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Wednesday, September 25, 2024

The ACA Achieved None of Its Goals

It's been more than ten years since the ACA was fully implemented, and by most measures it has failed. In the 2008 election and the later part of 2009, healthcare reform was a top issue. For much of the campaign, before the financial crisis hit in mid to late 2008, it was the top issue. Candidates Obama and Clinton sparred frequently on the topic. The documentary film Sicko, Michael Moore's follow-up to his enormously popular Bowling for Columbine, and not quite as popular Fahrenheit 9/11 investigated the health care industry from many angles and served as a foundation for much of the criticism of the industry and urgency for reform.

The goals of healthcare reform were numerous. The overarching goal was to reduce the number of uninsured in the U.S. Almost as important was to reduce costs and improve outcomes. Few people have looked back at the full slate of goals of the ACA or the projections that accompanied it. Mostly, policy wonks focus on the one goal for which it was relatively effective and ignore the rest. Looking at all of the dimensions, though, and how they progressed over the past fifteen years shows that the ACA didn't solve almost any of the problems that were the biggest discussion points before the legislation even existed, and it often didn't meet the expectations set for it after it was written.

Uninsured

The primary goal of the ACA was to reduce the number of Americans who didn't have insurance. In the run-up to the legislative effort, the number of uninsured was ubiquitous in the news. While that goal was based on numbers that were greatly misrepresented (70% of the new Medicaid enrollees were eligible prior to ACA and chose not to sign up, and another large subset were illegal immigrants), even the expected reduction was never achieved.

CBO estimated that, by 2019, the number of uninsured would fall by 31 million. In reality, it fell by less than 15 million, before accounting for population growth and the booming 2019 economy. The Urban institute estimated a reduction of around 28 million.

Behind the numbers, Medicaid was expected to grow by 16 million, but it actually added 20 million more beneficiaries. The exchanges were projected to insure an additional 23 million Americans. By 2019, only 11 million people enrolled in an exchange plan.

The largest miss, and the biggest failure of the ACA is that it completely decimated the existing non-group insurance option. Before the ACA, there were approximately 15-17 million enrolled in private plans. By 2019, the combined enrollment in ACA and non-ACA plans was just under 19 million, meaning that the exchanges and subsidies did not generate much net improvement in the insurance rate because most of the ACA gains came out of or at the expense of the existing private plans.

Premiums

It's a universally acknowledged miss that President Obama promised that the ACA would "bend the cost curve down." He specifically said that the ACA would lower premiums for families by $2500/year on multiple occasions.

In 2017, Forbes published an article already calling into question this result.

Using National Health Expenditure Data provided by CMS, one can verify that the Forbes article was correct. Increases in private per enrollee costs grew faster after the implementation of the ACA. Costs for "Other Direct Purchase" which includes off-exchange plans, rose 5.4% per year from 2001 to 2013, and 8.6% per year from 2013 to 2022, after the ACA was implemented. Marketplace plans, specifically, have increased, on average 5.3% per year.

While the ACA was supposed to make insurance more affordable, the costs of insurance rose faster after its implementation compared to before. Everyone doesn't incur those costs equally, however. People who are insured through Marketplace plans may be eligible for some level of subsidy, depending on their income, which reduces the costs to them of the increased premiums. Those millions who are not eligible are now much worse off than they were before the ACA.

Costs for Exchange Plans are higher than the private, non-exchange plans

Note also that studies were done in 2013 projecting, due to experience up to then, that premiums would save even more money. Few studies have been done since, but every indication is that this was just a temporary phenomenon.

Outcomes

The most widely discussed health outcome prior to the ACA was US life expectancy. The fact that Cuba had a higher life expectancy than the US was frequently used to claim that the Cuban health care system was superior to the US's. Remarkably, since the passage and implementation of the ACA, life expectancy has improved at a much slower rate than before passage.

src: Data Commons

In addition to life expectancy, a primary goal of healthcare reform was to reorient care towards prevention and reduce emergency visits. According to CDC, the ED visit rate was unchanged between 2009 and 2019.

Conclusion

A careful review of the main healthcare challenges that were being discussed in the run-up to 2010, the problems politicians and media said would be solved shows that for every one of them, the ACA failed to solve the problem. In one case--the insurance rate--it helped, but in every other dimension--affordability, outcomes, appropriate coverage--it failed. Maintaining a rich skepticism of government's proposed solutions and their expectations cannot be emphasized enough.

Assorted Links

Side Comment on Using AI Resources

I'm not optimistic about ChatGPT or its competitors. There's clearly an existing internet bias towards the left, because the left produces more content. Try a google news search on a topic where you know there's a good right-leaning argument. You probably won't find it.

— Chris Oldman (@ChrisOldman4) September 27, 2024

As a side note, multiple AI chatbots said that the ACA did better at providing insurance, but wouldn't give me any source.

In addition, multiple said premiums have risen more slowly after ACA. One pointed me to this study done in 2013, before full implementation, and based on a weird metric, this study that reports individual year results, not the trend after ACA or before.

Tuesday, August 15, 2023

The Great Endumbening

A More Nuanced Past

In the aftermath of the terrorist attacks on September 11th, President George W. Bush gave his historic Axis of Evil speech. In addition to the titular triumvirate, the other line from that speech that made a lasting impact was the proposition to other countries that "Either you are with us, or you are with the terrorists."

In the immediate reaction, the country so pro-America and standing behind the commander-in-chief, there was little consternation at this dichotomy, but as the months waned on, and a presidential election loomed, and President Bush used that line, among other things, to push for a war many thought was unrelated and a huge mistake, and to expand the security state at the expense of civil rights, people began to criticize that line.

The biggest criticism was over how it over-simplified the situation. That it's wrong, even if it's rhetorically effective, to paint the world as black and white. John Kerry, Bush's Democratic challenger, came to represent the opposite of Bush's simplistic world. Kerry was the candidate of thoughtfulness and nuance.

"During the last presidential campaign we were endlessly reminded that John Kerry was the standard bearer of the Nuance People, whereas President Bush was the intellectually incurious, black-and-whit, simplistic non-thinker who didn't appreciate life's shades of gray."

Etta Hulme 9/8/04. Fort Worth Star-Telegram

"Nuance is not a word Americans associate with strong leadership. But Kerry called it the essence of his presidency." --NBC News

In fact, it got to a point where George W. Bush was made into Darth Vader in the third and then-final Star Wars prequel.

The Endumbening

Sometime since then and now, however, nuance was thrown out the window, as even something to aspire to. Politicians have often resorted to the black and white-ification of public policy. Climate change policy is a battle between people who want to wreck the economy and those who want to eviscerate the environment. Journalists, though, and the Democratic media complex had promoted it, as an aspect of their push for technocratic rule. Experts, you see, understand policies have benefits and costs, and once they identify all of them, they would be able to govern perfectly.

If I had to pinpoint an exact moment when the zeitgeist changed, it would be when Donald Trump won the 2016 election. From then on, it seems like we are in an entirely different media environment. There is much less tendency to grant that the other side might have strong arguments or that their own arguments are weak, and much more tendency to vilify opponents.

How often does President Biden call every Republican that disagrees with him MAGA? Not to mention Kamala Harris claiming that Florida wanted to "replace history with lies", even though the instigating action by Florida was one that the AP had approved and Democrats (including Harris!) defended six months previously.

In the research for this story, this Slate article came up. In it, the authors gleefully observe that Bush painted himself into a corner with his over-simplistic, un-nuanced rhetoric. He then was in a position where he needed to make a more complicated argument but couldn't because he was trapped by his own one-dimensional world. Humorous in its supreme irony, advertised on this criticism of Bush for being unnuanced was a story about how DeSantis wanted to erase people.

Even in Supreme Court cases, the media consistently dumbs down the esoteric arguments to the point that they're more dissembling than informing. In a decision about whether or not business owners have the power to control their products (not their customers), the media calls that "legalizing discrimination."

Reaching another level is Matt Yglesias. He had the audacity to say that Richard Hanania, even if he was overall a bad person, had some interesting ideas that merited consideration. The left honed in on him.

It's fascinating that lefty Twitter has decided its archenemy is @mattyglesias. Just goes to show that @Atrios still has his mojo.

— Kevin Drum (@kdrum) August 8, 2023

Matt, here, is demonstrating a level of nuance that many on the left have heretofore abandoned. As a result, Matt must be destroyed. It's a particularly interesting episode, because Matt can be open-minded and inclusive but also impressively unforgiving of others who disagree with him, calling Peter Thiel, Marc Andreesen and Elon Musk "immoral."

What to make of all this? Previously, I argued that competition among media is bad for the country, and this is a manifestation of that. It is much easier to attract audience with simple themes of good and evil because people are primed for it. We observe that in fiction, history, and politics. People gravitate toward simple messages. Politicians ave been using it for as long as they needed to persuade people to vote for them. Fiction even longer. Media, though, have lately become more enthralled to it as a result of the increased competition for Americans' attention.

Friday, February 3, 2023

When Competition Goes Wrong

A recent paper provides a good example of how most people's view of competition, and the benefits it produces is slightly flawed. Understanding these examples helps ensure that competition is applied correctly. In the paper, researchers learn that as more health providers were allowed to prescribe treatment, more treatments, specifically opioids, were overprescribed to the point of harming patients. If you think about this for a moment, you realize it is because the competition between health providers was driving them to provide what consumers wanted--more opioid prescriptions. So, this is a case where competition is harmful, but it helps elucidate what competition actually does.

Many people think competition produces low costs, low prices, high quality goods and services and is unconditionally beneficial, but what competition actually does is push producers and sellers toward whatever the consumer desires. For most goods and services the desires of the consumer are beneficial to her and to society: high quality, low price cars, groceries, homes, computers, etc. In the case of opioids and other products that are beneficial in limited quantities yet are harmful in higher quantities, competitive forces benefit neither. This is due to the addictive nature of opioids. Consumers desire more than is good for them and so competition among providers results in what those consumers mistakenly desire.

Vehicle Inspections

This phenomenon is not limited to opioids. When I was in graduate school, I learned this concept from a fellow student whose Ph.D. thesis analyzed vehicle emissions inspections. He found that more inspectors led to more cheating. The reason was the same. While the inspectors were meant to be acting as agents of the state, their true customers were the vehicle owners. The vehicle owners' goals were not to have low emissions but to get a Pass from the inspector and so the more inspectors there were, the more they were driven to give consumers what they wanted to the detriment of state regulations.

News Media

The history of media consumption in the United States is an extremely illustrative example of this. From the advent of television until the 1990s, there were a handful of broadcasters vying for ratings. Up until the expansion brought on by cable, they fought with each other to appeal to the broadest possible audience. This focus on the highest possible rating coupled with journalists' ideology led to a slightly left-of-center framing of news.

Seeing an opportunity to provide audiences, particularly conservative audiences, with less available news and opinion, Fox News was created and quickly attracted a huge contingent of conservatives across the country. This led to the creation of its doppelganger MSNBC which appealed to liberal audiences. Then, the internet ushered in the further fracturing of the media landscape and ever more gradations of content to satisfy extremists and moderates of both sides (though notably, nothing to appeal to people who want objective journalism). Competition between news media companies has thus created a spectrum of information providers that reflect the biases, particularly confirmation bias, and whims of the entire electorate.

Artificial Intelligence

The next battlefield over which competition may eventually do us in is AI. Several companies have been working on AI for several years, but have been reluctant to offer AI-based services to consumers. Now, with Microsoft purchasing Chat GPT, which is already offered to the public, and also planning to integrate it into its offerings, other companies will feel the pressure to do the same. This will certainly kick off a zealous competition between these companies to further the capabilities of AI in an effort to provide their customers with an amazing product for a low price, meaning an ever-more advanced artificial intelligence that could potentially rival or surpass our own.

Many have pointed out the risks of AI advancement, but for the past ten years, development has been slow and of low concern. Now that companies have entered a new era of competition to provide it to consumers, though, growth will take off. Hopefully, not to our ruin.

Monday, November 7, 2022

Trump's Kryptonite

Main Takeaways:

• Free media is Trump's superpower
• Stop sharing the non-substantive things he says!
• Continuing to serve as Trump's conduit is evidence you want him to win

Over the decades, politics and entertainment have become harder and harder to disentangle. Since the 1930s, presidents have gradually adopted more and more of a celebrity personality. This culminated in a celebrity-president that had mastered the shock jock-driven nature of social media. A significant reason that Trump was elected and remained relatively popular with his base throughout the years was his penchant for making outrageous claims that won him free media attention. These statements impassioned both his biggest critics in the media and his strongest proponents in the electorate.

Everyone in America wanted to know what Trump was saying. They wanted to hate him for being offensive, racist, sexist, bigoted, crazy or they wanted to love him for poking the bear, being funny, saying things they were thinking. And because the public wanted to know, the media wanted to get in on that action (not to mention many in the media were also outraged and hoped to spread their own distaste).

Most people now recognize that the media erred by providing so much free press to Trump back in 2016. At the time, there were many reasons they did this, not just to cash in on the public's demand for all things Trump, and to tell the world how crazy he was, but also because they were convinced he would lose. All gain, no loss. But then he did the unthinkable.

Even while he was President, he would issue tweets that would dominate the news cycle for the day. They were very rarely substantive tweets; most of the time, they were only meant to be provocative. Provoke they did. As someone who wasn't on Twitter at the time, I could look at these controversies in a more detached way. I think there is much more detachment that is needed today, especially from the media.

This is why I want to propose that all journalists take a vow to no longer support Trump as they have in the past. I'm sure they believe they're doing their jobs by reporting on the things Trump says everyday, and to some extent, that's true. That's definitely not the only motivation though, and it's not the only effect. In fact, their reporting is probably counter-productive. The more they try to prove to Trump's supporters (and even to those on the fence) that Trump is bad, the more they solidify his support.

To really hurt Trump, what they need to do is stop playing his game. Stop sharing video of him doing crazy things. Suppress the urge to retweet and quote retweet.

Obviously journalists still need to report the news, so I suggest the following: think of Trump as two people--the shock jock provocateur and a politician running for office. If the politician says something important and substantive, report on that. If he calls a fellow Republican by a nickname, don't report on that. Don't even comment on it. It's really not important.

Every journalist should take this vow: I promise not to promulgate non-substantive stories pertaining to Donald Trump. If I encounter a tweet from him or others or an article about an outrageous claim he made, I will move on without comment. I will also criticize anyone who purports to be anti-Trump who does provide him with free coverage.

Many, many people both in the media and outside of it claim that they don't want Trump to ever be president again, that it is a danger to the country. It's time for them to start going beyond just saying so. It's time for them to start behaving that way as well. To me, the best way to prevent this eventuality is to use the one thing that saps his power: apathy. We must assume that anyone who continues to repeat Trump's comments wants him to win.

Wednesday, October 19, 2022

The Beat Beat Beat of the Abortion-Media Machine

Alexandra DeSanctis of National Review already beat me to writing a run-down of the media's obfuscation machine. In it, she provides an extensive list of media outlets who claim one way or another that there's no such thing as a fetal heartbeat. Readers should take care to mentally organize the different tacks media outlets take on this. Some claim that "fetal heartbeat" is a misnomer, because at 6 weeks, it's technically still an embryo, not a fetus. Others claim it's wrong because the activity taking place in the embryo, the pumping of blood, isn't making a sound. Finally, some claim that the heartbeat shouldn't matter either because it's not a "true" heart, with four chambers operating completely independently of the mother or even that there's no cardiac activity at all.1

What Stacey Abrams said was in line with the second grouping of claims--that the ultrasound machine is making the sound, not the embryonic heart.

Note that this entire controversy is 95% driven by political sides playing word games. Republicans chose "heartbeat" for a reason--it's salient, understandable, and persuasive. For that exact same reason, Democrats hate the term and will do everything in their power to prevent its use--focus on the sound aspect of the heartbeat, argue it's not a "fetal" heartbeat, argue it's not a "heart", all of the above. "Heartbeat" has enough ambiguity to allow for pedantic arguments.

The Facts of Life

Sources:

• "Fetal cardiac function during the first trimester of pregnancy." Journal of Prenatal Medicine
  • "The heart rate increases between the 5th week of gestation and 9th week of gestatio
  • "Cardiovascular development in a human embryo occurs between 3 and 6 weeks after ovulation."
  • "Cardiac function is the first sign of independent cardiac activity that can be explored with non-invasive techniques such as Doppler ultrasound."
  • "At the end of the 4th week of gestation, the heartbeats of the embryo begin."
  • "The heart, whose development starts at the 3rd week of gestation has rapid and irregular contractions capable of pumping the blood inside vessels."
• whattoexpect.com (which cites American College of Obstetricians and Gynecologists, British Medical Journal, Johns Hopkins, etc.)
  • "By week 5 of pregnancy, the cluster of cells that will become your baby's heart has begun to develop or pulse. If you have a first trimester ultrasound (around or after week 6 of pregnancy), your practitioner or a trained sonographer will check on this embryonic cardiac activity."
  • "You may see (and/or hear) cardiac activity for the first time from week 6 of pregnancy or later"
  • "By 6 weeks, the embryonic heart cells will pulse about 110 times a minute."
• Even Planned Parenthood said there was a fetal heartbeat, at least it did prior to Abrams's pronouncement.
• Here's a rundown of further scientific sources.

Twitter Facts

Given all of this information, why did Twitter decide to side with Abrams?

Well, Twitter cites NPR and NBC news. In the NPR piece, the author cites an OB-GYN who "specializes in abortion care" and an OB-GYN who is an associate professar at UC-San Francisco. The former should probably be ignored given there is no pro-life specialist provided to provide balance. She claims that it is electrical activity that can be seen in the ultrasound and the sound itself is created by the ultrasound machine. The other specialist concurs. "In no way is this detecting a functional cardiovascular system or a functional heart." It goes on to say that "fetal heartbeat" is just short-hand and shouldn't be taken literally. It seems that the reporter did not ask why physicians would even bother referring to sounds the ultrasound machine makes instead of saying the parents aren't really hearing anything of note.

In the NBC news fact-check, the expert it cites says that at six weeks, the embryo develops a tube that generates sporadic electric pulses which is "far from a fully formed heart." Note here that they are throwing out the "this isn't a fully-formed heart", which is a claim that no one is making. This is the journalist's addition, as it's not in quotes and is meant to shift, either deliberately or conveniently, the terms of the debate away from "Is there a heart beat?" to "Is there a fully formed heart in a 6-week embryo?" A second expert says that it's accurate to say there's "cardiac activity." Finally, a third expert comes in to say that the heartbeat that is heard during an ultrasound is just "an electrical pulse", seemingly confirming what NPR said. But, in fact, this is the same person NPR cited, so it's not confirmation at all.

In neither article did the author report on seemingly significant questions to this entire debate: "Is blood circulating? Is the heart pumping? In what ways is the embryonic heart at six weeks functioning like a baby's heart?" These questions get to the heart of the issue at hand, is the developing baby's heart functioning as a normal heart. Whether it's fully formed or not doesn't matter, whether this is the exact same source of sound that we hear as an adult's heartbeat doesn't matter. What matters is whether the sound significant biologically.

Given the missing questions, the similarities in the fact-checks, and even citing the same person, both articles don't seem particularly objective or thorough, yet Twitter relied on them to support a political claim. In addition, neither of those fact-checks indicated that the author's reached out to others with a different opinion or verified that the sounds heard in ultrasound were generated by the machine.

This isn't a slam-dunk 'they were wrong' case, but it's indicative of a real problem being caused by today's news media complex, social media and their ties. Journalists and social media workforces are dominated by left-leaning individuals. Ideally, they would keep their opinions in check, separate from their work and would provide objective analysis and moderation, but I think we all understand that the world isn't ideal and that their positions bleed through their work leading to biased outcomes. Unfortunately, these biases when combined compound causing even larger biases. Imagine a case where a biased reporter gets a fact-check wrong, and then social media moderators who, because they are biased, are more aware of that fact-check and the issue itself and unaware of legitimate, contradictory information, applies that fact-check to suppress contradictory, yet correct information. This propagates the misinformation even further.

1The Atlantic article cited is quite something. It's clearly written by a pro-abortion absolutist. It contains 5 factual errors, including the one DeSanctis notes about whether there's any cardiac activity at all at 6 weeks. It also contains gems such as "Ultrasound made it possible for the male doctor to evaluate the fetus without female interference" and "The origins of fetal ultrasound lie in stealth warfare." Both of which are true statements, but are such narrow interpretations of the facts and are meant to imply something nefarious. Does anyone believe ultrasound was developed in any way so male doctors could exert more control over women or fetuses?