Who's Counting Our Paper Ballots?

Guest Contributor - Paul Burke

Places like Georgia which do not have paper ballots are not democracies. They are letting themselves be run by hackers, not voters. Hackers can choose the "elected" officials, undetectably.

However states with paper ballots have a false sense of security. Like paperless states, they report results from election machines, but they don't test whether machines were hacked, and they rarely tally the paper. Paper ballots protect us only if we have practical ways to tally them. Assurances that no one has found a hack ring hollow when people rarely look.

Computer hacking of elections goes back at least 24 years to the election which put Nelson Mandela in office. That was hand-counted, but the computer summation of thousands of hand tallies was hacked and had to be redone independently. In the US, hand-counting 100 million ballots will be a nightmare if a widespread hack is noticed and changes winners all over the country. Hand-counting is slow and costs $1 to $7 per ballot, depending on the design and number of contests on the ballot.

There is a more practical approach: scan paper ballots, check that scans are accurate, and tally the ballot images on several independent computers, so no one can hack them all.

Election machines can be hacked even when they stay offline. They can be hacked at the manufacturer, when the manufacturer sends annual updates to local machines, when machines wait unguarded in precincts the night before the election, and when results are copied out electronically for posting on the web. VR Systems, which handles web posting in a lot of places, was hacked in 2016. Maryland's election web host is majority owned by a Russian; many other vendors may be owned by adversaries. And the FBI said, "there are two kinds of big companies in the United States. There are those who've been hacked by the Chinese and those who don't know they've been hacked by the Chinese." Hacking is often invisible, and the only way to check it is to count again, independently.

About 29 states spot-check election tallies (states.votewell.net). Seventeen of these only check a few contests, so hackers can change other contests. The last 12 states check all contests, but if they find problems, only five expand to 100% tallies and revise the outcome (AK, MD, NY, VT, WV). Alaska excludes small precincts, so that is where hackers can strike. Maryland and most of New York check by using a single machine different from the one originally used, which is not enough to prevent hacking. Vermont checks six towns, so can miss hacking elsewhere, and depends on a single machine. West Virginia hand-counts 3% of precincts, which gives a 97% chance of missing a hack in one precinct, worse if someone can leave that precinct out of the hat when the random sample is drawn. All states can start using scans to do better, cheaply.

Humboldt County, CA, found an error of 197 ballots in 2008. All 197 were in a batch of mail-in ballots counted three days before election day. They were included in preliminary counts on election night and again three weeks later. Then a bug in the official software omitted this batch. Humboldt re-scans and re-tallies all ballots, so they found the 197 ballots, and staff tracked down the discrepancy. The problem was a bug, not a hack, but the independent checking will work just as well for a hack. Humboldt has independently scanned and tallied every election since then.

Seven Florida counties and Vermont's Secretary of State hire Clear Ballot, a Boston company, to scan and tally all contests independently. Maryland hires Clear Ballot to tally all contests independently, using images created by official election machines. Colorado's Secretary of State independently re-tallies one contest per ballot using records from the election machines, spot-checked against paper ballots. These four states have not found significant problems, but they are ready with their alternate scans and tallies when official tallies are hacked. So far so good.

If every state tallied ballots independently like these four, and checked all contests, we would be much safer. A good project for programmers and computer courses is to adapt open source tallying programs to process local ballots. Open source programs are available from TEVS (Transparent Electronic Voting System), and FreeAndFair.org. As a country we can solve this.

Other steps are needed too. Computers at Clear Ballot or Colorado's Secretary of State can be hacked. So the files of ballot images should be available to multiple officials to tally independently. Then no one can hack them all. Digital signatures, or hash values, will ensure reliable scans and copies. Storing some digital copies offsite, such as in a safe deposit box, will foil break-ins, fire, flood, and insider risks.

When we tally ballot images, we need to find out if the images were scanned accurately. California's Secretary of State had a contractor who changed ballot images in a test, so we know it can be done. Officials need to check samples of ballots, as Colorado does. If samples of ballots match the ballot images, we can use the images. If samples show problems, we need to bring unhacked high speed scanners into election offices, scan the ballots accurately, and use independent software to tally these scans. Again, samples can test the accuracy of the new scans. This is still much faster and cheaper than hand-counting thousands or millions of paper ballots.

News reports on elections need to say how ballots were tallied and checked. Unchecked results should be suspected, not respected.

In coming elections, all jurisdictions need to scan some precincts with office scanners, tally them with independent software, and compare scans to paper ballots as a quality control measure. Scanning is cheaper than hand-counting. Scanning will deter hacks, find mistakes, and give every jurisdiction practical experience, so they can expand when they need to. Ask your elected officials to start the process.

Paul Burke (admin@Votewell.net) analyzes election security in the August Journal of Physical Security.

DEADLY OBAMACARE

[GUEST CONTRIBUTOR - PAUL BURKE]

Obamacare causes 8,000 deaths per year, because of penalties it puts on hospitals The penalties started in October 2012. Death rates from heart failure have risen ever since, because hospital treatment for heart failure has fallen.

Obamacare fines hospitals when they treat Medicare patients for heart failure, if the patients need another hospital stay within a month. Hospitals need to avoid the fines, so now they treat 20,000 fewer patients for heart failure, compared to four years ago, before the penalties.

Do patients survive the loss of treatment?

No. CDC says death rates from heart failure rose after 2012, though these deaths had fallen every year from 2000 to 2012. Higher death rates in 2013 and 2014 mean 7,200 and 9,600 more people died from heart failure in these years than would have died if the 2012 death rate had continued.

http://cdc.gov/nchs/data/databriefs/db231.pdf

The term "heart failure" is also called "congestive heart failure" or cardiomyopathy. It refers to weak pumping because of muscle deterioration, stiffness, leaking valves, etc. It is not the same as a heart attack or heart stopping. It is a major cause of death in the US.

These are the latest national figures, but five earlier studies from 2010-2014 also showed that hospitals which had fewer re-hospitalizations had more deaths, especially among heart failure patients.

http://globe1234.info/medicare/category/research

Medicare said in August 2012, "We are committed to monitoring the measures and assessing unintended consequences over time, such as the inappropriate shifting of care, increased patient morbidity and mortality, and other negative unintended consequences for patients." They have not reported any of these monitoring results in 4 years.

http://federalregister.gov/d/2012-19079/p-1799

Re-hospitalization penalties give hospitals an incentive to treat fewer seniors. Medicare even gives hospitals an online tool to predict re-hospitalization risk for each potential patient.

Hospitals can avoid penalties by any mix of the following:

·         Avoid admitting the sickest Medicare patients with heart failure ("There's not much we can do for you. Treatments are risky. You're better off at home.")

·         Treat as many as possible of the least sick outside of hospitals

·         Improve subsequent care for those admitted, to reduce re-hospitalizations

It is easier to give less care than to improve it, though hospitals certainly are doing both. And the result we see is that death rates have started to rise.

The figures here count hospital admissions in July 2008-June 2011, compared to July 2012-June 2015. These are the oldest and newest comparable data available. Medicare released the older data in a comparable form in May 2013.

http://globe1234.com

Re-hospitalization penalties are large. Hospitals get $6,000 for treating a Medicare heart failure patient, but pay a $27,000 penalty for each re-hospitalization within 30 days, above the national average rate. So every hospital tries to be below the average, driving the average down and the risk of penalties up every year. There are also minimal adjustments for the mix of patients each hospital serves.

Penalties total $71 million this year, down from $76 million last year, because hospitals treat fewer Medicare patients for heart failure. The only way hospitals as a group can reduce their penalties is by treating fewer patients. And they do.

The penalties apply to patients treated under Medicare Part B. Hospitals which face the re-hospitalization penalties now admit 5% fewer Part B patients for heart failure than four years ago, even though the total number of seniors covered by Part B increased 12% in the same period.

There are also penalties for re-hospitalizing patients after coronary bypasses. The penalty is $188,000 for each one above the national average rate; penalties began October 2017. Penalties after elective hip and knee replacements are $239,000 and began October 2014. The penalty calculations are written into Obamacare. It is too early to see if the number of people treated has fallen, but the American College of Surgeons warned Medicare that treatment would be cut: "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue."

One state is exempt from the penalties: Maryland, where Medicare has its headquarters, and where many of its retirees live.

Medicare penalizes all unplanned re-hospitalizations, even if they are unrelated to the original care. The law only lets Medicare penalize readmissions related to the initial care, but Medicare found that law, "difficult to implement." So they decided not to follow the law. Obeying the law would help, but penalties would still discourage treatment of frail seniors, who have above-average risks. The law and the penalties themselves are wrong.

http://federalregister.gov/d/2013-18956/p-2129

In 67 metro areas, Medicare has a second way to discourage hip and knee replacements, especially for the frailest patients who may need them most: hospitals must pay nearly all medical expenses for 90 days after treatment, though they have almost no control over these costs. After coronary bypasses next year, hospitals will similarly have to pay for 90 days of costs. Fewer hip and knee replacements and coronary bypasses, when Medicare patients need them, condemn seniors to reduced activity and faster decline.

Medicare and Social Security do save money when patients die sooner, but that is not how the country wants to save money. 

Medicare Plans to Penalize Hospital Use

Guest Contributor Paul Burke

Published at: http://www.ireachcontent.com/news-releases/medicare-plans-to-penalize-hospital-use-267175701.html

Medicare plans to penalize hospital use for 4.9 million seniors who get health care from Accountable Care Organizations (ACOs). ACOs are groups of doctors and hospitals which sign up to receive rewards from Medicare if they cut Medicare spending on their patients. They also receive protection from antitrust and kickback rules.

 

The rewards which ACOs receive are changing. Out are rewards for cholesterol management and anti-clotting treatment. In are rewards for keeping patients out of hospitals.

 

Three quarters of ACOs do not cut costs enough to get rewards, so the changes are not aimed at them. Most ACOs include hospitals, so the new incentives to avoid hospital stays are not aimed at them either; they will just bring other patients into the hospitals, with little or no net saving.

The new rewards do show Medicare's thinking about how to care for seniors.

 

Medicare plans to penalize ACOs when patients in three categories have unplanned hospital stays. The three categories are: diabetes, heart failure and multiple chronic conditions. Even when these patients need hospital stays, such as for appendicitis or heart attacks, Medicare proposes a penalty on each stay.

 

ACOs are already penalized when their patients go to hospitals for treatment of heart failure, emphysema, chronic bronchitis or asthma, on the reasoning these can be treated without hospital stays. ACOs are supposed to minimize hospital stays for those treatments, and now are also supposed to minimize hospital stays for patients with diabetes, heart failure or multiple chronic conditions.

 

ACOs have also faced penalties each time a patient leaves a hospital and is readmitted within 30 days to the same or another hospital, for related or unrelated treatment. An extra penalty will apply in the future if the patient goes to a nursing home in between. Penalties are additive, so six penalties will apply for example to a patient with multiple chronic conditions who goes into a hospital for emphysema, then to a nursing home and back to a hospital for heart failure within 30 days.

 

Doctors and Medicare patients can avoid these penalties on hospital stays. They can try to identify ACOs which have cut costs enough to care about the penalties and avoid them, or avoid all ACOs, or choose hospice, which ends all curative care. Avoiding ACOs is wise, according to Regina Herzlinger, PhD, of Harvard Business School, when patients have serious issues such as "diabetes, cancer, or congestive heart failure. You need specialists for that. They are the opposite of organizations, such as ACOs, that do everything for everyone."

 

ACOs may not want seriously sick patients anyway. Simon Prince, MD, President of Beacon ACO in New York, which does earn rewards, presciently said before Beacon became an ACO, "If they're going to put the risk back onto the ACO and onto the physician, it's going to be more difficult and we could start self-selecting which patients we want to include in our ACO."

 

In each measure ACOs need to be above the 90^th percentile to get full rewards, so for example they get full rewards if they hospitalize fewer diabetes patients than 90% of their competitors. This high target shows Medicare's high priority for reducing hospital use. Medicare has already extended hospital readmission penalties to patients outside ACOs. It also cuts general hospital payments based on total patient cost from 3 days before the stay to 30 days after.

 

As Medicare extends penalties outside ACOs, it will be harder for patients with chronic illnesses to avoid the penalties and keep getting complete care.

 

Many goals of quality medicine are not covered in this reward system. There are no rewards for keeping patients alive or for prevention or treatment of most conditions, such as cancer, HIV, disabilities, osteoporosis, kidney disease, or pain. Tonya Saffer of the National Kidney Foundation says, "Quality measurement is not exactly where it needs to be yet. We need true outcomes measures that are associated with morbidity, mortality, and patient quality of life."

 

Medicare struggles even to follow medical guidelines. They are dropping rewards for cholesterol management and anti-clotting therapy because guidelines changed.

 

Aco.globe1234.com lists all the rewards, and it lists the 369 ACOs, which serve 4.9 million patients. Most doctors, 61%, do not plan to join ACOs, so patients have choices. Medicare accepts comments until Sept. 2 on the new reward structure. ACOs which cut costs will start earning the new rewards in October 2015.

Saving Yourself from Medicare Cut

Guest Contributors Paul Burke and Jan Kletter, MD

 

People know that Obamacare changed private insurance. It also changed Medicare, to save money.

 

Seniors with both Medicare and private health insurance need to think about dropping Medicare Part B, which covers doctors, outpatient procedures and equipment, but also imposes restrictions. This is a serious decision.

 

Medicare is changing the way it pays hospitals and physicians who agree to work together in alliances. These alliances are known as accountable care organizations. Essentially the alliance keeps half the savings when it cuts the care of Part B patients: it gets more money for doing less. Therefore Part B patients with complex medical problems may not get the type of care that was available in the past, and that private insurance still covers.

 

Additionally, hospitals can get hit with a penalty imposed by Medicare when patients have too many hospital stays. Medicare rates hospitals on the number of Part B patients admitted twice in 30 days, even if the stays are unrelated and the hospital is not at fault. Every readmission above average, in any of six categories, incurs a penalty of $30,000 to $265,000, far more than Medicare pays to treat a patient in the first place. The penalties are supposed to encourage better care; the side effect is to discourage certain hospital stays. Instead, hospitals use other resources to keep complex Part B patients, with above-average chance of readmission, out of hospital beds.

 

The American College of Surgeons warned Medicare on June 14 about "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue." Hospitals can afford to avoid these Part B patients, because Obamacare sends them many new private patients. The question is whether or not this is going to lead to better outcomes for patients.

 

Part B premiums cost $1,300 to $4,000 per person per year. Dropping Part B puts that money back in the patient's pocket. It also shields patients from the new restrictions on Medicare coverage.

 

According to the respected Guide to Health Plans, most federal retirees will save money by dropping Part B and keeping their federal health plan. "Medicare Part B will rarely save you nearly as much money as you spend on the Part B premium... Medicare Part B is of limited value to someone already covered by a good health plan."

 

Patients need to be certain of their own situation, but many have already bypassed Part B. Skipping it makes sense for many more, now that Medicare restrictions are in place.

 

Private insurers also want to cut care; Medicare has gone further, since it has more power. To drop Part B, patients file form 1763 with Social Security. They can re-enroll online the first three months of each year, which would take effect in July, with a 10 percent higher premium for each year without Part B. As the Guide to Health Plans says, "Thus, dropping Part B is not an irrevocable decision, and later rejoining Part B need not be highly costly."

 

It is understandable why Medicare has these restrictions. Seniors who get less treatment and die save money for both Medicare and Social Security. These programs are under intense pressure to cut costs. Patients who can pay doctors' bills with other insurance will avoid Medicare's reductions in care by dropping Part B.

 

Paul Burke is a retired federal researcher who manages a watchdog site, Globe1234.com

Jan Kletter currently practices general surgery in West Virginia.

MEDICARE KILLS

[Guest Contributor - Paul Burke]
Photo of Paul Burke's Father - age 98

Ironically after all the effort to expand coverage, Obamacare pays doctors to deny care.

In the first place doctors who advise Medicare patients against treatment can sign up to keep half the savings as a kickback.

Second, hospitals which talk Medicare patients into hospice, or out of coming back to a hospital, keep as much as $265,000 for each readmission they avoid.

With less treatment, seniors die, saving money for both Medicare and Social Security. Hospitals in Maryland, where Medicare and Social Security have their head offices, are exempt. So are military hospitals, where members of Congress go.

Medicare has become adversarial, because doctors and hospitals get these kickbacks from cutting care. As long as Democrats refuse all amendments of Obamacare and Republicans insist on complete repeal, the kickbacks will continue, and patients need to protect themselves by avoiding doctors who sign up for kickbacks, and by hiring a nurse-advocate in the hospital, just as we hire a lawyer in court.

My father was 98, active, and articulate about choosing life, in five languages. He used a wheelchair, worked out twice a week with a personal trainer, read the daily paper and the Atlantic, enjoyed restaurants and the opera. Before retiring he managed the Latin American business operations of Time-Life magazines and books.

He was fragile, and by some standards not so old. Many people live and contribute past 100. Yet hospitals urged him to give up the life he enjoyed. They tried to talk him into stopping dialysis, which would have meant death in a week. They urged palliative care and a "do not resuscitate" (DNR) order, contrary to his advance directive. They kept him without food for three days because of suspected swallowing problems. They started blood thinners, which gave them a reason not to operate to drain his chest. They convinced his assisted living to evict him unless he went on hospice and gave up dialysis. He refused.

His doctors had not signed up for kickbacks, but they did face Medicare penalties if above-average numbers of patients returned to a hospital within 30 days. A readmission penalty after congestive heart failure, which he had, cost the hospital $35,000. After knee or hip replacement it would cost $265,000. They paid no penalty when he died. We heard, and anyone who might come back in 30 days starts to hear, "Not a good candidate for treatment... Side effects can be bad... Palliative care... Hospice... DNR." We knew nothing of readmission penalties and did not hire an advocate. The readmission penalties propelled both the refusal to treat him and the pressure on his home to evict him, which left him in despair, and in two days he died.

Hospitals cannot bill patients or other insurance for readmission penalties, so they face draconian costs for treating anyone who might come back in 30 days. We all know readmissions save lives. Dr. Hawking, Senator Byrd and President Mandela were readmitted when needed. But Senator Byrd used an Army hospital, exempt. Medicare staff and retirees use Maryland hospitals, also exempt.

A penalty for readmission can be a death penalty when it drives hospitals to avoid treating you. The American College of Surgeons has warned about "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue" (letter to Medicare 6/14/13).

Medicare recommends death penalties in nursing homes too, for excess rehospitalizations. If that penalty is adopted, fragile patients would not be accepted into nursing homes, and if already there, would be urged to forego needed hospital stays.

Four published studies, from Veterans Affairs, New England Journal of Medicine, New York Hospital Association, and Medicare's own contractors at Yale, show as you would expect, that when fewer patients return to hospitals, more patients die. Three other studies, from an Oklahoma hospital, Kaiser, and Healthgrades, show that patients with palliative care or DNR die sooner than they would otherwise, so signing up patients leads to more deaths and fewer readmission penalties.

Medicare knows its penalties can lead to more sickness and death, "We are committed to monitoring … increased patient morbidity and mortality" (Federal Register 8/31/12 p. 53376). Its contractor has already found higher deaths. Any NIH study would monitor deaths and stop the experiment when death rates rose. Medicare does not.

Medicare is explicit that "end-of-life/palliative care" is an "efficiency" which should increase kickbacks to doctors (2009 p.6). MedPAC, a Congressional agency, recommends "hospice use and the presence of advance directives" as methods to decrease rehospitalizations (2012 p.195). MedPAC did the original unpublished 2005 study justifying readmission penalties. They said 76 percent of readmissions within 30 days were "potentially preventable," but the study was based on experimental software without clinical reviews (2007 p.108).

If you think 20%-55% of your care is unnecessary, you will do fine, since kickbacks are designed to cut your care that much. Be aware that quality controls are minimal. Or if you have no interest in life, the system will oblige. My mother had cancer and died on hospice at age 88. But people deserve to choose. Seniors have paid for insurance and count on treatment without the government micro-managing hidden penalties and kickbacks to sway professionals against their wishes.

With research you can avoid doctors who sign up for kickbacks. Readmission penalties are harder to avoid. Your own doctors do not manage your hospital stay. Staff doctors do, and they need the hospital to be financially strong. Patients need to hire independent expertise during hospital stays, to get full information. We cannot trust hospitals which face $35,000-$265,000 penalties.

A bipartisan majority should repeal the penalties. In the meantime Medicare needs to exempt more patients, as it now exempts people under 65, or without Part B, or in Maryland. It should exempt patients over 95 or 100, since they are most at risk of improper pressure to die, and they are too few to affect the statistics. Medicare should also offer demonstration programs to exempt patients who pay an extra premium, or patients willing to have a copay for every hospital stay. Currently only the first stay in each 60 days has a copay, of $1,200. These alternatives reduce Medicare costs, while leaving hospitals willing to readmit when needed.

Paul Burke is a researcher who has analyzed data for HUD, Congress' Office of Technology Assessment, and the UN Development Programme. He manages a watchdog site, Globe1234.com, and is not connected to the health care industry. He has declined Medicare for himself to avoid its interference in his healthcare.