About mtomasson

Physician-scientist into multiple myeloma genetics, raising kids, educating MDs and PhDs. Posts are mostly what catches my mind's eye. This I believe: science can be a guide for social change in health care.

The Affordable Care Act gets support from where? Are we still in Kansas?

I don’t live there, but I’ve been watching what’s going on in Kansas because there’s a fascinating battle between ideology and reality going on there.My wife and I have gone ketotic, and after a refreshing cup of “bulletproof coffee“, I have a lot of energy to write about it!!

Sam Brownback has been governor of Kansas since 2010, made it his explicit mission in his state to demonstrate the magic of supply-side economics. That is simply, if they made massive tax cuts, the benefits to the economy would be so great, that not only would businesses thrive, but the budget would actually improve and life would be better for everyone because of all the growth. Never mind that economists who have looked at this hypothesis have found no evidence to support it. It’s a firm belief of some conservatives. And so Brownback and the Kansas legislature did it. In 2012 they passed a massive tax cut bill. And then they sat back and waited for the free market to work her magic. And they waited. And the budget got redder and redder and their fairy godmother refused to show. Brownback said that the experiment just needed more time, there were reasons. He was narrowly reelected.

Now, the Kansas economy has lagged significantly behind the nation as a whole for years. Private businesses have benefited from tax cuts, as have the wealthy, but the public sector budget, schools and roads, have been hemorrhaging money–through 2019 the deficit is project at over $1 billion.

Republicans in the Kansas legislature are starting to revolt. Yesterday, they narrowly failed to overturn Brownback’s veto of a tax increase that was designed to end the experiment in huge tax cuts that never seem to pay for themselves as advertised. The great thing about an experiment is that if you’re paying attention, you learn something. Brownback hasn’t learned yet, but more and more Kansans appear to be.

This story gets more fascinating when the Affordable Care Act (ACA) gets factored in. Because the deep red state of Kansas has of course refused on principle to take advantage of the ACA to expand Medicaid. Conservative philosophy is the only reason I can think of for refusing  to accept federal dollars to pay for the health care of the poorest in your state. Then, seemingly out of nowhere, Kansas lawmakers have reopened the issue of  Medicaid expansion with the House voting overwhelmingly to expand and sending the bill to the Senate. Mike Pence referred to the ACA as a national nightmare, but apparently, Kansas is looking to the law to help them out of the nightmare budget hole they have created. Interesting to see where this goes.

Also interesting to see how long we drink the butter coffee. Not going to lie, it was pretty tasty!

 

Narcissists and narratives

Binge watched and listened to Marc Maron and WTF the past few weeks. I didn’t know who he was until I heard him on Fresh Air a few weeks ago.  A comedian, he was one of the original godfathers of the podcast medium. He has had EVERYONE on his podcast. So respect, and jealousy.

“You really have to stop listening to Marc Maron.” – M

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One thing I learned from Maron: Isis was right. Her advice was that I needed to keep writing consistently. Maron keeps to a rigorous posting schedule despite a chaotic artistic life. One of the secrets to being a productive neurotic is to be dependable. Let’s see if I can post every week.

Recently heard a podcast with the Robert Shiller explaining narrative economics and it sparked a connection with narcissists. Shiller believes that for economics to evolve, they must transcend raw mathematics and borrow from the humanities the art of narrative. I’ve been thinking a lot about narcissists, both the one in Washington, and ones in my life, and it dawned on me that narcissists are narrative ninja warriors.

The entire nation is learning about narcissistic personality disorder, but I had a head start — I have more than one malignant narcissist in my family. A signature feature is if you suggest to a narcissist that they are doing something wrong, causing someone pain for example, they respond with angry counterattack.  They can’t hear it. You are a bad person if you suggest to a narcissist that they are a bad person. Trying to explain my feelings and find compromise in these relationships has caused me a lot of suffering that I’m just now getting past. The narcissist is the Golden Child of their story and their psyche absolutely refuses this principle to be challenged. With a malignant narcissist, you’re either on the bus or off the bus. Facts and discussion won’t help. I’ve needed to move on from that, and so will opponents of the current administration.

Charismatic narcissists have honed to perfection the art of the narrative — the spinning of a compelling story. We all crave a narrative and don’t feel satisfied with data alone until we have one. As scientists, we are counseled to tell a story. The internal life of the narcissist has been replaced with unceasing  narrative construction, so they are masters of this very powerful tool. Distrust and fear are quick participants in their process, and they can draw many people in to a story of heroes and villains that feels so true. I want to shake my friends that don’t understand that these dynamics are utterly unshakable. They seem to believe that more facts and more calling out of sins, the narcissist will be shamed or convinced. They can’t. To a narcissist, you are a prop, and props don’t participate in the writing of the story. Engaging a narcissist doesn’t work, the only way to transcend is to adopt a different narrative. This takes discipline and consistency. I’m scared for my country these days, but in my home life, I’m fortunate to have a partner who listens and loves me and with whom I can co-write our story together.

Disclaimer: if you’re reading this and are mortified that I’m talking about you…I’m not talking about you!! You’re amazing!! I’m talking about the other one!!

Cheers.

Obamacare is dead! Long live Obamacare?

Donald Trump’s first executive order as president appears to be aimed at fulfilling his promise of weakening the Affordable Care Act (ACA). The order is confusing, though, because it doesn’t really do anything immediately.  It emphasizes that the next Health and Human Services (HHS) secretary will be in charge of implementing the law as s/he sees fit, which is that job description anyway. The primary content of the order is the framing of the ACA as a burden on many groups of people and the intent is to reduce that burden. Okaaay, but…

The emphasis on giving more control to the states and reducing the financial burden on states is striking. This appears to show belief in disinformation about the law rather than the reality that the ACA has a been a boon to some states. The role of the states in ACA centers around Medicaid expansion. The reality is that the ACA for states that expanded Medicaid has been a windfall. In fact, governors are worried about ACA repeal because of the huge hole repeal will put in their budgets. Giving an order that the ACA must be implemented to reduce the burden on states could be interpreted as encouraging states that haven’t done so already to expand Medicaid. No?

A constant refrain about the ACA is that it is oppressive federal intrusion on the states, but calling it oppressive has always been disingenuous because the federal government has shown great willingness to grant wavers and flexibility to the states in how to implement Medicaid expansion. Trump’s first executive order seems to be encouraging efforts already underway to help craft expansion in a way that the states agree to.

Similarly, the ACA has provided subsidies to reduce the burden of the law on individuals, and the order could be interpreted to make sure these subsidies are maintained. Others have interpreted the order as an attack on the individual mandate. But the mandate is intended to reduce the burden of health costs on more people.

This order does nothing to repeal the law. That is up to congress. Tom Price, or whoever is chosen to lead HHS, will have huge discretion in how to implement the law as it stands now – just as Sylvia Burwell did. To my eyes, the order says, “Obamacare is dead! Long live Obamacare!” It underscores that the title of the law is despised, but the content is not. If I were a Democrat right now, I would see this as an opening for a win-win effort to improve upon the ACA by emphasizing the intent to reduce hardships. Yes, maintaining the framework of the ACA is at odds with the substance of plans GOP lawmakers have floated, but this order seems to suggest that Trump is not yet on their page.

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 benefit..in 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.