• On attributions of bad faith in policy debate

    Last week’s Halbig decision elicited a lot of anger between left and right intellectuals. Brian Beutler called the decision:

    a fundamentally dishonest solicitation of right-wing judicial activism

    In the first sentence of his dissent, Judge Edwards accused the appellants and, by implication, his colleague Judge Griffith, of bad faith :

    This case is about Appellants’ not-so-veiled attempt to gut the Patient Protection and Affordable Care Act (“ACA”).

    Conversely, conservatives had their eyeballs popping out of their heads in response to what they viewed as the feckless bad faith of liberal responses to Halbig. Liberals are just indifferent to what their own law actually said, because the text is absurd? The absurdity of the text reveals the infeasibility of the enterprise — and you’re calling that a typo?

    I’ve nothing to say on the merits of these arguments (for that, read Nick!). But I don’t think attributions of bad faith should have much role in policy debates.

    It’s not because I want people to be nice. Great scholars have done an immense service by cutting down preposterous fools and letting them bleed out on the floor. Chomsky’s review of B. F. Skinner’s Verbal Behavior is a classic.

    Similarly, I’m not questioning the importance of a sincere motivation to be truthful. There are charlatans and liars. Look around.

    My point is rather that it is in your interest to focus on intellectual opponents whom you have reason to take seriously and to then actually take them seriously. This is your best chance of getting near the truth.

    Humanity’s natural mode of thought is self-serving misrepresentation of facts and inconsistency of argument. Read Dan Kahan on the distortions of ideologically-motivated cognition. But don’t read him to comfort yourself that others are knaves. Read him to get clear that you and I are likely the victims of our own intellectual self-deceptions.

    How do we get outside of our ideological bubbles? Here is J. S. Mill:

    In the case of any person whose judgment is really deserving of confidence, how has it become so? Because he has kept his mind open to criticism of his opinions and conduct. Because it has been his practice to listen to all that could be said against him; to profit by as much of it as was just, and expound to himself, and upon occasion to others, the fallacy of what was fallacious. Because he has felt, that the only way in which a human being can make some approach to knowing the whole of a subject, is by hearing what can be said about it by persons of every variety of opinion, and studying all modes in which it can be looked at by every character of mind… The steady habit of correcting and completing his own opinion by collating it with those of others, so far from causing doubt and hesitation in carrying it into practice, is the only stable foundation for a just reliance on it. (emphasis added)

    I find that my primary motivation for attributing bad faith is to escape the responsibility of answering a strong argument.

    If you are in politics, you have to answer arguments by frauds. But if you are trying to get at the truth, that’s not your best move. If you believe that someone is arguing in bad faith, just stop reading them. We’ll all be forgotten, soon enough.

    @Bill_Gardner

    Thanks to Paul Kelleher for the pointer to Mill.

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  • ARGH! – ACA renewal edition

    One of the nicer aspects of the ACA was that it allowed “automatic renewal” of your health insurance if you got it from an exchange. This allowed you to avoid the yearly “open enrollment” madness if you so desired. But now there’s a problem:

    If you have health insurance on your job, you probably don’t give much thought to each year’s renewal. But make the same assumption in one of the new health law plans, and it could lead to costly surprises.

    Insurance exchange customers who opt for convenience by automatically renewing their coverage for 2015 are likely to receive dated and inaccurate financial aid amounts from the government, say industry officials, advocates and other experts.

    The problem comes from the fact that since both subsidies and premiums change from year to year, the amount that people might have to pay can go up quite a bit. Those who want a “cheap” plan might find that the choice they made this year isn’t the same one they’d make next year. Assuming that you just want to continue is a potential costly mistake.

    The bottom line is that while automatic renewal sounds great in theory, it might not be for many of the people who are getting insurance through the exchanges. Just one more “benefit” the administration may need to backtrack on as November nears.

    @aaronecarroll

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  • Vacation

    Starting now, I’ll be off the internet and without screens for a week. I do this annually and love it. (Yeah, I had a bonus week last month, but normally this is a once-per-year event.)

    As I’ve said before, you should try this too. I find that when I come back, I get about 7-10 days during which almost nothing irritates me. I more accurately (in my view) recognize most of the chatter designed to play on my emotions as noise (yes, I’m looking at you social media and you traditional media). It’s a great way to live!

    When I return, I expect you all to have fully sorted out all Halbig-related issues. Talk amongst yourselves.

    @afrakt

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  • The regions of Australia

    Via tastefullyoffensive:

    austrailia dog cat

    @afrakt

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  • What does the Gruber video tell us about Halbig?

    When it comes to the exchange litigation, what should we make of the Jonathan Gruber video that just came to light? In 2012, Gruber, who was heavily involved in debates over the ACA, responded to a question from the audience after a speaking engagement:

    [T]hese health-insurance Exchanges … will be these new shopping places and they’ll be the place that people go to get their subsidies for health insurance. In the law, it says if the states don’t provide them, the federal backstop will. The federal government has been sort of slow in putting out its backstop, I think partly because they want to sort of squeeze the states to do it. I think what’s important to remember politically about this, is if you’re a state and you don’t set up an Exchange, that means your citizens don’t get their tax credits. But your citizens still pay the taxes that support this bill. So you’re essentially saying to your citizens, you’re going to pay all the taxes to help all the other states in the country. I hope that’s a blatant enough political reality that states will get their act together and realize there are billions of dollars at stake here in setting up these Exchanges, and that they’ll do it. But you know, once again, the politics can get ugly around this.

    He apparently said something similar earlier that year. Gruber has since clarified that what he said “was just a mistake. People make mistakes. Congress made a mistake drafting the law and I made a mistake talking about it.”

    Clarification notwithstanding, does Gruber’s statement tell us something about what the ACA means? For their part, the courts probably won’t care all that much. One person’s (disavowed) view offered two years after the ACA was enacted can’t substitute for a careful analysis of the statute.

    Still, I don’t think Gruber’s statement can be written off altogether. As I’ve explained, I’m skeptical of the challengers’ claim in part because they’ve got no remotely credible evidence that Congress meant to use the loss of tax credits as a threat to get states to set up their own exchanges. To date, this Gruber video is the best they’ve found. It ain’t nothing.

    But if you think what Gruber said is some evidence about what the ACA means, you can’t ignore other, similar evidence. That’s cherry-picking. So go ask John McDonough, who was intimately involved in drafting the ACA and is as straight a shooter as there is: “There is not a scintilla of evidence that the Democratic lawmakers who designed the law intended to deny subsidies to any state, regardless of exchange status.” Or ask Senator Max Baucus’s chief health adviser, Liz Fowler. She says the same thing. Or ask Doug Elmendorf, the current CBO Director: “To the best of our recollection, the possibility that those subsidies would only be available in states that created their own exchanges did not arise during the discussions CBO staff had with a wide range of Congressional staff when the legislation was being considered.” Or ask Peter Orszag, then-OMB Director: “[A]s someone who was there, [there is] zero chance this was the intent (as opposed to typo/poor drafting).”

    Or ask Jonathan Cohn or Ezra Klein, both of whom followed the deliberations over the ACA closely. Neither heard a whisper about any supposed threat. Or ask Abbe Gluck, a law professor at Yale who details how “a basic understanding of the ACA’s legislative process makes clear that Congress intended for the subsidies to be available on the federal exchanges.” Or ask Aaron, who wonders, if this threat was so clear, why TIE never mentioned it. “Do you think we would have ignored this? We wouldn’t have been concerned?”

    Better still, ask the states, which were on the receiving end of the supposed threat. According to a report from the Georgetown University Health Policy Institute, there’s no contemporaneous evidence that the states feared that declining to set up an exchange might lead to a loss of tax credits. How can it be that Congress unambiguously threatened the states with the possible loss of tax credits if the states never understood that threat?

    In that vein, it’s telling that Gruber’s statement was made long after the ACA was passed. If Congress really meant to level a threat at the states to force them to establish exchanges, surely someone—anyone!—during the extended debate over the ACA would have said something—anything!—that made the point with comparable directness. The absence of any such statement still speaks volumes to me, whatever Gruber said in 2012.

    @nicholas_bagley

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  • Stand Up! – July 25, 2014

    I was a guest this morning on Stand Up! with Pete Dominick, which airs on Sirius/XM radio, channel 104 from 6-9AM Eastern. The show immediately replays on the channel, so those on the West Coast can listen at the same times.

    We talked about—you guessed it—Halbig and the exchange litigation. It was a hoot. It wouldn’t have happened without Aaron’s much-too-kind introduction, so I owe him thanks for that.

    You can play the audio right here, after the jump…

    Read the rest of this entry »

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  • What did Congress mean by “established by the State”?

    Over at the Volokh Conspiracy, Jonathan Adler, one of the architects of the exchange litigation, has posted a thoughtful response to a post I wrote defending the extension of tax credits to those purchasing health plans on federally established exchanges. You should read it; he’s really sharp.

    But he’s still wrong. Adler argues that I haven’t offered a satisfactory explanation for why Congress used the phrase “an Exchange established by the State” in the tax-credit calculation. He rejects my suggestion that the best way to understand the phrase is that it was a shorthand for exchange, whoever happened to establish it. “When Congress wanted to use a shorthand for ‘exchange,’” he writes, “it did just that— and said ‘exchange.’” As Adler sees it, the use of “by the State” in the tax-credit calculation must serve some distinct purpose.

    In making this claim, Adler is invoking two hoary canons of statutory interpretation: the canon against surplusage and the canon of consistent usage. These are useful canons—usually. But neither can help make sense of Congress’s meaning unless we can safely assume that Congress carefully used “exchange” when it meant “any exchange” and “exchange established by the State” when it meant “only state exchanges.”

    We can’t assume that here. Elsewhere in the statute, Congress referred to state-established exchanges when it clearly meant exchanges more generally. The ACA, for example, limits who can buy insurance on an exchange to those who “resid[e] in the State that established the Exchange.” Read literally, this would prohibit anyone in states with federal exchanges from buying insurance on those exchanges. Federal exchanges would be useless. That can’t be what Congress meant.

    Similarly, the ACA says that states have to maintain their Medicaid eligibility standards until “an Exchange established by the State” is up and running. This provision was meant to provide stopgap protection for Medicaid beneficiaries until the exchanges went live. But, read literally, it would forbid a state that declined to establish an exchange from ever relaxing its Medicaid standards. Again, that’d be batty.

    So Congress wasn’t meticulous about its references to state-established exchanges. At times, it did use “Exchange established by the State” as a shorthand for exchange. If that’s true elsewhere in the statute, it may be equally true when it comes to calculating tax credits. And reading the “established by the State” language to allow tax credits on federal exchanges makes much better sense of the statute as a whole.

    Can I be completely, absolutely confident about Congress’s meaning here? No. Without question, the statute is a bit of a mess. What do you expect? It’s a big statute, drafted by a lot of different people working under immense pressure.

    But here’s the thing. Adler can’t be completely confident in his interpretation either. At a minimum, Congress’s inconsistent use of the phrase “established by the State” gives rise to an ambiguity as to its meaning. And when you’ve got an ambiguity, it’s up to the agencies charged with interpreting the ACA to resolve that ambiguity. The tie goes to the government.

    @nicholas_bagley

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  • Too few kids get the HPV vaccine. Did you all not watch my video?

    From the CDC:

    To assess progress with HPV vaccination coverage among adolescents aged 13–17 years,* characterize adherence with recommendations for HPV vaccination by the 13th birthday, and describe HPV vaccine adverse reports received postlicensure, CDC analyzed data from the 2007–2013 National Immunization Survey-Teen (NIS-Teen) and national postlicensure vaccine safety data among females and males. Vaccination coverage with ≥1 dose of any HPV vaccine increased significantly from 53.8% (2012) to 57.3% (2013) among adolescent girls and from 20.8% (2012) to 34.6% (2013) among adolescent boys. Receipt of ≥1 dose of HPV among girls by age 13 years increased with each birth cohort; however, missed vaccination opportunities were common. Had HPV vaccine been administered to adolescent girls born in 2000 during health care visits when they received another vaccine, vaccination coverage for ≥1 dose by age 13 years for this cohort could have reached 91.3%. Postlicensure monitoring data continue to indicate that HPV4 is safe. Improving practice patterns so that clinicians use every opportunity to recommend HPV vaccines and address questions from parents can help realize reductions in vaccine-preventable infections and cancers caused by HPV.

    Still, too few kids are getting the HPV vaccine. I could write another post on this, but I’ve got Healthcare Triage instead. Watch, and spread the word!

    @aaronecarroll

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  • My one comment on Gruber and Halbig

    I said it on Twitter, but I’ll expand here.

    Is there a single CBO analysis which documents what would happen if states refused to set up exchanges and would therefore “lose” their subsidies? Were any of Gruber’s models set up in this manner? If not, then I don’t understand how anyone in Congress or who set up the law thought it was going to work that way.

    I accept that the law was written poorly. I accept that there may be individuals who thought it would work in the way the DC Circuit majority said. But there are tons of analyses, reports, interviews, and more that show that no one involved thought that way.

    This blog has been going since before reform was passed. Find me a single post where we discussed this. Find a post where we discussed others discussing this. Do you think we would have ignored this? We wouldn’t have been concerned?

    @aaronecarroll

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  • Methods (kinda): Rubin on Rubin and Campbell

    Yesterday I encouraged you to read at least the paper by Stephen West and Felix Thoemmes if not all the papers on Campbell’s and Rubin’s causal frameworks in this 2010 issue of Psychological Methods. I also encourage you to read the response by Rubin. It’s much shorter and so much fun. Here are my highlights.

    Because my doctoral thesis was on matched sampling in observational studies under Cochran, I thought that I understood the general context fairly well, and so I was asked by the Educational Testing Service to visit Campbell at Northwestern University in Evanston, Illinois, which is, incidentally, where I grew up. I remember sitting in his office with, I believe, one or two current students or perhaps junior faculty. The topic of matching arose, and my memory is that Campbell referred to it as “sin itself” because of “regression to the mean issues” when matching on fallible test scores rather than “true” scores. I was flabbergasted!

    Rubin later showed that he was correct about matching but that Campbell was not wrong because Rubin had misunderstood his objection.

    Of course, the situation with an unobserved covariate used for treatment assignment is far more complex, and that situation, coupled with the naive view that matching can fix all problems with nonrandomized studies, appears to have been the context for Campbell’s comment on matching.

    (I may put up a methods post on matching at some point, though I haven’t decided.)

    The drive for clarity in what one is trying to do expressed in this passage resonates deeply:

    Perhaps because of my physics background, it seemed to me to make no sense to discuss statistical methods and estimators without first having a clear concept of what one is attempting to estimate, which, I agree with Shadish (2010), was a limitation of Campbell’s framework. Nevertheless, Campbell is not alone when implicitly, rather than explicitly, defining what he was trying to estimate. A nontrivial amount of statistical discussion (confused and confusing to me) eschews the explicit definition of estimands. [...] My attitude is that it is critical to define quantities carefully before trying to estimate them.

    Elsewhere in the paper, Rubin reveals that even Campbell did not think very highly of his own ability to do math. Rubin studied physics with John Wheeler at Princeton, which one can’t do without a lot of math ability and confidence in it.

    Later in the paper he has a very nice discussion of the stable unit treatment value assumption (SUTVA), which I won’t repeat here. Very roughly, the aspect of it that’s relevant below is that there be one treatment (or at least a clearly defined set of them), not a vague, uncountable cloud of them. (See also, Wikipedia.) It’s due to this assumption that the problem of, say, the causal effect of gender on wages is “ill defined,” as I raised in my prior post.

    For example, is the statement “She did well on that literature test because she is a girl” causal or merely descriptive? If [being assigned to the "control" group] means that this unit remains a girl and [being assigned to the "treatment" group] means that this unit is “converted” to a boy, the factual [the outcome from assignment to "control"]  is well defined and observed, but the counterfactual [outcome due to "treatment"] appears to be hopelessly ill-defined and therefore unstable. Does the hypothetical “converted to a boy” mean an at-birth sex-change operation, or does it mean massive hormone injections at puberty, or does it mean cross-dressing from 2 years of age, and so forth? Only if all such contemplated hypothetical interventions can be argued to have the same hypothetical [outcome] will the requirement of SUTVA that there be no hidden versions of treatments be appropriate for this unit.

    But this does not mean there can be no well-defined study of the causal effects of gender.

    An example of a legitimate causal statement involving an immutable characteristic, such as gender or race, occurs when the unit is a resume of a job applicant sent to a prospective employer, and the treatments are the names attached to the resume, either an obviously Anglo Saxon name ["control"] or an obviously African American name ["treatment"].

    They key here is that though you can’t in a reasonably defined, unique way imagine changing the gender of a person, you can imagine changing the gender as listed on a person’s resume.

    Later still, Rubin explains how, before his work, the “observed outcome notation” that had been the norm made it impossible to be clear how and why certain designs permit unbiased estimates. You really have to read the paper (at least) to see this. I’m still not sure I get it, but I believe him!

    To repeat, using the observed outcome notation entangles the science [all the potential outcomes and observable factors] and the assignments [the mechanism by which observed outcomes are selected among potential ones]—bad! Yet, the reduction to the observed outcome notation is exactly what regression approaches, path analyses, directed acyclic graphs, and so forth essentially compel one to do. For an example of the confusion that regression approaches create, see Holland and Rubin (1983) on Lord’s paradox or the discussion by Mealli and Rubin (2003) on the effects of wealth on health and vice versa. For an example of the bad practical advice that the directed acyclic graph approaches can stimulate, see the Rubin (2009) response to letters in Statistics in Medicine. [...]

    To borrow Campbell’s expression, I believe that the greatest threat to the validity of causal inference is ignoring the distinction between the science and what one does to learn about the science, the assignment mechanism—a fundamental lesson learned from classical experimental design but often forgotten. My reading of Campbell’s work on causal inference indicates that he was keenly aware of this distinction.

    (I may read and then post on Lord’s paradox. I don’t know what it is yet.)

    @afrakt

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