Obamacare forces the question: how should universities treat graduate students?

The University of Missouri (Mizzou) just gave its graduate students one hell of a surprise quiz: go find your own health insurance, we’re done helping. This broadside reduction in benefits left hundreds of students without healthcare insurance and was swiftly billed as another “outrageous” effect of Obamacare. The university acted as the victim of a surprise attack by the IRS.

One strategy the students came up with dismayed me: to petition the IRS to amend it’s rule. This strategy lets Mizzou off the hook for its negligent lack of planning and more importantly will very likely fail. The students have swallowed Mizzou’s lie that this IRS rule was a surprise that they could not avoid.

Here’s why: the writing was on the wall for Mizzou long before July 1. The lay business press was aware of this issue, and the Department of Labor was crystal clear that reimbursements like Mizzou provided were in violation of the ACA and would be severely penalized. From the Department of Labor’s web site November 6, 2014:

Q1: My employer offers employees cash to reimburse the purchase of an individual market policy. Does this arrangement comply with the market reforms?
No. [it goes on the explain in detail]

I strongly suspect that the Mizzou administration fervently believed the sturm und drang of the King v Burwell case would cripple Obamacare and somehow rescue them from this provision of the act. From the chancellor:

Why did you wait until the last minute to tell us?

We became aware of this issue on July 21, 2015. We hoped the national groups lobbying on our behalf would motivate the IRS to issue an alternate ruling or exception for graduate employees. At the same time, we were working very hard to create an alternative plan to ensure all current and new eligible student employees would have additional resources at the start of the year for such additional expenses. We knew we absolutely had to have this in place by Aug. 15. [emphasis added]

Mizzou was most certainly aware of this issue prior to July 21, 2015. What they mean perhaps is that in July their lawyers told them that wishful thinking was no longer going to help and compliance with the law was unavoidable.

A petition to the IRS will likely not work because the rule is not an accident of some kind or an unintended consequence of Obamacare. The IRS is deliberately putting an end to the practice of employer subsidies. Why? The Congressional Budget Office explains, “The favorable tax treatment of employment-based health insurance is the largest single tax expenditure by the federal government.” And secondly, “..the open-ended nature of the tax exclusions has increased health care spending..

Some students have expressed confusion. What is Obamacare demanding of them and their university? It’s confusing because Obamacare is not dictating one solution, it’s forcing a decision. The university can decide to save money and let students fend for themselves or they can step up and provide health insurance for their employees. But reaping the benefits of the old tax structure is no longer an option.

Mizzou has the chance to step up and pay graduate students a wage that allows them to buy insurance on the exchange, or they can provide healthcare coverage outright, or they can throw the students out into the street. Frankly, the best option would be to throw the students out in the street…but only if the stone age Missouri legislature can be convinced to expand Medicaid. The Obamacare plan in this situation was to provide a broad net via Medicaid expansion for people like graduate students unable to afford health insurance. This would be much cheaper for Mizzou because some students are still eligible to be on their parent’s insurance and there would be no penalty at all for the university not to provide them insurance. But MO has adamantly refused the Medicaid deal, and so the graduate students are screwed.

I support the students planned walk out to protest the administration, as does some MU faculty. The law makers in Jefferson City have been spending their time recently worrying about what their interns are wearing, and they could certainly help students here if they wanted to. There are millions of federal dollars available to solve the students’ healthcare problem if the MO legislature would allow Medicaid expansion. I’d like encourage the students to view this debacle as a team screw up between the University and Missouri lawmakers and keep protesting until they are satisfied that Mizzou is a good place to learn and work.

Additional link: The Chronicle of Higher Education published a good piece on this situation here.

Why failing to understand evolution makes your NIH reform ideas suck

Ron Germain’s “people not projects” solution to fix the NIH funding scheme has been praised, apparently by people I don’t know, and roundly criticized by my friends and colleagues on line. In my med school applications, I wrote that having been an East Asian Studies major, I had the experience of having my world-view challenged and that this might be useful in science and medicine. It’s clear to me that the current reformers (let’s throw in ASBMB President Steve McKnight’s latest essay about how the NIH peer review process works) are working under some different cultural assumptions about how science works, as Physioprof has noted and I’d like to extend on that point. I’d go further and say that as brilliant as Germain and McKnight may be, their approach to science policy is flawed because they apparently do not understand the theory of natural selection.

Herbert Spencer’s phrase “survival of the fittest,” used by Darwin has promulgated the view that evolution proceeds when an individual survives because it is “better.” Evolutionary biologists dislike the phrase because it fails to encompass the diversity of reproductive strategies, but “survival of the fittest” has also shackled our understanding by putting too great an emphasis on the individual. I am a physician and cancer researcher, not an evolutionary biologist, and my understanding of this topic is rudimentary, but I think a lot about cancer cell growth as a Darwinian process, and it would be better if the phrase were “survival of the best fit.” For decades, cancer researchers have been trying to understand “the cancer cell,” and we certainly have learned volumes of molecular and cellular biology. Yet we remain baffled. In the case of the cancer I study, multiple myeloma, we have analyzed cancer cells with all available technologies including whole genome sequencing, and yet we are unable explain how these cells are different from pre-malignant versions that fail to grow and do not kill patients. Many of us feel the answer to how myeloma cells grow rests just as much in the environment around the tumor cells as in the cancer cell itself. The individual is not determinative, the environment plays a central role.

With that in mind, it becomes clear why the fixation that Germain and McKnight share of finding “the best” scientists is misguided. It fails to take into consideration that the “fittest” scientists are those that have been fortunate enough to find a suitable environment. It also fails to consider how terrifying it is for non-traditional scientists to be judged by their CVs alone. I know many outstanding scientists that have leveraged their stable upbringings and supportive environments to achieve great success. Germain’s own description of his career is one where his brilliance was recognized early and he was ushered into the club where he continued to thrive. I have done pretty well myself. But I know without a doubt that being a white dude has helped me immensely. I have great sympathy for people who have been kept out of the boys club because they just weren’t quite the right fit. Not everyone blooms early, and what motivates me is the possibility that hard work and creativity will pay off in the future. Any plan that fails to account for the fact that amazing contributions can be made by people with unassuming backgrounds is flawed.

That outstanding scientists may be diverse and thrive in unique niches. Basically that the tree of life is not linear but multi-dimensional. Even smart people are terrible at predicting the success of project ideas, but “people not projects” is only palatable when examined from within the cloistered environment of the NIH and HHMI. Successful people fall into two traps: they take personal credit and discount the role of the environment, or they think their environment was objectively the best for anyone’s success. Evolution happens from completely unexpected matches between diverse environments and diverse individuals. I like simple solutions, but by setting up a narrow criteria of success you will select for those that match your criteria but you will lose creative individuals without ever having realized what you have missed. Life thrives in diverse environments with unexpected solutions. Any single environment, or selection criteria, is an arbitrary one and we should provide an array of different paths to success so we allow people the opportunity to find one that fits them. 

Germain’s proposal is a useful starting point for reforming the NIH. It captures very well the ideas of some very successful insiders. The monoculture produced a document, but there should be a little humility regarding the stink of nepotism that hangs over it. While the proposal represents a change from business as usual, it risks further perpetuating a monoculture or making it even less diverse. The challenge is how to get a counter-proposal from outside the gates from a group that does not believe there is a single best strategy for success.

Mark Cuban Understands the Future of Health Care

Yesterday, on twitter Mark Cuban revealed that he has his blood checked quarterly to keep tabs on his own health and there was backlash from the medical cognoscenti. The exchange revealed an interesting disconnect between where health care is now–those tests are a waste of money, and where healthcare is heading– they won’t be. My own knee jerk response was that the tests were silly, but the more I reflected, the more I thought it would be a bad idea to bet against the owner of the Dallas Mavericks.

McCoyThe kerfuffle actually highlights two schisms in the medical firmament: healthcare costs and the role of prevention. Why not check your blood every 3 months? Because it’s expensive (more so if we consider offering this to large numbers of people), and we don’t know if it will be helpful. But Cuban can easily afford the cost of these tests and the bald fact is that despite the long-held notion that Americans don’t want “two tiered” medicine, we should admit that we already have tiers in our current system. I believe that acknowledging different tiers might make our healthcare system more efficient. Every US citizen is entitled to basic healthcare and that it is ridiculous that many states, by not expanding Medicaid, are failing to provide basic care to it’s poorest citizens. But at the same time, there is a huge pile of medical tests and procedures that are not cost effective, not basic, but hell, if folks like Cuban wants to spend their money on “doing everything,” then why the hell not. This is where the cutting edge belongs. He didn’t say this, but given Cuban’s proximity to high performance athletes, I strongly suspect that his quarterly tests might involve hormone assays and therapeutic adjustments. Testosterone and other hormones can be adjusted in a personalized manner to optimize performance. Multiple medical societies have made clear there is no evidence for benefit of this practice, but it seems dishonest to dismiss it totally while the same establishment is going crazy over the idea of “personalized medicine.”

In the Forbes piece and elsewhere, there is discussion about the failures of preventive medicine which are real (e.g PSA screening for prostate cancer, as Otis Brawley has eloquently told) and the idea of over-medicalization of our lives. Obama’s Precision Medicine Initiative has been sold as the way forward for finding “the cure” for diseases. In cancer, I’m getting a bit tired of hearing the molecular studies that reveal horrifying complexity of cancer, as a key to individualized treatments. I certainly don’t want to interfere with the ability of my colleagues to raise money, but just between you and me, it’s marketing. But what this technology will allow us to do is to improve and individualize disease prevention. PSA is an early generation screening test. One day it is perfectly reasonable to assume, yearly blood tests will be able to scan for cancer-causing mutations allowing treatment at the earliest possible point in cancer development.

The idea that Cuban would evangelize for his type of screening horrified some healthcare professionals, and I understand why–there are no data that these tests will do anything but waste money and generate false positive worries. But you know what? Understanding and treating cancer when it is advanced is hard. And by hard, I mean it may be impossible. Cancer sequencing data show us that the genome of a cancer cell is shattered like Humpty Dumpty*. Right now, we are putting tremendous resources into trying to put Humpty Dumpty back together again, but some of the best cancer researchers feel that genome data will be much more effective in the setting of prevention.

“Don’t encourage people to do what we don’t understand,” seems hypocritical to me given the history of US healthcare. “Spend money on what you want to,” seems about as American as apple pie, and in healthcare, just may be the stimulus to get our technology in line, eventually, with health needs of more people. Many companies are pushing big data in healthcare, I see no reason why Cuban can’t push too in his own way. Maybe quarterly is too frequent. Maybe we don’t agree on what tests are needed. But if the richest among us are willing to provide data and enthusiasm for high tech precision medicine, that’s a good thing. If something really useful comes out of these experiments, those of us with more limited means will likely benefit in the long run.

So yeah, ha ha, that Mark Cuban is a silly rich dude who doesn’t understand healthcare. Personally, I think he has the right idea.

* Actually, whole genome sequencing of cancer biopsies show that most cancers are made up of multiple distinct sub-clones with unique mutation profiles–a dozen Humpty Dumptys shattered in different ways. So all the king’s horses and all the king’s men had it easy!!

On my son’s birthday, memories of 7th grade

Like all of you, I’ve been riveted by the King v Burwell challenge to Obamacare, but there has been so much written about it, I don’t see the need to add more. My prediction is that the court will find in favor of with the government, creatively, as Roberts did previously. As we wait for the dust to settle on the latest drama, I had some personal thoughts to share. Forgive me some navel gazing..

My son turned 13 last month, and along with love and admiration for the dude, I’ve been awash in memories of my own childhood. He reminds me so much of myself, the best parts of me, but the thing that I marvel at most, because I didn’t have it at his age, is his self-confidence. His comfort among his peers. He is cruising through 7th grade with a wink and a smile, and I can’t help but remember..my 7th grade experience was so very different.


Peter Max artwork

My parents were divorced when I was 2, and I was raised as an only child by my mom, a struggling writer. It’s fair to say we didn’t have much money. It is a testament to my mom that I never felt poor. Which boggles my mind when I think back. It wasn’t until years later I realized how little we had..and it dawned on my a few years ago, we were essentially homeless for my 7th grade. My mother had moved us from the upper West side in Manhattan to the suburbs, Carmel, NY, for my 5th grade, after I got mugged at knifepoint on the way back from school, (it’s not safe!) and we spent two years in a house “in the country” with my mom’s boyfriend who lived with us. When they split up two years later, it took us a year to find our footing again. I spent a month or so with my grandparents back in Manhattan (Chelsea before it was sexy), until mom found a sublet a few blocks uptown. I remember that place for having a Peter Max mural on the wall and a copy of the Sgt Pepper’s Lonely Hearts Club Band that I listened to 100 times. We didn’t stay in that place long. For some months we rented a spare room in another friend of my mom’s house, and after they fought, we got thrown out literally on the street. Coming home from school to see all of our possessions in the driveway was a shock, but for some reason it didn’t phase me long, I was so focused on my life in school. I spent the entire year as “the new kid” because I went to 3 different middle schools. We spent a bunch of months in Mahopac, I’m not even sure when that was, but the house was big and old, maybe haunted. It was the only time I played in fall leaves as a kid. I spent another month on the sofa of a friend of my mom’s, until we finally found our own place. And by “own place,” I mean another place we rented from a friend, this time in Golden’s Bridge. Eventually, we settled in Katonah, NY in a duplex right next to the Metro North tracks, where I spent my high school years. The house would shake every time the train would go by, and I could touch opposite walls of my room with my fingers. I quickly stopped noticing the trains, but it amused me whenever a friend over to the house for the first time would look up startled as a train went by, the windows rattling, not knowing what was going on.

As I watch my boy at this stage of his life..seeing so much of me in him, a swirl of emotion. He’s had stability in his life that I never had. He’s gained a confidence that eluded me for many many years. And mixed in with my glowing pride in the boy, is a recognition that by giving him what I didn’t have growing up, he’s become a poster child for privilege. And how can we not give our children every possible advantage? Indeed he has all the advantages. The son of two doctors. I’m getting more and more another emotion …a powerful sense of responsibility that he not take these advantages for granted. Of course, I’m going to keep loving him hard, but I want him to have humor and perspective, most of all perspective, and the next few years will see about that.

Feedback on the NIH Emeritus Award for Senior Investigators idea

A few days ago the NIH posted a request for information (RFI) on a new type of award aimed at senior investigators moving away from grant-supported work. At first blush, I thought the idea was terrible, but as I write below, there may something good in there somewhere..


On the face of it, the Emeritus award seems like a stupid idea. Investigators who would be awarded such an honor would be extraordinarily talented individuals who could just as easily be supported by institutional soft money and who have already received generous amounts of NIH funding. As a mid-career investigator, I do not support this idea as it is presented here. I have complete sympathy for junior investigators who may even be resentful of the idea.

On the other hand, an Emeritus Award might be a good idea if the intentions of the mechanism were less muddled. I support a mechanism that would encourage senior NIH investigators to retire. I would be interested in such a mechanism myself in a few years. No blah, blah about partnerships, senior PIs have already trained their scientific replacements many times over. Senior PIs that have survived their entire career by bagging grants need no help in acquiring skills for transitioning to a new role. By definition, these folks are adults who can take care of themselves. What some senior folks may need is a kick in the pants to stop applying for funds and retire already. To achieve this role, the NIH could make a mechanism for senior folks that requires very little work, would have a high success rate, and came with the stipulation that, “that’s all you get.” It would be an easy-to-get final award. Period. Like being president. No more running for office. Adding all the gravy about transitioning skills is bogus.

The award should be for three or at most four years of support. The junior faculty partner idea is particularly terrible. The last thing we need is for junior investigators to be smothered by their elders any more than they already are!!

The incentive for the investigator would be the simplicity of the award mechanism, based primarily on the accomplishments of the PI and a very brief statement of plans. The NIH should also institute a reverse new investigator policy and make grants harder to get if the PI has been funded for 25 years. It is a problem that well-connected, senior investigators compete on the same playing field as new PIs. I don’t know that institutions respond well to much of anything except more money.

The impediments would likely be inertia. If applying for R01 grants is what you know, why change?

Reflections while visiting my mother in the hospital

The Florida sun and swaying palm trees are lovely, but I’m in Sarasota because my mother is in the hospital, and I don’t have much time to enjoy them.  The plan was to help my mom around the house after her hip replacement surgery. For two days, I felt like the dutiful son keeping busy with errands, laundry and house cleaning. Then, on the third day, disaster struck— we treated ourselves to breakfast out, and as we left the restaurant, mom’s walker slipped and she tumbled down two small steps, landing with a cry of pain flat on her back. We spent the day being seen by the doctor, getting X-rays and a CT scan that found she broke her femur, non-displaced, but excruciatingly painful and that night she was back in the hospital, unable to walk. Not the worse thing that could have happened, maybe, she’s alive and sharp as ever, but looking at another six weeks of rehab, it was a depressing setback.

Listening to ourselves face palm side-by-side was darkly funny, we blamed ourselves, her: “that was so stupid of me! Why did I do that??” and me: “If I hadn’t left her side..this was my fault..”  As I get older, I notice  more similarities between our temperaments. We fuss at each other a lot, but I love my mother very much. She raised me as a single parent and in many ways made me the man I am today. She has always been there for me. It was difficult to see her in pain, but I was glad that I was there, able to call the insurance company, arranging getting the mail with her neighbor. Now I was alone in her small house, somber and reflective.

How anyone without an advanced degree can navigate our fractured and dysfunctional healthcare system is a mystery. After mom fell, we went back to her house to figure out what to do. She was in pain. The simplest thing would be to take her to the emergency room, but it was not really an emergency. As a physician, I’ve rolled my eyes at the many people who come to the ER when they should really be in a doctor’s office, and I thought we could easily avoid misusing the ER that way. I called her primary doctor who told me my mom was so recently post-op (two weeks) that we should call her surgeon. So I called her surgeon’s office, and they were great—they saw us two hours later with barely any wait, we got X-rays and then were sent for a CT scan. But after the scan, my mother was still unable to walk. There was no way she could take care of herself once I left. The surgeon’s nurse practitioner, who did an amazing job diagnosing the fracture, said that their office would not admit her to the hospital, we should go home or go to the ER. Ugh. With both doctors refusing to direct admit, we were forced to go to the ER where we waited for hours until she was evaluated..the CT scan on the DVD that we brought with us showed a broken femur, thank you we knew that..and finally her primary MDs office sent someone to admit her to the hospital. The on-call internist freaked my mother out by saying that he could not imagine that she would not have to go back to the operating room. He didn’t look at the CT and had no idea what he was talking about, she did not have to be re-operated on. The hospital where she was admitted was another unnecessary stop, they could do nothing for her except get her readmitted to the rehabilitation facility.

I also spent several hours going over my mom’s insurance coverage, and while I’ve written here about Obamacare and thought I knew a thing or two about how health insurance works, I could not understand her coverage without talking with a visiting social worker. It turns out she was sold a Medicare replacement plan..which I had confused with a Medicare extension plan. Rather than covering costs above and beyond Medicare, her lousy private coverage replaced her Medicare coverage, and surprise surprise my mother was frequently told that they would not cover services. The idea of such coverage is that a private plan should be so much more efficient than Medicare, they can make money, but guess what, it does not seem to work. With the help of a social worker, we were able to change her back to straight Medicare which was cheaper and at least easier to understand.


Madame Germaine de Stael, a public intellectual and foe of Napoleon. My mother wrote and acted in a one-woman play based on her life. Germaine de Stael held a salon in her home where artists and intellectuals would discuss ideas and events of the day. When she was arrested for inciting political opposition, she said, “But I just like to throw parties!”

While alone in her house, I loved looking over mom’s vast collection of esoteric out-of-print books, a repository of a lost intellectual subculture that I grew up admiring but which has disappeared from the popular consciousness. Mom’s a leftist and an old school feminist, and her shelves are overstuffed with the Bhagavad Gita, “A History of the Labor Movement,” “Studies and Further Studies in a Dying Culture,” “Women of Ideas (and what men have done to them)” as well as more more familiar books like Howard Zinn’s A People’s History of the United States, Saul Alinsky’s Rules for Radicals. Who gives a damn anymore about the passion and sacrifice that went into the US labor movement?

My grandparents were literally card-carrying communists. Russian jews. With my mom a devoted socialist, I grew up thinking thinking myself a conservative, like the Michael J. Fox character on Family Ties. Politicians these days it seems run the gamut from center to right, and what I always thought of as conservative-leaning centrism has been recast by a country that no longer has a left wing of significance. I can only shake my head in disbelief when I hear people call Barak Obama a socialist. This makes absolutely no damn sense. If Obama is a socialist, then Lady Gaga is an astrophysicist.

In closing here, I had a little thought reading about Charles Schumer (D-NY), recently stumping for his party to grow a pair, advocating for the positive role of government.

Michael Tomasky is right that Democrats should stop being scared of their own damn shadows and start advocating for good government. The view that government can do no good is ridiculous and yet widely held. The conservatives have branded Democrats as being the party of Big Government. Democrats, or anyone for chrisssakes, should rally around the idea of small.  Pro-small government. Pro-small business. Big can take care of itself. We need advocates for the the small.  Small government, small business. The little guy.

Big is bad. Big government, Big Brother, the Big Bad Wolf… Little is good.  Little Red Riding Hood, the little guy, little slice of heaven.

Latest Obamacare battle: fighting for the right to ignore those who can’t pay

Opponents of Obamacare don’t want the government to help poor sick people, and they are going to court to stop it from trying. Even with a Republican-controlled Congress, repeal of the Affordable Care Act (ACA) is impossible with Obama in the White House, so haters of the law have mounted a clever legal attack. The case is called King v. Burwell, and it’s headed to the Supreme Court. If you care one bit about the mind-bending income disparity in the US, then you should pay attention to this case, which is about trying to make our feeble attempts to redistribute income even worse.


The King challenge is based on an arcane part of the law. Obamacare provides health insurance for the poor in part by providing financial subsidies.  In the form of tax credits, these subsidies are for people with limited means to buy health insurance on the exchanges, which are run either by the state or by the federal government depending on whether the state has their own web site. The text of the law states that the subsidies are available for people on the State exchanges, and, in what may or may not have been an oversight, the law does not say that subsidies are available for people on the federal exchange. The case seeks to prevent the IRS from giving tax credits to millions of individuals on the federal exchanges.

Most of us thought that Obamacare was already ruled on by the high court, but the King case will provide the Supremes with another chance to undermine the administration’s attempt to get healthcare insurance to more people. Linda Greenhouse, a veteran court watcher, expressed despair that the unusual, we want a do-over nature of this case made it impossible for her to maintain her hope that the court was “not just a collection of politicians in robes.

If successful, this attack would have huge consequences. It could cripple the law by undermining the goal of providing more Americans healthcare insurance, and might cause the failure of the most ambitious healthcare reform experiment in almost 50 years. The ACA is succeeding beyond liberals’ expectations and has proved most of the dire predictions of the right wing wrong. Many anti-Obamacare pols at this point are dead-ender Braveheart fans, but there are a handful of razor-sharp right-wingers leading the charge, like Michael Cannon (@mfcannon) who fights with impressive zeal. A firestorm of discussion of this case and the Halbig case that preceded it exploded online, but I worry most people are blissfully unaware.

I hope those of you playing at home will take an interest in the Supreme Court’s deliberations on King. When I first read about this case, I thought it silly, that clearly the wording of the law was an mistake that needed a simple fix. After some reading, I’m must admit that the challengers have a valid argument: that the law was written with State-only subsidies to encourage States to establish their own exchanges. They will argue that it was only after that incentive proved insufficient, that the IRS decided to provide subsidies to federal exchange participants. The administration will argue that preventing the federal subsidies will undermine the intent of the law to decrease the rolls of the uninsured. If King is successful, then health insurance will get significantly more expensive for people in states without state-run exchanges.

States that oppose Obamacare are strongly defending their freedom to avoid helping those in need. Many of the states that do not have their own exchanges also have not expanded Medicaid. If King wins the case, the disparity between the number of uninsured in friendly and unfriendly states will become even more dramatic. With the Republicans in control Congress, “fixing” the law will not happen any time soon. Obamacare will survive this challenge, but millions of Americans for whom the law was designed to help, will not get the help they need.

Post-script: interesting piece today in the New Yorker suggests that if King wins, there will be a backlash against the GOP for having gone a long way toward making healthcare unaffordable for some. A GOP argument that it was Obamacare’s fault will be tough to make when states with exchanges won’t have the same problems.