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Crisis: Hospitals in Houston ‘Are Full” With New Covid-19 Patients

Reprinted with permission from ProPublica

HOUSTON — Houston hospitals have been forced to treat hundreds of COVID-19 patients in their emergency rooms — sometimes for several hours or multiple days — as they scramble to open additional intensive care beds for the wave of seriously ill people streaming through their doors, according to internal numbers shared with NBC News and ProPublica.

At the same time, the region's 12 busiest hospitals are increasingly telling emergency responders that they cannot safely accept new patients, at a rate nearly three times that of a year ago, according to data reviewed by reporters.

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As Virus Overtakes Texas, Houston Hospitals Face Crisis

Reprinted with permission from ProPublica.

HOUSTON — At Lyndon B. Johnson Hospital on Sunday, the medical staff ran out of both space for new coronavirus patients and a key drug needed to treat them. With no open beds at the public hospital, a dozen COVID-19 patients who were in need of intensive care were stuck in the emergency room, awaiting transfers to other Houston area hospitals, according to a note sent to the staff and shared with reporters.

A day later, the top physician executive at the Houston Methodist hospital system wrote to staff members warning that its coronavirus caseload was surging: "It has become necessary to consider delaying more surgical services to create further capacity for COVID-19 patients," Dr. Robert Phillips said in the note, an abrupt turn from three days earlier, when the hospital system sent a note to thousands of patients, inviting them to keep their surgical appointments.

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State Coronavirus Data Debunk Trump’s False Testing Claims

Reprinted with permission from ProPublica.


President Donald Trump and Vice President Mike Pence have repeatedly attributed the increase in the coronavirus case count in the United States to an increase in testing.

“We're doing so much testing, so much more than any other country," Trump said in an interview with CBN News on Monday. “And to be honest with you, when you do more testing, you find more cases. And then they report our cases are through the roof."

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How America’s Hospitals Survived The First Wave Of The Pandemic

Reprinted with permission from ProPublica.

The prediction from New York Gov. Andrew Cuomo was grim.

In late March, as the number of COVID-19 cases was growing exponentially in the state, Cuomo said New York hospitals might need twice as many beds as they normally have. Otherwise there could be no space to treat patients seriously ill with the new coronavirus.

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Here’s The Message You Need To Heed In This Crisis: Stay Home!

Reprinted with permission from ProPublica.

On Saturday afternoon, Sen. Ted Cruz took to Twitter to ask his followers to heed the advice of public health officials and politicians on the other side of the aisle:

“If you can stay home, stay home,” the Texas Republican wrote. “And wash your hands.”

Hours later, the Republican governor of Oklahoma tweeted from a packed restaurant in Oklahoma City showing that he is performatively not doing this. “Eating with my kids and all my fellow Oklahomans at the @CollectiveOKC. It’s packed tonight! #supportlocal #OklaProud”

He deleted the tweet an hour later.

On Sunday morning, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, told CBS’ “Face the Nation,” “Right now, personally, myself, I wouldn’t go to a restaurant.”

Meanwhile, Rep. Devin Nunes, a California Republican, spoke on Fox News and said, “If you’re healthy, you and your family, it’s a great time to just go out, go to a local restaurant, likely you can get in easy. Let’s not hurt the working people in this country … go to your local pub.”

Stay Home, Even if You Feel Fine

The discordant messages underscore the immense challenges conveying common messages during a public health crisis, one that has happened time and again as the novel coronavirus that causes COVID-19 has swept across the country.

“The most important thing is for people to change their daily routines and really reduce their social interactions,” said Dr. Joshua Sharfstein, a former federal and state health official who is now vice dean for public health practice and community engagement for the Bloomberg School of Public Health at Johns Hopkins University.

“I don’t think it is the consistent message from all health and political officials. If people are going to change the way they live their lives, they need to hear about the need to do that from every credible source of information they have because if they get mixed messages it’s easy to lapse back to not changing.”

From the availability of testing to the need to avoid handshakes, from where patients should go if they develop symptoms to whether to touch your face, the messages — and the actions by the public officials and even sometimes the doctors delivering those messages — have been contradictory.

Go to the ER; Don’t Go to the ER

One day last week, for example, a New York City allergy practice sent patients an email telling them what to do if they suspect they have symptoms consistent with infection with COVID-19.

“As you may be aware, there is a shockingly low number of available tests, and all testing now is done through local emergency departments in the area,” the note read.

Hours later, the advice was retracted: “It has been brought to our attention that the recommendation to visit the ED if one suspects COVID19 is incorrect. One should call their primary care provider to be screened and whether a visit to a lab or emergency department is necessary. … We are sorry for the confusion.”

While the government’s inability to get coronavirus tests in the hands of doctors and local health departments has been roundly criticized for preventing leaders from understanding how the virus is spreading, the mixed messages being given by leaders and others throughout this outbreak threatens to have a continuing effect.

“In some places, at least, there’s an advice vacuum and that leaves a lot of people trying to figure out what’s available and what to do,” Sharfstein said.

Conflicting Information Causes Real Harm

Accurate information is the coin of the realm in public health emergencies such as this one. Setting expectations and sharing accurate information is vital, experts say.

At all levels of government and medicine, that hasn’t happened.

During a visit to the Centers for Disease Control and Prevention this month, President Donald Trump said: “Anybody that wants a test can get a test. That’s what the bottom line is.” In fact, tests were not available. And public health officials told doctors and patients seeking them that they didn’t qualify.

The failure to provide clear answers has continued regarding the availability of ventilators in the event hospitals are overloaded. Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, was asked on Fox News whether hospitals could run out in a crisis. Several times, she didn’t answer the question. “Well, that’s why we have an emergency preparedness system,” Verma responded. “We’re used to dealing with disasters.”

On ABC’s “This Week” on Sunday morning, Fauci was more direct when asked whether the federal ventilator stockpile would be enough: “That may not be enough if we have a situation where we really have a lot of cases.”

The gap between government messages and reality applies to travel as well. Trump restricted travel from Europe and imposed additional health checks on Americans returning from European countries to protect Americans from the virus. “This president is going to continue to take every step necessary to protect the American people and put the health of the American people first,” Vice President Mike Pence said Saturday.

Yet, hours later, airports in Dallas, Chicago and Washington, D.C., were teeming with crowds waiting to get through the immigration checks. Some lamented that they were being exposed to others who may have the virus, the exact opposite of the stated reason for the additional checks.

Mark Morgan, acting commissioner of U.S. Customs and Border Protection, tweeted on Sunday morning that his agency is “aware of the reports of increased wait times at some airports across the nation. CBP along with medical personnel are working diligently to address the longer than usual delays. Nothing is more important than the safety, health and security of our citizens.”

Hours later, Morgan wrote another tweet, calling the waits at some airports “unacceptable.”

Do as I Say, Not as I Do

It goes beyond that. Public health officials have repeatedly called for members of the public to stop shaking hands, but the president has been resisting that advice, at least so far. “Shaking hands is not a great thing to be doing right now, I agree,” Trump said Saturday. “But people put their hand out. Sometimes I’ll put the hand out. You don’t think about it. People are thinking about it more and more. We have to think about it; it’s important.”

Public health officials also have told the public to avoid touching their faces, but sometimes those same officials have touched their faces. A public health official in California held a press conference to tell the public to avoid touching their faces, during which she licked a finger to turn a page in her remarks. (As this reporter has learned, it’s nearly impossible to stop touching your face.)

In a column in The Washington Post, two experts say communication is key, and sports and cultural icons should be brought in to reinforce important messages.

“A communications failure in the face of a pandemic amounts to not just a political problem; it is a public health problem,” wrote Lorien Abroms, a professor and associate dean at the Milken Institute School of Public Health at George Washington University, and Kenneth Baer, a communications consultant and former associate director of communications at the White House Office of Management and Budget.

“Communications can also be the solution: What is needed to help mitigate the severity of the coronavirus epidemic is a few, simple messages delivered by the right messengers. We need a whole-of-culture response — not just political leaders, but also the most influential athletes, actors, social media influencers, singers and personalities using every medium at our disposal to encourage Americans to change their behavior and inspire us to stick with it.”

The Tough Days Ahead

In the days ahead, consistent public health messages will be crucial, Sharfstein said, particularly if the virus continues spreading and places a burden on hospitals. Patients will need to know who to call if they get sick and when and where to seek medical care. Doctors will need to know where to send their patients.

In most cases, the answer is to avoid sending patients to the emergency room if they are showing mild or moderate symptoms of the virus. Those who become sicker or develop trouble breathing should follow up immediately with doctors or seek emergency care.

“A test itself is not treatment,” Sharfstein said. “A test illuminates what’s going on a little bit better. The response may just be to stay at home and monitor yourself. While it’s better to have more testing capability, we’re not powerless because the major response is just going to be to stay at home.”

Report: ‘Extreme’ Use Of Painkillers And Doctor Shopping Plague Medicare

Reprinted with permission from ProPublica.

In Washington, D.C., a Medicare beneficiary filled prescriptions for 2,330 pills of oxycodone, hydromorphone and morphine in a single month last year — written by just one of the 42 health providers who prescribed the person such drugs.

In Illinois, a different Medicare enrollee received 73 prescriptions for opioid drugs from 11 prescribers and filled them at 20 different pharmacies. He sometimes filled prescriptions at multiple pharmacies on the same day.

These are among the examples cited in a sobering new report released today by the inspector general of the U.S. Department of Health and Human Services. The IG found that heavy painkiller use and abuse remains a serious problem in Medicare’s prescription drug program, known as Part D, which serves more than 43 million seniors and disabled people. Among the findings:

  • Of the one-third of Medicare beneficiaries in Part D (or roughly 14.4 million people) who filled at least one prescription for an opioid in 2016, some 3.6 million received the painkillers for at least six months.
  • Consistent with data released last week by the Centers for Disease Control and Prevention, there were wide geographic differences in prescribing patterns. Alabama and Mississippi had the highest proportions of patients taking prescription painkillers — more than 45 percent each — while Hawaii and New York had the lowest — 22 percent or less.
  • More than half a million beneficiaries received high doses of opioids for at least three months, meaning they took the equivalent of 12 tablets a day of 10-milligram Vicodin. The figure does not include patients who have cancer or those who are in hospice care, for whom such doses may be appropriate.
  • Almost 70,000 beneficiaries received what the inspector general labeled as extreme amounts of the drugs — an average daily consumption for the year that was more than 2 1/2 times the level the CDC recommends avoiding. Such doses put patients at an increased risk of overdose death. Extreme prescribing could also indicate that a patient’s identity has been stolen, or that the patient is diverting medications for resale.
  • Some 22,000 beneficiaries seem to be doctor shopping — obtaining large amounts of the drugs prescribed by four or more doctors and filled at four or more pharmacies. All states except for Missouri operate Prescription Drug Monitoring Program databases that allow doctors to check whether their patients have received drugs from other doctors before writing their own prescriptions.
  • More than 400 doctors, nurse practitioners and physician assistants had questionable prescribing patterns for the beneficiaries most at risk (meaning those that took extreme doses of the drugs or showed signs of doctor shopping). One Missouri prescriber wrote an average of 31 opioid prescriptions each for 112 patients on Medicare. And four doctors in the same Texas practice ordered opioids for more than 56 beneficiaries who seemed to be doctor shopping. “The patterns of these 401 prescribers are far outside the norm and warrant further scrutiny,” the inspector general said.

To be sure, many seniors suffer from an array of painful conditions, and some opioids are seen as more harmful and addictive than others. Tramadol, often used to treat chronic osteoarthritis pain, was the most frequently prescribed opioid and carries a lower risk of addiction than other opioids, according to the Drug Enforcement Administration.

Moreover, last week’s report from CDC shows that painkiller use is ticking downward after years of explosive growth.

Still, officials in the inspector general’s office said more can and should be done to combat the problems they observed, even if the numbers are beginning to subside.

“I think what we’re saying here is this is still a lot of Medicare beneficiaries,” said Jodi Nudelman, regional inspector general for evaluation and inspections in the New York regional office, who supervised the report. “Regardless of if you are turning a corner, you’re still at these really high levels.”

The inspector general previously has called for Medicare to use its data to focus on doctors who are prescribing drugs in aberrant ways.

The inspector general’s numbers differ somewhat from an April report from the Centers for Medicare and Medicaid Services, which runs Medicare. The CMS report said that 29.6 percent of Part D enrollees used opioids in 2016, down from 31.9 percent in 2011. The inspector general pegged the 2016 figure at 33 percent but did not offer any historical comparisons. It was unclear why the two agencies came up with different figures.

In a statement, CMS said opioid abuse is a priority for the Trump administration. “We are working with patients, physicians, health insurance plans, and states to improve how opioids are prescribed by health care providers and used by patients, how opioid use disorder is diagnosed and managed, and how alternative approaches to pain management could be promoted,” it said.

Officials have known for years that opioid prescribing has been a problem in Medicare. ProPublica first highlighted the problem in 2013 when we published data on the drugs prescribed by every physician in the Part D program. Following that report, CMS put in place what it called an Overutilization Monitoring System, which tracked beneficiaries at the highest risk for overdoses or drug abuse. It asked the private insurance companies that run the drug program on its behalf, under contract, to review the cases and provide a response.

In a memo released in April, CMS said its monitoring system has been a success. From 2011 to 2016, it said, there was a 61 percent decrease in the number of beneficiaries who were labeled as “potential very high risk opioid overutilizers.” People were flagged that way if they were taking high doses of opioids for 90 consecutive days and received prescriptions from three or more doctors at three or more pharmacies. But the agency also said it would be implementing changes in January to better target those at highest risk of abuse.

Separately, in 2014, CMS told health providers they would have to register with the Medicare program in order to prescribe medications for beneficiaries. That way, the government could screen them and take action if their prescribing habits were deemed improper. Up to that point, doctors could prescribe drugs to Medicare patients even if they weren’t registered Medicare providers. Delay after delay has pushed back the requirement until 2019.

Dr. Cheryl Phillips, senior vice president for public policy and health services at LeadingAge, an association of nonprofit service providers for older adults, said managing pain in seniors is complex. Seniors are more likely to have conditions, such as orthopedic problems, cancer or degenerative joint disorders, which result in chronic pain. They sometimes don’t react well to non-prescription pain relievers, such as Tylenol, aspirin or nonsteroidal anti-inflammatory medicines. Health care providers like nursing homes are still evaluated, in part, on how well they manage pain, creating an incentive to turn to drugs.

“We have to challenge the notion that being pain free is a goal,” Phillips said. “It’s not that I want to see people suffering, but being pain free is perhaps a myth that not only society has been seduced with but physicians have as well.”

Phillips said she encourages physicians to explore nondrug alternatives, including meditation, mindfulness, moist heat and exercise.

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Medicare Halts Release Of Much-Anticipated Data

Reprinted with permission from ProPublica.
by Charles Ornstein

In the past few years, many seniors and disabled people have eschewed traditional Medicare coverage to enroll in privately run health plans paid for by Medicare, which often come with lower out-of-pocket costs and some enhanced benefits.

These so-called Medicare Advantage plans now enroll more than a third of the 58 million beneficiaries in the Medicare program, a share that grows by the month.

But little is known about the care delivered to these people, from how many services they get to which doctors treat them to whether taxpayer money is being well-spent or misused.

The government has collected data on patients’ diagnoses and the services they receive since 2012 and began using it last year to help calculate payments to private insurers, which run the Medicare Advantage plans. But it has never made that data public.

Officials at the Centers for Medicare and Medicaid Services have been validating the accuracy of the data and, in recent months, were preparing to release it to researchers. Medicare already shares data on the 38 million patients in the traditional Medicare program, which the government runs. (ProPublica has created a tool called Treatment Tracker that enables people to compare how doctors and others use services in the traditional Medicare program.)

The grand unveiling of the new data was scheduled to take place at the annual research meeting of AcademyHealth, a festival of health wonkery, which just concluded in New Orleans.

But at the last minute, the session was canceled.

The change caught researchers — and even some former Medicare officials — off guard as the data’s release was a highly anticipated expansion of the government’s effort to share information.

In a statement, CMS said there were enough questions about the data’s accuracy that it should not be released for research use. CMS said it will examine the data for 2015 “to determine if it is robust enough to support research use.”

Niall Brennan, until January the chief data officer of the Centers for Medicare and Medicaid Services, worked on the data — known as encounter data — during his time in office. “Hugely disappointing,” he tweeted, with a photo of the sign announcing the session’s cancellation. “Hope CMS not backsliding on #opendata.”

In response to a question about whether the data had problems, he tweeted, “Like any new data source [Medicare Advantage] data had some quirks to be sure but if it was used for payment why can’t it be used for research?” he said in a tweet this week.

Health economist Austin Frakt, who is affiliated with a number of academic institutions, said he was disappointed by the decision to halt the data’s release. He said he wants access to the data as a researcher — and as a taxpayer. “We are paying an enormous amount of money to private insurance companies … but we know very little about what we’re getting for that money,” he said.

Frakt notes that researchers know “vastly more” about traditional Medicare because the data has been available for decades. “The claim is that private insurers are innovating in ways that traditional program is not. We need to validate that. We need to know what they’re doing for the benefit of everyone. We can’t do that without the data.”

Frakt acknowledged that the data has limitations, “but I don’t think it justifies withholding the data. … Researchers are highly skilled at dealing with messy data. We’ve done it before.”

In recent years, private insurers that run Medicare Advantage plans have been under fire for allegedly overcharging Medicare. The Center for Public Integrity reported last year that more than three dozen audits had found that plans overstated the severity of enrollees’ medical conditions to garner more money. (The Center had to file a Freedom of Information lawsuit to access the audits.) In 2014, the Center’s reporting suggested that insurers had collected $70 billion in improper payments from 2008 to 2013.

The Department of Justice recently intervened in two federal lawsuits in Los Angeles (here and here) accusing UnitedHealth Group of providing “untruthful and inaccurate information about the health status of beneficiaries” to boost its revenues. The company has denied wrongdoing.

If the data on Medicare Advantage plans was made available to researchers, it could shed light on these kinds of issues.

For its part, the insurance industry has been raising questions about the accuracy of the encounter data but said it did not ask CMS administrator Seema Verma to delay its release to researchers.

“The system used to capture encounter data has numerous unresolved operational and technical issues and fails to capture a reliable, comprehensive picture of beneficiaries’ diagnoses,” a spokeswoman for America’s Health Insurance Plans said in an email. “This could put payments at risk, which could also increase premiums and decrease benefits. We look forward to working with Administrator Verma and CMS to improve the encounter data and address these issues.”

Earlier this year, the Government Accountability Office issued a report calling on CMS to do more to validate the completeness and accuracy of the encounter data before using it as a basis for paying the health plans.

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Veterans Affairs Official Downplays Agent Orange Risks, Questions Critics

Reprinted with permission from ProPublica.
by Charles Ornstein

A key federal official who helps adjudicate claims by veterans who say they were exposed to Agent Orange has downplayed the risks of the chemical herbicide and questioned the findings of scientists, journalists and even a federal administrative tribunal that conflict with his views.

Jim Sampsel, a lead analyst within the Department of Veterans Affairs’ compensation service, told a VA advisory committee in March that he believes much of the renewed attention to Agent Orange — used during the Vietnam War to kill brush and deny cover to enemy troops — is the result of media “hype” and “hysteria,” according to a transcript of the meeting released to ProPublica.

“When it comes to Agent Orange, the facts don’t always matter,” said Sampsel, himself a Vietnam veteran who also handles Gulf War-related illness questions. “So we have to deal with the law as written.”

Part of Sampsel’s job entails reviewing evidence to determine whether a veteran or group of veterans came in contact with Agent Orange outside of Vietnam. By law, veterans are presumed to have been exposed to Agent Orange if they served or stepped foot in Vietnam; they have to prove exposure if they served at sea or in another country during the war. They also must have a disease that the VA ties to exposure to the herbicide.

“From my point of view, I will do anything to help veterans, any legitimate veteran, and I’ve done it plenty of times,” he told the Advisory Committee on Disability Compensation, a group that advises the VA. “Unfortunately when it comes to this Agent Orange, we have to have a lot of denials.”

Sampsel also offered a window, for the first time, into ongoing internal deliberations at the VA about adding new diseases to the list of those connected to Agent Orange exposure. He suggested that despite increasing evidence tying the herbicide to hypertension, or high blood pressure, the VA is not going to extend benefits to veterans with that condition.

Reached by phone, Sampsel said, “You’re going to try to frame me, too,” before referring a reporter to the VA’s media relations office. ProPublica and The Virginian-Pilot examined the effects of Agent Orange on veterans and their offspring in a series of articles in 2015 and 2016, raising questions about the VA’s handling of the matter.

The VA provided two written statements in response to questions for this article. Initially, a spokesman said that Sampsel was speaking as an individual at the meeting, and not for the VA.

“The objective of a federal advisory committee is to have open and public discussion of the issues for which it is chartered from the experts who understand and bring their own unique perspectives,” the statement said. “The March 2017 meetings were no exception and Mr. Sampsel’s comments did not fully or accurately reflect VA’s position concerning these issues.”

The VA said no decisions have been made about which new diseases to add to its list of those linked to Agent Orange exposure.

Asked whether it continued to support Sampsel, the VA said in a subsequent statement that he “is highly dedicated and respected within and outside of VA for the work he has done to establish many of the present policies that provide veterans, their families and survivors the benefits they are entitled to under the law.” The department also questioned the quotes a reporter asked about from the advisory committee meeting. “Taking quotes out of context without fully understanding the law, science, reasons or intent behind those words is a disservice to the advisory committee and the veteran community at large as well as Mr. Sampsel.” (Read the full transcript.)

Veteran advocates said they were furious to learn a VA official charged with objectively weighing evidence related to Agent Orange had shared controversial personal views.

Rick Weidman, legislative director for Vietnam Veterans of America, said he met with VA Secretary David Shulkin last week and told him, among other things, that Sampsel and others in the Veterans Benefits Administration need to be replaced. “Where they are now is doing active evil,” Weidman said. He added that he doesn’t expect Sampsel and other VA employees to necessarily be advocates “but we do expect them to be neutral and honest arbiters of science — and they are not.”

Although Agent Orange hasn’t been used in more than 40 years, it remains controversial because it contained dioxin, one of the world’s most toxic chemicals. Its effects can take decades to show up. Scientists continue to associate exposure to Agent Orange with diseases, and the VA continues to weigh whether to extend benefits to groups who say they were exposed to it outside of Vietnam.

Members of Congress who are leaders on veterans’ issues said the VA has an obligation to care for vets injured by Agent Orange. “I strongly believe we must do everything in our power to ensure veterans struggling with negative health effects as a result of exposure to Agent Orange receive the care and compensation they deserve; we owe nothing less to these brave men and women who have sacrificed more than enough for our country,” Rep. Tim Walz, D-Minn., the ranking Democrat on the House Committee on Veterans’ Affairs, said in a statement.

Among Sampsel’s statements:

  • He said he believes Agent Orange contained “very, very small amounts” of dioxin, which was quickly destroyed by sunlight and the open air. “That’s not commonly acknowledged by advocates,” he said. Moreover, Sampsel said, U.S. planes did not spray it when American troops were in the area.

    In fact, a report by the Aspen Institute notes that on leaf and soil surfaces, dioxin will last one to three years and that dioxin under the surface could have a half-life of more than 100 years. Moreover, scientists have said that there are numerous ways in which American troops may have been exposed to the herbicide and some disagree that few troops were exposed.

  • Sampsel pushed back against claims that veterans who served outside of Vietnam were exposed to Agent Orange. “When we get to outside of Vietnam, there’s a lot of controversy about Agent Orange use. And primarily it’s media hype, in my opinion.”

    In fact, veterans who served in Thailand, near the Korean demilitarized zone, in Okinawa, Japan, and aboard ships off the coast of Vietnam contend they were exposed in a variety of ways. Some have produced memos, photos and testimonials that have been enough to convince the Board of Veterans Appeals, the VA’s tribunal, that there was sufficient evidence to prove exposure and that they were entitled to benefits.

  • Sampsel criticized the Board of Veterans Appeals for its decisions. “BVA is, can do anything they want. I don’t know if everybody understands BVA. BVA has caused a lot of, what I would call misinformation about Agent Orange issues.”

    A member of the advisory panel, Thomas J. Pamperin, responded to Sampsel at the March meeting: “A decision by the Board of Veterans Appeals is the secretary’s final decision. I mean, we can’t distance ourselves from the Board of Veterans Appeals. It is part of the VA.”

    And in its statement, the VA said it, too, respects the BVA. “BVA is the highest appellate authority in VA,” it said. “They are attorneys who review the evidence of record and make decisions.” While the VA may not always agree with a decision, “their decisions are final and are implemented when issued.”

  • Sampsel criticized the prestigious Institute of Medicine, a congressionally chartered research organization hired by the VA, which in 2015 determined that the evidence suggested that a group of Air Force reservists could have been exposed to Agent Orange years after the Vietnam War when they flew aboard the C-123 planes that had been used to spray the herbicide.

    “One scientist from Harvard or somewhere said that dried, solidified TCDD dioxin never stops emanating molecules into the air,” Sampsel said. “Hardly anybody bought that at the time, but the IOM went with it.”

    He added a bit later: “I don’t think the science supports it. Most scientists don’t think the science supports it, but the law is what it is.”

    The Institute of Medicine, now called the National Academy of Medicine, found that the dioxin present on the aircraft could have exposed reservists who flew the planes years later. In its report, it said one contention of the VA and its expert, Alvin Young, was “inaccurate,” another “appears to be conjecture and not evidence-based” and a third was based on a study funded by Dow Chemical Co., one of the herbicide’s makers.

    In its statement, the VA said the Institute of Medicine “provides a valuable service to VA.”

  • Sampsel favorably cited Young, an Air Force officer, federal official and later the government’s go-to consultant, who has guided the stance of the military and the VA on Agent Orange and whether it has harmed service members. “I’m not the scientist,” Sampsel said at one point. “But I know that Dr. Alvin Young and the majority, the vast majority, of scientists don’t think that anybody gets any harmful effects from something that’s in the soil, buried in the soil.”

    But ProPublica and The Virginian-Pilot reported last fall that critics say Young’s work is compromised by inaccuracies, inconsistencies or omissions of key facts, and relies heavily on his previous work, some of which was funded by Monsanto Co. and Dow Chemical Co., the makers of Agent Orange. Young also served as an expert for the chemical companies in 2004 when Vietnam vets sued them. In an interview at the time, Young defended his work.

  • Sampsel said Young’s research showed that Agent Orange “never went to the Philippines, never went to Okinawa, never went to Guam,” as some veterans contend.

    A member of the panel interjected because he felt that Sampsel was being overly broad.

    “I’m sorry. I’m sorry. Yes, yes. You’re, you’re absolutely correct,” Sampsel said, noting he should have said there was currently no evidence. “And if evidence does show up, we’ll certainly change our policy. … You’re right.”

During his presentation, Sampsel also summarized internal deliberations within the VA about which diseases should be formally linked to Agent Orange. Last year, the Institute of Medicine said there is now evidence to suggest that Agent Orange exposure may be linked to bladder cancer and hypothyroidism. It also confirmed, as previous experts have said, that there is some evidence of an association with hypertension, stroke and various neurological ailments similar to Parkinson’s Disease.

Since then, a VA-led study has found stronger evidence to link hypertension to Agent Orange exposure. The VA has been reviewing the matter since last year to decide whether to cover the diseases.

Sampsel said the Veterans Health Administration had recommended that the VA acknowledge the connection between Agent Orange and hypertension, but that benefits officials at the VA worked to kill that effort and believe they succeeded.

“I believe the secretary, the information I got recently, is not going to go with hypertension. As to the other ones, there’s the likelihood that they’ll become added to the list,” Sampsel said.

The VA, in its statement, said it could not comment on internal discussions “other than to say those deliberations are underway.” But it did note that no recommendations had gone to the secretary for his consideration.

If the VA ultimately decides to add hypertension to its list of covered diseases, it could be costly. Hypertension is the most common ailment among veterans seeking health care at the VA — indeed it is one of the most common ailments among older adults generally.

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Trump’s Not The Only One Blocking Constituents On Twitter

Reprinted with permission from ProPublica.

As President Donald Trump faces criticism for blocking users on his Twitter account, people across the country say they, too, have been cut off by elected officials at all levels of government after voicing dissent on social media.

In Arizona, a disabled Army veteran grew so angry when her congressman blocked her and others from posting dissenting views on his Facebook page that she began delivering actual blocks to his office.

A central Texas congressman has barred so many constituents on Twitter that a local activist group has begun selling T-shirts complaining about it.

And in Kentucky, the Democratic Party is using a hashtag, #BevinBlocked, to track those who’ve been blocked on social media by Republican Gov. Matt Bevin. (Most of the officials blocking constituents appear to be Republican.)

The growing combat over social media is igniting a new-age legal debate over whether losing this form of access to public officials violates constituents’ First Amendment rights to free speech and to petition the government for a redress of grievances. Those who’ve been blocked say it’s akin to being thrown out of a town hall meeting for holding up a protest sign.

On Tuesday, the Knight First Amendment Institute at Columbia University called upon Trump to unblock people who’ve disagreed with him or directed criticism at him or his family via the @realdonaldtrump account, which he used prior to becoming president and continues to use as his principal Twitter outlet.

“Though the architects of the Constitution surely didn’t contemplate presidential Twitter accounts, they understood that the president must not be allowed to banish views from public discourse simply because he finds them objectionable,” Jameel Jaffer, the Knight Institute’s executive director, said in a statement.

The White House did not respond to a request for comment, but press secretary Sean Spicer said earlier Tuesday that statements the president makes on Twitter should be regarded as official statements.

Similar flare-ups have been playing out in state after state.

Earlier this year, the American Civil Liberties Union of Maryland called on Gov. Larry Hogan, a Republican, to stop deleting critical comments and barring people from commenting on his Facebook page. (The Washington Post reported that the governor had blocked 450 people as of February.)

Deborah Jeon, the ACLU’s legal director, said Hogan and other elected officials are increasingly foregoing town hall meetings and instead relying on social media as their primary means of communication with constituents. “That’s why it’s so problematic,” she said. “If people are silenced in that medium,” they can’t effectively interact with their elected representative.

The governor’s office did not respond to a request for comment this week. After the letter, however, it reinstated six of the seven people specifically identified by the ACLU (it said it couldn’t find the seventh). “While the ACLU should be focusing on much more important activities than monitoring the governor’s Facebook page, we appreciated them identifying a handful of individuals — out of the over 1 million weekly viewers of the page — that may have been inadvertently denied access,” a spokeswoman for the governor told the Post.

Practically speaking, being blocked cuts off constituents from many forms of interacting with public officials. On Facebook, it means no posts, no likes and no questions or comments during live events on the page of the blocker. Even older posts that may not be offensive are taken down. On Twitter, being blocked prevents a user from seeing the other person’s tweets on his or her timeline.

Moreover, while Twitter and Facebook themselves usually suspend account holders only temporarily for breaking rules, many elected officials don’t have established policies for constituents who want to be reinstated. Sometimes a call is enough to reverse it, other times it’s not.

Eugene Volokh, a constitutional law professor at the UCLA School of Law, said that for municipalities and public agencies, such as police departments, social media accounts would generally be considered “limited public forums” and therefore, should be open to all.

“Once they open it up to public comments, they can’t then impose viewpoint-based restrictions on it,” he said, for instance allowing only supportive comments while deleting critical ones.

But legislators are different because they are people. Elected officials can have personal accounts, campaign accounts and officeholder accounts that may appear quite similar. On their personal and campaign accounts, there’s little disagreement that officials can engage with — or block — whoever they want. Last month, for instance, ProPublica reported how Rep. Peter King, R-N.Y., blocked users on his campaign account after they criticized his positions on health reform and other issues.

But what about their officeholder social media accounts?

The ACLU’s Jeon says that they should be public if they use government resources, including staff time and office equipment to maintain the page. “Where that’s the situation and taxpayer resources are going to it, then the full power of the First Amendment applies,” she said. “It doesn’t matter if they’re members of Congress or the governor or a local councilperson.”

Volokh of UCLA disagreed. He said that members of Congress are entitled to their own private speech, even on official pages. That’s because each is one voice among many, as opposed to a governor or mayor. “It’s clear that whatever my senator is, she’s not the government. She is one person who is part of a legislative body,” he said. “She was elected because she has her own views and it makes sense that if she has a Twitter feed or a Facebook page, that may well be seen as not government speech but the voice of somebody who may be a government official.”

Volokh said he’s inclined to see Trump’s @realdonaldtrump account as a personal one, though other legal experts disagree.

“You could imagine actually some other president running this kind of account in a way that’s very public minded — ‘I’m just going to express the views of the executive branch,'” he said. “The @realdonaldtrump account is very much, ‘I’m Donald Trump. I’m going to be expressing my views, and if you don’t like it, too bad for you.’ That sounds like private speech, even done by a government official on government property.”

It’s possible the fight over the president’s Twitter account will end up in court, as such disputes have across the country. Generally, in these situations, the people contesting the government’s social media policies have reached settlements ending the questionable practices.

After being sued by the ACLU, three cities in Indiana agreed last year to change their policies by no longer blocking users or deleting comments.

In 2014, a federal judge ordered the City and County of Honolulu to pay $31,000 in attorney’s fees to people who sued, contending that the Honolulu Police Department violated their constitutional rights by deleting their critical Facebook posts.

And San Diego County agreed to pay the attorney’s fees of a gun parts dealer who sued after its Sheriff’s Department deleted two Facebook posts that were critical of the sheriff and banned the dealer from commenting. The department took down its Facebook page after being sued and paid the dealer $20 as part of the settlement.

Angela Greben, a California paralegal, has spent the past two years gathering information about agencies and politicians that have blocked people on social media — Democrats and Republican alike — filing ethics complaints and even a lawsuit against the city of San Mateo, California, its mayor and police department. (They settled with her, giving her some of what she wanted.)

Greben has filed numerous public-records requests to agencies as varied as the Transportation Security Administration, the Seattle Police Department and the Connecticut Lottery seeking lists of people they block. She’s posted the results online.

“It shouldn’t be up to the elected official to decide who can tweet them and who can’t,” she said. “Everybody deserves to be treated equally and fairly under the law.”

Even though she lives in California, Greben recently filed an ethics complaint against Atlanta Mayor Kasim Reed, a Democrat, who has been criticized for blocking not only constituents but also journalists who cover him. Reed has blocked Greben since 2015 when she tweeted about him … well, blocking people on Twitter. “He’s notorious for blocking and muting people,” she said, meaning he can’t see their tweets but they can still see his.

In a statement, a city spokeswoman defended the mayor, saying he’s now among the top five most-followed mayors in the country. “Mayor Reed uses social media as a personal platform to engage directly with constituents and some journalists. … Like all Twitter users, Mayor Reed has the right to stop engaging in conversations when he determines they are unproductive, intentionally inflammatory, dishonest and/or misleading.”

Asked how many people he has blocked, she replied that the office doesn’t keep such a list.

J’aime Morgaine, the Arizona veteran who delivered blocks to the office of Rep. Paul Gosar, a Republican, said being blocked on Facebook matters because her representative no longer hosts in-person town hall meetings and has started to answer questions on Facebook Live. Now she can’t ask questions or leave comments.

“I have lost and other people who have been blocked have lost our right to participate in the democratic process,” said Morgaine, leader of Indivisible Kingman, a group that opposes the president’s agenda. “I am outraged that my congressman is blocking my voice and trampling upon my constitutional rights.”

Morgaine said the rules are not being applied equally. “They’re not blocking everybody who’s angry,” she said. “They’re blocking the voices of dissent, and there’s no process for getting unblocked. There’s no appeals process. There’s no accountability.”

A spokeswoman for Gosar defended his decision to block constituents but did not answer a question about how many have been blocked.

“Congressman Gosar’s policy has been consistent since taking office in January 2010,” spokeswoman Kelly Roberson said in an email. “In short: ‘Users whose comments or posts consist of profanity, hate speech, personal attacks, homophobia or Islamophobia may be banned.'”

On his Facebook page, Gosar posts the policy that guides his actions. It says in part, “Users are banned to promote healthy, civil dialogue on this page but are welcome to contact Congressman Gosar using other methods,” including phone calls, emails and letters.

Sometimes, users are blocked repeatedly.

Community volunteer Gayle Lacy was named 2015 Wacoan of the Year for her effort to have the site of mammoth fossils in Waco, Texas, designated a national monument. Lacy’s latest fight has been with her congressman, Bill Flores, who was with her in the Oval Office when Obama designated the site a national monument in 2015. She has been blocked three times by Flores’ congressional Twitter account and once by his campaign account. One of those blocks happened after she tweeted at him: “My father died in service for this country, but you are not representative of that country and neither is your dear leader.”

Lacy said she was able to get unblocked each time from Flores’ congressional account by calling his office but remains blocked on the campaign one. “I don’t know where to call,” she said. “I asked in his D.C. office who I needed to call and I was told that they don’t have that information.”

Lacy and others said Flores blocks those who question him. Austin lawyer Matt Miller said he was blocked for asking when Flores would hold a town hall meeting. “It’s totally inappropriate to block somebody, especially for asking a legitimate question of my elected representative,” Miller said.

In a statement, Flores spokesman Andre Castro said Flores makes his policies clear on Twitter and on Facebook. “We reserve the right to block users whose comments include profanity, name-calling, threats, personal attacks, constant harping, inappropriate or false accusations, or other inappropriate comments or material. As the Congressman likes to say — ‘If you would not say it to your grandmother, we will not allow it here.'”

Ricardo Guerrero, an Austin marketer who is one of the leaders of a local group opposed to Trump’s agenda, said he has gotten unblocked by Flores twice but then was blocked again and “just kind of gave up.”

“He’s creating an echo chamber of only the people that agree with him,” Guerrero said of Flores. “He’s purposefully removing any semblance of debate or alternative ideas or ideas that challenge his own — and that seems completely undemocratic. That’s the bigger issue in my mind.”

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Three Strategies To Defend GOP Health Bill: Euphemisms, False Statements And Deleted Comments

Reprinted with permission from ProPublica.
by Charles Ornstein

Earlier this month, a day after the House of Representatives passed a bill to repeal and replace major parts of the Affordable Care Act, Ashleigh Morley visited her congressman’s Facebook page to voice her dismay.

“Your vote yesterday was unthinkably irresponsible and does not begin to account for the thousands of constituents in your district who rely upon many of the services and provisions provided for them by the ACA,” Morley wrote on the page affiliated with the campaign of Rep. Peter King, R-N.Y. “You never had my vote and this confirms why.”

The next day, Morley said, her comment was deleted and she was blocked from commenting on or reacting to King’s posts. The same thing has happened to others critical of King’s positions on health care and other matters. King has deleted negative feedback and blocked critics from his Facebook page, several of his constituents say, sharing screenshots of comments that are no longer there.

“Having my voice and opinions shut down by the person who represents me — especially when my voice and opinion wasn’t vulgar and obscene — is frustrating, it’s disheartening, and I think it points to perhaps a larger problem with our representatives and maybe their priorities,” Morley said in an interview.

King’s office did not respond to requests for comment.

As Republican members of Congress seek to roll back the Affordable Care Act, commonly called Obamacare, and replace it with the American Health Care Act, they have adopted various strategies to influence and cope with public opinion, which polls show mostly opposes their plan. ProPublica, with our partners at Kaiser Health News, Stat and Vox, has been fact-checking members of Congress in this debate and we’ve found misstatements on both sides, though more by Republicans than Democrats. The Washington Post’s Fact Checker has similarly found misstatements by both sides.

Today, we’re back with more examples of how legislators are interacting with constituents about repealing Obamacare, whether online or in traditional correspondence. Their more controversial tactics seem to fall into three main categories: providing incorrect information, using euphemisms for the impact of their actions, and deleting comments critical of them. (Share your correspondence with members of Congress with us.)

Incorrect Information

Rep. Vicky Hartzler, R-Mo., sent a note to constituents this month explaining her vote in favor of the Republican bill. First, she outlined why she believes the ACA is not sustainable — namely, higher premiums and few choices. Then she said it was important to have a smooth transition from one system to another.

“This is why I supported the AHCA to follow through on our promise to have an immediate replacement ready to go should the ACA be repealed,” she wrote. “The AHCA keeps the ACA for the next three years then phases in a new approach to give people, states, and insurance markets plenty of time to make adjustments.”

Except that’s not true.

“There are quite a number of changes in the AHCA that take effect within the next three years,” wrote ACA expert Timothy Jost, an emeritus professor at Washington and Lee University School of Law, in an email to ProPublica.

The current law’s penalties on individuals who do not purchase insurance and on employers who do not offer it would be repealed retroactively to 2016, which could remove the incentive for some employers to offer coverage to their workers. Moreover, beginning in 2018, older people could be charged premiums up to five times more than younger people — up from three times under current law. The way in which premium tax credits would be calculated would change as well, benefiting younger people at the expense of older ones, Jost said.

“It is certainly not correct to say that everything stays the same for the next three years,” he wrote.

In an email, Hartzler spokesman Casey Harper replied, “I can see how this sentence in the letter could be misconstrued. It’s very important to the Congresswoman that we give clear, accurate information to her constituents. Thanks for pointing that out.”

Other lawmakers have similarly shared incorrect information after voting to repeal the ACA. Rep. Diane Black, R-Tenn., wrote in a May 19 email to a constituent that “in 16 of our counties, there are no plans available at all. This system is crumbling before our eyes and we cannot wait another year to act.”

Black was referring to the possibility that, in 16 Tennessee counties around Knoxville, there might not have been any insurance options in the ACA marketplace next year. However, 10 days earlier, before she sent her email, BlueCross BlueShield of Tennessee announced that it was willing to provide coverage in those counties and would work with the state Department of Commerce and Insurance “to set the right conditions that would allow our return.”

“We stand by our statement of the facts, and Congressman Black is working hard to repeal and replace Obamacare with a system that actually works for Tennessee families and individuals,” her deputy chief of staff Dean Thompson said in an email.

On the Democratic side, the Washington Post Fact Checker has called out representatives for saying the AHCA would consider rape or sexual assault as pre-existing conditions. The bill would not do that, although critics counter that any resulting mental health issues or sexually transmitted diseases could be considered existing illnesses.

Euphemisms

A number of lawmakers have posted information taken from talking points put out by the House Republican Conference that try to frame the changes in the Republican bill as kinder and gentler than most experts expect them to be.

An answer to one frequently asked question pushes back against criticism that the Republican bill would gut Medicaid, the federal-state health insurance program for the poor, and appears on the websites of Rep. Garret Graves, R-La., and others.

“Our plan responsibly unwinds Obamacare’s Medicaid expansion,” the answer says. “We freeze enrollment and allow natural turnover in the Medicaid program as beneficiaries see their life circumstances change. This strategy is both fiscally responsible and fair, ensuring we don’t pull the rug out on anyone while also ending the Obamacare expansion that unfairly prioritizes able-bodied working adults over the most vulnerable.”

That is highly misleading, experts say.

The Affordable Care Act allowed states to expand Medicaid eligibility to anyone who earned less than 138 percent of the federal poverty level, with the federal government picking up almost the entire tab. Thirty-one states and the District of Columbia opted to do so. As a result, the program now covers more than 74 million beneficiaries, nearly 17 million more than it did at the end of 2013.

The GOP health care bill would pare that back. Beginning in 2020, it would reduce the share the federal government pays for new enrollees in the Medicaid expansion to the rate it pays for other enrollees in the state, which is considerably less. Also in 2020, the legislation would cap the spending growth rate per Medicaid beneficiary. As a result, a Congressional Budget Office review released Wednesday estimates that millions of Americans would become uninsured.

Sara Rosenbaum, a professor of health law and policy at the Milken Institute School of Public Health at George Washington University, said the GOP’s characterization of its Medicaid plan is wrong on many levels. People naturally cycle on and off Medicaid, she said, often because of temporary events, not changing life circumstances — seasonal workers, for instance, may see their wages rise in summer months before falling back.

“A terrible blow to millions of poor people is recast as an easing off of benefits that really aren’t all that important, in a humane way,” she said.

Moreover, the GOP bill actually would speed up the “natural turnover” in the Medicaid program, said Diane Rowland, executive vice president of the Kaiser Family Foundation, a health care think tank. Under the ACA, states were only permitted to recheck enrollees’ eligibility for Medicaid once a year because cumbersome paperwork requirements have been shown to cause people to lose their coverage. The American Health Care Act would require these checks every six months — and even give states more money to conduct them.

Rowland also took issue with the GOP talking point that the expansion “unfairly prioritizes able-bodied working adults over the most vulnerable.” At a House Energy and Commerce Committee hearing earlier this year, GOP representatives maintained that the Medicaid expansion may be creating longer waits for home- and community-based programs for sick and disabled Medicaid patients needing long-term care, “putting care for some of the most vulnerable Americans at risk.”

Research from the Kaiser Family Foundation, however, showed that there was no relationship between waiting lists and states that expanded Medicaid. Such waiting lists pre-dated the expansion and they were worse in states that did not expand Medicaid than in states that did.

“This is a complete misrepresentation of the facts,” Rosenbaum said.

Graves’ office said the information on his site came from the House Republican Conference. Emails to the conference’s press office were not returned.

The GOP talking points also play up a new Patient and State Stability Fund included in the AHCA, which is intended to defray the costs of covering people with expensive health conditions. “All told, $130 billion dollars would be made available to states to finance innovative programs to address their unique patient populations,” the information says. “This new stability fund ensures these programs have the necessary funding to protect patients while also giving states the ability to design insurance markets that will lower costs and increase choice.”

The fund was modeled after a program in Maine, called an invisible high-risk pool, which advocates say has kept premiums in check in the state. But Sen. Susan Collins, R-Maine, says the House bill’s stability fund wasn’t allocated enough money to keep premiums stable.

“In order to do the Maine model — which I’ve heard many House people say that is what they’re aiming for — it would take $15 billion in the first year and that is not in the House bill,” Collins told Politico. “There is actually $3 billion specifically designated for high-risk pools in the first year.”

Deleting Comments

Morley, 28, a branded content editor who lives in Seaford, New York, said she moved into Rep. King’s Long Island district shortly before the 2016 election. She said she did not vote for him and, like many others across the country, said the election results galvanized her into becoming more politically active.

Earlier this year, Morley found an online conversation among King’s constituents who said their critical comments were being deleted from his Facebook page. Because she doesn’t agree with King’s stances, she said she wanted to reserve her comment for an issue she felt strongly about.

A day after the House voted to repeal the ACA, Morley posted her thoughts. “I kind of felt that that was when I wanted to use my one comment, my one strike as it would be,” she said.

By noon the next day, it had been deleted and she had been blocked.

“I even wrote in my comment that you can block me but I’m still going to call your office,” Morley said in an interview.

Some negative comments about King remain on his Facebook page. But King’s critics say his deletions fit a broader pattern. He has declined to hold an in-person town hall meeting this year, saying, “to me all they do is just turn into a screaming session,” according to CNN. He held a telephonic town hall meeting but only answered a small fraction of the questions submitted. And he met with Liuba Grechen Shirley, the founder of a local Democratic group in his district, but only after her group held a protest in front of his office that drew around 400 people.

“He’s not losing his health care,” Grechen Shirley said. “It doesn’t affect him. It’s a death sentence for many and he doesn’t even care enough to meet with his constituents.”

King’s deleted comments even caught the eye of Andy Slavitt, who until January was the acting administrator of the Centers for Medicare and Medicaid Services. Slavitt has been traveling the country pushing back against attempts to gut the ACA.

Since the election, other activists across the country who oppose the president’s agenda have posted online that they have been blocked from following their elected officials on Twitter or commenting on their Facebook pages because of critical statements they’ve made about the AHCA and other issues.

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Secret Hospital Inspections May Become Public At Last

Reprinted with permission from ProPublica.
by Charles Ornstein 

The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation’s hospitals that put patients’ health and safety at risk, under a groundbreaking proposal from federal health officials.

The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by those accreditors, not the government.

There’s increasing concern among regulators that private accreditors aren’t picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.

In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity “raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies” during inspections, CMS officials wrote when they released draft regulations including the proposed change on Friday.

The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool, Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.

Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.

But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS’ proposed rules are designed to fix this.

“We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements” publicly available, CMS officials wrote.

“It’s huge, absolutely,” says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. “Right now the public has very little information about the places where they’re putting their life on the line, and that’s just not acceptable. If you’re a good place, what are they afraid of?”

Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.

To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn’t fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.

State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commission conducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise. Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,018 hospitals listed on the The Joint Commission’s website, more than 99 percent have full accreditation and only seven are on track to lose their “gold seal of approval.”

The Joint Commission said it is reviewing the CMS proposal and couldn’t comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. “We haven’t talked to our hospital partners,” says Gary Ley, its executive director. “It would be a major change for them also. It’s hard not to support the goals but we have to look at the execution.”

For its part, the American Hospital Association said it supports providing the public “useful information” about hospital quality, but has doubts that detailed inspection reports fit that description.

“It’s important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,” says Nancy Foster, AHA’s vice president of quality and patient safety, in a statement. “We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.”

Foster says it might be more useful to provide a one- or two-page “accurate summary” of inspection findings, with “key takeaways” and why they are important. “This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,” Foster says.

For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, the Chicago Tribune reported how The Joint Commission gave its seal of approval to “medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.”

Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a “Top Performer in Key Quality Measures” by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it “is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.”

In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it “is proud of the care it provides patients at Shadow Mountain Behavioral Health.”

On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, even when hospitals are described as receiving a “preliminary denial of accreditation.” For one hospital, the explanation is: “Existence at time of survey of a condition, which in The Joint Commission’s view, poses a threat to patients or other individuals served.” The threat itself is not disclosed.

Consumers Union’s Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. “The information that’s available now is so minimal and would not really inform anyone about real quality of a hospital,” she says.

Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.

Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so.

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On Health Reform, Democrats And Republicans Don’t Speak The Same Language

Turns out that Democrats have more to say than Republicans when it comes to legislation that would repeal major parts of the Affordable Care Act, better known as Obamacare.

With the House set to vote today on the Republican replacement plan, called the American Health Care Act, we decided to look at the messages coming from members of both parties.

A ProPublica review of 576 press releases posted on the websites of representatives and senators since Jan. 20 found that a higher proportion of Democrats have released statements criticizing the GOP bill than Republicans have backing it.

Though Republicans control both houses of Congress, many have stayed silent, at least on their websites. Sen. Richard Shelby, an Alabama Republican, put out a press release last week about a study of red snapper in the Gulf of Mexico, but nothing on health care. (You can see all of the statements in ProPublica’s Represent news app, which tracks votes and statements by members of Congress.)

Among members of the House, where the action is now focused, about 46 percent of Republicans have issued statements about health care reform from the start of the Trump administration to this week. Among Democrats, 67 percent.

The dynamics are similar in the Senate, which would take up the bill if and when it passes the House. Only 35 percent of Republicans have weighed in, compared to 60 percent of Democrats and independents who caucus with them.

All told, Republicans have issued some 240 press releases about health reform; Democrats and independents at least 336. (The analysis includes statements members have posted on their websites and doesn’t include statements to reporters or on social media.) House Speaker Paul Ryan, R-Wisc., had the most of any member, 36, four times as many as the next-highest statement-writer, Rep. Diana DeGette, D-Colo.

Moreover, Democrats are much more united in their opposition to the repeal-and-replace bill than Republican members are in support, according to our analysis.

Dr. David Blumenthal, president of the Commonwealth Fund, a health care nonprofit in New York, said that doesn’t surprise him. When the Affordable Care Act was under consideration in 2009 and 2010, Republicans were united in their opposition while Democratic support was “quite fractured,” said Blumenthal, who was the national coordinator for health information technology during the early years of the Obama administration.

Blumenthal said this dynamic is “part of the burden of governance and the opportunity of opposition.”

“When you are in the driver’s seat, as the Republican majority is at this point, you are forced to look in detail at the thing you want to try to create, and that can be sobering, whereas the opposition has a much easier time drawing lines in the sand.”

A lot can be gleaned by the words officials use — and avoid.

The Words Democrats Use:

Medicaid, the joint federal-state health insurance program for the poor. The Affordable Care Act allowed states to expand Medicaid to cover millions more people living in poverty or near-poverty, including childless adults. The GOP bill would cut Medicaid spending by $880 billion over the next decade, according to the Congressional Budget Office.

About half of the press releases we analyzed, 285, mention Medicaid. And of those, 198 came from Democrats. “42,200 individuals in our Congressional District who are covered by the ACA’s Medicaid expansion now stand to lose coverage if Washington Republicans eliminate Medicaid expansion,” wrote Rep. Cheri Bustos, D-Ill., echoing what many colleagues did by personalizing the data for her district.

When they do raise the issue, Republicans said their plan makes needed changes to Medicaid. “We also refocus Medicaid’s limited resources to the patients most in need,” said Rep. Tom Rice, R-S.C.

Congressional Budget Office. Of the 213 statements mentioning the CBO or Congressional Budget Office, only 28 came from Republicans. Democrats mentioned the CBO in two ways: At first, they criticized Republicans for considering the bill before having the results of the CBO analysis; then Democrats held up the CBO report, also called a score, as proof that the law would roll back many of the gains made by the ACA.

“The report released today by the non-partisan Congressional Budget Office underscores that the Republican health care bill will result in millions of currently-insured Americans no longer having coverage,” wrote Rep. Steve Cohen, D-Tenn.

The few Republicans who addressed the CBO analysis, including Speaker Ryan, pointed to its conclusion that the legislation would reduce the deficit and said the GOP bill is only the first step in a multipart plan to reform the health care system.

Trump. President Donald Trump remains a polarizing figure and Democrats are trying to tie the repeal legislation to him personally, dubbing it “Trumpcare.” Of the 216 mentions of Trump in the releases, 141 came from Democrats and independents. “Trumpcare is a great deal for insurance companies,” Rep. David N. Cicilline, D-R.I. wrote. “It’s a great deal for drug companies. But it’s a really bad deal for hardworking Americans.”

By contrast, Republicans who mention Trump do so in the context of working with his administration and his commitments to change health care delivery.

24 million. One hundred thirty-five statements mention this figure — the number of Americans projected by the CBO to lose health insurance by 2026 under the Republican proposal. Of those, only four are from Republican members. “Under Trumpcare, middle class families will pay more for less care, and 24 million Americans may lose their coverage altogether,” wrote Rep. Dan Kildee, D-Mich.

The Words Republicans Use:

Obamacare. Early on, the ACA was dubbed “Obamacare” in an attempt by Republicans to tie it to the president. Over time, Obama himself tried to co-opt the phrase to make the point that “Obama cares.” Some public polling shows that people do not know that the ACA and Obamacare are one and the same, favoring the former while opposing the latter. The term Obamacare was mentioned in 228 releases. A whopping 196 of them were by Republicans, often to emphasize the program’s negative effects. “Obamacare is collapsing under its own weight, driving up health care costs, and limiting options for individuals and families,” wrote Rep. Jackie Walorski, R-Ind.

Choice. One of the GOP selling points about their proposal is that it lets people choose whether they want insurance and which plan to buy, freeing them from many current requirements. Of the 154 statements that mention the word “choice” or “choose,” 133 of them come from Republicans. “We are driving down costs and giving patients more choice in their health care,” Rep. Michael Burgess, R-Texas, a physician, said in a statement.

One of the few Democrats to mention the word, Rep. Donald Beyer, D-Va., wrote, “The President promised a healthcare program that would ‘expand choice, increase access, lower costs, and at the same time, provide better health care.’ The bill which House Republicans unveiled last night does none of these things.”

Mandate. The ACA requires that employers provide coverage to their workers and that Americans be covered by health insurance — or pay a penalty. The so-called employer and individual mandates are unpopular with Republicans because they are perceived as requiring people to buy health insurance they may not want or need. Of the 111 releases that mentioned mandates, 93 were by Republicans. “We are providing a more consumer focused marketplace, not a government mandate with burdensome taxes,” wrote Rep. John Carter, R-Texas.

Relief. GOP lawmakers say their legislation provides relief from the requirements of the ACA. Of the 81 statements that use this word, 78 are from Republicans. “For years, Nebraskans have called on us to provide relief from Obamacare’s rising premiums and dwindling choices,” said Rep. Adrian Smith, R-Neb. “Too many Americans have been hurt by this failing law, and now we finally have the opportunity to reset our health care system.”

Check out all statements in ProPublica’s Represent tool.