There's a specific quirk about how this plays out—which @dylanlscott references in his write-up—that is worth, I think, elaborating at more length. It helps explain why the "marginal" patients here are actually older-but-healthier, not those we'd conventionally label "high-risk"
Upon acquiring nursing homes, PE firms don't appear to universally scale back nursing staff. RN time actually increases. But so-called "frontline" nurses—CNAs and LPNs—their staff hours fall, more than offsetting the increase in RN effort.
RNs are, plausibly, the nurses you'd imagine to be most important for medically complex patients. But LPNs and CNAs play a critical role for patient health in supporting ADLs, doing things like bed-turning and infection prevention measures.
One of the most interesting hypotheses that the authors offer, from my perspective, is that the regulatory focus on RNs could be the driver here. PE firms might know where CMS is looking, so they're cutting elsewhere.
To be clear, the authors aren't actually able to marshal evidence on this front—it's a post hoc exercise in making sense of the findings. But it strikes me as eminently plausible (and this is probably an "and" not "or" scenario, vis-a-vis explanations)

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More from @onceuponA

14 Dec 20
Every policy person I know who thinks about health insurance is on board with "smart defaults."

I see the primary problems as political (concerning carriers more than individuals) and logistical (including legal questions), not broader public opinion.
Even with soft-defaults, like indicating that a certain plan is someone's probable "best" option, will get pushback from carriers.

That's because if these nudges worked well—and my prior is that they would—they'd have considerable influence over market share.
I'm not merely speculating here: the Obama administration tried to do an extremely weak version of these nudges, prioritizing standardized "Simple Choice" plans on

Insurers did not love it.…
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25 Feb 20
I hadn't read last week's Lancet paper on M4A, but thought I would today since Bernie cites it in his newish-mostly-old set of pay-fors.…

Now that I've read it, I wonder—quite sincerely—how this article got past peer review.
The thing that jumped out to me most glaringly was the stipulation that utilization will ONLY increase among the 24% of Americans who are currently uninsured or underinsured (the yellow box has the underinsurance criteria from the cited Commonwealth Fund)
The implication here is that going from modest cost-sharing to zero cost-sharing will have no impact on utilization. None.

This is not a tenable assumption. The RAND HIE is dated, but it's not obsolete—it's backed up by a whole canon of health economics research now.
Read 26 tweets
7 Jul 18
What the actual hell. Risk adjustment was a permanent feature of the ACA because you can't have a functional regulated insurance market without it.
Risk adjustment is necessary in a market-based insurance system because some plans—maybe because of benefit design, maybe by chance—are going to attract sicker (more expensive) beneficiaries, and shouldn't be punished for that. Punishment encourages cream skimming.

And yet.
The Trump administration may suspend risk adjustment payments—which help stabilize the marketplaces—"because of" lawsuits brought by co-ops in 2016.

CMS refined the risk adjustment formula since the damages claimed in those lawsuits.

Make no mistake, this is more sabotage.
Read 4 tweets
29 Jun 18
"The Secretary never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid."…
"The Secretary never provided a bottom-line estimate of how many people would lose Medicaid with Kentucky HEALTH in place. This oversight is glaring, especially given that the risk of lost coverage was 'factually substantiated in the record.'"
Guys, Judge Boasberg is extremely not impressed: "For starters, the Secretary never once mentions the estimated 95,000 people who would lose coverage, which gives the Court little reason to think that he seriously grappled with the bottomline impact on healthcare."
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