A Bigger Computer Fiasco For The Obama Administration Than Healthcare.gov

The fiasco with the initial opening of the exchanges at healthcare.gov has become a well-known IT glitch from the Obama administration, but that might not turn out to be their biggest mistake regarding computers and health care. As it primarily involves physicians and hospitals, as opposed to the general public, far fewer people are aware with the ongoing problems regarding implementation of Meaningful Use Stage 2 requirements for electronic medical records.

The original stimulus package after Barack Obama took office included a program to provide funds to medical practices to be used for conversion to electronic medical records. In order to qualify for the incentive payments, physicians and hospitals have to follow a set of Meaningful Use requirements which have increased requirements for each stage. Initially there would be incentive payments (which turned out to be far less than the costs of conversion to electronic medical records), and subsequently there are penalties for failing to comply. The first stage was successful in terms of getting large numbers of doctors to adopt electronic medical records, but it is more questionable as to whether this is really resulting in the desired cost savings.

Stage 2 was initially required by October 2014. This would have greatly increased the use of electronic medical records, possibly resulting in more medical cost savings, but the requirements were unrealistic. The law originally required that physicians comply with the requirements of Stage 2 for a 90 day period in 2014, which essentially meant that we could wait until October 1 to implement them. When it was apparent that most physicians could not comply with this, the government postponed this until January 2015.

It was quickly apparent that this was no solution, partially as the new requirements required a full twelve months of compliance with the Stage 2 rules. By requiring compliance by this January, this only gave an additional three months. The same problems which prevented compliance with the rules by October 2014 are still present this January.

The biggest obstacle is that the rules require communication between systems which do not exist in the present software. Before making such requirements, the government should have set up a secure system for communication between computer systems rather than hoping that each individual vendor would offer a solution. Another problem is that the requirements include factors which are outside of a medical office’s control. For example, a medical office could set up a patient portal as required in order for patients to assess medical information. However, there are requirements not only to establish this, but for five percent of patients to utilize it. Many physicians, such as those with primarily elderly patients are especially concerned that not enough will even be interested in using such computerized tools. Fortunately this requirement was at least reduced from ten percent in the original regulations to five percent.

Compliance with the rules is further complicated by it being all or nothing. A medical office might follow 90 percent of the rules but will get zero incentive money and pay the full penalties for non-compliance. There are some exclusions and some flexibility in some areas, but this still creates far too great a burden on physician practices.

When the government first changed the rules last fall delaying the requirements for Stage 2 until January, some members of Congress did realize that this was not long enough to have any impact. There was a bipartisan bill introduced to reduce the requirements for a 90 day period in 2015, essentially giving physicians until October instead of January. This was not introduced until shortly before Congress went on recess prior to the election, and died before the end of the last session. Earlier this month Renee Ellmers (R-N.C.) and Ron Kind (D- Wis.) introduced The Flexibility in Health IT Reporting (Flex-IT) Act of 2015 to restore the 90 day requirement. The bill also has the support of organizations including the American Academy of Family Physicians, American Hospital Association, American Medical Association, College of Healthcare Information Management Executives and Medical Group Management Association.

Even this only postpones the problem and we don’t know if the technology will be any better this fall than it is now. A recent survey of physicians found that 55 percent do not plan to attest to Stage 2, despite the financial penalties.

This failure in the implementation of computerized medical records could be a far worse fiasco than the initial roll out of the exchanges under the Affordable Care Act. The manner in which the Obama administration quickly fixed that problem turned out to be a tremendous success, and this problem is also fixable. A real fix will take more than just postponing requirements.

The government must rethink the logic behind the requirements. Most industries have computerized on their own without being forced to by the government. Some government assistance in conversion to electronic medical records would be helpful, such as establishing standards for communication between systems. Physicians must also be given flexibility to determine for ourselves which aspects of computerization are really of value for caring for our patients and which are not, rather than being forced to follow a long set of rules and only receive credit for 100 percent compliance, or being dependent on factors beyond our control.

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Will The State Of The Union Address Matter After This Week?

Obama SOTU

I certainly liked Obama’s State of the Union Address while listening to it. In a room dominated by Republicans, Obama was once again the adult in the room–the sensible one interested in governing and not bogged down in extremist ideology. His economic numbers provided real evidence of success, despite Republican obstructionism, and Obama was right in addressing the need to extend the benefits of economic recovery to more in the middle class.

The question is whether the speech, and Obama’s aggressiveness on policy matters, will make a difference matters beyond this week. David Corn summed up some of my concerns:

Barack Obama is very good at getting elected president (two for two!) and pretty darn good at policy (Obamacare; the stimulus; the auto industry rescue; Wall Street reform; ending Don’t Ask, Don’t Tell; Cuba; immigration reform executive action; dumping DOMA; middle-class tax cuts; new EPA limits on emissions that cause climate change; banning torture; downsizing the wars in Iraq and Afghanistan, and killing Osama bin Laden). But there’s one key piece of the job description where he’s fallen short: shaping the ongoing political narrative of the nation.

The president is the country’s storyteller in chief. And despite his inspiring powers of oratory (see Campaign 2008) and his savvy understanding of the importance of values in political salesmanship (see Campaign 2012), Obama, as his aides concede, has not effectively sold the nation on his own accomplishments, and, simultaneously, he has failed to establish an overarching public plot line that explains the gridlock in Washington as the result of GOP obstructionists blocking him on important issues where public opinion is in his favor. With his State of the Union speech Tuesday night, Obama had one last chance to take a swing at forging this narrative. Though he did adopt a muscular stance in presenting a forceful and vigorous vision—going on offense in the fourth quarter of his presidency, as his advisers have put it—the president let the Republicans off easy.

Throughout his presidency, as the GOP has consistently sought to block him, Obama has responded inconsistently. He often has pleaded for reason and looked to craft a deal—frequently (and justifiably) to prevent a hit to the economy. (This was the adult-in-the-room strategy.) At times, he has praised House Speaker John Boehner, while pointing to Boehner’s tea party wing as the cause of the partisan paralysis. And then he has occasionally—but not too often—flashed anger and slammed Republicans for being irresponsible and reckless (the debt ceiling scuffle, the assorted government shutdown showdowns). He has not presented a steady and stark tale in which he stars as the fighter for the middle- and lower-income Americans who are stymied repeatedly by always-say-no Republicans aligned with plutocrats, the gun lobby, corporate polluters, and other foes of progress. Consequently, he has often borne blame for the sluggish economy and the mess in Washington, with the Democratic Party paying the price for the dips in his approval rating.

For this to have meaning, Obama must stick to pushing his views, and the Democratic Party must be there behind him. The reaction of the Democratic Party has been even more inconsistent than Obama’s. Here’s what I thought during the speech:

Of course the general election is an entirely different ballgame than the midterms, and Democrats who thought there was benefit in running as Republican-lite in a midterm election where the big contests were in the red states might act more boldly. Or maybe not.

On the other hand, maybe we should just be happy that Obama had a good speech, the positive results from his policies are real, and that the speech was well accepted. Beyond that, I’m not sure that a State of the Union address ever really matters all that much.

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Obama Approval Now Rises To Reagan-Levels As Economy Improves

president-obama-in-the-white-house

An ABC News/Washington Post poll shows Obama’s approval reaching 50% on the eve of his State of the Union Address:

Obama’s overall approval rating now stands at 50 percent, the highest in a Post-ABC poll since the spring of 2013. His standing is nine points higher than in December and seven points higher than in October, just before Republicans captured control of the Senate, increased their House majority to its highest level in eight decades and recorded advances in the states.

The Post-ABC survey puts the president’s approval rating slightly higher than some other recent public polls. But most have shown improvement since the November elections as the president has moved aggressively and unilaterally on issues such as immigration and climate change.

A breakdown of the poll also shows greater support for Obama than for Republicans on the issues, which could be significant now that Obama will be facing a Republican-controlled Congress. These numbers put him well on course to exceed Ronald Reagan’s approval at this point in his presidency, which is quite an improvement after the many comparisons to George Bush’s approval ratings last year.

It is far too early to predict where his popularity will be at the time of the 2016 election. Nate Cohn, looking at his average improvement and not this specific poll, wrote on the political impact Obama’s popularity might have on the 2016 election:

There is a well-established relationship between the pace of economic growth and a president’s approval ratings, and Mr. Obama is clearly benefiting from signs of accelerating economic growth. For the first time since the start of the recession, more Americans believe the economic conditions are good or excellent than poor. Consumer confidence rose to an 11-year high last week, according to the University of Michigan consumer sentiment index…

Only a handful of modern elections have not had an incumbent president on the ballot. In these contests, the president’s approval ratings are unsurprisingly less important than when a president is running for re-election. So Mr. Obama’s approval ratings will matter in 2016, but it is hard to say exactly how much.

The balance of evidence suggests that the break-even point for the presidential party’s odds of victory is at or nearly 50 percent approval. If the only thing you knew about the 2016 election was Mr. Obama’s approval rating on Election Day, you might guess that the Democrats had a 37 percent chance of holding the White House with a 46 percent rating — rather than a 23 percent chance with a 41 percent rating. The difference between 41 and 46 might be worth between one and two percentage points to the Democratic candidate in 2016 — the difference between a close race and a modest but clear Republican victory.

Mr. Obama’s surge among Hispanic voters might be particularly telling. It is a sign that Democratic-leaning voters dissatisfied with Mr. Obama’s performance might not be so disillusioned that they can’t be lured back to the Democrats by the issues and messages that brought them to the party in the first place. The president’s ratings among liberals and Democrats remain mediocre — perhaps only in the low 70s and low 80s, respectively — suggesting that there are additional, low-hanging opportunities for Mr. Obama and his party’s next nominee.

 

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Potential Conservative Attacks On Obama If He Had Attended Paris March

I recently discussed why the right wingers attacking Obama regarding the recent rally in France are wrong as it was both impractical and noted why it would have been inappropriate for Obama to have attended. If he had gone there is no doubt he would have been attacked by the right for multiple reasons, including:

  • The cost of the trip
  • The security risks in appearing at such an event with inadequate time to prepare
  • Hogging the limelight, making the trip about him
  • The disruption his security measures would have caused in Paris if he attended
  • Ignoring the request of the French government that he not attend because of the disruption it would have caused
  • Wearing the wrong color suit
  • Having the wrong skin color (more implied than said out loud)
  • Not being in Washington at a time when there would have been a greater risk of terrorist attacks
  • Just for going to France, because conservatives usually hate France
  • For allowing his kids to remain home without parental supervision where they might listen to Beyoncé (and they would be even madder when this led to Jimmy Carter defending him)

On the other hand, if a Republican president had not attended, they would have had no complaints and would have praised him for not going to France.

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Right Wing Outrage Over Obama Missing A Photo-Op In Paris

The latest lunacy from conservatives like Ted Cruz  is to make a huge fuss about Obama not attending the Paris memorial march, while ignoring the substantive assistance he has been providing to fight terrorism.

Considering the security measures utilized whenever the president leaves the White House, it was not practical for Obama to have attended with such short notice. Even if time permitted, his presence would have been disruptive for such an event.

The French certainly are not offended:

 French President François Hollande’s office also defended Obama. A senior official told CNN’s Christiane Amanpour that the U.S. president has been “very present” since the attacks, noting that he was one of the first leaders to call Hollande last Wednesday.

The official also pointed to Obama’s visit to the French Embassy in Washington last week. “For us It was an emotional moment of solidarity,” the official said.

They actually would have preferred that Obama and Biden not attend due to the security issues, already having to contend with Benjamin Netanyahu attending when asked not to.

Obama essentially missed a photo op–not a true case of world leaders leading a March, as pictures from the march have demonstrated:

Many on the right repeated their automatic opposition to anything Obama does. We know that if he had gone, the same conservatives would have been the first to attack Obama for grabbing the limelight, the cost of the trip, and disrupting the march with his security measures. We also know that if it had been a Republican president who did not attend they would have had no complaints.

Ron Fournier, not a common defender of Obama, had several points on this faux controversy:

His critics seem to forget a few things.

1. The United States has some 66,000 military personnel deployed in Europe. More than 6,800 U.S. service members have died in post-9/11 operations in Iraq and Afghanistan. Hundreds of billions of dollars from the U.S. treasury finance intelligence and military operations across the globe, making the United States the most stalwart enemy of terrorists.

2. The president of the United States doesn’t need to march in the streets of Paris to prove his nation’s commitment.

3. Somebody should find out how many federal agents, spies, and intelligence assets the United States has dispatched to Europe since the Charlie Hebdo attacks. Does anybody think the Obama administration hasn’t flooded the zone?

4. Obama’s presence at the rally would have been disruptive. The apparatus that follows the U.S. president is isolating and suppressive – a direct counter to the vibe that organizers achieved in the streets of Paris.

5. Obama and his national security team are rightly worried about the next 9/11. Only hard work and good luck have kept the wolves at bay this long. An attack like the ones in Paris last week keeps U.S. national security personnel awake at night because among their greatest fears are so-called lone wolf attacks on soft targets in the United States. There could have been a copycat.

Here’s my thought process: Had there been an attack on U.S. soil while Obama marched in Paris, I would have wondered whether the president and his team had taken their eyes off the ball. Wouldn’t that be the natural reaction? The conservative Outrage Machine would have demanded impeachment proceedings.

Personally, I’ve got no problem with the U.S. ambassador representing my country in Paris. If it was my call to make, I would have put Biden on a plane.

But did Obama let the world down? Take a breath. After all this country has done for Europe in the last century, let’s not confuse a mistake with something more meaningful.

He wrote this earlier in the day before all the information was in, and the same security issues related to Obama would probably also apply to Biden. Whether it was still a mistake not to send Biden is far more debatable with more facts now in, but regardless Fournier is correct that, even if it was a mistake, it is “no disgrace” and hardly anything meaningful.

Update: Dana Milbanks wrote about the hypocrisy of the Republican attacks. He also pointed out that sending Obama with this little lead time was “never a possibility, for security and logistical reasons.” As most reasonable people (meaning non-Republicans) would, he characterizes the failure to send anyone else of higher rank than the ambassador a faux pas. He also states that, “Officials I spoke to said it was a simple screw-up: They didn’t understand how significant the event would be, with leaders of some 40 countries in attendance.” There was no strategic importance to Obama being there and there was no insult to the French (which until this week would hardly be of concern to conservatives).

The White House admits it was wrong, but again the error was one of public relations, not of anything of real significance or to justify the current attacks from the right, which are more about their usual pattern of attacking anything done by Obama.

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Red State Republicans Are A Minority Of Population Despite Senate Gains

Congress

The Senate is probably the strongest example of how our political system is (small-d) non-democratic. Each state receives two Senators, regardless of size, and the District of Columbia, with a population greater than several states, receives zero. The difference in size between the smallest and largest states has also increased significantly since this compromise was reached in the writing of the Constitution. A combination of factors including Senate races primarily in red states, the usual problems faced by either party in the sixth year of a presidency (with Republicans even losing control of the Senate under Ronald Reagan), and several tactical errors by Democratic candidates, led to the Republicans taking control. However, Vox has an interesting calculation:

But here’s a crazy fact: those 46 Democrats got more votes than the 54 Republicans across the 2010, 2012, and 2014 elections. According to Nathan Nicholson, a researcher at the voting reform advocacy group FairVote, “the 46 Democratic caucus members in the 114th Congress received a total of 67.8 million votes in winning their seats, while the 54 Republican caucus members received 47.1 million votes.”

Republicans also receive an advantage in the House due to a combination of gerrymandering and the fact that Democratic votes are more concentrated in cities, leading to Democrats winning a smaller number of districts by higher margins, and in some years allowing Republicans to control the House with a minority of the vote.

Republicans will be forced to defend more seats in blue states in 2016 but the magnitude of the Republican pick up in 2014 will make it much harder for Democrats to actually regain control. The Atlantic looked at key election races, pointing out:

Democrats will be benefiting from a favorable landscape, with Republicans defending 24 seats (many of them in blue territory) while Democrats will be defending only 10. To leverage that advantage into control of the Senate, however, Democrats need to net at least four seats (five, if Republicans win the presidency). That requires sweeping out blue-state freshman Republicans in states such as Illinois, Pennsylvania, and Wisconsin while also defeating a couple of brand-name senators, such as Rob Portman or Marco Rubio, in perennial swing states.

Other factors could help Democrats in 2016 beyond the geography. The economy will hopefully be even stronger, unless the Republican-controlled Congress, or even factors beyond political control, create further problems. The Affordable Care Act will be even more established, assuming Republicans aren’t successful in dismantling it in Congress or the courts, and might be less of a divisive political issue. Perhaps most importantly, the Democrats will be running a more national campaign behind a presidential candidate as opposed to running as Republican-lite and hiding from Obama.

The Los Angeles Times reports, Obama to hit the road, selling economic progress:

Eager to stay on the offensive as new Republican majorities are seated in Congress, the president plans to take a more bullish economic message on the road next week in something of an early test drive of his State of the Union message.

During stops in Michigan, Arizona and Tennessee, Obama plans to draw a connection between actions his administration took early in his presidency and increasingly positive economic trends in sectors such as manufacturing and housing.

Officials say he’ll also offer specific new proposals — some that he’ll pursue with Congress and others he’ll advance with his own authority — that are intended to build on that progress, particularly for the middle class.

It’s an approach that upends the traditional White House script to start the year, when new policy rollouts are usually reserved for the president’s annual address to Congress.

But the White House is eager to sustain momentum  it says started to build after November with major actions on immigration and Cuba as Obama began what he calls the “fourth quarter” of his presidency.

Obama, and other Democrats, should have been made the successes of Democratic policies the major point of the campaign, as opposed to running away from their successes. They might have still lost in deep red states, but Democratic turnout would have been better and they would have done better in less red areas. Besides the benefits of running on Obama’s previous record, as a result of Obama’s post-election actions his approval has shot up in the Gallup and other polls.

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Republican State Governments Expected To Renew The Culture Wars And Promote Conservative Pseudo-Science On Abortion

Democrats made a tremendous tactical mistake in the 2014 midterms. As the key Senate battles were in red states, Democrats ran as Republican-lite and Obama stayed quiet. As a consequence, turn out was at historic lows as Democratic voters saw no reason to turn out across the country, giving Republicans increased control in both Congress nationally along with in many state governments. (In contrast, once Obama became active after the election, his support shot up in the Gallup poll and multiple other polls).

While many Republicans ran with little talk of their positions on social issues, knowing that doing so might get many more people to turn out to vote against their unpopular views, The Washington Post points out that they plan to pursue conservative goals on social issues now that they are in office:

Renewal of culture wars

A new round of the culture wars is also inevitable in 2015. Mallory Quigley, a spokeswoman for the antiabortion Susan B. Anthony List, said she expects that measures to ban abortions after 20 weeks of pregnancy will advance in Wisconsin, South Carolina and West Virginia. Missouri, too, is likely to take up some abortion-related bills.

In Tennessee, voters gave the legislature new powers to regulate abortion, and state House Speaker Beth Harwell (R) has said her chamber will take up three measures requiring mandatory counseling, a waiting period and stricter inspections of clinics.

Conservative efforts to ban abortions after 20 weeks are based on ignoring science, just as many conservatives do in denying evolution and climate change. Conservatives make pseudo-scientific claims that the fetus can feel pain at this point, despite the cerebral cortex not being developed until well after this point. There is no real controversy over this point in medicine. Conservatives sometimes twist studies showing simple reflexes as indicating that the fetus is feeling pain. Often they misquote researchers to falsely claim their is a scientific basis for their bogus claims. More on this faux controversy over the science here and here.

The 20 week ban is especially harmful to the rights of women as fetal abnormalities are often not discovered until after this point. It is understandable that a woman who discovers after 20 weeks that she is carrying a fetus which has severe brain abnormalities which would prevent survival might want to abort, but Republicans would deny them this choice by setting an arbitrary limit before such abnormalities are apparent. It is also feared that once they set the line at 20 weeks they will use more pseudo-science to justify moving it up.

Conservatives have also practiced pseudo-science in trying to make the abortion debate over the moment when life begins, when development of the human embryo and fetus is a continuum. Conception is a process without an exact moment at which it occurs, and even fertilization can take twenty-four hours.

If conservatives are really concerned about preventing fetal pain their policies are counterproductive. Late term abortions are very rare in this country, primarily done when the mother’s health is in danger. Another common reason for abortions being delayed until after 20 weeks is the inability of the mother to obtain the abortion earlier, often due to roadblocks placed by Republicans making abortions more difficult to obtain. Of course Republican opposition to contraception further increases the number of abortions. If conservatives were consistent in desiring to prevent fetal pain, they should facilitate the ability of women to obtain both contraception and to obtain early abortions even beyond twenty weeks and before the actual ability to feel pain is present.

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Fox Twitter Hashtag Backfires

On Tuesday Fox & Friends asked Twitter users to post things they were over with the hashtag #OverIt2014. They started with Fake Journalist Barbie tweeting, “I’m over attacks against Christianity.” This worked out about how you might expect.  Gawker reported some of the snarky responses, and far more are now up:

You get the idea. The responses are continuing to come in at a rapid rate.

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Obama Approval Reaches 48%

Obama Affordable Care Act

Gallup reports that President Obama’s job approval has increased to 48 percent, the highest since August, 2013. This matches his disapproval rate, being the first time this gap has not been negative since September, 2013. They don’t give firm data to explain this improvement, but note that this partially can be explained by an improvement among Hispanics. They further speculate that the increase might be due to improved views on the economy, as well as people being more generous in their ratings around Christmas.

I wonder if other factors are involved, including his recent successes on foreign policy, the disappearance of the Ebola crisis in the United States which Republicans spread considerable misinformation about prior to the midterm elections, and the success of the Affordable Care Act.

As a sign of how desperate conservatives are to deny the considerable success of Obamacare in both expanding insurance coverage and making it more affordable, they are going further in cherry picking and distorting statements from Jonathan Gruber going back to 2009, with many conservative sites falsely calling him both the architect of Obamacare and its leading spokesman. Strangely, they don’t pay any attention to the far greater statements from him on the benefits of the Affordable Care Act. The Tea Party New Network, which is essentially a dishonest propaganda outlet like Fox but more honest about its political position, even defends Sarah Palin for her rants about death panels, and repeats all the other claims greatly distorted by conservatives. Their complaints about Obama’s poorly worded statements about keeping one’s own doctor or insurance are hardly meaningful considering that their policies would greatly increase the likelihood that people would lose their doctor and insurance, while Obamacare (even if unable to guarantee this will never happen in a market-based system) greatly reduces this risk.

Obama’s improvement in the polls could be a consequence of him becoming more aggressive after the midterm elections, no longer being fearful of taking actions which might place Democratic candidates at risk in red states (a foolish plan which backfired when it led to Democrats staying home). I believe that the Democrats would have still lost seats because of the seats which were up for grabs in 2014, but would have done better if they hadn’t run as Republican-lite. On the other hand,  Dan Pfeiffer told Huffington Post that he believes that if Obama had not waited until after the election, his actions would have been overwhelmed by politics.

The big question is whether this is a transient bounce or if this improvement will continue. Either way his approval is certainly far greater than for Congress. The Republican Congress might give Obama an opportunity to gain further public support if the Republicans actually proceed to pass legislation pushing many elements of their agenda which will be unpopular with a majority of American voters.

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End Of Temporary Increase In Medicaid Payments May Impact Treatment In 2015

The Affordable Care Act has been a tremendous benefit to those who purchase insurance on the individual market, but success has been mixed for the working poor who receive coverage from an expansion of Medicaid as opposed to obtaining private plans. While reimbursement varies by state, it is significantly lower than what Medicare and private insurance plans pay, and often insufficient to meet overhead expenses of private physicians. Many people who might benefit from the expanded Medicaid plan were denied coverage in Republican-controlled states which refused to allow the program, despite the vast majority of the costs being paid by the federal government, following a Supreme Court decision allowing them to opt out of the program. There are also concerns as to whether those covered by Medicaid will be able to obtain sufficient coverage.

In order to increase the number of physicians who accept Medicaid patients, the Affordable Care Act provided for an increase in payment to Medicare levels for primary care services for two years. As The New York Times reports, this period ends at the end of 2014, raising questions as to whether as many private physicians will continue to see Medicaid patients. President Obama has recommended an extension of this increased pay but it is unlikely to be approved by a Republican Congress which is more likely to continue to talk about repealing Obamacare as opposed to work to improve upon it.

It is difficult to predict exactly what the impact of the end of the increased Medicaid payment will be. The article does quote one physician of complaining that this was a “bait and switch” tactic. In reality, the federal government was quite open about the two year time frame for the plan, but it is possible that not all physicians paid adequate attention to information available. Private physicians have historically limited the number of Medicaid patients they accept due to the poor reimbursement, among other problems with Medicaid programs, and I doubt that many have taken a significantly larger number in the past two years in response to a temporary plan.

Much of the Medicaid population is treated by clinics and hospital facilities which are paid different from private physicians, with  Medicaid reimbursement representing an improvement over providing free care as in the past. Contrary to claims frequently made at conservative sites, expanding Medicaid does provide significant benefits for many people, but this will not be an ideal situation as long as Medicaid reimbursement is often less than overhead costs for private physicians. Most likely Medicaid patients will continue to be treated by a combination of clinics and by private doctors who take limited numbers of Medicaid patients.

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