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Most of Jeff Goldsmith’s writings the last six years have been blog postings for Health Affairs, the leading journal of health policy in the US, and the Health Care Blog, the leading technology-oriented health industry blog based in San Francisco.

You can find links to these postings below in chronological order. They tell an evolving story of the most fascinating political event of our time (the 2010 Affordable Care Act). Below the health reform-related posts are a chronological file of other postings on the US health economy. Read and enjoy.

Health Costs and the US Economy-Policy Options

Nov 10, 2017: What to Do About Hospitals’ Medicare Financial Losses. This Harvard Business Review blog posting is a follow up to the October blog, and explores why losses in treating Medicare patients have soared (to more than triple the losses from Medicaid patients!), and how hospitals can work with their clinicians to improve care processes, eliminate needless variation in use of the hospital’s services and reduce those losses. Nov 10, 2017

Oct 5, 2017: What Hospitals Can Do to Reverse their Sliding Financial Performance. This Harvard Business Review blog posting examine the causes of the sharp deterioration in hospital operating earnings during 2016 and early 2017, and outlines essential strategies managements should pursue to reverse those declines. Oct 5, 2017

Aug 22, 2017: Confessions of a SuperUser This posting explores what Jeff Goldsmith learned about the health system he has worked in for over forty years as a patient. It examines his experience of five complex surgical episodes in four different health systems, and how theories of how the health system works match up against the patient experience. Aug 22, 2017

Aug 1, 2017: The Great Trump Healthcare Trainwreck This posting provides a scorecard to evaluate President Trump’s performance in managing the multiple unsuccessful attempts to repeal the Affordable Care Act, and provide some clues to this political defeat. Aug 1, 2017

May 30, 2017: California’s Coverage Expansion: Fiscal and Political Risks This posting explores how California got the number of uninsured in its state down to 7% by dramatically expanding its MediCal progam and standing up Covered California, one of the most successful health exchanges in the nation. Can this expansion be sustained as Congress considers unwinding the Affordable Care Act? May 30, 2017

May 9, 2017: To Profit from Uncertainty, Hospitals Must Become Anti-Fragile This Modern Healthcare OpEd discusses Nasim Taleb’s book Anti-Fragile: Things that Gain from Disorder and its relevance to healthcare management. In particular, health systems actually become more difficult to manage and their business risks increase as they become larger, and diversify into unrelated businesses. How hospital managements can manage uncertainty is an increasing challenge as the industry consolidates. May 9, 2017

Mar 8, 2017: Geisinger’s Transformation: Balancing Risk and Growth This posting in Health Affairs blog examines the unconventional turnaround Strategy which Glenn Steele pursued as CEO of the Geisinger Health System that led both to financial success and a remarkable clinical transformation that made Geisinger one of the national leaders in healthcare redesign. Mar 8, 2017

Mar 8, 2017:The Rust Belt is Burning This posting explores how legislation prompted by President Trump to repeal and replace ObamaCare would harm his own constituents in the troubled Appalachian and Midwestern states that provided his margin of victory. Mar 8, 2017

Jan 10, 2017: Oregon's High Risk, High Reward Coverage Expansion This posting explores how Jeff’s home state of Oregon dramatically expanded health coverage under the Affordable Care Act, and its effects on Oregon’s health insurance market and care system. Jan 10, 2017

Sept 29, 2016: Fail to Scale In winemaking, some wines only grow in highly defined localities. The concept is terroir. In US health policy, multiple examples of the same phenomenon exist: Kaiser, physician sponsored independent practice associations, hospital system sponsored health plans thrive in some parts of the US and wither in others. Why is this? Why do great ideas in healthcare repeatedly fail to scale up nationally? Read Fail to Scale: Sept 29, 2016

June 16, 2016: All Risk is Local We all knew how this was going to go, or thought we did. Healthcare payment is moving from volume to value, led by the Medicare program’s historic ACO program, and private markets are going to be fundamentally restructured by ObamaCare. Well, it didn’t work out as we expected, and the shift to value is HIGHLY dependent not on the federal government, but rather state Medicaid programs, some of which pay at 65 cents on the dollar relative to cost. Private insurance markets are in turmoil as a result of ACA, and new payment models are taking a back seat to major underwriting losses. What difference does it make? Read All Risk is Local and find out. June 16, 2016

May 9, 2016: The Tangled Hospital Physician Relationship Hospitals have employed tens of thousands of physicians in the past decade, a sixty percent increase from 2003 to 2014. Tens of thousands more depend on hospital subsidies of various kinds. And yet the private practice of medicine is far from dead, as single specialty physician groups increasingly dominate lucrative medical and surgical specialty markets. Power is shifting between hospitals and physicians with the growth in new payment models, but in which direction? How to make sense of this troubled and tangled relationship is discussed in The Tangled Hospital Physician Relationship. May 9, 2016

The C Word: Why Calling Patients "Consumers" Is an Insulting Caricature: That patients are becoming consumers of healthcare implies both discretionary purchasing power and leverage that, in most real world situations does not accurately reflect either their powerlessness or their priorities. Why we need to find better language to describe the patient role in the health system. April, 2016

Why the Health System's Performance is Improving: Death rates for the three major killers of Americans has plummeted in the past thirty years, despite the fact that we have cured none of them. How has professional collaboration and continuous improvements both in technology and care processes has made the health system safer and more effective. March, 2016

2014 Health Spending: The Great Moderation is Likely Not Over: Health spending growth spiked upward in 2014, after a decade of moderation.
In this posting, Jeff Goldsmith argues that the factors leading to the 2014 spike are one time costs related to the Affordable Care Act's implementation and does not alter the trajectory of core costs. December, 2015

October, 2015: In attempting to explain the seemingly endless rise in health costs, politicians and the health policy community have evolved two explanations of the root cause: moral failure by either care providers or by patients. Read why both conservative and progressive policy narratives are flawed, and should be replaced by a broader and more nuanced explanation, leading to different remedies. Read Moral Failure and Health Costs: Two Simplistic Spending Narratives October 27, 2015

July 26, 2015: Healthcare executives and clinicians seem to spend half their lives in meetings of questionable productive effect. Read why this is likely to change as younger people replace boomers in key positions and new technology makes better decisionmaking possible in: Death by Meeting

July, 2015: Population health-based payment (e.g. capitation) is expected by many in the health industry to replace the current fee-for-service methods of paying doctors and per admission or per procedure payment of hospitals. Read why this is unlikely to happen: Shift to Population-health payment unlikely to come anytime soon July 18, 2015

March, 2015: Is it inevitable that most care in the US will be delivered by so-called Integrated Delivery Networks, that span hospital, physician and post-acute services and offer these services through their own health plans? This model of care organization was felt to offer less expensive care at higher quality than less integrated enterprises. In a comprehensive review of the economics literature as well as a preliminary look at new data, Jeff Goldsmith and Rob Burns of the Wharton School of Finance at the University of Pennsylvania found no evidence either of savings or improved quality from these complex care models. Read Integrated Delivery Networks: Is the Whole Less than the Sum of the Parts? March 7, 2015

November, 2014: In this essay, Jeff Goldsmith surveys the US healthcare landscape and finds a remarkable amount of good news: subsiding health cost growth, an honest societal conversation about value rather than merely cost, improving hospital/physician relations, declining mortality rates from major diseases and other developments. Why isn’t all good news fully appreciated by those who organize and deliver care? When It Comes To Healthcare, The Glass is Half Full November 11, 2014

October, 2014: In this article, Jeff Goldsmith and James Orlikoff ask the question: when considering a merger, do hospital trustees honestly separate the future of the hospital from their own future as leaders? Are many mergers simply a reflection of a failure of succession planning, both for the Board and its management, or the actual prospects for their institution? The authors urge trustees to consider their own legacies and to plan effectively for leadership succession. Mergers as a Substitute for a Strategy October 15, 2014

September, 2014: In this interview, Jeff Goldsmith talks with the recently retired CEO of the $60 billion Kaiser Permanente Health Plan about his turnaround strategy at Kaiser, his activism during the 2008-2010 health reform debate, the health system’s unfinished business and his future plans as an advocate for reducing healthcare disparities. Interview with George Halvorson September 30, 2014

June, 2014: Hospital systems like Boston’s Partners Healthcare and Northern California’s Sutter Health are supposed to exert virtually unchecked economic power in their local health insurance markets. Many health policy experts believe they have enough clout with health insurers to charge what they wish for their own services. So why did these and other high quality health systems suffer sharp economic reversals at the end of 2013? See How Much Market Power Do Hospital Systems Have: June 12, 2014

May, 2014: Physicians are spending more than a day a week on paperwork, and nearly $85 thousand a year on administrative costs related to billing and “quality reporting”. Administrative costs are drowning independent physicians and driving them to sell their practices. Jeff Goldsmith proposes a solution: Charting Day May 10, 2014

March, 2014: Hospitals all over the United States are seeing fewer inpatients and their revenues have basically ceased growing, despite five years of economic recovery. Traditional strategies such as merging to get market power with health insurers and acquiring physician practices don’t seem to be working. What is happening to the nation’s hospital industry and what do boards and managements need to do to cope with a rapidly worsening economic outlook? Can Hospitals Survive, Part II: March 14, 2014

August, 2013: Health costs are slowed to a near standstill. What caused it? What does it mean? Is the pause durable or transient? Read: Health Cost Inflation at Historic Low. August 1, 2013

May, 2013: The US hospital of 2013 is remarkably similar in technology and services to the US hospital of 1998. Have hospitals entered a 21st Century Time Warp? May 21, 2013

March, 2013: The largest problem the health system faces in the next decade is the retirement of the baby boom primary care physicians, just in time for boomers enrolling in Medicare and millions of newly covered by health reform. Younger physicians are not entering primary care because it pays so poorly. Can we design new primary care models to alleviate the impending shortage, or is something more fundamental required? March 28, 2013

January, 2013: For the third year in a row, health spending continues at pre-Medicare rates of cost growth. Is this new and welcome trend sustainable? Where is health spending headed? January 31, 2013

January, 2013: n December,2012, Jeff Goldsmith journeyed to Thailand, and visited the storied Bumrungrad Hospital. He was really impressed with what he saw. Read about why in The Accidental Tourist. January 24, 2013

August, 2012: While the US economy continues to labor to create new jobs, the health system has added over a million jobs since the beginning of the recession, despite falling physician office visits, hospitalizations, etc. What gives? Is health care an alternate economic universe? August 29, 2012

May, 2012: US health cost growth has reached a fifty year low. What does this mean for health policy? The key problem: nearly half the country cannot afford to use the health system without massive public subsidy. Why affordability, not cost growth, is the major health policy challenge. May 8, 2012

November, 2011: In a failed Congressional experiment with "global spending caps" on physician services, US physicians ended up owing Congress and the Medicare program over $300 billion. The Congressional advisory panel MedPac issues a flawed proposal for cleaning up the so-called Sustainable Growth Rate (SGR) mess. November 16, 2011

August, 2011: Continued economic troubles may be bringing healthcare’s three decade long run to an end. Can the health system adjust to scarcity? August 10, 2011

July, 2010: The US economy languishes while the health system continues adding jobs. Are the two phenomena related? Is America marooned in the horse latitudes? July 6, 2010

October, 2008: The world economy crashes, and comes within a hairs’ breadth of a catastrophic worldwide depression. For those of us genetically incapable of pessimism, the crash presented a dilemma. This, my sole posting on Huffington Post, proposed a new support group, called Optimists Anonymous. October 10, 2008

October, 2007: Health costs, which have risen at double digit rates for decades, began slowing down in the mid-2000’s, and no-one believed it. This posting, my first, discusses the politics of the perpetual health care crisis, and generated a lot of angry responses. October 3, 2007

Health Reform

June, 2015: The Pioneer ACO was certified this spring as the first new Alternative Payment Model to be expanded under the Affordable Care Act. A close look at the program’s performance, however, reveals the use of “Lake Wobegon” accounting. The program lost nearly half its participants, and those with the most managed care experience fared the worst. Read: Pioneer ACO: Anatomy of a Victory June 18, 2015

January, 2014: As Congress wrestles with how to end the Sustainable Growth Rate Fiasco, a bipartisan proposal has emerged which will probably make things worse than they are now. Read about Congress’ Inadequate SGR Solution. January 24, 2014

August, 2013: The most controversial and heavily hyped healthcare payment reform idea in the Affordable Care Act has been the Accountable Care Organization. Thirty two high performing health systems participated in the Pioneer ACO demonstration, which reported its first year results in the summer of 2013. The blizzard of hype and press releases concealed a lot of problems. Read about the Pioneer ACO’s Disappointing First Year. August 15, 2013

July, 2012: The Supreme Court unexpectedly affirms the constitutionality of the Affordable Care Act. In doing so, however, it invalidates a key piece of the law, rendering the expansion of Medicaid “optional” for states. Why the Supreme Court may have dealt a serious blow to health reform. July 7, 2012

July, 2011: Intense White House criticism of a McKinsey study predicting a large number of employers dropping coverage when the ACA is implemented begs a question. Suppose health reform actually foretells the end of employer based coverage? It might not be a bad thing. This posting is about Letting Go of Employer Based Coverage. July 11, 2011

June, 2011: Controversy rages over health reform. A Republican landslide in November, 2010 strips the Democrats of control of the House of Representatives, and brings into office a new wave of conservative Republicans committed to repealing the Affordable Care Act. Many of the newly elected Republican majority do not believe there is a problem of access to healthcare. This posting discusses the unbridgeable gap between Republicans and Democrats on health reform. June 8, 2011

Here is Jeff Goldsmith's review of Paul Starr’s excellent history of health reform in the United States, Remedy and Reaction: The Peculiar American Struggle over Health Reform (Yale Univ Press, 2011) which includes an extensive analysis of the Obama health reforms.

November, 2010: Republicans have set themselves the political goal of “repealing and replacing” ObamaCare. They are unlikely to succeed and face significant political dangers, as they confront the Swamp Creature called the Affordable Care Act of 2010. November 5, 2010

March, 2010: In his book on Presidential politics and health reform, Heart of Power, health policy analyst Dr. David Blumenthal offered eight rules for Presidential conduct of health policy. How did President Obama do? March 29, 2010


March, 2010: President Obama is running out of time and public patience in the health reform debate. Obama must move quickly or health reform will slip from his grasp. The political price paid for health reform will be steep. March 7, 2010

January, 2010: After Scott Brown’s shocking election to Ted Kennedy’s Massachusetts vacant Senate seat, the Democrats lose their filibuster proof Senate majority. Can health reform be saved? This posting advocated starting over with a stripped down, affordable new bill. January 24, 2010

December, 2009: The core of health reform is transforming a nearly $1 trillion private health insurance market. Health reform legislation will eliminate most of the health insurance industry’s risk management practices (medical underwriting, etc.) and restrict its gross margins and earnings. The Congressional Budget Office issues an astonishingly rosy forecast of how health reform will affect private health insurance markets. What is wrong with their forecast? What are the fiscal and policy risks of health insurance reform? December 14, 2009

December, 2009: Critical to health reform’s enactment is President Obama’s pledge that the bill will not increase federal deficits, already running at $1 trillion a year. Why no-one believes health reform will be deficit neutral, despite Congressional Budget Office assurances. December 1, 2009

September, 2009: Will divisions inside the Democratic Party doom health reform? Can the “safe seat” and “running scared” Democrats find a health reform plan both can support? This posting predicted that health reform could blow up in the President’s face and cost the Democrats control of Congress. September 3, 2009

August, 2009: A major component of health reform is how to change healthcare payment to make it less inflationary. Unfortunately, the most discussed idea in the debate, the so-called Accountable Care Organization, or ACO, isn’t ready for prime time. August 17, 2009

July, 2009: The White House decision to let the House of Representatives take the lead in drafting health reform legislation may have dealt a fatal blow to the process. The House Democratic leadership releases an inflammatory and highly partisan draft of health reform legislation, alienating Republicans and trapping moderate Democrats. This draft ignites the Tea Party summer. A Wild Pitch Brushes Back Health Reform. July 20, 2009

July, 2009: Squaring his campaign promises for health reform with political realities will be a difficult enough challenge for President Obama. But the real problem will be a shortage of bandwidth in Congress. Why health reform is "no country for old men". July 6, 2009

May, 2009: The so-called “public option”, a Medicare like publicly sponsored health insurance plan to be offered as part of health reform, is not worth the fiscal and economic risks. Why the public option will not be a part of health reform. May, 15, 2009

Here is Jeff Goldsmith's review of Blumenthal (and James Morone’s) book, Heart of Power: Health and Politics in the Oval Office (Univ of California Press, 2009).

November, 2008: Obama hits the ground running. Based on his reported transition planning, this posting inaccurately predicted an effort to enact health reform by mid spring, 2009, based on Tom Daschle’s policy blueprint. November 25, 2008

November, 2008: President Obama is elected. His three choices for proceeding on health reform: complete the New Deal by enacting an expensive new entitlement to complement Medicare and Medicaid financed by new taxes, take on the healthcare industry and carve the funding out of their existing payments, or wait and let the economy recover. What Will Obama Do? November 5, 2008

February, 2008: Do we want to reform health care by providing universal health insurance coverage, or by funding access to safety net health systems for those without insurance, e.g. direct access? The safety net is the reason the US could have 50 million uninsured without a revolution. It's the health reform debate we never had. February 2, 2008