What if Trump fixed the healthcare system – and no one knew it?

So let’s start with an article in yesterday’s Chicago Tribune, a wire report from AP, that took me by surprise:

Employers start sending workers shopping for health coverage.”

The article described a new form of employer healthcare provision, the Individual Coverage Health Reimbursement Arrangement or ICHRA.  This approach takes the well-established Healthcare Reimbursement Account, which combines a high-deductible healthcare plan and a reimbursement account, money provided by the employer which can be used to offset some healthcare costs while meeting the deductible, and adds a twist:  the employer can provide money which individuals can use to purchase health insurance — and they can do so with the same tax advantages as if they were providing the insurance coverage directly.

To be sure, there are limitations that mean that the government’s forecast is that only 11 million employees will benefit:  the employer must not offer group health insurance already (that is, employees can’t select this as an alternative to group health insurance), or can only offer the ICHRA to categories of employees to whom it doesn’t otherwise offer insurance (like part-time employees).  Also, an employee buying insurance through the Obamacare “exchange” can’t “stack” the employer benefit and the premium credits, and can’t pay for the additional costs in a pre-tax manner, but that is possible if an employee purchases insurance outside of the ACA exchange.  And, of course, a “regular” employer-sponsored healthcare plan is still preferable for employees when they benefit from group rates and don’t have to wade through a potentially overwhelming number of plan choices.

(For lots of detail, see “New Final Rule Lets Employees Use HRAs to Buy Health Insurance” at SHRM.)

Now, it turns out, this isn’t new.  This was a rule issued by the departments of HHS, Labor, and the Treasury issued the rule enabling this on June 13 of 2019.  And, yes, this is a “rule” — an administration interpretation/implementation of existing legislation, so in principle Biden could simply issue a new rule which overrules this (with the applicable comment period and other bureaucracy).  It seems likely that two other Trump “rules” — one allowing “association health plans” and the other allowing low-cost short-term insurance — will be sent to the circular file, but I have a hard time imagining that Biden will oppose this one (though perhaps my imagination is faulty).

But I do believe that this small regulation, over time, could have a very outsized impact on the healthcare system.

Bear with me for a minute here:

Remember the staff model HMO?

That was supposed to fix our healthcare system.  Rather than the existing expectation of “consumer-driven healthcare plans” that we healthcare customers will work with our healthcare providers to ensure that our medications are the lowest-cost options possible, that no unnecessary procedures and tests are performed, and that such tests and procedures as are necessary, are done by the most cost-effective provider (e.g., through look-up tools at insurer websites), the staff model HMO’s providers did all that as professionals.

And back in the day — well, not only is my own family’s current health plan a high-deductible one, but our choices are high deductible, or very high deductible.  You likely have the same (unless you’re a public sector employee).  When my first son was born, we paid a $10 copay.  That was it.  Oh, and a $300 upcharge for a private room.  Later, when he needed speech therapy, we paid copays, then were issued a refund check, because, it turned out, there was a no copay, it was first-dollar coverage.

But let me backtrack:  the original HMO concept was staff-model.  Its name, Health Maintenance Organization, was adopted because of the focus on preventive care, in a manner that wasn’t the norm in traditional insurance, which, at the time, did not necessarily cover ordinary annual check-ups and the like.  HMOs came about in the 1970s as doctor practices which were affiliated with particular hospitals; they were also called “prepaid healthcare” and the idea was that they were not an “insurance” product but you simply paid in advance for all your healthcare from that particular healthcare system.

What happened to them?  Some time ago, I tried to figure out the story and there is no good book on the matter. Perhaps that’s now changed.

In the 70s and 80s, they became popular — not mainstream, necessarily, but popular.  In some cases, they became too popular — doctors filed lawsuits in areas (e.g., small towns) where an HMO dominated medical practice, and pushed for “any willing provider” laws as their medical practice was limited to the portion of the population not a part of that HMO.  I vaguely recall that that it wasn’t just about losing clients to the competition but that they ended up with the less-desirable customer base.

At the same time, major insurance companies established their own version of “HMOs” which promised customers (and employers) that they could have their cake and eat it too — medical care with the low cost-share requirements of a staff-model HMO, but with thick booklets of participating providers rather than specific medical clinics to visit.  We were for a number of years in the late 90s and early 2000s enrolled (via our employer) with HMO Illinois, a Blue Cross Blue Shield of Illinois “product.”  We had to choose a primary care physician and women choose an OB/GYN, and an “Independent Practice Association,” a collection of doctors and one or more affiliated hospitals.  (In-between my first and second child, the doctor’s practice I was at, switched from an IPA associated with the hospital down the street to one a half-hour away, which was a nuisance; later, they left the HMO entirely as the networks shrank and, in our last year in the HMO, I had an annual exam with a doctor whom I had picked somewhat randomly from the provider listings.)  This worked on the basis of “capitation” — the IPA was paid a fixed fee per patient, but rather than resulting in a focus on preventive care and health maintenance, each visit consisted largely of handing out referrals to specialists to churn patients out.  This wasn’t sustainable.  (Why didn’t it work?  These weren’t groups of doctors who had come together to provide managed care, but were purely financial arrangements — and specialists and hospitals were not a part of this system in any case so shunting a patient to a specialist was a financial gain, not a loss.)

The end point of this pathway was the movement from HMO to what was called HMO-POS, where the POS was “point of service” and it referred to the creation of an out-of-network reimbursement level, and to the PPO, what we’re now generally used to today, with networks but with the requirement for referrals having been abandoned.  Was it planned, or foreseen, when BCBS and other providers set up their HMO competitors, that this would be the outcome?  Surely not.

And traditional HMOs have not entirely disappeared — Kaiser still remains, having built itself up during the 70s and 80s to such a point that laments about “the provider list is too narrow” are not relevant.  I, again, tried to dig into their story more as well at some point, to understand why there are not dozens of other competitors with their business model, but concluded that it’s just not possible for a plan to become a truly-integrated staff-model HMO in this environment.

But –

in the meantime, we are witnessing the ever-increasing consolidation of hospitals and doctors’ practices.  Locally, my nearby hospital has a growing list of urgent care centers, sites for lab work, and affiliated doctors’ practices.  They had been a wholly-independent hospital but are now themselves merging with a large hospital chain in the area.  There are many similar networks, and growing numbers of them.  As I had watched this trend, I had thought that this would make it possible for a new type of staff-model HMO, one in which alongside their usual roles in the community as medical care providers to anyone who showed up, with any sort of insurance or none at all, the entire network could offer a prepaid/self-insured “medical care product” in which care within that system would be coordinated, with doctors and hospitals alike sharing the objective of providing the best and most cost-effective care — with care while travelling or for rare circumstances requiring even greater levels of specialization being managed through a re-insurance product.  Over time, if coordinated care produced the best outcomes for patients, more patients would switch.

But there was a missing piece.  Employers want to offer their employees medical care that’s reasonably one-size-fits-all.  If you have employees scattered across the country, or even across a wide metropolitan area, it adds one more layer of complexity to your process of providing employee benefits.  In order for the way health insurance works to change, the relationship between employers and health insurance has to change.

And yes, finally, I get to why I think that the ICHRA has the power to reinvigorate health insurance — if increasing numbers of workers are “shopping” themselves, and without the constraints of Obamacare plans which are obliged to use a very small number of tools in their toolbox (high deductibles, narrow networks based on doctors willing to accept low reimbursements), then we might eventually get to the point where a hospital network might find it financially feasible to offer a coordinated care product.

Yes, that’s a big if.  I’m not an expert, and I suspect that, even if somewhere, someone is looking at taking that step, there are likely too many regulatory hurdles in the way.  But it’s a start.

 

Image: http://www.dodlive.mil/2017/10/03/usns-comfort-how-the-hospital-ship-helps-during-disasters/(U.S. Air Force photo by Staff Sgt. Courtney Richardson)

Covid update: contact tracing, hospitalizations, international comparisons

Yesterday, the state of Illinois announced that suburban Cook County is now subject to covid mitigations, in which, as of tomorrow, indoor dining and bar service will be prohibited and groups at any one gathering will be capped at 25 people.  As the Chicago Tribune reported,

By Wednesday, more than half of Illinois residents will be living under stricter measures meant to slow the latest surge of the coronavirus as suburban Cook County and the Metro East region outside St. Louis join four other regions where the state has shut down indoor dining and bar service and lowered the cap on crowds to 25.

A week ago, only one of the 11 regions in Gov. J.B. Pritzker’s reopening plan was subject to those rules. . . .

Suburban Cook County has had eight consecutive days of test positivity rate increases and seven days of increased hospital admissions. It is the first region to surpass the state-set thresholds for those two metrics at the same time. The other region have triggered tougher rules by reaching an 8% positivity rate threshold for three consecutive days. As of Friday, the rolling seven-day positivity rate for the Cook County suburbs was 7.7%.

With that context, I wanted to write down some of my recent thoughts on developments.

First, why did contact tracing fail?

Contact tracing was, after all, the subject of my May 15 Tribune commentary, in which I observed that the state’s reopening metrics required that for Phase 3, contact tracing would be fully-rolled out, and for Phase 4, contact tracing would be fully scaled up, so that tracing would begin within 24 hours for 90% of new diagnoses in a region.  Turns out, Phase 3 began according to the timeline for all the other metrics, at the end of May, and Phase 4 began at the end of June.  But according to the organization TestAndTrace, as reported at Patch, Illinois has a failing grade in their assessment of Illinois’ contact tracing, due to their very low number of tracers and lack of transparency about their progress.

With respect to Cook County, the Cook County Department of Health announced on June 11 the receipt of a $41 million grant to scale up contact tracing.  But even just last week, Daily Line reporter Alex Nitkin had this to say:

Now, the question above is, I admit, partly rhetorical.  I have my own suppositions as to why, when it really would have made a difference in the late spring/early summer, when cases were down and when Illinoisans were relatively more hunkered down — that is, when a contact tracing effort would have uncovered fewer contacts for any given individual — the state, and Cook County and the city of Chicago as well, fumbled this:  the desire to create union jobs, for one, and the focus on “equity” even when a focus on “low-hanging fruit” might have been more effective.  Various reports in the meantime have described the suspicion with which immigrants and low-income Chicagoans treat contact tracer outreach; focusing resources on parts of the state which would have a greater success rate, as well as more rural areas where there would have been fewer contacts to trace in the first place, would surely have found more success.

In any event, at this point, it is far less effective to contact-trace when cases are becoming increasingly prevalent, as is the case now.

And, in addition, it would appear that the state is misinterpreting the data that it does garner from contact tracing, in any case.

Earlier in the month, Capitol Fax provided a graph produced by the state which was used as justification for its focus on bars and restaurants.  The graph is appallingly difficult to read (and is shown only as a picture, with no data accessible), but claims that, statewide, when contact tracees were asked where they had “visited or worked” within the past 14 days, the second-largest category of response was “restaurant/bar,” with 2300 responses.  The top response was “other,” which includes “vacations, family gatherings, weddings, college parties.”

But this graph is exceedingly unhelpful.  Respondents could give multiple answers, and the graph’s “n” is given as 17,939, but that’s the total number of boxes checked; a true “n” from such a survey would be the number of people surveyed.  We don’t know what percent of tracees visited bars or restaurants, and, more importantly, we don’t know whether people who went to bars/restaurants were disproportionately likely to have been diagnosed with covid.  In other words, to tell us something meaningful, this graph would need to be paired with another one, in which a random sampling of people who matched the demographic characteristics of covid-diagnosed tracing respondents.

And, in fact, here’s my transcript of Dr. Ngozi Ezike’s comments at the press briefing last Friday, upon being asked why bars and restaurants are being singled out for closure despite being linked to only 6% of outbreaks (about the 28 minute mark):

Ezike:  An outbreak would be something if somebody works like say at a manufacturing plant and a lot of people work in close proximity and 50 people develop covid in that setting we would have that as a documented outbreak where this person knows that I was working next to this person, this person contracted the virus, a week later so did I, a week later this person did, three days later, so that is like a clearly documented outbreak.  In most cases of covid, the person who has it cannot tell you exactly who they got it from, they cannot say, “oh, I was working in this setting and all these people got it and I got similar symptoms, so in the absence of a documented outbreak all those individuals that did contract the virus the way that you look at where they may have gotten it from is to look at the time at which, the time frame from when you catch the virus to when you show symptoms or to whey you’re diagnosed, in those preceding two weeks,  we ask the cases, where have you been, and all of those places that they list, that they have been in the preceding two weeks are exposure sites.  Any of those places could have been where they contracted the virus.  And time after time, bars and restaurants come up as the number two or the number three place of all of these places frequented, so that’s why we put it as a high because it consistently comes up as a place where people who are infected listed as one of their exposure sites.

What’s remarkable is that Pritzker appears to recognized that this is a poor rationale for closing bars and restaurants, and he jumps in:

Pritzker:  And I would just add that there are literally a dozen studies, many many articles about these bars and restaurants being exposure sites, and the effect of bars and restaurants on the spread of the virus and that is why there is a focus on bars and restaurants.

Ezike’s specialty is pediatrics and her expertise within public health comes from working on health care within juvenile detention centers.  Is it possible that she just doesn’t have the grounding in statistics that’s necessary to grasp these concepts?

Second, why are hospitalizations level in suburban Cook County?

Wirepoints has been tracking key covid data for Illinois as a whole since early on.  When cases rose starting in July, in a way that did not appear to be clearly linked to the ramping up of testing (because at that point the state had already increased testing substantially), I followed their tracking of hospitalizations and deaths and observed that these numbers were holding steady, in a manner that fit the theory that the rise in cases were due to increasing numbers of low-risk young adults becoming diagnosed, or that masks were having the effect of reducing the viral load and thus the severity of the infection.

But that’s no longer the case.  On September 19, hospitalizations stood at 1,417.  They rose gradually, to reach 1,575 on Oct. 3; since then they’ve risen steadily, to 2,605 on October 24.

What’s more, deaths have been increasing during the same time period.  Ranging from the upper teens to the low 20s all summer and early fall, the 7 day average stood at 42 on Oct. 26.  It’s also difficult to make a visual judgement, but there is no apparent lag, as you’d expect there should be, from the start of the increase in hospitalizations to the start of the increase in deaths; these are occurring simultaneously.

Frustratingly, it is not easy, from the information available at the Illinois Department of Health’s website, to look at hospitalizations by region or county.  With a little bit of patience, we can look at admissions for Covid-like illnesses region-by-region:

Region 1, northwest Illinois:  hospitalizations level over the summer, then steadily increase from 4 on September 20 to 14 on October 21.

Region 2, north-central-west:  steady increase in hospitalizations over July (4 on July 3) to early August (12 on August 4), then another small increase in recent weeks (14 on Oct 22).

Region 3, central-west: again, small incease in mid-July, level to mid-October, then increase from 8 on Oct. 12 to 12 on Oct. 18.

Region 4, south- west (St. Louis area): relative peaks in late July and again in late August; decline since then to match the level of June.

Region 5, south:  level/very gradual increase through September; then increase from 4 on Oct. 1 to 8 on Oct. 21.

Region 6, east: same pattern as south, very gradual increase through end of September, then jump: 8 on Oct. 2 to 19 on Oct. 22.

Region 7, far southern suburbs/exurbs: lots of bouncing around: peak in mid-August, decline, then increase from the beginning of October to now (6 to 16).

Region 8, western/far western suburbs: increase in mid-June, level through the end of September, then steep increase since then: 14 on Oct. 5 to 27 on Oct. 23.

Region 9, northeast Illinois (Lake and McHenry counties/far north suburban Chicago): increase in June, level through August, drop through mid-Sept. and level to the end of September, then increasing from 7 on Oct. 5, to 13 on Oct. 23.

Region 10, suburban Cook County: level-ish through the end of August, a small drop through the end of September, then a jump from Oct. 2, at 23 to Oct, 22, at 49.

and Region 11, Chicago: level through July and August, drop in September to a low of 21 on Oct. 3, then up to 41 on Oct. 23.

(Note that the Wirepoints numbers are total hospitalizations; these are admissions on any given day.)

But, again, here’s suburban Cook County according to the IDPH dashboard:

Covid-like admissions, October 27 data. https://www.dph.illinois.gov/regionmetrics?regionID=10.

But at the same time, the Cook County Department of Public Health‘s own website’s reported hospitalizations have been level, showing no change other than a drop-off for the past week due presumably to lags in data reporting.  (Note: as of today, they have removed the data on hospitalizations; I have requested an explanation.)

What’s going on?  You’ll have to trust me that the CCDPH data was level, because it’s been removed, but is the fact that the state includes “covid-like illnesses” regardless of whether a patient has covid, causing an increase in the numbers?  I can well understand using this broader definition back when testing was difficult, but covid tests are no routine for anyone who enters a hospital even for unrelated reasons.

What’s more, here’s the equivalent graph for region 11, Chicago:

But here are the hospitalizations as reported by the city of Chicago (as downloaded here on October 27):

— and this, despite rising case numbers:

Ugh.

Again, are hospitalizations due to covid really on the uptick?  Or is it due to “covid-like illnesses”?  Or — benefit of the doubt here — is there something faulty about the “covid hospitalizations” figure even after tests have become available without practical limits in terms of hospital access?

Third, what about Europe?

Biden, and Trump opponents generally speaking, are willing to say that a considerable number of America’s covid infections and deaths can be blamed on Trump’s poor management of the pandemic, and it’s easy to point to countries which have had extremely low infection rates — Japan, Taiwan, South Korea.  It’s also easy to point to stunningly foolish things Trump has done and said, and the whole mask debacle, well, it’s been a debacle — insisting in March that masks were useless only to later on conclude they weren’t, but stoking substantial suspicion due to that prior insistence.

But claims that the US has been singularly incompetent in managing the pandemic are falling apart.

According to the Financial Times‘ website, measured on a cases-per-million basis, averaged over 7 days, the European Union’s rate equaled that of the US on October 11 or thereabouts.  Now it’s rate is substantially higher, at 284.2 cases per million, compared to 200.7 in the US (as of Oct. 22 and 23, respectively).  In fact, very few countries within Europe are lower than the US, and many of those which are, are seeing steady increases.  Even Germany, lauded for its successful handling of the pandemic early on, is now seeing a surge in cases, with a 14 day change of 191% for new cases and 198% for deaths, compared to an increase of 40% and 14% for cases and deaths, respectively, for the US, according to the New York Times.  (Remember, to increase by 191% is not to double, but to triple, that is, for the new case rate to be 3 times that of the original rate.)  That means that seems quite likely indeed for Germany to reach our level of cases relative to the population by Election Day, which would be ironic when Joe Biden claims that he would have had German-levels of success in avoiding infections in the U.S.

Why are cases spiking in Europe?

Does that mean that there’s nothing, really, that can be done but hope that a vaccine and/or an antibody treatment is approved, manufactured, and distributed?  What does an observation of the case increases in Europe mean for our decision-making about whether to shut down restaurants or merely restrict their capacity, or even to re-institute lockdowns?

This is where I end, as I don’t have answers to these questions, and I’ve achieved my short-term goal of writing now new information I’ve learned and issues I wanted to share.

coronavirus

What, really, is District 214’s plan for reopening? Or are they making it up as they go along?

school bus
school bus, public domain, https://www.maxpixel.net/Bus-Vehicle-Education-Transport-School-Bus-School-4406479

It’s time for another update on the hyper-local issue of the School District 214 reopening plan!  (See my prior update for my comments on the district’s officially-announced metrics.)

There was a school board meeting last night, during which no actions were taken.  The superintendent gave a brief update at the beginning of the meeting which — in all honesty — I only heard parts of, having arrived just at the start of the meeting and missing some items due to making my way to the overflow room.  According to others that were there, these comments consisted of some cheerleading statements about a band concert, internships, test kits and N95 mask access, and some comments about a teacher who passed away suddenly.

Then, this morning, the Daily Herald published an article on the meeting citing the superintendent making more substantial announcements.  Were these also a part of the initial updates?  I can’t confirm or deny.  In fact, the district livestreamed the meeting but did not make a recording available.  And, likewise, there has been no update from the district on its website, nor in e-mails sent to families of students or to residents.  But here are the key pieces of that article:

About 125 students are in school buildings, Superintendent David Schuler said, including those in special education, and those in programs such as automotive, aviation, and practical architecture in construction.

This is odd to me, given that the District 214 twitter account is still sharing pictures of automotive teachers working remotely, having the students check the fluids in their parents’ cars.  In any case, the article also says:

The superintendent reiterated Cook County Department of Public Health guidance that anyone who has been in contact with someone testing positive for COVID-19 for 15 cumulative minutes over a two-day period — essentially a few hallway passing periods — would need to quarantine.

“If you have smaller numbers, you can really stagger the times for passing time and we just can’t do that with a school of 2,000,” Schuler said. “It makes it much more challenging.”

But Schuler did announce plans to incrementally welcome back more students — as much as half of the 11,000 enrollment. Whether in this stage or next, he said first priority would be to bring back students who don’t have reliable internet, those who need academic support, those taking lab-based classes and, eventually, all freshmen.

With respect to the issue of numbers, public-comment speakers pointed out that local private schools have re-opened — and not just small schools, but Loyola Academy, with an enrollment larger than all but one district high school.  In addition, other public high schools have reopened on a rotational basis, which is not officially the plan until Cook County reaches less than 70 cases per 100,000.

(My son says:  “this is why nobody should get tested unless they have symptoms — it just drives up the number of cases and the number of restrictions.”  The trouble is that in other respects, the governor is super-focused on positivity rates, and a low positivity rate requires substantial asymptomatic testing, or, if not, a significant cold-and-flu season to increase the number of people getting tested for covid-like symptoms who don’t actually have covid.)

But this last statement of Schuler’s really set off alarm bells for me.

In the first place, the “official” plan has four clearly-delineated stages:  all-remote for a severe outbreak, “special populations” only (that is, special ed and homeless kids), rotational, and “fully flexible” (option for students to come in every day).

Brining in students with lab-based classes “in this stage or next” is not a part of the official plan as posted on the website.  Personally, I think it’s a good idea and the right thing to do, but they should not post a plan which makes the opposite statement.  So far as I can tell, they don’t even have any weasel-words in that reopening plan.  At best, one can label this unprofessional.  In reality, that communicates:  “we’ll do what we want without regard for what statements we might make.”

But more concerningly, a plan to prioritize some groups is not the rotational plan they announced for reaching 70 cases per 100,000.  Other schools have one-quarter or one-half the student body in class on a given day.  If his plan is instead to fill up the “quota” of half the enrollment by priority group, with those with various sorts of special concerns (but who aren’t the Stage 2 “special ed” kids in self-contained classrooms) coming first and freshmen “eventually” later, this suggests that non-freshmen without a concern that gives them priority simply will not come to school until Pritzker’s Phase 5, which, Trump’s hyping of a vaccine notwithstanding, is likely not until the spring, at the earliest.

Now, it’s possible that the Herald reporter didn’t transcribe Schuler’s statements correctly and, again, I can’t independently verify them because there has been nothing announced publicly by the district administration; this is all we have to go on.  It’s possible that the “eventually” refers to “before fully implementing the rotational model”, so that Shuler really envisions a process of, first, self-contained classrooms; second, other sorts of special needs kids; third, freshmen rotationally; and, finally, all students, rotationally.  But the fact that I have to parse his paraphrased comments to try to come up with a way to make it fit within their prior framework, even when it doesn’t, really, is, to put it nicely, frustrating.

I suspect that if they polled parents, at this point in time, with the question, yes or no, “do you believe that you child will attend in-person school this academic year?” most parents would say that, no, they don’t believe that.  The school district administration and school board have given parents no reason to believe they are working towards achieving this, and every reason to believe they are not.  And lacking confidence in a return-to-school will impact students, in ways such as academic progress, mental health, willingness to take “desirable” classes or participate in activities, and so on. Which means: this has got to stop, and the school board and administration must get serious about sharing information and plans, and about re-opening as soon as possible.

Don’t be fooled by “fair tax” ads!

https://media.defense.gov/2019/Feb/12/2002088973/-1/-1/0/181206-A-UM169-0001.JPG; https://www.dover.af.mil/News/Article/1755127/what-you-should-know-about-filing-2018-taxes/ (public domain/US gov)

Oh, the irony:  back in 2015, before Trumpism, long before the Illinois General Assembly placed on this November’s ballot a measure to enable a graduated income tax, I supported such a tax at my Patheos blog.  I called it “the Jane Tax Plan” and advocated for lots of tax brackets, with moderate increases from one to the next, so that there was never a point at which a jump from one bracket to the next felt punitive.  Separately, I wrote that, with respect to graduated income tax rates, ” is that it is most reasonable and appropriate to ask those who are most able to, to pay a disproportionate share of the total income tax burden.”

Which means that I might appear, were I to say, “vote no on the fair tax!” to be a hypocrite.

In reality, well, it’s a mess.

In principle, a graduated income tax is reasonable and appropriate, and, what’s more, it’s not appropriate for the state’s constitution to spell out what sorts of taxes are and aren’t permitted and, in particular, to mandate that any income tax be flat across all income levels.

In reality, I have serious doubts as to whether Illinois politicians can handle the responsibility that comes with this increased power.

It is, after all, well-established that states that succumb to temptation, end up with marginal tax rates on higher income levels so high that, first, they drive residents away, and, second, they are highly susceptible to swings in revenue, as the highest earners’ income fluctuates so much from year to year (bonuses, sales of stocks, etc.).  And the fact that the tax rates stay low(er) for low(er) earners creates a mindset that the possible tax revenue from higher earners is “free” money for the legislators’ spending wishes.

Of course, plenty of states manage to be responsible about their tax-rate-setting abilities.  But I simply don’t believe that Illinois is.

And with that in mind, let’s look at the message of the ads in support of this amendment, via the website “Vote Yes for Fairness.”

In the first place, of course, the label “fair tax” is so loaded as to be itself untrustworthy.  Why is a graduated income tax “fairer” than a flat tax?  As it happens, until Pritzker began his campaign, another group was using the “fair tax” moniker for a type of tax that Pritzker would surely label extremely unfair:  the swapping out of our existing national income tax and its replacement by a national consumption tax.  The website FairTax.org is still active, with the organization Americans for Fair Taxation, and the left-leaning Tax Policy Center, in 2015, wrote “The Trouble with the Fair Tax,” which rejects the tax because it would disproportionately impact lower-income workers.

But beyond that, here are that site’ promises, which are the same as in ads everywhere:

  • Bring our tax system up-to-date with the one used by a majority of states and the federal government
  • Lift the burden off of lower and middle-income Illinoisans by asking the wealthiest to pay their fair share
  • Require only individuals making over $250,000 a year to pay more
  • Ensure at least 97% of Illinoisans see their taxes cut or remain the same
  • Keep taxes the same or less for all small business owners making less than $250,000 a year in profit
  • Generate additional revenue to fund our schools and lower the property tax burden
  • Address Illinois’ structural budget deficit and put the state on the path toward fiscal sustainability
  • Make sure essential workers aren’t forced to pay the same tax rate as millionaires and billionaires

Are these claims legitimate?

In the last session of the General Assembly, they passed a law which sets new tax rates if the voters approve the graduated tax amendment.  These rates — which, incidentally, at the top level are not marginal tax rates at all but a jump to a new tax rate on all income — include a 0.05% drop in rate for taxpayers earning less than $100,000, allowing supporters to claim that their taxes will “drop” without acknowledging how little the drop will be.  Then, for those with incomes of $250,000 or over, rates increase from 4.95% to 7.75%, and then further to 7.9% for millionaires.  (Note that there is no differentiation between singles and couples.)

But these rates are not locked into the amendment.  Once authorized, the legislature can make any changes it likes, so that making promises such as “only individuals making over $250,000 per year [would] pay more” is extremely misleading.

In addition, that a graduated tax system may be more common than a flat tax is one thing — but that’s only one characteristic of tax systems.  As the Illinois Policy Institute reports, of those states with graduated income tax rates, it is actually a more common approach to use the marginal tax rate structure to reduce taxes on the lowest-income taxpayers than it is to “as the wealthiest to pay their fair share,” as the pro-amendment ads say.  10 states’ highest tax rate is for income of $20,000 or less.  8 states’ highest rates are at “middle class” income levels, between $30,000 – $73,710.  Only 15 states’ highest tax brackets start at upper-middle income levels, ranging from Oregon’s $125,000 to New York’s $1,077,550 bracket.  And, of course, if you’ve done the math, that leaves 18 states with flat rates.

Which means that “bring our tax system up-to-date with the one used by a majority of states and the federal government” is not really true.  A tax system in which the “wealthy” pay higher rates than most others is, generously, used by only 30% of states, or only 22% if you discard the states with top brackets in the $100,000’s range (4 states).

What’s it boil down to?

It boils down to, really, the fact that the untrustworthiness of Gov. Pritzker, House Speaker Mike Madigan, and everyone promoting the graduated income tax using this rhetoric and these misleading claims, makes a proposal that would otherwise be reasonable and appropriate, highly suspect indeed.

“Malicious compliance” and the School District 214 return-to-school metrics

school bus, public domain, https://www.maxpixel.net/Bus-Vehicle-Education-Transport-School-Bus-School-4406479

Last Friday marked that end of the second week the kids of Illinois School District 214 were “in school” — virtually, that is, except for, apparently (it’s not entirely clear), homeless kids and special ed kids.  And after countless parent pleas, the school district provided a set of metrics to chart the eventual return to school — at the end of the day/end of the workweek.

Ever heard of the expression “malicious compliance”?  That’s what it felt like.

Here are the metrics:

The plan requires that the weekly cases per 100,000 for suburban Cook County drop from the current 112 to no greater than 70, to enable a hybrid learning option, in which students will be in buildings rotationally.  That’s 10 cases per day, per 100,000.  In order for the students to return to class “full time” (with the option remaining to attend remotely), cases must be at a rate less than 7 per 100,000 per week.  In addition, if at any point, the testing positivity rate increases to over 3%, all students will be quarantined for 14 days.  (This is not clearly defined — is this 3% of the student body or 3% of those students who happen to be tested at any point in time, by obtaining records from the state or requiring that families report all tests?)  In addition, “outbreaks” will require 14 days remote.

So here are some questions:

Are these new metrics feasible?

Are they appropriate for their purpose?

And was the school honest in deciding on and communicating these metrics?

Are these rates feasible?

On the face of it, the 70-case requirement appears feasible — at least, according to the New York Times, a considerable number of states have rates lower than this, including Arizona (53 per 100,000), which was not took long ago the site of a substantial outbreak.  What’s more, suburban Cook County was below this metric until the first week of August, when it jumped from 67 to 99 per 100,000 with a stable or increasing positivity rate that suggests that this is not a matter of increased testing.  At the same time, there appears to be a significant drop in the “cluster %” — which is not defined except indirectly:  “this metric helps explain large increases in cases.”  What explains the suburban Cook increase?  It’s well past the time that the protests, or the restaurant reopenings, could account for it, and the state’s warnings come without any explanations on their part — which means that there’s no way to understand whether the current cases per 100,000 rate is the result of a true increase in incidence or an artifact of measurement, an outbreak that’s localized to a particular area or group, whether partying young adults or long-term care facilities.

(One explanation is that of a collective burn-out and weariness with complying with restrictions.  Does that really explain the suddenness of the jump?  I had wondered whether the domino-falling cancellations of in-person school, including at colleges, have played a role, as resignation that mitigation makes a difference results in less compliance.)

And the 7 case requirement?

That isn’t remotely achievable — at least not without a vaccine, which won’t happen until sometime in 2021 at the earliest.  Not even the state with the lowest incidence rate — Vermont — has a rate that low (it’s 8 cases per 100,000 there).   Even in countries cited as the top role models we don’t generally see rates this low — in Germany (again according to the NYT) only the very rural, isolated former East German states have rates this low.  In Canada, Ontario and Quebec are right at this cut-off.

The District 214 document also references “Northern Illinois Return to School Metrics,” published August 14, 2020, but it is not clear whether their incidence rates are per day or per week.  If per day, they call for in-person learning when there are fewer than 49 cases per 100,000 per week and hybrid learning with fewer than 98 cases per week — a looser requirement.  If per week, the numbers are 7 and 14, far stricter.

In any event, their metrics appear to come from another document, from the Harvard Global Health Institute, which sets forth four categories, red, orange, yellow, and green, each with weekly case rates which match those of the district.  But, again, do they offer feasible metrics, or was this developed in an Ivory Tower?  The document, after all, begins with the statement, “The single best policy to support school re-opening prior to the development of a vaccine or treatment is suppression of COVID to near zero case incidence via Testing, Tracing and Supported Isolation (TTSI).”  And the reason for keeping high school students virtual until the “yellow” or even “green” case rates are achieved, in the Harvard model, appears to be that the high schools’ classroom space would be used for providing elementary and middle-school kids with classroom space with sufficient social distancing:  “if sufficient pandemic resilient learning space is available AFTER allocation to K-8, grades 9-12 open on a hybrid schedule.”  This is clearly not relevant in the case that elementary and secondary districts are separate entities.

(In any case, this seems to be a bit odd — are they assuming that enough extra teachers will be hired to enable smaller class sizes, so that elementary students will require more classrooms?  That any school district will have a limited number of suitably-ventilated classrooms?  That an elementary/middle school teacher with students rotating in will have separate classrooms for the Monday/Tuesday vs. the Wedenesday/Thursday groups?)

And “near zero”?  This requirement sounds absurd.

Are these metrics reasonable and appropriate for the district?

There are two problems with these metrics:  first, that they are based on the entirety of Cook County, and second, that they have nothing to do with school-specific issues.

In the first place, using a metric for all of suburban Cook County fails to acknowledge the vast geographical difference that the county spans — it is effectively two separate areas, divided by O’Hare Airport.  And that’s not merely a matter of saying that “our” part of suburban Cook is “better” — more middle-class, more compliant with the rules.  A county-wide metric means everything is out of our control.  For our students to wear face masks and steer clear of parties won’t make a difference if outbreaks elsewhere are driving the increase, so there’s no incentive to cooperate.

Even the Harvard document says:

For schools, the first reference point should be district and county, and decision-makers should consider both the rates in their own districts and counties and the rates in the districts and counties with which they share a border.

Of course, some school districts can form the larger portion of a county, but ours clearly does not.

(How does the county compare with our corner of it?  Over the past month, the cases per 100,000 week average was about 60 for the towns in which our high schools are located.  That’s considerably less than the 92 cases, averaging the past 4 weeks, though — watch this space — I’m missing data that I will try to track more carefully over the next week.)

What’s more, these metrics have nothing to do with whether schools can deliver instruction safely.  What matters is whether in-person instruction is causing the prevalence of covid to increase or not.  A more reasonable approach would be to gradually bring students in and identify whether there are outbreaks traceable to in-person instruction.  If outbreaks are the result of students attending parties outside of school, but facemasks and other precautionary measures mean there are no outbreaks at school, then school is being closed needlessly — and it may be that school closures are increasing outbreaks, if students are more likely to party in larger groups when they lack the ability to interact with each other at school.

Was the school honest in deciding on and communicating these metrics?

When the school district announced that students would not be able to learn in-person, they blamed overly-burdensome state requirements.  In fact, here’s what the school district still says:

While the latest plan called for groups of students, including special education and homeless students, to be educated in-person beginning August 24, new guidance from the Illinois Board of Education — including that nurses wear specific masks we currently do not have — means that may not happen.

We still hope to get small groups of students back into buildings as soon as is practical, but it is imperative that we follow the guidance from ISBE, the Illinois Department of Public Health and other entities.

The new plan, with county-wide incidence metrics, has nothing to do with the Illinois DPH requirements.  They complained that nurses would be obliged to wear specific masks (to be clear, only when treating a student suspected of being infected) — but the new metrics have nothing in them about availability of specific types of PPE.  The school superintendent further objects to county quarantine requirements, but their metrics don’t address this (except indirectly — that is, if no one ever comes on campus, no one will be kicked off campus for quarantine).  They’ve even changed the plan’s stages, which previously included the intention (however vaguely stated), “to bring in vocational students and dual credit lab-based classes” as an intermediate step after the special ed kids are in but before the general rotational classes begin.  Now this is gone (and a friend reports that “fabrication” class students are getting personal “woodworking” kits instead).

Another concerning item is the newly fleshed-out policy regarding face masks (page 21 of the document); where they’d previously said students will be required to wear face masks, full stop, they now list a series of steps taken for noncompliance, in which they will include staff for “problem-solving” and only after a long list of steps will a student be excluded from school.  This is not a serious policy — this is not the work of someone who believes “we need to do everything we can to get kids into classrooms as soon as possible”; it’s someone following a script on disciplinary procedures without any greater sense of urgency than, say, a kid who vapes in the bathroom.  (Likewise, a noncompliant staff member is afforded the full benefit of the “progressive discipline” of their union agreement.)

What’s it mean?

Was this all nothing more than BS, than an arbitrary set of excuses?  Is the new set of metrics essentially a form of malicious compliance, giving a middle finger to parents who had pleaded for a specific path forward, by giving them metrics that are useless?  In fact, their new plan provides no particular reasoning for why they have chosen the benchmarks they have, which lends credence to the cynical assumption my son and his friends have made:  “no in-person school this year.”

I am even tempted to take it a step further:  at the last school board meeting, the school board did not simply vote to authorize the superintendent to make whatever decisions he chose.  They voted to authorize a specific plan, one that included bringing vocational/dual credit kids on-site as an intermediate step, one that pledged to get everyone else on-site as soon as possible, one that promised that the reason for the delay was state/county roadblocks which they would work to resolve.  This new plan, with these metrics, is not the plan the school board approved.

Of course, it doesn’t matter.  Watching this play out, reading through past meetings’ minutes and seeing that the school board appears to rubber-stamp administration decisions (or perhaps work out a consensus out of view of the public) makes it clear that there is no accountability, except to the degree to which residents vote these board members out of office when their terms expire.

So can parents and residents actually have a voice?  Can we call on the school district to revise their metrics?  Would they even listen to us if we did?  To be perfectly honest, I just don’t know.