Democrats Seek To Fix Bug In Obamacare Deadline

The Affordable Care Act has been a tremendous success in increasing the number of people insured, reducing the cost of health care coverage, and eliminating the ability of insurance companies to deny coverage to those who develop medical problems. However it is not surprising that a law of its complexity does get some details wrong. When I first heard that open enrollment would end in mid-February I thought this was a mistake.

Some of those who failed to purchase coverage last year might not realize that they risk paying penalties, and they might not realize this until around April 15 if they wait until the last minute to complete their taxes. If the goal of the mandate is to encourage people to sign up to avoid penalties, enrollment should extend through April 15. That way people could sign up for insurance to avoid the mandate.

I was glad to see that some Democrats have realized this and are working to fix the problem by urging the Obama administration to have a special enrollment period:

Three senior House members told The Associated Press that they plan to strongly urge the administration to grant a special sign-up opportunity for uninsured taxpayers who will be facing fines under the law for the first time this year.

The three are Michigan’s Sander Levin, the ranking Democrat on the Ways and Means Committee, and Democratic Reps. Jim McDermott of Washington, and Lloyd Doggett of Texas. All worked to help steer Obama’s law through rancorous congressional debates from 2009-2010.

The lawmakers say they are concerned that many of their constituents will find out about the penalties after it’s already too late for them to sign up for coverage, since open enrollment ended Sunday.

That means they could wind up uninsured for another year, only to owe substantially higher fines in 2016. The fines are collected through the income tax system.

This year is the first time ordinary Americans will experience the complicated interactions between the health care law and taxes. Based on congressional analysis, tax preparation giant H&R Block says roughly 4 million uninsured people will pay penalties.

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John Oliver Exposes Pharmaceutical Marketing

John Oliver and Last Week Tonight returned on HBO last weekend with a biting expose of the pharmaceutical industry (video above). Like Jon Stewart, Oliver’s comedy version of the news is far more revealing than what is seen on most actual news reports. Last Week Tonight also has the advantage of spending more time on a single story than either Jon Stewart or actual news shows.

Oliver pointed how how Americans are addicted to prescription drugs, spending almost $330 billion on them. He suggested that Walter White of Breaking Bad could have made a lot more money cooking up drugs for rheumatoid arthritis instead of meth. He lampooned the efforts of pharmaceutical companies to influence the prescribing habits of physicians, describing their ethics with this comparison:  “Drug companies are a bit like high school boyfriends; they are much more concerned with getting inside you than being effective once they are in there.”

Oliver concluded with a warning about doctors who take large amounts of money from the pharmaceutical industry with a mock public service commercial, Ask Your Doctor:

Here’s how it works. Money combines with the cash receptors in your doctor’s wallet to create fast-acting financial relief, so your doctor can rest easy and enjoy life.

Common side effects of doctors taking money may include chronic overprescription, unusually heavy cash flow, dependency on free samples, inflammation of confidence, affluenza and an increased tendency to suggest off-label prescriptions, which in turn can cause heart attack, stroke, loss of feeling in arms and legs, seizures, blurred vision, grinding of the teeth, temporary deafness, total blindness, numbness, sudden bursts of rage, angry erections lasting over 17 hours, and death.

Ask your doctor today if he’s taking pharmaceutical company money. Then ask your doctor what the money is for. Ask your doctor if he’s taken any money from the companies that make the drugs he’s just prescribed for you. Then ask yourself if you’re satisfied with that answer.

The story was quite accurate. If this was a documentary as opposed to a comedy show my only complaint is that it concentrates on one side of the story in portraying doctors who take money and are susceptible to pharmaceutical sales pitches. Many doctors actually are quite aware of the problem and many do not take any meaningful amount of money from pharmaceutical companies.

For example, Oliver quoted a drug rep as being disturbed when a doctor asked her for advice on treating a patient as she is just a poli-sci major. I often feel the opposite, when pharmaceutical reps act as if they are qualified to give me advice (invariably involving greater use of their drug), knowing how little pharmaceutical or medical background most of them have. While I do accept samples in order to help out patients, which requires me to have some contact with drug reps, I am certainly not going to consider anything they say to be anything other than advertising. One time I even had a drug rep run out of my office crying when I didn’t play long with her sales pitch. We also have not been too welcoming to the rare drug rep who attempts to get back into our sample room in order to put his drugs in front and hide the samples form the competition.

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Rand Paul’s Past May Catch Up With Him

Rand Paul

Paul Waldman reminds us of some of the nutty things Rand Paul has said in the past, such as his belief in the NAFTA Superhighway conspiracy theory and past statements on the Civil Rights Act. He got in trouble again this week, along with some other Republicans, when discussing measles vaccination. It is not surprising that Paul, as is the case with the many in the Tea Party faction of the Republican Party (along with some mainstream Republicans) has a history of association with anti-vaccine groups. Paul has gone further than most other Republicans in the past in both questioning the science of vaccines and questioning the right of the state to mandate vaccinations.

Waldman has a good suggestion as to why Paul has made it to the Senate despite a history of holding views which would have prevented others from winning such a position:

But that’s not the path Rand Paul followed. Whatever his talents, he’s a United States senator because he’s Ron Paul’s son. Over his time in Congress, Ron Paul developed a small but fervent national constituency, made up of some ordinary libertarians and a whole lot of outright wackos. That constituency was greatly expanded by his 2008 presidential campaign. Despite the fact that Paul had plenty of interesting and reasonable things to say, it’s also the case that if you were building a bunker to prepare for the coming world financial crash and ensuring societal breakdown (and possible zombie apocalypse), there was only one presidential candidate for you. When Rand Paul decided to run for Senate in 2010, having never run for anything before, the Ron Paul Army mobilized for him, showering him with money and volunteers. He also had the good fortune to be running in a year when Republicans everywhere were looking for outsider, tea party candidates, so he easily beat the choice of the Kentucky GOP establishment in the primary.

You may remember that early on, and unseasoned Rand Paul got in trouble for his ideas about things like the Civil Rights Act. But he quickly discerned what was acceptable and what wasn’t, and he set about moderating his views, sanding down the rough edges of libertarianism to find something that would fit more neatly within the Republican Party while also finding issues where he could say something distinctive. It’s been very effective, but you can’t erase the past.

And I’m guessing there’s more in Paul’s past that will be of interest now that we’re getting into the 2016 campaign. I don’t mean scandalous behavior, I mean scandalous notions. I wouldn’t be at all surprised if there are a dozen more videos like this one out there, in which the now-respectable senator says some alarming things to groups of people who revere his father in all the elder Paul’s eccentric glory. I could be wrong, of course—the NAFTA superhighway and vaccines causing autism may be the only conspiracy theories Rand Paul has ever entertained. But we’re going to find out.

Rand Paul is not Ron Paul and we cannot attribute all of Ron Paul’s nuttier views and actions to Rand without evidence. I do bet that plenty more will come out if he has to face the scrutiny of a presidential campaign, and his Republican opponents for the nomination won’t hesitate to begin the opposition research.

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Measles Outbreak Shows How Republicans Have A Serious Problem With Science And Facts

Statements from many prominent Republicans, including Chris Christie and Rand Paul, on the measles outbreak have served to remind people that Republicans really are the Party of Stupid. This follows recent problems with Republicans ignoring the science to promote hysteria in response to Ebola.  As The New York Times wrote:

The vaccination controversy is a twist on an old problem for the Republican Party: how to approach matters that have largely been settled among scientists but are not widely accepted by conservatives.

It is a dance Republican candidates often do when they hedge their answers about whether evolution should be taught in schools. It is what makes the fight over global warming such a liability for their party, and what led last year to a widely criticized response to the Ebola scare.

As concern spread about an Ebola outbreak in the United States, physicians criticized Republican lawmakers — including Mr. Christie — who called for strict quarantines of people who may have been exposed to the virus. In some cases, Republicans proposed banning people who had been to the hardest-hit West African countries from entering the United States, even though public health officials warned that would only make it more difficult to stop Ebola’s spread.

On climate change, the party has struggled with how to position itself, with some Republicans inviting mockery for questioning the established science that human activity is contributing to rising temperatures and sea levels.

There are two types of misinformation being spread by conservatives regarding vaccines. The most extreme is to deny the basic science, claiming that vaccines do not work or are harmful. Some limit their arguments to denying the public health dangers resulting when some people refuse to vaccinate their children, often on libertarian grounds. While herd immunity has generally protected Americans from the effects of some refusing vaccines, the current measles outbreak shows what can happen. This also highlights a major problem with libertarianism. Sometimes, as even Fox’s Megyn Kelly has argued, “some things do require some involvement of Big Brother.”

It is also hard for Chris Christie to hide behind any libertarian justification for allowing parents to refuse to vaccinate their children after he involuntarily quarantined nurse Kaci Hickox despite the lack of either legal or medical justification.

It does make it much worse for the Republicans when they show similar problems with science and facts on other issues, not limited to evolution, climate change, vaccines, and Ebola. As I discussed yesterday, Republicans are also basing their attempts to restrict abortion rights on pseudo-science, such as claiming that a fetus can feel pain before it has developed a cerebral cortex, and framing the debate around unscientific claims that there is a definite point when life begins.

While economics is not as exact a science, there is ample data which disputes Republican Voodoo Economics. Tax cuts on the wealthy do not pay for themselves, do not stimulate the economy, and do not lead to wealth trickling down. The multiplier effect of government spending on economic development, along with the benefits of giving tax breaks to the poor and middle class, as opposed to the wealthy, often provide far greater benefit. These are among the reasons that the economy does so much better under Democrats than Republicans.

We are still seeing the disastrous effects of Republicans ignoring the facts in Iraq to go to war.

Facts matter, and Republican denial of the facts do not change this. What does happen is that we all suffer when Republicans decide public policy while denying science and facts.

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Republicans Plan To Impose Huge Tax Increase On Middle Class In Opposing Obamacare Fix

Republicans are increasingly seeing King v. Burwell as a way to do what they couldn’t accomplish in over fifty votes–repeal the Affordable Care Act. While it defies logic, the Supreme Court could conceivably rule that the Affordable Care Act only provides subsidies for plans purchased on state exchanges but not on the federal exchange.

A majority of people want Congress to pass a simple legislative fix should this occur, guaranteeing a continuation of the subsidies for those who purchase plans over the federal exchange. The health care and insurance industries also support such a fix.

This does not mean that the Republican Party will take the rational path. The Wall Street Journal reports:

Congressional Republicans say they won’t move to preserve consumers’ health insurance tax credits if the Supreme Court strikes them down, raising the stakes in the latest legal challenge to the Affordable Care Act…

Leaders in the GOP-controlled House and Senate see the court challenge as their best hope for tearing apart a law they have long opposed. If the court strikes down the subsidies, Democrats are expected to clamor for lawmakers to pass a measure correcting the language in the law to revive them. Congressional Republicans say there is no possibility they would allow that.

“No, no, no, no,” said Sen. Dan Coats (R., Indiana). “Even Democrats have acknowledged that this needs fixing.”

That position would force lawmakers to confront people in as many as 37 states where the federal government is currently running some or all of the exchange where consumers buy plans and tap the tax credits. There are 6.1 million people in those states who have the credits for 2015, according to federal data released this week. The average tax credit this year is $4,330, the Congressional Budget Office said this week.

Eleven of the states where the federal government has a hand in running the insurance exchange – including seven with Republican governors – signed onto a brief submitted late Wednesday asking the Supreme Court to uphold their tax credits. The brief said the loss of the credits “would deprive millions of low-and moderate-income Americans of billions of dollars in federal premium assistance essential to buy health insurance, thereby disrupting state insurance markets throughout the United States.”

The brief was filed by a group of mostly Democratic attorneys general. The lone Republican, North Dakota’s Wayne Stenehjem, declined to comment…

Nobody in the Senate Republican caucus has said the party should tweak the law so it can continue as it is, particularly since such a move would preserve the unpopular requirement for people to buy coverage or pay a fine, said Don Stewart, a spokesman for Senate Majority Leader Mitch McConnell of Kentucky.

Republicans are also increasingly preparing to use the budget procedural tactic known as reconciliation to repeal large parts of the law and potentially enact alternative provisions after the court ruling, whatever the outcome. The reconciliation process allows party leaders to pass changes with a simple majority, rather than the 60 votes most bills need to clear procedural hurdles in the Senate.

A loss of the subsidies would amount to a tax increase on the middle class. Republicans tend to concentrate on lowering taxes for the wealthy, at the expense of the middle class, and therefore see no problem in this. They mistakenly believe this will not affect their more affluent supporters, who do not qualify for the subsidies. What they fail to realize is that reducing the number of people in the risk pool will result in higher premiums for everyone.

Republicans are again talking about proposing their own plan, but they have repeatedly failed at doing so. The last time the Republicans did propose a plan it was remarkably similar to Obamacare, except then it was proposed as the conservative alternative to Hillarycare.

Any Republican plan which avoids harming millions of people will not only have to provide a mechanism for assisting those who cannot afford insurance coverage. Any plan must also ensure that insurance companies could not return to denying coverage to those who have medical problems. Republicans will find that this is not so simple, and will require the type of compromises seen in the Affordable Care Act.

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CMS Agrees To Demands From Physicians & Congress To Modify Rules For Electronic Medical Records

I recently discussed the problems with the government regulations for conversion to electronic medical records. The majority of doctors have been unable to comply with the regulations which were scheduled to begin this January (already postponed from last October) for reasons beyond our control. A bill with bipartisan sponsors was introduced in Congress to postpone the current requirements further until October, 2015. While this would be helpful, further changes are also needed in the requirements.

CMS has responded to the complaints, sending out an email to physicians today stating that the rules will be reevaluated this spring. This includes considering changing the requirement from a 365 day reporting period for 2015 to a 90 day reporting period, which would essentially postpone the requirements until October. The email also stated they would be “Modifying other aspects of the programs to match long-term goals, reduce complexity, and lessen providers’ reporting burden.” Modifications have already been made in the past to the regulations to reduce their complexity, but further modifications remain necessary.

While no official changes were announced at this time, it seems inconceivable that they will not go long with recommendations to postpone when the changes are due until October now that they have announced plans to consider this. It will also be necessary to make other revisions to the rules, which also now is under consideration. Complicating matters further, in addition to these requirements for electronic medical records, conversion to ICD-10 diagnoses codes (which has also been postponed several times) is also now scheduled to occur in October.

CMS has also announced plans to reconsider the regulations on their blog.

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Kaiser Health Tracking Poll Shows Most Support Fix For Subsidies Under Affordable Care Act

While you can never be certain as to what the Supreme Court would do, I’ve always felt that it is most likely that they would ultimately find that King v. Burwell is a frivolous case. (In other words, the most conservative justices might accept it, but John Roberts will cast the deciding vote against it if needed). This case is the latest Republican attempt to overturn the Affordable Care Act in the courts because of some language in the law, contradicting other portions, which could be taken to mean that subsidies are only available to those who obtain coverage through state exchanges, and not the federal exchange.

As I’ve pointed out in the past, it would politically be bad for Republicans if the court ruled against the Obama administration in this case. If the Supreme Court does accept the absurd argument that subsidies should only be available under the law for policies purchased on state exchanges, the simplest solution would be for Congress to revise a few words in the law to fix the problem. It is rather common for Congress to pass laws after major legislation to fix minor problems, except in this case Republicans in Congress are more interested in repeated, futile efforts to repeal ObamaCare as opposed to making such fixes–with yet another repeal vote now planned.

The Kaiser Health Tracking Poll for January finds that relatively few people are now aware of King v. Burwell, but most people do think that Congress should fix the problem. Among total voters, passing a law to fix this is supported 64 percent to 27 percent. There is similar support among independents, greater support among Democrats, and even a substantial number of Republicans (40 percent) would support such a fix:

King v Burell

If this is not fixed by Congress passing such a law, the second solution would be for states to start their own exchanges. A majority would also support this in affected states. Even Republicans support this, although at lower levels than Democrats and independents:

King v Burell2

I suspect that Republican leaders would much prefer to see the Supreme Court not put them in a position to have to take such action, either in Congress or at a state level. Failure to take such action would make displease the majority of voters, while taking such action would displease their base, who might take revenge in primaries where they dominate.

Update: Hospitals and insurance companies also lose if the subsidies are not continued, and are therefore also defending the subsidies before the Supreme Court.

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CBO Shows ObamaCare Costing Less Than Projected–Ignore Conservative Attempts To Distort The Data

There was more good news from the Congressional Budget Office today regarding the Affordable Care Act. The latest’s estimates significantly reduce the costs of expanding medical care under the law:

 The Congressional Budget Office on Monday significantly lowered its estimate of the cost of providing health insurance coverage to millions of Americans under the Affordable Care Act.

Douglas W. Elmendorf, the director of the budget office, said the changes resulted from many factors, including a general “slowdown in the growth of health care costs” and lower projections of insurance premiums that are subsidized by the federal government.

In March 2010, when President Obama signed the health care law, the Congressional Budget Office estimated that the expansion of coverage would cost the federal government $710 billion in the fiscal years 2015 through 2019, Mr. Elmendorf said.

“The newest projections indicate that those provisions will cost $571 billion over that same period, a reduction of 20 percent,” he said. The Affordable Care Act not only subsidized the purchase of private insurance, but also authorized a major expansion of Medicaid, the federal-state program for low-income people.

As usual, conservatives are cherry picking and distorting the numbers to portray this as a negative. Among other distortions of the facts, they fail to take into account the fact that having a substantial portion of the country be uninsured results in higher costs for both government programs, as well as costs which are passed on to those who do pay for insurance. The bottom line is that, even before these more favorable numbers, the CBO found that the Affordable Care Act results in a reduction in the deficit. Strange that conservatives who place such a high priority on reducing the deficit (which was run up by Republicans during the Bush years) oppose a program which will help reduce the deficit.

Of course if conservatives are unhappy with the cost of the Affordable Care Act, they should keep in mind the fact that costs are much higher due than they otherwise might be due to providing coverage through private insurance companies rather than through a single-payer system modeled on Medicare. Somehow I doubt many conservatives would go for the far more cost effective single-payer model.

Conservatives are also attacking the law because, while reducing the number of uninsured by 27 million people, there will still be 31 million uninsured in 2025. However, when looking at who will remain uninsured, I wonder which group conservatives are complaining about. Of this 31 million, 30 percent are illegal aliens and conservatives would sure protest if health care coverage were extended to them. Another 1o percent are ineligible for coverage because of living in states which did not expand Medicaid–a decision which conservatives support. The remainder are people who will qualify for coverage but choose not to purchase it.

The number of uninsured might fall as more red states go along with the expanded Medicaid program. It was just announced that Indiana is the latest to offer the expanded Medicaid program.

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Conservative Argues That It Is Not A Bad Thing If People Die Due To Repealing Obamacare

If the Affordable Care Act were to be repealed, as most Republicans are calling for, we would see millions of Americans lose their insurance. We would return to past problems, including people being denied insurance when they have medical problems, people once again being forced to declare bankruptcy due to medical costs, and we would see many more deaths than we will otherwise see.  Michael R. Strain of the American Enterprise Institute has an op-ed in The Washington Post under the headline, End Obamacare, and people could die. That’s okay.

Note again that the author is from the American Enterprise Institute and this is published in The Washington Post. This is not just some isolated blogger or conservative shouting out their personal opinion.

Strain’s logic is that “We make such trade-offs all the time.” For example, “Consider, for example, speed limits. By allowing people to drive their cars at speeds at which collisions result in death, our government has decided that the socially optimal number of traffic fatalities is not zero.”

He has other such examples, but they do not apply to the type of trade-off he is advocating. There are good reasons for having a society in which people can drive, and it is an unavoidable fact that this will lead to a certain number of traffic fatalities. The types of trade offs he discussed are not analogous to taking away health care coverage.

While there are reasons for having a society in which people can drive, despite traffic fatalities,  there is no good reason for either having people uninsured or for a system in which insurance companies are allowed to profit by denying coverage to those who become sick.

Strain argues that, “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals.” This falsely assumes that health care coverage is something which we cannot afford to provide. However every other industrialized nation on the planet, existing in the same “world of scarce resources,” is able to provide health care coverage to its citizens. The Affordable Care Act is a valuable step in the right direction, but it is an incremental step which still falls short of what is provided in the rest of the industrialized world.

There is no good reason why the United States cannot provide the same level of health care coverage as is seen in the rest of the industrialized world. One reason why we have been unable to do this is the unnecessary middleman–private insurance companies making huge profits while making health care more expensive than elsewhere. Perhaps the answer is that in a world of scarce resources, a system of private insurance is an unacceptable price to pay, and we should be thinking in terms of conversion to a far more cost-effective single payer system.

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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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