Friday, November 11, 2016

What's in Store for Obamacare?

November 11, 2016

The election upset took most of us by surprise. Given the tenor of the lead up to the election and Republican control of Congress, the healthcare space sees Obamacare squarely in the crosshairs.

In the broader public’s mind, Obamacare or the Affordable Care Act is viewed mostly as the individual mandate, exchanges, and certain provisions that impact coverage like pre-existing conditions and adult children remaining covered through a parent’s insurance. The ACA is much more than just these items. It was intended to be a massive shift in how healthcare is financed and managed. And like any public policy, especially one that is trying to manage $3T or so in spending, the ACA was in need of serious adjustments. The high profile problems with the exchange business would have to be tackled regardless of who was elected. 

While it’s impossible to predict how it will ultimately play out, here’s my take.

Some modifications to individual insurance, but mostly status quo
What will stay: accepting members regardless of pre-existing conditions and the ability to keep adult children under 26 on their parent’s insurance. These have been very popular pieces of healthcare reform and the public is unlikely to support any change.

What will change: the health exchanges are the most visible sign of Obamacare, covering 12.7 million people this year, with a significant surge in enrollments occurring this week. Expect a “rebranding,” and if previous Republican thinking holds, a move towards allowing insurers to sell across state lines as a means to introduce competition in pricing. Most policy research suggests that this will not make a significant impact to pricing provided that the pre-existing conditions guarantee is maintained, but there is a strong will to remove government intervention in the model, so expect it to be the initial strategy.

Medicare will be untouched; Medicare Advantage will remain strong and continue to grow
MA will be strongly in play for two reasons: first, in general tinkering with Medicare, a popular program, is incredibly dangerous politically. Second, Medicare Advantage was originally conceived of as a private-market alternative to traditional fee for service Medicare. Despite concerns about the overall cost of the program as compared to traditional FFS Medicare, expect MA plans to gain traction and continue to be a key driver of revenue for many health plans.

Value Based Contracts and ACOs will still be in play
While the concepts and programs of Accountable Care Organizations and Value Based Contracts are hallmarks of the ACA, they are largely hidden from public view, despite the fact that 23 million Americans are now being serviced in some type of ACO arrangement. This is more than CMS at work. As of 2015, over 132 private payers (health plans and employers) are now engaged in some type of ACO activity. Even if CMS pulls back on its aggressive plans to move all of its payments to some type of value basis, the horse is out of the barn. The effectiveness of these types of programs, while incremental, is meaningful at controlling costs. Expect commercial payers and providers to be actively engaged in ACOs and VBCs for the foreseeable future.

Wild Cards: Medicaid Expansion, Drug Costs, Medical Loss Ratio
Extremely hard to predict. This is where the alchemy of lobbying will come into play. Medicaid expansion not only helps millions gain coverage they wouldn’t otherwise have, the dollars that are flowing into hospitals in expansion states are shoring up billions in what would otherwise be uncompensated care and bad debt. Expect these stakeholders to be highly vocal in the coming months as healthcare employers (especially rural) are a significant driver of good quality, well-paying jobs in many cities.

Drug costs are a rallying cry for payers and consumers. Expect the administration to be torn between heeding a populist call for relief and a pro-business mindset led by the pharmaceutical industry.

Similarly, we could expect to hear calls to adjust the Medical Loss Ratio (MLR) for payers if the costs of covering the individual market are in any way capped to protect consumers or if additional benefits are added to individual plans to assuage consumers over prices increases, for example by mandating Behavioral Health benefits as a component of all coverage.

Regardless of where one stands politically, it’s one thing to repeal a policy of this magnitude that impacts 20% of the US economy. It’s wholly another to replace it with another policy that will make an appreciable impact on those costs as the non-partisan Congressional Budget Office noted in June of last year. The landscape is dynamic and will be for at least the next decade. But it would be no matter who is elected.

However, the principles of improving population health, patient experience and reducing the overall cost of care will have to be addressed if we are going to meaningfully impact cost and outcomes. Among other tactical items, that will require continued focus on reducing variability in systems and the reliability of data to guide both systemic change and improved quality of care.

Monday, October 17, 2016

A slightly dated list of places to check out in New Orleans

All of these distances apply if you are staying in or around the Marigny, which I believe is an ideal location to experience the city.

Marigny – Triangle (very close to you)
Spotted Cat – great music club, little or no cover, great dancing
Dba – cocktail lounge with cool New Orleans bands
La Peniche Horn's – a fine update of an iconic location with good breakfasts by the Slim Goodies people.
Snug Harbor – Burgers as big as your head

Marigny – Rectangle (a cheap cab ride/Uber away - <$8)
Mimi’s in the Marigny (Bar-upstairs they serve tapas and have great bands play in an intimate setting)1
Orange Couch – Great coffee shop and an easy walk from Royal Street Inn.  During the day, the neighborhood is a visual delight2

French Quarter
Coop’s – Dive bar with a great kitchen of classic food.  Oyster po-boys. 3
Cosimo’s – What a bar in the French Quarter should be.  Local, chill and affordable4
Molly’s on the Market – bar with a great jukebox, people watching.  Check out the frozen Irish Coffee.  This place stayed open the whole time through Katrina and the aftermath5

Mid-City (take the Canal Streetcar to these places)
Mandina’s – Seriously old-school seafood joint6
Brocato’s – a quick jog from Mandina’s.  Family owned ice cream shop that has been blowing minds for 75 years7

Uptown (take the St. Charles streetcar to these places)
Cooter Brown’s – maybe the world’s best bar food.  Try the Radiator Special (1/2 shrimp/oyster poboy with melted cheese on top) 8
Mat and Naddie’s – excellent (but not pretentious) restaurant and a streetcar ride away from downtown9
  1. This is where I spent many many happy hours through very late nights. 
  2. This is the neighborhood where Cassie and I owned a home (920 Spain St).  I once tried to launch a coup of the neighborhood association here
  3. This is where steampunk people eat food
  4. One of the few bars I will tolerate in the French Quarter
  5. I love sitting in the window and watching the people around 4pm until dusk
  6. Neon in the window and old dudes at the bar
  7. The strawberry ice is made with Ponchatoula strawberries.  Amazing.  Great selection of sweets.
  8. There is a bartender there who has been serving drinks for 20 years.  That’s amazing.  It amazes me that I have had at least one drink and often many more there every year for that same 20
  9. Locally owned, locally grown fine dining.  This is where progressive New Orleanians eat

Monday, June 20, 2016

Managing Through Plateaus and Disappointment

This is the hardest thing I struggle with. And I struggle with many things. I'm constantly amazed at how feedback (or the lack of it) drastically impacts me. I'm very motivated by positive feedback in general and very demotivated by a lack of feedback. I’m actually slightly less demotivated by feedback poorly given. 

So, I take this as a challenge to me. Of course, I can complain about the delivery or quality of the feedback, but it seems more constructive to inoculate myself to it, especially when it comes from those with whom I disagree with or don’t share their perspective. The best feedback comes from those who a) have actually viewed what I've done over time and don't rely on one sample, b) give me meaningful points to build on and finally c) have struggled to build skills themselves versus having some degree of natural aptitude or demonstrating that they indeed need to practice. 

But the problem is being too driven by feedback, good or bad. That means you are looking outside yourself for validation and self-worth. Still, it’s a balance. We still need to honestly assess and be honestly assessed.

So the challenge is to identify good teachers for any goal and work with them exclusively, or more attainably, to inoculate myself against bad instruction, because I think I’d rather get less than ideal feedback given with authenticity, then to hear nothing. So while I will work to identify teachers that expect good performance but are also supportive, inoculation is most important. Finding ideal instruction will be a unique circumstance at best. So, how do I do that?  

I remember an improv instructor once giving a group of us the advice of taking the feedback that works for you and ignoring the rest. I like this because it means that you don't have to be influenced by trying to achieve something just like someone else with different strengths and talents did. I’ve also watched people that I think are good learners who do the same thing. They try the advice out and if it works for them, they pursue it. And if it doesn’t work for their style, they drop it. Treat everything like an experiment. Some experiments work out and some don’t.

After that, I have to remember that my goals may or may not be different from my teacher’s goals. Do I want to be great at something, or merely competent? And by whose standards? I need to keep in mind the reasons why I practice anything and remember to measure myself by those standards. Another great piece of improv advice was “if you’re not having fun, then you’re the asshole.” Life won’t always be fun as in uninterrupted amusement, but your actions should lead you good places. If you think you’re getting lost, reassess. Maybe you need to get back on course, or maybe you’re heading someplace new.

A great deal of this comes back to remember who you are trying to satisfy. Are you achieving a goal you’ve set for yourself? Are you in competition? Are you trying to impact other people’s perceptions of you? Win someone’s opinion? Any of these can be an absolutely desirable goal, as long as you understand that motivation, especially when you are looking outside yourself for an evaluation and you might not like the feedback. But if this matters for you, go for it with abandon. Just make sure you check your head along the way.

Wednesday, March 23, 2016


I read an interesting study the other day. I say “interesting” in this case because it confirmed my instincts. The study was a way of measuring how much people crave power and exactly what they want from it. In sum, the study found that most people don't want to control others, but rather they want power so they have autonomy, i.e. they get to control themselves. I've thought about this for years.

While I would love to have a VP title to round out my resume, I have not wanted to be anyone's boss in a long time. I like the prestige that can be conferred by the title, the possible perks and greater autonomy, but I don't necessarily want to tell others what to do. My experience managing 50 people when I was in my 20’s was a lesson I learned well. In fact, I am now suspicious of anyone who actually wants to be a boss. That's not to say that I don't like being a coach and helper to my colleagues. I often enjoy these types of positive engagements with people and I crave feedback from my bosses, worded with care, that helps me get better. I like to give others feedback as well, but try hard  to offer it in a spirit of "take it or leave it." But most of all, I like being responsible for myself and the good and bad results of my work.

I find power and money to be synonymous to autonomy. The most pleasurable time in my life was when I had a big pile of money saved up. While I certainly spent some of it on a few gadgets, I was generally pretty conservative financially and we lived fairly simply, with a small mortgage to pay on our home, a paid off car and a bicycle that was my primary transportation. The wonderful thing about having two to three years of salary in the bank was the freedom. I wasn’t worried about satisfying a boss or a market in order to be able to eat, keep a roof over my head, or get health care if I fell off my bike. This was the time of greatest productivity for me. I co-founded the Urban Conservancy, helped launch other non-profit groups, took an active role in my community and major issues, and grew a huge network of friends that I keep to the present day.

While we still live fairly simply, we’re now a single income family in an expensive city. Houses cost a lot in Austin. A lot. A car is an absolute necessity in the sprawl, even though we live in the core of the city. What we do spend our money on is mostly experiences: travel, classes of all sorts, exercise. But the wolves never sound too far away from the door. It’s easy to imagine all sorts of economic disasters in the fragile world we live in right now.

My commitment however, is rather than let that fear gnaw quietly in the back of mind, use those thoughts to inspire a pruning down of spending and consumption, to try to tighten up on something that I have spent money on that I could do without. Because reducing the expenses buys a little bit of freedom. I think that's a good investment.

Monday, March 21, 2016

Know Yourself

Here are some things that I know about myself. I learned them through some type of quantification, either formal or informal.

  • My average weight over the past three years has been 151 pounds
  • I can subsist on 24oz per day of water, assuming moderate physical activity and 80-85 degrees temperature
  • I can survive for 3-4 days with no food with minimal impact to my energy or mood.
  • I typically sleep 7.5 hours per night. I almost always wake up at 5:30 AM. 
  • My mental state suffers at less than 6 hours of sleep. The result is typically slower reaction time, mild depression and irritability
  • When I travel, I sleep less. I am also more depressed
  • My stress behavior is typically to want to connect MORE, rather than less with others

What do you know about yourself? How do you use this information to be more self-aware and manage yourself more effectively?

Know your limits. Know what you can do with yourself. Test yourself before you're tested.

Monday, March 07, 2016


Yesterday was the last day of a weekend of baseball tournaments for this guy. Unfortunately, the team was bested by their opponents in a three hotly contested games. 

My son is a pretty good ballplayer. He makes up for his average athleticism with a good mind for the game and incredible powers of observation. 

What really amazes me is his absolute love of the game. After playing a hard game, his only wish besides eating the sandwich he had stuffed in his gear bag was to watch some other teams play. It wasn't watching the team he had just played, it was ANY game. So, after a long day, we sat in the stands and watched more games played by teams we've never heard of. Then we walked to another field where he could watch a team in his league play for the championship.

Hunger and baseball overload finally got the best of me and I made the suggestion that we go get some dinner. 

On our way out of the fields, a homerun baseball came flying over a fence. Santiago shagged it and ran it to the other side, in case the kid who hit it wanted it as a keepsake.

I'm grateful to be around someone who does what they love and makes me better by just watching them interact with the world.

Wednesday, March 02, 2016


Last night I tried to stay on top of my "sleep hygiene," namely turning off screens and going to bed on time with an appropriate amount of winding down time. While I didn't execute it perfectly, I did get seven and a half hours of some of the most blissful sleep I've gotten in a while. That makes for a good day all around. I have already banged out a workout and I'll do another one at lunch. Plus, my mood is so much better automatically. When I think of how chronically under rested we Americans are (and maybe all of us modern people - my sleep app shows that a lot of countries get even crappier sleep), it's pretty amazing we can get anything done.

Now, I will say that I think we want to avoid a slavish devotion to doing the same thing all the time. While generally getting a good nights sleep is good -and when you're in your late 40's, it's a freaking blessing every time it happens- I also think that we need to break patterns every now and again to give our body new and slight stress to compensate for. So, every now and again, I try to experiment with staying up late and getting up on time, staying out all night doing something moderately exciting like doing that ride along with APD or something else that messes with that pattern. Then watching as the body compensates. 

I still avoid doing anything too tricky on days with minimal sleep as my reaction times and my frustration thresholds are pretty lousy on those days. Rather on those days, I try to do moderate exercise, like long walks with exposure to lots of sun to help the brain and body compensate. Your mileage may vary, but just like eating and exercise, occasionally mixing it up is probably good for you as long as you take precautions against injury or stupid errors. I remember once being so tired that I dozed off while being stuck in traffic on Mopac (the busy Austin highway), which absolutely scared the bejeezus out of me. Don't do that.

Tuesday, March 01, 2016


In keeping with my alarmist postings about people being "checked out," I am thinking about the lack of good listening that goes on in my world. Probably yours too. How many times do you feel like someone is just keeping quiet while you are talking, waiting for the chance to insert what they were going to say, regardless of your point? How many times have you done this, if you're being honest with yourself? I'm a major offender myself. Oftentimes, I've thought up something witty and likely very what was said five minutes earlier.

This week, along with practicing good sleep hygiene (damn you, Words with Friends!), I'm going to practice listening more and talking less. The challenge I have right now is that we're all competing for airtime and people are so used to being interrupted that they talk and talk and talk if no one busts in. My experiment will be to see how long it takes for someone to finish what they have to say and then hold my tongue for a few seconds more.

Wednesday, February 24, 2016


Lately, I've been very alert to people who are checked out while doing their job. It's fairly obvious with people who have service jobs, or office workers. It's not always so apparent when I'm observing professionals with high requirements for safety: doctors, first responders, truck drivers, etc. But if at least some percentage of these folks are checked out (or distracted by their phones, their own thoughts or otherwise not fully present), this has incredible ramifications for the people they serve, i.e. all of us.

There is so much competing for our attention all the time. I'm certainly not immune. I'm one inch of finger movement away from checking Facebook RIGHT NOW. What if I'm driving a car at the same time? What if I should be making an important decision at work?

Pay attention.