YetanotherObamacareincentiveprogramcrashesandburns

Yet another Obamacare incentive program crashes and burns

posted at 11:21 am on August 8, 2014 by Noah Rothman

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It seems as though yet another of Obamacare’s many “nudging” efforts, aimed at creating incentives for the population to behave in ways deemed by technocrats to be of maximum public benefit, has failed dismally.

The Hospital value-based purchasing program (HVBP), established by the Affordable Care Act, was designed to link the payments hospitals received with the quality of care they provided.

“CMS took back 1.25 percent of Medicare reimbursement at hospitals paid under the IPPS in fiscal year 2014,” a report in Becker’s Hospital Review read. “The resulting $1.1 billion was dispersed to hospitals based on how well they performed on healthcare quality measures, like treatment of heart attack and congestive heart failure, as well as patient satisfaction.”

In fiscal year 2014, 778 hospitals lost more than 0.2 percent of their Medicare pay, while 630 hospitals received a bonus of more than 0.2 percent.

For 2015, CMS is increasing the applicable percent reduction, the portion of Medicare payments available to fund the value-based incentive payments under the program, to 1.5 percent of Medicare reimbursements, resulting in about $1.4 billion in value-based incentives.

In short, the program was designed to “nudge” those hospitals deemed to be underperforming to increase the standards of the care they provided. However, a report in Vox.com noted that a study of hospitals was recently conducted by Cornell University’s Andrew Ryan and a team of researchers with the intention of determining whether or not that program was effective. They found no noticeable change in the care provided by the hospitals that were punished under the HVBP program.

“It’s possible that the incentives in this particular program might be too small to encourage hospital administrators to make big investments,” Vox’s Sarah Kliff wrote. “They could be making a calculation: it would be more work than its worth to do better.”

In order to address that issue, she suggests that the British National Health Service, which ties 20 percent of a doctor’s pay to the quality of care they provide based on government evaluations, seems like the way to go.

In other words, the only solution to the problems of government “nudging” is more “nudging.”

But here is the true rub in Kliff’s report:

One other possibility: Ryan and his colleagues noticed, in the data, is that when you look back at 2008, there is some evidence that hospitals were improving back then at a faster rate than the non-participants. This suggests that hospitals may have begun improving quality in preparation for these policy changes a few years in advance, and are now reaping the benefits of that advance planning.

So, hospitals were increasing the standards of care well before a massive health care overhaul was passed and that rate of improvement stalled in the wake of the implementation of this new law. Whatever could that mean…

“This would have meant the hospitals were preparing for the program two years prior to the Affordable Care Act passing, and would have had a sense whether they would fall in the bonus pool or not,” Kliff writes. She notes that, while it was not federal policy until the passage of the ACA in 2010, people had been talking about an incentive program like this since at least 2003.

One would have to assume then that she is suggesting that hospital administrators were adjusting their behavior according to a law which had not passed. Which is… positively baffling.

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Tags: ObamaCare, sarah kliff, vox

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Vox:ThepresidentbecomesmorepowerfulwhenCongress

Vox: The president becomes more powerful when Congress doesn’t act

posted at 2:41 pm on August 6, 2014 by Allahpundit

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That’s news to me, but if you asked me to guess what Vox’s line would be on O’s ever more ambitious power grabs, this would’ve been it. Ezra Klein:

Just as Congress is too divided to do anything; it’s also too divided to stop the other parts of government from doing something. Congress can’t pass a law solving the immigration crisis but it also can’t pass a law stopping Obama from trying to solve it. It can’t pass a law regulating carbon emissions but it also can’t pass a law stopping the Environmental Protection Agency from regulating carbon emissions. And that’s because big portions of Congress want these actions to be taken; they happen because they enough congressional support to survive.

A point made by skeptics of Obama’s executive actions is that inaction is a congressional choice that needs to be respected. But if Congress is making a choice when it doesn’t pass a bill to do something, it’s also making a choice when it doesn’t pass a bill to stop another branch of government from doing something. Inaction cuts both ways as an expression of congressional will.

Either I’m misreading that or Klein’s replacing the idea of enumerated powers with some sort of congressional right of first refusal on policy. We prefer that Congress handle major legislative changes, he seems to be saying, but if they’re deadlocked along partisan lines then Obama and the Supreme Court have little choice but to step in and handle some of Congress’s business. (How much isn’t clear.) Where this idea comes from, I don’t know. Klein seems to assume that sometimes government simply must, must act, and if the branch responsible for action is frozen for whatever reason, then the others pick up the slack. Maybe you could make that argument in a case of dire emergency — although even then, as we saw with TARP, Congress can heal its rifts pretty quickly — but how does it justify massive executive action on immigration, a policy problem that’s lingered for decades? The point of enumerated powers is to restrain government by narrowly defining what each branch can constitutionally do; the idea that one branch gets to claim the powers of another if the other doesn’t act fast enough, whatever that means, is the opposite of that. Vodkapundit Steven Green summarizes Klein’s argument this way: “[A] good way for Congress to keep the President from getting too powerful is to do what he wants.” Precisely.

In fact, says Leon Wolf, enumerated powers means that the president has less power when Congress doesn’t act, not more:

By way of reminder, under Article 2, the President’s power exists within the domestic sphere to enforce the laws that are passed by Congress. If Congress does not pass a law, the President does not have a law to execute, and therefore his power shrinks, at least under the Constitution.

The Constitution does not envision a regime in which “smart” people like Ezra Klein and Barack Obama decide that a given policy must exist – and then following this decision, Congress gets a ceremonial first bite at the apple of passing a law in accordance with this policy, and if they fail to do so, the President gets to just enact the policy anyway. That is not how the separation of powers works. There is no universe in which it simply must be that an immigration reform proposal makes it to the President’s desk within the calendar year, and if it does not do so, everyone simply accepts that the President has the authority to do what Congress clearly meant to do in the first place.

To be fair to Klein, he doesn’t go so far as to endorse Obama’s executive amnesty, having not seen the actual order yet, and he admits that the precedent being set here could take the country down an antidemocratic road. And yet he’s laying the ideological groundwork for it by arguing this way. For instance, explain this to me:

And there are, of course, real dangers to the president repeatedly stretching his powers. Conservative critics go too far when they pretend that Obama’s actions are unprecedented. President Jimmy Carter, for instance, unilaterally pardoned hundreds of thousands of draft dodgers — an action more extreme than anything Obama is said to be considering. At the same time, there do need to be limits on the president’s ability to win policy fights by selectively enforcing laws.

How is pardoning a few hundred thousand draft dodgers “more extreme” than unilaterally amnestizing five million illegals? You can disagree with what Carter did but the pardon power squarely belongs to the president under Article II. Which clause gives the president the power to formally legalize people who’ve come here without following the procedures set forth under federal law? And another thing: What happens under Klein’s argument if Congress does act but the president himself moves to block it? That is to say, if Republicans retake the Senate this fall and Congress passes a bill formally ending DACA next year, would Klein support Obama vetoing that bill and then turning around and expanding DACA? Because if that’s okay too in the name of taking “necessary” action, with Congress left with no recourse against executive decrees except supermajority veto overrides in both chambers, then we’ve already arrived at the sort of caesarism Ross Douthat was worried about in his NYT column this weekend.

The irony of Klein’s piece is that it inadvertently undermines the left’s best defense to Obama’s mega-amnesty They could argue that if voters don’t like it, they can always express their upset with O and his party at the polls this fall. That’s how democracies are supposed to work, in theory; if the president overreaches, the people will punish him for it. That’s not how constitutional democracies work, where the Constitution itself limits the president’s power whether or not the majority of voters supports expanding it, but framing one’s argument in terms of popular will is always appealing. Klein’s argument tosses that out the window, though. Instead of arguing that we should let the people decide both ends of this issue — if they dislike congressional gridlock, they’ll give the House back to the Democrats or the Senate back to the GOP, and if they dislike what Obama does with executive action in the meantime, they’ll punish Democrats accordingly — he seems to allow no democratic remedy for gridlock. We simply can’t wait for the damned voters to resolve this impasse by electing a Congress capable of forming a consensus on tough policy matters. We need Obama to act, now. But why?

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Tags: amnesty, carter, executive, Ezra Klein, obama, pardon, separation of powers, unilateral, vox

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VoxconcedesIRSinvolvedin‘scandal,’iswrong

Vox concedes IRS involved in ‘scandal,’ is wrong about most everything else

posted at 4:41 pm on June 18, 2014 by Noah Rothman

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The pithy explainer site Vox has endeavored to “voxsplain” the scandal involving the IRS’s targeting of conservative groups with undue scrutiny. It’s a wonder they felt that this was even necessary, considering the lengths to which political reporters went in order to diminish what Slate’s Dave Weigel called the “Q-rating,” or popular interest, in the story.

But the IRS, which stumbled into this controversy in the first place, has forced a reluctant press to relitigate the issues surrounding the targeting of conservative groups when they claimed two years’ of former IRS executive Lois Lerner’s emails had simply disappeared. This excuse was met with earned incredulity from lawmakers and media figures alike.

The IRS scandal’s renewed “Q-rating” has forced Vox’s Dylan Matthews to concede that this is, indeed, a “scandal.” Not, however, for the reasons you might expect; incompetent management, stifling bureaucracy, a culture that rewarded political retribution, etc. No, the problem is as it ever was – not enough taxpayer funding.

“The IRS has been underfunded for years, and there’s strong reason to believe that it needs more money if it’s going to avoid issues like the one it ran into with conservative non-profits in the future,” Matthews wrote.

“As ironic as the budgetary cost of the budget cuts is, the ultimate irony is that they could wind up replicating the scandal House Republicans are trying to address,” he continued. “There were a number of reasons for why the IRS started singling out groups with words like ‘Tea Party’ and ‘patriot’ in the name, but a lack of resources to do more effective screening was a major factor.”

The Vox columnist later explained that the rules governing 501(c)(4)s, which changed radically in the wake of the Supreme Court’s Citizens United decision, resulted in a spike in the number of groups seeking tax-exempt status. “So considerably fewer employees were suddenly charged with considerably more work,” he added, noting a rise in applications coincided with a decline in IRS staffing. “And it’s safe to say the work was more politically fraught and challenging.”

The claim that the 2010 Citizens United decision resulted in a surge in tax-exempt applications which swamped the IRS and forced them to do shoddy work was among the first submitted by the administration’s most eager defenders. It was also one of the earliest exculpatory claims to be debunked.

Via a Politifact post discrediting this claim from June, 2013:

Here’s how the activity breaks down for 501(c)(4) applications, the sort of tax-exempt group where political activity is allowed:

2009: 1,751
2010: 1,735
2011: 2,265
2012: 3,357**
….
The earliest that there might have been a jump in applications would have been in October 2010. That is well after the IRS began its effort to give selective treatment to tea party groups.

It’s true that 501(c)(4) applications have increased in recent years, but they had not “shot up dramatically,” as Matthews describes it, in the immediate wake of the Citizens United decision in 2010. “The real surge in applications did not come until 2012 — the year the IRS stopped the practice of treating the Tea Party class of groups differently from others,” wrote The Atlantic’s Garance Franke-Ruta.

Matthews goes on to favorably quote a New York Times story which he said “ looked into the IRS Cincinnati office, the epicenter of the scandal.” This assertion is simply insulting to anyone who has been following the IRS scandal. Another of the early efforts by the administration to “voxsplain” the IRS scandal away was the claim that two rogue IRS employees in a provincial Cincinnati outpost were solely responsible for the targeting.

That did not turn out to be the case. “I was essentially a front person, because I had no autonomy or no authority to act on [applications] without [D.C.-based IRS attorney] Carter Hull’s influence or input,” said Cincinnati-based IRS employee Elizabeth Hofacre in congressional testimony leaked to The Wall Street Journal in June of last year.

The interview transcripts suggest it began with a search for tea-party groups by name among applications from groups seeking tax-exempt status. The Cincinnati employee who conducted the search, Gary Muthert, said he started gathering applications in March 2010, at the request of an unidentified local manager, who allegedly told him that “Washington, D.C., wanted some cases,” according to the transcripts. Mr. Muthert first heard of tea-party applications from another Cincinnati employee.

In May of 2014, the activist group Judicial Watch obtained documents following a FIOA request which showed clearly that the Cincinnati office was directed to heavily scrutinize “tea party applications” out of Washington.

Via Katie Pavlich:

On July 6, 2012, former Director of the IRS Rulings and Agreements Division and current Manager of Exempt Organizations Guidance Holly Paz sent an email to IRS Attorney Steven Grodnitzky asking for an explanation of how tea party group applications were being handled. Grodnitzky responded by confirming the cases were being handled in Washington.

“EOT is working the Tea party applications in coordination with Cincy. We are developing a few applications here in DC and providing copies of our development letters with the agent to use as examples in the development of their cases. Chip Hull [another lawyer in IRS headquarters] is working these cases in EOT and working with the agent in Cincy, so any communication should include him as well. Because the Tea party applications are the subject of an SCR [Sensitive Case Report], we cannot resolve any of the cases without coordinating with Rob,” Grodnitzky wrote.

While Matthews cites testimony from National Taxpayer Advocate Nina Olson and a Government Accountability Office report, both of which do point to problems with agency funding and staffing, the Vox columnist referenced few of the most recent developments which make the IRS scandal a scandal in the first place.

There is no mention of the implausible vanishing emails, no reference to leaked communications which indicate that Rep. Elijah Cummings’s (D-MD) office had coordinated with the IRS, no mention of the fact that the IRS may have violated federal tax law when it forwarded confidential taxpayer information to the FBI in an effort to explore the potential to bring criminal charges against some nonprofit groups.

It is unlikely that this manner of apparently voluntary misconduct would have been avoided had Congress simply increased the IRS’s funding before 2010.

The post is just another vehicle to claim that this or the other federal agency needs more funding. It’s a familiar pattern. That is not, however, to suggest that there is no value to this Vox post. It is essential, if only because it freely and without qualification refers to the IRS scandal a “scandal.” Baby steps.

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Tags: Dylan Matthews, IRS, Lois Lerner, vox

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HottipfromEzraKlein’snewsite:Stop

Hot tip from Ezra Klein’s new site: Stop freaking out about the national debt

posted at 4:41 pm on March 26, 2014 by Allahpundit

Take it away, Mark Hemingway.

If you thought Vox wouldn't just be lefty talking points, their second "explainer" will disabuse you of that notion. http://t.co/8yep0YItDN

— Mark Hemingway (@Heminator) March 26, 2014

Of all the current affairs they could be usefully Voxplaining to the BuzzFeed generation right now — a primer on Crimean geopolitics or Venezuela post-Chavez, a quickie take on what the Fed’s “taper” could mean to the average paycheck, etc — it’s revealing that they put out a sort of Krugman-for-kindergarteners video like this. Also revealing is how self-contained it is: There’s no hint of counterarguments, like, say, what growing interest payments on ballooning debt will do to a federal budget that’s already slowly being cannibalized by Medicare, nor is there even a hint that the issue might be more complex than this. That’s smart rhetorically, especially given the time constraints, but … complicates, shall we say, the site’s pretensions to explanation. What sort of “explanatory journalism” launches by encouraging its readers not to spend too much time thinking about a particular subject, especially one this politically salient?

But never mind all that. I warned you a few weeks ago that you shouldn’t underestimate the reach of a site that’s targeting people who would need an “explainer” as simple as this one. Lemme quote, er, myself:

My sense of it after watching the [introductory] vid is that it’s basically going to be Wonkblog but with more background in each piece and probably lots more charts and graphics… It’ll be as reliably liberal as ever but it’ll be presented as straightforward exposition; as lefties love to tell themselves, it’s reality that has a liberal bias, not them. (Actual quote from the site: “Our end goal isn’t telling you what just happened, or how we feel about what just happened, it’s making sure you understand what just happened.” Uh huh.)…

Someone who enjoys a BuzzFeed post with 37 GIFs in it might not sit still for a long Nate Silver data-crunch but they might be willing to devote three minutes to Ezra patiently leading them through an easily digestible Q&A annotated with simple graphs. If you want to bring people around to your side politically, you should aim for the low-information readers; they’re the natural target for “explanatory journalism.”

That’s almost exactly what this is, no? The only thing that’s different is that it’s Matt who’s narrating, not Ezra, and they’re not using “lots” of graphics, they’re using nothing but graphics. This is aimed squarely at the low-information voter with a short attention span, whose views on the debt are sufficiently primitive that they might theoretically be affected by a two-minute cartoon. It won’t change your mind, but so what? Your vote isn’t the one that decides elections. Between the “shiny object” appeal and Klein’s brand as a capital-w Wonk, there are surely many casually political readers who’ll come to the site and trust it. Maybe not enough to justify a multimillion-dollar investment, but if you’re a filthy rich liberal looking to buy influence online, I can imagine worse ways to spend your money.

Tags: Ezra Klein, inflation, interest, national debt, vox, yglesias

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