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 or just use this nifty link to start an email: Start an Email to send a Picture to Post on Balloon Juice

Read more

Open Thread: More Global Adventures with the Trump Crime Cartel

They look like any other bunch of rich kleptocrats on parade. Remember when the Repubs thought Secretary of State HR Clinton’s official trips were embarrassing-bordering-on-treasonous?

Caption Contest

This has been all over Twitter today. It’s for those of us who don’t know anything about CUPS in dogs.

I spent a good part of the afternoon at the New Mexico History Museum’s new exhibit on the 1960s counterculture in New Mexico. It was so-so.

But this does look like something out of an acid trip.

CUPS Disease in Dogs

Do any of you have any experience with CUPS? My friend’s dog is in really bad shape and they are at their wits end.

WordPress Update In a Few Minutes

Just a (hopefully!) quick update to the core WordPress install.

I’m hitting the sack after doing it, so I won’t be in the comments; feel free to suggest site tweaks or what-have-you as I will be planning a lot of that this coming week.

‘night all!

Oh – Open Thread!

Open Thread: We’ll Always Have Paris Snark

Absolutely *not* fleeing the Titanic, per fellow WH cronies:

The decision for Priebus to return to the US was pre-planned, not spur-of-the-moment, White House spokeswoman Sarah Huckabee Sanders and a second Trump adviser said.

“He was planning to come for the first stop and then head back for the budget roll out,” Sanders said.

The chaotic nature of this White House has prevented Trump’s team from doing much strategic planning, the second Trump adviser said. Leaving the trip early would give Priebus time to plan for the President’s return, the adviser said.

Some major issues are awaiting Trump back home, including the possible hiring of outside legal counsel in the Russia probe, the selection of a new FBI director, and the effort to pivot back to the President’s domestic agenda…

Yeah, like that’s any different than when Priebus was on the plane.

Reince’s job is to (try to) ram the oligarchs’ agenda through Congress, voters be damned. Trump’s agenda is to loot everything not nailed down, or that his thieving spawn can pry loose. No point in the GOP’s hand-chosen ‘Chief of Staff’ trying to keep them in line, as the Saudi portion of the trip has made abundantly clear.

We can write letters too

Write a letter to Senator Hatch at and give him your interested stakeholder input. For some of us, your interest is your life. For all of us, it is the type of society we want to live in.

Open Thread: Just Desserts

A compost creme pie right inna kisser, and who’s done more to deserve it?

Human Auto-Tune’s Vapid Pitch

Low hanging synergy-fruit Ivanka Trump brought her women’s empowerment corporate cliché roadshow and shakedown fest to Saudi Arabia along with her embarrassing father. Unsurprisingly, real-life activists who are resisting the nightmarish autocracy in Saudi Arabia weren’t buying what the auto-tuned Trump was selling. Via WaPo:

“All the women that Ivanka Trump met have a guardian,” said Aziza al-Yousef, a 58-year-old activist here who has campaigned to abolish the guardianship rules [i.e., necessity of obtaining male permission for work, education, travel, healthcare, etc.]. A retired professor of computer science at King Saud University, she was recently rebuffed when she tried to deliver a 14,700-signature petition on eliminating the guardian system to the government.

“All these achievements depend on whether you’re lucky to be born in a family where your guardian will be understanding, will help you,” Yousef said. “If Ivanka is interested in women empowerment and human rights, she should see activists, and not just officials.”

“It’s not about Ivanka speaking at the meeting,” said activist Loujain al-Hathloul, “but is it actually useful for these women from Saudi Arabia to speak as well? Is their contribution in such events helpful to us Saudi women in general, not princesses or business owners or rich women? Does it actually help us? I doubt it.”

I hear you, Saudi sisters. The ambulatory teeth whitening strip’s* patter about women’s empowerment rings a bit hollow in the States too. Particularly when she holds herself up as an example of how pluck and determination drive entrepreneurial success.

Pffft. It would be a lot easier to watch these entitled pricks monetize the U.S. government if they didn’t expect us to pretend that they’re doing us all a favor.

PS: Help the sweet old lost dog pictured below find his way home — details here!

And open thread!

* H/T: Sam Bee

UPDATED: Fancy Grub + Lost Dog (Open Thread)

Had breakfast at a place we’ve wanted to try forever, but it was always too crowded until today. I had the shrimp and grits:

So good! The shrimp were on the shrimpy side but fresh, well-seasoned and not overdone. They’d cut the grits up into wedges and fried them as if they were polenta (which grits are a cousin of, I suppose). Never seen anyone treat grits that way, but it was GOOD!

Then we went walking in the woods until it got too hot. On the way home now. What are y’all up to today?

Open thread!

UPDATE: Faithful reader “bl” has found an old dog that needs to be reunited with its owner. Here’s his message:

I have a lost dog that I am trying to get home… I live in the Maryland suburbs of DC, and have notified the county animal shelter and posted on various lost and found pet sites, but no response.

The dog is an old black lab mix that only had a invisible fence collar and no tags. I took the dog to the vet and he is not microchipped.

He is very stiff and doesnt walk well so I thought his owner would be easy to find since he must live close by, but so far no luck. I tried to walk him around the neighborhood but we couldn’t get very far.

I travel for my job every week and leave Tuesday morning. I need to do something with him, at least while I am gone, by Monday evening. I am hoping someone in the DC area has a contact with a rescue group that I can work with.

He is very good with people and dogs, but not cats. I have a call into one local rescue group, but they havent gotten back to me.

Thanks for any help.

Anyone have ideas on how to help this dog?

UPDATE II: Here’s a photo:

He looks like a sweet fellow.

Sunday Morning Garden Chat: “What Were We Thinking?!?”

Beloved gardening regular & photography whiz Marvel:

Here in the Willamette Valley, we’ve had a very wet, very cool (not in the good way) Spring. This week and next finally, FINALLY, are delivering warm sunny days. Suddenly, it’s OMG WE’LL NEVER CATCH UP time.

Lucky dogs that we are, with the possible exception of a newish (4-year-old?) tree peony [at top] that still takes a fair amount of coddling, the ornamental portion of the grounds hereabouts is well-established and, except for seemingly endless cycles (starting NOW) of beating down weeds & bugs, we’re free to enjoy the stunning color & grace of the perennials we haven’t yet killed. Out front, an agreeable assortment of rhodies & azaleas give eye-catching spots of color to even the most
mundane surroundings.

Out back, there also are pockets of Spring color that deliver the goods with little or no encouragemt from us, including a swath of iris (some of which are just lovely natturalized Japanese purples, the
others are a ‘gene farm’ from a friend’s garden — we grow cuttings from her favorites in case her long-listed house finally sells) andferns (etc.), tucked here & there.

Elsewhere, we’re breaking our butts to encourage another year’s supply of garden goodies, f’rinstance: today started out overcast so we decided to wrestle with Area 51, getting it ready for the 110+ corn starts that have been growing in the greenhouse these last few weeks. My partner roto-tilled while I watched & worried, then I worked a bunch of compost into the fluffy soil and set up irrigation. We
brought the lovelies out for their first taste of Oregon sunshine and called it a day.

Every year we remind ourselves that Panic & Desperation always overtake us at the beginning of our gardening season. We repeat our mantras (e.g., “It’s not an infinite number of weeds, just a whale of a lot…it’s not an infinite number of weeds….”) and try to remember that some people pay good money to get this much stretching & lifting exercise in…and we trust that in a month or two, all this work will slack off and we’ll start plucking sweet fresh fruit & veggies from the dirt out there.

Meanwhile, we’ve commenced our late afternoon practice: a lovely glass of wine with an ibuprofen chaser.

Around our house, the vibrant unkillable purple species irises are called ‘Auburndales’, because that’s the town where I first dug up a no-longer-flowering overcrowded patch beside the house we were renting, and put the leftover rhizomes into a plastic planter that moved with us when we finally bought this place.

Since we’re very much hobby (lazy) gardeners, we spent Saturday at our favorite garden center, picking out annuals and replacement planters and a couple more bags of mulch. (Every weekend between now and August will involve at least one trip to purchase mulch or potting soil or both.) Today I’ll be transferring those annuals into the planters, and hopefully finding enough daylight to spread the new mulch before Monday’s predicted downpours…

What’s going on in your gardens this week?

Donald of Arabia: A Photo Album


(Nice cup of tea, but no accompanying large bowl of individually-wrapped pharmaceuticals)


(Edgar suit, Men in Black)

Conjure your own images:

We Have Ignition!

Despite Adam’s attempts to jinx me, I picked up the car this afternoon and there were no problems. Pretty seamless all the way around. The Subaru broke down Wednesday, they called me and gave me the details on the repair costs and likelihood of success, Thursday morning, that afternoon I went and test drove it, put down the down payment Friday, and picked it up today. I’d spent the last couple months researching CRV’s and Lexuses, so when the CRV was available in that shapoe and with that mileage, it was a no brainer.

Mom took me down to pick it up, and afterwards I treated her to lunch at Avenue Eats in Wheeling (I think David Anderson went there once on my recommendation), and while there took some pictures for my sister which I will now share with you:

This is the first car I have ever had with bluetooth (I had to play itunes through one of those shit fm transmitters in the Subaru), and the CRV has this nice seven speaker system and sounds great, so that is a real plus. Mileage is really good and it rides well, and I don’t miss the HP the Subaru