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A Public Health Plan, and Alternatives

NYT

December 1, 2009

http://www.nytimes.com/2009/12/01/opinion/l01health.html

Months to Live

Hard Choice

for a Comfortable Death:

Sedation

December 27, 2009
The New York Times
By ANEMONA HARTOCOLLIS

In almost every room people were sleeping, but not like babies. This was not the carefree sleep that would restore them to rise and shine for another day. It was the sleep before — and sometimes until — death.

In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream on Long Island, the patients were sleeping because their organs were shutting down, the natural process of death by disease. But at least one patient had been rendered unconscious by strong drugs.

The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart failure and kidney problems, was brought from home by his wife and son, who were distressed to see him agitated, jumping out of bed and ripping off his clothes. Now he was sleeping soundly with his mouth wide open.

“Obviously, he’s much different than he was when he came in,” Dr. Edward Halbridge, the hospice medical director, told Mr. Oltzik’s wife. “He’s calm, he’s quiet.”

Mr. Oltzik’s life would end not with a bang, but with the drip, drip, drip of an IV drug that put him into a slumber from which he would never awaken. That drug, lorazepam, is a strong sedative. Mr. Oltzik was also receiving morphine, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. In so doing, it can hasten death.

Mr. Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counseling, physicians like Dr. Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.

Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm.

Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone’s life, but only to make the patient more comfortable.

But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of “slow euthanasia,” and that doctors who say otherwise are fooling themselves and their patients.

There is little information about how many patients are terminally sedated, and under what circumstances — estimates have ranged from 2 percent of terminal patients to more than 50 percent. (Doctors are often reluctant to discuss particular cases out of fear that their intentions will be misunderstood.)

While there are universally accepted protocols for treating conditions like flu and diabetes, this is not as true for the management of people’s last weeks, days and hours. Indeed, a review of a decade of medical literature on terminal sedation and interviews with palliative care doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.

Discussions between doctors and dying patients’ families can be spare, even cryptic. In half a dozen end-of-life consultations attended by a reporter over the last year, even the most forthright doctors and nurses did little more than hint at what the drugs could do. Afterward, some families said they were surprised their loved ones died so quickly, and wondered if the drugs had played a role.

Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. Still, most families felt they and the doctors had done the right thing.

Mr. Oltzik died after eight days at the hospice. Asked whether the sedation that rendered Mr. Oltzik unconscious could have accelerated his death, Dr. Halbridge said, “I don’t know.”

“He could have just been ready at that moment,” he said.

With their families’ permission, Dr. Halbridge agreed to talk about patients, including Mr. Oltzik and Frank Foster, a 60-year-old security guard dying of cancer. He said he had come to terms with the moral issues surrounding sedation.

“Do I consider myself a Dr. Death who is bumping people off on a regular basis?” he asked. “I don’t think so. In my own head I’ve sort of come to the realization that these people deserve to pass comfortably.”

 

An Uncomfortable Topic

For every one like Dr. Halbridge, there were other doctors who, when asked about their experiences, would speak only in abstract and general terms, as if giving a medical school lecture, and declined requests to arrange interviews with families who had been through the process. It is a difficult subject to discuss.

The medical profession still treats its role as an art as much as a science, relying on philosophical principles like the rule of double effect. Under this rule, attributed to the 13th century Roman Catholic philosopher Thomas Aquinas, even if there is a foreseeable bad outcome, like death, it is acceptable if it is unintended and outweighed by an intentional good outcome — the relief of unyielding suffering before death. The principle has been applied to ethical dilemmas in realms from medicine to war, and it is one of the few universal standards on how end-of-life sedation should be carried out.

At Metropolitan Hospital Center, a city-run hospital in East Harlem, Dr. Lauren Shaiova, the chief of pain medicine and palliative care, has issued 20 pages of guidelines for palliative sedation. The guidelines include definitions, criteria, what to discuss with family and hospital workers and a list of drugs to induce sleep, control agitation and relieve pain.

The checklist of topics to be discussed with the family includes whether to offer intravenous food and water. Another checklist anticipates that some hospital workers may be upset by the process, and recommends a discussion with questions like: “Were you comfortable with the sedation of this patient? If not, what were your concerns?”

But clarity, doctors say, is hardly the rule. In 2003, Dr. Paul Rousseau, then a Veterans Affairs geriatrician in Phoenix, wrote an editorial in the Journal of Palliative Medicine calling for more explicit guidelines and research. He noted that some researchers include intermittent deep sleep in the category of palliative sedation, while others limit it to continuous sedation, which he said might explain some of the variance in estimates of how often it occurs.

And he proposed more systematic research into the types of medications used, how long it takes for patients to die, and the feelings of family and medical staff.

Doctors at two prominent New York City hospitals, Beth Israel Medical Center and NewYork-Presbyterian Hospital, freely discussed their policies on terminal sedation, but were reluctant to allow a reporter to talk to patients or families. The policy adopted by Beth Israel’s hospice endorses palliative sedation to “carefully selected patients” at the end of life. The three-page policy reviews legal, ethical and clinical considerations in broad strokes, but refrains from providing names of drugs and checklists.

Dr. Russell Portenoy, chairman of pain medicine and palliative care at Beth Israel, said the policy reflected the perceived perils of too much specificity. The hospice ethics committee decided that every patient was different, he said, and that “it was better to present a policy at this 10,000-foot level.”

The Metropolitan guidelines authorize certain drugs to induce palliative sedation, or in conjunction with sedation for pain, delirium and agitation. The sedation drugs are lorazepam, midazolam, phenobarbital and, in the intensive care unit only, sodium thiopental.

For pain, the guidelines list opioid drugs, including morphine, methadone and fentanyl.

Doctors say that other drugs used for sedation are ketamine, an anesthetic and sedative popular at rave parties, and propofol, an anesthetic, which was ruled, with lorazepam, to have caused Michael Jackson’s death. In very high doses, sodium thiopental is used as a sedative in the three-drug combination used for lethal injections.

There is one ethical guidepost for all the protocols: Terminal sedation should not become so routine that the end of life is scheduled like elective surgery, for the convenience of the doctor or the family, or because the patient’s care is no longer economically viable.

Physicians occasionally feel pressure to turn up the medication, said Dr. Pauline Lesage, Beth Israel’s hospice medical director. The pressure may come from weary relatives, who say, in effect, “Now it’s enough; I just want him to disappear.”

Sometimes the pressure is institutional. “You may be tempted to jump over because, oh well, ‘I need the bed,’ or ‘That’s enough, I don’t see what we are doing here,’ ” she explained.

The doctors resist pressure to deliberately hasten death, she said. “Otherwise you see that you are jumping into a different field.”

 

The Conversation

Leo Oltzik was a lanky man with a piercing gaze, a draftsman who, among many of his projects, worked on plans for the Second Avenue subway. In 57 years of marriage, he and his wife, Eleanor, had a son and a daughter and hardly ever argued.

They slept in the same bed, even after a railing had to be installed on one side to keep Mr. Oltzik from jumping out. But around Thanksgiving, Mr. Oltzik became too agitated for his wife and son to continue caring for him at home. “He was fighting death,” Mrs. Oltzik said.

After three days of efforts to calm Mr. Oltzik in the hospice failed, Dr. Halbridge told the family that he was going to try an IV drip. Mr. Oltzik was connected to an intravenous bag of Ativan, a brand name of lorazepam, and he was given Roxanol, a liquid morphine, for pain and shortness of breath. He lay in a large room where the December sun washed over flowered curtain ruffs, plush carpeting and lavender chairs. He looked as if he was sleeping, except to his wife.

“That’s not him,” she said, pulling out a photograph from better times.

On the sixth day, the staff invited Mrs. Oltzik and their son into a cozy meeting room, equipped with an overstuffed couch and chairs. They were joined by Dr. Halbridge; Barbara Walsh, a nurse managing the hospice team; and Lynne Kiesel, a medical social worker, who called the Oltziks’ daughter, Barbara Ladin, in Florida, and put her on a speakerphone.

“We have these meetings to talk about how you’re doing, how he’s doing, and to give you a chance to ask us questions,” Ms. Walsh began, then turned to Dr. Halbridge, who signaled his profession with the stethoscope wrapped over his dark blazer like a shawl.

“Our biggest challenge was to try to get him not to be so agitated,” Dr. Halbridge began.

The staff had tried to calm him with various medications by mouth, without success. “So we put him on an IV medication, which is dripping in at a continuous rate,” he said.

The doctor pressed ahead, in a cheerful, upbeat voice, tinged with regret, saying that the staff had to decide what was better for Mr. Oltzik in the long run and wanted the family’s opinion. His blood pressure was falling, “which implies that his body is slowing down, but he’s comfortable, and that’s what we’re looking for,” Dr. Halbridge continued. (Low blood pressure can be a side effect of Ativan and Roxanol, according to the drug manufacturers, as well as a consequence of the dying process.)

Ms. Walsh added consolingly, “He really looks like he’s sleeping.”

She said, apologetically, that the hospice had tried to find a balance between controlling Mr. Oltzik’s agitation and making him too sleepy.

“We did go to this IV as kind of a last measure, because we know that people do get sleepy and may not be as responsive, and we know how hard that is for the family to see,” she said.

Mr. Oltzik’s daughter zeroed in on the question that had been hanging over the discussion: “This is the end?”

“Yes, pretty much,” Dr. Halbridge said, “because what we’re seeing is a man who had a rather significant blood pressure on admission, and over the past day now, and today again, his blood pressure is even lower. So we’re talking about a poor prognosis and a shorter time.”

Mr. Oltzik’s son detected an almost imperceptible change in his mother. “Stay calm,” he urged her.

Moments later, the social worker gently entered the discussion, saying, “You’ve given him excellent care at home.”

“I worked very hard,” Mrs. Oltzik said.

Although throughout the half-hour meeting the staff had never explicitly asked to continue sedating Mr. Oltzik, his daughter now gave them tacit permission: “We understand that the inevitable is here, but we wish him to go in peace and to find solace in that,” Ms. Ladin said.

When the conference was over, Mrs. Oltzik still seemed to be ruminating. As many relatives do, she had hesitated over whether her husband should be given nutrition and water through tubes, now that he could not feed himself. The thought of someone dehydrating or starving is one of the most difficult emotional burdens for families, and was the crux of the famous fight over Terri Schiavo, a vegetative Florida woman whose husband wanted to let her die, but whose parents did not.

Palliative care doctors generally agree that sedated patients do not feel pain from dehydration or starvation, and that food and water may only prolong agony by feeding the fatal disease.

Mrs. Oltzik had done some research, and decided that nutrition and water would only burden her husband’s system. “The idea is now not to make him work harder, but to be as peaceful and calm as he can,” she said. “Common sense dictates that that would be the way to go.”

Much of the conversation had proceeded not in black and white like a legal document, but in shades of gray. By the end, they all seemed to understand one another, though ultimately Mrs. Oltzik would express some sadness at being unable to interact with her husband.

 

The Family’s Dilemma

From Karen Foster’s perspective, watching her husband, Frank, die while sedated was the least in a series of cruel blows. Mr. Foster, who arrived at the Franklin hospice about the same time as Mr. Oltzik, had stoically hidden his liver cancer from his family for years. As recently as October, he was still driving, Mrs. Foster said; then he suddenly went downhill.

The night before Thanksgiving, her husband was acting bizarrely, and soon he was admitted to the hospice, Mrs. Foster said. Dr. Halbridge put him on morphine for pain and Ativan to calm his shortness of breath and anxiety. It was terminal sedation, Dr. Halbridge said, but Mr. Foster’s liver was failing so rapidly that no medication could have hastened his death.

Mrs. Foster sat stiffly at his bedside in a cloche hat and long coat, as if she expected him to go any second. She said she was relieved that her husband was no longer suffering. The sight of him sedated, his mouth open in a premonition of death that some doctors call “the O sign,” was less shocking than the disease he kept secret, she said.

But families sometimes push back. Marguerite Calixte, a day care worker, asked Dr. Halbridge to wake her husband out of deep sedation — begun the day before because he had trouble breathing — so she could say goodbye.

Her husband, Alix, who was 53, had trained as a nurse and had told her that if he was going to die of his colon cancer, he wanted to die at home, with his wife and their two teenage children.

On a Thursday night, Dr. Halbridge began decreasing the morphine drip, and by the next morning, Mr. Calixte’s eyes fluttered open. “I’ve been talking to him,” his wife said on Saturday, in Haitian cadences. “I say, ‘If you want to go home, squeeze my hand tight.’ He keep doing it over and over.”

Ms. Walsh, the team manager, patiently gave Mrs. Calixte a lesson in how to take care of her husband, but doubted that he would be able to go home on Monday, and she was right.

He died that Saturday night, when his wife went home to have dinner with their children.

Mrs. Calixte believed the morphine was to blame. “He died quicker,” she said. “I don’t know when it was going to be, but it wasn’t going to be now. The thing is, he was going to suffer. I know that. But he wasn’t going to die so quick.”

Dr. Halbridge said there was “no way of knowing which would have taken him sooner,” the medication or the disease. He said the conflict between his desire to make Mr. Calixte comfortable and Mrs. Calixte’s wishes made the case “a tough one, I admit.”

 

Teaching a Difficult Subject

The American Academy of Hospice and Palliative Medicine has endorsed “palliative sedation to unconsciousness” and in 2008, the American Medical Association issued a policy statement supporting palliative sedation, except when it is used primarily for emotional distress. Even the United States Supreme Court, while rejecting a constitutional right to physician-assisted suicide, has opened the door to palliative sedation.

There is general agreement that “a patient who is suffering from a terminal illness and who is experiencing great pain has no legal barriers to obtaining medication, from qualified physicians, to alleviate that suffering, even to the point of causing unconsciousness and hastening death,” Justice Sandra Day O’Connor wrote in a 1997 case, Washington v. Glucksberg.

One provision of the House health care bill, which passed in November, recognizes that palliative care may include treatment “furnished for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death.” The bill — but not the Senate version, passed on Thursday — also allows doctors to be reimbursed for discussions with patients about what treatments they would want or decline. This gave rise to charges by some Republicans that “death panels” would be convened to decide who deserves life-saving treatment.

Amid the furor, the bill was revised to make clear that patients would not be forced to forgo treatment.

Terminal sedation remains touchy enough that last month, Dr. Lyla Correoso, Bronx medical director of the Visiting Nurse Service of New York, and Dr. Shaiova spoke with doctors, nurses, administrators and social workers at Metropolitan Hospital about how to explain the process to families and colleagues, so no one would feel guilty or betrayed.

The title of the lecture, projected on a giant PowerPoint screen, conveyed the crux of the dilemma: “The Double Effect: Is it the Drug or the Disease?”

“Some people speculate that people are really covering up the fact that this is really perhaps a type of euthanasia or maybe something else that’s really afoot,” Dr. Correoso said. “You have to have good overall intent, and most physicians, that’s what we’re here for — we’re here to do something good.”

She advocated setting “goalposts” in advance, by asking patients to stipulate “the farthest line I’m not going to cross” — including sedation.

The most pointed questions came from a chaplain, Rabbi Isaac H. Mann. Was it possible, he asked, that a person under deep sedation could still be feeling pain, and how would the staff know?

“Yes,” Dr. Shaiova replied. But they often expressed pain through agitation or grimacing, she said, adding, “Err on the side of treating them” with pain-controlling drugs.

The chaplain pressed for more clarity, even after the meeting had broken up. Was she trying to say, he asked Dr. Correoso, that if morphine killed a patient, “you wouldn’t mind?”

“Then you’ve already broken the principle of double effect,” Dr. Correoso replied.

“The doctor knows that this can kill the patient,” Rabbi Mann insisted.

“The doctor doesn’t know,” Dr. Correoso said. Then she repeated a refrain often heard in the world of palliative medicine: “It’s not easy to kill a patient. People think it’s easy, but it’s really not. That’s why Dr. Kevorkian had to use all that” combination of drugs.

 

The Gray Zone

On the day Dr. Shaiova and Dr. Correoso lectured on terminal sedation, they were also consulting with a patient at Metropolitan Hospital who was dying of lung cancer. The patient, Gloria Scott, 50, had learned of her cancer in June.

End-of-life treatment often has a kind of studied ambiguity to it, and such was the case with Ms. Scott.

After she was moved to the hospice wing of Margaret Tietz Nursing and Rehabilitation Center in Jamaica, Queens, she received fentanyl, a synthetic opioid pain reliever, through an IV line that gave her the drug continuously, and allowed her or a nurse or doctor to push a pump for more when she had “breakthrough” pain. Under her right ear, she wore a scopolamine patch, used to reduce secretions. Scopolamine has sedative and mood-altering properties, and was once combined with morphine to induce “twilight sleep” for women giving birth. Ms. Scott also had standing orders for Ativan, the sedative, and Haldol, for delirium, two more drugs in the palliative sedation arsenal.

At first, though in pain, she was lively. She sat on the bed in the lotus position, which eased her pain, and in her Betty Boop voice, punctuated by an infectious giggle, she talked about her favorite Motown music and her plans to get a business degree.

She fiercely resisted signing a “do not resuscitate” order, although she would later change her mind. “I don’t know when is my last day,” she said. “I might outlive one of you all.”

She asked her doctor at the hospice agency, Erik Carrasco, to keep the fentanyl, which she had begun taking at the hospital, turned down low. Otherwise, she said, “you sit here and you nod. I don’t want to be like that.”

Two weeks later, the change in Ms. Scott was marked. She was still alive but dessicated and barely responded to visitors. Her companion, Milton Cruz, was troubled by her “semi-dreamland” state, as he put it, but was shy about asking questions.

In her last days, she lost the desire to eat or drink, though nurses continued offering food and water, Dr. Carrasco said. The textbook survival time for patients who stop eating and drinking is two weeks, Dr. Carrasco said, but he said he had seen people last longer — elderly people who had survived the Holocaust and “people who are waiting for someone, like a son.”

She died after 22 days. Dr. Shaiova said she did not consider Ms. Scott’s sedation to be palliative or terminal sedation, because that was not her doctor’s intention. Her body had sedated itself as a defense against the disease, Dr. Shaiova said, and she had been on fentanyl long enough to develop some tolerance, making it unlikely to have hastened her death.

“When you’re sick, you’re sick, and everything else is somewhere in the gray zone, and that’s the problem,” Dr. Shaiova said.

Dr. Carrasco said that while the medication might have contributed to her drowsiness, he believed she had died a natural death. “What I’ve been seeing sometimes is you release the pain,” he said, “and even though you are using very small amounts of morphine or narcotic, they relax and pass away.”

 

The Semantics

Even when everybody agrees that terminal sedation is a humane response to unyielding suffering, many doctors seem to feel a prick of conscience.

“There should be ambivalence,” said Dr. Joseph J. Fins, chief of medical ethics at Weill Cornell Medical College. “If it became too easy and you weren’t ambivalent, then I would really start worrying about it. But the fact that you’re worrying about it doesn’t mean you’ve done something wrong.”

In a 1996 paper in the Journal of Palliative Care that is still debated within that community, Dr. J. Andrew Billings, a Harvard professor and palliative care doctor at Massachusetts General Hospital, and Dr. Susan D. Block, a psychiatrist, took on the moral ambiguity surrounding terminal sedation. They argued that the main distinction between terminal sedation and euthanasia was time.

Terminal sedation would lead inexorably to death, but “not too quickly,” they said. They derided the rule of double effect in this context as a rationalization, a subtle cover-up, of what they called “slow euthanasia.”

Even a simple morphine drip, they said, could put patients into a stupor at the right dose or when combined with other drugs or when concentrated by the inefficiency of a damaged liver or kidneys.

“If the morphine drip becomes a code word for slow euthanasia,” they wrote, “laypersons may be increasingly wary of the other uses of opioids.”

Both Dr. Billings, who is still at Harvard, and Dr. Block declined requests to be interviewed.

The authors did not endorse euthanasia, but their arguments have been used by others looking to make the case for public acceptance of euthanasia, to the dismay of some doctors who defend terminal sedation.

People who adopt this argument say, “We know what you’re really doing, it’s crypto-euthanasia,” Dr. Fins said. “Polemics really have no place at the bedside.”

Dr. Fins said he sometimes told families that terminal sedation was altruistic, because they might be giving up an extra day or two “of communication with the person you love in the service of that love.”

As for the argument that double effect is overly scholarly, Dr. Fins said: “I can’t imagine a world at the end of life without double effect. We’d be highly impoverished without it, and patients would suffer needlessly without it. We do need our philosophical contrivances in order to be pragmatic physicians and caregivers.”

 

Ambivalent, Then Accepting

Mr. Oltzik died two days after the meeting between Dr. Halbridge and his family, and Dr. Halbridge was frank in describing his treatment.

Asked if he would call it palliative sedation, Dr. Halbridge said, “This would be called terminal sedation, almost.” He said he hesitated only because the word “terminal” sounded negative and might make the family feel bad, when “it’s really comfort care.” The terms “palliative” and “terminal” were interchangeable, he said.

Speaking with considerable passion, he said he saw himself as the doctor who would not “forsake” patients by telling them he could do nothing for them. If there was no cure, he could at least offer comfort. “We are not gods who can cure everything, and I think at some point in time you have to accept that,” he said, “and to me, it’s the mark of an honest doctor who understands when that time has come.”

The decision to administer terminal sedation was based on a review of the patient’s history that convinced him that Mr. Oltzik was “terminally agitated,” he said. “It means that he is entering the dying process and for whatever reason — whether it’s physical, spiritual — something is interrupting the peaceful passing, and to me, because it’s so uncomfortable for the family and for the patient, that’s the time to medicate the patient and make them comfortable, because no matter what you do, he’s not going to go back to the old Leo that he was.”

He then told a self-deprecating joke about a doctor who gets to the gates of heaven and demands to jump to the head of the line, only to be turned back by St. Peter. But St. Peter opens the gates to someone else carrying a doctor’s bag. “That’s God,” St. Peter explains. “He just thinks he’s a doctor.”

Young residents often challenge him, saying things like, “If I’m 105 years old, I want to be fed, no matter what,” Dr. Halbridge said. His response is, “O.K., but did you ask your patient what he wants?”

Some patients are getting “multimillion-dollar workups” in the intensive care unit, he said, but make their wishes known by pulling out tubes. “I think a light bulb should go off in somebody’s head after the third time he pulls it out. Am I going to change the outcome of this, and if I’m not, why am I doing it?”

At one point, however, Mrs. Oltzik changed her mind.

“She was having second thoughts on that, and then she was saying, ‘I wonder if we should cut back on his medication,’ ” Dr. Halbridge said.

She hoped for a last chance to communicate with her husband, but Dr. Halbridge said he warned her that Mr. Oltzik was more likely to wake up agitated and suffering. Dr. Halbridge did not want to feel like he was experimenting. “I have a little bit of a problem with using the patient as kind of a guinea pig and saying, ‘Well, the medication worked nicely, now we’ll take it away and see if they bounce back the other way,’ ” he said.

Did he wake Mr. Oltzik? There was no need, Dr. Halbridge said: “He passed away within a couple of minutes.”

A couple of weeks later, Mrs. Oltzik still felt a bit uneasy. “They had him so heavily sedated that he was in a stupor,” she said. “I didn’t say goodbye to him, which hurts me.”

But she did not fault the hospice team’s judgment. She could not think of any other way to handle her husband’s agitation. As to whether his death had been speeded up, even a tiny bit, she said philosophically, “There was no way of knowing.”

    Hard Choice for a Comfortable Death: Sedation, NYT, 27.12.2009, http://www.nytimes.com/2009/12/27/health/27sedation.html

Senate Passes Health Care Overhaul on Party-Line Vote

December 25, 2009
The New York Times
By ROBERT PEAR

WASHINGTON — The Senate voted Thursday to reinvent the nation’s health care system, passing a bill to guarantee access to health insurance for tens of millions of Americans and to rein in health costs.

The 60-to-39 party-line vote, starting at 7:05 a.m. on the 25th straight day of debate on the legislation, brings Democrats closer to a goal they have pursued for decades and brings President Obama a step closer to success in his signature domestic initiative. When the roll was called, with Vice President Joseph R. Biden Jr. presiding, it was the first time the Senate had gathered for a vote on Christmas Eve since 1895.

If the bill becomes law, it would be a milestone in social policy, comparable to the creation of Social Security in 1935 and Medicare in 1965. But unlike those programs, the initiative lacks bipartisan support. Only one Republican supported a broadly similar bill that the House approved last month 220 to 215, and no Republicans backed the Senate version.

After the vote, lawmakers and Mr. Obama wasted no time leaving for their holiday break, well aware that their return to Washington would mean plunging into negotiations to reconcile the measures passed by the two chambers.

If a deal can be struck, as seems likely, the resulting law would vastly expand the role and responsibilities of the federal government. It would, as lawmakers said repeatedly in the debate, touch the lives of nearly all Americans.

The bill would require most Americans to have health insurance, would add 15 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $871 billion over 10 years, according to the Congressional Budget Office.

The budget office estimates that the bill would provide coverage to 31 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

Mr. Obama hailed the Senate action. “We are now incredibly close to making health insurance reform a reality,” he said, before leaving the White House to celebrate Christmas in Hawaii.

The president, who endorsed the Senate and House bills, said he would be deeply involved in trying to help the two chambers work out their differences. But it is unclear how specific he will be — if, for example, he will push for one type of tax over another or try to concoct a compromise on insurance coverage for abortion.

Senator Olympia J. Snowe of Maine, a moderate Republican who has spent years working with Democrats on health care and other issues, said she was “extremely disappointed” with the bill’s evolution in recent weeks. After Senate Democrats locked up 60 votes within their caucus, she said, “there was zero opportunity to amend the bill or modify it, and Democrats had no incentive to reach across the aisle.”

Like many Republicans, Ms. Snowe was troubled by new taxes and fees in the bill, which she said could have “a dampening effect on job creation and job preservation.” The bill would increase the Medicare payroll tax on high-income people and levy a new excise tax on high-premium insurance policies, as one way to control costs.

When the roll was called Thursday morning, the mood was solemn as senators called out “aye” or “no.” Senator Robert C. Byrd, the 92-year-old Democrat from West Virginia, deviated slightly from the protocol.

“This is for my friend Ted Kennedy,” Mr. Byrd said. “Aye!”

Senator Kennedy of Massachusetts, a longtime champion of universal health care, died of brain cancer in August at age 77.

Senator Jim Bunning, Republican of Kentucky, did not vote.

The fight on Capitol Hill prefigures a larger political battle that is likely to play out in the elections of 2010 and 2012, as Democrats try to persuade a skeptical public of the bill’s merits, while Republicans warn that it will drive up costs for those who already have insurance.

“Our members are leaving happy and upbeat,” said the Senate Republican leader, Mitch McConnell of Kentucky. “The public is on our side. This fight is not over.”

After struggling for years to expand health insurance in modest, incremental ways, Democrats decided this year that they could not let another opportunity slip away. As usual, lawmakers were deluged with appeals from lobbyists for health care interests who have stymied similar ambitious efforts in the past. But this year was different.

Lawmakers listened to countless stories of hardship told by constituents who had been denied insurance, lost coverage when they got sick or seen their premiums soar. Hostility to the insurance industry was a theme throughout the Senate debate.

Senator Sherrod Brown, Democrat of Ohio, said insurance companies were often “just one step ahead of the sheriff.” Senator Dianne Feinstein, Democrat of California, said the industry “lacks a moral compass.” And Senator Sheldon Whitehouse, Democrat of Rhode Island, said the business model of the industry “deserves a stake through its cold and greedy heart.”

The bill would establish strict federal standards for an industry that, since its inception, has been regulated mainly by the states. Under it, insurers could not deny coverage because of a person’s medical condition; could not charge higher premiums because of a person’s sex or health status; and could not rescind coverage when a person became sick or disabled. The government would, in effect, limit insurers’ profits by requiring them to spend at least 80 to 85 cents of every premium dollar on health care.

The specificity of federal standards is illustrated by one section of the bill, which requires insurers to issue a benefits summary that “does not exceed four pages in length and does not include print smaller than 12-point font.”

Another force propelling health legislation through the Senate was the Democrats’ view that it was a moral imperative and an economic necessity.

“The health insurance policies of America, what we have right now is a moral disgrace,” said Senator Tom Harkin, Democrat of Iowa. “We are called upon to right a great injustice, a great wrong that has been put upon the American people.”

Costs of the bill would, according to the Congressional Budget Office, be more than offset by new taxes and fees and by savings in Medicare. The bill would squeeze nearly a half-trillion dollars from Medicare over the next 10 years, mainly by reducing the growth of payments to hospitals, nursing homes, Medicare Advantage plans and other providers.

Republicans asserted that the cuts would hurt Medicare beneficiaries. But AARP, the lobby for older Americans, and the American Medical Association ran an advertisement urging senators to pass the bill, under which Medicare would cover more of the cost for prescription drugs and preventive health services.

Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group, said the bill appeared to be unstoppable. But she added: “We are not sure it will be workable. It could disrupt existing coverage for families, seniors and small businesses, particularly between now and when the legislation is fully implemented in 2014.”

    Senate Passes Health Care Overhaul on Party-Line Vote, NYT, 25.12.2009, http://www.nytimes.com/2009/12/25/health/policy/25health.html

Months to Live

Weighing Medical Costs of End-of-Life Care

December 23, 2009
The New York Times
By REED ABELSON

LOS ANGELES — The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life.

“If you come into this hospital, we’re not going to let you die,” said Dr. David T. Feinberg, the hospital system’s chief executive.

Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

Take the case of Salah Putrus, who at age 71 had a long history of heart failure.

After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant.

Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said his physician there, Dr. Tamara Horwich.

Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.” They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection.

His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant.

Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government. The Senate bill calls only for studies of Medicare spending variations, so it will be up to House-Senate negotiators to resolve the matter in the final legislation.

That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing.

“There’s a real risk of doing harm here — real harm,” he said.

Indeed, U.C.L.A. and five other big California medical centers recently published their own research results with a striking conclusion: for heart failure patients, the hospitals that spend the most seem to save the most lives.

 

Testing the Thesis

Dr. Rosenthal remembers a pivotal meeting back in 2005 when he and officials at the other California hospitals met with Dartmouth researchers to discuss their findings.

“We were inspired,” Dr. Rosenthal recalled, saying he found himself agreeing with much of the criticism aimed at his institution for its aggressive approach.

The Dartmouth analysis prompted Dr. Rosenthal to seek further data. He collaborated with colleagues at U.C.L.A. and four other medical centers affiliated with the University of California system, as well as Cedars-Sinai Medical Center in Los Angeles, to design a study of why some hospitals spent so much more on dying patients than others and what they got from their efforts.

To focus their analysis, the researchers chose to look only at a single category of patients: elderly people with heart failure. The dead would be counted, as Dartmouth does, but so would the living.

What they found seemed to contradict the Dartmouth thesis. The hospital that spent the most on heart failure patients had one-third fewer deaths after six months of an initial hospital stay.

The researchers did not disclose which of the six hospitals had the best results. But for the doctors involved, the implications were clear: spending more can sometimes save lives.

“It doesn’t look like it is all waste,” said Dr. Michael K. Ong, a U.C.L.A. internist and health policy researcher who was one of the authors of the study, which was recently published in the peer-reviewed medical journal Circulation: Cardiovascular Quality and Outcomes.

Another of the authors was Dr. Michael A. Gropper, a critical care specialist at the University of California, San Francisco. The Dartmouth research has consistently portrayed his hospital as much more cost-effective in end-of-life care than U.C.L.A. But the California study gave Dr. Gropper a new perspective. “There’s no doubt that additional investments may be worthwhile,” he said.

Some other experts take a similar view.

“If you only look at the failures, you miss the benefit,” said Dr. Peter Bach, an epidemiologist at Memorial Sloan-Kettering Cancer Center in Manhattan, who has examined the medical histories of cancer patients who have died, including women with early-stage breast cancer.

“No one in their right mind would tell you not to treat these women,” he said, “even though some of them will die.”

The California researchers say they also found much less variation among the six hospitals than the Dartmouth data would indicate after they took account of significant differences among the patients the hospitals treat, including the many patients who come to U.C.L.A. for a transplant, who are, by definition, extraordinarily sick.

Over all, the California researchers found that the variation in spending among the six hospitals was significantly less than the level reported by Dartmouth. When looking at all patients hospitalized for heart failure, for example, the variation in use of resources was 27 to 44 percent lower than when they looked at only the patients who died. And that corresponded with a separate, informal analysis of Medicare spending by the Congressional Budget Office, which after adjusting for the severity of illness in patients and differences in prices among regions, found less striking variations in spending.

A report from the Medicare Payment Advisory Commission released this month also found less variation.

Dr. Rosenthal, who argues that there are also fundamental socioeconomic differences between patients in the poorer sections of Los Angeles and those in the Mayo Clinic’s small and solidly middle-class hometown of Rochester, Minn., was co-author of an op-ed article in The Los Angeles Times last summer making that case. “Health care costs are significantly higher in areas of poverty,” he wrote.

The Dartmouth researchers tend to dismiss such counterarguments, saying their conclusion — higher spending does not necessarily buy better patient outcomes — is backed by decades of research. While more spending may have yielded benefits among these six hospitals, a Dartmouth official said, hospitals generally have not shown they deliver better results when they provide more care.

Still, Dr. Elliott S. Fisher, one of the lead investigators at the Dartmouth Atlas Project, acknowledged that the California researchers’ analysis might be better able than Dartmouth’s to identify cases in which more intensive care might prove beneficial. “Sometimes more medical care is better,” he said, “but the question is when.”

He says he believes that cost-effective hospitals with good medical outcomes should be financially rewarded for their efforts and results. But he says that public policy aimed primarily at penalizing high spenders would not be the solution. “Simply reducing their prices,” he said, “won’t fix anything.”

 

‘Hail Mary Pass’

Just how hard it is to determine who will most benefit from expensive care is clear in the case of George Klidaras, a 49-year-old stay-at-home father of two who arrived by ambulance late at night in mid-June in need of a heart transplant.

His age might have made him a good candidate for the procedure. And so might his overall state of health. He was lucidly answering doctors’ questions when he arrived. And although he had suffered a stroke in his early 40s and had a chronic heart condition, as recently as March, Mr. Klidaras had been living a relatively normal life.

By the time Mr. Klidaras arrived at U.C.L.A., though, his heart had weakened significantly. In the preceding weeks he had already received a pacemaker and defibrillator, and his local cardiologist decided it was time to ask U.C.L.A. — a highly regarded transplant center and regional magnet for cases beyond the skill of many other hospitals — to tackle his case.

Coming to U.C.L.A. “was our Hail Mary pass,” said his wife, Andra, a postal worker.

Mr. Klidaras’s lungs were damaged from a pulmonary embolism, and he had a high white-blood-cell count — a possible sign of infection. So the first order of business was to try to determine the source of infection so he would be well enough to undergo surgery.

The flurry of activity in the intensive care unit was “overwhelming,” Ms. Klidaras recalled. Her husband saw a dizzying array of specialists, including an infectious disease doctor and a dermatologist after he developed a rash. “They gave him every antibiotic and every test,” she said.

Mr. Klidaras spent nearly five weeks in the intensive care unit, at a cost of about $10,000 a day and a total cost in the neighborhood of $300,000. And the doctors never could stabilize his condition enough for the transplant surgery.

After the doctors told Ms. Klidaras there was nothing more they could do, she told them not to resuscitate him if his heart stopped beating on its own. He died July 20.

“Until the last week, I believed he was going to make it,” Mrs. Klidaras said. “I wanted them to do everything they could to save him.”

Someone giving the strictest of reading to the Dartmouth doctrine might argue that, given the outcome, the effort devoted to the Klidaras case was a futile expenditure of time and money.

 

Family Struggles

For U.C.L.A.’s doctors, deciding when enough is enough is not ultimately their call. Even when they recommend against a patient’s getting another procedure or test, it may be the patients and families who cannot let go.

When doctors, patients and families have trouble agreeing when to stop medical treatment, the person typically called in is Dr. Neil S. Wenger, a practicing physician who also serves as director of the U.C.L.A. Health System Ethics Center.

“For someone to die who is in the clutches of medical care, decisions have to be made,” Dr. Wenger said. “Otherwise, you don’t get to die a reasonable death.”

The decisions may include turning off life-prolonging technologies that were put in place when there was still hope — the dialysis machine to keep the kidneys functioning, the ventilator for the lungs — but now may be the only thing keeping the patient alive.

Dr. Wenger often sees difficult family dynamics. He spent more than an hour recently counseling the relatives of a woman with a traumatic head injury who was unlikely to ever regain consciousness. When a family member suggested stopping treatment, a sibling protested, saying, “You’re killing my sister.” Such intense emotions are “extremely common,” Dr. Wenger said.

Doctors, too, often have trouble letting go.

Many acknowledge that the current payment system encourages more care, because it rewards doctors for providing additional tests and procedures — not for spending the hours sometimes necessary to guide patients and families through the long, difficult process of deciding when to stop.

“The more tubes you put in, the more you get paid,” said Dr. Patrick T. Dowling, chairman of the department of family medicine at U.C.L.A.

But the bigger challenge may be changing the “we’re not going to let you die” culture at places like U.C.L.A.

Doctors at other leading medical centers, like the one at the University of California, San Francisco, say one big difference among institutions is how doctors and nurses talk with patients and families about their choices.

“It’s a cultural thing,” said Dr. Gropper. He says the doctors and nurses at the San Francisco medical center take the time to keep talking with patients’ families and even other doctors when they seem reluctant to end treatments. “You chip away at them,” he said.

At U.C.L.A., such palliative care — treatment devised to relieve pain and make patients more comfortable, particularly at the end of life — was essentially an afterthought until just a few years ago, when an internal task force recommended that the hospital add it to its many other specialties. The hospital now has a formal unit devoted to palliative care and is building up its expertise in the field. Residents, in training to be doctors, are being taught how better to discuss these issues with patients and their families.

Some doctors are resistant, particularly those with patients who had hoped for a transplant but were removed from the list when it became clear they had no realistic chance of recovery.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

    Weighing Medical Costs of End-of-Life Care, NYT, 23.12.2009, http://www.nytimes.com/2009/12/23/health/23ucla.html

Smoking Rate Drops in Massachusetts, Drawing Attention

December 17, 2009
The New York Times
By ABBY GOODNOUGH

BOSTON — When Massachusetts started offering virtually free treatments to help poor residents of the state stop smoking in 2006, proponents hoped the new Medicaid program would someday reap benefits.

But state officials never expected it would happen so soon.

New state data show a steep drop in the smoking rate among poor people. When the program , about 38 percent of poor Massachusetts residents smoked. By 2008, the smoking rate for poor residents had dropped to about 28 percent, a decrease of about 30,000 people in two and a half years, or one in six smokers, said Lois Keithly, director of the state’s Tobacco Cessation and Prevention Program.

There are also indications that the drop has lowered rates of hospitalization for heart attacks and emergency room visits for asthma attacks, she said.

The data has not yet been peer-reviewed. But the numbers have already grabbed national attention, with several United States senators and antismoking advocates using the data to push for similar new Medicaid coverage for tobacco addiction in the national health care legislation.

Senators Richard J. Durbin of Illinois and Bernard Sanders of Vermont have introduced an amendment that would do so, and the Senate could vote on it by the weekend. If the amendment fails, Senator Tom Harkin of Iowa said he would try another avenue: seeking an expansion through a conference committee that will ultimately reconcile the House and Senate bills.

"We should be able to find an opening," Mr. Harkin said in an interview. "This is one demonstrable way we can actually bend the cost curve and keep people healthy."

The Massachusetts program, part of the state’s landmark universal health care law, covers almost the entire cost of counseling and prescription drugs for Medicaid enrollees trying to quit smoking. Most states do not provide nearly as much help for poor smokers.

The rate of smoking among Medicaid patients had not changed in a decade before the program was introduced. It was much higher than the rate in the general population, which stands at about 18 percent.

Under the current Senate health care bill, only pregnant women on Medicaid would qualify for comprehensive smoking-cessation treatment, including drugs and counseling. The bill passed by the House last month would provide broader Medicaid coverage of such treatment, and antismoking groups are lobbying the Senate to adopt that approach.

Massachusetts lawmakers wanted to cover stop-smoking treatments for Medicaid enrollees, because the poor smoke at much higher rates than the general population.

Under the Massachusetts program, Medicaid recipients from age 18 to 64 are eligible for 180 days of antismoking drugs, including Chantix and bupropion, and 16 counseling sessions per year. Co-payments do not exceed $3, Ms. Keithly said, and preauthorization is usually not required.

The state spent a total of $11 million on the program during its first two years, she said; the costs since July 2008 have not been tallied.

Insurance plans for higher-income residents provide less coverage for smoking-cessation treatment, Ms. Keithly said, or none at all.

“This is really the gold standard,” she said.

Michael Siegel, a professor at Boston University’s School of Public Health, said the main finding — a significant drop in the smoking rate of Medicaid recipients — was “very compelling.”

State researchers also looked at the smoking rate for uninsured residents, who also tend to be poor, over the same period and found it did not change.

“That’s something you need to see,” Dr. Siegel said, “because if they had just found that the rate among Medicaid recipients dropped, it might be coincidental or dropping among everyone.”

The researchers found that smokers who took advantage of the cessation program had much lower rates of hospitalization for heart attacks and emergency room visits for asthma attacks than before starting the treatment.

But Dr. Siegel and other researchers said those findings were not as persuasive because the state had not used a control group.

“It’s intriguing but still quite preliminary,” said Nancy A. Rigotti, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital.

Still, Dr. Rigotti said, Congress should take the Massachusetts data seriously as it debates health care reform. She said that pregnant women — the only Medicaid recipients who would receive broad smoking-cessation benefits under the Senate plan — are often advised to avoid stop-smoking drugs.

Senator Harkin said that even though the Congressional Budget Office has predicted that covering smoking-cessation treatment for pregnant women alone would save $100 million in health care costs over 10 years, concern about up-front costs has made many senators reluctant to expand the benefits to all Medicaid recipients.

“It’s very frustrating,” he said.

According to the American Lung Association, Massachusetts is among only six states that offer extensive stop-smoking benefits for Medicaid recipients. The others are Indiana, Minnesota, Nevada, Oregon and Pennsylvania. Massachusetts is the only one of those states that has reported a significant drop in the smoking rate for Medicaid patients; several experts said the others might not have promoted their programs as aggressively or kept track of results.

Terry F. Pechacek, associate director for science for the Office on Smoking and Health at the Centers for Disease Control in Atlanta, said he had reviewed the Massachusetts data and found the numbers “shocking” given that smoking rates around the nation have barely budged since 2004.

About 20.6 percent of Americans were smokers in 2008, the C.D.C. reported last month, down from 20.9 percent in 2004. Smoking-related illnesses cost the Medicaid system more than $22 billion a year, Dr. Pechacek said — about 11 percent of overall Medicaid expenditures.

“The fact is we need to expand it to everyone,” he said of the type of coverage offered in Massachusetts.

Dr. Pechacek and others said that if the federal health care overhaul does include smoking-cessation coverage, publicizing it will be as crucial to its success as the cessation tools themselves.

“Even in the some of the states that offer wider coverage,” he said, “there’s been minimal promotion. People have to know about a benefit for it to have an effect.”

    Smoking Rate Drops in Massachusetts, Drawing Attention, NYT, 17.12.2009, http://www.nytimes.com/2009/12/17/us/17smoke.html

Senate Grinds to A Halt on Healthcare

December 16, 2009
Filed at 2:53 p.m. ET
The New York Times
By REUTERS

WASHINGTON (Reuters) - The slow-moving U.S. Senate debate on healthcare reform ground to a complete halt on Wednesday, with Republicans forcing the reading of a 767-page amendment as Democrats scrambled to finish work this year.

Republican Senator Tom Coburn invoked his right to require an amendment by independent Senator Bernie Sanders be read aloud by a Senate clerk -- a task expected to take well into the night.

Republicans so far are united in opposition to a sweeping healthcare overhaul that is President Barack Obama's top domestic priority, and have vowed to use every tool possible to slow the debate.

The move did not dramatically disrupt the snail's pace of the Senate, which has largely been in healthcare limbo awaiting cost estimates on provisions in a manager's amendment to be offered in a few days by Senate Democratic leader Harry Reid.

The proposed overhaul of the $2.5 trillion healthcare industry has been bogged down in the Senate amid disputes among Democrats over costs, plans for the government-run insurance program and how it would affect abortion.

Reid's amendment will make final adjustments designed to win the 60 Senate votes needed to overcome Republican procedural hurdles. The Democrats have no margin of error -- they control exactly 60 seats.

The Senate bill would extend coverage to 30 million uninsured Americans, provide subsidies to help them pay for the coverage and halt practices like refusing insurance to people with pre-existing medical conditions.

Coburn had threatened earlier in the debate to force the public reading of the entire 2,074-page healthcare bill but relented before the Thanksgiving holiday.

This time he followed through after Democrats rejected his request that all remaining amendments be filed for at least 72 hours and given a cost estimate by budget analysts before they are considered.

He also asked Democrats to accept his amendment requiring certification that all senators had read the bill and understood it before they voted on it.

'IMPOSSIBLE TO SAY THEY UNDERSTAND'

"I think it is impossible to certify that any senator fully understood. They may read but not fully understand for a variety of reasons," Democratic Senator Max Baucus said in rejecting the request.

Republican Senate leader Mitch McConnell has said he may use other procedural means to slow the bill as Democrats try to reach a final vote before the Christmas holiday.

Reid must file his manager's amendment and three procedural motions to end debate within the next few days, setting off a series of votes that will lead to a vote on final passage.

Obama has pushed the Senate to finish the healthcare bill this year to keep the issue from slipping into next year's congressional election campaigns.

The Senate bill would then be reconciled in early January with a version approved by the House of Representatives on November 7, and each chamber would have to pass it again.

House Speaker Nancy Pelosi told reporters on Wednesday she was still confident the Congress could pass the final measure before Obama's State of the Union address in late January.

But the Democratic House leader voiced exasperation with the Senate. "We should have had a bill months ago," Pelosi said.

Union leaders including the executive body of the AFL-CIO, the largest U.S. labor federation, met on Wednesday to discuss how to respond to Reid's decision to accommodate moderates by eliminating proposals for a government-run insurance option and an expansion of the Medicare health program for the elderly.

Those moves have angered liberals. Unions also have been unhappy with the Senate's proposal to tax high-cost health insurance plans -- like those many unions have -- to help pay for the overhaul.

"This afternoon, the executive board of the AFL-CIO is meeting to discuss the most recent developments in the health care negotiations, what our position is and what our next steps will be," AFL-CIO spokesman Eddie Vale said.

 

(Additional reporting by Thomas Ferraro and David Morgan; editing by Paul Simao)

    Senate Grinds to A Halt on Healthcare, NYT, 16.12.2009, http://www.nytimes.com/reuters/2009/12/16/us/politics/politics-us-usa-healthcare.html

Letters

Giving Psychiatric Drugs to Children

December 16, 2009
The New York Times

To the Editor:

Re “Poor Children Likelier to Get Antipsychotics” (front page, Dec. 12):

I am the mother of a teenage boy who received a diagnosis of attention deficit disorder and oppositional defiant disorder eight years ago and was prescribed antipsychotic medication. Throughout the years, we have visited no fewer than five psychiatrists and countless other therapists.

I would often question why my son was prescribed medications (at one point three at a time) that failed to do as they promised. For example, the ones that were designed to help him sleep at night did the reverse, and the ones to keep him awake made him lethargic.

I decided that it was in my son’s best interest to take a break from the weekly therapy and daily medication. Surprisingly, he functioned much better: His sleeping patterns and appetite improved. He is now back on medication, but with new therapists and with the parents’ considerations in mind.

Families like ours are often duped into believing that there aren’t options other than medication, or should we refuse to comply, charges of neglect could be brought.

Suzanne Joblonski
Ridgewood, N.Y., Dec. 14, 2009

•

To the Editor:

In discussing the “off label” use of antipsychotic medications to treat children with attention deficit hyperactivity disorder and other disruptive behavior disorders, the article did not mention that there are well-established, effective, evidence-based treatment protocols for children with these diagnoses.

These programs use cognitive behavioral interventions with children, and, of at least equal importance, provide parent training and coordination between family, school and treatment provider. These treatment models are often used in conjunction with medication, but may reduce or in some cases obviate the need for medication.

Effective use of these protocols requires coordination and follow-up with teachers and parents, much of which is not currently reimbursable either by private insurance or Medicaid.

Arlene Klingman
New York, Dec. 14, 2009

The writer is director of the Child and Family Clinic-Plus Program of the Riverdale Mental Health Association.

•

To the Editor:

As a practicing child psychiatrist for the last 22 years, I am not surprised that poorer children on Medicaid are prescribed antipsychotic drugs at four times the rate of middle-class children. Sadly, it is symptomatic of the general trend in psychiatry over the last 15 years to “medicalize” complex behavioral problems and label them with an overly simplistic medical diagnosis, like bipolar disorder, implying that the right medication will solve the problem.

In a Medicaid population, the temptation for overwhelmed doctors and understaffed clinics to succumb to a potentially quick fix with a readily available treatment is often too compellingly expedient. If only the simple act of writing a prescription could cure the emotional distress of children subjected to the social ills of poverty.

Richard Levine
Berkeley, Calif., Dec. 12, 2009

•

To the Editor:

We are parents of a 10-year-old son who is on Medicaid as a result of long-term disability. He has been prescribed antipsychotics for more than five years. We have tried numerous times to taper off the medication and instead focus on counseling with various therapists.

After a few sessions with these therapists, we have been told either that his disorder is not their specialty or that his situation is too complex. We have always felt — and the study behind this article lends credence to our suspicions — that the motivation for not offering long-term counseling was tied to the reimbursement offered by his insurance.

We are fearful that the heavy reliance on medication is leaving our son ill equipped to live independently when he becomes an adult. He and every other child deserve to be provided the treatment that offers them the best chance to be functioning members of society, and a pill is not always the answer.

Duncan Cameron
Aimee Gunn
Eau Claire, Wis., Dec. 12, 2009

•

To the Editor:

One of the reasons for the disparate use of medication has to do with the large cohort of poor children and adolescents in residential treatment centers, foster care, group homes and juvenile justice facilities. These institutions often do not or cannot provide the kind of mental health services that ultimately would help children face issues like profound rage and deep sadness that fuel behaviors that are often frightening and violent, but not necessarily psychotic.

Because these institutions focus on controlling behavior instead of the more time-consuming process of helping children identify and understand their feelings, they are given drugs that, in the long run, do more harm than good. This is not only a disservice to children who already face tremendous hurdles, but will also ultimately increase the costs borne by Medicaid when it becomes necessary to address the physical and psychological damage done by the use of these drugs.

Debra Kuppersmith
Dobbs Ferry, N.Y., Dec. 12, 2009

The writer is a psychoanalyst.

•

To the Editor:

Federal funding allocated to help treat and study psychiatric disorders pales in comparison to that for other medical conditions. Research on cancer, heart disease and infectious diseases receives three to four times the annual funding of the National Institute of Mental Health. Within that small pool, childhood psychiatric disorders are allocated an even smaller portion of funds.

Because of the limited funds, few children with psychiatric disorders are treated by doctors with advanced training in this area. Rather, they are often managed by family practitioners and pediatricians.

Can the same be said of children with cancer or heart disease? Doesn’t a child with a serious psychiatric disorder deserve to be seen by a doctor with specialized training just as children with cancer are? Sadly, the answer from our current system of distributing medical funds is a resounding no.

Jonathan E. Posner
New York, Dec. 13, 2009

The writer is a child and adolescent psychiatrist.

    Giving Psychiatric Drugs to Children, NYT, 16.12.2009, http://www.nytimes.com/2009/12/16/opinion/l16drugs.html

Poor Children Likelier to Get Antipsychotics

December 12, 2009
The New York Times
By DUFF WILSON

New federally financed drug research reveals a stark disparity: children covered by Medicaid are given powerful antipsychotic medicines at a rate four times higher than children whose parents have private insurance. And the Medicaid children are more likely to receive the drugs for less severe conditions than their middle-class counterparts, the data shows.

Those findings, by a team from Rutgers and Columbia, are almost certain to add fuel to a long-running debate. Do too many children from poor families receive powerful psychiatric drugs not because they actually need them — but because it is deemed the most efficient and cost-effective way to control problems that may be handled much differently for middle-class children?

The questions go beyond the psychological impact on Medicaid children, serious as that may be. Antipsychotic drugs can also have severe physical side effects, causing drastic weight gain and metabolic changes resulting in lifelong physical problems.

On Tuesday, a pediatric advisory committee to the Food and Drug Administration met to discuss the health risks for all children who take antipsychotics. The panel will consider recommending new label warnings for the drugs, which are now used by an estimated 300,000 people under age 18 in this country, counting both Medicaid patients and those with private insurance.

Meanwhile, a group of Medicaid medical directors from 16 states, under a project they call Too Many, Too Much, Too Young, has been experimenting with ways to reduce prescriptions of antipsychotic drugs among Medicaid children.

They plan to publish a report early next year.

The Rutgers-Columbia study will also be published early next year, in the peer-reviewed journal Health Affairs. But the findings have already been posted on the Web, setting off discussion among experts who treat and study troubled young people.

Some experts say they are stunned by the disparity in prescribing patterns. But others say it reinforces previous indications, and their own experience, that children with diagnoses of mental or emotional problems in low-income families are more likely to be given drugs than receive family counseling or psychotherapy.

Part of the reason is insurance reimbursements, as Medicaid often pays much less for counseling and therapy than private insurers do. Part of it may have to do with the challenges that families in poverty may have in consistently attending counseling or therapy sessions, even when such help is available.

“It’s easier for patients, and it’s easier for docs,” said Dr. Derek H. Suite, a psychiatrist in the Bronx whose pediatric cases include children and adolescents covered by Medicaid and who sometimes prescribes antipsychotics. “But the question is, ‘What are you prescribing it for?’ That’s where it gets a little fuzzy.”

Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors have given antipsychotics that the patients do not seem to need. Recently, for example, he met with a 15-year-old girl. She had stopped taking the antipsychotic medication that had been prescribed for her after a single examination, paid for by Medicaid, at a clinic where she received a diagnosis of bipolar disorder.

Why did she stop? Dr. Suite asked. “I can control my moods,” the girl said softly.

After evaluating her, Dr. Suite decided she was right. The girl had arguments with her mother and stepfather and some insomnia. But she was a good student and certainly not bipolar, in Dr. Suite’s opinion.

“Normal teenager,” Dr. Suite said, nodding. “No scrips for you.”

Because there can be long waits to see the psychiatrists accepting Medicaid, it is often a pediatrician or family doctor who prescribes an antipsychotic to a Medicaid patient — whether because the parent wants it or the doctor believes there are few other options.

Some experts even say Medicaid may provide better care for children than many covered by private insurance because the drugs — which can cost $400 a month — are provided free to patients, and families do not have to worry about the co-payments and other insurance restrictions.

“Maybe Medicaid kids are getting better treatment,” said Dr. Gabrielle Carlson, a child psychiatrist and professor at the Stony Brook School of Medicine. “If it helps keep them in school, maybe it’s not so bad.”

In any case, as Congress works on health care legislation that could expand the nation’s Medicaid rolls by 15 million people — a 43 percent increase — the scope of the antipsychotics problem, and the expense, could grow in coming years.

Even though the drugs are typically cheaper than long-term therapy, they are the single biggest drug expenditure for Medicaid, costing the program $7.9 billion in 2006, the most recent year for which the data is available.

The Rutgers-Columbia research, based on millions of Medicaid and private insurance claims, is the most extensive analysis of its type yet on children’s antipsychotic drug use. It examined records for children in seven big states — including New York, Texas and California — selected to be representative of the nation’s Medicaid population, for the years 2001 and 2004.

The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid fee-for-service programs received antipsychotic drugs, compared with less than 1 percent of privately insured children and adolescents. More recent data through 2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers professor who led the study. Experts generally agree that some characteristics of the Medicaid population may contribute to psychological problems or psychiatric disorders. They include the stresses of poverty, single-parent homes, poorer schools, lack of access to preventive care and the fact that the Medicaid rolls include many adults who are themselves mentally ill.

As a result, studies have found that children in low-income families may have a higher rate of mental health problems — perhaps two to one — compared with children in better-off families. But that still does not explain the four-to-one disparity in prescribing antipsychotics.

Professor Crystal, who is the director of the Center for Pharmacotherapy at Rutgers, says his team’s data also indicates that poorer children are more likely to receive antipsychotics for less serious conditions than would typically prompt a prescription for a middle-class child.

But Professor Crystal said he did not have clear evidence to form an opinion on whether or not children on Medicaid were being overtreated.

“Medicaid kids are subject to a lot of stresses that lead to behavior issues which can be hard to distinguish from more serious psychiatric conditions,” he said. “It’s very hard to pin down.”

And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author of the study, said at least one thing was clear: “A lot of these kids are not getting other mental health services.”

The F.D.A. has approved antipsychotic drugs for children specifically to treat schizophrenia, autism and bipolar disorder. But they are more frequently prescribed to children for other, less extreme conditions, including attention deficit hyperactivity disorder, aggression, persistent defiance or other so-called conduct disorders — especially when the children are covered by Medicaid, the new study shows.

Although doctors may legally prescribe the drugs for these “off label” uses, there have been no long-term studies of their effects when used for such conditions.

The Rutgers-Columbia study found that Medicaid children were more likely than those with private insurance to be given the drugs for off-label uses like A.D.H.D. and conduct disorders. The privately insured children, in turn, were more likely than their Medicaid counterparts to receive the drugs for F.D.A.-approved uses like bipolar disorder.

Even if parents enrolled in Medicaid may be reluctant to put their children on drugs, some come to rely on them as the only thing that helps.

“They say it’s impossible to stop now,” Evelyn Torres, 48, of the Bronx, said of her son’s use of antipsychotics since he received a diagnosis of bipolar disorder at age 3. Seven years later, the boy is now also afflicted with weight and heart problems. But Ms. Torres credits Medicaid for making the boy’s mental and physical conditions manageable. “They’re helping with everything,” she said.

    Poor Children Likelier to Get Antipsychotics, NYT, 12.12.2009, http://www.nytimes.com/2009/12/12/health/12medicaid.html

Mind

Postpartum Depression Strikes Fathers, Too

December 8, 2009
The New York Times
By RICHARD A. FRIEDMAN, M.D.

The pregnancy was easy, the delivery a breeze. This was the couple’s first baby, and they were thrilled. But within two months, the bliss of new parenthood was shattered by postpartum depression.

A sad, familiar story. But this one had a twist: The patient who came to me for treatment was not the mother but her husband.

A few weeks after the baby arrived, he had become uncharacteristically anxious, sad and withdrawn. He had trouble sleeping, even though his wife was the one up at night breast-feeding their new son. What scared her enough to bring him to my office was that he had become suicidal.

Up to 80 percent of women experience minor sadness — the so-called baby blues — after giving birth, and about 10 percent plummet into severe postpartum depression. But it turns out that men can also have postpartum depression, and its effects can be every bit as disruptive — not just on the father but on mother and child.

We don’t know the exact prevalence of male postpartum depression; studies have used different methods and diagnostic criteria. Dr. Paul G. Ramchandani, a psychiatrist at the University of Oxford in England who did a study based on 26,000 parents, reported in The Lancet in 2005 that 4 percent of fathers had clinically significant depressive symptoms within eight weeks of the birth of their children. But one thing is clear: It isn’t something most people, including physicians, have ever heard of.

At first, my patient insisted that everything was just fine. He and his wife had been trying to conceive for more than a year. He was ecstatic at the prospect of fatherhood, and he did not acknowledge feeling depressed or suicidal.

Suspicious of his rosy appraisal, I pushed a little.

It turned out that he had just taken a new high-pressure job in finance six months before the birth of his son. Though he was reluctant to admit it, he clearly had more than a little concern about his family’s financial future.

And he was anxious about his marriage and his new life. “We go out a lot with friends to dinner and theater,” he said wistfully, as I recall. “Now I guess that’s all going to end.”

He had spent the nine months of pregnancy in a state of excitement about being a father without really registering what a life-transforming event it was going to be.

Unlike women, men are not generally brought up to express their emotions or ask for help. This can be especially problematic for new fathers, since the prospect of parenthood carries all kinds of insecurities: What kind of father will I be? Can I support my family? Is this the end of my freedom?

And there is probably more to male postpartum depression than just social or psychological stress; like motherhood, fatherhood has its own biology, and it may actually change the brain.

A 2006 study on marmoset monkeys, published in the journal Nature Reviews Neuroscience, reported that new fathers experienced a rapid increase in receptors for the hormone vasopressin in the brain’s prefrontal cortex. Along with other hormones, vasopressin is involved in parental behavior in animals, and it is known that the same brain area in humans is activated when parents are shown pictures of their children.

There is also some evidence that testosterone levels tend to drop in men during their partner’s pregnancy, perhaps to make expectant fathers less aggressive and more likely to bond with their newborns. Given the known association between depression and low testosterone in middle-aged men, it is possible that this might also put some men at risk of postpartum depression.

By far the strongest predictor of paternal postpartum depression is having a depressed partner. In one study, fathers whose partners were also depressed were at nearly two and a half times the normal risk for depression. That was a critical finding, for clinicians tend to assume that men can easily step up to the plate and help fill in for a depressed mother. In fact, they too may be stressed and vulnerable to depression.

And there is the child to think about. Research has clearly shown that maternal postpartum depression can impair the emotional and cognitive development of infants. A father could well buffer the infant from some of the adverse effects of maternal depression — but that is a tall order if he too is depressed.

Dr. Ramchandani, who also followed children for three and a half years after birth, reported that they were affected differently depending on which parent was depressed. Maternal postpartum depression was associated with adverse emotional and behavioral effects in children regardless of sex; depression in fathers was linked only with behavioral problems in boys. (The study did not report on possible effects when both parents were depressed.)

As for my patient, he recovered within two months with the help of psychotherapy and an antidepressant. Afterward, he summed up the situation in just 10 words: “And I thought only women get this kind of thing.”

All too many doctors think so too.

Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College.

    Postpartum Depression Strikes Fathers, Too, NYT, 7.12.2009, http://www.nytimes.com/2009/12/08/health/08mind.html

Millions in U.S. Drink Dirty Water, Records Show

December 8, 2009
The New York Times
By CHARLES DUHIGG

More than 20 percent of the nation’s water treatment systems have violated key provisions of the Safe Drinking Water Act over the last five years, according to a New York Times analysis of federal data.

That law requires communities to deliver safe tap water to local residents. But since 2004, the water provided to more than 49 million people has contained illegal concentrations of chemicals like arsenic or radioactive substances like uranium, as well as dangerous bacteria often found in sewage.

Regulators were informed of each of those violations as they occurred. But regulatory records show that fewer than 6 percent of the water systems that broke the law were ever fined or punished by state or federal officials, including those at the Environmental Protection Agency, which has ultimate responsibility for enforcing standards.

Studies indicate that drinking water contaminants are linked to millions of instances of illness within the United States each year.

In some instances, drinking water violations were one-time events, and probably posed little risk. But for hundreds of other systems, illegal contamination persisted for years, records show.

On Tuesday, the Senate Environment and Public Works committee will question a high-ranking E.P.A. official about the agency’s enforcement of drinking-water safety laws. The E.P.A. is expected to announce a new policy for how it polices the nation’s 54,700 water systems.

“This administration has made it clear that clean water is a top priority,” said an E.P.A. spokeswoman, Adora Andy, in response to questions regarding the agency’s drinking water enforcement. The E.P.A. administrator, Lisa P. Jackson, this year announced a wide-ranging overhaul of enforcement of the Clean Water Act, which regulates pollution into waterways.

“The previous eight years provide a perfect example of what happens when political leadership fails to act to protect our health and the environment,” Ms. Andy added.

Water pollution has become a growing concern for some lawmakers as government oversight of polluters has waned. Senator Barbara Boxer, Democrat of California, in 2007 asked the E.P.A. for data on Americans’ exposure to some contaminants in drinking water.

The New York Times has compiled and analyzed millions of records from water systems and regulators around the nation, as part of a series of articles about worsening pollution in American waters, and regulators’ response.

An analysis of E.P.A. data shows that Safe Drinking Water Act violations have occurred in parts of every state. In the prosperous town of Ramsey, N.J., for instance, drinking water tests since 2004 have detected illegal concentrations of arsenic, a carcinogen, and the dry cleaning solvent tetrachloroethylene, which has also been linked to cancer.

In New York state, 205 water systems have broken the law by delivering tap water that contained illegal amounts of bacteria since 2004.

However, almost none of those systems were ever punished. Ramsey was not fined for its water violations, for example, though a Ramsey official said that filtration systems have been installed since then. In New York, only three water systems were penalized for bacteria violations, according to federal data.

The problem, say current and former government officials, is that enforcing the Safe Drinking Water Act has not been a federal priority.

“There is significant reluctance within the E.P.A. and Justice Department to bring actions against municipalities, because there’s a view that they are often cash-strapped, and fines would ultimately be paid by local taxpayers,” said David Uhlmann, who headed the environmental crimes division at the Justice Department until 2007.

“But some systems won’t come into compliance unless they are forced to,” added Mr. Uhlmann, who now teaches at the University of Michigan law school. “And sometimes a court order is the only way to get local governments to spend what is needed.”

A half-dozen current and former E.P.A. officials said in interviews that they tried to prod the agency to enforce the drinking-water law, but found little support.

“I proposed drinking water cases, but they got shut down so fast that I’ve pretty much stopped even looking at the violations,” said one longtime E.P.A. enforcement official who, like others, requested anonymity for fear of reprisals. “The top people want big headlines and million-dollar settlements. That’s not drinking-water cases.”

The majority of drinking water violations since 2004 have occurred at water systems serving fewer than 20,000 residents, where resources and managerial expertise are often in short supply.

It is unclear precisely how many American illnesses are linked to contaminated drinking water. Many of the most dangerous contaminants regulated by the Safe Drinking Water Act have been tied to diseases like cancer that can take years to develop.

But scientific research indicates that as many as 19 million Americans may become ill each year due to just the parasites, viruses and bacteria in drinking water. Certain types of cancer — such as breast and prostate cancer — have risen over the past 30 years, and research indicates they are likely tied to pollutants like those found in drinking water.

The violations counted by the Times analysis include only situations where residents were exposed to dangerous contaminants, and exclude violations that involved paperwork or other minor problems.

In response to inquiries submitted by Senator Boxer, the E.P.A. has reported that more than three million Americans have been exposed since 2005 to drinking water with illegal concentrations of arsenic and radioactive elements, both of which have been linked to cancer at small doses.

In some areas, the amount of radium detected in drinking water was 2,000 percent higher than the legal limit, according to E.P.A. data.

But federal regulators fined or punished fewer than 8 percent of water systems that violated the arsenic and radioactive standards. The E.P.A., in a statement, said that in a majority of situations, state regulators used informal methods — like providing technical assistance — to help systems that had violated the rules.

But many systems remained out of compliance, even after aid was offered, according to E.P.A. data. And for over a quarter of systems that violated the arsenic or radioactivity standards, there is no record that they were ever contacted by a regulator, even after they sent in paperwork revealing their violations.

Those figures are particularly worrisome, say researchers, because the Safe Drinking Water Act’s limits on arsenic are so weak to begin with. A system could deliver tap water that puts residents at a 1-in-600 risk of developing bladder cancer from arsenic, and still comply with the law.

Despite the expected announcement of reforms, some mid-level E.P.A. regulators say they are skeptical that any change will occur.

“The same people who told us to ignore Safe Drinking Water Act violations are still running the divisions,” said one mid-level E.P.A. official. “There’s no accountability, and so nothing’s going to change.”

 

Griffin Palmer contributed reporting.

    Millions in U.S. Drink Dirty Water, Records Show, NYT, 8.12.2009, http://www.nytimes.com/2009/12/08/business/energy-environment/08water.html

Battle on Late-Term Abortions Shifts to a Clinic in Nebraska

December 4, 2009
The New York Times
By MONICA DAVEY

BELLEVUE, Neb. — The national battle over abortion, for decades firmly planted outside the Kansas clinic of Dr. George R. Tiller, has erupted here in suburban Omaha, where a longtime colleague has taken up the cause of late-term abortions.

Since Dr. Tiller was shot to death in May, his colleague, Dr. LeRoy H. Carhart, has hired two people who worked at Dr. Tiller’s clinic and has trained his own staff members in the technical intricacies of performing late-term abortions.

Dr. Carhart has also begun performing some abortions “past 24 weeks,” he said in an interview, and is prepared to perform them still later if they meet legal requirements and if he considers them medically necessary.

“There is a need, and I feel deeply about it,” said Dr. Carhart, visibly weary after a day when eight patients had appointments at his clinic here.

The late-term abortions, coming after the earliest point when a fetus might survive outside the womb, are the most controversial, even among some who favor abortion rights. A few of Dr. Carhart’s employees quit when he told them of his plans to expand the clinic’s work.

Opponents of abortion, who had devoted decades to trying to stop Dr. Tiller’s business with protests and calls for investigations, are now turning their efforts to stopping Dr. Carhart. Troy Newman, the president of Operation Rescue, an anti-abortion group, said he had traveled from the group’s headquarters in Wichita, Kan., to Nebraska six times in recent months, portraying this suburb of fewer than 50,000 as a new battlefield in the abortion fight.

“We’re trying to get criminal charges against him, to get his license revoked, and to get legislators there to look at the law,” Mr. Newman said of Dr. Carhart.

State law in Nebraska bans abortions in cases when a fetus clearly appears to have reached viability, except to “preserve the life or health of the mother.”

Abortion-rights advocates say the need exists for late-term abortions, in cases of extraordinary genetic defects and other dire health circumstances, and some had worried that only a few physicians would be willing to provide such care after Dr. Tiller’s killing, an act prosecutors say was carried out by an abortion foe.

“He’s standing up, and so are some others,” Vicki Saporta, president of the National Abortion Federation, said of Dr. Carhart.

A few other doctors have long performed late-term abortions, and some said both the threats against them and their efforts at security had increased since Dr. Tiller’s death.

Dr. Carhart, 68, knew Dr. Tiller for years, and would make regular trips to his clinic in Wichita to perform abortions there, as other physicians did. Though Dr. Tiller’s clinic was not the only one in the country performing late-term abortions, it was a focal point for controversy. Operation Rescue even moved its headquarters to Wichita because of Dr. Tiller’s practice.

Dr. Carhart, who has been performing abortions since the 1970s, is no stranger to the debate; he has been a litigant in two abortion-related cases decided by the United States Supreme Courtover a particular method of abortion referred to by critics as “partial-birth abortion.” And immediately after Dr. Tiller’s killing, Dr. Carhart offered to continue operating his clinic, but the Tiller family decided to close it.

Still, in the months since the killing, Dr. Carhart has made changes at his clinic and to his lifestyle as he has openly moved to take up Dr. Tiller’s cause.

Visitors to the clinic here must pass through a metal detector, new security cameras scan outside the building and a security consultant is employed full time. Dr. Carhart says he goes out publicly only on short, unscheduled trips and rarely eats out (and when he does, he says he stays less than 30 minutes). Dr. Carhart, an Air Force veteran, said his daughter was wed this fall on a nearby military base, mainly for security and privacy.

“We do everything differently now,” he said.

Dr. Carhart declined to provide specifics on how late in a pregnancy he would be willing to perform an abortion. Dr. Tiller performed them, in some cases, as late as in the third trimester of pregnancy. Dr. Carhart’s fee schedule lists prices for abortions up to 22 weeks and 6 days (at that point, $2,100 in cash or $2,163 on a credit card), but notes that abortions after 23 weeks are available “after consultation with our doctor,” and that abortions after the 27th week may take four days.

At his clinic in the past, Dr. Carhart said, he had performed abortions up to about 22 weeks into gestation — considered by some to be near the earliest point at which a fetus can survive outside the womb, a notion known as viability and one that is cited in many laws related to abortion.

Dr. Carhart’s opponents insist that late-term procedures violate state and federal statutes as well as professional rules. They have approached officials in Nebraska seeking an investigation. Mr. Newman, who had regularly called for investigations into Dr. Tiller’s work but strongly denounced his killing, has submitted a complaintabout Dr. Carhart to Jon Bruning, Nebraska’s attorney general. In it, Mr. Newman accuses Dr. Carhart of using improper operating procedures under shoddy conditions.

Representatives of Mr. Bruning would not comment on whether an investigation was taking place. Marla Augustine, a spokeswoman for the State Department of Health and Human Services, which regulates physicians, said Dr. Carhart had no formal disciplinary actions on his record.

(In 1993, she said, he signed an assurance of compliance with the state, promising not to do certain things, like talk on the phone during surgical procedures, but the agreement says it did not mean he had admitted committing any violations and was not considered a disciplinary action.)

Dr. Carhart, meanwhile, said he had heard nothing lately from state officials. “Anybody can file a claim,” he said.

A brochure for his clinic shows a photograph of Dr. Carhart beside Dr. Tiller, and says that the clinic dedicates “our services to women in honor of” Dr. Tiller. Asked whether he feared a similar fate as Dr. Tiller’s, Dr. Carhart said he had signed up for this life.

“They have never targeted me more,” he said of abortion opponents. “But to me, the most dangerous response would be for me to stop what I am doing. The thought that killing Tiller might also succeed in closing another clinic — that’s my main reason for keeping open.”

    Battle on Late-Term Abortions Shifts to a Clinic in Nebraska, NYT, 4.12.2009, http://www.nytimes.com/2009/12/04/us/04abortion.html

Editorial

The Swine Flu, as of Now

December 1, 2009
The New York Times

So far, the news about swine flu is better than expected. The pandemic may have reached its peak and is heading downward in all regions of the country; weekly deaths from swine flu have started to decline; the virus remains relatively mild; there seem to be few claims of serious side effects from the vaccine; and despite widespread complaints about shortages, vaccine supplies are steadily building up.

By mid-October, the latest estimates available, the swine flu had infected some 22 million Americans, sent roughly 98,000 to the hospital and killed roughly 3,900. Those numbers may sound high, but they are not apt to reach the levels of harm caused by a normal flu season. One big unknown is whether we will see a normal flu epidemic on top of the swine flu outbreaks or whether the swine flu will crowd out the seasonal flu, which has barely been detected here.

Supplies of seasonal flu vaccine have also been running short. The five companies licensed to make flu shots for this country had expected to make more than 118 million doses, but manufacturing glitches and the need to convert production to swine flu vaccine cut the supply of seasonal flu vaccine to 114 million doses. Even 118 million would not have been enough to meet demand that was revved up this year by all the publicity surrounding the new swine flu. (The vaccines are not interchangeable.)

Even as the swine flu seemed to be waning last week, health officials voiced concerns that Thanksgiving travels and get-togethers could lead to new outbreaks. And there were a few hints of troubling developments.

Some swine flu patients have developed serious bacterial infections in their lungs, including pneumococcal infections that invade the blood and other internal sites. The victims are mostly those with underlying chronic health problems like asthma, diabetes, heart disease and other longstanding ailments. There is a vaccine that can protect them from 23 strains of pneumococcal infection, and health officials are urging adults with chronic conditions to get it from their doctors now.

There have also been scattered reports of mutations in the swine flu virus that cause harm deep in the lungs of some patients or make the virus resistant to one of the standard drug treatments. However, neither mutation seems to be spreading widely.

This is no time for Americans to let down their guard. The number of children and teenagers killed by the flu continues to rise. Even if it is past its peak, the swine flu will go on to infect many millions more before it disappears. And if the swine flu follows the pattern of some previous pandemic strains, it could return in a new wave early next year.

As of last Wednesday, some 61 million doses of the swine flu vaccine had been used or were available to order, far less than needed to vaccinate the original target groups of 159 million Americans. As vaccine supplies build up, those who are at highest risk or could endanger others at high risk — pregnant women, people caring for infants less than 6 months old, health care workers with direct patient contact, children 6 months through 4 years old, and children 5 through 18 with chronic medical problems — would be wise to get immunized. So would others deemed at some risk, like young adults and older adults with medical problems.

The Swine Flu, as of Now, NYT, 1.12.2009, http://www.nytimes.com/2009/12/01/opinion/01Tue1.html