Avik Roy-Transcending Obamacare

Avik Roy will be addressing my Intro to US Health Care System course on Tuesday, Oct 21, and presenting his plan Transcending Obamacare. This link will livestream, and later a tape of the event will be at the same link (8:30am-9:45am, EST).

PCRC semi-annual meeting

I am in Chicago for the semi-annual Palliative Care Research Cooperative (PCRC) annual meeting. This is a great meeting–one of the most intellectually stimulating meetings that I attend.

The National Institute of Nursing Research (NINR) has funded the PCRC, which is at its heart a cooperative group for research projects (think Cancer cooperative group except that the RCTs are of palliative interventions as opposed to investigational drugs). A big focus on this weeks meeting is around caregiver research. We at Duke submitted an RO1 last week to expand the study reported here nationally, using the patient recruitment sites in the PCRC.

The impact of caregiving is easily the most important public policy question of our time that receives very little public discussion. Papers like this one and the work of the PCRC will hopefully change this.

Duke updates Ebola/Travel Policy

In August, Duke issued warnings about travel to certain West African countries due to Ebola. Duke has updated its policy to include a full ban on Duke-sanctioned travel to Liberia, Guinea, Nigeria and Sierra Leone for undergraduates. Graduate students, faculty and staff are being “discouraged” from travelling to these countries. There are many nations (or parts of countries) with current travel restrictions for Duke students and/or faculty and staff.

Full email below.


Ever since Ebola began spreading in West Africa, Duke officials have been monitoring the situation closely with infectious disease experts in Duke Medicine. As a reminder, Ebola is not an airborne virus and cannot be spread through casual contact. It can be contracted only through direct contact with bodily fluids, such as the blood or vomit of an infected patient.

While the risk of infection in the United States remains extremely low, Duke Medicine has been preparing for contingencies, no matter how unlikely they may seem, should a possible Ebola patient present in one of its hospitals or clinics. Planning has been done in conjunction with the Centers for Disease Control and Prevention and the N.C. State Department of Health and Human Services, as well as leaders from Duke’s Division of Infectious Diseases and Emergency Preparedness.

Medical protocols have been established and are in effect across Duke Medicine to screen all patients entering the system for possible risk of exposure to Ebola. Any patient thought to be at risk as a result of screening questions will be interviewed by infectious disease experts to determine any next steps. Specific plans are in place to ensure the utmost safety and care for patients and health care providers, including the use of personal protective equipment for all emergency departments and clinics.

Duke Medicine is also coordinating closely with Duke’s Student Health Center to ensure the safety of our students. Duke has imposed full country travel restrictions on Liberia, Guinea, Nigeria and Sierra Leone for undergraduate students, and all graduate students, faculty and staff members are discouraged from traveling to these countries. But at any given time, Duke has students, faculty and staff in locations around the world, and conditions related to Ebola could change quickly based on potential cases that may arise in other countries. It is critical that Duke be able to identify the location of individuals traveling internationally and provide support as conditions warrant. So all students, faculty and staff traveling abroad are strongly encouraged to use the International Travel Registry (https://travel.duke.edu/).

Duke has also established a process by which any student, faculty or staff member who has traveled to West Africa recently must contact Employee Occupational Health & Wellness or the Student Health Center to consult with medical staff prior to returning to campus.

Duke’s emergency management team continues to monitor the situation closely and will provide updates as new information becomes available. For more information about Ebola, visit the special website created by the Duke Global Health Institute: http://globalhealth.duke.edu/ebola


Managing@Duke is an electronic memo distributed to university managers to inform, support and enable them to fulfill their supervisory roles at Duke.  For more information, visit:https://www.hr.duke.edu/managers/memos/index.php

Conservatives rediscover their dislike of ESI

Mark Warshawsky and Andrew Biggs have a fairly standard conservative take on employer sponsored health insurance, combined with a new twist–noting that stagnant wages and faster rising premiums from 1999 onward have increased inequality, because higher paid workers get more tax free income via employer sponsored health insurance than do low paid ones.

I totally agree with this, and they make what used to be the standard conservative arguments about the desirability of altering the tax treatment of employer sponsored insurance, morphed into a way to talk about it viz the language of inequality. However, this produces a political problem for conservatives, because the ACA actually does something about the tax treatment of ESI for the first time, via the so-called Cadillac Tax that is a de facto capping of a heretofore unlimited tax subsidy that disproportionately benefits high wage workers (as Warshawsky and Biggs note).

The most surprising aspect of my debate with Jim Capretta on the ACA a few weeks back was him seeming to forget that Conservatives have long talked about altering the tax treatment of ESI (he didn’t really forget, he just hasn’t shifted gears yet as the WSJ piece has, but he will). The Dems actually did something about the tax treatment of the ESI (some of them didn’t realize they did or have) an aspect that conservatives should have cheered if they were thinking in policy terms (if you take seriously what they said for the 30 years prior to the passage of the ACA).

The piece by Warshawsky and Biggs is part of conservatives preparing to re-embrace actual health policy positions after the 2014 election, and not merely whatever attack maximizes chances for the next election. That is good news.

If you listen carefully….

Obamacare and the 2014 election

I will be joining Jim Capretta (a Duke Grad) and AEI fellow from 4-5pm today discussing the role of Obamacare and the election for an online debate/discussion….last week was the first in the series on the issues that will shape the 2014 election. As I think about the topic (how will Obamacare impact the 2014 election?) I think my first answer is that I am unsure. Better think of something else to say. Will work in bar b que and football if need be.

And I realize I have not been blogging much. I have an RO1 due October 5, and a U19 proposal due October 5 on top of the normal chaos of life.

IOM report “Dying in America”

The Institute of Medicine yesterday released its report “Dying in America: Honoring Individual Preferences Near the End of Life.” It is a 500 page report with lots of interesting and relevant information, and it suggests many avenues for improvement. One key theme that comes through is the call for a focus on individual preferences near the end of life. The study that we recently published in the Journal of Clinical Oncology is directly relevant to this conversation.

This report is plainly, and comprehensively written, and I think its publication signals the end of our long, national stupid that began when a proposal in the ACA to pay for advanced care planning was termed “death panels.”

In defense of football

I don’t write to defend domestic violence, drug abuse, denigration of women, or the many other ways in which professional football players misbehave. I don’t write to defend what I consider to be the unjust withholding of money from college players. And I don’t write to defend lack of transparency and not paying for the health needs of players injured while playing.

I do write to defend the game of football, as it was played yesterday in a middle school game in Durham, N.C. I loved playing middle school and high school football, and I now have the privilege of being a volunteer assistant coach with my son’s team, who won the game 14-12. The other team easily could have won and both played well and hard. No parents misbehaved. The refs did a good job. And no one got seriously hurt.

I realize that none of the good outcomes listed above was inevitable.And there are long term worries about head injuries in football, and the finding of a JAMA study in May, 2014 is the most worrying that I have seen–that exposure to football (years playing among college players) is associated with cognitive impairment independent of head injury. If that finding holds up, then it really could be a game changer.

Several people have asked me how I could let my 14 year old son play football given the risks. The simplest answer is that there are obvious risks of playing. However, the counter factual of him not playing football also carries risks, just of a different type. For example, he tends to do better in school during football season. The motivation of “I have to do my work because if my teachers don’t sign off I can’t play and it will hurt my team” is a better school motivator for him than anything else I have found as a dad.

There are also some benefits of football that may not be clear from  afar. My son’s football team is far more integrated racially and on an income basis than is our church or neighborhood. It is good for kids to learn that they can work together toward common goals with people who are different. And football is the consummate team game. Players have to depend upon one another. On one play yesterday that was set up perfectly, one kid missed a block. 10 guys did their job and 1 did not and the play failed terribly. This is a strong life lesson of inter-dependence and also accountability (the film doesn’t lie). Finally, some of the most practical examples of redemption I have experienced have come via football.  I’ll tell you just one.

There is a kid who last year could not run 1 lap around the track because he was so out of shape. He had lots of anger issues and couldn’t be trusted to keep his head in games. This year, he ran extra after practice the first few weeks to try and get in better shape. His improvement in fitness in 1 year is hard to imagine. Yesterday, he played both offense and defense and almost never came out of the game, and I watched him help a younger kid get in the correct position on a few plays. He did not correct with a harsh anger, but as a leader who knew it was in everyone’s best interest for him to help the other kid understand.

None of these good outcomes is inevitable. However, they are possible if football is done in the correct way.


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