++Study: UK patients died more often and were readmitted more frequently after hospital mergers. +
++The past few decades have seen the growing concentration of hospitals and other health care services in the United States. In 2005, about half of US hospitals were part of a larger system. By 2017, two-thirds were. Most places in the US have what is considered a highly concentrated hospital market, which means one company operates most of the hospital facilities in the area. +
++This concentration is one of the most significant trends in American health care. It can lead to fewer options for patients and higher prices. Recent research has found that higher hospital prices are driving much of the recent increases in US health care spending. Hospitals that are acquired by larger systems sometimes cut important services, such as maternity care, forcing patients to travel hours to receive medical services they used to be able to get locally. +
++As I wrote late last year, America’s smaller community hospitals, many of which operate with a deficit, have often been forced to explore mergers with larger health systems to keep the doors open. +
++Higher costs are bad news for patients. But it’s notoriously difficult to analyze the clinical consequences of these mergers: Does a more concentrated hospital system also lead to worse care? There are many variables in play, and mergers can disrupt the health care market (through those higher prices) in ways that make it difficult to isolate how any changes to a hospital’s operations post-merger have contributed to any increase in deaths or readmissions. +
++A new study of hospital mergers in the United Kingdom is trying to shed light on that question. It found that after hospitals merge, patients are more likely to die during or soon after a hospital stay and they are also more likely to be readmitted a second time in the near term, according to new research from scholars at Cornell University and the University of London. These increases begin within a few months of the merger and persist for at least two years, the researchers found. +
++Most UK hospitals are publicly owned, but the national government has still made mergers a priority in order to improve its health system’s performance by merging hospitals that are struggling financially with another hospital. In practice, a UK hospital merger often looks a lot like a US hospital merger does: Separate facilities that once operated under separate management are brought under the purview of one board and one senior leadership team. +
++The size of the mergers’ impact, especially on mortality, is substantial: The likelihood that a patient will die in the hospital or within 30 days of being discharged increased by 0.4 percentage points, a 27 percent increase from the pre-merger mortality rate of 1.4 percent. They are also 11 percent more likely to be readmitted within 30 days of being discharged from the hospital. +
++At the 139 hospitals involved in 13 different mergers from 2006 to 2015, this increase in mortality and readmissions translated to 60 additional deaths and 140 readmissions when compared to a large control group of UK hospitals that did not experience a merger over that period. +
++“Mergers and acquisitions raise a number of antitrust concerns, chief among them that market consolidation may lead to higher prices or poorer product quality,” the authors, the University of London’s Elena Ashtari Tafti and Cornell’s Thomas Hoe, wrote to open their conclusions. “Both of these effects are incredibly important in health care markets, which have experienced significant merger activity over the past two decades, and where prices and quality can literally be a matter of life or death.” +
++In the US, the evidence on how mergers affect the quality of care is limited and mixed. But the UK and its National Health Service are arguably an ideal setting to study these effects, the authors argue, because payment and the mix of payers do not change as a result of the merger. That removes one variable that can confound similar research in the US. They studied the period from 2006 to 2015 in part because it followed reforms to the NHS that gave patients more choice about where to seek care and put hospitals on a fixed budget for their operations. +
++Ashtari Tafti and Hoe tout that special feature of the UK health system as a virtue of their research. They also point out that their findings are the logical extension of prior studies that found the quality of care was better in more competitive hospital markets. But they acknowledged more work needs to be done to determine whether the results would be replicated in a different health system with a different payment structure, such as the US. +
++I asked Hannah Neprash, a health care economist at the University of Minnesota, who did not contribute to the research, whether she thought what the researchers detected in the UK would be applicable in the US. She pointed out that the study sample was fairly small (13 mergers affecting 139 acute care hospitals; for context, the UK control group included about 1,100 hospitals and the US has about 5,000 similar facilities). She also noted some of the specific findings (such as a particularly sizable increase in kidney-related mortality) that demand more scrutiny and explanation, and the researchers cited how specific changes in a hospital’s operations post-merger affected clinical quality should be the subject of future inquiry. +
++“For me, there’s a lingering question about generalizability, but that isn’t really because of the differences between US and UK hospital stuff,” she said. +
++Patients in the US already report a worse experience when treated at hospitals that have gone through a merger. This new research suggests that there is also a measurable effect on the more objective quality of care they receive. +
++The US health system, given its perverse financial incentives, has driven more and more hospitals to merge together in an attempt to stay open, to operate more efficiently, and in theory, to better coordinate services for their patients. Federal regulators have tried to stop those mergers at times, but they face various obstacles and constraints. Hospitals have meanwhile made the case that consolidation does actually benefit patients — with little empirical evidence to contradict them — to justify those mergers to public officials. +
++But the lingering concern has been that the quality of care could deteriorate if hospitals face less competition. What Ashtari Tafti and Hoe saw in their research indicates those concerns should be taken seriously as regulators review future mergers and acquisitions. +
++A new study suggests Russian trolls had little impact. But there was more going on. +
++The Russian trolls were overhyped. +
++That’s the implication from a new study in Nature Communications, written by a team of six academics who tried to assess whether the Russian government’s Twitter propaganda effort during the 2016 campaign actually changed users’ minds. “We find no evidence of a meaningful relationship between exposure to the Russian foreign influence campaign and changes in attitudes, polarization, or voting behavior,” the authors wrote. +
++This isn’t a surprise to me — I’ve long believed the Russian troll farms had little impact. But with the afterlife of the Trump-Russia scandal remaining fiercely contested — with many on the right and some “heterodox” leftists continuing to question whether Russia did anything at all of significance — it’s worth looking back and taking stock of what the Russian government did do that year. Because it wasn’t nothing. +
++Basically, the Russian government tried to intervene in the 2016 election, and it did so in two main ways. +
++First, there was that social media propaganda effort: the Russian trolls. On Facebook, Twitter, and Instagram, Russians posed as Americans and posted content designed to inflame US political tensions, often attacking Hillary Clinton and supporting Donald Trump. This happened, and it was rather unusual, but as this new study corroborates, there’s no convincing reason to believe it made any difference to Americans’ voting behavior. The Russian propaganda was just some more drops in an ocean of media and social media messaging that Americans were swimming in. +
++Second, and more consequentially, there were the stolen emails: the hack-and-leak. Russian intelligence officers hacked and obtained emails and documents from many top Democrats and had those put out publicly — giving some to WikiLeaks, providing others to reporters, and posting more on websites they controlled. +
++These hacks and releases did make an impact — notably, they were a negative story for Clinton that simmered throughout the last month of the campaign. But did they swing the election? That is, in a counterfactual world with no Russian interference, would Clinton have won? My assessment is “probably not,” but it’s difficult to conclusively say for sure. +
++Still, these interventions were quite unusual in the context of American elections; it was appropriate to treat them as a big deal and understandable that Americans might resent Russia trying to swing their votes. There were real victims here, in the people who saw their private correspondence dumped on the internet, and it’s certainly important to deter interventions like this from happening in the future. +
++The Russian trolls didn’t swing the 2016 election +
++The Russian social media propaganda effort was carried out by the Internet Research Agency, an organization based in St. Petersburg and funded by Yevgeny Prigozhin — a Russian oligarch close to Putin who also heads the Wagner Group (a paramilitary group active in the Russia-Ukraine war). The IRA is not officially a government agency, but a bipartisan report from the Senate Intelligence Committee concluded that “the Russian government tasked and supported” its 2016 election interference efforts. +
++Employees of the IRA created online accounts, claimed to be American, and posted inflammatory or trollish material about US politics. Much of this material was rather crude or silly, but the overall thrust was clear: It tended to praise Trump and attack Hillary Clinton. The IRA also paid for online ads featuring the following pro-Trump, anti-Clinton messaging, as seen in this table from an indictment brought by Robert Mueller’s team, which was tasked with investigating Russian interference with the election: +
+/cdn.vox-cdn.com/uploads/chorus_asset/file/24369542/Screen_Shot_2023_01_18_at_2.54.05_PM.png)
Internet Research Agency indictment, US Justice Department
++All this was the source of much fascination and media attention when news of it emerged after the election. Facebook estimated that IRA messaging reached as many as 126 million people on their platform, which certainly seems like a big number. “It leaves all of us who use social media to keep up with friends, share photos and follow news wondering: How’d the Russians get to me?” the Washington Post’s Geoffrey Fowler wrote in November 2017. +
++But there were always solid reasons to doubt that the IRA posts had much of an impact, despite those scary numbers. If I scroll through Twitter for just 15 minutes, I could be “reached” by messages from hundreds of sources, if not more. I’ll use the metaphor again that these were drops in an ocean: Americans were swimming in messaging about the 2016 election from all sorts of traditional media and social media sources for months (as well as the campaigns and their ads), and there was no reason to believe Russian posts or ads had extra-special persuasive powers that all those other messages lacked. +
++Now, the authors of the Nature Communications study — Gregory Eady, Tom Paskhalis, Jan Zilinsky, Richard Bonneau, Jonathan Nagler, and Joshua A. Tucker — have conducted their own analysis driving this home. Back in 2016, they surveyed nearly 1,500 US Twitter users at various points in the campaign, returning to those same respondents to track how their opinions changed. They also analyzed all the Twitter accounts those respondents followed to see how many were exposed to Internet Research Agency content. +
++Overall, they found that 70 percent of exposures to IRA posts were concentrated among 1 percent of their respondents, and those respondents were mostly highly partisan Republicans who already liked Trump. That makes sense, given what we know of social media — if you go looking for anti-Clinton, pro-Trump content, that’s what you’ll find, either due to algorithmic recommendation or the accounts you follow simply retweeting messages they agreed with without knowing too much about who was saying them. And that’s the sort of content the IRA was providing. But the finding suggests the IRA messaging was not finely calibrated to target wavering swing voters. +
++The authors also put the exposure to this messaging in perspective by finding that users had far more posts from traditional media and politicians in their timelines than Russian trolls — an “order of magnitude” more, they write. And ultimately, their survey results “did not detect any meaningful relationships between exposure to posts from Russian foreign influence accounts and changes in respondents’ attitudes on the issues, political polarization, or voting behavior.” +
++Now, it is true that this is just a study of Twitter posts and not other social media platforms like Facebook where the IRA was also active. The overall logic is sound, though. Americans can certainly resent the Russian effort to propagandize their views, and Mueller’s team argued that much of what they did violated US laws. But the Russians didn’t have some magically effective messaging that warped Americans’ minds and forced them to support Donald Trump. +
++The hack-and-leak was a bigger deal (but still may not have swung the election) +
++In 2016, the GRU, Russia’s foreign military intelligence agency, went on a spree of hacking of Americans involved in politics or government. +
++Using simple spear-phishing emails (links to a fake Google page that asked people to enter their password), they obtained access to the email accounts of Clinton campaign chair John Podesta, as well as several Clinton staffers, volunteers, and advisers. According to the Mueller report, they spear-phished an employee of the Democratic Congressional Campaign Committee, which got them credentials for access to the DCCC computer network and eventually the connected Democratic National Committee network. The hackers then used malware to scoop up emails and documents. +
++(Some critics of the Russia investigation like journalist Matt Taibbi still purport to be skeptical that the hacks were the Russian government’s doing, but Mueller’s report and his indictment of 12 Russian intelligence officers provide a wealth of specific detailed allegations about exactly how these hacks happened and which specific officers and units in the GRU were responsible. This is inconvenient for the Russiagate skeptics, so they tend to ignore it.) +
++Foreign hacking is far from unusual; the Chinese government, for instance, was said to have hacked Barack Obama’s and John McCain’s presidential campaigns in 2008, and the US has likely done a fair amount of it as well. The jarring departure was what happened next: The stolen information began showing up publicly, in massive accounts. (Another unusual aspect was that one major candidate openly welcomed this intervention, with Trump publicly urging Russia to “find” more Clinton emails.) +
++The GRU used the persona of “Guccifer 2.0” (“Guccifer” was a name used by a jailed Romanian hacker) and registered a website, DC Leaks, posting hacked material there and providing some to reporters. But two specific batches were saved for WikiLeaks, a nonprofit that had posted leaked US government material in the past. +
++First, in late July 2016, just before the Democratic National Convention, WikiLeaks posted thousands of DNC emails and revealed that many DNC members privately spoke of Bernie Sanders with disdain. The revelations drove DNC Chair Debbie Wasserman Schultz and other top staffers to resign, and overall made an ugly start for the Democratic convention. +
++Second, in early October 2016, WikiLeaks began posting Podesta’s emails — and would continue to post them, in batches, up through the election. The Podesta emails weren’t as explosive, but in anyone’s private email there will be embarrassing material they’d prefer to keep private, and if that embarrassing material is only being released about one candidate, there could be an impact. So each new release drove some media coverage, and they were touted constantly by Trump on the campaign trail, who often baselessly claimed they revealed some malfeasance or another. +
++Trump sank in the polls for the first half of October, as controversy over his Access Hollywood tape hit the news. In the second half of the month, the news cycle moved on and his poll numbers rebounded. He didn’t pass Clinton in the polls, but he got closer — close enough to pull out a win by less than 1 percentage point in three key swing states. +
++Yet I would be hesitant to claim that the drip-drip-drip of Podesta email coverage was responsible for Trump’s recovery. Part of it could simply be about Republican partisans briefly turned off by his scandals “coming home” to him before the election — a process that may have unfolded even if there had been no Russian interference. (Trump improved in the polls in the last half of October 2020, as well.) +
++The case could be made that, simply by keeping the words “Clinton” and “emails” in the news for a month, the Podesta releases hurt her campaign (since any coverage of the leaks would remind voters of a separate matter, the FBI investigation into Clinton’s emails). Still, it’s far easier to make the case that FBI Director James Comey’s late October letter saying new Clinton emails had been discovered changed the outcome, as Nate Silver has argued, than the Russian hack-and-leaks. The Comey letter was a discrete event that dominated headlines and preceded a sharp change in the polls, while the Podesta leaks were one of many stories simmering in the background throughout October. +
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+So I’ve never been persuaded that Russia fully got Trump elected. That is a high bar, though, and despite the overhyped Russian trolls, it seems to me the hack-and-leak was a consequential intervention that damaged Clinton and the Democrats to some extent. And it really was an attempt to affect Americans’ votes and hurt a presidential candidate who Russia didn’t like — an attempt that violated US laws against hacking and disclosing campaign activity. The intervention was real, the investigation into it was justified, and the anger at the Russian government for what it tried to do is justified as well. +
++Biden can end the debt ceiling. But can he handle the bond market? +
++So it’s come to this: another debt ceiling crisis. +
++This is the fifth standoff I’ve covered as a reporter. There was the big one in 2011, of course, but then the 2013 standoff related to Obamacare, the lower-profile standoff in 2015, and the 2021 fight that required a temporary change to the Senate filibuster. I’m 32 years old. As I tell myself in the mirror every morning, that is not old. And I’m on my fifth debt ceiling crisis. All of this has happened before, and it will all happen again. +
++The first-best solution to the standoff between President Joe Biden and the new Republican majority in the House would be for the latter to simply relent and pass legislation repealing the debt ceiling, or at least raising it without strings attached. House Speaker Kevin McCarthy is clear he won’t do that; he got his speakership specifically by promising the least responsible members of his caucus that he’d hold the debt ceiling hostage. But past speakers in his position, notably John Boehner in 2013, have blinked and wound up passing a “clean” debt ceiling bill anyway. Hopefully he does the same. +
++The absolute worst solution to the standoff would be for the federal government to default: to stop paying interest on its loans, or paying for programs from Social Security to the military, sending the economy into recession and the world into a financial crisis. +
++Somewhere in the middle are the two likeliest outcomes. One is for Biden to, like President Barack Obama in 2011, come to the table and cut a deal with McCarthy for a debt ceiling hike in exchange for spending cuts. This would avoid a recession but likely involve cuts to important programs from education to health research, which could have major negative long-term repercussions. +
++The final option is for Biden to use executive action to render the debt ceiling moot. There are several ways for him to do this, which I ran through in this piece. The funniest involves minting a platinum coin worth hundreds of billions or trillions of dollars. The most boring involves issuing a novel kind of debt to fund the government. Somewhere in the middle are the options to invoke the 14th Amendment and claim the debt ceiling is unconstitutional, or to claim that obeying Congress’s previously passed spending and tax legislation forces the president to ignore the debt ceiling, which some experts consider the least unconstitutional option. +
++Debates about these options often devolve into discussions of legal arcana and political perceptions: would it look bad for Biden to seize more power like this? Would it seem silly to mint a trillion-dollar coin? And while the legal details and the politics matter, I think much of the discussion of these options gives short shrift to their biggest challenge: the bond market. +
++The bond market challenge for the debt ceiling +
++“I used to think if there was reincarnation, I wanted to come back as the president or the pope or a .400 baseball hitter,” the political consultant James Carville once quipped. “But now I want to come back as the bond market. You can intimidate everybody.” +
++Bond traders obviously love that quote, but it’s not just gas for their egos. Modern governments rely on international bond markets to finance themselves, and while those governments’ control over their currencies gives them some protection from the vicissitudes of the markets, this power is hardly absolute. History is littered with cases of governments forced to abandon policies because of bond market revolts. Just a few months ago, a mass selloff by currency and bond traders forced the Tory government in the UK to abandon its plans for a massive deficit-ballooning tax cut and axe Chancellor of the Exchequer Kwame Kwarteng, before Prime Minister Liz Truss herself was forced to resign after just 45 days in office. Banks like Citigroup were openly declaring that unless the UK got a different prime minister, the markets would continue to punish it. +
++We know how bond markets respond to routine increases in the debt ceiling that are not attached to any other policies: they don’t at all. At first glance, the debate around the October and December 2021 debt ceiling increases, which were contested but not in much doubt given Democratic control of Congress, didn’t cause any major changes to the interest investors demanded on short, medium, and long-run Treasury bonds. Yields on those bonds didn’t spike as that debate progressed. +
++We also know how bond markets respond to actually dangerous debt ceiling standoffs, even if they ultimately result in the ceiling being increased. The Government Accountability Office estimated that the 2011 fight, which came really close to disaster, raised interest rates by enough to cost the Treasury $1.3 billion in 2011. That’s not nothing, but it’s pretty tiny in the scheme of the federal budget. By far the largest costs of that showdown were the budget cuts enacted in the deal Boehner and Obama cut. +
++What we don’t know is how the bond markets will respond to Biden making the debt ceiling history, whether through a platinum coin, or invoking the 14th Amendment, or some other means. I certainly don’t know, but people far more expert than me don’t know either. “I would stick with the answer, ‘I don’t know,’” Shai Akabas, director of economic policy at the Bipartisan Policy Center and an expert on the debt ceiling, told me. Unpredictable market reaction, he said, “has been my biggest concern about all these approaches, not that the substance would create some major economic disruption itself.” +
++David Kamin, an NYU law professor and former senior economic adviser to Biden, has said the same: if Biden declares he’s ignoring the debt ceiling, “Republicans will surely scream that he is acting illegally and that the debt issued over the limit is invalid. … it’s imaginable that the market could react badly — and shoot up interest rates on Treasuries.” Minting the coin could have the same result. Kamin isn’t saying this will happen: just that we’re in truly uncharted territory and it might happen. +
++If that just means the inflation-adjusted interest on five-year Treasury bonds goes from, say, 1.42 percent to 1.75 percent (to use the GAO’s higher-end estimate of what happened in 2011) … honestly, that seems fine. It’s not great but it would be a small price to pay for ending the debt ceiling. +
++But the freakout would be longer than in 2011. The matter would go to the courts. Some lower courts would likely rule against the Biden administration, which would spook markets more. The Supreme Court might ultimately rule against the administration, suggesting that its bond payments since it declared it would ignore the debt ceiling were illegal. That could push interest rates really, really high, as investors realize some of the bonds they own might have been illegally issued and perhaps not pay out. +
++And not just on government debt! Economist Filippo Gori has looked at how the 2011 crisis affected the cost of loans not just for the government, but for banks. He found that about half of the increased borrowing costs were passed along to banks. And if bank interest rates rise, then everyone’s interest rates rise. Other businesses borrow their money from banks, and banks will only lend them money if it’s profitable, which means the banks have to charge more than they themselves paid to borrow the money they’re lending out. So all of a sudden everyone’s interest rates are increasing. The Federal Reserve sometimes increases interest rates (as it has in recent months) specifically in order to get people to spend less money and slow down the economy. A debt ceiling crisis could have a similar effect, and potentially a bigger one. It’s easy to imagine this resulting in a full-scale recession. +
++This is not a problem unique to ideas like the 14th Amendment option or minting the coin. If the US were to hit the debt ceiling and the Treasury chose (as it was prepared to in the Obama years) to “prioritize” payments, paying interest on debt and a few select government programs but otherwise skipping out on trillions in government bills, bond markets would almost certainly go nuts. If the Treasury stopped paying interest on debt, and defaulted, that would be as bad or worse. Compared to those options, basically anything from minting the coin to issuing new kinds of debt is far, far preferable. +
++I also think these are risks worth taking relative to the option of making spending concessions to House Republicans. The trillion-plus dollars of spending cuts enacted in 2011 were harmful. They hurt millions of real people deeply. They undermined our ability to prepare for pandemics, right before we experienced the worst pandemic in a century. Worst of all, they taught congressional Republicans that they could take the debt ceiling hostage and extract big concessions, a lesson they are taking to heart now. The only way to break that precedent and prevent the ceiling from being used as a hostage for decades to come is for the debt ceiling to end — by legislation if possible, by fiat if necessary. You have to shoot the hostage. +
++But I think it behooves supporters of these options, like myself, to think more seriously about how to answer the challenge of the bond market. I can imagine Biden and his advisers making a choice between a deal with McCarthy and something like minting the coin, and defaulting to the former because there’s less bond market risk, and thus less risk of crisis and recession, involved. I think they’d be wrong, but it really is true that making a spending deal would have more predictable consequences in this regard. The 2011 deal did considerable harm but did not result in a recession, which would have been even worse. +
++Convincing the administration to take another path requires figuring out some way to reassure markets in the aftermath of Biden nullifying the debt ceiling, and to prevent the legal risk inherent in that measure from wreaking economic calamity. I don’t know how to do that myself; if I did, I’d say something. But luckily there are many people who know these markets better than I do who are hopefully working on ways to make this option more attractive to the administration. If Biden isn’t persuaded, we could be in for another decade of spending retrenchment and a lifetime of debt ceiling crises to come. +