Daniel O'Neil

Three easy reforms to our health insurance system

Last month my son had a major operation. As we checked him in, I asked the person processing the paperwork for an estimate of how much this would cost. She replied, “I don’t know, but don’t worry your insurance covers it.” We are now receiving a steady stream of bills from each different doctor, the anesthesiologists, the hospital, and on and on. There are currently 29 separate insurance claims related to this visit. Naturally, most show up as fully covered but others do not. This is a crazy system.

I’m lucky. I have good health insurance. I understand enough about the system to know that if a charge isn’t covered by my insurance it is likely due to a mistake. I am fluent enough in English and bureaucracy fighting that I am confident that I will get it resolved.  

I would like to suggest three different reforms that we could do to our health insurance system that would not involve doing away with all private insurance but could make things better:

1. Require health care providers to offer the same price to everyone: One of the biggest benefits of insurance is that it is a discount club. Each of the hospital or doctor’s bill comes initially with a very high amount which is then marked down to the insurer’s negotiated rate. An initial bill might be $1500 that is marked down to $500. So who has to pay the higher amount? The uninsured—the people least able to pay. How does this make sense? Do we really expect the uninsured to subsidize the cost of healthcare for the rest of us? Instead, why not require hospitals to fix their prices and publish them. Everyone pays the same price for the same service.
2. Require all insurance companies who sell insurance to the federal government to offer the same plans to everyone: We get our health insurance through our employers since that is an easy way to lump a lot of people together. Some companies have given me good insurance and others have given me poor insurance. I do not like being dependent on my employer for this choice. Since, the federal government is one of the largest purchasers of health insurance. Why not make this same insurance available to anyone who wants it? Small businesses would not need to negotiate their own deal. Individual employees could opt to buy from the government list instead of from their employer. This would give us many more options than we got from the Affordable Care Act and would not require any extra government funding.
3. Offer Medicare to anyone who wants to buy it: Medicare is supposedly the least expensive health coverage. Why not offer this bare bone insurance to anyone who would settle for it? It should be priced to fully cover its cost. If it works as well as some of the democratic candidates think it will, then people will switch to it. But no one will be forced to switch.

I’ve always suspected that the most vocal defenders of our current system are those who either don’t use it or profit from it. Reform is hard but if we can continue to make incremental progress we can slowly make this work better without risking breaking it all.

My favorite productivity hack

Just over two years ago I was looking for a new way to get organized. I had tried many different systems but none seemed to work. I followed the philosophy of Steven Covey's Seven Habits of Effective People such as Begin with the End in Mind, Think Win-Win, and Sharpen your Saw. I tried to maintain the discipline of David Allen's system of Getting Things Done by keeping detailed lists of tasks. But I never found a means of tying it all together. My "to do" list was spread across my emails, outlook task list, and handwritten notes. I tried to keep organized by using an iPad Mini for writing down notes, but didn't keep it up. I knew that I needed something different. That is when I found the concept of bullet journaling.

 

Bullet Journaling is an analog system for a digital world. At its most basic, it is simply using a blank notebook to plan and track your days. Everything goes into a single notebook--annual, monthly, weekly, and daily plans; meeting notes and reflections, collections of ideas, trackers for following progress, and of course all the "to dos." Through daily logs and monthly reviews, it is easy to keep up on what you should be doing. By writing down notes, I tend to remember them better (and am amazed to see how I sometimes have misremembered events compared to what I wrote). While my bullet journal is pretty basic and utilitarian, there are beautiful examples of what can be done.

 

When Steve Caroll, the originator of Bullet Journaling came out with his book, I preordered it as a thanks for how his system had helped me. Two years into Bullet Journaling, I was a bullet journal devotee and had my system down. But I was curious to get his perspective and see what tips I could pick up. His book is divided into three sections. The first is a nice overview of bullet journaling. I picked up a few tips as to how to improve my system. I liked the presentation of the book which included frequent examples of what a page from a bullet journal might look like. The middle section is the soft side--why we should be organized. I didn't find this as helpful, but I have read dozens of self-help and business books. The final section had examples of extras--special lists and examples of how other people had used bullet journals. I love how different the systems can be. I think that it would be easy to make a book with nothing but fun ideas for how to use bullet journals. 

 

Steve's book is a great overview of bullet journaling. It is a handy guide for someone just getting started or a good reference book for someone already using this system.

 

Side note: My favorite journal is the Rhodia Dot Grid (solid cover, thick pages that don't bleed) and my favorite pen is the Pilot Metropolitan fine tipped fountain pen.

 

 

What I wish our politicians would say about the border

Our government has been shut down now for four weeks ostensibly about border security, but really because both sides like the fight. President Trump is acting like there is no barrier at the border and the Democrats act as if walls are immoral. I wish we could have an honest discussion of what is needed. Here is what I would like to hear a politician say:

 

"We are a nation of immigrants but we are also a nation of laws. We welcome legal immigrants. But we welcome them badly. By law, we allow refugees to resettle in the US. In practice, they remain stuck in a legal limbo--not knowing if they can stay or not. Our immigration courts are backed up so badly that people can spend years waiting for their day in court--years waiting to find out if they are legally allowed to remain. With our legal immigration system so overloaded, it is no wonder that there are so many people here illegally. We have 10 million people living and working here without legal permission. These include students who overstay their visa. Tourists who don't return home. And the hundreds of thousands of people who sneak across our southern border every year. These are 10 million people who live in fear of deportation. 10 million people who are ripe for abuse. 10 million people who can't vote for a government to protect them.

 

To combat this problem, we will undertake the following four-pronged approach:

1. We will double the number of judges reviewing immigration cases. Within a month of being picked up or applying for asylum, an immigrant should have his or her case resolved. We need enough judges to be able to conduct hearings fairly and quickly. We will work quickly through the backlog and establish a fair system to ensure that we can sort through those who are allowed to stay and those who are not.
2. We will increase the security on the southern border. We have made great strides to reduce this number, but haven't solved it. Before 9/11, we had 1.6 million people coming across our southern border in a single year. We built fences and barriers and have reduced that down to 400,000. But that is still too many. Some of the barriers we built have fallen apart and people have found new routes across the border. To increase border security, we will increase electronic surveillance, hire more border guards, and reinforce weak points along the border. We want to be sure that we know what is coming through our border crossing points and what is trying to cross outside of those points.
3. We will continue to improve vetting at our consulates around the world: Anyone is welcome to apply to come to the United States, regardless of their race, nationality, or religion. However, we get to choose who we allow to receive those visas. We will carefully vet each applicant. If we have any doubts about a person or their application, we will reject it. We recognize that this makes it difficult for people from countries with weak governments to satisfy our requirements. However, we have to keep our country safe.
4. We will limit chain migration: Anyone born in the United States is a US citizen. However, anyone with a US relative is not entitled to US citizenship. Relatives of US citizens can apply for visas and citizenship in the same way that anyone else can apply. Their claims will be processed as will any other applicants.

Finally, we will continue to defer deportation of children who were brought here illegally but have lived their lives in the United States. We recognize that our immigration system is broken and that these people fell through the cracks. By taking the four steps outlined above, we won't allow this to happen again. However, we have invested heavily in educating these Dreamers. We want them to stay. We will begin reviewing the people registered for DACA and will issue green cards to those who meet the legal requirements. With a green card, they will be eligible to apply for citizenship in five years. 

 

We also recognize that strong walls and strong laws will not end the problem of migration alone. We need strong neighbors. We are significantly increasing our commitments to helping our neighbors to grow their economies through trade and increased assistance.

 

By taking a comprehensive approach to improving our immigration system, we hope to reduce the population of those living here without proper paperwork. We will continue to welcome legal immigrants, tourist, student, and business travelers. We are proud of our country and understand why people want to come here. However, we will manage the flow of migrants to protect the jobs of our citizens."

Liberia's Paths to Prosperity

I first came to Liberia four years ago—just as the Ebola epidemic was starting to spread. The classic image of Liberia’s roads was that of a four-wheel drive vehicle stuck in a sea of mud. Today, the situation has dramatically improved. I spent the last week driving around Bong, Nimba, Lofa, and Grand Bassa Counties inspecting the roads that we have improved through the USAID-funded Feeder Roads Alternative and Maintenance Program (FRAMP). I drove on nearly 400 km of these small roads and probably twice as much on the primary and second network to reach them and 90% of the time I was on good roads! The main roads from Monrovia through Bong County and up to Nimba County and over to Grand Bassa are all paved. The road from Bong County up through Lofa County was nicely rehabilitated (we helped with that). Even the feeder roads that were fixed several years ago under a different program remain in good condition.

That last point surprised me. When we talk about the work that we do, we talk about how we “rehabilitate” rural roads and how maintenance is critical especially since Liberia can get over three meters of rain a year. Of course if you don’t maintain these gravel roads, they will just wash away again. But I’ve learned a new narrative. These roads that we are improving were just tracks. They never had a proper driving surface or side drains. If there were any cross-drains, they were built out of rough timber and prone to collapse. When we work on the road, we install culverts and bridges so that water does not need to pass over the road. We build a proper road surface with side drains so water stays off the roadway. We compact the road surface so that the gravel (really a mixture of clay and small pebbles) does not wash away with the rain. Although the road condition will deteriorate over time—especially if the improved road ends up with significant traffic. However, it will never again be as poor a road as it was before we started.

The biggest challenge that we face in maintaining the road is the sudden growth in traffic. Although we designed these roads to be feeder roads—to feed traffic from small villages to the secondary and primary roads—some road segments have become popular shortcuts and now have significant car and truck traffic. Several of our road segments ought now to be upgraded to be secondary roads—given wider carriageways and more gentle curves to allow for faster driving speeds. This is another nice success of our project—helping Liberia to grow.

The four counties that I visited have about half of the feeder roads in the entire country. I understand that there is still much to be done in the rest of the country and especially in the southern counties. I am proud that we were able to play our part in helping Liberia on its path to prosperity.

Eight years of Hope

Shortly before Obama took office, I wrote a post with the title What will the world look like after this economic crisis? I saw the big economic crisis of the time as an inevitable correction. The US had been living too big for too long. I saw that Africans were taking over international jobs once reserved for expatriates. The rest of the world was catching up to America in terms of the ability to get tings done. I said that American would come out of this recession poorer than it went in--the glory days were gone.

After Obama's inauguration, I changed my mind. He convinced me that I had been thinking too small. I remember almost titling that post Slapped down by Obama. 

Trump won because I was right. For much of America, we did not recover from that economic crisis. Last summer, we drove through Indiana and I saw the communities that never recovered. I think Obama did a great job. He brought hope and change to many. However the world has changed. Whereas in the 1950s, a blue color american could support a middle class family, that will never be true again.

There are great jobs for well educated people. There are plenty of opportunities for those with the right skills and in the right place. This is a golden age for entrepreneurship. But what do you do for those who are unwilling or unable to to take advantage of those opportunities? 

So what do you want to do with your life?

Chris Guillebeau is back with a new book on managing your career. After he wrote about how to live the life that we want (The Art of Non-Conformity), how to start the business of our dreams (The $100 Startup), and how to create and chase our dreams (The Happiness of Pursuit); he is now tackling how to create the career of your dreams.

If you are set on starting your own business, stick with The $100 Startup. If you are working for someone else or unsure of which path to take, this is a great overall guide. Chris starts off by helping you figure out how to align your work dreams with your life goals--revising your script so that your actions actually lead you to be happier not just higher up the ladder. He covers the pros and cons of working for yourself, working for someone else, or figuring out how to do both.

 

This is an ideal book for someone either early in their career or feeling stuck. Chris does a beautiful job of showing the incredible range of opportunities that are out there and provides solid advice no matter which way you might want to jump.

Note that Chris was kind enough to send me a copy of the book in exchange for this unbiased review. However, since I am a fanboy of Chris', he knew that I would love it! 

 

Yes, Muslims should try to root out extremists in their midsts

... and so too should anti-abortion activists, environmentalists, political activists, Christians, and all other groups. The United States is founded on the belief that all men [women and children] are created equal and have the inalienable  right of life, liberty, and the pursuit of happiness. We have to work together to protect these rights, protect our neighbors, and build the country that we want to live in. Can you imagine the shame of knowing that a neighbor had imprisoned women in his house for years and you did nothing to help? That your talk encouraged someone to open fire on a health center that offered abortions? Or that you had a friend who became such an extremists that he shot innocent people in the name of your religion? Are we not our brother's keeper?

What would I do if I was in charge of the American Red Cross?

After I published my post last week on the American Red Cross (ARC), a few people have asked me what I would do if put in charge of it. Given all of the bad publicity that they have generated with their response to each major disaster, they certainly need to change their approach and to rebuild trust. The ARC plays a critical role in disaster response. They have an incredible ability to raise funds and are part of a broad international organization that has branches in nearly every country. They are perfectly placed to provide leadership on disasters all over the world.

So how do they pull themselves out of their deep hole and reestablish their leadership? I would suggest focusing on the following three areas:

1. Figure out what they are best in the world at doing and focus on it: The ARC seems to try to be all things to all people. They provide emergency kits, build shelters, feed people, finance grants, rebuild communities, and on and on. Sometimes they work through the local Red Cross, sometimes they set up their own organization and work around the local partner. Instead, I would have the ARC keep only a small number of high level experts who would implement only through the local Red Crosses and other partner organizations. The role of the ARC team members would be similar to the role of the OFDA staff. They would provide technical assistance to their partners and review grant requests. By being in the field and focused on implementation, they could help their partners be flexible in their approach. Given that the ARC is an NGO, they ought to be the most flexible of the funding organizations. By having highly trained people in the field, these experts could be trusted to guide the funding decisions.
   
   
2. Embrace Radical Transparency: Since the ARC will be subcontracting out most of the work, it will be easier for them to be very transparent. Their management costs should be around 10-20% of the donations that they receive. This would cover all of their home office costs and the costs for their field teams. The rest would be given out in grants. They can require that all funded proposals are published and have an open database that tracks the results. Financial data should only be published at the line item level (showing for example how much goes into all salaries but not showing how much an individual is paid). In this way, it will be clear not only what the ARC is doing but how their money is spread around. After all, the money being spent isn’t really the ARC’s money—it is money donated through the ARC to help the disaster victims. By having the funded proposals published, other organizations can see what is being done and better understand both how to coordinate with the implementer and how to learn from the funded approaches. This would encourage learning by doing and improve the quality of proposals over time.
   
   
3. Publish Evaluations Consistently: Because the ARC is focused on being the best in the world at what they do and on being radically transparent, it only makes sense that they conduct thorough evaluations and publish the results. Yes, these will highlight mistakes and shortcomings and will sometimes be embarrassing both for the ARC and for their partners. Implementing projects in a disaster or post-disaster environment is tough. You have to move fast which means making mistakes. But we shouldn’t be repeating the same mistakes. If the ARC committed to conducting thorough evaluations and publishing the results, the ARC could help share best practices and prevent repeated mistakes. Besides, as most politicians have learned, the best way to avoid a public scandal is to own up to your shortcomings.

The ARC ought to be a very powerful force for good and a key actor in every major disaster. Instead, their brand seems to be continually weakening. Each scandal hurts not only the ARC but every NGO who ends up painted with the same brush. 

If only the American Red Cross was as efficient as the US Government...

Inspectors assessing the earthquake damage in a house in Port-au-Prince, Haiti

"I still have a lot more questions for the Red Cross," said Sen. Charles Grassley in a statement. "I have other questions about the spending numbers and how they add up and the overhead costs for both the Red Cross and the grantee organizations. Also, I'd like to see more details of the results achieved from each of the partner organizations."

Propublica and NPR have done an admirable job of trying to figure out what the American Red Cross (ARC) has done with the nearly half a billion dollars that they raised for the Haiti earthquake. However, I fear that Senator Charles Grassley will lead this in the wrong direction. The ARC should be encouraged to give out the money that it raises rather than trying to do it all themselves.

As we’ve seen with nearly every disaster, the ARC does a great job of raising money and a lousy job of using it. Even in domestic disasters like Katrina or Sandy, the ARC seems poor at delivering results. Imagine how much harder it is to set up a large organization in a foreign country in the middle of a disaster response. It is just a recipe for failure.

Instead, the ARC should follow the example of the US Government’s disaster response agency: the Office of Foreign Disaster Assistance (OFDA). As soon as a disaster hits, OFDA sends a small team of experts to help assess the situation and to review funding requests. They focus on working with organizations that are already on the ground with a solid track record of success. Because they are on the ground, they understand the situation and can work with their grantees to ensure that proposals make sense. The field team is senior enough that they can frequently review proposals on the spot.

This model allows OFDA to quickly get funds injected into where they are needed the most. They keep their overhead low by focusing on channeling money to those who can use it effectively. Their field teams are able to work with their partners to keep projects moving. By channeling money through other organizations, they build local capacity and make it easy to wrap up their work as quickly as possible.

The ARC’s problem is that it establishes a large bureaucracy that is unable to implement projects directly and very slow to issue subgrants. I did succeed in getting a large grant funded through the ARC, but it took nearly 10 months to get it worked out. Once awarded, we were micromanaged from beginning to end. I have worked with funding from a wide range of donors and found the ARC to be the most difficult. We did succeed in repairing 4,000 houses for the ARC and the work was of higher quality than what he had done for OFDA and others, but it was a soul-sucking process that left all of us exhausted.

I would love to be able to support the American Red Cross. With their incredible name recognition, they have enormous potential to help. Instead, their repeated and very public failures make it that much harder for everybody else to raise money and help out.

 

Why is the Ebola Response considered a success and the Haiti Earthquake Response considered a failure?

The International Response to the Ebola Outbreak was a huge success. Back in September, it seemed as if the Ebola outbreak was spinning out of control. When the death toll didn't seem high enough, the stories became that the toll was under reported and stories that the outbreak could plunge Liberia back into civil war.Remember the September 23 New York Times headline: Ebola Cases Could Reach 1.4 Million in Four Months, CDC Estimates?

 

Instead, the number of new cases began to decline in late November. By late December, they had slowed to a trickle. Liberia has only had 12 cases in the last 21 days. Guinea and Sierra Leone are down to less than 200 new cases a week. The total case load will likely not exceed 25,000. This dramatic turnaround was a direct result of the strong international response.

Three activities were key to stopping the spread of the Ebola:

1. Community Awareness: Ebola was spread through contact with the bodies of those that it had killed or were dying. Funeral rites had to change. People had to be convinced to give their loved ones over to foreign doctors draped in protective gear. Physical contact had to be limited. Changing attitudes is hard, but this was key to slowing the spread of Ebola. Some organizations took this on as a primary mission through radio messages and posters that still blanked Liberia. Others added this component to their work such as distributing Ebola awareness information to the farmers with whom they work.
2. Safe Burials: An Ebola victim is hardly contagious until he is so sick that he can hardly move. His body remains highly contagious long after he has died. Touching the body of an Ebola victim is one of the easiest ways to contract Ebola. Traditionally, mourners would hug the corpse of their loved one to say goodbye. Stopping that practice was a key component of the community awareness. But bodies still had to be disposed of. In Liberia, the US government funded a large program to provide safe burials for all Ebola victims. This was very dangerous work and done very effectively by Global Communities. It is probably the reason that Ebola disappeared first in Liberia even though it had been hit the hardest.
3. Constructing the Ebola Treatment Units: As the Ebola outbreak was growing, there was not enough room to treat the victims. The few treatment units were overwhelmed and the centers were forced to turn away people who were clearly very sick. Building more treatment units became an international priority. Once there were enough treatment units to house those who needed care, it was possible to isolate those sick with Ebola and prevent them from contaminating others. It also became easier to trace their contacts and seek out others that might become sick.

I believe that a decade from now, we will talk about the Ebola response as one of the great victories of foreign assistance. The international response was critical in turning the tide on the epidemic. Those people who went to Liberia to help and those who stayed in country are the heroes that saved West Africa and the rest of the world from a terrible disease.

The response to the Haiti Earthquake was also a great success and yet is frequently portrayed as a failure. Five years after the earthquake, Haiti’s economy is stronger than it has been in decades. There is more electricity, government services function better, and there are even twice as many international-standard hotel rooms. Does the International Community not get any credit for helping to rebuild Haiti?

In both cases, there was great chaos in the response. In Haiti, one of the biggest wastes of money was building camps and temporary shelters that ended up housing people who had never lost their home in the first place and became very difficult to close. In Liberia, one of the biggest wastes was the construction of the Ebola Treatment Units—although desperately needed in the beginning, construction of new ones continued long after the need for the units had disappeared. There were still units being built in January when there were only a handful of cases of Ebola. In both cases, once a need is identified and projects are funded, it is very hard to redirect that funding.

I loved that Time magazine named the Ebola Fighters as Person of the Year for 2014. I think that those who responded to the Haiti earthquake and those who donated to support it deserved the same honor in 2010.