Category Archives: General

Sunk Cost

I find myself struggling with sunk cost these days. I preach the concept to my friends and family all the time. That decisions you made in the past, unless they have a direct bearing on future events, aren’t relevant to your decision making process. Rationally, this should reduce the guilt, or the regret, over doing the best thing there was to do at the time. Realistically, though, sunk cost decisions can impact our future, through that same guilt or regret. The choices we make in the past do provide a roadmap for the decisions we make in the future. We don’t want to feel that regret in the future, or the pain, and because of this, we create new pathways that allow us to choose better in the future. Personally, it’s hard to integrate the choices I’ve made in the past with what is happening now. I can only keep trying!


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10 things I learned reading through the PPACA

So, it’s the last day of the year, and in the spirit of the Internet, I’m going to do a “10 things I learned about the ACA” post.

10) I got really bored reading the PPACA, and the funniness quotient of my blog posts fell off dramatically. For this I apologize.

9) It doesn’t really matter what is in the PPACA to most people, they are going to make things up.

8) Taking a broad, comprehensive law such as the PPACA and turning it in to reality is very complicated.

7) People don’t like change, especially change they don’t understand.

6) People in the U.S. want to enjoy every freedom, including the freedom to be screwed over by health “insurance” plans that don’t actually cover very much of their health care.

5) It’s going to take me a looooooong time to read the whole ACA, mostly so I don’t want to gouge my own eyes out doing it.

4) The PPACA expanded the adoption child tax credit.

3) The PPACA includes a tax on tanning.

2) Congresspeople will find a way to complicate even the simplest sentence.

1) 2014 is going to be an interesting year!


In light of the fact that the ACA is essentially fully implemented, starting tomorrow, with a few hiccups and exceptions, I’m going to switch the focus of this blog back to general economics questions, although I may toss in a visit to the PPACA now and again. I am also going to follow the lead of the ineffable Angélique Jamail, and commit to a weekly post, let’s say on Wednesdays. See you next week!

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Health Care Quality Improvements

Ah, now we get to something very personal in the PPACA. A call for Health Care Delivery Systems Research.

Section 3501 calls for the AHRQ to conduct research in various areas of patient safety and quality improvement and gives out $20,000,000! It also provides quality improvement technical assistance grants.

Section 3502 sets up community health teams to support the patient-centered medical home. Necessary Sums!

Section 3503 provides grants and contracts to support medication management services for chronic diseases. Necessary Sums!

Section 3504 provides grants and contracts for design and implementations of regionalized systems for emergency care, including grants for emergency care research. $100,000,000!

Section 3505 provides grants for trauma care centers. $100,000,000!

Section 3506 creates a program to facilitate shared decision making. Necessary Sums!

Section 3507 calls for reports on evidence based presentation of prescription drug benefit and risk information.

Section 3508 creates a demonstration program for integrating quality improvement and patient safety training into clinical education of health professions. No money listed!

Section 3509 calls for Improving Women’s Health. I’ve got a few ideas, but they aren’t neutral. Establishes an office of Women’s Health! With Goals, and Advice. And Coordinating Committees! All paid for with necessary sums. Necessary and appropriate!

Section 3510 creates a patient navigator program with absolutely no details about it but you do get $3,500,000 a year till 2015.

Section 3511 authorizes appropriation.

Section 3512 makes a GAO study and a Report!



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The Fashion Sense of Toddlers

Professor X turned 22 months yesterday, on the 22nd. His last magic birthday until he is 22. At which time he will be taller than me, and possibly his father (but probably not his brother) and graduating college. The time will go too fast. Heaven only knows what he will be wearing then – if I knew what the fashions of 2035 would be, I could be a billionaire.

For now, though, he has developed his first fashion sense. Unlike when he is 22, his toddler self isn’t thinking about how cool he looks, or how to get a date with the cute boy or girl across the way, or impressing a future boss. No – his toddler self has two clothing loves – Vehicles and Dinos. And this outfit is a riotous combination of both.


Every day that isn’t a day where he gets to wear either Thomas or Lightning McQueen on his shirt is a sad day. And every night should be a night where dinosaurs roam the earth once more, at least as long as they are attached to him via his jammies.

It is both delightful and poignant that his personality is developing so quickly. I wouldn’t trade it for the anything, but he is past babyhood, running through toddlerhood, and will soon be a young man. And when he is 22, and moving off on his own, dressed in some natty shirt and the latest trend in jeans, I will undoubtedly shed a tear that a train on his shirt and dinos on his pants no longer fill him with the utmost joy and happiness.


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Subtitle E – Ensuring Medicare Stability

I’m desperate to finish reading this thing. I can totally understand why the Supremes didn’t want to touch it.

Section 3401 of the PPACA alters Market Baskets and incorporates Productivity Improvements. These things have to do with some complicated accounting that the government does to determine how they pay for things. Now, I’m not an account, but the gist of this section is that the government wants to pay less for higher productivity. Hey – don’t we all?!?

Section 3402 (notable for its brevity in contrast to the verbosity of the previous section) make temporary adjustments to the calculation of Part B premiums by making the income thresholds for these premiums the same as the ones in 2010 for the period 2011-2019.

Section 3403 (amended by section 10320 to change its name) sets up an Independent Medicare Advisory Payment Board. This advisory board is supposed to help reduce per capita spending by making recommendations on how to do so. It links the ideal growth of Medicare to the growth of GDP, which is interesting. It also gives a list of procedural rules on how changes to Medicare, as advised by the Board, should be implemented.


And that’s all they got for ensuring Medicare Stability. Leeches and blood-letting anyone?


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Subtitle D

Subtitle D is about Medicare Part D. Maybe they were being subtly ironic, but maybe they just didn’t notice. Who knows!

Section 3301 looks at the Medicare Coverage Gap Discount Program. This is the so called “Medicare Doughnut Hole” where after a certain point, participants were expected to pay 100% of drug costs, up to a catastrophic point. This section changes that to only 50%.

Section 3302 improves the determination of Medicare Part D’s low income benchmark premium. That’s pretty much what it does.

Section 3303 will allow a waiver of monthly premium for those people who are subsidy eligible, if the premium is de minimis, which is fancy Latin for trifling or minimal. It doesn’t actually say how much that it is though.

Section 3304 makes special rules for widows and widowers regarding eligibility for low-income assistance which basically extends the eligibility period for a year after their death.

Section 3305 improves information for subsidy eligible individuals reassigned to prescription drug plans. Specially formulary differences, and coverage determination.

Section 3306 increases funding and outreach for low-income programs.

Section 3307 improves formulary requirements for Medicare Part D, specifically requiring the inclusion of anticonvulsants, antidepressants, antineoplastic, antipsychotics, antiretroviral and immunosuppressants for treatment of transplant rejection. I wonder why there aren’t more pro-drugs. They seem so….negative.

Section 3308 reduces Part D subsidies for higher income individuals.

Section 3309 eliminates cost-sharing for dual eligible individuals (specifically here dual eligible for Medicaid and Medicare).

Section 3310 reduces wasteful dispensing of outpatient prescription
drugs in long-term care facilities. Or at least it tries to by allowing drugs to be prescribed in weekly or daily doses, rather than 30 days.

Section 3311 tries to improve Medicare prescription drug plans by creating a complaint system for problems with this plan.

Section 3312 creates uniform exceptions and appeals process for prescription drug plans including an Internet Website and a toll-free telephone number!

Section 3313 sets up another study! Of Prescription Drug plans!

Section 3314 allows for the inclusion of costs incurred by AIDS drug assistance programs and the Indian Health Service towards the annual out-of-pocket threshold.

Section 3315 was repealed and replaced. So no section 3315 for you!



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Fashion Friday

I’m doing a guest post, on my friend Angélique’s blog – Sappho’s Torque.

I moved to Seattle almost exactly 4 years ago. One of the hardest changes, in addition to leaving my friends, was getting used to the new fashion of the city. I was used to sundresses and sandals, having lived in Houston since I was 4. Seattle has those – for about 2 months between July 5th and September 5th. The rest of the year is rainy.

It’s been quite a struggle to adjust to my new surroundings – I’ve purchased leggings to wear under my beloved dresses, tried (and failed) to embrace pants, and purchased at least three pairs of waterproof boots.

But the biggest change has been embracing the hoodie. I mentioned it rains – right? And people don’t use umbrellas (the rain is almost never that heavy). So instead, they wear an assortment of waterproof gear from REI. Or, apparently, if they are born here, they just walk out in the rain like my 20 month old son. I wasn’t, hence the hoodie. And they usually wear black. Never been a big fan of black for clothes.

I saw a hoodie at REI three years ago that I just loved. It was pink, and fuzzy on the inside, and beautiful and wonderful. I had just bought a bunch of other jackets so being a good economist, we didn’t buy it then. But I thought about it. My 10 year old son, who was 7 then, said repeatedly, “Don’t think about the pink fuzzy jacket!” Months went by. I would tease him about thinking about the pink fuzzy jacket. Finally, for my birthday, I received it, my beloved pink fuzzy jacket. It’s made me feel a little bit more like me as I wander through this dark and rainy land.


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Health Care in America – a brief tutorial

Let’s start with some background. Why did we even need health care reform? What was driving the passage of this legislation? What does health care in American look like?

Health care in the U.S. is a patchwork of different institutions, at different times in a person’s life. Children are usually covered under their parent’s health insurance, if their parents have it, or a child-only policy. As with all health insurance the benefits of these policies can vary widely. Before PPACA, many of these policies would have both annual and lifetime caps.

If a child’s parents cannot afford health care insurance, either through work, if it is offered, or individually, states have lower-income health insurance plans that are available for small premiums, typically called CHIP or SCHIP plans. These plans are intended to cover those families that are not eligible for Medicaid.

When a child is from a family that meets the low-income and other qualifications for Medicaid, then they are eligible for this program, which is jointly funded by the federal government and the states.

Even with all of these programs, 11% of the nation’s children were uninsured in 2010.

In 2010, most insurance plans allowed children to stay on their parent’s insurance until they were 19, or 23 if they were enrolled in college. After that, you were responsible for your own health insurance. Most adults who have health insurance have it through their employer. There were no laws requiring employers to offer health insurance. The prevalence of employer-based health insurance arose during WWII, when wages were restricted. As any economist would tell you, this lead to non-wage offerings in order to entice workers. One of these was the employer paying for some or all of a health insurance policy. This was supported by the tax-deductibility, for the employer only, mind you, of this cost.

If your employer doesn’t choose to offer health insurance you have to either get it independently, which is usually more expensive due to the concept of adverse selection (the fact that people who need insurance are more likely to want to buy it) or go without. In 2010, 16% of the adult population did just that, and had no health insurance.

If you make it to 65, then you are eligible for the social insurance program known as Medicare. This federally run program guarantees medical care for all citizens over the age of 65. As of 2010, this program accounted for 3.6% of GDP. This was about 75% of what US defense spending was in 2010. It was also more than the GDP of all but 19 of the countries in the world. Because this is an age-based system, no person over 65 is technically without health insurance, although they don’t have to use it if they don’t want to.

What does it matter if people are uninsured? When people aren’t insured, they don’t go to the doctor regularly. This can lead to illnesses that are more expensive to treat, resulting in higher bills overall, when they do finally go to the emergency room, where they are required to be treated. It can lead to higher public health costs, as they are sick and continue to work rather than treating illness. It also forces them to spend money on health care that they could be spending on new cars and sweaters, which can lead to lower employment. Plus there’s the human suffering. But that’s harder to put a number on (but we can try!)

So there you have it, the basic motivation for why health care needed reforming, in 600 words or less.

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Getting to Know the Patient Protection and Affordable Care Act

The Supreme Court is about to start hearing oral arguments to determine the fate of part, or all, of the 2010 health care reform law known as the Patient Protection and Affordable Care Act (PPACA) and perhaps more popularly, as Obamacare.

I suspect that very few people have read the entire document. It is, after all, roughly 1000 pages long and written in policyese. The table of contents takes up 32 pages. Additionally, most of document amends other policies written previously, that will have to be addressed and explained. Therefore, on this the two year anniversary of the signing of the bill, I begin to go through the document, part by part, in order to explain what each section means. True understanding will require a great deal of background information, relating economic theory, and presumptions about the implementation of the various parts of the law. My credentials to do this? A doctorate in Economics and a master’s in Public Health. My motivation? A desire to understand it myself, and to share that understanding with you, my dear readers. My reward? Self-satisfaction and gloating at the next conference I attend.

Join me then, on this journey into the mysteries of health care, insurance, and government.

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Madder than the Hatter

I’ve been remiss in my posting here. I could pin the blame on many things, including my thesis for my MPH, but mostly I am just really mad. Now, little birdies tell me that when you are mad, the Internet is the place to be. But I have a hard time wanting to add my screeches to the already overwhelming mass of opinion that exists. So, I’ve remained silent, invoking the old adage ‘if you don’t have anything nice to say, don’t say anything’.

However, in the next four weeks, I hope that my thesis will be complete. I will then have some time to do some well thought out, and well researched, posts on topics such as the gold standard, employer-based health care, and other topics that are related to the mess occurring outside our windows everyday, but hopefully with some objectivity and care.

So until then, we should all take a break from watching the news, and focus on the coming spring, the warming of the earth, and the smile of our loved ones.

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