Tom Price for HHS wants patients to receive the best care they can afford.

Dr. Price was on Capitol Hill testifying to Congress to be chairperson of the Department of Health and Human Services. Price is an opponent of the Affordable Care Act (ACA) and believes that the attempt to provide uniform health insurance was misguided. By focusing on “options,” he intentionally blurs the difference between healthcare (e.g. doctors and nurses) and health insurance (how we pay for them).

Price wants healthcare to be accessible and affordable. He wants more options. I agree with Tom Price on those goals. But I applauded the ACA’s attempt to first and foremost to provide comprehensive coverage for people. When the rubber meets the road, we don’t need many options on insurance. More insurance options may not be a good thing. What the ACA demanded was that insurance provide deep coverage, and that is what Price opposes. I agree with him that diverse healthCARE choices are good for patients. We agree that costs will come down for many people if we renege on our commitment providing deep insurance coverage. He’s got an essentially free market approach and wants the government out of the business of regulating health insurance, which will reduce costs for many people. But when people get sick many patients with cheap insurance will be in deep trouble. Price is not concerned about that because he believes marketplace magic will make cheap wonderful care available. The healthcare reform Price wants is to occur in the doctor’s office. The pain will no longer be asking healthy people to ask for insurance they don’t feel they need..the pain will be when patients will be unable to afford options that they want. Some patients will be able to afford some options and other patients who will be unable to afford those options. That is the “improved choices” that we are heading for.

The sky won’t fall with ACA repeal. But things will get worse for patients

These have been lonely years to be a supporter of the Affordable Care Act (ACA), in the face of sustained attacks from its enemies and neglect from its friends. I find dark humor now reading about plans to replace the ACA. For example, when I read, “lawmakers are working to forge a consensus on what form the ACA replacement will take” I hear, “congress has no clue how to pull this off.” Then there are those poor souls I have read about who are celebrating Obamacare’s repeal but hope they can keep the insurance they received through the ACA.

Democrats have suddenly found religion and are defending the law, claiming that repeal will bring catastrophe. Repeal alone would bring catastrophe, but that won’t happen. Lawmakers are smart enough to avoid ACA repeal doomsday scenarios that would hurt them in the next election. Repeal will bring many negative effects, but the replacement, whatever form it takes will mean it won’t unfold the way many ACA supporters think. I foresee a disaster unfolding more slowly, where many healthy people and people with means will be less affected. They may even the short term.

ACA supporters focusing on people losing health insurance when the ACA is repealed are forgetting something critical. The number of uninsured matters only when we all agree on what it means to have health insurance. And that agreement is about to unravel. Defining health insurance as a set of broad and deep benefits was something the ACA did. Without emphasizing that the ACA provided critical definitions for what being insured meant, ACA defenders are setting themselves up for failure when these definitions are destroyed upon repeal. The non partisan Congressional Budget Office (CBO) recognized the concern about counting people with cut-rate plans as “insured:”

The CBO is providing an important safeguard, but only by reminding lawmakers what is in the ACA. Lawmakers are doing their best to circumvent the CBO. Anticipate that repeal will dismantle the definitions of what being insured means, because dramatically loosening the definition is how to lower costs and maintain “coverage” at the same time, i.e. by slight of hand.

The dramatic decrease in the number of uninsured under the ACA was a spectacular achievement because the insurance they received was of high quality. Once the ACA is repealed, this number will become less meaningful. Supporters of the law have doomed themselves with this one dimensional focus. After repeal, maintaining the number of insured people will be simple: sell everyone health insurance for $10 a month that covers band-aids and crutches. This is how coverage will be “solved.”

ACA supporters are wrong to predict immediate catastrophe because lawmakers will “repeal” the ACA with a built in multi-year delay to cover their asses. The delay will allow lawmakers to  grab headlines and peacock their way around the talk shows, all the while spinelessly protecting themselves from immediate catastrophe. They repealed Obamacare and the sky didn’t fall!! Nothing will actually have happened yet. Lawmakers can and will say, “look, we repealed Obamacare, and no one lost their insurance like the scaremongers said!” Yeah, right. Not yet.

Ironically, another way the GOP is protecting people from losing their ACA-provided healthcare right away is by spending billions of dollars on the ACA that months ago they were dead set against. The time bomb will go off eventually. The hand wavy lip service to the magical effects ACA repeal will have is just that, and the only way congress will be able to lower costs and avoid a huge drop in the number of insured will be by defined payments or vouchers. If lawmakers give everyone in the US a coupon for $1000 for their health insurance (it will be more complicated than that, but) they can say, a) we gave everyone insurance! So much better than ACA!! and b) we did it with so much less money!! Look at the cost savings of our genius!! I am bracing myself for the fact that this will be seen as a good thing by many healthy Americans. It will be a problem at first mostly for the sick.

Focusing the pain on people with disease is part of the plan. Another way that cheaper insurance will become available for most people is with “high risk pools.” Which is a nice way of breaking the social contract of taking care of the sick among us. If we separate the healthy from the sick when dealing with healthcare insurance, then the healthy people will pay less. Lawmakers will put aside money for high risk people likely with defined contributions, i.e. a set amount. Only with time will it be revealed that in order to save money, voucher/defined contribution plans will be catastrophically insufficient for people with modest incomes who get sick.

I have one last prediction directed at thoughtful critics of the ACA like @avik and @mfcannon who earnestly believe, based on their free market principles, that ACA repeal will bring wonderful results: the lousy situation after ACA repeal won’t shake their beliefs. When costs go up, when sick people receive worse care, when job creation stalls, the free market folks will have a simple explanation: “sure, I said we should repeal the ACA..but not like *that!*” Their well-intentioned arguments will have been used as a smoke screen for political ends.

The repeal effort may yet stall, but I doubt it. Affordable Care Act RIP. It was ungainly and unloved. It should have been improved, not removed in a game of political football. The law wasn’t magic but nothing is, and it was clear to nonpartisan observers that it worked surprisingly well while it lasted. Now, patients and those that care for them need  to prepare for what’s coming next.


The risk of a long post-doc

On the heels of the recent announcement that the NIH will increase post-doc salaries, an article suggested that the proposed increase doesn’t go far enough. Leading the charge was a scientist in Boston who has been a post-doc for seven years. Maybe I was a bit of a troll for sending that Dr. Isis’s way. Seven years is too long for a post-doc, she posted, a post-doc should be no more than four years and a few people on line lost their minds at this suggestion. No way! Everyone is an individual! Different fields demand more time! Science doesn’t work on a schedule! You’re making our shakras come unaligned! Came the retorts. (I may have made that last one up.) Differences of opinion between intelligent people are fascinating, and I enjoy contemplating the roots of a disagreement. I don’t pretend to know the right answer, but I noticed a parallel with something apparently unrelated and I love making weird connections:

Extending your post-doc past four years is like going into debt. And I believe debt is a bad thing. “The borrower is the slave to the lender.”There is a fundamental disagreement amongst us about whether a post-doc is an employee and deserves a stable fair wage to send their kids to summer camp and have a nice place to live in a nice neighborhood with all the other fancy people. Or is it slavery*? I respect my post-docs tremendously and their professional and personal success is important to me. But they are more like slaves than employees. They are not paid enough for the work they do and that is as it should be because they a) receive training; and b) should be motivated to conclude their post-doc as soon as possible. We have staff scientist and technician positions that are straight-up get paid for the work of science, but a post-doctoral fellowship is not that.

Sure, some people spend 7 years and do just great. So do some people take on debt and pay it off without problems. But the hard nosed anti-debt philosophy is justified because the vast majority of people are victims while they are being swindled into believing they are the beneficiaries. Post-docs, like debtors, are victims in subtle ways like lost opportunities and a failure to build wealth. But more concretely, what post-docs are not facing hard enough is the reality of risk. Optimism is essential in science and in life and it’s difficult to put my own optimism on hold and contemplate the reality that things don’t always go as planned. Just like Dave Ramsey counsels “gazelle intensity” to get out of debt as fast as possible, post-docs should not get comfortable or chart an extended course, but should focus on getting their work done as soon as possible, like they were in a burning building. Because they are. There is the very real risk that the paper won’t work out, or the PI’s grant gets cut, or the imagined job opportunity won’t materialize, and this risk is real. Having debt assumes a rosey future path, that life will continue on without major interruption, but in the event of a crisis, the bank will be fine, but debtor is screwed. As a PI, I’m going to be fine. The primary job of the post-doc, for their own good, is to find a permanent job.

PS. The four years limit is of course arbitrary, but the number works because it is within the working span of many grants. A post-doc fellowship that extends beyond the scope of a single grant is also indirectly a violation of a promise to the granting organization.

* Addendum: Friends on line have expressed dismay and offense at the use of slavery in any way shape or form here. I know the missing and critical ingredient that differentiates slavery is consent. I agree wholeheartedly that post-docs are not slaves and it’s offensive to suggest that.

Saying that I should call post-docs “underpaid employees”or “exploited workers,” misses my point though, which was that it is not helpful to suggest we need a fix so post-docs can be contented workers. Post-docs are intentionally and consensually exploited workers and the fix is to wrap things up and get out ASAP.


Kids, it’s up to you to fix healthcare

For the past six months, I’ve been on a David Ramsey and @drisis-inspired mission to rid myself of debt. My grandmother instilled in me her Depression-era distrust of debt, but I lived in a way that forgave and demanded borrowing for years. I was told that her lessons were old-fashioned and tried to ignore the pains in my gut and the sleepless nights that debt gave me. In vain. I felt dread and a constant feeling of limitation imposed by what I owed.  Sweet Sweet Dave, as we call him, gave me permission to pay off my debt with missionary zeal, and at the end of this month, I will have paid off all my debts (except my mortgage). It feels amazing, like lead weights being lifted off me. More than that, like a hot poker being removed from my guts. It’s been a philosophical journey too, more than I would have expected. Ramsey was right. My family thinks I’m weird (and that’s being charitable). Rejecting the majority culture’s ends justifies the means view on debt has been challenging for a few of my relationships and better for others, but it feels very right.

The debt-free journey has also made me think differently about Obamacare. I watched the Democratic debate last night and was stunned by the disconnect between Hillary Clinton and Bernie Sanders on healthcare. Martin O’Malley is too level-headed to have any chance in this carnival of a race. Michael Cannon is the exception to the rule that intelligent libertarian is an oxymoron, and to my chagrin found myself agreeing with him:

Clinton came out as the voice of “Obamacare is a good start, let’s keep going,” while Sanders, the unapologetic socialist pitched his just-announced, multi-$ trillion with a T “Medicare for all” plan. Sanders’s goal is to get private insurance out of healthcare (while claiming to support Obamacare, an insurance regulatory framework, proving that even socialists can be slippery). Others have written about the economics of his proposal: I applaud Sanders for being realistic about the costs and that taxes would be required (h/t @mikethemadbiol) to pay for his plan. Conservative gun-for-hire Avik Roy estimates that Berniecare would increase federal spending $28 trillion using Sanders’s own estimates.

Yes, government-sponsored, universal healthcare, like the rest of the industrialized world has embraced, is a good idea, but one without the support of the majority of Americans. And opponents of single payer have a point. Americans don’t have the stomach for European-style limits on healthcare, so universal healthcare in the US would be stupendously expensive. Add to that the opposition of goliath capitalist interests, the insurance and pharmaceutical industries, and you are a few miles away from a feasible proposal. Americans’ worship of freedom, love of capitalism and distain for European socialism are the reasons we wound up with the hybrid conservative approach of Obamacare. Frankly, as a transplant from the East-Coast to the Midwest, Democrats giving life to the stereotype that “we know what’s best for you because we’re smarter and are going to ram it down your throat” makes me a bit ill.

Half of America thinks Obamacare doesn’t go nearly far enough, and and the other half thinks it goes way too far. That, plus the fact that there is no real Plan B, makes me conclude that this may be as good as it gets. The system is messy and imperfect and there’s no end in sight for the arguments over it.

To get the most out of our current healthcare system, it helps if you understand that it is fundamentally a conservative system. Ramsey’s advice on personal responsibility are a good approach to fixing healthcare. If you want Obamacare to work for you, you need to follow three steps:

  1. Have an emergency fund. Ramsey suggests 3-6 months of living expenses, and it should be modified to cover your medical deductible. Healthcare is expensive and Obamacare doesn’t fix that. Having healthcare insurance will shield you from having to sell your house or go bankrupt to pay for healthcare, but to keep your monthly premiums under control, you will be responsible for unavoidably hefty deductibles when you use the system.
  2. Do everything you can to avoid touching your emergency fund. Subsidies are available for many and preventative care services are free. Do your research. Getting sick is expensive. Diet, exercise, no smoking..boring but good investments.
  3. If you have to spend your emergency fund on healthcare, haggle. It may seem strange suggesting that you treat the healthcare system of the most prosperous nation on earth like a bazaar, but here we are.

Navigating the healthcare system, finding out how much healthcare services cost, and what procedures and medicines are “needed” is a major challenge. The idea of consumer-driven healthcare  is not without its critics, but the current trends in medicine, including consumerism, is occurring with or without Obamacare. If enough of us can be prepared to pay deductibles and can be engaged in making cost-benefit decisions in healthcare, our medical system will be transformed. Time will tell about that. Staying out of debt and having an emergency fund is the best strategy you can take no matter what.  Politicians want to tell you that voting for them means you won’t have to work so hard for things you “deserve.” Free “puppies and rainbows.” Don’t believe them.

For all my kids’ lives, I’ve sheltered them and tried to give them things that I never had. Getting out of debt (or staying out) and putting aside an emergency fund required hard work and sacrifice. Period. But I’m happier now and more peaceful than I have been in a long time. I hope they see that.


One reason you didn’t get that grant is because Theranos

I’ve been tweeting lately about Theranos, a privately held lab testing company, and the troubles it’s been having after an expose came out in the Wall Street journal. When I first heard about Theranos and its superstar CEO Elizabeth Holmes, it bothered me that there was a gap between the over-the-moon accolades they were receiving and my ability to find out details about how the technology behind company was supposed to work. Will Theranos revolutionize medicine, or is it the Emperor’s New Lab Testing Company? I’ve become obsessed with the saga. I won’t do a detailed analysis of the company here, but will explain why the mixture of medical science, showmanship and journalism got under my skin.

Elizabeth Holmes founded Theranos after dropping out of Stanford at the age of 19, and it has made her the youngest self-made female billionaire in the world. At Stanford, she was mentored by the legendary chemical engineer Channing Robertson. Dr. Robertson has a number of claims to fame, including bringing Big Tobacco to its knees. Robertson noted that tobacco companies were the largest consumers of ammonia, and he deduced and demonstrated to the courts that the reason was to increase the pH of the tobacco in cigarettes causing more rapid cellular uptake of nicotine when inhaled. Robertson’s expert testimony demonstrated that tobacco companies intentionally increased the addictiveness of their products, and it cost the four major companies billions of dollars and restricted their activities in the largest class action settlement of its kind. Bravo Channing Robertson! When Holmes approached Professor Robertson with her start up idea, at first he tried to convince her to complete her degree, but then supported her decision to drop out when he realized that he could be looking at the next Steve Jobs– high praise from a high place indeed. There is little doubt that Ms. Holmes is brilliant and there is still a part of me that wants to see her rise triumphant from the specter of suspicion that has arisen recently.

We all admire genius. So…what is her billion dollar idea? To collect tiny amounts of blood from a finger stick rather than traditional phlebotomy and running hundreds of tests using a few drops of blood in “nanotainer” tubes. Thernos technology, it is claimed, will change the face of medicine as we know it because it can be employed not just in the doctor’s office, but anywhere. At Walgreens or the grocery store for example. And for a fraction of the price of standard laboratory tests. And not just by doctors, patients can check their own labs! Bam. Industry upended. How exactly would Theranos run many tests on tiny amounts of blood quickly and accurately? Holmes’ answer was, essentially, “we could tell you, but then we’d have to kill you.” Venture capitalists in Silicon Valley and then the business press ate this stuff up. “Of course..*secret* technology is exactly what’s needed to transform healthcare!” But science geeks and transparency geeks were bothered by the secrecy– no peer reviewed publications, no public demonstrations of any kind. I was born and raised in New York City and my bullshit meter is always set to 11. I couldn’t find any information to convince me that the entire enterprise wasn’t a sham. A colleague recently told me one of his trainees went to work for Theranos on the technical side for a time, and left the company with no idea of how it was supposed to work. It didn’t help that Holmes responded to criticisms by adamantly attributing critical questioning to a lab testing industry conspiracy. Conscientious business reporters continue to give Holmes the benefit of the doubt, but have strongly suggested that she needs to stop bobbing and weaving in response to questions and start revealing. I have a sinking feeling that this has been a con.

What does this have to do with grants? I admire Holmes’ ability to convince people of the brilliance of her ideas–it’s exactly the skill needed to write a good grant. Significance 1, innovation 1. Once upon a time, I assumed that excellent work would transcend the need for clever marketing and charismatic presentation to sell it to the proper audience, but the longer I work in science, the more I see examples of necessary hard work labeled as incremental and dismissed and attention lavished on the well constructed story. The veracity of which appears secondary, or is assumed. I no longer think scientists have a special ability to see past hype and pressures for time make it difficult to tell the difference between working productively and spinning the zeitgeist, but I don’t think this is the case.

Don’t worry about people stealing an idea. If it’s original, you will have to ram it down their throats. – Howard Aiken

In communicating about science we say, “it’s important to tell a story,” and Elizabeth Holmes has demonstrated the power of a story unmoored from underlying reality. As Americans, we love the maverick genius who comes from nowhere to upend a field or industry, and there is desperation in our society obsessed with growth and paradigm shifts to see this narrative fulfilled. But someone should have actually changed the world before getting credit for doing so.

This story would not get under my skin if science funding were not a zero sum game, but it is. It angers me to see hard working scientists be denied money and resources because they aren’t flashy or charismatic enough to spin a fantastical tale. Holmes has some time and millions of dollars to make some magic happen. Not everyone is so lucky.

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.