MU & HITECH: The Death of EHR Innovation

In 2009 the Obama Administration became the drivers of healthcare policy by implementing a series of legislative acts including the HITECH Act and its Meaningful Use (MU) standards. Over the last eight years, sweeping reforms and regulations effectively transformed the world’s 5th best healthcare system into an industry riddled with frustration. Today, many question the advantages of such regulations while others desperately yearn for the pre MU days of healthcare.

There is no doubt MU and HITECH had positive impacts on the healthcare industry at large. For example, the Medicaid EHR incentive program has increased EHR adoption in hospitals from 11.9% in 2009 to 59% in 2014 – a nearly fivefold increase. During roughly the same period, EHR adoption in office-based physician practices rose from 48% in 2009 to 78% in 2013 (Meigs, Solomon 2). Moreover, many

“physicians perceive that EHR use yields overall clinical benefits, more efficient practices and financial benefits, and improves timely access to medical records as well as the quality of communication with other providers” (Jamoom, Patel, Furukawa, King 1).

Despite these success stories and positive claims, the introduction of HITECH and MU is not without consequence from an end-user perspective.

In the wake of HITECH and MU, many EHR vendors were forced to slam on the breaks of technological innovation in order to satisfy strict regulations. This is particularly true for small-scale EHR vendors, the forerunners of healthcare IT innovation, who must accelerate the standards of innovation to compensate for a lack of abundant resources. Unfortunately, focusing on meeting the strict standards of MU hindered the abilities of small-scale EHR vendors to work intimately with physicians and truly understand their needs. Indeed,

“many people blame the HITECH Act and its meaningful use EHR program for incentivizing software vendors to craft products that meet the federal government’s specific criteria at the expense of innovative features and functionality” (Monegain 1).

What is more frustrating for EHR vendors is the significant growth in physician dissatisfaction with their technology. In Electronic Health Record Use a Bitter Pill for Many Physicians, Stephen Meigs and Michael Solomon argue,

“a recent study revealed that the use of EHR systems is a contributing factor to professional dissatisfaction among physicians. Dissatisfaction with EHR technology is trending upward, with 12% more physicians expressing unhappiness with their EHR system in 2012 than in 2010” (Meigs, Solomon 2).

It is likely this increase in dissatisfaction can be partially linked to the continuous roll out of burdensome regulations within MU stages 1 and 2. Moreover, it is naturally expected this level of dissatisfaction will rise with further impending regulations included in MU stage 3, expected to roll out in 2018. Indeed, Dr. John Halmaka, Chief Information Office of Beth Israel Deaconess Medical Center, recently stated,

“Stage 1 created a foundation of functionality for everyone, that was good. Stage 2 tried to change too much too fast and required an ecosystem of applications and infrastructure that did not exist. Stage 3 makes many of the same mistakes as Stage 2, trying to do too much too soon. There needs to be a new approach” (Shaw 1).

But what exactly will this new approach look like?

In many cases, EHRs that were designed pre-MU originally had high user satisfaction. Unfortunately, many software systems were redesigned to obtain MU subsidies and, subsequently, user satisfaction dropped (Monegain 1). Ultimately, federal regulations have incentivized EHR vendors to produce and implement a product that does not align with their innovative missions nor meets the expectations of healthcare facilities. In turn, what was expected to be a win-win scenario has increasingly resulted in a lose-lose.

Frustration is felt on both sides; both from the EHR provider and the physician. This notion is reinforced by the recent actions taken by the American Hospital Association (AHA). On November 30th, 2016, the AHA wrote a letter to President Trump and his administration asking to cancel Stage 3 of the Meaningful Use program (Slabodkin 1). In a letter signed by 5,000 member hospitals, CEO Richard Pollack quotes, “we urge your Administration to modify or eliminate duplicative, excessive, antiquated, and contradictory provider regulations.”Pollack also noted that hospitals are advancing health information technology and must ensure they “have the workforce and health IT infrastructure to best support care delivery” (Slabodkin 1).

The same can be said for EHR vendors who would love for the opportunity to get back to their mission of providing the most technologically innovative products available. According to Charles Webster, MD,

“most physicians today would not go back to pre-EHR days, but many who used EHRs before MU use would definitely go back to pre-MU days. The incentive-driven mandates have essentially pinned down the current crop of EHR technology from significant advancements” (Monegain 1)

and may continue to do so if MU Stage 3 is implemented. As physician dissatisfaction rises, EHR innovation stagnates, and tax payers continue to support this $35 billion dollar project, it is becoming increasingly difficult for anyone to justify MU or HITECH. Perhaps this is why Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services announced,

“MU as it has existed – with MACRA – will be effectively over and replaced with something better” (Shaw 1). It is time EHR vendors get back to business and “ratchet up the competition based on features and functionality rather than merely meeting government criteria” (Monegain 1).

Until then, both hospitals and EHR vendors will have to anxiously wait until the HITECH and MU era is effectively replaced or ultimately canceled.



Jamoom, Eric W. et al (2016). “EHR Adopters vs. Non-Adopters: Impacts Of, Barriers To, and Federal Initiatives for EHR Adoption.” Healthcare (Amsterdam, Netherlands) 2.1 (2014): 33–39. PMC. Web. 14 Apr. 2017.

Meigs, Stephen L., and Michael Solomon (2016). “Electronic Health Record Use a Bitter Pill for Many Physicians.” Perspectives in Health Information Management 13.Winter (2016)

Monegain, Bernie (2017). “Paper or Pixels? Clunky EHRs Have Providers Looking to the Past.” HealthcareIT News, 4/11/2017.

Shaw, Gary (2016). “Cerner Growing Fast, But Health Care IT Rules Grow Faster.” Investor’s Business Daily, 1/26/2016.

Slabodkin, Greg (2016). “AHA asks Trump to Cancel Meaningful Use Stage 3.” Health Data Management, 12/02/2016.

EHR vs. ROI: Is it Worth it?

Written By: John Cosenza

In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) initiated a large-scale implementation of Electronic Health Record (EHR) systems. Despite broad consensus EHR systems can significantly improve healthcare performance and patient outcomes while reducing costs, many healthcare facilities resisted the incentive. According to Julia Adler-Milstein, Carol E. Green, and David Bates,

“The primary barriers to adoption have been financial: most physicians have cited lack of capital and uncertain return on investment as substantial hurdles” (Adler-Milstein, Green & Bates 562).

Government initiatives have certainly encouraged adoption but existing literature reports mixed results on the financial benefits. Such implementations are often “fast-tracked in an effort to meet meaningful use requirements, typically restricting providers from realizing a clear return on investments” (KPMG Institutes). However, almost one decade after the introduction of HITECH, sufficient time has passed to more accurately assess a correlation between EHR implementation and a ROI.

In “Return on Investment in Electronic Health Records in Primary Care Practices: A Mixed-Methods Study”, Yeona Jang, Michael Lortie, and Steven Sanche analyze this correlation in primary care practices. According to the authors,

“the implementation of EHR systems within primary care practices is seen as particularly complex, with physicians and other staff in primary care practices citing obstacles such as difficulty in adapting to the significant changes in workflow and the time commitment required to learn to use the new software while prioritizing patient care” (Jang, Lortie, Sanche 1).

Despite these obstacles the sampled primary clinics typically recovered their investment within an average of 10 months; primarily due to a drastic increase in patient visits with improved “active-patients-to-clinician-FTE and active-patients-to-clinical-support-staff-FTE rations” post implementation (Jang, Lortie, Sanche 3). Moreover, the ability to quickly process claims enabled all but one clinic to report an increase in annual net revenue. However, this study focuses solely on primary care clinics and is therefore limited. If other healthcare settings are analyzed they may not necessarily bare similar results.

In fact, certain healthcare organizations including M.D. Anderson attribute the annual loss of revenue and layoffs to EHR implementation; recently the University of Texas M.D. Anderson Cancer Center announced its plans to eliminate at least 1000 jobs through layoffs and retirements. According to Cara Smith of the Houston Business Journal,

“The institution’s financial woes started when it rolled out a new electronic health records system in March. The nonprofit cancer hospital anticipated the system would create an initial loss in productivity as the users – physicians and mid level clinicians – started using the system. To combat that, the institution bolstered its cash reserves and staffed additional contractors and part-time personnel to create a smoother transition” (Smith).

The cuts in staff are expected to save M.D. Anderson approximately a $120 million a year with the hopes off countering the costly implementation of the EHR system; a system which could have cost M.D. Andersen somewhere in the realm of $100 – $200 million or more.

New York City Health + Hospital Corporation (NYC HHC) experienced similar issues to M.D. Andersen since implementation of their new EHR system in 2013; the original contract and subsequent maintenance over six years cost NYC HHC an approximate $764 million. Since implementation, a number of C-suite execs have been fired and replaced due to poor budgeting and a series of unforeseen delays. More recently

“In the last six months, the system has also juggled recent layoffs of 70 positions dubbed ‘redundant managerial level, non-clinical’ positions, as well as changes in leadership”(Sanborn 1).

A single ROI narrative is difficult to establish because circumstantial differences across the healthcare spectrum result in disparate outcomes. Underlying differences including facility type, facility size, the specific practice or field of care, staff size, and EHR products themselves all play a role in determining a ROI. However, there is a universal factor that most authors and healthcare information technology experts agree upon.

This universal factor is the ability of healthcare practices and facilities to optimize their EHR systems to the utmost extent. The studies reveal the most successful facilities and practices are those systematically raising the bar of EHR innovation. Indeed,

“Some clinics seem to be more innovative than others in using EHR in their practices to achieve significantly better operational and financial results. The analysis suggests that a clinic’s ability to take advantage of EHR to support process changes has a significant effect on the time required to achieve cost recovery from an investment in EHR” (Jang, Lortie, Sanche 6).

Julia Adler-Milstein, Carol E. Green, and David W. Bates, authors of “A Survey Analysis Suggests That Electronic Health Records Will Yield Revenue Gains for Some Practices and Losses for Many” similarly argue,

“When we examined what distinguished practices that were able to achieve a positive ROI from those that were not, we found the largest difference was that successful practices used their EHR system to increase revenue to a greater degree. Our study suggests the adoption of an EHR system can have a markedly positive financial impact, particularly for practices that effectively leverage their systems” (Adler-Milstein, Green & Bates 566-568).

Heather Haugen, vice president of Healthcare Provider Solutions at Conduent, 2017 HIMSS Conference attendee, and the creator of the Breakaway learning methodology echoes the same notion. In an interview with Show Daily: The Official News of HIMSS 2017, she states, “the commitment of organizations to really get the outcomes they expect from their EHRs is what we’re trying to achieve now. It’s our focus today in healthcare” (Haugen 11).

These experts suggest a positive ROI is likely to depend on a facility’s commitment to leverage their EHR systems in new and innovative ways for years to come; not simply after go-live. When considering EHR adoption physicians and administrators typically think of short-term outcomes. This mindset discourages pockets of medical community leaders from realizing the financial benefits are a complex and long term endeavor and, in turn, do not focus on developing long term strategies. Indeed, Haugen argues “many organizations look at the initial cost of implementation but fail to consider the long-term resources needed to sustain and leverage an EHR” (Haugen 11).

Designing a long-term plan meeting the specific needs of a facility is often a greater obstacle than the lack of funds. However, as noted above, partnering with the right EHR vendor that presents a financially feasible system is equally important. Ultimately,

“practices and health systems must complete an arduous journey to revise care delivery processes so that they can leverage the full capabilities of Health IT” (Berger 20).

When this arduous journey is visualized and effectively put into action in accordance with specific needs, even the most financially challenged healthcare facilities can implement the right EHR system and experience a positive long-term ROI.





Adler-Milstein, Julia., Green, Carol E., & Bates, David W (2013). “A Survey Analysis Suggests That Electronic Health Records Will Yield Revenue Gains for Some Practices and Losses for Many.” Health Affairs Vol.32, No.3, (2013).

Berger, Eric (2013). “Electronic Health Records, Promises Promises: Experts Advise Patience for Return on Investment.” Annals of Emergency Medicine, Vol.62, No.1 (2013).

Haugen, Heather (2017). “Getting the Most out of Your EHR Implementation and Adoption.” Show Daily: The Official News of HIMSS 17, 2017.

Jayanthi, Akanksha (2015). “Execs fired as Cost of Epic EHR Rollout Grows at NYC Health and Hospitals.” Health IT & CIO Review, 8/21/2015.

Jayanthi, Akanksha (2016).”What’s the Deal With NYC Health + Hospitals’ EHR Transition? 9 Things to Know.” Health IT & CIO Review, 3/25/2016.

KPMG Institutes (2017). “Beyond Implementation: Optimizing EHRs to Realize Results.” Healthcare & life Sciences Institute, Feb. 8th (2017).

Sanborn, Both Jones (2017). “NYC Health + Hospitals Delays Next Phase of $764 Million Epic EHR Implementation.” Healthcare Finance, 2/16/2017.

Smith, Cara (2017). “M.D. Andersen to cut 1,000 Jobs in Houston.” Houston Business Journal

Yeona, Jang., Lortie, Michael A., & Sanche, Steven (2014). “Return on Investment in Electronic Health Records in Primary Care Practices: A Mixed-Methods Study.” Journal of Medical Internet Research, Vol.2, No.2 (2014).

Vexed Veterans: The Continuum of Care in the VA

Written By: John Cosenza

On January 6th, 2016 outrage ensued across the nation as Esteban Santiago-Ruiz, a military veteran with a history of mental health issues, opened fire on innocent travelers in Fort Lauderdale-Hollywood International Airport. Shortly after the shooting, Florida Governor Rick Scott labeled the incident a ‘senseless act of evil.’ Yet, is it that simple? Was this simply a random act of evil or another unfortunate event stemming from a much larger issue? Should the American public support the execution of this troubled man? Or, should the American public take a moment and ask why veterans are more prone to act out violently?

The effectiveness of preventing acts of violence by means of execution or imprisonment is up for debate, but is no doubt a short-term solution. Moreover, the Veteran’s Health Administration (VA) has faced intense public scrutiny in recent years; the 2014 Phoenix facility scandal being the catalyst for uncovering widespread corruption and incompetence. Perhaps then, it is time to reevaluate the VA’s ability to implement effective means of long-term care for veterans suffering with mental and behavioral health illness.

However, before any solution can be brought to the table, it is first necessary to determine the origins of this melancholy event. In order to gain more knowledgeable insight on this topic, Meta interviewed a military veteran who wishes to remain anonymous. The following conversation highlights struggles of transitioning veterans and discusses strategies that may improve the continuum of care within the VA.

Q: If you were in a position to prevent another incident like Ft. Lauderdale, what would you do or change about the VA?

A: First, I would just like to say the VA has excellent programs like free healthcare, free education, financial compensation, therapy, and employment opportunities. I was able to get a college degree because of the VA. But there is definitely room for improvement. There should be a serious effort to establish more accessible care. Local VA facilities like VA urgent care centers or VA walk in clinics should be established rather than have one hospital that might be 40, 50, or more miles away. Second, and more importantly, the VA needs to take a stronger stance on educating returning veterans and their families. It should be mandatory for the VA to register returning veterans so they can quickly reach out and discuss the programs they offer, where you can seek help, etc. Many veterans don’t seek help because they simply feel as if no one cares, or they don’t matter to our society, or don’t know what kind of help is available. If you don’t make an effort to seek help, then you will never get it. A simple phone call from a VA physician or employee, a call that veterans usually never get, can, in my opinion, make a big difference.

Q: Were you contacted by the VA when you arrived home?

A: No. I was home for 5 months and was never contacted by anyone from the VA. It was not until a friend finally convinced me to visit my closest facility that I spoke with someone from the VA. If I had not made the effort to go, I don’t think I would have ever been contacted.

Q: Do you think the VA failed Esteban in this manner?

A: It was not just the VA. Many channels failed. His family noticed his behavioral changes when he came home and that should have been the first red flag. In his mind he was, what we call ‘down range’, or still back in Iraq or Afghanistan. He went to the FBI and sought help, who then washed their hands and turned him over to the local police because he apparently did not present any serious issues, even after admitting to hearing voices and other things that should have been taken as serious red flags. This man sought help and it should have been followed all the way through, from the FBI, to the local police, to his local VA facility. Once his local VA facility learned of the situation, they should have reached out to him and continued to keep tabs on him. I don’t know if they did or didn’t, but this is where we must improve. Getting veterans to seek care is hard enough so when a veteran actually seeks care because they know things aren’t right you can’t let them slip through the cracks.

Q: Do you think this is a method the VA can use to bring about a more effective continuum of care?

A: Yes. The VA can improve long-term care by establishing a serious outreach community and culture. Did the FBI or police contact his local VA facility and warn them of his condition? I don’t know, but if they did, did the VA contact Esteban and ask him to come in for an evaluation? Did anybody contact his family to see how he was doing or to educate them on VA services? Did anybody check with him after he got his weapon back or call him to just see how he’s doing, or if he needed help? These are the questions we need to start asking. It is very easy for someone to slip through the cracks if nobody is keeping tabs or showing concern. Beyond follow up appointments or getting back lab or test results, you typically don’t hear from anybody in the VA. It seems like nobody learns their lessons or is held accountable, or updates policies to handle these situations that present similar red flags. They often wash their hands and move on. The VA ought to update their standard procedures or protocols to meet this type of persistent outreach.

This conversation of course does not reflect the experiences of every veteran. As stated above, the VA provides excellent services that benefits thousands of veterans throughout their transition process. However, as our conversation ended it became more apparent Esteban, a mentally disturbed man who sacrificed his life to serve our country, possibly faces execution; likely due to the lack of proper care, education, and outreach. Not necessarily because he was an incarnation of evil. Yet, there may be solutions to prevent further acts of violence.

Firstly, the VA can be localized to meet needs of veteran communities. Integrating urgent care centers or walk in clinics with VA physicians and services can be an incentive for veterans to seek care who currently have to drive hours or across state boarders. Secondly, the establishment of serious and persistent outreach may prove effective. In fact, the VA has cited studies in suicide prevention which support this notion. Indeed, a 2009 report titled Strategies for Suicide Prevention in Veterans cited a study in which two groups of patients, one controlled and one experimental, were seen in a Pittsburgh hospital. The study reveals, after discharge,

“Patients were in contact with staff at least biweekly to provide treatment, or to monitor the treatment when it was provided by other services. Patients assigned to the control group were treated in the usual manner in the ER or hospital, and released with written appointments; no attempts were made to provide outreach to those who failed to follow up. The outcome was the number of suicide reattempts in the 4 month follow up period. The treatment group had 4.8% reattempt rate, while the control group had a 15.8% reattempt rate, a statistically significant difference” (Shekelle, Bagley, Munjas 20).

In the same report, a study conducted in San Francisco on patients admitted to psychiatric hospitals for depression and violent outbreaks bare significant similarities to the previous study. Indeed, the results reveal,

“Patients in the contact group received short, personalized letters from staff who had conducted their initial interviews expressing concern about the patient, and inviting the patient to respond. Patients in the no-contact group and those who had complied with the initial post-discharge therapy received no letters. In five years after the index contact, the treatment (contact) group had a suicide rate of 3.9% compared to the control (no-contact) group at 4.6%” (Shekelle, Bagley, Munjas 24).

It is difficult to determine whether civilian based strategies will have the same effect on military veterans, whose life experiences are drastically different. However, if the VA is aware of these benefits, have they taken necessary measures to implement wide scale outreach programs?  If not, perhaps the VA can invest in outreach methodologies such as registering and contacting returning veterans to schedule evaluations and discuss different pathways of care, as the interviewee suggests. From there, the VA can improve long-term outreach efforts with their patients to accurately determine the next steps of care, if needed. This experiment may produce similar results from the studies above and, in turn, reduce violence among veterans and ultimately improve the VA’s continuum of care. These simple strategies can bring a glimmer of hope to veterans who feel they don’t matter to society or don’t know if they should seek care. In some cases, a simple glimmer of hope may have a significant impact. Although establishing local VA facilities and providing persistent outreach will not solve every issue within the VA, it apparently continues to be an overlooked, but obvious starting point.




Bowman, Dan. “Lawmakers Approve $260M for VistA Modernization, but Demand Interoperability With DOD.” FierceHealthcare, Mar. 28th, 2016.

Shekelle, Paul MD., Bagley Steven MD, MS., Munjas, Brett BA. “Strategies for Suicide Prevention in Veterans.” Department of Veterans Affairs Health Services Research & Development Service, January 2009.

Interview with: Anonymous Military Veteran. January 10th, 2016.

Trump, EHR, & Meaningful Use: Continued Investment in Healthcare IT? Or the End of an Entitlement?

Written By: John Cosenza

The twenty first century is often characterized as the age of information with rapid advances in technology fundamentally altering human interaction and perception. Making up nearly 20% of the U.S. domestic economy, the healthcare industry is naturally adopting new technologies such as Electronic Health Records (EHRs) to achieve a higher standard of efficiency and patient care. Indeed, a 2008 New England Journal of Medicine study revealed,

82% of EHR users report improved clinical decision-making, 92% report improvement in communication with other providers and their patients, and 82% of users report a reduction in medication errors” (Palabindala, Pamarthy, Jonnalagadda 1).

In 2009, the Obama Administration enacted the Health Information Technology for Economic and Clinical Health Act (HITECH) and the American Recovery and Reinvestment Act (ARRA). Since enactment, the federal government has provided tens of billions of dollars to incentivize healthcare facilities to adopt and implement three stages of ‘Meaningful Use’ (MU) based EHR systems. As expected, this initiative has significantly increased EHR implementation across healthcare facilities within United States.

However, President Elect Donald Trump and the dominant Republican Congress view government responsibility and roles entirely differently than the Obama administration. Limited regulatory oversight and government funded projects are at the core of conservative ideology. If conservative thought prevails in Washington, what does this mean for MU standards and EHR implementation, which have been funded by the federal government in accordance with the HITECH and ARRA?

As of now it is unclear whether businessman Donald Trump, a strong proponent of lowering tax rates to stimulate economic growth, will continue to support government funded programs like HITECH. Although improvements to the U.S. healthcare system was a core component of Trump’s campaign, he did not specifically address EHR systems or MU standards. In a series of interviews with MedCity News, healthcare professionals and EHR experts argue it is unlikely a Trump presidency will slow down digital health momentum. Julie Papanek, pharma and digital health venture capitalist at Canaan Partners, argues,

“the election of President Trump is unlikely to derail the future of digital health. Many of the incentives in the government including the HITECH act as well as value based incentive programs are not all tied to the ACA” (Parmar, Baum 1).

In fact, certain individuals argue a Trump presidency will increase the demand and utilization of EHR systems. Indeed, Andrew Danielson, vice chair of licensing at the Mayo Clinic Ventures in Minnesota, confidently predicts,

 “any changes to the ACA will have a relatively small impact on the need/enthusiasm/drive for using digital health. Providers like Mayo, Cleveland Clinic, and others see digital health as a key initiative. I would imagine that whatever replaces the ACA will take this into account and continue the push for IT efficiency gains in healthcare(Parmar, Baum 1).

If these individuals are correct the future of government supported digital health systems are secure. This claim can be further supported with the recent bipartisan passing of the 21st Century Cures Act, which among other healthcare issues, calls for continued efforts in government funded EHR incentivization. Albeit a Trump administration taking office in a couple of weeks,

“the Secretary of Health and Human Services shall issue guidance to further the voluntary transition of health care providers between different certified EHR technology by removing disincentives to such transition” (114th Congress).

However, it is wise to presume Trump will attempt to deliver on his campaign promises and aggressively push for a significant transition of healthcare funding to sectors such as infrastructure or job stimulation. A prolonged era of public tax reduction and a gradual decrease in healthcare expenditures may directly result in healthcare facilities, who previously relied on government funding, to foot much of their own EHR costs. This likely transition may convince healthcare administrators to postpone or even abandon EHR implementation, unraveling years of government funded projects. Is there an alternative method that effectively ensures incentivization independent of federal funding? Possibly.

It is possible the Trump Administration will use a conservative approach similar to the Carrier deal. The Trump administration could potentially implement corporate tax breaks and deregulate MU standards for EHR corporations and businesses. This possibility becomes more realistic with organizations like the American Hospital Association (AHA) pleading the Trump administration to cancel MU stage 3 so hospitals don’t have to spend a fortune “upgrading their electronic health records solely to meeting regulatory requirements” (Slabodkin). Indeed, Richard Pollack, AHA president and CEO quotes,

“We urge your Administration to modify or eliminate duplicative, excessive, antiquated and contradictory provider regulations. Reducing the administrative complexity of healthcare would save billions of dollars annually and would allow providers to spend more time on patients, not paperwork” (Slabodkin).

Deregulation can potentially save EHR vendors and hospitals large quantities of money and result in a significant reduction of costs for their products and services. Perhaps this can create an alternate incentivization program; one that is market based and enables healthcare facilities to shop among competing businesses rather than be entirely dependent on federal funding. This strategy may appear more sensible over time considering,

“Federal investment in EHR implementation across the country as part of HITECH has already reached $25 billion, and without addressing the barriers to successful implementation, this venture threatens to be an ongoing waste of public tax dollars with limited benefit to patients and physicians alike” (Palabindala, Pamarthy, Jonnalagadda 3).

At this rate, the average American tax payer, numbered at approximately 122 million, has already contributed at least $200. On the contrary, deregulation may potentially underpin unprecedented consequences within the digital health industry. Increasing market competition or deregulating MU standards may potentially hinder objectives such as achieving high quality patient care or nationwide interoperability. At this point, it is unclear if this strategy would be more efficient or more cost effective in delivering EHR implementation. Regardless, it is interesting to speculate what may potentially happen as the political shift radically changes with President Elect Trump, his administration, and the 115th Congress taking office in the coming weeks.



Kruse, Clemens Scott, Katy Bolton, and Greg Freriks. “The Effect of Patient Portals on Quality Outcomes and Its Implications to Meaningful Use: A Systematic Review.” Ed. Gunther Eysenbach. Journal of Medical Internet Research 17.2 (2015): e44. PMC. Web. 6 Dec. 2016.

Palabindala, Venkataraman, Amaleswari Pamarthy, and Nageshwar Reddy Jonnalagadda. “Adoption of Electronic Health Records and Barriers.” Journal of Community Hospital Internal Medicine Perspectives 6.5 (2016): 10.3402/jchimp.v6.32643. PMC. Web. 6 Dec. 2016.

Parmar, Arundhati and Baum, Stephanie. Is President-elect Trump an Existential Threat to Digital Health? MedCity News, Nov 14, 2016: Web. 6 Dec. 2016

Slabodkin, George. “AHA asks Trump to Cancel Meaningful Use Stage 3.” Health Data Management, Dec. 2nd, 2016.

The Future of American Trumpcare

Written By: John Cosenza

Over the past year, the historical 2016 presidential election ignited an exhaustive campaign that fed on several divisive issues and policies. At the core of this heated debate was the United States’ healthcare system, which under the Obama Administration, underwent a revolutionary transformation. The primary role of the Affordable Care Act (ACA), commonly referred to as Obamacare, was to improve access to health insurance, expand Medicaid eligibility, and provide subsidies for socio-economically disadvantaged citizens. Indeed, the ACA accomplished its primary objective by

 “considerably expanding access, with more than 20 million individuals gaining coverage – 60% through Medicaid” (Gostin, Hyman, Jacobson 1).

Yet, it quickly appeared the ACA was a double-edged sword not absent of pejorative consequences. Criticism soon followed when failed to launch, employers were forced to provide more costly insurance plans, individuals experienced costly premium spikes, costly deductible spikes, and decreased access to competitive insurance plans (Claxton, Rae, Panchal, Whitmore, Damico, Kenward, Long 1). Additionally, a 2014 study published by the Commonwealth Fund, an organization that strongly supports the ACA, described the U.S. health care system as the most expensive and the worst in quality of 11 nations studied, dropping from fifth in 2004 (Manchikant, Hirsch 3). In wake of these unprecedented events, and as a campaign promise, President Elect Donald Trump pledged to repeal and replace the ACA. Now that Mr. Trump has secured the White House and is backed by a Republican Congress determined to alter or entirely remove the ACA, many Americans can’t help but beg the question; what is in store for America’s healthcare system? According to Gail Wilensky, a health economist and author of The Future of the ACA and Health Care Policy in the United States,

 “it is always useful after elections to review what presidents can do and what Congress needs to do. Presidential policies are important because they frequently set the tone or direction of future legislation” (Wilensky 1).

President Elect Trump has certainly set a specific tone during his campaign over the last year. In regards to the ACA however, this familiar tone has evolved into something less subtle. Indeed, Trump’s first meeting with President Obama in November seemed promising as the current and future presidents discussed the benefits of the ACA and the future of America’s healthcare system. Perhaps in somewhat of a surprise, Trump supports existing policies of the ACA including,

 “health plans must enroll applicants regardless of preexisting conditions and health plans must keep dependent children on their parent’s plan until age 26” (Gosting, Hyman, Jacobson 1).

However, after a strong era of implementing universal healthcare, what else should Americans, especially the 20 million individuals now covered under Obamacare, expect in the coming months? Trump supports healthcare policies including privatizing VA insurance, “expanding health savings accounts (HSA’s), turning Medicaid into a block-grant program, allowing insurance plans to be sold across state lines, and allowing individuals who purchase their own health insurance to deduct their premiums from their income taxes” (Wilensky 1). The pros and cons of these policies can be analyzed individually to better predict the future of American healthcare.

A benefit of VA healthcare is the guarantee to low cost coverage. Unfortunately, many low-income veterans suffer from limited coverage options and long wait times due to inefficiency and bureaucratic ties. The privatization of VA healthcare may create networks of insurers, physicians, and hospitals that provide better quality coverage and care. Block grant programs are often effective because they allow states to tailor innovative Medicaid programs specific to their populations and underlying circumstances. In turn, innovative cost friendly plans can be replicated throughout the country. However, states with large pools of Medicaid populations such as New York and California would,

“probably reduce Medicaid eligibility and lower benefits, as states try to save taxpayer dollars” (Gosting, Hyman, Jacobson 2).

This may directly impact individuals in those states covered by Medicaid under the ACA. Allowing insurance to be sold across state lines can also be effective as this encourages healthy market competition. This policy may counter potential consequences of block grant programs because middle-low income individuals can seek low cost coverage. Unfortunately, many healthcare organizations and professionals establish networks that don’t accept out of state insurance. If the Trump administration can remove regulations that prevent out of state insurers from creating competitive networks in different states, this may be an effective policy that plays into the hands of all Americans.

Health savings accounts, tax-advantaged savings accounts one receives from their employer, have become increasingly popular in the U.S. due to cost effectiveness. On average, an HSA is less than traditional health insurance premiums and gives the individual more control over their health care choices. Furthermore, individuals who can purchase their own insurance and keep low cost deductibles via income tax is also a proven method. Consequently, many of the 20 million people covered under Obamacare receive incomes well below the poverty line. Such individuals are reluctant to purchase their own insurance and are not truly applicable to HSA’s. Those who pay little to no income tax receive government subsidies to fund their insurance coverage and thus, may not benefit from traditional conservative policies. Not all is lost however. Indeed, House Speaker Paul Ryan and Republicans in both the House and Senate

 “have made it clear that Republicans are not going to repeal the ACA without having alternative strategies in place that will cover approximately similar numbers of the newly insured populations” (Wilensky 2).

What is the American population to make of this unprecedented healthcare crossroad? Furthermore, what alternative strategies will be implemented to ensure those under Obamacare stay covered? Firstly, and regardless of political allegiance, it is clear the majority of Americans

“have been slowly climbing against Obamacare with 54% now opposing the law” (Manchikant, Hirsch 4).

Secondly, it is clear President Elect Trump and the Republican Party are not going to abandon 20 million newly insured citizens. To do so would be entirely detrimental to the conservative image; which is reluctant to be portrayed negatively after securing both the presidency and House for the first time in nearly a decade.

In fact, it is possible the ACA will be modified via legislative action in accordance with the Republican mandate known as the “Better Way” rather than be entirely repealed. It is likely President Elect Trump and the Republican Party will institute a hybrid system that utilizes market based methodologies to support and continue our current system. Congress must garnish the necessary super majority of 60 representatives within the Senate to implement full scale repeal, which is unlikely. If this fails, the ACA may be effectively repealed through a reconciliation process, which is also unlikely. If full scale repeal fails, the ACA will most likely undergo alteration. Ultimately, we must wait and see if market oriented reforms in “A Better Way” will be more or less successful in making healthcare more affordable and accessible than the ACA.






Claxton, Gary. Rae, Matthew. Panchal, Nirmita. Whitmore, Heidi. Damico, Anthony. Kenward, Kevin. Long, Michelle. “Health benefits in 2015: Stable Trends in the Employer Market.” Health Aff (Millwood). 2015;34(10):1779-1788.

Gostin, Lawrence O. Hyman, David A. Jacobson, Peter D. “The Affordable Care Act Moving Forward in the Coming Years.” JAMA. Published online November 28, 2016. doi:10.1001/jama.2016.18908

Manchikanti, Laxmaiah MD, Hirsch, Joshua A. “Repeal and Replace of Affordable Care: A Complex, but Not an Impossible Task.” Health Policy Review, Nov-Dec 2016 Vol. 19, Issue. 8.

Wilensky, Gail R. “The Future of the ACA and Health Care Policy in the United States.” JAMA. Published online November 28, 2016. doi:10.1001/jama.2016.18762