History > 2007 > USA > Health (I)

Philip Morris Parent

Pays Full $3.5 Billion to States

in ’98 Deal

March 31, 2007
The New York Times
By BLOOMBERG NEWS

Altria Group Inc., parent of the world’s largest tobacco company, made its full payment of $3.5 billion to states under a 1998 health care settlement, a move that may bolster the prices of municipal bonds backed by the payments.

The payment includes $400 million that the Altria unit Philip Morris USA disputes it owes, the company said yesterday in a statement distributed by Business Wire.

“While it’s certainly positive news for the tobacco sector, I don’t believe it’s a surprise to most investors,” said Mike Pietronico, a portfolio manager in New York who oversees about $6.1 billion of municipal bonds for Evergreen Investments.

The states have issued more than $40 billion of bonds payable from the proceeds of the 1998 settlement. Under that deal, tobacco companies agreed to reimburse states $246 billion for treating smoking-related illnesses.

Under the settlement, Philip Morris, Reynolds American Inc. and the Lorillard Tobacco Company make payments to the states based on their market share. The companies can seek to reduce their payments if they lose more than 2 percent of their market share.

Last year, a report by the Brattle Group, a consulting firm, led Reynolds American and Lorillard to put about $800 million of a total $2.7 billion of annual payments in a so-called disputed-payments account. The report said the companies had lost market share because of restrictions imposed under the settlement. States are challenging the withholding.

Philip Morris did not divert any of its share into the account and will not this year, the company said.

Philip Morris Parent Pays Full $3.5 Billion to States in ’98 Deal, NYT, 31.3.2007,
http://www.nytimes.com/2007/03/31/us/31altria.html

Living With Alzheimer’s

Before a Window Closes

March 29, 2007
The New York Times
By JANE GROSS

Mary Blake Carver gazes from the cover of a neurology magazine this month, under the headline “I’m Still Here!” She often feels like shouting the message to her friends, her children, her husband.

Ms. Carver, 55, is among the growing ranks of people in the early stages of Alzheimer’s disease, when short-term memory is patchy, organizational skills fail, attention wanders and initiative comes and goes. But there is still a window of opportunity — maybe one year, maybe five — to reason, communicate and go about her life with a bit of help from those around her.

Yet Ms. Carver is often lonely and bored. Her husband leaves her out of many dinner table conversations, both say, because she cannot keep up with the normal patter. He insists on buttoning her coat when she fumbles at the task. She was fired as a massage therapist because she lost track of time. So Ms. Carver fills her days by walking her neighborhood on the Upper West Side of Manhattan, always with her dog, so she looks like “an ordinary person,” she said, not someone with “nothing better to do.”

Five million people in the United States have Alzheimer’s disease, according to a study last week by the Alzheimer’s Association. About half, 2.5 million, are at the early stages of the disease, other studies have found, struggling to pass for normal.

They are impaired but not helpless or demented, and now a growing number are speaking out about how it feels to be them: Silenced prematurely or excluded from decision making. Bristling at well-meaning loved ones who boss them around. Seeking meaningful activities to fill their days.

Out of their individual frustrations, these patients are creating a grass-roots movement to improve services and change public perceptions. And they are making a mark.

Early stage patients like Ms. Carver, telling their own stories, have become popular speakers at national conferences and persuasive lobbyists with state and federal lawmakers. Closer to home, they are pushing for more patient support groups, creating social networks and taking part in couples counseling to restructure their marriages after diagnosis.

Rarely have ill spouses and well spouses participated in joint support groups because of the widespread belief that their fears and frustrations are very different and that Alzheimer’s patients were too far gone to benefit. Historically, social service agencies have focused on the needs of caregivers. But that, too, is changing. “We’ve given wide attention to the caregivers and ignored the psychological and relational aspects of the lives of people with the disease,” said Peter V. Rabins, a professor of psychiatry at the Johns Hopkins University and a co-author of “The 36-Hour Day,” a guidebook for caretakers. “So these are important steps toward redressing this imbalance.”

Ms. Carver’s husband, Stephen, an electrician at a Broadway theater, is mindful that spouses — fearful and overwhelmed — can be insensitive and impatient as their mates’ abilities decline.

“They can’t always follow what’s going on if there’s too much input,” Mr. Carver said. “Their brains have to work so much harder, which tires them out, and their logic isn’t always linear, so there’s a tendency to think they don’t comprehend. I’m not a patient person by nature, and Mary’s losing her mental capabilities. So I have to slow down and adapt. And I have to remind myself that she still has feelings and perceptions. She still has an emotional life.”

Absent a cure, or more effective drugs, Alzheimer’s disease is a march to oblivion. But the process can unfold over two decades. Patients at the front end, said Paulette Michaud, manager of early stage services at the New York City Alzheimer’s Association chapter, “lose the sense of independence and control much more quickly than they need to because everyone focuses on their deficits.”

“These are still viable people,” Ms. Michaud continued. “What are they supposed to do for the next three, four, five years of life?”

Some answers are emerging, as patients request and help design new programs at academic medical centers and social service agencies. Among them is a speakers’ bureau at the New York City chapter of the Alzheimer Association that grew out of complaints of boredom.

Ms. Carver is among the most popular speakers. She flushes with accomplishment when she is on the podium at a conference but recalls none of it moments after leaving the stage. Ms. Carver sobs at the extent of her short-term memory loss. Her support group friends comfort her, reminding her that their memories may be better, but their speech or concentration is worse.

At the Alzheimer’s clinic at Northwestern University Medical School, support group participants told Darby Morhardt, the facilitator, that they yearned to spend more time together. As a result, in partnership with the Council for the Jewish Elderly in Chicago, Ms. Morhardt’s support group takes regular bus trips to historical and cultural sites of their choosing like an African-American art museum, a glass blower’s studio and a Hindu temple.

Social groups are also springing up for couples. In San Anselmo, Calif., Peter and Judy Hebert regularly entertain new friends from Mr. Hebert’s two support groups, each with different deficits but all relatively high-functioning.

Mr. Hebert, once an official at the General Services Administration, is 67 and retains his short-term memory, but his speech and motor skills are deteriorating five years after diagnosis, and he cannot reassemble a sandwich should one piece of bread fall off. But he can maintain a busy schedule visiting assisted-living centers and nursing homes to exhibit his landscape photography, and sometimes his speech flows.

“It feels like I’m working,” Mr. Hebert said.

His wife accompanies him, struggling not to fill in the blanks in his halting sentences. “We all have that tendency to take over,” she said.

How much hovering is too much has been a common topic in couples counseling sessions at New York University that are part of a research study by Dr. Mary S. Mittelman.

The study, in which couples receive six counseling sessions together, was to have included 200 couples, but 16 have signed up, an indication, some of Dr. Mittelman’s colleagues said, that many couples still do not welcome frankness.

At the sessions, a counselor with expertise in Alzheimer’s disease can guide the conversation, slow everything down and offer enough encouragement so the ill spouse can participate. In reviewing early results, Dr. Mittelman said, the patients with dementia said they enjoyed being included, and their spouses said they learned ways to make that happen.

Months later, the patients remembered the counselor and were happy to be back, though the content of the sessions had disappeared from memory and they veered between confusion and understanding.

“What am I doing now?” asked John McCrosky, 75, directing the question at his wife, Corinne Samios.

The counselor intervened, asking, “Are you the same John as when I saw you last?”

“No, I’m not the same,” he said, slyly setting up the punch line to his own joke. “Now I can’t remember to flush.”

The second study involving couples, led by Carol J. Whitlatch of the Cleveland Institute, compared the expectations of the ill spouse and the caregiver spouse, with an eye toward planning for the future.

Both began the counseling assuming that all needs would be met by the well spouse but quickly saw that this was unfair and together sought areas where care could be delegated.

A result, Dr. Whitlock said, was that patients felt involved in the decision making and caregivers felt relieved at having more options than they had imagined, sometimes even the acknowledgment of the ill spouse that a nursing home might someday be necessary.

The groundwork for the current self-help movement is the 20-year-old work of Robyn Yale, a social worker in Northern California, who ran patient support groups when most Alzheimer’s agencies considered them incapable of benefiting. Ms. Yale is now organizing groups for early stage patients in assisted-living centers and nursing homes.

“It’s been a long process of changing stereotypes,” Ms. Yale said. “But we’re finally hearing their voices, and we need to respond to that.”

One frustration among innovators in the field is creating volunteer opportunities for people who are too forgetful or confused to do many jobs. An agency tried that in California, pairing a cognitively intact volunteer with a second volunteer with mild dementia, but, over time, the labor-intensive project could not be sustained.

Last year, the national office of the Alzheimer’s Association declared early stage services a priority. The association now has an advisory board made up of patients, most whom have a rare early onset form of the disease, which sometimes runs in families.

People struck with dementia of various sorts in the prime of life — 200,000 to 500,000, according to last week’s study — have been the most aggressive advocates, experts say. They have not settled into retirement or been slowed by other infirmities, and they also came of age in an era of activism.

“This younger group, we’re mouthy,” said Chuck Jackson, 53, one of the board members, a former outplacement counselor for loggers who left his job upon diagnosis, wanting to “enjoy daily life” as long as possible.

“I know where I’m going to end up,” Mr. Jackson said.

So do John Carpenter and Mary Carver, but they are not there yet.

Mr. Carpenter, who once performed in Broadway musicals, was determined to perform again after his illness was diagnosed recently at age 82. One of his “big hurts,” Mr. Carpenter said, “is not knowing what I’m going to do tomorrow or the next day or the day after that.” His wife, Milly, “doesn’t talk to me like she used to,” he said.

“And,” he added, “when people say, ‘Tell me what you did,’ it’s gone, just gone. I want to be who I was.”

So he petitioned the Alzheimer’s Association to let him star in a play about the disease. And he and Ms. Carver, a former singer, told Ms. Michaud, the group leader, that they would enjoy performing together. Could she help them find an adult day care center where they could entertain? She can, and she will.

Living With Alzheimer’s Before a Window Closes, NYT, 29.3.2007, http://www.nytimes.com/2007/03/29/health/29alzheimers.html?hp

Citywide

For Smaller Fighters of H.I.V.,

Weapons Dwindle

March 27, 2007
The New York Times
By DAVID GONZALEZ

If it can be sold, traded or swiped, you can find it at the intersection of Mother Gaston Boulevard and Belmont Avenue in Brownsville. In this crazy corner of Brooklyn, bleary-eyed men and women with faces worn from hustling a buck — or more — stand outside all-night delis, their eyes shifting about as quickly as their feet.

This is also the kind of place where you can catch a few things nobody wants, like a bullet, or a beating.

A small group of women here have taken on another problem ravaging the area: H.I.V. They hit the streets and stores twice a week dispensing condoms and advice about protected sex while urging people to get tested for the virus that causes AIDS. It is hard work, stopping other women in midstride to ask them about how they protect themselves behind closed doors.

Yet as much as these peer educators from Life Force, a Brooklyn-based H.I.V./AIDS education agency for minority women, are used to the streets, they are not prepared to wind up on them. This weekend the agency may have to start laying off some workers after failing to win a renewal of financing for its grass-roots programs. While medical advances are helping people with the disease live longer, some of the very groups that helped them survive are confronting their own demise.

“People are not dying like they used to years ago,” said Ivone Negron, a peer educator who is H.I.V.-positive. “But people are still getting infected, and we know how to stop that. We are doing what we got to do.”

Advocates for people living with H.I.V. and AIDS said community-based groups like Life Force, which have emerged over the past 20 years to confront health crises in poor and minority neighborhoods, could not compete with larger groups and hospitals that offer one-stop shopping for a variety of services. Others said city health officials favor Manhattan-based groups, even though the other boroughs have borne the brunt of the disease.

“A lot of groups in New York are feeling the burn because the opportunities for little groups are drying up as the bigger ones come in,” said Kwame Banks, a project director at the Community Resource Exchange, which advises nonprofit organizations. “They’re out on the streets doing the work and don’t have time to be philosophical about it. They don’t even have the time to do strategic thinking.”

A substantial amount of financial support for the smaller groups has come from the $120 million the city receives each year from the federal government through what are known as Ryan White funds. About three years ago, a council that recommends how that money should be spent reviewed program priorities. The council recommended changes that were subsequently adopted by the city’s Department of Health and Mental Hygiene. The city then turned to the nonprofit Medical and Health Research Association of New York City to solicit proposals from service providers.

Judith A. Verdino, vice president for special initiatives and H.I.V. at the medical association, said the new priorities placed greater emphasis on access to care and maintaining treatment. Outreach work — which had focused on the distribution of condoms and clean syringes, among other approaches — shifted to getting people into treatment. Proposals her agency received were scored on a 100-point scale on how well they met program requirements.

The resulting grant decisions alarmed some neighborhood groups, including Life Force, that failed to make the cut after years of support. After a review of those grants last year, the city’s comptroller said the boroughs outside of Manhattan were shortchanged. Officials at the city’s department of health and the medical association countered by saying they had a mix of services and groups covering the five boroughs. “I can say unequivocally it was a fair process,” Ms. Verdino said. “It is based on how well people are able to present their program and show there will be some results.”

Nonetheless, the smaller groups have been scrambling since last year, trying to survive while scaling back programs, laying off staff members and referring clients to new programs. Chris Norwood, the executive director of Health People, a community education organization in the Bronx, said her group was among 59 programs in the city that did not get financing through the Ryan White funds. She did receive some money from the City Council to follow up on former clients.

Her group, which had run family programs for adults with the virus and mentoring programs for teenagers at risk of contracting it, had to refer more than 400 clients to new programs, though she said that in some cases, the new programs had not started. That, she said, placed people at risk of interrupting their treatment.

Other advocates said that a greater emphasis on medical approaches failed to provide enough financing for groups working on other issues, like social services or legal assistance for people facing eviction. Sometimes the pressures caused by those problems can make an individual take a turn for the worse, the advocates said.

“It’s not a manageable illness if you are not housed,” said Terri Smith-Caronia, director of New York City policy for Housing Works, an advocacy group that promotes AIDS awareness. “It’s not manageable if you are selling your body for shelter, food or to meet some need the government decided is not a core medical service.”

Those are the kinds of vulnerable people, she said, who are best served by peer educators who take to the streets in the hope of reaching people who live below the official radar. In a bittersweet twist for Life Force’s two dozen peer educators, it was that kind of work that inspired “Life Support,” a movie starring Queen Latifah, now showing on HBO.

Gwen Carter, the executive director of Life Force, said her group was a crucial complement to the medical work being done by the larger institutions.

“The role of a community-based organization is to get people to realize the need to get to those medical places; to get yourself tested and take care of yourself.” she said. “If we all work together, it will be more effective. Face it, we’re out there. If you are waiting for people to come to you, it ain’t going to happen.”

In recent days, her group has been able to raise from grants about a third of the $193,000 in Ryan White financing that will run out by the end of this week. (Those funds account for about 40 percent of Life Force’s budget. The agency also receives money from the Centers for Disease Control and Prevention.) And she is exploring the possibility of joint fund-raising with another health group facing a similar cash crunch. Even some of her peer educators have gotten donations — in the form of $10 money orders — from local merchants.

Last week, a half-dozen women from Life Force went to the offices of a needle-exchange program in Brownsville. Outside, several of them stopped women on the street, asking them about how they protected themselves during sex. Carol Magee, an outreach specialist who started out 13 years ago as a peer educator, asked passers-by how long it had been since they had been tested for H.I.V.

“A long time,” one woman said.

“Are you sexually active?” Ms. Magee countered.

Less than three minutes later, Ms. Magee was walking with her to get tested inside the needle-exchange offices.

“I can identify with these people,” Ms. Magee said. “I know all the games. They invented a few new ones, but I’m hip to those, too.”

Around the corner, three peer educators wedged themselves into a coffee shop, where the regulars met them with smiles and questions. One woman huddled with a peer to ask about how to use a female condom, because her husband refused to wear a condom. A couple of women went away with strips of free condoms the educators were handing out.

A hard-faced woman inside the coffee shop who would give only her first name, Mary, has known the Life Force workers for almost a year. Mary used to be a teacher and wife; she is now a widow and recovering heroin addict. Her stony gaze eased when she saw the peers.

“For people involved in the situation we are in, these women are supportive and nonjudgmental,” she said. “They are a necessary community service. They educate the ignorant.”

As she spoke, an incoherent woman staggered into the coffee shop, only to be hustled outside by Mary and a friend. The woman went down the block, bumping into men and trying — without luck — to cadge a dollar or a cigarette.

“Man, we are like the forgotten people out here,” Mary said. “We don’t count.”

For Smaller Fighters of H.I.V., Weapons Dwindle, NYT, 27.3.2007, http://www.nytimes.com/2007/03/27/nyregion/27citywide.html

Aged, Frail and Denied Care

by Their Insurers

March 26, 2007
The New York Times
By CHARLES DUHIGG

CONRAD, Mont. — Mary Rose Derks was a 65-year-old widow in 1990, when she began preparing for the day she could no longer care for herself. Every month, out of her grocery fund, she scrimped together about $100 for an insurance policy that promised to pay eventually for a room in an assisted living home.

On a May afternoon in 2002, after bouts of diabetes had hospitalized her dozens of times, Mrs. Derks reluctantly agreed that it was time. She shed a few tears, watched her family pack her favorite blankets and rode to Beehive Homes, five blocks from her daughter’s farm equipment dealership, content that she would not be a financial burden on her family.

But when she filed a claim with her insurer, Conseco, it said she had waited too long. Then it said Beehive Homes was not an approved facility, despite its state license. Eventually, Conseco argued that Mrs. Derks was not sufficiently infirm, despite her early-stage dementia and the 37 pills she takes each day.

After more than four years, Mrs. Derks, now 81, has yet to receive a penny from Conseco, while her family has paid about $70,000. Her daughter has sent Conseco dozens of bulky envelopes and spent hours on the phone. Each time the answer is the same: Denied.

Tens of thousands of elderly Americans have received life-prolonging care as a result of their long-term-care policies. With more than eight million customers, such insurance is one of the many products that companies are pitching to older Americans reaching retirement.

Yet thousands of policyholders say they have received only excuses about why insurers will not pay. Interviews by The New York Times and confidential depositions indicate that some long-term-care insurers have developed procedures that make it difficult — if not impossible — for policyholders to get paid. A review of more than 400 of the thousands of grievances and lawsuits filed in recent years shows elderly policyholders confronting unnecessary delays and overwhelming bureaucracies. In California alone, nearly one in every four long-term-care claims was denied in 2005, according to the state.

“The bottom line is that insurance companies make money when they don’t pay claims,” said Mary Beth Senkewicz, who resigned last year as a senior executive at the National Association of Insurance Commissioners. “They’ll do anything to avoid paying, because if they wait long enough, they know the policyholders will die.”

In 2003, a subsidiary of Conseco, Bankers Life and Casualty, sent an 85-year-old woman suffering from dementia the wrong form to fill out, according to a lawsuit, then denied her claim because of improper paperwork. Last year, according to another pending suit, the insurer Penn Treaty American decided that a 92-year-old man had so improved that he should leave his nursing home despite his forgetfulness, anxiety and doctor’s orders to seek continued care. Another suit contended that a company owned by the John Hancock Insurance Company had tried to rescind the coverage of a 72-year-old man when he was diagnosed with Alzheimer’s disease four years after buying the policy.

In court filings, all three companies said the denials had been proper. They declined further comment on the cases, though Bankers Life and John Hancock eventually settled for unspecified amounts.

In general, insurers say criticisms of claims-handling are unfair because most policyholders are paid promptly and some denials are necessary to root out fraud.

In a statement, Conseco said the company “is committed to the highest standards for ethics, fairness and accountability, and strives to pay all claims in accordance with policy contracts.” Penn Treaty said in a statement, “We strive to treat all policyholders fairly, and to deliver the best, most efficient evaluation of their claim as possible.”

But policyholders have lodged thousands of complaints against the major long-term-care insurers. A disproportionate number have focused on Conseco, its affiliate, Bankers Life, and Penn Treaty. In 2005, Conseco received more than one complaint regarding long-term-care insurance for every 383 such policyholders, according to data from the insurance commissioners’ association. Penn Treaty received one complaint for every 1,207 long-term-care policyholders. (The complaints touch on a variety of topics, including claims handling, price increases and advertising methods.)

By comparison, Genworth Financial, the largest long-term-care insurer, received only one complaint for every 12,434 policies.

Conseco is among the nation’s largest insurers, collecting premiums worth more than $4.2 billion in 2006, of which long-term-care policies contributed 21 percent. Penn Treaty focuses primarily on long-term-care products and collected premiums of about $320 million in 2004, the last year the company filed an audited annual report.

In depositions and interviews, current and former employees at Conseco, Bankers Life and Penn Treaty described business practices that denied or delayed policyholders’ claims for seemingly trivial reasons. Employees said they had been prohibited from making phone calls to policyholders and that claims had been abandoned without informing policyholders. Such tactics, advocates for the elderly say, are becoming common throughout the industry.

“These companies have essentially turned their bureaucracies into profit centers,” said Glenn R. Kantor, a California lawyer who has represented policyholders.

Yet these concerns have been ignored by state regulators, advocates say, and have gone unnoticed by federal lawmakers who recently passed incentives intended to promote purchases of long-term-care policies, in the hopes of forestalling a Medicare funding crisis.

Conseco and Bankers Life “made it so hard to make a claim that people either died or gave up,” said Betty J. Hobel, a former Bankers Life agent in Cedar Rapids, Iowa.

“When someone is 70 or 80 years old,” she said, “how many times are they going to try before they just give up?”

A Race to Sell Policies

When Mrs. Derks bought her long-term-care policy from a door-to-door salesman in 1990, she was unaware that she represented the insurance industry’s newest gold mine.

Her husband had died eight years earlier of a stroke, leaving her to run a barley farm in northern Montana, where she lived with her three children and her aging mother. As she watched her own parent decline, Mrs. Derks became preoccupied with sparing her children the expense of her final years.

“She was terrified that she would bankrupt us or get sent to a public nursing home,” said Ken E. Wheeler, her son-in-law.

At the time, long-term-care policies, which can cover the costs of assisted-living facilities, nursing homes and at-home care, were becoming one of the insurance industry’s fastest-growing products. Companies like Conseco, Bankers Life and Penn Treaty were aggressively signing up clients who were not in the best health at rates far below their competitors’ in order to win more business, former agents said. From 1991 to 1999, long-term-care sales helped drive total revenue gains of roughly 500 percent each at Penn Treaty and Conseco, including its affiliate Bankers Life.

Cracks in the business, however, soon started to appear. Insurance executives began warning they had underestimated how long policyholders would live after entering nursing homes. The costs of treating Alzheimer’s, Parkinson’s and diabetes ballooned.

As insurers began realizing their miscalculations, they persuaded insurance commissioners in California, Pennsylvania, Florida and other states to approve price increases of as much as 40 percent a year.

By 2002, Conseco’s long-term-care payouts exceeded revenue. Those and other disappointing results prompted the company to file for bankruptcy, from which it emerged 10 months later.

That same year, Mrs. Derks entered Beehive Homes, a cheery, 12-bed center one block from the Prairie View elementary school. In the previous four years, she had been hospitalized more than two dozen times. She had once lain unconscious in her living room for a day and a half. Her physician ordered her into an assisted-living center.

Initially, Conseco told Mrs. Derks’s daughter, Jackie Wheeler, that her claim would go through smoothly, Mrs. Wheeler said. The family began paying Beehive Homes’s $1,900 monthly fee.

But three months after submitting her claim, Mrs. Derks received a letter from Conseco saying she had waited too long, and her earliest costs would not be reimbursed. Two months later, she received another letter denying her entire claim because she had not submitted proof of illness.

Yet a copy of Mrs. Derks’s policy, sent to the Wheelers by Conseco in 2004 and reviewed by The Times, mentions no requirement for proof of illness. The policy requires only that the confinement be ordered by a physician, and it allows for a notice of claim to be sent “as soon as reasonably possible.”

Mrs. Derks’s daughter called Conseco and explained that her mother could not recall the date or people’s names and had started multiple fires by forgetting to turn off the stove. She sent letters stating that her mother needed assistance to dress, eat, go to the bathroom and inject insulin.

“This is medically necessary!!!” reads a form signed by Mrs. Derks’s physician in 2004. “This has been filled out three times! This person needs assistance!”

Seven months later, Conseco sent another letter, this time denying Mrs. Derks’s claim because her policy “requires a staffed registered nurse 24 hours per day.” Her policy does not mention such a requirement.

Conseco also sent letters denying Mrs. Derks’s claim because her policy had an “assisted living facility rider,” and because Mrs. Derks “does not have an assisted living facility rider.” In all, the family received more than a dozen letters from the company. Many contradict one another, and frequently cite requirements that are nowhere mentioned in Mrs. Derks’s policy.

“There was always a new step in the runaround,” Mrs. Wheeler said. “It felt like everything was designed to make me just go away.”

Over two years, Mrs. Wheeler estimated, she called the company about 100 times. Twice a month, she sent envelopes stuffed with medical records. Some afternoons, she spent hours making calls. After one conversation, Mrs. Wheeler slammed down the phone and started to cry. Then she drove to Beehive Homes, where her mother was surrounded by faded photos of her childhood and boxes of adult diapers.

“I wouldn’t tell her about the problems we were having with Conseco, because I knew it would cause her so much worry,” Mrs. Wheeler said.

Eventually, the Wheelers sold part of their John Deere dealership to raise money to pay for her mother’s care. In October 2006, they sued.

Conseco, asked by a reporter about the company’s handling of the Derks claim, declined to answer, citing the pending litigation. In court documents, the company denied Mrs. Derks’s allegations without specifying why her claim was denied.

“We did everything they asked,” Mrs. Wheeler said. “And this company just treats us like dirt.”

Tales of Bureaucracy

Inside the large Conseco headquarters in Carmel, Ind., scores of employees receive the flood of documents and calls that arrive each day. At times, according to depositions and interviews, that deluge became so overwhelming that documents were lost, calls went unreturned and mistakes occurred.

Some employees describe vast mailrooms where documents appear and disappear. One call-center representative said he was afforded an average of only four minutes to handle each policyholder’s call, no matter how complicated the questions. Employees said they were instructed not to say when the company was behind in processing paperwork, even when the backlog extended to 45 days. Workers were prohibited from contacting each other by phone, although such calls might have quickly resolved obstacles, according to depositions.

Conseco, asked in detail about the company’s policies, declined to respond.

Bureaucratic obstacles were pervasive, according to interviews with 10 former Conseco employees and depositions of more than a dozen others. Robert W. Ragle, a former Bankers Life branch manager, once contacted the claims department on behalf of a client, and “they just laughed us off the phone,” he said. “Their mentality is to keep every dollar they can.” Mr. Ragle was dismissed by Bankers Life in 2002. He sued for wrongful termination and settled out of court.

In lawsuits, complaints and interviews, policyholders contend that Conseco, Bankers Life or Penn Treaty denied claims because policyholders failed to submit unimportant paperwork; because daily nursing notes did not detail minute procedures; because policyholders filled out the wrong forms after receiving them from the insurance companies; and because facilities were deemed inappropriate even though they were licensed by state regulators.

In depositions conducted on behalf of angry policyholders, Conseco employees described bureaucratic obstacles that prevented payment of claims. Those depositions were sealed in settlement agreements but were obtained by The Times.

In a 2006 deposition, a Bankers Life and Conseco claims adjuster, Teresa Carbonel, testified that she denied claims because of missing records but was prohibited from calling nursing homes or physicians to request the documents. She also testified that when a claim was denied, she was forbidden to phone a policyholder, but instead used a time-consuming mailing system.

Ms. Carbonel’s testimony, recorded during lawsuit on behalf of a 94-year-old policyholder, Rhodes K. Scherer, also disclosed that if policyholders did not mail requested documents within 21 days, Conseco might abandon their claim, sometimes without informing them.

In the case of Mr. Scherer, who was institutionalized after a bathroom fall, it was difficult to obtain a response, Ms. Carbonel said, because the company’s requests were mailed to his home address, rather than the nursing center where the company had been notified that he had moved. Ms. Carbonel, who is no longer with the company, did not return calls. Conseco declined to comment on her testimony.

In another deposition, Conseco’s then-senior manager for long-term- care claims, Jose S. Torres, testified that Conseco would sometimes withhold payments until it received documents not required by customers’ policies. In Mr. Scherer’s case, Mr. Torres said, the company refused to pay his nursing home costs unless he sent copies of the home’s license, payment invoices and medical records, even though those documents had no bearing on approving his claim.

Mr. Scherer’s claim “was handled not in the best way, but it was handled according to the processes and procedures placed at the time,” Mr. Torres testified. “Mistakes are going to be made, you know.”

Other executives testified that when Conseco appeared to have lost important documents in Mr. Scherer’s claim, no investigation was initiated. Shawn Michael Schechter, a Conseco claims supervisor who left the company in 2005 on positive terms, according to the deposition, testified that the handling of Mr. Scherer’s claim violated the principle of good faith, which requires insurance companies to treat customers fairly.

“The claim adjuster could have made that very easy and not have put the burden back onto the policyholder,” he testified.

Mr. Torres did not return calls. Mr. Schechter declined to answer questions.

Mr. Scherer died in 2004 without receiving benefits from Conseco. His estate settled with the company in February for an undisclosed amount, according to a lawyer representing the estate.

Conseco declined to discuss its complaint history or individual cases, citing confidentiality agreements. In its statement, the company said that in 2006, Conseco paid nearly $2.3 billion on 9.8 million claims in all types of insurance sold by the company.

The company added: “Conseco, through training, education and process improvements in all of its insurance companies, is continuously focused on enhancing service and resolving any problems expeditiously. The Conseco Insurance Group’s overall insurance department complaints decreased 20 percent from 2005 to 2006.”

Depositions of executives at Penn Treaty also point to questionable practices. In a 2005 lawsuit, a Penn Treaty senior vice president, Stephen Robert LaPierre, testified that the company rejected one claim without informing the policyholder why, asked for information that was not required to process a claim, gave incomplete information about a claim’s status and said the company was delaying payment because of an investigation while failing to take steps that might have resolved the inquiry.

Mr. LaPierre declined to discuss his testimony. Penn Treaty settled the lawsuit by paying the policyholder an unspecified amount, the policyholder’s lawyer said.

Penn Treaty said in a statement that evaluating a company by measuring its complaints was flawed, and that since 2003, the company has denied an average of less than 1.7 percent of the up to 8,000 claims it received every year because of reasons related to policyholder eligibility. “From time to time, Penn Treaty is compelled to investigate fraud or questionable billing activities,” the company added.

Few Regulatory Inquiries

Few of the cases or complaints filed against Conseco, Bankers Life, Penn Treaty or other insurers have received much attention, in part because many lawsuits filed against long-term-care insurers have been settled with the requirement that depositions, documents and settlement terms be kept confidential. Frequently, say policyholders’ lawyers, the companies have been willing to pay millions of dollars in exchange for confidentiality.

Furthermore, despite the complaints against long-term-care insurers, few states have conducted meaningful investigations.

Ron Gallagher, a deputy commissioner with the Pennsylvania Insurance Department, said, “I don’t know that we have a real problem with improper claim denials.”

Yet data from the National Association of Insurance Commissioners show that from 2003 to 2005, Pennsylvania received more complaints regarding Conseco, Bankers Life and Penn Treaty than any other state. Mr. Gallagher said he might begin a new review of those companies.

Other states with large numbers of long-term-care complaints, including California, Missouri, Maryland, Indiana and Washington have not begun investigations, or have reviewed only small numbers of policies.

As a result, other seniors may end up like Mrs. Derks.

While she was waiting for her lawsuit to proceed, Medicaid began contributing to Ms. Derks’s care. Taxpayers now pay Beehive Homes about $32 daily for her care.

“Long-term-care insurance is supposed to result in less pressure on Medicaid, not more,” said Ms. Senkewicz, the former executive at the insurance commissioners’ association.

For Mrs. Derks’s family, things have already broken down.

“How many other people are out there who don’t have a family to fight for them and have just given up?” asked Jackie Wheeler. “This company should be ashamed.”

Aged, Frail and Denied Care by Their Insurers, NYT, 26.3.2007, http://www.nytimes.com/2007/03/26/business/26care.html

Pediatricians Voice Anger

Over Costs of Vaccines

March 24, 2007
The New York Times
By ANDREW POLLACK

The nation’s pediatricians, the foot soldiers in the campaign to vaccinate America’s children, are starting to revolt.

The soaring cost and rising number of new vaccines, doctors say, make it increasingly difficult for them to buy the shots they give their patients. They also complain that insurers often do not reimburse them enough, so they can lose money on every dose they deliver.

As a result, some pediatricians are not offering the newest and most costly vaccines. And some public health experts say that if the situation worsens, it could lead to a breakdown in the nation’s immunization program, with a rise in otherwise preventable diseases.

“We cannot pay for the vaccination of the American public any longer,” said Dr. Dorothy A. Levine, a pediatrician in Stamford and New Canaan, Conn. “We’re not giving them with as much vigor as we should, and the main reason is financial.”

Dr. Levine, for instance, is not offering Gardasil, the new vaccine that prevents cervical cancer; it costs $360 for three shots. Nor is she giving shots of RotaTeq, the $190 vaccine against the diarrhea-causing rotavirus.

The situation underscores the role played in the United States by market dynamics in providing immunization, a public health service in many other countries.

About 85 percent of the nation’s children get all or at least some of their inoculations from private physicians’ offices, which operate as businesses. The federal and state governments pay for vaccines for about 55 percent of children, mainly poor ones. But even those government-subsidized vaccines are mainly administered by private doctors.

Private physicians have been taking on a greater role in immunization since a 1989 measles outbreak spurred efforts to increase vaccination rates. Now, however, “we’re worried about seeing a reverse trend,” back to public health departments, said Dr. Howard D. Backer, chairman of the Association of Immunization Managers, a group of state vaccine officials.

To be sure, most pediatricians continue to offer most or all vaccines. And immunization rates for the older vaccines remain higher than ever. More than 90 percent of children get shots for polio, mumps and hepatitis B, for instance.

Merck, which makes both Gardasil and RotaTeq, says the problem is transitory and that most insurers are already paying for those products. It says that 70 percent of the largest pediatric practices are stocking Gardasil and 60 percent carry RotaTeq.

Michael F. Thomas, a senior vice president in Merck’s vaccine division, defended the company’s prices saying, “Historically, vaccines have been undervalued.”

But some doctors are balking. Teri Perryman, a doctor in Kerrville, Tex., is not only avoiding Gardasil and RotaTeq, but also not offering the new meningitis vaccine, flu shots or new expensive combination products like one that combines the chickenpox vaccine with the measles-mumps-rubella vaccine, according to her husband, Kevin Perryman, who helps manage the practice.

Other doctors are asking patients to pay upfront or, in a new twist, are sending them to the drugstore. Typically, physicians have not written prescriptions for vaccines, as they do for drugs, but instead buy and store them, recouping their money when they give the vaccines to patients.

Michele Rabito of Douglaston, Queens, was given prescriptions for the first two Gardasil shots for her 15-year-old daughter, Paige. Her pediatrician would not provide the vaccine himself because Ms. Rabito’s insurance did not cover it.

The pharmacy took a day or two to fill each prescription because it did not normally carry Gardasil, Ms. Rabito said. And it charged her $185 a dose, about $65 more than the wholesale cost. Ms. Rabito then brought each vial back to the doctor’s office, where her daughter was vaccinated.

“It’s a lot of trouble and a lot of money,” she said, although she added that she did not blame her pediatrician.

Getting a vaccination was not always so difficult. In 1980, it cost only about $23, or $59 adjusted for inflation, for the seven shots and four oral doses needed to immunize a child, according to data provided by Dr. Thomas Saari, who is emeritus professor of pediatrics at the University of Wisconsin.

Today, though, a child who receives all the recommended vaccines would receive as many as 37 shots and 3 oral doses by the 18th birthday — at a cost exceeding $1,600.

Costs have nearly tripled since 2001 alone. And several new and costly vaccines have been added just since 2005. Besides Gardasil and RotaTeq, both made by Merck, the new ones include Menactra, a $80 meningitis vaccine made by Sanofi-Aventis.

Also newly recommended are a vaccine against hepatitis A, a booster shot for chickenpox, a booster shot against whooping cough, and yearly flu shots until a child’s fifth birthday instead of only until the second birthday.

Public health experts say vaccines, including the new ones, are among the most cost-effective of health measures. And higher prices have attracted new companies to the vaccine business, which was once considered a moribund backwater of the pharmaceutical industry.

But money has become a problem, not only for pediatricians but for doctors who give adult vaccines, and also for the federal and state governments.

Some states that once provided free vaccines to all children, like North Dakota, have had to abandon that practice. The Washington State Department of Health, which is still trying to provide vaccines for all, is requesting an additional $13 million a year from the state Legislature to pay for the new vaccines, which would nearly double the $16 million current appropriation.

Spending by the federal Vaccines for Children program, which pays for immunizations for Medicaid children and some others, has grown to $2.5 billion, up from $500 million in 2000.

But the loudest complaints are coming from pediatricians. “I cannot remember a time when I’ve heard this much anger,” said Dr. Walter A. Orenstein of Emory University, who ran the national immunization program at the federal Centers for Disease Control and Prevention from 1988 until 2004.

Doctors say it is getting too difficult to tie up so much of their capital in vaccines.

“If we simply purchased Gardasil for every eligible girl each year, it would cost 25 percent of every dollar I collect,” said Dr. Herschel R. Lessin, medical director of Children’s Medical Group, a practice with more than 20 doctors based in Poughkeepsie, N.Y.

Even without stocking Gardasil or RotaTeq, the group spent more than $600,000 to buy vaccines last year and has $150,000 worth sitting in its refrigerators at any time.

Dr. Lessin said the eroding economics of practicing basic medicine was a reason fewer medical students were going into primary care, which pays much less than specialties.

“I’m a good guy,” he said, “but I’m not a social worker.”

If the physicians made a profit on vaccines, the advance purchase could be considered a good investment, especially since vaccinations bring in children who can then be provided other services.

But doctors say reimbursement is often inadequate. Moreover, insurers often do not reimburse for new vaccines at all during their first few months on the market. While doctors can charge what they want for a vaccine to a wealthy patient without insurance, for insured patients they generally have to accept what the insurer pays.

There are also the costs for administering vaccines: the nurses’ time, the syringes, the record-keeping, the refrigerator, even insurance in case the refrigerator malfunctions.

Dr. Anne Francis, a pediatrician in Rochester, said her practice once lost $9,000 worth of chickenpox vaccine when a refrigerator door was left ajar and had $5,000 of flu vaccine left over when flu season ended. (Because the flu vaccine changes every year, leftover shots are worthless.)

Unavoidable waste is also more costly in an era of expensive vaccines. If a child pulls her arm away at the last second, “a $120 syringe goes flying through the air and you can’t reuse it,” said Dr. Francis, who heads a committee of the American Academy of Pediatrics dealing with reimbursement.

Insurers and the Vaccines for Children program do reimburse separately for such administrative costs, but often far below the roughly $20 per injection that some pediatricians say is necessary to cover expenses.

Some steps are being taken to remedy the problem. The pediatrics academy and the American Medical Association organized a three-day meeting in Chicago last month to discuss the issue.

Cigna, a big insurer, said it recently raised its reimbursement rates for vaccines. WellPoint, another large insurer, said it was steering doctors to distributors that charge less than it reimburses. Merck is giving doctors 60 days to pay for vaccines instead of 30, although at some time in the past it had given as much as 180 days.

More radical proposals, like mandating that insurance companies cover vaccines or having the government buy all vaccines, are not likely to gain political traction, experts said.

Another idea would be to have doctors pay only for the vaccines they use. But manufacturers in general have resisted this because it would mean more risk of oversupply for them.

The government’s National Vaccine Advisory Committee is also looking at the issue. Its chairman, Dr. Gary L. Freed, said that beyond complaints from physician trade groups, there was actually little data available on the extent of the problem.

But that does not mean Dr. Freed, who is also director of the child health and evaluation unit at the University of Michigan, is not concerned. “Do we want to wait until we have epidemics,” he asked, “before we want to do something about the financing questions?”

    Pediatricians Voice Anger Over Costs of Vaccines, NYT, 24.3.2007, http://www.nytimes.com/2007/03/24/business/24vaccine.html

Editorial

Fairness for Mental Health

March 24, 2007
The New York Times

After a decade of small-bore measures and frustrating stalemates, it looks as if Congress may be ready to require that insurance coverage for mental illness and substance abuse be provided on the same terms as coverage for physical ailments. So-called parity legislation would be a boon to the millions of Americans who suffer from mental illness or addiction and find it hard to afford treatment. It should also reduce the high productivity losses from depressed or stressed workers.

The Senate and the House should move aggressively to pass this much-needed legislation and send it to President Bush for his signature.

Neither the Senate nor the House versions of the bill would require employers or health plans to cover mental illness. But if they do provide such coverage, the financial terms and treatment limits would have to be the same as they are for medical and surgical benefits. No longer could health plans limit mental patients to fewer days in the hospital or fewer outpatient visits. Nor could they make mental patients pay higher deductibles, co-payments or other out-of-pocket charges than other patients.

The most striking development this year is the broad consensus behind the Senate bill, the fruit of extended negotiations with employer groups and insurance plans that have fought such measures in the past, lest their costs be driven up. The bill is backed by Senators Ted Kennedy, Democrat of Massachusetts, and Pete Domenici, Republican of New Mexico — both long-time champions of equal treatment for mental health — whose staff members worked out the compromise. The final product may not be perfect, but it gives mental health advocates much of what they want.

The House bill, whose chief sponsor is Representative Patrick Kennedy, Democrat of Rhode Island and the senator’s son, looks stronger in some respects. It would require that any plan that covered mental health provide coverage for, at a minimum, the same wide range of mental and addiction disorders that are currently covered by the health plan with the largest enrollment of federal employees. The Senate bill does not say what conditions must be covered, and focuses simply on ensuring equal cost-sharing and treatment limits. That is based on a tactical judgment that the business community would fight broad coverage requirements.

Given that President Bush has endorsed the idea of mental health parity, and that both houses seem poised to enact it, the prospects look good for ending the long stalemate. But the House will need to be careful not to overreach and upset the carefully built compromise that has finally brought recalcitrant insurers and employers to the side of equal treatment for mental health and addiction.

    Fairness for Mental Health, NYT, 24.3.2007, http://www.nytimes.com/2007/03/24/opinion/24sat1.html

Editorial

A Cleaner Food and Drug Agency

March 23, 2007
The New York Times

In our highly medicated, high-technology society, it is essential that the Food and Drug Administration regulates drugs, medical devices and other products with complete objectivity — free from the taint of industry influence. So it is encouraging that the agency has proposed new rules to exclude experts who have significant financial ties to regulated industries from serving on committees that recommend whether a product should be approved.

The proposed rules may still need to be strengthened after they are critiqued during a required comment period. But even in their current form they look like a big, and long needed, improvement over the agency’s previously lax efforts to screen out conflicts of interest. The pharmaceutical industry, in particular, doles out lots of money to doctors and academic experts in the form of speaking fees, consultancies, research grants and other financial benefits. And many of these recipients end up on federal advisory committees.

All too often consumer interests are shortchanged. In one egregious example, a panel that favored marketing the controversial painkillers Bextra and Vioxx would have made the opposite recommendation if the experts with industry ties had been excluded from voting.

The new rules would bar from an advisory committee anyone whose financial interests in a company with a product up for review — or its competitors — exceed $50,000, whether in stock ownership, consulting arrangements or individual research grants. Those with smaller financial interests could participate in discussions but would not be allowed to vote. Only those with no potential conflicts could participate as full, voting members. The food and drug commissioner could still grant waivers, but officials expect them to be rare.

Some patient advocates believe the $50,000 exclusion is too generous, and the agency needs to explain more fully how it decided that was the proper cutoff point. It also needs to address whether nonvoting experts — those with smaller financial ties — might still unduly sway a committee’s decision.

Congress needs to confront another worrisome source of industry’s influence: the $300 million in annual fees paid by pharmaceutical manufacturers that help finance the approval process and regulation of drugs. Critics have long complained that these user fees distort the agency’s objectivity and make for a too cozy atmosphere between the industry and its regulators.

The Bush administration, unfortunately, is seeking to increase reliance on user fees. That’s the wrong direction to go. To ensure that the public’s interests are its only concern, the F.D.A. should be supported entirely by public funds.

    A Cleaner Food and Drug Agency, NYT, 23.3.2007, http://www.nytimes.com/2007/03/23/opinion/23fri1.html

U.S. stays vigilant against TB

21.3.2007
USA TODAY
By Anita Manning
 

NEWARK — Maria Garcia is 26, pregnant and has tuberculosis. A Honduran immigrant, she speaks no English and spends her days in the small, immaculate apartment she shares with her boyfriend, a construction worker.

But Garcia is one of the lucky ones. Every day, public-health worker Gloria Leifer of the Global Tuberculosis Institute at the New Jersey Medical School delivers a small envelope containing four anti-TB pills and watches as Garcia takes each one. The treatment, known as directly observed therapy, is given for six to nine months to ensure that all the TB germs are killed and to prevent the emergence of drug-resistant strains.

Garcia is recovering and is no longer able to spread the disease. By the time her baby arrives in July, she'll be cured.

TB is contagious and airborne, spread by coughing. The World Health Organization, which today releases its 2007 Global TB Control Report in advance of World TB Day on Saturday, estimates a third of the world population is infected. In healthy people, TB can remain inactive, emerging only when there is a weakening of the immune system because of illness or malnutrition.

In 2005, 1.6 million people died of TB, WHO says. Most cases are in Africa and Asia, but the USA is not immune: Last year there were more than 14,000 cases, says Kenneth Castro, director of the Centers for Disease Control and Prevention's TB division.

Each of these cases is tested to be sure it can be treated by standard drug regimens. Drug-resistant strains, which are emerging all over the world, require a daily drug combination taken for 18 months to 2 years.

"And now we have the specter raised globally" of extensively drug-resistant TB, Castro says. XDR-TB can occur when drug-resistant strains are not thoroughly treated. Its emergence "threatens to throw us into a pre-antibiotic era, unless we develop new drugs for those rendered virtually untreatable."

Once a case of active TB is identified, local health officials have to track down and test everyone who might have been exposed to the sick person. Last week, New York city health officials were tracking more than 700 hospital patients and employees potentially exposed to TB by a health care worker, and Delaware health officials tested 336 employees at a poultry plant after a worker was found to be infected. In both cases, no other active TB cases were found, but health officials did find people who tested positive for exposure to the virus.

Castro says TB rates in the USA are dropping each year, but the rate of decline has slowed, from 7.3% per year between 1992 and 2000 to 3.8% each year since. "We are concerned that the slowing in rate of decrease signals a stagnation in our progress against TB," he says.

Once considered a disease confined to the inner-city poor, drug users and homeless, "today our typical patient is foreign-born and living in a family unit," says Eileen Napolitano, deputy director of the Global TB Institute. Many are migrant workers or day laborers, and some are hesitant to seek medical care when symptoms start, fearing lost wages or concerns about their legal status. "Eventually, people who are sick enough with TB end up in the hospital, but they could be sick a long time," Napolitano says. "They could be spreading it."

Typically, it takes a year for people with TB to get sick enough to seek treatment, and during that time they are likely to infect 10 to 12 others, says TB expert Carl Nathan, chairman of Microbiology and Immunology at Weill Cornell Medical College in New York. That's one reason it's so hard to wipe it out, he says. "They replace their own numbers before getting treated," he says.

HIV infection increases TB risk, and in developing countries, the epidemics of TB and HIV are linked. "We don't have a grip on it," Nathan says. "It's absolutely not under control, and the situation is not improving overall because HIV is spreading in places where TB is common, like India and China."

Global health organizations are stepping up the drive for new, better drugs and programs to treat HIV and TB simultaneously, often working in partnerships that involve private drug companies and non-profits. Drug company Lilly, for instance, which makes two of the treatments for drug-resistant TB, has transferred the technology to make those drugs to China, South Africa, India and Russia.

A survey by the World Economic Forum's Global Health Initiative found only 30% of companies with an AIDS program also have a TB program. "The concern is that, particularly in Africa, a third of all the HIV/AIDS patients die of TB," says Francesca Boldrini, who heads the initiative. "This puts companies at risk, because they think they're protecting their employees from HIV, but by not having a TB component, they're not providing them with what they could."

The theme of Saturday's World TB Day — "TB anywhere is TB everywhere" — is no exaggeration, Nathan says. "As a society, the world so interconnected, it isn't enough to say it's somebody else's problem."

    U.S. stays vigilant against TB, UT, 21.3.2007, http://www.usatoday.com/news/health/2007-03-21-tuberculosis-prevention_N.htm

More than 5 million

have Alzheimer's in U.S.

Tue Mar 20, 2007
10:52AM EDT
Reuters

WASHINGTON (Reuters) - More than 5 million people in the United States have Alzheimer's disease and an aging population is likely to fuel a steady rise in new cases, a report released by the Alzheimer's Association said on Tuesday.

The association's figure of 5 million is up about 10 percent from its previous estimate in 2000, and it said there are about 400,000 new cases a year.

The group predicts that the number of Alzheimer's cases will rise to 7.7 million people by 2030 as the U.S. baby boom population ages, unless a cure or a way to prevent the disease is found.

Alzheimer's is the seventh leading cause of death in the United States, and it is the leading cause of dementia. It is marked by a steady loss of memory that soon takes away a person's ability to cope and care from himself or herself, and there is no cure.

Drugs can help slow its progression but they eventually stop working. Patients die of pneumonia or other causes as their bodily functions deteriorate.

"In 2005, Medicare spent $91 billion on beneficiaries with Alzheimer's and other dementias and that number is projected to more than double to $189 billion by 2015," the association said in its report.

"However there is hope. There are currently nine drugs in Phase III clinical trials for Alzheimer's, several of which show great promise to slow or stop the progression of the disease," Harry Johns, president and chief executive officer of the Alzheimer's Association, said in a statement.

"This, combined with advancements in diagnostic tools, has the potential to change the landscape of Alzheimer's."

More than 5 million have Alzheimer's in U.S., R, 20.3.2007, http://www.reuters.com/article/domesticNews/idUSN2035124420070320

Citizens Who Lack Papers

Lose Medicaid

March 12, 2007
The New York Times
By ROBERT PEAR

WASHINGTON, March 11 — A new federal rule intended to keep illegal immigrants from receiving Medicaid has instead shut out tens of thousands of United States citizens who have had difficulty complying with requirements to show birth certificates and other documents proving their citizenship, state officials say.

Florida, Iowa, Kansas, Louisiana, New Mexico, Ohio and Virginia have all reported declines in enrollment and traced them to the new federal requirement, which comes just as state officials around the country are striving to expand coverage through Medicaid and other means.

Under a 2006 federal law, the Deficit Reduction Act, most people who say they are United States citizens and want Medicaid must provide “satisfactory documentary evidence of citizenship,” which could include a passport or the combination of a birth certificate and a driver’s license.

Some state officials say the Bush administration went beyond the law in some ways, for example, by requiring people to submit original documents or copies certified by the issuing agency.

“The largest adverse effect of this policy has been on people who are American citizens,” said Kevin W. Concannon, director of the Department of Human Services in Iowa, where the number of Medicaid recipients dropped by 5,700 in the second half of 2006, to 92,880, after rising for five years. “We have not turned up many undocumented immigrants receiving Medicaid in Waterloo, Dubuque or anywhere else in Iowa,” Mr. Concannon said.

Jeff Nelligan, a spokesman for the federal Centers for Medicare and Medicaid Services, said the new rule was “intended to ensure that Medicaid beneficiaries are citizens without imposing undue burdens on them” or on states. “We are not aware of any data that shows there are significant barriers to enrollment,” he said. “But if states are experiencing difficulties, they should bring them to our attention.”

In Florida, the number of children on Medicaid declined by 63,000, to 1.2 million, from July 2006 to January of this year.

“We’ve seen an increase in the number of people who don’t qualify for Medicaid because they cannot produce proof of citizenship,” said Albert A. Zimmerman, a spokesman for the Florida Department of Children and Families. “Nearly all of these people are American citizens.”

Since Ohio began enforcing the document requirement in September, the number of children and parents on Medicaid has declined by 39,000, to 1.3 million, and state officials attribute most of the decline to the new requirement. Jon Allen, a spokesman for the Ohio Department of Job and Family Services, said the state had not seen a drop of that magnitude in 10 years.

The numbers alone do not prove that the decline in enrollment was caused by the new federal policy. But state officials see a cause-and-effect relationship. They say the decline began soon after they started enforcing the new rule. Moreover, they say, they have not seen a decline in enrollment among people who are exempt from the documentation requirement — for example, people who have qualified for Medicare and are also eligible for Medicaid.

Wisconsin keeps detailed records listing reasons for the denial or termination of benefits. “From August 2006 to February of this year, we terminated benefits for an average of 868 people a month for failure to document citizenship or identity,” said James D. Jones, the eligibility director of the Medicaid program in Wisconsin. “More than 600 of those actions were for failure to prove identity.” In the same period, Mr. Jones said, the state denied an average of 1,758 applications a month for failure to document citizenship or identity. In 1,100 of those cases, applicants did not provide acceptable proof of identity.

“Congress wanted to crack down on illegal immigrants who got Medicaid benefits by pretending to be U.S. citizens,” Mr. Jones said. “But the law is hurting U.S. citizens, throwing up roadblocks to people who need care, at a time when we in Wisconsin are trying to increase access to health care.”

Medicaid officials across the country report that some pregnant women are going without prenatal care and some parents are postponing checkups for their children while they hunt down birth certificates and other documents.

Rhiannon M. Noth, 28, of Cincinnati applied for Medicaid in early December. When her 3-year-old son, Landen, had heart surgery on Feb. 22, she said, “he did not have any insurance” because she had been unable to obtain the necessary documents. For the same reason, she said, she paid out of pocket for his medications, and eye surgery was delayed for her 2-year-old daughter, Adrianna.

The children eventually got Medicaid, but the process took 78 days, rather than the 30 specified in Ohio Medicaid rules.

Dr. Martin C. Michaels, a pediatrician in Dalton, Ga., who has been monitoring effects of the federal rule, said: “Georgia now has 100,000 newly uninsured U.S. citizen children of low-income families. Many of these children have missed immunizations and preventive health visits. And they have been admitted to hospitals and intensive care units for conditions that normally would have been treated in a doctor’s office.”

Dr. Michaels, who is president of the Georgia chapter of the American Academy of Pediatrics, said that some children with asthma had lost their Medicaid coverage and could not afford the medications they had been taking daily to prevent wheezing. “Some of these children had asthma attacks and had to be admitted to hospitals,” he said.

In Kansas, R. Andrew Allison, the state Medicaid director, said: “The federal requirement has had a tremendous impact. Many kids have lost coverage or have not been able to obtain coverage.” Since the new rule took effect in July, enrollment in Kansas has declined by 20,000 people, to 245,000, and three-fourths of the people dropped from the rolls were children.

Megan J. Ingmire, a spokeswoman for the Kansas Health Policy Authority, which runs the state Medicaid program, said the waiting time for applicants had increased because of a “huge backlog” of applications. “Applicants need more time to collect the necessary documents, and it takes us longer to review the applications,” Ms. Ingmire said.

The principal authors of the 2006 law were Representatives Charlie Norwood and Nathan Deal, both Georgia Republicans. Mr. Norwood died last month.

Chris Riley, the chief of staff for Mr. Deal, said the new requirement did encounter “some bumps in the road” last year. But, he said, Mr. Deal believes that the requirement “has saved taxpayers money.” The congressman “will vigorously fight repeal of that provision” and will, in fact, try to extend it to the Children’s Health Insurance Program, Mr. Riley said. He added that the rule could be applied flexibly so it did not cause hardship for citizens.

In general, Medicaid is available only to United States citizens and certain “qualified aliens.” Until 2006, states had some discretion in deciding how to verify citizenship. Applicants had to declare in writing, under penalty of perjury, whether they were citizens. Most states required documents, like birth certificates, only if other evidence suggested that a person was falsely claiming to be a United States citizen.

In Virginia, health insurance for children has been a top priority for state officials, and the number of children on Medicaid increased steadily for several years. But since July, the number has declined by 13,300, to 373,800, according to Cindi B. Jones, chief deputy director of the Virginia Medicaid program.

“The federal rule closed the door on our ability to enroll people over the telephone and the Internet, wiping out a full year of progress in covering kids,” Ms. Jones said.

State and local agencies have adopted new procedures to handle and copy valuable documents. J. Ruth Kennedy, deputy director of the Medicaid program in Louisiana, said her agency had received hundreds of original driver’s licenses and passports in the mail.

Barry E. Nangle, the state registrar of vital statistics in Utah, said, “The new federal requirement has created a big demand for birth certificates by a group of people who are not exactly well placed to pay our fees.” States typically charge $10 to $30 for a certificate.

Citizens Who Lack Papers Lose Medicaid, NYT, 12.3.2007, http://www.nytimes.com/2007/03/12/us/12medicaid.html?hp

FDA Chief:

Don't Regulate Tobacco

March 6, 2007
By THE ASSOCIATED PRESS
Filed at 12:30 p.m. ET
The New York Times

WASHINGTON (AP) -- Government regulation of tobacco could backfire by inadvertently forcing smokers to light up more and inhale more deeply, the head of the Food and Drug Administration said Tuesday.

In an interview with The Associated Press, Dr. Andrew von Eschenbach said that if the FDA reduced nicotine levels in cigarettes, people would tailor their smoking habits to maintain current levels of the addictive drug.

''We could find ourselves in the conundrum of having made a decision about nicotine only to have made the public health radically worse. And that is not the position FDA is in; we approve products that enhance health, not destroy it,'' said von Eschenbach, a cancer surgeon.

A bipartisan group of lawmakers introduced legislation last month that would give the FDA the authority to regulate tobacco, in part by reducing its nicotine content.

Smoking kills more than 400,000 Americans a year.

Von Eschenbach said repeatedly that the issue of regulating tobacco is a complex one.

''What I don't want to see happen is that we are in a position where we are determining that a cigarette is safe,'' von Eschenbach said.

In 1996, the FDA moved to regulate tobacco. The Supreme Court ruled in 2000 that Congress had not authorized the agency to do so.

    FDA Chief: Don't Regulate Tobacco, NYT, 6.3.2007, http://www.nytimes.com/aponline/us/AP-FDA-AP-Interview.html

Without Health Benefits,

a Good Life Turns Fragile

March 5, 2007
By ROBERT PEAR
The New York Times

SALISBURY, N.C. — Vicki H. Readling vividly remembers the start of 2006.

“Everybody was saying, ‘Happy new year,’ ” Ms. Readling recalled. “But I remember going straight to bed and lying down scared to death because I knew that at that very minute, after midnight, I was without insurance. I was kissing away a bad year of cancer. But I was getting ready to open up to a door of hell.”

Ms. Readling, a 50-year-old real estate agent, is one of nearly 47 million people in America with no health insurance.

Increasingly, the problem affects middle-class people like Ms. Readling, who said she made about $60,000 last year. As an independent contractor, like many real estate agents, Ms. Readling does not receive health benefits from an employer. She tried to buy a policy in the individual insurance market, but — having had cancer — could not obtain coverage, except at a price exceeding $27,000 a year, which was more than she could pay.

“I don’t know which was worse, being told that I had cancer or finding that I could not get insurance,” Ms. Readling (pronounced RED-ling) said in an interview in her office, near the tree-lined streets and stately old homes of this city in the Piedmont region of North Carolina.

It is well known that the ranks of the uninsured have been swelling; federal figures show an increase of 6.8 million since 2000.

But the surprise is that the uninsured are not necessarily the poor, the unemployed and the undocumented. Solidly middle-class people like Ms. Readling are one of the fastest growing subgroups.

And that is one reason, according to a recent New York Times/CBS News poll, that the problems of the uninsured have jumped to the top of the domestic political agenda in Washington and on the campaign trail.

Today, more than one-third of the uninsured — 17 million of the nearly 47 million — have family incomes of $40,000 or more, according to the Employee Benefit Research Institute, a nonpartisan organization. More than two-thirds of the uninsured are in households with at least one full-time worker.

Ms. Readling’s experience is typical; people who have had serious illnesses often have difficulty obtaining insurance. If coverage is available, the premiums are often more than they can afford.

While the government does not have an official definition of “middle class,” one commonly used point of reference is the median household income, which was $46,326 in 2005.

Katherine Swartz, a professor of health policy and economics at Harvard, said the soaring cost of health care was a major reason for the increase in the number of uninsured. She said it also reflected long-term changes in the economy, like the decline in manufacturing jobs and the growth in the share of workers in service industries and small businesses, which are less likely to provide health benefits.

Moreover, Ms. Swartz said, “Companies have become more aggressive in hiring people as temporary or contract workers with no fringe benefits.”

The National Association of Realtors says 28 percent of its 1.3 million members are without health insurance.

“Because real estate agents are independent contractors, they are forced into the individual insurance market, where there is no negotiating or leverage,” said Pat V. Combs, president of the association.

As an independent contractor with a Century 21 real estate brokerage, Ms. Readling had bought insurance on her own, a temporary extension of coverage from a prior job. But she was unable to renew it after she had surgery for breast cancer in 2005. Most insurers would not offer her coverage, she said, and one carrier quoted a price of $2,300 a month for coverage with a deductible of $5,000 a year.

Concerns about health insurance permeate her life.

To save money, Ms. Readling said, she defers visits to the doctor and stretches out her cancer medication, which costs her about $300 a month. She takes the tiny pills three or four times a week, rather than seven days a week as prescribed.

“I really try to stay away from the doctor because I am so scared of what everything will cost,” said Ms. Readling, who is divorced and has twin 18-year-old sons. Before every doctor’s visit and test, she asks, “How much are you going to charge me?” She says she tries to arrange “the best deals I can.” But in many cases, the price is still unaffordable, and “I have to do without.”

Even those with insurance have reason to be concerned, economists say, because they end up paying for the uninsured in various ways. Some of the costs are also passed on to taxpayers and employers. To help cover the cost of treating the uninsured, hospitals often increase charges to other patients. Insurers then increase premiums for companies that provide health benefits, and they in turn shift some costs to employees.

Ms. Readling is engaged to be married in June, to another real estate agent. But she said she may postpone the wedding because she would not want her husband to be legally responsible for her medical bills.

“I am scared to get married because I don’t have insurance,” Ms. Readling said. “If I have to go to the hospital and I can’t pay my hospital bills, what happens? Do they go after him? Can they take your home?”

To collect unpaid medical bills, health care providers often obtain judgments against a patient’s spouse, as well as the patient, and file liens against their homes. Ms. Readling says she does not own a house, but her fiancé does.

The idea of universal coverage, in the form proposed by President Bill Clinton, proved politically untenable. Since the Clinton plan collapsed in 1994, the politics of health care have changed because of the steady rise in health costs, the increase in the number of uninsured and the erosion of employer-sponsored insurance. Politicians are once again speaking about universal coverage as a goal, though opinion polls show that many voters still oppose the idea of a government-run health care system.

Ms. Readling said it was stressful enough visiting doctors every few months for her cancer follow-ups. Without coverage, she said, the experience is even more stressful.

“When you go to any medical person and they ask for your insurance card, you are so ashamed because you have to say, ‘I don’t have insurance,’ ” Ms. Readling said. “You just feel like you are dirt.”

Ms. Readling said she often woke up at night, terrified of the cost of getting sick without insurance.

“Anything that goes wrong with my health could destroy me financially,” Ms. Readling said. “I could be ruined.”

She said she had never voluntarily allowed her insurance to lapse and could not understand why she was being blackballed.

“What did I do wrong?” Ms. Read-ling asked. “Why am I being punished? I just don’t understand how I could have fallen through this horrible, horrible crack.”

Knowing her health benefits from her prior job would expire in January 2006, she began shopping for a new policy in May 2005. But in June 2005, she learned she had cancer.

“At that point,” Ms. Readling said, “I called everybody I could think of, begging for help. But no insurer would touch me.”

Barbara Morales Burke, the chief deputy insurance commissioner of North Carolina, said state law did not guarantee the availability of health insurance for individuals. “Most insurers decline to issue policies to those individuals whom they deem to be too risky because of their medical history,” Ms. Morales Burke said.

Blue Cross and Blue Shield of North Carolina will sell to anyone, regardless of the person’s medical condition, she added, but the premiums may be very high for people who have had serious illnesses.

Heidi Deja, a spokeswoman for Blue Cross and Blue Shield of North Carolina, said, “Rates are based on the anticipated cost of providing care.” For people who have had serious illnesses, she said, monthly premiums “can run into the thousands of dollars.”

A 1996 federal law limited the ability of insurers to discriminate against people because of pre-existing conditions. But consumer protections are much more extensive in the group health insurance market.

“In the individual market, the federal protections provide precious little help to people seeking coverage,” said Karen L. Pollitz, a research professor at the Georgetown University Health Policy Institute.

When Ms. Readling was shopping for insurance, she found two responses particularly galling. One insurer, she said, suggested she return to her prior job, at a furniture company, so she could participate in its group health plan, though she loved her work as a real estate agent. Another insurer suggested she remarry her former husband to get back on his insurance plan.

Working with her doctors, Ms. Readling raced to get as many tests as possible before her coverage expired. She recalled her anxiety in the final months: “It’s like a freight train coming at you, and it’s going to get you. And there was nothing I could do.”

Ms. Readling said she was mystified by the inability of real estate agents to band together and buy health insurance as a group.

“Why can’t Realtors in North Carolina, or a few counties, have coverage under one umbrella?” she asked. “You would think that some insurance company would want our business.”

Janet S. Trautwein, executive vice president of the National Association of Health Underwriters, which represents insurance agents and brokers, said employee groups were more attractive to insurers for several reasons.

“In a group health plan,” Ms. Trautwein said, “the employer typically pays a large share of the premium, so most employees sign up as soon as they are eligible, regardless of their health status.”

“The health plan covers a mix of sick and healthy workers,” she said. “By contrast, individuals and independent contractors are more likely to defer coverage until they need it, so the pool of people insured is, over all, less healthy. Sick people consume more health care. As a result, the cost to insure them is higher.”

Though satisfied with her care, Ms. Readling continually wonders if doctors and nurses treat her differently because she is uninsured.

“Are they going to turn their nose up at you because you don’t have insurance?” Ms. Readling asked. “Will they take care of other people first? They can make more money on patients with insurance. What am I? I am just a financial loss to them.”

    Without Health Benefits, a Good Life Turns Fragile, NYT, 5.3.2007, http://www.nytimes.com/2007/03/05/us/05uninsured.html?hp

2 New Drugs Offer Options

in H.I.V. Fight

February 28, 2007
The New York Times
By LAWRENCE K. ALTMAN
and ANDREW POLLACK

LOS ANGELES, Feb. 27 — Two new AIDS drugs, each of which works in a novel way, have proved safe and highly successful in large studies, a development that doctors said here on Tuesday would significantly expand treatment options for patients.

The two drugs, which could be approved for marketing later this year, would add two new classes of drugs to the four that are available to battle H.I.V., the AIDS virus. That would be especially important to tens of thousands of patients in the United States whose treatment is failing because their virus has become resistant to drugs already in use.

“This is really a remarkable development in the field,” Dr. John W. Mellors of the University of Pittsburgh said at a news conference here at the 14th Annual Conference on Retroviruses and Opportunistic Infections.

Dr. Mellors, who was not involved in the studies but has been a consultant to the manufacturers of the drugs, said he “wouldn’t be going out on a limb” to say the new results were as exciting as those from the mid-1990s, when researchers first discovered that cocktails of drugs could significantly prolong lives.

Dr. Scott Hammer, chief of infectious diseases at Columbia University Medical Center, who also was not involved in the studies but has been a consultant to the manufacturers, agreed that the new drugs “will provide extended years of meaningful survival to patients.”

One drug, maraviroc, was developed by Pfizer, which has already applied for approval to sell it. The Food and Drug Administration has scheduled an advisory committee meeting on April 24 to discuss the application.

The other drug, raltegravir, was developed by Merck, which has said it will apply in the second quarter for approval.

Experts said the new drugs would be used in combination with older drugs. Both drugs stem from scientific findings made a decade or more ago that have peeled back the intricate molecular process used by H.I.V. to infect human immune system cells and to replicate themselves.

While there are now more than 20 approved drugs to treat H.I.V. and AIDS, there are only four different mechanisms by which the drugs work. In many patients, the virus develops resistance to one or more drugs, usually because patients do not take their drugs on time as prescribed.

And if the virus develops resistance to one drug in a class, it often becomes resistant to others in that class and sometimes in other classes. So AIDS experts have said there is an urgent need for drugs that work by new mechanisms.

The two new drugs would represent the first new classes since 2003, when an injectable drug called Fuzeon was approved. They would be the first new classes of oral H.I.V. drugs in a decade.

Merck’s drug works by inhibiting the action of integrase, an enzyme produced by the virus that incorporates the virus’s genetic material into the DNA of a patient’s immune cell. Once incorporated, the viral DNA commandeers the cell to make more copies of the virus.

In two Merck studies involving a total of 700 patients, virus levels dropped to below 50 copies per milliliter of blood, an amount considered undetectable, in about 60 percent of patients who received raltegravir. That compared with about 35 percent of those who received a placebo.

The patients in the two Phase 3 trials, typically the last stage of testing before approval, were resistant to at least one drug in each of three classes of antiretroviral drugs. All the patients also received a combination of older drugs that their doctors deemed to be the most appropriate. The results reported here were after 16 weeks, in a study that is continuing so it is possible that longer-term side effects might yet arise.

Other integrase inhibitors, like one from Gilead Sciences, are also under development. Gilead’s drug is 18 months to 2 years behind Merck’s.

Pfizer’s drug works by blocking a protein on human immune system cells that H.I.V. uses as a portal to enter and infect the cell. It would be the first drug that targets the human body rather than the virus.

The portal, known as CCR5, was discovered in 1996 by several groups of scientists, and there has been a race to develop drugs to block it.

In two Phase 3 studies sponsored by Pfizer involving 1,049 patients, more than 40 percent of patients who received maraviroc had undetectable levels of virus after 24 weeks of a 48-week study. That was about twice the rate of those who received placebo. As in the Merck trials, patients were resistant to three classes of drugs and were receiving an optimized combination of older drugs.

Some experts said they were a bit cautious about maraviroc, in part because it blocks a human protein instead of a viral one, with possible unknown long-term effects. One CCR5 inhibitor that was being developed by GlaxoSmithKline was dropped because it caused liver toxicity, and a second being developed by Schering-Plough appeared to possibly raise the risk of blood cancers.

But in Pfizer’s study there was no increased incidence of cancers. In one study there was a higher rate of death among those who took the drug, but Pfizer said the deaths were not associated with the drug.

Experts are also encouraged that about 1 percent of Caucasians have a particular mutation in both copies of their CCR5 gene that knocks out its function. These people are resistant to H.I.V. infection and apparently live otherwise normal lives.

Yet another issue is that some viruses use a different entry portal called CXCR4. Before getting maraviroc, patients will have to be tested to see which portal their virus uses, which would make the drug an early example of “personalized medicine” tailored to the patient.

The test, which will probably take two weeks for results, was developed by Monogram Biosciences of South San Francisco, Calif. It is expected to cost as much as $1,000, or more.

About 85 percent of newly infected patients have a virus that uses CCR5 while only about half of highly drug-resistant viruses use that portal. There has been some concern that blocking CCR5 would encourage the development of viruses that use the alternative portal — and those viruses seem to be associated with worse outcomes.

But that has not proven so far to be a big problem, according to Edward A. Berger of the National Institute of Allergy and Infectious Diseases, who played a key role in the discovery of the two portals.

Government, academic and industry experts said there was no reliable estimate of the number of people who would need one of the new drugs. But the number is declining as more and better AIDS drugs become available.

“The numbers are not what they used to be six years ago,” said Norbert Bischofberger, executive vice president for research and development at Gilead, which makes some widely used AIDS drugs.

Both Merck and Pfizer say they are conducting studies testing their drugs for use as initial treatments. They would not say how much their drugs would cost.

    2 New Drugs Offer Options in H.I.V. Fight, NYT, 28.2.2007, http://www.nytimes.com/2007/02/28/health/28hiv.html?hp

Child Health Care

Splits White House and States

February 27, 2007
The New York Times
By ROBERT PEAR

WASHINGTON, Feb. 26 — Governors clashed with the White House on Monday over the future of the popular Children’s Health Insurance Program, an issue that some members of both parties said was as important as money for the Iraq war.

In the session at the White House, when President Bush reported on progress of the war, governors pressed him to provide more money so they could guarantee health insurance for children. In response, administration officials said states should make better use of the money they already had.

Gov. Sonny Perdue of Georgia, a Republican, said afterward, “Health care for children ought to be a priority, irrespective of anyone’s views on the war.”

Georgia will exhaust its allotment of federal money for the Children’s Health Insurance Program within three months, Mr. Perdue said. Thirteen other states expect to run out by September, according to data released here at the winter meeting of the National Governors Association.

Governors said the Clinton and Bush administrations had encouraged them to expand children’s coverage and had granted waivers allowing them to cover parents and even some childless adults.

Having successfully expanded the health insurance programs in their states, some governors now suggest that the Bush administration is pulling the safety net out from under many children.

In his budget this month, Mr. Bush said he wanted to return the program to its “original objective” of covering children with family incomes less than twice the poverty level. Budget documents note that 16 states cover children above that level and that “one state, New Jersey, covers children up to 350 percent of the federal poverty level.”

A family of four is classified poor if its annual income is less than $20,650.

An influential member of Congress said Monday that he would not be taking up White House proposals to restrict eligibility and financing for the child health program.

“I have absolutely no intention of moving the president’s proposals through our subcommittee,” said the lawmaker, Representative Frank Pallone Jr., Democrat of New Jersey.

Mr. Pallone is chairman of the Health Subcommittee of the Energy and Commerce Committee, which has authority over the children’s program.

Speaker Nancy Pelosi said Monday that “Democrats in Congress understand the urgency” of the problem and would provide money to the 14 states that did not have enough to cover their current enrollment. Although Mr. Bush would reduce federal payments for adults and for children with family incomes above 200 percent of the poverty level, Mr. Pallone said states should have discretion to cover children above 200 percent of the poverty level and adults in some circumstances, too.

“In New Jersey, we made a decision to go up to 350 percent of the poverty level, because we have the highest cost of living in the country,” Mr. Pallone said.

Likewise, he said, New Jersey found that covering adults increased the likelihood that their children would stay on the rolls.

“The hallmark of all this is flexibility,” Mr. Pallone said. “A robust Children’s Health Insurance Program is an important part of any effort to try to achieve universal coverage.”

The federal government spends $5 billion a year on the program. Mr. Bush wants to continue that level, and he is seeking an ”additional allotment” of $4.8 billion over the next five years.

States would need substantially more to continue their programs with current eligibility rules and benefits. New estimates from the Congressional Budget Office show that the states face shortfalls of $700 million this year and a total shortage of $13.4 billion from 2008 to 2012.

Gov. Jim Douglas of Vermont, a Republican, said the Bush proposals would jeopardize his state’s phenomenal success in covering children. In Vermont, he said, fewer than 4 percent of the children are uninsured, and “we don’t want to lose ground.”

Bush administration officials emphasized that states received a fixed amount of federal money each year, and they said individual children did not have a legal entitlement to benefits. Michael O. Leavitt, secretary of health and human services, said he would work with Congress to find “a short-term solution” for states exhausting their allotments this year. He said states could avoid shortfalls by managing their programs better.

In his experience as governor of Utah, Mr. Leavitt said, “when we were out of an allotment, we just discontinued enrolling people until we had room.” Likewise, he said, states could cover more people if they provided less comprehensive benefits.

Gov. Ted Strickland of Ohio, a Democrat, said: “If we don’t get the money we need, children will go without coverage.”

“In the meeting with the president and Secretary Leavitt,” Mr. Strickland said, “when questions were raised about children maybe having to be removed from the program or eligible children not being able to participate, we were told that that was basically a management problem.”

Gov. Jon Corzine of New Jersey, a Democrat, said that under the president’s proposals “we will end up having fewer children covered.” That prospect “was chilling to some of us,” Mr. Corzine said, adding that states wanted to avoid “rationing health care to our most vulnerable and our most needy.”

Gov. Edward G. Rendell of Pennsylvania, a Democrat, said Mr. Bush’s budget request was “clearly insufficient” to continue coverage for the six million children enrolled in the program.

Many governors want to expand the program, which they see as a foundation for their efforts to expand coverage generally.

Mr. Rendell framed the issue as a choice, asking: “Should we be giving tax cuts to billionaires and millionaires or should we be giving health care to children? Should we make health care for children, at the very least, an entitlement?”

Domestic policy is in a straitjacket because of the cost of the war, the cost of tax cuts and the president’s plan to balance the budget within five years, Mr. Rendell said.

Gov. Arnold Schwarzenegger of California, a Republican, said federal aid was essential to his $12 billion plan for universal health coverage. Mr. Schwarzenegger said that in a private meeting he told the president, “We need the federal government’s help.” He did not say whether he got a commitment.

    Child Health Care Splits White House and States, NYT, 27.2.2007, http://www.nytimes.com/2007/02/27/washington/27govs.html?hp

‘Dumping’ of Homeless by Hospitals Stirs Debate

February 23, 2007
The New York Times
By RANDAL C. ARCHIBOLD

LOS ANGELES, Feb. 22 — For a year, reports have surfaced that hospitals here have left homeless patients on downtown streets, including a paraplegic man wearing a hospital gown and colostomy bag who witnesses say pulled himself through the streets with a plastic bag of his belongings held in his teeth.

Now, prosecutors are hoping a bill introduced last week in the State Senate will give them stronger legal firepower to charge the hospitals.

Of the 55 or so reports of “patient dumping,” principally in the dilapidated quarter known as Skid Row, only a handful are being investigated for criminal activity, said Rocky Delgadillo, the city attorney. Only one hospital has been charged, using a misdemeanor count that has never been tested in court.

The problem is that while California state law requires hospitals to have written procedures outlining follow-up care for patients, it does not expressly prohibit leaving them on the street.

Advocates for the homeless said it was common in many cities for homeless people still requiring medical treatment to end up on the street or at the doors of shelters ill prepared for their medical needs.

“Hospitals don’t know what to do with them, and they think it’s the homeless agencies’ responsibility,” said Michael Stoops, executive director of the National Coalition for the Homeless, a Washington advocacy group.

Mr. Stoops said local and federal laws were murky, at best, over where homeless patients should be discharged.

The proposed California law, written by members of Mr. Delgadillo’s staff and introduced by Senator Gilbert A. Cedillo, a Democrat from Los Angeles, would require hospitals to transport discharged patients to their residence or, if they lack one, to the place they identify as their home, typically a shelter.

“There currently is no law making dumping homeless hospital patients on Skid Row a crime,” Mr. Delgadillo said Thursday at a news conference. “What we really need is legal clarity that specifically prohibits it.”

The bill calls for a jail term up to two years and a fine of $1,000 for anyone violating the law. Hospitals could be fined $10,000 and placed on probation, opening the way to court orders dictating how they treat discharged patients who are homeless.

Mr. Delgadillo said homeless patients often lacked insurance or other means to pay for their care, prompting hospitals to discharge them quickly. Skid Row seems a logical place to take them, with its profusion of shelters and social service agencies, but advocates for the homeless said few places could provide the necessary medical care.

“We are set up to get people back on their feet, but we are not set up as a hospital,” said the Rev. Andrew J. Bales, president of the Union Rescue Mission on Skid Row.

Prospects for the bill were unclear. A spokesman for Fabian Núñez, a Democrat from Los Angeles who is the Assembly speaker, said he supported it, but a spokeswoman for Gov. Arnold Schwarzenegger, a Republican, said it was too early to take a position on it. A similar measure Mr. Cedillo introduced last year was unsuccessful.

Among the suspected patient-dumping cases that have drawn attention is one in which Mr. Delgadillo has charged Kaiser Permanente with misdemeanor false imprisonment involving a case last year caught on videotape.

The case that has drawn headlines and indignation more recently involved the paraplegic man found crawling in the street on Feb. 8. A dozen people say they saw a woman driving a van from Hollywood Presbyterian Medical Center leave the man in the street, with some saying she got back in the van and spruced up her makeup.

Mr. Delgadillo said he was still investigating the case. Dan Springer, a spokesman for the hospital, said it had acknowledged that its procedures for releasing the patient had not been followed. Mr. Springer said the hospital was taking steps to ensure it did not happen again.

James Lott, an executive with the Hospital Association of Southern California, criticized the proposed legislation, calling it “in a word, stupid,” and an example of Mr. Delgadillo’s “grandstanding.” Mr. Lott said federal laws already required hospitals to treat and stabilize patients before discharge and to provide a plan for follow-up care if needed.

In addition, he said, hospitals downtown agreed two months ago to new procedures ensuring that homeless patients were not left on the street. He conceded the protocol had been violated in the case of the man found crawling in the street.

    ‘Dumping’ of Homeless by Hospitals Stirs Debate, NYT, 23.2.2007, http://www.nytimes.com/2007/02/23/us/23dumping.html

Autism more common in U.S.

than thought: survey

Thu Feb 8, 2007 2:11PM EST
The New York Times
By Maggie Fox, Health and Science Editor

WASHINGTON (Reuters) - Autism is more common in the United States than anyone had estimated, affecting about one in every 150 children, the U.S. Centers for Disease Control and Prevention reported on Thursday.

CDC estimated that about 560,000 people up to age 21 in the United States have autism.

"Autism is more common than we believed and is an urgent public health concern," said Catherine Rice of the CDC's birth defects division, who helped lead the study.

Two surveys by the agency encompassed 14 states and represented the largest and most comprehensive studies of how many children have autism. It showed a wide variation among the states, ranging from 4.5 per 1,000 children having an autism-related disorder in West Virginia to 9.9 per 1,000 in New Jersey.

"There's been a lot of concern about what the prevalence of autism is in the United States and we haven't really had the data systems to answer that completely," Rice said.

The surveys look at 8-year-olds, the first in six states and the second looks at 8-year-olds in 14 states. On average, they found that about one in 150 children born in 1992 and 1994, or 6.7 per thousand, have autism.

Rice said that for decades the common estimate of autism incidence was four to five per 10,000 children. More recent previous estimates had put the incidence at somewhere between one in 166 children and one in 175.

"Finally, we can end the debate on the prevalence of autism in our nation and focus on getting the services and supports the families need," said Lee Grossman, chief executive officer of the Autism Society of America.

The reports are the first from the government-funded Autism and Developmental Disabilities Monitoring Network.

'ACCURATE PICTURE'

"We really do think that these data are important because they represent the most complete and accurate picture of autism spectrum disorders in the United States to date," Rice said in a telephone interview.

Types of "autism spectrum disorder" range from autism, which can severely disable a child by interfering with speech and behavior, to Asperger's syndrome, a much milder behavioral problem.

The surveys did not examine what causes autism, but Rice said it appears to stem from "complex genetic and environmental interactions."

The researchers hope to eventually use the surveys to help figure out what causes autism. They also want to be able to verify suspicions autism may be growing more common in the United States.

"We hope these findings will build awareness," Rice said.

Activists have said for years that autism was becoming more common. Some experts discount claims of skyrocketing rates, saying the definition of autism has changed over the years, but reliable survey figures have been scarce.

"A lot of professionals were asking what had changed, had we seen more children than in the past?" said Dr. Marshalyn Yeargin-Allsopp, who helped lead the study.

The CDC surveys, published in Thursday's weekly report on death and disease, use a variety of sources such as schools, physician reports and other data. Rice said it took years to get required approvals to see the data.

The autism rates remained fairly stable over the two years in which the surveys were taken, Rice said, except in West Virginia, where the prevalence rose greatly. Rice said it is unclear why.

The studies also showed far fewer of the autistic children had mental retardation than in previous estimates.

"The older statistics always estimated 70 to 75 percent of kids with autism had cognitive impairment," Rice said. "We found 33 to 62 percent."

    Autism more common in U.S. than thought: survey, R, 8.2.2007, http://www.reuters.com/article/domesticNews/idUSN0842367820070208

FACTBOX-Autism a common and serious disorder

Thu Feb 8, 2007 12:52PM EST
Reuters

(Reuters) - Autism is more common across the United States than previously believed, according to a survey published on Thursday by the U.S. Centers for Disease Control and Prevention.

-- The newest numbers suggest that 1 in every 150 children in the United States has autism, higher than previous estimates of 1 in 166 to 1 in 175.

-- Autism spectrum disorders range from Asperger syndrome, a relatively mild communication disorder, to severe autism in which patients communicate little or not at all with others and may display severely debilitating behaviors such as rocking or banging their heads. About 40 percent of children with autism do not speak at all.

-- Autism usually is diagnosed between the ages of 3 and 5. There is no cure and no one knows the causes.

-- Doctors are eager to identify autism as early as possible , because some behavioral therapy can reduce its effects and the earlier the better.

-- Autism appears to have a genetic component and some scientists believe that an environmental trigger may be involved. Some groups believe vaccines may be involved although most scientists, including the U.S. government, say vaccines are almost certainly not to blame.

FACTBOX-Autism a common and serious disorder, R, 8.2.2007, http://www.reuters.com/article/idUSN0816834020070208

In Connecticut,

World’s Oldest Woman Dies at 114

January 30, 2007
The New York Times
By JENNIFER MEDINA

EAST HARTFORD, Conn., Jan. 29 — To say Emma Faust Tillman lived a full life would be an epic understatement.

She was one of 23 children born to former slaves in North Carolina, and one of only 15 who lived to adulthood. She was the first black student to graduate from Glastonbury High School, just a few miles south of here, and voted in the first election in which women were allowed to do so. Discrimination prevented her finding a job as a secretary, so she began catering, eventually baking cakes for Katharine Hepburn’s father and Jackie Robinson.

Mrs. Tillman, who died Sunday, was known as the “mother” of the Metropolitan A.M.E. Zion Church in Hartford, where she sang in the choir for more than 70 years.

And last Wednesday she was declared the oldest person in the world, at 114 years, 63 days and counting.

Whether she ever knew she received the title is unclear. When the television news cameras crowded into the lobby of her nursing home here, Mrs. Tillman acknowledged them but was unable to speak, her head hanging down, a blank look on her face.

By the time they left, she was exhausted and returned to the bedroom she moved to in 2003, after decades of living independently. She went to sleep and never woke up again.

The title of “world’s oldest person” is now apparently passed to Yone Minagawa of Japan, who was born within weeks of Mrs. Tillman and turned 114 this month.

And though it is perhaps impolite to mention, recent history suggests that Ms. Minagawa may not hold the crown for long. In the last month alone, the title of oldest person has changed hands three times, according to the Gerontology Research Group, an authority on the matter.

“The Guinness Book of World Records will not be able to keep up,” said Dr. L. Stephen Coles of the University of California, Los Angeles, the executive director of the group. “This has been a pretty volatile time. Usually we’ve had a more stable No. 1 position.”

On average, Dr. Coles said, the “oldest person” retains the title for about eight months. But since August, there have been five. Dr. Coles said that this was nothing more than a statistical anomaly.

Even among those who age gracefully, few live long enough to become supercentenarians, the term given to those older than 110. With the death of Mrs. Tillman, the gerontology group has records of 84 such people in the world: 6 men and 78 women.

Dr. Coles acknowledged, though, that it is likely that the list, which relies on notification from relatives or neighbors, vastly underestimates the number.

For those who are known to be in that select circle, life as a very old person can become quite a public affair. Mrs. Tillman, for her part, did not shy away from the attention, happy to take in the birthday parties for her at the convalescent home.

On her 113th birthday in 2005, Mrs. Tillman received 113 long-stem red roses from a much younger man — Donald Pitkin, a member of the East Hartford Town Council, who at the time was 84. “My, my, what a lot of beautiful flowers,” those who were present recall her saying. “It makes a woman think she might want to get married again.”

Mrs. Tillman’s husband died in 1939, before the United States entered World War II. She outlived countless other relatives, including one of her two daughters. But of the four siblings who moved north with Mrs. Tillman at the turn of the 20th century, all lived past age 100.

There is no consensus on what allows certain people to live so long, but there is wide agreement that good genes are the best predictor of a long life. It probably helped, too, that Mrs. Tillman neither smoked nor drank.

She also did not drive. But with the exception of relying on others for rides, Mrs. Tillman lived quite independently. After first voting in 1920, she cast a ballot in every election until 2006. She attended church weekly until her 114th birthday, on Nov. 22.

That day, Mrs. Tillman was quite subdued, but she perked up when the choir sang two of her favorite songs, “In the Garden” and “Passing Through,” said John Stewart Jr., one of her great-nephews, who attended the service with her.

It was the last time Mrs. Tillman would leave her home, he said. He recalled her remarking on the milestone: “I’m 114. It’s enough now,” she said. “I’ll go whenever the man upstairs calls me home.”

Mrs. Tillman is survived by her 80-year-old daughter, Majorie. But the large extended family is something of a complicated clan: the funeral program will list 7 grandchildren, 36 great-grandchildren, 16 great-great-grandchildren and 16 great-great-great-grandchildren.

“She was the glue that held us all together,” said Mr. Stewart, the family historian and a former chief of the Hartford Fire Department — the first African-American fire chief in New England. “She has served the good Lord, she has served the church, she has served us. What better legacy can she leave?”

Once it became clear on Friday that Mrs. Tillman was entering her final days, family members filed into her room. They quickly decided they would not attach her to a feeding tube or other machines, preferring to let her die in what doctors said would be a matter of days.

By Sunday evening, Mr. Stewart said, she looked as though she had more color in her face, and a smile seemed to have appeared on her lips.

    In Connecticut, World’s Oldest Woman Dies at 114, NYT, 30.1.2007, http://www.nytimes.com/2007/01/30/nyregion/30old.html?hp&ex=1170219600&en=c3f97cf882bd8c13&ei=5094&partner=homepage

Editorial

The President’s Risky Health Plan

January 26, 2007
The New York Times

The new health care proposals announced by President Bush this week purport to tackle the two toughest problems confronting the American health care system: the rising number of uninsured Americans and the escalating costs of medical care.

But on both counts, they fall miles short of what is needed to fix a system where — scandalously — 47 million Americans go without health insurance.

The financial sinkhole in Iraq and huge tax cuts for wealthy Americans have left the administration with no money to really address the problem. To keep the program “revenue neutral,” Mr. Bush would instead use tax subsidies to encourage more people to buy their own health insurance, while imposing additional taxes on people who have what Mr. Bush deems “gold plated” insurance.

It is a formula that would do little to reduce the number of uninsured Americans and would have a high risk of producing pernicious results. Even White House officials acknowledged earlier this week that they expected the number of uninsured to drop by only three million to five million people as a result of Mr. Bush’s proposals. They expect the states to take on most of the burden.

One enlightened element is that the plan would provide equal tax treatment to those who bought their insurance policies on the individual market and those who got coverage through group policies at work, thus ending a longstanding inequity that favors employer-based policies. To level the playing field, the administration proposes to grant everyone who gets qualifying health insurance a standard deduction — $15,000 for family coverage or $7,500 for single coverage — off their income subject to taxation. Those with family policies exceeding $15,000 in value would have to pay taxes on the excess amount.

After the proposed starting date in 2009, the administration estimates, about 80 percent of workers with employer-provided policies would pay lower taxes and 20 percent would pay higher taxes, unless they reduced the value of their health coverage to fit within the standard deduction.

The new standard deduction would almost certainly entice some people to buy health insurance who had previously elected not to. But a tax deduction is of little value to people so poor that they pay little or no income tax. And unfortunately, it is those people who account for the vast majority of the nation’s uninsured.

Instead of trying to fix that fundamental flaw, the administration has decided instead to buck it to the states. The White House has offered few details. But its idea is to allow states to redirect federal money that now helps to finance hospitals that provide charity care and use it instead to subsidize health insurance for the poor.

In an ideal world, it would make good sense to insure people in advance rather than wait for them to show up in a high-cost emergency room. But this plan could quickly cripple the safety-net hospitals. Fortunately, no governor would have to accept the offer to redirect funds. The scheme is mostly a reflection of how the administration is unwilling to accept true responsibility for the uninsured.

If the administration really wanted to help low-income people, it would have proposed a refundable tax credit that would have the same dollar value for everyone — instead of a tax deduction, which primarily helps people in high tax brackets. Even those who do not pay taxes would get a check for the dollar value of the credit, providing them at least some money to help pay for health insurance. Congress ought to recognize that credits are the better approach for even such a limited plan.

As for the tax increases on those “gold plated” health policies, the White House is hoping to discourage people from using high-priced comprehensive health policies that cover everything from routine office visits to costly diagnostic procedures that are not always necessary.

The administration’s goal is to instead encourage people to take out policies that might reduce the use of medical services, like policies with high deductibles or co-payments, or managed care plans. But even “copper plated” policies can exceed $15,000 in cost if they are issued in areas where medical prices are high or to groups with high numbers of older or chronically ill workers.

The whole approach rests on the premise that comprehensive prepaid health policies are a major factor in driving up costs; the theory is that people will tend to use services if they are covered. There is probably some truth in that.

But the main drivers in rising health costs are the costly services, high-priced drugs and hospitalizations for people who are seriously ill with catastrophic diseases or multiple chronic illnesses. Making their health coverage less generous would simply make it harder for them to get the care they need.

The greatest risk in the president’s proposal is that it would seem likely to lead many small- and medium-size employers to stop offering health benefits altogether on the theory that their workers could buy affordable insurance on their own. That would leave many more Americans at the mercy of the dysfunctional individual policy market, where administrative costs are high and insurers strive to avoid covering people who are apt to become sick and need costly care.

For all its fanfare, Mr. Bush’s plan would be unlikely to reduce the ranks of the uninsured very much. And if things went badly, it could actually increase their numbers. That’s not the answer Americans are waiting for and not what they deserve.

    The President’s Risky Health Plan, NYT, 26.1.2007, http://www.nytimes.com/2007/01/26/opinion/26fri1.html

Bush unveils

new health insurance plan

Sat Jan 20, 2007 8:11 PM ET
Reuters
By Caren Bohan

WASHINGTON (Reuters) - President George W. Bush on Saturday proposed tax breaks to make health insurance more affordable to the nearly 47 million Americans who lack it and suggested removing some tax benefits for the most expensive employer-provided health care plans.

Health care is emerging in opinion polls as a top concern among many Americans as private health insurance costs soar, putting a burden on workers and companies.

The president, looking to gain momentum for his domestic agenda that is at risk of becoming overshadowed by the Iraq war, will include the health proposal in his State of the Union address on Tuesday.

"We must address these rising costs, so that more Americans can afford basic health insurance. And we need to do it without creating a new federal entitlement program or raising taxes," Bush said in his weekly radio address.

Democrats, newly in control Congress, reacted skeptically to Bush's proposal although Sen. Edward Kennedy of Massachusetts said he was pleased the president "is finally talking about the growing crisis in health care."

Most Americans who have health coverage get it through their employers, but others receive it through government programs such as those for the elderly, the disabled and low-income children. Some people also buy it on their own.

Bush's proposal would for the first time allow people to take a tax deduction -- similar to the one used by homeowners for their mortgage costs -- when they buy health coverage on their own instead of through an employer.

The program is intended to have no effect on government revenues because the cost of the tax breaks would be offset with other tax changes, according to a senior administration official who described the proposal to reporters.

Currently, employees who receive health coverage through their jobs do not pay taxes on the benefit. Bush would cap the amount of coverage that would be considered tax-free. Anything above that would be taxed as income. The limit for deductions would be $15,000 for families and $7,500 for individuals. The average cost of family health coverage is $11,500.

TAX DEDUCTIONS

While some people would get hit with higher taxes, there would be a windfall for those who opted for low-cost plans.

For example, a family who bought a $10,000 plan could still take the full $15,000 deduction and pocket the extra money.

"This is essentially a standard deduction for health care, and the size of the deduction will be significantly higher than the cost of an average policy," said a senior White House official. "Because of this, about 80 percent of people with employer-based plans will see their tax liability fall because their insurance policies cost less than the deduction."

Bush said the current tax code unfairly penalized people who buy health insurance on their own while steering some toward "gold-plated" plans that drive up the cost of coverage.

But Kennedy said he was concerned that the tax changes could undermine employer-provided coverage while failing to do enough to help the uninsured.

New York Democratic Rep. Charles Rangel, chairman of the House Ways and Means Committee, said the Bush plan would increase the tax burden on working families.

"This is a dangerous policy that ultimately shifts cost and risk from employers to employees and could result in a higher number of uninsured," Rangel said.

A few states are experimenting with ways to extend coverage to the uninsured, including California and Massachusetts. The Bush plan would redirect some money that now goes to hospitals and other institutions to help states broaden health coverage.

    Bush unveils new health insurance plan, R, 20.1.2007, http://today.reuters.com/news/articlenews.aspx?type=newsOne&storyID=2007-01-21T011140Z_01_N19343305_RTRUKOC_0_US-BUSH-HEALTHCARE.xml&WTmodLoc=Home-C2-TopNews-newsOne-4

Anti - Smoking American Milestone

Reached

January 20, 2007
By THE ASSOCIATED PRESS
Filed at 3:15 a.m. ET
The New York Times

RENO, Nev. (AP) -- Thirty years after it began as just another quirky movement in Berkeley, Calif., the push to ban smoking in restaurants, bars and other public places has reached a national milestone.

For the first time in the nation's history, more than half of Americans live in a city or state with laws mandating that workplaces, restaurants or bars be smoke-free, according to Americans for Nonsmokers' Rights.

''The movement for smoke-free air has gone from being a California oddity to the nationwide norm,'' said Bronson Frick, the group's associate director. ''We think 100 percent of Americans will live in smoke-free jurisdictions within a few years.''

Seven states and 116 communities enacted tough smoke-free laws last year, bringing the total number to 22 states and 577 municipalities, according to the group. Nevada's ban, which went into effect Dec. 8, increased the total U.S. population covered by any type of smokefree law to 50.2 percent.

It was the most successful year for anti-smoking advocates in the U.S., said Frick, and advocates are now working with local and state officials from across the nation on how to bring the other half of the country around.

In a sign of the changing climate, new U.S. House Speaker Nancy Pelosi banned smoking in the ornate Speaker's Lobby just off the House floor this month, and the District of Columbia recently barred it in public areas. Arizona, Colorado, Hawaii, Louisiana and New Jersey also passed sweeping anti-smoking measures last year.

''That's how life is now. They're banning smoking everywhere,'' said Rep. Devin Nunes, R-Calif., an occasional smoker.

Susan Burgess, the mayor pro tem of Charlotte, N.C., said what's fueling the push is a U.S. Surgeon General's report released last June that found just a few minutes inhaling someone else's smoke harms nonsmokers, and separate smoking sections don't offer enough protection.

She said the report gave momentum to the anti-smoking front even in North Carolina -- the nation's No. 1 tobacco state -- and influenced Nevada voters to approve a ballot measure banning smoking at restaurants, bars that serve food, and around slot machines at supermarkets, gas stations and convenience stores. Nevada, where gambling and smoking had been assumed to go hand in hand, previously had one of the nation's least restrictive smoking laws.

''The Nevada vote shows that when people are given accurate information about the dangers of secondhand smoke, it's almost a no-brainer'' they'll support smoking controls, said Burgess, founder of the anti-smoking group Smokefree Charlotte.

Not all elected officials and business owners embrace the cause. They maintain such laws drive away smoking customers and cut profits.

''There's a fear that we would lose restaurant business to nearby towns if we passed a smoking ordinance,'' Moline, Ill., Mayor Don Walvaert said. ''Before acting, we would need real proof that cities have not experienced business losses because of smoking regulations.''

Nevada's smoking restrictions have been challenged in state court by a coalition of businesses. Opponents say the ban, which does not apply to the gambling floors of casinos on and off the Las Vegas Strip, is unconstitutional, vague and unenforceable.

In Columbia, Mo., one business owner displayed his displeasure at a new local ordinance banning smoking with a sign: ''Smoking allowed until Jan. 9, City Council banning beer next, and hopefully, karaoke!''

R.J. Reynolds Tobacco Co. plans to continue to fight smoking bans at adult-only businesses because it thinks such restrictions infringe on the rights of owners and adversely affect business, spokesman David Howard said from the company's headquarters in Winston-Salem, N.C.

But Columbia Mayor Darwin Hindman said studies show bans will not force smoking customers to go elsewhere. The Surgeon General's report reached a similar conclusion.

''I don't think it's a legitimate fear that bars and restaurants will lose business,'' Hindman said. ''From what I've read, smokers keep going to bars and restaurants even after smoking is banned. Smoking restrictions should be based on health issues anyway.''

Amy Winterfeld, health policy analyst for the National Conference of State Legislatures based in Washington, D.C., said smoke-free legislation is pending in at least seven states.

''When you see an issue like this passing in a number of states it does give it momentum in other states,'' Winterfeld said. ''It's certainly possible that a number of states will take it up this year.''

------

On the Net:

Americans for Nonsmokers' Rights: http://www.no-smoke.org

R.J. Reynolds Tobacco Co.: http://www.rjrt.com 

    Anti - Smoking American Milestone Reached, NYT, 20.1.2007, http://www.nytimes.com/aponline/us/AP-Smoke-Free-America.html

Nicotine in cigarettes rising:

Harvard study

Thu Jan 18, 2007 4:24 AM ET
Reuters
By Jason Szep

BOSTON (Reuters) - The amount of nicotine that smokers typically inhale per cigarette rose by 11 percent from 1998 to 2005, perpetuating a "tobacco pandemic" that makes it harder for smokers to quit, a Harvard study said on Thursday.

Harvard School of Public Health researchers analyzed data submitted by major cigarette brands to the Massachusetts Department of Public Health, which in August released its own study showing nicotine levels steadily rising.

The amount of nicotine that smokers typically consume per cigarette regardless of brand per year rose by an average of 1.6 percent between 1998 and 2005, according to the Harvard analysis of the state's health records.

Massachusetts has required tobacco companies to submit annual reports on cigarette nicotine yields since 1997, longer than any U.S. state.

"Cigarettes are finely tuned drug delivery devices designed to perpetuate a tobacco pandemic," said Howard Koh, the school's associate dean for public health practice and former Massachusetts commissioner of public health.

To boost amounts of nicotine inhaled by smokers, cigarette makers intensified the concentration of nicotine in their tobacco and modified cigarette designs to increase the number of puffs per cigarette, the Harvard researchers said.

"The end result is a product that is potentially more addictive," the study said.

Nicotine yields rose in cigarettes of each of the four major manufacturers and across all major cigarette market categories -- from mentholated and non-mentholated to full-flavored, light and ultralight, the study said.

Tobacco industry officials were not immediately available to comment. Phillip Morris, part of Altria Group Inc and the largest cigarette maker, has said nicotine levels fluctuate from year to year but there has been no steady increase.

TOUGHER SCRUTINY URGED

The most recent federal tobacco tax figures showed that the number of cigarettes sold in the United States fell in 2005 to the lowest level in 55 years, dropping 4.2 percent from 2004, the largest one-year percentage decrease since 1999.

That continued an eight-year decline in cigarette smoking since the 1998 Master Settlement Agreement between U.S. states and the tobacco industry that settled state lawsuits over the costs of treating smoking-related illnesses.

"Our findings call into serious question whether the tobacco industry has changed at all in its pursuit of addicting smokers since signing the Master Settlement Agreement," said Gregory Connolly, director of the Harvard School of Public Health's Tobacco Control Research Program.

He said tobacco companies had failed to warn consumers about rising levels of nicotine since the 1998 settlement, urging U.S. states to step up scrutiny of the industry.

The major companies that signed the agreement are Philip Morris, a unit of Altria Group Inc.; R.J. Reynolds Tobacco Holdings Inc.; British American Tobacco Plc's Brown & Williamson unit; and Lorillard, which trades as Carolina Group and is part of Loews Corp.

The study received funding from the American Legacy Foundation and the National Cancer Institute.

The U.S. Centers for Disease Control and Prevention considers cigarette smoking the leading preventable cause of death in the United States. About 440,000 people die each year from lung cancer and other diseases related to tobacco use.

    Nicotine in cigarettes rising: Harvard study, R, 18.1.2007, http://today.reuters.com/news/articlenews.aspx?type=domesticNews&storyID=2007-01-18T092352Z_01_N17368249_RTRUKOC_0_US-NICOTINE-STUDY.xml&WTmodLoc=Home-C5-domesticNews-2

Overall cancer deaths

decline again,

but statistics not as rosy

for blacks

Updated 1/17/2007 10:52 PM ET
USA Today
By Anita Manning and Steve Sternberg

The number of Americans dying of cancer declined for second year in a row, this time by a much greater number, the American Cancer Society reports, a signal that decades of advances in prevention and treatment are paying off, experts say.

Although black women have a 9% lower cancer rate than their white peers, black women have an 18% higher death rate for all forms of cancer. Black men have a 15% higher rate of cancer and a 38% higher death rate than white men, a trend that extends from 1999 to 2003.

These statistics stand in stark contrast to the cancer society's overall tally, out Wednesday, showing 3,014 fewer cancer deaths in 2004 than in 2003. Cancer rates have been declining since 1991, the society says, but the first reported drop in actual numbers of deaths was a decline of 369 deaths from 2002 to 2003. The 2004 numbers represent only the second drop in more than 70 years of record-keeping.

"The prognosis is grim for African-Americans," says Carla Boutin-Foster, co-director of New York-Presbyterian/Weill Cornell's Center for Multicultural and Minority Health. She blamed the disparity on multiple factors, including a lack of street-level cancer education programs, spotty insurance coverage and widespread poor nutrition, obesity and inactivity.

Making major gains among blacks represents a challenge because many lack access to the preventive services and treatment available to other Americans, says Bruce Chabner, clinical director of the Massachusetts General Hospital Cancer Center.

"It's a combination of poverty and where they live," he says. "Many live in rural areas or urban centers served by large municipal hospitals that may not offer access to early diagnosis and specialty treatments." He said biology also plays a role. Breast and prostate cancers in blacks can be "more advanced at diagnosis and more difficult to treat."

Taken as a whole, the report yielded good news. "One of the reasons this is so remarkable is that we're living to be older, and cancer, like most chronic diseases, is more common as we age," says Richard Wender, American Cancer Society president. "So if we can actually reduce the true number of deaths, even while we're getting older … that's real progress."

The report, Cancer Statistics 2007, says that in 2004 there were 553,888 cancer deaths compared with 556,902 in 2003.

Other highlights of the report:

•Deaths from colorectal cancer showed the greatest decline. The rates dropped 5.7%, says Elizabeth Ward, director of surveillance research for the cancer society. No one factor is responsible, but "the efforts (TV news anchor) Katie Couric and others have made to educate people about the importance of colorectal cancer screening, as well as efforts to make it available, for example, for coverage under Medicare, have played an important role."

•Lung cancer deaths dropped by 333 for men but increased by 347 for women, because women historically begin smoking later than men, the report says. Men's lung cancer deaths peaked 15 years ago. "Women are peaking now," Ward says.

•Breast cancer deaths in women declined by 666 cases. The disease is expected to account for 26% of new cancer cases in women.

•Prostate cancer deaths decreased by 552 cases; prostate cancer accounts for 29% of new cases.

    Overall cancer deaths decline again, but statistics not as rosy for blacks, UT, 17.1.2007, http://www.usatoday.com/news/health/2007-01-17-cancer_x.htm

Cancer deaths

finally on decline in U.S.

Wed Jan 17, 2007 12:12 PM ET
Reuters
By Maggie Fox,
Health and Science Editor

WASHINGTON (Reuters) - About 3,000 fewer people died from cancer in the United States from 2003 to 2004, the American Cancer Society reported on Wednesday.

It said the big decrease shows that not only has the death rate from cancer been reversed -- but it has been reversed so much that fewer people are dying, even though the population of elderly people, who are most susceptible to cancer, is growing.

The American Cancer Society projected there will be 559,650 deaths from cancer in 2007. "The Society also predicts there will be 1,444,920 new cases of cancer in 2007; 766,860 among men and 678,060 among women," it said in a statement.

The society uses a different method to project and calculate deaths now, so the 2007 numbers cannot be compared directly with the 2004 numbers.

"Cancer death rates have been declining for a long time. The declines have now outpaced the growth and aging of the population," Elizabeth Ward, director of surveillance research for the American Cancer Society, said in a telephone interview.

She said a small decline seen in the previous report had grown considerably, showing the trend was real.

Decreases in smoking may be a major factor, Ward said.

"I think tobacco control has had a real impact. There is also the influence of early detection and screening and thirdly the influence of improvements in treatment," Ward said.

The biggest fall in deaths was seen in colorectal cancer, the second-leading cause of U.S. cancer deaths, which will affect 112,000 people in 2007 and kill 52,000.

"Colorectal cancer really stands out," Ward said.

"There was a drop in both men and women, both a drop in mortality rates and in cancer incidence." The death rate from colon cancer fell by 5.7 percent in 2003-2004 from the previous year.

GET THAT COLONOSCOPY

The often-dreaded colonoscopy, recommended for everyone when they reach 50, may be making a difference, Ward said. "Early detection and screening probably do make a contribution," she said, adding that better treatments also were a factor.

Yet only 50 percent of Americans over 50 get the recommended screening.

"We need to continue to encourage colorectal cancer screening because if we are seeing this much progress at the current rate, we certainly could achieve more," Ward said.

The organization makes a yearly compilation of cancer deaths based on data from the Centers for Disease Control and Prevention, the National Cancer Institute, the North American Association of Central Cancer Registries, the U.S. Census Bureau, state and local health agencies, and thousands of cancer registries.

In 2004, 553,888 people died from cancer, compared to 556,902 in 2003. Fewer people died from the four leading cancers -- lung, breast, prostate, and colorectal cancer -- with the exception of lung cancer in women.

The five-year survival rate for all cancer patients between 1996 and 2002 was 66 percent, the group said. That compares to 51 percent between 1975 and 1977.

The four leading causes of cancer in the United States are:

-- Lung cancer, which will be detected in 213,000 people in 2007 and kill 160,000

-- Prostate cancer, which will be diagnosed in 218,000 men and kill 27,000

-- Breast cancer, which will be found in 180,510 men and women and kill 40,900

-- Colon cancer, which will be diagnosed in 112,000 people and kill 52,000.

The statistics do not include skin cancers known as squamous and basal cell carcinoma, which affect a million people a year.

The full report is available on the Internet at http://www.cancer.org/statistics .

    Cancer deaths finally on decline in U.S., R, 17.1.2007, http://today.reuters.com/news/articlenews.aspx?type=healthNews&storyID=2007-01-17T171122Z_01_N17375851_RTRUKOC_0_US-CANCER-USA.xml&src=011707_1213_TOPSTORY_cancer_rate_drops

Schwarzenegger

takes center stage

in U.S. health reform

Fri Jan 12, 2007 9:39 PM ET
Reuters
By Lisa Baertlein

LOS ANGELES (Reuters) - Gov. Arnold Schwarzenegger's plan to extend health insurance to California's 6.5 million uninsured could help put universal health coverage back on the national agenda at a time of political change in Washington.

Doubts have been voiced about whether the celebrity governor would be able to fully fund the ambitious, $12 billion proposal he put forward on Monday.

But after more than a decade since the last big national health care reform push, Schwarzenegger's timing just may be perfect with a new Democrat-run Congress taking over in Washington and presidential elections less than two years away.

"We're really seeing the return of universal health coverage to the national dialogue," Diane Rowland, executive director of the Kaiser Commission on Medicaid and the uninsured, told Reuters.

"It propels the discussion and puts more pressure on national candidates, Congress and the president," she said.

The proposal announced by California's Republican governor -- a budding reformer who has also crossed party lines to back a state law aimed at curbing greenhouse gas emissions -- would require everyone in the state to carry insurance and tax doctors, and hospitals and all but the smallest companies that do not provide health benefits.

Insurers would no longer be able to deny coverage based on age or pre-existing health conditions and overhead would be limited to $15 of every $100 in premiums. The state would also need its federal funding increased to the tune of more than $5 billion to pay for the proposed plan.

Massachusetts, which has a population about as large as California's ranks of uninsured, last year became the first state to pass a law requiring all individuals to buy health coverage.

Employers are the main provider of health insurance in the United States, where the government pays for the care of the elderly and the poor. Nearly 47 million Americans lack health coverage, a number expected to continue to rise as the skyrocketing cost of health care drives up insurance premiums.

Since killing former President Bill Clinton's proposal for universal health coverage in 1994, U.S. lawmakers have failed to address the health care crisis.

In the current spiral, rising insurance costs are prompting employers to cut coverage, swelling the ranks of uninsured and overwhelming hospital emergency rooms with very sick people who cannot pay and who, by law, cannot be turned away.

'INTERLOCKING PUZZLE'

As federal lawmakers grapple with national issues such as the war in Iraq and the threat of terrorism, governors in states like Massachusetts, Maine and Vermont already have adopted plans to cover virtually everyone.

States set a precedent for similar efforts in the early 1990s, when Wisconsin's then-governor led welfare reform efforts that resulted in a major federal program that helped states cover children from low-income families.

Schwarzenegger, nursing a broken leg from a holiday ski accident, has received kudos for bringing relevant interest groups -- doctors, insurers, hospitals, small business, unions and the Democrats that control the state legislature -- to the table.

"Health care reform is an interlocking puzzle ... if someone tries to take their piece out, it doesn't work. I think it reflects his understanding that, at the end of the day, it's not his plan," said health care consultant Peter Harbage, who participated in the discussions.

Doubts about funding plague any reform effort, and the Schwarzenegger plan is no different.

"Ultimately, the question here is whether there is enough money to guarantee that people have access to a quality health plan," said Jacob Hacker, a Yale University political science professor and author of "The Great Risk Shift," about Americans' increasing health care cost burden.

"The answer, it seems pretty clear, is no."

    Schwarzenegger takes center stage in U.S. health reform, R, 12.1.2007, http://today.reuters.com/news/articlenews.aspx?type=politicsNews&storyID=2007-01-13T023938Z_01_N12213199_RTRUKOC_0_US-CALIFORNIA.xml&WTmodLoc=Home-C5-politicsNews-3

House backs broader

embryonic stem cell research

Thu Jan 11, 2007 5:52 PM ET
Reuters
By Will Dunham

WASHINGTON (Reuters) - The new Democratic-led U.S. House of Representatives voted on Thursday to lift President George W. Bush's restrictions on federal funding for human embryonic stem cell research.

But the vote of 253-174, largely along party lines, fell short of the two-thirds majority needed to override a promised presidential veto.

The measure passed after an emotional debate in which supporters touted the research as the best hope for potential cures for ailments such as Alzheimer's disease, diabetes, Parkinson's disease and spinal cord injuries.

Opponents condemned it as unethical and immoral. Bush restricted funding for the research in August 2001.

Bush, whose support base includes conservative Christian voters who tend to oppose the use of stem cells taken from human embryos, in July used the only veto of his presidency to date to reject an identical measure.

The White House reiterated Bush's intention to use his veto power, saying American taxpayers should not pay for research involving the intentional destruction of human embryos.

The bill is part of a six-measure package that House Democrats vowed to vote on during their "first 100 legislative hours" after winning control of Congress from Bush's Republicans in November elections.

Already this week, the House passed two other bills in the Democrats' legislative package, one to bolster U.S. security and the other to raise the federal minimum wage.

The stem cell bill now goes to the Senate, where supporters believe it will pass with a veto-proof two-thirds majority.

The debate can transcend party politics, with some anti-abortion Republicans strongly supporting the research. Thirty-seven Republicans backed the bill on Thursday, while 16 Democrats opposed it.

SANCTITY OF LIFE

"I believe this legislation does not seek to destroy life," said House Democratic leader Steny Hoyer of Maryland.

"It seeks to preserve and protect life," he said. "We have a moral obligation to provide our scientific community with the tools it needs to save lives."

Many scientists view embryonic stem cells as the potential raw material for a new era of regenerative medicine, hoping to harness the unique qualities of the cells to repair damaged tissue. Such therapies are seen as years in the future.

Stem cells are a kind of master cell for the body, capable of growing into various tissue and cell types. Those taken from days-old embryos are especially malleable but "adult" stem cells found in babies and adults also have shown promise.

Rep. Christopher Smith, a New Jersey Republican, favors research on stem cells not taken from embryos but opposes the current measure.

"Where will this all take us? If this bill were to be passed and signed into law, we would see the demise -- the destruction -- over time ... of millions of embryos," he said.

There is no U.S. law against human embryonic stem cell research. Bush's 2001 policy limited federal funding to research on the human embryonic stem cell colonies, or lines, that existed at the time.

Some scientists say many of those roughly 20 lines are deteriorating, contaminated or were developed through obsolete methods, making them inadequate to determine the potential therapeutic value of embryonic stem cells.

The bill would allow federal funding on research involving stem cell lines derived from embryos created at fertility clinics that would otherwise be thrown away because they are not needed to implant in a woman to make a baby.

The bill is sponsored by Reps. Mike Castle, a Delaware Republican, and Diana DeGette, a Colorado Democrat. Last year, the House passed the bill 235-193 before Bush's veto.

House backs broader embryonic stem cell research, R, 11.1.2007, http://today.reuters.com/news/articlenews.aspx?type=politicsNews&storyID=2007-01-11T225001Z_01_WAT006848_RTRUKOC_0_US-USA-CONGRESS-STEMCELL.xml&WTmodLoc=Home-C5-politicsNews-3

California’s Governor

Seeks Universal Care

January 9, 2007
The New York Times
By JENNIFER STEINHAUER

LOS ANGELES, Jan. 8 — Gov. Arnold Schwarzenegger on Monday proposed extending health care coverage to all of California’s 36 million residents as part of a sweeping package of changes to the state’s huge, troubled health care system.

A total of 6.5 million people, one-fifth of the state’s population, do not have health insurance, far more than in any other state. At least one million of the uninsured are illegal immigrants, state officials say.

Under Mr. Schwarzenegger’s plan, which requires the approval of the Legislature, California would become the fourth and by far the largest state to attempt near universal health coverage for its citizens. The other three states are Maine, Massachusetts and Vermont.

The governor outlined his proposal to an audience of health care experts and reporters via satellite from Los Angeles. He made it clear that a variety of mechanisms would be used to provide all Californians with insurance and that the responsibility of providing it would fall on the government, employers, health care providers and the uninsured themselves.

The plan, which Mr. Schwarzenegger estimated would cost $12 billion, calls for many employers that do not offer health insurance to contribute to a fund that would help pay for coverage of the working uninsured. It would also require doctors to pay 2 percent and hospitals 4 percent of their revenues to help cover higher reimbursements for those who treat patients enrolled in Medi-Cal, the state’s Medicaid program.

“Everyone in California must have health insurance,” Mr. Schwarzenegger said.

As he made his proposal, the federal government announced that health care spending in 2005 showed the slowest growth in six years. [Page A13.]

Mr. Schwarzenegger’s plan includes elements that quickly provoked opposition from many powerful interests, including doctors and the governor’s Republican colleagues in the Legislature.

But the speaker of the State Assembly, Fabian Núñez, a Democrat, said in a statement, “I’m glad the governor is on board with coverage for all kids.”


Over the last two years, state legislatures have grown increasingly concerned with how to provide health insurance to citizens as the number of employers offering coverage has fallen and the number of workers entering fields where health insurance is not an option has grown.

Because of its great size, California is likely to set the stage for a national conversation about health care this year.

“This is a very significant proposal,” said Karen Davis, president of the Commonwealth Fund, a nonprofit foundation. “It is not just children he is talking about. It is really dealing with the whole problem of the uninsured, with concrete positions to raise revenues to pay for that coverage, and the philosophy of shared responsibility. I think this shows health care is going to be a major issue in the 2008 presidential election.”

In many ways, Mr. Schwarzenegger’s proposal mirrors the plan in Massachusetts, the most comprehensive of its sort, which is projected to cover about 515,000 of the state’s 550,000 uninsured. The law enacted there transformed a $1 billion pool that had long paid for health care for uninsured patients into a mechanism to help subsidize insurance for those who could not afford it.

In many states, spending on Medicaid, the federal government’s health program for the poor, has surpassed that for education in recent years. In New York, Gov. Eliot Spitzer has vowed to insure all the state’s children and enroll all eligible adults in Medicaid. And New Jersey is among a handful of states considering some form of universal coverage.

Under Mr. Schwarzenegger’s proposal, Medi-Cal would be extended to adults who earn as much as 100 percent above the federal poverty line and to children, regardless of their immigration status, living in homes where the family income is as much as 300 percent above that line, about $60,000 a year for a family of four. Medi-Cal is currently limited to adults with children, and children with documented residency are covered if their family’s income is up to 250 percent above of the poverty line.

Adult illegal immigrants would continue to be barred from Medicaid benefits but would still be entitled to health services from their counties and the state’s hospital system.

Employers would have new responsibilities as well. Businesses with 10 or more workers that choose not to offer coverage would be required to pay 4 percent of their total Social Security wages to a state fund that would be created to subsidize the purchase of coverage by the working uninsured. The cost of such coverage would be measured on a sliding scale depending on what an employee earned, and employees would be able to pay for it using pretax dollars.

This component seems intended to give employers an incentive to offer health insurance, and to level the playing field between employers that do not offer insurance — and are therefore essentially paying lower wages — and those that do.

“If you look at where the uninsured lie,” said Laura Tobler, a health policy analyst for the National Conference of State Legislatures, “most of them are working, and most work for small businesses.”

On the provider side, the governor’s plan contains privileges and responsibilities. Doctors and hospitals, which have long complained about Medi-Cal’s low reimbursement rates, would benefit from a $4 billion increase in annual reimbursement. But the state would tax doctors 2 percent of their total revenues, and hospitals 4 percent, to help pay for the greater reimbursement.

The proposal would prohibit insurance companies from denying coverage to people because of their age or health status. They would also be required to put 85 percent of their profits directly into health care services.

Aides to the governor said financing for the program would come from roughly $5 billion in federal money the state believes it will be owed through restructuring of its health care programs, and through a redirection of state money that now goes toward what is basically charity care, among other measures.

The chief executive of Blue Shield of California, Bruce G. Bodaken, described what might happen once the Legislature began to debate the governor’s proposal.

“Taking each part separately, there’s something for everyone to hate,” Mr. Bodaken said. “But taken as a whole, there’s a lot to like.”

The governor’s plan signals a growing trend among state legislatures. “What we are seeing this year,” said Enrique Martinez-Vidal, acting director of the State Coverage Initiatives, a program that assists states looking to expand health care programs, “is that instead of just trying to take on reform in an incremental way, there are some states trying to do this in a comprehensive way, by trying to get buy-ins from all the different players.”

But it is likely to set Mr. Schwarzenegger, a Republican, on a collision course with many state lawmakers from his party, who are the minority in the Legislature.

“Some of the areas he put out there we are probably not going to support,” said State Senator Dick Ackerman, the minority leader. Among his concerns, Mr. Ackerman said, were the coverage of illegal immigrants, which he said his members would not support, and a tax on doctors or providers.

“We don’t think taxing folks is something that is popular in California,” he said in a telephone interview from Sacramento. “But this isn’t going to be an up-or-down vote on one bill. It will be a debate. And we welcome it.”

California’s Governor Seeks Universal Care, NYT, 9.1.2007, http://www.nytimes.com/2007/01/09/us/09calif.html

Lilly Settles

With 18,000 Over Zyprexa

January 5, 2007
The New York Times
By ALEX BERENSON

Eli Lilly agreed yesterday to pay up to $500 million to settle 18,000 lawsuits from people who claimed they had developed diabetes or other diseases after taking Zyprexa, Lilly’s drug for schizophrenia and bipolar disorder.

Including earlier settlements over Zyprexa, Lilly has now agreed to pay at least $1.2 billion to 28,500 people who said they were injured by the drug. At least 1,200 suits are still pending, the company said. About 20 million people worldwide have taken Zyprexa since its introduction in 1996.

The settlement covers cases filed in state and federal courts by law firms or groups of firms for 18,000 clients, Lilly said. The federal suits have been overseen in Brooklyn by Judge Jack B. Weinstein of the Eastern District of New York.

The settlement will not affect continuing civil or criminal investigations of Zyprexa by state attorneys general and federal prosecutors.

Both Lilly and lawyers for plaintiffs said they were pleased with the agreement. With global sales of roughly $4.2 billion last year, Zyprexa is Lilly’s largest-selling drug and a major contributor to the company’s profits. Lilly shares were relatively flat after the settlement announcement. They rose 11 cents yesterday, to $52.36.

Zyprexa is the brand name for olanzapine, a potent chemical that binds to receptors in the brain to reduce psychotic hallucinations and delusions. Clinical trials show that in many patients, Zyprexa also causes severe weight gain and increases in cholesterol and blood sugar.

Documents provided to The New York Times last month by a lawyer who represents mentally ill patients show that Lilly played down the risks of Zyprexa to doctors as the drug’s sales soared after its introduction in 1996. The internal documents show that in Lilly’s clinical trials, 16 percent of people taking Zyprexa gained more than 66 pounds after a year on the drug, a far higher figure than the company disclosed to doctors.

The documents also show that Lilly marketed the drug as appropriate for patients who did not meet accepted diagnoses of schizophrenia or bipolar disorder, Zyprexa’s only approved uses. By law, drug makers may promote their drugs only for diseases for which the Food and Drug Administration has found the medicines to be safe and effective, though doctors may prescribe drugs in any way they see fit.

In response to questions about the information in the documents, Lilly has denied any wrongdoing and said it provided all relevant information to doctors and the F.D.A. Lilly has also said it did not promote Zyprexa for conditions other than schizophrenia or bipolar disorder.

In 2004, a panel of the American Diabetes Association found that Zyprexa caused diabetes more than other widely used antipsychotic drugs, in part because it tends to cause much more weight gain. But the F.D.A. has never made a similar finding. Instead, the F.D.A. added a warning in 2003 to the label of Zyprexa and other new antipsychotic drugs about their tendency to cause high blood sugar.

In 2005, a $700 million agreement covered 8,000 patients, and the company has made 2,500 individual settlements whose total value has not been disclosed, Lilly said. The 2005 settlement valued claims at about $90,000 a plaintiff, while yesterday’s agreement values claims at about $27,000 a plaintiff, at most.

The lower value for the new claims comes in part because of the F.D.A. label change, which has allowed Lilly to say that it adequately warned doctors of the risks of Zyprexa after 2003. The label change may also help to protect Lilly from future lawsuits, analysts and lawyers say.

In its statement, Lilly said the settlement did not change its view that Zyprexa is a safe and effective treatment for mental illness.

“We wanted to reduce significant uncertainties involved in litigating such complex cases,” Sidney Taurel, Lilly’s chief executive, said in the statement.

Richard Meadow, one of the lead lawyers for the plaintiffs, said the deal was fair to both sides. “Prolonging this litigation further is in no one’s best interest,” he said.

Lilly Settles With 18,000 Over Zyprexa, NYT, 5.1.2007, http://www.nytimes.com/2007/01/05/business/05drug.html

The Paths to Universal Health Care

(8 Letters)

January 4, 2007
The New York Times

To the Editor:

Re “A Healthy New Year,” by Paul Krugman (column, Jan. 1):

Yes! We have a fresh Congress and the promise of new approaches. This could be the year to break free from the crippling grip of private insurance companies and provide health care for all, as every other advanced country has long been doing.

Medicare, despite some fumbles, works extraordinarily well for millions of our senior citizens. Why not for all? This year we should end our national shame with respect to health care and join the civilized world. Dora B. Goldstein

Palo Alto, Calif., Jan. 1, 2007

•

To the Editor:

Paul Krugman’s proposed solution for our health care mess is half right. We do need a public tax-supported insurance system, like Medicare, to replace the hundreds of private, high-overhead insurance companies. These take 10 to 15 percent of the health care dollar and give little in return.

But that would not control rising costs. Despite much lower overhead, Medicare’s costs have risen nearly as rapidly as the private sector’s. That’s because economic incentives encourage overuse of expensive medical technology even when it is of unproven or marginal benefit.

Fee-for-service payments of physicians, investor-owned facilities and a market ideology will have to be replaced by salaried physicians working in prepaid medical groups and by nonprofit ownership. A difficult agenda, but nothing less will do.

Arnold S. Relman, M.D.

Boston, Jan. 2, 2007

The writer is professor emeritus of medicine and social medicine at Harvard Medical School and a former editor of The New England Journal of Medicine.

•

To the Editor:

With a tragic milestone reached in Iraq, it is noteworthy that the milestone of 50 million Americans with no medical care coverage is rapidly approaching.

Few working Americans can afford to pay for their health care if they are seriously ill or injured, or for insurance even when they can obtain it. Employers pay about half of health care costs, which are rising faster than inflation because of many factors, including advances in technology and expensive new medicines.

As a doctor, I often see the tragedy when patients delay needed care because they can’t pay for it. As an employer, I am faced annually with whether to accept onerous increases in insurance costs or to ask my employees to shoulder more of the burden. Our fragmented payment system for health care makes no sense.

I hope that Congress will begin at once to rectify this disgrace.

William E. Bowman, M.D.

Greensboro, N.C., Jan. 1, 2007

•

To the Editor:

Paul Krugman is correct that the nation must find a path to universal, publicly financed and administered health care. But where is that path?

The fiscal consequences of a leap to such health care appear to be insurmountable, yet could it be done in steps?

Perhaps coverage through the Veterans Administration could be the first to be folded into Medicare. Many veterans are over 65, and all would be offered broader services.

Covering all children under 16 could be next. Then high-expense procedures like transplants, as is done with dialysis. Then Medicaid recipients. Finally, allowing the remaining people — relatively healthy, relatively affluent and overwhelmingly employed — to use their current private insurance payments to buy into Medicare.

Could that be the path?

Michael P. Alexander, M.D.

Newton Centre, Mass., Jan. 3, 2007

The writer is a professor of neurology at Harvard Medical School.

To the Editor:

Thank goodness for Paul Krugman’s willingness to repeat his argument on behalf of us all.

Sadly, his appeal for significant and meaningful change has fallen on deaf ears.

Legislators, not willing to confront a powerful middleman, are sitting by while lives, jobs, small businesses, international competitiveness and true freedom of choice in health care are mangled by an entity whose value to our overall health is questionable.

Carol Salter

Boulder, Colo., Jan. 1, 2007

The writer is a registered nurse.

•

To the Editor:

Paul Krugman (column, Jan. 1) does not discuss a major reason we spend so much and get so little for our health care dollar.

Insurance and pharmaceutical companies are publicly traded companies whose main goal is to make money. Their primary mission is not to provide health care coverage for their members; these are merely tools through which profits are generated.

Why do we delude ourselves in thinking that these companies would behave more altruistically than other companies? And why do we think these companies would relinquish these goals to help provide health care coverage for all?

Kenneth R. Silk, M.D.

Ann Arbor, Mich., Jan. 1, 2007

The writer is a professor of psychiatry at the University of Michigan Medical School.

•

To the Editor:

In thinking about Paul Krugman’s review of the failed history of health reform, I am struck by the inherent irony.

Here we are, more than a decade after being buffaloed by the “Harry and Louise” propaganda of the insurance industry, still watching the numbers of uninsured millions escalating, still worried about being at the mercies of the H.M.O.’s, and now hoping that “big government” will finally step in and help us out of this crazy system.

Yet, with all this, including the clamor to retain and even expand that big government program — Medicare — we still can’t envision getting to where we need to be because of our cynicism and distrust of government! John Schlager

Springfield, N.J., Jan. 1, 2007

•

To the Editor:

Paul Krugman’s appeal for universal health care is right on.

While we suffer without the assurance of annual checkups, France, Canada, Scandinavia, Germany, Britain and others find it within their economic abilities to leave no person without annual medical exams and more.

The principal reason for our haplessness is, as Mr. Krugman wrote, the lobbying power of insurance businesses. Just why their intrusion into the equation is tolerated is beyond logic.

I never saw an insurance agent cure so much as a hangnail.

Gil Weiss

Stamford, Conn., Jan. 1, 2007

The Paths to Universal Health Care (8 Letters), NYT, 4.1.2007, http://www.nytimes.com/2007/01/04/opinion/l04krugman.html

Mother Wonders

if Psychosis Drug

Helped Kill Son

January 4, 2007
The New York Times
By ALEX BERENSON

At first, the psychiatric drug Zyprexa may have saved John Eric Kauffman’s life, rescuing him from his hallucinations and other symptoms of acute psychosis.

But while taking Zyprexa for five years, Mr. Kauffman, who had been a soccer player in high school and had maintained a normal weight into his mid-30s, gained about 80 pounds. He was found dead on March 27 at his apartment in Decatur, Ga., just outside Atlanta.

An autopsy showed that the 41-year-old Mr. Kauffman, who was 5 feet 10 inches, weighed 259 pounds when he died. His mother believes that the weight he gained while on Zyprexa contributed to the heart disease that killed him.

Eli Lilly, which makes Zyprexa, said in a statement that Mr. Kauffman had other medical conditions that could have led to his death and that “Zyprexa is a lifesaving drug.” The company said it was saddened by Mr. Kauffman’s death.

No one would say Mr. Kauffman had an easy life. Like millions of other Americans, he suffered from bipolar disorder, a mental illness characterized by periods of depression and mania that can end with psychotic hallucinations and delusions.

After his final breakdown, in 2000, a hospital in Georgia put Mr. Kauffman on Zyprexa, a powerful antipsychotic drug. Like other medicines Mr. Kauffman had taken, the Zyprexa stabilized his moods. For the next five and a half years, his illness remained relatively controlled. But his weight ballooned — a common side effect of Zyprexa.

His mother, Millie Beik, provided information about Mr. Kauffman, including medical records, to The New York Times.

For many patients, the side effects of Zyprexa are severe. Connecting them to specific deaths can be difficult, because people with mental illness develop diabetes and heart disease more frequently than other adults. But in 2002, a statistical analysis conducted for Eli Lilly found that compared with an older antipsychotic drug, Haldol, patients taking Zyprexa would be significantly more likely to develop heart disease, based on the results of a clinical trial comparing the two drugs. Exactly how many people have died as a result of Zyprexa’s side effects, and whether Lilly adequately disclosed those risks, are central issues in the thousands of product-liability lawsuits pending against the company, and in state and federal investigations.

Because Mr. Kauffman also smoked heavily for much of his life, and led a sedentary existence in his last years, no one can be sure that the weight he gained while on Zyprexa caused his heart attack.

Zyprexa, taken by about two million people worldwide last year, is approved to treat schizophrenia and bipolar disorder. Besides causing severe weight gain, it increases blood sugar and cholesterol in many people who take it, all risk factors for heart disease.

In a statement responding to questions for this article, Lilly said it had reported the death of Mr. Kauffman to federal regulators, as it is legally required to do. The company said it could not comment on the specific causes of his death but noted that the report it submitted to regulators showed that he had “a complicated medical history that may have led to this unfortunate outcome.”

“Zyprexa,” Lilly’s statement said, “is a lifesaving drug and it has helped millions of people worldwide with schizophrenia and bipolar disorder regain control of their lives.”

Documents provided to The Times by a lawyer who represents mentally ill patients show that Eli Lilly, which makes Zyprexa, has sought for a decade to play down those side effects — even though its own clinical trials show the drug causes 16 percent of the patients who take Zyprexa to gain more than 66 pounds after a year.

Eli Lilly now faces federal and state investigations about the way it marketed Zyprexa. Last week — after articles in The Times about the Zyprexa documents — Australian drug regulators ordered Lilly to provide more information about what it knew, and when, about Zyprexa’s side effects.

Lilly says side effects from Zyprexa must be measured against the potentially devastating consequences of uncontrolled mental illness. But some leading psychiatrists say that because of its physical side effects Zyprexa should be used only by patients who are acutely psychotic and that patients should take other medicines for long-term treatment.

“Lilly always downplayed the side effects,” said Dr. S. Nassir Ghaemi, a specialist on bipolar disorder at Emory University in Atlanta. “They’ve tended to admit weight gain, but in various ways they’ve minimized its relevance.”

Dr. Ghaemi said Lilly had also encouraged an overly positive view of its studies on the effectiveness of Zyprexa as a long-term treatment for bipolar disorder. There is more data to support the use of older and far cheaper drugs like lithium, he said.

Last year, Lilly paid $700 million to settle 8,000 lawsuits from people who said they had developed diabetes or other diseases after taking Zyprexa. Thousands more suits are still pending.

But Ms. Beik is not suing Lilly. She simply wants her son’s case to be known, she said, because she considers it a cautionary tale about Zyprexa’s tendency to cause severe weight gain. “I don’t think that price should be paid,” she said.

Mr. Kauffman’s story, like that of many people with severe mental illness, is one of a slow and steady decline.

Growing up in DeKalb, Ill., west of Chicago, he acted in school plays and was a goalie on the soccer team. A photograph taken at his prom in 1982 shows a handsome young man with a messy mop of dark brown hair.

But in 1984, in his freshman year at Beloit College in Wisconsin, Mr. Kauffman suffered a breakdown and was found to have the most severe form of bipolar disorder. He returned home and, after medication stabilized his condition, enrolled in Northern Illinois University. He graduated from there in 1989 with a degree in political science.

For the next year, he worked as a bus driver ferrying senior citizens around DeKalb. In a short local newspaper profile of him in 1990, he listed his favorite book as “Catch-22,” his favorite musician as Elvis Costello, and his favorite moment in life as a soccer game in which he had made 47 saves. A few months later, he followed his mother and stepfather to Atlanta and enrolled in Georgia State University, hoping to earn a master’s degree in political science.

“He wanted so much to become a political science professor,” Ms. Beik said.

But trying to work while attending school proved to be more stress than Mr. Kauffman could handle, Ms. Beik said. In 1992, he suffered his most severe psychotic breakdown. He traveled around the country, telling his parents he intended to work on a political campaign. Instead, he spent much of the year homeless, and his medical records show that he was repeatedly admitted to hospitals.

Mr. Kauffman returned home at the end of 1992, but he never completely recovered, Ms. Beik said. He never worked again, and he rarely dated.

In 1994, the Social Security Administration deemed him permanently disabled and he began to receive disability payments. He filed for bankruptcy that year. According to the filing, he had $110 in assets — $50 in cash, a $10 radio and $50 in clothes — and about $10,000 in debts.

From 1992 to 2000, Mr. Kauffman did not suffer any psychotic breakdowns, according to his mother. During that period, he took lithium, a mood stabilizer commonly prescribed for people with bipolar disorder, and Stelazine, an older antipsychotic drug. With the help of his parents, he moved to an apartment complex that offered subsidized housing.

But in late 1999, a psychiatrist switched him from lithium, which can cause kidney damage, to Depakote, another mood stabilizer. In early 2000, Mr. Kauffman stopped taking the Depakote, according to his mother.

As the year went on, he began to give away his possessions, as he had in previous manic episodes, and became paranoid. During 2000, he was repeatedly hospitalized, once after throwing cans of food out of the window of his sixth-floor apartment.

In August, he was institutionalized for a month at a public hospital in Georgia. There he was put on 20 milligrams a day of Zyprexa, a relatively high dose.

The Zyprexa, along with the Depakote, which he was still taking, stabilized his illness. But the drugs also left him severely sedated, hardly able to talk, his mother said.

“He was so tired and he slept so much,” Ms. Beik said. “He loved Shakespeare, and he was an avid reader in high school. At the end of his life, it was so sad, he couldn’t read a page.”

In addition, his health and hygiene deteriorated. In the 1990 newspaper profile, Mr. Kauffman had called himself extremely well-organized. But after 2000, he became slovenly, his mother said. He spent most days in his apartment smoking.

A therapist who treated Mr. Kauffman while he was taking Zyprexa recalls him as seeming shy and sad. “He was intelligent enough to have the sense that his life hadn’t panned out in a normal fashion,” the therapist said in an interview. “He always reminded me of a person standing outside a house with a party going on, looking at it.”

The therapist spoke on the condition that her name not be used because of rules covering the confidentiality of discussions with psychiatric patients.

As late as 2004, Mr. Kauffman prepared a simple one-page résumé of his spotty work history — evidence that he perhaps hoped to re-enter the work force. He never did.

As Mr. Kauffman’s weight increased from 2000 to 2006, he began to suffer from other health problems, including high blood pressure. In December 2005, a doctor ordered him to stop smoking, and he did. But in early 2006, he began to tell his parents that he was having hallucinations of people appearing in his apartment.

On March 16, a psychiatrist increased his dose of Zyprexa to 30 milligrams, a very high level.

That decision may have been a mistake, doctors say. Ending smoking causes the body to metabolize Zyprexa more slowly, and so Mr. Kauffman might have actually needed a lower rather than higher dose.

A few days later, Mr. Kauffman spoke to his mother for the last time. By March 26, they had been out of contact for several days. That was unusual, and she feared he might be in trouble. She drove to his apartment building in Decatur the next day and convinced the building’s manager to check Mr. Kauffman’s apartment. He was dead, his body already beginning to decompose.

An autopsy paid for by his mother and conducted by a private forensic pathologist showed he had died of an irregular heartbeat — probably, the report said, as the result of an enlarged heart caused by his history of high blood pressure.

Ms. Beik acknowledged she cannot be certain that Zyprexa caused her son’s death. But the weight gain it produced was most likely a contributing factor, she said. And she is angry that Eli Lilly played down the risks of Zyprexa. The company should have been more honest with doctors, as well as the millions of people who take Zyprexa, she said.

Instead Lilly has marketed Zyprexa as safer and more effective than older drugs, despite scant evidence, psychiatrists say.

Ms. Beik notes that Stelazine — an older drug that is no longer widely used even though a federally financed clinical trial showed it works about as well as Zyprexa — stabilized Mr. Kauffman’s illness for eight years without causing him to gain weight.

“He was on other drugs that worked,” she said.

Mother Wonders if Psychosis Drug Helped Kill Son, NYT, 4.1.2007, http://www.nytimes.com/2007/01/04/business/04drug.html