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Expansion of Clinics
Shapes a Bush Legacy
December 26, 2008
The New York Times
By KEVIN SACK
NASHVILLE — Although the number of uninsured and the cost of coverage have
ballooned under his watch, President Bush leaves office with a health care
legacy in bricks and mortar: he has doubled federal financing for community
health centers, enabling the creation or expansion of 1,297 clinics in medically
For those in poor urban neighborhoods and isolated rural areas, including Indian
reservations, the clinics are often the only dependable providers of basic
services like prenatal care, childhood immunizations, asthma treatments, cancer
screenings and tests for sexually transmitted diseases.
As a crucial component of the health safety net, they are lauded as a
cost-effective alternative to hospital emergency rooms, where the uninsured and
underinsured often seek care.
Despite the clinics’ unprecedented growth, wide swaths of the country remain
without access to affordable primary care. The recession has only magnified the
need as hundreds of thousands of Americans have lost their employer-sponsored
health insurance along with their jobs.
In response, Democrats on Capitol Hill are proposing even more significant
increases, making the centers a likely feature of any health care deal struck by
Congress and the Obama administration.
In Nashville, United Neighborhood Health Services, a 32-year-old community
health center, has seen its federal financing rise to $4.2 million, from $1.8
million in 2001. That has allowed the organization to add eight clinics to its
base of six, and to increase its pool of patients to nearly 25,000 from 10,000.
Still, says Mary Bufwack, the center’s chief executive, the clinics satisfy only
a third of the demand in Nashville’s pockets of urban poverty and immigrant
One of the group’s recent grants helped open the Southside Family Clinic, which
moved last year from a pair of public housing apartments to a gleaming new
building on a once derelict corner.
As she completed a breathing treatment one recent afternoon, Willie Mai Ridley,
a 68-year-old beautician, said she would have sought care for her bronchitis in
a hospital emergency room were it not for the new clinic. Instead, she took a
short drive, waited 15 minutes without an appointment and left without paying a
dime; the clinic would bill her later for her Medicare co-payment of $18.88.
Ms. Ridley said she appreciated both the dignity and the affordability of her
care. “This place is really very, very important to me,” she said, “because you
can go and feel like you’re being treated like a person and get the same medical
care you would get somewhere else and have to pay $200 to $300.”
As governor of Texas, Mr. Bush came to admire the missionary zeal and
cost-efficiency of the not-for-profit community health centers, which qualify
for federal operating grants by being located in designated underserved areas
and treating patients regardless of their ability to pay. He pledged support for
the program while campaigning for president in 2000 on a platform of
In Mr. Bush’s first year in office, he proposed to open or expand 1,200 clinics
over five years (mission accomplished) and to double the number of patients
served (the increase has ended up closer to 60 percent). With the health centers
now serving more than 16 million patients at 7,354 sites, the expansion has been
the largest since the program’s origins in President Lyndon B. Johnson’s war on
poverty, federal officials said.
“They’re an integral part of a health care system because they provide care for
the low-income, for the newly arrived, and they take the pressure off of our
hospital emergency rooms,” Mr. Bush said last year while touring a clinic in
With federal encouragement, the centers have made a major push this decade to
expand dental and mental health services, open on-site pharmacies, extend hours
to nights and weekends and accommodate recent immigrants — legal and otherwise —
by employing bilingual staff. More than a third of patients are now Hispanic,
according to the National Association of Community Health Centers.
The centers now serve one of every three people who live in poverty and one of
every eight without insurance. But a study released in August by the Government
Accountability Office found that 43 percent of the country’s medically
underserved areas lack a health center site. The National Association of
Community Health Centers and the American Academy of Family Physicians estimated
last year that 56 million people were “medically disenfranchised” because they
lived in areas with inadequate primary care.
President-elect Barack Obama has said little about how the centers may fit into
his plans to remake American health care. But he was a sponsor of a Senate bill
in August that would quadruple federal spending on the program — to $8 billion
from $2.1 billion — and increase incentives for medical students to choose
primary care. His wife, Michelle, worked closely with health centers in Chicago
as vice president for community and external relations at the University of
Chicago Medical Center.
And Mr. Obama’s choice to become secretary of health and human services, former
Senator Tom Daschle of South Dakota, argues in his recent book on health care
that financing should be increased, describing the health centers as “a
The federal program, which was first championed in Congress by Senator Edward M.
Kennedy, Democrat of Massachusetts, has earned considerable bipartisan support.
Leading advocates, like Senator Bernie Sanders, independent of Vermont, and
Representative James E. Clyburn, Democrat of South Carolina, the House majority
whip, argue that any success Mr. Obama has in reducing the number of uninsured
will be meaningless if the newly insured cannot find medical homes. In
Massachusetts, health centers have seen increased demand since the state began
mandating health coverage two years ago.
At $8 billion, the Senate measure may be considered a relative bargain compared
with the more than $100 billion needed for Mr. Obama’s proposal to subsidize
coverage for the uninsured. If his plan runs into fiscal obstacles, a vast
expansion of community health centers may again serve as a stopgap while
universal coverage waits for flusher times.
Recent job losses, meanwhile, are stoking demand for the clinics’ services,
often from first-time users. The United Neighborhood Health Services clinics in
Nashville have seen a 35 percent increase in patients this year, with much of
the growth from the newly jobless.
“I’m seeing a lot of professionals that no longer have their insurance or
they’re laid off from their jobs,” said Dr. Marshelya D. Wilson, a physician at
the center’s Cayce clinic. “So they come here and get their health care.”
Studies have generally shown that the health centers — which must be governed by
patient-dominated boards — are effective at reducing racial and ethnic
disparities in medical treatment and save substantial sums by keeping patients
out of hospitals. Their trade association estimates that they save the health
care system $17.6 billion a year, and that an equivalent amount could be saved
if avoidable emergency room visits were diverted to clinics. Some centers,
including here in Nashville, have brokered agreements with hospitals to do
Many centers are finding that federal support is not keeping pace with the
growing cost of treating the uninsured. Government grants now account for 19
percent of community health center revenues, compared with 22 percent in 2001,
according to the Health Resources and Services Administration, which oversees
the program. The largest revenue sources are public insurance plans like
Medicaid, Medicare and the State Children’s Health Insurance Program, making the
centers vulnerable to government belt-tightening.
The centers are known for their efficiency. Though United Neighborhood Health
Services has more than doubled in size this decade, Ms. Bufwack, its chief
executive, manages to run five neighborhood clinics, five school clinics, a
homeless clinic, two mobile clinics and a rural clinic, with 24,391 patients, on
a budget of $8.1 million. Starting pay for her doctors is $120,000. Patients are
charged on an income-based sliding scale, and the uninsured are expected to pay
at least $20 for an office visit. One clinic is housed in a double-wide trailer.
Because of a nationwide shortage of primary care physicians, the clinics rely on
federal programs like the National Health Service Corps that entice medical
students with grants and loan write-offs in exchange for agreements to practice
as generalists in underserved areas. Of the 16 doctors working for United
Neighborhood, seven are current or former participants.
Dr. LaTonya D. Knott, 37, who treated Ms. Ridley for her bronchitis, is among
them. Born to a 15-year-old mother in south Nashville, she herself had been a
regular childhood patient at one of the center’s clinics. After graduating as
her high school’s valedictorian, she went to college on scholarships and then to
medical school on government grants, with an obligation to serve for two years.
She said she now felt a responsibility to be a role model. “I do a whole lot of
social work,” she said, noting that it was not uncommon for children to drop by
the clinic for help with homework, or for a peanut butter sandwich. “It’s not
just that we provide the medical care. I’m trying to provide you with a future.”
Despite such commitment, national staffing shortages have reinforced concerns
about the quality of care at health centers, notably the management of chronic
diseases. This year, the government started collecting data at the centers on
performance measures like cervical cancer screening and diabetes control.
“The question is not just, ‘Are you going to have more community health
centers?’ ” said Dr. H. Jack Geiger, founder of the health centers movement and
a professor emeritus at the City University of New York. “It’s, ‘Are you going
to have adequate services?’ ”
A deeper frustration for health centers concerns their difficulty in securing
follow-up appointments with specialists for patients who are uninsured or have
Medicaid. All too often, said Ms. Bufwack, medical care ends at the clinic door,
reinforcing the need to expand both primary care and health insurance coverage.
“That’s when our doctors feel they’re practicing third world medicine,” she
said. “You will die if you have cancer or a heart condition or bad asthma or
horrible diabetes. If you need a specialist and specialty tests and specialty
meds and specialty surgery, those things are totally out of your reach.”
Expansion of Clinics
Shapes a Bush Legacy,
One for the Ages:
October 31, 2006
The New York Times
By MICHAEL MASON
How depressing, how utterly unjust, to be the
one in your social circle who is aging least gracefully.
In a laboratory at the Wisconsin National Primate Research Center, Matthias is
learning about time’s caprice the hard way. At 28, getting on for a rhesus
monkey, Matthias is losing his hair, lugging a paunch and getting a face full of
Yet in the cage next to his, gleefully hooting at strangers, one of Matthias’s
lab mates, Rudy, is the picture of monkey vitality, although he is slightly
older. Thin and feisty, Rudy stops grooming his smooth coat just long enough to
pirouette toward a proffered piece of fruit.
Tempted with the same treat, Matthias rises wearily and extends a frail hand.
“You can really see the difference,” said Dr. Ricki Colman, an associate
scientist at the center who cares for the animals.
What a visitor cannot see may be even more interesting. As a result of a simple
lifestyle intervention, Rudy and primates like him seem poised to live very
long, very vital lives.
This approach, called calorie restriction, involves eating about 30 percent
fewer calories than normal while still getting adequate amounts of vitamins,
minerals and other nutrients. Aside from direct genetic manipulation, calorie
restriction is the only strategy known to extend life consistently in a variety
of animal species.
How this drastic diet affects the body has been the subject of intense research.
Recently, the effort has begun to bear fruit, producing a steady stream of
studies indicating that the rate of aging is plastic, not fixed, and that it can
In the last year, calorie-restricted diets have been shown in various animals to
affect molecular pathways likely to be involved in the progression of
Alzheimer’s disease, diabetes, heart disease, Parkinson’s disease and cancer.
Earlier this year, researchers studying dietary effects on humans went so far as
to claim that calorie restriction may be more effective than exercise at
preventing age-related diseases.
Monkeys like Rudy seem to be proving the thesis. Recent tests show that the
animals on restricted diets, including Canto and Eeyore, two other rhesus
monkeys at the primate research center, are in indisputably better health as
they near old age than Matthias and other normally fed lab mates like Owen and
Johann. The average lifespan for laboratory monkeys is 27.
The findings cast doubt on long-held scientific and cultural beliefs regarding
the inevitability of the body’s decline. They also suggest that other
interventions, which include new drugs, may retard aging even if the diet itself
should prove ineffective in humans. One leading candidate, a newly synthesized
form of resveratrol — an antioxidant present in large amounts in red wine — is
already being tested in patients. It may eventually be the first of a new class
of anti-aging drugs. Extrapolating from recent animal findings, Dr. Richard A.
Miller, a pathologist at the University of Michigan, estimated that a pill
mimicking the effects of calorie restriction might increase human life span to
about 112 healthy years, with the occasional senior living until 140, though
some experts view that projection as overly optimistic.
According to a report by the Rand Corporation, such a drug would be among the
most cost-effective breakthroughs possible in medicine, providing Americans more
healthy years at less expense (an estimated $8,800 a year) than new cancer
vaccines or stroke treatments.
“The effects are global, so calorie restriction has the potential to help us
identify anti-aging mechanisms throughout the body,” said Richard Weindruch, a
gerontologist at the University of Wisconsin who directs research on the
Many scientists regard the study of life extension, once just a reliable
plotline in science fiction, as a national priority. The number of Americans 65
and older will double in the next 25 years to about 72 million, according to
government census data. By then, seniors will account for nearly 20 percent of
the population, up from just 12 percent in 2003.
Earlier this year, four prominent gerontologists, among them Dr. Miller,
published a paper calling for the government to spend $3 billion annually in
pursuit of a modest goal: delaying the onset of age-related diseases by seven
Doing so, the authors asserted, would lay the foundation for a healthier and
wealthier country, a so-called longevity dividend.
“The demographic wave entering their 60s is enormous, and that is likely to
greatly increase the prevalence of diseases like diabetes and heart disease,”
said Dr. S. Jay Olshansky, an epidemiologist at the University of Illinois at
Chicago, and one of the paper’s authors. “The simplest way to positively affect
them all is to slow down aging.”
Science, of course, is still a long way from doing anything of the sort. Aging
is a complicated phenomenon, the intersection of an array of biological
processes set in motion by genetics, lifestyle, even evolution itself.
Still, in laboratories around the world, scientists are becoming adept at
breeding animal Methuselahs, extraordinarily long lived and healthy worms, fish,
mice and flies.
In 1935, Dr. Clive McCay, a nutritionist at Cornell University, discovered that
mice that were fed 30 percent fewer calories lived about 40 percent longer than
their free-grazing laboratory mates. The dieting mice were also more physically
active and far less prone to the diseases of advanced age.
Dr. McCay’s experiment has been successfully duplicated in a variety of species.
In almost every instance, the subjects on low-calorie diets have proven to be
not just longer lived, but also more resistant to age-related ailments.
“In mice, calorie restriction doesn’t just extend life span,” said Leonard P.
Guarente, professor of biology at the Massachusetts Institute of Technology. “It
mitigates many diseases of aging: cancer, cardiovascular disease,
neurodegenerative disease. The gain is just enormous.”
For years, scientists financed by the National Institute on Aging have closely
monitored rhesus monkeys on restricted and normal-calorie diets. At the
University of Wisconsin, where 50 animals survive from the original group of 76,
the differences are just now becoming apparent in the older animals.
Those on normal diets, like Matthias, are beginning to show signs of advancing
age similar to those seen in humans. Three of them, for instance, have developed
diabetes, and a fourth has died of the disease. Five have died of cancer.
But Rudy and his colleagues on low-calorie meal plans are faring better. None
have diabetes, and only three have died of cancer. It is too early to know if
they will outlive their lab mates, but the dieters here and at the other labs
also have lower blood pressure and lower blood levels of certain dangerous fats,
glucose and insulin.
“The preliminary indicators are that we’re looking at a robust life extension in
the restricted animals,” Dr. Weindruch said.
Despite widespread scientific enthusiasm, the evidence that calorie restriction
works in humans is indirect at best. The practice was popularized in diet books
by Dr. Roy Walford, a legendary pathologist at the University of California, Los
Angeles, who spent much of the last 30 years of his life following a
calorie-restricted regimen. He died of Lou Gehrig’s disease in 2004 at 79.
Largely as a result of his advocacy, several thousand people are now on
calorie-restricted diets in the United States, says Brian M. Delaney, president
of the Calorie Restriction Society.
Mike Linksvayer, a 36-year-old chief technology officer at a San Francisco
nonprofit group, embarked on just such a diet six years ago. On an average day,
he eats an apple or some cereal for breakfast, followed by a small vegan dish at
lunch. Dinner is whatever his wife has cooked, excluding bread, rice, sugar and
whatever else Mr. Linksvayer deems unhealthy (this often includes the entrée).
On weekends, he occasionally fasts.
Mr. Linksvayer, 6 feet tall and 135 pounds, estimated that he gets by on about
2,000 to 2,100 calories a day, a low number for men of his age and activity
level, and his blood pressure is a remarkably low 112 over 63. He said he has
never been in better health.
“I don’t really get sick,” he said. “Mostly I do the diet to be healthier, but
if it helps me live longer, hey, I’ll take that, too.”
Researchers at Washington University in St. Louis have been tracking the health
of small groups of calorie-restricted dieters. Earlier this year, they reported
that the dieters had better-functioning hearts and fewer signs of inflammation,
which is a precursor to clogged arteries, than similar subjects on regular
In previous studies, people in calorie-restricted groups were shown to have
lower levels of LDL, the so-called bad cholesterol, and triglycerides. They also
showed higher levels of HDL, the so-called good cholesterol, virtually no
arterial blockage and, like Mr. Linksvayer, remarkably low blood pressure.
“Calorie restriction has a powerful, protective effect against diseases
associated with aging,” said Dr. John O. Holloszy, a Washington University
professor of medicine. “We don’t know how long each individual will end up
living, but they certainly have a longer life expectancy than average.”
Researchers at Louisiana State University reported in April in The Journal of
the American Medical Association that patients on an experimental low-calorie
diet had lower insulin levels and body temperatures, both possible markers of
longevity, and fewer signs of the chromosomal damage typically associated with
These studies and others have led many scientists to believe they have stumbled
onto a central determinant of natural life span. Animals on restricted diets
seem particularly resistant to environmental stresses like oxidation and heat,
perhaps even radiation. “It is a very deep, very important function,” Dr. Miller
said. Experts theorize that limited access to energy alarms the body, so to
speak, activating a cascade of biochemical signals that tell each cell to direct
energy away from reproductive functions, toward repair and maintenance. The
calorie-restricted organism is stronger, according to this hypothesis, because
individual cells are more efficiently repairing mutations, using energy,
defending themselves and mopping up harmful byproducts like free radicals.
“The stressed cell is really pulling out all the stops” to preserve itself, said
Dr. Cynthia Kenyon, a molecular biologist at the University of California, San
Francisco. “This system could have evolved as a way of letting animals take a
timeout from reproduction when times are harsh.”
But many experts are unsettled by the prospect, however unlikely, of Americans
adopting a draconian diet in hopes of living longer. Even the current
epidemiological data, they note, do not consistently show that those who are
thinnest live longest. After analyzing decades of national mortality statistics,
federal researchers reported last year that exceptional thinness, a logical
consequence of calorie restriction, was associated with an increased risk of
death. This controversial study did not attempt to assess the number of calories
the subjects had been consuming, or the quality of their diets, which may have
had an effect on mortality rates.
Despite the initially promising results from studies of primates, some
scientists doubt that calorie restriction can ever work effectively in humans. A
mathematical model published last year by researchers at University of
California, Los Angeles, and University of California, Irvine, predicted that
the maximum life span gain from calorie restriction for humans would be just 7
percent. A more likely figure, the authors said, was 2 percent.
“Calorie restriction is doomed to fail, and will make people miserable in the
process of attempting it,” said Dr. Jay Phelan, an evolutionary biologist at the
University of California, Los Angeles, and a co-author of the paper. “We do see
benefits, but not an increase in life span.”
Mice who must scratch for food for a couple of years would be analogous, in
terms of natural selection, to humans who must survive 20-year famines, Dr.
Phelan said. But nature seldom demands that humans endure such conditions.
Besides, he added, there is virtually no chance Americans will adopt such a
severe menu plan in great numbers.
“Have you ever tried to go without food for a day?” Dr. Phelan asked. “I did it
once, because I was curious about what the mice in my lab experienced, and I
couldn’t even function at the end of the day.”
Even researchers who believe calorie restriction can extend life in humans
concede that few Americans are likely to stick to such a restrained diet over a
long period. The aging of the body is the aging of its cells, researchers like
to say. While cell death is hardwired into every organism’s DNA, much of the
infirmity that comes with advancing years is from an accumulation of molecular
insults that, experts contend, may to some degree be prevented, even reversed.
“The goal is not just to make people live longer,” said Dr. David A. Sinclair, a
molecular biologist at Harvard. “It’s to see eventually that an 80-year-old
feels like a 50-year-old does today.”
In a series of studies, Dr. Kenyon, of the University of California, San
Francisco, has created mutant roundworms that live six times longer than normal,
largely because of a mutation in a single gene called daf-2. The gene encodes a
receptor on the surface of cells similar to a receptor in humans that responds
to two important hormones, insulin and the insulin-like growth factor 1 or
Insulin is necessary for the body to transport glucose into cells to fuel their
operations. Dr. Kenyon and other researchers suggest that worm cells with
mutated receptors may be “tricked” into sensing that nutrients are not
available, even when they are. With its maintenance machinery thereby turned on
high, each worm cell lives far longer — and so does the worm.
Many experts are now convinced that the energy-signaling pathways that employ
insulin and IGF-1 are very involved in fixing an organism’s life span. Some
researchers have even described Type 2 diabetes, which is marked by
insensitivity to the hormone insulin, as simply an accelerated form of aging.
In yeast, scientists have discovered a gene similar to daf-2 called SIR2, that
also helps to coordinate the cell’s defensive response once activated by calorie
restriction or another external stressor. The genes encode proteins called
sirtuins, which are found in both plants and animals.
A mammalian version of the SIR2 gene, called SIRT1, has been shown to regulate a
number of processes necessary for long-term survival in calorie-restricted mice.
Scientists are now trying to develop synthetic compounds that affect the genes
daf-2 and SIRT1.
Several candidate drugs designed to prevent age-related diseases, particularly
diabetes, are on the drawing boards at biotech companies. Sirtris
Pharmaceuticals, in Boston, already has begun testing a new drug in patients
with Type 2 diabetes that acts on SIRT1 to improve the functioning of
mitochondria, the cell’s energy factories.
While an anti-aging pill may be the next big blockbuster, some ethicists believe
that the all-out determination to extend life span is veined with arrogance. As
appointments with death are postponed, says Dr. Leon R. Kass, former chairman of
the President’s Council on Bioethics, human lives may become less engaging, less
meaningful, even less beautiful.
“Mortality makes life matter,” Dr. Kass recently wrote. “Immortality is a kind
of oblivion — like death itself.”
That man’s time on this planet is limited, and rightfully so, is a cultural
belief deeply held by many. But whether an increasing life span affords greater
opportunity to find meaning or distracts from the pursuit, the prospect has
become too great a temptation to ignore — least of all, for scientists.
“It’s a just big waste of talent and wisdom to have people die in their 60s and
70s,” said Dr. Sinclair of Harvard.
for the Ages: A Prescription That May Extend Life,
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