Another year, another look back post

Six years in, and almost 1,800 Mayhew Anderson on Insurance posts written. Another anniversary and another exploration of the odd esoterica of the US healthcare system completed as I begin writing for a seventh year at Balloon Juice. I need to say the same thing that I said last year:

Writing here at Balloon Juice has been and continues to be an amazing experience. I get to play with ideas that fascinate me, and John gives me the keys to write to an audience…..

One of the big changes since I’ve come to Duke, beyond saying good bye to the persona of Richard Mayhew, is that I’ve changed my writing targets. When I was Richard Mayhew, I had to write at Balloon Juice…. Now, the audience is sometimes all jackals. Other days, the intended audience is a few score of geeks and policy professionals who need to know about some esoteric corner case. I apologize when I take over the blog for those purposes as I feel like I am hijacking your attention to pay the cost of entry into conversations that I want to be in….

But mainly, I just want to thank all of the jackals, the front-pagers and John for a community where I can nerd out on something that I find fascinating. I’ll figure out what Year Six SEVEN looks like, but the first five six have been wonderful.

My writing has become even more narrowly focused over the past year. Part of that has been that I set a goal for myself to play in the peer review space this year. And the very nature of that space requires far more targeting. At this point last year I had a single peer reviewed research project that was almost to the point of acceptance at the Journal of Health, Politics, Policy and Law and a letter to the editor for Health Affairs where I made the point that 2018 is an analytically weird year.

This summer I had a cluster of original research come out and an invited commentary already published. I have an article forthcoming in two weeks where a co-author and I will be looking at one of two topics which will dominate the 2021 rule making process for the ACA exchanges. The two of us have another paper accepted last night  which engages on the other major topic of the 2021 rule making process. We, along with a third collaborator, are again looking at that question from a different angle with a paper that is likely to come out this fall. I had a moment of quasi-maniacal super-villain laughter this summer when I looked at a revised version of Exhibit 3 for that manuscript and realized it will be entered as evidence in future litigation.

This afternoon, I am expecting to get back a second round of co-author edits for a manuscript that uses public use files to show something bloody obvious but not recorded. Insurance is complicated and this project shows some additional forms of complications in a way that no one else has even thought about. We’re using public, downloadable data, and part of our analytical data set has less than fifty downloads (and I am responsible for 6 of them as I lost track of the file a few times). Over the weekend, I need to make edits to the discussion section of a methods paper on matching for a small and unusual population (TLDR: It is really tough to do with reasonable assumptions). We hope to get that manuscript submitted for the first time next week. Another half dozen projects are in various stages of review, revision, and rewriting even as I’m building my 2020 project pipeline that builds on what I did in 2018 and 2019.  Under the most pessimistic assumptions I anticipate having six accepted manuscripts this year, median assumptions are eight or nine acceptances while wildly optimistic assumptions have a bakers dozen acceptances.   I will have four first or solo authorships from this current tranche of papers.

From an academic point of view, that is a wildly productive year especially as a good number of those manuscripts will be landing at very good journals.

But there are trade-offs. I have narrowed my thinking a lot and it shows that a lot of my Balloon-Juice writing is technocratic tinkering. Beyond that, my non-Balloon Juice public writing has crashed. I have only published three blogs at Health Affairs this year. I have not written an op-ed although I am in the process of prepping one around a topic that will be relevant around Thanksgiving. I became very narrow this year.

I needed a year to demonstrate that I can work well within the peer review paradigm. I think I achieved that. I enjoyed myself as I would like to think that I have added some unique value to the conversation and the knowledge that my co-authors, collaborators, colleagues and I are sharing will be meaningful and important in policy development. Next year will also be a productive but hopefully at a slightly less insane pace of production in the peer review universe. I hope I can grab some of those thoughts back from the ultra-specific to slightly broader questions that are more important that describing a particular form of financial plumbing.

I still get tremendous energy writing here.  I would like to de-geekify and make some of my writing more pragmatic over the next year.  I would really appreciate help on that and suggestions as to how to be more responsive to the needs of Jackals instead of merely paying the cost of entry to other conversations. But that is a thought for another day and another post, so onto year seven.

 






76 replies
  1. 1
    Gin & Tonic says:

    suggestions as to how to be more responsive to the needs of Jackals

    I think the dildo story really was a step in the right direction, but you didn’t seem to pursue that.

    Oh, you mean on health policy, sorry.

  2. 2
    frosty says:

    Congratulations on the peer reviewed papers! This year I published my first in 45 years of a career where it’s not typical and the employers don’t give you time to do it. Just in time before retiring too!

  3. 3
  4. 4
    Bill K says:

    I have really enjoyed your detailed explanations of the arcane workings of our health system. Best of luck in your new pursuits.

  5. 5
    laura says:

    Happy Nerdnaversary!
    Your posts are so data rich and informative. We ALL need health care but the “market” is a black box on purpose so the “consumer” is denied what is necessary to make informed choices while the industry profits. You hold up a lamp and point out the ways the black box can be dismantled. You demystify. You’ve helped many a jackal. Thank you!

  6. 6
    Mathguy says:

    Thanks once again for your commentary. Even the nerdiest posts are always worth browsing for interesting nuggets. You’ve made us all appreciate the absurd complexity of this kludge we call American health care.

  7. 7
    Mathguy says:

    BTW, need moar football (rest of the world version) posts.

  8. 8
    zhena gogolia says:

    I think people are reading this as a farewell to BJ — that’s not so, is it? You’re just saying you’re going to write a different style of post.

    You give this blog some class! I hope you’re sticking around.

  9. 9
    zhena gogolia says:

    I think people are reading this as a farewell to BJ — that’s not so, is it? You’re just saying you’re going to write a different style of post.

    You give this blog some class! I hope you’re sticking around.

  10. 10
    zhena gogolia says:

    FYWP

  11. 11
    Gelfling 545 says:

    I have always found your posts informative & though occasionally my response has been “Huh. You don’t say.” in general I have found the information useful even if once in a while only for amazing my friends with a “Hah! But did you know….?” On the whole, the info has been of more practical use.
    Your instincts have been good. Follow them.

  12. 12
    Anonymous At Work says:

    I enjoy those posts I can follow and I mean this sincerely, but “In the near future, may the need for your posts on private insurance pricing go away.”

  13. 13
    RAM says:

    David, I understand about half of what you write about, but I always know that if I need an exploration of what’s in the health insurance weeds, you’re the MAN! What’s a real, ongoing problem is that health insurance is so complicated that even a good writer like you can’t explain it to regular folks like me in a way that makes much sense. After reading you for all these years, it’s also clear that the confusion is a feature, not a bug, of the system. As I never tire of telling my friends, health insurance companies are not in the business of paying the costs of medical treatment. They’re in the business of making money. Anyway, I recommend your posts to people interested in the topic all the time. Here’s hoping you’ll be around these parts for at least another seven years.

  14. 14
  15. 15
    Anya says:

    I really appreciate your explanation of the workings of our complex healthcare system. I do not say anything because I have nothing informative to say but I always read all of your postings and I often share it with others so thank you!

  16. 16
    Josie says:

    @David Anderson:

    Glad to hear this. I always read your posts and feel better informed because of them. I don’t comment since you answer my questions before I ask them. I also appreciate your soccer posts.

  17. 17
    rikyrah says:

    You have been a joy, Mayhew. A complete joy to read. I appreciate from the bottom of my heart what you have done here, and your patience with us. BJ has been so lucky to have you.

  18. 18
    satby says:

    Happy Blogiversary! Glad you’re here!

  19. 19
    wvng says:

    That you have found such a productive niche in academia and still are able to write for this blog is a marvel. Your explanations of complex issues have been enormously helpful to me over the years and expect they will continue to be so.

  20. 20
    RoonieRoo says:

    I may not comment but I always read your posts. I don’t often understand all of it but I definitely understand more now than I did 6 years ago. It’s simply nice to have a topic so far out of my wheelhouse and yet so important to all our lives to wrap my mind around.

  21. 21
    Kristine says:

    Happy Anniversary. Many more!

  22. 22
    Felanius Kootea says:

    Thank you for your posts! They’ve helped me in conversations with colleagues who are more health policy focused, though I never feel that there’s much for me to add in the comments.

    Please know that your geeky posts are indeed appreciated even when they don’t generate the volume of comments that the sharpie shenanigans of an addle-brained ignoramus do.

  23. 23
    MazeDancer says:

    Congratulations to you – and us – for six excellent years!

    So happy you get happiness from writing for BJ. Because it always upgrades the place.

    One easy suggestion – You don’t have to post every day. 3 times a week would be generous. That might give you a chance to add a “What this means to you” paragraph at the end of each heavily techno post.

    Like the “conclusions” on medical studies at PubMed. That paragraph is usually decipherable to a lot of people.

    And you would 1) be serving both your audiences and 2) laying your cred for expanding to consumer commentary gigs.

    Thanks again!

  24. 24

    @MazeDancer: That is a good idea. This summer I had far fewer weeks where I had five unique health insurance posts up in a week. I think that was a good thing including an actual week long break at some point.

    Writing up the SO WHAT at the beginning should provide more clarity and impact. I like this idea.

  25. 25
    CaseyL says:

    That’s an astonishing number of publication results – congratulations!

    You have been and and continue to be invaluable here, helping lead us through the sticky wickets of the American health insurance/healthcare system.

    I’ll be very interested to see what you post about in the coming year.

  26. 26
    Neldob says:

    So happy to have the opportunity to read your mind, uh, thats thoughts, read your thoughts.

  27. 27
    beth says:

    I rarely comment but always enjoy your posts. My husband passed away earlier this year and we spent five years navigating the insurance world of employer insurance, COBRA, disability and Medicare as we cobbled together ways to pay for his cancer treatments and get insurance for me so I could work part time and help care for him. Your posts made me more knowledgeable about what to look for and what was available so I thank you for that. I always wish I had an insurance terms index though when reading some of the posts. Just a suggestion. Congratulations on all your successes and here’s to many more years writing at BJ!

  28. 28
    kindness says:

    Your Healthcare/Insurance posts are always exemplary. I miss the soccer officiating stuff. The cases on the field usually had tangents to life off the field.

  29. 29
    lurker dean says:

    @David Anderson: @MazeDancer: great idea!

    really appreciate your posts here, even though i don’t usually comment on them. as others have said, they really make you appreciate the complexity of the system, and make you understand that some orange idiot claiming it will be easy to give everyone healthcare is a charlatan.

  30. 30
    JAFD says:

    @MazeDancer: “That might give you a chance to add a “What this means to you” paragraph at the end of each heavily techno post.

    Like the “conclusions” on medical studies at PubMed. That paragraph is usually decipherable to a lot of people.”

    If I might second that, and add that IMVHO, maybe you could add a post occasionally on ‘definitions and explanations of terms and phrases’. Someone new to serious discussions of health insurance may take a while to outfigure that ‘silver spread’ doesn’t refer to ‘canoodling at the Old Age Home’.

  31. 31
    JAFD says:

    @beth: Evidently we were both typing at same time. As my mother would say “Great minds think in the same direction”.

  32. 32
    Aurona says:

    Geeks R Us salutes you and your continuing medically-induced education of jackals and their associates. I for one, thank you. I have the experience of working for Blue Cross in So Cal and Blue Shield in Nor Cal, executive assistant/office manager positions, so not a technical nerd. But your information was enough to assist me in my retirement years of doing ‘audits’ for Medicare plans (being a secret shopper for their plans to make sure they hit all their marks), and I keep informed into the changes yearly of our Medicare plans, both supplemental and HMO plans. Thanks much, keep up the wonderful work!

  33. 33
    Kay says:

    I just wanted to thank you, David. I don’t comment but I do read the posts and I appreciate how much effort you put into them.

  34. 34
    Spanky says:

    Congratulations on the anniversary. And on the publications! It’s amazing how much time gets freed up when you give up reffing, eh?

    There’s also the (military?) term BLUF. Bottom Line Up Front, for when you want to summarize at the beginning. Of course, then no one will read to the bottom :^)

  35. 35
    ruemara says:

    Well, we’re glad to have you. Even if sometimes, I just barely understand all the details you’re conveying. But I try to understand, so thanks!

  36. 36
    Yarrow says:

    So very appreciative of your posts. You have helped me navigate some difficult insurance choices and I appreciate your knowledge and willingness to post and engage with commenters here.

    There have been some cases where someone makes a comment and you take that comment and use it as the basis for another post. I find those posts quite interesting so maybe that’s a place to start since you’re asking for for ways to be more responsive. I think you might have also done a “What health insurance topics would you like to see covered?” post in the past. If I’m misremembering, then that’s a possibly way to see what’s most important for people.

    Congrats on your anniversary and thanks again for everything you do.

  37. 37
    Yarrow says:

    @MazeDancer:

    One easy suggestion – You don’t have to post every day. 3 times a week would be generous. That might give you a chance to add a “What this means to you” paragraph at the end of each heavily techno post.

    Like the “conclusions” on medical studies at PubMed. That paragraph is usually decipherable to a lot of people.

    And you would 1) be serving both your audiences and 2) laying your cred for expanding to consumer commentary gigs.

    REALLY like this suggestion. Sometimes your posts are hard to follow for those of us not in your field yet we know the subject is important and likely will impact our lives. I want to understand how.

    I also agree that you have a future as a consumer commentator abut health insurance should you choose to. You write well and break a difficult subject down so it’s easy to understand. You could even do gigs on cable shows. “Mr. Mayhew, are you ready for your close up?”

  38. 38
    206inKY says:

    Your posts over the years have almost single-handedly helped me understand the Affordable Care Act. In the process, I feel like I have become a better and more informed citizen. For example, you were offering a totally different analysis of the consequences of eliminating CSR payments than I was reading elsewhere. During those months of the early Trump years when the ACA was under siege, I had a better sense of what we were fighting to protect because of you. I am really grateful for the insights that you’ve shared here over the years.

  39. 39
    b says:

    I don’t comment, but I do appreciate your posts. They have been very helpful in understanding how the exchanges work (or dont work). They have been especially helpful in understanding the impact of some of the Republican attempts at sabotage of the ACA, where the end result has actually been unintentionally helpful.

  40. 40
    Chris Johnson says:

    I have narrowed my thinking a lot and it shows that a lot of my Balloon-Juice writing is technocratic tinkering.

    I would like to de-geekify and make some of my writing more pragmatic over the next year. I would really appreciate help on that and suggestions as to how to be more responsive to the needs of Jackals instead of merely paying the cost of entry to other conversations.

    I would like to ask: do you mean this?

    Because in your own words, you are technocratic tinkering in your posts here and it is only to get access to other, more exclusive places.

    I have often been very cross with you, but it wouldn’t have occurred to me to accuse you of that, yet you’ve said it.

    I feel you’re the recipient of gratitude born of desperation from this largely older (I’m over 50 and one of the annoying young sprouts in THIS crowd) blog readership, who are actively being preyed upon by the industry you enable. I completely understand when they are brimming with fawning gratitude, but I respect your willingness to try and actually help them more than your technocracy.

    As a tech industry person I feel like I have a different window onto a different ‘toxic and given to technocracy’ world, so I can’t act too appalled at yours. It does, however, regularly shock me. It should shock me that you’ve been using Balloon Juice for your own ends, but that can’t shock me either: everybody’s very desperate these days and I would be rude to exempt you from that, you’re only trying to get ahead.

    Do please try to help jackals rather than just gaining entry into other conversations. They trust you. I know I felt better in my life when I went over from software development to open source patreon-funded software development: I stopped exploiting people and being an active part of a toxic system. It did cost me some money, and I could only do it once I’d made my bones in the very toxic system I rejected. Maybe you can do something like that now that you’ve made your bones in your own toxic system.

  41. 41
    Omnes Omnibus says:

    @David Anderson: Is this the healthcare wonk version of “Go fuck yourself?”

  42. 42
    SiubhanDuinne says:

    Hard to believe it’s been six years already! Congratulations on this milestone, and on your many accomplishments. So glad you are a key member of this community!

  43. 43
    Sab says:

    @Chris Johnson: Jeez, is there no space where you won’t slither in to be a jerk?

    Mayhew Anderson was enormously, possibly lifesavingly helpful to me when I was in my fifties, previously uninsurable, and first dealing with Obamacare.

    Helpful to me in buying insurance. Helpful to me in calling politicians when it was all at risk.

  44. 44
    guachi says:

    I love Mayhew on Healthcare posts. I look forward to them as a morning read.

    The only problem: after years of reading them I can’t talk to other people about healthcare as I know so much more than them!

    And that’s all thanks to your posts. Invaluable.

  45. 45
    Cathie Fonz (formerly Cathie from Canada) says:

    @David Anderson: if you want to write a “so what” paragraph, one easy trick for a writer to do this is to write the usual type of post, then just move your last paragraph up to the top. Its hard to actually write this summary first, but it’s a good way for a reader to read it. Usually a last paragraph is pretty good summary of a whole piece, so moving this to the top is a good way to give a reader your conclusions right off the bat.
    When I am reading a longer technical piece and don’t understand where it is going I often scroll down to the end and read that, then go back to the text if I want more detail.
    Hope this is helpful

  46. 46
    Gin & Tonic says:

    @Omnes Omnibus: Understanding almost nothing about NFL football, I didn’t have any idea how to take it. I thought I was being complimentary, but I may have missed the mark.

  47. 47
    Omnes Omnibus says:

    @Chris Johnson: You’re an asshole.

  48. 48
    Omnes Omnibus says:

    @Gin & Tonic: I can’t see any way it which it might be a good thing.

  49. 49
    J R in WV says:

    @Chris Johnson:

    Chris, I’m not going to quote any of what I received as a hostile post based upon false premises, but I think you’re (for whatever reason) a very bitter person projecting your own guilt onto people who do not share that guilt at all.

    Dave is here to help us understand something — he is NOT toxic and is not using us for his own purposes. You should go away now, and try to heal yourself, perhaps through meditation, or psychoactive drugs, or something, because you are seriously broken right now.

    I was going to include a stock phrase involving rusty farm implements, but I’ll just stop there.

    Please get help.

  50. 50
    Omnes Omnibus says:

    @Omnes Omnibus: @J R in WV: It is possible that CJ is talking about Mayhew who we all know was just in it for the hookers and blow.

  51. 51
    jl says:

    I appreciate the work David puts into his posts. I think even the very technical ones are interesting and important. I’ve tweaked him a bit about getting too deep in the weeds, but I read them carefully, even when hard to understand, since I think stuff deep in the weeds is important to try to understand in order to check on whether big picture thinking fits with what is going on in the real world. For me, reading some of the posts is like eating some vegetable I don’t particularly like (beets) because it is good for me. Sometimes, when I think I do have a good grasp of the weeds, I find the posts grimly amusing, since I see it as a detailed history of how the wheels are coming off an a still unstable insurance system. I don’t think the regulatory reforms of the PPACA were nearly strong enough to produce a stable insurance system, and some of David’s posts confirm that, IMHO.

    I think a summary of the intuitive significance of the post is a good idea. More peer reviewed journals require that anyway, so it is good practice if David needs to jump through that hoop on a regular basis.

    I think another good idea is to occasionally write a simple didactic primer, or basic refresher, written with the goal to keep readers prepared to understand the deep in the weeds stuff. Maybe keep links to those handy to plop into posts so readers can refer to them. A refresher on the intuition of how the Silver Gap works and why it is important to understand is just one example. I think this is also good practice on old saying in math that you don’t understand a subject until you try to teach it.

    Another idea is to emulate Krugman in his use of his non-column posts at the NYT, which is to try out new ideas, and see what the reaction is and get feedback.Also, try to connect the big picture on social insurance to the weeds.The late Uwe Reinhardt is not longer with us, and we need someone to take up the work he did. So, maybe review his stuff to get ideas on important directions for research.

    IMHO, the US health care system is completely dysfunctional, and this dysfunction infects how health policy work is financed, judged, and published. Sometimes I wonder what use it is. A lot of it seems to be just documenting all the ways the US health care system is degenerating from extreme dysfunction to even more dysfunction.

    US health policy research is also one of the most insulated fields I’ve ever seem It lives in its own little world with much less connection to other fields than I’ve seen in engineering, or management, energy, agricultural policy and economic research. And it is particularly bad in the US compared to other countries. David is in a good position to fix that, since he has a better understanding of the theory of how insurance markets work and do not work than many other researchers.

    I deeply appreciated David’s thoughtfulness and his willingness to grow and keep exploring new direction. Ruts can be very very deep in health policy research, and staying in your rut is strongly encouraged, often a requirement for existence in certain places, due to the dysfunctional way much of the applied research is funded, IMHO.

  52. 52
    Richard Guhl says:

    @David Anderson:
    Congratulations on your success. I’m sure you’ve noticed that your posts seldom generate many comments. For my part, sometimes you dive so deep into the data that my eyes glaze over, but more often I’m so blown away by the expertise and thoroughness of the analysis that I have nothing to say, but what I should have said more: thank you.

  53. 53
    Felanius Kootea says:

    @Chris Johnson: This seems to be a whole lot of projection based on your own personal experiences in tech. That’s understandable in some ways but your approach leaves a lot to be desired.

    I gravitated away from computer science and software development as a profession partly because I was repulsed by the large numbers of rabid libertarians (mostly male) I encountered, many on the spectrum, with no self-awareness, empathy, sense of ethics, or knowledge of history, yet filled with an abundance of arrogance and greed. Many of these people do dominate our tech sector today.

    Facebook and Google may yet bring down the world with that arrogance – maybe you can focus your energies in that space rather than attacking someone who shares valuable knowledge freely, unpaid.

  54. 54
    jl says:

    @Chris Johnson: I think you are twisting David’s post into a false dilemma and false choice that does not exist.
    He can, and I think should, use this blog to try to explain things in an intuitive way to this readership. His posts here often get links in very respectable places that get him a very wide readership. And he should use his experience here to inform his professional work.

    Those are three distinct communities and all of them can benefit from his work here at this blog.

  55. 55
    cursorial says:

    I’ve always appreciated your posts – especially during the times when a great deal of ACA-related misinformation was flying about in the popular press. Reading your analysis here made me feel much more well-grounded in a complex topic, like reading the Economist or Scientific American.

    Good luck with whatever direction your future writing takes. There’s a great deal of value in your past posts, and I often think that some publisher should collect and edit them into a coherent whole, a guide to how the insurance industry works for the non-specialist. (If that’s something that could be crowdfunded/crowdsources, I’d be happy to contribute) It’s a remarkable body of work.

  56. 56
    Genine says:

    Happy Anniversary, David! I like your posts a lot. I definitely think you should continue and adding a “this is what this means to you” bit is a great idea. Kudos to the jackals that suggested it. I hope we keep you around for a long time.

    On a side note, though: @Chris Johnson: Really, dude?

  57. 57
    FelonyGovt says:

    I really appreciate your posts, David, and this thread shows that although your posts don’t generate lots of comments, we do read your posts carefully and with gratitude. Sometimes they are over my head but on the whole you do a good job of breaking down an (intentionally) arcane subject.

  58. 58
    StringOnAStick says:

    @cursorial: I agree, it is a remarkable body of work. When health care comes up in our dental office, I’m the one who knows the topic better than the rest of the group and that is entirely due to reading David’s stuff here.

    David, congratulations on all the accepted articles, that’s a lot of hard work!

  59. 59
    StringOnAStick says:

    @Felanius Kootea: That’s funny about the libertoonian bend of most software shops. My husband is a senior software developer but at a European-based travel/tourism company, and it is nothing like that. It could be that’s because the travel industry has always been very GLBT-friendly so the office has a large number of out and proud people; perhaps that is kryptonite to Libertoons? Someone spouting all the usual Libertoonian crap (I used to be in consulting civil engineering, so I well know the type) wouldn’t last a month there, but people willing to be out and living their best life on their own terms do great there. It’s a very accepting environment.

  60. 60
    Jacel says:

    So what is different about being in the peer review space of writing? Does it not provide occasions to use the (in your hands) enlightening phrase “more hookers and more blow”?

  61. 61
    J R in WV says:

    @Felanius Kootea:

    I was fortunate to work for an environmental protection agency, and most of the tech staff was willing to work for less money in order to do good work. In the industrial shops I worked in, yes, lots of that behavior you note.

    I’m glad I wasn’t the only person to take exception to Chris J’s remarks, which were based upon an extreme misreading of what Dave had to say. I think Dave is a great positive for everyone here, and hope he keeps up the good work of sharing knowledge with those of us who have less of a clue about the artificial complexities of the health insurance business.

  62. 62
    jl says:

    @Jacel: Only person I know of who could get away with that was the late Uwe Reinhardt, who managed to slip in the appropriate sarcasm in peer reviewed publications. Someone needs to continue that work as well.

  63. 63

    @Gin & Tonic: I was trying to play in good fun; the Bills fans have a “history” of throwing life like personal massaging products on the field when the team is not doing well.

  64. 64

    @Jacel: Really good question.

    1) Yeah, I have yet to convince both an editor, and co-author that “hookers and blow” is a meaningful analytical term to anything that has made it to final acceptance.

    2) Peer review pieces tend to be much narrower in scope and a much deeper dive in one particular question. For instance, I had a manuscript published at the Journal of Health Politics, Policy and Law that looked at the enrollment declines in the last 2 weeks of the 2017 Open Enrollment Period as the administration of the exchanges changed from a supportive group of folks and leadership under Obama to a vehemently opposed leadership group. We used publicly available but not widely disseminated data at the enrollment/week level, half a dozen different controls, looked at partisan ship and developed two sophisticated models to tease out inference. Our final result is that ~250,000 enrollment applications never happened that we otherwise would have expected to have happened. My co-author and I worked on that paper for 12 months and it took another six months to get it published.

    A very rough/quick and dirty model was presented here on Balloon-Juice a week after the data stabilized. that model had no controls and it was directional but I got it out fast. No journal would publish that model because it had no strong controls and I was assuming but not proving underlying trends.

    https://www.balloon-juice.com/2017/02/07/4-25-enrollment-loss-is-the-cost-of-trumps-first-day-eo/

    3) Some of the peer review work is with data sets that are available only for research and not for me to futz around with on Balloon-Juice. The next paper that will be published uses one of those data sets and we reported the data at a high enough level that no one is identifiable.

    4) Peer review research should be hypothesis driven (Since A is happening, I think B will be a result, and we will test for B using X, Y and Z techniques….” instead of “Wow, that is weird, let me write about it.” Good descriptive work is needed (Paper under 2nd round of review right now at a good place is precisely that ) but an explicit hypothesis is a very good thing.

    I can write a lot about my predictions for the ACA market with MLR being weird going forward and how cancelling CSR payments in the Fall of 2017 would not be a killer blow at Balloon-Juice and other non-peer review spaces. I can’t write those arguments in peer reviewed spaces as they are predictions of the future which are informed by data but not proven by data.

    5) It is just a different genre of writing with very different tropes, and expectations of language and claims.

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    jl says:

    ” 4) Peer review research should be hypothesis driven (Since A is happening, I think B will be a result, and we will test for B using X, Y and Z techniques….” instead of “Wow, that is weird, let me write about it.” Good descriptive work is needed (Paper under 2nd round of review right now at a good place is precisely that ) but an explicit hypothesis is a very good thing.

    I can write a lot about my predictions for the ACA market with MLR being weird going forward and how cancelling CSR payments in the Fall of 2017 would not be a killer blow at Balloon-Juice and other non-peer review spaces. I can’t write those arguments in peer reviewed spaces as they are predictions of the future which are informed by data but not proven by data. ”

    I respectfully disagree. All three approaches have their uses and there should be space for them in peer reviewed journals, but too much emphasis is given to whatever can be dressed up in the hypothesis driven framework. And this is especially a problem in health services and health policy research. Believe me, I know. As a statistician I deal with applied researchers knocking on my door with requests (often implicit commands) to wrangle a p < 0.05 out of some disorganized mess, usually at the last minute.

    Mystery meat modeling results and burden of disease estimates are often published in peer reviewed journals. Very few of the modelling exercises published in peer reviewed journals are validated in any way. But they are considered more respectable than exploratory research or prediction and forecasting research. I see no reason for this attitude at all.

    Many standards for peer review research in health policy and health services research are mere custom and historical accident, and I don't think there is any reason to respect them except out of necessity (the publish or perish imperative).

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    azlib says:

    Hi David,

    I love your posts and I have learned a lot about our healthcare system, warts and all. Keep up the good work!

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    Chris Johnson says:

    I hate this guy’s industry. Don’t necessarily hate him. It depends.

    I don’t understand why he continues to work in that industry, and that’s coming from somebody who works in the frickin’ music business o_O

    Carry on, I guess. Dear God, do people protect insurance companies around here. I hate them. How I hate them.

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    Omnes Omnibus says:

    @Chris Johnson: It is true that political scientists who study and write about fascism are fascists themselves. Every lawyer who writes about the death penalty is dreaming of getting a chance to execute someone. Fucking idiot.

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    @Chris Johnson: In case you didn’t get the picture yet, fuck off.

    David: I agree with everyone except Chris. I think one other thing that could be a tremendous value add is to have a sort of Insurance 101 primer over the next few months. I’ve been working in a finance-adjacent field for over a year (in fact, I just got offered and am almost certain to accept a promotion), and I still find health and especially life insurance borderline incomprehensible in places. I’m convinced this is a feature, not a bug. If anyone can demystify this field for laypeople, though, I’m convinced you can. I feel like I understand about half of many of your posts, just because there’s so much insurance industry jargon I still don’t grok, but I’m really glad you’re writing them.

    Ceterum censeo factionem Republicanam esse delendam.

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    Gin & Tonic says:

    @David Anderson: Thanks for the explanation. Not being a Buffalonian nor an NFL aficionado, I’d have had no idea.

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    @Chris Johnson: I don’t work in health insurance. I have not gotten a paycheck from a health insurer since December 26, 2016.

    Since then, I have only received a paycheck from Duke University, and a variety of soccer associations.

    My research interest is health insurance and more specifically the individual chooser segments with a focus on the ACA individual market structures.

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    @jl:

    Believe me, I know. As a statistician I deal with applied researchers knocking on my door with requests (often implicit commands) to wrangle a p < 0.05 out of some disorganized mess, usually at the last minute.

    That is when you should be asking to see the pre-specified, pre-registered analysis plan before laughing at them.

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    Gin & Tonic says:

    @Chris Johnson: You’re absolutely right. We should just abolish insurance. I mean, if your house burns down, it’s probably because you did something stupid, and you should go live under a bridge and go bankrupt.

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    Chris Johnson says:

    @David Anderson: Welp, I stand corrected (since 2016? Sounds like you stopped working for ’em: this I applaud, not that anybody in this thread values that). Cheers to Duke and the soccer associations for rescuing you.

    Hope you find both interest and some sort of harmoniousness in sorting through the mess. I feel like you will eventually lose all faith in the insurers even as functional market actors, but that’s not mine to conclude. (or rather, I totally and obviously have done just that, but I am clearly not the boss of you, and ya know that’s just as well. I don’t expect to affect things where I have no sympathy or stake, and in this area I’ve abandoned all hope (unlike electoral politics, Democrats, climate, gun control, etc…)

    I also abandoned all hope in Bernie, for what it’s worth: I don’t know whether that speaks well or ill of the insurers that they are also filed into that category.

    Be well: don’t let blog static worry you. It is a full-contact sport, and it’s no fun unless someone loses an eye :)

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    Kelly says:

    Thanks for all the useful info on health insurance. You’ve saved me a lot of stress by helping me understand what to focus on when shopping on the exchange.

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    debbie says:

    @laura:

    Seconded. I wish I could be one-tenth as knowledgable about any single thing as you are about healthcare.

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