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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Commonwealth Fund Shows That Obamacare Has Made Health Care More Affordable

Another study has shown that the Affordable Care Act is exceeding expectations in increasing access to health care to Americans. A Commonwealth Fund survey has found that Obamacare has resulted in a reduction in the number of working-age adults without insurance from 20 percent of the population in 2010 to 16 percent in 2014 (the first year insurance was available through the exchanges) with further reductions in uninsured expected this year. Even more significantly, the number of adults who did not get needed health care because of cost decreased from 80 million people (43 percent) in 2012 to 66 million (36 percent) in 2014.

The percentage who reported problems paying medical bills in the previous 12 months decreased from 30 percent to 23 percent.

The percentage who did not fill a prescription fell from 27 percent to 19 percent. The percentage who did not get needed specialist care decreased from 20 percent to 13 percent.

“These declines are remarkable and unprecedented in the survey’s history,” said Sara Collins, the study’s lead author. “They indicate that the Affordable Care Act is beginning to help people afford the healthcare they need.”

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Goals Of The New Republican Congress: Repeal Obamacare Despite Success In Lowering Uninsured, Declare War On Math, Promote Pseudoscience To Restrict Abortion

Uninsured 2015

While Republicans are probably on the verge of voting yet again to repeal the Affordable Care Act, and will continue to make false claims that it has been a failure, Gallup shows once again how successful the law has been. The uninsured rate has fallen to 12.9 percent, down from 17.1 percent a year ago. The open enrollment period for 2015 remains open making it likely that the uninsured will fall further, especially if there is a last minute surge in people enrolling as last year. The number will further increase if more states go ahead and accept the expanded Medicaid program, and more people are also likely to receive insurance from employers with the trend towards decreased unemployment. Gallup also found that most who have obtained insurance plan to continue coverage, either through the same or a different insurance company.

Even before the inevitable vote to repeal Obamacare, the new Republican controlled Congress has declared war on math, as Jonathan Chait described it, and have introduced a national ban on abortions after twenty weeks. I recently discussed the pseudo-science used by Republicans to justify this, and there is more at Think Progress.

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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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Ideological Republican Legislatures Blocking Attempts At Expanding Medicaid By More Pragmatic GOP Governors

Governors are often more pragmatic than other politicians, having to actually run the state government and consider fiscal realities. Accepting Medicaid expansion is an obvious decision for governors, as long as they consider economic factors rather than Republican ideology, as the federal government picks up most of the cost. The federal government pays 100 percent of the cost of Medicaid expansion for the first three years with this gradually dropping to 90 percent in 2020. In contrast, the federal government pays approximately half the cost of the original Medicaid program,with state governments responsible for the rest.

So far some Republican-run state governments have accepted and others have rejected Medicaid expansion. Additional Republican governors would like to participate in the expanded Medicaid system but this is being blocked by more ideological members of the state legislature. AP reports:

Partisan politics have driven states’ Medicaid decisions ever since the Supreme Court ruled in 2012 that expansion was optional, not mandatory, under the new law. Within months, every Democratic governor agreed to expand Medicaid (although Republican legislatures blocked a few of those efforts).

Only nine states with Republican governors accepted the offer…

The law expanded Medicaid eligibility to adults with annual incomes up to 138 percent of the federal poverty level. That will qualify an individual making less than $16,105, and a family of four earning less than $32,913.

So far, 27 states have agreed to expand Medicaid. But several more, including some with Republican governors, now want in. These governors note that their residents pay the federal taxes that fund expansions, so declining to participate amounts to subsidizing other states without receiving benefits.

Several Republican governors and one independent are meeting Republican legislative resistance to their expansion proposals. Some have tried to woo conservatives by adding “free enterprise” provisions, which require federal approval.

Perhaps the most aggressive GOP governor is Bill Haslam of Tennessee, who won re-election in November. Meeting with newspapers and others, Haslam now says Medicaid expansion is “morally and fiscally the right thing to do.”

The full article also reports on Republican legislatures blocking Medicaid expansion in Wyoming and Alaska, as well as reporting that “Arkansas could become the first state to rescind a decision to expand Medicaid.”

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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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Federal Government Ends Prohibition On Medical Marijuana

The Los Angeles Times reports on a surprise in the recently passed spending bill–an end to the federal government’s prohibition on medical marijuana. The was passed with support of both Democrats as well as some Republicans who opposed raid by the federal government in states which have legalized medical marijuana on states’ rights grounds:

Tucked deep inside the 1,603-page federal spending measure is a provision that effectively ends the federal government’s prohibition on medical marijuana and signals a major shift in drug policy.

The bill’s passage over the weekend marks the first time Congress has approved nationally significant legislation backed by legalization advocates. It brings almost to a close two decades of tension between the states and Washington over medical use of marijuana.

Under the provision, states where medical pot is legal would no longer need to worry about federal drug agents raiding retail operations. Agents would be prohibited from doing so.

The Obama administration has largely followed that rule since last year as a matter of policy. But the measure approved as part of the spending bill, which President Obama plans to sign this week, will codify it as a matter of law.

Pot advocates had lobbied Congress to embrace the administration’s policy, which they warned was vulnerable to revision under a less tolerant future administration.

More important, from the standpoint of activists, Congress’ action marked the emergence of a new alliance in marijuana politics: Republicans are taking a prominent role in backing states’ right to allow use of a drug the federal government still officially classifies as more dangerous than cocaine…

Some Republicans are pivoting off their traditional anti-drug platform at a time when most voters live in states where medical marijuana is legal, in many cases as a result of ballot measures.

Polls show that while Republican voters are far less likely than the broader public to support outright legalization, they favor allowing marijuana for medical use by a commanding majority. Legalization also has great appeal to millennials, a demographic group with which Republicans are aggressively trying to make inroads.

Approval of the pot measure comes after the Obama administration directed federal prosecutors last year to stop enforcing drug laws that contradict state marijuana policies. Since then, federal raids of marijuana merchants and growers who are operating legally in their states have been limited to those accused of other violations, such as money laundering.

“The federal government should never get in between patients and their medicine,” said Rep. Barbara Lee (D-Oakland).

Tony Newman, Director of Media Relations, Drug Policy Alliance, added this to his list of More Nails in the Drug War Coffin.

In addition to ending fears of raids by federal drug agents, this should also alleviate the fears of many physicians who are currently afraid to treat patients with medical marijuana even in states where it is legal. Many physicians, including some pain clinics, have been unwilling to treat patients with chronic pain who are using medical marijuana out of fear of retaliation by the DEA.

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PolitiFact Lie of The Year: Exaggerations about Ebola

Conservatives used Ebola as one means of spreading fear, helping them in the 2014 midterm elections. PoltiFact has now made exaggerations about Ebola their 2014 Lie of the Year. This includes both conservative hysteria which greatly exaggerated the threat faced in a developed nation such as the United States and many of the right wing conspiracy theories. I have already discussed many of these false claims, often in the context of debunking right wing attempts to restrict civil liberties while ignoring the science. From PoltiFact:

Thomas Eric Duncan left Monrovia, Liberia, on Sept. 19, for Dallas. Eleven days later, doctors diagnosed Duncan with Ebola.

Eight days after that, he was dead.

Duncan’s case is just one of two Ebola-related fatalities in the United States, and since Duncan traveled to Dallas, more Americans — at least nine, and likely many more — have died from the flu.

Yet fear of the disease stretched to every corner of America this fall, stoked by exaggerated claims from politicians and pundits. They said Ebola was easy to catch, that illegal immigrants may be carrying the virus across the southern border, that it was all part of a government or corporate conspiracy.

The claims — all wrong — distorted the debate about a serious public health issue. Together, they earn our Lie of the Year for 2014…

Fox News analyst George Will claimed Ebola could be spread into the general population through a sneeze or a cough, saying the conventional wisdom that Ebola spreads only through direct contact with bodily fluids was wrong.

“The problem is the original assumption, said with great certitude if not certainty, was that you need to have direct contact, meaning with bodily fluids from someone, because it’s not airborne,” Will said. “There are doctors who are saying that in a sneeze or some cough, some of the airborne particles can be infectious.” False.

U.S. Sen. Rand Paul, R-Ky., described Ebola as “incredibly contagious,” “very transmissible” and “easy to catch.” Mostly False.

Internet conspirators claimed President Obama intended to detain people who had signs of illness. Pants on Fire. Bloggers also said the outbreak was started in a bioweapons lab funded by George Soros and Bill Gates. Pants on Fire.

A Georgia congressman claimed there were reports of people carrying diseases including Ebola across the southern border. Pants on Fire. Sen. John McCain, R-Ariz., said Americans were told the country would be Ebola-free. False.

When combined, the claims edged the nation toward panic. Governors fought Washington over the federal response. The Centers for Disease Control and Prevention stumbled to explain details about transmission of the virus and its own prevention measures. American universities turned away people from Africa, whether they were near the outbreak or not.

The post went on to discuss the actual medical facts.

Not surprisingly the misinformation came from many of the usual subjects such as Fox and Republicans such as John McCain and Rand Paul. Their conspiracies theories also involved the usual subjects of right wing attacks like Barack Obama and George Soros.

At least one good thing did come about from the Ebola hysteria. Republicans, with the help of the NRA, had blocked the appointment of Vivek Murthy for Surgeon General for months. The Ebola outbreak placed increased attention on this vacancy and he was finally confirmed by the Senate today.

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