The Skinny On Narrow Networks

Philip Klein complains about the narrow healthcare networks of many Obamacare plans:

Insurers throughout the country offering coverage through the new health insurance exchanges drove a hard bargain with medical providers, and thus many of those providers chose not to participate. The end result was that Americans who obtained coverage through the healthcare law often found that they didn’t have much choice when it came to doctors or hospitals. Those who averted “rate shock,” in other words, often found themselves exposed to “access shock.”

Lawmakers and regulators have been taking measures to try to address the problem going into the 2015 benefit year, but it is not clear whether the moves will actually improve the consumer experience.

But how much harm do narrow networks really do? A new working paper by Jonathan Gruber and Robin McKnight tries to answer that question. Jonathan Cohn is encouraged by their findings:

People who switched to narrow network plans saved both themselves and their employers huge amounts of money: Spending on medical bills declined by approximately one-third, according to the paper. Partly this was because people were getting care only from providers that charged less, Gruber and McKnight found, and partly that was because they were seeing fewer specialists.

That wasn’t necessarily good news: In theory, it could have meant that these people were getting worse medical care. But Gruber and McKnight detected no evidence of that. The hospitals in the narrow networks performed just as well on typical measures of quality. And while people were using fewer specialty services, Gruber and McKinght write, these people were also spending more time with their their general practitioners and family doctors—and less time in the emergency room. That’s exactly the kind of transformation many experts say is necessary.

Kliff fully admits that cutting “patient spending by one-third is no small feat for a health insurance plan.” But she isn’t confident “that every foray into limited choice will go equally as well”:

Its probably most fair to read this study as a proof of concept: set up correctly, limited choice plans can save money without sacrificing quality. Whether all plans work this way is something we’ll learn more about, as more people on Obamacare keep enrolling in these products.

Book Club: Waking Up

Well, I couldn’t resist, could I? Sam Harris is a friend and great interlocutor. We’ve hashed out the issues on Israel and, indeed, religion itself in dialogues. See the Gaza conversation here; and the longer exchange of emails on religion here. I always learn something from him – and I have always thought of him as somewhat different than an atheist like Hitch. Why? I cannot imagine Hitch spending time in an ashram, or being dedicated to regular and disciplined meditation, or writing something like this:

I once spent an afternoon on the northwest shore of the Sea of Galilee, atop the mount where Jesus is believed to have preached his most famous sermon … As I gazed at the surrounding hills, a feeling of peace came over me. It soon grew to a blissful stillness that silenced my thoughts. In an instant, the sense of being a separate self – an “I” or a “me” – vanished. Everything was as it had been – the cloudless sky, the brown hills sloping to an inland sea, the pilgrims clutching their bottles of water – but I no longer felt separate from the scene, peering out at the world from behind my eyes. Only the world remained.

That’s a passage from Sam’s new book, Waking Up: A Guide To Spirituality Without Religion. It tackles big subjects – neuroscience, consciousness, meditation, faith – in his sometimes dense but always pellucid fashion. At times, the book is actually quite funny – there’s a 51d++OL+kYLpart about him dealing with various water leaks in his house that cracked me up.

And the book’s argument is a rare and serious one: that it is possible to find a place in one’s mind where one is no longer in one’s mind. This elusive idea of consciousness is the basis of a peace and serenity and balance that we in the West have so often failed to achieve, even as our civilization constantly scales new heights. This can be achieved within a religious tradition – such as Buddhism or a Merton-like Christianity – but Sam also insists there need be no religion to the experience at all.

Now, I’m religious as well as spiritual, a believer in prayer and meditation as vital parts of any healthy faith life – while Sam is unrepentantly hostile to any idea of divine revelation, or anything but consciousness beyond our own delusional egos. And it struck me that many Dish readers – some engaged in our religious and spiritual coverage, some hostile to religion but open to the sublime and the spiritual – would get a huge amount out of the book, and the conversation it could prompt.

So drum roll … this is our September book of the month.

Buy the book now at Amazon and help us get a little affiliate revenue while you’re at it. I have a head start, because Sam got me an advance copy. He’s agreed to join the conversation in its final stages. I hope we can get somewhere in a debate often defined by polarization and cheap rhetoric – and see where we overlap and where we still differ.

And with your input, religious and spiritual people, I hope we can advance the conversation about spirituality as opposed to religion as well. I’ve long believed that the key thing we need right now is a revival of a Christianity less concerned with dogma and more focused on faith as a way of being in the world. Sam’s is as good a provocation on those issues as any out there. So join in! Get the book here – and we’ll start the discussion after the beginning of October. Send your thoughts to bookclub@andrewsullivan.com and there’s a good chance you’ll see them posted.

Fighting Without Fatalities

Contra Steven Pinker, political scientist Tanisha Fazal argues that war is not necessarily less common than it used to be. Rather, she says, improvements in battlefield medicine simply mean that more people are surviving:

These medical advances have several implications for scholarship and policy. Major academic data sets on war and armed conflict typically use a battle death threshold to determine which cases count as wars/armed conflict. This battle death threshold is constant over the time period covered by these data sets. But a conflict that produced 1,000 battle deaths in 1820 will likely produce many fewer overall casualties (where casualties, properly understood, include the dead and wounded) than a conflict with 1,000 battle deaths today. In other words, the events scholars (including this one) are comparing may not be as similar as we think they are.

Improvements in medical care in conflict zones also hold important implications for policy. While the recent Veterans Affairs Department scandal was surely driven by an aging population of Korean War and Vietnam War veterans, it seems at least possible that pressure on the VA system also emerged from unexpectedly large numbers of returned wounded coming home with a new set of injuries and illnesses. The widespread use of personal protective equipment in the U.S. military, for example, has saved many lives, but surviving soldiers are more likely to come home with traumatic brain injuries, severe facial disfigurement, or as amputees. More broadly, our thinking about casualties and the costs of war has tended to focus on the dead rather than the wounded, while the wounded are growing in number. Medical advances in conflict zones are a positive development, but one that will not be fully realized until we recognize that both the wounded and the dead “count” as casualties.

“Not Mission Creep; Mission Gallop”

Greenwald is shocked but not surprised at how the notions that ISIS is a grave national security threat and “of course we’re going to war with them” have both become conventional wisdom:

If the goal of terrorist groups is to sow irrational terror, has anything since the 9/11 attack been more successful than those two journalist beheading videos? It’s almost certainly the case that as recently as six months ago, only a minute percentage of the American public (and probably the U.S. media) had even heard of ISIS. Now, two brutal beheadings later, they are convinced that they are lurking in their neighborhoods, that they are a Grave and Unprecedented Threat (worse than al Qaeda!), and that military action against them is needed. It’s as though ISIS and the U.S. media and political class worked in perfect unison to achieve the same goal here when it comes to American public opinion: fully terrorize them.

Larison fumes over the war’s rapidly expanding objectives:

It hasn’t taken very long for last month’s “limited” intervention in Iraq to expand far beyond anything that the administration originally described to the public.

Administration officials were denying that they planned for a “sustained” campaign just a few weeks ago, and now they’re saying the opposite. Obama said that he wouldn’t “allow” the U.S. to be dragged into a new war, and he is now setting out to take the U.S. into that war. What we’re seeing now is not so much mission creep as mission gallop, and it all seems to be happening without any serious consideration of the costs or the potential dangers of such an expansive campaign.

Even if the U.S. does not eventually commit large numbers of ground troops to this campaign, the U.S. will be at war in two countries where it does not need to be fighting. This is every bit as much a war of choice as the earlier wars in Iraq and Libya, and it hasn’t been thought through any better than those were.

Christopher Dickey thinks the ISIS threat is being overhyped, though he worries about lone ISIS-inspired nut-jobs like Mehdi Nemmouche, who killed four people in an attack on a Jewish museum in Brussels in May:

Veteran terrorism expert Brian Jenkins notes the alarmism in Washington has reached such proportions, there’s a kind of “shock and awe in reverse.” Thus, as Jenkins writes, Defense Secretary Chuck Hagel proclaims ISIS is an “imminent threat to every interest we have.”  A congressional staffer argues that it is “highly probable ISIS will…obtain nuclear, chemical, biological or other weapons of mass death…to use in attacks against New York [or] Washington.” Texas Governor Rick Perry claims there is a “very real possibility” that ISIS forces may have crossed the U.S.-Mexican border. Senator James Inhofe asserted, “We are in the most dangerous position we’ve ever been in as a nation,” and retired Marine four-star Gen. John Allen goes so far as to say, “World War III is at hand.”

All this plays to the advantage of the self-proclaimed Caliph Ibrahim, formerly known as Abu Bakr al-Baghdadi, whose ragtag army conquered a huge swathe of Iraq mainly by filling the vacuum left by incompetent Iraqi government military commanders. The conquest—and the reaction to it—have given him an aura of invincibility that holy-warrior wannabes find quite thrilling.

I actually hadn’t absorbed the sheer hysteria in Washington after the beheadings-bait. It’s truly shocking – and utterly insane. My earlier thoughts here.

#WhyIStayed

A trending hashtag is providing insight into why abuse victims stay with their abusers. Alex Abad-Santos spotlights the powerful tweets, which are a response to the Ray Rice video:

Looming over this violent act is the fact that Janay went on to marry the man who beat her — leading some people, most notably the anchors on Fox News’s Fox and Friends,  to wonder why she, and other abused women, wouldn’t just immediately flee an abusive relationship. They don’t, because it’s not that simple.

Hence the hashtag #whyistayed.

It was started by writer Beverly Gooden, who wrote, “I believe in storytelling. I believe in the power of shared experience. I believe that we find strength in community. That is why I created this hashtag.” It began trending on Twitter on Monday night, as women used the hashtag to explain the psychology and the reality of their domestic abuse situations — some thought it would get better, others didn’t have a place to turn, many felt shame, several wanted to keep the family together. The testimonies are powerful to read, and they shred the idea that it’s easy for victims to leave their abusers.

Olga Khazan rounds up #whyistayed tweets and research on domestic abuse:

In 1999, law professor and domestic violence survivor Sarah Buel offered up 50 obstacles to leaving, most of which remain unchanged. She points out that the end of the relationship can be just the start of the most serious threats. A battered woman is 75 percent more likely to be murdered when she tries to flee than if she stays.

Welfare is the major safety net for single moms, but its monthly benefit levels are far below living expenses for a family of three. In a study of Texas abuse victims who returned home, the number-one reason cited for returning was financial, Buel writes.

Sarah Kaplan adds another important detail:

The National Coalition for Prevention of Domestic Violence estimates that 25 percent of women experience intimate partner violence, and according to the National Domestic Abuse hotline, it takes an average of seven tries for a victim to leave an abusive relationship.

The types of tweets you will find over at #whyistayed:

Iraq’s New Government

Yesterday, the Iraqi parliament approved a new government headed by Prime Minister Haider al-Abadi. While John Kerry calls the swearing-in a “major milestone”, Juan Cole advises us not to get our hopes up:

Although al-Abadi is a more congenial and less paranoid figure than his predecessor, Nouri al-Maliki, he derives from the same fundamentalist Shiite political party, the “Islamic Call” or “Islamic Mission” (al-Dawa al-Islamiya), founded around 1958 with the aim of creating a Shiite state. The Dawa Party did very well in securing cabinet appointments. The cabinet lacks a Minister of the Interior (akin to the US FBI or Homeland Security director) and a Defense Minister, because the parties could not agree on the names that had been put forward. Hadi al-Ameri, the head of the Iran-backed Badr Corps militia, had been bruited as an Interior Minister, but apparently calmer heads prevailed (or perhaps there was severe American pressure). The Badr Corps in the past has been accused of involvement in torture, and it is despised by many of the Sunni Arabs.

Given the revolt of the Iraqi Sunni Arabs this summer, that anyone even considered al-Ameri for such a sensitive position is astonishing. During the first Ibrahim Jaafari government, the Badr Corps was accused of abuse and the extra-judicial jailings of Sunni Arab rebels. If the Iraqi elite were smart they’d put a Sunni Arab in as head of the Department of Defense.

But Jill Carroll asserts that no amount of representation in a failed political system will assuage the fears of Iraq’s Sunni Arab minority. Only autonomy, she argues, will solve the problem that enabled the rise of ISIS:

Sunni trust in the political process and central government is broken beyond repair. Sunnis do not see the Shiite-led government as a political opponent they disagree with. They see it as an existential threat. The local Iraqi players who aid the Islamic State — Sunni tribesman and former Saddam Hussein regime military elements — need to be enticed to turn against the organization. Getting them to “buy back in” will require a powerful incentive, and what this Shiite-dominated government in Baghdad currently has to offer is not enough.

It is time for a bold solution. Baghdad should offer the Sunni tribes some sort of political autonomy, or perhaps even independence in the territory the Islamic State has carved out, on the condition that they ruthlessly eject the jihadists. This new Iraqi Sunni political entity could be a new country, a semi-autonomous regional government like Kurdistan, or a federation of tribal powers under a loose national framework like the United Arab Emirates.

On the other hand, Michael Rubin blames a lack of Sunni leadership for Iraq’s governance problems:

The real problem facing Iraq—and the reason why no amount of military reform or imposed political quotas will succeed—is that the Arab Sunni community is leaderless. Like them or hate them, the Shi‘ite community has established political parties like Da’wa and the Islamic Supreme Council of Iraq and, if political infighting grows too great, the clerical hierarchy will use their offices to kick the Shi‘ite politicians into gear. The Kurdistan Regional Government is far from democratic, but its parties are well established: Kurds may resent their political leadership, but they do not doubt it.

The Iraqi Sunni Arab community has no real leadership. There is no religious structure among Iraqi Sunni Arabs (or Sunnis in general) that approximates what exists in Najaf. Those assisting the U.S. military and diplomats new to the Iraq issue often talk about the importance of tribes, but there is hardly a tribe in Iraq whose leadership is uncontested. Former President Saddam Hussein—and, indeed, almost every leader before him–promoted rivals to tribal sheikhs in order to better control the tribes. The result is often a mess. Make a Dulaim minister of defense? Don’t count on assuaging the Dulaim because chances are few will recognize the individual as legitimate, or will criticize him as coming from the wrong sub-clan.

Recent thoughts on the governance of Iraq here.

The World From Off Grid, Ctd

photo-10

A reader quotes me:

But when I ask myself what has changed since I took off, I see nothing truly new. Russia continues to dick around with eastern Ukraine; the latest Sunni insurgency in Iraq has been beaten back a bit, but is still strong; the militarization of the police in the US has been more fully understood after Ferguson (Radley Balko, your hour is now); and the president should never, ever wear a tan suit.

Does that sound too calm an analysis? Maybe, and it usually takes a little time for me to acclimate myself to the news cycle and the conversation. So give me some time to get excitable again.

No, Andrew, you hit on something important. Don’t apologize for it.

Just yesterday I was reading about reactive vs. responsive mindsets. Reactivity is exactly what you’re describing as being “pressed against history’s window”. It’s a short-term, highly excitable state that reacts to each stimulus with equal weight. Responsivity is what you get when you step back, allow yourself to prioritize, and gain perspective before wading back in. It’s the state that allows you to find your authentic voice and your true thoughts, and distinguish them from the echoes of the noise machine. It’s where we all do our best work – and it’s what many of us hope to hear from you more often. Don’t get caught prioritizing speed and quantity over depth and clarity. It’s a bad trade, and one that Buzzfeed will beat you at every time.

That’s my new year’s resolution, actually, since my new year always really begins in September. I’m going to try each day to take a step back from the news cycle – even as the Dish aggressively dissects and analyzes it – and concentrate on writing with more distance and moderation. I couldn’t do it without my wonderful colleagues. And I may fail. But I’m gonna try.

(Photo: Bowie and me watching the tide, not the news)