Study Debunks Claims That Medicaid Patients Abuse Emergency Rooms

Opponents of Medicaid expansion have often distorted reports of increase Emergency Room use after their expansion of the Medicaid program in Oregon as reason to oppose the program. MACPAC, a nonpartisan federal agency that provides policy and data analysis on Medicaid and CHIP to Congress, has found the problem to not be as serious as suggested as the vast majority of the use of Emergency Rooms is for valid reasons. Fierce Health Finance summarized their findings:

The Medicaid population uses hospital emergency departments (EDs) at a higher rate than patients with other forms of insurance, but for the most part such visits are necessary, according to a new report from the Medicaid and CHIP Payment and Advisory Commission (MACPAC).

The report aims to debunk the notion that Medicaid patients show up at the emergency room (ER) for care because they have been conditioned to do so. “The majority of ED visits by non-elderly Medicaid patients are for urgent symptoms and serious medical problems that require prompt medical attention,” the report said. It noted that Medicaid patients tend to have much higher rates of chronic diseases and debilitating conditions than those in the privately insured population, or even among those who lack health insurance altogether. In many cases, their conditions are so compromised that even their primary care physicians will refer them to the ER.

Moreover, MACPAC also engaged in a systematic review of all the research regarding ED use and the Medicaid population between 1990 and 2010. It concluded that there was no “consistent association” between Medicaid enrollees and unnecessary ER use.

MACPAC also noted that some conditions treated at the ER that are classified as non-urgent  are best treated there anyway. “Some problems, such as chest pain in a 50-year old or an infant’s fever and rash, carry high risks for patients and are best evaluated in an ED,” the report said. “This is true even if–after a physician’s evaluation and some rapid testing–the vast majority of cases are resolved.”

Experience from Medicaid expansion in Ohio also showed that better management of the Medicaid patients can lead to better control of chronic disease while limiting Emergency Room use.

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Obamacare Health Insurance Premiums Expected To Increase By Average Of 7.5 Percent; Kaiser Lowering Rates In California

As the data comes in, we are seeing that another of the scare stories about Obamacare isn’t coming true. For example, there was a report in March claiming rates would sky rocket which many lazy journalists repeated despite it originating from a story with no sources, written by someone who had interned at The National Review. The same writer at The Hill now says that premiums will increase an average of 7.5 percent. In the past, double digit increases were common on the individual market.

I previously reported on predictions that premiums in California would increase by an average of 4.2 percent. We now have more detailed data from the major California insurance companies. Last year Kaiser set their rates higher than the competition and suffered by coming in fourth place in exchange enrollment. In response, and in hopes of increasing their market share, they plan a 1.4 percent decrease next year. Anthem Blue Cross, which received the most subscribers in the exchanges, plans an increase of 4.6 percent. The next two largest insurers of exchange plans, Blue Shield of California and Health Net, plan increases of 6 percent and 4.9 percent.

Kaiser is not expected to significantly increase market share due to continuing to have rates higher than the competition. For example, here is a comparison in Los Angeles:

In region 15, for a 40-year-old buying a silver plan this year, Kaiser was the highest-priced coverage at $297 a month. That’s before any federal premium subsidies based on a person’s income.

In 2015, that same silver plan would cost $287 from Kaiser. That’s still the second-highest price in L.A. behind an Anthem exclusive-provider-organization, or EPO, plan.

Next year, Health Net’s HMO remains the cheapest coverage on the silver tier in L.A. at $231 a month for a 40-year-old, up $7 from this year’s premium.

Those low rates made Health Net the market leader in L.A. with 33% market share, beating out Blue Shield and Anthem.

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Media Support For Legalization Of Marijuana and Prostitution

Legalize Pot and Sex

There is a welcome trend towards support of decriminalization of victimless crimes. The New York Times recently came out for legalization of marijuana, outlining the harm done by the unsuccessful prohibition:

America’s four-decade war on drugs is responsible for many casualties, but the criminalization of marijuana has been perhaps the most destructive part of that war. The toll can be measured in dollars — billions of which are thrown away each year in the aggressive enforcement of pointless laws. It can be measured in years — whether wasted behind bars or stolen from a child who grows up fatherless. And it can be measured in lives — those damaged if not destroyed by the shockingly harsh consequences that can follow even the most minor offenses…

The costs of this national obsession, in both money and time, are astonishing. Each year, enforcing laws on possession costs more than $3.6 billion, according to the American Civil Liberties Union. It can take a police officer many hours to arrest and book a suspect. That person will often spend a night or more in the local jail, and be in court multiple times to resolve the case. The public-safety payoff for all this effort is meager at best: According to a 2012 Human Rights Watch report that tracked 30,000 New Yorkers with no prior convictions when they were arrested for marijuana possession, 90 percent had no subsequent felony convictions. Only 3.1 percent committed a violent offense.

The strategy is also largely futile. After three decades, criminalization has not affected general usage; about 30 million Americans use marijuana every year. Meanwhile, police forces across the country are strapped for cash, and the more resources they devote to enforcing marijuana laws, the less they have to go after serious, violent crime. According to F.B.I. data, more than half of all violent crimes nationwide, and four in five property crimes, went unsolved in 2012.

The sheer volume of law enforcement resources devoted to marijuana is bad enough. What makes the situation far worse is racial disparity. Whites and blacks use marijuana at roughly the same rates; on average, however, blacks are 3.7 times more likely than whites to be arrested for possession, according to a comprehensive 2013 report by the A.C.L.U.

Now The Economist has called for legalization of prostitution, partially due to the changes in the profession with prostitution increasingly being arranged on line:

Moralisers will lament the shift online because it will cause the sex trade to grow strongly. Buyers and sellers will find it easier to meet and make deals. New suppliers will enter a trade that is becoming safer and less tawdry. New customers will find their way to prostitutes, since they can more easily find exactly the services they desire and confirm their quality. Pimps and madams should shudder, too. The internet will undermine their market-making power.

But everyone else should cheer. Sex arranged online and sold from an apartment or hotel room is less bothersome for third parties than are brothels or red-light districts. Above all, the web will do more to make prostitution safer than any law has ever done. Pimps are less likely to be abusive if prostitutes have an alternative route to market. Specialist sites will enable buyers and sellers to assess risks more accurately. Apps and sites are springing up that will let them confirm each other’s identities and swap verified results from sexual-health tests. Schemes such as Britain’s Ugly Mugs allow prostitutes to circulate online details of clients to avoid.

Governments should seize the moment to rethink their policies. Prohibition, whether partial or total, has been a predictable dud. It has singularly failed to stamp out the sex trade. Although prostitution is illegal everywhere in America except Nevada, old figures put its value at $14 billion annually nationwide; surely an underestimate. More recent calculations in Britain, where prostitution is legal but pimping and brothels are not, suggest that including it would boost GDP figures by at least £5.3 billion ($8.9 billion). And prohibition has ugly results. Violence against prostitutes goes unpunished because victims who live on society’s margins are unlikely to seek justice, or to get it. The problem of sex tourism plagues countries, like the Netherlands and Germany, where the legal part of the industry is both tightly circumscribed and highly visible…

The prospect of being pressed to mend their ways makes prostitutes less willing to seek care from health or social services. Men who risk arrest will not tell the police about women they fear were coerced into prostitution. When Rhode Island unintentionally decriminalised indoor prostitution between 2003 and 2009 the state saw a steep decline in reported rapes and cases of gonorrhoea.

Prostitution is moving online whether governments like it or not. If they try to get in the way of the shift they will do harm. Indeed, the unrealistic goal of ending the sex trade distracts the authorities from the genuine horrors of modern-day slavery (which many activists conflate with illegal immigration for the aim of selling sex) and child prostitution (better described as money changing hands to facilitate the rape of a child). Governments should focus on deterring and punishing such crimes—and leave consenting adults who wish to buy and sell sex to do so safely and privately online.

More on the effects of the unintentional decriminalization of indoor prostitution in Rhode Island here.

I think  tolerance of marijuana use and prostitution will increase with the millennial generation, which is more socially liberal, and find it a good sign to see long-established portions of the media also moving in this direction. I also fear that, as with same-sex marriage, even the Democrats will lag behind the general population in acceptance of liberal views.

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Ohio Experiment Shows Way To Save Money With Medicaid Expansion And Avoid Increase In ER Utilization

Opponents of the expanded Medicaid program have often cherry-picked data from Oregon to point out an increase in Emergency Room use and to question the benefits of the program. NPR’s Morning Edition looked at a program in Ohio to expand Medicaid coverage before the expansion in the Affordable Care Act and found positive results. The program was formed due to the problem of unreimbursed high cost care when uninsured people with problems such as diabetes received their care in the emergency rooms:

So, long before Ohio expanded Medicaid, the hospital redirected more than $30 million it receives from county taxpayers each year into a new pot.

It used the money to create its very own Medicaid program for county residents. And then it tracked the patients.

The results from the first nine months are in.

“All of the clinical outcomes are really amazing,” says , a researcher at MetroHealth.

The hospital used extensive electronic medical records to carefully select uninsured patients and send them Medicaid cards before they even applied. Then MetroHealth gave personalized attention to patients. Cebul says they focused on 18,000 of them who came to the hospital a lot.

“The diabetes outcomes were probably the most impressive,” he says. “The sugar control, the blood pressure control, the lipid control — virtually everything was much better and dramatically so.”

Here’s how it works. Each patient is assigned a nurse. That nurse books their appointments, calls them if they miss one and checks to make sure they take their medications.

In nine months, emergency department visits dropped 60 percent and primary care visits went up 50 percent.

The hospital also ended up spending less than it budgeted, saving an average of $150 on each patient every month.

“Better care, better outcomes, better costs,” Cebul says.

This program is probably showing better outcomes earlier than in Oregon due to increased oversight of the people receiving benefits. If people are just given health care coverage, it takes time to get established with primary care physicians as opposed to utilizing the Emergency Rooms. The experiment in Ohio showed that this problem could be avoided by making a greater effort to supervise the newly insured and actually set them up with primary care doctors.

Not surprisingly, the states which are participating in the expanded Medicaid program are seeing the largest drops in uninsured. It will be interesting to see how the individual states handle their new Medicaid patients, as the program in Ohio has demonstrated that there could be greater potential cost savings when the newly insured receive greater oversight, at least for those with expensive medical problems such as diabetes.

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Health Insurance Premiums In California Expected To Rise Only 4.2 Percent Next Year With Considerable Variation Nation Wide

California covered 300

When the Affordable Care Act went through Congress many of the ideas which would have lowered costs failed to make it, with the final law concentrating more on expanding the number of people who are covered. Insurance has always been very expensive on the individual market, and many are watching to see how rate large increases will be compared to the past.  It was expected that on average premiums would go up the first year before subsidies are considered because insurance in the individual market often only provided very limited coverage with sales limited to healthy people.

There is good news out of California where premiums are only expected to rise 4.2 percent after years of double digit increases, but there is disagreement as to the reason.

After years of double-digit rate hikes in health insurance premiums, California will see average increases of 4.2 percent in 2015 for people who purchase insurance through the Covered California exchange, the state’s Obamacare marketplace.

It’s good news for consumers, but two of the top insurance officials in the state disagree about why it’s happening.

Covered California’s executive director and other analysts pointed to specific factors for this moderate increase. For starters, enrollment was very strong in 2014, more than a million people. In addition, healthy people signed up, spreading the risk.

But the state’s insurance commissioner, Dave Jones, sees a different force in play. He believes that a statewide ballot measure, Proposition 45, has insurers scared.

“Health insurers have hit the pause button” on rate hikes, Jones said Thursday, just hours after Covered California announced its 2015 rates.

Proposition 45, which voters will consider in November, would give his office the authority to reject excessive rate hikes. Jones believes insurers held their fire on 2015 premium increases so as not to create a backlash from consumers and enable the passage of Prop. 45…

When rates were introduced in May 2013 for Covered California’s opening year many experts said they were surprisingly low and thought those low rates might be a “loss leader” strategy, said UCLA health policy professor Jerry Kominski. There was a concern that rates were low to get people into the market and then “jack up prices” later, he said.

“That didn’t happen,” Kominski said. He doesn’t think it’s happening now, either. “I don’t think the insurers are lying in wait, waiting to spring enormous increases on the public next year.”

Earlier this week, Jones released an analysis done by his staff, looking at 2014 vs. 2013 individual plan rates and found average increases of 22 to 88 percent for people who bought non-subsidized policies.

But those 2013 pre-ACA plans existed in a fundamentally different insurance market, Kominski argued. “In 2013, premiums were artificially lower, and prior to the ACA, premiums could be held down by excluding high-risk patients from the market and by offering skinny benefits.”

In contrast, Florida’s largest insurance company, Florida Blue, is increasing rates by an average of 17.6 percent next year due to attracting more older adults who were previously uninsured and are now using more services. By comparison, rates increased by amounts almost as high before the Affordable Care Act. Their rates increased by 16.5 percent in 2014, 16 percent in 2013 and 11.5 percent in 2012. Those in more restrictive networks from Florida Blue will see lower rate increases averaging 13 percent. The full effect of this increase will be on a limited portion of the population as almost 90 percent in Florida receive subsidies, which is a little higher than the national average.

This report of a 17.6 percent rate increase is higher than is being reported elsewhere:

Nationally, 2015 rates that have been made public have varied sharply, with some insurers increasing rates, some reducing them and others keeping them stable.

Avalere, a consulting firm, found in June that average premiums for a 40-year-old, non-smoker would increase by about 8 percent next year, based on an analysis of “silver” plan rates in nine states. Changes ranged from a 1.4 percent average decrease in Oregon to a 16 percent average increase in Indiana.

There is not yet information on what other insurers in Florida will be charging next year and potentially people in Florida could avoid this increase by looking at other insurance companies. A Kaiser Tracking Poll shows that many people are unaware of this option:

The July poll finds that fewer than four in ten Americans (37 percent) are aware that people who got new health insurance under the ACA had a choice between private health plans, while about a quarter (26 percent) think the newly insured were enrolled in a single government plan and about four in ten (38 percent) say they don’t know enough to answer the question.

Most likely much of the negative impression of Obamacare is based upon such lack of understanding of what the Affordable Care Act actually does, complicated by a relentless misinformation campaign being spread by the Republicans.

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Another Frivolous Suit Against Obamacare Thrown Out Of Court

There have  been a lot of frivolous suits filed by various Republicans lately, ranging from suits to try to block the Affordable Care Act to the House Republicans’ own suit. While we had contradictory rulings in the case making the absurd argument that the ACA did not intend to allow subsidies to those who obtained coverage on the federal as opposed to a state exchange, another ridiculous argument was thrown out of court this week.

The argument was that the Affordable Care Act is unconstitutional because of the requirement that revenue bills originate in the House, and the ACA does include mechanisms to raise revenue to pay for the law. The argument never made much sense but it has attracted increased attention among conservatives since George Will had a column on how the Supreme Court doomed the ACA in its ruling that the government had the power to charge a penalty for noncompliance with the mandate based upon the power to tax.

There are two major errors in this argument. First is that there is precedent for the Senate to take a House bill and then pass it with major changes, and still have this considered to have originated in the House. As the House also passed their own version of health care reform, this was sufficient to meet this criteria. Secondly, the courts have long differentiated between a bill with a primary purpose of levying taxes versus a bill which incidentlaly raises revenue. The Appeals court argued that, “The Supreme Court has held from the early days of this nation that revenue bills are those that levy taxes in the strict sense of the word, and are not bills for other purposes which may incidentally create revenue.”

Consider the irony in two of the Republican arguments against the bill. In this case the Republicans oppose the Affordable Care Act because it contains provisions to pay for itself. While Democrats have adopted a pay as you go attitude towards new government programs, Republicans prefer to purchase their programs on credit, such as with the Iraq War and George Bush’s Medicare D Program. When it is Republicans spending the money, deficits don’t matter.

In the case of the House law suit, Republicans are suing Obama for delaying implementation of a portion of the law (the mandate on small business) which they have claimed would be harmful and want repealed. Republicans also had no objection to a similar delay by George Bush in enforcing requirements of the Medicare D program.

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Decriminalization of Prostitution Led To Reduction In Rape And Gonorrhea

An unintended experiment in Rhode Island found that when prostitution conducted indoors  was decriminalized due to a loophole in the law, there was a decrease in rape and cases of gonorrhea. The Wall Street Journal reports:

A loophole in Rhode Island law that effectively decriminalized indoor prostitution in 2003 also led to significant decreases in rape and gonorrhea in the state, according to a new analysis published by the National Bureau of Economic Research.

“The results suggest that decriminalization could have potentially large social benefits for the population at large – not just sex market participants,” wrote economists Scott Cunningham of Baylor University and Manisha Shah of the University of California, Los Angeles, in a working paper issued this month.

Mr. Cunningham and Ms. Shah got an opportunity to study the effects of decriminalized prostitution on crime and public health because Rhode Island lawmakers made a mistake. A 1980 change to state law dealing with street solicitation also deleted the ban on prostitution itself, in effect making the act legal if it took place indoors. The loophole apparently went unnoticed until a 2003 court decision, and remained open until indoor prostitution was banned again in 2009.

As you might expect, the economists found that decriminalizing indoor prostitution was a boon to the sex business. “Decriminalization decreased prostitute arrests, increased indoor prostitution advertising and expanded the size of the indoor prostitution market itself,” they wrote.

Rhode Island also saw “a large decrease in rapes” after 2003, while other crimes saw no such trend in the state, they wrote. There also was “a large reduction in gonorrhea incidence post-2003 for women and men,” they wrote.

The economists then used several economic models to track the decriminalization’s effects versus other possible causes. They found “robust evidence across all models that decriminalization caused rape offenses and gonorrhea incidence to decrease.” One model estimated a 31% decrease in per-capita rape offenses and a 39% decrease in per-capita female gonorrhea cases due to the decriminalization of indoor prostitution.

This sounds like a strong argument for decriminalizing prostitution.

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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

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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.

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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.

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