11/07/2014 11:21 am ET Updated Jan 07, 2015

Blaming Obama for Ebola? Dysfunctional Politics and Dread Disease


Did the Democrats lose the Senate over Ebola? Pundits are parsing the exit polls, and they'll no doubt come to contradictory conclusions. But the surreal notion that President Obama's incompetence put America at risk for dread disease fed Republican efforts to cast Democrats as a danger to the nation.

Republicans pitched this message to national media, and the media bought in. To a degree that approached the delusional, Ebola-in-America became part of a national narrative of Administration ineptitude.

Fact-free punditry is part of our political tradition. But rarely do press coverage and popular understanding diverge so sharply from reality as they have with the myth that Ebola's appearance here is due to the federal government's failure.

True, the halting performance of the federal Centers for Disease Control contrasted poorly with the CDC's swift responses to scary disease -- in disaster movies. (And in Outbreak and Contagion, federal disease fighters were sexier.) But outside the multiplex, the CDC can't command clinical or public health practice. Nor can the White House.

American health care provision is largely private -- something Republicans normally celebrate -- and the CDC lacks authority to swoop in, like a SWAT team, to take over hospitals.

Our Constitution's constraints on federal power (which Republicans usually seek to strengthen) make the states sovereign over public health matters. The kerfuffle over quarantines illustrates this. Overreach by Governors Chris Christie, Andrew Cuomo, and others -- confinement for Ebola caregivers without symptoms of illness -- came despite a presidential plea for restraint. And a state judge ordered an end to Maine's quarantine of nurse Kaci Hickox upon her return from a month of volunteer work with Ebola patients in Sierra Leone.

The Obama Administration can cajole, even shame state officials for pandering to fear and disregarding science. And the CDC can offer guidelines for hospitals and help to train their clinical staff.

But American health law is an unruly mix -- a jumble of state and federal regulatory schemes that no one actor -- not even the president -- can command. And hospitals are fragmented fiefdoms, ruled by department heads who collaborate only sometimes and doctors who fiercely guard their autonomy.

It's a myth that we have a health care "system," as most Americans who've tried to coordinate care for loved ones with complex illnesses painfully realize. That's why the Affordable Care Act is so messy. It's an attempt to coax thousands of unconnected government and private actors into a semblance of coordination, on behalf of broader access to better, less costly care.

This "system" (or lack thereof) protects doctors, hospitals and local public health authorities against the perceived threat of overweening federal power. But the price of fragmentation is diminished capacity to adopt best clinical practices and to cope with crises in coordinated fashion.

That's the real lesson we should learn from Ebola in America. When two nurses contracted the illness at a Dallas hospital after its emergency room doctors misdiagnosed an infected traveler from Liberia and sent him home, the recriminations began, putting Ebola in the political spotlight as a purported icon of President Obama's ineptitude. But as an enterprising team of Dallas Morning News reporters learned last month, slip-ups of this sort at the hospital, Texas Health Presbyterian, are unexceptional.

The hospital's emergency department performed below national and Texas averages on five of six federal benchmarks. And its 2013 and 2014 readmission rates for recently-discharged Medicare patients (a metric of both clinical quality and care in discharge planning) were among the worst in the Dallas area.

Its performance on six federal measures of hospital-acquired infection frequency (which reflects safety lapses) was about average -- better than the federal benchmark for one metric, worse on another, and right at the benchmark for the other four. Tolerable, it would seem -- until you consider the CDC's estimate that there are 1.7 million cases of hospital-acquired infection each year, causing or contributing to approximately 100,000 deaths.

The number of Americans who die prematurely from hospital safety lapses more generally is almost certainly greater. Fifteen years ago, the Institute of Medicine (part of the National Academies of Sciences) famously estimated (based on data from the 1980s) that 44,000 to 98,000 Americans a year die prematurely from avoidable hospital errors.

More recent estimates have been much higher. In 2010, the Inspector General of the U.S. Department of Health and Human Services calculated (based on 2008 data) that hospital errors played a part in the deaths of 180,000 Medicare patients per year. A well-regarded study published last year put annual deaths from preventable harm in hospitals at a minimum of 210,000 -- and more likely higher than 400,000.

That our politics tolerates these numbers is astonishing. If the 210,000 figure is correct, almost 600 of us die prematurely each day from preventable mistakes in hospitals. That's the equivalent of one 9/11-sized fatal event every five to six days.

Texas Health Presbyterian's lapses of diagnosis and infection control are of a piece with this larger, deadly context. The hospital's initial misdiagnosis (which led to its sending Thomas Duncan home when he appeared in the emergency room with Ebola symptoms) was, as an online piece in the prestigious journal Health Affairs pointed out, the likely product of a breakdown in its electronic medical record system.

As has been widely reported, Duncan told a triage nurse he'd just arrived from Liberia. But the hospital's record system didn't communicate this vital information to Duncan's ER doctors, who thus understandably saw his symptoms as insufficient to merit admission, let alone isolation with the CDC's recommended precautions against Ebola contagion.

It's unclear whether the medical records software siloed this information to nursing staff only, whether the software didn't adequately spotlight it for ER doctors, or whether the doctors failed to pay heed. What is clear is that these possibilities represent common breakdowns -- breakdowns that cause avoidable death and suffering nationwide.

Government can't command an end to such breakdowns. But the Affordable Care Act is laden with incentives for doctors and hospitals to avoid them. Financial penalties for too-frequent hospital readmissions, rewards for physicians who exceed clinical-quality benchmarks, tools to enable patients to compare health care providers' rates of error, and subsidies for less mistake-prone medical record systems are among the ACA's approaches to reducing deadly lapses in clinical performance.

These steps are a start, but more is needed. There's been a revolution in best clinical-safety practice over the past 15 years. To-do lists for risky procedures, redesign of administrative arrangements to better coordinate care, use of smart software to offer suggestions (and warnings of possible error), and elimination of perverse incentives are among the approaches that have become state-of-the-art, yet are nowhere near to becoming standard.

The Congressional campaign's focus on a few Ebola cases while other clinical lapses killed thousands is a case study in democracy's potential for dysfunction. But for a few months, at least, electoral politics are on break. The President and Congress should seize this moment to tackle the larger challenge of lifting medical care to state-of-the-art safety levels nationwide.

I write regularly on subjects at the interface between law, culture, politics and your health. Follow me on Twitter: @greggbloche