More Than You Are Probably Interested In Regarding The Sequester,The Affordable Care Act, and Physician Payment

I had been wondering why I have not received a notice from CMS that Medicare payments would be cut by two percent starting March 1 due to the sequester. It has become quite common to receive notices of possible cuts considering all the threatened cuts due to the sustainable growth formula which Congress repeatedly circumvents at the last minute. I found out today that the sequester doesn’t begin to affect Medicare payments until April 1. As Medicare routinely holds payments for two weeks, this actually means we will have six weeks for the sequester to be resolved before this becomes an issue.

Of course there are many other problems which will be caused by the sequester, some now and some down the road, and I don’t expect others to be overly concerned about small cuts in physician payment. Still for me this is a headache, not only because of a decrease in payments but because of the accounting headaches should this turn out to be temporary and the balance of the payments are sent at a later date.

We already have another situation causing us to have to receive partial payment and then the remainder at a later date. The Affordable Care Act calls for Medicaid payment for primary care services to be increased to Medicare levels for two years as of his January. Unfortunately what sounds like something simple has turned out to be bureaucratically quite difficult as the federal government has to approve the updated fee schedules from Medicaid programs from all fifty states. As of now, zero states have completed the approval process. This means that we are now being paid under the old fee schedules and will be paid the higher amounts retroactively to January at a later date. Those who understand how cumbersome medical billing is will recognize the nuisance this causes. Hopefully we won’t go through the same problems because of the sequester.

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Michigan Court Decision Restricts Access To Medical Marijuana

While Michigan Governor Rick Snyder has come under well-deserved national criticism for giving into the right wing recently, Michigan elected far more dangerous conservatives in 2010. This includes Attorney General Bill Schuette, who has been working to undermine the medical marijuana laws passed by Michigan voters. Schuette received a huge boost in his efforts from a Michigan Supreme Court decision:

The Michigan Supreme Court ruled Friday the state’s medical marijuana law makes dispensaries illegal, throwing owners and patients into panicked uncertainty.

State officials said the justices’ 4-1 decision goes into “immediate effect” and could mean legal action against dispensaries that don’t close.

“It’s really up in the air at this point as to whether we’ll open tomorrow or not,” said Jamie Lowell, a co-founder of 3rd Coast Compassion Center in Ypsilanti, on Friday. “We’re still evaluating the decision with our attorneys. What it comes down to is whether we have any protections or defenses in the event we decide to continue helping people.”

Michigan Attorney General Bill Schuette, who joined the Isabella County prosecutor in a suit seeking the closure of another dispensary as a public nuisance, offered this interpretation of the ruling:

“Today, Michigan’s highest court clarified that this law is narrowly focused to help the seriously ill, not an open door to unrestricted marijuana sales,” he said in a statement Friday. “Dispensaries will have to close their doors. Sales or transfers between patients or between caregivers and patients other than their own are not permitted under the Medical Marihuana Act.”

This interpretation of the law provides very limited access to medical marijuana:

According to the ruling, the only legal sales of medical marijuana in Michigan are those specifically allowed in the state act. It states that as many as five state-approved users may register with a single state-approved caregiver, who then becomes a long-term provider of the drug — but only to those five users.

There is a bill in the Michigan legislature to legalize dispensaries, but for now it is doubtful the current dispensaries will be able to remain open without facing  prosecution. Schuette has been working to prevent the use of medical marijuana since taking office and I’m sure he will be able to find additional means to harass users regardless of whether dispensaries are legalized.

The best solution is to prevent any legal harassment of those who desire to use marijuana for medical purposes is to end attempts at prohibition and totally remove prosecutors from the issue by either legalizing or at least decriminalizing marijuana. The California Medical Association has previously called for legalization of marijuana with current laws creating an untenable situation.

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Proposal To Make Cigarettes A Controlled Substances–What Would The Indications Be For Prescribing?

A bill proposed in the Oregon legislature would make cigarettes available only by prescription. They would also be a Schedule III controlled substance, in the came class as drugs such as Vicodin. The Representative proposing this realizes this is not going to happen, but is trying to make a point in the hopes of reducing cigarette use.

It doesn’t really matter as this is not a bill anyone expects to pass, but I couldn’t help but consider the implications of requiring that cigarettes be prescribed as a controlled substance. While other Schedule III drugs might have risks and, like tobacco, can be addictive, cigarettes are unique. Cigarettes would probably be the only drug which, when used as prescribed, are very likely to kill their users, and have minimal benefits which might offset the risk. I don’t see how any physician could justify writing a prescription for cigarettes in such a situation. Perhaps they might be prescribed to handle addiction to cigarettes, but I couldn’t legally order Vicodin on a regular basis for somebody who has no medical indications for the drug in order to handle their addiction. What possible medical indications would there be for prescribing cigarettes?

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Conservative Hysteria Over Obama and The Medical Profession Working Together To Reduce Gun Violence

Today’s announcement of plans by the Obama administration shows that 1) Barack Obama is paying attention to input from the medical profession, and 2) the right wing still has its problem with paranoid kooks seeing conspiracy theories in benign statements.

The conservative Weekly Standard posted the relevant passage under a fairly neutral headline, Obama Asks Doctors to Help Deal With Guns:

PRESERVE THE RIGHTS OF HEALTH CARE PROVIDERS TO PROTECT THEIR PATIENTS AND COMMUNITIES FROM GUN VIOLENCE: We should never ask doctors and other health care providers to turn a blind eye to the risks posed by guns in the wrong hands.

Clarify that no federal law prevents health care providers from warning law enforcement authorities about threats of violence: Doctors and other mental health professionals play an important role in protecting the safety of their patients and the broader community by reporting direct and credible threats of violence to the authorities. But there is public confusion about whether federal law prohibits such reports about threats of violence. The Department of Health and Human Services is issuing a letter to health care providers clarifying that no federal law prohibits these reports in any way.

Protect the rights of health care providers to talk to their patients about gun safety: Doctors and other health care providers also need to be able to ask about firearms in their patients’ homes and safe storage of those firearms, especially if their patients show signs of certain mental illnesses or if they have a young child or mentally ill family member at home. Some have incorrectly claimed that language in the Affordable Care Act prohibits doctors from asking their patients about guns and gun safety. Medical groups also continue to fight against state laws attempting to ban doctors from asking these questions. The Administration will issue guidance clarifying that the Affordable Care Act does not prohibit or otherwise regulate communication between doctors and patients, including about firearms.

These measures were requested by the American Medical Association. The government has strict regulations to protect the privacy of medical information. The rules govern both when information must be kept secret and when information might be revealed to others and HIPPA rules never prevented physicians from warning law enforcement about threats of violence. It is helpful to make this clear as many people do have misconceptions about the law. The protection of the rights of health care provides to talk about gun safety is in response to conservatives who have wanted to use government to intrude in the physician/patient relationship and prohibit such discussion.

Rational people would find nothing controversial here, but many conservatives are not rational. The Examiner is running this story with a headline making an absurd claim that Obama makes your doctor a spy for the federal government. The article makes a number of false claims, including those in this paragraph:

Thus, the inherent, traditional privacy that has characterized the doctor-patient relationship is now gone, unless Congress rescinds the executive orders in question. Obama stated in one of the executive orders that his new Obamacare law contains no requirement of privacy and supersedes the healthcare portability act of 1998 in which Congress strengthened the privacy of healthcare patients. Obamacare wiped out all legal protections of privacy.

This makes absolutely no change in in the HIPPA law they cite, which always included the right of physicians to release patient information under several specific situations, including to warn law enforcement about threats of violence. This does not wipe out a single legal protection of privacy. I would suggest reading the HIPPA disclosure which all medical facilities provide to patients. Such statements (including the one used in my office) typically inform patients that information regarding threats of violence can legally be released to law enforcement agencies. If someone told their doctor about a  plan to kill you, or to start shooting in a public school, do you really think the doctor should be forced to keep this information secret?

Misinformation such as this is contributing to the conservative calls to impeach Obama over his executive orders on gun control. Where were these people when Bush and Cheney actually did want to exceed the Constitutional limits on the power of the president?

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Electronic Medical Records And Cost Savings

The New York Times has a story on  an analysis by the RAND Corporation showing limited health care savings from electronic medical records. This has given fuel to some Republicans to attack Obama who (along with Republicans such as Newt Gingrich) pushed heavily for adopting EMR’s. While I have written in the past that I believe the Obama administration has been overly confident about savings from EMR’s, looking at information on the program beyond what is in the New York Times article does show a more favorable picture.

Any study on the savings is premature as we are so early into the transition to EMR’s. The government is providing physicians and hospitals incentive payments for both adopting EMR’s and meeting a list of requirements for their use. Incentive payments have become increasingly common in health care as a partial transition away from pure fee for service payment. I also receive thousands of dollars a year in incentives for providing information to Medicare on the quality of health care provided by my practice, for switching to electronic transmission of prescriptions to pharmacies, and following many policies required of Medical Homes. If the goal is to have physician offices and hospitals change to EMR’s, incentive payments are necessary. The actual cost of switching to an EMR, considering both direct expenses and lost productivity, exceeds the government incentive payments. The incentive payments make doctors more willing to convert by replacing part of the lost income.

The incentive payments are not simple handouts with no strings–a false impression which might be obtained from criticism from a member of the Bush administration:

Dr. David J. Brailer, who was the nation’s first health information czar under President George W. Bush, said he still believed tens of billions of dollars could eventually be squeezed out of the health care system through the use of electronic records. In his view, the “colossal strategic error” that occurred was a result of the Obama administration’s incentive program.

“The vast sum of stimulus money flowing into health information technology created a ‘race to adopt’ mentality — buy the systems today to get government handouts, but figure out how to make them work tomorrow,” Dr. Brailer said.

The incentive program does not allow doctors to take the handout and then figure out the computer system afterwards. In order to receive the incentive payments, doctors and hospitals must meet a number of requirements with the actual use of the system. These requirements are called Meaningful Use.

In order to receive the maximum possible incentive payments over a five year period, doctors had to show Meaningful Use beginning in either 2011 or 2012. Only three months are required the first year, with twelve months of Meaningful Use required in subsequent years. This means that doctors could have started using a computer system in October 2012 and still qualify for the maximum incentive payment. Most likely many doctors did not begin using their computer systems until this time, or shortly before. (My system went live in September to give an extra month in case of any problems).

With many system not being in place until a few months ago, the RAND study was premature in coming to any conclusions.

Complicating this even further, the current requirements under Meaningful Use Stage I do not require that all functions of an EMR be in use–a necessary break to make implementation realistic. The Stage 2 Meaningful Use requirements which will be required as of October 2014 are far stricter. Presumably the requirements for far greater use of electronic medical records will also provide increased potential for savings. Actually in some ways the requirements are too strict, and hopefully will be revised. The Stage 2 Meaningful Use requirements include requirements which are to some degree out of the control of the physician. For example, there is a requirement to have an electronic portal which will allow patients to view their medical records on line, but this includes a requirement that five percent of patients actually view their records. It hardly seems fair to penalize a physician if less than five percent of patients decide to view their medical records on line as long as they are available, which could be a problem for practices with older and less affluent populations. There are also requirements to provide a patient summary after office calls, and after receiving this summary patients might have less interest in using the patient portal.

The plan established by the Obama administration was not devised to see major cost savings by this date, considering how recently many physicians have begun using EMR’s and as the Stage 2 requirements don’t take effect until 2014. The program, by providing payments to offset the costs of implementing EMR’s, has been effective in getting a large percentage of physician offices and hospitals to adopt such systems in a few years, providing the potential for savings in the future.

In retrospect, there is one thing which might have been done better to provide savings earlier in the use of EMR’s. At this time there are difficulties in communicating between different systems. I still receive paper copies of laboratory results and they must be manually typed or scanned into the EMR if they are to be included in the electronic record. I will have to pay more to add a laboratory interface, provided that the outside laboratories I send work to are willing to work with my system.  It might have been wiser to set up better systems for communication between different physician EMR’s, hospital system, public health facilities, and laboratories so that this would be easily available as soon as an EMR is used, as opposed to being a more difficult function which we have to pay to set up afterwards.

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Nude Protestors Tell Speaker Boehner Not To Be A Dick

There is probably no better way to get attention for a demonstration than to have topless women present, as with the demonstrations at the World Economic Forum in Davos earlier this year. While most of the reports I have seen of nude demonstrations have been in Europe, this phenomenon has now spread to the United States. Seven people protested against cuts to AIDS funding nude at John Boehner’s office. Chants included “Boehner, Boehner, don’t be a dick, budget cuts will make us sick,”  “Fight AIDS. Act up. Fight back,” “End AIDS with the Robin Hood tax, no more budget cuts on our back,.” and “Budget cuts are really rude, that’s why we have to be so lewd.” Three people were arrested in the protests

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Frequent Chocolate Consumption Reduces BMI

This might be the most important scientific finding ever: A study in the March 26 issue of the Archives of Internal Medicine found that frequent chocolate consumption was associated with lower body mass index (BMI). Here is a summary from Medscape:

A recent study showed that frequent chocolate consumption was associated with lower body mass index (BMI), even when adjusting for calorie intake, saturated fat intake, and mood.

Beatrice A. Golomb, MD, PhD, associate professor of medicine at the University of California, San Diego, and colleagues described their findings in a research letter published in the March 26 issue of the Archives of Internal Medicine.

The authors used data from 1018 patients already being screened for inclusion in a widely sampling clinical study evaluating noncardiac effects of statin medications. Of the 1018 participants, 1017 answered the question, “How many times a week do you consume chocolate?” BMI was calculated for 972 participants (95.6%); and 975 (95.8%) answered the validated Fred Hutchinson Food Frequency Questionnaire.

The investigators performed analyses with and without adjustment for calorie intake, saturated fat (satfat) intake, and mood. Fruit and vegetable intake was not associated with chocolate consumption (β, 0.004; P = .55), but satfat intake was significantly related to both chocolate consumption (β, 0.035; P < .001) and higher BMI.

The amount of chocolate consumed was examined, in addition to the frequency of chocolate consumption. Activity (number of times in a 7-day period the participant engaged in vigorous activity for at least 20 minutes) and mood (Center for Epidemiological Studies Depression scale [CES-D]) were also examined.

The relationship between chocolate consumption frequency and BMI was calculated in unadjusted models, in models adjusted for age and sex, and in models adjusted for activity, satfats, and mood.

Study participants consumed chocolate a mean 2.0 (SD, 2.5) times per week and exercised 3.6 (SD, 3.0) times per week. Frequency of chocolate consumption was associated with greater intake of calories and satfats and higher CES-D scores (P < .001 for each of these 3 associations); these all related positively to BMI. Chocolate consumption frequency was not associated with greater activity (P = .41), but it was associated with lower BMI (unadjusted P = .01). This association remained with and without adjustment for age and sex, as well as for calories, satfats, and depression.

Although chocolate consumption frequency was associated with lower BMI, the amount of chocolate consumed was not (eg, per medium chocolate serving or 1 oz [28 g], β, 0.00057 and P = .97, in an age- and sex-adjusted model).

“The connection of higher chocolate consumption frequency to lower BMI is opposite to associations presumed based on calories alone, but concordant with a growing body of literature suggesting that the character — as well as the quantity — of calories has an impact on [metabolic syndrome (MetS)] factors,” write the authors.

They further explain that as chocolate products are frequently high in sugar and fat, they are often assumed to contribute to an increased BMI. The authors note that this may still be true in some cases.

“[O]ur findings — that more frequent chocolate intake is linked to lower BMI — are intriguing,” write the authors. “They accord with other findings suggesting that diet composition, as well as calorie number, may influence BMI. They comport with reported benefits of chocolate to other elements of MetS,” the authors write, noting that a randomized trial studying the metabolic benefits of chocolate in humans may be warranted.

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AMA Calls For Blocking Required Coding Change To Reduce Unnecessary Practice Expenses

One of the many reasons that health care costs so much is that billing is an enormous expense for physician offices and all health care facilities.  There are complexities to billing for services in health care which are not present in most industries. If most people want to send out a bill, they can just list the services in plain English. In health care everything has a number, both for the diagnosis and for the services provided. The current ICD-9 diagnosis system used in the United States uses up to five digits to describe every medical problem. Much of the world has already changed to ICD-10, which has a whole new set of codes and goes out to six digits, allowing for even greater specificity.  The United States plans to convert in October, 2013, resulting in a tremendous increase in medical practice expenses.

Bureaucrats think that the five digit numbers are not enough and we need six digit numbers to describe more exactly what diagnosis is involved. They don’t seem to have questioned whether this degree of specificity is needed, or if the results they get are accurate. It is somewhat like the game of telephone. By the time diagnoses go from the doctor, who writes them in English, through staff members and on to the payers, many inaccuracies enter into the system. Any type of study based upon ICD-9 codes is likely to have a tremendous amount of erroneous data.  The ICD-9 codes typically have choices for the fifth digit of “other” or “unspecified” which are commonly used. This practice will continue, defeating the purpose of adding yet a sixth digit to describe a diagnosis.  Besides, if anyone really needs to see the exact details before paying, they could always review the actual notes (as  is commonly done by payers such as auto insurance and workers compensation).

The ICD-9 system is in place and is working. In an era of trying to cut unnecessary expenses it is foolish to spend the money it would take to convert to ICD-10. The goal should be to reduce complexity to reduce costs, not to increase complexity or to require costly changes. The AMA House of Delegates voted today to attempt to block the implementation of ICD-10.

The AMA House of Delegates voted today to work vigorously to stop implementation of ICD-10 (The International Classification of Diseases and Related Health Problems, 10th Revision), a new code set for medical diagnoses. ICD-10 has about 69,000 codes and will replace the 14,000 ICD-9 diagnosis codes currently in use.

“The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients’ care,” said Peter W. Carmel, M.D., AMA president. At a time when we are working to get the best value possible for our health care dollar, this massive and expensive undertaking will add administrative expense and create unnecessary workflow disruptions. The timing could not be worse as many physicians are working to implement electronic health records into their practices. We will continue working to help physicians keep their focus where it should be — on their patients.”

A 2008 study found that a small three-physician practice would need to spend $83,290 to implement ICD-10, and a 10-physician practice would spend $285,195 to make the coding change.

As noted above, the timing is especially bad as the government is now pushing medical offices towards changing to electronic medical record system. Such implementation is made more difficult when the systems have to be set up to handle ICD-9 until October, 2013 and then abruptly change to an entirely new system. Besides the costs resulting from changing system, the government is also requiring a change in electronic billing formats in January, 2012 which is also causing added expense.

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Disease Management Models Fail To Show Cost Savings

Winston Churchill’s view of democracy is well known: “Democracy is the worst form of government, except for all those other forms that have been tried from time to time.” Something similar might be said about fee for service health care. The system has frequently, and erroneously, been blamed for the the high cost of health care, ignoring the simple economic facts such as that you get what you pay for and there is no such thing as a free lunch. There have been multiple attempts at finding alternatives, such as the disastrous trend toward HMO’s which led to restrictions in health care availability while often leading to increased costs due to the increased bureaucracy. Other efforts, such as the disease management model, attempt to modify fee for service plans.

The Medicare Modernization Act of 2003 requires that the Centers for Medicare and Medicaid Services test a commercial disease management model in the fee-for-service program. A study in the November  3 issue of the New England Journal of Medicine entitled Results of the Medicare Health Support Disease-Management Pilot Program found no demonstrable savings. (If this report is not available to non-subscribers, there is a summary in Medical News Today). From the results:

The study included 242,417 patients (163,107 in the intervention group and 79,310 in the control group). The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits, as compared with usual care. We observed only 14 significant improvements in process-of-care measures out of 40 comparisons. These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ($400 million), with no demonstrable savings in Medicare expenditures.

From my personal experience, such programs when utilized by third party payers, typically based upon reviews of claims with zero knowledge of the actual patient, lead to the generation of large amounts of letters which quickly wind up in the trash due to their lack of applicability to the actual patient. Lately an increased number of payers have been paying to obtain further information on patients in their plans with the hopes of better managing their care. This leads to a small amount of additional income, more paperwork, but it remains questionable if this has any impact on health care.

The discussion included five reasons for the failure of the programs. I found two to be particularly of interest:

Second, the care of elderly, chronically ill patients is difficult to manage. They are much more likely than younger persons to have new acute conditions such as stroke, pneumonia, and hip fracture. Although each of the companies in our study intended to manage the care of the “whole person,” the health coaches were surprised by the number of health and psychosocial problems that were prevalent among Medicare fee-for-service beneficiaries.

Yes, the patients who account for the highest costs under fee for service plans account for these costs for a reason. They are sicker and are more difficult to manage. A nurse calling from an insurance company’s call center who has never examined the patient is not likely to know how the patient should be handled. Giving cook-book medicine recommendations based upon one diagnosis can often cause serious problems rather than be of benefit if all the other problems of that patient are not considered. Systems which do not provide adequate fee for service will lead to these sicker patients not being able to receive the amount of care they need.

Fifth, the health coaches were not integrated into the beneficiary’s primary health care team. This hindered their ability to interact directly with the beneficiary’s primary care provider and facilitate changes in medical care plans made by the primary care provider to mitigate deterioration in health status and avoid the need for acute care services.

Insurance company health coaches frequently have no idea as to why a patient is having problems or not responding to their physician’s treatment. Recommendations from such people are often worthless. Therapeutic failures might be due to a physician not following the proper treatment guidelines, but often the problem is that the patient does not follow their doctor’s advice. People often don’t follow medical recommendations because they cannot afford the medications needed, or afford the out-of-pocket expenses required for their health care. When insurance plans are operating with no coordination with the patient’s physician they are not going to be aware of the actual problems.  On the other hand, if these programs were better organized to take recommendations from the physician and work with the physician, as opposed to trying to tell the physician what should be done, they might be able to provide a service which actually does help the patient and lower management costs.

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Conservatives Again Show That They Are The Supporters Of Big Government, Opposing Trend Towards Support For End Of Marijuana Prohibition

The medical marijuana laws are failing at ensuring that people can use marijuana if it helps with symptoms of various diseases. In some states individuals can obtain a card allowing for the legal possession of marijuana. This might be obtained from a physician who is familiar with their medical history, or it might have been purchased from doctors who will give approval for marijuana use for $100. The laws typically do a poor job of stipulating how marijuana can be obtained. There is no doubt that many people are taking advantage of the program to obtain legal access to marijuana without legitimate need, leading to government crack-downs which make it  more difficult  to obtain marijuana.

With all the problems caused by these laws there is one obvious solution–legalize marijuana and eliminate the need for the poorly-constructed medical marijuana programs. The California Medical Association agrees:

The state’s largest doctor group is calling for legalization of marijuana, even as it pronounces cannabis to be of questionable medical value.

Trustees of the California Medical Assn., which represents more than 35,000 physicians statewide, adopted the position at their annual meeting in Anaheim late Friday. It is the first major medical association in the nation to urge legalization of the drug, according to a group spokeswoman, who said the larger membership was notified Saturday.

Dr. Donald Lyman, the Sacramento physician who wrote the group’s new policy, attributed the shift to growing frustration over California’s medical marijuana law, which permits cannabis use with a doctor’s recommendation. That, he said, has created an untenable situation for physicians: deciding whether to give patients a substance that is illegal under federal law.

“It’s an uncomfortable position for doctors,” he said. “It is an open question whether cannabis is useful or not. That question can only be answered once it is legalized and more research is done. Then, and only then, can we know what it is useful for.”

While the medical benefits remain uncertain, it is best to keep the government out of this issue and let people decide for themselves whether it is helping them. Prohibition does not work, and creates many problems. A Gallup poll today showed that a record high of 50 percent now support legalization. Not unexpectedly, conservatives who falsely claim they support smaller government are less likely to support legalization:

Support for legalizing marijuana is directly and inversely proportional to age, ranging from 62% approval among those 18 to 29 down to 31% among those 65 and older. Liberals are twice as likely as conservatives to favor legalizing marijuana. And Democrats and independents are more likely to be in favor than are Republicans.


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