Come for the politics, stay for the snark.

When someone says they “love freedom”, rest assured they don’t mean yours.

They were going to turn on one another at some point. It was inevitable.

I really should read my own blog.

The desire to stay informed is directly at odds with the need to not be constantly enraged.

The Giant Orange Man Baby is having a bad day.

Let’s show the world that autocracy can be defeated.

This blog will pay for itself.

You come for women, you’re gonna get your ass kicked.

One of our two political parties is a cult whose leader admires Vladimir Putin.

People identifying as christian while ignoring christ and his teachings is a strange thing indeed.

Fuck these fucking interesting times.

There is no right way to do the wrong thing.

This country desperately needs a functioning fourth estate.

If you cannot answer whether trump lost the 2020 election, you are unfit for office.

Well, whatever it is, it’s better than being a Republican.

I’d hate to be the candidate who lost to this guy.

How stupid are these people?

It’s not hopeless, and we’re not helpless.

When I was faster i was always behind.

Balloon Juice, where there is always someone who will say you’re doing it wrong.

Thanks to your bullshit, we are now under siege.

They are lying in pursuit of an agenda.

Peak wingnut was a lie.

Come for the politics, stay for the snark.

You are here: Home / Archives for David Anderson

I am fundamentally fascinated by insurance markets, consumer choice and the navigation of complex choice environments.

I am an assistant professor at the Department of Health Services Policy and Management, University of South Carolina. I earned my PhD in Population Heath Sciences at Duke University (2024).

I used to be Richard Mayhew, a mid-level bureaucrat at UPMC Health Plan. I started writing here and have not found a reason to stop.

Conflicts of interest: Previously employed at UPMC Health Plan until 12/31/16. I also worked full time as a research associate at the Duke University Margolis Center for Health Policy (2017-2021). I have received direct funding from the National Institute for Healthcare Management (2020) the Commonwealth Fund (2024-2026) and the Pharmacy Care Management Association Foundation (2024-2025).

I have been on projects funded by the Rockefeller Foundation, Kate B. Reynolds Charitable Trust, Gordan and Betty Moore Foundation, Duke University Health System, CMMI, and various value based payment consortiums. I have received consulting fees from the Pharmaceutical Care Management Association, Alliant Health Plans, EvenSun LLC and MEAPTA LLC. I own and am the sole principal of Silverload Consulting LLC.

Research Production is here: https://scholar.google.com/citations?user=zof9b4IAAAAJ&hl=en

David Anderson has been a Balloon Juice writer since 2013.

David Anderson

Medicaid and the Freedom Caucus

by | 51 Comments

This post is in: 

Repeal and Replace in 2017 was not really an anti-ACA bill.  It was, but that was not where the net cuts were coming from.  It was a massive cuts to Medicaid bill.

We’re repeating the process:

💸 Scoop in this morning’s Early Brief:

The House GOP is kicking around a $1.5 trillion budget number for the “big, beautiful bill,” @mariannasotomayor.bsky.social and I can report.

Still spaghetti-on-the-wall phase of talks, but they’re tilting toward what the Freedom Caucus wants.

[image or embed]

— Jacob Bogage (@jacobbogage.bsky.social) February 6, 2025 at 9:03 AM

From a political pressure point of view this reinforces that all of the leverage is in the House. At the moment, Johnson can afford 0 NO votes and 2 Republicans who got delayed flying into National Airport to pass a party line bill.  His majority has a dozen members who won in 2024 with less than a 4% margin.  We’re highly likely to get a much bluer generic ballot in 2026 than 2024.  Those members are at substantial risk of losing in November 2026.  And now they are likely going to be voting for bills that tickle the fancy of the hardest of hard liners from safe to very safe Republican seats.

 

Medicaid and the Freedom CaucusPost + Comments (51)

IT Folks — this is bad, right?

by | 191 Comments

This post is in: 

I am not a programmer (I am at best a mediocre SAS and vaguely decent STATA programmer — let me use SQL please) and more importantly I am not an IT project manager.  However I worked at UPMC Health Plan in the System Configuration department which maintained and updated the claims system that was mission critical to paying billions of dollars in claims per year. One of my first assignments for 2+ years was tracking system change requests. The big project was “EXPANSION” which meant adding either two and three additional characters to Plan ID, member ID, and a few other fields to a claims system that had been first deployed in 1983( +/- a year or two as my memory is faulty.)  That project took over a year, and most of the company’s dedicated claims systems programmers.  We had multiple promotions from DEV to TEST and back to DEV as weird things happened, and then back to TEST and finally to UAT for a month before a 96 hour mandatory overtime promotion to PROD.  If EXPANSION failed in PROD, roll-back would have occurred to a stable saved version but it would have been painful.

So this is bad, (per Josh Marshall), right?

The DOGE team, which appears to be mainly or only Elez for the purposes of this project, has already made extensive changes to the code base for the payment system. They have not locked out the existing programmer/engineering staff but have rather leaned on them for assistance, which they appear to have painedly provided hoping to prevent as much damage as possible — “damage” in the sense not of preventing the intended changes but avoiding crashes or a system-wide breakdown caused by rapidly pushing new code into production with a limited knowledge of the system and its dependencies across the federal government.

Bring on the meteor

 

IT Folks — this is bad, right?Post + Comments (191)

Medication, supply chains and tariffs

by | 14 Comments

This post is in: 

On November 11th, I gave a few pieces of advice/thought regarding health policy prep for the Trump Administration:

Third, if you have medications or other medical consumable goods that have substantial foreign components in them, see if you can stockpile or extend your script to a longer prescription in December.  If we are to see 20-30-40-50-100% tariffs the entire supply chain is going to be an omni-shambles.  Extending a 30 day scrip to 90 days might let you skip the initial ombi-shambling implementation and give you until March until you need to figure out what to do next.

This is still relevant and true today.  If you can get longer fills and if you can afford to do so, it is probably a good idea to talk to your doctor/NP about it to get some policy insurance against tariff implementation omni-shambles.

Now onto deadlifting/shower thoughts from this morning — assuming there are either tariffs or substantial threats of tariffs on broad categories of goods including medication and medical supplies, how does this effect insurers in the next few years.  Costs are likely to go up for each unit consumed but there might be fewer units consumed due to a combination of shortages and increased cost-sharing.

 

Medication, supply chains and tariffsPost + Comments (14)

US Produced Goods and Tariffs

by | 125 Comments

This post is in: 

My wife is making cinnamon waffles for breakfast.   We have a big jug of Costco maple syrup out on the table.  It is made in Canada and the next shipment will be hit by a 25% tariff.

I’m thinking about substitutes.  There are two basic substitutes for Canadian maple syrup; first there is US maple syrup and then there is maple flavored and colored high fructose corn syrup sold as pancake syrup.  US maple syrup ranges from really good (Vermont) to adequate (Ohio and elsewhere).  Pancake syrup’s primary differentiator is that it is CHEAP.

Some people are maple syrup only people.  Some people will switch between maple syrup and pancake syrup.  My family has a strong maple syrup preference but not a strong preference between good US and good Canadian syrup.  We bought Canadian because it was available at a good price at Costco.  We would substitute US syrup next fall when we run out of our current stockpile.  One of my friends and likely future co-author has STRONG preferences on their syrup and likely won’t substitute Quebec syrup for anything else.  They will pay the higher price.  We are less likely to pay an extra five dollars a quart for Canadian syrup.  Instead we’ll increase demand for American syrup; increased demand means higher prices.  The US syrup price won’t go up as much as the Canadian price will increase but it will increase.

Now I have to go eat some waffles and think through the dynamic pricing effects of tariffs.  I have pity for the folks who study US spirit pricing and logistics as things are highly likely to get WEIRD there now and in the next few weeks even as the Great Lakes automobile manufacturing cluster gets creaky.

US Produced Goods and TariffsPost + Comments (125)

SD 35 in Iowa flips Blue

by | 42 Comments

This post is in: ,

The first special election flip of the cycle happened tonight.  A very Trump leaning Iowa Senate District (R+21) had a special election as the prior Republican State Senator is the new Iowa Lt. Gov.  And it flipped to the Dems:

THE DEMOCRATS HAVE FLIPPED IOWA’S #SD35:

Mike Zimmer (D)- 51.8%
Katie Whittington (R)- 48.2%

THIS WAS A TRUMP+21 DISTRICT!

— Uncrewed (@uncrewed.bsky.social) January 28, 2025 at 10:06 PM

The story, much like 2017, is most likely a story of differential turnout. Energized Democrats voted (as the Dem won the Election Day vote) while Republicans stayed home. However, this reinforces two stories.

First, non-Presidential elections are likely bluer electorates and the further down the attention scale, the bluer it gets.

Secondly, and building on the first, this is why the House is the leverage point. A triple the decisive amount of Republicans won in 2024 by less than 4 points. If there are consistent Dem overperformances in the special elections, it reminds them that they are extremely vulnerable in November 2026.

SD 35 in Iowa flips BluePost + Comments (42)

All about the House

by | 92 Comments

This post is in: ,

This afternoon, Senators Murkowski and Collins, along with every Democrat voted against cloture to confirm Hegseth as Secretary of Defense.

He is highly likely to be confirmed for if Murkowski and Collins had two more Republicans willing to vote no, they would have had a discussion with Thune to tell him to tell Trump to pull the nomination before anyone got embarrassed.

The Senate will not be the leverage point on anything that does not require 60 votes for cloture or 67 for treaty ratification.

However, Politico reinforces that the House is the leverage point:

GOP lawmakers in the room included Rep. Brian Fitzpatrick (Pa.), Young Kim (Calif.), David Valadao (Calif.), Andrew Garbarino (N.Y.), Tom Barrett (Mich.) and Don Bacon (Neb.).

And the group asserted that Republicans need to protect more than just Obamacare. A large swath of the GOP is discussing significant spending cuts, including to social safety net programs like Medicaid and the Supplemental Nutrition Assistance Program, formerly known as food stamps. Centrists warned their colleagues not to pursue deep cuts to those programs, which benefit low-income Americans, according to the four Republicans…

Emmer’s team ticked through slides of possible cuts to “feel out problems,” according to another person familiar with the meeting. As they went down the list, it became clear there were still many points of disagreement.

“Almost everything is: ‘That’s a problem. That’s a problem,’” said one of the people who was in the room.

Right now, the House Republican caucus can afford to lose zero NO votes or 2 “present”/”flight cancelled” Republicans on any vote where every Democrat shows up and votes NO in the House. Once special elections are held, the House HOP can afford 2 NO votes.

The House is the pressure point.  We know that Fitzpatrick voted against ACHA in 2017. We know that local political and economic actors will be having very extensive discussions with vulnerable Republicans about the effects of multi-trillion dollar Medicaid and/or ACA cuts will have to their district’s healthcare system.

The House is the pressure point that will bend first.

All about the HousePost + Comments (92)

Health expenditure is mostly for the really sick

by | 12 Comments

This post is in: 

Mark Cuban is a good dude trying to figure out tough problems. CostPlus Drugs is awesome at injecting price competition into several spaces that need it.

But healthcare is complex and simple solutions aren’t always the best solution. He had some thoughts on financing healthcare in a blog post a few weeks ago:

Hypothetically, It should look like 1955 (I picked this year because of Back to the Future :). Patients go to providers for care. Providers provide that care. Patients get a bill and if they can afford it, they pay that bill. That’s it.

The ONLY question in healthcare should be “How should care for people who can’t afford to pay for their care be paid?”

Let me reintroduce one of my favorite health economics exhibits.

Distribution of US Healthcare spending by percentile 2016 MEPS analysis

As you can see the spending distribution in the US is extremely right hand skewed (really few people are really expensive!)

Here are some of the relevant numbers from the same brief:

Bottom 50% of the spending distribution in 2016 has an average spend on all healthcare utilization of $276 in 2016 dollars.
Top 1% of the spending distribution in 2016 has an average spend on all healthcare of $110,003 in 2016 dollars.

As I disclose in my health economics class, my utilization history in 2024 is pretty close to the median American. I got a flu and covid shot. I went to urgent care once. I had a dental visit. I picked up either one or two $4 generic prescriptions at Walmart and bought a 365 pill bottle of Costco brand Zyrtec plus some chicken noodle soup, tea and honey for a head cold that would not shake itself for a few days.

I’m lucky. I should see my PCP more. I am starting to get to that age. But almost any system of healthcare finance “works” well enough for me. I can do cash pay with catastrophic insurance (I am lucky to have assets). I can do the ACA with either a Gold or Bronze plan. I can do Medicare for All. I can do the current system of the state of South Carolina insuring me in a high deductible plan. Any of these systems work well enough for me.

And sure, finding ways to reduce administrative costs would be great but it would do almost nothing.  For most of the over 150% Federal Poverty Line population, we already have a system of high-ish deductibles and substantial out of pocket spending that makes most day to day care and little acute episodes already not insured.  People are hideous shoppers though.

The real money in the US healthcare system is for the “people who can’t afford to pay for their care be paid”

Pragmatically, almost no one can afford to pay to be in the top 1% of US healthcare spend over multiple years (many can’t do it for a day or a year as is).  Being in the top 1% can be a persistent condition if you need complex biologics still on patent to keep cancer suppressed for instance. Figuring out how to pay and finance care for the top X% of the US healthcare spending distribution is a nasty ugly problem (5% of the population is 50% of the spend retrospectively).  Given the level of assets/savings in the US, the X% is highly likely to be well above the top 5%.  I would guess the big challenge is the top 20% to 30% but that is both a judgement call and a moral/political decision, not a technocratic one.

Yes, improving administrative efficiencies and making the system easier and more transparent to use and understand are good things that will, on the margin, likely reduce costs, but the big challenge is that the US healthcare system (hell any system in a middle or upper income country globally) is paying for care for a fairly small population and not worrying too much about paying for care for the bottom 50% of the retrospective spending distribution.  That particular problem is easy.

 

 

Health expenditure is mostly for the really sickPost + Comments (12)