Breaking Through The Floor

Update: You’ve probably noticed that Wright on Health posts have been few and far between lately. The simple explanation is that academic life pre-tenure is time consuming–especially when you try to be attentive to other even more important things like being a husband and father–and writing a blog, as important and personally fulfilling as it is, doesn’t “count” towards my success in those areas. And I’m not paid to write this blog, so it necessarily takes a back seat to everything else. In fact, several times, I’ve considered hanging up the blog altogether. But I maintain hope that I will one day find the time to blog more regularly once again. At any rate, if you’re reading this, I thought you deserved an explanation for my absence, and I couldn’t just write you this update without an accompanying post, so here you go…..

Yesterday, the Congressional Budget Office released new projections on the number of Americans expected to sign up for health insurance through the ACA/Obamacare Marketplace in 2016. If you’re the kind of person who likes to see things for yourself, take a look at page 69 of this report. You have to go digging around in the footnotes, but there you’ll find that CBO originally projected 21 million Americans to purchase coverage through the Marketplace in 2016, a number they’ve now revised downward to just 13 million. As is being widely reported this morning from outlets like The Hill, that’s a 40% reduction. There are two ways you’re likely to respond to that information, assuming you pay it any mind at all.

The first is to think: “Wow. The government really got it wrong. They missed the mark on that one.” And that’s absolutely right. Now, how you spin that is a matter of your pre-existing political beliefs. If you’re more progressive, you’re probably inclined to discount that failure. “No one has a crystal ball,” you might say. “Of course their numbers are going to be off sometimes,” your buddy will chime in. Conversely, if you’re more conservative, you’ll jump to the obvious conclusion that this is simply more evidence of government ineptitude. “They can’t ever get anything right,” you might say. “Yeah, tell me about it. Thanks, Obama!” your buddy will reply sarcastically. While it might seem, given their diametrical opposition, that one of these perspectives must be true and the other false, let me suggest that other from the obvious fact that the CBO’s projection was off target, they’re both wrong in their interpretation of that.

The second, and I would submit more accurate, way to think about this is to dig a little deeper and ask what it truly means. Although they can be interpreted at will, the numbers don’t lie. The CBO estimate was off target. This mistaken projection should neither be written off by the progressive, nor given undo importance as evidence of government’s incompetence by the conservative. The truth is that, to the extent that Obamacare’s major goal was to reduce the number of uninsured Americans, it has been a success. The rate of uninsured Americans is the lowest it has ever been since we started tracking that data more than 50 years ago. At the same time, the country still has a long way to go if the goal is to ensure that every American has some form of health insurance coverage. In that respect, Obamacare has underperformed. The CBO projections have proven to be overly optimistic. The reduction in the number of uninsured seems to be leveling off. In short, we’re approaching a floor. Now, on the other side of that floor, there are people who qualify for benefits under the ACA as originally enacted. The question we face now is how to improve implementation and outreach efforts. First off, there are the 20 states that have still refused to expand their Medicaid programs, denying insurance coverage to their most vulnerable residents. Unfortunately, there’s not much the Obama administration can do about that. But then there are the Marketplaces and it’s imperative that we do more to make sure that people are knowledgeable about how they work, how to find out if they are eligible for subsidies, and how to get and keep coverage. An alarming number of people signed up for coverage and then never sent in their first premium payment, so their policies were never in force. There are certified application counselors and the like out there, but we also need to better understand the barriers people face in navigating our complex healthcare system. This is public policy and community outreach. This is health services research and implementation science. The point is, it’s going to take a real concerted and ongoing push from many fronts to break through the floor. Millions of Americans would benefit. It is up to us to help them.


Posted by on January 26, 2016 in Uncategorized


Health Wonk Review: Counting Our Blessings Edition

Next Thursday is Thanksgiving. A holiday that, despite its very name, has become all about gorging ourselves on turkey, dressing, mashed potatoes and pie(s). A day consumed with televised parades featuring giant inflatable cartoon characters and televised sporting events featuring giant muscled athletes running into one another at full speed. But it is meant to be a day to pause and reflect. To evaluate the past year and count our blessings. To give thanks for all that we have. In that spirit, this edition of the Health Wonk Review takes a look at the best of the health policy blogosphere from the last two weeks. While not all the entries are good news, I think you’ll find that there’s a lot here to be thankful for. And, of course, I’m thankful for such a talented group of bloggers with which I get to interact. And, for good measure, I’ve interspersed this post with some of my favorite paintings by the classic American artist, Norman Rockwell, whose work evokes the holiday spirit for me.

We lead off this edition with a post from the Health Affairs Blog entitled “To Understand Climbing Death Rates Among Whites, Look To Women Of Childbearing Age,” that examines one of the biggest stories in health services research this year. Laudan Aron, Lisa Dubay, Elaine Waxman, and Steven Martin of the Urban Institute look at a recent study by Anne Case and Angus Deaton, describing rising mortality among whites, that received national attention. Aron and coauthors focus on one important missing point in the Case-Deaton study: the particularly notable mortality rate increase among women. They write: “By not looking at men and women separately, Case and Deaton failed to see that rising mortality is especially pronounced among women…Our own analysis of the same data used by Case and Deaton shows that the average increase in age-specific mortality rates for whites age 45-54 was more than three times higher for women than men….By lumping women and men together, the study also missed the important point that the increases in mortality are affecting women of reproductive and childrearing ages, a finding that has huge implications for children, families, and communities.” Thus, a fitting picture would be a young couple breaking a turkey’s wishbone. Perhaps she’s wishing for a decrease in mortality for her and her peers?

Next in a post entitled “Dreaming On – The Illusions of the Leaders of Large Health Organizations, as Illustrated by Medtronic’s Founder,” we have Roy Poses of Health Care Renewal writing about the recidivism of large healthcare organizations, which have repeatedly been subject to legal actions and settlements for allegations, sometimes proven, of various bad behavior. According to Poses, “These behaviors seem to recur partly because they are so remunerative for the organizations involved and their top managers, and because while the organizations may sometimes be subject to monetary penalties, the managers almost always have complete impunity.” He offers up the case of Medtronic’s founder and the corporation’s troubled legal history as an example. What picture best encapsulates just about any post from Roy Poses? Why, Rockwell’s “Freedom of Speech” of course.

We health wonkers have pretty positive regard for our fellow wonkers. Case in point: Julie Ferguson cites an article by Joe Paduda in her post “Misunderstanding the Business of Workers Comp” at Workers Comp Insider. While it’s no mud wrestle, there’s some controversy afloat that you may want to check out. Since the post seemed to call for a little playful confrontation, what better than a pilgrim fleeing the arrows of the Native Americans?

Next up, David Williams of the Health Business Blog asks the pressing question: “What do obese, middle-aged and older mute Americans with Type II diabetes do for fun?” His answer, in a post entitled “Invokana Makes Diabetes Fun Again!” is that they pull Invokana frisbees down from the sky and change their lives. It’s a different kind of post, for a very different kind of pharmaceutical commercial. Check it out. If we’re talking diabetes, I think that warrants this painting of an older, overweight chef, smoking a cigarette and enjoying a cup of coffee at the end of his shift on Thanksgiving.










Speaking of pharmaceuticals, Peggy Salvatore contributes “Federal Health IT Strategic Plan: Where Are The Incentives?” at the Health System Ed Blog. She tells us that the Federal Health IT Strategic Plan shows the pathway to pay-for-performance through population health, requiring a fully functional national health IT infrastructure. This leads us to the push for outcomes-based payments, coming upon the health system rather quickly, and the various players are lining up to figure out how to get paid under this new system. You know what else people line up for? Thanksgiving dinner. Just above on the right is Rockwell’s classic “Freedom from Want.”

Another post about paying for value rather than volume comes from Jason Shafrin at the Healthcare Economist. Jason writes a post entitled “Does Tying Payment To Quality Improve Quality?” in which he examines efforts by CMS to tie 90% of reimbursement to measures of quality and explores whether or not it will work to improve quality. You’ll have to read his blog to find out. And–I’m really stretching the metaphors here–speaking of quality, why not a picture of a son spending quality time with his mother peeling potatoes in preparation for the big feast?

Speaking of CMS, Brad Flansbaum writes “CMS Just Paid for Advance Care Planning, But You’ll Still Make More Giving Injections” at The Hospital Leader about the agency’s decision to reimburse conversations between doctors and their patients about advance care planning. Somewhere Sarah Palin is freaking out that the death panels have arrived. However, Flansbaum questions whether the reimbursement will be enough to change a medical culture that has not prioritized these important discussions, and is still driven largely by fee-for-service volume-based payments despite the best efforts of the ACA. Perhaps a reminder that we should learn to be more satisfied and less greedy is in order. After all, no one likes a gluttonous pilgrim.

And that brings us to the ACA, which a lot of folks wrote about. First up is Joe Paduda of Managed Care Matters with a post entitled “ACA – What Can We Expect In The Healthplan Market In 2016.” He says markets are evolving, healthplans are failing, and hospitals are complaining. About what we’d expect in this brave new world! What are really failing are the co-ops.

Writing at the Colorado Health Insurance Insider, Louise teaches us all a “Lesson From CO-OP Failures: Low Premiums Aren’t Sustainable Unless We Reduce Healthcare Costs.” According to her, “while it’s popular to condemn rate increases as carriers profiting on the backs of sick people, profit margins in the health insurance industry have been hovering around 3% since 2008. However, the pharmaceutical industry’s profit margin is closer to 20%, and in 2013, Pfizer’s profit margin was 42%. Clearly, we have a spending problem, but as long as the actual regulations are aimed at insurers rather than the entire health care industry, we’re going to be fighting an uphill battle. Incidentally, the Trans-Pacific Partnership free-trade deal would only strengthen U.S. pharmaceutical companies protection from cheaper generic drug competition.”

As critics continue to hype the steepest health insurance rate increases, and co-ops fail, this might make a lot of people wonder “Is Obamacare Collapsing?” but health insurance industry whistleblower Wendell Potter reassures us that the Affordable Care Act is far from a disaster for the millions who are gaining coverage in a post at the blog.

And even more importantly, a lot of people don’t realize how blessed they are. At InsureBlog, Hank Stern writes “Leaving Money On The Table – An Update” underscoring that more than 2 million people eligible for federal subsidies to help them purchase insurance aren’t getting a penny of that money, because they failed to purchase a qualified health plan through the Marketplace. So, on that note, let us all take a moment to pause and give thanks for the many blessings which he have received, and continue our efforts to make sure that we do what we can to bless others less fortunate in our midst. Happy Thanksgiving all!


Posted by on November 18, 2015 in Uncategorized


Fall Has Begun and Louise Norris Hosts Health Wonk Review To Honor The Occasion

I say the same thing every time, because it’s true: This is good stuff. You should go read it. Here’s the link.

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Posted by on September 24, 2015 in Uncategorized


Peggy Salvatore Hosts Health Wonk Review

Head on over to the Health Systems Ed Blog and give it a read. Here’s the link!

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Posted by on August 19, 2015 in Uncategorized


Medicaid Managed Care in Iowa

The state of Iowa is about to conduct a bold experiment by putting everyone in Medicaid and the Children’s Health Insurance Program (known here as HAWK-I) into private managed care plans. There was a recent story on the subject by Iowa Public Radio’s Clay Masters, which ran on NPR’s All Things Considered and was also featured in the Kaiser Health News. In full disclosure, yours truly was interviewed for the piece, and was rewarded with a small quote towards the end of the story. I share it here with you not only for the obvious purpose of shameless academic self-promotion, but also because it is a very important story that offers a foretaste of what may be soon to come in your own state, as more and more states consider ways to relieve the pressure that Medicaid puts on their budget.

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Posted by on August 18, 2015 in Uncategorized


Hank Stern’s Health Wonk Review

We’re officially into summer, and Hank Stern hosts the latest edition of the Health Wonk Review, with a theme of Hot Summer Nights, Cool Summer Drinks. I encourage you to beat the heat by reading his wonderful piece, which summarizes some of the best health policy blogging of the past two weeks.

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Posted by on July 17, 2015 in Uncategorized


A Further Reflection on Give 1 For Dad

You may recall that about 3 weeks ago, I wrote a piece on this blog in honor of my Dad and in support of a novel and important charity to fund prostate cancer research at Duke University called Give 1 For Dad. If you missed that piece, I urge you to read it here.

The charity was founded by Sam Poley, whose father, Neil, had metastatic prostate cancer. I’ve actually never met Sam or his father. I know Sam’s wife, Stephanie, from my time at the University of North Carolina. I learned of the Give 1 For Dad charity through Facebook. I visited the website, watched the video Sam posted, and found myself moved by the cause and the concept. So I did the least I could do in support: I gave a donation and I wrote my blog post urging anyone who read it to do the same. I made an appeal echoing Sam’s own–to consider what our Dads mean to us and to give accordingly.

At last count, the charity had raised just $19,000. On the one hand, that’s fantastic–it’s nearly halfway to the amount that needs to be raised for the project to begin enrolling and treating patients with cancer. On the other hand, it’s disappointing that much more hasn’t been raised already. This week, when you go out for a dinner and drop $50 or $100 without a thought, you should think again. Could you, perhaps, sacrifice on that one meal? You needn’t go without. Just scale back. Make a conscious decision to say that, rather than a fancy meal out, we’ll stay in, or order off the value menu. Take the difference and give it to the cause of Give 1 For Dad.

You may think, “Oh, I intend to give, I’ll do it next week, or the week after, or at the end of the month when I get paid.” Friends, I urge you to do it today. Time matters. People are sick now who might benefit. People will get sick tomorrow and the next day. Sadly, for some, it is now too late. Neil Poley–Sam’s father–passed away on July 4th. Yet it is not too late for those others–known to us or unknown–whom we might help through a modicum of charitable sacrifice. Indeed, to honor Mr. Poley’s memory, the family has asked for donations to Give 1 For Dad. This blog post is, once more, echoing that call in hopes of disseminating it to a wider audience. Martin Luther King, Jr. reminded us that “It may well be that we will have to repent…for the appalling silence and indifference of the good people…” I’m not asking you to give until it hurts. I’m merely asking you to give something in the hopes that it might ameliorate the hurts of others.

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Posted by on July 7, 2015 in Uncategorized


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