around the country:

Screen Shot 2015-01-19 at 3.13.50 PMMany of the shaded states such as Wyoming and Montana are huge but sparsely populated. Others such as Wisconsin have small populations left uncovered for other reasons.

Harvard post-doctoral researcher Laura Yasaitis is an expert at drawing different kinds of maps. At my request, she made me a map in which the size of every state was proportional to the number of people who landed in the “Medicaid gap.” (She couldn’t quite do that, since states such as California and New York would simply vanish. We drew each of these states as if they had shut out 2,000 state residents instead of zero. She also taught me how to make Cartograms. SO you may see more such items in this space.)

When we did all that, here’s what the US map would like if it were scaled by the number of affected people in each state (see below): Continue reading “This weird-looking Medicaid expansion map would sadden Dr. King on his holiday”

Another Day, Another Misinformed Article on Obama’s Addiction Treatment Record

Writing about President Obama’s record on drug addiction treatment without mentioning the passage of the Affordable Care Act and the development of the regulations for the Mental Health Parity and Addiction Equity Act (MHPAEA) is analogous to writing about LBJ’s record on health care without mentioning Medicare and Medicaid. But alas, Christopher Ingraham of the Washington Post is the latest journalist to do so. The transformative impact of the ACA and MHPAEA on addiction treatment is not a hard-to-uncover secret. It has been written about extensively in the scholarly literature (see for example here and here) and in the mass media (see for example here and here). But like a number of other journalists, Ingraham critiqued the Obama Administration’s alleged lack of commitment to drug treatment without even mentioning either landmark piece of legislation.

To Ingraham’s credit, he did at least look at some data, which was the budget for federal drug control spending across agencies:

So on the one hand, yes – it’s true that more federal dollars are going toward drug treatment. On the other hand, treatment and prevention account for less than half of federal drug spending, most of which still goes toward law enforcement efforts.

This conclusion rest on the false assumption that an administration’s financial commitment to addiction treatment is equal to federal spending on addiction treatment. But the ACA and MHPAEA are major federal actions that drive private dollars into addiction treatment by improving coverage for over 100 million people with private insurance. Analyzing what an administration has done in any health care policy area without looking at its laws and regulations for private insurance is generally misleading, and is certainly so in this case where none of the private investment is captured in federal drug control budget data.

Health care policy analysts generally see the Obama Administration’s addiction treatment record as the most praiseworthy in at least 40 years, and some journalists (e.g., Jesse Singal) have done a fine job reporting that fact. That does not however make it less disappointing to see yet another misinformed article written as if the ACA and MHPAEA never happened.

This is what we fought for in ACA

Via the indispensible Sarah Kliff at Vox, this pre-post map of Kentucky health insurance coverage puts a lump in my throat. This is what we fought for ACA, and what we will eventually achieve when low-income red states eventually embrace the Medicaid expansion.

I’ll never be involved in another presidential campaign as I was with the Obama campaign and the fight for health reform between 2007 and 2012. I knocked on hundreds of doors, made I-don’t-know-how-many-phone-calls in the hope of achieving near-universal coverage. Maps like this make me so glad that I participated in that fight. That map reflects hundreds of thousands of lives changed, in a single small state that went against President Obama, big time, in both 2008 and 2012.

More from Sarah Kliff here.

This speaks for itself.
This speaks for itself.

Curbside consult with David Cutler

My latest Curbside Consult at was a conversation with Harvard economist David Cutler regarding his book, the Quality Cure.

Screen Shot 2014-06-03 at 9.00.36 PM
Trying to make David Cutler look impressive for our interview….

Our wide-ranging conversation covered his pride in health reform, his thoughts on how our health care system is changing, Princeton University’s high-ranking law school, and his disappointment in implementation screw-ups typified by the flawed rollout of

Cutler was the author of a prescient and scathing 2010 analysis warning of the need for stronger management of information technology (and other matters) in the implementation of health reform. During the darkest days of website malfunction, theWashington Post‘s Ezra Klein labeled Cutler’s analysis “the memo that could have saved Obamacare.”

More here.

Zeke Emanuel on the troubled start (but bright future) of the ACA

Over at the Washington Post‘s Wonkblog section, I had a long conversation with Zeke Emanuel about his new book Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System. 

Dr. Ezekiel Emanuel (Photo by Candace diCarlo for University of Pennsylvania)
Dr. Ezekiel Emanuel (Photo by Candace diCarlo for University of Pennsylvania)

We covered the full range of health-wonk topics. Emanuel is scathing about many short-term implementation failures of the Affordable Care. Yet he is quite bullish about health reform’s long-term prospects.

There are a few surprises, too. For starters, Emanuel notes that ACA might have included further malpractice reforms had physician groups or Republican senators really wanted that. Whatever was said in public, behind closed doors doctors didn’t prioritize malpractice; nor were Republicans ready to actually negotiate about it. President Obama and others were ready to deal–were there a deal to be had.

Emanuel also offers some striking blue-sky predictions. Most notably, he predicts that the long trend of explosive health care cost growth will abate. Over the coming decades, he predicts, health expenditures will grow no faster than the national economy: “GDP+0.” If this actually happened, our nation’s public finances would be fundamentally different.

Thoughts on Burr, Coburn, Hatch Health Reform Plan

Republican Senators Richard Burr, Tom Coburn and Orrin Hatch released “The Patient Choice, Affordability, Responsibility, and Empowerment Act” today. I am going to call it PCARE. A few quick thoughts/highlights:

  • It acknowledges gravity, while making changes. While PCARE talks of repeal of the ACA, it locks in a good deal of the structure of the ACA, and addresses changes from that new status quo. For example, no lifetime limits (sec 201) is retained from the ACA, as is keeping people up to 26 on their parents health insurance, while the current 3-to-1 age banding premium regulation is replaced with 5-to-1 (now a 64 year old could not be charged more than 3 times what a 20 something could be charged;now they could be charged 5 times as much). Winner 20-somethings, loser 60-somethings. Eventually they say they plan to allow States to set these rules with a looser federal touch, meaning a state could decide to stick with the 3-to-1 premium banding by age, for example. I want to hear more about guaranteed renewability and related insurance market regulations as the 2nd full paragraph of page 2 is a bit slippery. For example, it contains this quote: “Insurance companies would also be banned from making unfair coverage terminations of health coverage.” (emphasis mine). What might “fair” ones be? Continue reading “Thoughts on Burr, Coburn, Hatch Health Reform Plan”

Marginal Labor Income Tax Rates under the ACA

I was a discussant of Casey Mulligan’s paper Average Marginal Labor Income Tax Rates Under the ACA at the UNC Tax Symposium hosted in Chapel Hill, NC by Doug Shackelford this past Saturday. His figure 3 summarizes changes in the marginal tax rate of labor income over the past 7 years, accounting for both explicit and implicit taxes for someone with median wages. For example, in 2014, there is an increase in the marginal rate due to a reduction in work incentive that occurs for someone with median wages because premium subsidies are based on a income-linked sliding schedule–an implicit tax on earning more because you lose insurance subsidy as you earn more income. The paper also identifies increased implicit incentives to work more, for example, the fact that exchange subsidies cannot flow to those below 100% of poverty.

ScreenHunter_01 Jan. 21 16.15

Continue reading “Marginal Labor Income Tax Rates under the ACA”