History > 2009 > USA > Health (V)

Illustration: Ruth Gwily

A Better Way to Get a Kidney

NYT

11 July 2009

https://www.nytimes.com/2009/07/11/
opinion/11rose.html 

Letters

Seeking Choice in Health Reform

August 30, 2009
The New York Times

To the Editor:

Re “Real Choice? It’s Off Limits in Health Bills” (Economic Scene, front page, Aug. 26):

As a physician, I was encouraged by David Leonhardt’s article. He hits the nail on the head. Real consumer choice is not addressed in the bills currently being considered in Congress and by the White House.

In contrast, the Wyden-Bennett bill speaks directly to the issue of choice by phasing out employer-based health insurance and allowing individuals and families to choose the health plan that’s best for them. Moreover, the universal coverage this bill proposes is comprehensive, portable, affordable and financially sustainable.

Unfortunately, President Obama seems to feel that universal coverage can be accomplished without changing the status quo. It is time to rethink this position, educate the American public on the real costs of employer-based health care and move in the direction of true health care reform.

Those who stand to benefit most are the American people themselves.

Daniel N. Ovadia
Santa Barbara, Calif., Aug. 26, 2009

•

To the Editor:

David Leonhardt correctly argues that private insurance plans and employers exercise too many of the choices in today’s health care system, and that a better system would give people more control of their own care. But the other essential half of the dyad that should control the use of medical resources is physicians.

Doctors in consultation with their patients — not insurance plans, not employers and not government officials — now make most of the decisions that determine how health dollars are spent. Fee-for-service payment and an entrepreneurial, fragmented system heavily weighted in favor of specialists cause unsustainable cost inflation.

A reform that does not address these problems, as well as eliminate or reduce the role of private insurers and employers, cannot succeed. Regrettably, none of the proposals now before Congress meet this requirement.

Arnold S. Relman
Marcia Angell
Cambridge, Mass., Aug. 26, 2009

The writers are physicians and former editors in chief of The New England Journal of Medicine. Dr. Relman is professor emeritus of medicine and social medicine at Harvard Medical School, and Dr. Angell is a senior lecturer in social medicine there.

•

To the Editor:

David Leonhardt’s article promoting “real choice” in health insurance alludes to a fundamental difficulty with this approach. Without some system for helping the consumer know what he is choosing, the whole premise of the free market breaks down.

As Mr. Leonhardt observes, today’s employee depends on his company to provide a menu of sensible choices. As the well-known problems with Medicare Part D insurance demonstrate, having the consumer deal directly with insurance companies is a risky undertaking.

The two major issues, which apply to the broader case as well, are understanding what is covered and being able to change providers if the coverage is modified.

This is not to say that the current system should continue. Mr. Leonhardt’s description of its fatal flaws is spot on. But any proposal for “competition” and “free market” mechanisms must include some way to make the consumer an educated consumer.

I expect that one part of this must be government regulation of the details of the insurance that can be offered. Until such mechanisms are added to any free-market scheme, the sensible fears of the currently insured will prevent its adoption.

Marc Auslander
Millwood, N.Y., Aug. 26, 2009

•

To the Editor:

For most people, “real choice” in health care is not the choice of an insurance plan; it’s the choice of a primary care physician.

Employer options come and go, and one private plan is usually as good as another, as long as an involuntary switch doesn’t come between a family and a trusted, longtime caregiver. Fragmented physician panels that capriciously interrupt continuity of care are resented by patients and physicians alike.

As in so many other ways, single-payer health care provides the answer: one big panel of doctors, with complete freedom of choice for patients. Of course, that’s not politically viable.

It might protect hard-won, deeply valued doctor-patient relationships, and it might save money and produce better health outcomes. But we wouldn’t want to harm the insurance industry!

Bruce Soloway
Bronx, Aug. 26, 2009

The writer, a physician, is vice chairman of the department of family and social medicine at Montefiore Medical Center.

•

To the Editor:

Historically, Americans have believed in economic competition, freedom of choice and fairness in seeking economic opportunity.

During the rampant industrialization of the nation near the end of the 19th century, competition fell victim to monopolies. The passage of the Sherman Antitrust Act in 1890 was watershed legislation by the federal government to maintain competition.

During the Progressive Era leaders like Woodrow Wilson and Theodore Roosevelt were obliged to call for regulation in business and finance. Franklin D. Roosevelt ushered in even greater federal regulation during the Great Depression.

The current recession has compelled the federal government to become a more gigantic player in the marketplace. President Obama should stick with his call for a public option to bring about choice and competition within the health insurance industry.

Don Blankenbush
Pennington, N.J., Aug. 26, 2009

•

To the Editor:

Regardless of their respective strengths and weaknesses, all of the bills for health care reform are too complex to explain, grasp and support. And Republicans have made it abundantly clear that they will oppose any truly meaningful change.

Yet these very obstacles present the president with the opportunity to do what is sensible and right: to put his conviction, passion and clout behind a single-payer system.

Will people be afraid of so radical a change? The majority probably will; people tend to fear the unknown.

But “the shock of the new” is as old as innovation itself. Eventually, people adapt to change and ultimately embrace it.

Byron Alpers
Shorewood, Wis., Aug. 26, 2009

•

To the Editor:

Re “World’s Best Health Care” (editorial, Aug. 26):

The United States health care system is not the world’s best by almost any measure. But one must understand that health care is typically measured by its outcomes. These outcomes, like longevity and infant mortality, are more than just a consequence of availability of health insurance and access to doctors and hospitals.

Health care outcomes are influenced by many complex and poorly understood factors that relate to society’s structure, including socioeconomic forces and race. This is true in the United States and globally.

The American health care system is in bad need of reforms that will eliminate the tragedy of 46 million uninsured people.

But our government and its citizens also need to study and address the broader issues, like economic inequity and racial segregation, that underlie our inability to achieve the health care outcomes that other societies have achieved. Otherwise, we will be very disappointed with the results of the current legislative efforts.

Garrett M. Nash
New York, Aug. 26, 2009

The writer, a physician, is an assistant professor of surgery at Weill-Cornell Medical College.

    Seeking Choice in Health Reform, NYT, 30.8.2009, http://www.nytimes.com/2009/08/30/opinion/l30health.html

Letters

Helping Patients Cope With Death

August 29, 2009
The New York Times

To the Editor:

“At the End, Offering Not a Cure but Comfort” (“Months to Live” series, front page, Aug. 20) presented a detailed, sensitive look at one aspect of palliative care — hospice care — but could leave the impression that palliative care is only for patients who are dying. That is not true. It can help patients who will live years after they receive a diagnosis of a life-threatening or chronic illness.

Too many patients fail to receive the pain relief, emotional support and guidance in navigating the health care system that palliative care provides because they think it comes at a terrible price: giving up on a cure. In fact, palliative care can help patients better tolerate treatments as they recover.

Patients battling serious illnesses should talk to their doctors about palliative care. It’s possible to have comfort and a cure.

Gail Austin Cooney
West Palm Beach, Fla., Aug. 20, 2009

The writer, medical director of Hospice of Palm Beach County, is president of the American Academy of Hospice and Palliative Medicine.

•

To the Editor:

Your article portrayed the challenges a New York doctor faces when discussing end-of-life care options with dying patients, and the preference of many for palliative rather than aggressive care. But the article does not address the legal obstacles faced by families in this state when making such decisions for dying, incapable patients.

In most states, when a patient is dying, lacks capacity and did not leave an advance directive, doctors can seek guidance from close family members about how aggressively the patient would want to be treated. In New York, unless the patient left clear evidence of a decision to forgo treatment or appointed a health care agent, the law demands continuing life-sustaining treatment — even when the patient probably would oppose it, the family opposes it and the doctors advise against it.

The Family Health Care Decisions Act would give close family members greater flexibility to make these decisions. The State Senate passed the bill in July; the Assembly had passed an earlier version, but did not get to the new bill before its summer recess. It needs to pass the bill promptly when it reconvenes.

Robert N. Swidler
East Greenbush, N.Y., Aug. 21, 2009

The writer is general counsel to Northeast Health, a not-for-profit health care system.

•

To the Editor:

Dealing with patients near the end of life is more a part of the art, rather than the science, of medicine, and as such it is an intensely personal matter that varies from doctor to doctor. In the more than 40 years that I practiced internal medicine, I was guided by three precepts regarding the care of the dying patient:

Tell the truth with mercy.

Never destroy hope.

As much as possible preserve human dignity.

Telling the truth without destroying hope gives the patient a chance to organize his life while facing the finality of death. Not only does he have an opportunity to determine what is important in his life, but he also has time to prepare his family for his death, say goodbye and, not mentioned in your article, make his peace with God.

Hospice care is an ideal way to preserve human dignity because it removes the burden of caring for the physical needs of the patient from the immediate family. The hospice organizations with which I dealt supplied nurses, aides and physicians who were compassionate, caring and effective. Almost without exception, my patients and their families were happy with and consoled by their help.

Palliative care certainly deserves a place in whatever health reform bill is formulated by Congress and the Obama administration.

John A. Wood
Water Mill, N.Y., Aug. 20, 2009

The writer was a clinical professor of medicine at the College of Physicians and Surgeons at Columbia University.

•

To the Editor:

Thank you for your good description of palliative medicine. Dr. Sean O’Mahony exemplifies the specialty’s exquisite attention to patient and family suffering, preferences and needs. This quality is what really allows difficult conversations — including about “bad news” — to take place, and effective comfort to be provided.

At the end of the article, however, you note that the doctor doesn’t expect to have further contact with the patient’s spouse. Actually, one would hope that Dr. O’Mahony or his staff did follow up in some way. A critical element of palliative care is bereavement support for the family after a loved one dies.

Stuart Green
Summit, N.J., Aug. 20, 2009

The writer is behavioral sciences director at Overlook Hospital.

•

To the Editor:

While reading about palliative care, I thought of a way to challenge this “death panel” talk. Simply withdraw all proposals for elective consultations on end-of-life care, and inform the public that such doctor visits will not be covered by Medicare — as they are not, now.

Then watch the outrage build, as people recognize the benefits of such care and regret that they cannot have it free.

My wife died of ovarian cancer nearly five years ago. We had consultations with two such practitioners, and they were invaluable, as were the living-will decisions we had made earlier. We had excellent insurance, in addition to my Medicare, so we never had to think about paying. But many less fortunate Americans do not.

Few people anticipate these things before they are confronted with them, and then it is too late, especially if they come with an additional price tag at the worst possible moment.

Kenneth R. Johnston
Princeton, N.J., Aug. 20, 2009

•

To the Editor:

Many patients with catastrophic or degenerative illness will describe their state as being worse than death itself. As a psychologist and a neutral advocate for patients navigating the complexities of end-of-life care, I am able to address their principal anxieties — about being alone and the loss of agency — in ways that reduce suffering and unwanted treatments.

Our use of psychologists in end-of-life care is dismally low. Leaving us out of current health reform proposals would increase both suffering and costs.

E. Martin Walker
Ridgewood, N.J., Aug. 20, 2009

The writer is director of the Later Lifespan Development Center at the William Alanson White Institute.

    Helping Patients Cope With Death, NYT, 29.8.2009, http://www.nytimes.com/2009/08/29/opinion/l29hospice.html

Forty Years' War

Weighing Hope and Reality

in Kennedy’s Cancer Battle

August 28, 2009
The New York Times
By GINA KOLATA
and LAWRENCE K. ALTMAN

Like almost no one else, Senator Edward M. Kennedy embodied the frustrations of the nation’s 40-year war on cancer.

Mr. Kennedy strongly supported the idea of a war on cancer, promoting it for months before President Richard M. Nixon announced the battle was to begin in 1971, and advocating for more money than Nixon initially wanted to spend.

And when Mr. Kennedy learned he had brain cancer last year, he became one of the millions whose fate was not much changed by the cancer war. Despite billions that have been spent, the death rate from most cancers barely budged.

Mr. Kennedy’s cancer, a glioblastoma, kills almost everyone who gets it, usually in a little over a year. Although he got the most aggressive treatment, Mr. Kennedy lived just 15 months after his diagnosis — just about the median survival for patients with his type of tumor who got the radiation and chemotherapy regimen that has become the standard of care.

“This remains just a dreadful tumor,” said Dr. Eugene S. Flamm, a neurosurgeon at Montefiore Medical Center in New York. Dr. Flamm, who was not involved with Mr. Kennedy’s treatment, added that when a patient developed glioblastoma, “there is not a hell of a lot you can do.”

The story of Mr. Kennedy’s battle with glioblastoma is one that raises questions of hope and reality and of how much the health care system should pay for hope. As has happened with most cancers in the nation’s 40-year war on cancer, progress on glioblastomas has been incremental. With these deadly brain cancers in particular, the disease remains poorly understood. And even though many patients, like Mr. Kennedy, who sought care at Duke University Medical Center, travel looking for cutting-edge care, there are limited options for treatment that have been shown to help.

Yet the cost is high. Estimates of the total cost from experts at various medical centers range from $100,000 to $500,000.

“If you have the insurance to come to Duke, no problem,” said Dr. Henry Friedman, co-director of the brain tumor center at Duke. But if patients are uninsured or underinsured, the situation is different. Then, he said, “we will work with their home physician to give them our expertise.”

Of course, for Mr. Kennedy, who had insurance as a senator, was eligible for Medicare and was personally wealthy, cost was never an issue.

“My wife, Vicki, and I have worried about many things, but not whether we could afford my care and treatment,” he wrote in Newsweek.

The bright side is that median survival time for glioblastoma patients has more than tripled in the past 40 years, from about four and a half months to 14 or 15 months today. And there are now a few rare patients who live four, five or six years. “We never saw that before,” said Dr. Lisa M. DeAngelis, chairwoman of the department of neurology at Memorial Sloan-Kettering Cancer Center.

Those extra months are mostly good quality life, said Dr. Mitchel S. Berger, chairman of neurosurgery at the University of California, San Francisco.

But few are sanguine.

“In no way do I want to come off making it sound like we’ve done a great job,” said Dr. Howard A. Fine, chief of the neuro-oncology branch at the National Cancer Institute.

Mr. Kennedy was extensively involved in the efforts to combat cancer. In the late 1960s, Mary Lasker, a Manhattan philanthropist, was campaigning for an all-out war on cancer and Senator Kennedy became a leading legislative supporter, setting off a tug of war between him and President Nixon for political credit.

In his State of the Union address in January 1971, Nixon proposed the likes of a Moon shot program to conquer cancer. In response, Mr. Kennedy advocated an even larger research budget and a boost in status for the National Cancer Institute. Nixon signaled that he would support those ideas, as long as Mr. Kennedy’s name was not on the bill, a condition Mr. Kennedy accepted, wrote Adam Clymer, a biographer of Mr. Kennedy and former reporter for The New York Times. In December 1971, Nixon signed the cancer bill.

On May 20, 2008, Mr. Kennedy announced that he himself had cancer. He had had a seizure three days before and been diagnosed with glioblastoma, the most common and most deadly of brain tumors, at the Massachusetts General Hospital. Ten days later, more than a dozen brain cancer experts met to discuss his treatment.

Everyone agreed that Mr. Kennedy should have the standard regimen of chemotherapy and radiation. Radiation had been standard since 1978, when a rigorous study showed it could extend survival to 36 weeks. Without radiation, median survival was 14 weeks.

In 2005, glioblastoma therapy had another advance. Radiation had improved — it was targeted to the tumor and not directed at the entire head, and patients were living longer, about a year. Then, a rigorous study found that if a drug, temozolomide, was added to radiation, median survival time was 14.6 months. That drug plus radiation became the standard of care.

The disagreement about Mr. Kennedy was over surgery. Ordinarily, if a tumor can be removed, it is removed when surgeons take tissue for a biopsy. Of course, Dr. DeAngelis says, even then, there is some tumor left behind.

“It may be microscopic, but we all know it’s there,” she said.

Mr. Kennedy’s tumor was diffuse, covering a large area, and his doctors at Massachusetts General had not tried to take it out when they removed tissue for biopsy. Some in the conference argued that the senator should have no further surgery. Others said he should.

Mr. Kennedy was in the middle of a common medical dilemma — doctors who disagree. At this point, with no definitive data, most have made up their minds for or against surgery in such cases, Dr. Fine said. In fact, doctors are so set in their opinions on this issue that most would be unwilling to suggest that patients enter a study in which their treatment — surgery or no surgery — would be decided at random.

“We’ve been talking about doing a clinical trial for 20 years,” Dr. Fine said, but, he added, it probably would be impossible to get patients. “Since there are no hard data, it becomes an issue of individual physician bias.”

Mr. Kennedy was apparently convinced that surgery might help. He flew to Duke for a three-and-a-half-hour operation on June 3. His doctors said it was “successful” but did not define success.

He was far from the only glioblastoma patient to travel to Duke. Most of the 1,000 new brain tumor patients treated there each year come from distant places, Dr. Friedman said.

They come, Dr. Friedman said, “because we give them hope.”

“If you go to the Internet and do a search on outcomes in glioma, everyone will call it a terminal illness,” he said, referring to the class of brain tumors that include glioblastomas. “Your outcome is ‘dead on diagnosis.’ If you don’t have the philosophy that you can win, you have lost before you started.”

Others say there was nothing extraordinary about the treatment Mr. Kennedy got at Duke.

“I believe he received the standard of care,” said Dr. Raymond Sawaya, chairman of the department of neurosurgery at M. D. Anderson Cancer Center and one who was part of Mr. Kennedy’s initial medical conference and argued against the surgery.

And while care for glioblastoma has steadily improved, experts agree that, as Dr. Mark Gilbert, a professor in the department of neuro-oncology at M. D. Anderson, put it, glioblastoma remains “a scary, grim disease.”

Forty years ago, when the war on cancer began, patients had minimal surgery, if any, Dr. Berger said. That was sometimes followed by radiation to the entire brain, which caused “tremendous cognitive defects within months.” Some also got a chemotherapy drug like carmustine. But the chemotherapy was not very effective. A paper published in 2003 in the Journal of Clinical Oncology stated that “the effect of chemotherapy on this disease has been minimal.”

But while chemotherapy did not improve until 2005, surgery and radiation began improving about 20 years ago. The advent of M.R.I.’s meant that surgeons could see exactly where a tumor was and carefully plan operations. And doctors learned to target radiation to small areas. Mr. Kennedy’s ability to function, Dr. Berger said, “would have been very different if he had gotten the standard treatment 30, 40 years ago.”

Now, most major medical centers offer the same treatment: surgery, if the tumor can be safely removed, chemotherapy, radiation, and a new drug, Avastin. Yet glioma specialists say it is common for patients to travel, often long distances, to get what they hope will be the most aggressive care.

“That is almost part of the American culture as it relates to health care,” Dr. Berger said. “We feel empowered to go anywhere we want for the most part.”

These days, with a focus on controlling health care costs, it might seem that limiting patients’ options and restricting treatments that add maybe a few months of life might be a good place to start. But health economists say that would be a terrible idea.

“We are all in favor of eliminating waste,” said Mark Pauly, a professor of health care management at the Wharton School at the University of Pennsylvania. “But when it’s your life that’s on the line, you tend to behave quite differently.”

“The economist in me says, If you want to save money, this is probably a good place to take it from,” Dr. Pauly said. “The human being in me says, I don’t want to do it.”

    Weighing Hope and Reality in Kennedy’s Cancer Battle, NYT, 28.8.2009, http://www.nytimes.com/2009/08/28/health/28brain.html

Some Roman Catholic Bishops

Assail Health Plan

August 28, 2009
The New York Times
By DAVID D. KIRKPATRICK

WASHINGTON — The United States Conference of Catholic Bishops has been lobbying for three decades for the federal government to provide universal health insurance, especially for the poor. Now, as President Obama tries to rally Roman Catholics and other religious voters around his proposals to do just that, a growing number of bishops are speaking out against it.

As recently as July, the bishops’ conference had largely embraced the president’s goals, although with the caveat that any health care overhaul avoid new federal financing of abortions. But in the last two weeks some leaders of the conference, like Cardinal Justin Rigali, have concluded that Democrats’ efforts to carve out abortion coverage are so inadequate that lawmakers should block the entire effort.

Others, echoing the popular alarms about “rationing,” contend that the proposals could put a premium on efficacy that could penalize the chronically ill.

“No health care reform is better than the wrong sort of health care reform,” Bishop R. Walker Nickless of Sioux City, Iowa, declared in a recent pastoral letter, urging the faithful to call their members of Congress.

In a diocesan newspaper column this week, Archbishop Charles J. Chaput of Denver agreed, saying the proposal was “not only imprudent; it’s also dangerous.”

The bishops’ opposition — published in diocesan newspapers, disseminated online by conservative activists, and reported in a Roman Catholic newspaper to be distributed this weekend at churches around the country — is another setback for Mr. Obama’s health care efforts. His administration has been counting on the support of Catholic leaders to help rally believers behind his health care plan. Just last week, he held a conference call with 140,000 religious voters to appeal to what he called their “moral convictions.”

The bishops’ backlash reflects a struggle within the church over how heavily to weigh opposition to abortion against concerns about social justice.

“It is the great tension in Catholic thought right now,” said M. Cathleen Kaveny, a professor of law and theology at Notre Dame.

The same question, Professor Kaveny said, set off the debates over whether conscientious Catholics could vote for Mr. Obama despite his support for abortion rights, whether he should be invited to speak at Notre Dame, or whether Catholic politicians who support abortion rights, like Vice President Joseph R. Biden Jr., should present themselves for Communion.

Mr. Obama has said the health care overhaul should preserve the current policy that federal money not pay for elective abortions, and congressional Democrats say they are trying to do that. House health care legislation would allow the secretary of Health and Human Services to decide whether a proposed government insurance program would cover abortions. But any health insurance plan that does cover abortion — whether government-run or private — would be required to segregate its government subsidies from its patients’ premium payments so that no taxpayer money would pay for the procedure. And all patients would have the choice of plans that do and do not cover it.

House Democrats say many states similarly segregate federal money when they cover abortion under Medicaid. But abortion opponents say they take as a model the federal employees benefits program, which excludes health plans that cover abortion.

In an Aug. 11 letter to Congress, Cardinal Rigali of Philadelphia, head of the bishops’ anti-abortion efforts called the proposed division of funds “an illusion,” arguing that taxpayers would still indirectly help cover abortion. He urged lawmakers to block the current House legislation from coming up for a vote unless it can be amended to expressly prohibit financing for the procedure.

In his conference call with religious voters last week, Mr. Obama denied that his plan would mean government financing for abortions, calling such assertions “fabrications that have been put out there in order to discourage people from meeting what I consider to be a core ethical and moral obligation.”

Now, a prominent Catholic newspaper, Our Sunday Visitor, is declaring that the president was wrong, citing Cardinal Rigali’s letter about the House bill.

“U.S. Bishops, fact-checkers contradict Obama’s health claims on abortion,” declares the headline in the issue of the paper that will be distributed in many churches this weekend.

Liberal Catholic groups argued that most bishops still strongly supported the broader goals of the health care proposals. “There are certainly some strident voices out there that want to see health care reform abandoned on the back of this issue,” said Victoria Kovari, acting director of the liberal Catholics in Alliance for the Common Good, “but I don’t think that is where the bishops are.”

As recently as July 17, a letter to Mr. Obama and Congress from Bishop William F. Murphy, chairman of the bishops’ domestic justice, appeared eager to back the Democrats’ effort.

Bishop Murphy of Rockville Centre, N.Y., noted that the “we strongly oppose inclusion of abortion as part of a national health care benefit.” But he emphasized the priority the church placed on coverage for the poor, calling health care “not a privilege but a right.”

“Health care is not just another issue for the Church or for a healthy society,” he wrote. “It is a fundamental issue of human life and dignity.”

On its Web site this summer, the bishops’ conference published a commentary by the Rev. Douglas Clark of Savannah, Ga., arguing that the country now rationed “health care on the basis of wealth.” Father Clark cited an encyclical last month from Pope Benedict XVI about the evils of global economic inequality.

Catholic Charities and the Catholic Health Association endorsed the president’s plan without reservation.

But as the focus has shifted to the health care overhaul’s ramifications for abortion provisions, bishops who oppose it on many grounds have grown more vocal.

“The Catholic Church does not teach that government should directly provide health care,” Bishop Nickless of Sioux City wrote, adding, “Any legislation that undermines the vitality of the private sector is suspect.”

    Some Roman Catholic Bishops Assail Health Plan, NYT, 28.8.2009, http://www.nytimes.com/2009/08/28/health/policy/28catholics.html?hp

Loss of Health Care Champion

Creates Uncertainty

August 27, 2009
The New York Times
By CARL HULSE
and KATHARINE Q. SEELYE

WASHINGTON — The death of Senator Edward M. Kennedy has quickly become a rallying point for Democratic advocates of a broad health care overhaul, a signature Kennedy issue that became mired in partisanship while he fought his illness away from the Capitol.

“The passion of his life was health care reform,” said Representative David R. Obey, the liberal Wisconsin Democrat who is chairman of the Appropriations Committee. “Above all else, he would want us to redouble our efforts to achieve it.”

Yet Democrats have serious internal differences on how to approach health care, and Republicans and Democrats remain deeply divided on the policy proposals — a gulf some say Mr. Kennedy was uniquely equipped to bridge.

It seemed unlikely that Republicans would suddenly soften their firm opposition in the aftermath of Mr. Kennedy’s death or that Democrats would relent on their push for substantial change, especially for a government-run insurance plan, which Mr. Kennedy endorsed.

But Democrats and others said the senator’s death should provide at least a temporary respite from the angry denunciations that flowed this summer, putting Democrats on the defensive as they met with voters back home. One advocacy group opposed to the Democratic proposals, Conservatives for Patients’ Rights, announced that it was suspending its advertising out of respect for the senator and his family.

Some lawmakers used the moment to appeal for a new tone in the discussion of the volatile issue. “Let us stop the shouting and name calling and have a civilized debate on health care reform which I hope, when legislation has been signed into law, will bear his name for his commitment to insuring the health of every American,” Senator Robert C. Byrd, Democrat of West Virginia, said in a statement on Mr. Kennedy’s death.

Some, however, expressed little hope for a permanent cease-fire. “We’ll pause out of respect for our fallen comrade, but nothing seems to have any effect on the partisanship,” said Senator Arlen Specter of Pennsylvania, who recently switched parties and became a Democrat.

Whether the loss of health reform’s longtime champion will substantially alter the dynamic or the outcome of the Congressional fight will be determined only when Congress returns in September. Mr. Kennedy’s colleagues said they hoped his example would provide new inspiration.

“Maybe Teddy’s passing will remind people once again that we are there to get a job done as he would do,” said Senator Christopher J. Dodd, the Connecticut Democrat and close friend of Mr. Kennedy who filled in for him as chairman of the Health, Education, Labor and Pensions Committee.

Republicans said they did not ultimately expect much change in the health debate.

“Democrats will rally, but they still have to come up with a bill that works,” said one senior Republican official who did not want to be identified when talking about the delicate subject of how Mr. Kennedy’s death would play out in the policy fight. Another top Republican said the fight was already somewhat suspended with President Obama on vacation and would most likely “pick up right where we left off in a week or two.”

Republicans also noted that Mr. Kennedy, though an ideological liberal, was a legislative pragmatist who worked with Republicans to strike compromises on difficult subjects like health care, education and immigration. They said they saw little such reaching across the aisle in his absence.

Several Republicans also said they believed Congress would be closer to a health deal than it is now if Mr. Kennedy had regularly been on hand in the Senate, working face-to-face with his colleagues and using his prestige and credibility to advance the issue.

In a recent interview, Senator Orrin G. Hatch, Republican of Utah, said Mr. Kennedy was “the only Democrat who could really move all the Democrats’ special interests into coming along” with a bipartisan approach. Mr. Hatch said that in his absence, Mr. Kennedy’s staff members had written a “one-sided, partisan bill,” approved by the health committee on July 15. But Democrats say Mr. Kennedy had been deeply involved in putting together the legislation, had been consulted regularly on even the fine points and had been elated when the health committee approved its measure.

“He felt confident that we were on track even though there is a lot of ranting and raving going on right now,” Mr. Dodd said.

Howard Dean, the former presidential contender and national Democratic chairman, said it was “conjecture” to imagine how the course of health legislation might have changed had Mr. Kennedy lived. But, he said, “his death absolutely will stiffen the spine of the Democrats to get something this year for this extraordinary giant in Senate history.”

Other Democrats and health care advocates said they also viewed enacting health care legislation as the best tribute they could pay to the senator who had pursued accessible health coverage for every American for decades.

“Ted Kennedy’s dream of quality health care for all Americans will be made real this year because of his leadership and his inspiration,” Speaker Nancy Pelosi said.

In the most concrete effect of Mr. Kennedy’s death on Capitol Hill, the Democratic majority in the Senate will be reduced to 59 for at least the coming weeks, since Massachusetts law requires a special election to fill the seat and one might not be held until early next year. But Senate Democrats had for weeks accepted the fact that Mr. Kennedy would not be able to return to the floor even for a critical filibuster-breaking vote.

With only 59 seats, the Democrats are one short of the number they need to overcome procedural tactics that prevent a vote; if they face a filibuster, the leadership would have to hold its own members together and attract at least one Republican supporter beyond that. The math may lead Democrats to look more closely at considering health care under a procedural shortcut that could avert filibusters but also leave them with a health plan far reduced in scope.

The White House declined to comment Wednesday about what impact — if any — Mr. Kennedy’s death would have on the health care debate. Mr. Obama did not mention the health care debate in a written statement about Mr. Kennedy’s death or in brief televised remarks delivered from Martha’s Vineyard on Wednesday morning. He did, however, recall the bipartisan manner in which Mr. Kennedy often approached legislative fights.

“He could passionately battle others, and do so peerlessly, on the Senate floor for the causes that he held dear, and yet still maintain warm friendships across party lines,” Mr. Obama said.

 

Carl Hulse reported from Washington, and Katharine Q. Seelye from New York. Jeff Zeleny contributed reporting from Oak Bluffs, Mass., and Robert Pear from Washington.

    Loss of Health Care Champion Creates Uncertainty, NYT, 27.8.2009, http://www.nytimes.com/2009/08/27/us/politics/27health.html

Op-Ed Columnist

Health Care Fit for Animals

August 27, 2009
The New York Times
By NICHOLAS D. KRISTOF

Opponents suggest that a “government takeover” of health care will be a milestone on the road to “socialized medicine,” and when he hears those terms, Wendell Potter cringes. He’s embarrassed that opponents are using a playbook that he helped devise.

“Over the years I helped craft this messaging and deliver it,” he noted.

Mr. Potter was an executive in the health insurance industry for nearly 20 years before his conscience got the better of him. He served as head of corporate communications for Humana and then for Cigna.

He flew in corporate jets to industry meetings to plan how to block health reform, he says. He rode in limousines to confabs to concoct messaging to scare the public about reform. But in his heart, he began to have doubts as the business model for insurance evolved in recent years from spreading risk to dumping the risky.

Then in 2007 Mr. Potter attended a premiere of “Sicko,” Michael Moore’s excoriating film about the American health care system. Mr. Potter was taking notes so that he could prepare a propaganda counterblast — but he found himself agreeing with a great deal of the film.

A month later, Mr. Potter was back home in Tennessee, visiting his parents, and dropped in on a three-day charity program at a county fairgrounds to provide medical care for patients who could not afford doctors. Long lines of people were waiting in the rain, and patients were being examined and treated in public in stalls intended for livestock.

“It was a life-changing event to witness that,” he remembered. Increasingly, he found himself despising himself for helping block health reforms. “It sounds hokey, but I would look in the mirror and think, how did I get into this?”

Mr. Potter loved his office, his executive salary, his bonus, his stock options. “How can I walk away from a job that pays me so well?” he wondered. But at the age of 56, he announced his retirement and left Cigna last year.

This year, he went public with his concerns, testifying before a Senate committee investigating the insurance industry.

“I knew that once I did that my life would be different,” he said. “I wouldn’t be getting any more calls from recruiters for the health industry. It was the scariest thing I have done in my life. But it was the right thing to do.”

Mr. Potter says he liked his colleagues and bosses in the insurance industry, and respected them. They are not evil. But he adds that they are removed from the consequences of their decisions, as he was, and are obsessed with sustaining the company’s stock price — which means paying fewer medical bills.

One way to do that is to deny requests for expensive procedures. A second is “rescission” — seizing upon a technicality to cancel the policy of someone who has been paying premiums and finally gets cancer or some other expensive disease. A Congressional investigation into rescission found that three insurers, including Blue Cross of California, used this technique to cancel more than 20,000 policies over five years, saving the companies $300 million in claims.

As The Los Angeles Times has reported, insurers encourage this approach through performance evaluations. One Blue Cross employee earned a perfect evaluation score after dropping thousands of policyholders who faced nearly $10 million in medical expenses.

Mr. Potter notes that a third tactic is for insurers to raise premiums for a small business astronomically after an employee is found to have an illness that will be very expensive to treat. That forces the business to drop coverage for all its employees or go elsewhere.

All this is monstrous, and it negates the entire point of insurance, which is to spread risk.

The insurers are open to one kind of reform — universal coverage through mandates and subsidies, so as to give them more customers and more profits. But they don’t want the reforms that will most help patients, such as a public insurance option, enforced competition and tighter regulation.

Mr. Potter argues that much tougher regulation is essential. He also believes that a robust public option is an essential part of any health reform, to compete with for-profit insurers and keep them honest.

As a nation, we’re at a turning point. Universal health coverage has been proposed for nearly a century in the United States. It was in an early draft of Social Security.

Yet each time, it has been defeated in part by fear-mongering industry lobbyists. That may happen this time as well — unless the Obama administration and Congress defeat these manipulative special interests. What’s un-American isn’t a greater government role in health care but an existing system in which Americans without insurance get health care, if at all, in livestock pens.

 

Gail Collins is off today.

    Health Care Fit for Animals, NYT, 27.8.2009, http://www.nytimes.com/2009/08/27/opinion/27kristof.html?hpw

Economic Scene

Real Choice?

It’s Off Limits in Health Bills

August 26, 2009
The New York Times
By DAVID LEONHARDT

Consider the following health insurance plan.

It refuses to pay for certain medical care and then doesn’t offer a clear explanation. It does pay for unhelpful care that ends up raising premiums. Its customer service can be hard to reach or unhelpful. And the people who are covered by this insurer have no choice but to remain with it — or, at best, to choose from one or two other insurers that are about as bad.

In all likelihood, I have just described your insurance plan.

Health insurers often act like monopolies — like a cable company or the Department of Motor Vehicles — because they resemble monopolies. Consumers, instead of being able to choose freely among insurers, are restricted to the plans their employer offers. So insurers are spared the rigors of true competition, and they end up with high costs and spotty service.

Americans give lower marks to their health insurer than they do to their life insurer, their auto insurer or their bank, according to the American Customer Satisfaction Index. Even the Postal Service gets better marks. (Cable companies, however, get worse ones.) No wonder President Obama’s favorite villain is health insurers.

You might think, then, that a central goal of health reform would be to offer people more choice. But it isn’t.

Real choice is not part of the bills moving through the Democratic-led Congress; even if the much-debated government-run insurance plan was created, it would not be available to most people who already have coverage. Republicans, meanwhile, have shown no interest in making insurance choice part of a compromise they could accept. Both parties are protecting the insurers.

That’s a reflection of the thorny politics of health care. On one hand, big interest groups are lobbying hard to keep some form of the status quo. Insurers don’t want people to have more choice. Neither do employers and labor unions, which now control huge piles of money spent on health care. Nor do hospitals and drug makers, which benefit from all the waste now in the system.

On the other hand, the people who stand to benefit most from having more choice — all of us — are not agitating for change, because the costs of the system are hidden from us. A typical household spends $15,000 each year on health care. But most of it comes in the form of taxes or employer deductions from paychecks, which means insurance can seem practically free.

As a result, people may not like their insurer, but they don’t hate it, either. If anything, they are more anxious about losing their insurance than they are eager to be given more choice. And that anxiety has driven the White House’s decision to pursue a fairly conservative form of health reform.

To be clear, the versions of reform now floating around Congress would do a lot of good. They would make it far easier for people without an employer plan to get health insurance and would make some modest attempts to nudge the health system away from its perverse fee-for-service model.

Yet they would not improve most people’s health care anytime soon. Giving people more control over their own care would. White House advisers, however, decided against that option long ago. They worried that opening up the insurance market would destabilize employer-provided insurance and make Mr. Obama’s plan vulnerable to the same criticism that undid Bill Clinton’s: that it was too radical.

They may well have been right. Then again, given all the flak they have been taking anyway, they may have been wrong.

•

The best-known proposal for giving people more choice is the Wyden-Bennett bill, named for Ron Wyden, an Oregon Democrat, and Robert Bennett, a Utah Republican, who introduced it in the Senate in 2007. There are other broadly similar versions of the idea, too. One comes from Victor Fuchs, a Stanford professor sometimes called the dean of health economists, and Ezekiel Emanuel, an oncologist and an Obama health-policy adviser.

In the simplest version, families would receive a voucher worth as much as their employer spends on their health insurance. They would then buy an insurance plan on an “exchange” where insurers would compete for their business. The government would regulate this exchange. Insurers would be required to offer basic benefits, and insurers that attracted a sicker group of patients would be subsidized by those that attracted a healthier group.

The immediate advantage would be that people could choose a plan that fit their own preferences, rather than having to accept a plan chosen by human resources. You would be able to carry your plan from one job to the next — or hold onto it if you found yourself unemployed. You would never have to switch doctors because your employer switched insurance plans.

The longer-term advantage would be that health insurance would become fully subject to the brutal and wonderful forces of the market. Insurers that offered better plans — plans that drew on places like the Mayo Clinic to offer good, lower-cost care — would win more customers.

“That’s the way the rest of the economy works,” says William Lewis, former director of the McKinsey Global Institute.

Politically, though, the full voucher plan is still too radical, which is why the Wyden-Bennett bill has attracted support from only 13 other senators — four Republicans, eight Democrats and Joe Lieberman. So Mr. Wyden has come up with a narrower version.

It expands the exchange that Democratic leaders are already planning to create for the uninsured so that many more people would be allowed to use it. (If the exchange were limited to the uninsured, any government-run insurance plan, a crucial part of reform for many liberals, would not be available to most people.) But Mr. Wyden isn’t having much luck with this idea, either. The support for the employer-based system is simply too strong.

And the defenders of the employer system have some legitimate arguments. An insurance exchange may end up having some of the same pitfalls as 401(k) plans, in which some workers make poor choices. Having employers navigate the complex landscape of insurance, the defenders say, may be better for employees.

Here’s what I would ask those defenders, however: Given all the problems with health care — the high costs and decidedly mixed results — how comfortable are you defending the status quo? Why force people into a system you think is better for them?

If people were instead allowed to choose, all but a small percentage might indeed stick with their employer plan. In that case, a Wyden-like proposal wouldn’t amount to much. It certainly would not destabilize the employer-provided insurance system.

Then again, if lots of families did switch to a plan on the exchange, the impact would be quite different. With fewer employees signing up for on-the-job insurance, companies might shrink their benefits departments. The number of companies offering insurance would keep dropping. The employer insurance system could begin to crumble.

But wouldn’t that be precisely the fate that the system deserved?

    Real Choice? It’s Off Limits in Health Bills, NYT, 26.8.2009, http://www.nytimes.com/2009/08/26/business/economy/26leonhardt.html

Letters

Count Them Among the Uninsured

August 25, 2009
The New York Times

To the Editor:

Re “The Uninsured” (editorial, Aug. 23):

I was disappointed that your itemization of who the uninsured are did not mention the large number of Americans whom the private, for-profit insurance industry deems “uninsurable.”

If you have a pre-existing condition, you often can’t get private insurance for that condition at an affordable price, or sometimes at any price. This is one of the gravest failures of our free-market system: sick people are deliberately and legally excluded from the insurance system. The only way they can get coverage is through an employer group policy or by being poor enough to qualify for public programs.

This pool of people continues to grow as people are laid off, as jobs with group health become more scarce generally and as the population grows older and gets “uninsurable” chronic diseases.

David Tallman
Atlanta, Aug. 24, 2009

•

To the Editor:

Your editorial pondered who, exactly, are the uninsured. Where I live in rural Northern California, it seems that at least half of the working people I know have no insurance.

These are average folks of all ages and backgrounds who work for local small businesses. Their employers can’t afford to insure them, and they can’t afford to buy insurance on the open market.

These uninsured small-business employees include the very people who work at my doctor’s office. My internist isn’t able to offer reasonably priced insurance to his own staff. When the nurses who are taking my blood pressure and the nice front-office people who are booking my medical appointments can’t themselves have affordable access to medical care, something is disastrously wrong with the system.

Ellen Golla
Bayside, Calif., Aug. 24, 2009

•

To the Editor:

Inequalities in access to health care do not have a negative effect only on the health and well-being of the uninsured. There is a serious body of evidence to suggest that middle-income groups in less equal societies have worse health than comparable population groups in more equal societies.

These findings, reported by Norman Daniels, Bruce Kennedy and Ichiro Kawachi in their essay “Justice Is Good for Our Health,” deserve scrutiny.

If they can be substantiated, then it is in the interests of the already insured middle classes to promote universal coverage and to work toward reducing other social inequalities. Simply put, making sure that everyone has equal access to high-quality medical care could make us all healthier.

Darian Meacham
Brussels, Aug. 23, 2009

•

To the Editor:

Many Americans get health insurance through their employer. So if they become chronically ill to the extent that they can’t work, they lose both income and access to health care. That fact alone ought to be enough to scrap our current system and come up with a universal plan for everyone.

The rich probably can’t even imagine the plight of being seriously ill and having no help available. But how dare anyone condemn plans that would assure coverage for everyone. Who among us believes that we ourselves don’t deserve access to health care when needed? We don’t know in advance what will befall us, what care we’ll need or when. It’s not a choice.

To allow human suffering and death because of lack of health insurance is beyond a moral outrage. It is primitive, uncivilized, barbaric and unforgivable in a country as rich as the United States.

Nancy Bennett O’Hagan
Swatragh, Northern Ireland
Aug. 24, 2009

•

To the Editor:

I suggest that if Congress does not adopt the “public option” provision as part of health care reform, all members of Congress be required to obtain their health care insurance through private carriers exclusively.

Paul G. Bursiek
Boulder, Colo., Aug. 24, 2009

•

To the Editor:

“The Uninsured” speaks to the concerns that every thinking American should have about the backlash against health insurance reform. Except for the very rich, everyone in this country is one illness or one layoff away from having no health insurance.

More and more companies are offering insurance only to the employee and not to his or her family. Many are no longer offering health insurance. With the economic downturn and lower-paying jobs replacing those that have been lost, this is likely to continue.

As things stand now, the uninsured cost all of us money when they go to the emergency room. If they can’t afford to pay their bills, either the government pays for them with taxpayer dollars or those of us with insurance pay for them with higher premiums.

How would the millions without any or adequate insurance affect our society during an epidemic? I hope we don’t have to find out if an even more extensive swine flu outbreak occurs, as is being predicted.

I’ve heard it said that a nation’s greatness is measured by how it treats its weakest members. If we are truly as great a nation as we believe, let’s prove it by passing health insurance reform now.

Jacqueline Parrish
Philadelphia, Aug. 24, 2009

•

To the Editor:

Re “A Public Option That Works,” by William H. Dow, Arindrajit Dube and Carrie Hoverman Colla (Op-Ed, Aug. 22):

It is gratifying to see San Francisco’s universal health plan, Healthy San Francisco, receive glowing marks from economists. But a few salient points might limit this program’s applicability elsewhere.

San Francisco has long preserved a relatively extensive safety net of public health clinics and other services, including a large public hospital — a sadly endangered species. We also have one of the highest ratios of physicians per resident anywhere.

Nationally, a broader “public option” is probably necessary for true reform. Locally, San Francisco has been called “49 square miles surrounded by reality,” and this program is one reason many of us here are proud of that.

Steve Heilig
San Francisco, Aug. 22, 2009

The writer was a member of the Universal Health Council, which designed Healthy San Francisco, and is co-editor of Cambridge Quarterly of Healthcare Ethics.

•

To the Editor:

San Francisco boasts that it gives its citizens health benefits under the Healthy San Francisco program, but in reality local employers do not bear the ultimate cost — the workers do.

Studies show that corporate profits have soared during the last 30 years while hourly workers’ earnings have been stagnant. To say that San Francisco provides health benefits paid for by employers under the notion of “shared responsibility” is misleading and leads to nowhere regarding health care reform.

Spyros Andreopoulos
Stanford, Calif., Aug. 22, 2009

The writer is director emeritus, Office of Communication and Public Affairs, Stanford University School of Medicine.

•

To the Editor:

How encouraging to learn that a problem as challenging as health care reform can be resolved when people behave in a responsible manner that builds community and defines our humanity.

Bill Lavine
West Hartford, Conn., Aug. 22, 2009

The writer is a periodontist.

    Count Them Among the Uninsured, NYT, 25.8.2009, http://www.nytimes.com/2009/08/25/opinion/l25health.html

Officials Weigh Circumcision

to Fight H.I.V. Risk

August 24, 2009
The New York Times
By RONI CARYN RABIN

Public health officials are considering promoting routine circumcision for all baby boys born in the United States to reduce the spread of H.I.V., the virus that causes AIDS.

The topic is a delicate one that has already generated controversy, even though a formal draft of the proposed recommendations, due out from the Centers for Disease Control and Prevention by the end of the year, has yet to be released.

Experts are also considering whether the surgery should be offered to adult heterosexual men whose sexual practices put them at high risk of infection. But they acknowledge that a circumcision drive in the United States would be unlikely to have a drastic impact: the procedure does not seem to protect those at greatest risk here, men who have sex with men.

Recently, studies showed that in African countries hit hard by AIDS, men who were circumcised reduced their infection risk by half. But the clinical trials in Africa focused on heterosexual men who are at risk of getting H.I.V. from infected female partners.

For now, the focus of public health officials in this country appears to be on making recommendations for newborns, a prevention strategy that would only pay off many years from now. Critics say it subjects baby boys to medically unnecessary surgery without their consent.

But Dr. Peter Kilmarx, chief of epidemiology for the division of H.I.V./AIDS prevention at the C.D.C., said that any step that could thwart the spread of H.I.V. must be given serious consideration.

“We have a significant H.I.V. epidemic in this country, and we really need to look carefully at any potential intervention that could be another tool in the toolbox we use to address the epidemic,” Dr. Kilmarx said. “What we’ve heard from our consultants is that there would be a benefit for infants from infant circumcision, and that the benefits outweigh the risks.”

He and other experts acknowledged that although the clinical trials of circumcision in Africa had dramatic results, the effects of circumcision in the United States were likely to be more muted because the disease is less prevalent here, because it spreads through different routes and because the health systems are so disparate as to be incomparable.

Clinical trials in Kenya, South Africa and Uganda found that heterosexual men who were circumcised were up to 60 percent less likely to become infected with H.I.V. over the course of the trials than those who were not circumcised.

There is little to no evidence that circumcision protects men who have sex with men from infection.

Another reason circumcision would have less of an impact in the United States is that some 79 percent of adult American men are already circumcised, public health officials say.

But newborn circumcision rates have dropped in recent decades, to about 65 percent of newborns in 1999 from a high of about 80 percent after World War II, according to C.D.C. figures. And blacks and Hispanics, who have been affected disproportionately by AIDS, are less likely than whites to circumcise their baby boys, according to the agency.

Circumcision rates have fallen in part because the American Academy of Pediatrics, which sets the guidelines for infant care, does not endorse routine circumcision. Its policy says that circumcision is “not essential to the child’s current well-being,” and as a result, many state Medicaid programs do not cover the operation.

The academy is revising its guidelines, however, and is likely to do away with the neutral tone in favor of a more encouraging policy stating that circumcision has health benefits even beyond H.I.V. prevention, like reducing urinary tract infections for baby boys, said Dr. Michael Brady, a consultant to the American Academy of Pediatrics.

He said the academy would probably stop short of recommending routine surgery, however. “We do have evidence to suggest there are health benefits, and families should be given an opportunity to know what they are,” he said. But, he said, the value of circumcision for H.I.V. protection in the United States is difficult to assess, adding, “Our biggest struggle is trying to figure out how to understand the true value for Americans.”

Circumcision will be discussed this week at the C.D.C.’s National H.I.V. Prevention Conference in Atlanta, which will be attended by thousands of health professionals and H.I.V. service providers.

Among the speakers is a physician from Operation Abraham, an organization based in Israel and named after the biblical figure who was circumcised at an advanced age, according to the book of Genesis. The group trains doctors in Africa to perform circumcisions on adult men to reduce the spread of H.I.V.

Members of Intact America, a group that opposes newborn circumcision, have rented mobile billboards that will drive around Atlanta carrying their message that “circumcising babies doesn’t prevent H.I.V.,” said Georganne Chapin, who leads the organization.

Although the group’s members oppose circumcision on broad philosophical and medical grounds, Ms. Chapin argued that the studies in Africa found only that circumcision reduces H.I.V. infection risk, not that it prevents infection. “Men still need to use condoms,” Ms. Chapin said.

In fact, while the clinical trials in Africa found that circumcision reduced the risk of a man’s acquiring H.I.V., it was not clear whether it would reduce the risk to women from an infected man, several experts said.

“There’s mixed data on that,” Dr. Kilmarx said. But, he said, “If we have a partially successful intervention for men, it will ultimately lower the prevalence of H.I.V. in the population, and ultimately lower the risk to women.”

Circumcision is believed to protect men from infection with H.I.V. because the mucosal tissue of the foreskin is more susceptible to H.I.V. and can be an entry portal for the virus. Observational studies have found that uncircumcised men have higher rates of other sexually transmitted diseases like herpes and syphilis, and a recent study in Baltimore found that heterosexual men were less likely to have become infected with H.I.V. from infected partners if they were circumcised.

    Officials Weigh Circumcision to Fight H.I.V. Risk, NYT, 24.8.2009, http://www.nytimes.com/2009/08/24/health/policy/24circumcision.html

Editorial

The Uninsured

August 23, 2009
The New York Times

One of the major goals of health care reform is to cover the vast numbers of uninsured. But how vast, really, is that pool of people? Who are they? And how important is it to cover all or most of them?

Critics play down the seriousness of the problem by pointing out that the ranks of the uninsured include many people who have chosen to forgo coverage or are only temporarily uninsured: workers who could afford to pay but decline their employers’ coverage; the self-employed who choose not to pay for more expensive individual coverage; healthy young people who prefer not to buy insurance they may never need; people who are changing jobs; poor people who are eligible for Medicaid but have failed to enroll. And then there are the illegal immigrants, a favorite target of critics.

All that is true, to some degree. But the implication — that lack of insurance is no big deal and surely not worth spending a trillion dollars to fix — is not.

No matter how you slice the numbers, there are tens of millions of people without insurance, often for extended periods, and there is good evidence that lack of insurance is harmful to their health.

Scores of well-designed studies have shown that uninsured people are more likely than insured people to die prematurely, to have their cancers diagnosed too late, or to die from heart failure, a heart attack, a stroke or a severe injury. The Institute of Medicine estimated in 2004 that perhaps 18,000 deaths a year among adults could be attributed to lack of insurance.

The oft-voiced suggestion that the uninsured can always go to an emergency room also badly misunderstands what is happening. By the time they do go, many of these people are much sicker than they would have been had insurance given them access to routine and preventive care. Emergency rooms are costly, and if uninsured patients cannot pay for their care, the hospital or the government ends up footing the bill.

•

So how many uninsured people are out there, facing those risks? The most frequently cited estimate, 45.7 million in 2007, comes from an annual census survey. That number was down slightly from the year before, but given the financial crisis, it is almost certainly rising again.

Some or even many of those people may have only temporarily lost or given up coverage, but even that exposes them to medical and financial risk. And many millions go without insurance for extended periods.

The Agency for Healthcare Research and Quality in the Department of Health and Human Services estimates that 28 million people were uninsured for all of 2005 and 2006 and that 18.5 million of them were uninsured for at least four straight years. That does not sound like a “temporary” problem, and the picture today is almost certainly bleaker.

Various analyses have tried to decipher just who the uninsured are. These are the main conclusions, with the caveat that there is overlap in these numbers:

THE WORKING POOR The Kaiser Family Foundation estimates that about two-thirds of the uninsured — 30 million people — earn less than twice the poverty level, or about $44,000 for a family of four. It also estimates that more than 80 percent of the uninsured come from families with full-time or part-time workers. They often cannot get coverage at work or find it too expensive to buy. They surely deserve a helping hand.

THE BETTER OFF About nine million uninsured people, according to census data, come from households with incomes of $75,000 or more. Critics say that is plenty of money for them to buy their own insurance. But many of these people live in “households” that are groups of low-wage roommates or extended families living together. Their combined incomes may reach $75,000, but they cannot pool their resources to buy an insurance policy to cover the whole group.

Still, about 4.7 million uninsured people live in families that earn four times the poverty level — or $88,000 for a family of four — the dividing line that many experts use to define who can afford to buy their own insurance.

Those people who could afford coverage but choose not to buy it ought to be compelled to join the system to lessen the possibility that a serious accident or illness might turn them into charity cases and to help subsidize the coverage of poorer and sicker Americans.

YOUNG ADULTS Some 13 million young adults between the ages of 19 and 29 lack coverage. These are not, for the most part, healthy young professionals making a sensible decision to pay their own minimal medical bills rather than buy insurance that they are unlikely to need. The Kaiser foundation estimates that only 10 percent are college graduates, and only 5 percent have incomes above $60,000 a year, while half have family incomes below $16,000 a year. Many of these younger people would be helped by reform bills that would provide subsidized coverage for the poor and an exchange where individuals can buy cheaper insurance than is now available.

ALREADY ELIGIBLE Some 11 million of the poorest people, mostly low-income children and their parents, are thought to be eligible for public insurance programs but have failed to enroll, either because they do not know they are eligible or are intimidated by the application process. When such people arrive at an emergency room, they are usually enrolled in Medicaid, but meanwhile they have lost out on routine care that could have kept them out of the emergency room. They will presumably be scooped up by the mandate under reform bills that everyone obtain health insurance.

THE UNDERINSURED The Commonwealth Fund estimates that 25 million Americans who had health insurance in 2007 had woefully inadequate policies with high deductibles and restrictions that stuck them with large amounts of uncovered expenses. Many postponed needed treatments or went into debt to pay medical bills.

NON-CITIZENS Some 9.7 million of the uninsured are not citizens; of those, more than six million may be illegal immigrants, according to informed estimates. None of the pending bills would cover them.

If nothing is done to slow current trends, the number of people in this country without insurance or with inadequate coverage will continue to spiral upward. That would be a personal tragedy for many and a moral disgrace for the nation. It is also by no means cost-free. Any nation as rich as ours ought to guarantee health coverage for all of its residents.

    The Uninsured, NYT, 23.8.2009, http://www.nytimes.com/2009/08/23/opinion/23sun1.html

Letters

Health Care

for the Old, and the Young

August 23, 2009
The New York Times

To the Editor:

Re “Health Care’s Generation Gap,” by Richard Dooling (Op-Ed, Aug. 17):

While I wholeheartedly agree that overtreatment in the United States has reached epidemic proportions, pitting health care for older adults against care for children is a mistake. Age should not be a marker of a less valuable life. Many people continue to live with a high quality of life well into their later years.

Mr. Dooling’s revelations of high-cost intensive care should instead point us toward better financing for home care, hospice and palliative care programs that provide all patients with treatment that is person-centered and cost-saving.

And, really, shouldn’t everyone have access to preventive care? Whether we are putting programs into place to reduce falls, or financing pediatric immunization, preventive health can be beneficial at every age.

Health care financing should be aimed toward evidence-based, cost-effective programs, not simply at those deemed most “deserving.”

Amanda Hunsaker
Pittsburgh, Aug. 18, 2009

The writer is a doctoral student in the School of Social Work at the University of Pittsburgh.

•

To the Editor:

I commend Richard Dooling for having the courage to utter the unspeakable truth: Despite our vast medical/technological hubris, we cannot cheat death, and shame on those who cling to the belief that we can. Shame also on the many readers who will inevitably excoriate Mr. Dooling for a perceived lack of compassion for the elderly, and the self-interested politicians who will foolishly accuse him of supporting “death panels.”

The fact is that old people eventually die; they are supposed to. Yet the medical establishment makes huge profits peddling the notion that the end of life can be delayed indefinitely. Economics aside, this is inhumane.

We must somehow conjure the common sense to allow people to die with dignity, without suffering, and at the reasonable time when their bodies give up even if their families refuse to do so.

Lisa Wesel
Bowdoinham, Me., Aug. 17, 2009

•

To the Editor:

After reading Richard Dooling’s Op-Ed article, I made my usual morning rounds on my patients. They are — almost to a person — exactly the kind of people who the author feels do not deserve the advanced health care that I am privileged to provide them.

It saddens me to know that my octogenarian — and yes, even nonagenarian — patients, who have paid a lifetime of taxes, fought for their country, live independently and often even still work — have raised the generation that now, increasingly, seems to feel that the surgeries I routinely perform that save lives and enhance their quality are wasteful expenses that our selfish society cannot afford.

Albert C. DiMeo
Fairfield, Conn., Aug.

18, 2009

The writer is a doctor and the director of minimally invasive cardiac surgery at St. Vincent’s Medical Center in Bridgeport, Conn.

•

To the Editor:

In 2006, I learned that I had myeloma, a bone-marrow cancer that is treatable but at present not curable. I am 68 and have led a most satisfying life, but myeloma will most likely shorten that life.

The treatment I have received has been very expensive, but it has kept me robust, and I am thankful. But Richard Dooling’s Op-Ed article is enlightened: if the quality of my life makes me no longer want to live, I want someone to pull the plug on me; I do not want my misery prolonged by any treatment, particularly “insanely expensive procedures.”

I hope that then, I, or someone I designate, will insist on my wishes now: don’t keep me alive for misguided reasons; let me die for enlightened ones. And spend the money thus saved on preventive medicine, making it more likely that younger folks will live long and satisfying lives of their own.

Peter Greer
Exeter, N.H., Aug. 18, 2009

•

To the Editor:

As an ageless, 40-something woman who cares equally about people of all ages, I must object to Richard Dooling’s suggestion to cut “some of the money spent on exorbitant intensive-care medicine for dying, elderly people and redirect it to pediatricians and obstetricians offering preventive care for children and mothers.”

He may not be, as he states, “talking about euthanasia.” But his suggestion reflects the unloving philosophy of ageism that so many elderly encounter daily. Our elders have just as much right as any to life, liberty and the pursuit of happiness, as they see fit and to their very last breath, however and whenever that occurs.

Helena Babington Guiles
San Francisco, Aug. 17, 2009

•

To the Editor:

Richard Dooling’s Op-Ed article is both timely and accurate. It points up the importance of advance directives, so disparagingly and wrongly referred to as “pulling the plug on Grandma.”

I’m a 73-year-old grandma. As is the case with many elderly people, my fear of hospitals is directly related to the fear of being put in some sort of time warp of machine-generated life support, tortured with tubes and left to rot in an undignified and helpless state with no hope of recovery, a heartbreaking burden to my children.

The conversation about end-of-life care should be held in all families. Everyone should provide his or her family, as well as family physician, with a health care proxy and a living will. A lawyer who can help put on paper the necessary directives to conform with the person’s wishes and with the law is helpful, but not required.

Grandmas of the world, take the responsibility for your own end-of-life care now. Tell your families what you want and put it in writing.

Adele Welty
Flushing, Queens, Aug. 17, 2009

•

To the Editor:

I’m an elderly person, have worked professionally in care of the elderly, and have helped and visited several friends and relatives at the end of their lives.

I wish Richard Dooling had not expressed the problem in terms of generational conflict, but his statements about end-of-life medicine are accurate and trenchant. If people have enough money, they can (and will, unless they have well-expressed medical directives) buy themselves prolonged and excruciating deaths. That is the main reason for reconsidering what we’re doing now, not an analysis of what else could be done with the money.

Anne Watson
Friday Harbor, Wash., Aug. 17, 2009

•

To the Editor:

Richard Dooling writes that we are “incurring enormous debt to pay for bypass surgery and titanium-knee replacements for octogenarians and nonagenarians” and suggests that the money be spent elsewhere.

I will be 82 in several months and have had bypass surgery and a hip replacement. Any time Mr. Dooling would like, I will race him swimming, bicycling or kayaking. I would race him running also, but my orthopedist says I mustn’t run. I further suggest that Mr. Dooling bring along an oxygen tank and a well-fitting mask for his own post-race use.

Paul R. Packer
New Rochelle, N.Y., Aug. 17, 2009

The writer is a doctor.

    Health Care for the Old, and the Young, NYT, 23.8.2009, http://www.nytimes.com/2009/08/23/opinion/l23gap.html

Months to Live

At the End,

Offering Not a Cure but Comfort

August 20, 2009
The New York Times
By ANEMONA HARTOCOLLIS

Deborah Migliore was pushed into a small conference room in a wheelchair, looking kittenish in red and white pajamas and big gold hoop earrings. Her weight was down to about 90 pounds, from 116, her face gaunt, her sad eyes droopier than ever.

Dr. Sean O’Mahony had been called in to tell her the bad news: she was sicker than she realized, and the prognosis did not look good.

“What’s the cancer I have?” Mrs. Migliore, a 51-year-old former cocktail waitress, asked jauntily. “I have no idea.”

“Carcinoid,” Dr. O’Mahony replied.

“I don’t want to lose my hair,” she said, laughing nervously.

“Currently, there are no established cures,” the doctor said. “Think very carefully about what treatments you do and don’t want to have as these issues arise.”

It was what doctors in the end-of-life business call “firing a warning shot,” but Mrs. Migliore did not seem to hear the bullet whizzing past.

“It’s more or less, I want to be alive again,” she interjected. “Going here, going there. My husband, I want to be able to do things for him.”

Part psychoanalyst, part detective, Dr. O’Mahony had to listen to the cues and decide what to do next.

Most doctors do not excel at delivering bad news, decades of studies show, if only because it goes against their training to save lives, not end them. But Dr. O’Mahony, who works at Montefiore Medical Center in the Bronx, belongs to a class of doctors, known as palliative care specialists, who have made death their life’s work. They study how to deliver bad news, and they do it again and again. They know secrets like who, as a rule, takes it better. They know who is more likely to suffer silently, and when is the best time to suggest a do-not-resuscitate order.

Palliative care has become a recognized subspecialty, with fellowships, hospital departments and medical school courses aimed at managing patients’ last months. It has also become a focus of attacks on plans to overhaul the nation’s medical system, with false but persistent rumors that the government will set up “death panels” to decide who deserves treatment. Many physicians dismiss these complaints as an absurd caricature of what palliative medicine is all about.

Still, as an aging population wrangles with how to gracefully face the certainty of death, the moral and economic questions presented by palliative care are unavoidable: How much do we want, and need, to know about the inevitable? Is the withholding of heroic treatment a blessing, a rationing of medical care or a step toward euthanasia?

A third of Medicare spending goes to patients with chronic illness in their last two years of life; the elderly, who receive much of this care, are a huge political constituency. Does calling on one more team of specialists at the end of a long and final hospital stay reduce this spending, or add another cost to already bloated medical bills?

Dr. O’Mahony and other palliative care specialists often talk about wanting to curb the excesses of the medical machine, about their disillusionment over seeing patients whose bodies and spirits had been broken by the treatment they had hoped would cure them. But their intention, in a year observing their intimate daily interactions with patients, was not to limit people’s choices or speed them toward death.

Rather, Dr. O’Mahony and his colleagues were more subtle, cunning and caring than their own words sometimes suggested.

An Escort for the Dying

They are tour guides on the road to death, the equivalent of the ferryman in Greek myth who accompanied people across the river Styx to the underworld. They argue that a frank acknowledgment of the inevitability of death allows patients to concentrate on improving the quality of their lives, rather than lengthening them, to put their affairs in order and to say goodbye before it is too late.

Dr. O’Mahony, 41, went to medical school in his native Dublin, straight out of high school. He intended to go into oncology. But during training at a prominent cancer hospital in New York, he changed his mind as he saw patients return to the hospital to die miserable deaths, hooked to tubes, machines and chemotherapy bags until the end.

“In Ireland, and I think most other places, it would be very much frowned upon,” he said.

Sandy-haired, a wiry marathon runner, Dr. O’Mahony is the sixth of eight children; his father is a university professor devoted to preserving Gaelic as a second language, and his mother a painter. When he was 3, his brother, who had cerebral palsy, died at age 4. His awareness of his parents’ helplessness, burnished through years of family conversations, helped steer him to palliative care, he said.

Dr. O’Mahony entered the field a decade ago, shaped by an almost messianic movement that began as a rebuke to traditional medicine but has become more and more integrated into routine hospital practice.

As medical director of Montefiore’s palliative care service, he helps train fellows, supervises research projects and manages the pain, often with powerful drugs like fentanyl, methadone and morphine, of patients with a range of illnesses, like cancer and AIDS.

He consults on questions with ethical, moral and sometimes religious overtones, like whether to remove life support. He acts as a troubleshooter with recalcitrant patients, like an elderly man who was sneaking cigarettes (they negotiated a schedule of when he could get out of bed to smoke), and advises the terminally ill and their families.

Dr. O’Mahony favors crisp button-down shirts, but no white coat. His bedside manner ranges from gentle amusement to studied neutrality; he eerily resembles the unemotive Steve McQueen of “Bullit.”

His coolness is his armor. “I do not feel obligated to be sort of eternally involved with the experience of death,” Dr. O’Mahony said. “It’s not healthy to be there all the time.”

But the danger is that “death gets to be banal,” he said.

“Do you know that poem by Dylan Thomas?” Dr. O’Mahony asked with a faint smile. “After the first death, there is no other.”

But How to Tell Her

He had seen many deaths before he met Debbie Migliore. She left her home in the Bronx at 19 to pursue the one talent she knew she had, looking good in a bikini.

Old photographs show her flaunting a saucy smile and a mane of black hair. “I used to be a topless dancer, excuse the expression,” she said. She worked at clubs in Manhattan and upstate, and was married twice before meeting Joe.

It was a marriage of opposites. Joe had always been socially awkward and studious, a nerd, he said with a touch of defiance. He went to New York University part time, got a culinary degree and worked as a chef in a casino. Finally, he got a job with the New York City parks department as a horticulturist. Working with plants suited him, because he worked more or less alone.

He had embraced his solitude so completely that when he met Debbie he had been thinking of becoming a priest.

They met 12 years ago through a personal ad she had put in The New York Post, and married almost instantly. Joe’s mother had spotted the ad, which said, roughly, “Likes to dance.”

Debbie’s big regret was never having children, after a hysterectomy in her 30s; Joe would have liked a large family but accepted that it was too late.

Her health started to fail soon after they married. Over the last decade, she suffered two strokes and developed an autoimmune disorder. Three or four years ago, doctors found a tumor in her lung, which was attributed to a neuroendocrine cancer known as a carcinoid tumor. She was treated through surgery and radiation. Apart from a dry cough, her husband said, “she was wonderful.”

In March, she broke her arm while turning a mattress. While repairing the arm, doctors found more cancer, and Dr. O’Mahony was called in to talk about her uncertain future.

They met at Morningside House, the Bronx nursing home where she was recovering from surgery, joined by Mr. Migliore, social workers, nurses and a physical therapist. For about an hour, Dr. O’Mahony asked open-ended questions, looking for clues as to how much she knew and how much she wanted to know.

“What are your biggest concerns?” was his opening move.

“First of all, the food is terrible,” Mrs. Migliore said. She was trying to fatten up with spaghetti — the thought of other food disgusted her, which is often a sign of deteriorating health. But the pasta was cold, she said.

One leg would not support her weight. Her back hurt; she would like a massage. “I get annoyed when things are not my way,” she said. “And I cry too much.”

“Well, it’s hard for most of us not to have control over things,” Dr. O’Mahony said.

“Aside from the food,” he pressed, “what are the things that concern you?”

“I want to get better,” Mrs. Migliore said.

“What’s your understanding of the status of the tumor?” Dr. O’Mahony asked.

“The doctor that took it out, he was just amazed,” she said. “He says, ‘Oh, Debbie, I did a good job.’ I said, ‘Yes, you did.’ ”

Dr. O’Mahony tried to remind her that she still had cancer. “One of the frustrating things about this illness is the way it can pop up in different parts of the body,” he said.

Mr. Migliore joined in, asking whether there was a way to slow the growth of the cancer.

“The treatments that are available for it can provide some local control, and they can slow the progression of the illness,” Dr. O’Mahony replied.

“But there is no way of knowing it, right?” Mrs. Migliore asked, astutely, apparently registering the equivocation in the doctor’s tone.

Then Dr. O’Mahony fired his warning shot: “There are no established cures.” And Mrs. Migliore fired back with her wish to be “alive again.”

Picking up on her cue, Dr. O’Mahony asked, “What gives you strength?” She liked to shop, she said. Perking up, she chided her husband for forgetting to bring the Victoria’s Secret catalog.

“You sit home and watch ‘I Love Lucy,’ ” Mr. Migliore said. “Do you think ‘I Love Lucy’ cares if you wear a $400 outfit or a $22.95?”

The meeting ended on a lighthearted note, and Dr. O’Mahony never returned to the prognosis that the nursing home staff thought Mrs. Migliore would want to know.

Beyond Mrs. Migliore’s hearing, he said: “People giving very concrete estimates of survival can in essence cause as much harm as good. I think she was signaling to us quite a lot that it was important to her to be able to go home, to walk, to be able to promote her self-image, to shop for clothes.”

He predicted that her disease would progress, perhaps rapidly, through a series of crippling events.

But he said he had learned from mistakes early in his career that it was not always helpful to presume to have answers, to mark a spot on the calendar. He said he would rather focus on things he really could help with, like making sure Mrs. Migliore was getting enough pain medication.

But before leaving, he made sure that she had a health care proxy — her husband — who would make decisions for her if she became incapacitated. He knew it would be harder to get one later.

Palliative care doctors are taught to lead by example. Dr. O’Mahony’s proxy is his companion, an oncologist himself.

But Dr. O’Mahony does not press hard for a written advance directive, sometimes called a living will, in which patients can specify treatments — like cardiopulmonary resuscitation, breathing machines, dialysis, transplantation, blood transfusion, antibiotics, and food and water delivered through a tube — that they would or would not want if they were unable to speak for themselves. “The mere fact of putting words on paper may be very distressing,” he said.

Perfecting the Technique

Delivering a grim prognosis used to be something that doctors figured out how to do on their own, or did not do at all.

Now “Breaking Bad News” is a standard part of the curriculum at many medical schools, including the Albert Einstein College of Medicine, the school affiliated with Montefiore.

In an experimental role-playing exercise, fourth-year medical students were given 10 minutes to tell an actress, Susan Telcher, that her mammogram indicated a high likelihood of breast cancer. During one session, led by Dr. Charles Schwartz, a wisecracking internist and psychiatrist armed with a stopwatch and a Coke, not every student proved to be a natural.

The students, most in their late 20s, often had a hard time getting beyond medical jargon. One of them, who planned to become a pediatrician, failed to read the handout on the patient, with disastrous results. She spent most of her 10 minutes sneaking peeks at the clinical notes, trying to divine the problem, while the actress blithely chattered on about how well she had been feeling.

A student named Paul (most asked to have their last names withheld for fear of harming their careers) told Ms. Telcher that her mammogram had revealed a “finding.”

“You’ve got to get that cancer word out there early and often,” Dr. Schwartz admonished.

Students often excuse a poor performance by saying they would have behaved differently in real life. But “the data is, they do what they do,” said Dr. Schwartz, who conducts the training with Dr. Sharon Parish, an associate professor of clinical medicine at Einstein.

In his experience, physicians who themselves have signed advance directives are more comfortable talking to their patients about dying.

But Dr. Nicholas Christakis, an internist and social scientist at Harvard who has studied end-of-life care, has found that doctors are generally bad at making prognoses. The better they know a patient, the worse they are at prognosticating, possibly, Dr. Christakis has theorized, because they view death as a personal failure. Most predictions are overly optimistic, he has found, and the sicker the patient, the more likely the doctor is to overestimate the length of survival.

In one study by Dr. Christakis, doctors who privately believed that patients had 75 days to live told them they had 90; the actual median survival period was 26 days.

“Go to the bathroom mirror, look yourself in the mirror and say, ‘You’re dying,’ ” Dr. Christakis said. “It’s not easy.”

Lessons Learned

Along the way, Dr. O’Mahony has picked up the wisdom of the trade. He has learned that older people tend to take bad news better than younger people.

That patients with advanced cancer generally go into a sharp decline three months before death, but those with dementia, heart disease or diabetes may have a bad month and then get better, making their prognosis trickier.

That people who do not have family or friends, or are alienated from them, are more likely to want to hasten death than those with more social support.

That patients who are agreeable by nature may not admit that they are in pain.

That people who blame their self-destructive behavior for their illness are less likely to ask for help, and that hard-charging professionals sometimes would rather not manage their own illness.

That people can know in their darker moments that the prognosis is grim, yet at other moments imagine they will go back to being their old selves.

And Dr. O’Mahony knows that the family is sometimes best at delivering bad news, as in the case of Eddie Ascanio.

Mr. Ascanio, a 52-year-old limousine garage attendant, arrived in Montefiore’s emergency room last spring, in the last stages of head and neck cancer.

The palliative care staff immediately called a meeting of Mr. Ascanio’s family members to determine whether they realized he was near death.

Mr. Ascanio was too angry about being in the hospital to attend the meeting. His sister, Helen Wilson, who had taken on the role of family anchor while her husband, a plumber, served time for bank robbery, told the doctors she had brought her brother to Montefiore because she was unhappy with his treatment at another hospital.

“Listen, I need to know what’s going on with my brother; he’s losing massive weight, not eating,” she said she had begged the previous doctor. “Something is not right.”

Two doctors on Dr. O’Mahony’s team listened quietly, and she seemed relieved just to be able to talk things through. When one of the doctors asked if she wanted to take her brother home to die, she said, “That probably will make him very happy. We’ll set him up in my daughter’s bedroom.”

Her nephew, Tony, balked. “Is that to say there isn’t even a 1 percent chance of recovery?” he said.

Mrs. Wilson answered before the doctors could. “The cancer’s spread too far, Tony,” she said. Mr. Ascanio died four days later, in his niece’s bedroom, surrounded by stuffed animals and his family.

Lagging on Hospice Care

While palliative care is available to give patients a chance to die without being tormented by excessive medical care, statistics suggest that in New York, the world center of academic medicine, aggressive treatment is still the rule.

At Montefiore, only 12 percent of dying patients from 2001 to 2005 entered hospice care, for an average of 4.9 days, during their last six months of life, according to the latest data from the Dartmouth Atlas of Health Care.

At Mount Sinai, it was 14 percent of patients for 4.6 days; at NewYork-Presbyterian, 15 percent for 5.2 days; and at New York University Medical Center, 20 percent for 6.7 days, according to the Dartmouth data.

Nationally, nearly 32 percent of dying patients had hospice care during the same period, for an average of 11.6 days.

In New York, hospice is “brink-of-death care,” said Dr. Ira Byock, the director of palliative medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and the author of “Dying Well.”

While treatments that try to extend lives produce more fees for doctors and hospitals, they may be given for reasons besides money. “Many clinicians don’t want to send the message that they’re giving up on their patients,” said Dr. David Goodman, a co-author of the Dartmouth Atlas. “They see palliative care as diminishing hope.”

Dr. O’Mahony suggested that family finances also played a part in decisions on hospice care, because Medicare typically covers only a few hours a day of such care at home.

The health care bill being discussed in the House would ensure Medicare reimbursement for consultations about end-of-life treatment between patients and their doctors, nurse practitioners or physician assistants every five years, or more often in the case of a life-threatening change.

The bill would help validate the work of palliative care doctors, who often work on salary and whose services are often subsidized by the rest of the hospital because they do not generate much revenue.

But the provision has fueled criticism. Former Gov. Sarah Palin of Alaska has raised the specter of “death panels” that would rule on whether to treat defenseless patients like her son Trig, who has Down syndrome. While there is nothing in the House bill to suggest that such panels would exist, the end-of-life language became so radioactive that several members of the Senate Finance Committee said they would not include it in their version of the bill.

The Congressional Budget Office estimated that the proposal would cost $2.7 billion over 10 years.

There was no estimate of savings at the other end, from patients forgoing expensive tests and treatment. A few studies have found that hospital care for patients who get palliative care consultations costs thousands of dollars less than care for those who do not. But some of these studies have been conducted by advocates, and they have looked at hospital costs after the fact, rather than using randomized controlled trials, the gold standard in medical research.

The author of one study, Dr. Edmond Bendaly, an oncologist in Marion, Ind., said cost studies had been hampered by the ethical and practical difficulties of signing up dying patients for trials that might provide disparate care. But he said the research so far showed a “strong signal” of savings from palliative care.

Dr. O’Mahony and his colleagues are well aware of the ethical debates over the boundaries between proper conduct and euthanasia. “We’re not vested in having patients refuse treatment,” Dr. O’Mahony said. “We are there to support patients and their families.”

Families sometimes worry that by refusing treatment for a patient — especially food and water, which are so closely associated with comfort and love — they are approaching euthanasia.

Deep sedation, to the point of unconsciousness, may also be used to relieve intractable suffering, and it “has caused almost as much distress and debate in the palliative care-hospice world as euthanasia has,” said Dr. David Casarett, a palliative care doctor at the University of Pennsylvania, who is leading a national evaluation of end-of-life care at Veterans Affairs hospitals.

“Is it used to end a life, or up until the end of life?” Dr. Casarett said, summarizing the debate. Among those who use it, he said, the consensus is that “we would never sedate with the goal of hastening death.”

Palliative care doctors talk about the difference between prolonging life and prolonging death.

“So it’s not euthanasia,” said Dr. Desiree Pardi, who went into palliative care after learning that she had breast cancer, and is now the director of the service at the Weill Cornell Medical College of NewYork-Presbyterian Hospital. “It’s just sort of letting them die completely naturally. It’s hard to explain to a lay person, because we know we need food and liquid to live. But we don’t need them to die. We’re just feeding whatever is killing them.”

In the political wars over end-of-life care, advocacy groups for the disabled are often as adamant as religious groups in challenging measures that could be seen as hastening death. “Health care providers encounter people at a time of crisis; they see the worst happening,” said Diane Coleman, the founder of an advocacy group for the disabled, Not Dead Yet. “They don’t see them get through it and say, ‘Even with my functional losses, I’m still having a good time.’ ”

A Resistance Among Doctors

Palliative care still goes against the core beliefs of many doctors.

In a teaching session one day last winter, Dr. Lauren Shaiova criticized a group of idealistic young residents for sending a 42-year-old patient with end-stage liver disease and a lifetime of drinking to a nearby hospital for a liver transplant.

Dr. Shaiova is a friend of Dr. O’Mahony’s — he marched in her wedding procession — and is chief of palliative care at Metropolitan Hospital, a city-run hospital serving the poor and working class of East Harlem.

She is also Dr. O’Mahony’s counterpoint, demonstrative and impulsive where he is cautious and unemotional. Married to a hospice doctor, with three young children adopted from Russia, Dr. Shaiova, 50, would be a rebel and something of a nonconformist in most settings. She plays a harmonium for chemotherapy patients and chants a Buddhist prayer before staff meetings. She says that her husband once confided to her, as they were lying in bed one night, that he was not afraid to die. Her Russian grandmother in Brighton Beach has made a do-not-resuscitate order, and so has she.

Dr. Shaiova’s older brother, Michael, a car mechanic, was shot in the head on a street in Chicago, their hometown. She heard the news from emergency room doctors who called to ask about “harvesting” his organs.

“Harvest?” Dr. Shaiova recalled thinking. “I’m growing beans? Nobody was willing to say he was brain-dead.”

Now, facing the abashed residents in their white coats, she reviewed the history of the patient, who was living in a single-room-occupancy hotel: He was agitated and confused, and had alcoholic brain damage. He could no longer walk. To qualify for a transplant, he had to be alcohol-free for six months.

“We had done a day’s work on him — got the D.N.R., treated his pain, arranged for hospice,” she said. The receiving hospital, she believed, was part of the conspiracy of denial, only too happy to get the payment for accepting the patient, who ended up dying before he could be evaluated.

But, several residents objected, the man kept asking for a liver transplant. It seemed unprofessional, even inhumane, to refuse.

“They say when a person is drunk or out of it, he tells the truth,” one resident said. “His options should not stop.”

“Was it really a viable option for him?” Dr. Shaiova demanded.

“Maybe we should take it as a last wish,” the senior resident said, from the back of the room.

Dr. Shaiova said they should have realized the patient would never survive. “Doctors are the worst predictors,” she said after the session.

Asked how she deals with the death of her patients, Dr. Shaiova said, “I play the harmonium.”

 

Her Final Days

In early June, Dr. O’Mahony went to Ireland on vacation. He was looking forward to seeing his mother, Kathrina, 74. She had received a diagnosis of breast cancer in 1995. The cancer returned in 2006, and she was told it was not possible to remove all of the tumor.

She had recently painted over the image of her body on a PET-CT scan, used to confirm the presence of a local recurrence of cancer. “I got her the scan,” Dr. O’Mahony said gleefully.

While Dr. O’Mahony was away, Mrs. Migliore received radiation to try to shrink a tumor that the doctors said could wrap around her spine and paralyze her. She would return from the treatments — administered every day for 29 days, her husband said — in a stupor. “Most of these doctors are convinced they’re doing the right thing,” he said. “It’s just that I don’t want to have a walking wife who’s in zombieland, you know?”

He was taking things a day at a time, and taking sedatives. “I’m on 350 milligrams of Zoloft every day, so I feel pretty good,” he said.

When Dr. O’Mahony returned, he learned that Mrs. Migliore had been admitted to Montefiore a few days earlier, as cancer infiltrated her bone marrow and she became dehydrated. He scheduled a bedside conference his first day back.

Mrs. Migliore could no longer walk, or even sit up on her own. She was checked in to Room 954A North. Her window had a panoramic view of the Bronx, with Calvary Hospital, which cares for terminal cancer patients, in the foreground, its red-brick bulk marked by three crosses.

Dr. O’Mahony and Mr. Migliore stood side by side at the foot of the bed. Mrs. Migliore looked incorporeal, so slight she melted into the bedsheets.

“So we’re just here to see how you’re doing today,” Dr. O’Mahony began.

“Well, I want to go home; that’s all I want to do,” Mrs. Migliore said. “I do not want to stay here.”

“O.K,” her husband answered, sniffling.

“So when are you taking me home?” Mrs. Migliore said.

“Well, we just need to get you a little bit stronger, O.K.?” Mr. Migliore said. “That’s what we’re here to discuss. We’re here to tell you what’s going on.”

“How are you doing?” Mrs. Migliore asked her husband, her voice softening.

“I’m doing O.K.,” he said.

Growing agitated, Mrs. Migliore said that a woman at the nursing home had tried to marry her. She said that she objected that she was already married, and that she was locked into a room in what seemed to be a funeral home. She said she had thrown china plates out the window in a vain bid to be rescued. It sounded like an elaborate parable about the bride of death, and her husband could not convince her that it was all in her head.

Turning to a visitor, she kept asking, “Are you pregnant?” as if she wished she herself could be.

Dr. O’Mahony adjourned the conversation to a conference room, leaving Mrs. Migliore alone.

Mr. Migliore immediately asked how much time his wife had left.

“I can’t give a definite response in terms of the number of days or weeks,” Dr. O’Mahony said.

Mr. Migliore said another doctor at the hospital had estimated four to six months.

Dr. O’Mahony gave his standard warning: It is hard to go from prognostic estimates based on large populations to individual cases. Nonetheless, he conceded that she was getting much worse.

Mr. Migliore said he did not think he could take care of her at home and proposed she go to Calvary. “How do we convince her this is the right decision?” he asked.

“During these times when her thinking is impaired, you are her voice,” Dr. O’Mahony replied.

Two days later, Mrs. Migliore was across the street at Calvary. Her husband tacked photos of their wedding to the bulletin board. Within a few days, her speech had deteriorated to “baby talk,” as her husband put it, and she was eating little more than Italian ices.

She turned 52 on June 30, and her husband managed to feed her a spoonful of birthday cake. He was thrilled when she said it tasted like excrement. For that moment, she sounded like herself.

Much of the time, she was heavily sedated to stop her from screaming. She was given morphine for pain and haloperidol, an antipsychotic, for delirium, which can be a side effect of advanced cancer and opiate drugs. “She seems terrified,” Mr. Migliore said.

He said the staff had asked if they should disconnect the tube feeding her sugar and water. “Then what, she starves to death?” Mr. Migliore said. “I can’t. I can’t, even though I’m the proxy.” A fatal injection, if that were possible, seemed more merciful to him. “The way things are going now at this point,” he said, “I’m hoping God takes her tonight. Living like this is barbaric.”

He got his wish three days later. “She never asked me, ‘Am I going to die?’ ” he said, so he never had to do what he feared most: give her an answer.

Mrs. Migliore died on July 3, after eight days at Calvary, less than four months after Dr. O’Mahony fired his warning shot. He had several conversations with her before she died, a luxury that other types of doctors might not have. But he never told her directly that she was going to die.

Asked why, Dr. O’Mahony said that Mrs. Migliore had appointed her husband as her surrogate, and that she had responded to open-ended questions with a focus on the details of her everyday life, rather than a desire to foresee the future. He saw that as a road map for his approach to her prognosis.

“Patients sometimes will be very explicit about wanting that information very, very clearly delivered,” he said. “Whereas other people don’t.”

Dr. O’Mahony has not spoken to Mr. Migliore since his wife died, and he does not expect to. Once the ferryman has delivered his patients across the river, he rarely looks back.

    At the End, Offering Not a Cure but Comfort, NYT, 20.8.2009, http://www.nytimes.com/2009/08/20/health/20doctors.html

Op-Ed Contributor

Health Care’s Generation Gap

August 17, 2009
The New York Times
By RICHARD DOOLING

IN the 1980s, I worked as a respiratory therapist in intensive-care units in the Midwest, taking care of elderly, dying patients on ventilators. I remember marveling, along with the young doctors and nurses I worked with, over how many millions of dollars were spent performing insanely expensive procedures, scans and tests on patients who would never regain consciousness or leave the hospital.

When the insurance ran out, or Medicare stopped paying, patients and their families gave the hospital liens on their homes to pay for this care. Families spent their entire savings so Grandma could make yet another trip to the surgical suite on the slim-to-none chance that bypass surgery, a thoracotomy, an endoscopy or kidney dialysis might get her off the ventilator and out of the hospital in time for her 88th birthday.

That was back in the mid-’80s, when the nation was spending around 8 percent of its gross domestic product on health care. I and other health care workers solemnly agreed that the spending spree could not continue. Taxpayers and insurance companies would eventually revolt and refuse to pay for such end-of-life care. Somebody would surely expose the ruse for what it was: an enormous transfer of wealth based on the pretense that getting old and dying is a medical emergency requiring high-tech intensive-care intervention and armies of specialists, which could cost $10,000 or more per day. (Europeans have so far resisted this delusion, one reason they spend much less than we do on health care, with far better results.)

But we were wrong. Health care spending has since doubled, to around 16 percent of our gross domestic product, and in the next 25 years or so is projected to reach 31 percent of G.D.P. Despite having those figures in hand, Congress might still pass legislation calling for spending more, not less, on health care, even though we’ve been told for decades that what we spend has almost nothing to do with the quality of care we receive.

In fact, expensive care is often worse care, because it snowballs into what some are calling an “epidemic of overtreatment,” in which unnecessary procedures, tests and medications all spawn more tests, more meds (to treat the side effects of the first batch) and more follow-up scans and procedures (in stand-alone clinics owned by the same doctors prescribing the tests, scans and procedures).

With so much evidence of wasteful and even harmful treatment, shouldn’t we instantly cut some of the money spent on exorbitant intensive-care medicine for dying, elderly people and redirect it to pediatricians and obstetricians offering preventive care for children and mothers? Sadly, we are very far from this goal. A cynic would argue that this can’t happen because children can’t vote (even if their parents can), whereas members of AARP and the American Medical Association not only vote but can also hire lobbyists to keep the money flowing.

One thing’s for sure: Our health care system has failed. Generational spending wars loom on the horizon. Rationing of health care is imminent. But given the political inertia, we could soon find ourselves in a triage situation in which there is no time or money to create medical-review boards to ponder cost-containment issues or rationing schemes. We’ll be forced to implement quick-and-dirty rules based on something simple, sensible and easily verifiable. Like age. As in: No federal funds to be spent on intensive-care medicine for anyone over 85.

I am not, of course, talking about euthanasia. I’m just wondering why the nation continues incurring enormous debt to pay for bypass surgery and titanium-knee replacements for octogenarians and nonagenarians, when for just a small fraction of those costs we could provide children with preventive health care and nutrition. Eight million children have no health insurance, but their parents pay 3 percent of their salaries to Medicare to make sure that seniors get the very best money can buy in prescription drugs for everything from restless leg syndrome to erectile dysfunction, scooters and end-of-life intensive care.

Sir William Osler, widely revered as the father of modern medicine, said, “One of the first duties of the physician is to educate the masses not to take medicine.” Perhaps the second duty should be to administer an ounce of prevention instead of a pound of cure.

 

Richard Dooling is the author of “Critical Care,” a novel.

    Health Care’s Generation Gap, NYT, 17.8.2009, http://www.nytimes.com/2009/08/17/opinion/17dooling.html

Op-Ed Contributor

Science Is in the Details

July 27, 2009
The New York Times
By SAM HARRIS

PRESIDENT OBAMA has nominated Francis Collins to be the next director of the National Institutes of Health. It would seem a brilliant choice. Dr. Collins’s credentials are impeccable: he is a physical chemist, a medical geneticist and the former head of the Human Genome Project. He is also, by his own account, living proof that there is no conflict between science and religion. In 2006, he published “The Language of God,” in which he claimed to demonstrate “a consistent and profoundly satisfying harmony” between 21st-century science and evangelical Christianity.

Dr. Collins is regularly praised by secular scientists for what he is not: he is not a “young earth creationist,” nor is he a proponent of “intelligent design.” Given the state of the evidence for evolution, these are both very good things for a scientist not to be.

But as director of the institutes, Dr. Collins will have more responsibility for biomedical and health-related research than any person on earth, controlling an annual budget of more than $30 billion. He will also be one of the foremost representatives of science in the United States. For this reason, it is important that we understand Dr. Collins and his faith as they relate to scientific inquiry.

What follows are a series of slides, presented in order, from a lecture on science and belief that Dr. Collins gave at the University of California, Berkeley, in 2008:

Slide 1: “Almighty God, who is not limited in space or time, created a universe 13.7 billion years ago with its parameters precisely tuned to allow the development of complexity over long periods of time.”

Slide 2: “God’s plan included the mechanism of evolution to create the marvelous diversity of living things on our planet. Most especially, that creative plan included human beings.”

Slide 3: “After evolution had prepared a sufficiently advanced ‘house’ (the human brain), God gifted humanity with the knowledge of good and evil (the moral law), with free will, and with an immortal soul.”

Slide 4: “We humans used our free will to break the moral law, leading to our estrangement from God. For Christians, Jesus is the solution to that estrangement.”

Slide 5: “If the moral law is just a side effect of evolution, then there is no such thing as good or evil. It’s all an illusion. We’ve been hoodwinked. Are any of us, especially the strong atheists, really prepared to live our lives within that worldview?”

Why should Dr. Collins’s beliefs be of concern?

There is an epidemic of scientific ignorance in the United States. This isn’t surprising, as very few scientific truths are self-evident, and many are counterintuitive. It is by no means obvious that empty space has structure or that we share a common ancestor with both the housefly and the banana. It can be difficult to think like a scientist. But few things make thinking like a scientist more difficult than religion.

Dr. Collins has written that science makes belief in God “intensely plausible” — the Big Bang, the fine-tuning of nature’s constants, the emergence of complex life, the effectiveness of mathematics, all suggest the existence of a “loving, logical and consistent” God.

But when challenged with alternative accounts of these phenomena — or with evidence that suggests that God might be unloving, illogical, inconsistent or, indeed, absent — Dr. Collins will say that God stands outside of Nature, and thus science cannot address the question of his existence at all.

Similarly, Dr. Collins insists that our moral intuitions attest to God’s existence, to his perfectly moral character and to his desire to have fellowship with every member of our species. But when our moral intuitions recoil at the casual destruction of innocents by, say, a tidal wave or earthquake, Dr. Collins assures us that our time-bound notions of good and evil can’t be trusted and that God’s will is a mystery.

Most scientists who study the human mind are convinced that minds are the products of brains, and brains are the products of evolution. Dr. Collins takes a different approach: he insists that at some moment in the development of our species God inserted crucial components — including an immortal soul, free will, the moral law, spiritual hunger, genuine altruism, etc.

As someone who believes that our understanding of human nature can be derived from neuroscience, psychology, cognitive science and behavioral economics, among others, I am troubled by Dr. Collins’s line of thinking. I also believe it would seriously undercut fields like neuroscience and our growing understanding of the human mind. If we must look to religion to explain our moral sense, what should we make of the deficits of moral reasoning associated with conditions like frontal lobe syndrome and psychopathy? Are these disorders best addressed by theology?

Dr. Collins has written that “science offers no answers to the most pressing questions of human existence” and that “the claims of atheistic materialism must be steadfastly resisted.”

One can only hope that these convictions will not affect his judgment at the institutes of health. After all, understanding human well-being at the level of the brain might very well offer some “answers to the most pressing questions of human existence” — questions like, Why do we suffer? Or, indeed, is it possible to love one’s neighbor as oneself? And wouldn’t any effort to explain human nature without reference to a soul, and to explain morality without reference to God, necessarily constitute “atheistic materialism”?

Francis Collins is an accomplished scientist and a man who is sincere in his beliefs. And that is precisely what makes me so uncomfortable about his nomination. Must we really entrust the future of biomedical research in the United States to a man who sincerely believes that a scientific understanding of human nature is impossible?

 

Sam Harris is the author of “The End of Faith” and co-founder of the Reason Project, which promotes scientific knowledge and secular values.

    Science Is in the Details, NYT, 27.7.2009, http://www.nytimes.com/2009/07/27/opinion/27harris.html

An Abortion Battle,

Fought to the Death

July 26, 2009
The New York Times
By DAVID BARSTOW

WICHITA, Kan. — It did not take long for anti-abortion leaders to realize that George R. Tiller was more formidable than other doctors they had tried to shut down.

Shrewd and resourceful, Dr. Tiller made himself the nation’s pre-eminent abortion practitioner, advertising widely and drawing women to Wichita from all over with his willingness to perform late-term abortions, hundreds each year. As anti-abortion activists discovered, he gave as good as he got, wearing their contempt as a badge of honor. A “warrior,” they called him with grudging respect.

And so for more than 30 years the anti-abortion movement threw everything into driving Dr. Tiller out of business, certain that his defeat would deal a devastating blow to the “abortion industry” that has terminated roughly 50 million pregnancies since Roe v. Wade in 1973.

They blockaded his clinic; campaigned to have him prosecuted; boycotted his suppliers; tailed him with hidden cameras; branded him “Tiller the baby killer”; hit him with lawsuits, legislation and regulatory complaints; and protested relentlessly, even at his church. Some sent flowers pleading for him to quit. Some sent death threats. One bombed his clinic. Another tried to kill him in 1993, firing five shots, wounding both arms.

In short, they made George Tiller’s clinic the nation’s most visible abortion battleground, a magnet for activists from all corners of the country.

Dr. Tiller would not budge.

Instead he dug in, pouring his considerable profits into expanding his clinic and installing security cameras, bulletproof glass, metal detectors, fencing and floodlights. He hired armed guards, bought a bulletproof vest and drove an armored S.U.V. He spent hundreds of thousands of dollars on some of the state’s best lawyers and recruited an intensely loyal staff that dubbed itself Team Tiller. He lobbied politicians with large donations and photographs of severely deformed fetuses.

Confident and dryly mischievous, he told friends he had come to see himself as a general in an epic cultural war to keep abortion legal, to the point of giving employees plaques designating them “Freedom Fighters.” His willingness to abort fetuses so late in pregnancies put him at the medical and moral outer limits of abortion. Yet he portrayed those arrayed against him as religious zealots engaged in a campaign whose aim was nothing less than to subjugate women.

“If a stake has to be driven through the heart of the anti-abortion movement,” he said, “I want to have my hand on the hammer.”

The son of a prominent Wichita physician, married 45 years, the father of 4 and grandfather of 10, a former Navy flight surgeon, a longtime Republican, Dr. Tiller, 67, insisted that he would not be driven from his hometown, where he belonged to its oldest country club, was a devoted member of one of its largest churches, was active in Alcoholics Anonymous, was deeply involved in his alma mater, the University of Kansas, and adored his local Dairy Queen.

Indeed, he made a point of performing abortions the day after he was shot in the arms.

“His is the only abortion clinic we’ve never been able to close,” Troy Newman, president of Operation Rescue, said in an interview.

Yet what thousands could not achieve in three decades of relentless effort, a gunman accomplished on May 31 when he shot Dr. Tiller in the head at point-blank range while the doctor was ushering at church.

Scott Roeder, an abortion foe with the e-mail name “ServantofMessiah,” awaits trial in the murder. In a jailhouse interview, Mr. Roeder did not admit guilt but told a reporter that if he is convicted, his motive was to protect the unborn, a goal seemingly advanced when the Tiller family closed the clinic.

But in the weeks since the killing, supporters and opponents of Dr. Tiller have been measuring the larger ramifications. Implacably divided for so long, they now agree on a fundamental point: Dr. Tiller’s death represents an enormous loss for each side.

Abortion opponents are bracing for a drop in support, especially from those in the murky middle ground of the debate. Worse yet, after years of persuading supporters to work within the law, they say they have already lost credibility among the most ardent abortion opponents who cannot help pointing out that one gunman achieved what all their protests and prayers could not.

“The credit is going to go to him,” Mark S. Gietzen, chairman of the Kansas Coalition for Life, said of Mr. Roeder. “There are people who are agreeing with him.”

Advocates of abortion rights, meanwhile, are reeling from the loss of one of their most experienced and savviest leaders. One of only three doctors in the United States who openly and regularly performed late-term abortions, Dr. Tiller mentored abortion providers across the country. Some of the nation’s most influential women’s groups celebrated him as an American hero.

“This is so much more than just a murder in Wichita,” said Gloria Allred, a prominent women’s rights lawyer.

 

A Career Choice

Dr. Tiller’s career in abortion began with family tragedy.

In August 1970, his parents, sister and sister’s husband were killed when the small private plane his father was piloting crashed near Yellowstone National Park. Dr. Tiller, who had carried his father’s bag on house calls as a boy, left the Navy and returned home to care for his grandparents and wind down his father’s family practice. He and his wife, Jeanne, adopted his sister’s baby son, and he talked of settling into life as a dermatologist.

But he discovered his father had been performing significant numbers of illegal abortions, and before long women began turning to him for abortions, too, often under desperate circumstances. “The women taught him about life in Wichita,” said Linda Stoner, who worked for Dr. Tiller for a decade. The more skilled he became, the more referrals he got, the more he undercut prices of competitors, the more he began to specialize in abortion, making it the main focus of his practice by the late 1970s.

Friends said Dr. Tiller knew he would become a target. Pickets first showed up in 1975, two years after he performed his first abortion. Years later, an anti-abortion group put him on a “wanted” poster of prominent abortion providers and offered $5,000 for information leading to his arrest. When an abortion provider in Florida was assassinated in 1994, Dr. Tiller spent the next few years under the protection of federal marshals. By 1997, he had been labeled “the most infamous abortionist in the United States” by James C. Dobson, founder of Focus on the Family.

“He chose his life,” said Dan Monnat, his longtime lawyer. “And having chosen it, he wasn’t going to complain about the restrictions on his liberty by those who saw it another way.”

Dr. Tiller also accepted that his career would inevitably bring scrutiny of his private life, including his struggle with substance abuse, which resulted in a 1984 arrest for driving under the influence and an agreement with the Kansas State Board of Healing Arts to seek treatment. (He would later serve on the Kansas Medical Society’s impaired physicians committee.)

Still, his family strongly supported his choice. He described his daughters, two of whom became physicians, coming into his study during one especially stressful period. “What they said to me was, ‘Daddy, if not now, when? If not you, who?’ ” he recalled this spring in a court hearing.

Dozens of anti-abortion groups of varying sizes and philosophies were out to shut down his clinic, Women’s Health Care Services. While their tactics constantly changed, they shared the same basic goal. “We wanted it to get to the point where it was no longer feasible to stay open,” Mr. Gietzen of the Coalition for Life said.

Every vendor who showed up at the clinic was warned that if they continued to do business with Dr. Tiller they would be boycotted. Those who ignored the threat were listed on anti-abortion Web sites. “We had nobody in town that would deliver pizza,” said an employee, Linda Joslin.

Protesters confronted his employees, demanding that they quit. If they refused, activists passed out fliers in their neighborhood accusing them of working for a baby killer.

Patients would encounter a gantlet of protest.

They would see a “Truth Truck,” its side panels displaying large color photographs of dismembered fetuses. Over the clinic gate, strung between two poles, they might see a banner, “Please Do Not Kill Your Baby.” Planted in the grass by the sidewalk were 167 white crosses, representing the average number of abortions that protesters said were performed there each month.

Protesters approached patients’ cars, offering them baby blankets and urging them to visit an anti-abortion pregnancy clinic they had set up next door. Sometimes they followed patients to their hotels and slipped pamphlets under their doors. A few years ago anti-abortion campaigners spent weeks in a hotel room with a view of the Tiller clinic entrance. Using a powerful telephoto lens, they took photographs of patients, which were posted on a Web site with their faces blurred.

Much of this activity was methodically tracked by Mr. Gietzen, who said he presides over a network of 600 volunteers, some of whom drove hundreds of miles for a protest “shift.” Protesters counted cars entering the clinic gate, and they tracked “saves” — patients who changed their minds. According to Mr. Gietzen’s data, over the last five years they had 395 “saves” for an “overall save rate” of 3.77 percent.

They also kept detailed “incident reports” of unusual activity. It was a bonanza if an ambulance was summoned; photographs were quickly posted as evidence of another “botched” abortion.

There seemed an endless supply of fresh accusations.

“Wichita shoppers unknowingly sprinkled with the burnt ash of fetal remains,” declared one news release, referring to the clinic’s crematorium.

“If I can’t document it, I don’t say it,” Mr. Newman of Operation Rescue said, moments before suggesting without any proof that Dr. Tiller had bought off the local district attorney, Nola T. Foulston, by giving her a baby for adoption. He referred a reporter to a Web site that vaguely asserted that Dr. Tiller “may have delivered the ultimate bribe to Nola Foulston.” A spokeswoman for Ms. Foulston declined to discuss the accusation.

Anti-abortion activists routinely portrayed Dr. Tiller’s campaign contributions as “blood money” that co-opted politicians. “He owned the attorney general’s office,” Mr. Newman said. “He owned the governor’s office. He owned the district attorney’s office.”

They relished each confrontation, both for public relations value and for the legal costs inevitably incurred by Dr. Tiller. He spent years, for example, fighting a legal battle to stop them from planting the crosses, and just about every inch of land outside his clinic was subject to litigation or negotiation.

“We know what you can do on the blacktop,” Mr. Gietzen said. “We know what you can do on the driveway. We know what you can do on the sidewalk.”

In April 2006, though, a volunteer spotted an opportunity for confrontation in one small strip of pavement that he thought had been overlooked: the gutter running between the street and the clinic driveway. The volunteer knelt in the gutter to pray, placing himself in the path of vehicles entering the clinic.

According to the “incident report,” a clinic nurse pulled up and “laid on her horn repeatedly.” When the volunteer “acted as if he did not know that she was there,” the report continued, a clinic guard told him that he was reporting him to the police.

The next day, Mr. Gietzen was standing in the gutter with his volunteer discussing the new tactic when Dr. Tiller pulled up in his armored S.U.V. In another “incident report,” Mr. Gietzen wrote: “Tiller floored his accelerator, and aimed his Jeep directly at us!”

Mr. Gietzen claimed that Dr. Tiller’s vehicle hit him, causing bruising. He promptly filed a police report, generating more news coverage. He then wrote to Dr. Tiller demanding a $4,000 settlement. When that went nowhere, he sued. He also demanded that Ms. Foulston prosecute Dr. Tiller for attempted murder.

And when she refused, this became more proof of the public “corruption” they traced to Dr. Tiller.

 

Developing a Sense of Mission

Jacki G., 29, went to Dr. Tiller for an abortion in 1996 after she was raped. She can still remember her trepidation when she and her mother pulled up to the clinic a few weeks into her pregnancy.

In middle school in Wichita, she said, children chanted “Tiller, Tiller, the baby killer.” She recalled the gory Truth Trucks driving around town and the 1991 “Summer of Mercy” protests, when hundreds were arrested for blockading Dr. Tiller’s clinic.

“It makes an impression,” she said.

Not only did she fear the protesters, she also worried about whether Dr. Tiller would be gruff and cold, “only in it for the money,” as his critics alleged. It was almost a shock, she said, to instead meet a slightly nerdy doctor who gently explained every step and kept asking, “Are you doing O.K.?”

Employees said Dr. Tiller did not have moral qualms about his work, in part because he defined it as saving women’s lives and giving them freedom to determine their futures.

“We have made higher education possible,” he said in a speech. “We have helped correct some of the results of rape and incest. We have helped battered women escape to a safer life. We have made recovery from chemical dependency possible. We have helped women and families struggle to save their unwell, unborn child a lifetime of pain.”

Dr. Tiller recruited a staff that shared his outlook. Mostly women, several used the same word to describe the clinic: “sisterhood.”

They worked under intense pressure, caring for women in distress while constantly confronting protesters eager to pounce on their every mistake. Abortion protesters sent pregnant women into the clinic “under cover,” hoping to catch the staff violating Kansas abortion regulations. One employee, Ms. Joslin, 68, pulled out an anonymous letter she received a week before Dr. Tiller’s death. “Somebody should kill you, so you can’t kill anymore,” it said.

As Wichita’s three other abortion clinics closed under the pressure of protesters, Dr. Tiller cultivated a sense of mission. Throughout the clinic he hung hundreds of framed thank-you letters from patients. He posted a list of “Tillerisms” — his favorite axioms, including, “The only requirement for evil to triumph is for good people to do nothing.”

He also paid well and gave bonuses to mark legal victories. In 2001, after heavy protests, he held a party and gave each employee a dozen roses, a medal engraved with the torch of liberty, a T-shirt depicting Rosie the Riveter and the words, “We can do it Team Tiller,” and an American flag that had flown over the clinic.

His defiance was as relentless as the protests. When his clinic was bombed, he put up a sign that said “Hell, no. We won’t go!” In a fit of anger, he once told an anti-abortion leader, “Too bad your mother’s abortion failed.” Employees and protesters alike said he even drove into his clinic “with attitude,” accelerating slightly as if to emphasize that protesters had no right to block his gate. And when he drove by Mr. Gietzen, he sometimes smiled and lifted an editorial cartoon depicting Mr. Gietzen as a lunatic.

In 2001, protesters began appearing at Dr. Tiller’s church with Truth Trucks and a demand that the church ex-communicate the Tiller family.

“They were abusively shouting at people not to take their children into the church because there was a murderer there,” recalled the Rev. Sally C. Fahrenthold, then the interim pastor at the church, Reformation Lutheran.

For at least two years, protesters showed up each Sunday, sometimes disrupting services from the pews. Protesters obtained a copy of the membership address book and sent all members postcards showing aborted fetuses.

Years earlier, friends said, the Tillers had been asked to leave another church because of his abortion practice. Reformation Lutheran made no such request. The Tillers were mainstays in the church. Jeanne Tiller sings in the choir, and her husband was a regular in Bible study. Still, the Tillers were saddened by the protests, Pastor Fahrenthold said, and a couple of families left the church.

Eventually the Sunday protests petered out, although every so often protesters returned. Last fall, when the church was recruiting a new pastor, it listed abortion as one of the main challenges facing the membership. “Everybody there was not on the same page on this issue,” the new pastor, Lowell Michelson, said in an interview.

Pastor Michelson said he and Dr. Tiller sometimes spoke about abortion. This, he said, is how he learned of adoptions Dr. Tiller sometimes arranged for his patients, in some cases even having women live with his family until after childbirth. “He was giving women in the most desperate of situations options when they had none,” he said.

One lingering question in the church, though, was whether to improve security, and there was talk about buying a camera for the church entrance. Dr. Tiller did not perceive any significant threat. He did not, at least in recent years, take his guards to church.

“The church was the one place he felt safe,” Ms. Joslin said.

 

New Strategies by Opponents

Several years ago it became clear to anti-abortion leaders that they needed a new strategy to shut down Dr. Tiller. They eased off their more combative protest tactics and resolved to rely more on the courts, the Kansas Legislature and the news media to attack him.

They also decided to sharpen their focus on late-term abortions.

Dr. Tiller’s clinic Web site boasted that he had more experience with late-term abortions “than anyone else currently practicing in the Western Hemisphere.” Since 1998, interviews and state statistics show, his clinic performed about 4,800 late-term abortions, at least 22 weeks into gestation, around the earliest point at which a fetus can survive outside the womb. At 22 weeks, the average fetus is 11 inches long, weighs a pound and is starting to respond to noise.

About 2,000 of these abortions involved fetuses that could not have survived outside the womb, either because they had catastrophic genetic defects or they were simply too small.

But the other 2,800 abortions involved viable fetuses. Some had serious but survivable abnormalities, like Down syndrome. Many were perfectly healthy.

Like many states, Kansas has long placed limits on late-term abortions of viable fetuses. They can be done only to save the woman’s life or because continuing the pregnancy would cause her a “substantial and irreversible impairment of a major bodily function,” a phrase that Kansas legal authorities, citing United States Supreme Court cases, have said encompasses the woman’s physical and mental health. The state also requires the approval of a second Kansas physician “not legally or financially affiliated” with the doctor performing the abortion.

Even so, Kansas law gives considerable deference to physicians’ judgments. Dr. Tiller and his staff said they had a rigorous screening process to comply with the law.

The vast majority of women seeking late-term abortions from Dr. Tiller’s clinic were from other states, records and testimony show. Dozens more came each year from Canada and other countries. Many were referred by their obstetrician. Law enforcement officials sometimes gave Dr. Tiller’s name to victims of rape or incest.

Prospective patients were required to submit a battery of medical records. They were asked whether they had considered adoption. Before meeting Dr. Tiller, women were interviewed by at least two clinic counselors. Many of the questions — about appetite, sleep habits, thoughts of suicide — were intended to detect symptoms of severe mental illness. Patients were also examined by a second physician, as required by law.

According to sworn testimony by his staff, hundreds of women were turned away each year because they did not meet the legal requirements for a late-term abortion.

When late-term abortions were done, Dr. Tiller typically injected a lethal drug into the fetus’s heart, then induced labor after the heart stopped. The entire process typically took several days, and many patients have written tributes about the sensitive care they received.

Abortion opponents focused on a different aspect of the procedure: the fees. Describing Dr. Tiller’s “decadent, lavish lifestyle,” an Operation Rescue Web site included a photograph of his 8,500-square-foot home.

Based on Dr. Tiller’s sworn testimony, his clinic grossed at least $1.5 million in 2003 from late-term abortions, a small fraction of the total number of abortions his clinic performed. On average, he charged $6,000 for a late-term abortion, and by his calculation the clinic’s profit margin was 38 percent.

Anti-abortion leaders were determined to demonstrate that Dr. Tiller enriched himself by performing late-term abortions for trivial reasons, and they believed that Kansas law offered the key to exposing that and closing him down. A billboard in Wichita asked, “Is Tiller above the law?”

They found two powerful champions.

The first was Phill Kline, a conservative radio host and fierce abortion opponent who was elected attorney general of Kansas in 2002 and promptly opened an investigation into Dr. Tiller.

In 2004, Mr. Kline subpoenaed case files of 60 women and girls who had late-term abortions performed at Dr. Tiller’s clinic. (He also sought 30 files from Planned Parenthood in Overland Park.) Mr. Kline said his inquiry centered on potential violations of the late-term abortion law and a second law requiring physicians to report evidence of sexual abuse against minors.

The second champion was Bill O’Reilly of Fox News, host of the nation’s most-watched cable news program, who began attacking Dr. Tiller in 2005, eventually referring to him as simply “Tiller the baby killer.” Mr. Gietzen said he and other activists fed tips to Mr. O’Reilly’s staff. Mr. O’Reilly began one program this way: “In the state of Kansas, there is a doctor, George Tiller, who will execute babies for $5,000 if the mother is depressed.”

Dr. Tiller assembled a legal team to derail Mr. Kline’s investigation. While the Kansas Supreme Court refused to quash Mr. Kline’s subpoena, it was clearly uneasy. Noting that the files “could hardly be more sensitive,” the court ordered identifying information redacted and warned both sides to “resist any impulse” to publicize the case.

Mr. Kline’s investigators tried to identify patients anyway, court records show. Mr. Kline also hired medical experts recommended by anti-abortion groups and gave them access to the files without requiring them to pledge confidentiality.

One expert, Paul McHugh, a professor of psychiatry at Johns Hopkins, then discussed the files — though not identities — in a videotaped interview arranged by anti-abortion activists that quickly made its way to Mr. O’Reilly and others in the news media.

Calling Mr. Kline’s conduct “inexcusable,” the Kansas Supreme Court reprimanded him in an opinion that questioned his ethics and honesty. “Essentially, to Kline, the ends justify the means,” the justices said.

 

Legal Victories

Nonetheless, Dr. McHugh’s interview raised the question of whether Dr. Tiller had used readily treatable mental health maladies as a pretext to justify late-term abortions.

According to Dr. McHugh, the files he saw contained diagnoses like adjustment disorder, anxiety and depression that to his eyes were not “substantial and irreversible.” He also claimed that some women offered “trivial” reasons for wanting an abortion, like a desire to play sports. “I can only tell you,” he said in his taped interview, “that from these records, anybody could have gotten an abortion if they wanted one.”

Yet Dr. McHugh’s description of the files left out crucial bits of context. He failed to mention, for example, that one patient was a 10-year-old girl, 28 weeks pregnant, who had been raped by an adult relative. Asked about this omission by The New York Times, Dr. McHugh said that while the girl’s case was “terrible,” it did not change his assessment: “She did not have something irreversible that abortion could correct.” (Dr. Tiller’s lawyers, who have called Dr. McHugh’s description of the patient files “deeply misleading,” declined to discuss their contents.)

Not content to rely only on Mr. Kline, anti-abortion leaders also took advantage of an obscure Kansas statute allowing residents to petition for grand jury investigations. They gathered thousands of signatures to convene two grand juries focusing on Dr. Tiller.

The first, in 2006, investigated the case of Christin A. Gilbert, a 19-year-old with Down syndrome who died two days after having an abortion at Dr. Tiller’s clinic. The autopsy concluded that Ms. Gilbert “died as a result of complications of a therapeutic abortion,” most likely infection. But the Kansas Board of Healing Arts, after an 11-month investigation by two separate panels, cleared Dr. Tiller of wrongdoing. The grand jury declined to indict.

Mr. Newman of Operation Rescue appeared before the second grand jury armed with a thick briefing book summarizing his group’s investigation into Dr. Tiller. The grand jury was also given access to medical records for more than 150 randomly selected patients who had late-term abortions.

It also declined to indict.

But it did so in a way that was less an exoneration than a criticism of the Legislature for failing to provide clearer guidelines. The law as written and interpreted, the grand jury complained in a statement, seemed to allow late-term abortions to prevent health problems that “as a matter of common interpretation” were not “substantial and irreversible.” The grand jury said lawmakers had intended to limit these late-term abortions to “only the gravest of circumstances,” yet Dr. Tiller’s files “revealed a number of questionable late-term abortions.”

In 2006, Mr. Kline lost his re-election bid by 17 percentage points to Paul J. Morrison, who made Mr. Kline’s abortion investigation a major issue. To anti-abortion activists, Mr. Kline’s defeat was yet another example of Dr. Tiller’s raw clout. Dr. Tiller, they said, had given hundreds of thousands of dollars to a political action committee that criticized Mr. Kline, who was labeled the “Snoop Dog.” They claimed that Dr. Tiller would press the new attorney general to end Mr. Kline’s investigation.

Instead, Mr. Morrison charged Dr. Tiller with 19 misdemeanor violations of the late-term abortion law involving the very files Mr. Kline had subpoenaed.

Dr. Tiller was charged with violating the provision requiring the independent approval of a second Kansas doctor. The same doctor, Ann K. Neuhaus, had signed off on all 19 cases. She typically saw patients at Dr. Tiller’s clinic once a week. Although patients paid her directly, prosecutors claimed that she and Dr. Tiller had a symbiotic relationship because his patients were her only source of income.

Dr. Tiller responded with customary self-confidence, insisting that he would take the stand.

The trial so long sought by abortion foes took place this March. It quickly became clear that the case was far from ironclad. The prosecutor produced no evidence of shared fees, partnership agreements or kickbacks. He was reduced to pointing out that Dr. Neuhaus had hugged Dr. Tiller before testifying.

Worse still, there was evidence that an official for the Kansas Board of Healing Arts had suggested the arrangement with Dr. Neuhaus, who had closed her own women’s health clinic to care for her diabetic son. There was also evidence that several times a year Dr. Neuhaus disagreed with Dr. Tiller about whether an abortion was necessary. As for Dr. Neuhaus examining women at his clinic, Dr. Tiller told jurors that was done to spare patients repeated confrontations with protesters.

Why, he was asked, were so few doctors in America willing to perform late-term abortions? “Because of the threat to themselves and to their family,” he replied.

Why had he not switched to another kind of medicine? “Well,” he said, “quit is not something I like to do.”

The jury took less than 30 minutes to acquit Dr. Tiller of all charges.

It was an enormous victory, but Dr. Tiller’s supporters feared a backlash. Anti-abortion activists who had attended court sessions were disgusted. Mr. Newman remembered one new face among the regulars in court — Scott Roeder, who told other protesters that the trial was a “sham” and had argued in years past that homicide was justifiable to stop abortions.

 

Facing the Risks

On Sunday, May 31, Reformation Lutheran Church celebrated the Festival of Pentecost with a special prelude of international music.

Most members were already settled in the pews, but Dr. Tiller, an usher that morning, was greeting stragglers in the foyer by the sanctuary entrance. His wife was in the sanctuary where Pastor Michelson, beating a darbuka drum, was midway through an African song called “Celebrate the Journey!”

Pastor Michelson heard a sharp noise but thought it was probably a child dropping a hymnal. Then an usher beckoned him toward the sanctuary entrance. “George has been shot,” the usher told him quietly.

Two church members were already performing CPR on Dr. Tiller by the juice and coffee table. Pastor Michelson heard someone say a gunman — later identified by the police as Mr. Roeder — had fled.

Pastor Michelson thought of the families, the children, in the sanctuary. An assistant pastor, trying to avoid panic, went ahead with the service. Dr. Tiller died in the foyer.

Long ago, he had accepted the possibility he might be assassinated. It was something he and his fellow abortion providers had quietly discussed, and friends said he had lost count of all the death threats.

Even so, there was a mood of stunned rage when local abortion rights advocates gathered the Friday after his killing at First Unitarian Universalist Church in Wichita.

Marla Patrick, the Kansas state coordinator of the National Organization for Women, spoke of all the other abortion providers who had been killed, injured or threatened. Including Dr. Tiller, four doctors have been slain in the United States since 1993. It was time, she said, for law enforcement to treat abortion violence as “domestic terrorism.”

Pedro L. Irigonegaray, a lawyer for Dr. Tiller, aimed his fury at Mr. Kline and Mr. O’Reilly, saying their “fraudulent charges” had surely been meant to incite “a response from radicals.”

But it was a demoralized group. In Topeka, the state capital, they have long been outmuscled by conservative Christians, who have been steadily chipping away at abortion rights. One woman, a lobbyist for abortion rights, described how some legislators literally turned their backs when she testified.

Gail Finney, a junior member of the Legislature, stood and asked why there had not been more outcry from the state’s leaders over Dr. Tiller’s killing.

“Where’s the anguish?” Ms. Finney said.

Not a single Kansas politician of statewide prominence showed up the next morning for Dr. Tiller’s funeral, which drew 1,200 mourners. Nor were any at Reformation Lutheran the next day, the first Sunday service after his death.

In the foyer where he was shot, the juice and coffee table had been turned into a memorial, with Dr. Tiller’s photograph next to a basket of buttons he had passed out by the boxful to patients, employees and friends. “Attitude is Everything,” they said.

Outside, Pastor Michelson greeted families with hugs. “There was no way I was going to hide inside,” he later said.

The Tiller clan took their usual spot in the pews, and Mrs. Tiller, radiant in red, was embraced again and again. Flowers from her husband’s funeral framed the altar.

The church was more crowded than usual.

In his sermon, Pastor Michelson openly acknowledged his own apprehensions. “Our sanctuary has been violated,” he said. He urged his congregation to rise above fear and anger, and took note of the supportive letters and e-mail messages from churches all over the country.

Only later, during an interview, did he mention all the hate mail.

 

An End to the Fight

The next morning the Tillers announced the clinic’s closing.

“We are proud of the service and courage shown by our husband and father and know that women’s health care needs have been met because of his dedication and service,” the family said in a statement. “That is a legacy that will never die.”

Mr. Gietzen absorbed the news in his dimly lighted basement, surrounded by dusty stacks of anti-abortion literature, news releases and petitions. Dozens of campaign signs, including one for Mr. Kline, covered one wall. In a corner he had built a crude assembly line for producing the crosses he planted at Dr. Tiller’s clinic. In his driveway was Truth Truck No. 3, proclaiming “Abortion is an ObamaNation.”

Mr. Gietzen juggled two phones, one for his volunteers and one for his Christian dating service.

A volunteer called and Mr. Gietzen issued instructions to call off a protest at the clinic. No need now, he said.

The phone rang again. A volunteer wondered whether the announcement was a trick.

“Listen, Donna,” he said, “I’m sure it’s not a ploy.”

Another call: The voice was jubilant. “God has his own way,” Mr. Gietzen replied, “but you can’t say our prayers weren’t answered.”

Yet later, Mr. Gietzen said his feelings were more complex. Many years ago, he explained, he had wrestled with the question of whether it would be moral to kill Dr. Tiller. Only after months of reading and praying, he said, did he conclude that violence could never be justified. Killing men like Dr. Tiller, he said, will only put off the day when abortion is outlawed altogether.

“He has killed more babies than he has saved,” Mr. Gietzen said of Mr. Roeder. “I don’t care how much fan mail he is getting.”

As he explained himself, Mr. Gietzen did something unexpected. He spoke admiringly of the man he reflexively referred to as “Abortionist Tiller.” He said he was “very smart” and a “great businessman.” He said that if he had been in town he would have attended Dr. Tiller’s funeral to pay his respects.

“A worthy adversary,” he said. “He was right back at us.”

    An Abortion Battle, Fought to the Death, NYT, 26.7.2009, http://www.nytimes.com/2009/07/26/us/26tiller.html

Editorial

Health Care Reform and You

July 26, 2009
The New York Times

The health care reform bills moving through Congress look as though they would do a good job of providing coverage for millions of uninsured Americans. But what would they do for the far greater number of people who already have insurance? As President Obama noted in his news conference last week, many of them are wondering: “What’s in this for me? How does my family stand to benefit from health insurance reform?”

Many crucial decisions on coverage and financing have yet to be made, but the general direction of the legislation is clear enough to make some educated guesses about the likely winners and losers.

WHAT ARE THE ELEMENTS OF REFORM? The House bill and a similar bill in the Senate would require virtually all Americans to carry health insurance with specified minimum benefits or pay a penalty. They would require all but the smallest businesses to provide and subsidize insurance that meets minimum standards for their workers or pay a fee for failing to do so.

The reforms would help the poorest of the uninsured by expanding Medicaid. Some middle-class Americans — earning up to three or four times the poverty level, or $66,000 to $88,000 for a family of four — would get subsidies to help them buy coverage through new health insurance exchanges, national or state, which would offer a menu of policies from different companies.

IS THERE HELP FOR THE INSURED? Many insured people need help almost as much as the uninsured. Premiums and out-of-pocket spending for health care have been rising far faster than wages. Millions of people are “underinsured” — their policies don’t come close to covering their medical bills. Many postpone medical care or don’t fill prescriptions because they can’t afford to pay their share of the costs. And many declare personal bankruptcy because they are unable to pay big medical debts.

The reform effort should help ease the burdens of many of them, some more quickly than others. The legislation seems almost certain to include a new marketplace, the so-called health insurance exchange. Since there will be tens of millions of new subscribers, virtually all major insurers are expected to offer policies through an exchange. To participate, these companies would have to agree to provide a specified level of benefits, and they would set premiums at rates more comparable to group rates for big employers than to the exorbitant rates typically charged for individual coverage.

Under the House bill, the exchanges would start operating in 2013. They would be open initially to people who lack any insurance; to the 13 million people who have bought individual policies from insurance companies, which often charge them high rates for relatively skimpy coverage; and to employees of small businesses, who often pay high rates for their group policies, especially if a few of their co-workers have run up high medical bills. By the third year, larger businesses might be allowed to shift their workers to an exchange. All told, the Congressional Budget Office estimates that 36 million people would be covered by policies purchased on an exchange by 2019.

IS THERE MORE SECURITY FOR ALL? As part of health reform, all insurance companies would be more tightly regulated. For Americans who are never quite certain that their policies will come through for them when needed, that is very good news.

The House bill, for example, would require that all new policies sold on or off the exchanges must offer yet-to-be-determined “essential benefits.” It would prohibit those policies from excluding or charging higher rates to people with pre-existing conditions and would bar the companies from rescinding policies after people come down with a serious illness. It would also prohibit insurers from setting annual or lifetime limits on what a policy would pay. All this would kick in immediately for all new policies. These rules would start in 2013 for policies purchased on the exchange, and, after a grace period, would apply to employer-provided plans as well.

WHO PAYS? Current estimates suggest that it would cost in the neighborhood of $1 trillion over 10 years to extend coverage to tens of millions of uninsured Americans. Under current plans, half or more of that would be covered by reducing payments to providers within the giant Medicare program, but the rest would require new taxes or revenue sources.

If President Obama and House Democratic leaders have their way, the entire tax burden would be dropped on families earning more than $250,000 or $350,000 or $1 million a year, depending on who’s talking. There is strong opposition in the Senate, and it seems likely that at least some burden would fall on the less wealthy.

Many Americans reflexively reject the idea of any new taxes — especially to pay for others’ health insurance. They should remember that if this reform effort fails, there is little hope of reining in the relentless rise of health care costs. That means their own premiums and out-of-pocket medical expenses will continue to soar faster than their wages. And they will end up paying higher taxes anyway, to cover a swelling federal deficit driven by escalating Medicare and Medicaid costs.

WHO WON’T BE HAPPY? Healthy young people who might prefer not to buy insurance at all will probably be forced to by a federal mandate. That is all to the good. When such people get into a bad accident or contract a serious illness, they often can’t pay the cost of their care, and the rest of us bear their burden. Moreover, conscripting healthy people into the insured pool would help reduce the premiums for sicker people.

Less clear is what financial burden middle-income Americans would bear when forced to buy coverage. There are concerns that the subsidies ultimately approved by Congress might not be generous enough.

WHAT IF I HAVE GOOD GROUP COVERAGE? The main gain for these people is greater security. If they got laid off or chose to leave their jobs, they would no longer be faced with the exorbitant costs of individually bought insurance but could buy new policies through the insurance exchanges at affordable rates.

President Obama has also pledged that if you like your current insurance you can keep it.

Right now employers are free to change or even drop your coverage at any time. Under likely reforms, they would remain free to do so, provided they paid a penalty to help offset the cost for their workers who would then buy coverage through an exchange. Under the House reform bill, all employers would eventually be allowed to enroll their workers in insurance exchanges that would offer an array of policies to choose from, including a public plan whose premiums would almost certainly be lower than those of competing private plans.

Some employers might well conclude that it is a better deal — for them or for you — to subsidize your coverage on the exchange rather than in your current plan. If so, you might end up with better or cheaper coverage. You would probably also have a wider choice of plans, since most employers offer only one or two options.

WILL I PAY LESS? Two factors could help drive down the premiums for those who are insured. In the short-term, if reform manages to cover most of the uninsured, that should greatly reduce the amount of charity care delivered by hospitals and eliminate the need for the hospitals to shift such costs to patients who have private insurance. One oft-cited study estimates that cost-shifting to cover care for the uninsured adds about $1,000 to a family’s annual insurance premiums; other experts think it may be a few hundred dollars. In theory, eliminating most charity care should help hold down or even reduce the premiums charged for private insurance. When, if ever, that might happen is unclear.

In the long run, if reform efforts slow the growth of health care costs, then the increase in insurance costs should ease as well. And if the new health insurance exchanges — and possibly a new public plan — inject more competition into markets that are often dominated by one or two big private insurance companies, that, too, could help bring down premiums. But these are big question marks, and the effects seem distant.

WILL MY CARE SUFFER? Critics have raised the specter that health care will be “rationed” to save money. The truth is that health care is already rationed. No insurance, public or private, covers everything at any cost. That will not change any time soon.

It is true that the long-term goal of health reform is to get rid of the fee-for-service system in which patients often get very expensive care but not necessarily the best care. Virtually all experts blame the system for runaway health care costs because it pays doctors and hospitals for each service they perform, thus providing a financial incentive to order excessive tests or treatments, some of which harm the patients.

An earlier wave of managed care plans concentrated on reining in costs and aroused a backlash among angry beneficiaries who were denied the care they wanted. The most expensive treatment is not always the best treatment. The reform bills call for research and pilot programs to find ways to both control costs and improve patients’ care.

The bills would alter payment incentives in Medicare to reduce needless readmissions to hospitals. They would promote comparative effectiveness research to determine which treatments are best but would not force doctors to use them. And they call for pilot programs in Medicare to test the best ways for doctors to manage and coordinate a patient’s total care.

Any changes in the organization of care would take time to percolate from Medicare throughout the health care system. They are unlikely to affect most people in the immediate future.

WHAT DOES IT MEAN FOR OLDER AMERICANS? People over 65 are already covered by Medicare and would seem to have little to gain. But many of the chronically ill elderly who use lots of drugs could save significant money. The drug industry has already agreed to provide 50 percent discounts on brand-name drugs to Medicare beneficiaries who have reached the so-called “doughnut hole” where they must pay the full cost of their medicines. The House reform bill would gradually phase out the doughnut hole entirely, thus making it less likely that beneficiaries will stop taking their drugs once they have to pay the whole cost.

Not everyone in Medicare will be happy. The prospective losers are likely to include many people enrolled in the private plans that participate in Medicare, known as Medicare Advantage plans. They are heavily subsidized, and to pay for reform, Congress is likely to reduce or do away with those subsidies. If so, many of these plans are apt to charge their clients more for their current policies or offer them fewer benefits. The subsidies are hard to justify when the care could be delivered more cheaply in traditional Medicare, and the subsidies force up the premiums for the beneficiaries in traditional Medicare to cover their cost.

Reformers are planning to finance universal coverage in large part by saving money in the traditional Medicare program, raising the question of whether all beneficiaries will face a reduction in benefits. President Obama insisted that benefits won’t be reduced, they’ll simply be delivered in more efficient ways, like better coordination of care, elimination of duplicate tests and reliance on treatments known to work best.

The AARP, the main lobby for older Americans, has praised the emerging bills and thrown its weight behind the cause. All of this suggests to us that the great majority of Americans — those with insurance and those without — would benefit from health care reform.

    Health Care Reform and You, NYT, 26.7.2009, http://www.nytimes.com/2009/07/26/opinion/26sun1.html

Letters

Health Care:

Obama States His Case

July 24, 2009
The New York Times

To the Editor:

Re “President Seeks Public’s Support on Health Care” (front page, July 23):

I listened to President Obama’s news conference on the subject of health care for all Americans. I must say it left me with a deep sense of frustration.

We already have a successful federal health care program: Medicare. Even many physicians prefer it over the various programs sold by insurance companies. Why don’t we just gradually lower the age of eligibility until all Americans are covered? Or is that too easy?

Bernard F. Erlanger
New York, July 23, 2009

The writer is emeritus professor of microbiology at Columbia University.

•

To the Editor:

Once again, on reading the various pundits, I feel as if I’m in a looking-glass world.

Did we hear the same news conference? I heard President Obama make a cogent, intelligent argument for fixing a health care system that is very broken; they heard that he did not lie or pander to the American public, which is apparently bad politics. Maybe it is.

More’s the pity.

Michelle Bisson
Tarrytown, N.Y., July 23, 2009

•

To the Editor:

President Obama pointed out in his news conference that every member of Congress has great health insurance, and yet some are resisting making it available to all Americans. Maybe it’s kind of hard to feel the pain of those without it when you have created the best for yourselves.

Nancy Oliveira
San Francisco, July 23, 2009


•

To the Editor:

Re “Real Challenge to Health Bill: Selling Reform” (Economic Scene, front page, July 22):

David Leonhardt says that the “typical person,” one of the 90 percent of voters who already have health insurance, thinks that the Democratic health care plans offer nothing for them except higher taxes.

As one of those 90 percent, I disagree. Beyond thinking that a rich society ought to be able to provide this basic need of life as a matter of course, the main reason to support strong universal health care is personal and family security: removing the weight of vulnerability to misfortune.

This is not just personal: we should not underestimate the corrosive effects of pervasive insecurity on American democracy. The recent trajectory of our society has whole segments seeing an increasingly tenuous hold on a middle-class lifestyle, and health care economic worries are a big part of that. This is a deeply destructive dynamic that bodes poorly for the American project.

Those who can’t conceive of losing their health insurance (which includes members of Congress and most influential political actors, and most of their friends) do not seem to appreciate that widespread personal vulnerability can translate into a caustic political culture.

Avoiding that future concerns me greatly, even though I myself have no worry about my own insurance.

William S. Kessler
Seattle, July 22, 2009

•

To the Editor:

“What’s in it for me?” may be asked by healthy people who are covered by health insurance plans — that is, until they become ill. Once serious illness strikes, profit-minded insurance bureaucrats come between patient and doctor; and uncovered bills and expenses mount.

Everyone has a stake in health care reform. He just might not know it yet.

Carol Messineo
Brooklyn, July 22, 2009

•

To the Editor:

As David Leonhardt rightly points out, one of the great barriers to health reform is that because most Americans already have health insurance, they don’t see “what’s in it for me.” Consequently, there is considerable resistance to the increased cost that health reform will require.

One possible answer is to include coverage for home- and community-based long-term care services — the kinds of services that help people avoid nursing home placement. This is a huge issue for many elderly Americans and their baby boomer children, two of the most powerful groups of voters.

In fact, a recent poll released by the SCAN Foundation, a private foundation dedicated to improving long-term care, found that almost 8 of 10 Americans (including two-thirds of Republicans) say that if health care reform included coverage for home- and community-based long-term-care services, it would personally benefit them or someone in their families.

The added cost of these services would at least in part be offset by reduced nursing home costs, but more to the point, the vast majority of Americans would clearly be able to see “what’s in it for me.”

Paul Jellinek
Mercerville, N.J., July 22, 2009

The writer is a consultant who works with foundations, including the SCAN Foundation.

•

To the Editor:

According to David Leonhardt, most Americans are satisfied with their present coverage in part because tests and treatments “appear to be free” under the current employer-provided health care system. For many of us this is puzzling. Except for a few fully covered screening tests, my insurance, and that of millions of others, functions with a system of deductibles and co-pays that add up quickly.

A few years back, a simple broken wrist set in the emergency room cost me $700 out of pocket.

While I support health care reform and would even be willing to pay more to cover more folks, I am tired of hearing that I am blithely demanding care I might not need because it is free to me. Usually I weigh the costs I know I will incur when deciding whether to visit a doctor or not.

Anne-Marie Hislop
Davenport, Iowa, July 22, 2009

•

To the Editor:

Selling reform is a problem for President Obama because he is not delivering what he is selling. If he were selling reform that increases access, manages costs and improves outcomes, he might not be having such a problem.

Americans are savvy consumers and can understand a sales pitch when they see it.

Andrea Economos
Scarsdale, N.Y., July 22, 2009

    Health Care: Obama States His Case, NYT, 24.7.2009, http://www.nytimes.com/2009/07/24/opinion/l24health.html

Obama Moves

to Reclaim the Debate

on Health Care

July 23, 2009
The New York Times
By SHERYL GAY STOLBERG
and JEFF ZELENY

WASHINGTON — President Obama tried on Wednesday to rally public support for overhauling the nation’s health care system and said for the first time that he would be willing to help pay for the plan by raising income taxes on families earning more than $1 million a year.

“If I see a proposal that is primarily funded through taxing middle-class families, I’m going to be opposed to that,” Mr. Obama said in a prime-time news conference in the East Room of the White House. A surcharge on the highest-income Americans, under consideration in the House, “meets my principle,” he said.

On a day when the leader of fiscally conservative Democrats said a deal was a long way off and House Speaker Nancy Pelosi insisted that she had the votes to push a bill through, Mr. Obama used the news conference to take his message over the heads of lawmakers and straight to the public. Conceding that “folks are skeptical,” he sought to convince Americans that overhauling the nation’s health care system would benefit them and strengthen the economy.

“If somebody told you that there is a plan out there that is guaranteed to double your health-care costs over the next 10 years,” he said, “that’s guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that,”

“That’s what we have right now,” he said. “So if we don’t change, we can’t expect a different result.”

While Mr. Obama declared, “it’s my job, I’m the president,” he did not use the appearance at the White House to make any fresh demands on Congress, which is struggling to meet his timetable for both chambers to pass legislation before members break for August recess. Mr. Obama did not repeat that demand Wednesday night.

Instead, he sounded cerebral as he delved into policy specifics for nearly an hour and tried to link them to the concerns of ordinary Americans.

As he sought to reassure the public that a new health care system would be an improvement, he also acknowledged that there would be changes that could be unsettling, a point that is often raised by critics of overhauling the health care system.

“Can I guarantee that there are going to be no changes in the health-care delivery system? No,” Mr. Obama said. “The whole point of this is to try to encourage changes that work for the American people and make them healthier.”

Health legislation is Mr. Obama’s highest legislative priority, and his success or failure could shape the rest of his presidency. But while he is under increasing pressure from leading Democrats to delve more deeply into the negotiations by taking positions on specific policy issues, he largely resisted doing so Wednesday night.

But the president did weigh in how the government might pay for the plan.

In addition to saying he would be open to taxing those households earning more than $1 million — a scaled-back version of an earlier proposal that would have imposed a surcharge on households earning $350,000 or more — he signaled that he was also receptive to another idea under consideration in the Senate: taxing employer-provided health benefits, as long as the tax did not fall on the middle class.

On Capitol Hill, Ms. Pelosi said Democrats remained on track to reach a deal on major health care legislation. But she acknowledged that the process had slowed in response to concerns among conservative Democrats about the cost of the bill, and that some House Democrats were reluctant to embrace the income surtax on high-earners without knowing whether the Senate would go along.

Indeed, even as Ms. Pelosi insisted that Congress was closer than ever to achieving a comprehensive overhaul of the nation’s health care system, leaders of the Blue Dogs, a conservative faction of Democrats, said a deal was still a long way off. Asked if the House Energy and Commerce Committee could resume work on the bill by late Thursday, as House leaders hoped, Representative Charlie Melancon, a Blue Dog from Louisiana, said: “No way.”

A senior Democratic aide on Capitol Hill said party leaders now believed it was essential for Mr. Obama to be more specific about what he wanted in a health care bill — and not just exhort Congress to pass one.

“The president needs to step in more forcefully and start making some decisions,” said the aide, speaking on condition of anonymity because he did not want to be publicly identified as criticizing Mr. Obama. “Everyone appreciates the fact that Obama has devoted so much time to health care. The bully pulpit is powerful. But in view of the deadlines Congress has missed, we would like to hear more from the president about what he wants in this bill.”

While he faces pressures from fellow Democrats, Mr. Obama is also fending off attacks from Republicans who sense an opportunity to knock him off his stride by arguing that the health care bill, estimated as costing more than $1 trillion over the next decade, will not slow or reduce the growth of health spending.

The White House has been in a running debate this week with Senator Jim DeMint, Republican of South Carolina, who predicted that health legislation would prove to be Mr. Obama’s “Waterloo moment” and would break the president. To that, Mr. Obama said: “This isn’t about me. I have great health insurance, and so does every member of Congress.”

In his opening remarks Wednesday night, Mr. Obama said he was aware that many Americans are asking, “What’s in this for me?” But he also tried to appeal to the nation’s conscience, casting the issue as a matter of urgency to families who are losing their life savings trying to pay for medical care and to businesses burdened by trying to provide coverage to their employees.

Asked what the rush was to meet his August deadline for passage of House and Senate bills, Mr. Obama replied: “I’m rushed because I get letters every day from families that are being clobbered by health care costs. They ask me, ‘Can you help?’ ”

In fact, there is another reason Mr. Obama is rushed: he knows time is not on his side. The more Congress delays passage of a health bill, the more time his Republican opponents will have to marshal their opposition and kill it.

“If you don’t set deadlines in this town, things don’t happen,” Mr. Obama said. “The default position is inertia.”

 

David M. Herszenhorn and Robert Pear contributed reporting.

    Obama Moves to Reclaim the Debate on Health Care, NYT, 23.9.2009, http://www.nytimes.com/2009/07/23/us/politics/23obama.html

The Work-Up

Costly Drugs Known as Biologics

Prompt Exclusivity Debate

July 22, 2009
The New York Times
By ANDREW POLLACK

A bitter Congressional fight over the cost of superexpensive biotechnology drugs has come down to a single, hotly debated number: How many years should makers of those drugs be exempt from generic competition?

But what few people in Washington seem to recognize — or publicly acknowledge, anyway — is that this magic number may ultimately not matter as much as the most vitriolic debaters insist.

At issue are such drugs as Biogen Idec’s Avonex, for multiple sclerosis, which can cost more than $20,000 a year; Genentech’s Avastin for cancer, which can cost more than $50,000; and several Genzyme drugs for rare diseases that can cost $200,000 a year or more. Typically, such drugs are given by injection or intravenous infusions.

These drugs, known as biologics, are complex proteins made in vats of living cells. Because they are hard to copy exactly, they have not been subject to the generic competition that eventually knocks down the price of drugs like Lipitor and Prozac. Pills like Lipitor, known in the industry as small-molecule drugs, are made from simple chemicals whose recipes are easy to reproduce.

But now Congress, as a cost-cutting piece of the overall health care effort, is preparing legislation to enable the Food and Drug Administration to approve copycat versions of biologic drugs. That could save consumers, insurers and the government billions of dollars in the coming years.

The trick is to allow competition without undermining the financial incentives the pharmaceutical industry needs to undertake the risky job of developing the next drugs for cancer and other diseases. That is where the magic year number comes in. Trade groups for the big pharmaceutical and biotechnology companies say that to recoup their investments, they need an exclusivity period free of generic competition that would last 12 to 14 years from the time the F.D.A. approves a drug for sale.

But consumer groups, insurers, employers and generic drug companies say anything more than five years — the exclusivity period now given to small-molecule drugs like Lipitor — would eviscerate any potential savings from the new competition.

So far, the biotechnology industry appears to be winning. The Senate’s health committee, for example, has agreed to 12 years of exclusivity. In the House, a bill that provides at least 12 years of exclusivity has many more co-sponsors than one that would provide five years. The Obama administration has said that seven years would be a “generous compromise.”

But in reality, neither the threats to innovation nor the potential savings from generic competition are as great as claimed.

For starters, whatever the exclusivity period, biologic drugs would also continue to be protected from copycats by patents. And in many cases, the patent protection would last longer than the exclusivity period, making the Congressionally mandated exclusivity a moot point.

Genentech’s Avastin, for instance, has patent protection until 2019 — 15 years after the drug’s 2004 approval by the F.D.A. The company’s breast cancer drug, Herceptin, has patents that extend 21 years from its 1998 approval.

Where the exclusivity period might matter most would be in the cases of drugs whose patents were nearing expiration by the time the developer succeeded in winning F.D.A. approval. But that seldom happens.

“I can’t think of a biotech drug that’s been on the market that doesn’t have more than 7 to 14 years of patent protection,” said Eric Schmidt, biotechnology analyst at Cowen & Company.

Still, it is probably not true, as the other side claims, that the legislation would be virtually worthless if it granted a long exclusivity period. There are plenty of blockbuster biologics, like Epogen and Neupogen from Amgen, that have been on the market more than 12 or 14 years and thus would get no extra protection from even an exclusivity period at the long end of the ranges now being discussed.

As for cost savings, the Congressional Budget Office has estimated that generic biologics might save the government only about $10 billion in the next 10 years. That is a relative drop in the bucket when it comes to paying for health care reform, which is expected to cost about $1 trillion over 10 years.

One reason for limited savings in the first decade is that it would probably take a few years for copycat biologics to reach the market after the law was enacted. Another factor is that biologics accounted for only 16 percent — about $46 billion — of total prescription drug spending last year, according to the market researchers IMS Health. And pharmaceuticals represent only about 10 percent of the nation’s overall health care spending.

The real savings might come more than 10 years out, as new biologic drugs appeared and as biologics represented an increasingly greater part of overall spending on drugs. That ramp-up is already evident: Express Scripts, a pharmacy benefits manager, says its spending on biologics grew 10 percent last year, compared with 2.5 percent for other drugs.

But anyone expecting the price wars that ensue when generic pills come on the market — when prices often drop by more than 60 percent — might be disappointed by the way competition plays out in biologic drugs.

Because it is harder and costlier to make biologic drugs than it is to copy pills, fewer generic competitors are likely to enter the fray. Many experts, including the Federal Trade Commission, expect price declines of more like 10 to 40 percent in biologics.

Even that would be a substantial savings for the overall health care system. But for many individuals, a $35,000 copycat version of a $50,000 cancer drug would still be unaffordable.

Another factor is that generic biologics are likely to undergo greater regulatory scrutiny than generic pills require.

It is difficult or impossible to verify that a copy of a biologic is exactly the same as the original — which is why the drugs are often called “biosimilars” rather than generic biologics. Because even small changes might affect the drug’s safety or activity, it is likely that makers of biosimilars will have to conduct at least some clinical trials to win F.D.A. approval of their drugs, which makers of generic small-molecule pills are not required to do. Such trials can cost a lot of money.

Since biosimilars will not be exact replicas, generic makers will probably need sales forces to persuade doctors to prescribe their drugs and pharmacists to dispense them. All of that costs money, too.

In Europe, which has approved biosimilar versions of three biologic drugs, companies generally price their biosimilar drugs about 20 to 30 percent lower than the originals. The impact in Europe has been limited so far, but in Germany the biosimilars have captured about 30 percent of the market for anemia drugs and forced the brand-name manufacturers to lower their prices.

The likelihood that biosimilar competition might be somewhat muted means that sales and profits of the originals may not necessarily dry up.

Kevin W. Sharer, Amgen’s chief executive, told investors in May that he hoped biotechnology companies would retain 30 to 50 percent of the cash flow from their drugs even after biosimilars reached the market. That, he said, “is a dramatically different outcome than we see in the small-molecule companies.” That is also one reason the Federal Trade Commission, in a report last month, said that no exclusivity period at all was needed. At the very least, because biologic drugs do not require appreciably more time or money to bring to market than small-molecule drugs, it is reasonable to ask why they should deserve longer protection from competition than the five years that small-molecule drugs now receive.

The reason, biotechnology executives say, is that patents may offer less protection for biologics than for small-molecule drugs. Because a biosimilar is not an exact knock-off of the original, a competitor might persuasively claim that it is not infringing the patents on the original drug.

So far biologic patents have held up well in court cases. Amgen, for example, has won legal victories preventing competitors from introducing anemia drugs that are slightly different from its own Epogen.

But generic makers and their supporters, sensing that many of the biologic patents may not withstand court challenges, are lobbying for the shortest possible exclusivity period.

“If your patents are strong, let your patents stand for themselves,” said Katie Huffard, executive director of the Coalition for a Competitive Pharmaceutical Market, a group of employers, insurers, pharmacies and generic makers lobbying for easier access to biosimilars. “That’s what every other industry has to do.”

    Costly Drugs Known as Biologics Prompt Exclusivity Debate, NYT, 22.7.2009, http://www.nytimes.com/2009/07/22/business/22biogenerics.html

Forty Years' War

In Push for Cancer Screening,

Limited Benefits

July 17, 2009
The New York Times
By NATASHA SINGER

“Don’t forget to check your neck,” says an advertising campaign encouraging people to visit doctors for exams to detect thyroid cancer.

In another cancer awareness effort, Representative Debbie Wasserman Schultz, a Florida Democrat, has more than 350 House co-sponsors for her bill to promote the early detection of breast cancer in young women, teaching them about screening methods like self-exams and genetic testing.

Meanwhile, the foundation of the American Urological Association has a prostate cancer awareness campaign starring Hall of Fame football players. “Get screened,” Len Dawson, a former Kansas City Chiefs quarterback, says in a public service television spot. “Don’t let prostate cancer take you out of the game.”

Nearly every body part susceptible to cancer now has an advocacy group, politician or athlete with a public awareness campaign to promote routine screening tests — even though it is well established that many of these exams offer little benefit for the general public.

An upshot of the decades-long war on cancer is the popular belief that healthy people should regularly examine their bodies or undergo screening because early detection saves lives. But in fact, except for a few types of cancer, routine screening has not been proven to reduce the death toll from cancer for people without specific symptoms or risk factors — like a breast lump or a family history of cancer — and could even lead to harm, many experts on health say.

That is why the continued rollout of screening campaigns, and even the introduction of a Congressional bill, worries some health experts. And these experts say such efforts add to the large number of expensive and unnecessary treatments each year that help drive up the nation’s health care bill. Rather than heed mass-market calls for screening, these experts urge people without symptoms or special risks to talk to their own doctors about what cancer tests, if any, might be appropriate for them.

Blanket screenings do come with medical risks. A recent European study on prostate cancer screening indicated that saving one man’s life from the disease would require screening about 1,400 men. But among those 1,400, 48 others would undergo treatments like surgery or radiation procedures that would not improve their health because the cancer was not life-threatening to begin with or because it was too far along. And those treatments could lead to complications including impotence, urinary incontinence and bowel problems.

Then there is the economic cost. There are no credible estimates for the amount that routine cancer screening contributes to the approximately $700 billion spent each year in this country on unneeded medical treatment of all types. But health policy experts say such screenings and the cascade of follow-up tests and treatments do play a role.

For example, Americans spend an estimated $4 billion annually on mammograms, according to Dr. David H. Newman, author of the book “Hippocrates’ Shadow: Secrets from the House of Medicine.” Some of those tests cause false alarms that lead to unnecessary follow-up surgery on normal breasts, at a cost of $14 billion to $70 billion over a decade, according to Dr. Newman, the director of clinical research in the department of emergency medicine at St. Luke’s Roosevelt Hospital Center in Manhattan.

 

Check Your Neck?

Cancer awareness campaigns can be a disservice to the public by making people overestimate their risk of dying from cancer, according to Dr. Steven Woloshin, a researcher at the Dartmouth Institute for Health Policy and Clinical Practice. Thyroid cancer, for example, is a rare disease that kills an estimated 1,600 Americans a year. But the campaign called “Check Your Neck” makes it seem as if everyone should worry about the disease, Dr. Woloshin said.

“Confidence kills. Thyroid cancer doesn’t care how healthy you are,” reads the text of one ad that has appeared in national magazines like People. The ads promote a quick physical exam, called palpation, in which doctors feel for unusual lumps in the thyroid, a small gland in the front of the neck. “Ask your doctor to check your neck. It could save your life.”

The campaign is part of an effort by the Light of Life Foundation, an advocacy group for thyroid cancer patients founded by Joan Shey, who was told she had the disease in 1995.

A Manhattan advertising agency designed the ads as a pro bono project after one of its own employees was found to have the disease. Bernie Hogya, one of the creators behind the “Got Milk” ads, created the cancer awareness campaign. Full-page ads valued at $800,000 have run free in national magazines like Sports Illustrated.

Ms. Shey said the campaign was intended to save lives through the early detection of cancer.

Dr. R. Michael Tuttle, an endocrinologist at Memorial Sloan Kettering Cancer Center in Manhattan who is on the foundation’s board, said he hoped the campaign would remind busy family care doctors and gynecologists to check routinely for the disease. The campaign could also prompt people with symptoms like nodules or swollen lymph nodes in their necks to see their doctors, Dr. Tuttle said.

But there is no evidence that routine neck exams reduce the risk of dying from thyroid cancer, said Dr. Barnett S. Kramer, the associate director for disease prevention at the National Institutes of Health, which has a cancer Web site describing the potential benefits and risks of many cancer screening tests. Most thyroid cancers are so slow-growing and curable that early detection would not improve their prognosis, he said, while a rarer form of thyroid cancer is so aggressive that a surge in screening would be unlikely to have an impact on the death rate.

But routine screening, he said, does have the potential to do harm because neck exams can find tumors that would not otherwise have required treatment, potentially setting off a cascade of unnecessary events like ultrasounds, needle biopsies in the neck, operations to remove the thyroid and complications like damage to the vocal cords. Meanwhile, Dr. Kramer said, the exams can miss some life-threatening cancers that are not detectable by touch.

The “Check Your Neck” campaign is one of many that prompt Dr. Kramer to compare mass cancer screening to a lottery. “In exchange for those few who win the lottery,” he said, “there are many, many others who have to pay the price in human costs.”

Dr. Ned Calonge, the chairman of the United States Preventive Services Task Force said, “There are five things that can happen as a result of screening tests, and four of them are bad.” His group consists of independent medical experts that Congress has commissioned to make recommendations, based on medical evidence, about what preventive measures actually work.

 

When Screenings Are Bad

The one good result of screening, Dr. Calonge said, is identifying a life-threatening form of cancer that actually responds to timely intervention.

The possible bad outcomes, he said, are results that falsely indicate cancer and cause needless anxiety and unnecessary procedures that can lead to complications; that fail to diagnose an existing cancer, which could lull a patient into ignoring real symptoms as the cancer progresses; that detect slow-growing or stable cancers that are not life-threatening and would not otherwise have required treatment; and that detect aggressive life-threatening cancers whose outcome is not changed by early detection.

Experts like Dr. Calonge say screening is useful only if, on balance, the deaths prevented by treating cancers outweigh the harm done by treatments that are not medically necessary. The problem is, most current screening tests are not sophisticated enough to determine which cancers might not require treatment — or to predict which life-threatening cancers will respond to treatment.

He is among those suggesting that people consult their doctors about whether to be screened and not make decisions based on public awareness campaigns. And doctors, experts say, should make sure they understand the pros and cons of screening and be sure to tell patients about the possible risks.

No one advocates that people eschew tests if they have symptoms or special risk factors. “Once something bothers you or changes or is unusual, this is no longer routine screening,” Dr. Calonge said.

But, for otherwise healthy people with no symptoms, he said, only a few routine tests have proven to significantly reduce cancer deaths among certain age groups. The task force recommends pap smears for cervical cancer beginning no later than age 21; regular mammograms to screen for breast cancer in women starting at age 40; and tests for colon cancer starting at age 50. And the task force notes that the evidence supporting the breast cancer screening is not as strong as for cervical and colon cancers.

Most other types of screening, meanwhile, have not been proved to reduce the death toll from cancer, said Dr. Kramer at the National Institutes of Health.

“You need a high bar of evidence to start advertising screening to healthy people, most of whom will not benefit,” Dr. Kramer said.

Indeed, the federal Centers for Disease Control makes it clear on its Web site: there is no medical proof yet that routine screening for lung, ovarian, prostate and skin cancer reduces deaths from those cancers.”

Legislation in Congress that deals with breast cancer has become a flashpoint in the debate over cancer screening for the general public.

The bill, introduced in the House in March, is called the Breast Cancer Education and Awareness Requires Learning Young Act of 2009, or the Early Act. It mandates an education and media campaign, aimed at women under 45 and their physicians, on the early detection of breast cancer.

 

A Teaching Campaign

The bill would spend $45 million over five years to teach young women and their doctors to recognize breast abnormalities. It would promote lifestyle changes like eating habits to reduce the chances of getting the disease. It would focus special attention on members of certain racial or ethnic groups who are at higher risk for more aggressive cancers. It would also provide grants to groups supporting young women with breast cancer.

The bill’s sponsor, Ms. Wasserman Schultz, was told she had breast cancer in 2007. Breast-cancer advocacy groups, like the Young Survival Coalition and Susan G. Komen for the Cure, said they hoped the bill would teach young women to notice changes in their bodies, talk to their doctors and seek second opinions when necessary.

“It is worth spending the federal government’s money, because it will save lives,” Ms. Wasserman Schultz said in an interview.

But critics say the House bill promotes techniques like breast self-exams that have not proved to find cancer at an earlier stage or to save lives. The concern is that the technique could cause younger women — a group for whom breast cancer is a rare disease — to find too many medically insignificant nodules that would lead doctors to perform unneeded biopsies, in which tissue is removed for testing.

Scarring from biopsies could make breast cancer harder to detect when the women are older and have a much higher risk of getting the disease, critics say. And such false alarms can also cause women to distrust the medical system and skip mammograms later in life when the tests have been proved to reduce the death toll, said Dr. Otis W. Brawley, an oncologist who is the chief medical officer of the American Cancer Society.

The breast self-exam is a formal procedure in which women are taught to examine their breast tissue monthly, inch by inch and layer by layer, in a grid pattern. But instead of such a thorough probing, which might detect minute irregularities of no medical significance, many cancer institutions now recommend a less formal process called “breast self-awareness”. Its premise is that women should become familiar with their breasts and seek medical attention if they notice a change like a persistent lump or rash.

Opposition to the Early Act surfaced soon after its introduction, in a specialist newsletter called the Cancer Letter.

In it, some prominent public health and cancer experts attacked the bill’s central tenet — that lifestyle changes and early-detection methods had been proved to reduce breast cancer deaths in women in their 20s and 30s who have no special risks for the disease.

Routine mammograms, for example, which have been shown to reduce deaths from breast cancer in older women, have not proved to reduce the toll in women in their 20s and 30s, said Dr. Susan M. Love, a breast cancer surgeon in Santa Monica, Calif. That is because breast tissue in younger women is typically too dense for routine mammograms to be effective. And this test can needlessly expose young women to radiation, Dr. Love said.

“Once you have made women more ‘aware’ of their potential risk, you will have nothing to tell them to do!” Dr. Love wrote in a letter to Ms. Wasserman Schultz asking her not to pursue the bill.

Dr. Love and other critics have also argued that a public health campaign could cause younger women to overestimate their chances of dying from breast cancer. Of the estimated 41,000 deaths a year in the United States from breast cancer, about 1 in 14 involve women younger than 45, according to the C.D.C. Only 1 in 33 breast cancer deaths — about 1,200 a year — occurs in women younger than 40.

 

Defending the Bill

Ms. Wasserman Schultz says her bill is necessary because too many women do not pay attention to their breast health until they are 40 or older. “Leaving young women in the dark, just because there is a group of experts who believe we don’t know what to tell them, isn’t right,” she said. Ms. Wasserman Schultz said a panel of experts overseen by the federal Centers for Disease Control and Prevention would create the breast cancer campaign based on the latest medical science. She said the legislation did not endorse any particular methods of early detection. Yet it does call for a report to measure the campaign’s impact — including the percentage of young women who perform breast self-exams and the frequency of such exams.

Ms. Wasserman Schultz’s bill has been referred to committees in both the House and Senate. “Ultimately,” she said, “Congress will decide.”

But Dr. Brawley of the American Cancer Society said the Early Act reminded him of the 1960s, when the cancer society teamed up with the advice columnist Ann Landers for an awareness campaign to promote routine chest X-rays for the early detection of lung cancer. The test later proved to increase medical complications without reducing the cancer death toll, he said.

“It is a real problem,” Dr. Brawley said of well-meaning members of Congress. “They are doing things that might actually harm the people they want to help.”

    In Push for Cancer Screening, Limited Benefits, NYT, 17.7.2009, http://www.nytimes.com/2009/07/17/health/17screening.html

Vets’ Mental Health Diagnoses Rising

July 17, 2009
The New York Times
By JAMES DAO

A new study has found that more than one-third of Iraq and Afghanistan war veterans who enrolled in the veterans health system after 2001 received a diagnosis of a mental health problem, most often post-traumatic stress disorder or depression.

The study by researchers at the San Francisco Department of Veterans Affairs Medical Center and the University of California, San Francisco, also found that the number of veterans found to have mental health problems rose steadily the longer they were out of the service.

The study, released Thursday, was based on the department health records of 289,328 veterans involved in the two wars who used the veterans health system for the first time from April 1, 2002, to April 1, 2008.

The researchers found that 37 percent of those people received mental health diagnoses. Of those, the diagnosis for 22 percent was post-traumatic stress disorder, or PTSD, for 17 percent it was depression and for 7 percent it was alcohol abuse. One-third of the people with mental health diagnoses had three or more problems, the study found.

The increase in diagnoses accelerated after the invasion of Iraq in 2003, the researchers found. Among the group of veterans who enrolled in veterans health services during the first three months of 2004, 14.6 percent received mental health diagnoses after one year. But after four years, the number had nearly doubled, to 27.5 percent.

The study’s principal author, Dr. Karen H. Seal, attributed the rising number of diagnoses to several factors: repeat deployments; the perilous and confusing nature of war in Iraq and Afghanistan, where there are no defined front lines; growing public awareness of PTSD; unsteady public support for the wars; and reduced troop morale.

Dr. Seal said the study also underscored that it can take years for PTSD to develop. “The longer we can work with a veteran in the system, the more likely there will be more diagnoses over time,” said Dr. Seal, who is co-director of the mental health clinic for Iraq and Afghanistan veterans at the San Francisco veterans medical center.

The new report joins a growing body of research showing that the prolonged conflicts, where many troops experience long and repeat deployments, are taking an accumulating psychological toll.

A telephone survey by the RAND Corporation last year of 1,965 people who had been deployed to Iraq or Afghanistan found that 14 percent screened positive for PTSD and 14 percent for major depression. Those rates are considerably higher than for the general public.

“The study provides more insight as to just how stressed our force and families are after years of war and multiple deployments,” said René A. Campos, deputy director of government relations for the Military Officers Association of America. “Our troops and families need more time at home — more dwell time, fewer and less frequent deployments.”

The study was posted Thursday on the Web site of The American Journal of Public Health.

Dr. Seal cautioned that, unlike the RAND study, the results from her research could not be extrapolated to the roughly 1.6 million veterans who have served in Iraq or Afghanistan because about 60 percent of them were not receiving health care through the veterans system.

But she noted that the number of Iraq and Afghanistan war veterans receiving care through the veterans system was at a historic high, 40 percent, potentially making the study’s results more universal.

The study also found that veterans older than 40 with the National Guard or the Reserves were more likely to develop PTSD and substance abuse disorders than those under 25. A possible reason, Dr. Seal said, is that older reservists go to war from established civilian lives, with families and full-time jobs, making combat trauma potentially more difficult to absorb.

“It’s the disparity between their lives at home, which they are settled in, and suddenly, without much training, being dropped into this situation,” she said.

In contrast, the study found that among active-duty troops, veterans under 25 were more likely to develop PTSD and substance abuse problems than those over 40, possibly because those younger troops were more likely to have been involved in front-line combat, Dr. Seal said.

    Vets’ Mental Health Diagnoses Rising, NYT, 17.7.2009, http://www.nytimes.com/2009/07/17/health/views/17vets.html

Op-Ed Contributor

A Better Way to Get a Kidney

July 11, 2009
The New York Times
By DANIEL ASA ROSE

SO Steve Jobs, the chief executive of Apple, may or may not have jumped to the front of the transplant queue in his quest to get a new liver. What else is new? Wake up and smell the curry, fellow Americans. This is the way the greater world operates.

In China, where my cousin Larry and I went to get him a kidney two summers ago (despite the official Chinese restriction against Westerners doing so), jumping the line is so commonplace as to be unworthy of comment. No one gets angry at a pretty secretary or harried businessman who cuts in front; everyone just takes a half step back and resumes gesticulating on their cellphones. If anything, there’s a grudging admiration of such blatant self-advancement.

First come first served, that’s the American fantasy. But in fact strength and speed prevail, as they tend to do in other contests. Dog eat dog. Darwinism of the waiting line. Call it what you like, it’s not only accepted in most places around the globe, it’s expected. No wonder there’s so much medical tourism — up to 10 percent of the world’s transplant surgery.

In light of this larger reality, may I suggest that we’re misdirecting our moral outrage when we take it out on Steve Jobs? It’s not the line-jumpers of the world who deserve our indignation — it’s the American system that makes us wait in line to begin with, the result of policies that impoverish the supply of organs available for transplant.

Say you need a kidney, the organ most needed the world over. If you sign up today, the wait in most American states will be 5 to 10 years, depending on your underlying medical condition and how suitable a recipient you are.

Seem like a long line ahead of you? You’re not imagining it. There are 85,000 people biding their time, most of them on thrice-weekly dialysis that leaves them with an enervated excuse for a life the rest of the time. More than 4,500 of them died last year waiting. On average, that’s 13 people dying each day awaiting a kidney.

(Maybe you should hope for liver disease: there are only about 16,000 people on the liver waiting list, and one-third of them get their liver in any one year.)

Patients have even resorted to “domino transplants,” like the one recently in which 10 doctors in four hospitals transplanted eight kidneys among 16 patients. It doesn’t have to be this way. In our push for health care reform, only a few changes in our attitudes and laws could open the floodgates for organs and assure a plentiful supply for everyone who needs them.

No one would need to wait more than a year for an organ transplant if we revolutionize organ donation in three ways: better finance stem-cell research so we can start simply growing kidneys; build better mechanical organs; and change the presumed consent option so that people would have to opt out of donating organs rather than opt in.

As much as I’m looking forward to robotic and vat-grown organs, this last option could be achieved tomorrow. All lawmakers would need to do is reverse the donation default — that way, unless you go out of your way to specifically state you don’t want your organs to be donated after your death, they will automatically be considered available.

Several countries, including Belgium and Norway, have done this with encouraging results. The most successful country of all is Spain, where presumed consent has resulted in a “conversion rate” (that is, the percentage of potential donors who actually donate organs) of an astonishing 80 percent to 85 percent.

It’s all about finding psychologically astute ways to make donating your organs easier than holding on to them. Perhaps we could just try appealing to people’s innate narcissism. I’d love to see a bumper sticker that declares: “Live Forever! (Or at Least Parts of You.) Donate Your Organs!”

Simpler still, we could make motorcycle helmets optional, as my cousin Larry suggests. But that’s just Larry being Larry. Don’t get mad at him.

Daniel Asa Rose is the author of “Larry’s Kidney: Being the True Story of How I Found Myself in China With My Black-Sheep Cousin and His Mail-Order Bride, Skirting the Law to Get Him a Transplant ... and Save His Life.”

    A Better Way to Get a Kidney, NYT, 11.7.2009, http://www.nytimes.com/2009/07/11/opinion/11rose.html

Months to Live

Sisters Face Death

With Dignity and Reverence

July 9, 2009
The New York Times
By JANE GROSS

PITTSFORD, N.Y. — Gravely ill with heart disease, tethered to an oxygen tank, her feet swollen and her appetite gone, Sister Dorothy Quinn, 87, readied herself to die in the nursing wing of the Sisters of St. Joseph convent where she has been a member since she was a teenager.

She was surrounded by friends and colleagues of nearly seven decades. Some had been with her in college, others fellow teachers in Alabama at the time of the Selma march, more from her years as a home health aide and spiritual counselor to elderly shut-ins.

As she lay dying, Sister Dorothy declined most of her 23 medications not essential for her heart condition, prescribed by specialists but winnowed by a geriatrician who knows that elderly people are often overmedicated. She decided against a mammogram to learn the nature of a lump in her one remaining breast, understanding that she would not survive treatment.

There were goodbyes and decisions about giving away her quilting supplies and the jigsaw puzzle collection that inspired the patterns of her one-of-a-kind pieces. She consoled her biological sister, who pleaded with her to do whatever it took to stay alive.

Even as her prognosis gradually improved from hours to weeks and even months, Sister Dorothy’s goal was not immortality; it was getting back to quilting, as she has. She spread her latest on her bed: Autumnal sunflowers. “I’m not afraid of death,” she said. “Even when I was dying, I wasn’t afraid of it. You just get a feeling within yourself at a certain point. You know when to let it be.”

A convent is a world apart, unduplicable. But the Sisters of St. Joseph, a congregation in this Rochester suburb, animate many factors that studies say contribute to successful aging and a gentle death — none of which require this special setting. These include a large social network, intellectual stimulation, continued engagement in life and spiritual beliefs, as well as health care guided by the less-is-more principles of palliative and hospice care — trends that are moving from the fringes to the mainstream.

For the elderly and infirm Roman Catholic sisters here, all of this takes place in a Mother House designed like a secular retirement community for a congregation that is literally dying off, like so many religious orders. On average, one sister dies each month, right here, not in the hospital, because few choose aggressive medical intervention at the end of life, although they are welcome to it if they want.

“We approach our living and our dying in the same way, with discernment,” said Sister Mary Lou Mitchell, the congregation president. “Maybe this is one of the messages we can send to society, by modeling it.”

Primary care for most of the ailing sisters is provided by Dr. Robert C. McCann, a geriatrician at the University of Rochester, who says that through a combination of philosophy and happenstance, “they have better deaths than any I’ve ever seen.”

Dr. McCann’s long relationship with the sisters gives him the time and opportunity, impossible in the hurly-burly of an intensive-care unit, to clarify goals of care long before a crisis: Whether feeding tubes or ventilators make sense. If pain control is more important than alertness. That studies show that CPR is rarely effective and often dangerous in the elderly.

“It is much easier to guide people to better choices here than in a hospital,” he said, “and you don’t get a lot of pushback when you suggest that more treatment is not better treatment.”

But that is not to say the sisters are denied aggressive treatment. Sister Mary Jane Mitchell, 65, chose radical surgery and radiation for a grave form of brain cancer. She now lives on the Alzheimer’s unit, unable to speak and squeezing shut her lips when aides try to feed her.

Then there is Sister Marie Albert Alderman, 84 and blind in one eye from a stroke. She sees a kidney specialist, who, she says, “is trying to keep me off the machine by staying on top of things.” By that she means dialysis, which she would not refuse. “If they want to try it, fine,” she said. “But I don’t want it to go on and on and on.”

But Sister Mary Jane and Sister Marie Albert are exceptions here. Few sisters opt for major surgery, high-tech diagnostic tests or life-sustaining machinery. And nobody can remember the last time anyone died in a hospital, which was one of the goals in selling the old Mother House, with its tumbledown infirmary — a “Bells of St. Mary” kind of place — and using the money to finance a new facility appropriate for end-of-life care.

“There is a time to die and a way to do that with reverence,” said Sister Mary Lou, 56, a former nurse. “Hospitals should not be meccas for dying. Dying belongs at home, in the community. We built this place with that in mind.”

In the old Mother House, the infirmary was a place apart. Here, everyone mixes. Of the 150 residents, nearly half live in the west wing, designated for independent living, in apartments with raised toilets, grab bars and the like. These are the sisters who have given up paying jobs and shared apartments in the community because of encroaching infirmity.

Forty sisters live in assisted-living studios, and another 40 in the nursing home and Alzheimer’s unit, all in the east wing, with the chapel, dining rooms and library at the central intersection. Closed-circuit television allows those confined to their rooms to watch daily religious services.

Remaining money from the sale of the Mother House went into a shared retirement fund covering the women’s lodging and medical care, along with Social Security payments of the retired and salaries of those still working — one is a surgeon, another a chief executive, and several are college professors. Dr. McCann bills Medicare for home visits, although most of the care he delivers is not covered by the government and goes without reimbursement.

Dr. McCann said that the sisters’ religious faith insulated them from existential suffering — the “Why me?” refrain commonly heard among those without a belief in an afterlife. Absent that anxiety and fear, Dr. McCann said, there is less pain, less depression, and thus the sisters require only one-third the amount of narcotics he uses to manage end-of-life symptoms among hospitalized patients.

On recent rounds, Dr. McCann saw Sister Beverly Jones, 86, a former music teacher losing her eyesight to macular degeneration. Upbeat, Sister Beverly told the doctor about the latest book she was reading using a magnifying device — “Beethoven’s Hair” by Russell Martin, about the composer’s DNA.

He also saw Sister Jamesine Riley, 75, once the president of the congregation, who barely survived a car accident that left her with a brain injury, dozens of broken bones and pneumonia. “You’re not giving up, are you?” Dr. McCann asked her.

“No, I’m discouraged, but I’m not giving up,” Sister Jamesine replied in a strong voice.

He told her he worried that she now found herself with so little control. She nodded in stoic assent.

Some days, Dr. McCann said, he arrives with his “head spinning,” from hospitals and intensive-care units where death can be tortured, impersonal and wastefully expensive, only to find himself in a “different world where it’s really possible to focus on what’s important for people” and, he adds, “what’s exportable, what we can learn from an ideal environment like this.”

Laura L. Carstensen, the director of the Center on Longevity at Stanford University, says the convent setting calms the tendency for public policy discussion about end-of-life treatment “to devolve into a debate about euthanasia or rationing health care based on age.”

“Every time I speak to a group about the need to improve the dying process, somebody raises their hand and says, ‘You’re talking about killing old people,’ ” Dr. Carstensen said. “But nobody would accuse Roman Catholic sisters of that. They could be a beacon in talking about this without it turning into that American black-and-white way of thinking: Either we have to throw everything we’ve got at keeping people alive or leave them on the sidewalk to die.”

Often the Roman Catholic position on end-of-life issues is misconstrued as “do anything and everything necessary” but nothing in Catholic theology demands extraordinary intervention, experts say, nor do the sisters here, or their resident chaplain, Msgr. William H. Shannon, 91, advocate euthanasia or physician-assisted suicide.

“Killing somebody who is very, very old, with a pill or something, that isn’t right,” Sister Dorothy said. “But everybody has their own slant on life and death. It’s legitimate to say no to extraordinary means. And dying people, you can tell when they don’t want to eat or drink. That’s a natural thing.”

Barbara Cocilova, the nurse practitioner here, sees differences in the health of these sisters compared with elderly patients in other settings. None have chronic obstructive pulmonary disease (perhaps because they do not smoke) and only three have diabetes (often caused by obesity). Among those with Alzheimer’s, Ms. Cocilova said, diagnostic tests tend to produce better-than-expected results among those who are further along in the disease process, a possible result of mental stimulation.

Dr. McCann and others say that the sisters benefit from advanced education, and new ventures in retirement that keep them active. Sister Jamesine was a lawyer who founded a legal clinic for Rochester’s working poor. Sister Mary Jane Mitchell was the first female chaplain in a federal penitentiary.

Sister Bernadine Frieda, 91, spry and sharp, spends her days visiting the infirm with Sister Marie Kellner, 77, both of them onetime science teachers. Sister Marie, who left the classroom because of multiple sclerosis, reminds an astounded sister with Alzheimer’s that she was once a high school principal (“I was?!”) and sings “Peace Is Like a River” to the dying.

“We don’t let anyone go alone on the last journey,” Sister Marie said.

Seven priests moved here in old age, paying their own way, as does Father Shannon, who presides over funerals that are more about the celebratory “alleluia” than the glum “De Profundis.” But he has been with the sisters since he entered the priesthood, first as a professor at Nazareth College, founded by the order, and now as their chaplain. He shares with them the security of knowing he will not die among strangers who have nothing in common but age and infirmity.

“This is what our culture, our society, is starved for, to be rich in relationships,” Sister Mary Lou said. “This is what everyone should have.”

    Sisters Face Death With Dignity and Reverence, NYT, 9.7.2009, http://www.nytimes.com/2009/07/09/health/09sisters.html

Op-Ed Contributor

The Patients Doctors Don’t Know

July 2, 2009
The New York Times
By ROSANNE M. LEIPZIG

AS they do every July, hospitals across America are welcoming new interns, fresh from medical school graduation. Given how much these trainees have yet to learn, common wisdom holds that it’s not a good time of year to get sick. This may be particularly true for older patients, because American medical schools require no training in geriatric medicine.

Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.

Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge — but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores.

This shouldn’t happen. All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics, even though patients 65 and older account for 32 percent of the average doctor’s workload in surgical care and 43 percent in medical specialty care, and they make up 48 percent of all inpatient hospital days. Medicare, the national health insurance for people 65 and older, contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on the unique health care needs of older adults.

Medicare beneficiaries receive care from doctors who may not have been taught that heart attacks in octogenarians usually present without chest pain, or that confusion can be due to bladder infections, heart attacks or Benadryl. They do not routinely check for memory problems, or know which community resources can help these patients manage their conditions. They’re uncomfortable discussing goals of care, and recommend screening tests and treatments to patients who are not going to live long enough to reap the benefits.

I was part of a group of doctors and medical educators who recently published in the journal Academic Medicine a set of minimum abilities that every medical student should demonstrate before graduating and caring for elderly patients. Nicknamed the “don’t kill Granny” list, it includes being able to prescribe medicines, assess patients’ ability to care for themselves, recognize atypical presentations of common diseases, prevent falls, recognize the hazards of hospitalization and decide on treatments based on elderly patients’ prognosis and their personal preferences.

The 2008 Institute of Medicine report “Retooling for an Aging America” resolved that all licensed health care professionals should be required to demonstrate such competence in the care of older adults. But this resolution lacks teeth. Medical resident training programs that receive Medicare money should be required to demonstrate that their trainees are competent in geriatric care. Medicare should finance medical training in nursing homes. And state licensing and medical specialty boards should require demonstration of geriatric competence for licensing and certification.

Basic geriatric knowledge is preventive medicine. Nurses, social workers, pharmacists and other health care professionals should have it, too, in order to improve care for older people. But until doctors get this basic training, we can’t even begin to give 80-year-olds the care they need.

 

Rosanne M. Leipzig, a physician, is a professor at Mount Sinai School of Medicine.

    The Patients Doctors Don’t Know, NYT, 2.7.2009, http://www.nytimes.com/2009/07/02/opinion/02leipzig.html

Many With Insurance

Still Bankrupted by Health Crises

July 1, 2009
The New York Times
By REED ABELSON

Health insurance is supposed to offer protection — both medically and financially. But as it turns out, an estimated three-quarters of people who are pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured.

And so, even as Washington tries to cover the tens of millions of Americans without medical insurance, many health policy experts say simply giving everyone an insurance card will not be enough to fix what is wrong with the system.

Too many other people already have coverage so meager that a medical crisis means financial calamity.

One of them is Lawrence Yurdin, a 64-year-old computer security specialist. Although the brochure on his Aetna policy seemed to indicate it covered up to $150,000 a year in hospital care, the fine print excluded nearly all of the treatment he received at an Austin, Tex., hospital.

He and his wife, Claire, filed for bankruptcy last December, as his unpaid medical bills approached $200,000.

In the House and Senate, lawmakers are grappling with the details of legislation that would set minimum standards for insurance coverage and place caps on out-of-pocket expenses. And fear of the high price tag could prompt lawmakers to settle for less than comprehensive coverage for some Americans.

But patient advocates argue it is crucial for the final legislation to guarantee a base level of coverage, if people like Mr. Yurdin are to be protected from financial ruin. They also call for a new layer of federal rules to correct the current state-by-state regulatory patchwork that allows some insurance companies to sell relatively worthless policies.

“Underinsurance is the great hidden risk of the American health care system,” said Elizabeth Warren, a Harvard law professor who has analyzed medical bankruptcies. “People do not realize they are one diagnosis away from financial collapse.”

Last week, a former Cigna executive warned at a Senate hearing on health insurance that lawmakers should be careful about the role they gave private insurers in any new system, saying the companies were too prone to “confuse their customers and dump the sick.”

“The number of uninsured people has increased as more have fallen victim to deceptive marketing practices and bought what essentially is fake insurance,” Wendell Potter, the former Cigna executive, testified.

Mr. Yurdin learned the hard way.

At St. David’s Medical Center in Austin, where he went for two separate heart procedures last year, the hospital’s admitting office looked at Mr. Yurdin’s coverage and talked to Aetna. St. David’s estimated that his share of the payments would be only a few thousand dollars per procedure.

He and the hospital say they were surprised to eventually learn that the $150,000 hospital coverage in the Aetna policy was mainly for room and board. Coverage was capped at $10,000 for “other hospital services,” which turned out to include nearly all routine hospital care — the expenses incurred in the operating room, for example, and the cost of any medication he received.

In other words, Aetna would have paid for Mr. Yurdin to stay in the hospital for more than five months — as long as he did not need an operation or any lab tests or drugs while he was there.

Aetna contends that it repeatedly informed Mr. Yurdin and the hospital of the restrictions in policy, which is known in the industry as a limited-benefit plan.

The company says such policies offer value by covering some hospital expenses, like surgeons’ fees or a stay in the intensive care unit. Aetna also says all of its policyholders receive significant discounts on the overall cost of hospital care. But Aetna also acknowledges that a limited-benefit plan was inappropriate in Mr. Yurdin’s case because his age and condition — an irregular heartbeat — made him likely to require more comprehensive coverage.

“Limited benefits aren’t right for everyone, and it clearly wasn’t right for Mr. Yurdin,” said Cynthia B. Michener, an Aetna spokeswoman.

Charles E. Grassley, the ranking Republican on the Senate Finance Committee, which is taking a lead on health legislation, says Congress needs to make “meaningful” insurance coverage more affordable and accessible. But “until that happens,” he said, “any presentation of limited-benefit plans ought to be completely straightforward, and not misleading in any way.”

Insurers like Aetna generally defend limited-benefit policies as a byproduct of the nation’s flawed health care system, which they say makes it too expensive to adequately insure someone like Mr. Yurdin.

If everyone in the country were required to have insurance, the industry says — a mandate that Congress is contemplating — the costs and risks of insurance would be spread over a large enough pool of people to let insurers provide full, affordable coverage even to people with pre-existing medical conditions.

Mr. Yurdin worked at TEKsystems, which employs people for short periods as contractors for other companies. TEKsystems says it does not pay for the contract workers’ health benefits, but it does enable them to purchase individual policies with limited benefits so they have at least some coverage.

“There’s no way we make this sound like regular coverage,” said Neil Mann, an executive vice president at Allegis Group, which owns TEKsystems.

Although Mr. Mann acknowledged that the plan Mr. Yurdin purchased excluded routine hospital care, he said he thought it still provided value to employees who wanted “peace of mind.”

True peace of mind, however, comes with a much higher price tag. When Mr. Yurdin no longer qualified for the Aetna coverage after he left TEKsystems and his eligibility eventually ended, his only option was a special state plan in Texas for people who are at high risk for expensive medical care. He has been paying more than $1,000 a month for comprehensive coverage, compared with the roughly $250 a month he was paying for the Aetna plan.

But as of Wednesday, his future insurance problems are largely solved: he qualifies for Medicare because he turns 65.

Many insurers, as part of the Congressional overhaul of their business, say they expect the demand for limited-benefit policies to fall. “Until the nation achieves the universal coverage that we strongly support, some individuals will want to be able to choose limited indemnity products, but with comprehensive health reform we think that need should diminish,” said Simon Stevens, an executive at UnitedHealth.

UnitedHealth drew criticism last year for selling policies with sharply limited coverage through AARP, the advocacy group for older people. One of the plans capped reimbursement for an operation at $5,000, for example, although many procedures cost at least several times that amount. After Senator Grassley began investigating its sales practices, UnitedHealth agreed to stop offering the limited AARP plans.

Mr. Yurdin and his wife say it was not clear that he was liable for tens of thousands of dollars in hospital bills until after he had the first two of what would eventually be four operations. St. David’s says it tried to persuade them to apply for charity care, under which the hospital would absorb much, or all, of the unpaid bills.

But the couple says a lawyer advised them to turn to bankruptcy as the way to be certain they would not be left with too much debt. “I knew we were getting way, way over our heads,” Mrs. Yurdin said.

While Aetna disputes the Yurdins’ and the hospital’s version of events, it also says it has tried to clarify the language it uses to describe the coverage. In its most recent brochure, the fine print describing the limits to “other” hospital services now defines what they are in a footnote on the same page and warns that the excluded expenses could be “significant.”

Senator John D. Rockefeller IV, Democrat of West Virginia, who is also on the Finance Committee, has introduced legislation that would require insurers to be more clear about what they do — and do not — cover. He says he advocates such a change, even if Congress cannot agree to a more sweeping overhaul of the health insurance industry.

But advocates for broad changes to the health care system say Congress can succeed only by making sure health reform goes beyond giving every American a buyer-beware insurance card. One such person is Len Nichols, a health economist for the New America Foundation.

“Conceptually,” he said, “insurance means normal people should not go bankrupt from serious medical conditions.”

Many With Insurance Still Bankrupted by Health Crises, NYT, 1.7.2009, http://www.nytimes.com/2009/07/01/business/01meddebt.html