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I needed to write this review of the last 12 months.

I was not going to, but then my dog died last night and now I need to. All the stored-up objections to writing this article melted in the face of that reminder of how precious, how miraculous our lives are. I have had humans die in my circle recently, and of course that’s much more serious and painful than losing a dog. But sometimes the smaller things become the bigger things when you hold back the bigger things for a while. Last straw, finger in the dam and all that.

For those of you who have followed my work these last few years, you have noticed I have an ongoing conversation with readers. It’s a strange conversation in which I am unable to separate work from life and life from work. This entangled-ness is perhaps because of the nature of Medicaid (it calls for all-in-ed-ness, and a bit of extremity in working), perhaps its because of working too hard (like so many of us are guilty of- and it is a real problem, not a badge of honor). Perhaps it (the entangled-ness, in case you lost the noun, which I almost did) is simply because I am no good at setting boundaries between readers and clients and friends.

My writing is also strange in that it’s a mix of macro-analysis about Medicaid, seasoned with sarcasm and redeemed (I think) with small glimpses into the human heart.

For those of you that read my writing, this entry is my Thank You Note for 2016 to you. Its me showing you what just falls out of my head when I let it. Thank you for reading, for commenting, for writing in, for calling and leaving voicemails just to say you appreciate what I am doing in the space. And thank you also to those who disagree in sometimes very frustrated manners.

What you all (who am I kidding? I mean, y’all!) may see as small gestures are incredibly powerful fuel and encouragement to me.

As is my way, after a top-heavy windup, here are my summarized reflections for 2016 across various topics:

Reflections on Work

1.  The industry itself has seen so much excitement this year. First there was the ongoing saga of expansion. And the guilt-tripping of those who still had concerns. And the ignoring of the gigantic cost overruns by those who leapt into expansion a few years back. It got so boring to see the same news articles written over and over again, just with different characters playing heroes and villains in the story of the Medicaid Expansion Crusades. It became scary to see otherwise Very Smart People unable to grapple with ideas they disagree with (i.e., not expanding Medicaid) by labeling expansion the Highest Moral Issue of the land. We often forget that there are other things discussed in state houses besides Medicaid. Important things. Yes – Medicaid is uniquely important. But not All Important. And those of us living in the bubble of the healthcare world would do well to remember that. We must continue our fight to help the Least of These, but not at the expense of what is important to other people (like education, and roads, and state parks and a hundred other things that don’t get enhanced Federal matching funds).
2. ACA’s nakedness is beginning to show. The true costs of ACA became painfully apparent in mid-2016. With a few years of data behind us, we were able to see that new bennies cost 50% more than promised during the sales phase. And that annual promises of “but it will go down next year, we’re sure of it!” were well-intentioned, but ultimately empty promises. All the wacky, tried-and-true health policy explainer theories stopped working. No matter how persuasive celebrity pop-economists are that the economy can be whatever we think it is, that common sense doesn’t matter, that new chapters in new best sellers peddling new sophistry will trump laws of economics (or that there are no laws, even there)- we hit the cold, hard wall of reality this year. Giving millions more people “coverage” will cost billions and soon trillions more. De-linking “access” to personal responsibility will risk the whole thing. And yes, of course, many good things happen when people have easier entry into the healthcare system via an insurance card – but if we want to the world to fund our Crusade, we must be crystal-clear about the true costs.
3. The election. I stopped there with just the subject of a sentence I honestly don’t know what verb to end it with. The election is disruptive innovation for Medicaid (though I don’t see all those hipsters who worshiped Uber for disruptive innovation looking at the New President this way). The election will bring change (as it always does). The election was divisive (as it always is). The election followed the established laws of the United States of America- but it will still be resented by those who lost (as it always is). Various forms of mutiny will be attempted. Hold on tight. Don’t trust any politician on either team until they deliver something tangible you want. If you haven’t seen my article focused on this, you can read it here – “Make Medicaid Great Again.”
4. Mostly Medicaid has had an incredible year. The Webinars were an insanely popular success. As are most things we do, we started the webinars because I had a random thought one morning at 4 am that webinars where people just talk about Medicaid would be interesting. So we started doing them. For the State Spotlight Series, we hit 8 states in 2016. The talent and passion by each of the Medicaid agency team members that joined the panel is incredible. The News Roundtable show was a blast – and I get to chat about Medicaid news with some of the smartest people in the space every month. The Weekly RoundUp continues to be my favorite part of all of this. I am still amazed that nearly 10,000 people read this thing (we think, based on various data points we have strung together). And it seems that about 96% of them love it. And the other 4% still read it, sometimes as a guilty pleasure I think. We also got to work with tons of new clients on the consulting side and training side in 2016. We assisted people with everything from basic and advanced Medicaid training in government agencies to implementing MCO programs in the private sector to winning technology RFPs and about two dozen other things that were rewarding and fun to do.

 Reflections on Life

1. There was a lot of really good and pleasant things in our life this year. The kids have met the new challenges placed on them in our homeschool model and flourished even more in 2016 than in 2015. My garden did well, considering (see item 2). Hot peppers of various Scoville heat units were had all around. A Zinnia forest sprung up and I rooted dozens of gardenias. We made our first batch of wine, and have started on a large batch of fig wine. We went on a safari with the kids (in Georgia, where you drive a car through a few acres of herbivores and they stick their heads in the car because you have food pellets). My wife and I celebrated our 10th anniversary. We met each other randomly in Disneyworld 11 years ago. Come up and say hi at a conference some time (so far I am chairing 3 of them in 2017) and I will tell you that story. It’s a good one.

There’s another story that I have become fonder of telling in 2016, too. It’s the Gospel and how it relates to Medicaid. I have realized there are many who have not heard the true Gospel, and there are many who are secret believers afraid to speak. I hope that I am bolder in 2017 about speaking, and that they are encouraged by that.

2. There was also sadness. And scary things, too. My wife almost died in my living room in July due to a pulmonary embolism. Our world was rocked by something neither of us had ever heard of (and I am a healthcare guy). She is recovering very well, but I still think of that moment often. It was terrifying and an incredibly clarifying experience. Everything stopped for about 3 weeks. I have wonderful clients who were 100% supportive when trips were cancelled and deliverables delayed. I think overall, the experience taught me that “healthcare” is a real thing when it hits you, and its not just an 1115 waiver application, or an MCO HEDIS report. Husbands love your wives. You are likely (like me) a fool who does not realize how precious they are until you are reminded by tragedy (or near tragedy). 2016 also saw a return of my father’s severe depression. Each year I learn more how deep the impact of a Father is on a Boy. Sometimes there’s nothing you can do but listen and sit with your loved ones. And to believe that they will get better.

2. And then there was the dog. I find that it is important to write while things are fresh on your mind. Keegan died about 12 hours ago. He was a beautiful dog, a Sheltie. A very good and well-trained dog. A vacuum cleaner under our table after the chaos of dinner with 4 children. A loud sentry when the UPS or postal person dropped packages at the door. An obstacle in the middle of the night on the tile floor of the bathroom, because the tile is cooler and he likes(d) that. A herding dog that actually got herded by our ducks. A friend. Especially to my young children who struggle this morning as they wake up and their friend who has been around most of their little lives is not where they expect him.

I am not yet to the part of the experience where I can offer insights other than this: Life is precious, and it is bound up in the relationships we have with people, animals, our work, and our God. Cherish it. Help others along the way.

 Looking Ahead to 2017

And now a few thoughts about next year.

1.  Work – We will continue with the webinars, and I am excited about that. I hope to get back to work on the book about Medicaid Directors themselves (working title: “A Day in the Life: Running a Medicaid Program Really is Rocket Science”). I look forward to what new clients I will meet and help.
2. Life – I am sure 2017 will be unique and bring its own mix of good and bad.
3. 2017 itself is a prime number. I like prime numbers.
4. I will turn 40. 40 is not a prime number.
5. I have big plans for the garden. I will keep you posted.
6. I plan to be more positive about Medicaid in general. Maybe reduce the sarcasm (I prefer “wit”) just a bit. A tad. A dollop. A smidgen. A hair.

Most of all I intend to focus on one simple thought: Live Today Now.

That’s it for this year. As always, please send me a note with your thoughts to clay@mostlymedicaid.com or give me a buzz at 919.727.9231. Get outside (build a fire with all those boxes from the presents) and keep running the race (you know who you are).

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