Monday, November 4, 2013

And then there was that issue of pre-existing conditions...

I should've known better than to have believe that I'd finally gotten to the end when I wrote my last Critical Information about Health Plans post.

Friday, just in the nick of time I sat down with the insurance broker and hastily filled out the application (again.  I'd already done it online but repeated the process again so that she'd get the credit) to get it submitted in time to get coverage effective 11/1.  Everything went swimmingly until we got to the final section where you had to list "other doctors" in which case I brought up the doctor my wife has seen for a pre-existing condition...  That condition was not called out at all in any of the prior questions except possibly as one of the "any other conditions" general catch-alls.  When I mentioned it the broker's face dropped and she said... "I need to be honest.  She will be declined, or HIPPA rated meaning she will get the highest rate."

Needless to say I was caught off-guard.  When the broker ran the quote for my wife ALONE at the highest rate the premium was double the rate that I had previously seen for my ENTIRE family.  Furthermore, while I don't have the final underwriting details yet it would appear that the new premium (for the entire family) will be a. nearly as expensive as COBRA (which I'm currently on) and b. as expensive as unsubsidized silver-level plans under the ACA.

It would seem that the ACA-compatible health exchange policies are:

  1. Necessary - because we now have a pre-existing condition that, remarkably and unbelievably, puts us in the same category as something really serious like having cancer
  2. More affordable premium - even if we don't get subsidies and definitely if we do (which would apply up until about $100k salary)
  3. More affordable deductibles and out of pocket limits.
  4. Subjectively more trustable - had I not discovered the significance of reporting the condition above I might have switched to the policy at the cheaper quoted rate only to discover that the policy (at least for my wife) was voided because I failed to report a pre-existing condition.  That won't happen with ACA-compatible plans.
Apparently this story is still not over yet as I haven't finalized a new policy so stay tuned.

Wednesday, October 30, 2013

Critical Information About Health Plans

This is to follow-up on my original "Analyzing Health Plans" post.

First a recap of some key details

  • Our family is currently insured through Aetna on a COBRA policy that we went on when I was laid off from Rosetta Stone.
  • COBRA premiums are about $1400/mo
  • When you leave a group plan (even under COBRA) to join an individual plan even for the same company you get no special treatment (i.e. you have to go through the same underwriting/quoting/etc.)
  • I've spent most of my time researching Anthem because, a. we had it in the past and b. I had a contact who pointed me there to get started.
Prior to the launch of I was 95% convinced that our best approach was to sign up for the Lumenos HSA Plus plan with a $10k deductible.  It offered a nicely bounded worst case scenario (about $25k ... premiums + in-network and out-of-network OOP maximums) and a very favorable best case scenario (~$450/mo premiums or $5400 annually).  However, when launched and with the prospect of a subsidy (since I'm starting a company and our only income currently is Shiree's) it seemed like a good idea to explore our options in the new plans.

Like everyone else did not work for me.  I was able to complete an application but could not view eligibility results, shop for or enroll in plans.  Knowing that is just acting as a broker for plans offered by private companies with constraints (like covering certain things, no pre-existing conditions, etc.) I figured I try to find the ACA plans on Anthem.  It wasn't hard.  In getting a quote you simply indicate that you want the plan to be effective in Jan. 2014.

The quoting process for ACA-approved Anthem plans takes you through a Kaiser Family Foundation subsidy calculator and then you end up with 11 possible HealthKeeper plans from Anthem summarized in this PDF.  Given our current income it appeared as if the coverage we could get under ANY of the plans was great and the subsidies made the premiums REALLY affordable.  So, I started to reconsider my Lumenos strategy.  I, instead decided to look into a 90-day short-term policy with Anthem that would cover us until January when we could sign up for plans under the ACA.

However, sensing the likelihood that a misunderstanding of the fine print (despite spending HOURS reading and analyzing it) might result in a giant mess I reached out to the local company LD&B.  My 10 minute phone call with Michelle Wodey was by far the most useful 10 minutes I've spent on any of this.

Without further ado, I give you a few more lessons...
  1. When short-term policies say they don't cover pre-existing conditions they mean it.  You find IDENTICAL language in long-term policies, but so long as you've been covered by insurance within the past 62 days it doesn't apply for long-term policies. NOT SO for short-term ones.
  2. Short-term policies have the same underwriting/qualifications process.  So you can be denied them just as easily as anything else.
  3. ACA subsidies are paid monthly but qualified for annually and you have to repay subsidies if you are no longer qualified at the end of the year.  For example... In January I qualify for 94% subsidy on my premium given income and that amounts to $800.  The rest of the year I no longer qualify (because I started making money).  In taxes for the year I have to repay the $800 subsidy I received in January.
  4. If you qualify for a long-term plan you lock it in for a year but aren't obligated to keep it that long.  So, as the kinks in the the ACA get ironed out and as it's clearer what our income for 2014 will look like we could cancel our policy and enroll early in 2014 (I think there is another open enrollment until March)
Given those additional tidbits I'm now 99% sure that the Lumenos strategy is the right one for our family.  It's not possible to be 100% certain when profit-seeking entities are involved; their interests and mine aren't really aligned.

Wednesday, October 9, 2013

Public debt and private wealth

One of my biggest complaints about typical conservative dialog in America is that it is, generally, argued by wealthy people and it, generally, understates the role that the government played in the accumulation of their wealth.  Try asking a conservative this question:
What percentage of your wealth is due to government spending, support, or intervention?
A totally reasonable response would be "how on earth could I possibly know that?"  However the response tends to gravitate towards "What do you mean 'I didn't build that!?'" to borrow a line from the rhetoric in the 2012 election.

Similarly, conservatives are very concerned about the national debt (to the point that we're legitimately risking a default on our debt obligation).  If you tweak the question and instead ask:
What percentage of the national debt should you be responsible for?
The response does not tend to take personal responsibility but instead blames "government bureaucrats", "entitlements," etc.

All of that got me wondering about the relationship between the public debt of America and the private wealth of America.  Consider two graphs:

This one pulled from the wikipedia article on the US national debt.

The second from the wikipedia article on wealth in the United States:

This is obviously an unscientific comparison, and the scales differ by multiple orders of magnitude but it doesn't take a scientist to suggest that the shape of the curves are nearly identical.   I contend that there is a strong hypothesis that there is a correlation between the dramatic increase in private wealth over the past forty years AND the dramatic increase in public debt over the same interval.

That is NOT to say that this trajectory is sustainable, even the most liberal voices on public debt (Paul Krugman ?) agree that we have a problem to address eventually (but now is the wrong time).  It does however give credibility to the question above ("what percentage of the national debt are you responsible for?") and arguably takes it further suggesting that the wealthy should be responsible for more of the debt since they have gained more wealth.

It has always been true that there is no such thing as a unique idea (I'm always stunned how most Nobel prizes are awarded to multiple people who discover amazingly complicated things "at the same time") and in the Information Age it's typically easy to confirm that...

A paper entitled "Public Debt and Private Wealth" by a Candian academic makes this exact argument.  He starts the paper...
The purpose of the present study is to show that, contrary to common belief, prosperity and “democratic wealth” in a capitalist economy depend in a crucial way on a greater government intervention.
and later concludes that
[T]he creation of private wealth and its equal distribution in capitalist societies depend in a crucial way on the implementation of a democratic public policy. In particular, it was shown that public deficits are an important source of wealth for the private sector, which also benefits from the positive effects of low interest rates (with the exception of the rentiers) and a more generous public spending on social programs. 
To be fair the paper feels a little flimsy and some of the macro-economic explanations and formulas are likely open to withering critique (having never formally studied economics myself) but nonetheless I believe it asks the right question.

What portion of your wealth are you willing to contribute to solve our national debt/spending problem?

Monday, August 19, 2013

Getting off the (wired telephony) grid - follow-up

After my first post about this I was pointed at the OBi-110 device which is a clever (and cheap) device that allows you to treat a Google Voice number like a home line.  The idea was to migrate my home number Google Voice and then get one of those devices.  The catch, though, is that Google Voice will not handle emergency calls.  So while the OBi-110 is a handy way to have traditional handsets it did not address the core question of my original post.

However, while thinking about that option I found this great tutorial on how to port your home number to Google Voice.  I followed those instructions almost exactly with one minor addition.  That is I needed to unlock my AT&T handset to be used with T-Mobile (a $10 cost though World GSM Phones).  I also discovered, quite on accident, that if you have a mobile phone that DOES NOT HAVE A SIM CARD it will still happily dial 9-1-1 ("no sir, I don't have an emergency.  I accidentally butt dialed you.").

So here's where I'll end up:

  1. No Verizon bill
  2. No mobile bill (for home service at least)
  3. Home phone ported to Google Voice (through the process above)
  4. Google Voice forwarding our home number to our mobile phones.
  5. A plethora of mobile phones hanging around the house and labelled with our street address for calling 9-1-1 in an emergency.
  • $8.05 for SIM card
  • $9.45 unlock codes to let an AT&T phone accept a T-Mobile SIM card
  • $10.00 pre-paid minutes so that our T-Mobile phone can receive some calls
  • $20.00 one time cost to port a number to Google Voice
  • $47.50 TOTAL

Monday, August 12, 2013

Getting off the (wired telephony) grid

While considering ways in which to shave dollars off the monthly cash flow needs my wife and I thought about getting rid of our landline which basically only has three purposes:
  1. Receive unwanted solicitations
  2. Receive political phone calls
  3. Place emergency calls
Given that only one of those is desirable (the reader may have different preferences of course) I wanted to know the answer to the question:
If you don't have a landline are wireless services adequate for dialing 911?
I did what any good researcher would do.  I asked my Facebook friends and turned up a treasure trove of good thoughts which I thought I should capture here.

Wireless Service Is "Enough"
Consulting the rules from the FCC and reading about "E-911" (or "enhanced 911") on wikipedia I learned that as of September 11, 2012:
Wireless network operators must provide the latitude and longitude of callers within 300 meters, within six minutes of a request by a PSAP (public safety answering point).
Furthermore, E-911 takes advantage of the GPS radio in most smart phones today.  So, in other words if you call 911 from a mobile phone today phone companies are required to be able to identify your location within 300 meters (or better... GPS has a "worst case" performance of 7.8 meters) in under 6 minutes to emergency services.  Anecdotally a friend reported that they called police about a drunk driver that they were observing and within minutes a police officer was on the spot.

However...  It is not "enough" in cases where a mobile phone is not present (obviously).  For example say your babysitter forgets his or her phone?  What are the options?

Low-fi Backup Mobile Phone
Another friend pointed out in the language in the E-911 legalese:
 All 911 calls must be relayed to a call center, regardless of whether the mobile phone user is a customer of the network being used
In other words ANY MOBILE PHONE, even one that doesn't have active service can dial 911 and the carrier is required to connect the call.  So find yourself an old clunker of a mobile phone (several actually) and leave them around your house as a backup means to make emergency calls.  A helpful suggestion from a friend who formerly worked with 911 was to make sure that any guest knows your street address so that they can confirm it with the 911 operator.  I suggest that you put a big sticker on the spare phone with that information.

Hi-fi Alternative Landline
Yet another friend suggested Ooma a free (excluding hardware and number porting costs) VoIP service that allows you to hook a plain old telephone up so that it can make and receive calls using your existing internet service.  You can even port your existing home number.

The Ooma Telo sells on Amazon for $99. You can then port your home number to Ooma for $39.  Once you have the device plug it into your network (you have to buy a WiFi adapter if you want to do it wireless) and plug your "landline" phone into the Ooma; port your home phone number and voilla you don't ever have to pay a bill for your landline again, and yet you have the ability to make and receive calls (even international calls), dial 9-1-1, etc. from your existing phone number.  In my case the total cost of $138 is paid back in a little over four months (since our landline costs us $30/mo for minimal services) and I don't even have to hassle with updating my phone number on websites, bank accounts, and other places that have my current number listed.

Routing your Existing Home Phone to Google Voice
A related variant, and cool idea from another friend is to move the land line to Google Voice, and set up Google Voice to route calls to that number to your mobile phone(s).  You still have to solve the "how does someone in my house without a mobile phone call 9-1-1" problem but this is also a free and clever way to get off your landline without giving up your existing phone number.

Wild Goose 2013

Shiree, Brody, and I went to the Wild Goose Festival last week and while it was different than last year (I went to the one out in Covalis, OR last year) it definitely had it high points.

  1. Nadia Bolz-Weber's "Screw the platitudes just say the truth."  Just plain awesome.  Particularly awesome was listening to her read her "lamentation" in the wake of the Trayvon Martin verdict.
  2. Listening to Frank Schaeffer and Richard Cizik reflect on (and in a nutshell turn away from) their past as leaders in the "religious right."  They both had such a gracious and humble view of their pasts and a hopeful vision for the future.
  3. Rev. Dr. William Barber's fiery and passionate admonition to preach the Word to the powerful which he has been doing for the past year plus as the leader of the "Moral Monday" protests in North Carolina.  I don't know what it would've been like to hear Dr. Martin Luther King speak, but it feels likely that Dr. Barber is carrying that torch.  Inspiring.
  4. Hearing Dr. Vincent Harding, a close friend of Dr. Martin Luther King and participant in the original civil rights movement, talk about issues facing our country today.
  5. Listening to Krista Tippet interview Brian McLaren (and others actually)
  6. Being surrounded by some really high caliber thinkers, artists, musicians, theologians, activists, and organizations.  Some other people whose name I have not previously dropped but whom I walked past in the woods, said hello to, or were otherwise just present with... Phyllis Tickle, Phillip Yancey, Speech...
  7. The "ephemeral art" installation in the Imaginarium with works by Ted Lyddon-HattenCyndi Gusler, and others.
  8. Hearing awesome new (and old) music from The Collection, Run River North, John Francis, Adam Crossley, Stuart Davis, Phil Madeira, and The Indigo Girls
  9. Being almost TOTALLY disconnected from the rest of the world.  No cell signal, and only a weak WiFi access point over half a mile a way that we ended up checking a couple of times.

  1. It rained a LOT.  We're still drying out.
  2. For whatever reason, it felt harder to meet people and really connect than the one out in Oregon (my guess is that being being stretched out across almost a mile of woodland made it easier to be an individual or a small group... In Oregon we were all in a big fair ground field so you didn't really have much choice but to have lots of neighbors).
  3. The Beer and Hymns was more beer than hymns (the musician leading it wasn't familiar with the hymns).  Now, I love beer, but there was something special that happened when you had a raucous group of folks belting out Amazing Grace, This is My Father's World, A Mighty Fortress is our God, etc. while lifting a mug.  That didn't happen (as much) this year.
  4. Having to haul nearly half a ton of stuff (not kidding... we packed for car camping... two coolers, kitchen stuff, a folding table, etc. etc. etc.) almost half a mile to the car.  We wanted to leave early on Sunday but couldn't get our car into the site until later...  So Shiree and I each made about 6 half-a-mile trips to haul all of that gear.  Let me say that that itself was a spiritual exercise for many reasons.
Overall it was totally worth it.  See photos on Smugmug, videos on YouTube, audio for Dr. Barber and Nadia Bolz-Weber

Monday, August 5, 2013

Education and innovation as community

While responding to an interview with Michael Crow I started to wonder whether we're missing an even more important part of the discussion (and opportunity for institutions or higher education).  The debate frequently orbits pedagogical techniques such as the flipped classroom, adaptive content and assessment, new teaching methods, etc.  There is certainly interesting innovation happening in those areas, however, it may be the case that the most significant innovations and explorations that are happening revolve around community.

Consider a few examples:
  1. Online discussion forums from the online classes (AI class discussion, Udacity forums, Coursera forums, reddit study groups, etc.)
  2. Seed accelerators (Y Combinator, TechStars, 500 Startups, etc.)
  3. Startup incubators/schools (Gig Tank, 1871, Starter League, The Hub Boulder, and dozens of others)
  4. Open source software (Hadoop, NodeJS, Linux, or multitudes of others)
  5. Crowdfunding (Indiegogo, Kickstarter, or even Kiva
The mission, products, and or services of the things mentioned above span a wide variety of areas but one thing that is true of all of them, and is perhaps the most important true thing of all of them, is that they're building and fostering community.

You could see Y Combinator as a venture firm, or the Gig Tank as value added office space, or the Starter League as an online "graduate degree", or Kickstarter as a way to fund projects, but unless you've seen them first as community I believe you're missing an important element of what they are.  The value of the investment that you get from Y Combinator pales in comparison to the community of peers and experts (investment, management, technology, legal, etc.) that you are immersed in as a member.  The value of the educational material that you get from the Startup League is worth far less than the relationships with other students and the teachers.  In all cases the above resources are infinitely more valuable because of the community you become a part of by participating.

Institutions of higher education, I believe, are also firstly a community.  At their best they are a learning community of researchers, teachers, and students across a wide variety of disciplines collaboratively exploring new ideas/technologies and teaching students.  Like the examples above there is enormous value in that community.  Higher education is under pressure from many things including innovations in technology (adaptive learning, Khan Academy, Coursera, etc.) and the response often pushes back arguing about pedagogical effectiveness.  I don't believe engaging (exclusively) in debates about pedagogy play to the the strengths of institutes of higher learning.  Instead administrators should embrace new technology and pedagogical methods and play up their strengths as learning communities that foster motivation, collaboration, multi-disciplinary solutions, and perhaps better learning outcomes.

Is higher education worth it?

Michael Crow, the president of Arizona State University, argues in an interview on the CNN Money blog that the return on investment in a four year degree is "unequivocally" positive.  I've spectated and participated in the revolution in online education over the last five years; building products at Rosetta Stone, taking several online courses through Coursera and Udacity, exploring everything from Khan Academy to Quizlet to Knewton, and actively following the transformations that we're in the midst of.  So when I read Mr. Crow's interview I can't help but see it as mildly mis-leading and full of conflict of interest.

I want to make one point about the interview.  For reference, this is his core thesis: "the return on investment for a college education, in terms of additional earnings, is about 12% per year over your lifetime."  For the sake of argument lets assume this statement is factually true.  The problem that I have is that it is that it is only true for the average (median? I bet that number is very different if it's not already median).  It's not hard to name crazy outliers for whom the statement wouldn't have been true in the past (Bill Gates, Steve Jobs, Mark Zuckerberg to name a few), but without a deeper breakdown it's hard to know whether there is much relevance in the statement for many other typical individuals.  For example does the 12% number hold across all degrees (computer science, mining engineering, philosophy, English, etc.), measures of student performance (high SAT vs. low SAT), socio-economic indicators, etc.?  Similarly it treats all "alternatives" to college equally.  Being a Thiel Fellow is lumped together with high school dropouts working minimum wage jobs.  However, when deciding on a college investment you're not making an abstract decision based on averages.  If you're a white, middle class, female, who wants to be an engineer, the answer to the question of whether college has a good ROI will be different than if you're a black, middle class, male, who wants to be a film director, and was offered a Thiel Fellowship to produce a new film.

Thursday, August 1, 2013

Analyzing Health Care Plans

I've spent way more time than I wanted to the past couple of weeks trying to find an answer to what you would think is a simple question.
What is the cheapest private health care plan available from Anthem given various risk tolerances (i.e. I want to guarantee that my expenses are on average the lowest no matter what happens vs. I'm willing to bet that I won't have a medical problem and if I'm wrong I'm willing to pay more in that case, etc.)?
In the name of "flexibility" or "choice" Anthem provides at least four different plans (as of 7/31/2013) Premier, SmartSense, CoreShare, and LHSAPlus (that is assuming you ignore temporary insurance plans).  Those plans come in dozens of different configurations for the amount of your premium, deductible, co-insurance percentage, and maximum out of pocket amounts.  Furthermore they don't give you any tools to help visualize the end result in various scenarios.  For example, if you're completely healthy in a given year which plan is better the $500 deductible plan or the $2500 deductible plan?  The answer to that question is the $2500 deductible plan.  Why?  Because the difference in premium is almost $300/mo. cheaper so you would save $3600 for the year.  Furthermore there are various gotchas that aren't obvious such as the fact that there are actually two deductibles (the deductible for anyone one individual and overall deductible for the whole family usually 2x individual) or the fact that prescription drugs may not contribute to your deductible/out-of-pocket limits and have pretty out separate out of pocket limits which seem to only apply to specialty drugs.

With those things in mind let me first give you a few tips and things to watch out for.  Then let me walk you through a model that I built for our family to make my decision.  NOTE the model and the examples below assume a 5 person family with 4 males and one female, 3 children, and no maternity coverage.

Here's what you need to be aware of.

  1. Premium is always listed monthly whereas deductible is listed annually.  The effect of this is that it's much easier to favor the higher premium lower deductible when often times that isn't optimal.  Consider the difference between $500 deductible vs. $2500 deductible given $815 premium and $561 premium.  It's hard to compare the two.  If instead premium were shown as an annual amount compare these two $500/$9792 vs. $2500/$6732.  Notice in the case of the $500 deductible you are guaranteed to pay $9792 (in exchange for having a limited $500 deductible).  In the case of the $2500 deductible you are only guaranteed to pay $6732.  The difference in premium amounts is $3060 where the difference in deductible is only $2000.  So in both the best case AND the worst case you're better off with the higher deductible option.
  2. Both deductible and co-insurance are typically shown as individual amounts but there is actually a family deductible which is usually 2x the individual amount.  Taking the example from that last point...  If you're a family your deductible is $500 per person up to a maximum of $1000 for the family (or $2500/$5000) meaning in a four person family you could have four people use $250 of their $500 deductible OR two people use $500 of theirs.  Doing the comparison from the last example again except for a family, you get $1000/$9792 vs. $5000/$6732.  This slightly changes the conclusion you might make because in the worst case where you use up the entire family deductible the cheaper deductible plan will have you spending $10792 vs. $11732 for the higher deductible plan (note in these examples I ignore co-insurance).
  3. Beware the trade-off between premium and co-insurance.  In the model below you'll see a plan option where the deductible is the same, the premiums are only slightly different and one has co-insurance/out-of-pocket maximums where the other does not.  In that case you've got a $34 difference in premium for a total of $408 more premium for the plan without co-insurance.  In exchange for the benefit of saving $408 dollars (in the plan with co-insurance) you run the risk of paying as much as $4000 additional out of pocket (assuming you hit the family out-of-pocket maximum).
  4. The listed plan options typically include a prescription drug benefit but it is often the case that prescription drugs do NOT contribute to meeting your deductible or co-insurance amounts.  For the Premier plan you have to pay the greater of $15 or 40% co-insurance with no out-of-pocket maximum for generic drugs.  There is an out-of-pocket maximum for specialty drugs of $10k.
  5. Make sure that you understand the prescription drug coverage.  In the case of the Anthem CoreShare plan (not modeled below) the medical coverage can have quite favorable best case and worst case scenarios because the premium is really cheap.  HOWEVER there are some drugs for which you have to pay 100% out of pocket with no out-of-pocket maximum.  So, I think, that if you're on the CoreShare plan and your treatment calls for a really expensive or special drug you may be 100% responsible for it and hence you will blow up your worst case scenario.
  6. Understand health savings accounts.  I haven't done my research here yet, but some of the plans (e.g. LHSAPlus from Anthem) are "HSA compatible".  An "HSA" is a tax-privileged "health savings account" that works similar to an "FSA" ("flexible spending account") without the restriction that you lose it if you don't use it (HSA's rollover from year to year).  If you combined an HSA compatible plan along with an HSA you may further be able to save on your total health care spending because of the tax benefits.
With that in mind embedded below is a model (link to google doc) that I built to help me internalize the lessons above and hopefully make a decision.  The assumptions that the model makes are noted in a text box in the bottom right-hand corner.  There are two sheets in the model; one for different premium/deductible/co-insurance configurations for the Premier plan and one for the different premium/deductible configurations for the LHSAPlus plan.  Each configuration considers what the TOTAL money spent on health care (premium+deductible+co-insurance+prescriptions) would be given three scenarios; one where you spend about $200 total on medical care (that's $200 to cover drugs, deductibles, etc.), one where you spend $800, and one where you spend $1600.

Here are my take aways:
  1. All of the plans have you spending something greater than $7000.
  2. The configuration with the best case is also the plan with the worst case (you might spend only $9072 but it could be as bad as $25872)
  3. I can't think of any reason why someone should buy the low deductible+co-insurance+out-of-pocket maximum options.
  4. If you're going to stick with the Premier plan a middle  of the road plan with no co-insurance and moderate deductible (>= $2500) gives you a pretty good optimization of risk vs. out of pocket spending.
  5. Prescription drugs are a bit of a wild card from a risk stand point.  When I transitioned health insurance I had to pay out of pocket for some prescriptions and they were $400...  If you have to pay 40% of $400 even just on two prescriptions a month you're going to get dinged on the Premier plan.
  6. As such I'm leaning towards the $10k deductible LHSAPlus plan.  Given that we're a generally healthy family the best case is both more likely AND the lowest of all other options ($6708).  Furthermore since the LHSAPlus plan deductibles include prescription drugs the absolute worst case ($14308) where we have a really bad medical year is WAY better than the absolute worst case of all the other plans (which start to tack on $10k out-of-pocket maximums per family member for drugs).
Getting to this point has been a real chore so hopefully these thoughts are helpful to someone.

If you want to run quotes for yourself you can do so with the Anthem rate quote tool.

UPDATE: I added the Anthem SmartSense plan to the model spreadsheet above.  I believe the analysis still holds.  The SmartSense plans have the weakness of having drugs potentially not be covered.  The one interesting things about the SmartSense plan is that you only have to pay 3 co-pays per person.  NOTE I did not model co-pays.  This disadvantages LHSAPlus (which still looks favorable) because it's costs are comprehensive (there are no copays... you pay everything up to the Max-OOP)...  When comparing Premier to SmartSense and ignoring co-pays it probably makes Premier look slightly better.  But I don't believe changes the conclusion.

NOTE: There are coming changes with Obamacare and the health exchanges that might require modifications to the above analysis, but at this point it's not clear what they will be.

Friday, July 19, 2013

Be careful what you ask for (or at least don't let yourself be inoculated when you get it)

Since the verdict in the Trayvon Martin case came down on July 13th there has been an outcry of "injustice!" in my infosphere.  I generally agree with the conclusions made in this piece, but I have found the outcry to be hollow.

Do this thought exercise...  Think of America on July 12th before the jury handed out the verdict.  Now imagine a guilty verdict for George Zimmerman (on all counts if you prefer or perhaps just the manslaughter count).  Then imagine American now; now that "justice has been served."  Would the present outcry over injustice still exist?  And would we would be better or worse off?

Justice is never only about one person or family.  Justice is systemic and surrounds and impacts all of us whether we are conscious of it or not.  There is good reason to believe that we have systemic issues of justice to work on in America.  Perhaps the greatest gift that the Trayvon Martin jury gave us and the greatest legacy of the tragedy of Trayvon Martin is that we weren't given a piece of local justice at the expense of a more lasting and global justice.

Wednesday, July 17, 2013

Fast exception notification in rails

There are several highly regarded hosted exception notification and paging services services for rails apps such as Exceptional, AirbrakeBugsnag, PagerDuty but all of those cost $10-30/mo and with the exception of Bugsnag none of them have a free tier (note all of them have free trials).  So if you're starting a new web app and you intend to operate it like a pro, i.e. you want to be woken up in the middle of the night when something goes wrong you've got some work to do...  But it's not very much.  In this post you'll see how to integrate Amazon's Simple Notification service with the exception_notification gem.


  1. You've got a Rails 3 app...
  2. Running on AWS...
  3. And you have a mobile phone that supports text messages
First install and setup the exception_notification gem as documented on their github page.  In a nutshell.  Add "gem 'exception_notification'" to your Gemfile and run "bundle install"

Next lets setup a new Simple Notification Service topic and subscribe our mobile phone to it (full SNS documentation).

Create the topic:

Topic details without a subscription:

Create a subscription for our mobile phone:

A confirmation is bounced to our phone:

Confirm from our phone:

Topic and subscription are setup and ready to use:
Next you should grab the aws-sdk for Ruby and follow the installation instructions.  In a nutshell...  A "gem 'aws-sdk'" to your Gemfile.  Run "bundle install".  Create an aws.yml with your access key ID, and secret access key.  Create an initializer that pulls the aws.yml in to your app and sets up various AWS clients.  Assuming you've done that lets create our SNS notifier and configure our app to use it on exceptions.

In config/environments/production.rb add this code:
  config.middleware.use ExceptionNotification::Rack, :sns => {:topic_name => 'test-topic'}

Create lib/exception_notifier/sns_notifier.rb:

module ExceptionNotifier
  class SnsNotifier   
    attr_accessor :topic
    def initialize(options)
        @topic = SNS_CLIENT.topics.detect {|t| == options[:topic_name]}
    def call(exception, options={})
      @topic.publish("#{}: '#{exception.message}' at '#{exception.backtrace.first}'") if active?
    def active?
That's it.  Except of course to add an exception into your app and watch the notification on your phone:


Monday, July 15, 2013

An investigation of fruit with regard to it's ripeness..

I think about this plot every time I attempt to eat a slightly unripe avocado:

For a comparison of tastiness to difficulty consult the brilliant XKCD.

Wednesday, April 24, 2013

Minimum Viable Process

As I've been thinking about the idea of a "minimum viable product" popularized by Eric Ries (famous for the "Lean Startup" movement) I had the idea that what was equally important in an organization is "minimum viable process."  Like any good idea, it had already been (mostly) had by someone else.  Have a read of Cindy Alvarez's piece.  Some noteworthy quotes:

Calling anything a “minimum viable product”, in some ways, allows us to fall back into the familiar trap of writing a bunch of requirements and then building a bunch of stuff.Maybe we should reassociate MVP with Minimum Viable Process, to emphasize that this is an ongoing, iterating cycle that never really allows us to rest in our comfort zone.
So, there’s no ONE minimum viable product.  You can’t identify one thing and then stop talking to your customers and go build.  Because you’re not really building a product – you’re building an environment that supports increasingly educated guesses. 

An additional thought that I had that isn't really reflected in Cindy's is that "minimum viable process" is important for *how* you build your "minimum viable product" as well.  If you do a great job building an MVP but it takes you 5x as long because of your processes then you've just traded back part of your savings for having pursued and built an MVP.

I don't know how it works in practice, but the culture at Netflix appears to nicely capture a "minimum viable process"