History > 2009 > USA > Health (IV)

Illustration: Michael Schmellin

Overseas, Under the Knife

NYT

9.6.2009

http://www.nytimes.com/2009/06/10/opinion/10milstein.html

Grant System

Leads Cancer Researchers

to Play It Safe

June 28, 2009
The New York Times
By GINA KOLATA

Among the recent research grants awarded by the National Cancer Institute is one for a study asking whether people who are especially responsive to good-tasting food have the most difficulty staying on a diet. Another study will assess a Web-based program that encourages families to choose more healthful foods.

Many other grants involve biological research unlikely to break new ground. For example, one project asks whether a laboratory discovery involving colon cancer also applies to breast cancer. But even if it does apply, there is no treatment yet that exploits it.

The cancer institute has spent $105 billion since President Richard M. Nixon declared war on the disease in 1971. The American Cancer Society, the largest private financer of cancer research, has spent about $3.4 billion on research grants since 1946.

Yet the fight against cancer is going slower than most had hoped, with only small changes in the death rate in the almost 40 years since it began.

One major impediment, scientists agree, is the grant system itself. It has become a sort of jobs program, a way to keep research laboratories going year after year with the understanding that the focus will be on small projects unlikely to take significant steps toward curing cancer.

“These grants are not silly, but they are only likely to produce incremental progress,” said Dr. Robert C. Young, chancellor at Fox Chase Cancer Center in Philadelphia and chairman of the Board of Scientific Advisors, an independent group that makes recommendations to the cancer institute.

The institute’s reviewers choose such projects because, with too little money to finance most proposals, they are timid about taking chances on ones that might not succeed. The problem, Dr. Young and others say, is that projects that could make a major difference in cancer prevention and treatment are all too often crowded out because they are too uncertain. In fact, it has become lore among cancer researchers that some game-changing discoveries involved projects deemed too unlikely to succeed and were therefore denied federal grants, forcing researchers to struggle mightily to continue.

Take one transformative drug, for breast cancer. It was based on a discovery by Dr. Dennis Slamon of the University of California, Los Angeles, that very aggressive breast cancers often have multiple copies of a particular protein, HER-2. That led to the development of herceptin, which blocks HER-2.

Now women with excess HER-2 proteins, who once had the worst breast cancer prognoses, have prognoses that are among the best. But when Dr. Slamon wanted to start this research, his grant was turned down. He succeeded only after the grateful wife of a patient helped him get money from Revlon, the cosmetics company.

Yet studies like the one on tasty food are financed. That study, which received a grant of $100,000 over two years, is based on the idea that since obesity is associated with an increased risk of cancer, understanding why people have trouble losing weight could lead to better weight control methods, which could lead to less obesity, which could lead to less cancer.

“It was the first grant I ever submitted, and it was funded on the first try,” said the principal investigator, Bradley M. Appelhans, an assistant professor of basic medical sciences and psychology at the University of Arizona. Dr. Appelhans said he realized it would hardly cure cancer, but hoped that “it will provide knowledge that will incrementally contribute to more effective cancer prevention strategies.”

Even top federal cancer officials say the system needs to be changed.

“We have a system that works over all pretty well, and is very good at ruling out bad things — we don’t fund bad research,” said Dr. Raynard S. Kington, acting director of the National Institutes of Health, which includes the cancer institute. “But given that, we also recognize that the system probably provides disincentives to funding really transformative research.”

The private American Cancer Society follows a similarly cautious path. Last year, it awarded $124 million in new research grants, with some money coming from large donors but most from events like walkathons and memorial donations.

Dr. Otis W. Brawley, chief medical officer at the cancer society, said the whole cancer research effort remained too cautious.

“The problem in science is that the way you get ahead is by staying within narrow parameters and doing what other people are doing,” Dr. Brawley said. “No one wants to fund wild new ideas.”

He added that the problem of getting money for imaginative but chancy proposals had worsened in recent years. There are more scientists seeking grants — they surged into the field in the 1990s when the National Institutes of Health budget doubled before plunging again.

That makes many researchers, who need grants not just to run their labs but also sometimes to keep their faculty positions, even more cautious in the grant proposals they submit. And grant review committees become more wary about giving scarce money to speculative proposals.

Philanthropies, which helped some researchers try outside-the-box ideas, are now having financial problems. And advances in technology have made research more expensive.

“Scientists don’t like talking about it publicly,” because they worry that their remarks will be viewed as lashing out at the health institutes, which supports them, said Dr. Richard D. Klausner, a former director of the National Cancer Institute.

But, Dr. Klausner added: “There is no conversation that I have ever had about the grant system that doesn’t have an incredible sense of consensus that it is not working. That is a terrible wasted opportunity for the scientists, patients, the nation and the world.”

A Big Idea Without a Backer

For 25 years, Eileen K. Jaffe received federal grants to run her lab. As a senior scientist at the Fox Chase Cancer Center, with a long list of published papers in prestigious journals, she is a respected, established researcher.

Then Dr. Jaffe stumbled upon results that went against textbook explanations, suggesting that it might be possible to find an entirely new class of drugs that could disable proteins that fuel cancer cells. Now she wants to find chemicals that might be developed into such drugs.

But her grant proposal was rejected out of hand by the institutes of health, not even discussed by a review panel. She had no preliminary data showing that the idea was likely to work, something reviewers always want to see, and the idea was just too unprecedented.

Dr. Jaffe epitomizes the scientist who realizes that if she were to single-mindedly pursue her unorthodox idea, her “career may be ruined in the process,” in the words of Dr. Brawley of the American Cancer Society.

Dr. Jaffe is just conceiving her project; it is much to soon to know whether it will result in a revolutionary drug. And even if she does find potential new drugs, it is not clear that they will be effective. Most new ideas are difficult to prove, and most potential new drugs fail.

So Dr. Jaffe was not entirely surprised when her grant application to look for such cancer drugs was summarily rejected.

“They said I don’t have preliminary results,” she said. “Of course I don’t. I need the grant money to get them.”

Dr. Young, chancellor at Fox Chase, said Dr. Jaffe’s situation showed why people with bold new ideas often just give up.

“You can’t prove it will work in advance,” he said. “If you could, it wouldn’t be a high-risk idea.”

It is a long haul, Dr. Jaffe knows. And she has already had to downsize her lab. But, she said, she will persist.

Angels Outside Government

At the Dana-Farber Cancer Institute in Boston, Dr. Ewa T. Sicinska knew she would have a similar problem with her research. She wanted to grow human cancers in mice. Unlike Dr. Jaffe, though, Dr. Sicinska did not even apply for government money.

It is not that the project was unimportant.

“Rather than have to start a human clinical trial to test new drugs, we want to test them first in mice with real human tumors,” said Dr. George D. Demetri, who leads the research group supporting Dr. Sicinska.

Researchers have studied mouse cancers but, they acknowledge, they are just not the same as human cancers — they are much easier to treat, and drugs that cure mice often do nothing in people. So, over the years, scientists have tried to implant human cancer cells in mice, but with little success.

“Everyone told us that if you take tumors out of patients and put them in mice, they don’t grow,” Dr. Demetri said. The tumor cells usually were put in a plastic dish before being implanted in mice. “We said — wait a minute. The cells are not growing in the plastic dish. They probably are dying. What if we bypass the dish?’”

With that idea in mind, Dr. Demetri, convinced it was too speculative to get federal money, tapped an unusual source, the Ludwig Fund. Endowed by Daniel K. Ludwig, one of the world’s richest men in the 1960s and 1970s, the fund supports unfettered cancer research at six medical centers in the United States, including Dana-Farber, to be used at the institutes’ discretion. That put Dr. Sicinska in a very different position from that of Dr. Jaffe. She could try something chancy without a grant.

Dr. Sicinska used a quarter of a million dollars of Ludwig money for this project, buying mice without immune systems, which meant they could not reject human tumors, and housing them in a germ-free basement lab. She spent months learning to implant tumors in the mice and enlisted geneticists to study the implanted tumors, making sure they did not mutate beyond recognition.

She spends her days in the lab, using a miniature ultrasound machine to scan the mice, hairless creatures with prominent ears. Four types of sarcomas — cancers of fat, muscle or bone — are growing in them and look genetically identical to the tumors removed from patients.

Dr. Elias A. Zerhouni, former director of the National Institutes of Health, said he was not sure that a grant for the project would have been turned down. The N.I.H., he said, does finance research on mouse models for human cancer.

But Dr. Demetri said he did not apply “because we have lots of experience in what’s fundable.” His mouse work, he said, is exploratory, and he cannot predict what he will find or when. He certainly could not lay out a road map of what he would do and promise results in a few years.

Studies With a Different Goal

Researchers like Dr. Appelhans, who is studying weight control and tasty foods, do not expect to change the outlook for cancer patients anytime soon. But, they say, that does not mean their work is unimportant.

Dr. Appelhans will study 85 overweight or obese women, measuring how much the tastes and textures of food drive their eating. Then they will be given a weight loss diet and nutritional counseling. Dr. Appelhans will ask whether those who are most tempted by the tastes and textures also have the most trouble following the diet.

As for the grant to assess a Web-based program to improve food choices, it is predicated on studies indicating that what people eat in childhood and adolescence may have an impact on cancer risk in middle and old age, said the grant recipient, Karen Weber Cullen, associate professor of pediatrics at Baylor College of Medicine. Some studies have found that people who reported having eaten fruits and vegetables when they were younger and maintaining a healthy weight were less likely to have cancer.

Of course, it would not be feasible to follow participants for 30 or 40 years to see if their cancer risk was altered, Dr. Cullen noted. But, she added, “we try to achieve improvements in diet and physical activity behaviors that become permanent and will make a difference in later years.”

In the study asking whether a molecular pathway that spurs the growth of colon cancer cells also encourages the growth of breast cancer cells, the principal investigator ultimately wants to find a safe drug to prevent breast cancer. She received a typical-size grant of a little more than $1 million for the five-year study.

The plan, said the investigator, Louise R. Howe, an associate research professor at Weill Cornell Medical College, is first to confirm her hypothesis about the pathway in breast cancer cells. But even if it is correct, the much harder research would lie ahead because no drugs exist to block the pathway, and even if they did, there are no assurances that they would be safe.

Dr. Howe said she hoped that she would find such drugs, or that companies would. Then she wants to develop a way to selectively deliver the drugs to precancerous breast cells. If it all works and the treatment is safe, women with precancerous conditions could avoid developing cancer.

Dr. Howe has reviewed grants for the cancer institute herself, she said, and realizes that, among other things, those that get financed must have “a novel hypothesis that is credible based on what we know already.”

Trying to Change the System

The National Institutes of Health has started “pilot experiments” to see if there is a better way of getting financing for innovative projects, its acting director, Dr. Kington, said.

They include “pioneer awards,” begun in 2004 for “ideas that have the potential for high impact but may be too novel, span too diverse a range of disciplines or be at a stage too early to fare well in the traditional peer review process.” But only 3 percent to 5 percent of the applicants get funded. Now the institutes have decided to set aside up to $25 million for “transformative R01 grants,” described as “proposing exceptionally innovative, high risk, original and/or unconventional research with the potential to create or overturn fundamental paradigms.”

About 700 proposals have come in, but only a small number are expected to be financed, according to Dr. Keith R. Yamamoto, a molecular biologist and executive vice dean of the school of medicine at the University of California, San Francisco, and co-chairman of the committee that reviewed the proposals last week.

“From reading the applications so far, there are really some fantastic things,” Dr. Yamamoto said.

There also is new money from the federal economic stimulus package passed by Congress, which gives the National Institutes of Health $200 million for “challenge grants” lasting two years or less.

But the N.I.H. has received about 21,000 applications for 200 challenge grants, and researchers who have applied concede there is not much hope.

“I did submit one of these challenge grants recently, like the rest of the lemmings,” said Dr. Chi Dang, professor of medicine, cell biology, oncology and pathology at the Johns Hopkins University School of Medicine. But, he added, “there are many, many more applications than slots.”

Some experienced scientists have found a way to offset the problem somewhat. They do chancy experiments by siphoning money from their grants.

“In a way, the system is encrypted,” Dr. Yamamoto said, allowing those in the know to wink and do their own thing on the side.

Great discoveries have been made with N.I.H. financing without manipulating the system, Dr. Klausner said.

“But,” he added, “I actually believe that by and large it is despite, rather than because of, the review system.”

    Grant System Leads Cancer Researchers to Play It Safe, NYT, 28.6.2009, http://www.nytimes.com/2009/06/28/health/research/28cancer.html

Swine Flu Cases in the U.S.

Pass a Million, Officials Say

June 27, 2009
The New York Times
By DONALD G. McNEIL Jr.

Swine flu has infected more than a million Americans, federal health officials said Friday, and is infecting thousands more every week even though the annual flu season is well over.

That total of those who have already been infected is “just a ballpark figure,” said Dr. Anne Schuchat, director of respiratory diseases at the Centers for Disease Control and Prevention, adding, “We know we’re not tracking every single one of them.”

Only a tiny fraction of those million cases have been tested, Dr. Schuchat said. The estimate is based on testing plus telephone surveys in New York City and several other locales where the new flu has hit hard.

A survey in New York City, she said, showed that almost 7 percent of those called had had flu symptoms during just three weeks in May when the flu was spreading rapidly through schools. If that percentage of the city has had it, then there have been more than 500,000 cases in the city alone, though most have been mild enough that doctors recommended nothing more than rest and fluids.

The flu has now spread to many areas of the country, Dr. Schuchat noted, and the C.D.C. has heard of outbreaks in 34 summer camps in 16 states.

About 3,000 Americans have been hospitalized, she said, and their median age is quite young, just 19. Of those, 127 have died.

The median age for deaths is somewhat higher, at 37, but that number is pushed up because while only a few elderly people catch the new flu, about 2 percent of them die as a result.

Of those who die, Dr. Schuchat said, about three-quarters have some underlying condition like morbid obesity, pregnancy, asthma, diabetes or immune system problems. Even those victims, she said, “tend to be relatively young, and I don’t think that they were thinking of themselves as ready to die.”

The new flu has now reached more than 100 countries, according to the World Health Organization. The world’s eyes are on the Southern Hemisphere, which is at the beginning of its winter, when flu spreads more rapidly. Australia, Chile and Argentina are seeing a fast spread of the virus, mostly among young people, while one of the usual seasonal flus, an H3N2, is also active.

Five American vaccine companies are working on a swine flu vaccine, Dr. Schuchat said. The C.D.C. has estimated that once the new vaccine is tested for both safety and effectiveness, no more than 60 million doses will be available by September. That means difficult decisions will have to be made about whom to give it to first.

    Swine Flu Cases in the U.S. Pass a Million, Officials Say, NYT, 27.6.2009, http://www.nytimes.com/2009/06/27/health/27flu.html?hp

Mind

Where Can the Doctor Who’s Guided

All the Others Go for Help?

June 23, 2009
The New York Times
By ELISSA ELY, M.D.

Psychiatry is a relatively safe profession, but it has a hazard that is not apparent at first glance: if you are in it long enough, there may be no one to talk to about your own problems.

It is not that way when you start out. Most psychiatric residents spend a good deal of time in therapy with a senior psychiatrist, for a number of reasons — not least, that it is the most intimate way to learn technical magic. Books teach the same thing to everyone who reads them. But no one forgets the crystalline remark their therapist made just to them, and how they viewed themselves differently ever after.

At a certain point, though, you stop being the student and become the teacher. You settle into the details of a career — hospital, research, private practice. Roots go down, time passes. Eventually, younger psychiatrists begin to approach you. Now you are the generation above, saving early-morning slots for residents before they head off to clinic and class. You lower fees and accommodate their hurtling, insane schedules. You remember how it was.

But no amount of wisdom prevents personal frailty. You are never too old for your own problems. Yet when you are the professional others go to, where do you bring your sorrows and secret pain?

Sometimes the situation is clear. During my training there was a formidable psychiatrist who disappeared periodically. Everyone knew she was being hospitalized for a recurrent manic psychosis, and that she would be back to intimidate the trainees as soon as medications had stabilized her.

There was an oddness about it, but no dishonor. Actually, her illness made her more impressive. We are taught to explain that mental illness has a biological component responsive to medical treatment, just like diabetes or heart disease. Her example brought conviction to our tone.

In my residency, I moonlighted in a medication clinic where an elderly psychiatrist was being treated for a dementia he did not recognize. He could not remember simple requests, raised his cane to strangers, screamed at family members; his wife met with me separately and told me she was ready to leave him.

Carefully writing “Dr.” on the top line of each of his prescriptions, I felt undersized and overregarded. Yet he took the pills without question and showed a fatherly interest in my career. Years later, I thought maybe his wife had chosen a student deliberately. My junior status allowed him to maintain his senior status.

Often, though, the situation is not straightforward, and medication is not the problem. Life is. Maybe we are overcome, maybe ashamed, maybe despairing. Self-revelation — the nakedness necessary in therapy — is hard when you have been a model to others.

“In my situation, it would be difficult to find someone,” Dr. Dan Buie, a beloved senior analyst in Boston, told me. It is not that psychiatrists aren’t waiting in wing chairs all over the city. It is that so many of them are former students and former patients. One generation of psychiatrists grows the next through teaching and treatment.

Surrendering that professional identity to become a patient reverses a kind of natural order. “You can’t be a simple patient,” Dr. Buie said. “Anyone I’d go to, I’ve known.” To avoid it, some travel to other cities for therapy (probably passing colleagues in trains heading in the other direction).

There is also the factor of experience. It is one thing if my internist is younger than I; she is closer to the bones of medicine, and with any luck we can get to know each other for years before serious illness requires more intimate contact. It is another thing if my therapist is younger than I.

“It would be a big mistake not to turn to someone,” Dr. Buie went on, “but I might have some trouble going to younger colleagues. It’s hard to understand the issues that come up in the course of a life cycle unless you’ve lived it yourself.”

Dr. Rachel Seidel, a psychoanalyst and psychiatrist in Cambridge, said that when people feel vulnerable, “we want someone with more insight than we have.”

“It’s a paradox,” she added. “Do I have to have gone through what you’ve gone through in order to be empathic to you? And yet, I’d have a preference for someone who’s been around longer.”

Some look laterally for help. Peer supervision is a well-known form of risk management; presenting troubling professional cases to colleagues prevents folly and mistakes at any age.

“I use a couple of peers,” said Dr. Thomas Gutheil, professor of psychiatry at Harvard Medical School. “Then they use me. It’s the reciprocity that’s key — you feel the comfort of telling everything about yourself when you know the reverse is also true.”

Other solutions are even closer. The playwright Edward Albee once wrote that it can be necessary to travel a long distance out of the way in order to come back a short distance correctly. The best source of help can be the nearest source of all. An elderly luminary at the Boston Psychoanalytic Society and Institute listened without comment when asked: Whom does he — the doctor others seek out for help — seek out for help himself? He wasted no words.

“My wife,” he said crisply.

 

Elissa Ely is a psychiatrist in Boston.

    Where Can the Doctor Who’s Guided All the Others Go for Help?, NYT, 23.6.2009, http://www.nytimes.com/2009/06/23/health/23mind.html

Obama Announces

Agreement With Drug Companies

June 22, 2009
Filed at 1:04 p.m. ET
By THE ASSOCIATED PRESS
The New York Times

WASHINGTON (AP) -- President Barack Obama on Monday welcomed the pharmaceutical industry's agreement to help close a gap in Medicare's drug coverage, calling the pact a step forward in the push for overhaul of the nation's health care system.

Obama said that drug companies have pledged to spend $80 billion over the next decade to help reduce the cost of drugs for seniors and pay for a portion of Obama's health care legislation. The agreement with the pharmaceutical industry would help close a gap in prescription drug coverage under Medicare.

''This is a significant breakthrough on the road to health care reform, one that will make a difference in the lives of many older Americans,'' Obama said in the White House's Diplomatic Room.

He was joined by Sen. Max Baucus, D-Mont., the chairman of the Senate Finance Committee who struck the deal with the White House; Sen. Chris Dodd, D-Conn., and Barry Rand, head of the senior citizens' advocacy group AARP. Notably absent was a representative from the pharmaceutical association.

''It was always designed to be an AARP event,'' said Ken Johnson, spokesman for the association. ''We don't think we should have been invited to it.''

Johnson said Billy Tauzin, the group's president and a former Republican congressman from Louisiana, will attend a town hall meeting on health care that Obama is staging at the White House on Wednesday.

Johnson said there are other parts to the agreement that have still not been completed, but he declined to provide details.

''There are a lot of discussions going on right now, there are a lot of moving pieces, there are a lot of elements to it that have not been finalized,'' Johnson said.

The president used the opportunity to make his sternest call yet for action, saying the drug agreement is one piece of ''health care reform I expect Congress to enact this year.''

Obama said the move on Medicare will help correct an anomaly in the program that provides a prescription drug benefit through the government health care program for the elderly and disabled. Under the deal, drug companies will pay part of the cost of brand name drugs for lower and middle-income older people in the so-called ''doughnut hole.'' That term refers to a feature of the current drug program that requires beneficiaries to pay the entire cost of prescriptions after initial coverage is exhausted but before catastrophic coverage begins.

Obama said some Medicare beneficiaries will find at least a 50 percent discount on prescription drugs. Obama says drug companies stand to benefit when more Americans can afford prescription drugs.

The drug companies' investment would reduce the cost of drugs for seniors and pay for a portion of Obama's proposed revamping of health care.

''This is an early win for reform,'' Rand said.

Under the agreement, part of the $80 billion would be used to halve the cost of brand name drugs for Medicare recipients when they are in a coverage gap of the program. AARP, which represents 40 million older Americans, has long lobbied to eliminate that coverage gap completely.

The deal would affect about 26 million low- and middle-income recipients of the program's enrollees, AARP said. It would apply to brand name and biologic drugs, but not generics, the group said, and likely take effect in July 2010, assuming drug overhaul legislation becomes law.

Under Medicare's Part D prescription drug program, recipients pay about 25 percent of the cost of their drugs until they and the government have paid $2,700.

At that point, beneficiaries must cover the full cost of drugs until they have spent $4,350 from their own pockets. When they reach that amount, Medicare's catastrophic drug benefit takes effect, and recipients only pay 5 percent of their drugs' costs until the end of the year.

--------

Associated Press Writer Alan Fram contributed to this report.

    Obama Announces Agreement With Drug Companies, NYT, 22.6.2009, http://www.nytimes.com/aponline/2009/06/22/us/politics/AP-US-Obama-Drugs.html

Editorial

A Public Health Plan

June 21, 2009
The New York Times
 

As the debate on health care reform unfolds, no issue has caused such partisan rancor — and spawned such misleading rhetoric — as whether to create a new public insurance plan to compete with private plans.

The nation already has several huge public plans, including Medicare for the elderly (once reviled by conservatives, it is now only short of the flag in its popularity) and Medicaid for the poor.

Now the issue is whether to establish a new public plan to encourage more competition among health insurers and provide Americans with an alternative.

Most Democrats and some Republicans have already accepted the need to create one or more health insurance exchanges where individuals without group coverage and possibly small businesses could buy insurance policies. Some proponents hope that big businesses could enroll their workers as well.

An exchange would give the government (federal or state) a lot more power over insurers that choose to participate in order to tap a vast new market of previously uninsured people. It would determine the range of benefits that all participating plans would have to offer. It would presumably require those plans to accept all applicants, regardless of “pre-existing conditions.”

What Republicans are adamantly opposed to is the idea of adding a public plan to that exchange. They portray it as a “government takeover” of the health care system, or even as socialized medicine. Those are egregious mischaracterizations.

There is no serious consideration in Congress of a single-payer governmental program that would enroll virtually everyone. Nor is there any talk of extending the veterans health care system, a stellar example of “socialized medicine,” to the general public.

The debate is really over whether to open the door a crack for a new public plan to compete with the private plans. Most Democrats see this as an important element in any health care reform, and so do we.

A public plan would have lower administrative expenses than private plans, no need to generate big profits, and stronger bargaining power to obtain discounts from providers. That should enable it to charge lower premiums than many private plans.

It would also provide an alternative for individuals who either can’t get adequate insurance from private insurers or don’t trust the private insurance industry to treat them fairly. And it could serve as a yardstick for comparing the performance of private plans and for testing innovative coverage schemes.

Unfortunately, many Senate Democrats are so desperate to find a political compromise with Republicans — or so bullied by the rhetoric — that they are in danger of gravely weakening a public plan, or eliminating it entirely. That would be a mistake.

Here is a look at the main proposals now under consideration:

THE MOST ROBUST This approach, favored by many analysts, would allow the new public plan to piggy-back on the rate-setting powers of Medicare. As a result, it is the one most feared by Republicans, the insurance industry and doctors and hospitals. Any doctors who wanted to participate in Medicare, as virtually all do, would also have to participate in this plan and would have to accept the same payment rates as Medicare provides.

With lower costs, it would be cheaper for consumers, charging its members premiums as much as 20 to 30 percent lower than premiums for comparable private coverage, a boon to hard-pressed families.

It would also shave hundreds of billions of dollars from the amount needed to cover the uninsured — a crucial advantage as Congress scrambles to finance the reform effort.

The risk is that if this plan, given its power, were too stingy, it might drive some financially stressed hospitals into bankruptcy. The hope is that the downward pressure on reimbursements might force them to innovate and find big savings.

Republicans and private insurers fear, with some reason, that such an inexpensive public plan would entice or drive tens of millions of Americans away from private insurance, especially if big employers were allowed to enroll their workers in an exchange. The challenge is to craft rules to discourage employers from simply dropping their own subsidies entirely.

The prospect of competing with a government plan terrifies the private insurers. But in our judgment, if that many Americans were to decide that such a plan is a better deal for them and their families, that would be a good thing. Innovative private plans that already deliver better services at lower costs would survive. Inefficient private plans would wither.

In an effort to address some of these fears, Senator Jay Rockefeller has introduced a bill that would use Medicare provider payment rates for only the first two years and let doctors opt out after three years while remaining in Medicare. That would get the new public plan off to a good start, after which it would compete on its own.

LIGHTER VERSIONS Other proposals are circulating that would level the playing field with private plans. They would require the public plan to hold the same reserves as private plans and sustain itself from premium income without drawing on the federal treasury. It would probably pay providers higher rates than Medicare but lower rates than most private plans. Its administrative costs would be far lower, allowing it to offer lower premiums. These more modest versions could be worth having, but they would save individuals and the health care system far less money.

STATE-BASED PLANS A bipartisan group, led by three former Senate leaders — Republicans Bob Dole and Howard Baker and Democrat Tom Daschle — has proposed leaving it to states to create public plans if they wish. The federal government would be able to step in after five years if a state has failed to establish an exchange with affordable insurance options. That looks like a formula for delay and inaction.

COOPERATIVES Propelled by a belief that no public plan could survive a Republican filibuster, Senator Kent Conrad, Democrat of North Dakota, has proposed instead setting up private nonprofit cooperatives — run for the benefit of their members rather than stockholders — to compete with profit making insurance plans.

The presumed advantage of this approach is that cooperatives might be able to charge lower premiums because they would not have to earn large profits. Their performance, too, would be a yardstick against which to measure whether profit making plans are charging fair premiums.

Health care cooperatives have existed at the local or regional level for decades in this country. Many have gone belly up. A few still provide high quality care at reasonable prices. Given sufficient size, seed money and negotiating power, a cooperative organization could help transform the health care system. But Republicans seem unlikely to accept a strong national organization, so creation of cooperatives is apt to be local and spotty. They would be unlikely to deliver as much savings as a large public plan.

TIGHT REGULATION Right from the start of the debate, some experts have suggested that much tighter regulation of the new insurance exchange could achieve many of the goals of a public plan.

Regulators could insist that insurers not exclude people with pre-existing conditions or charge them higher premiums. The exchange could offer customers a menu of private plans and be modeled on the federal program that serves Congress and other government personnel. Several European countries, including Germany, provide better health care at lower cost than the United States without relying on a public plan. And the near-universal coverage in Massachusetts was achieved without a public plan option.

We continue to believe that a public plan would be desirable. Surveys by the Commonwealth Fund have found that Medicare beneficiaries report fewer problems obtaining medical care, less financial hardship due to medical bills, and higher satisfaction with their coverage than do workers insured by private employers.

If Senate Republicans block a public plan, much tighter regulation will be essential to guarantee affordable private coverage for millions of Americans.

    A Public Health Plan, NYT, 21.6.2009, http://www.nytimes.com/2009/06/21/opinion/21sun1.html

House Unveils Health Bill,

Minus Key Details

June 20, 2009
The New York Times
By ROBERT PEAR
and DAVID M. HERSZENHORN

WASHINGTON — House Democrats on Friday answered President Obama’s call for a sweeping overhaul of the health care system, unveiling a bill that they said would cover 95 percent of Americans. But they said they did not know how much it would cost and had not decided how to pay for it.

The proposal would establish a new public health insurance plan to compete with private plans. Republicans and insurance companies strenuously oppose such an entity, saying it could lead to a government takeover of health care. The draft bill would require all Americans to carry health insurance. Most employers would have to provide coverage to employees or pay a fee equivalent to 8 percent of their payroll. The plan would also end many insurance company practices that deny coverage or charge higher premiums to sick people.

“Health insurance for most American families is just one big surprise,” said Representative George Miller of California, the chairman of the Education and Labor Committee. “When you go to use it, you find out it’s not quite as it’s represented, and you spend hours on the phone with exclusions and discussions and referrals to other legal documents that you didn’t have at the time you purchased it.”

The 852-page House bill, as expected, is more expansive than the legislation taking shape in the Senate, where work on the issue bogged down this week after early cost estimates came in far higher than expected. The initial price tag for a measure drafted by the Senate Finance Committee, for example, was $1.6 trillion over 10 years.

Similar sticker shock could hit House members when they see the cost of their bill, which incorporates many ideas from health policy experts about how to fix the health system.

Industry critics of the emerging Senate bill are likely to have even more objections to the House version, but House Democratic leaders can probably push their measure through on a party-line vote.

Under the House bill, health insurance would be regulated by a powerful new federal agency, headed by a presidential appointee known as the health choices commissioner.

The draft bill was unveiled by three committee chairmen — Mr. Miller; Henry A. Waxman of California, chairman of the Energy and Commerce Committee; and Charles B. Rangel of New York, chairman of the Ways and Means Committee. The chairmen, all first elected in the 1970s, have worked together in secret for months to develop a single bill.

The proposal would expand Medicaid eligibility, increase Medicaid payments to primary care doctors and gradually close a gap in Medicare coverage of prescription drugs known as a doughnut hole. The bill would also reverse deep cuts in Medicare payments to doctors scheduled to occur in the next five years. Taken together, these provisions could significantly drive up the bill’s cost.

The bill would impose a new “tax on individuals without acceptable health care coverage.” The tax would be based on a person’s income and could not exceed the average cost of a basic health insurance policy. People could be exempted from the tax “in cases of hardship.”

Asked why there was no cost estimate for the bill, the House Democratic leader, Steny H. Hoyer of Maryland, said: “Until we have a final product, we are reluctant to ask the Congressional Budget Office for a score. But whatever we do will be fully paid for.”

House Democrats pledged to offset the cost of their legislation by reducing the growth of Medicare and imposing new, unspecified taxes.

Republicans, who had no role in developing the bill, denounced it as a blueprint for a vast increase in federal power and spending.

“Families and small businesses who are already footing the bill for Washington’s reckless spending binge will not support it,” said the House Republican leader, John A. Boehner of Ohio, who raised the specter of federal bureaucrats’ making medical decisions for millions of people.

Business groups also were not pleased. “There is enough to see here already to know that we would be compelled to oppose this bill,” said E. Neil Trautwein, a vice president of the National Retail Federation.

But John J. Sweeney, president of the A.F.L.-C.I.O., praised the House bill, saying it provided “a road map for what health care reform should look like.”

The House chairmen described their bill as a starting point in a battle that would dominate Congress this summer and ultimately involve the full range of interest groups in Washington. The three House committees plan to hold as many as six hearings on the bill next week. Mr. Waxman said lawmakers were committed to considering all ideas, even a proposal to tax some employer-provided health benefits, which he opposes.

The House bill shows what Democrats mean when they speak of a “robust” public insurance plan.

Under the bill, the public plan would be run by the Department of Health and Human Services and would offer three or four policies, with different levels of benefits. The plan would initially use Medicare fee schedules, paying most doctors and hospitals at Medicare rates, plus about 5 percent. After three years, the health secretary could negotiate with doctors and hospitals.

But the bill says, “There shall be no administrative or judicial review of a payment rate or methodology” used to pay health care providers in the public plan.

Scott P. Serota, president of the Blue Cross and Blue Shield Association, said, “A government-run plan that pays based on Medicare rates, for any period of time, is a recipe for disaster.”

The bill would limit what doctors could charge patients in the public insurance plan, just as Medicare limits what doctors can charge beneficiaries.

In setting payment rates for doctors and hospitals under the public plan, the bill says, the government should try to reduce racial and ethnic disparities and “geographic variation in the provision of health services.”

The public plan would receive an unspecified amount of start-up money from the federal government. After that, it would have to be self-sustaining.

The bill would require drug companies to finance improvements in the Medicare drug benefit. Drug companies would have to pay rebates to the government on drugs dispensed to low-income Medicare beneficiaries.

The bill would expand Medicaid to cover millions of people with incomes below 133 percent of the poverty level ($14,400 for an individual, $29,330 for a family of four). The cost would be borne by the federal government.

The government would also offer subsidies to make insurance more affordable for people with incomes from 133 percent to 400 percent of the poverty level ($43,300 for an individual, $88,200 for a family of four).

    House Unveils Health Bill, Minus Key Details, NYT, 20.6.2009, http://www.nytimes.com/2009/06/20/health/policy/20health.html?hpw

Letters

The Rationing of U.S. Medical Care

June 19, 2009
The New York Times
 

To the Editor:

David Leonhardt (“Limits in a System That’s Sick,” Economic Scene, June 17) makes no mention of the most egregious form of medical care rationing — the decisions by insurance companies to pay or not to pay for medical procedures, decisions that are routinely based on cost rather than on sound medical practice.

Health care reform will get nowhere until the public understands that the insurance companies are the ones currently making the rationing decisions. The objection to a government-run plan — that it would compromise the relationship of doctor and patient — overlooks the fact that the relationship is already severely compromised by the insurance companies.

Howard Nenner
Whately, Mass., June 17, 2009

•

To the Editor:

Let’s not forget that health care is also already rationed by socioeconomic status: the very poor are covered by government plans, and the very rich can afford whatever treatment they want. It’s we folks in the middle who are left holding the bag.

Ted Claire
Berkeley, Calif., June 17, 2009

•

To the Editor:

David Leonhardt is correct that health care in the United States is rationed. Our present system reflects a flawed value system of society that does not recognize the value of the time, judgment and advice of a fully trained primary-care physician. Payment is for actions taken. This is different from the other learned professions.

Thoughtful, conscientious evaluation and management require more time and fewer actions than third parties pay for. This changes good primary-care doctors into referral centers to specialists. Paying for time and not just actions is a prerequisite for meaningful reform.

The cultural desire to know what is wrong immediately is another cause of higher costs. Immediacy requires myriad tests and imaging done quickly. Careful observation for a time can be just as effective, safer and less costly. Another prerequisite for lowering costs is for our national culture to develop some patience.

Marcus M. Reidenberg
New York, June 17, 2009

The writer, a medical doctor, is a professor of pharmacology, medicine and public health at Weill Cornell Medical College.

•

To the Editor:

“Doctors and the Cost of Care” (editorial, June 14) unfairly blames “profligate physician behavior” for high medical spending in the United States. Contrary to what the Dartmouth researchers claimed, regions with high Medicare per capita spending are not necessarily wasting money.

Medicare spending per capita is an inaccurate proxy for overall medical spending. Atul Gawande, in his New Yorker article cited in the editorial, relies on the Dartmouth Medicare data to identify McAllen, Tex., as the town with the highest per capita medical spending next to Miami.

But there are reasons other than physician behavior that explain Medicare costs in McAllen. It is a border town and cares for many newcomers who are uninsured and can’t pay. Therefore costs are shifted to insurance programs like Medicare.

In addition, to the extent actual medical spending per capita is high in McAllen, Dr. Gawande points out other reasons. McAllen’s population drinks 60 percent more than average and has a 38 percent obesity rate.

Most doctors put their patients first, and many doctors provide free treatment when a patient cannot pay. What a shame doctors are being vilified in the name of reform. Betsy McCaughey
New York, June 15, 2009

The writer is chairwoman of the Committee to Reduce Infection Deaths and a former lieutenant governor of New York State.

•

To the Editor:

I was disturbed to see your editorial suggest that the blame for “ever rising premiums” falls primarily on physicians. Let’s give credit where credit is due.

Between 2000 and 2007, the 10 largest publicly traded insurance companies increased their profits 428 percent, from $2.4 billion to $12.9 billion, according to Securities and Exchange Commission filings.

During the same period, the number of insurers fell by nearly 20 percent, largely because of a huge wave of mergers that led to stunning consolidation. And premiums increased by more than 87 percent, rising four times faster than the average American’s wages.

Today, 95 percent of American insurance markets qualify as tight oligopolies. As in so many industries, blind reliance on free-market forces has failed the American public.

Clearly, doctors bear a responsibility to curb costs. But the real culprits are the middlemen who, after years of lax regulation, now have such a tight grip on the market that they can — and do — charge whatever they want.

David A. Balto
Washington, June 14, 2009

The writer is a senior fellow with the Center for American Progress.

•

To the Editor:

Since its founding, Mayo Clinic has paid physicians with salaries to avoid financial conflicts of interest in clinical decision-making, and to promote multi-disciplinary coordination of care. Less well known, but important to Mayo’s early growth, was its principle of billing based on patients’ means.

Using a sliding scale, wealthier patients paid more than poorer patients did for the same care. Such means adjustment increased patient volumes, which strengthened Mayo’s expertise and efficiency, benefiting rich and poor alike.

Health reform warrants similar means-adjustment principles. Consumer-owned cooperatives could buy high-deductible, low-premium insurance policies, and pay below-deductible bills, using means-adjusted withdrawals from participants’ health savings accounts. Such a plan would improve outcomes and value more effectively than bureaucratic price-setting would.

Randall C. Walker
Rochester, Minn., June 15, 2009

The writer is a medical doctor at the Division of Infectious Diseases, Mayo Clinic College of Medicine.

    The Rationing of U.S. Medical Care, NYT, 19.6.2009, http://www.nytimes.com/2009/06/19/opinion/l19doctors.html?hpw

Report on Gene for Depression

Is Now Faulted

June 17, 2009
The New York Times
By BENEDICT CAREY

One of the most celebrated findings in modern psychiatry — that a single gene helps determine one’s risk of depression in response to a divorce, a lost job or another serious reversal — has not held up to scientific scrutiny, researchers reported Tuesday.

The original finding, published in 2003, created a sensation among scientists and the public because it offered the first specific, plausible explanation of why some people bounce back after a stressful life event while others plunge into lasting despair.

The new report, by several of the most prominent researchers in the field, does not imply that interactions between genes and life experience are trivial; they are almost certainly fundamental, experts agree.

But it does suggest that nailing down those factors in a precise way is far more difficult than scientists believed even a few years ago, and that the original finding could have been due to chance. The new report is likely to inflame a debate over the direction of the field itself, which has found that the genetics of illnesses like schizophrenia and bipolar disorder remain elusive.

“This gene/life experience paradigm has been very influential in psychiatry, both in the studies people have done and the way data has been interpreted,” said Dr. Kenneth S. Kendler, a professor of psychiatry and human genetics at Virginia Commonwealth University, “and I think this paper really takes the wind out of its sails.”

Others said the new analysis was unjustifiably dismissive. “What is needed is not less research into gene-environment interaction,” Avshalom Caspi, a neuroscientist at Duke University and lead author of the original paper, wrote in an e-mail message, “but more research of better quality.”

The original study was so compelling because it explained how nature and nurture could collude to produce a complex mood problem. It followed 847 people from birth to age 26 and found that those most likely to sink into depression after a stressful event — job loss, sexual abuse, bankruptcy — had a particular variant of a gene involved in the regulation of serotonin, a brain messenger that affects mood. Those in the study with another variant of the gene were significantly more resilient.

“I think what happened is that people who’d been working in this field for so long were desperate to have any solid finding,” Kathleen R. Merikangas, chief of the genetic epidemiology research branch of the National Institute of Mental Health and senior author of the new analysis, said in a phone interview. “It was exciting, and some people thought it was the finding in psychiatry, a major advance.”

The excitement spread quickly. Newspapers and magazines reported the finding. Columnists, commentators and op-ed writers emphasized its importance. The study provided some despairing patients with comfort, and an excuse — “Well, it is in my genes.” It reassured some doctors that they were medicating an organic disorder, and stirred interest in genetic testing for depression risk.

Since then, researchers have tried to replicate the gene finding in more than a dozen studies. Some found similar results; others did not. In the new study, being published Wednesday in The Journal of the American Medical Association, Neil Risch of the University of California, San Francisco, and Dr. Merikangas led a coalition of researchers who identified 14 studies that gathered the same kinds of data as the original study. The authors reanalyzed the data and found “no evidence of an association between the serotonin gene and the risk of depression,” no matter what people’s life experience was, Dr. Merikangas said.

By contrast, she said, a major stressful event, like divorce, in itself raised the risk of depression by 40 percent.

The authors conclude that the widespread acceptance of the original findings was premature, writing that “it is critical that health practitioners and scientists in other disciplines recognize the importance of replication of such findings before they can serve as valid indicators of disease risk” or otherwise change practice.

Dr. Caspi and other psychiatric researchers said it would be equally premature to abandon research into gene-environment interaction, when brain imaging and other kinds of evidence have linked the serotonin gene to stress sensitivity.

“This is an excellent review paper, no one is questioning that,” said Myrna Weissman, a professor of epidemiology and psychiatry at Columbia. “But it ignored extensive evidence from humans and animals linking excessive sensitivity to stress” to the serotonin gene.

Dr. Merikangas said she and her co-authors deliberately confined themselves to studies that could be directly compared to the original. “We were looking for replication,” she said.

    Report on Gene for Depression Is Now Faulted, NYT, 17.6.2009, http://www.nytimes.com/2009/06/17/science/17depress.html?hp

Economic Scene

Health Care Rationing Rhetoric

Overlooks Reality

June 17, 2009
The New York Times
By DAVID LEONHARDT

Rationing.

More to the point: Rationing!

As in: Wait, are you talking about rationing medical care? Access to medical care is a fundamental right. And rationing sounds like something out of the Soviet Union. Or at least Canada.

The r-word has become a rejoinder to anyone who says that this country must reduce its runaway health spending, especially anyone who favors cutting back on treatments that don’t have scientific evidence behind them. You can expect to hear a lot more about rationing as health care becomes the dominant issue in Washington this summer.

Today, I want to try to explain why the case against rationing isn’t really a substantive argument. It’s a clever set of buzzwords that tries to hide the fact that societies must make choices.

In truth, rationing is an inescapable part of economic life. It is the process of allocating scarce resources. Even in the United States, the richest society in human history, we are constantly rationing. We ration spots in good public high schools. We ration lakefront homes. We ration the best cuts of steak and wild-caught salmon.

Health care, I realize, seems as if it should be different. But it isn’t. Already, we cannot afford every form of medical care that we might like. So we ration.

We spend billions of dollars on operations, tests and drugs that haven’t been proved to make people healthier. Yet we have not spent the money to install computerized medical records — and we suffer more medical errors than many other countries.

We underpay primary care doctors, relative to specialists, and they keep us stewing in waiting rooms while they try to see as many patients as possible. We don’t reimburse different specialists for time spent collaborating with one another, and many hard-to-diagnose conditions go untreated. We don’t pay nurses to counsel people on how to improve their diets or remember to take their pills, and manageable cases of diabetes and heart disease become fatal.

“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, says, “that doesn’t mean you aren’t getting some treatments.”

Milton Friedman’s beloved line is a good way to frame the issue: There is no such thing as a free lunch. The choice isn’t between rationing and not rationing. It’s between rationing well and rationing badly. Given that the United States devotes far more of its economy to health care than other rich countries, and gets worse results by many measures, it’s hard to argue that we are now rationing very rationally.

On Wednesday, a bipartisan panel led by four former Senate majority leaders — Howard Baker, Tom Daschle, Bob Dole and George Mitchell — will release a solid proposal for health care reform. Among other things, it would call on the federal government to do more research on which treatments actually work. An “independent health care council” would also be established, charged with helping the government avoid unnecessary health costs. The Obama administration supports a similar approach.

And connecting the dots is easy enough. Armed with better information, Medicare could pay more for effective treatments — and no longer pay quite so much for health care that doesn’t make people healthier.

Mr. Baker, Mr. Daschle, Mr. Dole and Mr. Mitchell: I accuse you of rationing.

•

There are three main ways that the health care system already imposes rationing on us. The first is the most counterintuitive, because it doesn’t involve denying medical care. It involves denying just about everything else.

The rapid rise in medical costs has put many employers in a tough spot. They have had to pay much higher insurance premiums, which have increased their labor costs. To make up for these increases, many have given meager pay raises.

This tradeoff is often explicit during contract negotiations between a company and a labor union. For nonunionized workers, the tradeoff tends to be invisible. It happens behind closed doors in the human resources department. But it still happens.

Research by Katherine Baicker and Amitabh Chandra of Harvard has found that, on average, a 10 percent increase in health premiums leads to a 2.3 percent decline in inflation-adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel Emanuel, an oncologist now in the Obama administration, published an article in The Journal of the American Medical Association last year that nicely captured the tradeoff. When health costs have grown fastest over the last two decades, they wrote, wages have grown slowest, and vice versa.

So when middle-class families complain about being stretched thin, they’re really complaining about rationing. Our expensive, inefficient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition.

The second kind of rationing involves the uninsured. The high cost of care means that some employers can’t afford to offer health insurance and still pay a competitive wage. Those high costs mean that individuals can’t buy insurance on their own.

The uninsured still receive some health care, obviously. But they get less care, and worse care, than they need. The Institute of Medicine has estimated that 18,000 people died in 2000 because they lacked insurance. By 2006, the number had risen to 22,000, according to the Urban Institute.

The final form of rationing is the one I described near the beginning of this column: the failure to provide certain types of care, even to people with health insurance. Doctors are generally not paid to do the blocking and tackling of medicine: collaboration, probing conversations with patients, small steps that avoid medical errors. Many doctors still do such things, out of professional pride. But the full medical system doesn’t do nearly enough.

That’s rationing — and it has real consequences.

In Australia, 81 percent of primary care doctors have set up a way for their patients to get after-hours care, according to the Commonwealth Fund. In the United States, only 40 percent have. Over all, the survival rates for many diseases in this country are no better than they are in countries that spend far less on health care. People here are less likely to have long-term survival after colorectal cancer, childhood leukemia or a kidney transplant than they are in Canada — that bastion of rationing.

None of this means that reducing health costs will be easy. The comparative-effectiveness research favored by the former Senate majority leaders and the White House has inspired opposition from some doctors, members of Congress and patient groups. Certainly, the critics are right to demand that the research be done carefully. It should examine different forms of a disease and, ideally, various subpopulations who have the disease. Just as important, scientists — not political appointees or Congress — should be in charge of the research.

But flat-out opposition to comparative effectiveness is, in the end, opposition to making good choices. And all the noise about rationing is not really a courageous stand against less medical care. It’s a utopian stand against better medical care.

    Health Care Rationing Rhetoric Overlooks Reality, NYT, 17.6.2009, http://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?hp

Cost Concerns

as Obama Pushes Health Issue

June 16, 2009
The New York Times
By ROBERT PEAR
and JACKIE CALMES

WASHINGTON — President Obama went before a convention of receptive but wary doctors on Monday to make the economic case for a health care overhaul, both for the nation and for the physicians’ own bottom lines.

But as the president spoke at the annual conference of the American Medical Association in Chicago, it became clear that one of the major health plans on the table would cost at least $1 trillion over 10 years yet leave tens of millions of people uninsured.

Congress is wrestling with how to pay for Mr. Obama’s vision to extend health care to all Americans, and some lawmakers are considering tax increases and spending cuts different from the ones he has proposed. House Democrats, for example, are weighing a tax on soft drinks and a value-added tax, a broad-based consumption tax similar to the sales taxes many states levy.

An analysis released Monday by the nonpartisan Congressional Budget Office raised the hurdles for draft legislation in the Senate just as its Health, Education, Labor and Pensions Committee planned to begin voting on Wednesday. The office concluded that a plan by the committee’s Democratic leaders, Senators Edward M. Kennedy of Massachusetts and Christopher J. Dodd of Connecticut, would reduce the number of uninsured only by a net 16 million people. Even if the bill became law, the budget office said, 36 million people would remain uninsured in 2017.

That finding came as a surprise. Robert D. Reischauer, an economist who headed the budget office when Congress tackled the health care issue in the Clinton administration, said that if so many people remained uninsured, it might not be feasible to cut special federal payments to hospitals that serve many low-income people.

Mr. Obama said Saturday that the government could save $106 billion over 10 years by cutting such hospital payments as more people gained coverage.

Senator Orrin G. Hatch of Utah, a senior Republican on both committees drafting health legislation, said he found the office’s numbers stunning. He calculated that the Kennedy bill would cost taxpayers $62,500 per uninsured person over the 10 years.

Mr. Obama took the cost issue head on in Chicago. “The cost of inaction is greater,” he told the doctors, because rising health care prices are “an escalating burden on our families and businesses” and “a ticking time bomb for the federal budget.”

Opening a week in which health care will dominate attention in Congress, the president’s speech on Monday was the latest example of an oft-used ploy to press his case: appearing before skeptical audiences, confident of his powers of persuasion but willing as well to say what his listeners do not want to hear.

Mr. Obama spoke just days after the A.M.A. had signaled opposition to his proposal for a public health insurance plan to compete with private insurers as part of a menu of choices, much like the one for members of Congress.

“The public option is not your enemy,” Mr. Obama said. “It is your friend, I believe.” Saying it would “keep the insurance companies honest,” the president dismissed as “illegitimate” the claims of critics that a public insurance option amounts to “a Trojan horse for a single-payer system” run by the government.

Mr. Obama twice referred to the use of such “fear tactics” about “socialized medicine” in past legislative battles, without pointing out that the A.M.A., a traditionally Republican-leaning group, was among those using the charge, as in the mid-1960s debate over creating Medicare for people 65 and older.

Mr. Obama drew repeated applause, and even some standing ovations, when he called for incentives to get more medical students to go into primary care instead of the more lucrative specialty practices, and when he pledged to work with doctors to reduce their often unnecessary “defensive medicine” to avoid malpractice lawsuits. But scattered boos met his follow-up remark that he opposed any cap on malpractice awards.

The president’s emphasis on reducing health care costs over expanding insurance coverage, which dates to his campaign, reverses Democrats’ priorities of recent years. Obama advisers say the focus on cost savings has appeal for all Americans, not just the uninsured. Some advisers, including veterans of the Clinton administration, say President Bill Clinton’s emphasis on covering the uninsured helped doom his health care plan in 1994.

“We have made cost control a coequal objective, just as important as the expansion of insurance coverage, which has traditionally been the dominant goal for Democrats,” said Rahm Emanuel, the White House chief of staff. “The entire discussion has to be centered on controlling or reducing costs.”

That rationale has been Mr. Obama’s answer to those who, after his election, predicted that he would have to shelve his campaign promise to overhaul health care to attend instead to an economy in crisis. “If we fail to act, premiums will climb higher, benefits will erode further, the rolls of the uninsured will swell to include millions more Americans, all of which will affect your practice,” he told the A.M.A. members.

The practical problem for Mr. Obama is that by all accounts, the savings and efficiencies he envisions will not occur quickly, certainly not in the 10-year time frame of budget scorekeeping for purposes of passing legislation.

The budget office estimated that 39 million people would get coverage through new “insurance exchanges.” But at the same time, it said, the number of people with employer-provided health insurance would decline by 15 million, or about 10 percent, and coverage from other sources would fall by 8 million.

In effect, the office said, millions of people would get a better deal if they bought insurance through an exchange because they could qualify for federal subsidies not available if they stayed in their employers’ health plans. Subsidies are expected to average $5,000 to $6,000 a person.

Mr. Obama assured skeptics in the audience: “You did not enter this profession to be bean counters and paper pushers. You entered this profession to be healers. And that’s what our health care system should let you be.”

On Wednesday, leaders of the Senate Finance Committee hope to unveil what will be the one bipartisan measure in Congress.

Democrats on three House panels continue to meet privately to seek consensus on a single plan. Democrats on the House Ways and Means Committee said they were trying to decide whether to finance coverage of the uninsured with one broad-based tax, like the value-added tax, or a combination of smaller taxes.

The value-added tax, common in other countries, is collected in stages from each business that contributes to the production and sale of consumer goods. Economists say a 5 percent VAT could have raised $285 billion last year.

But a VAT could violate Mr. Obama’s campaign pledge not to raise taxes on households with incomes under $250,000 a year.

    Cost Concerns as Obama Pushes Health Issue, NYT, 16.6.2009, http://www.nytimes.com/2009/06/16/health/policy/16obama.html

Many in Congress

Hold Stakes in Health Industry

June 14, 2009
The New York Times
By JACKIE CALMES

WASHINGTON — As President Obama and Congress intensify the push to overhaul health care in the coming week, the political and economic force of that industry is well represented in the financial holdings of many lawmakers and others with a say on the legislation, according to new disclosure forms.

The personal financial reports, due late last week from members of Congress, show that many lawmakers hold investments in insurance, pharmaceutical and prescription-benefit companies and in hospital interests, all of which would be affected by the administration’s overhaul of health care.

The lawmakers’ stakes are impossible to quantify because the reports ask for ranges of value for each asset, and because many officials’ holdings are in stock index and mutual funds. The Senate majority leader, Harry Reid of Nevada, for example, has interests in a stock index fund for the health care sector of more than $50,000 and up to $100,000.

Representative Dave Camp of Michigan, the senior Republican on the Ways and Means Committee, one of three panels in the House with jurisdiction over health care, reported at least tens of thousands of dollars in health-related interests, including the medical technology giant Medtronic, the drug maker Wyeth and the insurance company Aetna.

In Congress, as members and aides of the three House committees continue to meet privately, the Senate health committee will begin publicly drafting and voting on its bill as soon as Tuesday. Later in the week, the Democratic chairman and senior Republican of the Senate Finance Committee, Max Baucus of Montana and Charles E. Grassley of Iowa, are expected to unveil a bipartisan plan.

Neither Mr. Baucus, from a ranching family, nor Mr. Grassley, a farmer, have major health-related holdings, their reports show.

Senator Edward M. Kennedy of Massachusetts, chairman of the health committee, has much of his wealth in blind trusts.

Senator Christopher J. Dodd, Democrat of Connecticut, leads the health committee in consultation with Mr. Kennedy. Mr. Dodd’s wife, Jackie Clegg Dodd, is a member of the board and a shareholder in several health-related companies, including Cardiome Pharma, Javelin Pharmaceuticals and Brookdale Senior Living.

Senator Tom Coburn of Oklahoma, a Republican on the health committee, is an obstetrician with income from his clinic in Muskogee. The wife of Representative Wally Herger of California, the senior Republican on the health subcommittee of the Ways and Means panel, works for Catholic Healthcare West, while the wife of Representative Joe L. Barton of Texas, the top Republican on the House Energy and Commerce Committee, works for JPS Health Network.

Mr. Obama’s chief adviser on health care, Nancy-Ann DeParle, also filed disclosure forms with the White House. Ms. DeParle, who served in the Clinton administration, went on to lucrative positions on the boards of health companies and as director of a private-equity firm with health investments, earning more than $2 million from 2008 to this year, according to forms signed on May 13.

The companies included Medco Health Solutions, a pharmacy benefits manager; Boston Scientific, a device maker; Cerner, a provider of medical information technology; and DaVita, an operator of dialysis services.

A handwritten note on the forms, dated June 4, says that “all conflicting assets have been divested.” Ms. DeParle is the wife of a reporter for The New York Times, Jason DeParle.

Janie Lorber, Ashley Southall and Jack Styczynski contributed reporting.

    Many in Congress Hold Stakes in Health Industry, NYT, 13.6.2009, http://www.nytimes.com/2009/06/14/us/politics/14cong.html

Obama Addresses

Paying for Health Care Reforms

June 14, 2009
The New York Times
By SHERYL GAY STOLBERG
and ROBERT PEAR

WASHINGTON — The White House said Saturday that President Obama intends to pay for his health care overhaul partly by cutting more than $200 billion in expected reimbursements to hospitals over the next decade — a proposal that is likely to provoke a backlash from cash-strapped medical institutions around the country.

Mr. Obama has insisted that his plan will not add to the federal deficit, and he had already set aside in his budget what he calls a $635 billion “down payment” toward the overall 10-year cost of the overhaul, which is expected to top $1 trillion. But Republicans and some Democratic legislators have been pressing him for details on how he would cover the rest. On Saturday, he used his weekly Internet and radio address to do so.

Mr. Obama said he had identified “an additional $313 billion in savings that will rein in unnecessary spending and increase efficiency and the quality of care,” bringing the total to nearly $950 billion. He did not offer a specific breakdown, but advisers said that in addition to the more than $200 billion in lowered hospital reimbursements, the president expects $75 billion in savings over 10 years by getting better prices for prescription drugs, and $22 billion in other savings.

“These savings will come from common sense changes,” Mr. Obama said in his address. “For example — if more Americans are insured, we can cut payments that help hospitals treat patients without health insurance.”

He added: “If the drug makers pay their fair share, we can cut government spending on prescription drugs. And if doctors have incentives to provide the best care instead of more care, we can help Americans avoid the unnecessary hospital stays, treatments, and tests that drive up costs.”

Saturday’s announcement comes amid an intense push by the White House to sell Mr. Obama’s health care plan, his highest legislative priority. Broadly speaking, Mr. Obama wants to extend coverage to the nation’s 45 million uninsured, preserve consumer choice and cut rising health care costs. He has argued that fixing the nation’s broken health care system is crucial to the economic health of the United States.

But as Congress contemplates the details of the legislation, the question of how to pay for the plan is among the thorniest it will face. Already, one of Mr. Obama’s early proposals — limiting tax deductions for high income people — has run into major roadblocks on Capitol Hill. By providing details in his weekly address on Saturday, Mr. Obama may be hoping to give lawmakers the political leeway to adopt other cost-saving measures.

The administration expects to achieve the lowered hospital payments in two major ways, by slowing the growth of reimbursements. First, said Mr. Obama’s budget director, Peter M. Orszag, payments to hospitals will be reduced to try to encourage them to work more productively and efficiently.

Mr. Orszag said hospitals could figure out ways of treating patients “more effectively, through health information technology, a nurse coordinator instead of an unnecessary specialist,” for example. These “productivity adjustments” would account for $110 billion in savings.

Second, the administration expects to lower payments to hospitals that treat large numbers of low-income patients. Medicare and Medicaid make special extra payments to these hospitals, but Mr. Orszag said those payments will become less necessary over time, as more of the nation’s 45 million uninsured acquire coverage through the new program. This would account for $106 billion in savings.

But hospital administrators, already nervous about lowered reimbursements, are likely to oppose such cuts. Less than 24 hours before Mr. Obama’s radio address, the president of the American Hospital Association, Richard J. Umbdenstock, issued a call to action to his members across the country, warning that Congress might cut provider payments.

Mr. Umbdenstock asked hospitals to "push back" against the proposed cuts. "Payment cuts are not reform," he said, denouncing "blunt cuts that cripple hospitals’ ability to do better for their patients."

Dr. Patricia A. Gabow, chief executive of the Denver Health and Hospital Authority, which operates a 477-bed public hospital, said it would be "pretty risky" for Congress to cut payments to safety net hospitals before knowing whether new legislation actually reduced the amount of uncompensated care they must provide.

"What about homeless people, the chronically mentally ill, substance abusers and people with low literacy?” Dr. Gabow asked. "You think they will be using the federal health insurance exchange to enroll in insurance plans? I don’t think so.”

Kenneth E. Raske, president of the Greater New York Hospital Association, said the proposed cuts could be "devastating to hospitals that serve inner-city communities."

Mr. Raske noted that none of the major proposals in Congress would provide health insurance to illegal immigrants, and many of them would still be unable to pay their hospital bills. In addition, he said, the federal payments will still be needed because "Medicaid woefully underpays for outpatient clinics” and other services in some states, including New York.

Five Congressional committees are working at a feverish pace to meet the president’s goal of passing a health care bill that he can sign by October.

The Democratic chairman of the Finance Committee, Senator Max Baucus of Montana, intends to unveil his plan this week. Aides said it would include a proposal to tax some employer-provided health benefits, a notion that Mr. Obama sharply criticized during his campaign for the White House. Workers might, for example, have to pay income tax on the value of family coverage exceeding $15,000 a year.

Labor unions, many employers and many House Democrats oppose such a tax, saying it would destabilize the employer-based system of health insurance on which millions of Americans depend.

The Congressional Joint Committee on Taxation said a proposal like Mr. Baucus’s could raise more than $400 billion over 10 years. Mr. Obama did not mention taxing health benefits in his Saturday address.

    Obama Addresses Paying for Health Care Reforms, NYT, 14.6.2009, http://www.nytimes.com/2009/06/14/us/politics/14address.html?hp

Disease of Rich

Extends Its Pain to Middle Class

June 13, 2009
The New York Times
By ANDREW POLLACK

Lonnie Matthews, a retired building maintenance engineer in Burlington, N.C., has something in common with King Henry VIII, Sir Isaac Newton and Benjamin Franklin. He has gout.

Often called the “disease of kings” because of its association with the rich foods and copious alcohol once available only to aristocrats, gout is staging a middle-class comeback as American society grows older and heavier.

The rising tide of gout — an extremely painful arthritis of the big toe and other joints — is leading the pharmaceutical industry to rediscover what it had considered a disease of the past. Companies are now racing to improve upon decades-old generic drugs that do not work well for everyone.

Already this year the Food and Drug Administration has approved the first new gout drug in more than 40 years, a product called Uloric from Takeda Pharmaceutical.

Another new drug, Krystexxa, made by Savient Pharmaceuticals of East Brunswick, N.J., will be reviewed for possible approval by an F.D.A. advisory committee on Tuesday.

And several other companies are testing drugs in clinical trials.

“It’s kind of like the forgotten disease,” said Barry D. Quart, chief executive of one of those companies, Ardea Biosciences of San Diego.

Ardea discovered accidentally that an AIDS drug it was developing might work against gout. Now the company has shifted its focus to gout, envisioning annual sales of $1 billion if its drug is successful.

That would mean a huge increase in spending on gout medicines, which had sales of only $53.4 million last year, according to IMS Health, a health care information company. Uloric, the drug from Takeda, sells a daily pill for at least $4.50 compared with 10 to 50 cents for the most commonly used generic, allopurinol.

It is estimated that two million to six million Americans have gout. Although the disease becomes more common as people age, some men develop gout in their 40s and 50s, or even younger. It is three to four times as common in men as in women, in part because estrogen is thought to protect premenopausal women from the illness.

Various studies suggest that the number of cases in this country has as much as doubled in the last three decades.

“We have accumulated a lot of people with severe disease,” said Dr. Robert A. Terkeltaub, section chief of rheumatology at the Veterans Affairs Medical Center in San Diego and a consultant to some of the companies developing gout drugs. And the typical case these days, is “not going to be someone who looks like Henry VIII,” he said. “Now it’s going to be some 80-year-old lady with congestive heart failure.”

One of the severe cases is Mr. Matthews, who had controlled his disease for many years with the generic allopurinol. But when he developed renal problems in 2006, he stopped taking allopurinol because it can be harmful to those with bad kidneys. After that, Mr. Matthews was bedridden or in a wheelchair and in such excruciating pain in many of his joints that he said he contemplated suicide.

“It was like having a toothache so bad you can’t stand it, all over your body,” he said.

Mr. Matthews, 76, says he found relief as a participant in a clinical trial of Savient’s Krystexxa, the drug now up for review by the F.D.A.

Gout is caused by the buildup of a chemical called uric acid in the blood. Uric acid is formed by the breakdown of purines, which are components of DNA, RNA and some other important molecules in the body.

Some types of meat and fish, as well as beer, are particularly rich in purines and can raise the risk of gout. There is also evidence that sugary soft drinks raise the risk.

When uric acid levels get too high, the chemical can form needlelike crystals that accumulate in joints.

In the early stages of the disease, gout attacks, which can last several days and are excruciating, occur only rarely. But over time, the frequency increases and people can develop disfiguring and disabling lumps of the chalky white crystals, called tophi. Michael Clayton of Atlanta, who has severe gout, said he had to quit a job as general manager of a restaurant after customers complained about the tophi on his hands, which sometimes oozed liquid resembling Wite-Out.

Many doctors and patients treat only gout attacks. They use either pain relievers like naproxen, steroids or colchicine — a crocus plant derivative that has been used for centuries.

Many of the new drugs lower uric acid levels in the blood, meaning they can prevent gout attacks and keep the disease under control.

A problem in getting doctors to prescribe chronic treatment for gout is that many patients are reluctant to admit they have the disease because of its association with gluttony.

“It’s part of society’s view of gout that this is something self-inflicted,” said Dr. N. Lawrence Edwards, professor of medicine at the University of Florida.

So the industry is trying to spread the word that genetics and other factors, not just diet, contribute to gout. Takeda and Savient bankroll the Gout and Uric Acid Education Society, which is led by Dr. Edwards and was formed in 2005 to raise awareness of the disease.

Another reason that gout is shedding its image as a disease of the past is preliminary evidence — though still far from proof — that high uric acid levels might also contribute to modern-day ills like hypertension, obesity, heart disease, kidney impairment and diabetes.

In one small study published last year, treatment with allopurinol reduced high blood pressure in adolescents.

Right now, it is estimated that 15 million to 20 million Americans have elevated uric acid levels, known as hyperuricemia. But they do not have gout symptoms and are therefore not treated.

If further studies prove that high uric acid levels contribute to other diseases, though, then “hyperuricemia” could be defined as a disease in its own right and millions of people might one day take drugs to lower uric acid levels, much as they now do to lower cholesterol.

Paul Hamelin, president of Savient, said, “There’s a huge amount of ground that nobody’s ever plowed yet.”

    Disease of Rich Extends Its Pain to Middle Class, NYT, 13.6.2009, http://www.nytimes.com/2009/06/13/health/13gout.html?hp

Senate Votes to Impose

U.S. Regulation on Tobacco

June 12, 2009
The New York Times
By DUFF WILSON

WASHINGTON — The Senate voted overwhelmingly Thursday to impose federal regulation on cigarettes and other forms of tobacco, passing a landmark bill to empower the Food and Drug Administration to control products that eventually kill half their regular users.

The legislation, with only minor differences from a version the House passed in April by a nearly 3-to-1 ratio. A White House spokesman, Reid H. Cherlin, said on Thursday that President Obama, who was a co-sponsor of the bill when he was in the Senate, would sign the legislation when it reached his desk.

An estimated one in five people in this country smoke, and more than 400,000 of them die each year from smoking-related disease. But for decades, even after the surgeon general’s 1964 report declaring cigarettes a health hazard, Congressional efforts to regulate tobacco had met stiff opposition from lawmakers from tobacco-growing states and their political allies.

And when the F.D.A. tried on its own to start regulating nicotine as a drug, the Supreme Court struck down that effort in 2000, saying the agency could not take such a step without Congressional authority. Cigarettes remained less regulated than cosmetics or pet food.

But with broad bipartisan support in both the Senate and House, and a campaign pledge by Barack Obama to sign such legislation if he became president, the anti-tobacco forces came into alignment.

“This long-overdue grant of authority to F.D.A. to regulate tobacco products means that the agency can finally take the actions needed to protect our people from the most deadly of all consumer products,” Edward M. Kennedy, the Massachusetts Democrat who was chief sponsor of the legislation in the Senate, said in a statement from home, where he is receiving treatment for a brain tumor.

The Family Smoking Prevention and Tobacco Control Act, as it is called, would empower the F.D.A. to set standards for cigarettes, regulating chemicals in cigarette smoke and outlawing most tobacco flavorings. It could also study whether to also ban menthol. Flavorings are considered a lure to first-time smokers, especially the young. Menthol is used by three-quarters of black smokers, who also have a disproportionate share of lung cancer.

The law would also further restrict marketing and advertising of tobacco products. Colorful advertising and store displays will be replaced by black-and-white-only text as part of restrictions aimed at reducing the appeal to youth to try smoking. Cigarette makers will be required to stop using terms like “light” and “low tar” by next year and to place large and graphic health warnings on their packages by 2012.

But while the F.D.A. could mandate a reduced level of nicotine, an addictive chemical, the law expressly says the agency cannot ban it. Public health advocates say outlawing nicotine would force addicts would turn to a black market or other sources.

Still, health advocates predict that F.D.A. product standards could eventually reduce some of the 60 carcinogens and 4,000 toxins in cigarette smoke, or make them taste so bad they deter users.

“This is a bill not for a one-year or two-year splash, but for a long-term impact,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, a Washington advocacy group that took a lead in coordinating support for the legislation. The Altria Group, the parent company of Philip Morris, whose Marlboro brand helps make it the nation’s leading tobacco seller, endorsed the F.D.A. legislation and negotiated some of its crucial provisions with Congress.

The Congressional Budget Office had estimated that the F.D.A. legislation would reduce youth smoking by 11 percent and adult smoking by 2 percent over the next decade beyond the declines that had already resulted from public education, higher taxes and smoke-free indoor space laws.

At least partly because of such other efforts, cigarette smoking has declined measurably over the last decade: in 2005, about 21 percent of adults in the United States were smokers, compared with about 25 percent in 1995.

Reynolds America and Lorillard, the second- and third-largest companies, opposed the legislation and criticized it as being intended to protect Philip Morris’s market dominance by restricting advertising and new products.

But Brendan McCormick, a spokesman for Philip Morris’s parent, Altria, argued that previous marketing restrictions, like the television advertising ban imposed in 1971, had not frozen companies’ market shares. He said his company supported “federal regulation and the benefits it will bring to tobacco consumers and the greater predictability and stability we think it will bring to the tobacco industry.”

There are only minor differences between the Senate bill and the one the House passed in April — the main one involving the size of the graphic warnings on cigarette packs, which would be bigger under the Senate version.

Henry A. Waxman, the California Democratic who was chief sponsor of the House bill, said in an interview that he hoped the House could simply pass the Senate version of the bill next week to send quickly to the President.

“I would prefer we do that,” Mr. Waxman said, adding that it was still possible to call a conference committee instead to negotiate the minor differences. But that process, he said, could delay action and risk another Senate filibuster of the type that was broken Monday in a crucial vote of 61 Senators, two more than needed to proceed to final action. That filibuster had been mounted by Richard M. Burr, Republican of North Carolina, the nation’s leading tobacco-growing state. Only one Democrat — Kay Hagan, also of North Carolina — had voted to uphold the filibuster.

On Tuesday, the Senate voted 60 to 36 against a substitute bill by Mr. Burr and Ms. Hagan to promote smokeless and other “reduced risk” products rather than strictly regulate all new tobacco products.

Under the law, new products could be approved only if makers could demonstrate health benefits to society as a whole — meaning the products would not induce too many nonsmokers or would-be quitters to try them, rather than abstaining.

Another crucial procedural vote Wednesday passed 67-30, cutting off amendments. And the final action Thursday came on a 79 to 17 vote, with Ms. Hagan of North Carolina the only Democrat voting against it.The voting reflected a political shift from years past, when tobacco state senators could count on support from other Southern conservatives.

John Cornyn of Texas, who is chairman of the Senate Republican campaign committee, co-sponsored the tobacco bill and voted against the filibuster. “This is a rarity these days in Washington,” Mr. Cornyn said in debate Tuesday. “It is actually a bipartisan bill.”

Michael B. Enzi of Wyoming, the ranking Republican on the Senate health committee, also supported the tobacco legislation. “Smoking killed my dad and my mom and my mother-in-law, and second-hand smoking conclusively affected me,” he said during the Senate debate. “So this isn’t political. This is about the health of all Americans.”

Although tobacco companies have also lost a series of recent rulings in court, tobacco industry financial analysts say federal regulation, higher taxes and court verdicts are all manageable because the companies, with a market of addicted customers, can raise prices to remain profitable.

A Goldman Sachs analyst, Judy Hong, wrote in a report to investors last week, “Some of the new remedies may be unpleasant but not financially disabling to the tobacco companies.”

Under the law, tobacco regulation would be introduced in stages. First, the F.D.A. would hire a director and staff and find space for a new Tobacco Center, to be financed by industry fees. The projected budget is $85 million the first year, $450 million by the third year and more than $700 million in 10 years. A scientific advisory committee would be set up by next year.

New marketing restrictions next year would include a ban on all outdoor advertising of tobacco within 1,000 feet of schools and playgrounds.

The Association of National Advertisers, a trade organization, says the legislation’s “massive crushing and unprecedently broad advertising restrictions” violate First Amendment protections for commercial speech. A court challenge is probable.

While cigarette consumption has declined in most Western countries, it is growing in Asia and Eastern Europe. An estimated 1.3 billion people now smoke worldwide, according to the World Lung Foundation.

“The unfortunate thing,” Nancy Brown, president of the American Heart Association, said in an interview, “is the bad American habit is now being exported to other countries.”

    Senate Votes to Impose U.S. Regulation on Tobacco, NYT, 12.6.2009, http://www.nytimes.com/2009/06/12/business/12tobacco.html

Regulating Tobacco Industry

Is a Recent Concept

June 12, 2009
The New York Times
By DUFF WILSON

Smoking has a long history of addiction, disease and deaths, but government efforts to control it have come relatively recently.

Tobacco began spreading around the world after Christopher Columbus first encountered Native Americans, who smoked and chewed the leaf. Not until the 20th century, though, did cigarettes became the main form of tobacco consumption — and the most lethal legal products on the market.

Their popularity grew rapidly in this country after giveaways to American soldiers in World Wars I and II, and the introduction of sophisticated marketing campaigns. And notwithstanding decades of industry denials, smoking-related cancer and lung disease started rising apace.

In the early 1950s the medical researcher Dr. Ernst L. Wynder published landmark studies linking smoking to lung cancer and showing that tars from tobacco smoke could cause skin cancer when brushed on mice.

Steps on the path to federal regulation include the first surgeon general’s report on smoking, in 1964. Congress banned smoking on most airplane flights starting in 1988.

In 1994, the chief executives of the nation’s seven largest tobacco companies appeared at a House hearing overseen by Henry A. Waxman, Democrat of California, and swore under oath that tobacco was not addictive and did not cause cancer. The six-hour hearing, carried live on national television, was considered a turning point in public perception of the tobacco industry.

“We had hearings on tobacco for decades,” Mr. Waxman, chief sponsor of the House version of the tobacco legislation, said in an interview Wednesday. “But it was not until 1994, after tobacco executives testified and lied to us, saying cigarettes weren’t harmful, nicotine wasn’t addictive, they didn’t manipulate the nicotine and of course they didn’t target kids — it wasn’t until after that that we started getting the inside information from tobacco companies and found the opposite was true.”

In 1998, seven tobacco companies agreed to a “master settlement agreement” with 46 states to resolve suits for $206 billion and to change marketing practices, including those appealing to youth. But subsequently, cigarette companies nearly doubled their marketing expenditures, peaking at $15.1 billion in 2003, and increased advertising in stores.

Last month, the federal appeal court in Washington upheld a landmark racketeering verdict against five major tobacco companies in a lawsuit filed in 1999 by the Department of Justice. The appeals court, saying consumer fraud continues to this day, ordered the companies to publish “corrective statements” about health risks.

The F.D.A. has previously tried on its own to regulate tobacco, most recently in 1996 when it asserted that cigarettes were medical devices and nicotine a drug. Philip Morris and other tobacco companies sued, and the Supreme Court ruled by a 5-4 vote that the F.D.A. lacked specific Congressional authority.

Since then, the Senate and House have each voted to give the F.D.A. that authority, but in different years. And President Bush had threatened to veto anti-tobacco legislation.

But President Obama, who himself has admitted difficulty quitting smoking, has promised to sign it into law.

    Regulating Tobacco Industry Is a Recent Concept, NYT, 12.6.2009, http://www.nytimes.com/2009/06/12/business/12tobaccobar.html

Op-Ed Contributors

Overseas, Under the Knife

June 10, 2009
The New York Times
By ARNOLD MILSTEIN,
MARK D. SMITH
and JEROME P. KASSIRER

ONE consequence of the high cost of medical care in the United States has been the rise of medical tourism. Every year, thousands of Americans undergo surgery in other countries because the allure of good care at half the price is too good to pass up.

Average total fees at well-regarded hospitals like Apollo and Wockhardt in India are 60 percent to 90 percent lower than those of the average American hospital, according to a 2007 study by the consulting group Mercer Health and Benefits (where Dr. Milstein is affiliated). Even compared with low-cost American hospitals, the offshore fees are 20 percent to 50 percent lower.

Most medical travelers seek cosmetic procedures like facelifts and liposuction, but an increasing number have high-risk operations like heart surgery and joint replacement in places like India, Singapore and Thailand.

Is this a good idea? The only way to know is to find out how foreign hospitals and surgeons compare with their American counterparts.

Which Americans consider this option? Typically, they are people who have either no health insurance or meager coverage. Though not poor enough to qualify for Medicaid, they cannot afford a good health plan. But lately, even some people with good coverage have been encouraged to take advantage of cost savings abroad.

A few pioneering American insurers like Blue Cross Blue Shield of South Carolina and self-insured employers like the Hannaford Brothers supermarket chain sent American doctors to evaluate foreign hospitals. Favorably impressed, they now offer payment for travel expenses and cash incentives as high as $10,000 for choosing offshore hospitals.

For very costly operations like open heart surgery or hip joint replacement, savings far exceed these payments. That is not to say that offshore surgery could substantially lower health care costs. Less than 2 percent of spending by American health insurers goes to the kind of non-urgent procedures that Americans seek overseas.

Other negatives are obvious: people having surgery done halfway around the world are far from their regular doctors as well as friends and family. Consider, also, what happens if an American abroad falls victim to negligent care. Arranging transfer to another hospital may be difficult — and malpractice suits typically face longer odds and smaller payments than in the United Sates. To mitigate these problems, some insurers and free-standing medical travel services offer coordination with American doctors, local concierge services and supplementary medical malpractice insurance.

There is reason to think the quality of care at some foreign hospitals may be comparable to quality in the United States. More than 200 offshore hospitals have been accredited by the Joint Commission International, an arm of the organization that accredits American hospitals. Many employ English-speaking surgeons who trained at Western medical schools and teaching hospitals.

So should offshore surgery be welcomed as a modest way to make American health care more affordable? We can’t know until we can directly compare the outcomes with those of American surgery. To begin, we must adopt a uniform way for American hospitals and surgeons to report on the frequency of short-term surgical complications.

Medicare could do this by requiring that all participating hospitals and surgeons count pre-surgical risk factors and post-surgical complications during hospitalization and for 30 days afterward, when most short-term problems become evident. The system used for many years by Veterans Affairs hospitals to reduce surgical complications is the best option for this, since it is available to all American doctors through the American College of Surgeons. So far, however, only a small minority of surgeons participate in this or any other valid national system of reporting surgical outcomes.

Patients and their surgeons also need comparable measurements of long-term success. Medicare should lead by adopting Sweden’s method of monitoring hip joint replacement outcomes. It tracks, for example, a patient’s ability to walk without pain six years after surgery.

Finally, Medicare should invite accredited offshore hospitals and their affiliated doctors to participate in all of its comparative performance reporting systems. Beyond informing Americans contemplating treatment abroad, such comparisons would allow us to learn if our care is the world’s best — and to accelerate our improvement efforts if it is not.

Arnold Milstein is a doctor specializing in health care improvement. Mark D. Smith is an internist and the chief executive of a health care foundation. Jerome P. Kassirer is a professor at Tufts University School of Medicine.

    Overseas, Under the Knife, NYT, 9.6.2009, http://www.nytimes.com/2009/06/10/opinion/10milstein.html

Editorial

Paying for Universal Health Coverage

June 7, 2009
The New York Times

For Congress and the administration to keep the promise of comprehensive health care reform, they will have to find the political will to pay for universal coverage and other investments that are needed right away but will not produce quick savings. The cost could reach $1.5 trillion over the next decade.

President Obama, who had already proposed some $634 billion in new taxes and spending cuts, endorsed additional ideas last week. But Congressional Democrats will almost certainly need to come up with a lot more money — and that is likely to mean new taxes.

There are at least two easy ways to duck the problem should Congress choose to be imprudent. One way out would be to abandon the goal of universal coverage until after costs have been controlled. That would be unfair to the 46 million uninsured Americans, who often suffer health damage because they are reluctant to seek treatment until their plight becomes desperate.

Another way out would be to finance universal coverage by adding to the deficit, the path that George W. Bush took to pay for his tax cuts for the wealthy. With deficits already at high levels, Mr. Obama has reasonably insisted that health care reforms have to be “deficit neutral” over a 10-year period, meaning that any upfront costs must be fully paid for through cost reductions or new revenues by the end of a decade.

Mr. Obama’s budget experts have proposed short-term savings of more than $300 billion in the Medicare and Medicaid programs. They would eliminate unjustified subsidies given to private plans that participate in Medicare and reduce payments to home health care providers, drug companies and many hospitals.

Last week, Mr. Obama said he would work with the Senate to find $200 billion to $300 billion more in Medicare and Medicaid savings. He endorsed one way to ensure that cuts would actually be made — saying he was open to giving an obscure panel, the Medicare Payment Advisory Commission, enormous power to set Medicare payment rates. That would insulate Congress from lobbying by every group whose income might be reduced.

Mr. Obama said he was receptive to proposals that would require most Americans to take out health insurance and most employers, except for small businesses, to share the cost. Both would pump money into the system and help defray the costs of reform.

Virtually all experts agree that more revenues will be needed. Mr. Obama’s proposal to limit itemized deductions by wealthy Americans met with a cool reception but ought to remain on the table. Significant money could be raised by increasing taxes on sugared drinks, alcohol, tobacco and other products that are bad for one’s health. But more taxes will probably be needed.

Even the liberal-leaning Center on Budget and Policy Priorities suggested last week that Congress is unlikely to be able to pay for universal coverage unless it takes the unpopular step of limiting the tax exclusion for the value of the health insurance provided by an employer. It is the nation’s costliest tax subsidy, and some experts believe it encourages overuse of medical services.

Congress has heavy lifting ahead. It must foster reforms that are apt to reduce costs in the long-run (past the 10-year mark) and find a mix of short-term savings and tax increases to put us on course without driving up the deficit.

    Paying for Universal Health Coverage, NYT, 7.6.2009, http://www.nytimes.com/2009/06/07/opinion/07sun1.html?hpw

Obama Urges Effort on Health Care

June 7, 2009
The New York Times
By HELENE COOPER

WASHINGTON — President Obama, signaling the start of his health care push, called on Congress and his government to tackle “the root causes of skyrocketing health care costs.”

In his weekly radio and Internet address on Saturday morning, Mr. Obama said that he wants to see health care reform that is built around lowering costs, improving quality and coverage and protecting consumer choice.

“That means if you like the plan you have, you can keep it,” the president said. “If you like the doctor you have, you can keep your doctor, too. The only change you’ll see are falling costs as our reforms take hold.”

Just how he plans to achieve that remains up in the air; the address was long on broad goals and short on specifics. Mr. Obama said that he had made it clear to Congress that health reform should not add to the budget deficit.

“We’ll work with Congress to fully cover the costs through rigorous spending reductions and appropriate additional revenues,” Mr. Obama said. “We’ll eliminate waste, fraud and abuse in our health care system, but we’ll also take on key causes of rising costs — saving billions while providing better care to the American people.”

Mr. Obama has been gearing up for a battle over health care reform since he took office, convening a health care summit and inviting industry leaders to the White House, where they publicly pledged to cut $2 trillion in health care costs over the next decade.

“Simply put, the status quo is broken,” Mr. Obama said in the address. “We cannot continue this way. If we do nothing, everyone’s health care will be put in jeopardy. Within a decade, we’ll spend one dollar out of every five we earn on health care — and we’ll keep getting less for our money.”

The address came as Mr. Obama neared the end of his trip abroad. On Saturday he was in France, attending the commemoration ceremonies surrounding the 65th anniversary of D-Day.

    Obama Urges Effort on Health Care, NYT, 7.6.2009, http://www.nytimes.com/2009/06/07/us/politics/07address.html?hp

Senators Set to Visit White House

to Discuss Health Care Overhaul

June 2, 2009
The New York Times
By SHERYL GAY STOLBERG
and ROBERT PEAR

WASHINGTON — President Obama will meet with influential Senate Democrats on Tuesday to discuss overhauling health care, as the White House releases a report asserting that revamping the system would increase the income of a typical family of four by $2,600 in 2020, and by $10,000 in 2030.

The Democrats on two Senate committees that are drafting health legislation have been invited to the White House to meet with Mr. Obama, hours before he leaves for the Middle East and Europe. As part of a push to secure Congressional passage of a bill this year, the administration will also make the case on Tuesday that reforming health care is critical to fixing the economy.

“If we don’t do this we’re going to be facing a real mess 30 years from now,” Christina Romer, the chairwoman of the White House Council of Economic Advisers, told reporters Monday on a conference call to discuss her new report, “The Economic Case for Health Care Reform.”

Also, six health care organizations followed up Monday on a commitment they made last month to Mr. Obama to trim $2 trillion in health care costs over 10 years. The groups, representing doctors, hospitals, drug companies and a labor union, proposed eliminating unnecessary medical tests and procedures, slashing red tape and better managing chronic diseases.

They said the potential savings could be $1 trillion to $1.7 trillion over 10 years.

Health care spending in the United States accounts for 18 percent of the gross domestic product, according to the White House report, and is expected to rise sharply, to as much as 28 percent in 2030 and 34 percent in 2040. The administration says it can slow the growth of health spending even as it expands coverage to the more than 45 million people who are now uninsured.

Republicans are doubtful. Referring to the health care groups’ proposals, Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said Monday, “I’m skeptical that these proposals will add up to anywhere near $2 trillion.”

The House Republican leader, Representative John A. Boehner of Ohio, called the White House report “nothing more than smoke and mirrors,” and said the administration had not offered a credible plan to expand coverage “without raising taxes or rationing care.”

The White House report — 51 pages, with charts, graphs and algebraic formulas — estimated that slowing the growth rate of health care spending by 1.5 percent a year would increase economic output by more than 2 percent in 2020 and nearly 8 percent in 2030. The report also states that revamping the health care system would “prevent disastrous increases in the federal budget deficit.”

The 1.5 percent figure was cited as a goal by the six organizations that proposed cost savings to the president. Each submitted recommendations, though it was not clear how much each was willing to sacrifice.

The Pharmaceutical Research and Manufacturers of America, representing drug companies, advocated greater use of certain prescription drugs, like medicines for high blood pressure — a move it said could save lives and money by keeping people healthier and reducing hospital admissions.

Doctors, represented by the American Medical Association, promised to try to curb the overuse of imaging services, like magnetic resonance imaging of the knee and the shoulder, and to reduce surgeries that might not be necessary, like Caesarean section deliveries and angioplasties in patients with stable coronary artery disease.

The Service Employees International Union said Medicaid and Medicare could save money by encouraging the use of home care services, instead of nursing homes. The union recommended that the federal government temporarily increase Medicaid payments to the states for home- and community-based services.

America’s Health Insurance Plans, representing insurers, vowed to establish standard claim forms and Web sites that allowed doctors to communicate more easily with insurers.

Congress may try to put some proposals into legislation, to help offset the costs of providing coverage for millions of the uninsured. This week, the chairmen of the two relevant Senate committees are finishing legislation to be considered by their panels this month.

    Senators Set to Visit White House to Discuss Health Care Overhaul, NYT, 2.6.2009, http://www.nytimes.com/2009/06/02/health/policy/02health.html?hpw

Cigarettes Without Smoke,

or Regulation

June 2, 2009
The New York Times
By KATIE ZEZIMA

FALL RIVER, Mass. — During 34 years of smoking, Carolyn Smeaton has tried countless ways to reduce her three-pack-a-day habit, including a nicotine patch, nicotine gum and a prescription drug. But stop-smoking aids always failed her.

Then, having watched a TV infomercial at her home here, Ms. Smeaton tried an electronic cigarette, which claimed to be a less dangerous way to feed her addiction. The battery-powered device she bought online delivered an odorless dose of nicotine and flavoring without cigarette tar or additives, and produced a vapor mist nearly identical in appearance to tobacco smoke.

“I feel like this could save my life,” said Ms. Smeaton, 47, who has cut her tobacco smoking to a pack and a half daily, supplemented by her e-cigarette.

That electronic cigarettes are unapproved by the government and virtually unstudied has not deterred thousands of smokers from flocking to mall kiosks and the Internet to buy them. And because they produce no smoke, they can be used in workplaces, restaurants and airports. One distributor is aptly named Smoking Everywhere.

The reaction of medical authorities and antismoking groups has ranged from calls for testing to skepticism to outright hostility. Opponents say the safety claims are more rumor than anything else, since the components of e-cigarettes have never been tested for safety.

In fact, the Food and Drug Administration has already refused entry to dozens of shipments of e-cigarettes coming into the country, mostly from China, the chief maker of them, where manufacture began about five years ago. The F.D.A. took similar action in 1989, refusing shipments of an earlier, less appealing version, Favor Smoke-Free Cigarettes.

“These appear to be unapproved drug device products,” said Karen Riley, a spokeswoman for the agency, “and as unapproved products they can’t enter the United States.”

But enough of the e-cigarettes have made their way into the country that they continue to proliferate online and in the malls.

For $100 to $150 or so, a user can buy a starter kit including a battery-powered cigarette and replaceable cartridges that typically contain nicotine (though cartridges can be bought without it), flavoring and propylene glycol, a liquid whose vaporizing produces the smokelike mist. When a user inhales, a sensor heats the cartridge. The flavorings include tobacco, menthol and cherry, and the levels of nicotine vary by cartridge.

Propylene glycol is used in antifreeze, and also to create artificial smoke or fog in theatrical productions. The F.D.A. has classified it as an additive that is “generally recognized as safe” for use in food. But when asked whether inhaling it was safe, Dr. Richard D. Hurt, director of the Nicotine Dependence Center at the Mayo Clinic, said, “I don’t think so, but I’m not sure anyone knows for sure.”

Of the e-cigarettes themselves, Dr. Hurt added: “We basically don’t know anything about them. They’ve never been tested for safety or efficacy to help people stop smoking.”

Public health officials also worry that the devices’ fruit flavors, novelty and ease of access may entice children.

“It looks like a cigarette and is marketed as a cigarette,” said Jonathan P. Winickoff, an associate professor at the Massachusetts General Hospital for Children and chairman of the American Academy of Pediatrics Tobacco Consortium. “There’s nothing that prevents youth from getting addicted to nicotine.”

Sales and use of electronic cigarettes are already illegal on safety grounds in Australia and Hong Kong, and some other countries regulate them as medicinal devices or forbid their advertising. So far the United States has focused only on stopping them at the border, although Senator Frank R. Lautenberg, Democrat of New Jersey, has asked the drug agency to take them off the market until they can be tested.

Distributors of electronic cigarettes fear that a bill making its way through Congress that would give the F.D.A. the authority to regulate tobacco could be used to put them out of business as well. The bill has passed the House and could be taken up by the Senate this week.

The only American study of electronic cigarettes, now under way at Virginia Commonwealth University and financed by the National Cancer Institute, deals not with the kind of safety questions raised by propylene glycol but rather with the amount of nicotine processed by the bodies of the products’ users.

Another study, conducted this year at the University of Auckland in New Zealand and financed by Ruyan, an electronic cigarette company, shows that users typically receive 10 percent to 18 percent of the nicotine delivered by a tobacco cigarette.

Smoking Everywhere, a Florida-based distributor of electronic cigarettes, sued the F.D.A on April 28, claiming that the agency did not have jurisdiction to refuse the imported devices.

“The F.D.A. has the power to regulate Nicorette gum and the like because it is marketed as a smoking cessation product,” said Kip Schwartz, a lawyer for Smoking Everywhere. But the company says its products are a cigarette alternative for adult enjoyment and make no claims to help smokers quit, Mr. Schwartz added.

Matt Salmon, a spokesman for the Electronic Cigarette Association, which represents six distributors, said e-cigarettes delivered nothing more than a mixture of nicotine and water vapor and emitted “no carcinogens.” The association declined to give sales figures, but said that “hundreds of thousands” of people used the products and that the average age of those users was the mid-40s.

“It’s a really good alternative for people who smoke tobacco,” Mr. Salmon said.

Edwin Schwab, who quit smoking regular cigarettes last year after trying e-cigarettes, likes them so much he has started selling them at a mall kiosk in Providence, R.I.

Mr. Schwab took his e-smoke along when he went out one night, he said, “and when everyone was smoking outside in the cold, I just stood in the warm bar, smoking.”

    Cigarettes Without Smoke, or Regulation, NYT, 2.6.2009,
    http://www.nytimes.com/2009/06/02/us/02cigarette.html?hp

Kan. Doctor Refused to Quit:

'I Know They Need Me'

June 2, 2009
Filed at 5:12 a.m. ET
By THE ASSOCIATED PRESS
The New York Times

To some he was an unflinching hero, to others a remorseless villain. As a late-term abortion doctor, George Tiller knew he had chosen a dangerous career, one that made him a lightning rod. His clinic was a fortress, his days marred by threats, but he refused to give up what he saw as his life's mission.

''He never wavered,'' says Susie Gilligan, who knew Tiller as part of her work in the Feminist Majority Foundation. ''He never backed away. He had incredible strength. When you spoke to him, he was a soft-spoken man, a very gentle man. He said, 'This is what I have to do. Women need me. I know they need me.'''

Tiller, 67, whose Wichita, Kan., clinic had been the target of anti-abortion protests for more than two decades, was fatally shot Sunday while serving as an usher at his church. The suspect, identified by police as Scott Roeder, was taken into custody three hours later. He was booked without bail on one count of first-degree murder and two counts of aggravated assault.

As one of a few doctors across the nation to perform third-trimester abortions, Tiller had survived an earlier shooting, his clinic was bombed, his home picketed. He hired a Brink's armored truck to take him to work for several weeks, he had federal marshals protecting him for 30 months. He built a new surgical center without windows and he was known to wear a bulletproof vest, sometimes even to church.

Through it all, he stood defiant.

When a pipe bomb heavily damaged his clinic in the mid 1980s, he hung a sign outside the rubble saying: ''Hell, No. We Won't Go!'' He offered a $10,000 award -- which was never collected.

When thousands of protesters gathered at the Women's Health Care Services clinic in 1991 for the 45-day ''Summer of Mercy'' demonstration staged by Operation Rescue, he was again unbowed.

''I am a willing participant in this conflict,'' he said at the time. ''I choose to be here because I feel that it is the moral, it is the ethical thing to do.''

He told The Wichita Eagle newspaper in 1991 that prayer and meditation helped him through hard times. ''If I'm OK on the inside,'' he said, ''what people say on the outside does not make much difference.''

When a woman passing out anti-abortion literature shot him in both arms outside the clinic two years later, he briefly pursued her by car, recalls Peggy Bowman, his former spokeswoman. ''He didn't even know he was shot and all of a sudden he saw this blood (and figured), 'I probably shouldn't spend my time chasing this woman,''' she says.

Tiller suffered minor wounds -- and was back at the clinic the next day. (That's when he hired the armored truck.)

This spring, Tiller was acquitted of misdemeanor charges of violating Kansas restrictions on late-term abortions. Shortly after, the state's medical board announced it was investigating allegations against him that were nearly identical to those a jury had rejected.

Tiller's outspokenness rankled his critics, who decried as a publicity stunt his offer several years ago to provide free abortions on the anniversary of the Roe vs. Wade Supreme Court decision that legalized abortion. He said at the time at least 32 low-income women signed up for the free first-trimester abortions.

Abortion opponents also claimed Tiller's large financial involvement in Kansas politics thwarted prosecutions against him. They routinely blamed Tiller's ''corrupt influences in the government'' whenever legislation strengthening state abortion laws failed to pass the Legislature or was vetoed by the governor.

While anti-abortion activists have condemned Tiller's death, Randall Terry, founder of Operation Rescue -- who also said the gunman was wrong -- told the National Press Club on Monday the doctor was ''a mass murderer and, horrifically, he reaped what he sowed.''

Tiller, a former Navy flight surgeon, hadn't planned to be an abortion doctor. He hoped to become a dermatologist.

But when his father, also a doctor, died in a plane crash (his mother, sister and brother-in-law also were killed), he took over the family practice. He soon learned the elder Tiller had performed abortions.

''In reading through some of his records, he realized his father had done abortions when they were illegal,'' says Bowman, his former spokeswoman. ''At first, he was really shocked. Then in going through those charts, he totally began to understand the importance of this service.''

Friends and colleagues say Tiller, a father of four and grandfather of 10, was a strong-willed, unassuming man who was quick with a hug or a joke. He decorated his office with family photos. He cherished rituals; he raised American flags in his clinic parking lot after the 1991 protests were over and later gave them to volunteers.

''He was never riled, he was always calm and cool,'' says Eleanor Smeal, president of the Feminist Majority Foundation. ''He was a very serious man, but a very good-natured one.''

In a 2008 speech to a young women's leadership conference sponsored by the foundation, he said he was on a hit list in 1994, leading to federal protection. His wife was stalked, he said, and the names of his vendors were made public on the Internet.

''But the good news,'' he said, ''is we still live in the United States of America'' and Roe vs. Wade allows women the opportunity to terminate pregnancies.

Dr. Susan Robinson, a California obstetrician-gynecologist who calls Tiller her mentor, recalls one day when she asked him: ''How can you stand it being in a pressure cooker?' He said, 'If it it's none of my business, I don't get involved. If it doesn't matter, I don't get involved. If there's nothing I can do about it, I don't get involved.' ''

But it was clear his work had taken a toll. Willow Eby, who worked as a volunteer escort at the clinic, remembers a conference she attended last year for abortion providers where he talked about his work.

''He explained that this would take your youth, it would take your energy, it would wear you down,'' she recalls. ''But he said he would not let down the women who needed him badly.''

Tiller once said his ''gifts of understanding'' helped him bring a service to women that aided them in fulfilling their dreams of a happy, healthy family. It was important, he said, that women have a choice when dealing with technology that can diagnose severe fetal abnormalities before a baby is born.

''Prenatal testing without prenatal choices is medical fraud,'' he declared.

Colleagues said Tiller's office walls were lined with letters from patients expressing their thanks.

One woman who turned to him was Miriam Kleiman, of northern Virginia. Nine years ago, a routine sonogram revealed her 29-week-old fetus had major brain abnormalities that prevented the baby's heart and lungs from functioning properly.

Doctors told her the baby would die in utero or soon after birth. Kleiman's doctors told her a third trimester abortion was not possible.

Kleiman says she could not bear a two-month death watch. ''There was a baby dying inside of me, and it wasn't if, but when,'' she says.

After desperate pleas, she says, a doctor scribbled Tiller's name on a scrap of paper. She and her husband flew to Wichita and drove through a gauntlet of protesters to the fortress-like clinic.

She remembers Tiller and his staff as kind and compassionate. She had the abortion and brought home her baby to be buried.

Kleiman, who now has two sons, says she cried when she heard of Tiller's death while watching her son's soccer game.

''I fear,'' she says, ''that other people might not have this option in the future -- to have a medical option that was safe, that was legal and allowed us to say goodbye with dignity.''

--------

Associated Press writers Roxana Hegeman in Wichita and Sam Hananel in Washington, D.C., contributed to this report and Rhonda Shafner in New York provided research.

    Kan. Doctor Refused to Quit: 'I Know They Need Me', NYT, 2.6.2009, http://www.nytimes.com/aponline/2009/06/02/us/AP-US-Tiller-Profile.html

Abortion Doctor Slain by Gunman

in Kansas Church

June 1, 2009
The New York Times
By JOE STUMPE and MONICA DAVEY

WICHITA, Kan. — George Tiller, one of only a few doctors in the nation who performed abortions late in pregnancy, was shot to death here Sunday in the foyer of his longtime church as he handed out the church bulletin.

The authorities said they took a man into custody later in the day after pulling him over about 170 miles away on Interstate 35 near Kansas City. They said they expected to charge him with murder on Monday.

The Wichita police said there were several witnesses to the killing, but law enforcement officials would not say what had been said, if anything, inside the foyer. Officials offered little insight into the motive, saying that they believed it was “the act of an isolated individual” but that they were also looking into “his history, his family, his associates.”

A provider of abortions for more than three decades, Dr. Tiller, 67, had become a focal point for those around the country who opposed it. In addition to protests outside his clinic, his house and his church, Dr. Tiller had once seen his clinic bombed; in 1993, an abortion opponent shot him in both arms. He was also the defendant in a series of legal challenges intended to shut down his operations, including two grand juries that were convened after citizen-led petition drives.

On Sunday morning, moments after services had begun at Reformation Lutheran Church, Dr. Tiller, who was acting as an usher, was shot once with a handgun, the authorities said. The gunman pointed the weapon at two people who tried to stop him, the police said, then drove off in a powder-blue Taurus. Dr. Tiller’s wife, Jeanne, a member of the church choir, was inside the sanctuary at the time of the shooting.

The police in Wichita described the man who was detained as a 51-year-old from Merriam, a Kansas City suburb, but declined to give his name until he was charged. The Associated Press reported that a sheriff’s official from Johnson County, Kan., where the man was taken into custody, identified him as Scott Roeder.

The killing of Dr. Tiller is likely to return the issue of abortion to center stage in the nation’s political debate. Until recently, President Obama, who supports abortion rights, had largely sought to avoid the debate. Last month, he confronted the issue in a commencement speech at the University of Notre Dame, an appearance that drew protests because of his views. During the speech, he appealed to each side to respect one another’s basic decency and to work together to reduce the number of unwanted pregnancies.

Mr. Obama issued a statement after Dr. Tiller’s killing, saying, “However profound our differences as Americans over difficult issues such as abortion, they cannot be resolved by heinous acts of violence.”

Advocates of abortion rights denounced the killing, saying it would send a renewed, frightening signal to others who provide abortions or work in clinics and to women who may consider abortions. Some described Dr. Tiller as one of about only three doctors in the country who had, under certain circumstances, provided abortions to women in their third trimester of pregnancy, and said his death would mean that women, particularly in the central United States, would have few if any options in such cases.

“This is a tremendous loss on so many levels,” said Peter B. Brownlie, president of Planned Parenthood of Kansas and Mid-Missouri, who had known Dr. Tiller for years.

Opponents of abortion, including those here who have been most vociferous in their protests of Dr. Tiller and his work, also expressed outrage at the shooting and said they feared that their groups might be wrongly judged by the act.

Troy Newman, the president of Operation Rescue, an anti-abortion group based in Wichita, said he had always sought out “nonviolent” measures to challenge Dr. Tiller, including efforts in recent years to have him prosecuted for crimes or investigated by state health authorities.

“Operation Rescue has worked tirelessly on peaceful, nonviolent measures to bring him to justice through the legal system, the legislative system,” Mr. Newman said, adding, “We are pro-life, and this act was antithetical to what we believe.”

By late Sunday, Mr. Newman said, some were already suggesting that there were links between the suspect and Operation Rescue. Someone named Scott Roeder had made posts to the group’s blog in the past, Mr. Newman said, but “he is not a friend, not a contributor, not a volunteer.”

Dr. Tiller’s death is the first such killing of an abortion provider in this country since 1998, when Dr. Barnett Slepian was shot by a sniper in his home in the Buffalo area. Dr. Tiller was the fourth doctor in the United States who performed abortions to be killed in such circumstances since 1993, statistics from abortion rights’ groups show.

Although most of the deadly violence occurred in the 1990s, advocates said, abortion clinics and doctors have continued to be the targets of intense, sometimes threatening protests. Some said they feared that Dr. Tiller’s death might signal a return to the earlier level of violence. At some clinics on Sunday, administrators were reviewing their security precautions.

Adam Watkins, 20, one of the church members, told The A.P. he was seated in the middle of the congregation when he heard a small pop at the start of the service. An usher came in and told the congregation to remain seated, and then escorted Mrs. Tiller out. “When she got to the back doors, we heard her scream,” Mr. Watkins said.

Dr. Tiller had long been at the center of the abortion debate here, one that rarely seemed to quiet much in this southern Kansas city of about 358,000.

In 1993, Rachelle Shannon, from rural Oregon, shot Dr. Tiller in both arms. Two years earlier, during Operation Rescue’s “Summer of Mercy” protests, thousands of anti-abortion protesters tried to block off the clinic, the site of a bombing in 1986.

Friends of Dr. Tiller also described regular incidents of vandalism at the clinic, and a barrage of threats to him and his family — threats they say had concerned him deeply for years.

Family members, including 4 children and 10 grandchildren, issued a statement through Dr. Tiller’s lawyer, which read in part: “George dedicated his life to providing women with high-quality health care despite frequent threats and violence. We ask that he be remembered as a good husband, father and grandfather and a dedicated servant on behalf of the rights of women everywhere.”

In recent years, Dr. Tiller had also been the focus of efforts by anti-abortion groups and others — including a former state attorney general, Phill Kline — who wished to see him prosecuted for what they considered violations of state law in cases of late-term abortions.

Two grand juries, summoned by citizen-led petition drives, looked into Dr. Tiller’s practices, including questions of whether he met a state law requirement that abortions at or after 22 weeks of pregnancy be limited to circumstances where a fetus would not be viable or a woman would otherwise face “substantial and irreversible impairment of a major bodily function” — words whose interpretation were at the root of much debate.

This year, Dr. Tiller was acquitted in a case that raised questions about whether he was too closely tied to a doctor from whom he sought second opinions in abortion cases. As recently as this spring, the State Board of Healing Arts was investigating a similar complaint against him.

 

Joe Stumpe reported from Wichita, Kan.,
and Monica Davey from Chicago.

Abortion Doctor Slain by Gunman in Kansas Church, NYT, 1.6.2009, http://www.nytimes.com/2009/06/01/us/01tiller.html