No Signs Of A Wave Election So Far

Nate Cohn looked at the small amount of generic Congressional polling there is available and concluded, consistent with other indicators, that there is no sign of a wave election this year. The polls he looked at showed an average 1.9 percent advantage for the Democrats over Republicans. Cohn wrote:

These findings bear no resemblance to the one-sided results at this point in 2010, when Republicans held a clear 4.7-point advantage, or in 2006, when Democrats were ahead by 10.1 points. The current slight Democratic edge is fairly similar to what generic ballot surveys showed in the days ahead of the 2012 presidential election.

It’s important to emphasize that these polls are of registered voters, not likely voters. Previous years’ surveys were also of registered voters. The Republicans probably have a slight advantage among the older and whiter electorate that’s likely to participate this November. But that’s a separate matter from national political conditions.

While some have predicted a Republican wave based upon Obama’s unpopularity in the polls, the fact that both Congress and the Republican Party have even worse favorability ratings must count for something. The actual result seems to be a decreased turn out at the polls in primary elections so far this year, possibly indicating that voters are fed up with everybody. There is still quite a while until the election, and an unforeseen event still might tilt things towards either party.

The lack of a Republican wave, assuming things stay as they are, should limit the expected loses by Democrats which we would normally see in the sixth year of a presidency. Unfortunately the Republicans are in a good position to take control of the Senate without a wave as the Democrats are forced to defend several Senate seats in red states which they picked up in 2008.

As it now stands, the Republicans have a very slight edge to take the Senate, but there are a number of reasons that Democratic incumbents might still hold onto enough seats to narrowly maintain control. The Hobby Lobby might get more single women to turn out to vote for the Democrats.  Republicans still could find ways to lose elections which are now close, such as with a call for nullification of federal laws by the states by the Republican Senate candidate in Iowa:

Joni Ernst, the Republican nominee for U.S. Senate in Iowa, appears to believe states can nullify federal laws. In a video obtained by The Daily Beast, Ernst said on September 13, 2013 at a form held by the Iowa Faith & Freedom Coalition that Congress should not pass any laws “that the states would consider nullifying.”

“You know we have talked about this at the state legislature before, nullification. But, bottom line is, as U.S. Senator why should we be passing laws that the states are considering nullifying? Bottom line: our legislators at the federal level should not be passing those laws. We’re right…we’ve gone 200-plus years of federal legislators going against the Tenth Amendment’s states’ rights. We are way overstepping bounds as federal legislators. So, bottom line, no we should not be passing laws as federal legislators—as senators or congressman—that the states would even consider nullifying. Bottom line.”

SciFi Weekend: Arrow; Constantine; SHIELD; Hannibal; Big Bang Theory; Community; Orphan Black; True Blood; Fargo; Sleepy Hollow

There’s a lot of news coming out of San Diego Comic-Con. The Arrow panel is above, followed by the season three trailer. Ra’s al Ghul  will be the main villain next season. Flashbacks next season will include characters who died earlier on the show, and will deal with characters beyond Oliver.  Thea will be back (but changed) and there will be a flashback to when she first got into Malcolm’s limo. John Barrowman will be a regular as Malcolm Merlyn. Brandon Routh will join the show as The Atom, and will also be the new head at Queen Consolidated and there will be a triangle between his character, Oliver, and Felicity. There will be cross over episodes with The Flash, with the other CW show being lighter than Arrow.

The Constantine preview above was unveiled at Comic-Con. There has also been a lot of talk this week about a change in the female lead.

Patton Oswalt discussed Agents of SHIELD as Agent Koenig x2 n the above video. Lucy Lawless will be joining the cast. There will also be a another new character, code name Mockingbird. More at the Marvel panel, video below, which includes Director Coulson:

Bryan Fuller reports that the third season of Hannibal will get into the plot of Red Dragon. The first half of the season will primarily deal with Hannibal, with Gillian Anderson also a regular. The second half will deal more with Will. The Hannibal panel is above.

Penny Gorilla Big Bang

Among the things learned about The Big Bang Theory, Sheldon getting on the train doesn’t necessarily mean disaster for Sheldon and Amy. Despite the fact that he died, Bob Newhart’s character Professor Proton  could be back. The elevator will probably never be fixed. It’s unlikely that we will ever see Penny’s (Kaley Cuoco-Sweeting) movie Serial Ape-ist 2: Monkey See, Monkey Kill  but there was a sneak peek of the trailer at Comic-Con  which included the line, “This film is not yet rated, but don’t worry, she gets naked in it.” There will be a comic book store to hang out at despite Stuart’s store burning down. Penny and Leonard will have a very long engagement: “They are engaged, but the wedding is sometime off in the future. Penny’s first goal is to put the date far enough in the future so everyone knows that she’s not pregnant.” The real challenge for the writers will be getting through the ceremony without revealing Penny’s last name. Bernadette and Howard will have babies, not not anytime soon.

Community probably won’t return until late 2014 or in 2015 and there will probably not be any holiday episodes this year so we don’t wind up having a Halloween episode showing in the winter. It does not sound like much will be different despite the increased freedom of being off network television, but there is talk of an orgy episode. There might be more paintball, and Dan Harmon says he will do anything to get Donald Glover back. Interview with Dan Harmon in the video above.

Part I of the Orphan Black panel is above, with links available there to the rest of the panel.

Information on the final five episodes of True Blood here, which will deal more with Bill and Sookie.

Fargo was renewed for a a second season and information was revealed at the Television Critics Association fall previews. The second season will take place in 1979 around  Luverne, Minnesota, Fargo, and Sioux Falls, showing events which were alluded to in the first season

In the first season, cop-turned-diner owner Lou Solverson (Keith Carradine) often mysteriously referred to a major incident that occurred back in Sioux Falls. At the time, he was 33-years-old and recently back from the Vietnam War. “Lou Solverson is a state police officer. His wife Betsy, her dad is the sheriff of Rock County,” Hawley said. “[Lou's] father-in-law is a character in this next go-round. I don’t know if we see any other Solversons… I’m excited to spend time with Molly’s mom.” He also added that Molly did not get her plucky spirit only from her dad

News from earlier in the week on Sleepy Hollow here.

Quote of the Day

“Marvel Comics announced that the next Captain America will be black. He has the same powers as white Captain America except he has to show ID when he votes.” –Bill Maher

Norm Ornstein On The Republican Battle Between The Conservatives And Lunatic Radicals

While, as should be obvious from the previous post, I am not thrilled by the prospect of Hillary Clinton being president, any Republican alternative would be far worse. With all her faults, Clinton isn’t bat-shit crazy. Norm Ornstein has written again about how extreme the Republican have become. He described the extremists who have become more common in the Republican Party, providing multiple quotations (not even resorting to quoting Sarah Palin or Michele Bachmann):

As for the radicals in elected office or in control of party organs, consider a small sampling of comments:

“Sex that doesn’t produce people is deviate.” —Montana state Rep. Dave Hagstrom.

“It is not our job to see that anyone gets an education.” —Oklahoma state Rep. Mike Reynolds.

“I hear you loud and clear, Barack Obama. You don’t represent the country that I grew up with. And your values is not going to save us. We’re going to take this country back for the Lord. We’re going to try to take this country back for conservatism. And we’re not going to allow minorities to run roughshod over what you people believe in!” —Arkansas state Sen. Jason Rapert, at a tea-party rally.

President Obama has “become a dictator” and needs to face the consequences of his executive actions, “whether that’s removal from office, whether that’s impeachment.” —Iowa state Sen. (and U.S. Senate candidate) Jodi Ernst, one of a slew of elected officials calling for impeachment or at least putting it front and center.

“I don’t want to get into the debate about climate change. But I’ll simply point out that I think in academia we all agree that the temperature on Mars is exactly as it is here. Nobody will dispute that. Yet there are no coal mines on Mars. There’s no factories on Mars that I’m aware of.” —Kentucky state Sen. Brandon Smith (fact-check: the average temperature on Mars is -81 degrees).

“Although Islam had a religious component, it is much more than a simple religious ideology. It is a complete geo-political structure and, as such, does not deserve First Amendment protections.” —Georgia congressional candidate Jody Hice.

“Slavery and abortion are the two most horrendous things this country has done, but when you think about the immorality of wild, lavish spending on our generation and forcing future generations to do without essentials just so we can live lavishly now, it’s pretty immoral.” —U.S. Rep. Louie Gohmert of Texas.

“God’s word is true. I’ve come to understand that. All that stuff I was taught about evolution and embryology and the big-bang theory, all that is lies straight from the pit of hell. It’s lies to try to keep me and all the folks who were taught that from understanding that they need a savior.” —U.S. Rep. (and M.D.) Paul Broun of Georgia.

“Now I don’t assert where he [Obama] was born, I will just tell you that we are all certain that he was not raised with an American experience. So these things that beat in our hearts when we hear the National Anthem and when we say the Pledge of Allegiance doesn’t beat the same for him.” —U.S. Rep. Steve King of Iowa.

He pointed out some of the less extreme forces in the Republican Party and concluded:

I am not suggesting that the lunatics or extremists have won. Most Republicans in the Senate are not, to use John McCain’s term, “wacko birds,” and most Republicans in office would at least privately cringe at some of the wild ideas and extreme views. At the same time, the “establishment” is fighting back, pouring resources into primaries to protect their preferred candidates, and we are seeing the rise of a new and encouraging movement among conservative intellectuals—dubbed “Reformicons” by E.J. Dionne—to come up with a new set of ideas and policy prescriptions to redefine the ideology and the party in a positive way.

But there is a darker reality. Many of the “preferred” candidates—including Ernst as well as James Lankford in Oklahoma and Jack Kingston in Georgia—are anything but pragmatic.

A few years ago, they would have been labeled hard-liners. (Kingston, a favorite of the U.S. Chamber of Commerce, was beaten in the Senate primary Tuesday by businessman David Perdue, who has said he would not vote for Mitch McConnell as party leader in the Senate.) It is a measure of the nature of this intra-party struggle that the mainstream is now on the hard right, and that it is close to apostasy to say that Obama is legitimate, that climate change is real, that background checks on guns are desirable, or even that the Common Core is a good idea. When we see presumably sane figures like Louisiana Governor Bobby Jindal shamelessly pander to the extremists, it tells us where the center of gravity in the GOP primary base, at least, is set. Of course, there are still courageous mainstream figures like Jeb Bush who are willing to deviate from the new orthodoxy, and it is possible that he can run and get the Republican presidential nomination, win the White House, and begin the process of recalibration.

But when one looks at the state of Republican public opinion (especially among the likely caucus and primary voters), at the consistent and persistent messages coming from the information sources they follow, and at the supine nature of congressional leaders and business leaders in countering extremism, it is not at all likely that what passes for mainstream, problem-solving conservatism will dominate the Republican Party anytime soon.

Even if the lunatics have not entirely won, they are the ones influencing the views of the rest of  the party. The establishment Republicans have beaten some primary challenges based upon disagreements on tactics, such as no longer wanting to shut down the government, but they have also adopted the ideology of the Tea Party.

Andrew Sullivan On The Vacuity of Hillary Clinton

Hillary Rodham Clinton Book Presentation

I almost feel like we are back in the 2008 primary battle seeing how Andrew Sullivan is really letting Hillary Clinton have it in a post entitled The Worrying Vacuity Of Hillary Clinton.

I’d like to find a reason to believe she’s a political force who stands for something in an era when there is a real appetite for serious change. She could, after all, decide to campaign vociferously in favor of the ACA this summer and fall (universal healthcare is, after all, one of her positions), but that might siphon money away from her foundation and candidacy. She could get out there and start framing a foreign policy vision. But, again, too risky. I see nothing that suggests a real passion for getting on with the fight – just the usual presumptions of a super-elite, super-rich and super-cocooned politician of the gilded age.

So I did watch the Daily Show interview last week, and was not surprised. As in most of her softball media appearances, she was both unctuous and vapid. But even I was aghast at the sheer emptiness and datedness of her one attempt to articulate a future for American foreign policy. She actually said that our main problem is that we haven’t been celebrating America enough, that we “have not been telling our story very well” and that if we just “get back to telling” that story about how America stands for freedom and opportunity, we can rebuild our diminished international stature. One obvious retort: wasn’t she, as secretary of state, you know, responsible for telling that tale – so isn’t she actually criticizing herself?

Next up: could she say something more vacuous and anodyne? Or something more out of tune with a post-Iraq, post-torture, post- Afghanistan world? Peter Beinart had the same reaction: “As a vision for America’s relations with the world,” he wrote, “this isn’t just unconvincing. It’s downright disturbing”:

I cited even more interesting comments from Beinhart on Clinton in this post: Peter Beinart Says It All: Hillary does learn from her mistakes. But only after the damage is done.

Sullivan concluded:

My fear is that she doesn’t actually mean any of this. She just needed to say something, and so came out with a stream of consciousness that is completely platitudinous and immune to Fox News attacks. It’s a defensive crouch that is always her first instinct. Think of the Terry Gross interview – and her discomfort in grappling with actual disagreement, from her own base that time. Her goal is always safety. And safety won’t cut it in a populist age.

So if she runs, my guess is she’ll wrap herself tightly in the maximalist concept of American exceptionalism and make this her appeal as a post-Obama presidency. See? she’ll say to the same voting groups she went for last time. I’m a real American, and I believe in America. And yay America!

Maybe this is merely a function that she isn’t running yet (and still may not). Why stir the pot if your goal at this point is merely selling books and raking in more corporate, Goldman Sacks dough? But when, I wonder, has she been otherwise? She remains scarred by the 1990s, understandably so. But the country has moved on in a way she seems to find hard to comprehend.

BooMan also sees the world as changing but still doesn’t go along with Sullivan:

In the next couple of decades, America is going to have to grapple with two major changes. The first is that there are going to be new first-world powers, like China, Brazil and India, that we will have to reckon with. The West will not be driving things the way we have been accustomed to since the end of World War Two.

The second is that the American electorate is going to be more diverse and left-leaning, more like Europe.

In both cases, Hillary Clinton seems ill-suited to be our leader. The future is more Bill de Blasio than Andrew Cuomo, and the Clintons probably don’t get that. Still, Andrew Sullivan’s dripping contempt of the Clintons is irritating. He opposes them for all the wrong reasons and none of the right ones.

While I think the Clintons are a bit “out of time,” I don’t necessarily think this is a terrible thing for a country that is going to have some serious difficulties adjusting to new realities. Clinton could serve as a bit of a buffer, allowing the country to adjust to the changed world in way that doesn’t put too much shock into the system.

See the post I linked to above for many of what I would consider the right reasons.

Why Many People In The Middle Now Identify With The Left

While the country has become more liberal in some ways, the Republican Party has moved to the extreme right, and the Democratic Party has filled in the vacuum in the middle by also moving to the right on many issues. As a consequence, many people who previously considered themselves in the middle are finding that the current views of the left are closer to their views. Thomas Ricks, who wrote Fiasco, and excellent look at the Iraq War, described why he moved to the left at Politico:

Disappointment in the American government over the last 10 years. Our wars in Afghanistan and Iraq were the first big shocks. I thought that invading Afghanistan was the right response to the 9/11 attacks, but I never expected the U.S. military leadership would be so inept in fighting there and in Iraq, running the wars in ways that made more enemies than were stopped. I believe that the invasion of Iraq was wrong, not only launched on false premises but also strategically foolish in that ultimately it has increased Iran’s power in the Middle East.

Torture. I never expected my country to endorse torture. I know that torture has existed in all wars, but to my knowledge, its use, under the chilling term “enhanced interrogation,” was never official U.S. policy until this century. In fact, until our recent wars, the American military had a proud heritage of handling its prisoners better than most. During the Revolutionary War, Gen. George Washington reminded his men of the need to “Treat [captives] with humanity, and Let them have no reason to complain of our Copying the brutal example of the British army.”

How we fought. I never thought that an American government would employ mercenaries in a war. And yet we did this in Iraq by hiring thousands of armed “security contractors” who in practice were subject neither to local law nor to the American military justice system, and so could and often did treat Iraqis badly. In September 2007, I remember, American officers, who by then understood the need to treat Iraqi civilians well, were outraged when Blackwater employees shot 37 Iraqis in Baghdad’s Nisour Square—the rough equivalent of opening up on the lunch crowd in Dupont Circle. Yet to my knowledge, the U.S. government has not studied how the use of mercenaries poisoned the conduct of the war. Indeed, it gives every indication of planning to operate the same way in the future.

Intelligence officials run amok. I think that American intelligence officials have shown a contempt for the way our democracy is supposed to work in turning a vast and unaccountable apparatus on the citizens it is supposed to be protecting. I remain wary of Edward Snowden’s motivations and connections, yet still am worried by the intrusive surveillance by the National Security Agency he has unveiled. At the very least, in a democracy, we should be able to be informed about the actions that have eroded our privacy but supposedly were taken in our name.

Growing income inequality. I also have been dismayed by the transfer of massive amounts of wealth to the richest people in the country, a policy supported over the last 35 years by successive administrations of both parties. Apparently income redistribution downward is dangerously radical, but redistribution upward is just business as usual. The middle class used at least to get lip service from the rich—“backbone of the country” and such. Now it is often treated like a bunch of saps not aware enough to evade their taxes.

This led to a lengthy discussion at The Moderate Voice, where I also blog. Many of the bloggers and regular commentators there are in a similar position, thinking of themselves as moderates but finding their views are now more in line with the left, especially on social issues. While Ricks didn’t mention social issues, the desire to keep government out of the private lives of individuals has led many people to abandon the Republicans and the conservative movement.

Opposition to the Iraq War and related issues has generally been the defining issue for the formation of the liberal “netroots” and this dominates Ricks’ reasons. Republicans typically use fear and distort Democratic views, such as with the misquotation of Obama as the theme of the last Republican convention, to falsely paint liberals as being for socialism. There are no such economic views listed by Ricks, and the same is typical of many liberals. There is a far greater variation in views on the left than on the right, but the center of gravity has moved rightwards on economic issues. Liberals tend to be  more pragmatists and closer to Eisenhower Republicans than anything close to socialist (by its classic meaning).

If the word conservative really meant anything, in many ways today’s liberals are the conservatives who want to preserve our market economy, while eliminating its abuses, while Republicans are the radicals who want to destroy the system and make our economy more like a banana republic. It is the Republicans who are irresponsible fiscally, financing their policies on credit (while Democrats are more likely to include financing for their policies), caring more about tax cuts for the rich as opposed to cutting the deficit, and rigging the system to redistribute wealth from the middle class to the rich. Besides the ethical problems with this, destroying the middle class is horrible for the economy, and in the long run doesn’t even benefit the rich either, unless you want to live in a banana republic. On top of this we have the Republicans engaging in irresponsible action such as shutting down the government and making an issue out of increasing the debt ceiling, resulting in a lowering of the country’s credit rating.

The Affordable Care Act is a good example of how both parties have moved to the right on health care. Obamacare is quite close to Richard Nixon’s health care plan, the GOP counter-proposal to HillaryCare in the 90′s, and Mitt Romney’s plan. Republicans used to push for mandates, exchanges, and recommended high deductible plans tied to medical savings accounts. Once Obama pushed for all of this, as opposed to previous more liberal health care proposals, the Republicans suddenly claimed that everything they supported in the past is socialism and amounts to a government takeover of health care. (Of course part of the Republican opposition is because Obamacare does differ from the old Republican proposals in including regulations to keep insurance companies from ripping off consumers while pushing to increase use of private insurance companies.)

Conservatives are likely to misinterpret the inclusion of concerns about income inequality by Ricks, as well as myself  in this post, as indicating support for socialism. Concern about the deleterious effects of  the concentration of wealth to our economy is not an exclusively liberal viewpoint–see the works of Kevin Phillips on this. Nor does this mean that socialism is being advocated as the solution.

Nicholas Kristof has an op-ed on income inequality which is worth reviewing:

First, economic inequality has worsened significantly in the United States and some other countries. The richest 1 percent in the United States now own more wealth than the bottom 90 percent. Oxfam estimates that the richest 85 people in the world own half of all wealth.

The situation might be tolerable if a rising tide were lifting all boats. But it’s lifting mostly the yachts. In 2010, 93 percent of the additional income created in America went to the top 1 percent.

Second, inequality in America is destabilizing. Some inequality is essential to create incentives, but we seem to have reached the point where inequality actually becomes an impediment to economic growth.

Certainly, the nation grew more quickly in periods when we were more equal, including in the golden decades after World War II when growth was strong and inequality actually diminished. Likewise, a major research paper from the International Monetary Fund in April found that more equitable societies tend to enjoy more rapid economic growth.

Indeed, even Lloyd Blankfein, the chief executive of Goldman Sachs, warns that “too much … has gone to too few” and that inequality in America is now “very destabilizing.”

Inequality causes problems by creating fissures in societies, leaving those at the bottom feeling marginalized or disenfranchised. That has been a classic problem in “banana republic” countries in Latin America, and the United States now has a Gini coefficient (a standard measure of inequality) approaching some traditionally poor and dysfunctional Latin countries.

Third, disparities reflect not just the invisible hand of the market but also manipulation of markets. Joseph Stiglitz, the Nobel Prize-winning economist, wrote a terrific book two years ago, “The Price of Inequality,” which is a shorter and easier read than Piketty’s book. In it, he notes: “Much of America’s inequality is the result of market distortions, with incentives directed not at creating new wealth but at taking it from others.”

For example, financiers are wealthy partly because they’re highly educated and hardworking — and also because they’ve successfully lobbied for the carried interest tax loophole that lets their pay be taxed at much lower rates than other people’s.

Likewise, if you’re a pharmaceutical executive, one way to create profits is to generate new products. Another is to lobby Congress to bar the government’s Medicare program from bargaining for drug prices. That

Fourth, inequality doesn’t necessarily even benefit the rich as much as we think. At some point, extra incomes don’t go to sate desires but to attempt to buy status through “positional goods” — like the hottest car on the block.

The problem is that there can only be one hottest car on the block. So the lawyer who buys a Porsche is foiled by the C.E.O. who buys a Ferrari, who in turn is foiled by the hedge fund manager who buys a Lamborghini. This arms race leaves these desires unsated; there’s still only one at the top of the heap.

Fifth, progressives probably talk too much about “inequality” and not enough about “opportunity.” Some voters are turned off by tirades about inequality because they say it connotes envy of the rich; there is more consensus on bringing everyone to the same starting line.

Unfortunately, equal opportunity is now a mirage. Indeed, researchers find that there is less economic mobility in America than in class-conscious Europe.

We know some of the tools, including job incentives and better schools, that can reduce this opportunity gap. But the United States is one of the few advanced countries that spends less educating the average poor child than the average rich one. As an escalator of mobility, the American education system is broken.

Cross posted at The Moderate Voice

Update: Norm Ornstein On The Republican Battle Between The Conservatives And Lunatic Radicals

Surveys Show Benefits Of Obamacare For Individuals And Hospitals

Two polls were released today regarding opinion of the effects of the Affordable Care Act, one from consumers and one from hospital administrators. The first is reported by CNN:

More than half the public says Obamacare has helped either their families or others across the country, although less than one in five Americans say they have personally benefited from the health care law, according to a new national poll.

A CNN/ORC International survey also indicates that a majority of Americans oppose the Affordable Care Act, but that some of that opposition is from people who don’t think the measure goes far enough…

According to the poll, only 18% of the public say they or their families are better off now that the major provisions of the health care law have been implemented. Another 35% report that, while their lives have not improved, the Affordable Care Act has benefited other people in the U.S. Add those two numbers together, and that means 53% say that Obamacare has helped either their families or others across the country.

Forty-four percent tell us that the health care law has not helped anyone in the country.

Any poll regarding whether the law has helped people has to be interpreted cautiously. First there are those who follow the Republican line and deny benefits which have been well-documented, such as an increase in the number of insured. Even those answering with an open mind might not realize ways in which they are benefiting.  Before the Affordable Care Act came into effect many people often did not realize the problems in the old system as they had not encountered them personally. In the past I often saw patients with very limited coverage who had no idea how limited their coverage was. Some policies would only cover inpatient or outpatient services. Some policies had severe limitations on how many office calls they would cover or how much they would pay for lab per year. I have seen patients with newly diagnosed diabetes who suddenly needed far more services than in the past but found that they had used up their coverage for the year by around March. Many people also do not realize the risk they previously faced of being dropped by their insurance plan should they develop expensive medical problems. Insurance companies can no longer drop people for medical problems or deny coverage for pre-existing conditions, along with being required to provide comprehensive coverage, including preventative care.

FierceHealthCare reported on a survey of hospital executives which showed that average inpatient admissions were increased by 0.4 percent in the second quarter of this year, following several years of deceases, as a consequence of the Affordable Care Act and other factors. They also found that “The ACA has made a positve impact on hospital performance, according to the survey, with hospitals in states that expanded Medicaid under the healthcare law expressing significantly more positive views about improvements in payer mix and diversity in the second half of the year.”

Hospital inpatient volumes trended positive for the first time in several years–albeit by only a slight margin–according to a new survey from Jefferies. The investment bank and securities firm also released data about hospital performance and payer mix.

Inpatient volume has trended negative for the last few years, due largely to the economic downturn and plan design changes, but average inpatient admissions were up 0.4 percent in the second quarter of 2014, according to the survey results. Researchers attribute the uptick to a combination of the improving economy, the implementation of the Affordable Care Act and patients waiting as long as possible for procedures, compounding demand.

Polling on provider optimism was also positive, according to the survey. Of the executives from 50 hospitals Jefferies polled, seven in 10 expected inpatient volume to be either flat or up in the third quarter, which is remarkable considering the multiyear trend of negative volumes, according to the survey results. Executives at hospitals with more than 250 beds were particularly optimistic, with all such respondents expecting volume increases in the third quarter.

The ACA has made a positve impact on hospital performance, according to the survey, with hospitals in states that expanded Medicaid under the healthcare law expressing significantly more positive views about improvements in payer mix and diversity in the second half of the year.

“That said, 54 percent of our surveyed hospitals indicated that the ACA has not impacted volume trends yet; it is worth noting though that half of hospitals with 500 or more beds noted improved admission trends as a result of the ACA,” the results stated. Jefferies will continue monitoring developments in states that have not yet expanded the program but are “key for the publicly traded hospitals,” including Tennessee, Pennsylvania and Florida.

Thirty-four percent of respondents overall said emergency department (ED) admissions had increased, but the numbers were higher in expansion states (42 percent) than non-expansion states (29 percent). This lines up with the results of a study which found Medicaid expansion in Oregon increased ED volumes, FierceHealthcare previously reported.

The benefits for hospitals in this survey was consistent with previous reports that Medicaid expansion has led to both increased care for the poor and improved revenues for hospitals. The same post also reported on a recent survey conducted by the American College of Emergency Physicians which found that 37 percent of ER physicians reported that patient volume had increased slightly, 9 percent reported that it had increased greatly, and 27 percent reported that the number of ER visits had remained the same.

Activist Conservative Judges Attempt To Destroy Obamacare, Causing Potential Problems For Republicans

We had two different federal appeals court panels give conflicting rulings on Tuesday regarding the legality of subsidies in the Affordable Care Act. This came about due to some ambiguities in the writing of the law–primarily a proof reading error at one point which suggests that only insurance purchased in state exchanges can allow subsidies. The bulk of the law makes it clear that people purchasing coverage can qualify for subsidies regardless of whether purchased on a federal or state exchange.

It is impossible to predict with certainty, but legal experts are generally predicting that the Supreme Court would follow precedent and go with the overall intent of the law as opposed to allowing the conservative activist judges from the United States Court of Appeals for the District of Columbia to overturn the law.

In the event that the Supreme Court should support this idea we could then have a rather chaotic situation. About 4.5 million people would lose their subsidies, making many people very angry at any Republican politicians who refused to work towards a fix.  There would be two potential solutions. One would be for each state to build their own exchange. Presumably they would now have the benefit of the experience of those working on the federal exchange, so this might not be as difficult as it sounds. However, a far simpler solution would be for Congress to pass legislation to clear up the ambiguous wording in the Affordable Care Act which led to this situation.

We could have rather interesting political battles if Republicans would continue to call for repeal and refuse to act to make the fix. This would anger many voters who in effect are receiving a significant tax increase by losing their subsidies, and ultimately might lose their medical care. Would Republicans stick to demanding repeal or be forced to give into demand to allow people to receive the subsidies and continue their insurance coverage? If I was a Republican politician, I think I might hope that the Supreme Court rules in favor of the current subsidies and avoids this political problem.

Reports Show More People Insured But No Increase In New Patient Volume For Physicians Since January Under Affordable Care Act

The New England Journal of Medicine has reviewed the increase in coverage under the Affordable Care Act and concluded:

Taking all existing coverage expansions together, we estimate that 20 million Americans have gained coverage as of May 1 under the ACA (Figure 3Figure 3Categories of Expanded Health Insurance Coverage under the Affordable Care Act (ACA).). We do not know yet exactly how many of these people were previously uninsured, but it seems certain that many were. Recent national surveys seem to confirm this presumption. The CBO projects that the law will decrease the number of uninsured people by 12 million this year and by 26 million by 2017. Early polling data from Gallup, RAND, and the Urban Institute indicate that the number of uninsured people may have already declined by 5 million to 9 million and that the proportion of U.S. adults lacking insurance has fallen from 18% in the third quarter of 2013 to 13.4% in May 2014.

However, these surveys may underestimate total gains, since some were fielded before the late March enrollment surge and do not include children. With continuing enrollment through individual marketplaces, Medicaid, and SHOP, the numbers of Americans gaining insurance for the first time — or insurance that is better in quality or more affordable than their previous policy — will total in the many tens of millions.

As we look to the future of the coverage provisions of the ACA and their effect on the U.S. health care system, several observations seem justified. First, as the number of individuals benefiting from the law grows, its wholesale repeal will grow less likely, although the law could still be importantly modified in the future.

Second, experience with the ACA will vary enormously among states. Those deciding not to expand Medicaid will benefit far less from the law, and since many of these states have high rates of uninsured residents and lower health status, the ACA may have the paradoxical effect of increasing disparities across regions, even as it reduces disparities between previously insured and uninsured Americans as a whole.17

Third, the sustainability of the coverage expansions will depend to a great extent on the ability to control the overall costs of care in the United States. Otherwise, premiums will become increasingly unaffordable for consumers, employers, and the federal government. Insurers who seek to control those costs through increasingly narrow provider networks across all U.S. insurance markets may ultimately leave Americans less satisfied with their health care. Developing and spreading innovative approaches to health care delivery that provide greater quality at lower cost is the next great challenge facing the nation.

The full article is available to non-subscribers and there is also further discussion at Talking Points Memo.

There has been concern that the increase in number of insured might lead to an increase in number of people seeing physicians despite predictions and early evidence that this would not be a significant problem in most areas. I have seen several reports indicating that doctors generally are not seeing more patients as a result of the Affordable Care Act. The most recent came from Athena Health and the Robert Wood Johnson Foundation. Here is a summary of their findings:

  • Influx in New Patient Volume Not Detected: In the first five months of 2014, a national sample of 14,300 health care providers across the athenahealth network did not see an increase in new patient volume.* Instead, the percentage of total visits with new patients actually dropped slightly compared to the same period in 2013. These findings suggest that an increase in newly insured patients, resulting from the ACA, has yet to have an impact on new patient volume at medical practices.
  • Health Care Reform Widening the Medicaid Gap: In states that are expanding Medicaid coverage under the ACA, the data shows an overall increase in adult (18-64) Medicaid beneficiary patient visits. In expansion states, on average, the percentage of Medicaid-covered patients who are being seen by primary care physicians is rising, with Medicaid patients accounting for 12.3% of care in December of 2013 compared with an increased rate of 15.6% in May 2014. Surgeons and other specialists also show increases. Conversely, states that are not expanding Medicaid coverage have seen Medicaid visits remaining flat. These findings indicate that the implementation of the ACA is widening the gap of the total share of Medicaid patients that doctors in expansion vs. non-expansion states are caring for.
  • No Increase in Chronic Disease Diagnoses Among New Patients: Findings from the first five months of 2014 indicate that established patients have a higher rate of chronic diseases compared with new patients seeking care. When comparing diagnosis rates of chronic conditions from the first five months of 2013 to the first five months of 2014, across both new and established patients, no increase in diagnosis rates of chronic conditions is detected for either population.

It is possible that some of the newly insured are initially going to the Emergency Room and therefore are not picked up as an increase in visits by primary care physicians. In May I reported on a study by the American College of Emergency Physicians which found that 37 percent of ER physicians reported that patient volume had increased slightly, 9 percent reported that it had increased greatly, and 27 percent reported that the number of ER visits had remained the same.

It is also a good finding that the newly insured are not turning out to be sicker than the previously insured. Many insurance companies held off on entering the exchanges last year out of fear that they might wind up with sicker patients, costing them more money. Those which sold coverage have wound up doing well with more insurance companies planning to enter the exchanges to sell coverage for next year. This should help reduce anticipated increases in premiums and give consumers more choice.

Forbes has further discussion of the differences in states which are offering the expanded Medicaid program compared to those which do not.

What’s The Matter With Thomas Frank?

Obama Green Lantern

Thomas Frank has fallen for the Green Lantern view of the presidency, thinking that the president has the power to do anything he wishes. His criticism of Obama:

Why did he do nothing, or next to nothing, about the crazy high price of a college education, the Great Good Thing that he has said, time and again, determines our personal as well as national success? Why didn’t he propose a proper healthcare program instead of the confusing jumble we got? Why not a proper stimulus package? Why didn’t he break up the banks? Or the agribusiness giants, for that matter?

Well, duh, his museum will answer: he couldn’t do any of those things because of the crazy right-wingers running wild in the land. He couldn’t reason with them—their brains don’t work like ours! He couldn’t defeat them at the polls—they’d gerrymandered so many states that they couldn’t be dislodged! What can a high-minded man of principle do when confronted with such a vast span of bigotry and close-mindedness? The answer toward which the Obama museum will steer the visitor is: Nothing.

In point of fact, there were plenty of things Obama’s Democrats could have done that might have put the right out of business once and for all—for example, by responding more aggressively to the Great Recession or by pounding relentlessly on the theme of middle-class economic distress. Acknowledging this possibility, however, has always been difficult for consensus-minded Democrats, and I suspect that in the official recounting of the Obama era, this troublesome possibility will disappear entirely. Instead, the terrifying Right-Wing Other will be cast in bronze at twice life-size, and made the excuse for the Administration’s every last failure of nerve, imagination and foresight. Demonizing the right will also allow the Obama legacy team to present his two electoral victories as ends in themselves, since they kept the White House out of the monster’s grasp—heroic triumphs that were truly worthy of the Nobel Peace Prize. (Which will be dusted off and prominently displayed.)

But bipartisanship as an ideal must also be kept sacred, of course. And so, after visitors to the Obama Library have passed through the Gallery of Drones and the Big Data Command Center, they will be ushered into a maze-like exhibit designed to represent the president’s long, lonely, and ultimately fruitless search for consensus. The Labyrinth of the Grand Bargain, it might be called, and it will teach how the president bravely put the fundamental achievements of his party—Social Security and Medicare—on the bargaining table in exchange for higher taxes and a smaller deficit. This will be described not as a sellout of liberal principle but as a sacred quest for the Holy Grail of Washington: a bipartisan coming-together on “entitlement reform,” which every responsible D.C. professional knows to be the correct way forward.

Frank both ignores the real obstacles which Obama faced and is not very accurate in describing Obama’s record. He forgets that the there was a very good reason that Obama never had a chance to reason with the Republicans–they decided right off the bat that they would oppose anything Obama supported for political reasons. Frank might check out the work of  centrists Norman Ornstein and Thomas Mann on how Republicans are responsible for the current gridlock along with  this Frontline documentary:

On the night of Barack Obama’s inauguration, a group of top GOP luminaries quietly gathered in a Washington steakhouse to lick their wounds and ultimately create the outline of a plan for how to deal with the incoming administration.

“The room was filled. It was a who’s who of ranking members who had at one point been committee chairmen, or in the majority, who now wondered out loud whether they were in the permanent minority,” Frank Luntz, who organized the event, told FRONTLINE.

Among them were Senate power brokers Jim DeMint, Jon Kyl and Tom Coburn, and conservative congressmen Eric Cantor, Kevin McCarthy and Paul Ryan.

After three hours of strategizing, they decided they needed to fight Obama on everything. The new president had no idea what the Republicans were planning.

There were clear institutional limits on Obama in a system where forty Senators could block the majority on anything. The Democrats had sixty votes for a very brief time due to the delays in swearing in Al Franken and later Ted Kennedy’s death.  Even when Obama technically had sixty Senators voting with the Democrats, this included Joe Lieberman and Ben Nelson who would never go for the type of leftist agenda Frank favored.

Obama chose to use his limited political political capital to concentrate on health care reform, passing a comprehensive health reform package after previous presidents from Harry Truman to Bill Clinton were unsuccessful. Ted Kennedy once expressed regret at working with Richard Nixon and instead insisting upon a single-payer system at the time. Similarly Hillary Clinton convinced Bill to threaten to veto anything other than her plan, rejecting a Republican proposal which was very similar to the Affordable Care Act. It would be far better to accept what can be passed and then work to improve it over time.

Sure the Affordable Care Act is a confusing jumble, but that is because it built upon our current system. It would have been better if the system was even more complex and perhaps confusing, including either the public option or Medicare buy-in. Neither could pass because both Lieberman and Nelson opposed them. Obama certainly could have never received sixty votes for a single-payer plan, breaking up the banks, or a bigger stimulus.

Beyond Congress, Obama was limited by conservative media bias on economic matters. Obviously Fox was out there spreading lies and attacking anything Obama wanted to do, but the problems weren’t limited to Fox and its viewers. Most of the media is owned by the wealthy, and much of the news, especially on television, is reported by wealthy television stars. They might not share the Republican views on social issues or their opposition to science and reason (leading to the conservative view of  a liberal media) but many of them are quite conservative on economic issues. They were biased towards tax cuts and cutting spending. Media reports on the economy typically stressed the size of the deficit and included the assumption that a reduction in government spending was necessary. Few pointed out the degree to which Republican spending and tax cuts in the Bush years contributed far more to the deficit than Obama’s stimulus spending. The atmosphere was hardly conducive to pushing an even bigger stimulus, regardless of how much more this would have helped the economy recover. He also ignores the degree to which Obama’s stimulus did help bring about economic recovery.

Just as Frank ignores the benefits of Obama’s policies, including the Affordable Care Act and the stimulus, he exaggerates what Obama did not do. No, Obama did not destroy Social Security and Medicare. It is the other party which has been seeking to do that. Offering  Chained CPI in exchange for a grand bargain on the deficit might never have been a good idea, but we can’t blame Obama for making a bad deal when such a deal was never made and we don’t know what he would have held out for before making such an agreement.

Obama’s record has much in it to displease the far left. It is doubtful that any other president would have achieved more than he actually did.