Andrew Sullivan's Blog, page 228

Bad Omens For Obamacare

Many small ones have popped up recently. First up, Adrianna McIntyre explains why ACA enrollees might have to switch plans next year:

The federal subsidies used to offset the cost of insurance are based on income, but they’re also pegged to the second-cheapest silver plan on each state exchange, which is called the “benchmark plan.” When people choose something cheaper than the benchmark plan (the cheapest silver plan, or one of the bronze plans), they will spend less money out of their own pocket on the insurance premium. If a person chooses a plan that’s more expensive than the benchmark plan, he’s responsible for the extra cost.

But annual changes to insurance premiums aren’t uniform across plans. That means the “benchmark plan” can change from year to year — with financial consequences for those with subsidies. These consequences will be most acutely felt by low-income enrollees.

Speaking of subsidies, Sarah Kliff wonders how states will pay for the upkeep of their exchanges when the federal money runs out next year:

The Affordable Care Act provided federal grant funding for states to get their new web portals up and running.  The Obama administration doled out $4.6 billion in grants to states launching their own marketplaces. But Obamacare also requires state exchanges to become self-sustaining by the start of 2015. That means every state exchange that will operate next year now needs to figure out how to pay their bills. …

“There won’t be any big pot of federal money,” says Elizabeth Carpenter, a director at health research firm Avalere. “When you think about being able to run an exchange without the federal backstop, it will take awhile to forecast and figure out what money is needed.”

Next, Adrianna McIntyre warns that the next ACA open enrollment period is at the worst time of year:

Open enrollment for 2015 will last from November through February. The Obama administration probably picked late fall for open enrollment because that is when Medicare and most employers permit insurance enrollment changes. But between Thanksgiving and Christmas, late fall is also incredibly stressful, both financially and emotionally.

According to a new study in Health Affairs, people’s capacity for decision-making is stretched especially thin during the lead up to the holiday season. And when people are stressed, behavioral economists have found that decision-making is done with a sort of tunnel vision: people focus only on their most pressing short-term problems, sidelining long-term issues.

Suderman digs into another new study, from Kaiser, that “suggest[s] the potential limitations of Obamacare’s coverage scheme”:

It’s not a precise instrument: More than 40 percent of exchange enrollees were already insured, suggesting that while Obamacare is expanding coverage to the uninsured, it’s also resulting in a fair amount of subsidized coverage going to people who already had coverage (the vast majority of exchange beneficiaries got subsidies). Digging a bit deeper into the survey also hints at the difficulty in measuring who, exactly, counts as previously uninsured. If someone had health insurance up until a month prior to getting new coverage under the law, should that person count as uninsured? Probably not. What about six months before? Or a year before? These questions are legitimately difficult to answer.

Kaiser’s survey finds that the majority of previously uninsured lacked coverage for two years, and that 45 percent reported not having coverage for five years. Which means that more than half of the previously uninsured were covered at some relatively recent point.

Jason Millman looks at other surveys that don’t bode well for Obamacare:

Just how much will people buying their own coverage shop around for a better deal on health insurance year-to-year? By creating a marketplace where plans have to compete for business under the same rules, Obamacare is supposed to facilitate the shopping experience. Some recent studies throw cold water on that idea, though.

Just 13 percent of seniors enrolled in Medicare’s prescription drug program changed plans during the annual enrollment period, according to an October 2013 Kaiser Family Foundation survey that reviewed the first five years of program enrollment. Those facing the highest premium increases were the most likely to switch plans — anywhere between two and four times of the average rate of all enrollees who switched plans. Still more than two-thirds of enrollees who faced the highest premium increases stuck with their plans.

And last but not least, Lanhee Chen argues that “data published in the Wall Street Journal suggest that [the possibility of an ACA death spiral] may not be so far-fetched after all”:

At its base, the data show that people insured through the law’s exchanges have higher rates of serious medical conditions. Of the enrollees who have seen a doctor or other health-care provider in the first quarter of this year, 27 percent have significant medical problems, including diabetes, cancer, heart trouble and psychiatric conditions. That rate is substantially higher than that for patients in nonexchange market plans over the same period. And it’s more than double the rate of those who were able to hold onto their existing individual market insurance plans after President Barack Obama was forced to allow them to keep them.

This outcome should not surprise anyone. The law’s one-size-fits-all regulatory regime, which requires insurers to offer coverage to all comers and prohibits pricing of coverage based on an applicant’s health status, was bound to increase the number of relatively sicker people purchasing insurance through the exchanges. Moreover, Obama’s executive action, which effectively allowed many people who had individual market plans to remain in them through at least 2016, bifurcated the insurance markets such that healthier people remained in the plans they already had, while relatively sicker patients were left to acquire coverage through the Affordable Care Act’s exchanges.

Some of the bad risk in the exchanges has been offset by the enrollment of relatively healthy people who acquired coverage because of the law’s generous subsidies. Yet the numbers make clear that the exchanges remain a haven for those who may consume more medical services than others.

The Best Of The Dish This Weekend

I’d start with this hoop video and this sublime Michigan window view.

Breaking news: Neanderthal poop suggests some early veg with their meat; casual sex is one of the most joyful things in life if you are not conflicted about it; and it’s even better if you keep your socks on.

Things to make you nostalgic: Bill Buckley going off on Ayn Rand; and Edmund White’s account of the Stonewall Riots in a letter written just a couple weeks after.

Things to make you go hmmmm: what a cocktail looks like under a microscope; and what a parasite in your body’s face looks like too. The poetry of John Clare, while in a lunatic asylum. And don’t worry about death; everyone who’s been there briefly and back says it’s lovely.

The most popular post of the weekend was Jesus vs John Galt; followed by Dudes With Beards Eating Cupcakes.

Many of this weekend’s posts were updated with your emails – read them all here.  You can always leave your unfiltered comments at our Facebook page and @sullydish. 16 more readers became subscribers this weekend. You can join them here - and get access to all the readons and Deep Dish - for a little as $1.99 month.

See you in the morning.

(Photo: Stuart Milne of Clan Ranald holds a buzzard raptor bird at a display during the Bannockburn Live festivities on June 28, 2014 in Stirling, Scotland. It was the 700th anniversary of the historic battle that saw the outnumbered Scots conquer the English led by Edward II in the First War of Scottish Independence. By Jeremy Sutton-Hibbert/Getty Images.)

Book Club: A Conversation With Alexandra And Maria, Ctd

In our latest audio sample, the two women discuss the email from the reader on the autism spectrum who senses too much of the world around her:

You can listen to the entire conversation from Alexandra and Maria below. Follow the whole book club discussion here, and email your thoughts and observations to bookclub@andrewsullivan.com. One reader writes:

I just finished the wonderful read of Alexandra Horowitz’s On Looking. Thanks for such a great selection and I’ve already bought many copies for family and friends.

So I paged through the chapter Sources and on the last page of Acknowledgements, Ms. Horowitz mentions her editor, Colin Harrison. She states that he has many theories about the gummed up spots on the sidewalk. Unless she plans to write the sequel of the Gummed Up Spots on the Sidewalks – will Mr. Harrison share his gummed up theories with The Dish Book Club? I’m dying to know. Living downtown Chicago, I look for Wrigley’s gum falling out of pedestrian mouths every hour and never see it happening. I look for pedestrians with sticky gum strands sticking to shoes while walking and never see it happening.  What are these gummy blobs all over our city sidewalks? I love a good conspiracy theory …

Another:

As a photographer –  someone who “looks” professionally – I’d actually downloaded the book before it became a book club choice, but I couldn’t get through it.

It’s mostly just a collection of different people observing different objects, people, sounds and smells (do sounds and smells even count in a book about “looking”?) – yes, there are a lots of objects, people, sounds and smells in the world, and no, they’re not always interesting. It seemed to me that most of the experts in the book were looking at stuff in a similar way; they just happen to be looking at different stuff.

Why wasn’t a photographer included? You can’t get more of a “professional observer” than that. As I’ve learned my craft, I realise that learning photography has very little to do with mastering all the knobs and dials on your DSLR and everything to do with learning to look, really look, and get beyond the endless collections of different objects and people. My love of photography is in direct proportion to how much I am learning to look, really look, by practising it.

To observe how the light falls on the side of someone’s face or on the pews of a church; to see interesting textural juxtapositions or beautiful colour palettes; to notice the fleeting stories conveyed in a look or a gesture or an old piece of furniture; to see the pleasing bend in the road, the interesting compositions created by unrelated shapes and colours, or the interplay of light and shadow through the trees. It’s a totally other way of looking, so very different from being yet another observational collector of stuff and facts, and it seemed a pity that this perspective wasn’t included at all.

Malkin Award Nominee

“Did America owe something to the slaves whose labor had been stolen? I think so, but that debt is best discharged through memory, because the slaves are dead and their descendants are better off as a consequence of their ancestors being hauled from Africa to America,” – Dinesh D’Souza.

A Shocking Number Of Refugees

According to a recent report from the UN Refugee Agency, December was the first time since World War II that the number of displaced people climbed over 50 million:

The sharp increase in the total number of refugees was in large part the result of the ongoing Syrian civil war, which has forced 2.5 million to flee the country and resulted in 6.5 million internally displaced people. In total, there were some 51.2 million refugees in the world at the end of 2013, an increase of more than six million on the previous year. On its own, the figure 51.2 million can be somewhat difficult to conceptualize, a figure so large that it’s difficult to imagine the human toll of conflict.

Will Freeman delves into the report, which shows how Iraq is driving the number up even further:

In just over a week, refugees fleeing insurgents battling to create an Islamic state in Iraq have tripled from 500,000 to 1.5 million. The swift takeover of towns such as Mosul and Tikrit by the Iraq Islamic State in Iraq and Greater Syria (ISIS), also known as the Islamic State in Iraq and the Levant (ISIL), has displaced nearly 1 in 30 Iraqis. UNICEF, the United Nation’s children’s agency, recently upgraded the crisis to a level 3 humanitarian disaster— its most severe ranking. … The future is grim for Iraq’s latest wave of displaced people, as only 31 percent of the United Nation’s funding requests have been met. With terrorists continuing to fight their way towards Baghdad, the number of refugees will likely continue to rise.

To make matters worse, the record number of refugees are experiencing brutal temperatures:

Temperatures have indeed been much hotter than average in the Middle East this year. According to the US National Oceanic and Atmospheric Administration, just about the entire region was classified as “Much Warmer Than Average” for the March-May period, while much of Iraq and bits of Syria saw record-high temperatures.

Image:  NOAA

In line with global warming’s habit of punishing the most vulnerable populations, other refugee-laden regions saw record heat too, such as the conflict-stressed area near the Golden Triangle, an opium-producing hotbed. Thailand’s border is riddled with refugee camps, where Burmese have sought shelter for decades, after fleeing the violently oppressive ruling junta.

I’ve been to one of those camps, and it was an abject, malarial place. Tens of thousands of people were cramped together in mud-pocked makeshift housing, with limited access to medical treatment, and totally exposed to the elements. Like the heat.

There are 16.7 million refugees in such situations, and 35 million more are displaced. And both trends, displaced people and rising temperatures, are only on track to worsen.

Previous Dish on the Iraqi refugee crisis here and here.

A Papered-Over Problem

Umbra Fisk looks into the limits of recycling:

Paper can indeed be recycled only a finite number of times before its fibers get too short and frayed to be recovered. And according to the EPA, that magic number is about five to seven trips through the paper mill. That means we must always turn to some amount of brand-new pulp – called virgin pulp in the biz – to fulfill our needs. According to estimates from a nonprofit and a paper industry group, if we tried to make all paper from 100-percent recycled content starting now, we’d run out of materials in just a few months.

(Video: Inside a paper recycling plant)

When The End Is Near

Helen Thomson examines research on near-death experiences:

Steven Laureys, a neuroscientist at the University of Liège in Belgium who works with people in comas and vegetative states, started to investigate after his patients told him of their own near-death experiences. “I kept hearing these incredible stories in my consultations,” he says. “Knowing how abnormal brain activity is during a cardiac arrest or trauma, it was impressive how rich these memories were. It was very intriguing.” …

His team looked at 190 documented events that resulted from traumas including cardiac arrest, drowning, head injury and high anxiety. Using statistical analysis and a measurement called the Greyson scale to assess the number and intensity of different features of the near-death experiences, the team discovered that surprisingly, the reports shared many similarities.

The most common feature was an overwhelming feeling of peacefulness. The next most common was an out-of-body experience. And many people felt a change in their perception of how time was passing. There were only a few examples of negative experiences. “It turns out to be not so bad to have a dying experience,” says Laureys. Having a life flashback or a vision of the future – the kinds of things often depicted in Hollywood movies – were only reported by a small minority of people.

Previous Dish on NDEs here and here.

By Almighty Amazon

A very 21st century swearing in; @AmbSuzi becomes the 1st U.S. Ambassador to take the oath over an electronic device. http://t.co/5E4bjIRQ2x—
U.S. Embassy London (@USAinUK) June 02, 2014

Earlier this month Suzi LeVine, the new American Ambassador to Switzerland and Liechtenstein, took the oath of office with her left hand on a Kindle “opened” to the 19th amendment of the U.S. Constitution. The episode prompted Hannah Rosefield to look back at where the tradition of using texts, especially the Bible, in such ceremonies began:

The earliest Western use of oath books in a legal setting dates to ninth-century England when, in the absence of a structured royal government, certain transactions were conducted at the altar, the participants swearing on a gospel book. Three centuries later, English courts adopted the practice, requiring jury members and individuals in particular trials to take an oath on the Bible. An unnamed thirteenth-century Latin manuscript, now held in the library of Trinity College, Cambridge, sets out the method and the significance of the act. By placing a hand on the book and then kissing it, the oath-taker is acknowledging that, should he lie under oath, neither the words in the Bible nor his good deeds nor his prayers will bring him any earthly or spiritual profit. In time, this became standard legal procedure—all witnesses swearing to tell the truth, the whole truth, and nothing but the truth—and made its way into American courts. British witnesses today still take their oaths “by Almighty God,” as American oath-takers conclude theirs with “so help me God.”

The View From Your Window

Jerusalem, Israel, 1 pm

Our Father Issues In Heaven

Robert Hunt takes aim at Mary Eberstadt’s contention in her recent book, How the West Really Lost God, that the breakdown of the conventional family has led to secularization, offering an alternative account of the institution’s ambiguous place in the Christian tradition:

It is hardly surprising that the biological family is a key assumption of both Jewish and Christian scripture. Yet scripture also understands that the family can also be a broken and even oppressive institution. The most memorable families in the Bible are the most dysfunctional. Indeed, with the exception of Ruth and Boaz all the families in the Bible are dysfunctional. Even Jesus was raised by his stepfather.

It is precisely in God’s care of the widow, the orphan, the childless, the outcast, the adulterer, the prostitute, and even the murderer that God’s full nature as lover and redeemer of the world are revealed.

Thus it is these for whom care is demanded by scriptural ethics, and these are among the first gathered into the family of those who call God father and Christ brother. Only God’s love for all these broken and incomplete families rescues the common trinitarian symbolism from itself being exclusive and oppressive. It isn’t the family that brings (or pace Eberstadt fails to bring) these refugees from the family to God, it is God that makes family a possibility even for them.

The root of this failure in Eberstadt’s analysis may be that she does not consider the role of fictive kinship and its importance in the formation of the early Christian community. Her promotion of the specifically biological family as fundamental to healthy Christianity leads her to ignore the ways that Christians have understood what Jesus means by “being born again by water and the Spirit.” And so she also fails to consider alternative families that are so central to Christian history, and particularly Catholic and Orthodox history. Convents and monasteries, and even though she doesn’t see it, brotherhoods like her oft mentioned Opus Dei are surely as critical to the church as the biological family unit, something which even a sociologist can see and any historian should note.

Previous Dish on Eberstadt’s book here.