Kaci Hickox Is A Hero–Now On Two Counts

Kaci Hickox is a hero. First for volunteering to help treat Ebola patients, as eradicating Ebola in West Africa is the only way to handle this disease. She became a hero again for standing up to unjust restrictions upon her civil liberties upon returning home and supporting the concept of making political decisions based upon science and reason as opposed to giving in to public hysteria.

It was Hickox’s protests which forced Governors Christie and Cuomo to back away from guidelines policies which were both unnecessary and counterproductive. Some state governments are still going beyond the extremely cautious CDC guidelines with policies such as home quarantine of individuals who show no sign of the disease for twenty-one days. We know that this is unnecessary based both upon our knowledge of how the Ebola virus is transmitted and based upon our experience to date.  Ebola is not contagious early in the disease and is not transmitted by casual contact. While highly contagious when people are having symptoms such as projectile vomiting and uncontrolled diarrhea, those who do not have symptoms are not contagious. People with Ebola do not yet pose a danger of spreading the disease when they initially reach the CDC’s threshold of a fever of 101.4 degrees, and they certainly are not contagious before reaching this point.

We have seen one patient in Texas be released in error by an Emergency Room and return to the community. We have seen a nurse later revealed to be infected with Ebola fly with a low grade fever. We have had a doctor traveling around a city as densely populated as New York City just prior to meeting criteria for isolation. Not a single person has contracted Ebola due to contact with these individuals. That is the nature of the disease.

Kaci Hickox, well aware of the science, has stated she plans to fight the involuntary home quarantine being imposed:

“I will go to court to attain my freedom,” Hickox told “Good Morning America” today via Skype from her hometown of Fort Kent, Maine. “I have been completely asymptomatic since I’ve been here. I feel absolutely great.”

One of her attorney’s explained her legal position:

New York civil rights lawyer Norman Siegel, said she would contest any potential court order requiring her quarantine at home.

“The conditions that the state of Maine is now requiring Kaci to comply with are unconstitutional and illegal and there is no justification for the state of Maine to infringe on her liberty,” he said.

Hickox will abide by daily monitoring, as recommended the by updated guidelines released Monday by the federal Centers for Disease Control and Prevention, Hyman said. She has been in regular contact with state health officials, Siegel said.

U.S. CDC Director Tom Frieden called for isolation of people at the highest risk for Ebola infection but said most medical workers returning from the three African nations at the center of the epidemic — Sierra Leone, Liberia and Guinea — would require daily monitoring without isolation.

The new guidelines recommend considering isolation only for individuals exposed to Ebola who show symptoms. Those with no signs of illness should be monitored for 21 days after the last potential exposure, with symptom-free individuals at the highest risk subject to “restricted movement within the community” and no travel on public transportation, according to the guidelines…

“She understands the nature of the disease, she treated it,” Hyman said. “She understands the nature of the risk.”

The American Civil Liberties Union has posted an article on the over-reaction to Ebola coming from some politicians, in contrast to the more rational guidelines proposed by the Center for Disease Control and the Obama administration:

One over-reaction to the disease that has emerged is a proposal for a blanket travel ban from the affected countries in West Africa. Public health experts say that such bans are not necessary, would not be effective, and would be a poor use of resources. Worse still, experts say they would most likely make matters worse by further isolating the countries where the outbreak is taking place, worsening the situation in those countries and therefore the threat to the United States. Travel bans “hinder relief and response efforts risking further international spread,” as the World Health Organization warned. Experts say such bans would also inevitably drive travelers underground, making it difficult to retrace the path of a disease when a case does appear.

Proposals to close the border to all travelers from affected nations are not a scientifically and medically legitimate exercise of government power and therefore would be arbitrary and discriminatory whether applied to citizens or non-citizens.

Now, of course, we are also seeing the questionable use of quarantine powers in some states. Medical experts have opposed such steps given that Ebola is not transmissible until after a fever begins and is not a highly transmissible disease generally, and given that individuals have strong incentives to carefully monitor themselves. Doctors Without Borders, for example, has condemned these quarantines as a threat to its battle against the disease in Africa. It cites the effect the quarantines will have in deterring doctors and nurses from taking the already remarkably brave step of entering the fight against the disease—and in stigmatizing them when they do. In short such quarantines threaten to weaken the most effective weapon we have in stopping the disease at its source. (It’s also shameful to treat returning health care workers, who have put their own lives at risk to help others, as anything less than heroes.)

Where individuals cooperate with the authorities in allowing close monitoring of their health and other reasonable precautions, the imposition of quarantines on those without symptoms appears to be driven by politics rather than science, and therefore raises serious civil liberties concerns.

While some political leaders have acted out of fear, Obama Administration officials deserve praise for largely sticking to science and not caving in to some of the fear mongering that is swirling around them. The White House has prioritized medicine over politics. It has resisted calls for travel bans, tried to persuade the governors of New Jersey and New York to reconsider their quarantines, and has largely followed the advice of public health experts in the recommendations that they have made. The Administration has also taken helpful steps such as expediting emergency FDA authorization for the use of new machines for rapid detection of the Ebola virus—which could allow detection of the disease before symptoms appear.

In fact, the Obama Administration has a history of good policy on communicable diseases. As we described in a 2009 white paper on that year’s H1N1 flu scare, the Administration acted calmly and appropriately in response to that epidemic, and overall, President Obama has turned away from his predecessor’s military/law enforcement approach to fighting disease, which we criticized in detail in our 2008 report on pandemic preparedness.

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Arguing Against Counterproductive Hysteria Over Ebola

While the outbreak of Ebola began in West Africa about ten months ago, we have now had only nine patients with Ebola in this country. Most were brought in for treatment after contracting it elsewhere. One is currently undergoing treatment. One died. All the rest have recovered. There have been zero cases of transmission in the general population but two nurses have become infected while treating the patient who died.

There is a remarkable amount of hysteria in this country for a disease which has had so little actual impact. Some of this is natural fear, seeing how less developed nations have been affected, and some is due to hysteria being generated by Republican politicians for political gain. Unfortunately the proposals made by Republicans would be counterproductive, making it harder to treat Ebola at its source. Eliminating Ebola in West Africa is the only way to eliminate the problem and prevent further spread.

This is also turning out to be a learning experience, at least for those who respect science and are willing to consider the facts. In terms of treatment, hospitals around the country have learned from the mistakes made in Texas, and these are not likley to be repeated.

In terms of the political reaction, there are many sources which are trying to counter the over-reaction with reason. As we have seen on so many issues, some will pay attention to the facts, and others won’t.

The New England Journal of Medicine has released their editorial for next week’s issue, which includes a repetition of how Ebola is transmitted and the dangers of over-reaction:

The governors of a number of states, including New York and New Jersey, recently imposed 21-day quarantines on health care workers returning to the United States from regions of the world where they may have cared for patients with Ebola virus disease. We understand their motivation for this policy — to protect the citizens of their states from contracting this often-fatal illness. This approach, however, is not scientifically based, is unfair and unwise, and will impede essential efforts to stop these awful outbreaks of Ebola disease at their source, which is the only satisfactory goal. The governors’ action is like driving a carpet tack with a sledgehammer: it gets the job done but overall is more destructive than beneficial.

Health care professionals treating patients with this illness have learned that transmission arises from contact with bodily fluids of a person who is symptomatic — that is, has a fever, vomiting, diarrhea, and malaise. We have very strong reason to believe that transmission occurs when the viral load in bodily fluids is high, on the order of millions of virions per microliter. This recognition has led to the dictum that an asymptomatic person is not contagious; field experience in West Africa has shown that conclusion to be valid. Therefore, an asymptomatic health care worker returning from treating patients with Ebola, even if he or she were infected, would not be contagious. Furthermore, we now know that fever precedes the contagious stage, allowing workers who are unknowingly infected to identify themselves before they become a threat to their community. This understanding is based on more than clinical observation: the sensitive blood polymerase-chain-reaction (PCR) test for Ebola is often negative on the day when fever or other symptoms begin and only becomes reliably positive 2 to 3 days after symptom onset. This point is supported by the fact that of the nurses caring for Thomas Eric Duncan, the man who died from Ebola virus disease in Texas in October, only those who cared for him at the end of his life, when the number of virions he was shedding was likely to be very high, became infected. Notably, Duncan’s family members who were living in the same household for days as he was at the start of his illness did not become infected…

The American College of Physicians has made the same argument:

The American College of Physicians is strongly concerned about the approach being taken by some state health departments to impose strict, mandatory quarantines for all physicians, nurses, and other health professionals returning from West Africa, regardless of whether they are showing symptoms of Ebola virus infection. ACP agrees that physicians and other health professionals must take the necessary precautions to ensure the safety of others and prevent the spread of infection. However, the College maintains that mandatory quarantines for asymptomatic physicians, nurses and other clinicians, who have been involved in the treatment of Ebola patients, whether in the United States or abroad, are not supported by accepted evidence on the most effective means to control spread of this infectious disease. Instead, such mandatory quarantines may do more harm than good by creating additional barriers to effective treatment of patients with Ebola and impede global efforts to contain and ultimately prevent further spread of the disease…

Some newspapers, such as The New York Times, have repeated these arguments for a larger audience:

The Dangers of Quarantines

Ebola Policies Made in Panic Cause More Damage

… two ambitious governors — Chris Christie of New Jersey and Andrew Cuomo of New York — fed panic by imposing a new policy of mandatory quarantines for all health care workers returning from the Ebola-stricken countries of West Africa through John F. Kennedy and Newark Liberty international airports. There is absolutely no public health justification for mandatory quarantines…

Lost in this grandstanding was one essential point. The danger to the public in New York in the case of Dr. Craig Spencer, who had worked in Guinea for Doctors Without Borders, was close to nonexistent. Health experts are virtually unanimous in declaring that people infected with the virus do not become contagious until after they develop a fever or other symptoms, such as diarrhea, vomiting, or severe headaches, at which time they need to be hospitalized and taken out of circulation.

Health care workers like Dr. Spencer know that it is in their interest to ensure that — if symptoms do arise — they get care quickly to improve their chances of survival and to reduce the risk of infecting their friends and families. Dr. Spencer reported his temperature promptly when it was a low-grade fever of a 100.3 degrees and was rushed to Bellevue Hospital Center for isolation and treatment while his fiancée and two friends were put into voluntary isolation…

The problem with a mandatory quarantine, even if done at home, is that it can discourage heath care workers from volunteering to fight the virus at its source in West Africa. Doctors Without Borders, the nongovernmental organization that has led the battle there, typically sends its workers on arduous four- to six-week assignments. The risk of being quarantined for another 21 days upon return has already prompted some people to reduce their length of time in the field and may discourage others from volunteering in the first place…

Fortunately the response has been more rational at the federal than state level, including the statement from Barack Obama earlier today, pointing out that “If we don’t have robust international response in West Africa, then we are actually endangering ourselves here back home.”

President Obama pledged support for health care and aid workers in West Africa Tuesday, saying new rules for monitoring them for Ebola once they return to the United States would be “sensible and based on science.”

Obama gave brief remarks on the federal response to the disease after speaking with U.S. aid workers on the front lines of battling Ebola in West Africa.

“They’re doing God’s work over there, and they’re doing that to keep us safe, and I want to make sure that every policy we put in place is supportive of their efforts. Because if they are successful, then we’re not going to have to worry about Ebola here at home.”

Besides being counterproductive, there are civil liberties concerns when the government forcibly quarantines people who do not have the disease or who are not contagious.

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Juan Williams Debunks GOP Attempts To Blame Democrats For Lack Of A Surgeon General

While discussing the Republican hypocrisy in their response to an Ebola Czar earlier this month, I pointed out how the Republicans blocked  Barack Obama’s nominee for Surgeon General due to his concerns about gun violence, which kills far, far more people than Ebola in this country. Republicans who 1) are rarely willing to take responsibility for their action,  and 2) are fond of projecting their faults upon others, have been trying to shift the blame and falsely claim that the Democrats are responsible for blocking the nomination. Juan Williams of Fox News has called them out on this in a column at The Hill (also a Republican-leaning site even as not as overtly Republican as Fox). Williams also debunked the Republican claims that Harry Reid has not been fair due to not allowing them to add their “poison pill” amendments to bills, which would cause even greater gridlock. Williams wrote:

Republicans on the campaign trail tell voters that the Senate gets nothing done because Senate Majority Leader Harry Reid (D- Nev.) blocks votes on GOP legislation.

Away from the Halloween funhouse mirror, the reality is this: Reid is willing to hold votes — but not with an endless open amendment process that merely creates a stage for Republican political theater. “Poison pill” amendments on partial birth abortions and gay marriage would sprout everywhere.

The real problem is that Senate Republicans can’t agree on which amendments to attach to bills because of the Tea Party versus Establishment war raging among them.

Yet I’ve personally seen voters nodding in agreement at Senate debates and campaign events as Republicans put the fright-night mask on Reid as the evil ogre responsible for dysfunction in the Senate.

The GOP is having success by repeating this distorted version of political life on Capitol Hill. Their tactic on that score is consistent with an overall strategy that includes blocking President Obama’s nominees to courts, federal agencies and ambassadorial posts while condemning any mistakes made by the administration.

According to the Senate’s website, there are currently 156 nominations pending on the executive calendar.

With all of the fear-mongering by Republican candidates over the administration’s response to Ebola — part of a broader approach to scare voters by undermining faith in government, the president and all Democrats — there is one screaming nomination still pending that reveals the corruption of the GOP strategy.

The nation has not had a surgeon general since November 2013 because the GOP is blocking the president’s nominee, Dr. Vivek Murthy. At a time of medical emergency, what is the Republicans’ problem with Murthy?

In October 2012, the doctor tweeted: “Tired of politicians playing politics w/guns, putting lives at risk b/c they’re scared of the NRA. Guns are a health care issue.”

Dr. Murthy, a graduate of Harvard and the Yale School of Medicine, has impressive credentials for a 36-year-old. He created a breakthrough new company to lower the cost of drugs and bring new drugs to market more quickly.

But his big sin, for Senate Republicans, is that as a veteran of emergency rooms Dr. Murthy expressed his concern about the nation’s indisputable plague of gun violence.

When Dr. Murthy was nominated, the National Rife Association announced plans to “score” a vote on the doctor’s nomination, meaning any Republican or Democrat running in a conservative state who voted for Murthy would be punished in NRA literature and feel the pain in their fundraising come midterm election season.

When public anxiety over Ebola became a GOP talking point, 29 House Democrats wrote to Reid calling for the Senate to expose the Republicans for their deceitful strategy. They wanted, and still want, Senate Democrats to push for a vote on the surgeon general nominee and force the Republicans to explain their opposition. Their thinking is that swift action is needed to put a surgeon general in place and give the American people a trusted source of guidance on Ebola.

The Tea Party’s favorite senator, Republican Ted Cruz of Texas, last week agreed on the need for a surgeon general in a CNN interview. But in the funhouse mirror-style so loved by the Republican base, Cruz blamed Obama for the vacancy.

“Of course we should have a surgeon general in place,” Cruz told CNN’s Candy Crowley. “And we don’t have one because President Obama, instead of nominating a health professional, he nominated someone who is an anti-gun activist.”

Sen. Roy Blunt (R-Mo.) was also put on the spot recently over the GOP’s refusal to deal with the surgeon general vacancy.  As he railed against the president for perceived errors in handling the situation, NBC’s Chuck Todd interrupted to ask: “The NRA said they were going to score the vote and suddenly everybody froze him… Seems a little petty in hindsight, doesn’t it?”

“Well, the president really ought to nominate people that can be confirmed to these jobs, and frankly then we should confirm them, there’s no question about that,” said the senator, trying to find his footing as he backpedaled.

The fact remains that Senate Republicans, in lockstep with the NRA, have left a worthy nominee dangling while this vital post remains vacant.

This kind of game playing is what led Senate Democrats to consider using the so-called “nuclear option.” In its original form, it would have changed the Senate rules to require a simple majority for all confirmations, instead of the current 60-vote supermajority. But the Democrats decided to go with a more modest change that allowed a simple majority vote to confirm only federal judicial nominees, not presidential picks for the Supreme Court, the cabinet or the position of surgeon general.

Reid, speaking on the Senate floor this summer, said that despite the rules change “Republicans are still continuing to try and slow everything down…It is just that they want to do everything they can to slow down [Obama’s] administration, to make him look bad…even though they’re the cause of the obstruction… Everyone will look at us and say, Democrats control the Senate — why aren’t they doing more?”

As a matter of brazen politics, the Republican strategy of obstruction has worked.

What a shame.

I have seen contradictory interpretations regarding the filibuster rules as to whether the Surgeon General can be confirmed with 51 votes or if the post still requires a super-majority. It is academic in this case. Republican Senators have placed a hold on this nomination and if it goes to a vote are likely to vote unanimously against it. The NRA has indicated that they will include a vote on Murthy in their ratings, which makes it difficult for some Democratic Senators in red states who are up for reelection. Between these Democrats and the uniform Republican opposition there are probably not 51 votes for confirmation, although this could change after the election.

Despite the Republican actions to block the Surgeon General nomination, it is questionable as to how much of a difference it would have made. We don’t know how much Murthy would have said on the topic, and if he could have gotten a discussion of the science through, considering all the fear and misinformation being spread about Ebola by Republicans.

Despite all the panic, we have seen how small a threat Ebola actually is in a developed nation such as the United States. Ebola is a problem of developing nations which lack an adequate Public Health infrastructure. While the outbreak began in West Africa last December, we have had a tiny number of people who are infected enter this country, and the potential harm has been easily contained. Even in Texas, which does share some of the problems of a third world nation due to Republican rule, multiple mistakes were made with minimal harm. A patient was sent home despite meeting criteria for hospitalization, and yet he did not spread the infection to anyone else in the community. This is because Ebola is not contagious early in the disease before someone is symptomatic, and even then it does not spread by casual contact.

Maybe if there was a Surgeon General speaking about Ebola, the Emergency Room staff at Texas Presbyterian Hospital would have been better acquainted with the guidelines and hospitalized Thomas Duncan when he first presented. Maybe the hospital would have done a better job at following protocols to protect the staff. While possible, it is far from certain that having a Surgeon General would have made any difference.

Perhaps if there was a Surgeon General discussing the science there would have been less panic when Dr. Craig Spencer was found to have traveled on the subway and visit a bowling alley, where he did not spread Ebola. (Similarly the nurse from Texas Presbyterian who flew with a low grade fever has not spread the disease despite turning out to be infected). This might have prevented the poor, and unscientific decisions made by the governors in states such as New Jersey and New York. While I can see Chris Christie make such a mistake, I would  hope for better from Andrew Cuomo, even if he is faced with a Republican using fear tactics against him in his reelection campaign. This might have spared Kaci Hickox from being quarantined in an unheated tent in New Jersey despite showing no signs of being infected. Inhibiting health professionals from volunteering can only harm the cause of eradicating Ebola in West Africa–which is the only way of ending this matter.

It is impossible to know if a Surgeon General could have been effective in reducing the hysteria. Republicans are masters at spreading fear, and never have any qualms about ignoring science. It is very possible they could have still won out. We already have many Infectious Disease experts explaining the facts about Ebola, but that hasn’t been enough to maintain reason. While a Surgeon General might have had a little bigger soap box to speak from, I don’t know if that would have really mattered.

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Not Hearing Anything Lately From Republicans About Their Frivolous Suit Against Obama

Remember a few months ago when John Bohner was talking about filing a ridiculous law suit against Barack Obama? Politico points out that, despite the Republican hype, we haven’t heard anything about this suit recently:

House Speaker John Boehner came out swinging hard last June when he announced that his chamber would take President Barack Obama to court. The suit, charging that the president grossly exceeded his constitutional authority by failing to implement portions of the Obamacare law, was billed as an election-season rallying point for aggrieved Republicans. But days before the midterms the House’s legal guns seem to have fallen silent.

Lawyers close to the process said they originally expected the legal challenge to be filed in September but now they don’t expect any action before the elections.

Some attribute the delay to electoral politics — suggesting that Republicans were worried it could rile up the Democratic base — though the GOP is mum on why the suit has yet to be filed.

Whatever the reason, the delay means the core of the suit could effectively be moot before the Obama administration even has to respond to it in court. The case was expected to center on an employer mandate provision that Obama twice delayed but is now set to kick in for many employers on Jan. 1.

Bloomberg says the suit might be more trouble than it is worth for the Republicans:

Part of the problem may lie in the troubled history of the suit. In mid-September, the GOP’s law firm dropped the case over “political pressure,” according to a Republican aide speaking to Politico. That same week, the Seventh Circuit Court of Appeals tossed out a lawsuit similar to the House’s from the Association of American Physicians and Surgeons.

Politically, the lawsuit presents catch-22s for the GOP. First, the party has to choose between upsetting conservatives (some of whom support impeachment) by not suing the president or bewildering the rest of the country by suing the president.

A July CNN/ORC poll found that 65 percent of Americans don’t think the president should be impeached, 57 percent don’t support the lawsuit, and less than half of respondents thought Obama has gone too far with his executive orders. Fifty-six percent of conservatives were in favor of the impeachment, compared to 26 percent of moderates.

The lawsuit was a compromise, but appeasement didn’t really work. The pro-impeachment conservative wing of the party has been given voice by Sarah Palin, who told Breitbart News that “you don’t bring a lawsuit to a gunfight.”

Second, if Boehner had gone through with suing the president before the midterm elections, it might have help Democrats fundraise and motivate the liberal base even more than it already had. The Democratic Congressional Campaign Committee made $7.6 million in the month after the suit was announced, including $2.1 million in one weekend off emails warning of impeachment.

Plus Republicans might be embarrassed if small businessmen realize that the Republican Party is pursuing a lawsuit which seeks to punish Obama for trying to make conversion to the Affordable Care Act easier for small business, as many small business owners had requested. This hardly sounds like where the Republicans should draw the line in the sand against what they claim is tyranny from the Obama administration. Of course they had to settle for this suit as they couldn’t find anything of substance with which to pursue this absurd claim.

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Bruce Bartlett Argues That Obama Is A Republican

Obama is a Republican

There’s nothing really new here, but it will be interesting to see conservative response to Bruce Bartlett’s article in The American Conservative entitled, Obama Is A Republican. The article is a rehash of how Obama’s record is actually quite conservative, clashing with the conservative myth that he is a socialist. He started with mentioning other Republicans who supported Obama’s election, and next discussed foreign policy:

One of Obama’s first decisions after the election was to keep national-security policy essentially on automatic pilot from the Bush administration. He signaled this by announcing on November 25, 2008, that he planned to keep Robert M. Gates on as secretary of defense. Arguably, Gates had more to do with determining Republican policy on foreign and defense policy between the two Bush presidents than any other individual, serving successively as deputy national security adviser in the White House, director of Central Intelligence, and secretary of defense.

Another early indication of Obama’s hawkishness was naming his rival for the Democratic nomination, Sen. Hillary Clinton, as secretary of state. During the campaign, Clinton ran well to his right on foreign policy, so much so that she earned the grudging endorsement of prominent neoconservatives such as Bill Kristol and David Brooks.

After further discission of foreign policy, he went on to discuss economic policy and the deficit. The most important point is how the deficit has fallen under Obama and how fiscally conservative Obama has been:

With the economy collapsing, the first major issue confronting Obama in 2009 was some sort of economic stimulus. Christina Romer, chair of the Council of Economic Advisers, whose academic work at the University of California, Berkeley, frequently focused on the Great Depression, estimated that the stimulus needed to be in the range of $1.8 trillion, according to Noam Scheiber’s book The Escape Artists.

The American Recovery and Reinvestment Act was enacted in February 2009 with a gross cost of $816 billion. Although this legislation was passed without a single Republican vote, it is foolish to assume that the election of McCain would have resulted in savings of $816 billion. There is no doubt that he would have put forward a stimulus plan of roughly the same order of magnitude, but tilted more toward Republican priorities.

A Republican stimulus would undoubtedly have had more tax cuts and less spending, even though every serious study has shown that tax cuts are the least effective method of economic stimulus in a recession. Even so, tax cuts made up 35 percent of the budgetary cost of the stimulus bill—$291 billion—despite an estimate from Obama’s Council of Economic Advisers that tax cuts barely raised the gross domestic product $1 for every $1 of tax cut. By contrast, $1 of government purchases raised GDP $1.55 for every $1 spent. Obama also extended the Bush tax cuts for two years in 2010.

It’s worth remembering as well that Bush did not exactly bequeath Obama a good fiscal hand. Fiscal year 2009 began on October 1, 2008, and one third of it was baked in the cake the day Obama took the oath of office. On January 7, 2009, the Congressional Budget Office projected significant deficits without considering any Obama initiatives. It estimated a deficit of $1.186 trillion for 2009 with no change in policy. The Office of Management and Budget estimated in November of that year that Bush-era policies, such as Medicare Part D, were responsible for more than half of projected deficits over the next decade.

Republicans give no credit to Obama for the significant deficit reduction that has occurred on his watch—just as they ignore the fact that Bush inherited an projected budget surplus of $5.6 trillion over the following decade, which he turned into an actual deficit of $6.1 trillion, according to a CBO study—but the improvement is real.

Screenshot 2014-10-20 12.59.16

Republicans would have us believe that their tight-fisted approach to spending is what brought down the deficit. But in fact, Obama has been very conservative, fiscally, since day one, to the consternation of his own party. According to reporting by the Washington Post and New York Times, Obama actually endorsed much deeper cuts in spending and the deficit than did the Republicans during the 2011 budget negotiations, but Republicans walked away.

Obama’s economic conservatism extends to monetary policy as well. His Federal Reserve appointments have all been moderate to conservative, well within the economic mainstream. He even reappointed Republican Ben Bernanke as chairman in 2009. Many liberals have faulted Obama for not appointing board members willing to be more aggressive in using monetary policy to stimulate the economy and reduce unemployment.

Obama’s other economic appointments, such as Larry Summers at the National Economic Council and Tim Geithner at Treasury, were also moderate to conservative. Summers served on the Council of Economic Advisers staff in Reagan’s White House. Geithner joined the Treasury during the Reagan administration and served throughout the George H.W. Bush administration.

There is certainly nothing new. Forbes pointed out a couple of years ago how Obama has been the most fiscally conservative president since Eisenhower.It is worth repeating considering how many people have been fooled by the Republican line that Obama and other Democrats, as opposed to the Republicans, are responsible for the size of the deficit.

Bartlett next discussed how Obamacare is based upon old Republican policies proposed by the Heritage Foundation and later Mitt Romney. He discussed at length how the individual mandate was originally an idea which was strongly promoted by Republicans. While Bartlett concentrated on Romney, many other Republicans shared this view.

Bartlett then had briefer discussions of several other issues–drugs, national-security leaks, race, gay marriage, and corporate profits. His argument for Obama being a Republican is weaker on social issues. While Obama took “two long years to speak out on the subject and only after being pressured to do so,” there remains a big difference between Obama keeping quiet on the issue and Republicans who actively promoted bans on same-sex marriage and Obama.

Bartlett concluded with:

I think Cornell West nailed it when he recently charged that Obama has never been a real progressive in the first place. “He posed as a progressive and turned out to be counterfeit,” West said. “We ended up with a Wall Street presidency, a drone presidency, a national security presidency.”

I don’t expect any conservatives to recognize the truth of Obama’s fundamental conservatism for at least a couple of decades—perhaps only after a real progressive presidency. In any case, today they are too invested in painting him as the devil incarnate in order to frighten grassroots Republicans into voting to keep Obama from confiscating all their guns, throwing them into FEMA re-education camps, and other nonsense that is believed by many Republicans. But just as they eventually came to appreciate Bill Clinton’s core conservatism, Republicans will someday see that Obama was no less conservative.

There is considerable truth to what Bartlett wrote, especially if social issues are ignored. However to be less progressive than Cornell West desires is not sufficient to prove someone is a Republican. Anyone who saw Obama as a candidate of the far left, as opposed to being more centrist, just wasn’t paying attention to what he was saying. Of course there is room for disappointment in some of these areas from the left, especially on drug policy and aspects of his foreign policy.

If Obama is said to be governing like a Republican, the key point which would need to be stressed is he is governing as a moderate Republican from the past–something which no longer exists. Obama certainly would not fit in with the Republican Party of today, which has moved to the extreme right. Bartlett is viewing Republicans from the perspective of his days as an adviser to Ronald Reagan and George W. Bush. The reality is that today neither Reagan nor Bush would be sufficiently conservative to survive in the Republican Party. Therefore, while it is ludicrous to consider Obama to be a socialist, or even from the far left, those who share the extreme views of current Republicans are correct in not seeing Obama as one of their own.

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Beware Of Those Politicians Who Spread Fear–We Have No Reason To Fear Ebola As Long As We Respond Sensibly

A mood of fear is engulfing the country which might very well affect the midterm elections. Hopefully people will react rationally and reject the Republicans who promote unwarranted fears, play politics, and advocate for counterproductive responses such as travel bans. Unfortunately but this is not the probable response.

As I discussed last week, even citing a report on Fox, we have no need to fear Ebola as long as proper precautions are taken.

There is no need to panic, or initiate measures which would be counterproductive such as a travel ban at this time. There is no meaningful problem with Ebola in this country and the biology of the virus makes it unlikely we will have a problem in the future. The nature of Ebola makes it a serious problem in countries without a Public Health infrastructure, but not in countries like the United States.

To date we have had exactly one patient with Ebola come into the country beyond medical personnel transported back here. Despite some serious mistakes being made, he did not infect a single person in the general population. The spread was limited to two nurses who cared for him at the most infectious stage, but before this stage the viral load is very low and Ebola is not likely to spread. This is also why, despite people who did come into contact with him having traveled, not a single other person has contracted Ebola.

Ebola is a serious problem in countries without sufficient infrastructure to deal with it, and if we are ever to be at serious risk it would be due to more widespread infection outside of the United States first. Our major focus must be on eradicating Ebola in West Africa, and anything which hinders this will make this more difficult and be counterproductive.

We also must closely track those who have been exposed, and a travel ban would also make this far more difficult. One of the major reasons for Ebola spreading in West Africa is an atmosphere which causes people who have been exposed to hide this until they are very sick and courageous. We must avoid an atmosphere such as this in the United States if we are going to prevent spread here.

We see in Nigeria that Ebola can be beaten, with the country now being free of the disease. Among the measures cited for eradicating Ebola are avoiding fear and keeping the borders open:

Nigeria has not closed its borders to travelers from Guinea, Sierra Leone and Liberia, saying the move would be counterproductive. “Closing borders tends to reinforce panic and the notion of helplessness,” Shuaib said. “When you close the legal points of entry, then you potentially drive people to use illegal passages, thus compounding the problem.” Shuaib said that if public health strategies are implemented, outbreaks can be controlled, and that closing borders would only stifle commercial activities in the countries whose economies are already struggling due to Ebola.

Similarly, Republicans are playing on exaggerated fears of terrorism and unfounded claims that the Affordable Care Act will cause increases in premiums when insurance companies are actually reporting plans for lower premium increases than were the norm prior to Obamacare.

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SciFi Weekend: Doctor Who; Dr. Cotton’s Bizarre Ideas, Boardwalk Empire & The Knick; DC and Marvel Movie Plans; Twin Peaks; The IT Crowd & Other British Adaptations

DoctorWho Flatline

Flatline managed to provide an episode of Doctor Who which successfully combined elements of both horror and humor. While not a totally original idea, it was something not seen on Doctor Who before, and realistically few television shows manage to come up with ideas which have not been influenced by other works. Think of it as if the residents of Flatland by Edwin Abbott Abbott were to invade earth, with a touch of The Adams Family thrown in.

Besides the idea of two dimensional beings invading, there was the added component of the TARDIS shrinking when the “structural integrity is compromised.” This did contradict The Name of the Doctor which showed such leaking to cause the TARDIS to swell in size, not shrink. The shrinking of the TARDIS, with the Doctor trapped inside, did enable Clara to take a leading role in this episode. This whole situation was quite difficult for the Doctor: “I mean this is just embarrassing. I’m from the race that built the TARDIS. Dimensions are kind of our thing.”

The Doctor did win out in the end. Ultimately the aliens from the two dimensional world were defeated by their inability to distinguish a two dimensional picture of a door from a real three dimensional door.

With the Doctor separated from the action for most of the episode, Clara took on the role of the Doctor, including taking on a companion, Rigsy, and calling herself the Doctor:

Rigsy: “What are you the doctor of?”
The Doctor: “Of lies.”
Clara: “Well, I’m usually quite vague about that. I think I just picked the title because it makes me sound important.”
The Doctor: “Why, ‘Doctor Oswald,’ you are hilarious.”

Clara did show Rigsy the inside of the shrunken TARDIS leading to the classic comment, “It’s bigger on the inside.” This set up the Doctor’s response:  “I don’t think that statement has ever been more true.”

Doctor Who Flatline1

Clara also showed that she can act like the Doctor, from using the Sonic Screwdriver to using his tactics:

Clara: “I just hope I can keep them all alive.”
The Doctor: “Ha. Welcome to my world. So, what’s next, ‘Doctor Clara’?”
Clara: “Lie to them.”
The Doctor: “What?”
Clara: “‘Lie to them.’ Give them hope. Tell them they’re all going to be fine. Isn’t that what you would do?”
The Doctor: “In a manner of speaking. It is true that people with hope tend to run faster, whereas people who think they’re doomed …”
Clara: “Dawdle. End up dead.”
The Doctor: “So, that’s what I sound like?”

Ultimately, when Clara asked if she did a good job, the Doctor did respond, “You were an exceptional Doctor, Clara. Goodness had nothing to do with it.” We still have the question from the start of the season as to whether the Doctor is a good man, and whether they are doing good.

The most amusing gag of all in the episode was seeing the Doctor’s full sized hand emerge from the tiny TARDIS to walk it away from an oncoming train.  The episode was very light on Danny Pink, but we did have another amusing scene with Clara talking on the phone with Danny, hiding the fact that she was in danger. The previews do show him taking an active part next week, but it still remains unclear whether we will ultimately see a return to two teachers from Coal Hill School being companions aboard the TARDIS as was teased last summer.

The ending scene with Missy took a different turn from her previous scenes, with Missy saying, “Clara, my Clara. I chose well.” It has already been suggested that it was Missy who gave Clara the Doctor’s phone number back in The Bells of Saint John, but we still have no idea as to what Missy’s overall plan is. Also uncertain is whether this has any connection to Clara’s role in The Name of the Doctor to become fragmented in time and have a role in each of the Doctor’s regenerations.

The writers this season do seem to be writing as if some of the past events have not taken place, almost starting fresh with Clara and the Peter Capaldi Doctor. Even going back to the season premiere in Deep Breath, the Clara who saw each regeneration in The Name of the Doctor should not have been as surprised by seeing the changes in the Doctor after his regeneration. Perhaps the events of The Time of the Doctor, with the Doctor gaining additional regenerations and not dying on Trenzalore, also mean there was never a giant TARDIS tomb for the Doctor and Clara never was fragmented in time. The Missy story line might wind up providing a completely different version of Clara’s life.

The Doctor Who Extra for Flatline is above.

While both the Doctor and now Clara having claimed to be a doctor without formal qualifications, there are some actual doctors who have done considerable harm despite having true medical degrees. One example, Dr. Henry Cotton, has appeared on cable television shows in the past week both on The Knick (at the start of his career and Boardwalk Empire (near the end). He was a real person. Henry Cotton believed that psychiatric problems were based upon infections and his treatment often began with pulling the teeth of psychiatric patients. If this did not provide a cure, then he would proceed to remove other organs which he believed were the cause of the infection. Needless to say, in an age before antibiotics, such unnecessary surgery could have catastrophic results. At one point during his career Cotton even had a nervous breakdown. He responded by pulling his own teeth, then proclaimed himself to be cured and returned to work.

Knowing the factual basis behind Dr. Cotton’s life leaves me concerned about Gillian Darmody’s fate after she told Dr. Cotton that she felt she was cured. We already saw another woman at the asylum undergo surgery, and Cotton would not be likely to accept Gillian’s assessment that she is cured without surgically removing what he believes to be the site of her infection. Being the final season,  Boardwalk Empire does have the ability to show tragic endings for its characters. This included the deaths of two long time characters last week. While Boardwalk Empire is ending, The Knick just ended its first season and has done an excellent job of showing what medical care was like back in 1900 and the development of new ideas such as transfusions.

News came in last week that a cable series which debut last summer, Manhattan, was renewed. While I have not seen the series, I feel comfortable in recommending this show about the development of the atomic bomb based upon several favorable reviews. (Although I have not seen Manhattan yet, do I get any points for reading Joseph Kanon’s novel, Los Alamos, several years ago?)

Still no news on whether Continuum will be renewed.

Episode 101

I would also recommend another new cable series which I did see the premiere of last weekend, The Affair. The main story involves an affair from the viewpoint of both parties, each telling their version for half the episode. We have narrators who are unreliable at least due to the faults in human memory. There might be additional reason for intentional deceit as we found that the stories are being told as part of a possible criminal investigation years afterwards, similar to in the first season of True Detective. It also reminds me of William Landay’s novel, Saving Jacob, in which there are glimpses of future questioning but we don’t know who the accused is or the crime until the end of the novel.

The creator of The Affair, Sarah Treem, discussed the dual narratives in an interview at The Hollywood Reporter:

With Noah and Alison remembering different accounts of the same stories, the series explores the notion of objective truth. Do you think there’s such a thing?

I think there is such a thing as objective truth. There are events that actually happen. As individuals our understanding of what happens is often quite limited. Sometimes the only way to get at objective truth is to have multiple people tell their own version of the same event. It is the job then of the interrogator, the therapist, the audience member, whomever, to basically try to find the commonality between the accounts in order to figure out what actually happened. That’s basically what we’re trying to do with this show. We’re not saying there’s no such thing as truth — there absolutely is — but we don’t think that one person is usually the arbiter of the truth. We think that it comes forward in conversation. There’s this quote, I think it’s from Hegel, but it’s the idea that all understanding is dialectic, meaning that nothing gets understood unless it’s as a result of a conversation. That’s how I think of the two sides of this show, that it’s a conversation from which the audience gains an understanding.

Will we see the perspectives of other characters besides Alison and Noah?

Not this season but maybe in subsequent seasons, if we get them.

We see a lot of overlapping stories that vary slightly depending on who’s telling them. What’s it like to have to regularly write two versions of the same event?

It’s a really fun exercise for a writer. It’s just about putting yourself in another character’s perspective, seeing the scene through the other character’s eyes. For the scene at the end of the pilot [where Alison and Cole have sex on their car], I was interested in writing a scene that looked like an attack on one side, and then coming back into it knowing more about what was actually happening to where all of the sudden the scene plays as a very different negotiation. Writers are trained at this because you’re always approaching the story through somebody’s eyes so it’s just a great, enjoyable exercise to go back and think, “Well, I wrote it this way the first time and now let me jump into a different character’s body and a different character’s mind and let me try it again and just see what happens.”

super-movies

Both Warner (DC) and the various studies which own the rights to Marvel characters have recently released news on their upcoming movie plans. Comics Alliance has more information and has put together the above infographic.

Here is an ambitious list from Warner Brothers:

  • “Batman v Superman: Dawn of Justice,” directed by Zack Snyder (2016)
  • “Suicide Squad,” directed by David Ayer (2016)
  • “Wonder Woman,” starring Gal Gadot (2017)
  • “Justice League Part One,” directed by Zack Snyder, with Ben Affleck, Henry Cavill and Amy Adams reprising their roles (2017)
  • “The Flash,” starring Ezra Miller (2018)
  • “Aquaman,” starring Jason Momoa (2018)
  • “Shazam” (2019)
  • “Justice League Part Two,” directed by Zack Snyder (2019)
  • “Cyborg,” starring Ray Fisher (2020)
  • “Green Lantern” (2020)

Batman v Superman: Dawn of Justice producer Charles Roven recently gave an interview with more information on the movie, including the origin story for Wonder Woman which is being used.

Unlike Marvel, DC is keeping their movie and television universes separate. While Gotham will probably need to be kept in a separate world of its own, Green Arrow, The Flash, and next Supergirl are forming their own television universe. Many fans are angry that Stephen Amell and Grant Guston won’t be appearing as Green Arrow and The Flash in the  Justice League movie. While fans would probably prefer such continuity, it does make it easier to wrote both the television shows and the movies if there is not a need for consistency. We saw how Agents of SHIELD was harmed by a need to postpone mention of HYDRA taking over SHIELD until after Captain America: The Winter Soldier was released.

avengers-captain-america-iron-man

Marvel fans are getting more excited by what appears to be planned. While Robert Downey, Jr. has not agreed to do another stand alone Iron Man movie, he may be appearing in Captain America 3, which reportedly involves the two being on opposing sides over the Superhero Registration Act. This could also be the end of Chris Evans as Steve Roberts. of There have also been rumors of Marvel making a deal with Sony, which owns the cinematic rights to Spider-Man, to allow him to appear, which sounds plausible as Spider-Man had a role in this storyline in the comics. Several other Marvel characters are also rumored to be appearing.

Emma-Stone-Cabaret_612x830

Meanwhile Emma Stone, when not playing the role of Gwen Stacy in Spider-Man, will be playing Sally Bowles on Broadway in Caberet.

With Twin Peaks coming back we have twenty-five years to catch up on. Mark Frost is writing a book to fill in this gap. I am looking forward to see what they do with the series and which characters return. I do hope that Audrey Horne returns and has a daughter who can tie a knot in a cherry stem with her tongue.

The IT Crowd

NBC has commissioned Bill Lawrence (Scrubs) to do a remake of the fantastic British sit-com, The IT Crowd. I have mixed feelings about such attempts to remake UK shows here. NBC’s first attempt at a remake, with cast including Joel McHale, was reportedly a total flop and never aired. NBC also failed in adapting Coupling, another excellent British sit-com written by Steven Moffat.

Fox has  had their own problems in attempting to remake British shows, both with Gracepoint (a remake of Broadchurch) and Us and Them (a remake of Gavin and Stacey).

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Republicans Attack Ebola Czar While Blocking Surgeon General Nomination

On the surface, Republicans have been all over the place regarding the idea of a government official to coordinate handling of Ebola. For example, there’s John McCain. Back in 2009 he attacked Obama over having too many czars:

Then McCain demanded an Ebola czar:

“From spending time here in Arizona, my constituents are not comforted,” Senator John McCain (R-AZ) told State of the Union host Candy Crowley Sunday morning. “There has to be more reassurance given to them. I would say that we don’t know exactly who’s in charge. There has to be some kind of czar.”

So Obama appointed an Ebola czar. Ezra Klein explained why Ron Klain is an excellent choice:

Today, the White House will announce that Klain is being named “Ebola czar.” It’s a good choice because it shows a healthy respect for how hard the bureaucratic job of coordinating the Ebola response really is.

The Ebola response involves various arms of the Department of Health and Human Services (particularly, though not solely, the Centers for Disease Control and Prevention), the Pentagon, the State Department, the National Security Council, the World Bank, the World Health Organization, President Obama’s office, private stakeholders, and many, many more.

The “czar” position requires someone who knows how these different agencies and institutions work, who’s got the stature to corral their efforts, who knows who to call when something unusual is needed, who can keep the policy straight…

Actual government experience is badly underrated in Washington. Politicians run for office promising that they know how to run businesses, not Senate offices. “Bureaucrat” is often lobbed as an insult. But in processes like this one, government experience really matters. Nominating Klain suggests the White House is thinking about this correctly: as an effort that requires the coordination of already ample resources, where the danger is that the federal government will be too slow in sharing information across agencies and getting the resources where they need to go.

John McCain’s reaction to the appointment of an Ebola czar was to again attack Obama for doing what he recommended:

“Frankly, I don’t think Mr. Klain fits the bill, as a partisan Democrat, certainly not in any effort to address this issue in a bipartisan fashion,” McCain said Friday evening on Fox News.

“He has no experience or knowledge or background in medicine,” he added.

McCain is hardly the only Republican with irrational attacks. For example, Steven Taylor has looked at even more irrational attacks from Mike Huckabee. The only common thread to Republican response appears to be a knee jerk opposition to whatever Obama does.

The duties of an Ebola czar are exactly the bureaucratic skills which Klain has, not being a medial expert. Of course there is a position in government which should have a background in medicine, and work closely with the Ebola czar. That would be the Surgeon General–a nomination which Republicans have blocked as Obama’s nominee has shown concern for gun violence.  Now Democrats are demanding that the Senate vote for approval of the Surgeon General nominee:

More than two dozen House Democrats are calling on the Senate to swiftly approve Vivek Murthy’s nomination to serve as surgeon general to help combat the spread of the deadly Ebola virus in the U.S.

Murthy’s nomination got sidelined after Republicans and vulnerable Senate Democrats voiced reservations about the Harvard Medical School physician’s outspoken views on gun violence and public health. But the House Democrats, in a letter set to be released next week, argue that the Obama administration needs a top official in place to help with the Ebola response.

“The American public would benefit from having a Surgeon General to disseminate information that is desperately needed,” the Democrats wrote. “The Surgeon General can also work to amplify the Center for Disease Control’s actions, reassure the American people, and combat misinformation here at home.”

We have around 30,000 deaths due to guns a year in this country, but Republicans would rather ignore this problem, while playing politics and creating hysteria with a disease which so far has resulted in exactly one death in this country.

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Avoiding Panic Regarding Ebola

With some conservatives playing politics with Ebola, it is good to see that Shepard Smith at Fox is being more responsible. See the video above where he explains why there is no reason to panic. Hopefully this will calm down the conservatives who are being incited to panic and see this as reason to vote against Democrats by other conservative voices.

As Shepard Smith explains, there is no outbreak of Ebola in the United States. We had an isolated case of one person with Ebola returning to the United States. Unfortunately, two nurses who cared for him when critically ill contracted the virus. Some mistakes were made. Hopefully what was learned in this case will help reduce the risk of this happening in the future, both in terms of handling patients with Ebola and in monitoring those who care for them. One key point is that Ebola is highly contagious when someone is this critically ill, but it is not contagious before symptoms appear.

Unfortunately far too many people in this country learned epidemiology from The Walking Dead. Some conservatives who otherwise deny evolution are now claiming Ebola could mutate to become an airborne menace–and this is far from the most absurd thing being claimed.

There is no need to panic and initiate bad policy such as a travel ban, which is primarily supported by Republicans.  A travel ban is unlikely to be effective and could have several adverse effects. It could make it harder to treat Ebola at its source. Further spread in West Africa would increase the risk of worldwide spread. Adverse effects on commerce in Africa could make it harder for local governments to deal with the problems. People who came from the region would be harder to track as this would give them motivation to come to the United States by less direct routes and deny possible exposure at borders. Even during the SARS outbreak a decade ago, with a disease which actually is airborne, travel bans were found to be unnecessary and ineffective.

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California Study Debunks Claims That Medicaid Expansion Will Increase ER Utilization Long Term And Excessively Increase Costs

Opponents of the Affordable Care Act and Medicaid expansion have often twisted the results of a study in Oregon showing an increase in Emergency Room utilization after their expansion of Medicaid. Subsequent studies have debunked claims that Medicaid patients are abusing Emergency Rooms and studies of the Medicaid expansion in Ohio showed that better management of the Medicaid patients can lead to better control of chronic disease while limiting Emergency Room use. A new analysis from the UCLA Center for Health Policy Research released Wednesday also specifically debunks claims made based upon the Oregon study, showing that the increase in Medicaid utilization is short-lived. From Kaiser Health News:

While the Medicaid expansion may lead to a dramatic rise in emergency room use and hospitalizations for previously uninsured people, that increase is largely temporary and should not lead to a dramatic impact on state budgets, according to an analysis from the UCLA Center for Health Policy Research released Wednesday.

Researchers reviewed two years of claims data from nearly 200,000 Californians, including a group  who had enrolled in public programs well in advance of the expansion of Medi-Cal,the state’s version of Medicaid, in January. These programs were designed to ease the expansion of Medicaid by providing insurance to low-income adults who were not eligible for Medi-Cal at that point but would be when the health law’s expansion went into effect earlier this year. The researchers  divided the group into four categories, based on the researchers’ assessment of each group’s pent-up demand for health care.

In July 2011, after being enrolled in California’s Low Income Health Program, the so-called “bridge to reform,” the group with the highest pent-up demand had a rate of costly emergency room visits triple — or more — that of the other groups. But from 2011 to 2013, that high rate dropped by more than two-thirds and has remained “relatively constant,” according to the analysis.

“We were hoping that this would be the case,” said lead author Jerry Kominski, director of the UCLA Center for Health Policy Research, “because we think that that’s what access to care does for low-income individuals … that there’s an additional increase in demand for services and that that demand, or utilization, drops off pretty rapidly.”

Rates of hospitalization for the “highest pent-up demand” group also started high and dropped by almost 80 percent over the two-year period. Curiously, if ER and hospitalization rates were dropping, it’s reasonable that outpatient visits might rise. But that wasn’t the case; the rate of outpatient visits was largely unchanged during the two-year period.

Kominski said that one of the fears of the Medicaid expansion was the potential high cost of low-income patients. He argued that this analysis should ease those fears: “What our findings say to the country is (that) concerns about Medicaid expansion being financially unsustainable into the future are unfounded.” Under the Affordable Care Act, the federal government provides 100 percent of the cost of the newly eligible under the Medicaid expansion, but in 2017 that contribution will phase down until it reaches 90 percent in 2020.

As was the case in Ohio, a key factor in keeping costs down was better coordination of patient care:

One factor in helping drive down the higher rates of use, Kominski said, is better efforts at coordination for Medi-Cal beneficiaries. For example, virtually all Medi-Cal beneficiaries are now enrolled into a Medi-Cal managed care plan. “To the extent that other states don’t have adequate coordinated care mechanisms in place for their Medicaid populations, then the kinds of drop off that we observed in California may not occur there,” Kominski said.

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