Author: mikemallaro

CEO of VGM Group, Inc., a 100% employee-owned company. Interested in healthcare, golf, restaurants, insurance, public policy and life.

The Impact of the ACA


I’m going to take a bit of a risk this week and talk about Obamacare. The Affordable Care Act, a/k/a Obamacare, was signed into law in 2010. This “reform” of our healthcare system remains an emotional flashpoint for many on both sides of the aisle, but at the same time is often misunderstood. If we can, I’d like to set aside the emotional baggage that surrounds the law for a moment and try to take a look at the actual impact that Obamacare has had on our country and our industry since it was passed:

  • About 20 million more Americans have insurance coverage because of the ACA. We know two things about people being insured: First, they are much better able to pay for healthcare than uninsured people. Second, the data tells us that insured people use significantly more healthcare resources than uninsured people. Insuring more people creates more paying customers for healthcare providers, including those in the DMEPOS industry.
  • The increase in the number of people with insurance is primarily because more people are on Medicaid. Prior to the ACA, about 13% of Americans had insurance coverage through Medicaid. That figure has since grown to 21%. An additional effect has been that nearly 7 in 10 people on Medicaid receive their coverage under MCOs (managed Medicaid plans that are run by private insurance companies) rather than under state-run plans. The proportion of Medicaid enrollees using MCOs has doubled since the passing of Obamacare.
  • Intriguingly, the mandates requiring individuals to have health coverage and businesses with more than fifty employees to provide it really didn’t have much of an effect. The percentage of the population insured through employer sponsored group plans has actually declined from 54% to 49% since the coming of Obamacare. Most of this decline came about because more people reached the age of 65 than reached the age of 18 during that time period, which led to a swelling of the Medicare rolls. The remainder is probably due to a shift of the working poor from employer plans to Medicaid. A slightly larger proportion of people got insured under individual plans after the ACA, but it was a relatively small impact.
  • Just like with Medicaid, there are more privately managed Medicare plans today, too. One-third of Medicare beneficiaries are opting to be covered under Advantage plans, which is about fifty percent more than prior to Obamacare.
  • There is, and has been, much dialog about shifting healthcare from pay for volume to pay for performance, with many efforts to evangelize for that objective. Despite this, it mostly remains an unfulfilled aspiration. Almost all healthcare reimbursement is still pay for volume. The pay for performance crusade is aimed at reducing the overall costs for healthcare, and it does remain a promising idea for the future. However, to date, it has gotten relatively little traction. Advocates of pay for value plans like to proclaim that more than a third of healthcare payments already fall under this payment structure. This is deceptive, as most of the actual reimbursements made under those types of arrangements are, in fact, fee-for-service with a tiny element of pay for performance. The shift to MCO in Medicaid, which does lower costs, is probably the biggest side-effect of the ACA impacting costs. Unfortunately, this is generally achieved by rationing through inconvenience. That’s one way to bring down costs, but it’s got to be one of the least desirable ways to do it.
  • Taxes were higher after Obamacare, but they’ve now been lowered, so that probably shouldn’t be a part of the discussion anymore.
  • There is more money spent on regulation and compliance today than prior to Obamacare.
  • Many young people stay on their parents plans until age 26, which is a popular provision of Obamacare.
  • For a relatively small group of people, pre-existing conditions are no longer a barrier to insurance coverage because of the ACA. This is often misunderstood, since people with pre-existing conditions have been protected for at least a decade prior to the ACA. As long as those people carried health insurance continuously, they had full protection for pre-existing conditions long before the ACA came into being.
  • There are many other provisions of the ACA that impacted narrow bands of people or narrow industry segments.

There were two major problems that led to the ACA in the first place – (1) there were far too many uninsured people in America, and, (2) healthcare costs were too high and increasing rapidly.

The law has driven significant progress toward solving the uninsured problem by reducing the ranks of people without insurance by 20 million and shifting the burden of paying for their healthcare from private healthcare providers to the government. On the other hand, Obamacare has largely failed to deliver results with respect to lowering costs, outside of working around the edges to slow cost inflation in some areas.

The Times, They Are A-Changin’

Young Workforce

“Come gather ’round, people
Wherever you roam
And admit that the waters
Around you have grown
And accept it that soon
You’ll be drenched to the bone
If your time to you is worth savin’
And you better start swimmin’
Or you’ll sink like a stone
For the times they are a-changin’”

Bob Dylan, from The Times They Are A-Changin’

Millennials are the largest generation in the workforce today. The Baby Boomers are a rapidly declining segment, while the Greatest Generation has almost entirely retired. Within seven years, Post-Millennials will begin to eclipse Baby Boomers. As recently as 2010, Boomers and Greatest Generation workers made up a combined 42% of the total workforce. By next year, Millennials and Post-Millenials will be at a combined 43%, while the Boomers and Greatest Generation will have declined to only 23%. If you’re a leader in any organization, these significant shifts in workforce demographics will require your awareness and, in many cases, adjustments to your thinking.

There are no “good” or “bad” age groups. There are simply segments of people who have differing priorities, aspirations, and values. To pivot your leadership approach and adjust for this seismic demographic flip, consider two very important values: Meaningfulness and Flexibility.

Meaningfulness is among the most important values to Millennial and Post-Millennial workers, and was not considered particularly important by prior generations. You can win these younger people’s hearts in three ways. First, you must make a clear and direct connection between the work you’re having them do and how it is helping someone else in a meaningful way. You must be clear and direct about this connection between societal impact and the work that they are doing, and then you must reinforce it. Often.

Second, keep an eye on your philanthropy strategy. It matters much more today than it did in the past. Younger workers want to work for companies that are making a positive impact in their communities, and doing so is great way to differentiate yourself from other employers in their eyes. Giving them some choice or say in the direction of your philanthropy efforts will lift your organization even higher in their estimation.

Finally, for many, meaningfulness comes from helping a team. They want those around them to succeed, and to share the fruits of their labors. They also want others around them to be treated fairly, and they want equality of opportunity for every member of our increasingly diverse workforce. In all three of these realms, connect the dots clearly and often for your employees so that they can see the meaning behind their work and share together in the rewards and opportunities that it creates.

Flexibility is a much higher priority for Millennial/Post-Millennial workers than it was for older generations. Employers often cling to a “one-size-fits-all” mentality when it comes to workplace policy, but the truth is that conventions around where and when people work for us are often the products of history and reactions to past events rather than carefully considered or optimally chosen tools to engage employees.

Step back and find ways to adjust your policies with an intent toward being more flexible while still meeting the needs of your customer. If your policies, work schedules, or other office rules are not directly derived from or established to meet customer needs, then they are worth reconsidering. Our world is increasingly large and complex, and the individual needs and circumstances of the people who work for us are more varied than ever before. If you can be adaptable and extend trust to your younger employees while holding them accountable for their performance, then they will often reward you with increased productivity and loyalty to your organization.

Remember that the flexibility of the younger members of your staff works both ways. Millennial and Post-Millennial workers are dramatically more flexible when it comes to accepting organizational change, adapting to new workplace procedures, solving unexpected problems, and adopting new technology. Since change is one of the few constants in business these days, the flexibility of your younger workers can be an enormous advantage if you can harness it properly by asking them to take lead roles when it comes to tackling unconventional projects, getting new initiatives off the ground, or selecting and implementing new technologies.

The word “Millennial” gets tossed around a lot, and too often it’s made to sound dirty. It’s easy to dismiss the needs of an increasingly youthful workforce as being nothing more than frivolous and selfish wants, but those who think this way do so at their peril. The times really are a-changin’, and if we don’t change with them, our organizations will pay a heavy price.

It’s worth remembering that these younger generations of workers desperately want to make meaningful and lasting contributions to their companies and their communities. If we’re willing to show them the meaning behind their work and grant them a little flexibility about when, where, and how it gets done, then they can and will achieve great things for us and for the customers that we serve.

Us vs Them


“When one half of the nation demonizes the other half, tendrils of resentment reach out and strangle whatever charitable impulses remain in us.” 

― Ben Sasse, Them: Why We Hate Each Other–and How to Heal

Division and divisiveness seem to be everywhere these days. From Capitol Hill to Main Street, the arguments surrounding the pressing issues of our day threaten to tear the fabric of our institutions asunder. Political tribalism has always been with us, but there certainly seems to be an unhealthy separation between “us” and “them” lately.

Our divisions are probably the most evident in the battles raging across the digital landscape on social media, but they manifest themselves in the workplace too. Leaders would be well served to combat the tribalism that is infecting our society whenever and wherever they can. Here are a few things I’ve been thinking about lately that might be helpful:

  • Help the people within your sphere of influence look for and find common ground. The truth is that most Americans actually agree on most things. We love our country, our state, and our community. We want our children to thrive and do better than we did. We want to be safe. We want to pursue our passions and want others to be able to pursue theirs.
  • Listen more than you talk. Look for similarities, not for differences. Try to understand where another person is coming from.
  • Be thoughtful about what you post on social media. You have every right to be opinionated, and to share your opinions wherever you choose. We’re fortunate to live in a country that affords us that right. Before you post, however, take a moment to think about whether your comment or “like” is going to bring people together and further your cause, or simply create more division.
  • Be intentional about the words you use. Certain words have long been a part of our English language, but they’ve picked up a lot of baggage over the years. Some have become code words that trigger emotional responses of division within the people who hear them. You know many of these words. Be cautious when using them in any context.
  • Be curious, not contemptuous, of differences of opinion. As Covey says, seek first to understand, then to be understood.  Rather than categorize the other person as “them”, or to condemn them for their viewpoint, engage in a curious discovery of why they hold the viewpoint. Usually, when you intend to understand their perspective, you will find something in common or a partial meeting of the minds.


Lives & Limbs – Soldiers

Robert Heinlein once wrote that the most noble fate a man can endure is to place his own mortal body between his loved home and the war’s desolation. The line is based on the fourth stanza of our national anthem, which no one ever seems to sing at sports games for some reason.

As my series inspired by Nicole Ver Kuilen continues, I’d like to take the opportunity to remind you all that there are a hell of a lot of women who put their bodies on the line as well, and a lot of them leave pieces behind when they come home.

Marine Turned Mountaineer

#11 - Kirstie Ennis Final

I was spending yet another layover at Chicago O’Hare on my way home from a business trip last month when I caught sight of a provocative painting on the wall. You don’t see a lot of pictures of beautiful, powerful-looking amputees in their underwear hanging around in airports, so I got curious and stopped to read the plaque underneath it. It turned out that I was looking at U.S. Marine Corps Sergeant Kirstie Ennis, who lost her leg in a chopper crash back in 2012.

That’s putting her injuries lightly, actually. The crash also tore her rotator cuff, damaged her spine, shattered her jaw, lacerated her face, and left her with a case of brain damage and PTSD. Her recovery took three years and required over 40 surgeries. That she was able to recover at all is a testament to the power of modern medicine. What she’s done since her brush with death on the battlefield is a testament to the power of the human spirit. Kirstie is a United States Marine, and Marines don’t quit.

As a life-long athlete, Kirstie turned to sports to get her back into fighting shape during her recovery. The same year that her leg was amputated, she participated in a 1,000 mile hike across England called Walking with the Wounded. She went on to compete in rowing, swimming, and cycling during the 2016 Invictus Games, and joined the U.S. Snowboarding Team for the 2018 Paralympics after that. Her current passion is rock-climbing. She’s the first woman with an above-the-knee amputation to reach the top of Mount Kilimanjaro, and she eventually plans to stand on top of each of the world’s Seven Summits.

Pilot Turned Politician

Back in the early Nineties, there weren’t a lot of combat roles for women in the United States Armed Forces. That’s why Tammy Duckworth, who comes from a long line of fighters going all the way back to the Revolutionary War, chose to train as a helicopter pilot after joining U.S. Army Reserve back in 1992. In 2004, Tammy’s unit was deployed to Iraq during the War on Terror, where her Blackhawk helicopter was struck by an RPG while on patrol. Tammy tried to land her damaged chopper, but had some trouble reaching the pedals because she’d lost both of her legs in the explosion. Fortunately, her co-pilot got the job done and pulled her from the wreckage.

Tammy recovered from her injuries at Walter Reed Army Medical Center, where OPGA’s Dennis Clark saw to her prosthetic care and rehabilitation. Unable to return to active combat duty, Tammy needed a new way to serve her country. She found it in politics. Returning to Illinois, Duckworth became the Director of the Illinois Department of Veteran’s Affairs. Her efforts got her noticed at the national level, and she was nominated by President Barak Obama to serve as Assistant Secretary of Public and Intergovernmental Affairs for the United States Department of Veterans Affairs in 2009.

She resigned her position in 2011 so that she could run for an open seat in the House of Representatives in 2012. Her election to that office made her the first disabled woman to serve in Congress. She was elected to the U.S. Senate in 2016, where her service continues today. Since her time at the VA, Senator Duckworth’s government service has been characterized by her common sense, fighting spirit, and dogged determination to do what’s best for her constituents. She’s been particularly active as an advocate for veterans, the disabled, women, and minorities.

Lives & Limbs – Science Fiction

Welcome back. Whether you’re a licensed O&P practitioner, an amputee fortunate enough to have a state-of-the-art prosthesis, or even just an industry outsider who’s amazed at the level of technological innovation that goes into creating today’s prosthetic devices, it’s hard not to be amazed by the sophisticated solutions available to amputees. As my series inspired by Nicole Ver Kuilen‘s visit continues, I’d like to keep the sci-fi theme that I started on Friday rolling just a bit longer. Enjoy.

World War I & The Rise of the Bionic Men

The thing that made WWI so incredibly unique was the sheer scale of it. When the guns fell silent and the soldiers started returning home in 1919, the world’s most powerful nations found themselves facing a new crisis on the home front. They had millions of newly disabled veterans to care for, and they were going to have to do it while their economies were in complete shambles. To make matters worse, the war had taken millions of able-bodied young men out of the workforce, and many feared that this would make the process of rebuilding slow and painful due to a massive loss in productivity. No matter which side of the war they’d been on, each of the belligerents came to the same conclusion:

If they were going to avoid going broke, they needed to find a way to return their veteran amputees to the workforce. Fast.

Fortunately, these brave men and women were extraordinarily willing to put their shoulders to the wheel…even if those shoulders were no longer always made of flesh and bone. Douglas C. McMurtrie of the American Red Cross, French engineer Jules Amar, and German innovator Georg Schlesinger were at the forefront of a revolution in prosthetic design where form was cast aside entirely in favor of functionality. Their innovative thinking ultimately made prosthetic limbs cheap and easy to mass-produce while also providing maximum utility to the amputees that would be expected to use them.

Schlesinger was especially excited about the potential of prosthetics, and went so far as to advocate for the idea that well-designed prosthetic devices could enhance the abilities of an amputee and give them a powerful advantage in the workplace. This idea got a lot of people talking about whether science could (or should) be used to create race of bionic “super men.” We never quite got around to turning everyone into cyborgs after the war, but we did see an enormous shift in the prosthetics industry from cosmetic limbs meant to fill space and hide “deformity” to the mass production of practical, functional limbs.

This change allowed millions of injured soldiers to return to work and, in many cases, completely shatter expectations for what they could do. No longer looked upon as cripples in need of government protection and assistance, amputees equipped with prosthetic devices were seen as being more than capable of contributing to society. This new, elevated status for amputees combined with their sheer numbers after the war went a long way toward reducing and even eliminating the social stigma that came with missing a limb.

Scotty’s Missing Middle Finger

Space: The Final Frontier…

Gene Roddenberry captured the imagination of millions of Americans when he brought Star Trek to the airwaves in 1966. Captain James T. Kirk had command of the Enterpise, but it was his loyal Chief Engineer, Montgomery Scott, that kept the ship flying through all of its crazy adventures. Being the Chief Engineer on a starship wasn’t easy. Scotty had to perform delicate repairs on extremely complex machinery under enormous pressure, often while the ship was being shot at by the villains of the week. One can only imagine that he had to have the kind of manual dexterity that would make a bomb-squad technician jealous…a quality he prided himself on despite the fact that he was missing the middle finger on his right hand.

You see, prior to being cast as Scotty, Canadian actor James Doohan served with the 14th Field Artillery Regiment of the 3rd Canadian Infantry Division during the Second World War. After storming the beaches of Normandy with his unit, he ended up being shot by friendly fire while moving between command posts the night after the battle. Doohan took four in the leg, one in the chest, and one through his middle finger, which had to be amputated. This may seem like a relatively small injury compared to some of the others that I’ve talked about in this series, but you have to remember that Hollywood is a pretty superficial place today. It was even worse in the 1960s. There weren’t a lot of casting calls going out in Tinsel Town for people who were missing body parts.

Obviously, Star Trek was an enormous success. My great grandchildren will probably be watching some version of it long after I’m dead. James Doohan’s part on the show helped open the door for other amputees to try their hand at acting…no pun intended…and also inspired a generation of kids to go into engineering. His character was cited by so many engineering students as their reason for choosing the profession that he was given an honorary doctorate in the subject to go with his star on the Hollywood Walk of Fame. Doohan passed away in 2005, but his legacy of inspiring young amputees, engineers, and astronauts will live on forever.

Lives & Limbs – Musicians

It’s Friday. Let’s all put down our history books and pick up our headphones. As my series inspired by Nicole Ver Kuilen‘s visit continues, I’d like to put the spotlight on an impressive pair of musicians who continue to play the music that they love despite having suffered what many would consider to be career-ending setbacks.

The Thunder God’s Missing Arm


Rick Allen has been drumming for Def Leppard since 1978, and is widely acknowledged as being one of the best drummers in the world. His legendary skill has earned him the fan nickname “The Thunder God,” and millions still come to Def Leppard concerts to hear him play. If your only experience with Def Leppard has been listening to their music on the radio, you may have missed the fact that Allen plays his custom-made drum set with only one arm.

Back in 1984, at the height of his band’s success, Allen was thrown from his car during an accident and lost his left arm in the process. Doctors initially re-attached it, but a nasty infection caused them to re-amputate it shortly thereafter. As you might imagine, Allen was devastated. It isn’t easy to make it big as a musician, and his career looked to be over just when it had finally taken off. Fortunately for his fans, Rick’s love of drumming was too great to walk away just because he could no longer hold both sticks.

It may seem to run counter to the theme of my series, but Allen was never fit with a prosthesis for his arm. Prosthetics aren’t just for replacing limbs and filling space, after all. In order to restore maximum function, Rick had his drums modified with a series of cables and foot pedals that allowed him to play the drums on the left side of his set with his feet. Through his use of this adaptive technology, Rick’s story and example have inspired countless amputees to adapt to their new circumstances and continue doing what they love.

The Force is Strong with This One


It’s easy to forget that Luke Skywalker was an amputee. A long time ago in a galaxy far, far away, his dad severed his right arm in one of the coolest sword fights ever captured on film. Things turned out all right for him though. By the end of the film, he got a prosthetic replacement that looked and worked just like the orginal. Back in 1983, Luke’s cybernetic arm was just as much of a fantasy as lightsabers or landspeeders, but recent developments have brought it a step closer to reality.

Jason Barnes was cleaning the exhaust vents on a restaurant roof in McDonough, Georgia when he was electrocuted by over 22,000 volts of electricity that arced to him from a nearby power line. Doctors managed to save his life, but not his right arm. Jason was devastated, as he believed that his chances of getting accepted to the Atlanta Institute of Music had been lost right along with it.

His hope was restored by researchers at Georgia Tech’s College of Design, who created a replacement hand and forearm for Jason that was inspired by Luke Skywalker. Jason’s prosthesis uses a combination of electromyogram (EMG) sensors, an ultrasound probe, and machine learning that allows it to read the movements of the muscles in Barnes’ residual limb while it adapts and learns to move as a natural hand would.

Barnes’ new hand has allowed him to play the piano, and another custom prosthesis provided by Georgia Tech has also restored his ability to play the drums. He was eventually accepted to the AIM, and his career is really starting to take off. He toured with Rick Allen during the summer of 2014, and continues to hone his skills and play in various venues to this day.

Lives & Limbs – Ancient History

My series of articles inspired by Nicole Ver Kuilen‘s visit continues.

I noticed over Thanksgiving that a lot of TV channels seemed to be embracing “Throwback Thursday” by airing old but awesome episodes of their most popular shows. I’m a few days late to the party, but I thought that this would be a good opportunity to highlight a couple of fascinating figures from our distant past.

The Original “Iron Man”

Iron artificial arm, 1560-1600.

We have evidence of prosthetics being used by the ancient Egyptians, but the first documented example of a prosthesis being worn to restore function to an amputee was a metal arm worn into battle by the Roman General Marcus Sergius Silas, who lost his right arm while fighting in the Second Punic War, which took place from 218 to 201 B.C.E. We don’t know how it came about, but Sergius managed to obtain an immobile prosthetic arm made of iron, which he attached to his residual limb with leather straps. His prosthesis allowed him to wear his shield again, so he returned to active duty, where he served with valor and distinction in many battles.

He was wounded almost thirty times over the course of his career. At the time, the mortality rate for soldiers wounded once in battle was north of 80%. Sergius not only survived, but he quickly returned to the front lines each and every time. His iron limb and incredible durability made him famous, and people eventually gave him the nickname Ferrous, which is Latin for “made of iron.”

Sorry, Tony Stark. Marcus Sergius was the original Iron Man.

Sergius’ reputation for dedicated military service eventually earned him a place in public politics, where he served as a Roman Praetor. He faced a certain amount of adversity while in office because of his amputation, with several of his colleagues attempting to bar him from taking part in public ceremonies because of his perceived “deformity.” Sergius was apparently quite successful in defending himself against his detractors, which probably makes him the world’s first advocate for the rights and dignity of amputees.

The World’s First Prosthetist Was a Barber

#2 - Pare Prosthetics

If you were unfortunate enough to need surgery in Europe during the Middle Ages, you wouldn’t have gone to see a doctor. Doctors at the time considered surgery to be barbaric practice that was beneath the dignity of their profession. If you needed surgery done, your local barber had the sharpest blades and the surest hands in town and was often trained to use them for medicine as well as shaving. Ambroise Paré, a barber who served in the French military during the mid to late 1500s, is widely considered to be a founding father in the fields of surgery and prosthetic care.

Paré is particularly celebrated in prosthetics circles for his ground-breaking work in the field of amputation surgery. He popularized the use of ligatures to repair severed arteries and developed an ointment that promoted healing in wounds, both of which greatly improved the survival rate of veteran amputees. Unfortunately, Paré’s brilliant new treatment methods weren’t enough to save all of his patients. Many of the soldiers that he had worked so hard to save on the battlefield later chose to take their own lives rather than live without their amputated limbs.

Horrified and saddened, Paré decided that it wasn’t enough to simply heal an amputee’s wounds or fill the space left empty by their missing arms and legs. If he truly wanted to save lives, he needed to restore a sense of wholeness and function to his patients. With this in mind, he was the first to take a holistic approach to managing prosthetic care. He also created the first artificial leg with a working knee joint as well as the first artificial hand with articulated fingers. Many of his designs are actually still in use today.

I don’t necessarily recommend that you let your barber perform your next surgery, but I would invite you to recognize and celebrate the achievements of this one barber in particular. As a surgeon, a scientist, and a humanitarian, Ambroise Paré was a cut above the rest.