Medicaid in the President’s budget request

The Department of Health and Human Services accidentally leaked their own budget this evening. Bob Herman at Axios saved a copy. The biggest aspect of the budget is it laid out another $600 billion dollars in cuts to Medicaid and CHIP over ten years in addition to the $820 billion in Medicaid cuts in the AHCA.

Between these two documents Medicaid would lose 47% of its federal funding over a decade.

Loren Adler at Brookings thinks the cuts would be to tie the AHCA block grants to no more than inflation rate growth without regard to population or case mixture. As the Baby Boomers retire, more of them will require nursing home care that is currently paid for by Medicaid but there would be no federal money.

This is a budget wishlist that pits old people versus kids, the disabled against the pregnant and state budgets against upper income tax cuts in the federal budget.

Call Congress and give them an earful.



Pet Bleg II: Sending Out the Signal

Commenter BL wrote and asked if I’d re-up the request for assistance.

Look at that face! You know you want to help that face!

BL writes:

The dog has been lost since at least Friday morning and we have had several bouts of rain. He only had an Invisible Fence collar, and no other tags or tattooes. He is not microchipped and his collar is not registered with Invisible Fence. I have posted on several lost pet sites, facebook, a local neighborhood social media site, and Craigs List. I’ve notified the county animal control and the community HOA. I filed a found dog report with the county shelter.
I have had only one response and that was not the right dog.
Today, the president of the HOA of my development (who is a big dog lover and just took in a puppy today or would help take in Buddy for the next 3 days) drove around our neighborhood and the next development over, and asked everyone she saw if they knew where Buddy belonged with no luck. I also drove around neighborhoods this weekend and saw no signs or anyone looking for a dog.
In my county, if you turn the dog into the county, you have 5 days to pick up your dog and then they start to look at adoption.
Tomorrow will be the 5th day.
I would like to go ahead and ask the Balloon Juice community to help place the dog for adoption somewhere.
Here is what I know:
He is an older, intact, black lab mix and weighs 69lb. The vet said everything looked good except for his heart (he may have an arrhythmia). He is stiff, and had trouble walking for me on Friday, but the vet says his hips and knees seemed good (at least as much as he could tell without an xray). The walking/stiffness may be more back related. He can go up and down stairs, but it is difficult for him. His teeth are in great shape. He is very friendly with people and ok with my dogs. He is a little protective of his food with my dogs, he is ok with me taking food from him. He, unfortunately, wants to chase cats, and so, I cant keep him in the house while I travel since I have cats.
However, he likes to mark – including in the house. I have started trying to correct that, but I expect that is going to take awhile as he is old and has years of habit to undo. But I doubt he is an outside dog, since I had trouble getting him to go out into the rain. Maybe the marking is due to some level of anxiety in a new setting, although he seems calm.
I had him vaccinated for rabies while at the vet this weekend to keep everyone safe. I can arrange for the rest of the vaccines later this week, when I get back. I am postponing my travel to WV until tomorrow evening, so I can take Buddy somewhere tomorrow. If I have no other option, I will ask my daughter (but she is pregnant, in that stage where you feel nauseous all the time, and is dealing with her own dog emergency – one of her dogs is going through chemo and had to be rushed to the emergency vet this morning, plus she also has cats). I suppose the last resort is the county shelter, but they do euthanize animals they cant place. They told me they have a 60% placement rate.
Let me know if you need anything else from me. I have been reading Balloon Juice for a couple of years and I’ve seen how the group rallies for pets.
Thanks,
BL
If you can help BL and this fine fellow out, let us know in comments or email me and I’ll put you in touch.
Open thread!


Open Thread: When Someone Tells You What They Are…



Explosions in the UK

Apparently something horrible has happened at an Ariana Grande concert in Manchester.








Fire on the mountain, run boys run

Jon Ossoff is up SEVEN POINTS in today’s Survey USA poll. If he wins this race at all, great Democratic candidates are going to come out of the woodwork to challenge Republican incumbents everywhere. The Montana special with Rob Quist on Thursday is looking tight too, though it’s tough terrain (Trump won by 20 points).

I’m not raising money for either of those two races anymore, since all the money will probably go to advertising of dubious efficacy.

I just emailed ActBlue about setting something up where we donate and money goes equally to all Democratic challengers. In the meantime, we’re still raising money against the asshole in NJ-6 (Rodney Frelinghuysen) who sent the letter that made the woman have to resign her job at a bank.

Goal Thermometer








Open Thread: “Peach” in Our Times

Didn’t “peach” used to be thieves’ cant for “incriminate one’s associates to the authorities”?



Open Thread: Now, the Happy Part Is Over…


Okay, the Secretary of Commerce thinks criminalizing protests isn’t such a bad thing, since he got ‘two gigantic bushels of dates’ from his security detail. One look at Wilbur Ross’s face, you can understand why dietary fiber is so valuable to him!



My New T-Shirt Came

I always hate the “Not my President” nonsense because that’s not how it works- yes, he is my President, unfortunately and god damnit. But I made an exception for this t-shirt.

The nice thing about this shirt is that even if Trump is impeached, it works for Pence, too! So its got good shelf life.








Site Tweaks and Suchlike

note: I pulled this and scheduled it for a later publish to not stomp on Betty’s post.  Sorry for the brief stomp, Betty!

Just a quick update:

The video as is back – yay more site revenue for good causes.

The video ad is back – boo, it makes the page refresh.

Well folks, we’re working on it. We’re seeing what we can do to make the best of both worlds.

Please don’t block all the ads on the site, they’re the lifeblood that a) keeps the community going, and b) ensure that good pet causes are supported. And, should you ignore this plea, once the refresh issue is past, please consider white-listing the site so that we get more ad revenue!

For today, perhaps tomorrow, as we experiment with some settings, the ad may go away, make the page refresh, or show an error message. Please be patient while we try to get it right.

This wouldn’t even be seen by you if we had a test server, but which we don’t…yet. I just started setting it up today, and expect to have it fully functional by the end of the week. When ready, it will be an almost clone of the full site, with a few configuration differences. It will be a full-time dedicated server for experimenting with new or changed features, etc. So less bumps in the future as we return to the ideal of a full-time test/development server!

Alongside this will be a proper Issues tracker so that problems, ideas, complaints, etc. about the technical side of the site can be put in one central, public place. No more spreadsheets, to-do lists, emails, comments, phone calls, etc. – just a simple, organized list of Issues.

More details will be forthcoming, but it is my sincere hope that we’ll be able to improve this site, smooth over rough patches, and hopefully add a feature or two here and there that makes your reader/commenter life better.

As a final piece of news, you may have noticed that there is an In Memoriam widget at the top of the sidebar. It’s temporary, just there for a few weeks, but please do keep greennotGreen’s family in your thoughts and prayers, and if you have a bit to spare, consider a donation to honor her, and to thank her and her family for sharing her journey. I know that I am changed from going through this; I suspect many of us are.

I don’t expect to be in the comments much, but feel free to post tech issues, ideas, etc. I am taking good ideas and adding them to the list. That won’t mean they all get done, but once they’re official issues, at least there’s a process and explanations if an issue is closed without resolution.

ETA: Please give feedback below if the desktop site is working better for you than earlier today or yesterday, or if it’s the same, or worse. If it is the same as before, also let me know.  I made some changes that seemed to fix things but then I just saw what I think was the partial reload, so now I’m not sure what to think.








Rewind the timer to 90 days

The Cost Sharing Reduction suit, House vs Price, had a status meeting this morning in front of the DC Court of Appeals. Nothing much happened. Both parties asked for another ninety day extension.

States are trying to become intervenors with the argument that the House does not have standing. Nicholas Bagley explains:

If the states are allowed to intervene, however, they could pursue the appeal even if Trump decides to drop it. With the appeal in place, the injunction couldn’t take effect until the case is heard and decided.

What’s more, the states are very likely to prevail. Not on the merits: as I’ve written before, the House is right that there’s no appropriation to make the cost-sharing payments. But the D.C. Circuit is likely to be skeptical of the district court’s conclusion that the House of Representatives has standing to sue. That’s why the states want to court to decide the case quickly: they hope to get rid of the lawsuit once and for all…
Courts try to strike a balance. They insist that third parties intervene as early as possible. They also don’t allow intervention if someone who’s already a party can be counted on to represent the third party’s interest.

That’s why the states couldn’t have intervened when the case was before the district court. The Obama administration was vigorously defending the constitutionality of the cost-sharing reductions, much as the states would have done. Their interests were aligned. Even after Trump’s election, it looked like the Justice Department would keep defending the payments—which is perhaps why an earlier effort to intervene in House v. Price was rebuffed.

Matters are very different today. Cementing his reputation as the world’s worst client, President Trump has publicly toyed with the idea of cutting off the cost-sharing reductions in an effort to force concessions from Democrats….

At this point, it’s nuts to think the states can count on the Trump administration to represent their interests.

A key reminder. The short cut fuse of the CSR bomb is limited. If it does not explode by early Fall, carriers can survive paying increased benefits without corresponding revenue if they jack up their rates in 2018 to compensate.

We have one more CSR court cycle to go through before it is resolved one way or another.








PSA: DeFOXifying Your Elders (Open Thread)

I’ve mentioned before that my grandma morphed from a sweet (if conservative) little old church lady into a frothing rage-bot due to toxic exposure to Fox News…and how we used subterfuge and deception to combat that malign influence. Below the fold, the cartoon version of the story! Open thread! Read more



The Price of Everything and the Value of Nothing

While we focus on the various obvious bathetic catastrophes (from blowing secrets to the Russians to the big man’s collapsing in a heap after a mere one day on the road) committed by the shitgibbon and his band of merry (but never gay — oh no! not that) men, it’s important to keep at least some attention on the rolling, very real damage the Trump administration wreaks on a daily basis.

I’m so far behind on a book project that I can’t really keep up, and I certainly can’t blog with anything remotely resembling depth and insight, so I’m going to try instead to throw up quick posts as various bits of policy news cross my magpie’s field of vision.

This morning’s treat comes via a Saturday story in FTFNYT.*  Under Scott Pruitt, it seems, the EPA has become the Captain Renault of environmental regulators: everything has its price, and the Captain is always eager to make a deal:

Devon Energy, which runs the windswept site, had been prepared to install a sophisticated system to detect and reduce leaks of dangerous gases. It had also discussed paying a six-figure penalty to settle claims by the Obama administration that it was illegally emitting 80 tons each year of hazardous chemicals, like benzene, a known carcinogen.

But something changed in February just five days after Scott Pruitt, the former Oklahoma attorney general with close ties to Devon, was sworn in as the head of the Environmental Protection Agency.

Devon, in a letter dated Feb. 22 and obtained by The New York Times, said it was “re-evaluating its settlement posture.” It no longer intended to move ahead with the extensive emissions-control system, second-guessing the E.P.A.’s estimates on the size of the violation, and it was now willing to pay closer to $25,000 to end the three-year-old federal investigation.

The administration’s response?

The E.P.A. has not yet made a public response to Devon’s new posture, and Mr. Pruitt declined to comment for this article.

Want to bet on how it will turn out?

In just the last three months, with Mr. Pruitt in charge, the E.P.A. postponed a long-planned rule requiring companies like Devon to retrofit drilling equipment to prevent leaks of methane gas — a major contributor to climate change — and to collect more data on how much of the gas is spewing into the air.

The Interior Department, meanwhile, announced this month that it would reconsider a separate rule limiting the burning of unwanted methane gas from wells drilled on federal and Indian lands, a process called flaring. That announcement came the same day the Senate narrowly rejected industry calls to repeal the same rule.

Interior officials have also announced their intention to repeal or revise a contentious rule requiring companies like Devon to take extra steps to prevent groundwater contamination caused by hydraulic fracturing, also known as fracking, a drilling technique in which chemicals and water are forced into rock formations.

You get the idea. Pruitt has a history of working with Devon Energy; the administration has both a pro-extractive industry bias and powerful faction and the always reliable motive of f**king with anything that Obama accomplished.  Some of what the shitgibbon’s people aim to do can, no doubt, be delayed, obstructed, tied up.  Much, perhaps most will go through, at least over the next year or so, up until the pressures of the next election begin to bite.

So:  constant vigilance and trust no Republican. They’ll load up anything they can on anything they can, transferring public goods (clean air, clean water, anything not nailed down) to private hands.

Over to y’all.

*Publication of such stories  is why I continue to subscribe. Their political desk is…dodgy…but they still field more fine reporters than just about anywhere else I can think of. YM, as always, MV.

Image: Elihu Vedder, Corrupt Legislation, mural in the Library of Congress, 1896.



Actually, this is a good bill

The Senate is actually working on a good healthcare bill.  No, not the AHCA or the doppelganger of the AHCA.  The Chronic Act is winding its way through the committee process. This bill is full of little technical corrections to Medicare and tweaks for experiments.  Let’s look at what’s happening in it.

Section 101 expands a demonstration project that has good initial results.  The Independence at Home program is a pilot program that uses intensive primary care and care coordination to specifically target high risk and high cost Medicare beneficiaries for more intensive services.  Its initial evaluation found significant savings and quality improvements.  This section expands the time frame and the number of beneficiaries who can be enrolled in the study.  The goal, I think, is to see how this project can scale up and move it towards a national model.

Section 102 allows for some telehealth visits to be used to supervise/coordinate dialysis care.  This would be an option not a requirement. It should improve access and quality of life for people on dialysis who live far away from their nephrologists and clinics.  It might save a little bit of money as the telehealth visit would not be allowed to charge a facility fee.

Section 201 modifies how care coordination is managed for individuals who are dual enrolled in Mediare Advantage and Medicaid through the SNP program.  Care coordination meetings are mandated.  Rules are to be developed for a uniformed complaints and grievances process.  Eligibility is defined as either rare or costly.  There is a section that warms the cockles of my heart on statistically validity of quality measures relating to population size.

Section 301 is a Medicare Advantage benefit design waiver pilot program.  The concept of Value Based Insurance Design (VBID) is that patients should pay nothing for very high value care and a lot for low value care.  In this frame work, insulin and test strips should be no cost sharing to Type 1 diabetics.  Ten states would be allowed to experiment with benefit design.  The goal is to get people better while lowering costs.  I don’t know if this will work but it is a reasonable experiment.

Section 302 allows Medicare Advantage firms to apply for waivers to give non-medical benefits to chronically ill patients.  Again, I don’t know if this will bend the cost curve and improve outcomes but it is a reasonable thing to try.

Section 303 and 304 and 305  expands telehealth options for Medicare Advantage and Accountable Care Organizations (ACO), and stroke patients.  I like that telehealth is not being allowed to count towards network adequacy.  The trade-off will be if lower cost visits leads to more visits and more net costs with or without net patient benefit.

Section 401 allows ACO patients to be assigned prospectively.  This means the ACO could be chosen by beneficiaries at the start of the year. Attribution is a major challenge and source of technical risk.  Retrospective attribution means the ACO is responsible for a population that is only defined after the contract.  Prospective attribution allows an ACO to know its patient roster at the start of the contract.  This is weedy but useful.

Section 501 allows ACO’s to use member incentive programs for primary care and care coordination purposes.  This ties into the same general concept of Section 301 where Congress would like Medicare to make it easier for people to make good choices.

And then there are several sections authorizing the Government Accountability Office (GAO) to conduct studies on interesting questions regarding care coordination.

None of these sections are home runs.  There might be a bunt single and perhaps a well hit ball that falls in between the shortstop and the left fielder for a hit.  But this is what a decent healthcare focused bill can actually look like.  We should encourage this.

NB — we should also encourage a better name for the bill to avoid late night Taco Bell jokes.








Monday Morning Open Thread

Props to Google for reminding us that activism has a long tail!

What’s on the agenda as we buckle in for another week?
***********


.

Commentary for the time capsule — John Oliver’s always good, but this is particularly sharp:



On The Road

Good Morning All,

This weekday feature is for Balloon Juicers who are on the road, travelling, etc. and wish to share notes, links, pictures, stories, etc. from their escapades. As the US mainland begins the end of the Earth day as we measure it, many of us rise to read about our friends and their transient locales.

So, please, speak up and share some of your adventures, observations, and sights as you explore, no matter where you are. By concentrating travel updates here, it’s easier for all to keep up-to-date on the adventures of our fellow Commentariat. And it makes finding some travel tips or ideas from 6 months ago so much easier to find…

Have at ’em, and have a safe day of travels!

Should you have any pictures (tasteful, relevant, etc….) you can email them to picstopost@balloon-juice.com or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

Read more