Sunday, September 17, 2017

"The Censorship That It is" - Now Threatens US Government Health Agencies (DHHS, CMS, CDC)

On Health Care Renewal we discus the dark side of health care, particularly of the leadership and governance of health care, that has enabled health care dysfunction.  Our discussions are based on publicly available information, often produced by dogged health care journalism.

Uur work has become more difficult as journalism is challenged by economic circumstances.  Yet now there are worse threats.  Despite First Amendment protections of freedom of speech and the press, journalism is now under fire from the highest reaches of US government.

Information Blockade at the Department of Health and Human Services

Two recent articles in the Columbia Review of Journalism pointed to specific problems  The first, "Under Trump, Health Reporters Confront an Information Blockade," September 7, 2017, focused on decreasing transparency at the US Department of Health and Human Services (DHHS), and its Center for Medicare and Medicaid Services (CMS).  It provided numerous examples of officials failing to respond to apparently straightforward requests for legitimate health care information.  For example,
Washington Post healthcare reporter Paige Winfield Cunningham recently raised a few serious questions about how the Trump administration planned to manage Obamacare’s fall enrollment season. 'The six-week sign-up period will be the first handled exclusively by an administration that’s hostile to the Affordable Care Act,' Cunningham wrote, 'and one that hoped by now to see Congress pass legislation unraveling much of the law.'

Any reporter might have asked the questions Cunningham put to the Department of Health and Human Services, some of which she published in her daily Health 202 column:

Will the government contact current enrollees to alert them that sign-ups will last just 45 days, about half as long as in the past three years? Will HHS run call centers for consumers who need help as they look for plans? Will the computer system be adjusted to accommodate a possible crush of shoppers given the shorter sign-up period? And how will automatic enrollment be handled?

HHS offered no answers, although a spokesperson for the department’s communications staff did provide Cunningham with a statement: 'As open enrollment approaches, we are evaluating how best to serve the American people who access coverage on' Even that statement did not stand for long, reported Cunningham:

An hour later, the spokeswoman, Jane Norris, requested that the statement be withdrawn, saying that she did not have permission to release it. When I asked her again for detailed answers, neither she nor anyone else at HHS responded further.

'Nobody at HHS ever reaches out to me,' Cunningham told CJR during an interview.


Matt Wynn, data reporter for MedPage Today, went public with his troubles prying loose the data underlying a series of maps CMS sent out this summer. One map published in early June identified counties without insurers selling policies on this fall, and a news release announced at least 35,000 active Exchange participants live in counties projected to be without coverage in 2018.' Wynn asked CMS to see the numbers supporting those conclusions.

I shot an email to the media relations office in the department, asking for the data behind the map.

About an hour later I got a response. No further information would be shared at this time, wrote Shelby Venson-Smith, a public affairs specialist. Adding insult to injury, the non-response was not to be used as a direct quote, the email said.

However, while DHHS and CMS officials resisted responding to uncomplicated requests for information,

they seem to have plenty to say in their news releases and email blasts, which disparage the health law and sound more like campaign propaganda and GOP talking points than routine communications from a federal agency. The Obama administration was not shy about using the same PR tools to boost the ACA. But messages from HHS now feel substantively different, perhaps because they are aimed at denigrating a law they have a legal responsibility to administer.
Thus officials at DHHS seem to now be more interested in following the party line of the current administration than in providing basic information to the public.

Many other health care journalists experienced similar problems, including Charles Ornstein from ProPublica, Dan Diamond of Politico, Harris Meyer of Modern Healthcare, and Noam Levy of the Los Angeles Times.

Trudy Lieberman, the author of the CJR article, wrote,

HHS and CMS are powerful agencies that could decide the future of critical programs like Medicaid and Medicare, the Obamacare insurance marketplaces, and whether or not hospitals are considered safe. But when agency press officials avoid interviews and refuse to answer questions, it’s hard to present their positions fairly and understand whose side they are on. Government agencies are supposed to be objective about industry practices under their jurisdiction. But if reporters cannot get honest information about the industries they regulate, where can they go?
Kathryn Foxhall, who "works with the Society of Professional Journalists on freedom of information issues," put it this way,
I don't see the administration ever stopping what they are doing, unless we as journalists pull out all stops and call it the censorship that it is.

Public Health Without Public Information?

Worse, one week later, CJR published another article  on the US Centers for Disease Control (CDC).  The CDC is the lead US public health agency.

Axios published text from a late August email by a CDC public affairs officer that directs staff to route any correspondence with journalists—'everything from formal interview requests to the most basic of data requests'—through the communication office at its Atlanta headquarters:

'The message—sent by public affairs officer Jeffrey Lancashire and dated Aug. 31—instructs all CDC employees not to speak to reporters, ‘even for a simple data-related question’… Lancashire did not respond to requests for comment about the policy. But I’d love to know what harm was being done by CDC employees answering ‘the most basic of data requests.’'
Thus CDC officials now seem to want to substitute public relations for straightforward information provision.  Given that the mission of CDC is public health, this seems to be an example of mission-hostile management, a concept we have used most often to refer to the management of private health care organizations, not US government agencies.  Charles Ornstein of ProPublica commented

This is genuinely disturbing. The idea that someone at CDC headquarters needs to sign off on responses to basic data requests shows a level of media control beyond which I have ever seen. What’s next?

Felice Freyer of the Boston Globe tweeted

CDC is employed by taxpayers. Why shouldn't its work be readily shared with them?
At Health Care Renewal, we have often discussed the anechoic effect, a taboo against public discussion of many aspects of health care dysfunction, particularly those that might discomfit people who are personally profiting from the current system.  In particular, the currently dysfunctional health care system has made the leaders of big health organizations, particularly for-profit corporations,  hugely wealthy.  Furthermore, big health care organizations have been eager to develop financial relationships with health care professionals, academics, leaders of non-profit organizations and NGOs, etc, leading to a web of conflicts of interest draped over health care.  Who wants to speak out when doing so may offend not only distant CEOs, but also one's colleagues, bosses, friends, relatives etc who may have financial ties to those CEOs' corporations?  Furthermore, who wants to speak out when large corporations command huge marketing and public relations operations that can be used to drown out unwanted ideas, and legal departments ready to threaten litigation?

Now government health care officials seem to be enlarging their own public relations efforts while shutting off access of honest information.  This will only make open discussion of the true causes of health care dysfunction more difficult. 

Even more chilling is the threat that health care officials now may be attempting actual censorship.  We have depended on health care journalists to root out bad behaviors that lead to health care dysfunction, and by doing break taboos about discussion such behaviors.  Up to now we have assumed at least that government would not make it harder for journalists to do their job, protected by the Bill of Rights protections of free speech and a free press.  But now the current administration seems to be taking the side of censorship.

From Censoship to Incitement of Violence?

Even worse, some worry that the regime's hostility to journalists  threatens their actual harm.  In early September, the New York Times reported on comments by the United Nations High Commissioner for Human Rights, who

was reacting to Mr. Trump’s recent comments at a rally in Phoenix during which he spoke of 'crooked media deceptions' in reports of the violent clashes at a white nationalist rally in Charlottesville, Va., that resulted in the death of a counterprotester.

In Phoenix, the president’s words also appeared to whip up audience hostility toward journalists.

The failing @nytimes writes false story after false story about me. They don't even call to verify the facts of a story. A Fake News Joke! — Donald J. Trump (@realDonaldTrump) June 28, 2017

'It’s really quite amazing when you think that freedom of the press, not only a cornerstone of the Constitution but very much something the United States defended over the years, is now itself under attack from the president himself,' [UN official] Mr. al-Hussein said. 'It’s a stunning turnaround.'


'To call these news organizations fake does tremendous damage,' Mr. al-Hussein added. 'I believe it could amount to incitement. At an enormous rally, referring to journalists as very, very bad people — you don’t have to stretch the imagination to see then what could happen to journalists.'

Ominously, the response from the White House included more unsubstantiated charges of "false narratives," and threatened media tha fails to be responsible as judged by the regime, never mind the First Amendment and its promise of free speech and a free press. 

the White House press secretary, Sarah Huckabee Sanders, said in an emailed statement, 'We believe in free press and think it is an important part of our democracy, but the press also has a big responsibility to the American people to be truthful. Their job is to report the news, not create it.

'Is it not ‘dangerous’ for the media,' she continued, 'to create false narratives and overzealous attacks against the president that the American people chose to be their leader? The president is focused on growing our economy, creating jobs, securing our border and protecting Americans. Since those are also the priorities of most Americans, hopefully the media will make covering them theirs.'

Strong, even overzealous verbal and written attacks on politicians, the president included, have been essential parts of American democracy since the Bill of Rights was ratified.  The First Amendment shows that our political system values such boisterous discourse.  The White House press secretary thus threatened not only the press but the fundamental US system of government.  

Strategic Hostility

Finally, there is an argument that the regime's attacks on the media may not be just reckless, but  strategic and calculated.  The UN Special Rapporteur on the promotion and protection of the right of freedom of opinion and expression, Prof David Kaye of University of California - Irvine School of Law, wrote,

The President’s attacks may be reckless – who knows whether someone in his audience will take the President’s word as license to take action against enemies of the American people? – but they are not without purpose. They have concrete aims: to intimidate reporters into certain kinds of coverage, or clarify for his favored outlets what coverage he desires, or plant the seeds of doubt about news stories (such as the Russia investigation led by Robert Mueller).


However, when we tie together the jeremiads and rhetoric with what the Trump administration is doing in other governing spaces, the practice of attacking the press becomes clearer as policy than solely reckless rant.

First, the attack on the press is not merely rhetorical; it is increasingly reflected in policy.


Second, Trump’s incendiary statements work in tandem with a pattern of lying and disinformation, both aiming to limit the accessibility of truthful information


Third, the administration operates as if it has something to hide.
Who knows what they might be hiding.  But there certainly have been plenty of accusations of  severe conflicts of interest and corruption affecting the Trump presidency?


Up to last year, I was cautiously optimistic that the anechoic effect was starting to erode, enabling the health care discussion to begin to encompass the deeper causes of health care dysfunction.  Since November, however, we seem to be going backward.  What little openness and transparency that were developing are at risk of sinking under a new tide of propaganda and censorship.  My concerns have primarily been about health care and health care dysfunction, but the larger trends threaten our whole society and the ability of the US to maintain itself as a republic.  Ben Franklin's warning becomes more acute.  What we have is only 

A republic if you can keep it. 

That will now take some work.  

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