History > 2007 > USA > Health (VI)

Bush signs

child health program extension

into law

Sat Dec 29, 2007
Reuters
11:43am EST

CRAWFORD, Texas (Reuters) - President George W. Bush on Saturday signed into law a temporary extension of a popular health insurance program for children after months of deadlock with the Democratic-led Congress.

The legislation extends the program that covers about 6.6 million poor children through March 31, 2009, leaving decisions about renewal to the next president and Congress.

The legislation also provides a 0.5 percent increase for Medicare doctors for six months, delaying a scheduled 10 percent pay cut.

Bush twice vetoed more ambitious earlier bills that would have expanded the children's health program to cover about 10 million children in low and moderate income families, despite bipartisan support.

Bush and Democrats have been locked in a fight over budget and spending and the president said the previous bills were too costly and would push more children into government-run health care instead of private plans.

Bush also objected to raising tobacco taxes to pay for the proposed expansion of the State Children's Health Insurance Program known as SCHIP.

Democrats had hoped for a short-term extension so they could reopen the battle before the November 2008 presidential and congressional elections, but Republicans forced them to extend it through March 2009.

In his weekly radio address, Bush vowed to push for spending restraint and low taxes in his last year in office.

"My resolution for the New Year is this: to work with Congress to keep our economy growing, to keep your tax burden low, and to ensure that the money you send to Washington is spent wisely -- or not at all," Bush said.
 

(Reporting by Tabassum Zakaria;

Editing by Jackie Frank)

Bush signs child health program extension into law, R, 29.12.2007, http://www.reuters.com/article/newsOne/idUSN2951327120071229

Six Killers: Alzheimer’s Disease

Finding Alzheimer’s

Before a Mind Fails

December 26, 2007
The New York Times
By DENISE GRADY

For a perfectly healthy woman, Dianne Kerley has had quite a few medical tests in recent years: M.R.I. and PET scans of her brain, two spinal taps and hours of memory and thinking tests.

Ms. Kerley, 52, has spent much of her life in the shadow of an illness that gradually destroys memory, personality and the ability to think, speak and live independently. Her mother, grandmother and a maternal great-aunt all developed Alzheimer’s disease. Her mother, 78, is in a nursing home in the advanced stages of dementia, helpless and barely responsive.

“She’s in her own private purgatory,” Ms. Kerley said.

Ms. Kerley is part of an ambitious new scientific effort to find ways to detect Alzheimer’s disease at the earliest possible moment. Although the disease may seem like a calamity that strikes suddenly in old age, scientists now think it begins long before the mind fails.

“Alzheimer’s disease may be a chronic condition in which changes begin in midlife or even earlier,” said Dr. John C. Morris, director of the Alzheimer’s Disease Research Center at Washington University in St. Louis, where Ms. Kerley volunteers for studies.

But currently, the diagnosis is not made until symptoms develop, and by then it may already be too late to rescue the brain. Drugs now in use temporarily ease symptoms for some, but cannot halt the underlying disease.

Many scientists believe the best hope of progress, maybe the only hope, lies in detecting the disease early and devising treatments to stop it before brain damage becomes extensive. Better still, they would like to intervene even sooner, by identifying risk factors and treating people preventively — the same strategy that has markedly lowered death rates from heart disease, stroke and some cancers.

So far, Alzheimer’s has been unyielding. But research now under way may start answering major questions about when the disease begins and how best to fight it.

A radioactive dye called PIB (for Pittsburgh Compound B) has made it possible to use PET scans to find deposits of amyloid, an Alzheimer’s-related protein, in the brains of live human beings. It may lead to earlier diagnosis, help doctors distinguish Alzheimer’s from other forms of dementia and let them monitor the effects of treatment.

Studies with the dye have already found significant deposits in 20 percent to 25 percent of seemingly normal people over 65, suggesting that they may be on the way to Alzheimer’s, though only time will tell.

“PIB is about the future of where Alzheimer’s disease needs to be,” said Dr. William E. Klunk, a co-discoverer of the dye at the Alzheimer’s research center at the University of Pittsburgh. “PIB is being used today to help determine whether drugs that are meant to prevent or remove amyloid from the brain are working, so we can find drugs that prevent the underlying pathology of the disease.”

Though PIB is experimental now, studies began in November that are intended to lead to government approval for wider use.

Currently, for the most common form of Alzheimer’s disease, which occurs after age 65, there is no proven means of early detection, no definitive genetic test. But PIB tests might be ready before new treatments emerge, making it possible to predict who will develop Alzheimer’s — without being able to help.

Researchers are also using M.R.I. scans to look for early brain changes, and testing blood and spinal fluid for amyloid and other “biomarkers” to see if they can be used to predict Alzheimer’s or find it early.

Studies of families in which multiple members have dementia are helping to sort out the genetic underpinnings of the disease.

Finally, experiments are under way to find out whether drugs and vaccines can remove amyloid from the brain or prevent its buildup, and whether doing so would help patients. The new drugs, unlike the ones now available, have the potential to stop or slow the progress of the disease. At the very least, the drug studies will be the first real test of the leading theory of Alzheimer’s, which blames amyloid for setting off a chain of events that ultimately ruin the brain.

Some scientists doubt the amyloid theory, but even a staunch skeptic said the studies were important.

Among the skeptics is Dr. Peter Davies, a professor at Albert Einstein Medical College, who said: “You’ve got to try. Somebody’s going to get this right.”

But if the amyloid hypothesis does not hold up, much of Alzheimer’s research could wind up back at Square 1.

Answers are urgently needed. Alzheimer’s was first recognized 100 years ago, and in all that time science has been completely unable to change the course of the disease. Desperate families spend more than $1 billion a year on drugs approved for Alzheimer’s that generally have only small effects, if any, on symptoms. Patients’ agitation and hallucinations often drive relatives and nursing homes to resort to additional, powerful drugs approved for other diseases like schizophrenia, drugs that can deepen the oblivion and cause severe side effects like diabetes, stroke and movement disorders.

Alzheimer’s is the most common cause of dementia (artery disease, Parkinson’s and other brain disorders can also lead to dementia). Five million people in the United States have Alzheimer’s, most of them over 65. It is the nation’s sixth leading cause of death by disease, killing nearly 66,000 people a year and probably contributing to many more deaths. By 2050, according to the Alzheimer’s Association, 11 million to 16 million Americans will have the disease. “Sixteen million is a future we can’t countenance,” said William H. Thies, the association’s vice president for medical and scientific relations. “It will bankrupt our health care system.”

The costs are already enormous, $148 billion a year — more than three times the cost of chronic lung disease, even though Alzheimer’s kills only half as many people. To a great extent, increases in dementia are the price of progress: more and more people are living long enough to get Alzheimer’s, some because they survived heart disease, strokes or cancer. It is a cruel trade-off. The disease is by no means inevitable, but among people 85 and older, about 40 percent develop Alzheimer’s and spend their so-called golden years in a thicket of confusion, ultimately becoming incontinent, mute, bedridden or forced to use a wheelchair and completely dependent on others.

“It makes people wonder whether they really want to live that long,” Dr. Klunk said.

The potential market for prevention and treatment is enormous, and drug companies are eager to exploit it. If a drug could prevent Alzheimer’s or just reduce the risk, as statins like Lipitor do for heart disease, half the population over 55 would probably need to take it, Dr. Thies said.

If new drugs do emerge, they will come from studies in patients who already have symptoms, Dr. Thies said. But he said the emphasis would quickly shift to treating people at risk, before symptoms set in. Many researchers doubt that even the best preventive drugs will be able to heal the brains of people who are already demented.

Treating preventively, Dr. Thies said, “will be more satisfying to patients and physicians, and there will be an economic incentive because you’ll wind up treating more people.”

The only thing that could slow the drive for early treatment, he said, would be serious side effects — and Dr. Morris, at Washington University, said drugs powerful enough to treat Alzheimer’s would probably have strong side effects.

Researchers are especially eager to study people like Ms. Kerley, because the children of Alzheimer’s patients have a higher-than-average risk of dementia themselves, and tracking their brains and minds may open a window onto the earliest stages of the disease.

“I want to do anything I can possibly do to help find a cure or find a way to identify it earlier,” Ms. Kerley said. “We need to stop this. I don’t know if it will help my generation, but it will help my son’s.”

She figures that being a research subject may have advantages, too.

“We’re the first ones in line,” she said. “If I am genetically predisposed, and they have a preventive medication, they’ll tell me right away.”

Alzheimer’s Beginnings

Some forgetfulness is normal. Distraction, stress, fatigue and medications can contribute. A joking rule of thumb about Alzheimer’s is actually close to the truth: it’s O.K. to forget where you put your car keys, as long as you remember what a key is for. But worsening forgetfulness is a cause for concern.

Doctors use standard memory and reasoning tests to diagnose dementia, along with symptoms reported by the patient and family members. The term “mild cognitive impairment” is sometimes applied to small but measurable memory problems. But its meaning is unclear: some studies find that the impairment can resolve itself, while others suggest that it always progresses to dementia.

Even if older patients think more slowly or take longer to remember, as long as they can still function independently, they are not demented, Dr. Morris said.

In her heart, Ms. Kerley suspects that her mother’s Alzheimer’s disease began long before the official diagnosis in 2001 or even the tentative one in 1995 — years before, maybe decades. She wonders if the disease might explain, at least in part, her mother’s difficult personality and lack of interest in reading or education.

When does Alzheimer’s begin? The question haunts families and captivates scientists.

Dr. Morris said, “We think that by the time an individual begins to experience memory loss, there is already substantial brain damage in areas critical to memory and learning.”

No one knows whether the disease affects thinking, mood or personality before memory fails. Researchers think that the brain, like other vital organs, has a huge reserve capacity that can, at least for a time, hide the fact that a disease is steadily destroying it.

“I’m speculating that it does affect you throughout life,” said Dr. Richard Mayeux, a professor of neurology, psychiatry and epidemiology at Columbia University, and co-director of its Taub Institute for Research on Alzheimer’s Disease and the Aging Brain. “I think there’s a very long phase where people aren’t themselves.”

If Dr. Mayeux asks family members when a patient’s memory problem began, they almost always say it started a year and a half before. If he then asks when was the last time they thought the patient’s memory was perfectly normal, many reply that the patient never really had a great memory.

Several studies in which people had intelligence tests early in life and were then evaluated decades later have found that compared with the healthy people, those with Alzheimer’s had lower scores on the early tests.

“It raises the possibility for me that this is a genetic disorder that starts early in life,” Dr. Mayeux said.

He said those findings also made him wonder about the widely dispensed advice to read, take courses, solve puzzles and stay mentally active to ward off Alzheimer’s. The advice is based on studies showing that highly educated people have a lower risk of Alzheimer’s than do less-accomplished ones. But does that mean that mental activity prevents Alzheimer’s — or vice versa?

‘I Have Lost Myself’

The disease is named for Alois Alzheimer, a German doctor who first described it in Auguste D., a 51-year-old patient he saw in 1901. Her memory, speech and comprehension were failing, and she suffered from hallucinations and paranoid delusions that her husband was unfaithful. Unable to finish writing her own name, she told Alzheimer, “I have lost myself.”

She died in 1906, “completely apathetic,” curled up in a fetal position and “in spite of all the care and attention,” suffering from bedsores, Alzheimer wrote.

A century later, patients still die in much the same way. Although Alzheimer’s itself can kill by shutting down vital brain functions, infections usually end things first — pneumonia, bladder infections, sepsis from bedsores.

When Alzheimer dissected Auguste’s brain, he found it markedly shrunken, a wasteland of dead and dying nerve cells littered with strange deposits.

There were two types of deposits, plaques and tangles. Plaques occur between nerve cells, and are now known to consist of clumps of beta amyloid, an abnormal protein. Tangles form inside nerve cells, and are made of a protein called tau that is normally part of a system of tubules that carry nutrients to feed the cell. Once tau is damaged, the nerve cells essentially starve to death.

Until the 1970s Alzheimer’s disease was considered a rare brain disorder that mysteriously struck younger people like Auguste D.

It was thought to be different from “senility,” which was assumed to be a consequence of aging. But then researchers compared the brains of younger people who had died of Alzheimer’s with those of elderly people who had been senile, and discovered the same pathology — plaques and tangles. Senility, they decided, was not a natural part of aging; it was a disease.

The Amyloid Hypothesis

The leading theory of Alzheimer’s says that beta amyloid, or A-beta, is the main culprit, building gradually in the brain over decades and short-circuiting synapses, the junctions where nerve cells transmit signals to one other. Gradually, the theory goes, the cells quit working and die.

Everybody produces A-beta, but its purpose is not known. People who develop Alzheimer’s either make too much or cannot get rid of it. Although scientists once blamed plaques for all the trouble, more recent research suggests that the real toxins are smaller bundles of A-beta molecules that form long before plaques do.

Dr. Dennis J. Selkoe, a professor of neurologic diseases at Harvard, said that just as lowering cholesterol can prevent heart disease, lowering A-beta may prevent Alzheimer’s or slow it, particularly in the early stages — provided that drugs can be created to do the job.

Several drugs and vaccines are now being tested that either block the production of A-beta or help the body get rid of it.

Researchers are also testing anti-amyloid antibodies, which are proteins made by the immune system, as well as blood serum that contains the antibodies.

Eventually, Dr. Selkoe said, screening tests for Alzheimer’s “will be like getting an EKG in the doctor’s office at 45 or 50, and you’ll start treating right away to prevent Alzheimer’s rather than treat it.”

Other researchers are less enthusiastic, noting that there have been numerous failures and disappointments along the way. A vaccine study had to be halted in 2002 because 18 of 300 patients developed encephalitis, and 2 died. Some scientists worry that anti-amyloid vaccines in general could be dangerous, in part because the role of amyloid is not well understood and the brain may actually need it.

No Choice but to Cope

Even if current research yields new drugs, there is not likely to be a miracle pill that will bring people back from deep dementia. For now, there is no choice but to cope with the disease. Seventy percent of Alzheimer’s patients are cared for at home, and millions of families are struggling to look after them, piecing together a patchwork of relatives, friends, paid health aides and adult day-care programs.

Barbara Latshaw, 79, lives with her husband, David, and her sister in Crafton, Pa., near Pittsburgh. Ms. Latshaw, whose dementia was diagnosed in 1991, has not spoken in four years, and she can no longer smile. But she locks eyes with visitors and will not let go.

“There is still something alive in there,” said her sister, Fritzie Hess, 69. “I’m convinced of it.”

The family believes that, at least some of the time, she still understands them. They speak to her as if she does. She is with them, and yet gone, and they miss her terribly.

“We hope to keep her here at home until she passes on,” Ms. Hess said. “She’s a joy to us.”

Many families hope to keep Alzheimer’s patients at home, but not all can manage it, especially if family members have to go work or patients become combative, incontinent, immobile or unable to sleep at night.

“There are three of us taking care of my sister, and it works out beautifully,” Ms. Hess said. “We spell each other. I don’t know how these spouses manage, when it’s one on one.”

Ms. Hess and her brother-in-law are retired, and Ms. Latshaw’s daughter, Becky Bannon, 53, is free to visit many mornings to help them get her mother out of bed, massage and exercise her arms and legs, change her diaper and dress and feed her.

Ms. Latshaw used to be full of life. She loved to cook, played tennis and bridge, raised two children and took charge of redecorating the grand old family home. Then her memory began to slip: guests would arrive for dinner, and she would have no memory of inviting them. She forgot to look before pulling into traffic, and nearly caused an accident. She would wander out of the house, and local store clerks would take her home. She never turned hostile or angry, as many demented patients do, but she had vivid hallucinations of strings being caught in her teeth, and little men getting into her bed and jabbing her with broom straws. On especially bad nights, her husband would get up with her at 2 or 3 a.m. and make the two of them hot chocolate.

Aricept, an Alzheimer’s drug, made the hallucinations worse, while another drug, an antipsychotic used for schizophrenia, seemed to quell them. But the second drug had side effects: after taking it for several years, Ms. Latshaw began to grind her teeth, and could not stop moving her arms and legs.

Their father also suffered from dementia, Ms. Hess said, admitting that she wonders about herself.

“Naturally I’m a little bit concerned, but I think worry is such a waste of time, so I don’t dwell on it; I just don’t,” she said. “My friends always said, ‘You always had a bad memory.’ I see Barbara and David’s children having that same kind of memory.”

Ms. Hess has volunteered for studies at the University of Pittsburgh Medical Center, where she became the first person in the United States to have a PIB study of her brain.

“I’m very anxious to get to the bottom of this whole Alzheimer’s thing,” she said.

Nothing Left to Give

In an interview in the summer of 2006, Ms. Kerley described her mother this way: “She’s completely withdrawn in herself. She hasn’t recognized us for a few years. Basically she hums one line of one song over and over again. She seems to be stuck somewhere in her life between age 4 and 5.”

Ms. Kerley said she and her son Michael, then 21, visited every week or two.

“She loves getting her back rubbed, being smiled at, being hugged,” Ms. Kerley said. “She doesn’t know who we are. We’re going for us, not for her, because she doesn’t remember us the minute we walk out the door.”

She had signed her mother up for hospice care at the nursing home, meaning that she would receive medical care to keep her comfortable but no extraordinary measures like resuscitation if she began to fail. She said her mother would not want to be kept alive in her present condition.

“She has nothing left to give the world, and the world has nothing left to give to her,” Ms. Kerley said.

Nearly a year and a half later, her mother is still alive, even though Ms. Kerley has declined liquid nutritional supplements, antibiotics and flu and pneumonia shots.

Her mother does not even hum anymore, and spends much of her time in a fetal position, except when she is at the dinner table. She can still walk, if led.

“If my mother had her own choice, she would have offed herself a long time ago,” Ms. Kerley said. “There is no quality to her life.

“When she does go, it will be a blessing.”

Ms. Kerley has already arranged to donate her mother’s brain and her own to Washington University. She seriously doubts that she will develop Alzheimer’s. She is more like her father than her mother, she said, and she is the most educated person in her family, reads constantly and stays in shape by swing dancing two to five nights a week. And her students keep her sharp.

“If you want to keep up with me until you retire, that’s fine,” she said. “I’m betting I’m not going to have that problem.”

Finding Alzheimer’s Before a Mind Fails, NYT, 26.12.2007, http://www.nytimes.com/2007/12/26/health/26alzheimers.html

Health Care Expansions

Hit Roadblocks

December 25, 2007
The New York Times
By KEVIN SACK

SACRAMENTO — A year that began with great ambition for major expansions of health insurance here and in other state capitals is ending with considerable uncertainty, as a second wave of change runs headlong into a darkening economy and political divisions over how to apportion the cost.

Though the governors of three big states — California, Illinois and Pennsylvania — proposed sweeping plans to restructure health care this year, none will finish 2007 with bills passed and signed. In each state, the initiatives confronted entrenched opposition from insurance and other business lobbies that made it far more difficult to build a consensus for change than in the smaller New England states that acted in recent years.

Yet it also was a year of intriguing achievement, here above all, where the Republican governor, Arnold Schwarzenegger, and the Democratic Assembly speaker, Fabian Núñez, drew up a bipartisan blueprint for bringing near-universal coverage to the country’s most populous state.

Mr. Schwarzenegger and Mr. Núñez have yet to close the deal by gaining the support of the State Senate. But they demonstrated in their yearlong negotiations that a consensus on basic principles could be reached, perhaps setting a template for other states and for Washington.

“It’s significant that what they’ve been talking about in California is similar to what many of the leading Democratic presidential candidates are talking about as well,” said Larry Levitt, vice president of the Kaiser Family Foundation, which researches health care issues. “There seems to be some convergence at least on the part of those supporting universal health care on how to get there.”

In addition to being the most populous state, California has among the country’s highest proportions of uninsured residents, about 20 percent. Indeed, there are more uninsured in California than there are total residents of Massachusetts, Maine or Vermont, the states that have set the pace for overhauling health care. Success here, therefore, would send a signal that such plans could be enacted in states with the heaviest burdens.

The Schwarzenegger-Núñez plan, which passed the Democratic-controlled Assembly last week, expands on the universal coverage law that Massachusetts passed in 2006. That state now requires insurance companies to offer coverage regardless of an applicant’s health status and mandates that most residents have insurance by Dec. 31, or face a tax penalty of $219.

State officials project that more than 300,000 previously uninsured people will sign up in time, a third of them in a surge over the last month. That has put Massachusetts more than halfway to its goal of insuring everyone.

The downside, and one noted by states with widening budget gaps, is that the program is expected to exceed its first-year budget by at least $150 million. And state officials are struggling to prevent double-digit premium increases next year.

Whether the momentum that began with State of the State addresses last January will continue into 2008 is not clear. It had been widely felt by health reform advocates that this nonelection year provided the best political climate for change.

Now the focus may shift to the presidential campaign, where the leading candidates for the Democratic nomination have each proposed major overhauls. Some state leaders may be tempted to wait out the year to gauge whether the next president will push for a national health plan that might subsume state efforts.

The essential problem, meanwhile, continues to worsen. The Census Bureau reported that the number of uninsured grew to 47 million in 2006, a one-year increase of 2.2 million. The share of United States residents who had employer-based coverage dropped to 60 percent from 64 percent in 2000, according to the Economic Policy Institute, a liberal research group. And though the rate of growth has slowed, the cost of employer-sponsored premiums still rose by 6.1 percent in 2007, more than double the inflation rate, according to the Kaiser Family Foundation.

Because of its national influence, California will continue to command attention as Mr. Schwarzenegger and Mr. Núñez try to bring along the Senate president pro tem, Don Perata, a Democrat. While supportive of universal coverage, Mr. Perata has said he is concerned about the plan’s $14.4 billion price tag when the state faces a budget gap of commensurate size.

As in Massachusetts, the California plan would mandate coverage for most individuals. It would raise money to subsidize policies for low-income residents through what Mr. Schwarzenegger calls shared responsibility — a tax on hospital revenues, a hefty increase in tobacco taxes and assessments on employers who do not contribute to their workers’ health care.

In a California innovation, the assessment rates would be graduated according to the size of the company. If the Senate passes the measure, voters will be asked to approve the revenue measures in a November referendum that would become the truest test of public support for change.

California, of course, is an idiosyncratic state, and at no time more than now, with its movie star governor and his mantra of “postpartisanship.” But even in a state as comparatively progressive as this one, the coalition that has formed around overhauling health care is notable.

At a postvote news conference beneath the Capitol rotunda last week, Mr. Schwarzenegger and Mr. Núñez stood with the chairman of Safeway grocery stores and the president of the San Diego Chamber of Commerce, as well as leaders of unions representing service workers, government employees and carpenters.

Andrew L. Stern, president of the Service Employees International Union, seemed to speak for many of those in attendance when he said in an interview that successful health reform would depend on “not letting the perfect be the enemy of the good.”

Against that backdrop, the bipartisan partnership between Mr. Schwarzenegger and Mr. Núñez seemed almost unremarkable. The two men need each other — Mr. Schwarzenegger to play on the big stage he enjoys, Mr. Núñez to leave a legacy before term limits may force him from office — and they praise each other lavishly in public.

That is not to say support for their plan is universal; it won not a single Republican vote in the Assembly. Some unions oppose it because they fear that mandatory insurance policies would not be affordable, even with government subsidies. The California Nurses Association opposes the plan because it would preserve private insurance rather than replacing it with universal government coverage.

Other governors, in more centrist states, made less headway this year in overcoming opposition generated by efforts to contain health costs and to raise the revenues needed to subsidize premiums.

Illinois’ Democratic governor, Rod R. Blagojevich, got nowhere with his proposals to pay for universal access to insurance by taxing gross business receipts and assessing employers who do not offer coverage to their employees. He then instigated a fight with his legislature and provoked a lawsuit by using his executive authority to widen eligibility for state-subsidized insurance programs.

In Pennsylvania, Gov. Edward G. Rendell, also a Democrat, failed to persuade his politically divided legislature to cover the state’s 900,000 uninsured through an employer assessment. Like the California leaders, Mr. Rendell has now proposed increasing cigarette taxes, as well as raiding the surplus in a state fund designed to help doctors pay for malpractice insurance.

In both New York and Connecticut, governors expect to receive plans for universal health coverage from advisory groups in 2008 and then to begin their own legislative battles.

“It remains incredibly difficult for states by themselves to get all the uninsured covered,” said Robert Blendon, a Harvard professor of health policy and political analysis. “There just is not a consensus on who should pay.”

While only a few states considered universal coverage plans, it was an active year for more incremental measures, said Laura Tobler, a health policy analyst for the National Conference of State Legislatures.

Maryland and Texas joined the 15 states that have created programs to subsidize insurance for small businesses and individuals, she said. Four states effectively guaranteed that all children could be insured through expanded eligibility for Medicaid and the State Children’s Health Insurance Program, known as S-chip. An additional 13 states passed more modest expansions for children.

Any continuation of that trend in 2008 would likely depend on Congress and President Bush settling their considerable differences over financing for S-chip.

Mr. Bush this year twice vetoed large increases approved by the Democratic-controlled Congress, and his administration used regulatory powers to restrict the ability of states to extend the program beyond its original target: the children of the working poor.

    Health Care Expansions Hit Roadblocks, NYT, 25.12.2007, http://www.nytimes.com/2007/12/25/us/25health.html?hp

Editorial

Slowing the Rise in Health Costs

December 20, 2007
The New York Times
 

With the disjointed American health care system in perpetual crisis, it is essential to find ways to slow the relentless rise in costs, without jeopardizing the quality of care. There is no single solution. But a broad range of reforms could combine to produce worthwhile savings.

The Commonwealth Fund, a New York-based foundation, issued a report this week analyzing 15 policy options for the federal government that could reduce national spending on health care by as much as $1.5 trillion over 10 years — even after spending more than $200 billion to provide health coverage for all Americans.

The estimated savings amount to a modest 4.5 percent reduction from a projected $33 trillion in cumulative health care spending over the decade, and even these will be hard to achieve. Yet there is no choice but to try. The good news is that many of the reforms might actually improve the quality of care delivered to Americans.

The essential reform is to adopt technology that would allow information to be shared among all the doctors and institutions that care for a patient, lessening the chances of errors and duplication and encouraging better coordination of treatment. That would require an initial investment in technology, but, according to the study, could produce a cumulative savings of $88 billion over a decade. The Commonwealth Fund also lays out a reasonable approach to pay for that initial investment: a 1 percent charge on private insurance premiums and on the government’s Medicare expenditures.

The study’s biggest projected savings — $368 billion over 10 years — would come from establishing a public-private center to evaluate which treatments work best for which patients. The goal is to deter doctors from dispensing expensive treatments and drugs that don’t work, aren’t needed or are no better than cheaper alternatives. That is a superb idea and could produce big savings over time, although we are skeptical that the initial payback would be that high. Other savings are projected if the health system stops paying doctors for each service performed — an incentive for multiplying services — and instead pays for treating an entire episode of illness.

A few options that make good sense are sure to excite strong lobbying opposition. One would eliminate the unjustified subsidies granted to private Medicare plans. Another would allow the government to negotiate lower prescription drug prices for Medicare. More savings could be found if the government limited Medicare payments to doctors and hospitals in high-cost areas of the country, giving them the strongest possible incentive to adopt more efficient practices.

The Commonwealth Fund stresses that it is not advocating any of these reforms but is simply examining the potential of various options to slow the rate of growth in future health care expenditures. Unfortunately, the foundation failed to assess one controversial proposal — a Medicare-like insurance program to replace private insurance — that, by some estimates, could produce even bigger savings.

Yet the Commonwealth Fund has performed a public service by putting dollar estimates on the rather abstract proposals being discussed by many of the presidential candidates. If the United States hopes to bring health costs under control, it will need to start on these or other options as soon as possible.

    Slowing the Rise in Health Costs, NYT, 20.12.2007, http://www.nytimes.com/2007/12/20/opinion/20thu1.html

Health Savings Accounts for Poor Tested

December 15, 2007
Filed at 3:08 a.m. ET
By THE ASSOCIATED PRESS
The New York Times

WASHINGTON (AP) -- The popularity of health savings accounts for the poor will be put to the test in Indiana under a program approved Friday by the Bush administration. Under the plan, someone making $20,000 a year could get health coverage for about $19 a week.

Bush has long pushed health savings accounts as a way to slow the rising cost of medical care and extend basic coverage to the uninsured.

Under the Indiana program, eligible residents can pay up to 5 percent of their incomes into state-subsidized ''Personal Wellness and Responsibility Accounts'' that cover their initial medical expenses up to $1,100. Once that deductible is reached, private insurance purchased by the state kicks in.

Eligibility is limited to adults with incomes below twice the federal poverty level. The poverty level is now $10,210 for an individual and $20,650 for a family of four.

The waiver is the first of its kind for the Medicaid program, a state-federal partnership that provides health coverage to the poor and disabled.

Indiana officials said they've already received inquiries from more than 1,000 people interested in applying.

The program will be monitored closely because of the philosophical divide among lawmakers about the value of health savings accounts for the poor. Many say such accounts work best for healthier and higher-income people with low medical expenses.

Judith Solomon, senior fellow at the Center on Budget and Policy Priorities, said she doubts that many people making $10,000 a year can afford to pay $500 for health insurance. She said that about 50,000 people lost Medicaid coverage in Oregon after that state got permission to raise insurance premiums to $20 a month.

''You can say it's better than nothing, but I just don't see how many of those folks will be able to afford it,'' Solomon said.

Indiana has allocated up to $114 million for the program in 2008 after its legislature voted to raise state taxes on cigarettes from 55.5 cents to 99.5 cents a pack.

The state is encouraging employers to contribute to their workers' accounts. Any money left at the end of the year can be rolled over to offset the following year's contributions if the beneficiary obtains certain screenings and services that help prevent illness.

''This is a big step forward that will lead to approximately 120,000 uninsured Hoosiers having the peace of mind of health insurance,'' said Indiana Gov. Mitch Daniels, a Republican who once served as Bush's director of the Office of Management and Budget.

------

On the Net:

Healthy Indiana Plan: http://www.hip.in.gov

    Health Savings Accounts for Poor Tested, NYT, 15.12.2007, http://www.nytimes.com/aponline/us/AP-Health-Savings.html

CDC: Suicides Among Middle - Aged Spikes

December 13, 2007
Filed at 10:56 p.m. ET
By THE ASSOCIATED PRESS
The New York Times

ATLANTA (AP) -- The suicide rate among middle-aged Americans has reached its highest point in at least 25 years, a new government report said Thursday.

The rate rose by about 20 percent between 1999 and 2004 for U.S. residents ages 45 through 54 -- far outpacing increases among younger adults, the U.S. Centers for Disease Control and Prevention reported.

In 2004, there were 16.6 completed suicides per 100,000 people in that age group. That's the highest it's been since the CDC started tracking such rates, around 1980. The previous high was 16.5, in 1982.

Experts said they don't know why the suicide rates are rising so dramatically in that age group, but believe it is an unrecognized tragedy.

The general public and government prevention programs tend to focus on suicide among teenagers, and many suicide researchers concentrate on the elderly, said Mark Kaplan, a suicide researcher at Portland State University.

''The middle-aged are often overlooked. These statistics should serve as a wake-up call,'' Kaplan said.

Roughly 32,000 suicides occur each year -- a figure that's been holding relatively steady, according to the Suicide Prevention Action Network, an advocacy group.

Experts believe suicides are under-reported. But reported rates tend to be highest among those who are in their 40s and 50s and among those 85 and older, according to CDC data.

The female suicide rates are highest in middle age. The rate for males -- who account for the majority of suicides -- peak after retirement, said Dr. Alex Crosby, a CDC epidemiologist.

Researchers looked at death certificate information for 1999 through 2004. Overall, they found a 5.5 percent increase during that time in deaths from homicides, suicides, traffic collisions and other injury incidents.

The largest increases occurred in the 45 to 54 age group. A large portion of the jump in deaths in that group was attributed to unintentional drug overdoses and poisonings -- a problem the CDC reported previously.

But suicides were another major factor, accounting for a quarter of the injury deaths in that age group. The suicide count jumped from 5,081 to 6,906 in that time.

In contrast, the suicide rate for people in their 20s -- the other age group with the most dramatic increase in injury deaths -- rose only 1 percent.

------

On the Net:

Morbidity and Mortality Weekly Report: http://www.cdc.gov/mmwr 

    CDC: Suicides Among Middle - Aged Spikes, NYT, 13.12.2007, http://www.nytimes.com/aponline/us/AP-Suicide-Middle-Aged.htm

Teenage Birth Rate Rises for First Time Since ’91

December 6, 2007
The New York Times
By GARDINER HARRIS

WASHINGTON, Dec. 5 — The birth rate among teenagers 15 to 19 in the United States rose 3 percent in 2006, according to a report issued Wednesday, the first such increase since 1991. The finding surprised scholars and fueled a debate about whether the Bush administration’s abstinence-only sexual education efforts are working.

The federal government spends $176 million annually on such programs. But a landmark study recently failed to demonstrate that they have any effect on delaying sexual activity among teenagers, and some studies suggest that they may actually increase pregnancy rates.

“Spending tens of million of tax dollars each year on programs that hurt our children is bad medicine and bad public policy,” said Dr. David A. Grimes, vice president of Family Health International, a nonprofit reproductive health organization based in North Carolina.

Robert Rector, a senior research fellow with the Heritage Foundation, said that blaming abstinence-only programs was “stupid.” Mr. Rector said that most young women who became pregnant were highly educated about contraceptives but wanted to have babies.

President Bush noted the long decline in teenage pregnancy rates in his 2006 State of the Union address, saying, “Wise policies such as welfare reform, drug education and support for abstinence and adoption have made a difference in the character of our country.”

The White House did not respond to requests for comment Wednesday.

In a speech last year, Senator Hillary Rodham Clinton said that rates of teenage pregnancy declined during the Clinton administration because of a focus on family planning.

Teenage birth rates are driven by rates of sex, contraception and abortion. In the 1990s, teenage sex rates dropped and condom use rose because teenagers were scared of AIDS, said Dr. John S. Santelli, chairman of the department of population and family health at Columbia University.

But recent advances in AIDS treatments have lowered concerns about the disease, and AIDS education efforts, which emphasized abstinence and condom use, have flagged.

Perhaps as a result, teenage sex rates have risen since 2001 and condom use has dropped since 2003. Abortion rates have held steady for a decade, although numbers from 2005 and 2006 are not available.

Kristin A. Moore, a senior scholar at Child Trends, a nonprofit children’s research organization, said the increase in the teenage birth rate was particularly alarming because even the 2005 rate was far higher than that in other industrialized countries.

“It’s really quite disappointing because we weren’t close to reaching our goal,” Dr. Moore said.

The lone bright spot in Wednesday’s report, issued by the Centers for Disease Control and Prevention, was that the birth rate for girls 14 and under dropped to 0.6 percent per 1,000 from 0.7 percent. Birth rates rose 3 percent among teenagers ages 15 to 17 and 4 percent among those ages 18 and 19.

The largest increase came among black teenagers, but increases were also seen among whites, Hispanics and American Indians. Birth rates among Asian teenagers continued to drop.

Unmarried childbearing reached a record high in 2006, according to the disease control centers, with unmarried mothers now accounting for 38.5 percent of all births. Births among teenagers and unmarried women tend to lead to poor outcomes for their children.

Helping to prevent these pregnancies was the reason advocates pushed for the wide availability of the morning-after pill known as Plan B. The Food and Drug Administration approved sales of Plan B without a prescription in August 2006, too late to have any effect on that year’s birth rate.

Mr. Rector of the Heritage Foundation said that teenage and unmarried birth rates were driven by the same factors: young women with little education who are devoted to mothering but see no great need to be married.

“We should be telling them that for the well-being of any child, it’s critically important that you be over the age of 20 and that you be married,” he said. “That message is not given at all.”

Dr. Santelli of Columbia said that many abstinence-only educational efforts tended to emphasize that contraceptives often fail. “They scare kids about contraception,” he said.

The report also found that the Caesarean delivery rate continued its rise, increasing 3 percent in 2006 to 31.1 percent of all births, a record. In recent years, women who have had one birth by Caesarean have often been discouraged from having subsequent births vaginally. And there is some evidence that a growing number of women are requesting Caesareans to avoid pain or vaginal stretching.

The American College of Obstetricians and Gynecologists published a position paper last month stating that some Caesareans-upon-request should be discouraged. Women who have multiple Caesarean births are more likely to suffer uterine rupture and other serious consequences.

Dr. Robert Freeman, a professor of obstetrics and gynecology at the University of California, Irvine, said that managed-care companies no longer discouraged Caesareans and malpractice fears often led doctors to opt for Caesarean at the first hint of trouble.

“These numbers are bad news,” Dr. Freeman said, “and I think it’s only going to get worse.”

For the first time since 1971, the nation’s overall fertility rate rose past the replacement rate, increasing 2 percent in 2006 to 2,101 births per 1,000 women. Women of almost every age had more children last year than the year before, except girls under 15 and women over 45.

    Teenage Birth Rate Rises for First Time Since ’91, NYT, 6.12.2007, http://www.nytimes.com/2007/12/06/health/06birth.html?hp

Study Shows Why the Flu Likes Winter

December 5, 2007
The New York Times
By GINA KOLATA

Researchers in New York believe they have solved one of the great mysteries of the flu: Why does the infection spread primarily in the winter months?

The answer, they say, has to do with the virus itself. It is more stable and stays in the air longer when air is cold and dry, the exact conditions for much of the flu season.

“Influenza virus is more likely to be transmitted during winter on the way to the subway than in a warm room,” said Peter Palese, a flu researcher who is professor and chairman of the microbiology department at Mount Sinai School of Medicine in New York and the lead author of the flu study.

Dr. Palese published details of his findings in the Oct. 19 issue of PLoS Pathogens. The crucial hint that allowed him to do his study came from a paper published in the aftermath of the 1918 flu pandemic, when doctors were puzzling over why and how the virus had spread so quickly and been so deadly.

As long as flu has been recognized, people have asked, Why winter? The very name, “influenza,” is an Italian word that some historians proposed, originated in the mid-18th century as influenza di freddo, or “influence of the cold.”

Flu season in northern latitudes is from November to March, the coldest months. In southern latitudes, it is from May until September. In the tropics, there is not much flu at all and no real flu season.

There was no shortage of hypotheses. Some said flu came in winter because people are indoors; and children are in school, crowded together, getting the flu and passing it on to their families.

Others proposed a diminished immune response because people make less vitamin D or melatonin when days are shorter. Others pointed to the direction of air currents in the upper atmosphere. But many scientists were not convinced.

“We know one of the largest factors is kids in school — most of the major epidemics are traced to children,” said Dr. Jonathan McCullers, a flu researcher at St. Jude Children’s Research Hospital in Memphis. “But that still does not explain wintertime. We don’t see flu in September and October.”

As for the crowding argument, Dr. McCullers said, “That never made sense.” People work all year round and crowd into buses and subways and planes no matter what the season.

“We needed some actual data,” Dr. McCullers added.

But getting data was surprisingly difficult, Dr. Palese said.

The ideal study would expose people to the virus under different conditions and ask how likely they were to become infected. Such a study, Dr. Palese said, would not be permitted because there would be no benefit to the individuals.

There were no suitable test animals. Mice can be infected with the influenza virus but do not transmit it. Ferrets can be infected and transmit the virus, but they are somewhat large, they bite and they are expensive, so researchers would rather not work with them.

To his surprise, Dr. Palese stumbled upon a solution that appeared to be a good second best.

Reading a paper published in 1919 in the Journal of the American Medical Association on the flu epidemic at Camp Cody in New Mexico, he came upon a key passage: “It is interesting to note that very soon after the epidemic of influenza reached this camp, our laboratory guinea pigs began to die.” At first, the study’s authors wrote, they thought the animals had died from food poisoning. But, they continued, “a necropsy on a dead pig revealed unmistakable signs of pneumonia.”

Dr. Palese bought some guinea pigs and exposed them to the flu virus. Just as the paper suggested, they got the flu and spread it among themselves. So Dr. Palese and his colleagues began their experiments.

By varying air temperature and humidity in the guinea pigs’ quarters, they discovered that transmission was excellent at 41 degrees. It declined as the temperature rose until, by 86 degrees, the virus was not transmitted at all.

The virus was transmitted best at a low humidity, 20 percent, and not transmitted at all when the humidity reached 80 percent.

The animals also released viruses nearly two days longer at 41 degrees than at a typical room temperature of 68 degrees.

Flu viruses spread through the air, unlike cold viruses, Dr. Palese said, which primarily spread by direct contact when people touch surfaces that had been touched by someone with a cold or shake hands with someone who is infected, for example.

Flu viruses are more stable in cold air, and low humidity also helps the virus particles remain in the air. That is because the viruses float in the air in little respiratory droplets, Dr. Palese said. When the air is humid, those droplets pick up water, grow larger and fall to the ground.

But Dr. Palese does not suggest staying in a greenhouse all winter to avoid the flu. The best strategy, he says, is a flu shot.

It is unclear why infected animals released viruses for a longer time at lower temperatures. There was no difference in their immune response, but one possibility is that their upper airways are cooler, making the virus residing there more stable.

Flu researchers said they were delighted to get some solid data at last on flu seasonality.

“It was great work, and work that needed to be done,” said Dr. Terrence Tumpe, a senior microbiologist at the Centers for Disease Control and Prevention.

Dr. McCullers said he was pleased to see something convincing on the flu season question.

“It was a really interesting paper, the first really scientific approach, to answer a classic question that we’ve been debating for years and years,” he said.

As for Dr. Palese, he was glad he spotted the journal article that mentioned guinea pigs.

“Sometimes it pays to read the old literature,” he said.

    Study Shows Why the Flu Likes Winter, NYT, 5.12.2007, http://www.nytimes.com/2007/12/05/health/research/05flu.html?hp

Figures on H.I.V. Rate Expected to Rise

December 2, 2007
The New York Timles
By GARDINER HARRIS

WASHINGTON, Dec. 1 — More people in the United States are infected each year with the AIDS virus than previously thought, according to federal health officials, in a finding that could affect the debate over how much money should be spent on prevention efforts.

No one is yet sure whether more people have actually been infected in recent years or the figures, still undergoing peer review, are simply a better estimate than the old ones.

For 14 years, the Centers for Disease Control and Prevention used informal methods to estimate that about 40,000 people annually in the United States are newly infected with H.I.V. In recent years, federal officials have worked to set up a more accurate assessment technique.

The numbers from the new system are now in, although the agency has not released them.

The Washington Blade, a gay newspaper, reported on Nov. 14 that the new estimates showed infection rates were 50 percent higher than previously believed, with 58,000 to 63,000 infected in the most recent 12-month period. The Washington Post and The Wall Street Journal had similar reports on Saturday.

“We currently have a paper going through a scientific review process,” Tom Skinner, a C.D.C. spokesman, said Saturday, “and until that process is complete, we’re not in a position to say one way or another whether the numbers will actually be up from current estimates.”

A federal official who would not speak for attribution about the new numbers because of the review process said they were indeed higher than the old estimate, but not by as much as The Blade and The Post reported.

It has been clear for at least a year that the old estimate would have to be revised upward, said David R. Holtgrave of Johns Hopkins University, a former director of one of the C.D.C.’s principal AIDS prevention programs.

From 2001 to 2005, more than 186,000 people in 33 states received diagnoses of H.I.V. or AIDS, according to figures. That amounts to more than 37,000 new cases each year from just two-thirds of the country.

“With just a little simple math, you get more than 40,000 new cases,” Dr. Holtgrave said.

Whether the number of infections is higher than previously believed and whether infection rates are rising are both politically charged issues.

President Bush has increased financing for AIDS treatment and prevention programs abroad, but spending for domestic prevention efforts dropped 19 percent in inflation-adjusted terms from 2002 to 2007.

Julie Davids, executive director of the Community H.I.V./AIDS Mobilization Project, a national advocacy group, said it planned to protest Tuesday in front of the C.D.C. headquarters in Atlanta to demand that the agency release the new figures and step up prevention efforts. “We don’t know whether infection rates are rising or they’ve just been higher than we thought,” Ms. Davids said. “But either way, this shows that prevention efforts are insufficient.”

Doctors and states are required to report cases of full-blown AIDS, but only some states report positive results on tests for H.I.V. infection to the agency. It takes years for someone who is infected to develop symptoms; many people have been infected for years before they are tested.

Under the C.D.C.’s new surveillance system, 19 states and cities are performing two different blood tests of H.I.V. antibodies — the first indication of an infection. One test is highly sensitive and is able to spot an infection even in its earliest months. The other test is cruder, and patients must nurse an infection for many months before it can be identified with this test.

When a blood sample receives a positive result on the first test and a negative result on the second, officials have decided that this person was probably infected recently. By adding up these mixed results and projecting them across the country, the agency is able to come up with an estimate for new infections.

The agency sent out a letter to scientists on Nov. 26 describing the new system and urging patience as the numbers are reviewed.

Donald G. McNeil Jr. contributed reporting from New York.

    Figures on H.I.V. Rate Expected to Rise, NYT, 2.12.2007, http://www.nytimes.com/2007/12/02/health/02aids.html

Biologist Seymour Benzer Dies at 86

December 1, 2007
Filed at 4:56 a.m. ET
By THE ASSOCIATED PRESS
The New York Times

LOS ANGELES (AP) -- Seymour Benzer, a groundbreaking biologist whose work linking behavior and genes laid the foundation for modern neuroscience, has died. He was 86.

Benzer died of a stroke Friday morning at Huntington Hospital in Pasadena, said Jill Perry, a spokeswoman for the California Institute of Technology, where Benzer was professor emeritus.

''Seymour was one of the great scientists of our era,'' Elliot Meyerowitz, chairman of Caltech's biology department, said in a statement. ''He was an amazing person, a truly original scientific thinker, and an adventurous character both in and out of his scientific work.''

Benzer's research in the 1960s countered the common belief that human behavior was shaped primarily by environment, giving genes a far bigger role than they were previously assigned.

''The impact is opening up the whole idea that behavior can be dissected by manipulation, studying the genes,'' Benzer told The Associated Press last year. ''It's an entire cycle. Every step of the way is under genetic control.''

His research led to major discoveries in the exploration of diseases like Alzheimer's and Parkinson's.

In April 2006, Benzer was awarded the nation's richest prize in medicine and biomedical research, the $500,000 Albany Medical Center prize.

He ''paved the way for scientists to uncover links between genes and human behavior which have resulted in our improved ability to treat diseases of the brain and central nervous system,'' James J. Barba, president and chief executive officer of Albany Medical Center, which gave Benzer the prize, said at the time.

In perhaps his most well-known work, Benzer manipulated the gene mutations of fruit flies in the late 1960s.

In one study, Benzer and a student corrected the sleep patterns of the flies by injecting them with genes from other fruit flies.

That and related work essentially led to the new field of neurogenetics, and many of his colleagues believe it ought to have won him a Nobel Prize, one of the few awards that eluded him.

''He was a giant in science,'' David Anderson, Caltech biology professor and an investigator at the Howard Hughes Medical Institute, said in a statement. ''He started an entire field, and few people can claim to have done that.''

Benzer was still working late in his life. As recently as the late 1990s, he and colleagues discovered a gene that let fruit flies live longer and resist heat, starvation and even poison.

Flies with this gene, dubbed the ''Methuselah'' after the long-lived man in the Bible, lived an average of 35 percent longer than those without it, Benzer, Yi-Juan Lin and Laurent Seroude said in an article in the journal Science.

Benzer received more than 40 major awards, including the Albert Lasker Award for Basic Medical Research, the National Medal of Science and the Peter Gruber Award for Neuroscience.

In 2000, he was the subject of the book ''Time, Love, Memory: A Great Biologist and His Quest for the Origins of Behavior,'' by Jonathan Weiner.

Benzer grew up in New York City, graduated from Brooklyn College and received his master's and Ph.D. degrees in physics from Purdue University.

He became interested in neurogenetics after the birth of his second daughter, who he said behaved radically differently from his first.

Benzer is survived by wife Carol Miller, daughters Barbara Freidin and Martha Goldberg, son Alexander Benzer, stepsons Renny and Douglas Feldman, and four grandchildren.

Biologist Seymour Benzer Dies at 86, NYT, 1.12.2007, http://www.nytimes.com/aponline/us/AP-Obit-Benzer.html