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Monday, July 31, 2017

From EMRs to EMTALA: Dorothy J. McNoble, MD, JD

Among my daily web surfing stops is the blog "Naked Capitalism," an always very busy, provocative, multi-contributor site established by acclaimed writer Yves Smith, whose book "Econned" is one of my favorites.

The focus at Naked Capitalism goes mostly to "FIRE Sector" (Finance, Insurance, & Real Estate) topics and issues. I resonate with this stuff owing in part to my intense 2000 - 2005 period working in risk management in Subprime. See, e.g., my old posts 'Tranche Warfare" and "The Dukes of Moral Hazard."

Well, last week Naked Capitalism published two delightful posts by Dorothy J. McNoble MD, JD going to the health care space -- specifically a national policy topic and a post concerning the shortcomings of Health IT (EHRs specifically).

The first one discusses the EMTALA (Emergency Medical Treatment and Active Labor Act of 1986).
Healthcare Hypocrisy: How Politicians Hide Behind the 1986 EMTALA Law to Avoid Healthcare Reform
Dorothy J. McNoble, MD, JD

A 46 year old man comes to the hospital by ambulance for severe abdominal pain. He is diagnosed with a perforated ulcer and undergoes emergency surgery. He receives post-operative fluids, antibiotics, pain medication and ulcer medication. He recovers after five days and is discharged. He is unemployed, has no insurance and neither the hospitals nor the physicians receive any payment for his care.

This story of timely and appropriate emergency medical care delivered to patients unable to pay for it occurs tens of thousands of times a day in this country. Though physicians and hospital administrators might provide such services for moral or ethical reasons, it is unnecessary to rely upon the consciences of these providers since a law mandates that they provide care.

Specifically, The Emergency Medical Treatment and Active Labor Act (EMTALA), passed by Congress in 1986 unequivocally requires that hospitals provide emergency medical and surgical care and other ancillary services to patients requesting this care irrespective of their ability to pay.

This law, though rarely mentioned by name during discussions of existing and proposed health care policy or law, has a profound and pervasive impact on the delivery of health care in this country. In fact, there is no area of government or privately provided health care which is not affected by the provisions of EMTALA and by the current economic sequela of this law.

In particular, many of the provisions of the Affordable Care Act were designed to remove some of the burdens imposed by the EMTALA. If the ACA is repealed, the benefits and burdens of EMTALA will emerge as more important than ever. It’s therefore important to make an explicit examination of EMTALA. Medicare, Medicaid, the Affordable Care Act and even rules governing private insurance cannot be fully understand without acknowledging the existence of this long standing health care safety net.

The Origins of EMTALA
EMTALA was passed in 1986 and requires that patients needing emergency medical care not be discharged or transferred to another hospital until the patient has received a medical screening exam. If the patient is found to have a condition requiring urgent medical or surgical care, that patient must receive the care unless he or she consents to discharge or transfer to another facility. The patient must receive this care without regard to his insurance status or his ability to pay for the care.

The law is an unfunded mandate. That is, unlike Medicaid, Medicare and the Affordable Care Act which establish taxpayer subsidy for the health care provided, EMTALA mandates the delivery of care, but contains no provision for funding the care. The law, as will be discussed below, has been interpreted very broadly and, as a result, it has a significant financial impact on health care in this country.

Uncompensated care represents up to an estimated 6% of total hospital costs. This number does not include the costs borne by the physicians and other providers as opposed to the institutional hospital costs, so the 6% is an underestimate of the cost. The hospitals in urban and rural areas with large numbers of medically indigent patients assume a much greater proportion of this cost and since the law is silent on funding and contains no provisions for reimbursement, there is no mechanism for spreading the cost among hospitals in a region in order to better distribute the loss…

…the EMTALA mandate has evolved to require a fairly expansive definition of emergency care, and, it is therefore remains a very costly proposition, especially for inner city and poor rural hospitals. It is impossible to know what would happen if the EMTALA mandate disappeared tomorrow, but I can predict with confidence that there would be a significant decrease in the amount of unreimbursed care provided by hospitals.

Finally, as the debate on health care reform continues, one should consider whether EMTALA may actually be responsible for allowing politicians and lawmakers to skirt responsibility for coming up with reasonable legislation to fund health care, especially care for the medically indigent.

As long as EMTALA is in place, patients will continue to receive all emergency care and even a great deal of arguably non-emergency care. Patients with strokes, diverticulitis, broken bones and even fingernail infections will be seen and treated irrespective of financial status and without regard to the existence or absence of any program for funding that care. This uncoupling of guaranteed care from payment for that care shields lawmakers from the consequences which would follow if hospitals and providers could turn away uninsured and indigent patients.

EMTALA is, in fact, a “forme frust” of single payer healthcare for the indigent. That is EMTALA requires a broad and deep level of care be provided for all patients, but has no mechanism for private or public funding of that service.

Instead, in our bastardized single player plan, the costs of the care are borne exclusively by the doctors and hospitals providing the care with no attempt to provide a sensible risk spreading plan for the multi-billion dollar EMTALA program.

President Trump and Secretary Price have stated their commitment to reduce this type of cost-shifting in health care. For example, they support the elimination of individual and employer mandates would end the program whereby healthy individuals are required to buy insurance to subsidize the sicker patients.

If the current Administration is serious about elimination unfair cost shifting, it seems that elimination of EMTALA, which is one of the most unfair cost-shifting systems in health care, should also be eliminated. If it is unfair to require healthy patients to purchase insurance to fund the sicker patients, then surely it is unfair to require individual physicians and hospitals to bear the burden of care for the medically indigent.

However, if EMTALA were to be eliminated, and hospitals and physicians responded by eschewing any responsibility for providing uncompensated care, politicians would arguably be faced with the prospect of dealing with a citizenry awash in illness, disease and suffering. I think that lawmakers recognize that EMTALA stands between them and health care chaos, and, in spite of platitudes about a fair distribution of the costs of health care they, will never have the courage to repeal this unfair law and replace it with an honest, universally accessible system of health care.
Link in the title. These are fairly long-read posts. Highly recommend you read them in full, inclusive of the numerous comments beneath the articles. Naked Capitalism attracts an astute, eloquent readership of varied (and predominantly well-reasoned) opinions.

The second McNoble post goes to to the by now long-standing complaints about EHRs.
How Electronic Health Records Degrade Care and Endanger Patients

Yves here. We’ve featured posts from the Health Care Renewal site that regularly warn about how electronic health care records are a serious hazard to patient health. Yet we’ve regularly had readers refuse to believe that, despite warnings like the ECRI Institute putting health care information technology as its top risk in its 2014 Patient Safety Concerns for Large Health Care Organizations report, or the president of the Citizen’s Council for Health Freedom warning that “EHRs are endangering your life” or press reports like this:

Arthur Allen at POLITICO Pro eHealth says government-imposed EHRs are:

  • Driving doctors to distraction
  • Igniting nurse protests
  • Crushing hospitals under debt
“In short,” he writes, “the current generation of electronic health records has about as many fans in medicine as Barack Obama at a tea party convention.“

Some readers assume that anything must be better than hand-written and potentially difficult-to-read doctor notes. And the 50,000 foot explanation, that the systems are a huge and costly fail from a care perspective because they are designed primarily, if not entirely, for billing, seems insufficient.

This post will hopefully satisfy the skeptics by giving granular detail with real-world examples of how these electronic record systems distract doctors, regularly employ dangerous “check the box” approaches, produce voluminous and repetitive patient files that routinely go unread, give nurses contradictory instructions, and too often result in patients being given “care” that harms them.

One of my friends, the daughter of an MD who worked for the NIH and later a Big Pharma co, said she’d never go to a hospital without her own private duty nurse. That was before EHRs. Once you read this article, you’ll think twice about going to a hospital in the US without that sort of extra protection.

By Dorothy J. McNoble, MD, JD, who can be reached at

In a now iconic experiment, subjects are asked to sit in bleachers watching a basketball practice and count the passes among players on one of the teams. A few minutes into the experiment a man in a gorilla costume walks across the court. Fewer than 50% of the subjects notice him.

In a variant of the experiment, a man stops a stranger on a somewhat busy street to ask directions. While they are talking, two men carrying a large piece of plywood walk between the two men and when the plywood has passed, the original questioner has been switched to a different man. Again fewer than 50% of people notice the change.

Recently, I witnessed an “invisible gorilla” episode in the hospital. I took my neighbor to the hospital after she had fainted. She had low blood pressure and a slow pulse. The nurse examined and interviewed her, but spent most of the interview facing the computer and inputting data. A few minutes later, my friend was moved two beds down and exchanged places with another patient due to some equipment problems. When the nurse returned to check on my friend, she addressed her by the incorrect name and questioned her about the symptoms of the patient who had been there earlier. I corrected her and she checked the armband to confirm.

There can be no denying that emergency rooms are busy and the staff are often overwhelmed, but I think this demonstrates that the new “three way” which dominates patient interactions – the patient, the computer and the nurse or doctor, risks turning patients from the central focus of all interactions into the invisible gorilla.

Anyone who has tried to wade through their own hospital records or watched as a primary care physician tried to decipher the “data dump” which is supposed to summarize the events of a recent hospitalization, will recognize that the promise of the efficient, orderly modern electronic record is far from being realized. In theory, the computer based electronic record should be perfectly suited to its task. In recent decades health care, especially inpatient hospitalization, has become increasingly complex. There are many more participants, doctors, nurses, dieticians, consultants, occupational therapists, respiratory therapists, social workers and the interventions and therapies and medications administered during a hospitalization have also increased dramatically.

The electronic record, with its ability to prompt clinicians with reminders, organize large amounts of data and allow access from any point in the hospital and even remote locations, seems the perfect tool to create an organized, complete, flexible document free of errors and redundancy. The EHR as a working document during the hospitalization should be able to immediately reflect changes in the patient’s condition, accommodate instantaneous changes in medication and therapy, allow input from a host of clinicians and remain clear and comprehensible. After the patient discharge, the EHR should be an easy to understand narrative of the event of the patient’s hospitalization with the patient as the obvious central figure.

However, instead, the EHR has become an unreadable, unholy mess in which the patient is increasingly eclipsed. How did this happen? Was it due to limitations of software capacity? Insufficient funds devoted to the development of the EHR?

All of these problems undoubtedly contribute to the difficulty of developing the optimal EHR system. However, I believe that the main impediment to the creation a good EHR is not technical limitations or financial constraint. Rather it is due to the decision to utilize the EHR as a billing document. Many of the decisions about how to organize the medical record, how to format the document, and what data to include or exclude arise from the need to use the record as the support for and documentation of “billable events” during the hospital stay...


Feeding at the Trough
Healthcare is the largest single industry in the country and the source of the greatest job growth. However, the growth in clinical care positions are not responsible for most of this increase. Medical and nursing schools have at most a negligible increase in graduates, and ancillary clinical training, such as occupational therapists is also growing slowly.

A large part of the increase in participants in the healthcare industry is due to the dramatic increase in federal, state, and local health care bureaucrats as well as the increases in hospital administrators, auditors, plan administrators and other non-clinical participants. These government and administrative bureaucracies are theoretically in place to insure efficiency in the delivery of care and to monitor and insure patient safety. The security of their roles as integral to patient care is assured if they can require that their particular area of concern is a mandated part of the medical record. For example, there must now be documentation in the EHR about smoking cessation, potential for elder abuse, vaccination status, use of seat belts use of child safety seats and a variety of other issues. Although the inclusion of these global safety and care concerns is laudable, the medical record has become bloated with repetitive, inappropriately placed mandatory documentation of these often peripheral and distracting subjects...

Focus Fatigue and Limited Bandwidth
As discussed above, the structure of the EHR is designed to serve its purpose as a billing document, but makes it very challenging as a dynamic health care management tool during hospitalization or a concise, complete, well organized, non- redundant narrative after discharge. These structural features are a real impediment to clinicians trying to care for patients or understand what happened to patients after the fact.

There is an ample body of literature discussing the inefficiency and inaccuracy which results from multi-tasking. When doctors and nurses attempt to examine and obtain histories from patients while scrolling between various lists on the computer screen to be certain that all the billable bases are covered, it is clear that their ability to attend to the patient is compromised.

In addition, when the record itself is lengthy, repetitive and contains large amounts of prominently placed, but extraneous information, the clinician is likely to lack the mental stamina to wade through the document, switching between screens to find the relevant information. Moreover, the much touted “safety” features of the EHR are themselves often so ubiquitous and distracting that they lose their efficacy...
Again, this post is a thorough long-read, one airing the broad litany of complaints that those of us who have worked in Health IT are utterly familiar with. And, also again, I recommend you read the numerous comments. Notwithstanding the usual naysaying straw man and related red herring grips are many views that deserve our attention and respect. e.g.,

I retired in 2010 at age 69, after 44 years of practice. The final 3 years involved EHRs at both a large multi-specialty clinic and at a teaching hospital, though the clinic and hospital systems were mutually incompatible. The clinic system was particularly clunky, despite frequent upgrades that required relearning the system. The deal-breaker, as far as I was concerned, was that the complexity of the system and tsunami of drop-down boxes (see Dr. McNoble’s superb discussion above) which required me to face the computer and interact with it, while having an over-the-shoulder discussion with the patient. This was anathema to me. My decades-long practice style had been face-to-face positioning with maximum eye contact and body language that said, “You have my full attention.” How could any patient possibly trust me otherwise?

My response to this situation probably fell under the rubric of ‘civil disobedience’. I abandoned any attempt at real-time data entry and continued my career-long face-to-face style, scribbling brief paper notes as the encounter progressed. Between patients (or more likely at the end of the day) I would rush back to my office and do the computer data entry. Obviously everything took twice as long as before. (That’s an exaggeration. A factor of 1.4 to 1.5 is probably more realistic.) Obviously, my productivity plummeted. To their credit, the MBAs who had assumed the power positions in the organization let me be, though they could not have been happy with what I was doing.

Probably I got by with slow-walking the transition only because I was the senior member of the group and everyone knew the checkered flag could be seen from my windshield. Younger physicians and mid-level practitioners who tried that would probably have been tossed out on their respective ears.

This is not intended to be a diatribe against electronic health records in general. Nor is the word ‘data’ the plural of the word ‘anecdote’. I don’t claim that EHRs cannot work, only that I was unable to make them work. In spite of being reasonably tech-savvy for an old goat. Would that I could offer a quick and easy solution for this nettlesome situation, which has been so well documented by Yves, Dr. Noble, and multiple eloquent commenters. Or any solution. Sorry, I can’t. Perhaps someone much smarter than me can.

“In theory, there is no difference between theory and practice. In practice, there is.” Yogi Berra

Kudos to you, Yves, to Dr. McNoble and to NC’s unsurpassed commentariat.

apropos, recall my earlier post "Are structured data the enemy of health care quality?"
Also of relevance, "Clinical workflow, clinical cognition, and the Distracted Mind."

I'd like to have Dr. Jerome Carter's (EHR Science) take on this second McNoble post.
My own hands-on EHR experience has become increasingly dated. My personal Meaningful Use client caseload extended to 14 different EHR platforms -- all of them ambulatory systems (whereas Dr. McNoble's lament dwells on the inpatient environment, a significantly different, far more complex beast).

As far as UX goes, I can just personally observe that my experience the past few years (now simply as a patient and now again as a caregiver) has been pretty much "all Epic all the time" (with the exception of my radiation oncologist). I'm a patient in the John Muir system. Epic EHR. I had my prostate cancer 2nd opinion at Stanford Medical Center. Epic. My daughter is now a Kaiser cancer patient. Epic. She was evaluated for clinical trials at UCSF Medical Center. Epic. When I'm at these encounters, I always watch the clinicians' EHR interactions carefully. I think a lot of the complaints about EHRs are hyperbolic. The UX I repeatedly witness is thoroughly trained-up, fast, and efficient. None of which is to argue that it couldn't be better. QI is an endless process, not a goal.

And paper is not better, net. Not by a long shot. Neither for patients nor any other stakeholders.
BTW, Dr. McNoble has launched a blog over on the platform:
Welcome to Bad Medicine
Bad Medicine is intended to help patients obtain the best possible medical care and to best utilize their precious health care dollars. Sadly, there are many barriers which seemed designed to get between patients and good health care — hospital bureaucracies, insurance authorizations, physicians overcrowded schedules, incomprehensible electronic health records, lack of network providers. In this series of blogs I am going to try to address some of these problems and provide practical advice for obtaining the best and most thorough medical care…
I wish her well with this effort. Hope she gets traction.



From THCB:
Single-Payer is the American Way

As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?...
Interesting. She voted for Trump. Self-avowed "Liberal to the left of Bernie." See her interesting earlier post on her own blog,"The Legend of Health Care."


In my inbox today from Scientific American:
First Human Embryos Edited in the U.S., Scientists Say
Reports suggest researchers have altered DNA and made few errors

In a step that some of the nation’s leading scientists have long warned against and that has never before been accomplished, biologists in Oregon have edited the DNA of viable human embryos efficiently and apparently with few mistakes, according to a report in Technology Review.

The experiment, using the revolutionary genome-editing technique CRISPR-Cas9, was led by Shoukhrat Mitalipov of Oregon Health & Science University. It went beyond previous experiments using CRISPR to alter the DNA of human embryos, all of which were conducted in China, in that it edited the genomes of many more embryos and targeted a gene associated with a significant human disease.

“This is the kind of research that is essential if we are to know if it’s possible to safely and precisely make corrections” in embryos’ DNA to repair disease-causing genes,” legal scholar and bioethicist R. Alta Charo of the University of Wisconsin, Madison, told STAT. “While there will be time for the public to decide if they want to get rid of regulatory obstacles to these studies, I do not find them inherently unethical.” Those regulatory barriers include a ban on using National Institutes of Health funding for experiments that use genome-editing technologies in human embryos.

The first experiment using CRISPR to alter the DNA of human embryos, in 2015, used embryos obtained from fertility clinics that had such serious genetic defects they could never have developed. In the new work, Technology Review reported, Mitalipov and his colleagues created human embryos using sperm donated by men with the genetic mutation that they planned to try to repair with CRISPR. The embryos are described as “clinical quality.”…
Wow. Things are moving quickly.

More to comes...

Wednesday, July 26, 2017

Obamacare Repeal whiplash week

Given that federal health care policy will drive the incentives (pro and con) and actions of every stakeholder sector of the U.S. health space -- both across the breadth of the goods and services providers' sides and with respect to those of patients, all eyes are now on the Senate. By the time you start to post about developments, they seem to change materially.

Yesterday the Senate voted 51 to 50 (VP Pence casting the tie-breaker) on a "Motion to Proceed" to open debate on "Calendar 120, H.R. 1628," the 132 page "budget reconciliation" AHCA bill. This bill does nothing beyond repealing funding for most provisions of the ACA that impact the 2017 federal FY17 budget.

Critics of "repeal" had better be vigilant regarding a "bait and switch" bill, given the GOP insistence on quickly ramming through a vote.

Steve Findlay just posted on update comment on his latest THCB post How Insane Could This Get?
Another vote will occur today, on the bill to “repeal and delay.” It will fail, as did last night’s Better Care Reconciliation Act, version 2.5.

After that, it looks as is the “skinny” bill will be introduced, possibly as early as tomorrow.

This is not a bill that any senator has yet seen! And it’s unclear whether the Republican moderate camp or conservative camp will support it.

In keeping with the bizarre nature of this process, the contents of the skinny repeal bill do not seem to matter. They’ll be symbolic—allowing some Republicans to say they voted to repeal the individual and employer mandates, for example.

Rather, the skinny repeal bill is a vehicle and tactic. If it musters 51 votes, its passage would lead to a conference committee with the House. Negotiations could then continue in both chambers, possibly past the August 11 recess and into September, in search of a larger-scope bill that could garner enough R support to pass.

McCain’s passionate plea yesterday to his colleagues to stop all this nonsense and reach across the aisle on big issues like health care is unlikely to change anything, particularly since McCain ended up voting for BCRA hours after he said he would not...
I'd previously left my own comment under that THCB post:
Calendar No. 120, H.R. 1628, “The American Health Care Act” is the bill now voted on “Motion to Proceed” for Senate debate (via 51-50 vote, Pence tie-breaker). 132 pages at this point (in my PDF download). The word “repeal” occurs 42 times. Salient because it’s a “budget reconciliation” bill not subject to 60-vote supermajority. Only speaks to rescinding spending authority provisions granted the PPACA pertaining to THIS federal fiscal year (that’s what “budget reconciliation” means).

The phrase “the Secretary” appears 36 times (goes to HHS “regulatory discretion”). “Amend,” 100 times, “amended” specifically 67 times. THAT stuff has you scurrying over to the other laws cited for amendment.

Notable for its utter lack of specifics, beyond cutting funding for ACA provisions. Nil amount of “Replace” language.

Will have to watch closely for ‘bait and switch” updates.
And, another:
Pen-in-hand-sitting-waiting-in-the-Oval-Office Trump in particular just wants a bill to sign. He will never read the first word of it; he simply doesn’t care, all he wants is to be able to go on to his next red state Trumpkin MAGA eternal campaign rally and crassly brag about his “Great Win on Health Care.” There will be PLENTY of time later to blame everyone else for the inevitable subsequent Custerfluck.
The Brink of the Unthinkable
The Senate has started down a path America has never taken: dismantling the social safety net.

On Tuesday, the Senate—with the late, dramatic arrival of Sen. John McCain, who cast a deciding vote—opened the floor to Obamacare repeal. A procedural vote, it was the remarkable capstone of an unprecedented effort to pass major legislation without hearings, independent testimony, or public input. What makes it potentially history-making, and not just noteworthy, is that it also marks a milestone for our country: the beginning of what is, thus far, one of the most aggressive attempts at revoking a broad guarantee of the American welfare state. A door that, once opened, may prove difficult to close…
Obama Stays Silent on Health Care Debate. Here’s Why.
Democrats worry if President Obama tries to publicly save his health care law, he might kill it.

As the process for repealing and replacing Obamacare incrementally advances through Congress, its namesake remains largely absent from the give-and-take of the debate.
President Barack Obama has weighed into the health care fray only occasionally—and always from a distance—even as his eponymous signature piece of domestic legislation comes under heightened threat.

It is not for lack of want. Aides and advisers say that the former president is, like all Democrats, troubled by ability of Republican leadership to keep repeal efforts alive. One official said he did not expect GOP lawmakers to get even this far. But he is wary of engaging in a highly visible way, even in this critical hour, for fear that it would backfire politically.

“We are acutely aware that opponents of the Affordable Care Act would like no better foil than him,” said one Obama advisor. “We don’t want to make this any harder than it is. Allowing opponents to make this about Obama’s legacy undermines the debate about the actual impact of the law.”

For now, Hill Democrats say they’re comfortable with Obama at a distance. Though the party has been unable to stop repeal-and-replace efforts at critical junctures—the most recent coming in the form of a narrowly-lost vote to start debate in the Senate—the prospect of turning the debate into a Obama-v-Trump narrative is viewed as counterproductive...
I have to agree.

"Nice little state ya got here. Be a real shame if something bad happened to it."
Previously on KHIT, The Presidential Oaf of Office.


The Senate "Skinny Repeal" bill went down to defeat at about 3 a.m. EDT. I was up.

 I'm sure there will be more. The cluelessness. He has 52 GOP members in the Senate.
"Let Obamacare implode."

Beyond that fact that every health care goods and services delivery sector stakeholder group opposed these nihilistic GOP "repeal" bills, the average of the most recent public opinion polls (spanning the most conservative to the most liberal) indicate that 5 of 6 American voters oppose them as well (~16% repeal approval).


From Trump's Saturday tweetstorm.


More to come...

Thursday, July 20, 2017

The Presidential Oaf of Office

     Article II, Section 1:
...Before he enter on the execution of his office, he shall take the following oath or affirmation:--"I do solemnly swear (or affirm) that I will faithfully execute the office of President of the United States, and will to the best of my ability, preserve, protect and defend the Constitution of the United States."
     Article II, Section 3:
...he shall take care that the laws be faithfully executed...
 My thoughts on Facebook earlier today:
When you become U.S. President, you swear/affirm the Oath set forth in Article II, Section 1 of the Constitution to "faithfully execute the Office of the President" and to "preserve, protect, and defend the Constitution." What you are bound to "execute" is also set forth in Section 3: "he shall take care that the laws be faithfully executed." 

Today I read two articles detailing Trump's explicit statements and his administration's overt actions aimed at deliberately sabotaging the LAW that is still "Obamacare" (whatever your opinion of it) to help make sure it "fails," irrespective of how many citizens get hurt in the process.
"Team Trump Used Obamacare Money to Run PR Effort Against It"
"Trump’s Clueless Abdication of Presidential Responsibility"

To me, that should be impreachable right there -- willful contravention of his Oath of Office, with regard to a law directly and substantively impacting nearly 20% of the U.S. economy and nearly every life in the nation. This is not about dissing or subverting some tiny Capitol Park Police Dog Leash law.
Yeah, I know..."wish in one hand..." "tu quoque" (they all do it).


President Trump just gave the New York Times a bizarre, on-the-record, audio-recorded interview (the one during which he threw his Attorney General under the bus, insulted the FBI, and threatened Special Prosecutor Mueller). From the health care segment of the 7,500 word transcript:
TRUMP: Hi fellas, how you doing?
BAKER: Good. Good. How was your lunch [with Republican senators]?
TRUMP: It was good. We are very close. It’s a tough — you know, health care. Look, Hillary Clinton worked eight years in the White House with her husband as president and having majorities and couldn’t get it done. Smart people, tough people — couldn’t get it done. Obama worked so hard. They had 60 in the Senate. They had big majorities and had the White House. I mean, ended up giving away the state of Nebraska. They owned the state of Nebraska. Right. Gave it away. Their best senator did one of the greatest deals in the history of politics. What happened to him?
But I think we are going to do O.K. I think we are going to see. I mean, one of my ideas was repeal. But I certainly rather would get repeal and replace, because the next last thing I want to do is start working tomorrow morning on replace. And it is time. It is tough. It’s a very narrow path, winding this way. You think you have it, and then you lose four on the other side because you gave. It is a brutal process. And it was for Democrats, in all fairness. I mean, you think of Hillary Clinton, and you look, she went eight years — very capable — went eight years as the first lady, and could not get health care. So this is not an easy crack. The one thing I’ll say about myself, so, Obama was in there for eight years and got Obamacare. Hillary Clinton was in there eight years and they never got Hillarycare, whatever they called it at the time. I am not in here six months, and they’ll say, “Trump hasn’t fulfilled his agenda.” I say to myself, wait a minute, I’m only here a very short period of time compared to Obama. How long did it take to get Obamacare?

BAKER: March, March 2010.
TRUMP: So he was there for more than a year.
HABERMAN: Fourteen months.
TRUMP: And I’m here less than six months, so, ah, you know. Something to think about.
BAKER: We wrote the same stories, though, in August of 2009. “Obama can’t get it.”
SCHMIDT: It died several times.
HABERMAN: Several times.
TRUMP: Well, it was a tough one. That was a very tough one.
BAKER: He lost that election [the 2010 midterms].
TRUMP: Nothing changes. Nothing changes. Once you get something for pre-existing conditions, etc., etc. Once you get something, it’s awfully tough to take it away.
HABERMAN: That’s been the thing for four years. When you win an entitlement, you can’t take it back.
TRUMP: But what it does, Maggie, it means it gets tougher and tougher. As they get something, it gets tougher. Because politically, you can’t give it away. So pre-existing conditions are a tough deal. Because you are basically saying from the moment the insurance, you’re 21 years old, you start working and you’re paying $12 a year for insurance, and by the time you’re 70, you get a nice plan. Here’s something where you walk up and say, “I want my insurance.” It’s a very tough deal, but it is something that we’re doing a good job of.
HABERMAN: Am I wrong in thinking — I’ve talked to you a bunch of times about this over the last couple years, but you are generally of the view that people should have health care, right? I mean, I think that you come at it from the view of …
TRUMP: Yes, yes. [garbled]
TRUMP: So I told them today, I don’t want to do that. I want to either get it done or not get it done. If we don’t get it done, we are going to watch Obamacare go down the tubes, and we’ll blame the Democrats. And at some point, they are going to come and say, “You’ve got to help us.”

BAKER: Did the senators want to try again?
TRUMP: I think so. We had a great meeting. Was I late?
TRUMP: It was a great meeting. We had 51 show up, other than John.
BAKER: Senator McCain.
TRUMP: That’s a lot. Normally when they call for a meeting, you have like 20.
HABERMAN: How about the last one in June? Do you guys remember how many came?
TRUMP: Ah, 49. It was actually 48, but John McCain was there. But I guess we had 51 today, so that counts. That shows the spirit.
BAKER: Who is the key guy?
TRUMP: Well, they are all key. The problem is we have 52 votes. Don’t forget, you look at Obama, he had 60. That’s a big difference. So, we have 52 votes. Now, I guess we lose Susan Collins. I guess we lose Rand Paul. Then we can’t lose any votes. That is a very tough standard. Statistically, you want to bet on that all day long. With that being said, I think we had a great meeting. I think we had a great meeting.
HABERMAN: Where does it go from here, do you think?
TRUMP: Well, I say, let’s not vote on repeal. Let’s just vote on this. So first, they vote on the vote. And that happens sometime Friday?
HABERMAN: Next week.
TRUMP: Or Monday? Monday. And then they’ll vote on this, and we’ll see. We have some meetings scheduled today. I think we have six people who are really sort of O.K. They are all good people. We don’t have bad people. I know the bad people. Believe me, do I know bad people.
And we have a very good group of people, and I think they want to get there. So we’ll see what happens. But it’s tough.

SCHMIDT: How’s [Mitch] McConnell to work with?
TRUMP: I like him. I mean, he’s good. He’s good. It’s been a tough process for him.
HABERMAN: He’s taken on some water.
TRUMP: Yeah. It’s been a tough process for him. This health care is a tough deal. I said it from the beginning. No. 1, you know, a lot of the papers were saying — actually, these guys couldn’t believe it, how much I know about it. I know a lot about health care. [garbled] This is a very tough time for him, in a sense, because of the importance. And I believe we get there.
This is a very tough time for them, in a sense, because of the importance. And I believe that it’s [garbled], that makes it a lot easier. It’s a mess. One of the things you get out of this, you get major tax cuts, and reform. And if you add what the people are going to save in the middle income brackets, if you add that to what they’re saving with health care, this is like a windfall for the country, for the people. So, I don’t know, I thought it was a great meeting. I bet the number’s — I bet the real number’s four. But let’s say six or eight. And everyone’s [garbled], so statistically, that’s a little dangerous, right?

BAKER: Pretty tight.
TRUMP: I hope we don’t have any grandstanders. I don’t think we do.
TRUMP: I think it will be pretty bad for them if they did. I don’t think we have any — I think it would be very bad for — I think this is something the people want. They’ve been promised it...
Okeee-dokeee, then. Mr. Dunning-Kruger.
A new interview reveals Trump’s ignorance to be surprisingly wide-ranging
He doesn’t know what he doesn’t know.

Nobody knows everything, and certainly nobody who’s ever sat in the Oval Office has entered with a complete mastery of all the varied issues that land on the desk of the president of the United States.

But reading the transcript of Donald Trump’s recent interview with three New York Times reporters, two things stand out. One is the sheer range of subjects that Trump does not understand correctly — from French urban planning to health insurance to Russian military history to where Baltimore is to domestic policy in the 1990s to his own regulatory initiatives. The other is that Trump is determined, across the board, to simply bluff and bluster through rather than admitting to any uncertainty or gaps in his knowledge.

It’s an approach that’s certainly commonplace among Trump’s cohort of rich Manhattanites. People who’ve spent years surrounded by flatterers and lackeys eager to get their hands on their money tend to come away with an inflated sense of their own domains of competence. But precisely because the demands of the presidency are so unimaginably vast, it’s a frightening attribute in a chief executive.

The complete interview is a little bit hard to parse, since Trump keeps ducking off the record and the transcript interrupts. But it really is worth taking in the whole thing — the scope is breathtaking.

Trump doesn’t seem to know what health insurance is
Health care policy is very complicated, but most Americans have at least some passing familiarity with how health insurance works because most of us have health insurance.
Trump himself, meanwhile, has spent years as a top executive at a business that provides health insurance to its employees. So you would think that even if he were completely ignorant of every single topic of public policy, he would at least be aware that to provide a person with health insurance is expensive. It is, after all, an expense that his businesses incur…
Noted in my prior post,
"You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy." - Donald Trump, Oct 2016 Florida campaign rally.

The most powerful man on earth.

From my November 9th, 2016 post, What will the 45th President do about health care?

"We have to come up, and we can come up with many different plans. In fact, plans you don't even know about will be devised because we're going to come up with plans, -- health care plans -- that will be so good. And so much less expensive both for the country and for the people. And so much better.” 

- Donald Trump, September 14th, 2016 on the Dr. Oz show


From The New Yorker:

John Cassidy
Donald Trump’s Addled and Ominous Interview with the Times 

It is often said, and with ample reason, that much of what Donald Trump says isn’t worth a jot. As Tony Schwartz, Trump’s ghostwriter, noted last year, “lying is second nature to him.” When he isn’t telling outright whoppers, he exaggerates things outrageously, and his utterances often bear little resemblance from one day to the next. On Tuesday, he said that Republicans should let Obamacare crash and burn. On Wednesday, he said that he wanted to see it replaced.

But, whereas Trump’s statements often fail to withstand inspection when examined individually, analyzing a group of them together can sometimes provide valuable insights into his mind-set, which, at this time, appears to be even more addled than usual. The interview that Trump gave on Wednesday to three reporters from the Times offers us that opportunity...
I don't find any of this the slightest bit amusing, given the significant major policy issues our nation needs to be forthrightly addressing. Like, duh, health care?


Again, from The New Yorker, excellent, this from Amy Davidson Sorkin, spot-on:
...The Republican leadership’s argument of last resort, when whipping votes, has been that the Party has to do something dramatic about Obamacare simply because, for the past seven years, it has said that it would. That is an explanation of a quagmire, not a call to arms...

...McConnell has said that he will delay the Senate’s August recess, if necessary, to try for another vote on something: repeal, replace, or a thrown-together bill to be named later; his zigzagging mirrors that of the President. If this attempt fails, the backup plan seems to be to turn the matter over to the executive branch and let it commit whatever acts of regulatory, budgetary, and administrative vandalism it can, to break the system bit by bit. For example, it could withhold crucial cost-sharing subsidies, or decline to defend Obamacare against various lawsuits that its opponents, including the House Republicans, have brought against it...
Yep. Jus' sayin'. Taking care "that the laws be faithfully executed" -- what a quaint notion.


Yesterday President Trump inflicted himself on the 2017 Boy Scouts Jamboree in West Virginia.

More to come...OafTrumpcare

Tuesday, July 18, 2017

Senate GOP ObamaCare Repeal bill goes "poof"

a.k.a. "Trumpcare," though The Donald is "not going to take ownership."

John Irvine at THCB:

Senators Mike Lee and Jerry Moran said yesterday that they would not vote for the Better Care Reconciliation Act, effectively killing the legislation.  As anybody who has been following this story would have predicted, President Trump reacted publicly on Twitter on Tuesday morning, vowing to let the ACA marketplace collapse and then rewrite the plan later.

Senate Majority leader Mitch McConnell attempted a quick punt this morning, calling for an immediate Senate vote on the House bill, a trick card that if it worked, would give Republicans two years to work things out.

Unfortunately for McConnell, it probably won’t.

The White House sees the failure as saying more about the political establishment in Washington than itself, which shouldn’t be all that surprising…

So much for Article II, Section I of the Constitution and owning the faithful execution of the  laws. The ACA remains the law.

"You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy." - Donald Trump, Oct 2016 Florida campaign rally.
See my old post (2009) "Public Optional."


Dr. Adrian Gropper posted an interesting comment at THCB under the foregoing post:
The substantive changes that are about to happen in US healthcare will be driven by technology (artificial intelligence, telemedicine, blockchain identity, longitudinal health records), not politics.

Our institutions have little choice but to pretend they are still in control of their traditional roles. Congress may be the most obvious example today, but insurers, employers, and hospitals are also lost in the ether. None of these institutions is pitching a solution.

To stabilize healthcare in the face of massive technological change start with the tech, not the incumbents.
Well, one hopes, anyway. I guess we'll see.

Interesting observations from Bob Cesca -
At some point, congressional Republicans will entirely abandon President Donald Trump. How do we know this? If you look closely, you’ll notice that it’s already happening. One by one, Republicans on the Hill are growing tired of Trump’s poorly-informed, lazy, self-centered lack of leadership, and it’s a safe bet that more than a few members are wondering whether the 2018 midterms will turn out better without Trump dragging them down.

Whether this precipitates a Barry Goldwater Watergate moment in which Republican leadership hikes down the block to insist upon Trump’s resignation remains to be seen, but what’s immediately observable is that the Trump coalition is rapidly vaporizing, leaving the chief executive with fewer and fewer influential defenders in Congress. The rapid, awkward demise of Trumpcare and the president’s confounding reaction in the aftermath might’ve been the last straw in an already ungainly relationship between both ends of Pennsylvania Avenue.

Frankly, if I were Senate Majority Leader Mitch McConnell or Speaker Paul Ryan, I’d strongly consider cutting bait with Trump given the way he has repeatedly set them up to fail while doing little to exercise any kind of meager leadership. Without a substantive ally in the White House, it becomes less likely they’ll continue to tolerate and backstop his uneducated, rookie gibberish and social media outbursts, embarrassing the party and tainting it with the stink of his failed administration. How much longer will they continue to tolerate Trump playing honk-honk-goes-the-truck and tweeting on the john while they spend valuable political capital on legislation he barely understands and, despite his marketing acumen, has repeatedly fumbled?

The failure of Trumpcare was partly about the president’s lack of even a basic, entry-level sense of how a bill becomes a law. It was also partly about Trump’s running-on-fumes political capital. The whole concept of repealing and replacing Obamacare with the snap of his short fingers merely set up Trump and Congress to fail. Not only is it nearly impossible for conservatives to create a affordable, universal health care program, but it was never going to get done within a few short months, much less “on day one.” Since Congress was unable to match a lofty goal established by a political amateur, Trump set them up to fail…

I just wanna sing...

I wrote and recorded that five years ago after SCOTUS upheld the Constitutionality of the ACA.

Links to some relevant prior KHIT posts:
House Calls, STAT!
Paying for Health Care
An American Sickness
Rationing by 'Price.'
There are more. That's enough for now. And, oh, yeah, review "Making the world a better place."


"Nice little Senate seat ya got there. Be a shame if something bad happened to it."


What a difference four years makes, 'eh? 


GOP Arizona Senator John McCain has been diagnosed with a glioblastoma brain tumor. Hate to hear that. Blogged about those here.

More to come...OafTrumpcare

Saturday, July 15, 2017

"Making the world a better place?"

First, from my fav, the insanely over-the-top, (painfully and scatalogically) hilarious Silicon Valley HBO.

After watching that entire 4-season series (many episodes numerous times), I still now have doubts I can continue to cover Health IT sector events with a straight face.

I saw a WaPo article this week comprising an interview with 32 yr old prominent Bay Area techie Sam Altman (President of Y Combinator).
Why this Silicon Valley magnate is funding a new wave of political candidates

Still reeling from Donald Trump’s election, a prominent technologist is taking a page from powerful donors the Koch brothers, who remade state politics by recruiting and funding a new generation of GOP candidates.

Sam Altman, president of the Silicon Valley start-up incubator Y Combinator, announced Wednesday that he would spend from his personal fortune to enlist candidates who want to run for statewide office in California on a platform of “technology, economic fairness, and maintaining personal liberty.” The next races will be in 2018.

Altman, whose fund has helped launch companies such as Dropbox and Airbnb, is part of a wave of tech elites who are now looking to extend their influence beyond Silicon Valley into the wider political spectrum. Many of Altman’s contemporaries, including Mark Zuckerberg, saw Trump’s victory as a wake-up call, pushing them further into politics. Zuckerberg and Altman have gone on listening tours this year with the goal of hearing from Trump voters and people outside the Silicon Valley bubble…

A tech dude with both a brain and a heart. "Still reeling from Donald Trump's election..." Me too, bro'.

Promptly went to his site "The United Slate."
I want to find and support a slate of candidates for the 2018 California elections. I think the current political process is not surfacing the best possible candidates, and our government is suffering for it. I want to help candidates who believe in creating prosperity through technology, economic fairness, and maintaining personal liberty.

Today, we have massive wealth inequality, little economic growth, a system that works for people born lucky, and a cost of living that is spiraling out of control. Most young people think their lives will be worse than their parents’ lives, which should set off alarm bells for us all.

Most people’s lives are not what they pictured—they feel like they have great potential that is being wasted.

We are in the middle of a massive technological shift—the automation revolution will be as big as the agricultural revolution or the industrial revolution. We need to figure out a new social contract, and to ensure that everyone benefits from the coming changes.

We need to get back to a functioning government. If the process can work again, we have a chance to solve our biggest problems.

Our government is in the way of this vision—it rigs the system in favor of a small number of special interests and campaign donors at the cost of everyone else. In the process, our government has gotten us into an unsustainable financial bubble and has given up on fiscal responsibility itself. California is on a trajectory to go bankrupt.

We can have a better world—we can have affordable housing, free health care, a great education system, economic security, and a healthy planet. We can also have opportunity, fulfilling work, and a voice in the future for everyone. It won’t be easy, but it’s also not impossible—we need new candidates who understand the future.

I think California is the right place to start this—we’re the 6th largest economy in the world, and we have a long history of leading this country. We can lead the way here…

I am a product of our time—I got a computer when I was eight years old, and technology has been my obsession and career ever since. I understand its potential for both good and bad. I am simultaneously nervous and excited about the world we are creating, and I’d like to live in the best version we can build…

My heart is on the left, but I’m a pragmatist. I want to use technology to generate a lot of prosperity, and use some of it to pay for programs to make life better for everyone. There is a massive technological shift coming to society, and we can either benefit from it or be hurt by it.

I was one of the last children of the American Century. I’m not quite ready to let it go. If we don’t take action now, the US will be surpassed as the world superpower. I’d like to get back to the values that made our country the envy of the world. I still believe in American exceptionalism, and even with Trump in the White House, my proudest identity of all is being American…

Three Principles

These are three principles I strongly believe in.

  1. Prosperity from technology
  2. Economic fairness
  3. Personal liberty
1. Prosperity from technology

Creating prosperity is how everyone’s lives get better every year.

Most real economic growth comes from technological progress. The US government has turned its back on this basic law of economics, and no longer provides funding for our best and brightest to build a better future. Instead, we’ve built an increasingly financialized economy, and steal from our future with debt. We are getting beaten by other countries.

Obviously, technology cannot solve everything, and getting policy right is more important than just getting the technology right…

2. Economic fairness

The economic growth we generate must be shared by all Americans. We can’t stand for a society in which all of the gains (or more recently, more than all of the gains—life has gotten worse for a lot of people) from progress accrue to a small number of individuals.

I’ve benefited from our current system in a way that would have been nearly impossible for a poor person born just a few miles from where I grew up, where it feels like a different country. The two most important gifts I got in life were the love of my parents and a great education—a great education should be a right for every child.

I believe that economic justice is social justice, and that we will not have true justice until all Americans, regardless of their background or how they look, have equal economic opportunity…

3. Personal liberty

Freedom is the bedrock of America. We must preserve and defend the freedom to choose who we are, what we want to be, what we do with our bodies, how we want to express ourselves, and maintain our privacy in the face of technology. The authoritarian streak currently running through the country is deeply troubling to me.

These are my 3 core principles, but a lot of people probably agree with them. Here are 10 more specific policy proposals I’d like to see candidates enact.

Ten Policy Goals

Here are 10 policy goals I’d like to see candidates work towards enacting.

  1. Lower the cost of living, especially housing
  2. Move to a Medicare-for-all system over time by gradually reducing the age of eligibility
  3. Set a target of 90% clean energy in the country by 2050
  4. World-class education
  5. We need to reform our tax system
  6. Shift 10% of our $600 billion annual defense budget to the research and development of future technologies
  7. Fair trade and fair jobs
  8. Expand the social safety net
  9. A fair government
  10. World-class infrastructure
"Move to a Medicare-for-all system." See down in my prior post.

I signed up to contribute however I can. We shall see. There's no time to waste. In Valley VC-speak, we have a "short runway."

Go to Sam's United Slate site, read all of it. Consider participating.
I forwarded it on to my wife. Told her she should consider running. "Right. In my spare time." "But, baby, 'Women Leaders' and all that.You are a Leader." (She most certainly is.)
Doubt that I'm gonna get any traction there. We got a continuing, indeterminate full plate anyway these days.
Also recommend you read the book "Four Futures."

I've cited it on this blog before. See, e.g., "What might Artificial Intelligence bring to humanity."

My concern regarding our sociopolitical trajectory toward a "Quadrant IV" remains.

The nice thing I see in Sam's idea is that he doesn't conflate "personal liberty" with the sophomoric (albeit broadly tech-cohort fashionable) "Libertarianism" -- the latter of which gets you dystopian, untenable stuff like Uber.

As I reflect on Sam Altman's foregoing humane, reasoned "United Slate" proffer, I am reminded of Facebook CEO Mark Zuckerberg's (HR Dept cringeworthy) assertion that "young people are just smarter." Regarding the tech elites among them, I can't disagree -- as to the "intellectual" aspect, anyway. Whether their aggregate relative distribution of prosocial "moral intelligence" is better than that of us "elders," well, I don't know at this point. In any event, this younger demographic is going to have to live a lot longer with the consequences of our sociopolitical shortcomings than people like me. So, it's entirely appropriate that they take a good whack at politics and leadership.


Interesting Salon article:
A vote for moral technology: Updating Reinhold Niebuhr to the age of Donald Trump
The great theologian's understanding of irony and hubris can help us figure out what happened, and where we go next

It’s the incongruities that perplex and provoke so many of us. The ideal versus the real. It’s hard to look at the imposing U.S. Capitol, all that strong, gleaming marble, and realize at the same time how the nation’s elected representatives have failed at their primary job: improving the lives of those who elected them. We have learned that “those who elected them” doesn’t even mean what the Constitution intended. Disgusting negative ads elected them. Money elected them. A minority of the eligible population voted – inertia reelected them. Politicians are professional fundraisers who principally target “swing voters.” This is who we are now.

Our idealized democracy is obviously not even close to a perfect system for obtaining the wisest deliberator as president. The inordinately long, obscenely costly campaign process, imitating nothing so much as a repetitive TV miniseries, is, effectively, a register of party loyalty, not a measure of the viability of one or another policy direction. With all the talent that exists in the United States – the scientists, engineers, artists, givers, problem-solvers – look what we have now: an inarticulate man of limited imagination, who worships himself and appears to care about nothing and no one else, and least of all the truth. He convinced 63 million people to vote for him.

We – the millions of us who voted a different way – feel corrupted by his undeserved presence in our lives, his repetitive bad behavior, his pettiness, his petulance, his arrogance. Our values have been betrayed, and we are all somehow, in some way, complicit. We didn’t do enough to help voters see through him. We allowed democracy to become a business in the hands of public relations firms, pollsters, financiers and advertisers. And tweets. Sad!...
Well, resonates with Sam's United Slate vision, no?

All of which resonates with George Lakoff's "Don't Think of an Elephant."

From the Amazon blurb:
Ten years after writing the definitive, international bestselling book on political debate and messaging, George Lakoff returns with new strategies about how to frame today’s essential issues.

Called the “father of framing” by The New York Times, Lakoff explains how framing is about ideas—ideas that come before policy, ideas that make sense of facts, ideas that are proactive not reactive, positive not negative, ideas that need to be communicated out loud every day in public.

The ALL NEW Don’t Think of an Elephant! picks up where the original book left off—delving deeper into how framing works, how framing has evolved in the past decade, how to speak to people who harbor elements of both progressive and conservative worldviews, how to counter propaganda and slogans, and more.

In this updated and expanded edition, Lakoff, urges progressives to go beyond the typical laundry list of facts, policies, and programs and present a clear moral vision to the country—one that is traditionally American and can become a guidepost for developing compassionate, effective policy that upholds citizens’ well-being and freedom.
Sam, you can count me in. Who's with me? Time's a wastin'. "Short runway."


How about a bit of music? One of my Swedish friends hipped me to this cat, Henrik Hansson (Swede by birth, lives in Japan). Listen to the lyrics.

Got no time for second-guessing,
Got no time for lookin’ back,
Don’t need anybody’s blessing,
Ain’t like all those fools
Playin’ by the rules.

When the night is over
He won’t realize
Who is real and who is in disguise.
He just plays along,
Don't know right from wrong...
'eh? Anyone come to mind via the lyrics?

More to come...