History > 2011 > USA > Health (I)

Steve Greenberg

The Ventura County Star

CA

Cagle

6 January 2011

Elephant = Republicans

20% Rise Seen

in Number of Survivors of Cancer

March 10, 2011
The New York Times
By PAM BELLUCK

About one in every 20 adults in the United States has survived cancer, including nearly one-fifth of all people over 65, according to new federal data.

The numbers, released Thursday by the Centers for Disease Control and Prevention and the National Cancer Institute, indicated that the number of cancer survivors increased by about 20 percent in just six years, to 11.7 million in 2007, the latest year for which figures were analyzed, from 9.8 million in 2001. In 1971, the number of cancer survivors was three million.

“There’s still a concept that cancer is a death sentence,” said Dr. Thomas R. Frieden, director of the Centers for Disease Control. But, he said, “for many people with cancer there’s a need for them and their families and caregivers to recognize that this is a stage. They can live a long and healthy life.”

About 65 percent of cancer survivors have lived at least five years since receiving their diagnosis, 40 percent have lived 10 years or more, and nearly 10 percent have lived 25 years or longer.

The implications, Dr. Frieden said, are that many cancers are treatable and that it is just as important for people who have had cancer not to assume that they will necessarily die early.

“You might think, ‘I’ve had cancer — I don’t have to worry about eating right, quitting smoking, exercising,’ ” Dr. Frieden said. But people with cancer “need to be just as concerned about heart disease and other risks as they would otherwise,” he said.

The study defined a survivor as anyone who ever received a diagnosis of cancer who was alive on Jan. 1, 2007, and it did not indicate if the person was cured, undergoing treatment, afflicted with a chronic cancer-related illness, or in the process of dying at that time.

And the numbers tell only a piece of the cancer story. Some cancers, like lung cancer, are aggressive and difficult to treat. And the death rate from cancer, an indicator that many health experts consider a more accurate measure of progress in fighting the disease, has stayed virtually the same as it was in 1950 — about 200 deaths per 100,000 people a year, and about 1,000 deaths annually per 100,000 people over 65.

Dr. Frieden said the increase in cancer survivors was due to several factors, some of which varied by type of cancer. In some cases of breast cancer and colon cancer, for example, improved treatment and increased follow-up after treatment have helped increase survival. In others, like prostate cancer, an explosion in screening has identified many men with the disease, but the cancer is often so slow-growing that they would be unlikely to die from it. And other cancer diagnoses are simply the consequence of the country’s aging population and improved care for other diseases — in other words, people are living long enough to develop cancer.

About a million more of the survivors were women than men, partly because women live longer than men, and partly because breast and cervical cancers are often diagnosed and treated at younger ages. About 22 percent of the survivors had breast cancer, about 19 percent had prostate cancer, and about 10 percent had colorectal cancer.

The study identified only the type of cancer first diagnosed in each person; additional tumors or cancer diagnoses were not recorded.

Health authorities urged families and physicians to be aware of the health needs of cancer survivors.

“Having cancer may be the first stage, really, in the rest of your life,” Dr. Frieden said. “We need to continue to scale up” the services available for cancer survivors.

    20% Rise Seen in Number of Survivors of Cancer, NYT, 10.3.2011, http://www.nytimes.com/2011/03/11/health/11cancer.html

Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy

March 5, 2011
The New York Times
By GARDINER HARRIS

DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.

Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.

Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.”

With thinning hair, a gray beard and rimless glasses, Dr. Levin looks every bit the psychiatrist pictured for decades in New Yorker cartoons. His office, just above Dog Daze Canine Hair Designs in this suburb of Philadelphia, has matching leather chairs, and African masks and a moose head on the wall. But there is no couch or daybed; Dr. Levin has neither the time nor the space for patients to lie down anymore.

On a recent day, a 50-year-old man visited Dr. Levin to get his prescriptions renewed, an encounter that took about 12 minutes.

Two years ago, the man developed rheumatoid arthritis and became severely depressed. His family doctor prescribed an antidepressant, to no effect. He went on medical leave from his job at an insurance company, withdrew to his basement and rarely ventured out.

“I became like a bear hibernating,” he said.

Missing the Intrigue

He looked for a psychiatrist who would provide talk therapy, write prescriptions if needed and accept his insurance. He found none. He settled on Dr. Levin, who persuaded him to get talk therapy from a psychologist and spent months adjusting a mix of medications that now includes different antidepressants and an antipsychotic. The man eventually returned to work and now goes out to movies and friends’ houses.

The man’s recovery has been gratifying for Dr. Levin, but the brevity of his appointments — like those of all of his patients — leaves him unfulfilled.

“I miss the mystery and intrigue of psychotherapy,” he said. “Now I feel like a good Volkswagen mechanic.”

“I’m good at it,” Dr. Levin went on, “but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate. A 2005 government survey found that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Recent studies suggest that talk therapy may be as good as or better than drugs in the treatment of depression, but fewer than half of depressed patients now get such therapy compared with the vast majority 20 years ago. Insurance company reimbursement rates and policies that discourage talk therapy are part of the reason. A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.

Competition from psychologists and social workers — who unlike psychiatrists do not attend medical school, so they can often afford to charge less — is the reason that talk therapy is priced at a lower rate. There is no evidence that psychiatrists provide higher quality talk therapy than psychologists or social workers.

Of course, there are thousands of psychiatrists who still offer talk therapy to all their patients, but they care mostly for the worried wealthy who pay in cash. In New York City, for instance, a select group of psychiatrists charge $600 or more per hour to treat investment bankers, and top child psychiatrists charge $2,000 and more for initial evaluations.

When he started in psychiatry, Dr. Levin kept his own schedule in a spiral notebook and paid college students to spend four hours a month sending out bills. But in 1985, he started a series of jobs in hospitals and did not return to full-time private practice until 2000, when he and more than a dozen other psychiatrists with whom he had worked were shocked to learn that insurers would no longer pay what they had planned to charge for talk therapy.

“At first, all of us held steadfast, saying we spent years learning the craft of psychotherapy and weren’t relinquishing it because of parsimonious policies by managed care,” Dr. Levin said. “But one by one, we accepted that that craft was no longer economically viable. Most of us had kids in college. And to have your income reduced that dramatically was a shock to all of us. It took me at least five years to emotionally accept that I was never going back to doing what I did before and what I loved.”

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group. To maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin’s office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

“Medication is important,” she said, “but it’s the relationship that gets people better.”

Dr. Levin’s initial efforts to get insurers to reimburse him and persuade his clients to make their co-payments were less than successful. His office assistants were so sympathetic to his tearful patients that they often failed to collect. So in 2004, he begged his wife, Laura Levin — a licensed talk therapist herself, as a social worker — to take over the business end of the practice.

Ms. Levin created accounting systems, bought two powerful computers, licensed a computer scheduling program from a nearby hospital and hired independent contractors to haggle with insurers and call patients to remind them of appointments. She imposed a variety of fees on patients: $50 for a missed appointment, $25 for a faxed prescription refill and $10 extra for a missed co-payment.

As soon as a patient arrives, Ms. Levin asks firmly for a co-payment, which can be as much as $50. She schedules follow-up appointments without asking for preferred times or dates because she does not want to spend precious minutes as patients search their calendars. If patients say they cannot make the appointments she scheduled, Ms. Levin changes them.

“This is about volume,” she said, “and if we spend two minutes extra or five minutes extra with every one of 40 patients a day, that means we’re here two hours longer every day. And we just can’t do it.”

She said that she would like to be more giving of herself, particularly to patients who are clearly troubled. But she has disciplined herself to confine her interactions to the business at hand. “The reality is that I’m not the therapist anymore,” she said, words that echoed her husband’s.

Drawing the Line

Ms. Levin, 63, maintains a lengthy waiting list, and many of the requests are heartbreaking. On a January day, a pregnant mother of a 3-year-old called to say that her husband was so depressed he could not rouse himself from bed. Could he have an immediate appointment? Dr. Levin’s first opening was a month away.

“I get a call like that every day, and I find it really distressing,” Ms. Levin said. “But do we work 12 hours every day instead of 11? At some point, you have to make a choice.”

Initial consultations are 45 minutes, while second and later visits are 15. In those first 45 minutes, Dr. Levin takes extensive medical, psychiatric and family histories. He was trained to allow patients to tell their stories in their own unhurried way with few interruptions, but now he asks a rapid-fire series of questions in something akin to a directed interview. Even so, patients sometimes fail to tell him their most important symptoms until the end of the allotted time.

“There was a guy who came in today, a 56-year-old man with a series of business failures who thinks he has A.D.D.,” or attention deficit disorder, Dr. Levin said. “So I go through the whole thing and ask a series of questions about A.D.D., and it’s not until the very end when he says, ‘On Oct. 28, I thought life was so bad, I was thinking about killing myself.’ ”

With that, Dr. Levin began to consider an entirely different diagnosis from the man’s pattern of symptoms: excessive worry, irritability, difficulty falling asleep, muscle tension in his back and shoulders, persistent financial woes, the early death of his father, the disorganization of his mother.

“The thread that runs throughout this guy’s life is anxiety, not A.D.D. — although anxiety can impair concentration,” said Dr. Levin, who prescribed an antidepressant that he hoped would moderate the man’s anxiety. And he pressed the patient to see a therapist, advice patients frequently ignore. The visit took 55 minutes, putting Dr. Levin behind schedule.

In 15-minute consultations, Dr. Levin asks for quick updates on sleep, mood, energy, concentration, appetite, irritability and problems like sexual dysfunction that can result from psychotropic medications.

“And people want to tell me about what’s going on in their lives as far as stress,” Dr. Levin said, “and I’m forced to keep saying: ‘I’m not your therapist. I’m not here to help you figure out how to get along with your boss, what you do that’s self-defeating, and what alternative choices you have.’ ”

Dr. Levin, wearing no-iron khakis, a button-down blue shirt with no tie, blue blazer and loafers, had a cheery greeting for his morning patients before ushering them into his office. Emerging 15 minutes later after each session, he would walk into Ms. Levin’s adjoining office to pick up the next chart, announce the name of the patient in the waiting room and usher that person into his office.

He paused at noon to spend 15 minutes eating an Asian chicken salad with Ramen noodles. He got halfway through the salad when an urgent call from a patient made him put down his fork, one of about 20 such calls he gets every day.

By afternoon, he had dispensed with the cheery greetings. At 6 p.m., his waiting room empty, Dr. Levin heaved a sigh after emerging from his office with his 39th patient. Then the bell on his entry door tinkled again, and another patient came up the stairs.

“Oh, I thought I was done,” Dr. Levin said, disappointed. Ms. Levin handed him the last patient’s chart.

Quick Decisions

The Levins said they did not know how long they could work 11-hour days. “And if the stock market hadn’t gone down two years ago, we probably wouldn’t be working this hard now,” Ms. Levin said.

Dr. Levin said that the quality of treatment he offers was poorer than when he was younger. For instance, he was trained to adopt an unhurried analytic calm during treatment sessions. “But my office is like a bus station now,” he said. “How can I have an analytic calm?”

And years ago, he often saw patients 10 or more times before arriving at a diagnosis. Now, he makes that decision in the first 45-minute visit. “You have to have a diagnosis to get paid,” he said with a shrug. “I play the game.”

In interviews, six of Dr. Levin’s patients — their identities, like those of the other patients, are being withheld to protect their privacy — said they liked him despite the brief visits. “I don’t need a half-hour or an hour to talk,” said a stone mason who has panic attacks and depression and is prescribed an antidepressant. “Just give me some medication, and that’s it. I’m O.K.”

Another patient, a licensed therapist who has post-partum depression worsened by several miscarriages, said she sees Dr. Levin every four weeks, which is as often as her insurer will pay for the visits. Dr. Levin has prescribed antidepressants as well as drugs to combat anxiety. She also sees a therapist, “and it’s really, really been helping me, especially with my anxiety,” she said.

She said she likes Dr. Levin and feels that he listens to her.

Dr. Levin expressed some astonishment that his patients admire him as much as they do.

“The sad thing is that I’m very important to them, but I barely know them,” he said. “I feel shame about that, but that’s probably because I was trained in a different era.”

The Levins’s youngest son, Matthew, is now training to be a psychiatrist, and Dr. Donald Levin said he hoped that his son would not feel his ambivalence about their profession since he will not have experienced an era when psychiatrists lavished time on every patient. Before the 1920s, many psychiatrists were stuck in asylums treating confined patients covered in filth, so most of the 20th century was unusually good for the profession.

In a telephone interview from the University of California, Irvine, where he is completing the last of his training to become a child and adolescent psychiatrist, Dr. Matthew Levin said, “I’m concerned that I may be put in a position where I’d be forced to sacrifice patient care to make a living, and I’m hoping to avoid that.”

    Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy, NYT, 5.3.2011, http://www.nytimes.com/2011/03/06/health/policy/06doctors.html

Edwin Kilbourne, Flu Vaccine Expert, Dies at 90

February 24, 2011
The New York Times
By DOUGLAS MARTIN

Dr. Edwin D. Kilbourne, a medical researcher who figured out how to outwit fast-evolving flu germs, developing a new vaccine each year by intermingling genes of different disease strains, died Monday in Branford, Conn. He was 90.

His family announced the death. He lived in Madison, Conn.

For all his prestigious discoveries, awards and positions, Dr. Kilbourne had his greatest visibility during the swine flu epidemic of 1976. When a soldier died at Fort Dix, N.J., after being infected by a particularly virulent flu virus, Dr. Kilbourne wrote an Op-Ed article in The New York Times warning of a worldwide flu pandemic, and personally led in developing a vaccine to meet its challenge.

President Gerald R. Ford ordered 200 million doses of the vaccine to be administered to that many Americans. Dr. Kilbourne was a principal adviser to the president on the program. But even as the disease seemed to subside on its own, several hundred people who received shots contracted a kind of paralysis. Some died.

Time magazine asserted that “election-year fever” had prompted the president to move quickly, while The Times called Mr. Ford’s scientific advisers “panicmongers.” The program was stopped after 43 million vaccinations.

A causative connection between the vaccinations and the paralytic syndrome was never proved. And Dr. Kilbourne remained convinced that the mass vaccinations were the right policy, pointing out that the virus that killed the soldier bore a sinister resemblance to the pandemic of 1918-19, which infected two billion people around the world and killed 20 million to 40 million. He also warned that the disease could be hibernating, which he had proved it could do.

“Better a vaccine without an epidemic than an epidemic without a vaccine,” he said years later. He called the episode “my 15 minutes of infamy.”

Although Dr. Kilbourne never stopped believing that Mr. Ford’s aggressive actions were warranted, only 230 cases of flu were diagnosed at Fort Dix, and none elsewhere.

Of the 43 million who got flu shots, 535 came down with the paralytic syndrome known as Guillain-Barré; 23 of them died.

Dr. Kilbourne’s early research examined links between hormones and viruses, but it was his work on the flu that earned him global note as early as the mid-1950s. His goal was to find weapons to combat the flu virus comparable to the way penicillin fights bacterial infections.

He was up against one of the most fickle, enigmatic, persistent microbes to attack man or beast. These microbes are capable of changing their surface characteristics to elude barriers the body has erected against them. Dr. Kilbourne’s solution was to mix, or “recombine,” the genes of different strains of the virus to “persuade” the body to come up with new defenses.

“This accomplishment represents the first deliberate genetic engineering of any vaccine,” the New York Academy of Medicine said in presenting Dr. Kilbourne with its highest award in 1983. For years after, he created annual versions of flu vaccine targeted at emerging viruses.

In 1973, Dr. Kilbourne proposed that worldwide epidemics might be terrestrial “Andromeda strains” coming to man from the barnyard and then retreating to await the next great outbreak. “The Andromeda Strain” in Michael Crichton’s novel of that name is an organism from outer space that Earth is not prepared to handle.

In delivering the R. E. Dyer lecture to the National Institutes of Health in 1973, Dr. Kilbourne suggested that two conditions must be met for a new viral strain to go from swine or other animals to man. One was the random recombination of a virus, making it infectious to man. The other was an ecological niche for the virus in a human population unprepared to fight back.

“If my hypothesis is correct,” he said, “the pandemic viruses of tomorrow and of remote yesterdays may already exist in our domestic animals today.”

Edwin Dennis Kilbourne was born on July 10, 1920, in Buffalo. He graduated from Cornell University in 1942 and Cornell Medical College in 1944. For the next two years he served in the Army, where he became intrigued with influenza while treating soldiers.

He next worked as a researcher at the Rockefeller Institute before working at four medical schools: Tulane, Cornell, Mount Sinai (as chairman of the microbiology department) and New York Medical College.

Dr. Kilbourne is survived by his wife of 58 years, the former Joy Schmid; his sister, Sylvia Hosie; his half-sister, Lynn Norton; his sons, Edwin, Richard, Christopher and Paul; and eight grandchildren.

Over the desk in Dr. Kilbourne’s laboratory, the most prominent award, obscuring honors like his membership in the National Academy of Sciences, was a plaque honoring his contribution to his team’s 1988-89 victory in a men’s bowling league in Ho-Ho-Kus, N.J.

He was also a published poet, devoted to extolling the bizarre mating habits of animals like hairy-legged fruit flies. A paean to the bighorn ram illustrates:

His wooly wooing is neither smooth nor is it unctuous,

And therefore can be fairly termed rambunctious.

    Edwin Kilbourne, Flu Vaccine Expert, Dies at 90, NYT, 24.2.2011, http://www.nytimes.com/2011/02/25/us/politics/25kilbourne.html

A Bush Rule on Providers of Abortions Is Revised

February 18, 2011
The New York Times
By ROBERT PEAR

WASHINGTON — The Obama administration on Friday rescinded most of a 2008 rule that granted sweeping protections to health care providers who opposed abortion, sterilization and other medical procedures on religious or moral grounds.

Kathleen Sebelius, the secretary of health and human services, said the rule, issued in the last days of the Bush administration, could “negatively impact patient access to contraception and certain other medical services.”

Federal laws make clear that health care providers cannot be compelled to perform or assist in an abortion, Ms. Sebelius said. The Bush rule went far beyond these laws and upset the balance between patients’ rights to obtain health care and “the conscience rights of health care providers,” she added.

The Obama administration retained and updated part of the 2008 rule that established procedures to investigate complaints from health care workers who believe they have been subjected to discrimination or coercion because of their “religious beliefs or moral convictions.”

Although the Bush rule is still on the books, the Obama administration has not enforced it. Eight states and several organizations filed a lawsuit in Federal District Court in Connecticut challenging the 2008 rule as vague and overly broad. The court suspended proceedings in the case, pending issuance of the rule published Friday.

The Roman Catholic Church and some Republicans, like Representative Joe Pitts of Pennsylvania, criticized the Obama administration’s decision to revoke the Bush rule. But advocates for abortion rights welcomed it.

“The administration’s action today is cause for disappointment,” said Deirdre A. McQuade, a spokeswoman for the Pro-Life Secretariat at the United States Conference of Catholic Bishops.

Senator Richard Blumenthal, Democrat of Connecticut, said: “I applaud the Obama administration for ensuring that women will have access to the information and services they need while still protecting the conscience rights of health care providers. The Bush rule clearly went too far and threatened the health and well-being of millions of patients.”

The 2008 rule provoked a torrent of criticism from doctors, pharmacists, hospitals and state officials. Pharmacies said the rule would allow their employees to refuse to fill prescriptions for contraceptives. State officials said the rule could void state laws that require insurance plans to cover contraceptives and require hospitals to offer emergency contraception to rape victims.

Clare M. Coleman, president of the National Family Planning and Reproductive Health Association, which represents hundreds of family planning clinics, said President Obama was rescinding “the most harmful elements” of the Bush rule.

The Obama administration said the 2008 rule might have mistakenly suggested that health care providers could refuse to treat entire groups of people on account of the providers’ religious or moral beliefs.

Federal laws provide no protection for such refusals, the administration said.

The bishops conference and the Catholic Health Association, representing Catholic hospitals, had supported the Bush rule as a way to protect health care providers against pressure to perform abortions.

Sister Carol Keehan, president of the Catholic Health Association, said that in recent years “we have seen a variety of efforts to force Catholic and other health care providers to perform or refer for abortions and sterilizations.”

In response to such concerns, the Obama administration said, “Roman Catholic hospitals will have the same statutory protections afforded to them for decades” because the laws were not affected by the cancellation of the Bush rule.

    A Bush Rule on Providers of Abortions Is Revised, NYT, 18.2.2011, http://www.nytimes.com/2011/02/19/health/policy/19health.html

Clearing the Fog in Nursing Homes

February 15, 2011
11:10 am
The New York Times
By PAULA SPAN

The woman, who was in her 90s, had lived for several years at the Ecumen Sunrise nursing home in Two Harbors, Minn., where the staff had grown accustomed to her grimaces and wordless cries. She took a potent cocktail of three psychotropic drugs: Ativan for anxiety and the antipsychotic Risperdal to calm her, plus an antidepressant. In all the time she’d lived at Sunrise, she hadn’t spoken. It wasn’t clear whether she could recognize her children when they came to visit.

Belinda Day Saylor Eva Lanigan, right, director of nursing at the Ecumen nursing home in Two Harbors, Minn., with a resident, Marjorie Labrie, 94.The Two Harbors home happened to be where Ecumen, which operates 16 nonprofit Minnesota nursing homes, was preparing an experiment to see if behavioral rather than pharmacological approaches could help wean residents off antipsychotic medications. They called it the Awakenings program.

“What’s people’s biggest fear? Being a ‘zombie’ in a nursing home,” said Laurel Baxter, the Awakenings project manager.

Any visitor can see what she means. Even in quality nursing homes, some residents sit impassively in wheelchairs or nod off in front of televisions, apparently unable to interact with others or to summon much interest in their lives. Nursing home reformers and regulators have long believed that this disengagement results in part from the overuse of psychotropic medication to quell the troublesome behaviors that can accompany dementia — yelling, wandering, aggression, resisting care. For nearly 25 years, federal law has required that psychotropic drugs (which critics call “chemical restraints”) be used only when necessary to ensure the safety of a resident or those around her.


The drugs can cause serious side effects. Since 2008, the Food and Drug Administration has required a so-called black box warnings on their packaging, cautioning that they pose an increased mortality risk for elderly patients. Nevertheless, a national survey reported that in 2004 about a quarter of nursing home residents were receiving antipsychotic drugs. (Among the antipsychotic drugs most commonly used in nursing homes are Risperdal, Seroquel and Zyprexa.)

Though they may be prescribed less frequently following the F.D.A.’s warnings, these drugs are still overused in long-term care, said Dr. Mark Lachs, chief of geriatrics at Weill Cornell Medical College. And once the pills are prescribed, residents keep taking them. “They get perpetualized, like insulin,” he told me, even though the behaviors they’re meant to soothe may wane anyway as dementia progresses.

“If a place is understaffed, if it takes particularly unruly patients, you can see how it happens,” Dr. Lachs added. “Behavioral interventions are far more time-consuming than giving a pill.”

Nevertheless, Ecumen’s Awakenings project emphasizes nondrug responses. “Medications have a place, but that shouldn’t be the first thing you try,” said Eva Lanigan, director of nursing at the Two Harbors facility.

So the home trained its entire staff (housekeepers, cooks, dining room servers, everyone) in a variety of tools to calm and reassure its 55 residents: exercise, activities, music, massage, aromatherapy. It taught people the kind of conversation known as “redirecting” — listening to elders and responding to them without insisting on facts that those with dementia can’t absorb or won’t recall.

“The hands-on, caring part is the most important,” Ms. Lanigan said. “Sometimes, people just want a hug. You sit and hold their hand.”

At the same time, consulting with a geriatric psychiatrist and a pharmacist, the home began gradually reducing the doses of antipsychotics and antidepressants for patients whose families agreed. Among them: the woman with the mysterious cries.

As Dr. Lachs pointed out, behavioral interventions are labor-intensive. Two Harbors hired an additional nurse to oversee those efforts, and Ms. Lanigan was available to answer staff questions around the clock. Ecumen estimates that introducing the program to a 60-bed nursing home cost an additional $75,000 a year for two full-time employees.

The results startled even the believers, however. Every resident on antipsychotics (about 10) was able to stop taking them, and 30 to 50 percent of those taking antidepressants also did well without them. When drugs still seemed necessary, “we tried to reduce them to the lowest dose possible,” Ms. Lanigan said.

Encouraged, Ecumen has introduced the Awakenings program to its 15 other nursing homes, using a $3.8 million, three-year grant from the state of Minnesota. “I believe we may learn that spending a little time now with a resident, preventing the use of psychiatric medications and their side effects, you’ll save time and money in the long run,” said Ms. Baxter, the project manager. “I’m optimistic.”

Of course, you can’t tell how well nondrug approaches work based on one facility’s outcomes. “We know how to reduce behavior problems and mood issues in controlled clinical trials,” said Kimberly Van Haitsma, a senior research scientist at the Polisher Research Institute in Philadelphia. “The actual nuts and bolts of how do you do this and keep it in place — over not weeks or months, but years — is a question the field is struggling with.” Turnover among both staff and residents is high in nursing homes, she pointed out.

But with reduced medications, the woman at the Two Harbors home did seem to awaken. She was able to speak — haltingly and not always understandably, but enough to communicate. And what she let Ms. Lanigan know, after years of being virtually nonverbal, was that she was suffering physical pain, the cause of her crying out.

It took doctors a while to find effective medications for her nerve condition, but they were eventually able to make her more comfortable without further fogging her mind. She stopped taking psychotropic drugs altogether.

None of this can halt dementia; it’s a terminal disease, and it took this resident’s life last year. But in her final months, she smiled and played balloon volleyball with other residents and could say she felt fine or was hungry.

“She engaged more. Her family came to help her eat,” Ms. Lanigan said. “It was a big change.”

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

    Clearing the Fog in Nursing Homes, NYT, 15.2.2011, http://newoldage.blogs.nytimes.com/2011/02/15/clearing-the-fog-in-nursing-homes/

Lymph Node Study Shakes Pillar of Breast Cancer Care

February 8, 2011
The New York Times
By DENISE GRADY

A new study finds that many women with early breast cancer do not need a painful procedure that has long been routine: removal of cancerous lymph nodes from the armpit.

The discovery turns standard medical practice on its head. Surgeons have been removing lymph nodes from under the arms of breast cancer patients for 100 years, believing it would prolong women’s lives by keeping the cancer from spreading or coming back.

Now, researchers report that for women who meet certain criteria — about 20 percent of patients, or 40,000 women a year in the United States — taking out cancerous nodes has no advantage. It does not change the treatment plan, improve survival or make the cancer less likely to recur. And it can cause complications like infection and lymphedema, a chronic swelling in the arm that ranges from mild to disabling.

Removing the cancerous lymph nodes proved unnecessary because the women in the study had chemotherapy and radiation, which probably wiped out any disease in the nodes, the researchers said. Those treatments are now standard for women with breast cancer in the lymph nodes, based on the realization that once the disease reaches the nodes, it has the potential to spread to vital organs and cannot be eliminated by surgery alone.

Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. Memorial Sloan-Kettering Cancer Center in Manhattan changed its practice in September, because doctors knew the study results before they were published. But more widespread change may take time, experts say, because the belief in removing nodes is so deeply ingrained.

“This is such a radical change in thought that it’s been hard for many people to get their heads around it,” said Dr. Monica Morrow, chief of the breast service at Sloan-Kettering and an author of the study, which is being published Wednesday in The Journal of the American Medical Association. The National Cancer Institute paid for the study.

Doctors and patients alike find it easy to accept more cancer treatment on the basis of a study, Dr. Morrow said, but get scared when the data favor less treatment.

The new findings are part of a trend to move away from radical surgery for breast cancer. Rates of mastectomy, removal of the whole breast, began declining in the 1980s after studies found that for many patients, survival rates after lumpectomy and radiation were just as good as those after mastectomy.

The trend reflects an evolving understanding of breast cancer. In decades past, there was a belief that surgery could “get it all” — eradicate the cancer before it could spread to organs and bones. But research has found that breast cancer can begin to spread early, even when tumors are small, leaving microscopic traces of the disease after surgery.

The modern approach is to cut out obvious tumors — because lumps big enough to detect may be too dense for drugs and radiation to destroy — and to use radiation and chemotherapy to wipe out microscopic disease in other places.

But doctors have continued to think that even microscopic disease in the lymph nodes should be cut out to improve the odds of survival. And until recently, they counted cancerous lymph nodes to gauge the severity of the disease and choose chemotherapy. But now the number is not so often used to determine drug treatment, doctors say. What matters more is whether the disease has reached any nodes at all. If any are positive, the disease could become deadly. Chemotherapy is recommended, and the drugs are the same, no matter how many nodes are involved.

The new results do not apply to all patients, only to women whose disease and treatment meet the criteria in the study.

The tumors were early, at clinical stage T1 or T2, meaning less than two inches across. Biopsies of one or two armpit nodes had found cancer, but the nodes were not enlarged enough to be felt during an exam, and the cancer had not spread anywhere else. The women had lumpectomies, and most also had radiation to the entire breast, and chemotherapy or hormone-blocking drugs, or both.

The study, at 115 medical centers, included 891 patients. Their median age was in the mid-50s, and they were followed for a median of 6.3 years.

After the initial node biopsy, the women were assigned at random to have 10 or more additional nodes removed, or to leave the nodes alone. In 27 percent of the women who had additional nodes removed, those nodes were cancerous. But over time, the two groups had no difference in survival: more than 90 percent survived at least five years. Recurrence rates in the armpit were also similar, less than 1 percent. If breast cancer is going to recur under the arm, it tends to do so early, so the follow-up period was long enough, the researchers said.

One potential weakness in the study is that there was not complete follow-up information on 166 women, about equal numbers from each group. The researchers said that did not affect the results. A statistician who was not part of the study said the missing information should have been discussed further, but probably did not have an important impact.

It is not known whether the findings also apply to women who do not have radiation and chemotherapy, or to those who have only part of the breast irradiated. Nor is it known whether the findings could be applied to other types of cancer.

The results mean that women like those in the study will still have to have at least one lymph node removed, to look for cancer and decide whether they will need more treatment. But taking out just one or a few nodes should be enough.

Dr. Armando E. Giuliano, the lead author of the study and the chief of surgical oncology at the John Wayne Cancer Institute at St. John’s Health Center in Santa Monica, Calif., said: “It shouldn’t come as a big surprise, but it will. It’s hard for us as surgeons and medical oncologists and radiation oncologists to accept that you don’t have to remove the nodes in the armpit.”

Dr. Grant W. Carlson, a professor of surgery at the Winship Cancer Institute at Emory University, and the author of an editorial accompanying the study, said that by routinely taking out many nodes, “I have a feeling we’ve been doing a lot of harm.”

Indeed, women in the study who had the nodes taken out were far more likely (70 percent versus 25 percent) to have complications like infections, abnormal sensations and fluid collecting in the armpit. They were also more likely to have lymphedema.

But Dr. Carlson said that some of his colleagues, even after hearing the new study results, still thought the nodes should be removed.

“The dogma is strong,” he said. “It’s a little frustrating.”

Eventually, he said, genetic testing of breast tumors might be enough to determine the need for treatment, and eliminate the need for many node biopsies.

Two other breast surgeons not involved with the study said they would take it seriously.

Dr. Elisa R. Port, the chief of breast surgery at Mount Sinai Medical Center in Manhattan, said: “It’s a big deal in the world of breast cancer. It’s definitely practice-changing.”

Dr. Alison Estabrook, the chief of the comprehensive breast center at St. Luke’s-Roosevelt hospital in New York said surgeons had long been awaiting the results.

“In the past, surgeons thought our role was to get out all the cancer,” Dr. Estabrook said. “Now he’s saying we don’t really have to do that.”

But both Dr. Estabrook and Dr. Port said they would still have to make judgment calls during surgery and remove lymph nodes that looked or felt suspicious.

The new research grew out of efforts in the 1990s to minimize lymph node surgery in the armpit, called axillary dissection. Surgeons developed a technique called sentinel node biopsy, in which they injected a dye into the breast and then removed just one or a few nodes that the dye reached first, on the theory that if the tumor was spreading, cancer cells would show up in those nodes. If there was no cancer, no more nodes were taken. But if there were cancer cells, the surgeon would cut out more nodes.

Although the technique spared many women, many others with positive nodes still had extensive cutting in the armpit, and suffered from side effects.

“Women really dread the axillary dissection,” Dr. Giuliano said. “They fear lymphedema. There’s numbness, shoulder pain, and some have limitation of motion. There are a fair number of serious complications. Women know it.”

After armpit surgery, 20 percent to 30 percent of women develop lymphedema, Dr. Port said, and radiation may increase the rate to 40 percent to 50 percent. Physical therapy can help, but there is no cure.

The complications — and the fact that there was no proof that removing the nodes prolonged survival — inspired Dr. Giuliano to compare women with and without axillary dissection. Some doctors objected. They were so sure cancerous nodes had to come out that they said the study was unethical and would endanger women.

“Some prominent institutions wouldn’t even take part in it,” Dr. Giuliano said, though he declined to name them. “They’re very supportive now. We don’t want to hurt their feelings. They’ve seen the light.”

    Lymph Node Study Shakes Pillar of Breast Cancer Care, NYT, 8.2.2011, http://www.nytimes.com/2011/02/09/health/research/09breast.html

Latest Hidden Video by Abortion Foes Shows Bronx Clinic of Planned Parenthood

February 8, 2011
The New York Times
By ANEMONA HARTOCOLLIS

An anti-abortion group released a videotape on Tuesday of a man whom the group said was posing as a pimp and a woman who was posing as a prostitute on a visit to a Planned Parenthood clinic in the Bronx. They appear to get information from a receptionist about how to obtain abortions and treatment for sexually transmitted diseases for under-age sex workers.

The videotape was the sixth released by the group, Live Action, of undercover visits to Planned Parenthood; the others were made at a clinic in New Jersey and four locations in Virginia. Its release comes as anti-abortion advocates and their allies in Congress are trying to cut off money for Planned Parenthood, which provides family planning, contraception and abortion.

Lila Rose, the president of Live Action, which is based in San Jose, Calif., said Tuesday that her group had gone after Planned Parenthood because “they’re the biggest abortion chain in the country.” She said the tape showed that Planned Parenthood used promises of confidentiality to cover up sex trafficking.

Planned Parenthood of New York City released a statement saying that Live Action was making “false claims” as part of a political agenda.

“These tapes are part of a nationwide campaign by this group,” the statement said. “Unlike other publicized tapes, the hoax patients in New York were not able to get beyond the reception desk for a private consultation.”

Joan Malin, president of Planned Parenthood of New York City, noted that the man and woman in the video were both adults. She said that if under-age women had come into the clinic, they would have been screened for violent or abusive relationships and referred to any necessary services.

“Under New York State law, we are not required to report criminal activity,” Ms. Malin said. “We are required to report anything we believe is child abuse or neglect by a parent or guardian, which we do.”

Roger Rathman, a spokesman for Planned Parenthood, said Tuesday that the organization believed the tape had been doctored to add the words “sex work” and “sex worker,” and that the two staff members interviewed on camera — a receptionist and a supervisor — had told the Federal Bureau of Investigation they did not hear those words.

Ms. Rose, the Live Action president, denied the doctoring claim.

The Live Action Web site shows two versions of the tape, a highly condensed version and a longer one. The short version shows what appears to be the man and woman walking toward a clinic, wearing summer clothing, even though the visit to the Bronx clinic was in the midst of a snowy January. Ms. Rose acknowledged that the introduction was shot elsewhere.

On the video, a man and a woman — their faces never visible — enter the clinic, apparently carrying a hidden camera.

A woman who appears to be a receptionist leads them through metal detectors. Standing in a hall, the man says in a whispery voice that he is wondering “about testing for the both of us.” The receptionist assumes he is talking about HIV testing. The man continues: “We’re involved in sex work. We have some other girls that we manage and work with that they’re gonna need testing as well.”

The receptionist says that everything is confidential and that “they don’t have to tell anybody what it is that they do.” She says the clinic treats people as young as 13. At this point the woman posing as a prostitute interjects that “some of them are 14 and 15.”

The man asks whether he could “sign off as a guardian,” and the receptionist explains that the clinic does not ask for a guardian’s signature. Under New York law, minors can get an abortion without parental permission.

Although Live Action describes the couple as posing as a pimp and a prostitute, they are not heard calling themselves such on the tape.

Planned Parenthood fired an office manager of a New Jersey clinic who was caught on one video encouraging the pimp to have the girls lie about their ages. The group ordered retraining for staff members across the country.


Nate Schweber contributed reporting.

    Latest Hidden Video by Abortion Foes Shows Bronx Clinic of Planned Parenthood, NYT, 8.2.2011, http://www.nytimes.com/2011/02/09/nyregion/09sting.html

On Health Care, Justice Will Prevail

February 7, 2011
The New York Times
By LAURENCE H. TRIBE

Cambridge, Mass.

THE lawsuits challenging the individual mandate in the health care law, including one in which a federal district judge last week called the law unconstitutional, will ultimately be resolved by the Supreme Court, and pundits are already making bets on how the justices will vote.

But the predictions of a partisan 5-4 split rest on a misunderstanding of the court and the Constitution. The constitutionality of the health care law is not one of those novel, one-off issues, like the outcome of the 2000 presidential election, that have at times created the impression of Supreme Court justices as political actors rather than legal analysts.

Since the New Deal, the court has consistently held that Congress has broad constitutional power to regulate interstate commerce. This includes authority over not just goods moving across state lines, but also the economic choices of individuals within states that have significant effects on interstate markets. By that standard, this law’s constitutionality is open and shut. Does anyone doubt that the multitrillion-dollar health insurance industry is an interstate market that Congress has the power to regulate?

Many new provisions in the law, like the ban on discrimination based on pre-existing conditions, are also undeniably permissible. But they would be undermined if healthy or risk-prone individuals could opt out of insurance, which could lead to unacceptably high premiums for those remaining in the pool. For the system to work, all individuals — healthy and sick, risk-prone and risk-averse — must participate to the extent of their economic ability.

In this regard, the health care law is little different from Social Security. The court unanimously recognized in 1982 that it would be “difficult, if not impossible” to maintain the financial soundness of a Social Security system from which people could opt out. The same analysis holds here: by restricting certain economic choices of individuals, we ensure the vitality of a regulatory regime clearly within Congress’s power to establish.

The justices aren’t likely to be misled by the reasoning that prompted two of the four federal courts that have ruled on this legislation to invalidate it on the theory that Congress is entitled to regulate only economic “activity,” not “inactivity,” like the decision not to purchase insurance. This distinction is illusory. Individuals who don’t purchase insurance they can afford have made a choice to take a free ride on the health care system. They know that if they need emergency-room care that they can’t pay for, the public will pick up the tab. This conscious choice carries serious economic consequences for the national health care market, which makes it a proper subject for federal regulation.

Even if the interstate commerce clause did not suffice to uphold mandatory insurance, the even broader power of Congress to impose taxes would surely do so. After all, the individual mandate is enforced through taxation, even if supporters have been reluctant to point that out.

Given the clear case for the law’s constitutionality, it’s distressing that many assume its fate will be decided by a partisan, closely divided Supreme Court. Justice Antonin Scalia, whom some count as a certain vote against the law, upheld in 2005 Congress’s power to punish those growing marijuana for their own medical use; a ban on homegrown marijuana, he reasoned, might be deemed “necessary and proper” to effectively enforce broader federal regulation of nationwide drug markets. To imagine Justice Scalia would abandon that fundamental understanding of the Constitution’s necessary and proper clause because he was appointed by a Republican president is to insult both his intellect and his integrity.

Justice Anthony Kennedy, whom many unfairly caricature as the “swing vote,” deserves better as well. Yes, his opinion in the 5-4 decision invalidating the federal ban on possession of guns near schools is frequently cited by opponents of the health care law. But that decision in 1995 drew a bright line between commercial choices, all of which Congress has presumptive power to regulate, and conduct like gun possession that is not in itself “commercial” or “economic,” however likely it might be to set off a cascade of economic effects. The decision about how to pay for health care is a quintessentially commercial choice in itself, not merely a decision that might have economic consequences.

Only a crude prediction that justices will vote based on politics rather than principle would lead anybody to imagine that Chief Justice John Roberts or Justice Samuel Alito would agree with the judges in Florida and Virginia who have ruled against the health care law. Those judges made the confused assertion that what is at stake here is a matter of personal liberty — the right not to purchase what one wishes not to purchase — rather than the reach of national legislative power in a world where no man is an island.

It would be asking a lot to expect conservative jurists to smuggle into the commerce clause an unenumerated federal “right” to opt out of the social contract. If Justice Clarence Thomas can be counted a nearly sure vote against the health care law, the only reason is that he alone has publicly and repeatedly stressed his principled disagreement with the whole line of post-1937 cases that interpret Congress’s commerce power broadly.

There is every reason to believe that a strong, nonpartisan majority of justices will do their constitutional duty, set aside how they might have voted had they been members of Congress and treat this constitutional challenge for what it is — a political objection in legal garb.


Laurence H. Tribe, a professor at Harvard Law School, is the author of “The Invisible Constitution.”

    On Health Care, Justice Will Prevail, NYT, 7.2.2011, http://www.nytimes.com/2011/02/08/opinion/08tribe.html

Pharmacies Besieged by Addicted Thieves

February 6, 2011
The New York Times
By ABBY GOODNOUGH

BINGHAM, Me. — The orange signs posted throughout Chet Hibbard’s pharmacy here relay a blunt warning: We Do Not Stock OxyContin.

Mr. Hibbard stopped dispensing the highly addictive painkiller last July, after two robbers in ski goggles demanded it at knifepoint one afternoon as shocked customers looked on. It was one in a rash of armed robberies at Maine drugstores last year, a sharp increase that has rattled pharmacists and put the police on high alert.

“I want people to know before they even get in the door that we don’t have it,” Mr. Hibbard said of OxyContin, which the authorities say is the most common target of pharmacy robberies here. “Outside hiring an armed guard to be in here 24/7, I don’t know what else to do.”

Maine’s problem is especially stark, but it is hardly the only state dealing with pharmacy robberies, one of the more jarring effects of the prescription drug abuse epidemic that has left drugstores borrowing heist-prevention tactics from the more traditional targets, banks. In at least one case, a tiny tracking device affixed to a bottle let the police easily track a thief after a robbery.

More than 1,800 pharmacy robberies have taken place nationally over the last three years, typically conducted by young men seeking opioid painkillers and other drugs to sell or feed their own addictions. The most common targets are oxycodone (the main ingredient in OxyContin), hydrocodone (the main ingredient in Vicodin) and Xanax.

The robbers are brazen and desperate. In Rockland, Me., one wielded a machete as he leapt over a pharmacy counter to snatch the painkiller oxycodone, gulping some before he fled. In Satellite Beach, Fla., a robber threatened a pharmacist with a cordless drill last week, and in North Highlands, Calif., a holdup last summer led to a shootout that left a pharmacy worker dead.

The crime wave has spurred pharmacists to tighten security measures and add ones they may never have imagined. Many have upgraded their surveillance cameras; some have installed bulletproof glass and counters high enough to keep would-be robbers from jumping them, giving these pharmacies the aesthetic of an urban liquor store. In Tulsa, Okla., where there was a steep increase in drugstore robberies last year, at least one pharmacist now requires customers to be buzzed in the door.

Meanwhile, the police are quietly experimenting with new tools. In Lewiston, Me., last fall, a Rite Aid pharmacist handed a robber who threatened to shoot her five bottles of OxyContin, including one that contained a tracking device.

According to court records, the device led the police to the suspect’s home on a rural road shortly after he fled the store. They gathered evidence there, arrested the suspect a few days later and indicted him last month.

The Drug Enforcement Administration does not routinely investigate reports of pharmacy robberies, and therefore “it cannot be determined what factors are contributing to these types of thefts,” a spokeswoman said.

But some local law enforcement officials have been overwhelmed enough by the incidents to seek help. Thomas Delahanty II, the United States attorney in Maine, announced recently that the federal authorities would help investigate the heists from now on and prosecute some of the cases.

Federal charges could bring more prison time, Mr. Delahanty said, describing the surge in such robberies as “staggering numbers that can’t be ignored.” There were 21 in Maine last year, according to the D.E.A., up from two in 2008 and seven in 2009.

In Biddeford, Me., a city of 21,000 that has had seven pharmacy robberies since December 2009, Roger Beaupre, the police chief, said he was urging the stores to require customers to remove hoods and sunglasses before entering and to consider caging in their pharmacy counters.

Police officers there got free training in how to investigate pharmacy heists last month from Purdue Pharma, the maker of OxyContin. The company also trains pharmacists on how to prevent robberies and what to do should they fall victim to one, said Rick Zenuch, its director of law enforcement liaison and education.

“The very first tip we give them is comply, comply, comply,” Mr. Zenuch said. “Do exactly what the suspect wants, to end the encounter as soon as possible.”

In Washington State, where more than 100 pharmacy robberies have taken place over the last three years, law enforcement officials say the penalty for second-degree robbery, when the pharmacist may be threatened but no weapon is shown, is too weak. Dan Satterberg, the King County prosecutor, said he had submitted a bill to the Legislature to increase the minimum jail time to three years from three months.

“Word travels fast on the street about what an easy target the pharmacies are and how much profit can be made and what small punishment is attached,” Mr. Satterberg said.

OxyContin goes for $1 a milligram on the street, Mr. Satterberg and other law enforcement officials said, and the most popular pill is 80 milligrams.

Many pharmacies in Washington have deterred would-be robbers by putting time-release locks on the safes where they store narcotics and staggering their inventory, Mr. Satterberg said. Perhaps as a result, the number of armed robberies at pharmacies there dropped to 23 in 2010 from 49 in 2008, according to the D.E.A.

Still, Mr. Satterberg said, the threat of robbery has made it difficult for retail chains in the state to recruit enough pharmacists in recent years.

“They feel very vulnerable when so many people are so desperate to get what they keep behind those counters,” he said.

In sheer numbers, Florida, Indiana, California, Ohio and Washington have had the most armed robberies of pharmacies since January 2008, according to the D.E.A. But Maine, Oklahoma and Oregon had the sharpest increases last year.

All but a handful of the Maine robberies took place at Rite Aid and CVS stores, some of which were hit multiple times.

In Tulsa, Okla., where pharmacy robberies last year far outpaced bank robberies, the police said the crimes were now more often committed by gangs who want to sell the drugs than addicts in search of a fix. Robbers there often demand Xanax, an anti-anxiety drug, along with opioids, said Sgt. Dave Walker, who runs the robbery unit of the Tulsa Police Department.

In Bingham, a remote town of about 1,000, the men who robbed Mr. Hibbard’s pharmacy, E.W. Moore & Son, were caught and sent to prison, as was another robber who held up the store at gunpoint in 2006. But despite that comforting fact and the store’s nine surveillance cameras and high-tech alarm system, Mr. Hibbard and his employees still jump when the place is quiet and they hear footsteps coming up the ramp, they said.

“I stood right between him and his knife,” said Lori Pratt, a pharmacy technician, referring to one of the robbers. “I was all ready to go on the Internet after it happened and get a Taser gun.”

Unlike Mr. Hibbard, Rite Aid has chosen to keep stocking the drugs that are popular with robbers, said Eric Harkreader, a spokesman. But the company now limits the amount of certain drugs in stores at any given time.

“If they are going for lots of quantity at once, we don’t want to help them out,” he said. “But we certainly want to have the prescription available for all its legitimate purposes.”

In Biddeford, a Rite Aid that was robbed twice last year was struck again last week. The suspect, who demanded OxyContin and fled into the night, remains at large.

    Pharmacies Besieged by Addicted Thieves NYT, 6.2.2011, http://www.nytimes.com/2011/02/07/us/07pharmacies.html

Too Much of a Good Thing

February 4, 2011
The New York Times

When Mayor Michael Bloomberg began his campaign against cigarette smoking eight years ago, most New Yorkers breathed a sigh of relief. The great indoors — bars, restaurants, hotels, office buildings — all are now smoke-free by law, making New York City a healthier place. And, for those already addicted or tempted, the city offered kits to help people stop smoking and gruesome television ads to try to keep them from starting.

That antismoking campaign has been a great public service, but now the mayor and City Council have overreached. The council voted — 36 to 12 — to ban smoking outdoors in city parks, beaches and even plazas, including in Times Square.

No smoking at the crossroads of the world? The vortex of tourism that brings smokers and nonsmokers in great numbers? The site of the world’s most famous New Year’s Eve party, where who knows what goes on? All of this takes the mayor’s nannying too far, even for those of us who want to avoid the hazards of secondhand smoke.

Already smokers are forced to huddle outside, these days perched on the city’s gray, leftover snowdrifts. Starting in early summer, after the mayor signs the bill into law, they will not be able to stray onto the 14 miles of city beaches or into the city’s 1,700 parks, not even Central Park or windswept Battery Park. Instead of smoking on Brighton Beach, what does a smoker do — take a boat out 12 nautical miles into international waters?

Some City Council members wanted to find a less-drastic solution — like having the ban but establishing smoking areas on the beach or patches of the park. It’s not great, but it’s better than an all-out ban. Also, the city would have to provide a lot more receptacles for cigarette butts and enforce antilittering laws in those areas.

Meanwhile, there is talk that the mayor and the City Council want even more, like banning smoking near doors of office buildings and apartments. They need to take a deep breath and remember that we tried prohibition 90 years ago. They called it a noble experiment. It turned into a civic disaster.

    Too Much of a Good Thing, NYT, 4.2.2011, http://www.nytimes.com/2011/02/05/opinion/05sat4.html

City’s High Abortion Rate Defies Easy Explanation

February 3, 2011
The New York Times
By ANEMONA HARTOCOLLIS

At a time when evidence suggests that people in New York City are smoking less, eating better and biking more, one health statistic that has not budged is the abortion rate.

Two of every five pregnancies in the city end in abortion, a statistic that has barely changed in more than a decade. At a news conference last month, Timothy M. Dolan, the Roman Catholic archbishop of New York, called the city’s 41 percent abortion rate “downright chilling,” and on Thursday, State Senator Rubén Díaz Sr. of the Bronx, an abortion opponent, is holding a community meeting to discuss the issue. Nationally, the issue is receiving a new round of attention, with numerous state legislatures and the House of Representatives considering bills that would add restrictions on abortion, and Planned Parenthood was recently a target of undercover videos by an anti-abortion group.

But city health officials and groups that support access to abortion say that behind the 41 percent statistic — nearly twice the national rate — are complex social and legal factors: fewer obstacles to abortion in state law; the absence of mandatory sex education in New York City public schools; the ignorance of people, especially young ones, about where to get affordable birth control; and the ambivalence of young women living in poverty and in unstable relationships about when and whether to have children.

And although the percentage of pregnancies that end in abortion is basically unchanged, a particularly vulnerable group, teenagers, is having fewer babies and fewer abortions.

The hand-wringing has led to a rare moment of synchronicity between the Catholic Church and pro-choice women’s groups, as both say they are disturbed that the rate is so high, but disagree over what to do about it.

“Listening to Archbishop Dolan, I took a little bit of comfort in that he recognizes it is important to bring this rate down,” said Joan Malin, president of Planned Parenthood of New York City. But, she added, “The way we think about these issues is to really step back a bit and say that the major concern or the underlying issue that we think is so important is the high rate of unintended pregnancies.”

The issue came to light with the city health department’s recent release of its annual Vital Statistics report, which showed that 41 percent of pregnancies, excluding miscarriages, in 2009 ended in abortion.

Health experts say the abortion rate is tied to factors like race and income.

“If you look at the pregnancy rates by race and ethnicity in New York City versus nationally, they are essentially the same for black and Hispanic teenagers, and lower for whites,” said Susan Craig, a spokeswoman for the city’s health department.

There were 126,774 births, 11,620 miscarriages and 87,273 abortions in New York City in 2009. Despite the contention of some critics that New York, with its liberal abortion laws, is a destination state for abortion, nonresidents accounted for only about 7,000 of these abortions. (Factoring out nonresidents does not alter the 41 percent abortion rate, because 10,000 nonresidents also gave birth in the city.)

The little-changed abortion rate figure is a commonly cited statistic. But it masks large changes in fertility among teenagers.

Since 1996, the number of babies born to teenagers has fallen by 39 percent. The number of abortions has fallen by more than 16 percent, even though the population of teenagers has risen modestly. Ninety percent of the teenage mothers were not married, according to health department estimates.

In that age group in 2009, the rate of abortions was strikingly high for blacks (74 percent), followed by whites (66 percent) and Hispanics (53 percent). The rate was also very high for Asians (74 percent), though they were much less likely to become pregnant.

The drop in teenage pregnancies and abortions, however, was not enough to significantly alter the overall abortion rate. Most abortions, like most pregnancies, occurred among women in their 20s. Women in their 30s had abortions 29 percent of the time, and women 40 and older about a third of the time. Unmarried women accounted for 84 percent of abortions in 2009.

New York State law does not place as many restrictions on abortion as laws in some other states, like requiring parental consent for minors, or requiring women to undergo counseling that discourages abortion or to go through a waiting period.

According to Rachel Jones, a senior research associate at the Guttmacher Institute, which studies reproductive health issues, the high rate of unwed pregnancy and abortion among poor women is a sign of ambivalence. They are torn, she said, between the desire to have a baby and the realization that it would be hard to bring up a child as a single mother.

“In the U.S., most women want to have kids,” Ms. Jones said. “If you don’t have a lot of money, when is the responsible time to say, Now I want to have a child? How long are you supposed to put this off?”

That inner conflict could be seen recently in several women coming out of Planned Parenthood’s Margaret Sanger Center, a family planning and abortion clinic in Greenwich Village.

A 17-year-old girl there to pick up a friend said she had had an abortion in May. It was her second; the first was when she was 15. The girl said she sometimes used condoms. “But I wasn’t using them when I got pregnant,” she said. “I might use them more now, but I don’t know.” Like the other women outside the clinic, she asked not to be named to preserve her privacy.

A 20-year-old woman being helped by two male friends said she had her first abortion at 16, and also had a 7-month-old child. “It was an accident,” the woman said. “I used a condom every time, but I already have a kid, and I’m not ready for another one.”

Another woman, who was 22, said she had become pregnant after not using birth control because a doctor had told her she was infertile. “I’ve always been against abortion,” the woman, who is white and lives on Staten Island, said. “But if I had a kid now, it would have a terrible life. I’d rather wait.”

The health department distributes a pocket-size guide to clinics where teenagers can get medical care and low-cost or free contraception (information that is also available through the city’s 311 hotline). It has provided training in issues like protecting confidentiality and dispensing contraception to 50 clinics serving 32,000 teenagers a year in the neighborhoods with the highest pregnancy rates among teenagers. School-based classes use role-playing to help teenagers “learn how to negotiate maybe saying, I don’t want to have sex,” said Deborah Kaplan, assistant commissioner of the health department’s bureau of maternal, infant and reproductive health.

Condoms are distributed through health offices at every public high school, Ms. Kaplan said.

Archbishop Dolan agreed to speak out with other religious leaders at a news conference last month at the invitation of the Chiaroscuro Foundation, an anti-abortion group coordinated by an investment banker active in conservative causes, according to the archbishop’s spokesman, Joseph Zwilling.

The archbishop “reaffirmed and was looking to spread the word as well of the archdiocese’s longstanding commitment that any woman who is pregnant and in need can come to the Archdiocese of New York for assistance,” Mr. Zwilling said.

On Thursday, Senator Díaz, a minister who, like the archbishop, advocates abstinence and not condom use, convened a meeting of other Hispanic ministers to discuss the abortion statistics and urge them to talk to their congregations about it.


Juliet Linderman contributed reporting.

    City’s High Abortion Rate Defies Easy Explanation, NYT, 3.2.2011, http://www.nytimes.com/2011/02/04/nyregion/04abortion.html

For Tucson Survivors, Health Care Cost Is Concern

February 3, 2011
The New York Times
By MARC LACEY and SAM DOLNICK

TUCSON — Seconds after gunfire erupted outside a supermarket here last month, Randy Gardner, one of those struck during the barrage, said another looming crisis immediately entered his mind.

“I wondered, ‘How much is this going to cost me?’ ” he said. “It was a thought that went through my head right away.”

Tucson’s medical system quickly swung into action after the shootings, with ambulances and medical helicopters rushing victims to hospitals where trauma specialists awaited them. The life-saving treatment the victims received over the ensuing days carried a heavy cost though, and the bills — the costliest of which may be in the hundreds of thousands of dollars for Representative Gabrielle Giffords — are still being tallied.

But despite the fears of some victims, it does not appear that the shooting will ruin anybody financially. Interviews with victims as well as advocates assisting them suggest that most, if not all, of the 13 people wounded that morning had health insurance, and health care providers say they expect insurance companies to cover the bulk of the medical costs.

On top of that, the fact that federal charges have been filed against Jared L. Loughner in the shootings means that state victim-compensation money will be supplemented by federal help. Private charitable efforts to aid victims have also been created.

Ms. Giffords, who received a bullet wound to the head and was the most gravely injured of those who survived the shooting, also had probably the best insurance, a Congressional plan known for its comprehensive coverage that was held out as a model during last year’s debate over the health care overhaul.

Dr. Peter Rhee, chief trauma surgeon at Tucson’s University Medical Center, has repeatedly said that Ms. Giffords received the same care there as any other gunshot victim. “We don’t have time or luxury to ask for insurance cards or to know if they are a good guy or how they are going to pay,” he said. “We deal with whoever comes in the door. We don’t know if they are immigrants, if they are legal, illegal. We just treat them.”

Still, some of those who are following Ms. Giffords’s treatment, including her speedy transfer from Tucson to a top rehabilitation facility in Houston, can only wish their health plans were as responsive.

Monique Pomerleau, a mother of three from Northern California, suffered a traumatic brain injury in a traffic accident last February but has not yet undergone rehabilitation because her insurer, Health Net of California, said it lacked such services within the network.. Her family has hired a lawyer to press the matter and recently received word that a 30-day rehabilitation program had been approved. A spokesman for the insurer said federal privacy laws prevented it from commenting on individual patient’s cases.

“We watched the congresswoman’s care and we thought, How marvelous, but there are real people out there like Monique who don’t get the same possibilities,” said Lisa Kantor, a lawyer who specializes in challenging insurance companies and was hired by Ms. Pomerleau’s father, Tom.

After a tragedy like the Tucson shooting, billing is a topic that appears almost unseemly to raise. But with health costs spiraling, it is one that was on the minds of some victims, not to mention their care providers.

“We have to recover our costs so that we can provide the service to others,” said Craig Yale, vice president of corporate development for the Colorado-based Air Methods Corporation, which operates LifeNet helicopter service in Tucson, one of three private helicopter operators that were called to the shooting scene.

At University Medical Center, where the most seriously injured victims were treated, Misty Hansen, the hospital’s chief financial officer, said she did not anticipate any problems recovering costs. “It is my expectation that the bills will be paid and the hospital will be appropriately compensated,” she said.

Declining to discuss the case of individual patients, Ms. Hansen said 5 percent of patients were “self pay,” which means they lack insurance and are billed personally.

Even those like Mr. Gardner, who lost a solid health insurance plan when he retired five years ago and now has a deductible in the $10,000 range, will most likely benefit from the plethora of special public and private victim funds to fill gaps in his coverage.

The Federal Bureau of Investigation’s victim assistant fund cannot be used directly for medical care. But the money was used after the Tucson shooting to replace the eyeglasses of two injured victims and to fly relatives of victims to Tucson and the remains of one victim to her home state, said Kathryn Turman, director of the F.B.I.’s office for victim assistance.

The Safeway supermarket where Mr. Loughner is accused of spraying the crowd with bullets has begun a fund to aid victims, although company officials have not yet detailed how the money will be spent. A nonprofit victims rights group based in Tucson, Homicide Survivors, is similarly raising money on behalf of victims.

“My fund is too small to cover their medical bills,” said Carol Gaxiola, who is director of the survivors group. “But we’ll be able to pitch in to cover other costs.”

Besides the ambulance bill ($991.80 and $16.96 a mile for ground transport) and the hospital expenses, victims could face travel costs if they wish to follow the federal court proceedings against Mr. Loughner, especially if the trial is moved out of state.

There are also the costs of funeral expenses for the six people who died, as well as trauma counselors and loss of wages for the injured.

Mary Reed, who was shot three times that morning, said her insurer, through her husband’s job at the University of Arizona, had been unusually responsive and accommodating since the shooting, approving medicines and services in 24 hours, significantly faster than usual.

One concern she has, though, is whether her 17-year-old daughter, who was at the scene but was not hit — Ms. Reed threw herself on her daughter to protect her — will qualify as a victim. Her husband and son were there as well, and they ran for cover. They are undergoing counseling, but Ms. Reed is uncertain who will pick up their costs.

Kenneth Dorushka, 63, was struck in the arm by a bullet and is still awaiting word on how much of his costs will be covered by his insurer, United Healthcare. “It’s hard to tell because we haven’t gotten any bills yet, so you don’t know how much they’re going to cover or not,” said Mr. Dorushka, adding that he had spent about $100 so far on co-payments and other medical costs.

Ron Barber, district director for Ms. Giffords’s Congressional office who was hit twice in the shooting, said he expected to emerge from the shooting without any financial cost.

“I was thinking at first about what kind of deductible I’d have to pay, but then I learned that workers compensation will cover everything,” said Mr. Barber, who was working when he was shot.

Even as he recovers at home, Mr. Barber said he was trying to ensure that the shooting does not cause undo financial strain on those affected.

“It’s obvious that those of us who were shot are victims, but there are others,” he said. “I don’t know anyone who didn’t have medical coverage, but I’m interested in making sure no one continues to suffer from this.”


Reporting was contributed by Timothy Williams, Jennifer Medina, Ford Burkhart and Joseph Goldstein.

    For Tucson Survivors, Health Care Cost Is Concern, NYT, 3.2.2011, http://www.nytimes.com/2011/02/04/us/04tucson.html

Close Look at a Flu Outbreak Upends Some Common Wisdom

February 3, 2011
The New York Times
By NICHOLAS BAKALAR

If you or your child came down with influenza during the H1N1, or swine flu, outbreak in 2009, it may not have happened the way you thought it did.

A new study of a 2009 epidemic at a school in Pennsylvania has found that children most likely did not catch it by sitting near an infected classmate, and that adults who got sick were probably not infected by their own children.

Closing the school after the epidemic was under way did little to slow the rate of transmission, the study found, and the most common way the disease spread was a through child’s network of friends.

Researchers learned all this when they studied an outbreak of H1N1 at an elementary school in a semirural community in spring 2009. They collected data in real time, while the epidemic was going on.

With this information on exactly who got sick and when, plus data on seating charts, activities and social networks, they were able to use statistical techniques to trace the spread of the disease from one victim to the next. Their report appears online in the Proceedings of the National Academy of Sciences.

The scientists collected data on 370 students from 295 households. Almost 35 percent of the students and more than 15 percent of their household contacts came down with flu. The most detailed information was gathered from fourth-graders, the group most affected by the outbreak.

The class and grade structure had a significant effect on transmission rates. Transmission was 25 times as intensive among classmates as between children in different grades. And yet sitting next to a student who was infected did not increase the chances of catching flu.

Social networks were apparently a more significant means of transmission than seating arrangements. Students were four times as likely to play with children of the same sex as with those of the opposite sex, and following this pattern, boys were more likely to catch the flu from other boys, and girls from other girls.

The progress of the disease from day to day followed these social interactions: from May 7 to 9, the illness spread mostly among boys; from May 10 to 13 mostly among girls.

“Our social networks shape disease spread,” said Simon Cauchemez, the lead author. “And we can quantify the role of social networks.”

Thirty-eight percent of children 6 to 12 were infected, compared with 23 percent of 11- to 18-year-olds and 13 percent of those older than 18. Adults were only about half as susceptible as children, but when they got sick they were just as likely to transmit the virus to others.

The school closed from May 14 to 18, but there was no indication that this slowed transmission. It may already have been too late — May 14 was the 18th day of the outbreak, and 27 percent of the students already had symptoms.

The scientists found no difference in transmission rates during the closure and during the rest of the outbreak. This, they write, confirms earlier studies showing that a school has to be closed quite early in an epidemic to have any effect on disease transmission.

Only 1 in 5 adults caught the illness from their own children, and this goes against one of the most common arguments for closing schools: that it will prevent the disease from moving from the school to households.

“Here we find that most of the infected adults were not infected by one of the children in their household,” said Dr. Cauchemez, a research fellow at Imperial College London. “This information could be used to understand whether it might be better to close a school, or to close individual classes or grades.”

Other experts were impressed with the work. “I think it’s a nice step,” said Ira M. Longini Jr., a professor of biostatistics at the Fred Hutchinson Cancer Research Center in Seattle. “It’s a beautiful analysis of an important dataset. This virus spreads very fast among school-age children, so the topic is important.”

    Close Look at a Flu Outbreak Upends Some Common Wisdom, NYT, 3.2.2011, http://www.nytimes.com/2011/02/08/health/research/08flu.html

Va. to Ask Supreme Court to Rule on Health Law

February 3, 2011
The New York Times
By KEVIN SACK

Virginia’s attorney general announced on Thursday that he hoped to bypass an initial appellate review by asking the United States Supreme Court to consider the constitutionality of the Obama health care law on an expedited basis.

Only rarely does the Supreme Court grant such hearings, and it has already rejected a similar request in another legal challenge to the health care act. But the commonwealth’s attorney general, Kenneth T. Cuccinelli II, said the legal and governmental confusion sown by conflicting lower-court opinions demanded a rapid resolution.

“Currently, state governments and private businesses are being forced to expend enormous amounts of resources to prepare to implement a law that, in the end, may be declared unconstitutional,” Mr. Cuccinelli said in a statement.

In December, Mr. Cuccinelli became the first plaintiff to win a challenge to the health care act, when Judge Henry E. Hudson of Federal District Court in Richmond, Va., struck down a provision that requires most Americans to obtain insurance. The judge ruled that the insurance requirement exceeded Congress’s authority under the Constitution to regulate interstate commerce.

Two other federal judges, including another in Virginia, had previously upheld the law. Then on Monday, Judge Roger Vinson of Federal District Court in Pensacola, Fla., joined Judge Hudson in striking down the insurance mandate. But unlike Judge Hudson, Judge Vinson invalidated the entire law.

The law, enacted last year by a Democratic Congress and signed in March by President Obama, aims to cover 32 million uninsured Americans by ending insurer discrimination against those with pre-existing health conditions and by providing government subsidies to make coverage affordable.

The Justice Department, which is defending the Obama administration in the health litigation, has already filed a notice of appeal of Judge Hudson’s ruling in the Court of Appeals for the Fourth Circuit in Richmond. Because of the geographic distribution of the four lower court rulings, three different courts of appeal are likely to hear the cases on their way to the Supreme Court.

Tracy Schmaler, a spokeswoman for the Justice Department, said the agency continued “to believe this case should follow the ordinary course” so that legal arguments could be fully developed before being presented to the Supreme Court. She pointed out that the insurance mandate does not take effect until 2014 and that the Fourth Circuit has already expedited its schedule by setting oral arguments for May.

The Justice Department also is considering whether to seek a stay of the Florida decision in order to clarify confusion about whether the health care act remains in effect in the 26 states that are plaintiffs in the case.

Mr. Cuccinelli said he recognized that an expedited Supreme Court review would be exceptional. But he said that this case and the others challenging the constitutionality of the Patient Protection and Affordable Care Act, as the law is known, were “truly exceptional in their own right.”

In November, the Supreme Curt refused to review another challenge to the health care act that had been dismissed by a California judge on grounds that the plaintiffs did not have standing to sue.

    Va. to Ask Supreme Court to Rule on Health Law, NYT, 3.2.2011, http://www.nytimes.com/2011/02/04/health/policy/04virginia.html

Senate Rejects Repeal of Health Care Law

February 2, 2011
The New York Times
By DAVID M. HERSZENHORN

WASHINGTON — Senate Democrats on Wednesday defeated a bid by Republicans to repeal last year’s sweeping health care overhaul, as they successfully mounted a party-line defense of President Obama’s signature domestic policy achievement.

Challenges to the law will continue, however, on Capitol Hill and in the courts, with the United States Supreme Court ultimately expected to decide if the law is constitutional.

The vote was 47 to 51, with all Republicans voting unanimously for repeal but falling 13 votes short of the 60 needed to advance their proposal.

Lawmakers in both parties joined forces, however, to repeal a tax provision in the law that would impose a huge information-reporting requirement on small businesses. That vote was 81 to 17, with 34 Democrats and all 47 Republicans in favor.

Senators Joseph I. Lieberman, independent of Connecticut, and Mark Warner, Democrat of Virginia, were absent.

Republicans said after the votes that they would persist in their efforts to overturn the law. Rejecting assertions that the repeal vote was a “futile act,” Senator John Cornyn of Texas, the chairman of the Republican Senatorial Campaign Committee, declared, “These are the first steps in a long road that will culminate in 2012.”

Senator John Thune, Republican of South Dakota and a potential presidential candidate in 2012, noted that Republicans had just 40 votes when they opposed the health care bill last year, but that they had 47 as a result of winning seats in November.

“Elections do have consequences,” Mr. Thune said.

The vote to eliminate the tax provision offered a brief moment of consensus on a day otherwise characterized by angry partisan disagreement. In the latest reprise of last year’s fierce debate over the health care law, senators crossed rhetorical swords for hours of floor debate.

Republicans denounced the overhaul as impeding job creation and giving the government too big a role in the health care system. Democrats highlighted the law’s benefits, especially for the uninsured, and noted that the nonpartisan Congressional Budget Office had projected that the law would reduce future deficits.

Senator Rand Paul, Republican of Kentucky, who is an ophthalmologist, cited the law’s requirement that nearly all Americans obtain insurance as evidence that it was unconstitutional and overly intrusive.

“If you can regulate inactivity, basically the non-act of not buying insurance, then there is no aspect to our life that would left free from government regulation and intrusion,” Mr. Paul said. He added, “From my perspective as a physician, I saw that we already had too much government involvement in health care.”

But Democrats hit back hard.

“The Republicans’ obsession with repealing the new health reform law is not based on budgetary considerations,” said Senator Tom Harkin, Democrat of Iowa, the chairman of the Health, Education, Labor and Pensions Committee. “It is based strictly on ideology. They oppose the law’s crackdown on abuses by health insurance companies and they oppose any serious effort by the federal government to secure health insurance coverage for tens of millions of Americans who currently have none.”

And Senator Charles E. Schumer of New York, the No. 3 Democrat, lambasted Republicans for seeking repeal of the law without proposing an alternative.

“If my colleagues on the other side of the aisle said: ‘You know, you’re right. We have to reduce costs. We have a better way,’ and they offered a bill on the floor, well maybe we’d take a look at it,” Mr. Schumer said. “But they’re silent.” He added: “Easy to sit there and say, ‘repeal.’ What would you put in its place?”

The repeal measure, which was adopted overwhelmingly by the Republican-controlled House last month, was put forward by the Senate Republican leader, Mitch McConnell of Kentucky, as an amendment to an aviation industry bill that is now on the Senate floor.

The willingness of the majority Senate Democrats to allow a vote on the amendment reflected a deal among leaders of both parties to limit the parliamentary warfare and ease the procedural stalemates that have bogged down the Senate in recent years.

The openness to a vote also reflected confidence among Democrats that they would be able to defeat the amendment.

And they did, challenging the amendment on the grounds that it violated the budget resolution by increasing the deficit. To overcome that challenge, and win approval, Mr. McConnell needed the votes of 60 senators.

On the repeal of the tax provision, a similar challenge on budget grounds was easily surmounted. Republicans had criticized the provision, which would require businesses to file a 1099 tax form identifying anyone to whom they paid $600 or more for goods or merchandise in a year. Businesses would also be required to send copies of the form to their vendors, suppliers and contractors. The House is expected to support its repeal.

Because the tax provision was expected to result in increased tax revenue, Democrats had to come up with another way to generate the same money. The plan that was approved, sponsored by Senator Debbie Stabenow, Democrat of Michigan, rescinds $44 billion in unspent money appropriated by Congress. But it exempts the Pentagon, the Department of Veterans Affairs and the Social Security Administration from those cuts.

    Senate Rejects Repeal of Health Care Law, NYT, 2.2.2011, http://www.nytimes.com/2011/02/03/health/policy/03congress.html

F.D.A. Declines to Approve Diet Drug

February 1, 2011
The New York Times
By ANDREW POLLACK

The Food and Drug Administration has declined to approve yet another prescription diet pill, saying the developer must first do a long-term study to demonstrate that the drug does not raise the risk of heart attacks.

The failure of the drug, known as Contrave, to gain approval was not totally unexpected. But the requirement that its developer, Orexigen Therapeutics, first do a study to rule out cardiovascular problems was somewhat unexpected and could pose a significant obstacle to approval.

The agency’s decision was announced Tuesday morning by Orexigen, a small company in San Diego. Its shares fell as much as 73 percent in premarket trading.

The rejection of the drug continues a string of setbacks for pharmaceutical companies trying to develop medical solutions for one of the country’s most pressing health problems.

The F.D.A. last year turned down two other drugs, lorcaserin from Arena Pharmaceuticals and Qnexa from Vivus. It also forced the withdrawal from the market of Abbott Laboratories’ Meridia.

But hopes had been higher that Contrave would win approval or that the F.D.A. would impose only minor new requirements, delaying approval for a few months. Unlike the other two drugs, Contrave won an endorsement from an F.D.A. advisory committee, which voted 13 to 7 in favor of approval in December.

While the committee called for more study of the potential cardiovascular risks of the drug, it voted 11 to 8 that such a study could be done after the drug was approved.

“We are surprised and extremely disappointed with the agency’s requirement in light of the extensive discussion and resulting vote on this topic at the Dec. 7 advisory committee meeting,” Michael A. Narachi, the chief executive of Orexigen, said in a statement.

Contrave is a combination of two existing drugs that together work to suppress food cravings, according to the company. One drug, bupropion, is an antidepressant known by the brand name Wellbutrin; it is also sold as Zyban to help people quit smoking. The second ingredient, naltrexone, is used to treat alcohol and drug addiction.

In a conference call with securities analysts Tuesday, Mr. Narachi said the company planned to meet with the F.D.A. to discuss details about the proposed study of cardiovascular risks.

In response to questions, Mr. Narachi said the company had not ruled out any options, including dropping Contrave or seeking approval only outside the United States.

Orexigen specializes in obesity drugs and has no products on the market yet. It has another diet drug, Empatic, which seems somewhat more effective than Contrave, in the middle stages of clinical trials. But Empatic is also a combination of two existing drugs, one of which is bupropion, raising questions about whether that drug would also be affected by safety concerns.

The F.D.A. asked for a randomized trial “of sufficient size and duration” to demonstrate that the cardiovascular risks of Contrave do not exceed the drug’s benefits, according to a statement Orexigen provided from the letter it received late Monday from the F.D.A.

The F.D.A. as a rule does not comment on such matters.

Mr. Narachi said Orexigen had about $100 million in cash as of the end of September but would need to raise more money if it is to conduct the required trial.

Such a large randomized trial could conceivably take years and involve 10,000 patients or more, experts said at the advisory committee meeting in December. One member of the committee said that if such a trial were required before approval it would kill the drug.

And experts have said that if the F.D.A. were to require such a trial for all diet pills, it would further discourage pharmaceutical companies from trying to develop obesity drugs. The agency now requires such big cardiovascular risk trials for diabetes drugs, and small companies, at least, are shying away from that field.

The F.D.A. has been very cautious about weight loss drugs, in part because there is the possibility that they will be very widely used, including by people who are not obese but might want to lose a few pounds. About a third of American adults are obese and another third merely overweight.

Still it is not clear that the request for the cardiovascular trial represents a precedent that would be applied to all obesity drugs. In clinical trials, Contrave raised pulse rates and blood pressure slightly, a warning that it might increase the risk of heart attacks, strokes or other cardiovascular problems.

Losing weight is supposed to lower the risk of heart attacks and strokes. And various diet drugs do produce an improvement in risk measures like blood pressure, cholesterol and blood sugar.

The F.D.A. could be basing its request for a cardiovascular study on the experience with Meridia, a weight loss drug by Abbott Laboratories that it approved in 1997 despite signs that it increased blood pressure and heart rate. Only last year, a large trial ordered by European regulators showed the drug did raise the risk of heart attacks and stroke in people already prone to cardiovascular risks.

Abbott argued that such people should not be getting Meridia in the first place. But the F.D.A. pushed the company to remove the drug from the market.

The possible cardiovascular risks of Orexigen’s Contrave, combined with only modest effectiveness in helping people lose weight, left the advisory committee somewhat lukewarm about the drug even as it voted to recommend approval.

“I think they made it by the hair of their chinny chin chin,” Melanie Coffin, the patient representative on the committee, said during the December meeting.

In four clinical trials involving a total of about 4,500 people, those who took Contrave lost an average of 4.2 percentage points of their weight more than those getting a placebo. This is below the F.D.A. standard of 5 percent.

However, the drug did meet a second requirement that twice as many patients on the drug as on the placebo lose at least 5 percent of their weight. Meeting only one of the two criteria is enough for approval.

There were also concerns that the drug could cause seizures and psychiatric or cognitive problems.

The F.D.A.’s decision is also a setback for Takeda Pharmaceutical of Japan, which had acquired the American marketing rights from Orexigen. It is also possible that Takeda might withdraw from the partnership, Orexigen executives said during a conference call.

    F.D.A. Declines to Approve Diet Drug, NYT, 1.2.2011, http://www.nytimes.com/2011/02/02/business/02drug.html

Federal Judge Rules That Health Law Violates Constitution

January 31, 2011
The New York Times
By KEVIN SACK

A second federal judge ruled on Monday that it was unconstitutional for Congress to enact a health care law that required Americans to obtain commercial insurance, evening the score at 2 to 2 in the lower courts as conflicting opinions begin their path to the Supreme Court.

But unlike a Virginia judge in December, Judge Roger Vinson of Federal District Court in Pensacola, Fla., concluded that the insurance requirement was so “inextricably bound” to other provisions of the Affordable Care Act that its unconstitutionality required the invalidation of the entire law.

“The act, like a defectively designed watch, needs to be redesigned and reconstructed by the watchmaker,” Judge Vinson wrote.

The judge declined to immediately enjoin, or suspend, the law pending appeals, a process that could last two years. But he wrote that the federal government should adhere to his declaratory judgment as the functional equivalent of an injunction. That left confusion about how the ruling might be interpreted in the 26 states that are parties to the legal challenge.

The insurance mandate does not take effect until 2014. But many new regulations are already operating, like requirements that insurers cover children with pre-existing health conditions and eliminate lifetime caps on benefits. States are also preparing for a major expansion of Medicaid eligibility and the introduction of health insurance exchanges in 2014.

David B. Rivkin Jr., a lawyer for the states, said the ruling relieved the plaintiff states of any obligation to comply with the health law. “With regard to all parties to this lawsuit, the statute is dead,” Mr. Rivkin said.

But White House officials declared that the opinion should not deter the continuing rollout of the law. “Implementation would continue apace,” a senior administration official said. “This is not the last word by any means.”

At the same time, Stephanie Cutter, an assistant to the president, noted in a post on the White House blog that the ruling had struck down the entire law. She called it “a plain case of judicial overreaching,” and added, “The judge’s decision puts all of the new benefits, cost savings and patient protections that were included in the law at risk.”

The Justice Department, which represents the Obama administration in the litigation, said it was exploring options to clarify the uncertainty, including requesting a stay of the decision, either from Judge Vinson or from the United States Court of Appeals for the Eleventh Circuit.

On Capitol Hill, Republicans sent out a stream of e-mails praising the ruling, while Senator Richard J. Durbin, Democrat of Illinois, said he would convene a Judiciary Committee hearing on Wednesday to examine the constitutionality of the law.

In his 78-page opinion, Judge Vinson held that the insurance requirement exceeded the regulatory powers granted to Congress under the Commerce Clause of the Constitution. He wrote that the provision could not be rescued by an associated clause in Article I that gives Congress broad authority to make laws “necessary and proper” to carrying out its designated responsibilities.

“If Congress can penalize a passive individual for failing to engage in commerce, the enumeration of powers in the Constitution would have been in vain,” the judge asserted.

In a silver lining for the Obama administration, Judge Vinson rejected a second claim that the new law violated state sovereignty by requiring states to pay for a fractional share of the planned Medicaid expansion.

The judge’s ruling came in the most prominent of more than 20 legal challenges to the sweeping health law, which was signed last March by President Obama.

The plaintiffs include governors and attorneys general from 26 states, all but one of them Republicans, as well as the National Federation of Independent Business, which represents small companies. Officials from six states joined the lawsuit in January after shifts in party control brought by November’s elections.

The ruling by Judge Vinson, a senior judge who was appointed by President Ronald Reagan, solidified the divide in the health litigation among judges named by Republicans and those named by Democrats.

In December, Judge Henry E. Hudson of Federal District Court in Richmond, Va., who was appointed by President George W. Bush, became the first to invalidate the insurance mandate. Two other federal judges named by President Bill Clinton, a Democrat, have upheld the law.

Judge Vinson’s opinion hangs on a series of Supreme Court decisions that have defined the limits of the Commerce Clause by granting Congress authority to regulate “activities that substantially affect interstate commerce.”

The plaintiffs characterized the insurance requirement as an unprecedented effort to regulate inactivity because citizens would be assessed an income tax penalty for failing to buy a product.

Justice Department lawyers responded that a choice not to obtain health insurance was itself an active decision that, taken in the aggregate, shifted the cost of caring for the uninsured to hospitals, governments and privately insured individuals.

In his decision, Judge Vinson wrote, “It would be a radical departure from existing case law to hold that Congress can regulate inactivity under the Commerce Clause.” If Congress has such power, he continued, “it is not hyperbolizing to suggest that Congress could do almost anything it wanted.”

The Pensacola case is now likely to head to the Eleventh Circuit in Atlanta, considered one of the country’s most conservative appellate benches. The Richmond case is already with another conservative court, the United States Court of Appeals for the Fourth Circuit in Richmond, which has set oral arguments for May.

That court will consider diametrically opposed rulings from courthouses situated 116 miles apart, as it was a judge in Lynchburg, Va., Norman K. Moon, who issued one of the two decisions upholding the law. Meanwhile, the United States Court of Appeals for the Sixth Circuit in Cincinnati is already receiving briefs on the other decision backing the law, which was delivered by Judge George C. Steeh in Detroit.

Judge Vinson’s ruling further arms Republicans in Congress who are waging a fierce campaign against the health care act. The new Republican majority in the House voted this year to repeal the law, a largely symbolic measure that is given no chance in the Democratic-controlled Senate.

The Obama administration argues that without the insurance mandate consumers might simply wait until they are sick to enroll, undercutting the actuarial soundness of risk pooling and leading to an industry “death spiral.”

But the mandate’s legal and political problems have prompted a few Democratic senators to join Republicans in exploring alternatives that would encourage citizens to buy insurance without requiring it.

For instance, people could be given a narrow window to enroll, and those who miss the deadline would face lengthy waiting periods for coverage.

Alternately, those who apply late and are eligible for government tax credits under the law coverage could be penalized through a reduction of their subsidies.


Sheryl Gay Stolberg contributed reporting.

    Federal Judge Rules That Health Law Violates Constitution, NYT, 31.1.2011, http://www.nytimes.com/2011/02/01/us/01ruling.html

The Two Abortion Wars: State Battles Over Roe v. Wade

January 29, 2011
The New York Times

Away from Washington, another ominous anti-abortion battle is accelerating in the states. Anti-abortion forces have been trying to take advantage of the 2007 ruling in which the Supreme Court upheld a federal ban on a particular method of abortion.

In 2010, more than 600 measures were introduced in state legislatures to limit access to abortion and some 34 secured passage, according to tallies by Naral Pro-Choice America and the Center for Reproductive Rights. November’s elections made the outlook even bleaker.

Twenty-nine governors are considered solidly anti-abortion, up from 21 before the election. In 15 states, both the legislature and the governor are anti-abortion, compared with 10 last year. This math greatly increases the prospect of extreme efforts to undermine abortion access with Big Brother measures that require physicians to read scripts about fetal development and provide ultrasound images, and that impose mandatory waiting periods or create other unnecessary regulations.

Such restrictions, combined with a persistent atmosphere of intimidation and violence, have taken a grievous toll on the fundamental right protected by Roe v. Wade, the 1973 decision that recognized a woman’s constitutional right to make her own child-bearing decisions. Eighty-seven percent of counties have no abortion provider, according to the Guttmacher Institute.

For the moment, most state legislatures are preoccupied with budget crises, so the next abortion battles are still taking shape. However, there are at least two areas where anti-abortion forces will be active in 2011.

The first is the fight over health insurance. The second is the expanding effort to ban later abortions.

Reigning Supreme Court precedent restricts the government’s ability to bar abortions prior to the point considered to be the earliest a fetus could survive outside the womb, around 22 to 26 weeks after conception.

Nebraska enacted a law last year directly challenging the viability standard. The statute, which went into effect in October, bans abortions 20 weeks after conception. It includes a very narrow exception for a woman’s life and physical health, and lacks any exception for the discovery of severe fetal anomalies. Copycat laws are now pending in other states.

About 90 percent of abortions take place in the first trimester, but that does not excuse some states’ efforts to require women to continue pregnancies after a tragic fetal diagnosis or pregnancies that result from rape or incest. The objective is to provide the Supreme Court’s conservative majority with a new vehicle for further tampering with Roe v. Wade’s insight that the decision about whether to terminate a pregnancy is best left to women and their doctors pre-viability.

Americans who support women’s reproductive rights and oppose this kind of outrageous government intrusion need to respond with rising force and clarity to this real and immediate danger.

    The Two Abortion Wars: State Battles Over Roe v. Wade, NYT, 29.1.2011, http://www.nytimes.com/2011/01/30/opinion/30sun2.html

Do Emotions Play a Role in Illness?

January 29, 2011
The New York Times

To the Editor:

Re “A Fighting Spirit Won’t Save Your Life,” by Richard P. Sloan (Op-Ed, Jan. 25):

Dr. Sloan cites a Finnish study to support his belief that emotions have no role in disease. In fact, this study examined extroversion and neuroticism as risk factors for cancer, not “a fighting spirit” or other positive emotions.

A wide body of evidence has shown clearly that our emotions often play a role in illness. Chronic anger, hostility and depression significantly increase the risk of coronary heart disease. Chronic emotional stress shortens telomeres, the ends of our chromosomes that control how long we live. Support groups prolong survival in women with metastatic breast cancer.

To empower is not to blame. It’s not all in our genes — for example, meditation beneficially changes gene expression. Positive emotions don’t always override our genes, but they can play an important role. We’re not victims; our genes are a predisposition, but our genes are not our fate.

Dean Ornish
Sausalito, Calif., Jan. 25, 2011

The writer is founder and president of the Preventive Medicine Research Institute and a clinical professor of medicine at the University of California, San Francisco.

•

To the Editor:

Dr. Richard P. Sloan is quite justified in puncturing the myth that one’s character or attitude greatly affects the development or outcome of serious illness. But as Dr. Sloan knows, the story becomes more complex when clinically significant depression accompanies certain other medical conditions.

For example, there is probably a “bidirectional relationship” between coronary artery disease and major depression. A recent review by Dr. I. S. Khawaja and colleagues concluded that coronary artery disease can cause depression, and that depression is an independent risk factor for coronary artery disease and its complications.

Although the evidence is not conclusive, some data suggest that appropriate treatment of the accompanying depression may decrease cardiovascular risk factors as well. Finally, a “positive attitude” can and often does play a role in enhancing rehabilitation and adherence to medication, in a variety of diseases.

Ronald Pies
Lexington, Mass., Jan. 25, 2011

The writer is a psychiatrist associated with SUNY Upstate Medical University and Tufts University School of Medicine.

•

To the Editor:

Having lost someone to cancer, someone who loved life and lived it more fully than most of us, I give my appreciation to Richard P. Sloan for his article citing studies showing “no significant association between personality traits and the likelihood of developing or surviving cancer.”

If a fighting spirit were key to conquering cancer, then we might want to send patients to psychotherapy rather than to a clinical trial. Perhaps it would distract us from the return on the dollar that has been invested in cancer research so far.

Perhaps it would deaden the connotation that if those who survive a potentially fatal disease are fighters, then those who succumb are not. They are losers.

We all know that this is not true. We see terrifically brave and stoic people die each day from a disease of the body that has not daunted their spirit. Please, let’s drop the battleground lexicon and treat all those dealing with such serious disease with more compassion and understanding.

Melissa Cole
Elgin, Tex., Jan. 25, 2011

•

To the Editor:

Richard P. Sloan argues that “positive characteristics like optimism, spirituality and being a compassionate person” have no enhancing effects on health and longevity. Although we endorse his skepticism regarding scientific evidence for the power of positive thinking, it is critical to qualify his point, so as not to throw the baby out with the bath water.

For example, our work, and that of others, has demonstrated that helping behavior (and accompanying compassionate motives) are associated with reduced morbidity and mortality for the helper. We are exploring the physiological basis for compassionate motivation, and how that physiology is related to stress, and the extent to which it mitigates the effects of disease.

Given the well-documented relationship between stress and immune system functioning, we must not let misinterpretation and misrepresentation of some scientific findings obscure others, or delay discoveries that might save lives.

Stephanie L. Brown
R. Michael Brown
Stony Brook, N.Y., Jan. 25, 2011

The writers are, respectively, an associate professor of preventive medicine at Stony Brook University and professor emeritus of psychology at Pacific Lutheran University.

•

To the Editor:

Richard P. Sloan’s rational and compassionate analysis of the scientific evidence is a boon to all who live with illness and feel that they are somehow to blame if they do not recover.

While it is true that optimism and positive thinking cannot overcome illness, it is also true that religious hope and trust in God do not ensure recovery. Belief in a loving God is a source of comfort and strength for millions of people when they are faced with illness. Yet just as “the rain falls on the just and the unjust,” so, too, illness comes to the believer and the unbeliever alike.

None of the great religions of the world promise protection from the vicissitudes of life. Instead, they teach us to care for one another when trouble strikes.

In my ministry I have counseled hundreds of people who are racked with guilt because they feel that their faith was not strong enough to bring healing. Pray for strength and healing, yes, but recognize that not everything that happens is God’s will. To borrow a phrase, linking health to personal faith is not only bad science, it’s also bad religion.

(Rev.) David W. Spollett
Fairfield, Conn., Jan. 26, 2011

•

To the Editor:

A fighting spirit alone may not save your life, as Dr. Richard P. Sloan argues. But it can get you a lot more attention, especially in today’s understaffed health care facilities. And that attention can save your life.

Patrick Maney
Chestnut Hill, Mass., Jan. 25, 2011

    Do Emotions Play a Role in Illness?, NYT, 29.1.2011, http://www.nytimes.com/2011/01/30/opinion/l30health.html

A Fighting Spirit Won’t Save Your Life

January 24, 2011
The New York Times
By RICHARD P. SLOAN

GABRIELLE GIFFORDS’S remarkable recovery from a bullet to her head has provided a heartening respite from a national calamity. Representative Giffords’s husband describes her as a “fighter,” and no doubt she is one. Whether her recovery has anything to do with a fighting spirit, however, is another matter entirely.

The idea that an individual has power over his health has a long history in American popular culture. The “mind cure” movements of the 1800s were based on the premise that we can control our well-being. In the middle of that century, Phineas Quimby, a philosopher and healer, popularized the view that illness was the product of mistaken beliefs, that it was possible to cure yourself by correcting your thoughts. Fifty years later, the New Thought movement, which the psychologist and philosopher William James called “the religion of the healthy minded,” expressed a very similar view: by focusing on positive thoughts and avoiding negative ones, people could banish illness.

The idea that people can control their own health has persisted through Norman Vincent Peale’s “Power of Positive Thinking,” in 1952, to a popular book today, “The Secret,” by Rhonda Byrne, which teaches that to achieve good health all we have to do is to direct our requests to the universe.

It’s true that in some respects we do have control over our health. By exercising, eating nutritious foods and not smoking, we reduce our risk of heart disease and cancer. But the belief that a fighting spirit helps us to recover from injury or illness goes beyond healthful behavior. It reflects the persistent view that personality or a way of thinking can raise or reduce the likelihood of illness.

The psychosomatic hypothesis, which was popular in the mid-20th century, held that repressed emotional conflict was at the core of many physical diseases: Hypertension was the product of the inability to deal with hostile impulses. Ulcers were caused by unresolved fear and resentment. And women with breast cancer were characterized as being sexually inhibited, masochistic and unable to deal with anger.

Although modern doctors have rejected those beliefs, in the past 20 years, the medical literature has increasingly included studies examining the possibility that positive characteristics like optimism, spirituality and being a compassionate person are associated with good health. And books on the health benefits of happiness and positive outlook continue to be best sellers.

But there’s no evidence to back up the idea that an upbeat attitude can prevent any illness or help someone recover from one more readily. On the contrary, a recently completed study of nearly 60,000 people in Finland and Sweden who were followed for almost 30 years found no significant association between personality traits and the likelihood of developing or surviving cancer. Cancer doesn’t care if we’re good or bad, virtuous or vicious, compassionate or inconsiderate. Neither does heart disease or AIDS or any other illness or injury.

And while we may be able to point anecdotally to a Gabrielle Giffords as an example of how a fighting spirit improves medical outcome, other people with a spirit just as strong die — think of Elizabeth Edwards, for example. And many patients who employ negative thinking nevertheless recover from illness every day. We want good things to happen to good people and this desire blinds us to evidence to the contrary.

But such beliefs have implications for how we regard people who are ill. If people are insufficiently upbeat after a cancer diagnosis or inadequately “spiritual” after a diagnosis of AIDS, are we to assume they have willfully placed their health at risk? And if they fail to recover, is it really their fault? The incessant pressure to be positive imposes an enormous burden on patients whose course of treatment doesn’t go as planned.

Very early in my career, I participated in a study of young women who were hospitalized and awaiting the results of biopsies to determine if they had cervical cancer. While I was interviewing one of my patients, the biopsy results of the woman in the next bed came back to her — negative. The fortunate woman’s father, who was there with her, said in relief: “We’re good people. We deserve this.” It was a perfectly understandable response, but what should my patient have said to herself when her biopsy came back positive? That she got cancer because she wasn’t a good person?

It is difficult enough to be injured or gravely ill. To add to this the burden of guilt over a supposed failure to have the right attitude toward one’s illness is unconscionable. Linking health to personal virtue and vice not only is bad science, it’s bad medicine.

Richard P. Sloan, a professor of behavioral medicine at Columbia University Medical Center, is the author of “Blind Faith.”

    A Fighting Spirit Won’t Save Your Life, NYT, 24.1.2011, http://www.nytimes.com/2011/01/25/opinion/25sloan.html

What Comes After No?

January 24, 2011
The New York Times

The Republicans have vowed to “repeal and replace” President Obama’s historic health care reform law. Now that House Republicans have muscled through a symbolic repeal bill, they will have to deliver their own alternative plan. Don’t expect much.

There are many more slogans than details. But it is already clear that their approach would do almost nothing to control skyrocketing health care costs and would provide little help to the 50 million uninsured Americans.

When Republican leaders talk of reducing medical costs they really mean reducing insurance premiums for some people, primarily by letting the young and healthy buy insurance in states that allow the sale of skimpy policies. That won’t help older and less healthy people and would probably drive up their premiums as they flock to states whose regulations guarantee them coverage.

The Republicans have offered no coherent plan for slowing the rapid rise in medical costs that is driving up insurance premiums, Medicare and Medicaid costs, and the federal deficit. The reform law, by contrast, has multiple provisions for changing the delivery of health care in ways that should reduce costs.

As for the Republicans’ calls to reduce waste and fraud in Medicare, reform the medical malpractice system, and expand high-risk pools to cover people with pre-existing conditions, most of these ideas are already in the reform law. They could surely be strengthened if both parties worked together.

Even as it denounces reform at every turn, the Republican leadership has figured out that many Americans want the many consumer protections that come with the new law. So, once reform is repealed, the leaders are vowing to reinstate such provisions as letting young people stay on their parents’ plans until age 26, preventing insurers from canceling policies after people become sick, and barring insurers from placing caps on what they will pay.

The problem is that such requirements will drive up the cost of insurance unless they are paired with a mandate (or comparable prod) requiring that everyone buy insurance so that healthy people offset the costs of less healthy beneficiaries. Yes, that’s the same mandate the Republicans have vowed to overturn.

Many Republicans have also vowed to restore more than $130 billion worth of unjustified subsidies to private Medicare Advantage plans that is needed to help pay for the expansion of coverage under health care reform.

In coming weeks, expect to see a lot more posturing on issues that might energize the party’s conservative base or poll well with people made skittish by months of Republican exaggerations about the new reform law. They have already introduced bills making it even harder for insurance policies in new insurance exchanges to cover abortions, never mind that the law already has incredibly strict provisions.

The Party of No will also try to use its new control of the House to block implementation of reform by withholding money needed to hire people to write necessary regulations. The House Republican Study Committee has proposed legislation that would prohibit using money in the annual budget to carry out any provision of the law or to defend it in court.

The Republicans need to explain how they plan to address the problems of covering the uninsured, wrestling down medical costs and controlling the deficit. Just saying no isn’t enough.

    What Comes After No?, NYT, 24.1.2011, http://www.nytimes.com/2011/01/25/opinion/25tue1.html

Lawmakers in Many States Pushing for Abortion Curbs

January 21, 2011
The New York Times
By ERIK ECKHOLM

Newly energized by their success in November’s midterm elections, conservative legislators in dozens of states are mounting aggressive campaigns to limit abortions.

The lawmakers are drafting, and some have already introduced, bills that would ban most abortions at 20 weeks after conception, push women considering abortions to view a live ultrasound of the fetus, or curb insurance coverage, among other proposals.

In Florida and Kansas, legislators plan to reintroduce measures that were vetoed by previous governors but have the support of the new chief executives, like ultrasound requirements and more stringent regulation of late-term abortions.

“I call on the Legislature to bring to my desk legislation that protects the unborn, establishing a culture of life in Kansas,” Gov. Sam Brownback said last week in his first State of the State message.

“This is the best climate for passing pro-life laws in years,” said Michael Gonidakis, executive director of Ohio Right to Life, expressing the mood in many states. “We’ve got a pro-life governor and a brand new pro-life speaker. Our government now is pro-life from top to bottom.”

Abortion opponents plan marches in Washington and elsewhere this weekend and on Monday to mark the anniversary of the 1973 Supreme Court decision, Roe v. Wade, that established a woman’s right to an abortion.

Republicans in Congress hope to strengthen measures to prevent even indirect public financing of abortions, but laws in the states have the greatest impact on access to them. Abortion opponents have been emboldened by major changes in the political landscape, with conservative Republicans making large gains.

Although social issues were often played down in the campaigns, many of the newly elected governors and legislators are also solidly anti-abortion, causing advocates of abortion rights to brace for a year of even tougher battles than usual.

The biggest shift is in the state capitols, with 29 governors now considered to be solidly anti-abortion, compared with 21 last year. “This is worrisome because the governors have been the firewall, they’ve vetoed a lot of bad anti-choice legislation,” said Ted Miller, a spokesman for Naral Pro-Choice America.

In 15 states, compared with 10 last year, both the legislature and the governor are anti-abortion, according to a new report by Naral, and those joining this category include larger states like Michigan, Ohio and Wisconsin, as well as Georgia and Oklahoma. Maine and Pennsylvania are now strongly anti-abortion as well, if not quite as solidly.

Just which measures will pass is impossible to predict, particularly because many states are bogged down by budget crises.

Elizabeth Nash, who tracks state policies on abortion for the Guttmacher Institute, a research organization, said that while states would be preoccupied with budget issues, it appeared rather likely that more measures would pass this year than in 2010, which anti-abortion advocates considered a banner year, with more than 30 restrictive laws adopted in at least nine states.

The elections brought even more gains for their side than expected, said Mary Spaulding Balch, state policy director of the National Right to Life Committee, leading her group to call in its affiliates for a special strategy session on Dec. 7.

While many anti-abortion measures have been adopted or debated over the years, including requiring parental consent for minors and waiting periods, advocates have set a few top priorities for the months ahead:

¶Banning abortions earlier in pregnancy. Most states place restrictions on later abortions, often defined as after fetal viability, or around 22 to 26 weeks after conception. But last year, Nebraska set what many advocates consider a new gold standard, banning abortions, unless there is imminent danger to the woman’s life or physical health, at 20 weeks after conception, on a disputed theory that the fetus can feel pain at that point. The measure has not been tested in court, but similar measures pushing back the permissible timing are being developed in Indiana, Iowa, New Hampshire, Oklahoma and other states.

The 20-week law in Nebraska, which took effect in October, forced a prominent doctor who performed late-term abortions to leave the state. Jill June, president of Planned Parenthood of the Heartland, said women suffering from complicated pregnancies but are not yet sick enough to qualify for an emergency abortion would be forced to travel to other states. Or, she said, doctors fearing prosecution will wait until such women become dangerously ill before considering an abortion.

¶Pressing women to view ultrasounds. While several states encourage women seeking abortions to view an ultrasound, Oklahoma last year adopted a requirement that doctors or technicians perform the procedure with the screen visible to the woman, and explain in detail what she is seeing. The measure is under court challenge, but the Kentucky Senate has passed a similar bill, and variants are expected to come up in states including Indiana, Maryland, Montana, Ohio, Texas, Virginia and Wyoming.

In Florida, former Gov. Charlie Crist vetoed an ultrasound bill. The new governor, Rick Scott, attacked him for that veto and is expected to support a new proposal.

¶Banning any abortion coverage by insurance companies in the new health insurance exchanges. Numerous states are poised to impose the ban on plans that will be offered to small businesses and individual insurance buyers under the Obama administration health plan.

The shifts to conservative governors, in particular, have opened new opportunities for abortion opponents. In Kansas, legislators said they would act quickly to adopt measures that were previously vetoed, including regulations that will make it harder to open abortion clinics or to perform abortions in the second trimester.

“There’s pent-up demand in the Legislature for these changes,” said State Representative Lance Kinzer, the chairman of the Judiciary Committee in the Kansas House. Once these long-debated steps are taken, he said, the Legislature will consider more sweeping restrictions, including banning most abortions after the 20th week.

The politics of abortion have changed profoundly in some larger states including Michigan, Pennsylvania and Wisconsin.

“We’re facing the biggest threat to reproductive rights we’ve ever faced in this state,” said Lisa Subeck, executive director for Naral Pro-Choice Wisconsin.

In Michigan, because of the switch to an anti-abortion governor, “the dominos are lined up well for us this time,” said Ed Rivet, legislative director for Right to Life of Michigan. For starters, advocates hope to pass a state ban on the procedure opponents call partial-birth abortion that had been vetoed twice. After that, he said, “We have quite a list.”

Many defenders of abortion rights argue that because the election hinged largely on the economy and the role of government, officials did not receive a mandate for sweeping new social measures. “This last election was not about these issues at all,” said Cecile Richards, president of the Planned Parenthood Federation of America. “We now are concerned about a real overreaching by some state legislators and governors that will make it very difficult for women to access reproductive health care.”

Daniel S. McConchie, vice president for government affairs with Americans United for Life, responded that laws restricting abortion have been adopted right along by the states and that while he expected large gains in the year ahead, they will be part of steady trend.

The abortion rate in the United States, which had declined steadily since a 1981 peak of more than 29 abortions per 1,000 women, stalled between 2005 and 2008, at slightly under 20 abortions per 1,000 women, according to a new report from the Guttmacher Institute.


Robbie Brown contributed reporting from Atlanta, Dan Frosch from Denver and Emma Graves Fitzsimmons from Chicago.

    Lawmakers in Many States Pushing for Abortion Curbs, NYT, 21.1.2011, http://www.nytimes.com/2011/01/22/us/politics/22abortion.html

Why Parents Fear the Needle

January 20, 2011
The New York Times
By MICHAEL WILLRICH

Wellesley, Mass.

DESPITE overwhelming evidence to the contrary, roughly one in five Americans believes that vaccines cause autism — a disturbing fact that will probably hold true even after the publication this month, in a British medical journal, of a report thoroughly debunking the 1998 paper that began the vaccine-autism scare.

That’s because the public’s underlying fear of vaccines goes much deeper than a single paper. Until officials realize that, and learn how to counter such deep-seated concerns, the paranoia — and the public-health risk it poses — will remain.

The evidence against the original article and its author, a British medical researcher named Andrew Wakefield, is damning. Among other things, he is said to have received payment for his research from a lawyer involved in a suit against a vaccine manufacturer; in response, Britain’s General Medical Council struck him from the medical register last May. As the journal’s editor put it, the assertion that the measles-mumps-rubella vaccine caused autism “was based not on bad science but on a deliberate fraud.”

But public fear of vaccines did not originate with Dr. Wakefield’s paper. Rather, his claims tapped into a reservoir of doubt and resentment toward this life-saving, but never risk-free, technology.

Vaccines have had to fight against public skepticism from the beginning. In 1802, after Edward Jenner published his first results claiming that scratching cowpox pus into the arms of healthy children could protect them against smallpox, a political cartoon appeared showing newly vaccinated people with hooves and horns.

Nevertheless, during the 19th century vaccines became central to public-health efforts in England, Europe and the Americas, and several countries began to require vaccinations.

Such a move didn’t sit comfortably with many people, who saw mandatory vaccinations as an invasion of their personal liberty. An antivaccine movement began to build and, though vilified by the mainstream medical profession, soon boasted a substantial popular base and several prominent supporters, including Frederick Douglass, Leo Tolstoy and George Bernard Shaw, who called vaccinations “a peculiarly filthy piece of witchcraft.”

In America, popular opposition peaked during the smallpox epidemic at the turn of the 20th century. Health officials ordered vaccinations in public schools, in factories and on the nation’s railroads; club-wielding New York City policemen enforced vaccinations in crowded immigrant tenements, while Texas Rangers and the United States Cavalry provided muscle for vaccinators along the Mexican border.

Public resistance was immediate, from riots and school strikes to lobbying and a groundswell of litigation that eventually reached the Supreme Court. Newspapers, notably this one, dismissed antivaccinationists as “benighted and deranged” and “hopeless cranks.”

But the opposition reflected complex attitudes toward medicine and the government. Many African-Americans, long neglected or mistreated by the white medical profession, doubted the vaccinators’ motives. Christian Scientists protested the laws as an assault on religious liberty. And workers feared, with good reason, that vaccines would inflame their arms and cost them several days’ wages.

Understandably, advocates for universal immunization then and now have tended to see only the harm done by their critics. But in retrospect, such wariness was justified: at the time, health officials ordered vaccinations without ensuring the vaccines were safe and effective.

Public confidence in vaccines collapsed in the fall of 1901 when newspapers linked the deaths of nine schoolchildren in Camden, N.J., to a commercial vaccine allegedly tainted with tetanus. In St. Louis, 13 more schoolchildren died of tetanus after treatment with the diphtheria antitoxin. It was decades before many Americans were willing to submit to public vaccination campaigns again.

Nevertheless, the vaccination controversy of the last century did leave a positive legacy. Seeking to restore confidence after the deaths in Camden and St. Louis, Congress enacted the Biologics Control Act of 1902, establishing the first federal regulation of the nation’s growing vaccine industry. Confronted with numerous antivaccination lawsuits, state and federal courts established new standards that balanced public health and civil liberties.

Most important, popular resistance taught government officials that when it comes to public health, education can be more effective than brute force. By midcentury, awareness efforts had proven critical to the polio and smallpox vaccination efforts, both of which were huge successes.

One would think such education efforts would no longer be necessary. After all, today’s vaccines are safer, subject to extensive regulatory controls. And shots are far more numerous: as of 2010, the Centers for Disease Control recommended that every child receive 10 different vaccinations. For most Americans, vaccines are a fact of life.

Still, according to a 2010 C.D.C. report, 40 percent of American parents with young children have delayed or refused one or more vaccines for their child. That’s in part because vaccines have been so successful that any risk associated with their use, however statistically small, takes on an elevated significance.

It also doesn’t help that, thanks to the Internet, a bottomless archive of misinformation, including Dr. Wakefield’s debunked work, is just a few keystrokes away. All of which means the public health community must work even harder to spread the positive news about vaccines.

Health officials often get frustrated with public misconceptions about vaccines; at the turn of the last century, one frustrated Kentucky health officer pined for the arrival of “the fool-killer” — an outbreak of smallpox devastating enough to convince his skeptical rural constituency of the value of vaccination.

But that’s no way to run a health system. Our public health leaders would do far better to adopt the strategy used by one forward-thinking federal health official from the early 20th century, C. P. Wertenbaker of the Public Health and Marine-Hospital Service.

As smallpox raged across the American South, Wertenbaker journeyed to small communities and delivered speech after speech on vaccinations before swelling audiences of townsfolk, farmers and families. He listened and replied to people’s fears. He told them about the horrors of smallpox. He candidly presented the latest scientific information about the benefits and risks of vaccination. And he urged his audiences to protect themselves and one another by taking the vaccine. By the time he was done, many of his listeners were already rolling up their sleeves.

America’s public health leaders need to do the same, to reclaim the town square with a candid national conversation about the real risks of vaccines, which are minuscule compared with their benefits. Why waste another breath vilifying the antivaccination minority when steps can be taken to expand the pro-vaccine majority?

Obstetricians, midwives and pediatricians should present the facts about vaccines and the nasty diseases they prevent early and often to expectant parents. Health agencies should mobilize local parents’ organizations to publicize, in realistic terms, the hazards that unvaccinated children can pose to everyone else in their communities. And health officials must redouble their efforts to harness the power of the Internet and spread the good word about vaccines.

You can bet that Wertenbaker would have done the same thing.

Michael Willrich, an associate professor of history at Brandeis University, is the author of the forthcoming “Pox: An American History.”

    Why Parents Fear the Needle, NYT, 20.1.2011, http://www.nytimes.com/2011/01/21/opinion/21willrich.html

House Votes for Repeal of Health Law in Symbolic Act

January 19, 2011
By THE NEW YORK TIMES
By DAVID M. HERSZENHORN and ROBERT PEAR

WASHINGTON — The House voted Wednesday to repeal the Democrats’ landmark health care overhaul, marking what the new Republican majority in the chamber hailed as the fulfillment of a campaign promise and the start of an all-out effort to dismantle President Obama’s signature domestic policy achievement.

The vote was 245 to 189, with 3 Democrats joining all 242 Republicans in support of the repeal.

Leaders of the Democratic-controlled Senate have said that they will not act on the repeal measure, effectively scuttling it.

While conceding that reality, House Republicans said they would press ahead with their “repeal and replace” strategy. But the next steps will be much more difficult, as they try to forge consensus on alternatives emphasizing “free market solutions” to control health costs and expand coverage.

Even as four House committees begin drafting legislation, Republicans said they would seek other ways to stop the overhaul, by choking off money needed to carry it out and by pursuing legislation to undo specific provisions, like a requirement for most Americans to carry health insurance or face penalties. The law is also under challenge in the federal courts, with the individual coverage requirements fueling a constitutional battle likely to be decided by the Supreme Court.

The House vote was the first stage of a Republican plan to use the party’s momentum coming out of the midterm elections to keep the White House on the defensive, and will be followed by a push to scale back federal spending. In response, the administration struck a more aggressive posture than it had during the campaign to sell the health care law to the public. With many House Democrats from swing districts having lost their seats in November, the remaining Democrats held overwhelmingly together in opposition to the repeal.

On the House floor, the resulting debate was a striking reprise of the one that engulfed Capitol Hill from the spring of 2009 until March 2010, when Mr. Obama signed the health care law.

And while the tone was slightly subdued in the aftermath of the attempted assassination of Representative Gabrielle Giffords in Arizona, the debate showed that the divisions over the law remained as deep as ever.

The three Democrats who crossed the aisle to support the repeal were Representatives Dan Boren of Oklahoma, Mike McIntyre of North Carolina, and Mike Ross of Arkansas, all of whom opposed the law last year.

Ms. Giffords, who had supported the law, remains hospitalized in Arizona and was the only House member who did not vote.

Republicans denounced the law as an intrusion by the government that would prompt employers to eliminate jobs, create an unsustainable entitlement program, saddle states and the federal government with unmanageable costs, and interfere with the doctor-patient relationship. Republicans also said the law would exacerbate the steep rise in the cost of medical services.

“Repeal means paving the way for better solutions that will lower the cost without destroying jobs or bankrupting our government,” the House speaker, John A. Boehner of Ohio, said. “Repeal means keeping a promise. This is what we said we would do.”

Democrats, eager for a second chance to sell the law, trumpeted the benefits that have already taken effect. These include protections for people who would otherwise be denied insurance coverage based on a pre-existing medical condition, the ability for children to stay on their parents’ policy until age 26, and new tax breaks for small businesses that provide health coverage to their workers.

Representative John Lewis, Democrat of Georgia, said, “It is unbelievable that with so many people out of work and millions of people uninsured, the first act of this new Congress is to take health care away from people who just got coverage.”

The health care law, which Congress approved last year without a single Republican in favor, seeks to extend insurance to more than 30 million people by expanding Medicaid and providing federal subsidies to help lower and middle-income Americans buy private coverage.

Republican leaders said they had not set any timetable for the four committees drafting alternatives to the law. “I don’t know that we need artificial deadlines for the committees to act,” Mr. Boehner said. “We expect them to act in an efficient way.”

Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages in medical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.

Republicans also want to help states expand insurance pools for people with serious illnesses. The new law includes such pools, as an interim step until broader insurance coverage provisions take effect in 2014, but enrollment has fallen short of expectations.

Representative Paul Broun, Republican of Georgia, said that allowing people to buy insurance across state lines would “expand choice and competition.” And he said businesses could negotiate better insurance rates if they could join together in “association health plans,” sponsored by trade and professional groups.

But state insurance officials have resisted such proposals, on the ground that they would weaken state authority to regulate insurance and to enforce consumer protections -- a concern shared by Congressional Democrats.

Some Republicans seemed sensitive to accusations that repeal would strip away new patient protections and leave millions of Americans without insurance.

Representative Joe Heck, Republican of Nevada and a physician, said he supported some goals of the new law: “making sure people don’t lose their coverage once they get sick; letting dependent children stay on their parents’ insurance until they turn 26; making sure anyone who wants to buy insurance can purchase a policy, regardless of pre-existing conditions.”

Representative Joe L. Barton, Republican of Texas, said, “There are some things in the new law that we think are worth keeping,” including a procedure for approval of generic versions of expensive biotechnology drugs.

But Mr. Barton and other Republicans returned to a core objection to the law, which they said extends the reach of government too far.

“We believe that you shouldn’t have the federal government mandate that an individual has to have health insurance, whether he or she wants it,” Mr. Barton said. “We want to repeal today so that we can begin to replace tomorrow.”

Representative Allyson Y. Schwartz, Democrat of Pennsylvania, said she doubted that the Republican alternatives would be effective in expanding coverage or controlling costs.

“Many Republicans want to repeal the law, but are not serious about replacing it,” Ms. Schwartz said.

    House Votes for Repeal of Health Law in Symbolic Act, NYT, 19.1.2011, http://www.nytimes.com/2011/01/20/health/policy/20cong.html

Basic Questions, Elusive Answers on Health Law

January 18, 2011
The New York Times
By DAVID M. HERSZENHORN and ROBERT PEAR

WASHINGTON — As the fight over health care returned to the House floor on Tuesday, the debate could largely be stripped down to four questions that are relatively simple to ask, if not to answer:

Will the health care law, approved last year by Democrats with no Republican support, increase or reduce future federal deficits?

Will the law lead to the elimination of jobs by overburdened employers as Republicans assert, or will it create jobs as Democrats maintain?

Will the law raise or lower the cost of medical care for individuals and families, employers, and state and federal governments?

And, will the law achieve President Obama’s goal of providing coverage to more than 30 million uninsured Americans?

Given the complexity of the issues, none of these questions can yet be answered definitively.

More certain is the fate of the Republicans’ bill to repeal the law, which contains 24 lines of legislative text and 38 lines of the names of the lawmakers sponsoring it. While House Republicans will vote to approve it on Wednesday, the Democratic-controlled Senate is highly unlikely to act on it.

Still, the assertions from the two sides highlight their radically different views about the proper role of government and market forces in the health care system. It is a policy fight that is likely to rage for the next two years in Congress and to figure prominently in the 2012 presidential campaign.

As floor debate on the repeal measure opened on Tuesday, Representative Paul Ryan, Republican of Wisconsin and chairman of the Budget Committee, who is a respected voice on fiscal issues, declared that the health care law would “accelerate our country’s path toward bankruptcy.”

Mr. Ryan expressed one of the Republicans’ main complaints: that Democrats and independent Congressional budget analysts have underestimated the costs of the law, which Republicans say will ultimately add hundreds of billions of dollars to future federal deficits.

The nonpartisan Congressional Budget Office disagrees.

In its official analysis, the budget office estimated that the cost of new benefits in the health care law would be more than offset by revenues from new taxes and by cuts in projected Medicare spending, reducing future deficits. Repealing the law, the budget office has predicted, would add $230 billion to federal deficits from 2012 to 2021.

Republicans dispute that, saying the cost will be far higher than expected.

“We believe that it is an unsustainable, open-ended entitlement that could very well bankrupt this country and the states,” the House majority leader, Representative Eric Cantor, Republican of Virginia, said at a news conference on Tuesday.

The budget office has said that its estimates are based on the most likely outcomes, and that the eventual cost of the bill is equally likely to be higher or lower.

The office has also said that lawmakers may find it difficult to follow through with some aspects of the law, particularly cuts in projected Medicare spending. If the cuts do not take hold, the cost of the law could soar.

Democrats, meanwhile, say the law could save even more money than expected because the budget office does not give them credit for likely improvements in the delivery of medical services that could slow the growth in costs for individuals, businesses and the federal and state governments.

Weighing into the debate, Mr. Obama said Tuesday that Americans were already enjoying many benefits of the new law, and that he would not let Republicans dismantle it.

“I’m willing and eager to work with both Democrats and Republicans to improve the Affordable Care Act,” Mr. Obama said in a statement. “But we can’t go backward.”

The White House and Congressional Democrats said the law would create more than 300,000 jobs, by slowing the growth of health costs so employers would have more to spend on wages and hiring. In addition, they said, the law provides tax credits to help many small businesses buy insurance for their employees.

By contrast, Representative Sam Graves, Republican of Missouri and chairman of the House Committee on Small Business, said the law “could cost our economy 1.6 million jobs, one million of which could come from small businesses.”

Many economists say the effects on jobs are likely to be modest. Most large companies already provide health benefits to employees. And many small businesses will be exempt from penalties if they fail to do so.

While employers often pay premiums for their employees, economists say, the cost of health benefits is, over time, generally passed on to workers, through reductions in wages or other compensation. But employers cannot reduce the wages of people earning the minimum wage.

Thus, the Congressional Budget Office says, the new law “will probably cause some employers to respond by hiring fewer low-wage workers,” or by using more part-time and seasonal workers.

But Democrats say that if the law provides coverage to more than 30 million currently uninsured people, as intended, it will increase demand for medical services, thus creating new job opportunities in the health care industry.

Representative Debbie Wasserman Schultz, Democrat of Florida, said, “There is not a single area of health care” that will experience job losses as a result of the law.

Republicans have emphasized the jobs issue, even naming their bill the “Repealing the Job-Killing Health Care Law Act.” But they have also pressed an argument that the law does not do much to slow the growth of health spending.

The law includes many provisions intended to restrain medical costs, which have long grown faster than general inflation.

For example, it would trim Medicare payment rates for hospitals and many other health care providers; create an independent advisory board to recommend further savings in Medicare; and encourage doctors and hospitals to coordinate care, eliminate duplicative tests and reduce the readmission of patients to hospitals.

But experts say they are not sure how effective these provisions will be, and note that countries around the globe have struggled to control medical costs.

Republicans say the law is geared less to limiting costs than to extending coverage to the uninsured. The budget office has estimated that by 2019 the law will have reduced the number of uninsured Americans by 32 million.

But even with a provision in the law requiring that most Americans obtain insurance, it is possible that the law will not cover as many people as expected. Some supporters of the law have questioned whether federal subsidies will be adequate to make insurance affordable for lower- and middle-income Americans. And while the law includes a broad expansion of Medicaid eligibility, many people now eligible do not enroll.

In addition, the continuing political controversy around the law has created even more uncertainty about how people will respond to it.

    Basic Questions, Elusive Answers on Health Law, NYT, 18.1.2011, http://www.nytimes.com/2011/01/19/us/politics/19cong.html

Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive

January 18, 2011
The New York Times
By A. G. SULZBERGER and BENEDICT CAREY

TUCSON —What are you supposed to do with someone like Jared L. Loughner?

That question is as difficult to answer today as it was in the years and months and days leading up to the shooting here that left 6 dead and 13 wounded.

Millions of Americans have wondered about a troubled loved one, friend or co-worker, fearing not so much an act of violence, but — far more likely — self-inflicted harm, landing in the streets, in jail or on suicide watch. But those in a position to help often struggle with how to distinguish ominous behavior from the merely odd, the red flags from the red herrings.

In Mr. Loughner’s case there is no evidence that he ever received a formal diagnosis of mental illness, let alone treatment. Yet many psychiatrists say that the warning sings of a descent into psychosis were there for months, and perhaps far longer.

Moving a person who is resistant into treatment is an emotional, sometimes exhausting process that in the end may not lead to real changes in behavior. Mental health resources are scarce in most states, laws make it difficult to commit an adult involuntarily, and even after receiving treatment, patients frequently stop taking their medication or seeing a therapist, believing that they are no longer ill.

The Virginia Tech gunman was committed involuntarily before killing 32 people in a 2007 rampage.

With Mr. Loughner, dozens of people apparently saw warning signs: the classmates who listened as his dogmatic language grew more detached from reality. The police officers who nervously advised that he could not return to college without a medical note stating that he was not dangerous. His father, who chased him into the desert hours before the attack as Mr. Loughner carried a black bag full of ammunition.

“This isn’t an isolated incident,” said Daniel J. Ranieri, president of La Frontera Center, a nonprofit group that provides mental health services. “There are lots of people who are operating on the fringes who I would describe as pretty combustible. And most of them aren’t known to the mental health system.”

Dr. Jack McClellan, an adult and child psychiatrist at the University of Washington, said he advises people who are worried that someone is struggling with a mental disorder to watch for three things — a sudden change in personality, in thought processes, or in daily living. “This is not about whether someone is acting bizarrely; many people, especially young people, experiment with all sorts of strange beliefs and counterculture ideas,” Dr. McLellan said. “We’re talking about a real change. Is this the same person you knew three months ago?”

Those who have watched the mental unraveling of a loved one say that recognizing the signs is only the first step in an emotional, often confusing, process. About half of people with mental illnesses do not receive treatment, experts estimate, in part because many of them do not recognize that they even have an illness.

Pushing such a person into treatment is legally difficult in most states, especially when he or she is an adult — and the attempt itself can shatter the trust between a troubled soul and the one who is most desperate to help. Others, though, later express gratitude.

“If the reason is love, don’t worry if they’ll be mad at you,” said Robbie Alvarez, 28, who received a diagnosis of schizophrenia after being involuntarily committed when his increasingly erratic behavior led to a suicide attempt. At the time, he said, he was living in Phoenix with his parents, who he was convinced were trying to kill him. In Arizona it is easier to obtain an involuntary commitment than in many states because anyone can request an evaluation if they observe behavior that suggests a person may present a danger or is severely disabled (often state laws require some evidence of imminent danger to self or others).

But there are also questions about whether the system can accommodate an influx of new patients. Arizona’s mental health system has been badly strained by recent budget cuts that left those without Medicaid stripped of most of their services, including counseling and residential treatment, though eligibility remains for emergency services like involuntary commitment. And the state is trying to change eligibility requirements for Medicaid, which would potentially reduce financing further and leave more with limited services.

Still, people who have been through the experience argue that it is better to act sooner rather than later. “It’s not easy to know when we could or should intervene but I would rather err on the side of safety than not,” said H. Clarke Romans, executive director of the local chapter of the National Alliance on Mental Illness, an advocacy group, who had a son with schizophrenia.

The collective failure to move Mr. Loughner into treatment, either voluntarily or not, will never be fully understood, because those who knew the young man presumably wrestled separately and privately about whether to take action. But the inaction has certainly provoked second-guessing. Sheriff Clarence Dupnik of Pima County told CNN last Wednesday that Mr. Loughner’s parents were as shocked as everyone else. “It’s been very, very devastating for them,” he said. “They had absolutely no way to predict this kind of behavior.”

Linda Rosenberg, president of the National Council for Community Behavioral Healthcare, said, “The failure here is that we ignored someone for a long time who was clearly in tremendous distress.” Ms. Rosenberg, whose group is a nonprofit agency leading a campaign to teach people how to recognize and respond to signs of mental illness, added, “He wasn’t someone who could ask for help because his thinking was affected, and as a community no one said, let’s stop and make sure he gets help.”

At the University of Arizona, where a nursing student killed three instructors on campus eight years ago before killing himself, feelings of sadness and anger initially mixed with some guilt as the university examined the missed warning signs.

The overhauled process for addressing concerns is now more responsive, even if there are sometimes false alarms, said Melissa M. Vito, vice president for student affairs. “I guess I’d rather explain why I called someone’s parents than why I didn’t do something,” she said.

Many others feel the same way.

Four years ago Susan Junck watched her 18-year-old son return from community college to their Phoenix home one afternoon and, after preparing a snack, repeatedly call the police to accuse his mother of poisoning him. She assumed it was an isolated outburst, maybe connected to his marijuana use. In the coming months, though, her son’s behavior grew more alarming, culminating in an arrest for assaulting his girlfriend, who was at the center of a number of his conspiracy theories.

“I knew something was wrong but I literally just did not understand what,” Ms. Junck, 49, said in a recent interview. “It probably took a year before I realized my son has a mental illness. This isn’t drug related, this isn’t bad behavior, this isn’t teenage stuff. This is a serious mental illness.”

Fearful and desperate, she brought her son to an urgent psychiatric center and — after a five-hour wait — agreed to sign paperwork to have him involuntarily committed as a danger to himself or others. Her son screamed for her help as he was carried off. He was diagnosed with paranoid schizophrenia and remains in a residential treatment facility.

This week Erin Adams Goldman, a suicide prevention specialist with a mental health nonprofit organization in Tucson, is teaching the first local installment of a course that is being promoted around the country called mental health first aid, which instructs participants how to recognize and respond to the signs of mental illness.

A central tenet is that if a person has suspicions about mental illness it is better to open the conversation, either by approaching the individual directly, someone else who knows the person well or by asking for a professional evaluation.

“There is so much fear and mystery around mental illness that people are not even aware of how to recognize it and what to do about it,” Ms. Goldman said. “But we get a feeling when something is not right. And what we teach is to follow your gut and take some action.”


A. G. Sulzberger reported from Tucson, and Benedict Carey from New York.

    Getting Someone to Psychiatric Treatment Can Be Difficult and Inconclusive, NYT, 18.1.2011, http://www.nytimes.com/2011/01/19/us/19mental.html

Reproductive Choices Women Face

January 8, 2011
The New York Times


To the Editor:

Re “The Unborn Paradox” (column, Jan. 2): Ross Douthat seems to be suggesting that women with unintended pregnancies should bear children rather than have abortions because infertile women want babies. In doing so, Mr. Douthat ignores the serious health risks that pregnancies sometimes incur. Should women with unwanted pregnancies be compelled to take those risks?

Consider New Year’s Eve, a typical night on my obstetrics floor. Several pregnant women were suffering from complications. Two needed emergency surgery. One was 19 years old and 20 weeks pregnant with an abnormal fetus. She had decided to see the pregnancy through. But the amniotic sac ruptured five months early. We had to stop the heavy bleeding and infection that followed. Her baby didn’t survive.

Abortion opponents would impose all the risks of pregnancy on women who wish to end their pregnancies. Instead, let’s make sure that everyone on the socioeconomic ladder can prevent and plan conception.

Anne Davis
New York, Jan. 3, 2011

The writer, an obstetrician, is medical director of Physicians for Reproductive Choice and Health.

•

To the Editor:

I have supported abortion rights for as long as I can remember, but nothing cemented my commitment to women’s reproductive freedom like my own very much wanted pregnancy nine years ago.

As I grew increasingly delighted about both my experience of pregnancy and planning for a life with twin babies, I imagined how differently I would feel in other circumstances. What if I were 14 rather than 34? What if my partner and I had as many children as we could handle, or more? What if one or both of us were unemployed?

How might our thrill at the short-term changes in my body and the long-term changes in our lives transform into dread, depression and anxiety?

Moreover, just because expectant parents are able to think of the fetus as a baby does not mean it actually is one, and that abortion is the same as the taking of an actual life, rather than a fantasized one.

Sarah E. Chinn
Brooklyn, Jan. 3, 2011

•

To the Editor:

Ross Douthat provides an eloquent analysis of the abortion conundrum. We embrace the humanity of our “wanted” babies while we strip the human rights from those whose conception was unplanned and unwanted. And yet, the circumstances of conception don’t change the fact that a child in the womb is a separate and unique human being, morally and ethically entitled to the same rights as you and I.

Mr. Douthat also points out that adoption has become an unlikely choice for young mothers like Markai Durham, the subject of an MTV show, who says she couldn’t bear to give up a child she carried in her womb for nine months, and opts, instead, to kill that child.

Did anyone along the way point out the deadly flaw in her thinking? Markai and the million-plus babies who fall into the “unwanted” category every year deserve to be given a choice that doesn’t involve murder. (Rev.)

Frank Pavone
National Director, Priests for Life
Staten Island, Jan. 3, 2011

•

To the Editor:

What MTV depicted in its documentary “No Easy Decision,” and what Ross Douthat does not acknowledge in his column, is that Markai Durham and thousands of women like her are capable of sensitively and wisely weighing the decisions that have consequences of life or death.

Mr. Douthat offers no evidence that fewer abortions would mitigate complex fertility treatments or the enormous amount of bureaucratic red tape surrounding the adoption process. Many studies in fact suggest that, in a culture that treasures biological children, prospective parents opt first for fertility treatments and then, if at all, pursue adoption.

A thoughtful look at reproductive decision-making is always welcome, but a broadside that once again seeks to demonize and make guilty those women who elect to terminate their pregnancies is not adding to the civil discourse.

Conflating fertility, adoption and abortion in no way alleviates the myriad challenges involved in deciding whether or not to become a parent.

Joan Malin
President and C.E.O.
Planned Parenthood of New York City
New York, Jan. 3, 2011

•

To the Editor:

I disagree with Ross Douthat’s appraisal of adoption as an answer to unplanned pregnancies and infertility. I have worked with many pregnant teenagers and young adult women in my 25 years as a director of an adoption agency, and adoption is only a small part of the solution.

While I am obviously sympathetic to the desire of infertile couples to become parents, their needs can never supersede those of pregnant women who are not prepared to be parents.

Research has shown that abortion very rarely leads to long-term negative psychological consequences for those women who choose it (myself included).

Yes, of course there is regret and sadness for some women, but carrying a baby to term and placing him or her for adoption more often than not leads to a lifetime of pain and sadness, regardless of how right the situation may seem. It is the right choice for the very few.

Abortion and adoption are two ends of the same spectrum — women having choices about their reproductive lives. But the agony of a woman placing a child for adoption cannot be understated.

Randie Bencanann
San Francisco, Jan. 3, 2011

    Reproductive Choices Women Face, NYT, 8.1.2011, http://www.nytimes.com/2011/01/09/opinion/l09douthat.html

The Unborn Paradox

January 2, 2011
The New York Times
By ROSS DOUTHAT

The American entertainment industry has never been comfortable with the act of abortion. Film or television characters might consider the procedure, but even on the most libertine programs (a “Mad Men,” a “Sex and the City”), they’re more likely to have a change of heart than actually go through with it. Reality TV thrives on shocking scenes and subjects — extreme pregnancies and surgeries, suburban polygamists and the gay housewives of New York — but abortion remains a little too controversial, and a little bit too real.

This omission is often cited as a victory for the pro-life movement, and in some cases that’s plainly true. (Recent unplanned-pregnancy movies like “Juno” and “Knocked Up” made abortion seem not only unnecessary but repellent.) But it can also be a form of cultural denial: a way of reassuring the public that abortion in America is — in Bill Clinton’s famous phrase — safe and legal, but also rare.

Rare it isn’t: not when one in five pregnancies ends at the abortion clinic. So it was a victory for realism, at least, when MTV decided to supplement its hit reality shows “16 and Pregnant” and “Teen Mom” with last week’s special, “No Easy Decision,” which followed Markai Durham, a teen mother who got pregnant a second time and chose abortion.

MTV being MTV, the special’s attitude was resolutely pro-choice. But it was a heartbreaking spectacle, whatever your perspective. Durham and her boyfriend are the kind of young people our culture sets adrift — working-class and undereducated, with weak support networks, few authority figures, and no script for sexual maturity beyond the easily neglected admonition to always use a condom. Their televised agony was a case study in how abortion can simultaneously seem like a moral wrong and the only possible solution — because it promised to keep them out of poverty, and to let them give their first daughter opportunities they never had.

The show was particularly wrenching, though, when juxtaposed with two recent dispatches from the world of midlife, upper-middle-class infertility. Last month there was Vanessa Grigoriadis’s provocative New York Magazine story “Waking Up From the Pill,” which suggested that a lifetime on chemical birth control has encouraged women “to forget about the biological realities of being female ... inadvertently, indirectly, infertility has become the Pill’s primary side effect.” Then on Sunday, The Times Magazine provided a more intimate look at the same issue, in which a midlife parent, the journalist Melanie Thernstrom, chronicled what it took to bring her children into the world: six failed in vitro cycles, an egg donor and two surrogate mothers, and an untold fortune in expenses.

In every era, there’s been a tragic contrast between the burden of unwanted pregnancies and the burden of infertility. But this gap used to be bridged by adoption far more frequently than it is today. Prior to 1973, 20 percent of births to white, unmarried women (and 9 percent of unwed births over all) led to an adoption. Today, just 1 percent of babies born to unwed mothers are adopted, and would-be adoptive parents face a waiting list that has lengthened beyond reason.

Some of this shift reflects the growing acceptance of single parenting. But some of it reflects the impact of Roe v. Wade. Since 1973, countless lives that might have been welcomed into families like Thernstrom’s — which looked into adoption, and gave it up as hopeless — have been cut short in utero instead.

And lives are what they are. On the MTV special, the people around Durham swaddle abortion in euphemism. The being inside her is just “pregnancy tissue.” After the abortion, she recalls being warned not to humanize it: “If you think of it like [a person], you’re going to make yourself depressed.” Instead, “think of it as what it is: nothing but a little ball of cells.”

It’s left to Durham herself to cut through the evasion. Sitting with her boyfriend afterward, she begins to cry when he calls the embryo a “thing.” Gesturing to their infant daughter, she says, “A ‘thing’ can turn out like that. That’s what I remember ... ‘Nothing but a bunch of cells’ can be her.”

When we want to know this, we know this. Last week’s New Yorker carried a poem by Kevin Young about expectant parents, early in pregnancy, probing the mother’s womb for a heartbeat:

The doctor trying again to find you, fragile,

fern, snowflake. Nothing.

After, my wife will say, in fear,

impatient, she went beyond her body,

this tiny room, into the ether—

... And there

it is: faint, an echo, faster and further

away than mother’s, all beat box

and fuzzy feedback. ...

This is the paradox of America’s unborn. No life is so desperately sought after, so hungrily desired, so carefully nurtured. And yet no life is so legally unprotected, and so frequently destroyed.

    The Unborn Paradox, NYT, 2.1.2011, http://www.nytimes.com/2011/01/03/opinion/03douthat.html

U.S. Alters Rule on Paying for End-of-Life Planning

January 4, 2011
The New York Times
By ROBERT PEAR

WASHINGTON — The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday.

The move is an abrupt shift, coming just days after the new policy took effect on Jan. 1.

Many doctors and providers of hospice care had praised the regulation, which listed “advance care planning” as one of the services that could be offered in the “annual wellness visit” for Medicare beneficiaries.

While administration officials cited procedural reasons for changing the rule, it was clear that political concerns were also a factor. The renewed debate over advance care planning threatened to become a distraction to administration officials who were gearing up to defend the health law against attack by the new Republican majority in the House.

Although the health care bill signed into law in March did not mention end-of-life planning, the topic was included in a huge Medicare regulation setting payment rates for thousands of physician services. The final regulation was published in the Federal Register in late November. The proposed rule, published for public comment in July, did not include advance care planning.

An administration official, authorized by the White House to explain the mix-up, said Tuesday, “We realize that this should have been included in the proposed rule, so more people could have commented on it specifically.”

“We will amend the regulation to take out voluntary advance care planning,” the official said. “This should not affect beneficiaries’ ability to have these voluntary conversations with their doctors.”

The November regulation was issued by Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services and a longtime advocate for better end-of-life care. White House officials who work on health care apparently did not focus on the part of the rule that dealt with advance care planning.

The decision to drop the reference to end-of-life care upset some officials at the Department of Health and Human Services, who said the administration ought to promote discussions of such care. Such discussions help ensure that patients get the care they want, the officials said.

During debate on the legislation, Democrats dropped a somewhat similar proposal to encourage end-of-life planning after it touched off a political storm. Republicans said inaccurately that the House version of the bill allowed a government panel to make decisions about end-of-life care for people on Medicare.

Sarah Palin, the 2008 Republican vice-presidential candidate, said in the summer of 2009 that “Obama’s death panel” would decide who was worthy of health care. Representative John A. Boehner of Ohio, the House Republican leader who is to become speaker on Wednesday, said the provision could be a step “down a treacherous path toward government-encouraged euthanasia.”

The health care bill passed by the House in 2009 allowed Medicare to pay doctors for discussions of end-of-life care, including advance directives, in which patients can indicate whether they want to forgo or receive aggressive life-sustaining treatment.

The provision for advance care planning was not included in the final health care overhaul signed into law by President Obama. Health policy experts assumed that the proposal had been set aside — until a similar idea showed up in the final Medicare regulation in November.

    U.S. Alters Rule on Paying for End-of-Life Planning, NYT, 4.1.2011, http://www.nytimes.com/2011/01/05/health/policy/05health.html