USA > History > 2010 > Health (I)

Pfizer Details Its Payments

to Doctors and Researchers

March 31, 2010
The New York Times
By DUFF WILSON

Pfizer, the world’s largest drug maker, said Thursday that it paid about $20 million to 4,500 doctors and other health care professionals in the United States for consulting and speaking on its behalf in the last six months of 2009, its first public accounting of payments to the people who decide which drugs to recommend.

Pfizer said it also paid $15.3 million to 250 academic medical centers and other research groups for clinical trials in the final six months of last year.

While several other pharmaceutical companies have previously disclosed payments to doctors, Pfizer is the first to disclose payments for the clinical trials where drugs are tested. The disclosure does not include payments outside the United States.

A spokeswoman for Pfizer, Kristen E. Neese, said the disclosures were required by an integrity agreement that the company signed in August to settle a federal investigation into the illegal promotion of drugs for off-label uses. Pfizer paid a $2.3 billion fine in that case, the largest criminal fine of any type in the nation’s history.

Company executives said they had long planned to be more transparent — an assertion met with skepticism by some outside experts.

“We’re proud of the relationships that we have with researchers and clinicians,” Dr. Freda C. Lewis-Hall, Pfizer’s chief medical officer, said Tuesday. She characterized the disclosure and Web site as part of “a march to disclosure” that Pfizer started in 2002.

Pfizer is the fourth major drug company to make such disclosures, following Eli Lilly, Merck and GlaxoSmithKline. All four Web sites are searchable by the names of doctors or organizations, but all are set up in ways that make it difficult to download and analyze the entire database.

“All of them are welcome, but none of them is a replacement for a single national database,” Allan Coukell, director of the Pew Prescription Project, a Boston nonprofit that seeks to protect consumers, said in a telephone interview.

Beginning in 2012, drug and medical device companies will be required to disclose payments to physicians of more than $10, with the first report available in 2013. The federal Physician Payment Sunshine Act was passed as part of health care reform and signed by President Obama last week. Some states also have disclosure laws.

Pfizer’s disclosure met with skepticism from one leading expert on conflicts of interest in medicine.

“I think it’s a good thing to do, but I put absolutely no trust in what drug companies voluntarily disclose to the public when those things are unaudited,” said Eric G. Campbell, lead author of a 2007 study of physician-industry relationships published in The New England Journal of Medicine.

The survey of 3,167 physicians in six specialties found 94 percent had some relationship with drug companies in 2003 and 2004, mostly receiving free meals, with 28 percent being paid for consulting, speaking or enrolling patients in clinical trials.

Professor Campbell, who is director of research at the Institute for Health Policy at Massachusetts General Hospital and an associate professor at Harvard Medical School, said drug companies were trying to get ahead of a rising tide of public opinion for disclosure.

“The drug companies are disclosing voluntarily now not necessarily because they believe it’s the right thing to do,” he said, “but because they want to get ahead of what is an inevitable thing in the United States.”

Pfizer executives reviewed the company’s disclosure system with the staff of Senator Charles Grassley, Republican of Iowa, who is investigating the influence of money in medicine. Senator Grassley said Wednesday in a statement: “It’s a real milestone for the transparency campaign to have one of the biggest drug makers in the world respond with an initiative like this.”

Pfizer’s clinical-trials disclosure identifies all such payments to academic medical centers from July 1, 2009 to Dec. 31, 2009, the company said, and payments for new clinical trials initiated in that time by non-academic research organizations. “These payments represent a small portion of Pfizer’s total investment in research and development,” the company said in a statement Wednesday.

The payments to doctors covered fees, travel and meals worth $25 or more and totaling $500 or more during the six-month period, Pfizer said. In all, Pfizer said, 1,500 licensed health care professionals were paid an average of $5,000 during the six-month period for consulting, and 2,800 were paid an average of $3,400 for speaking.

The company plans to post its next report on March 31, 2011, with expanded data on payments during 2010.

Pfizer Details Its Payments to Doctors and Researchers, NYT, 31.3.2010, http://www.nytimes.com/2010/04/01/business/01payments.html

Editorial

The Legal Assault on Health Reforms

March 29, 2010
The New York Times

No sooner had President Obama signed comprehensive health care reform than the attorneys general of 14 states scurried to the federal courts to challenge the law. Their claims range from far-fetched to arguable and look mostly like political posturing for the fall elections or a “Hail Mary” pass by disgruntled conservatives who cannot accept what Congress and the president have done.

They seem unlikely to succeed because the law was carefully drafted to withstand just this kind of challenge.

There are two separate suits by the attorneys general. The main one, led by Bill McCollum, a Florida Republican, has been joined by 12 other attorneys general, all but one Republicans. Many if not most are either running for higher office or seeking re-election. A separate suit by Virginia’s Republican attorney general is based on that state’s attempt (sure to be ineffective) to nullify the federal law by enacting a state law declaring that Virginians need not obey it.

A central contention of both suits is that Congress has no power under the Constitution to compel individuals to buy health insurance or pay a penalty. Congress has never before compelled people to buy anything from a private company, so there is no precisely apt Supreme Court precedent. Still, two provisions in the Constitution give Congress broad powers to regulate economic activity — the power to impose taxes for the general welfare and the power to regulate interstate commerce.

The new law has been framed to fall within both of those provisions. The penalties for not buying insurance have been structured as a tax, to be collected by the Internal Revenue Service. And the law’s text includes a series of Congressional findings: that health insurance and health care comprise a significant part of the economy, that most policies are sold and claims paid through interstate commerce, and that the mandate is essential to achieving the goals of creating effective health insurance markets and achieving near-universal coverage.

Such findings don’t make the new law bullet-proof, but they help to insulate it from attack. It seems a long shot that the Supreme Court would invalidate the mandate, if the cases ever reach that level.

A second contention, emphasized by the 13 state attorneys general, is that the new law amounts to an unprecedented encroachment on the sovereignty of the states. It will require them to greatly expand their Medicaid programs, imposing substantial costs, and add administrative burdens in setting up new insurance exchanges that will offer an array of private policies.

That seems a stretch. No state is required to set up an exchange. If states fail to do so, the federal government will take over. Nor is any state required to participate in Medicaid, a joint federal-state program in which Washington pays half or more of the costs.

It is true, as the suit contends, that it may not be practical for states to drop out of a Medicaid program that serves many of their poorest residents. But it is well established that Congress can attach conditions to the money it supplies, and Congress has long imposed Medicaid requirements that states must meet.

The attorneys general are doing a disservice to their constituents by opposing Medicaid expansion and a mandate that everyone buy insurance, with subsidies for low- and middle-income people. The mandates are needed to push enough healthy young people into insurance pools to help subsidize the cost of covering sicker people and make it feasible for insurers to cover people with pre-existing conditions. Alternative approaches to entice people to obtain coverage would likely be less successful.

    The Legal Assault on Health Reforms, NYT, 29.3.2010, http://www.nytimes.com/2010/03/29/opinion/29mon1.html

Editorial

The Day After

March 24, 2010
The New York Times

It is worth pausing to dwell on what happened in the White House on Tuesday: President Obama, just over a year into a tumultuous presidency in which he was sometimes wrong-footed and often adrift, signed the most momentous social legislation in many years.

The health care reform law is an overdue and vital step in the construction of a social safety net, which began after the Great Depression and slowly moved forward — often in a bipartisan manner — until it was interrupted by the Republican Party’s radical antigovernment fervor in the late 20th century.

It was a triumph for Mr. Obama and for the Democratic leadership in Congress. If Mr. Obama draws no other lesson, it is that his early and forceful personal engagement on big issues is indispensable. He waited a perilously long time to exercise his leadership on health care, but when he did, it paid off.

It is important to keep that in mind because Mr. Obama’s victory celebration had barely ended before people were asking, “Now what?” There was speculation, in some quarters, that the energy had been drained out of Mr. Obama and his Congressional allies by the struggle against a Republican Party whose only objective seemed to be to thwart the president, no matter his objective.

But there is important business ahead — lots of it. And while Mr. Obama deserves a break, he must build on this success, not rest on it.

First and foremost is the economy, specifically the creation of jobs. Mr. Obama offered a budget plan in February that called for cuts in discretionary spending and should have brought major Congressional action on jobs in return. After the Easter break, Congress will likely extend unemployment insurance and offer some fiscal relief to states. That may be enough for the economy to squeak through 2010, but persistently high joblessness is a plague that Congress may not confront in a comprehensive way unless Mr. Obama forces the issue.

He will also have to take the lead in improving the financial regulatory bills moving through Congress. Neither chamber’s version is adequate to fix the problems that led to the financial meltdown, and the banking lobby is working hard to render them even less effective.

Beyond jobs and financial reform — near-term issues that will bulk large in the midterm elections — there are longer-term issues. President Obama has promised to reform the country’s education system, and to address climate change and oil dependency by transforming the way Americans produce and use energy. In his campaign, he talked about immigration reform and restoring the rule of law to terrorist detention policies.

These are lofty objectives, and Mr. Obama may not reach them all. But the health care victory shows that big goals can be achieved — with Mr. Obama’s personal intervention and sustained leadership.

With rare exceptions, the Republicans are not going to help. Anyone who thinks otherwise should consider what Senator John McCain of Arizona said on Monday: “There will be no cooperation for the rest of the year.”

As shocking as that is from a man who more than once presented himself as a candidate for president, it sums up the political reality that Mr. Obama faces. Still, he should be able to sell the public at the very least on creating jobs and restraining a rapacious financial industry. The nation’s well-being depends on it.

    The Day After, NYT, 24.3.2010, http://www.nytimes.com/2010/03/24/opinion/24wed1.html

In Health Care Bill, Obama Attacks Wealth Inequality

March 23, 2010
The New York Times
By DAVID LEONHARDT

For all the political and economic uncertainties about health reform, at least one thing seems clear: The bill that President Obama signed on Tuesday is the federal government’s biggest attack on economic inequality since inequality began rising more than three decades ago.

Over most of that period, government policy and market forces have been moving in the same direction, both increasing inequality. The pretax incomes of the wealthy have soared since the late 1970s, while their tax rates have fallen more than rates for the middle class and poor.

Nearly every major aspect of the health bill pushes in the other direction. This fact helps explain why Mr. Obama was willing to spend so much political capital on the issue, even though it did not appear to be his top priority as a presidential candidate. Beyond the health reform’s effect on the medical system, it is the centerpiece of his deliberate effort to end what historians have called the age of Reagan.

Speaking to an ebullient audience of Democratic legislators and White House aides at the bill-signing ceremony on Tuesday, Mr. Obama claimed that health reform would “mark a new season in America.” He added, “We have now just enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care.”

The bill is the most sweeping piece of federal legislation since Medicare was passed in 1965. It aims to smooth out one of the roughest edges in American society — the inability of many people to afford medical care after they lose a job or get sick. And it would do so in large measure by taxing the rich.

A big chunk of the money to pay for the bill comes from lifting payroll taxes on households making more than $250,000. On average, the annual tax bill for households making more than $1 million a year will rise by $46,000 in 2013, according to the Tax Policy Center, a Washington research group. Another major piece of financing would cut Medicare subsidies for private insurers, ultimately affecting their executives and shareholders.

The benefits, meanwhile, flow mostly to households making less than four times the poverty level — $88,200 for a family of four people. Those without insurance in this group will become eligible to receive subsidies or to join Medicaid. (Many of the poor are already covered by Medicaid.) Insurance costs are also likely to drop for higher-income workers at small companies.

Finally, the bill will also reduce a different kind of inequality. In the broadest sense, insurance is meant to spread the costs of an individual’s misfortune — illness, death, fire, flood — across society. Since the late 1970s, though, the share of Americans with health insurance has shrunk. As a result, the gap between the economic well-being of the sick and the healthy has been growing, at virtually every level of the income distribution.

The health reform bill will reverse that trend. By 2019, 95 percent of people are projected to be covered, up from 85 percent today (and about 90 percent in the late 1970s). Even affluent families ineligible for subsidies will benefit if they lose their insurance, by being able to buy a plan that can no longer charge more for pre-existing conditions. In effect, healthy families will be picking up most of the bill — and their insurance will be somewhat more expensive than it otherwise would have been.

Much about health reform remains unknown. Maybe it will deliver Congress to the Republicans this fall, or maybe it will help the Democrats keep power. Maybe the bill’s attempts to hold down the recent growth of medical costs will prove a big success, or maybe the results will be modest and inadequate. But the ways in which the bill attacks the inequality of the Reagan era — whether you love them or hate them — will probably be around for a long time.

“Legislative majorities come and go,” David Frum, a former speechwriter for President George W. Bush, lamented on Sunday. “This health care bill is forever.”

•

Since Mr. Obama began his presidential campaign in 2007, he has had a complicated relationship with the Reagan legacy. He has been more willing than many other Democrats to praise President Reagan. “Reagan’s central insight — that the liberal welfare state had grown complacent and overly bureaucratic,” Mr. Obama wrote in his second book, “contained a good deal of truth.” Most notably, he praised Mr. Reagan as a president who “changed the trajectory of America.”

But Mr. Obama also argued that the Reagan administration had gone too far, and that if elected, he would try to put the country on a new trajectory. “The project of the next president,” he said in an interview during the campaign, “is figuring out how you create bottom-up economic growth, as opposed to the trickle-down economic growth.”

Since 1980, median real household income has risen less than 15 percent. The only period of strong middle-class income growth during this time came in the mid- and late 1990s, which by coincidence was also the one time when taxes on the affluent were rising.

For most of the last three decades, tax rates for the wealthy have been falling, while their pretax pay has been rising rapidly. Real incomes at the 99.99th percentile have jumped more than 300 percent since 1980. At the 99th percentile — about $300,000 today — real pay has roughly doubled.

The laissez-faire revolution that Mr. Reagan started did not cause these trends. But its policies — tax cuts, light regulation, a patchwork safety net — have contributed to them.

Health reform hardly solves all of the American economy’s problems. Economic growth over the last decade was slower than in any decade since World War II. The tax cuts of the last 30 years, the two current wars, the Great Recession, the stimulus program and the looming retirement of the baby boomers have created huge deficits. Educational gains have slowed, and the planet is getting hotter.

Above all, the central question that both the Reagan and Obama administrations have tried to answer — what is the proper balance between the market and the government? — remains unresolved. But the bill signed on Tuesday certainly shifts our place on that spectrum.

Before he became Mr. Obama’s top economic adviser, Lawrence Summers told me a story about helping his daughter study for her Advanced Placement exam in American history. While doing so, Mr. Summers realized that the federal government had not passed major social legislation in decades. There was the frenzy of the New Deal, followed by the G.I. Bill, the Interstate Highway System, civil rights and Medicare — and then nothing worth its own section in the history books.

Now there is.

    In Health Care Bill, Obama Attacks Wealth Inequality, NYT, 24.3.2010, http://www.nytimes.com/2010/03/24/business/24leonhardt.html

Obama Signs Health Care Overhaul Bill, With a Flourish

March 23, 2010
The New York Times
By SHERYL GAY STOLBERG

WASHINGTON —With the strokes of 20 pens, President Obama signed his health care overhaul — the most sweeping social legislation enacted in decades — into law on Tuesday during a festive, at times raucous, White House ceremony.

“We have just now enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care,” Mr. Obama declared in the East Room, before an audience of more than 200 Democratic lawmakers, White House aides and others who rode a yearlong legislative roller-coaster ride that ended with Sunday night’s House passage of the bill. They interrupted him repeatedly with shouts and standing ovations.

Moments later, the president sat down at a table, and affixed his left-handed, curlicue signature, almost letter by letter, to the measure, the Affordable Health Care for America Act, using 20 pens that he intended to pass out to key lawmakers and others as mementoes.

He was surrounded by House Speaker Nancy Pelosi, Senate Democratic Leader Harry Reid, Vice President Joseph R. Biden Jr. and other top Democratic leaders, as well as some special guests: 11-year-old Marcelas Owens of Seattle, who became an advocate for health care reform after his mother died without health insurance, and Connie Anderson, the sister of Natoma Canfield, the Ohio cancer survivor whose struggle to pay skyrocketing premiums became a touchstone of Mr. Obama’s campaign to overhaul the system.

Vicki Kennedy, the widow of the late Senator Edward M. Kennedy of Massachusetts, who had been a driving force for health care legislation before his death last year, was also by Mr. Obama’s side. Mrs. Kennnedy wore a blue plastic bracelet around her wrist that said “TedStrong,” and appeared emotional after the ceremony.

“I know how happy he would be,” she said of her husband, adding, “It was so meaningful for him, in a very personal way.”

And in the audience sat Mr. Kennedy’s son, Representative Patrick Kennedy of Rhode Island. He was also there, carrying a gift for the president: a copy of a bill his father introduced in 1970 to provide national health insurance. On it, the younger Mr. Kennedy had written a personal message to Mr. Obama.

For Mr. Obama, the bill signing marks a high point of his presidency. For the many House members in the audience, it marks the end of a trying, chapter, and they let the president know it as he remarked that many had “taken their lumps during this difficult debate.”

To that, Represenative Gary Ackerman, the New York Democrat, shouted, “Yes we did!” — a riff on Mr. Obama’s campaign slogan, “Yes we can.” The crowd, including Mr. Obama, broke up laughing.

“Our presence here today is remarkable, and improbable,” the president said. “With all the punditry, all of the lobbying, all of the game-playing that passes for governing in Washington, it’s been easy at times to doubt our ability to do such a big thing, such a complicated thing; to wonder if there are limits to what we as a people can still achieve.”

Vice President Joseph R. Biden Jr. began the ceremony with remarks lauding the president’s “perseverance” and “clarity of purpose.”

The White House took on a festive air for the occasion, as senators mingled in the grand foyer of the Executive Mansion before the signing ceremony. A Marine pianist was playing as lawmakers and other guests chatted in anticipation of Mr. Obama’s arrival. As they filtered into the East Room, many lawmakers took out cameras to photograph one another and record the moment.

The landmark bill, passed by the House on Sunday night by a vote of 219-212, will provide coverage to an estimated 30 million people who currently lack it. Its passage assures Mr. Obama a place in history as the American president who succeeded at revamping the nation’s health care system where others, notably Bill Clinton, tried mightily and failed.

The measure will require most Americans to have health insurance coverage; would add 16 million people to the Medicaid rolls; and would subsidize private coverage for low- and middle-income people. It will cost the government about $938 billion over 10 years, according to the non-partisan Congressional Budget Office, which has also estimated that the bill would reduce the federal deficit by $138 billion over a decade.

Despite the president’s signature, the legislative work on the measure is not over, nor is the intense partisan fight over it. Republicans are already vowing to repeal the bill. And the legislative battle will flare anew in the Senate on Tuesday, where lawmakers are set to take up a package of changes to the measure under the parliamentary procedure known as reconciliation.

    Obama Signs Health Care Overhaul Bill, With a Flourish, NYT, 24.3.2010, http://www.nytimes.com/2010/03/24/health/policy/24health.html

Editorial

Health Care Reform, at Last

March 22, 2010
The New York Times

The process was wrenching, and tainted to the 11th hour by narrow political obstructionism, but the year-long struggle over health care reform came to an end on Sunday night with a triumph for countless Americans who have been victimized or neglected by their dysfunctional health care system. Barack Obama put his presidency on the line for an accomplishment of historic proportions.

The bill, which was approved by the Senate in December and by the House on Sunday, represents a national commitment to reform the worst elements of the current system. It will provide coverage to tens of millions of uninsured Americans, prevent the worst insurance company abuses, and begin to wrestle with relentlessly rising costs — while slightly reducing future deficits.

Amendments approved by the House and awaiting approval in the Senate would provide additional coverage and make somewhat deeper reductions in the deficit.

All of this was managed despite the fact that not a single Republican in the House or Senate was willing to vote for the bill. Efforts by the White House and Congressional Democrats to draft bipartisan legislation were met by demagoguery. That is not likely to end now.

Republican leaders, who see opportunities to gain seats in the elections, have made clear that they will continue to peddle fictions about a government takeover of the health care system and about costs too high to bear. Mr. Obama took too long to get into the fight, but came on strong in the end and will have to keep pushing back so all Americans understand the benefits of reform.

Most Americans — those who already have employer-based insurance — will not see much change for a while and certainly not in the seven months before the elections. They will get one important benefit quickly: for an additional fee, parents will be able to keep adult dependent children on their policy through age 26. That is good news when so many young people are struggling to find jobs during the recession.

The biggest difference for Americans who have employer-based insurance is the security of knowing that, starting in 2014, if they lose their job and have to buy their own policy, they cannot be denied coverage or charged high rates because of pre-existing conditions. Before then, the chronically ill could gain temporary coverage from enhanced high-risk pools and chronically ill children are guaranteed coverage.

The focus of the reform is on improving the dysfunctional and hugely expensive insurance markets for individuals and small businesses, and on expanding Medicaid coverage for the poor. The big expansion of coverage will start in 2014, but some reforms start quickly, like tax credits to help small businesses provide coverage.

Over time the reforms could bring about sweeping changes in the way medical care is delivered and paid for. They could ultimately rival Social Security and Medicare in historic importance.

NEAR-UNIVERSAL COVERAGE The United States is the only advanced industrial nation that does not provide or guarantee health care coverage for virtually all of its citizens. It is a moral obligation to end this indefensible neglect of hard-working Americans. The bill does not quite reach full universality, but by 2019, fully 94 to 95 percent of American citizens and legal residents below Medicare age will have coverage. The bill achieves that by requiring most Americans to obtain health insurance, providing subsidies to help the middle classes buy policies on new competitive exchanges, and expanding Medicaid coverage of the poor to include childless adults and others not currently eligible.

INSURANCE REFORMS The legislation would rein in many of the insurance industry’s worst practices. Insurers would no longer be able to reject applicants with “pre-existing conditions” or charge them exorbitant rates. They could not rescind policies on specious grounds after people become sick (that becomes effective immediately) or cap the amount they are willing to pay toward a beneficiary’s illnesses in any given year or over a lifetime.

The most important reform — forcing insurers to accept all applicants regardless of their health status — cannot be achieved unless nearly all Americans are required to have coverage, so the costs can be spread among the healthy and the sick.

A START AT COST CONTROL The legislation won’t quickly bend the cost curve for medical care or insurance premiums — no one has yet found a surefire way to do that — but the reform will make an important start. Some experts believe it will lay the structural framework to mount the most serious effort ever made to control medical inflation. It will create competitive insurance exchanges that should help lower premiums for individuals and small businesses by offering an array of private policies and rates comparable to large group coverage.

The legislation will impose an excise tax in 2018 designed to drive employers and their workers away from the highest-cost insurance policies, which typically provide generous benefits at little out-of-pocket cost to the workers. Health economists consider the excise tax a very strong cost-control measure, because if workers have to pay more of the cost themselves, they and their doctors are apt to think more carefully about whether a test or procedure is really needed. The impact of the excise tax gets increasingly strong as the years pass.

The legislation creates an array of pilot programs within Medicare, to test other innovative cost-reduction strategies. They include encouraging new medical groups to better coordinate care of the chronically ill, and paying doctors and medical institutions based on the quality, not quantity, of services they deliver. The reform measure will establish an independent board to push approaches that work into widespread use in Medicare and ultimately, by force of example, the private sector.

With so many mechanisms available to hold down medical costs, it’s hard to believe that they won’t bear fruit, if not in the next several years then in the decade thereafter.

•

Just as Social Security grew from a modest start in 1935 to become a bedrock of the nation’s retirement system, this is a start on health care reform, not the end. A lot will depend on whether future presidents and Congresses stick to the savings and deficit targets set in this legislation; on how aggressively states administer the new exchanges; on how health care professionals and institutions respond to the challenge of changing their ways; and on how the public responds to the mandate that everyone obtain insurance or pay a penalty.

Our hope and belief is that this reform will in the end accomplish its great objectives. Right now, the good news for all Americans is that despite all the politics and the obstructionism, the process has finally begun.

    Health Care Reform, at Last, NYT, 22.3.2010, http://www.nytimes.com/2010/03/22/opinion/22mon5.html

For Consumers, Clarity on Health Care Changes

March 21, 2010
The New York Times
By TARA SIEGEL BERNARD

American consumers, who spent a year watching Congress scratch and claw over sweeping health care legislation, can now try to figure out what the overhaul would mean for them.

The uninsured are clearly the biggest beneficiaries of the legislation, which would extend the health care safety net for the lowest-income Americans.

The legislation is meant to provide coverage for as many as 32 million people who have been shut out of the market — whether because insurers deem them too sick or because they cannot afford ever-rising insurance premiums.

For people already covered by a large employer — most Americans, in other words — the effect would not be as significant. And yet, just about everyone might benefit from tighter insurance regulations.

“We think it’s a big step forward,” said Bill Vaughan, a policy analyst at Consumers Union. “It’s going to provide a peace of mind that many Americans who really want or need health insurance will always be able to get a quality product at a reasonable price regardless of their health or financial situation.”

There would be costs to consumers, too. Affluent families would be required to pay additional taxes. Most Americans would be required to have health insurance and face federal penalties if they do not buy it. And it is still unclear what effect, if any, the legislation would have on rising out-of-pocket medical costs and premiums.

But there is no question that the legislation should benefit consumers in various ways. Beginning in 2014, for example, many employers — those with 50 or more workers — could face federal fines for not providing insurance coverage. Several of the other changes would take effect much sooner.

Six months after the legislation is enacted, many plans would be prohibited from placing lifetime limits on medical coverage, and they could not cancel the policies of people who fall ill. Children with pre-existing conditions could not be denied coverage.

And dependent children up to age 26 would be eligible for coverage under their parents’ plans — instead of the current state-by-state rules that often cut off coverage for children at 18 or 19.

And within three months of the law’s taking effect, people who have been locked out of the insurance market because of a pre-existing condition would be eligible for subsidized coverage through a new high-risk insurance program.

That special coverage would continue until the legislation’s engine kicks into a higher gear in 2014, when coverage would be extended to a wider part of the population through Medicaid and new state-run insurance exchanges.

Those exchanges, or marketplaces, are meant to provide much more competitive, consumer-friendly online shopping centers of private insurance for people who are not able to obtain coverage through an employer.

In 2014, people with pre-existing conditions could no longer be denied insurance, all lifetime and annual limits on coverage would be eliminated and new policies would be required to meet higher benefit standards.

Even sooner, in 2013, affluent families with annual income above $250,000 would be required to pay an additional 3.8 percent tax on their investment income, while contributing more to the Medicare program from their payroll taxes. And eventually, the most expensive insurance policies would be subject to a new tax.

Here is a look at some of the main ways the health care overhaul might affect household budgets.

The Uninsured

Although most Americans who do not obtain health insurance would face a federal penalty starting in 2014, many experts question how strict the enforcement of that penalty would actually be.

The first year, consumers who did not have insurance would owe $95, or 1 percent of income, whichever is greater. But the penalty would subsequently rise, reaching $695, or 2 percent of income.

Families who fall below the income-tax filing thresholds would not owe anything. Nor would people who cannot find a policy that costs less than 8 percent of their income, said Sara R. Collins, a vice president at the Commonwealth Fund, an independent nonprofit research group.

EXPANDED MEDICAID More lower-income individuals under the age of 65 would be covered by Medicaid, the federal health insurance plan for the poor. Under the new rules, households with income up to 133 percent of the federal poverty level, or about $29,327 for a family of four, would be eligible.

EXCHANGES AND SUBSIDIES Most other uninsured people would be required to buy insurance through one of the new state-run insurance exchanges. People with incomes of more than 133 percent of the poverty level but less than 400 percent (that’s $29,327 to $88,200 for a family of four) would be eligible for premium subsidies through the exchanges.

Premiums would also be capped at a percentage of income, ranging from 3 percent of income to as much as 9.5 percent.

EMPLOYMENT FLEXIBILITY The exchanges would also help people who lose their jobs, quit or decide to start their own businesses.

“If you lose your employer-related insurance, you will be able to move seamlessly into the exchange,” said Timothy Stoltzfus Jost, a professor at the Washington and Lee University School of Law.

Moreover, people of any age who cannot find a plan that costs less than 8 percent of their income would be allowed to buy a catastrophic policy otherwise intended for people under age 30.

Those With Insurance

EMPLOYER COVERAGE People who receive coverage through large employers would be unlikely to see any drastic changes, nor should premiums or coverage be affected. But almost everyone would benefit from new regulations, like the ban on pre-existing conditions that would apply to all policies come 2014.

There might even be cases where people would be eligible to buy insurance through an exchange instead of through their employer, Professor Jost said: those who must pay more than 9.5 percent of their income for premiums, or those whose plans do not cover more than 60 percent of the cost their benefits.

CHANGES IN MEDICARE One of the biggest changes involves the Medicare prescription drug program. Its unpopular “doughnut hole” — a big, expensive gap in coverage that affects millions — would be eliminated by 2020. Starting immediately, consumers who hit the gap would receive a $250 rebate. In 2011, they would receive a 50 percent discount on brand name drugs.

HIGH-COST INSURANCE Starting in 2018, employers that offer workers pricier plans — or those with total premiums of $10,200 or more for singles and $27,500 for families — would be subject to a 40 percent tax on the excess premium, said C. Clinton Stretch, managing principal of tax policy at Deloitte. Retirees and workers in high-risk professions like firefighting would have higher thresholds ($11,850 for singles, or $30,950 for families), pegged to inflation.

Although the taxes would be levied on the insurer, experts expect the assessment to be passed on to the consumer in the form of higher premiums or reduced benefits.

    For Consumers, Clarity on Health Care Changes, NYT, 22.3.2010, http://www.nytimes.com/2010/03/22/your-money/health-insurance/22consumer.html

House Approves Health Overhaul, Sending Landmark Bill to Obama

March 21, 2010
The New York Times
By ROBERT PEAR and DAVID M. HERSZENHORN

WASHINGTON — House Democrats approved a far-reaching overhaul of the nation’s health system on Sunday, voting over unanimous Republican opposition to provide medical coverage to tens of millions of uninsured Americans after an epic political battle that could define the differences between the parties for years.

With the 219-to-212 vote, the House gave final approval to legislation passed by the Senate on Christmas Eve. Thirty-four Democrats joined Republicans in voting against the bill. The vote sent the measure to President Obama, whose yearlong push for the legislation has been the centerpiece of his agenda and a test of his political power.

After approving the bill, the House adopted a package of changes to it by a vote of 220 to 211. That package — agreed to in negotiations among House and Senate Democrats and the White House — now goes to the Senate for action as soon as this week. It would be the final step in a bitter legislative fight that has highlighted the nation’s deep partisan and ideological divisions.

On a sun-splashed day outside the Capitol, protesters, urged on by House Republicans, chanted “Kill the bill” and waved yellow flags declaring “Don’t Tread on Me.” They carried signs saying “Doctors, Not Dictators.”

Inside, Democrats hailed the votes as a historic advance in social justice, comparable to the establishment of Medicare and Social Security. They said the bill would also put pressure on rising health care costs and rein in federal budget deficits.

“This is the Civil Rights Act of the 21st century,” said Representative James E. Clyburn of South Carolina, the No. 3 Democrat in the House.

Mr. Obama celebrated the House action in remarks at the White House.

“We pushed back on the undue influence of special interests,” Mr. Obama said. “We didn’t give in to mistrust or to cynicism or to fear. Instead, we proved that we are still a people capable of doing big things.”

“This isn’t radical reform,” he added, “but it is major reform.”

After a year of combat and weeks of legislative brinksmanship, House Democrats and the White House clinched their victory only hours before the voting started on Sunday. They agreed to a deal with opponents of abortion rights within their party to reiterate in an executive order that federal money provided by the bill could not be used for abortions, securing for Democrats the final handful of votes they needed to assure passage.

Winding up the debate, Speaker Nancy Pelosi said: “After a year of debate and hearing the calls of millions of Americans, we have come to this historic moment. Today we have the opportunity to complete the great unfinished business of our society and pass health insurance reform for all Americans that is a right and not a privilege.”

The House Republican leader, Representative John A. Boehner of Ohio, said lawmakers were defying the wishes of their constituents. “The American people are angry,” Mr. Boehner said. “This body moves forward against their will. Shame on us.”

Republicans said the plan would saddle the nation with unaffordable levels of debt, leave states with expensive new obligations, weaken Medicare and give the government a huge new role in the health care system.

The debate on the legislation set up a bitter midterm campaign season, with Republicans promising an effort to repeal the legislation, challenge its constitutionality or block its provisions in the states.

Representative Paul D. Ryan, Republican of Wisconsin, denounced the bill as “a fiscal Frankenstein.” Representative Lincoln Diaz-Balart, Republican of Florida, called it “a decisive step in the weakening of the United States.” Representative Virginia Foxx, Republican of North Carolina, said it was “one of the most offensive pieces of social engineering legislation in the history of the United States.”

But Representative Marcy Kaptur, Democrat of Ohio, said the bill heralded “a new day in America.” Representative Doris Matsui, Democrat of California, said it would “improve the quality of life for millions of American families.”

The health care bill would require most Americans to have health insurance, would add 16 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $938 billion over 10 years, the Congressional Budget Office said.

The bill would require many employers to offer coverage to employees or pay a penalty. Each state would set up a marketplace, or exchange, where consumers without such coverage could shop for insurance meeting federal standards.

The budget office estimates that the bill would provide coverage to 32 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

The new costs, according to the budget office, would be more than offset by savings in Medicare and by new taxes and fees, including a tax on high-cost employer-sponsored health plans and a tax on the investment income of the most affluent Americans.

Cost estimates by the budget office, showing that the bill would reduce federal budget deficits by $143 billion in the next 10 years, persuaded some fiscally conservative Democrats to vote for the bill.

Democrats said Americans would embrace the bill when they saw its benefits, including some provisions that take effect later this year.

Health insurers, for example, could not deny coverage to children with medical problems or suddenly drop coverage for people who become ill. Insurers must allow children to stay on their parents’ policies until they turn 26. Small businesses could obtain tax credits to help them buy insurance.

The Democratic effort to secure the 216 votes needed for passage of the legislation came together only after last-minute negotiations involving the White House, the House leadership and a group of Democratic opponents of abortion rights, led by Representative Bart Stupak of Michigan. On Sunday afternoon, members of the group announced that they would support the legislation after Mr. Obama promised to issue an executive order to “ensure that federal funds are not used for abortion services.”

Mr. Stupak described the order as a significant guarantee that would “protect the sanctity of life in health care reform.” But supporters of abortion rights — and some opponents — said the order merely reaffirmed what was in the bill.

The vote to pass the Senate version of the bill means that it will become the law of the land as soon as Mr. Obama signs it, regardless of when — or even whether — the Senate acts on the package of changes the House also passed.

In his remarks, shortly before midnight in the East Room, Mr. Obama urged the Senate to complete the final pieces of the legislation. “Some have predicted another siege of parliamentary maneuvering in order to delay it,” he said. “I hope that’s not the case.”

He continued, “It’s time to bring this debate to a close and begin the hard work of implementing this reform properly on behalf of the American people.”

Mr. Obama watched the roll call with Vice President Joseph R. Biden Jr. in the Roosevelt Room in the White House.

The House galleries were full, and the floor was unusually crowded, for the historic debate on health care.

Working together, Mr. Obama and Ms. Pelosi revived the legislation when it appeared dead after Democrats lost their 60th vote in the Senate and with it their ability to shut off Republican filibusters.

Republicans said they would use the outcome to bludgeon Democrats in this year’s Congressional elections. The White House is planning an intensive effort to convince people of the bill’s benefits. But if Democrats suffer substantial losses in November, Mr. Obama could be stymied on other issues.

The campaign for a health care overhaul began as a way to help the uninsured. But it gained momentum when middle-class families with health insurance flooded Congress with their grievances. They complained of soaring premiums. They said their insurance had been canceled when they got sick.

“It’s not just the uninsured,” said Representative Jim McGovern, Democrat of Massachusetts. “We also have to worry about people with insurance who find, for crazy reasons, that they are somehow going to be denied coverage.”

In the end, groups like the United States Chamber of Commerce and the National Federation of Independent Business tried to stop the bill, saying it would increase the cost of doing business. But other groups, including the American Medical Association and AARP, backed it, as did the pharmaceutical industry.

Lawmakers agreed that Sunday’s debate was historic, but they were poles apart in assessing the legislation.

Representative Rodney Alexander, Republican of Louisiana, said, “You cannot expect to expand coverage to millions of individuals and to curb costs at the same time.”

Republicans said the picture painted by the budget office was too rosy, because the new taxes and fees would start immediately, while the major costs would not show up for four years.

Moreover, Republicans said Democrats would pay a price for defying public opinion on the bill.

“Are you so arrogant that you know what’s best for the American people?” Representative Paul Broun, Republican of Georgia, asked the Democrats. “Are you so ignorant to be oblivious to the wishes of the American people?”

Lawmakers spoke with deep conviction in explaining their votes.

“Health care is not only a civil right, it’s a moral issue,” said Representative Patrick J. Kennedy, Democrat of Rhode Island, who invoked the memory of his father, Senator Edward M. Kennedy, a Massachusetts Democrat and a lifelong champion of health care for all.

After the legislation passed, Mr. Obama sought to place the day in perspective.

“In the end what this day represents is another stone firmly laid in the foundation of the American dream,” the president said. “Tonight, we answered the call of history as so many generations of Americans have before us. When faced with crisis, we did not shrink from our challenges. We overcame them. We did not avoid our responsibilities, we embraced it. We did not fear our future, we shaped it.”


Carl Hulse contributed reporting.

    House Approves Health Overhaul, Sending Landmark Bill to Obama, NYT, 22.3.2010, http://www.nytimes.com/2010/03/22/health/policy/22health.html

Editorial

More Than Onerous

March 15, 2010
The New York Times

After a year of national debate, a handful of House Democrats who oppose abortion may be the ones to decide whether health care reform goes forward or not.

We strongly support a woman’s right to choose and are disturbed by the restrictions in both the House and Senate bills on a woman’s ability to buy insurance that covers abortions. But the opportunity to provide coverage for 30 million of the uninsured — and more security for all Americans — is too important to miss.

We are puzzled and dismayed that these legislators are willing to waste that opportunity because they say the onerous anti-abortion provisions in the Senate’s bill are still not onerous enough.

How did a small group get so much power? The answer has to do with the peculiarities of the legislative process and the fact that not a single Republican — for conviction or politics — is willing to vote for reform.

The most likely path forward is for the House to approve the Senate’s version and for both chambers to approve amendments that would make it more palatable to House members. To get those amendments past a Republican filibuster, Senate Democrats plan to use “reconciliation.” That only requires a majority vote, but it is just for budget-related issues, which means the abortion provisions can’t be changed.

Representative Bart Stupak, a Michigan Democrat, says that unless the Senate’s anti-abortion provisions are strengthened, perhaps a dozen House Democrats who voted for the House version won’t vote for the Senate’s bill. Before they push their party’s signature domestic issue over a cliff they need to recognize how incredibly restrictive the Senate’s provisions already are.

•

Most of these restrictions would apply to insurance policies sold on new exchanges where individuals and small businesses could choose from an array of private plans. The Senate bill would allow any state to ban insurers on the state’s exchanges from offering policies that cover abortion. In states that don’t impose that ban, the exchanges would be required to offer at least one policy that excludes abortion coverage. They would not be required to offer policies that cover abortions.

The Senate bill also bans the use of federal subsidies to pay for abortion services. And it would set up a hugely complicated scheme to make sure that happens.

All people who buy a policy that covers abortions — not just those receiving tax credits to help buy insurance — would have to divide their premium payment in two: a small part (at least $1 a month) to cover the plan’s projected cost of paying for abortions and a much bigger payment for the rest of the premium. The insurers would have to keep two separate accounts for the subsidized group, one to pay for abortions and one for all other care. It would be so cumbersome that it would likely discourage insurers from offering plans that cover abortion.

Those restrictions are a blatant government interference in a serious health care decision that should be made by a woman and her doctor. But for some House members they are still not enough.

They want a House provision that would not allow a woman even to use her own premium contributions to pay for abortion coverage in any plan that accepts subsidized enrollees; she would have to buy a separate rider that few insurers would likely offer.

They warn that the Senate bill does not make its restrictions permanent, but pegs them to the so-called Hyde amendment, passed each year to restrict government spending on abortions. The Hyde amendment — unfortunately — has been renewed for more than three decades and shows no signs of disappearing.

House opponents also complain that the Senate bill would appropriate billions of dollars to build and operate community health centers to serve poor patients, without an ironclad guarantee that such centers would not provide abortion services. That too denies reality. In 45 years of operation, such federally financed health centers have never provided abortions.

And they worry that the Department of Health and Human Services could include abortion on a list of “preventive services” for women that insurers would be required to cover without any cost sharing. Abortion has never been defined as a preventive service; the provision is aimed at ensuring that women get mammograms and pap smears.

Finally, they oppose the Senate bill’s provision requiring everyone enrolled in a plan that covers abortions to designate a small part of their premium to underwrite the plan’s abortion coverage. Those who object can always sign up for a plan that does not cover abortions.

•

Abortion is a legal and medically valid procedure that should be covered by insurance — without government interference. Legislators who support abortion rights are the only ones who have given ground in the interests of passing health care reform. Anti-abortion Democrats need to show similar statesmanship and accept the Senate’s restrictive provisions. They owe it to all Americans.

    More Than Onerous, NYT, 15.3.2010, http://www.nytimes.com/2010/03/15/opinion/15mon1.html

3 Rulings Find No Link to Vaccines and Autism

March 12, 2010
The New York Times
By DONALD G. McNEIL Jr.

In a further blow to the antivaccine movement, three judges ruled Friday in three separate cases that thimerosal, a preservative containing mercury, does not cause autism.

The three rulings are the second step in the Omnibus Autism Proceeding begun in 2002 in the United States Court of Federal Claims. The proceeding combines the cases of 5,000 families with autistic children seeking compensation from the federal vaccine injury fund, which comes from a 75-cent tax on every dose of vaccine.

Families of children hurt by vaccines — for example, who suffer fatal allergic reactions — are paid from it but are unable to sue the vaccine manufacturer. The fund has never accepted that vaccines cause autism; the omnibus proceeding, with nine test cases based on three different theories, was begun in 2002.

The antivaccine groups also lost the first three cases, which were decided in February 2009 by the same three judges, known as special masters. All three rulings were upheld on their first appeals.

Defenders of vaccines said they were pleased by Friday’s decision, while opponents were dismissive, saying they would never get a fair ruling from the omnibus arrangement.

In the three cases brought against the government, by the parents of Jordan King, Colin R. Dwyer and William Mead, all three special masters used strong language in dismissing the expert evidence from the families’ lawyers.

The master in the King ruling emphasized that it was “not a close case” and “extremely unlikely” that Jordan’s autism was connected to his vaccines. The master in the Dwyer case wrote that many parents “relied upon practitioners and researchers who peddled hope, not opinions grounded in science and medicine.”

Patricia Campbell-Smith, the master in the Mead case, also dismissed two subarguments made by a few opponents of vaccines, saying they “have not shown either that certain children are genetically hypersusceptible to mercury or that certain children are predisposed to have difficulty excreting mercury.”

She also echoed a contention by vaccine defenders that a shot is safer than a tuna sandwich. “A normal fish-eating diet by pregnant mothers” is more likely to deposit mercury in the brain than vaccines are, she wrote.

In a telephone press conference after the rulings, Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia and the inventor of a rotavirus vaccine from which he receives royalties, praised the decisions, saying: “This hypothesis has already had its day in scientific court, but in America we like to have our day in literal court. Fortunately, we now have these rulings.”

Fears of thimerosal emerged more than a decade ago and have cast a pall over vaccines ever since, even though it has been removed from most of them. The fear has caused some parents to avoid them and made outbreaks of diseases like measles and whooping cough more likely.

Even with this decision, Dr. Offit said, “it’s very hard to unscare people after you’ve scared them.”

The Coalition for Vaccine Safety, a group of organizations that believe vaccines cause autism, dismissed the rulings.

“The deck is stacked against families in vaccine court,” said Rebecca Estepp, of the coalition’s steering committee. “Government attorneys defend a government program using government-funded science before government judges. Where’s the justice in that?” The coalition claims to represent 75,000 families.

Amy Carson, founder of Moms Against Mercury, who has a son with brain damage, called the vaccine court arrangement “like the mice overseeing the cheese.”

The vaccine injury fund and the court overseeing it were created in 1988 after judgments in state court lawsuits over vaccines became so inconsistent and so expensive that vaccine companies started quitting the American market.

The third theory, that measles vaccine causes autism, is still to be ruled on by the special masters. But Lisa Randall, a lawyer with the Immunization Action Coalition, which defends vaccines, said she believed some of the test cases had been “abandoned” by the families that brought them after the 2009 decisions dismissed a variant of the same theory.

    3 Rulings Find No Link to Vaccines and Autism, NYT, 13.3.2010, http://www.nytimes.com/2010/03/13/science/13vaccine.html

Obama Turns Up the Volume in Bid for Health Measure

March 8, 2010
The New York Times
By HELENE COOPER and DAVID M. HERSZENHORN

PHILADELPHIA — President Obama challenged wavering members of his party on Monday not to give in to political fears about supporting health care legislation, asserting that the urgency of getting a bill through Congress should trump any concern about the consequences for Democrats in November.

In a high-octane appearance that harked back to his “yes we can” campaign days, Mr. Obama jettisoned the professorial demeanor that has cloaked many of his public pronouncements on the issue, instead making an emotional pitch for public support as he tries to push the legislation through a final series of votes in Congress in the next several weeks.

With the fate of his signature initiative on the line, and Republicans eager to portray Democrats as out of step with the country and incapable of governing, Mr. Obama seemed to relish the opportunity to cut loose and make his case on his terms, as he often has at pivotal moments.

And, with his back to the wall, the president appeared intent on reassuring his party that he was as confident as ever in his powers to explain, persuade and capture the politics of the moment.

Appearing before 1,800 students and other members of the public at Arcadia University, just outside Philadelphia, Mr. Obama cast himself almost as an outsider in Washington, expressing disdain for “the sport of politics” and saying the time for endless debates is over.

“They’ve warned us we may not win,” Mr. Obama said of his doubters and critics. “They’ve argued now is not the time for reform. It’s going to hurt your poll numbers. How is it going to affect Democrats in November? Don’t do it now.

“My question to them is: When is the right time? If not now, when? If not us, who?”

President Obama struck a populist tone, setting up the health insurance industry as his main target.

“We can’t have a system that works better for the insurance companies than it does for the American people,” he said.

Citing big rate increases for buyers of individual insurance policies in some states — 40 percent, 60 percent, even 100 percent — Mr. Obama sought to focus attention on provisions in the legislation that he said would protect consumers from the worst excesses of insurers, give people more choice among insurance policies, insure most people who do not have coverage, and put downward pressure on health care costs.

Boiling down his proposal to a few sentences, Mr. Obama asked, “How many people would like a proposal that holds insurance companies more accountable? How many people would like to give Americans the same insurance choices that members of Congress get? And how many would like a proposal that brings down costs for everyone? That’s our proposal.”

Mr. Obama also took direct aim at those who have warned that the health push could cost the Democrats their majority in the November elections. He alluded to letters he had received from cancer survivors and others who had been priced out of the health care market.

“What should I tell these Americans?” Mr. Obama said, to raucous cheering. “That Washington’s not sure how it will play in November? That we should walk away from this fight?”

Mr. Obama’s trip to Pennsylvania came as Democratic Congressional leaders raced to resolve the remaining differences between the House and Senate versions of the health care legislation and to draft formal legislative language that would allow for a new cost estimate by the Congressional Budget Office.

Without a final proposal and new cost figures, Democrats are in no position to start twisting the arms of wavering House Democrats whose votes would be crucial to adopting first the Senate-passed health care bill, and then a companion budget reconciliation measure that would include the final revisions.

As the White House and Congressional leaders continued to tinker, rank-and-file lawmakers found themselves under increasing pressure. Throughout Monday, Republicans sought to draw attention to the Democrats who are opposing the measure. They included Representatives Mike Ross of Arkansas and Artur Davis of Alabama, who is running for governor. Both Mr. Ross and Mr. Davis opposed the health care bill that passed the House in November. A spokesman for Mr. Ross, Brad Howard, said, “He is a ‘no’ at this time.”

Republicans also pointed to Representatives Daniel Lipinski of Illinois and Representative James L. Oberstar of Minnesota as examples of Democratic lawmakers who said they would oppose the health care legislation if it did not include tight restrictions on coverage for abortions.

Representative Bart Stupak, Democrat of Michigan, who sponsored an amendment that added the tighter abortion restrictions to the House’s bill in November, has said he will oppose the bill if those restrictions are replaced with the abortion language in the Senate bill. Democrats have concluded that they cannot make changes to the Senate abortion provisions using the budget reconciliation process and continued to search for some other compromise, perhaps with a third bill.

Over all, the Republican effort seemed intended to counteract a push by the White House and Democratic leaders to portray the passage of the health care measure as a political imperative for Democrats, and as a stark choice between success or failure that would shape their fate at the polls in November.

“We may be nearing the final act for this bill and the legislative process,” the Senate Republican leader, Mitch McConnell of Kentucky, said in a floor speech on Monday. “It’s just the beginning for those who support it. Americans don’t want this bill. They’re telling us to start over. The only people who don’t seem to be getting the message are Democrat leaders in Washington.”

Mr. Obama scoffed at Mr. McConnell’s warning.

“First of all, I generally wouldn’t take advice about what’s good for Democrats” from a Republican, Mr. Obama said to laughter in Pennsylvania. “But setting aside that, that’s not the issue here. The issue here is not the politics of it.”

Mr. Obama traveled to Pennsylvania with political allies, including Senators Bob Casey and Arlen Specter, both Democrats. On his return to Washington, Mr. Specter, who is involved in a primary battle, called Mr. Obama’s speech exactly the infusion of energy that the health package needed right now.

“That’s the most fiery I’ve seen him since the early campaign,” Mr. Specter told reporters traveling with the president.

On Wednesday, Mr. Obama is to travel to St. Louis for another campaign-style rally for health care, White House officials said. On Tuesday, the group Health Care for America Now plans a march in Washington in support of a health care package.

    Obama Turns Up the Volume in Bid for Health Measure, NYT, 9.3.2010,  http://www.nytimes.com/2010/03/09/health/policy/09health.html

New York Is Ordered to Move Mentally Ill Out of Group Homes

March 1, 2010
The New York Times
By A. G. SULZBERGER

New York State must immediately begin moving thousands of people with mental illness into their own apartments or small homes and out of large, institutional adult homes that keep them segregated from society, a federal judge ordered on Monday.

The decision by Judge Nicholas G. Garaufis of Federal District Court in Brooklyn followed his ruling in September that the conditions at more than two-dozen privately run adult homes in New York City violated the Americans With Disabilities Act by leaving the approximately 4,300 mentally-ill residents isolated from the outside world in warehouse-like conditions.

The remedial plan offered by Judge Garaufis, which drew from a proposal presented by advocates for the mentally ill and was backed by the Justice Department, calls on New York to develop at least 1,500 units of so-called supportive housing a year for the next three years. In supportive housing, a resident lives alone or in small groups and receives specialized services from counselors who visit as needed.

The judge said that only people with the most severe mental illness, including those deemed a danger to themselves or others, should be housed in adult homes. He also said that residents who were eligible for supportive housing may choose to stay in adult homes as long as they have been apprised of their options.

The order begins a process aimed at transforming a system that first took shape in the 1960s. The government embraced adult homes as a way to care for people with mental illness following the rapid closure of large state-run hospitals, a process known as deinstitutionalization, but that became defined by continued lax state regulation and poor private management of the adult homes.

A series of articles in The New York Times in 2002 described a system in which residents were poorly monitored and barely cared for, with residents left to swelter in the summer and sometimes subjected to needless medical treatment and surgeries for Medicaid reimbursement.

The state argued that conditions had improved markedly at adult homes in recent years, but the judge ruled last year that their very setup discriminated against residents by keeping them separated from society and providing little encouragement to find work, make friends or learn skills like cooking, shopping or budgeting.

The order by Judge Garaufis offered a stinging rebuke of the much less sweeping proposed remedy offered by the state, which continued to dispute many of the findings of his previous rulings and which sought to cap the number of new supportive housing units at 1,000, to be made available on a more restrictive basis over five years. “The court is disappointed and, frankly, incredulous that defendants sincerely believed this proposal would suffice,” the judge wrote in his ruling Monday.

The state had argued that, particularly in current economic conditions, such a mandate would be too expensive. But the judge wrote last year that evidence showed that supported housing would cost only $40,253 a year per resident, about $7,500 less than it costs to place them in a group home.

On Monday, the judge ordered the appointment of a federal monitor to ensure the state followed his plan and said that both sides must suggest candidates by the end of the week.

“Defendants’ demonstrated resistance to the remedy, as evidenced by their refusal to abide by the court’s findings in crafting their patently inadequate proposal, further highlights the need for a Monitor in this case,” he wrote.

    New York Is Ordered to Move Mentally Ill Out of Group Homes, NYT, 2.3.2010, http://www.nytimes.com/2010/03/02/nyregion/02mental.html

Utah Bill Would Criminalize Illegal Abortions

February 28, 2010
The New York Times
By KIRK JOHNSON

DENVER — The origins of Utah State House Bill 12 lie in an act of dark and desperate violence.

Last May in a small town in eastern Utah, a 17-year-old girl, seven months pregnant, paid a man she had just met $150 to beat her up in hopes of inducing a miscarriage that would resolve her crisis. He obliged, taking her to a basement and kicking her repeatedly in the stomach.

The fetus survived the assault and was born in August. The attacker went to jail. And the girl, whose name was never released because she was under age, became the center of a legal debate — and the piece of legislation now awaiting the governor’s signature or veto. The bill would formally criminalize what she did, that is, to seek an illegal abortion.

If it is signed into law by Gov. Gary R. Herbert, a Republican, who has said he agrees generally with its goals but is still studying the particulars, Utah would still allow legal abortions performed by a doctor. But it would go further than any other state, several legal experts said, in mapping out a much murkier question: when is a woman criminally liable for trying to end a pregnancy through other means or self-infliction?

The bill’s sponsor, Representative Carl D. Wimmer, a Republican and former police officer from the suburbs of Salt Lake City, said the beating case, and the decision by a judge last fall that the girl had committed no crime because seeking an abortion is not illegal, revealed “a loophole” in the law.

“A woman going out to seek any way to kill her unborn child, no matter how heinous or brutal, couldn’t be held liable,” Mr. Wimmer said.

But critics say legislation inspired by an unusual, perhaps even freakish criminal case, could open up a vast frontier around the question of intent and responsibility and give local prosecutors huge new powers to inquire about a woman’s intentions toward her unborn child.

For example, if a pregnant woman gets into a vehicle, goes on a wild ride way over the speed limit without wearing a seatbelt and crashes and the fetus is killed, is she a reckless driver? Or is she a reckless mother-to-be who criminally ignored the safety of her fetus?

Under the bill, a woman guilty of criminal homicide of her fetus could be punished by up to life in prison.

“So many things can happen, and it’s all in the eye of the beholder — that’s what’s very dangerous about this legislation,” said Marina Lowe, the legislative and policy counsel to the American Civil Liberties Union of Utah, which has urged Mr. Herbert to veto the bill.

Some women’s advocacy groups say the bill simply codifies what many states are already doing, using existing laws about the unborn to prosecute apparently errant mothers.

Just last month in Iowa, for example, a pregnant woman who fell down the stairs at home confided to emergency workers that she was not sure she really wanted to have her child. Though the woman did not immediately miscarry from the fall, she was arrested anyway under a state law that makes it a criminal act to harm a fetus. She was released after two days in jail, and the charges were dropped.

At least 38 states have laws against fetal homicide, generally intended to create additional penalties when a pregnant woman is assaulted or killed. And two states, Delaware and New York, also have laws specifically making self-abortion a crime. Both laws were passed before the United States Supreme Court decision in Roe v. Wade.

Some opponents of abortion also do not like the Utah bill because of the very fact that it does codify the language and limits of abortion law, with specific delineations about when ending a pregnancy in Utah is legal and when it is not.

“Well, it’s all right to kill a human being in this case, but not in this case,” said Jim Sedlak, vice president of the American Life League, a national group that works for what it calls “pro-life concerns.”

“I would urge him to not sign this law and to send it back,” Mr. Sedlak said, referring to Mr. Herbert. “He should ask the Legislature to address the real problem of personhood in the womb.”

Whether the bill, if it does become law, would be a rarely used symbolic declaration or a widely used law enforcement tool is part of the debate as well.

“Prosecutors have a lot of discretion, and miscarriage is a sad but common event in connection with pregnancy,” said Nancy Northup, president of the Center for Reproductive Rights, a nonprofit advocacy group for birth control and abortion rights. “This bill would cast suspicion, potentially, on every single miscarriage.”

Nonsense, said Mr. Wimmer, the sponsor. He said the language in the bill requiring “intentional, knowing or reckless” acts by a woman against her unborn child sets a high bar that would allow questions to be asked only in the most glaring of cases.

Behavior by a mother that might harm but not kill her fetus, including use of alcohol or tobacco, would not be covered by the bill, he said. But, he added, a mother who killed her fetus by taking illegal drugs might conceivably be charged.

The 17-year-old girl’s child, meanwhile, was adopted by a Utah couple.

Supporters of the bill said a letter from the baby’s adoptive mother, read aloud by Mr. Wimmer at a legislative hearing on the bill, was a powerful emotional moment that may have swung some votes.

The bill was ultimately approved by overwhelming majorities in the Republican-controlled Legislature: 59 to 12 in the House and 24 to 4 in the Senate.

“When Representative Wimmer read the letter, about the little girl playing with bubbles in the bathtub and learning to crawl and so full of life, you could have heard a pin drop,” said Laura Bunker, director of United Families Utah, a group that worked on behalf of the bill. “And all of a sudden people realized that there was a victim here, and the victim was alive and had a future.”

Lynn M. Paltrow, the executive director of National Advocates for Pregnant Women, a nonprofit group based in New York, said the focus on the child obscured the bleak story of the teenager, who also deserves, she said, empathy from the world, and the law.

“Almost nobody is speaking for her,” Ms. Paltrow said. “Why would a young woman get to a point of such desperation that she would invite violence against herself? Anybody that desperate is not going to be deterred by this statute.”

    Utah Bill Would Criminalize Illegal Abortions, NYT, 1.3.2010, http://www.nytimes.com/2010/03/01/us/01abortion.html

Depression’s Upside

February 28, 2010
The New York Times
By JONAH LEHRER

The Victorians had many names for depression, and Charles Darwin used them all. There were his “fits” brought on by “excitements,” “flurries” leading to an “uncomfortable palpitation of the heart” and “air fatigues” that triggered his “head symptoms.” In one particularly pitiful letter, written to a specialist in “psychological medicine,” he confessed to “extreme spasmodic daily and nightly flatulence” and “hysterical crying” whenever Emma, his devoted wife, left him alone.

While there has been endless speculation about Darwin’s mysterious ailment — his symptoms have been attributed to everything from lactose intolerance to Chagas disease — Darwin himself was most troubled by his recurring mental problems. His depression left him “not able to do anything one day out of three,” choking on his “bitter mortification.” He despaired of the weakness of mind that ran in his family. “The ‘race is for the strong,’ ” Darwin wrote. “I shall probably do little more but be content to admire the strides others made in Science.”

Darwin, of course, was wrong; his recurring fits didn’t prevent him from succeeding in science. Instead, the pain may actually have accelerated the pace of his research, allowing him to withdraw from the world and concentrate entirely on his work. His letters are filled with references to the salvation of study, which allowed him to temporarily escape his gloomy moods. “Work is the only thing which makes life endurable to me,” Darwin wrote and later remarked that it was his “sole enjoyment in life.”

For Darwin, depression was a clarifying force, focusing the mind on its most essential problems. In his autobiography, he speculated on the purpose of such misery; his evolutionary theory was shadowed by his own life story. “Pain or suffering of any kind,” he wrote, “if long continued, causes depression and lessens the power of action, yet it is well adapted to make a creature guard itself against any great or sudden evil.” And so sorrow was explained away, because pleasure was not enough. Sometimes, Darwin wrote, it is the sadness that informs as it “leads an animal to pursue that course of action which is most beneficial.” The darkness was a kind of light.

The mystery of depression is not that it exists — the mind, like the flesh, is prone to malfunction. Instead, the paradox of depression has long been its prevalence. While most mental illnesses are extremely rare — schizophrenia, for example, is seen in less than 1 percent of the population — depression is everywhere, as inescapable as the common cold. Every year, approximately 7 percent of us will be afflicted to some degree by the awful mental state that William Styron described as a “gray drizzle of horror . . . a storm of murk.” Obsessed with our pain, we will retreat from everything. We will stop eating, unless we start eating too much. Sex will lose its appeal; sleep will become a frustrating pursuit. We will always be tired, even though we will do less and less. We will think a lot about death.

The persistence of this affliction — and the fact that it seemed to be heritable — posed a serious challenge to Darwin’s new evolutionary theory. If depression was a disorder, then evolution had made a tragic mistake, allowing an illness that impedes reproduction — it leads people to stop having sex and consider suicide — to spread throughout the population. For some unknown reason, the modern human mind is tilted toward sadness and, as we’ve now come to think, needs drugs to rescue itself.

The alternative, of course, is that depression has a secret purpose and our medical interventions are making a bad situation even worse. Like a fever that helps the immune system fight off infection — increased body temperature sends white blood cells into overdrive — depression might be an unpleasant yet adaptive response to affliction. Maybe Darwin was right. We suffer — we suffer terribly — but we don’t suffer in vain.

ANDY THOMSON IS a psychiatrist at the University of Virginia. He has a scruffy gray beard and steep cheekbones. When Thomson talks, he tends to close his eyes, as if he needs to concentrate on what he’s saying. But mostly what he does is listen: For the last 32 years, Thomson has been tending to his private practice in Charlottesville. “I tend to get the real hard cases,” Thomson told me recently. “A lot of the people I see have already tried multiple treatments. They arrive without much hope.” On one of the days I spent with Thomson earlier this winter, he checked his phone constantly for e-mail updates. A patient of his on “welfare watch” who was required to check in with him regularly had not done so, and Thomson was worried. “I’ve never gotten used to treating patients in mental pain,” he said. “Maybe it’s because every story is unique. You see one case of iron-deficiency anemia, you’ve seen them all. But the people who walk into my office are all hurting for a different reason.”

In the late 1990s, Thomson became interested in evolutionary psychology, which tries to explain the features of the human mind in terms of natural selection. The starting premise of the field is that the brain has a vast evolutionary history, and that this history shapes human nature. We are not a blank slate but a byproduct of imperfect adaptations, stuck with a mind that was designed to meet the needs of Pleistocene hunter-gatherers on the African savanna. While the specifics of evolutionary psychology remain controversial — it’s never easy proving theories about the distant past — its underlying assumption is largely accepted by mainstream scientists. There is no longer much debate over whether evolution sculptured the fleshy machine inside our head. Instead, researchers have moved on to new questions like when and how this sculpturing happened and which of our mental traits are adaptations and which are accidents.

In 2004, Thomson met Paul Andrews, an evolutionary psychologist at Virginia Commonwealth University, who had long been interested in the depression paradox — why a disorder that’s so costly is also so common. Andrews has long dark brown hair and an aquiline nose. Before he begins to talk, he often writes down an outline of his answer on scratch paper. “This is a very delicate subject,” he says. “I don’t want to say something reckless.”

Andrews and Thomson struck up an extended conversation on the evolutionary roots of depression. They began by focusing on the thought process that defines the disorder, which is known as rumination. (The verb is derived from the Latin word for “chewed over,” which describes the act of digestion in cattle, in which they swallow, regurgitate and then rechew their food.) In recent decades, psychiatry has come to see rumination as a dangerous mental habit, because it leads people to fixate on their flaws and problems, thus extending their negative moods. Consider “The Depressed Person,” a short story by David Foster Wallace, which chronicles a consciousness in the grip of the ruminative cycle. (Wallace struggled with severe depression for years before committing suicide in 2008.) The story is a long lament, a portrait of a mind hating itself, filled with sentences like this: “What terms might be used to describe such a solipsistic, self-consumed, bottomless emotional vacuum and sponge as she now appeared to herself to be?” The dark thoughts of “The Depressed Person” soon grow tedious and trying, but that’s precisely Wallace’s point. There is nothing profound about depressive rumination. There is just a recursive loop of woe.

The bleakness of this thought process helps explain why, according to the Yale psychologist Susan Nolen-Hoeksema, people with “ruminative tendencies” are more likely to become depressed. They’re also more likely to become unnerved by stressful events: for instance, Nolen-Hoeksema found that residents of San Francisco who self-identified as ruminators showed significantly more depressive symptoms after the 1989 Loma Prieta earthquake. And then there are the cognitive deficits. Because rumination hijacks the stream of consciousness — we become exquisitely attentive to our pain — numerous studies have found that depressed subjects struggle to think about anything else, just like Wallace’s character. The end result is poor performance on tests for memory and executive function, especially when the task involves lots of information. (These deficits disappear when test subjects are first distracted from their depression and thus better able to focus on the exercise.) Such research has reinforced the view that rumination is a useless kind of pessimism, a perfect waste of mental energy.

That, at least, was the scientific consensus when Andrews and Thomson began exploring the depression paradox. Their evolutionary perspective, however — they see the mind as a fine-tuned machine that is not prone to pointless programming bugs — led them to wonder if rumination had a purpose. They started with the observation that rumination was often a response to a specific psychological blow, like the death of a loved one or the loss of a job. (Darwin was plunged into a debilitating grief after his 10-year-old daughter, Annie, died following a bout of scarlet fever.) Although the D.S.M. manual, the diagnostic bible for psychiatrists, does not take such stressors into account when diagnosing depressive disorder — the exception is grief caused by bereavement, as long as the grief doesn’t last longer than two months — it’s clear that the problems of everyday life play a huge role in causing mental illness. “Of course, rumination is unpleasant,” Andrews says. “But it’s usually a response to something real, a real setback. It didn’t seem right that the brain would go haywire just when we need it most.”

Imagine, for instance, a depression triggered by a bitter divorce. The ruminations might take the form of regret (“I should have been a better spouse”), recurring counterfactuals (“What if I hadn’t had my affair?”) and anxiety about the future (“How will the kids deal with it? Can I afford my alimony payments?”). While such thoughts reinforce the depression — that’s why therapists try to stop the ruminative cycle — Andrews and Thomson wondered if they might also help people prepare for bachelorhood or allow people to learn from their mistakes. “I started thinking about how, even if you are depressed for a few months, the depression might be worth it if it helps you better understand social relationships,” Andrews says. “Maybe you realize you need to be less rigid or more loving. Those are insights that can come out of depression, and they can be very valuable.”

This radical idea — the scientists were suggesting that depressive disorder came with a net mental benefit — has a long intellectual history. Aristotle was there first, stating in the fourth century B.C. “that all men who have attained excellence in philosophy, in poetry, in art and in politics, even Socrates and Plato, had a melancholic habitus; indeed some suffered even from melancholic disease.” This belief was revived during the Renaissance, leading Milton to exclaim, in his poem “Il Penseroso”: “Hail divinest Melancholy/Whose saintly visage is too bright/To hit the sense of human sight.” The Romantic poets took the veneration of sadness to its logical extreme and described suffering as a prerequisite for the literary life. As Keats wrote, “Do you not see how necessary a World of Pains and troubles is to school an intelligence and make it a soul?”

But Andrews and Thomson weren’t interested in ancient aphorisms or poetic apologias. Their daunting challenge was to show how rumination might lead to improved outcomes, especially when it comes to solving life’s most difficult dilemmas. Their first speculations focused on the core features of depression, like the inability of depressed subjects to experience pleasure or their lack of interest in food, sex and social interactions. According to Andrews and Thomson, these awful symptoms came with a productive side effect, because they reduced the possibility of becoming distracted from the pressing problem.

The capacity for intense focus, they note, relies in large part on a brain area called the left ventrolateral prefrontal cortex (VLPFC), which is located a few inches behind the forehead. While this area has been associated with a wide variety of mental talents, like conceptual knowledge and verb conjugation, it seems to be especially important for maintaining attention. Experiments show that neurons in the VLPFC must fire continuously to keep us on task so that we don’t become sidetracked by irrelevant information. Furthermore, deficits in the VLPFC have been associated with attention-deficit disorder.

Several studies found an increase in brain activity (as measured indirectly by blood flow) in the VLPFC of depressed patients. Most recently, a paper to be published next month by neuroscientists in China found a spike in “functional connectivity” between the lateral prefrontal cortex and other parts of the brain in depressed patients, with more severe depressions leading to more prefrontal activity. One explanation for this finding is that the hyperactive VLPFC underlies rumination, allowing people to stay focused on their problem. (Andrews and Thomson argue that this relentless fixation also explains the cognitive deficits of depressed subjects, as they are too busy thinking about their real-life problems to bother with an artificial lab exercise; their VLPFC can’t be bothered to care.) Human attention is a scarce resource — the neural effects of depression make sure the resource is efficiently allocated.

But the reliance on the VLPFC doesn’t just lead us to fixate on our depressing situation; it also leads to an extremely analytical style of thinking. That’s because rumination is largely rooted in working memory, a kind of mental scratchpad that allows us to “work” with all the information stuck in consciousness. When people rely on working memory — and it doesn’t matter if they’re doing long division or contemplating a relationship gone wrong — they tend to think in a more deliberate fashion, breaking down their complex problems into their simpler parts.

The bad news is that this deliberate thought process is slow, tiresome and prone to distraction; the prefrontal cortex soon grows exhausted and gives out. Andrews and Thomson see depression as a way of bolstering our feeble analytical skills, making it easier to pay continuous attention to a difficult dilemma. The downcast mood and activation of the VLPFC are part of a “coordinated system” that, Andrews and Thomson say, exists “for the specific purpose of effectively analyzing the complex life problem that triggered the depression.” If depression didn’t exist — if we didn’t react to stress and trauma with endless ruminations — then we would be less likely to solve our predicaments. Wisdom isn’t cheap, and we pay for it with pain.

Consider a young professor on tenure track who was treated by Thomson. The patient was having difficulties with his academic department. “This guy was used to success coming easy, but now it wasn’t,” Thomson says. “I made it clear that I thought he’d need some time to figure out his next step. His problem was like a splinter, and the pain wouldn’t go away until the splinter was removed.” Should the patient leave the department? Should he leave academia? Or should he try to resolve the disagreement? Over the next several weeks, Thomson helped the patient analyze his situation and carefully think through the alternatives. “We took it one variable at a time,” Thomson says. “And it eventually became clear to him that the departmental issues couldn’t be fixed. He needed to leave. Once he came to that conclusion, he started feeling better.”

The publication of Andrews and Thomson’s 36,000-word paper in the July 2009 issue of Psychological Review had a polarizing effect on the field. While some researchers, like Jerome Wakefield, a professor at New York University who specializes in the conceptual foundations of clinical theory, greeted the paper as “an extremely important first step toward the re-evaluation of depression,” other psychiatrists regarded it as little more than irresponsible speculation, a justification for human suffering. Peter Kramer, a professor of psychiatry and human behavior at Brown University, describes the paper as “a ladder with a series of weak rungs.” Kramer has long defended the use of antidepressants — his landmark work, “Listening to Prozac,” chronicled the profound improvements of patients taking the drugs — and criticized those who romanticized depression, which he compares to the glamorization of tuberculosis in the late 19th century. In a series of e-mail messages to me, Kramer suggested that Andrews and Thomson neglect the variants of depression that don’t fit their evolutionary theory. “This study says nothing about chronic depression and the sort of self-hating, paralyzing, hopeless, circular rumination it inspires,” Kramer wrote. And what about post-stroke depression? Late-life depression? Extreme depressive condition? Kramer argues that there’s a clear category difference between a healthy response to social stressors and the response of people with depressive disorder. “Depression is not really like sadness,” Kramer has written. “It’s more an oppressive flattening of feeling.”

Even scientists who are sympathetic to what Andrews and Thomson call the “analytic-rumination hypothesis” remain critical of its details. Ed Hagen, an anthropologist at Washington State University who is working on a book with Andrews, says that while the analytic-rumination hypothesis has persuaded him that some depressive symptoms might improve problem-solving skills, he remains unconvinced that it is a sufficient explanation for depression. “Individuals with major depression often don’t groom, bathe and sometimes don’t even use the toilet,” Hagen says. They also significantly “reduce investment in child care,” which could have detrimental effects on the survival of offspring. The steep fitness costs of these behaviors, Hagen says, would not be offset by “more uninterrupted time to think.”

Other scientists, including Randolph Nesse at the University of Michigan, say that complex psychiatric disorders like depression rarely have simple evolutionary explanations. In fact, the analytic-rumination hypothesis is merely the latest attempt to explain the prevalence of depression. There is, for example, the “plea for help” theory, which suggests that depression is a way of eliciting assistance from loved ones. There’s also the “signal of defeat” hypothesis, which argues that feelings of despair after a loss in social status help prevent unnecessary attacks; we’re too busy sulking to fight back. And then there’s “depressive realism”: several studies have found that people with depression have a more accurate view of reality and are better at predicting future outcomes. While each of these speculations has scientific support, none are sufficient to explain an illness that afflicts so many people. The moral, Nesse says, is that sadness, like happiness, has many functions.

Although Nesse says he admires the analytic-rumination hypothesis, he adds that it fails to capture the heterogeneity of depressive disorder. Andrews and Thomson compare depression to a fever helping to fight off infection, but Nesse says a more accurate metaphor is chronic pain, which can arise for innumerable reasons. “Sometimes, the pain is going to have an organic source,” he says. “Maybe you’ve slipped a disc or pinched a nerve, in which case you’ve got to solve that underlying problem. But much of the time there is no origin for the pain. The pain itself is the dysfunction.”

Andrews and Thomson respond to such criticisms by acknowledging that depression is a vast continuum, a catch-all term for a spectrum of symptoms. While the analytic-rumination hypothesis might explain those patients reacting to an “acute stressor,” it can’t account for those whose suffering has no discernible cause or whose sadness refuses to lift for years at a time. “To say that depression can be useful doesn’t mean it’s always going to be useful,” Thomson says. “Sometimes, the symptoms can spiral out of control. The problem, though, is that as a society, we’ve come to see depression as something that must always be avoided or medicated away. We’ve been so eager to remove the stigma from depression that we’ve ended up stigmatizing sadness.”

For Thomson, this new theory of depression has directly affected his medical practice. “That’s the litmus test for me,” he says. “Do these ideas help me treat my patients better?” In recent years, Thomson has cut back on antidepressant prescriptions, because, he says, he now believes that the drugs can sometimes interfere with genuine recovery, making it harder for people to resolve their social dilemmas. “I remember one patient who came in and said she needed to reduce her dosage,” he says. “I asked her if the antidepressants were working, and she said something I’ll never forget. ‘Yes, they’re working great,’ she told me. ‘I feel so much better. But I’m still married to the same alcoholic son of a bitch. It’s just now he’s tolerable.’ ”

The point is the woman was depressed for a reason; her pain was about something. While the drugs made her feel better, no real progress was ever made. Thomson’s skepticism about antidepressants is bolstered by recent studies questioning their benefits, at least for patients with moderate depression. Consider a 2005 paper led by Steven Hollon, a psychologist at Vanderbilt University: he found that people on antidepressants had a 76 percent chance of relapse within a year when the drugs were discontinued. In contrast, patients given a form of cognitive talk therapy had a relapse rate of 31 percent. And Hollon’s data aren’t unusual: several studies found that patients treated with medication were approximately twice as likely to relapse as patients treated with cognitive behavior therapy. “The high relapse rate suggests that the drugs aren’t really solving anything,” Thomson says. “In fact, they seem to be interfering with the solution, so that patients are discouraged from dealing with their problems. We end up having to keep people on the drugs forever. It was as if these people have a bodily infection, and modern psychiatry is just treating their fever.”

Thomson describes a college student who was referred to his practice. “It was clear that this patient was in a lot of pain,” Thomson says. “He couldn’t sleep, couldn’t study. He had some family issues” — his parents were recently divorced — “and his father was exerting a tremendous amount of pressure on him to go to graduate school. Because he’s got a family history of depression, the standard of care would be to put him on drugs right away. And a few years ago, that’s what I would have done.”

Instead, Thomson was determined to help the student solve his problem. “What you’re trying to do is speed along the rumination process,” Thomson says. “Once you show people the dilemma they need to solve, they almost always start feeling better.” He cites as evidence a recent study that found “expressive writing” — asking depressed subjects to write essays about their feelings — led to significantly shorter depressive episodes. The reason, Thomson suggests, is that writing is a form of thinking, which enhances our natural problem-solving abilities. “This doesn’t mean there’s some miracle cure,” he says. “In most cases, the recovery period is going to be long and difficult. And that’s what I told this young student. I said: ‘I know you’re hurting. I know these problems seem impossible. But they’re not. And I can help you solve them.’ ”

IT’S TOO SOON to judge the analytic-rumination hypothesis. Nobody knows if depression is an adaptation or if Andrews and Thomson have merely spun another “Just So” story, a clever evolutionary tale that lacks direct evidence. Nevertheless, their speculation is part of a larger scientific re-evaluation of negative moods, which have long been seen as emotional states to avoid. The dismissal of sadness and its synonyms is perhaps best exemplified by the rise of positive psychology, a scientific field devoted to the pursuit of happiness. In recent years, a number of positive psychologists have written popular self-help books, like “The How of Happiness” and “Authentic Happiness,” that try to outline the scientific principles behind “lasting fulfillment” and “getting the life we want.”

The new research on negative moods, however, suggests that sadness comes with its own set of benefits and that even our most unpleasant feelings serve an important purpose. Joe Forgas, a social psychologist at the University of South Wales in Australia, has repeatedly demonstrated in experiments that negative moods lead to better decisions in complex situations. The reason, Forgas suggests, is rooted in the intertwined nature of mood and cognition: sadness promotes “information-processing strategies best suited to dealing with more-demanding situations.” This helps explain why test subjects who are melancholy — Forgas induces the mood with a short film about death and cancer — are better at judging the accuracy of rumors and recalling past events; they’re also much less likely to stereotype strangers.

Last year Forgas ventured beyond the lab and began conducting studies in a small stationery store in suburban Sydney, Australia. The experiment itself was simple: Forgas placed a variety of trinkets, like toy soldiers, plastic animals and miniature cars, near the checkout counter. As shoppers exited, Forgas tested their memory, asking them to list as many of the items as possible. To control for the effect of mood, Forgas conducted the survey on gray, rainy days — he accentuated the weather by playing Verdi’s “Requiem” — and on sunny days, using a soundtrack of Gilbert and Sullivan. The results were clear: shoppers in the “low mood” condition remembered nearly four times as many of the trinkets. The wet weather made them sad, and their sadness made them more aware and attentive.

The enhancement of these mental skills might also explain the striking correlation between creative production and depressive disorders. In a survey led by the neuroscientist Nancy Andreasen, 30 writers from the Iowa Writers’ Workshop were interviewed about their mental history. Eighty percent of the writers met the formal diagnostic criteria for some form of depression. A similar theme emerged from biographical studies of British writers and artists by Kay Redfield Jamison, a professor of psychiatry at Johns Hopkins, who found that successful individuals were eight times as likely as people in the general population to suffer from major depressive illness.

Why is mental illness so closely associated with creativity? Andreasen argues that depression is intertwined with a “cognitive style” that makes people more likely to produce successful works of art. In the creative process, Andreasen says, “one of the most important qualities is persistence.” Based on the Iowa sample, Andreasen found that “successful writers are like prizefighters who keep on getting hit but won’t go down. They’ll stick with it until it’s right.” While Andreasen acknowledges the burden of mental illness — she quotes Robert Lowell on depression not being a “gift of the Muse” and describes his reliance on lithium to escape the pain — she argues that many forms of creativity benefit from the relentless focus it makes possible. “Unfortunately, this type of thinking is often inseparable from the suffering,” she says. “If you’re at the cutting edge, then you’re going to bleed.”

And then there’s the virtue of self-loathing, which is one of the symptoms of depression. When people are stuck in the ruminative spiral, their achievements become invisible; the mind is only interested in what has gone wrong. While this condition is typically linked to withdrawal and silence — people become unwilling to communicate — there’s some suggestive evidence that states of unhappiness can actually improve our expressive abilities. Forgas said he has found that sadness correlates with clearer and more compelling sentences, and that negative moods “promote a more concrete, accommodative and ultimately more successful communication style.” Because we’re more critical of what we’re writing, we produce more refined prose, the sentences polished by our angst. As Roland Barthes observed, “A creative writer is one for whom writing is a problem.”

This line of research led Andrews to conduct his own experiment, as he sought to better understand the link between negative mood and improved analytical abilities. He gave 115 undergraduates an abstract-reasoning test known as Raven’s Progressive Matrices, which requires subjects to identify a missing segment in a larger pattern. (Performance on the task strongly predicts general intelligence.) The first thing Andrews found was that nondepressed students showed an increase in “depressed affect” after taking the test. In other words, the mere presence of a challenging problem — even an abstract puzzle — induced a kind of attentive trance, which led to feelings of sadness. It doesn’t matter if we’re working on a mathematical equation or working through a broken heart: the anatomy of focus is inseparable from the anatomy of melancholy. This suggests that depressive disorder is an extreme form of an ordinary thought process, part of the dismal machinery that draws us toward our problems, like a magnet to metal.

But is that closeness effective? Does the despondency help us solve anything? Andrews found a significant correlation between depressed affect and individual performance on the intelligence test, at least once the subjects were distracted from their pain: lower moods were associated with higher scores. “The results were clear,” Andrews says. “Depressed affect made people think better.” The challenge, of course, is persuading people to accept their misery, to embrace the tonic of despair. To say that depression has a purpose or that sadness makes us smarter says nothing about its awfulness. A fever, after all, might have benefits, but we still take pills to make it go away. This is the paradox of evolution: even if our pain is useful, the urge to escape from the pain remains the most powerful instinct of all.

Jonah Lehrer is the author of “How We Decide” and of the blog The Frontal Cortex. This is his first article for the magazine.

    Depression’s Upside, NYT, 26.2.2010, http://www.nytimes.com/2010/02/28/magazine/28depression-t.html

Obama’s Plan for Health Bill Largely Follows Senate Version

February 23, 2010
The New York Times
By SHERYL GAY STOLBERG and DAVID M. HERSZENHORN

WASHINGTON — President Obama began what may be his final push to win enactment of a health care overhaul, laying out a legislative blueprint on Monday that seeks to unify House and Senate Democrats but makes no big new concessions to Republicans.

Mr. Obama’s plan, which the White House said would cost $950 billion over a decade, sticks largely to the version passed by the Senate in December but addresses some of the main concerns of House leaders who are demanding more help for the middle class.

Mr. Obama’s proposal — the first time the president has provided a detailed road map for what he wants a health overhaul to look like — is the opening act to a week of high drama that will culminate on Thursday, when the president convenes Democrats and Republicans at an all-day televised health care “summit” at Blair House. The White House is hoping the session can jump start the stalled health bill.

“We view this as the opening bid for the health meeting,” Dan Pfeiffer, Mr. Obama’s communications director, told reporters Monday morning, adding, “We took our best shot at bridging the differences.”

But among Republicans leaders, the initial reaction was negative. Representative John A. Boehner of Ohio, the House minority leader, said that Mr. Obama had “crippled the credibility” of Thursday’s meeting by proposing “the same massive government takeover of health care.”

Even Democrats took a wait-and-see attitude; House leaders did not immediately embrace the plan but instead scheduled a caucus meting for Monday. And the Congressional math is daunting for the administration. Mr. Obama has lost the 60-vote supermajority that allowed him to win passage of a bill in the Senate, which means he would either have to attract Republican support or push the bill through with a simple majority using the complex parliamentary maneuver known as reconciliation — a route that the White House pointedly did not rule out on Monday.

In the House, he needs 217 votes (the number is ordinarily 218, but two seats are vacant) — a number that could be difficult to muster, especially because Mr. Obama’s bill does not include the tighter restrictions on funding for abortion favored by abortion opponents among House Democrats.

The bill is intended to achieve Mr. Obama’s broad goals of expanding coverage to the uninsured while driving down health premiums and imposing what the White House calls “common sense rules of the road” for insurers, including ending the unpopular practice of discriminating against people with pre-existing conditions. It would offer more money to help cash-strapped states pay for Medicaid over a four-year period, and, in a nod to concerns among the elderly, end the unpopular “donut hole” in the Medicare prescription drug program.

The measure is posted on the White House Web site.

The White House projects that the bill would extend coverage to 31 million people who are currently uninsured, at a cost over 10 years of $950 billion — more than the $871 billion the Senate would have spent, but less than the $1.05 trillion for the version passed by the House. The administration estimates that its plan would reduce the federal deficit by $100 billion over the next 10 years — and about $1 trillion over the second decade — by cutting spending and reining in waste and fraud.

But the measure has not yet been evaluated by the non-partisan Congressional Budget Office, and White House officials said they were open to adjusting it if it cost substantially more than they have estimated.

In many respects, Mr. Obama’s measure looks much like the version the Senate passed on Christmas Eve — and indeed, senior White House officials acknowledged on a morning conference call that they had used the Senate bill as a template. But there are several critical differences that appear designed to appeal to House Democrats, who have voiced deep concerns about the Senate measure and its effects on the middle class.

To begin with, Mr. Obama would eliminate a controversial special deal for Nebraska — widely derided by Republicans as the “cornhusker kickback” — that called for the federal government to pay the full cost of a Medicaid expansion for that state. Instead, the White House would help all states absorb the cost of the Medicaid expansion from 2014, when it begins, until 2017.

And while the president adopts the Senate’s proposed excise tax on high-cost, employer sponsored insurance plans, Mr. Obama makes some crucial adjustments based on an agreement reached in January with organized labor leaders, while also trying to avoid the appearance of special treatment for unions. Most crucially, the president would delay imposing the tax until 2018 for all policies, not just for health benefits provided through collectively-bargained union contracts.

One unanswered question is whether the White House will attempt to push the bill through Congress using reconciliation, ordinarily reserved for budget bills. The procedure enables legislation to pass on a simple majority vote, but sharply restricts a bill’s language to provisions that have a direct impact on federal spending and revenues.

Mr. Pfeiffer suggested that is the route the White House would take in the event of a Republican filibuster. “The president expects and believes the American people deserve an up or down vote on health reform,” he said, “and our proposal is designed to give ourselves maximum flexibility to insure that, if the opposition decides to take the extraordinary step of filibustering health reform.”

In one sense, the release of the bill marks an extraordinary reversal for a president who has long said he would leave legislating to the legislators. Mr. Obama made clear from the outset of the health care debate that he would not follow the footsteps of the last Democratic president, Bill Clinton, who presented Congress with a sweeping health care proposal — only to see it fall flat on Capitol Hill.

Instead, Mr. Obama left it to Congress to produce its own measure. But after months of work, the House and Senate have been unable to close the gap between their bills. So the president, who had promised to post a Democratic measure on the Internet 72 hours in advance of Thursday’s health care meeting, was forced to take matters into his own hands.

Like the Senate version, Mr. Obama’s bill does not include a so-called public option, a government-backed insurance plan to compete with the private sector.

And the bill offers the Senate’s less restrictive language on abortion; it does not include the so-called “Stupak amendment,” which would bar insurers from offering abortion coverage to anyone buying a policy with a federal subsidy. The absence of the Stupak provision, named for Representative Bart Stupak, the conservative Michigan Democrat, could complicate matters for Mr. Obama in the House, where conservatives, led by Mr. Stupak, are adamant that the provision be included.

Mr. Obama largely adopted the Senate’s approach to paying for the legislation, including a proposed increase in the Medicare payroll tax for individuals earning more than $200,000 a year and for couples earning more than $250,000.

He opted for the Senate’s proposal to create state-based insurance exchanges, or marketplaces, rather than a single national exchange as proposed by the House. Many House Democrats worry that state exchanges would create uneven results by allowing states with lax insurance regulations to continue a hands-off approach.

And Mr. Obama adopted the Senate’s proposal to set a uniform eligibility threshold for Medicaid at 133 percent of the federal poverty level. The House had proposed setting eligibility at 150 percent of the poverty level.

House Democratic leaders, including Speaker Nancy Pelosi, had expressed serious concerns that, under the Senate bill, the subsidies provided to help moderate-income Americans afford private insurance would not be sufficient to make coverage affordable.

The Senate had provided somewhat less generous subsidies than the House for individuals and families earning below 300 percent of the federal poverty level or rough $66,150 for a family of four, while the House bill had been less generous to those earning between $66,150 and $88,200.

Mr. Obama generally favored the Senate’s approach, but made a stab at compromise by proposing larger federal subsidies than the Senate bill did for Americans in two income categories — those earning between 133 percent and 200 percent of the poverty level, or roughly $33, 075 to $44,100 for a family of four, and those earning between 300 and 400 percent of the poverty level, or $66,150 to $88,200 for a family of four.

Still, some rank-and-file lawmakers are likely to raise concerns that working-class families will still find it difficult to afford health benefits.

Under the president’s plan, a family earning about $88,000 a year would pay no more than 9.5 percent of income toward annual health insurance premiums, or about $8,380, not including out-of-pocket costs, such as co-payments or deductibles.

Under the Senate bill, such a family could have paid $8,643 a year in premiums and under the House bill as much as $10,584 a year.

Under the president’s plan, a family earning $22,050 would have to pay $441 in annual premium costs compare to $331 under the House bill. And a family earning $33,100 would have to pay up to $1,324 a year in premiums under Mr. Obama’s plan, compared to a maximum of $993 under the House bill.

    Obama’s Plan for Health Bill Largely Follows Senate Version, NYT, 23.2.2010, http://www.nytimes.com/2010/02/23/health/policy/23health.html

Research Ties Diabetes Drug to Heart Woes

February 20, 2010
The New York Times
By GARDINER HARRIS

Hundreds of people taking Avandia, a controversial diabetes medicine, needlessly suffer heart attacks and heart failure each month, according to confidential government reports that recommend the drug be removed from the market.

The reports, obtained by The New York Times, say that if every diabetic now taking Avandia were instead given a similar pill named Actos, about 500 heart attacks and 300 cases of heart failure would be averted every month because Avandia can hurt the heart. Avandia, intended to treat Type 2 diabetes, is known as rosiglitazone and was linked to 304 deaths during the third quarter of 2009.

“Rosiglitazone should be removed from the market,” one report, by Dr. David Graham and Dr. Kate Gelperin of the Food and Drug Administration, concludes. Both authors recommended that Avandia be withdrawn.

The internal F.D.A. reports are part of a fierce debate within the agency over what to do about Avandia, manufactured by GlaxoSmithKline. Some agency officials want the drug withdrawn because they believe there is a safer alternative; others insist that studies of the drug provide contradictory information and that Avandia should continue to be an option for doctors and patients. GlaxoSmithKline said that it had studied Avandia extensively and that “scientific evidence simply does not establish that Avandia increases” the risk of heart attacks.

The battle has been brewing for years but has been brought to a head by disagreement over a new clinical trial and a Senate investigation that concluded that GlaxoSmithKline should have warned patients earlier of the drug’s potential risks.

Avandia was once one of the biggest-selling drugs in the world. Driven in part by a multimillion-dollar advertising campaign, sales were $3.2 billion in 2006. But a 2007 study by a Cleveland Clinic cardiologist suggesting that the drug harmed the heart prompted the F.D.A. to issue a warning, and sales plunged. A committee of independent experts found in 2007 that Avandia might increase the risk of heart attack but recommended that it remain on the market, and an F.D.A. oversight board voted 8 to 7 to accept that advice.

Hundreds of thousands still take the medicine, although some top endocrinologists say they have sworn off the drug.

Since 2007, more studies have been done. In a December 2009 internal memorandum, Dr. Janet Woodcock, director of the F.D.A.’s drug center, wrote that “there are multiple conflicting opinions” about Avandia within the agency, and she ordered officials to assemble another advisory committee, expected this summer, to reconsider whether the drug should be sold.

“I await the recommendations of the advisory committee,” the agency’s commissioner, Dr. Margaret Hamburg, said Friday night. “Meanwhile, I am reviewing the inquiry made by Senators Baucus and Grassley and I am reaching out to ensure that I have a complete understanding and awareness of all of the data and issues involved.”

The bipartisan multiyear Senate investigation — whose results are expected to be released publicly on Monday but which were also obtained by The Times — sharply criticizes GlaxoSmithKline, saying it failed to warn patients years earlier that Avandia was potentially deadly.

“Instead, G.S.K. executives attempted to intimidate independent physicians, focused on strategies to minimize or misrepresent findings that Avandia may increase cardiovascular risk, and sought ways to downplay findings that a competing drug might reduce cardiovascular risk,” concludes the report, which was overseen by Senator Max Baucus, a Montana Democrat, and Senator Charles E. Grassley, an Iowa Republican.

Mr. Baucus said of the report, “Patients trust drug companies with their health and their lives, and GlaxoSmithKline abused that trust.”

In response, GlaxoSmithKline said that it disagreed with the Senate investigation’s conclusions. The company said that it could not comment on internal F.D.A. documents but that “the official ruling from F.D.A. is that Avandia remain on the market.”

In the wake of the controversy, agency officials ordered GlaxoSmithKline to undertake a study comparing how many heart attacks, strokes and heart-related deaths occur among patients given either Avandia, Actos or a placebo. Studies suggest that Actos, made by Takeda, lowers blood sugar as well as Avandia but without hurting the heart as much.

But Dr. Graham and Dr. Gelperin, working in the F.D.A.’s office of surveillance and epidemiology, argued in two separate internal reports that the new GlaxoSmithKline study, called TIDE, is “unethical and exploitative” because patients given Avandia face far greater risks than those given Actos, with no promise of any additional benefit. The trial may include patients who have had heart attacks or chest pains even though some foreign drug authorities have warned against Avandia’s use by precisely such patients, the reports note.

“Although the proposed TIDE trial is motivated by a desire for definitive answers regarding the cardiovascular safety of the drug rosiglitazone, the safety of the study itself cannot be assured and is not acceptable,” one of the reports concludes.

These concerns, in internal reports dated October 2008 but not made public until now, were later overruled by other agency officials, and GlaxoSmithKline is currently enrolling patients in the TIDE trial. The trial is not expected to be completed until 2020, although the company is hoping to report some results to the F.D.A. by 2014. The company’s patent on Avandia expires in 2012, and generic versions will probably swallow most remaining profits.

In a letter sent Thursday to Dr. Hamburg, the Food and Drug Administration commissioner, Mr. Baucus and Mr. Grassley asked “what steps the F.D.A. has taken to protect patients in the TIDE trial” and said the trial’s patients had never been told about the concerns raised by the agency’s own safety officers.

Mr. Grassley said the internal agency battle showed that the agency needed to be restructured to give more power to safety officials like Dr. Graham and Dr. Gelperin over their counterparts who approve medicines and deal more directly with drug makers.

“It doesn’t make any sense to have these experts who study drugs after they have been on the market for several years under the thumb of the officials who approved the drug in the first place and have a natural interest in defending that decision,” Mr. Grassley said. “The Avandia case may be the most alarming example of the problem with this setup.”

The question of when and how to communicate possible drug risks has long bedeviled drug makers and regulators. Hints are common that drugs may cause injuries; thousands of drug injury reports pour into the Food and Drug Administration every week. For example, Avandia ranked first among all prescribed drugs in the number of serious, disabling and fatal problems — including 304 deaths — reported to the agency in the third quarter of 2009, according to an analysis done by the Institute for Safe Medication Practice, a drug safety oversight group.

But companies say that such reports do not offer proof of a problem and that highlighting them can scare patients away from needed treatment, so they often argue that more certainty is needed before alarms are raised. GlaxoSmithKline said a “vast majority” of the recent reports regarding Avandia was related to litigation.

The Senate investigation — the result of years of digging through more than 250,000 internal company documents — concludes that GlaxoSmithKline and by extension the F.D.A. delayed far too long in this process.

In November 2003, for instance, the company completed a study in which diabetics given Avandia had far more heart problems than those given placebos. Two months later, the World Health Organization sent the company an alert linking Avandia to heart ailments. In a June 2004 meeting, the company’s Global Safety Board said a hard look should be taken at all Avandia clinical trials for more signs of heart problems, documents show.

European regulators had earlier ordered GlaxoSmithKline to conduct a study — called the Record trial — to examine Avandia’s heart risks because hints of these problems appeared in the company’s earliest trials.. But the Senate report shows that by at least 2004, company executives were aware that the Record trial was going so poorly that it would never answer the heart question with any kind of certainty.

So company executives gathered dozens of Avandia studies and sifted their combined data. Called a meta-analysis, this combined look found first in 2005 and in an updated look in 2006 that Avandia increased the risks of serious heart problems by nearly a third, the Senate investigation shows. Because two-thirds of diabetics die of heart problems, this was hugely worrying.

In 2005, executives revealed the results of their meta-analysis to the F.D.A., and in 2006 they provided the agency with the underlying data.

Two large company-sponsored trials — called Dream and Adopt — were published near the end of 2006, and each provided more hints that Avandia hurts the heart, the documents show. In a March 2007 meeting of the company’s Diabetes Franchise Cardiology Advisory Board, advisers called the safety worries found in these many studies “disquieting.” Negotiations with agency officials about how and whether to alert the public continued.

Meanwhile, the company continued to market and advertise Avandia aggressively. The Senate inquiry concludes that the company threatened doctors who suggested in public that Avandia might have serious risks.

In 1999, for instance, Dr. John Buse, a professor of medicine at the University of North Carolina, gave presentations at scientific meetings suggesting that Avandia had heart risks. GlaxoSmithKline executives complained to his supervisor and hinted of legal action against him, according to the Senate inquiry. Dr. Buse eventually signed a document provided by GlaxoSmithKline agreeing not to discuss his worries about Avandia publicly. The report cites a separate episode of intimidation of investigators at the University of Pennsylvania.

GlaxoSmithKline said that it “does not condone any effort to silence” scientific debate, and that it disagrees with allegations that it tried to silence Dr. Buse. Still, it said the situation “could have been handled differently.”

    Research Ties Diabetes Drug to Heart Woes, NYT, 20.2.2010, http://www.nytimes.com/2010/02/20/health/policy/20avandia.html

States Consider Medicaid Cuts as Use Grows

February 19, 2010
The New York Times
By KEVIN SACK and ROBERT PEAR

WASHINGTON — Facing relentless fiscal pressure and exploding demand for government health care, virtually every state is making or considering substantial cuts in Medicaid, even as Democrats push to add 15 million people to the rolls.

Because they are temporarily barred from reducing eligibility, states have been left to cut “optional benefits,” like dental and vision care, and reduce payments to doctors and other health care providers.

In some states, governors are trying to avoid the deepest cuts by pushing for increases in tobacco taxes or new levies on hospitals and doctors, but many of those proposals are running into election-year trouble in conservative legislatures.

In Nevada, which faces an $881 million budget gap, Gov. Jim Gibbons, a Republican, proposed this month to end Medicaid coverage of adult day care, eyeglasses, hearing aids and dentures, and, for a savings of $829,304, to reduce the number of diapers provided monthly to incontinent adults (to 186 from 300).

“We are down to the ugly list of options,” the state’s director of health and human services, Mike Willden, told a legislative committee last week.

The Medicaid program already pays doctors and hospitals at levels well below those of Medicare and private insurance, and often below actual costs. Large numbers of doctors, therefore, do not accept Medicaid patients, and cuts may further discourage participation in the program, which primarily serves low-income children, disabled adults and nursing home residents.

In Kansas, a 10 percent cut in provider payments that took effect on Jan. 1 has prompted such an outcry that Gov. Mark Parkinson, who imposed it, now wants to restore the money by raising tobacco and sales taxes.

Even if Mr. Parkinson, a Democrat, overcomes resistance in his Republican-controlled Legislature, it will be too late for Dr. C. Joseph Beck, a Wichita ophthalmologist who informed his Medicaid patients last month that he could no longer afford to treat them.

Dr. Beck said that over eight months last year, his practice wrote off $36,000 in losses from treating 17 Medicaid patients. The state-imposed payment cut, he said, was “the final straw.”

“I’m out, I’m done,” Dr. Beck said in a telephone interview. “I didn’t want to. I want to take care of people. But I also have three children and many employees to take care of.”

Concerns about health care costs are likely to dominate the winter meeting of the National Governors Association, which begins Saturday in Washington.

In advance of the gathering, administration officials have urged governors to endorse President Obama’s health care proposals, or at least to avoid criticizing them. The Democratic plan, which is stalled in Congress, would vastly expand eligibility for Medicaid as one means of reducing the number of uninsured.

But many governors said they were more concerned about the growth of existing health programs. The recession and high unemployment have driven up enrollment in Medicaid while depleting state revenues that help pay for it.

A survey released Thursday by the Kaiser Family Foundation found a record one-year increase in Medicaid enrollment of 3.3 million from June 2008 to June 2009, a period when the unemployment rate rose by 4 percentage points. Total enrollment jumped 7.5 percent, to 46.9 million, and 13 states had double-digit increases.

Because Medicaid enrollment often lags behind unemployment, this year’s increase could prove even greater.

The National Association of State Medicaid Directors estimates that state budget shortfalls in the coming fiscal year, which begins in July in most states, will total $140 billion. Because Medicaid is one of the largest expenditures in every state budget, and one of the fastest-growing, it makes an unavoidable target.

“For most states, the fiscal situation is still dire, and the Medicaid cuts are significant,” said Scott D. Pattison, executive director of the National Association of State Budget Officers.

Governors and legislators have managed to defer the deepest cuts because the federal stimulus package provided $87 billion to states in Medicaid relief. The cost of Medicaid is shared by the federal and state governments, with states setting eligibility, benefit and reimbursement levels within broad federal guidelines, and Washington covering the majority of the expense.

But the stimulus assistance is due to expire at the end of December, in the middle of many states’ fiscal years, leaving budget officials to peer over a precipice. Congress and the White House are considering extending the enhanced payments for six more months, at a cost of about $25 billion.

The House has passed such a measure and Mr. Obama included it in his budget this month, but the Senate has not acted.

The extension would not come close to filling the Medicaid gap in many states. In Georgia, for instance, Gov. Sonny Perdue assumed in his budget proposal that the additional federal money would be provided, but that the state would still face a Medicaid imbalance of $608 million, said Dr. Rhonda M. Medows, the commissioner of community health.

Mr. Perdue, a Republican, decided it would be unwise to cut optional benefits because that might drive Medicaid patients into expensive emergency rooms. He proposed instead to levy a 1.6 percent tax on hospital and managed care revenues and to cut payments to many providers by nearly 2 percent.

Without the tax increases, which face opposition in the General Assembly, the state will have to cut provider payments by 16.5 percent, Dr. Medows said.

“I won’t have any primary care doctors left, much less specialists,” she said. “Certainly down here nobody likes to talk about taxes, but sometimes you have to bite the bullet and do what’s right for a whole lot of people.”

In the Kaiser survey, almost every state reported that Medicaid enrollment for the current fiscal year was exceeding expectations, making midyear budget cuts necessary.

The options are limited by several realities. To qualify for Medicaid dollars provided in the stimulus package, states agreed not to tighten eligibility for low-income people. And any time a state cuts spending on Medicaid, it loses at least that much in federal matching money.

Despite the ban on restricting eligibility, hard-hit states like California and Arizona are considering proposals by their governors that would remove hundreds of thousands from the rolls once the federal financing ends. Gov. Jan Brewer of Arizona, a Republican, has called for eliminating Medicaid coverage for 310,000 childless adults and ending the Children’s Health Insurance Program to help close a two-year budget gap of about $4.5 billion.

Gov. Phil Bredesen of Tennessee, a Democrat, is proposing the largest cuts in the history of TennCare, his state’s Medicaid program. To trim 9 percent of the TennCare budget, he would establish a $10,000 cap on inpatient hospital services for nonpregnant adults and would limit coverage of X-rays, laboratory services and doctor’s office visits.

“I have no choice,” Mr. Bredesen said.

    States Consider Medicaid Cuts as Use Grows, NYT, 19.2.2010, http://www.nytimes.com/2010/02/19/us/politics/19medicaid.html

Editorial

The Lesson of Anthem Blue Cross

February 19, 2010
The New York Times

Clients were understandably furious when Anthem Blue Cross, the largest for-profit health insurer in California, announced huge rate increases for people who buy their own insurance: an average increase of 25 percent, and a 35 percent to 39 percent rise for a quarter of the purchasers. The move also provided a textbook example of why the nation badly needs comprehensive health care reforms.

The reform bills stalled in Congress would put a brake on such out-of-scale premium increases by broadening the pools of insured people to keep average premiums low, by setting up competitive insurance exchanges and by starting to rein in the cost of medical care that is driving up premiums everywhere.

Private insurers in several other states also have sought and won double-digit increases for policies sold to individuals. In one striking case, a Blue Cross Blue Shield plan in Michigan sought a 56 percent average increase in premiums for individually bought policies but settled for 22 percent in a compromise with regulators.

If the increases go through in California, where regulators have limited powers to control rates, Anthem’s enrollees would have to choose between paying the higher price, moving to lower-cost policies, perhaps with a high deductible, switching to another insurer if they can find one to take them, or dropping coverage entirely.

The nation’s largest health insurers reported substantial profits last year over all, but Anthem claims it lost money on the individual market in California. Its parent company, WellPoint Inc., attributed the need for the huge rate increase to a changing mix of customers as the recession forces many people to cut back on expenses.

The company says that healthier customers, gambling that they won’t need much care, are disproportionately dropping Anthem coverage or choosing not to enroll. The less healthy are staying with Anthem, where their higher medical costs are driving up premiums.

WellPoint will be asked to justify the increases at hearings in Congress and the State Legislature. California’s insurance commissioner is investigating whether Anthem will be meeting regulations to spend at least 70 percent of its premium revenues on claims.

It’s hard to know which conclusion would be worse: that Anthem is trying to fleece its individual customers or that Anthem’s rates are actuarially justified by its increasingly unhealthy enrollment pool.

The salient point is that the reform bills pending in Congress could almost certainly prevent this problem from developing. The bills would require everyone to buy health insurance (many with government subsidies). That would create large pools to spread the risk over both healthy and sick enrollees and keep average premiums low. On new insurance exchanges, people who buy their own insurance could benefit from group purchasing power and could choose from an array of policies. Competition among insurers on the exchanges is expected to help keep premiums down.

How about the Republicans’ health care proposals?

They would only address a small part of the Anthem problem. The Republicans reject the idea of mandates to spread the cost of care and instead call for ways for people dissatisfied with their insurer to buy cheaper coverage elsewhere. That could help relatively healthy people but would do nothing for the chronically ill or anyone with pre-existing conditions. They would be stuck in their health plans. State high-risk pools for sick people, another Republican solution, almost always have high premiums and would not provide a safe haven from rate increases in private plans.

Unless Congress passes comprehensive reform, we should expect many more Anthems in our future.

    The Lesson of Anthem Blue Cross, NYT, 19.2.2010, http://www.nytimes.com/2010/02/19/opinion/19fri1.html

Op-Ed Contributor

Disorder Out of Chaos

February 10, 2010
The New York Times
By ROY RICHARD GRINKER

Washington

IF you ask my daughter, Isabel, what autism means to her, she won’t say that it is a condition marked by impaired social communication and repetitive behaviors. She will say that her autism makes her a good artist, helps her to relate to animals and gives her perfect pitch.

The stigma of autism is fading fast. One reason is that we now understand that autism is a spectrum with an enormous range. Some people with autism are nonverbal with profound cognitive disabilities, while others are accomplished professionals.

Many people with milder symptoms of autism have, for the past 20 years or so, received a diagnosis of Asperger’s disorder. Some autistic adults call themselves “Aspies” to celebrate their talents and differences. And many parents have embraced the label because they have found it less stigmatizing, and so it has eased their sense of loss.

This may soon change, however. The American Psychiatric Association, with its release this week of proposed revisions to its authoritative Diagnostic and Statistical Manual of Mental Disorders, is recommending that Asperger’s be dropped. If this revision is adopted, the condition will be folded into the category of “autism spectrum disorder,” which will no longer contain any categories for distinct subtypes of autism like Asperger’s and “pervasive developmental disorder not otherwise specified” (a category for children with some traits of autism but not enough to warrant a diagnosis).

The change is welcome, because careful study of people with Asperger’s has demonstrated that the diagnosis is misleading and invalid, and there are clear benefits to understanding autism as one condition that runs along a spectrum.

When the American Psychiatric Association first recognized Asperger’s disorder in 1994, it was thought to be a subtype of autism. As the diagnosis became more common, it broadened the public understanding of autism as a spectrum. It helped previously undiagnosed adults to understand their years of feeling unconnected to others, but without bestowing what was considered the stigma of autism. And it helped educators justify providing services for children who, in the past, might have been unappreciated or even bullied because of their differences, but received no help from teachers.

It’s no longer a secret that people with autism can have careers and meaningful social relationships. Witness the spate of recent movies, from HBO’s “Temple Grandin,” about a woman with autism who became an animal scientist famed for her designs of humane slaughterhouses, to “Mary and Max,” an animated feature about a friendship between a 44-year-old man with Asperger’s and an 8-year-old girl.

But a culturally meaningful distinction isn’t always a scientifically valid one. Almost everyone with Asperger’s also fits the profile of the more classic autistic disorder. Indeed, in the current diagnostic manual, a child who has good language acquisition and intelligence qualifies as autistic if, in addition to having restricted interests and problems with social interactions, he has just one of the following symptoms, which are common among children with Asperger’s: difficulty conversing, an inability to engage in make-believe play or repetitive or unusual use of language. Even the best available diagnostic instruments cannot clearly distinguish between Asperger’s and autistic disorder.

People who now have a diagnosis of Asperger’s can be just as socially impaired as those with autism. So Asperger’s should not be a synonym for “high functioning.” Likewise, people with autism who are described as “low functioning,” including those without language, can have the kinds of intelligence and hidden abilities that are associated with Asperger’s — in art, music and engineering, for example — and can communicate if given assistance.

Moreover, large epidemiological studies have demonstrated that mild symptoms of autism are common in the general population. In particular, scientists have found that family members of a child with autism often exhibit isolated autistic traits. With autism, as with many medical diagnoses — like hypertension and obesity — the boundary lines are drawn as much by culture as by nature. Dividing up the workings of the mind is not as neat and orderly as categorizing species.

The proposed new diagnostic criteria, by describing severity and functioning along a single continuum, would also capture the often unpredictable changes among children with autism. When Isabel was 3, she had all the symptoms of autistic disorder, but if she walked into a doctor’s office today as a new patient — a chatty, quirky high school senior — she would more likely be given a diagnosis of Asperger’s disorder. Narrow diagnostic categories do not help us understand the way a person will develop over time.

We no longer need Asperger’s disorder to reduce stigma. And my daughter does not need the term Asperger’s to bolster her self-esteem. Just last week, she introduced herself to a new teacher in her high school health class. “My name is Isabel,” she said, “and my strength is that I have autism.”

Roy Richard Grinker, a professor of anthropology at George Washington University, is the author of “Unstrange Minds: Remapping the World of Autism.”

    Disorder Out of Chaos, NYT, 10.2.2010, http://www.nytimes.com/2010/02/10/opinion/10grinker.html

Editorial

Abstinence Education Done Right

February 8, 2010
The New York Times

The ongoing debate over sex education has been rekindled by a provocative new study suggesting that teaching abstinence can delay the start of sexual activity among inner-city youngsters — if it is freed from the moralistic overtones and ideological restrictions that were the hallmark of abstinence-only programs under the Bush administration.

It would be a mistake to place too much importance on a single study of black middle-school students in Philadelphia, but the study appears to be sound and its findings are worth further exploration.

The study, published in the Archives of Pediatrics and Adolescent Medicine, a journal of the American Medical Association, was led by a husband-wife team at the University of Pennsylvania. They randomly assigned 662 African-American students in grades six and seven to one of four different programs — an eight-hour abstinence-only program stressing the benefits of delaying intercourse; an eight-hour safer-sex program stressing condom use; a comprehensive intervention that covered both abstinence and condoms; and a control group that offered health information unrelated to sexual behavior.

The only program that successfully delayed the start of sexual activity was the abstinence-only instruction. By the end of two years, only a third of the abstinence-only group had engaged in sexual intercourse compared with almost half of the control group.

Advocates of abstinence-only education have seized on the new findings as evidence that their approach works best. Some are urging the Obama administration to reverse course and restore federal support for abstinence-only education. That is a willful misreading of the implications of this study.

Under current federal law, supported by the Bush administration and conservatives in Congress, abstinence-only programs that seek federal support must meet several rigid requirements that essentially make them abstinence-until-marriage programs.

They must teach, for example, that abstinence from sexual activity outside of marriage is the “expected standard” for all school-age children. This new study would have failed that test. It did not advocate abstinence until marriage but urged students to wait until they were more mature. It encouraged abstinence as a way to eliminate the risk of pregnancy and sexually transmitted diseases, had youngsters draw up lists of the pros and cons of sexual activity, and taught strategies for resisting pressure to have intercourse.

The Obama administration, with Congressional acquiescence, has wisely eliminated funding for abstinence-only programs that meet the old ideological criteria and is supporting a range of programs to prevent teenage pregnancy, provided they are based on rigorous science. This study fits the new rubric, not the old.

The new study will need to be replicated in older teenagers and other ethnic groups to see if the findings are broadly relevant, and teenagers will need to be followed long enough to measure the effects in avoiding pregnancy and sexually transmitted diseases. No single approach will suffice to reduce sexual activity in all teenagers, but the new study suggests that there is a sensible, effective way to teach abstinence.

    Abstinence Education Done Right, NYT, 8.2.2010, http://www.nytimes.com/2010/02/08/opinion/08mon1.html

A Federal Effort to Push Junk Food Out of Schools

February 8, 2010
The New York Times
By GARDINER HARRIS

WASHINGTON — The Obama administration will begin a drive this week to expel Pepsi, French fries and Snickers bars from the nation’s schools in hopes of reducing the number of children who get fat during their school years.

In legislation, soon to be introduced, candy and sugary beverages would be banned and many schools would be required to offer more nutritious fare.

To that end, Agriculture Secretary Tom Vilsack will deliver a speech Monday at the National Press Club in which he will insist, according to excerpts provided to The Times, that any vending machines that remain in schools be “filled with nutritious offerings to make the healthy choice the easy choice for our nation’s children.”

The first lady, Michelle Obama, said last month that she would lead an initiative to reduce childhood obesity, and her involvement “shows the importance all of us place on this issue,” Mr. Vilsack said.

The administration’s willingness to put Mrs. Obama’s popularity on the line is a calculated bet that concerns about childhood obesity have become so universal that the once-partisan fight over who should control school food offerings — the federal government or school boards — has subsided.

But Republican support is far from certain.

Senator Saxby Chambliss, a Georgia Republican and the ranking member on the Committee on Agriculture, Nutrition and Forestry, met at the White House with Mrs. Obama on Tuesday to talk about childhood obesity. And while Mr. Chambliss released a statement saying that “schools play an important role in shaping nutrition habits of young children,” an aide refused to say whether he would support a ban on junk foods.

Other Republicans said they would wait to see legislation before signaling whether they would put aside long-held views that school boards should control food offerings.

Senator Blanche Lincoln, a Democrat from Arkansas and the chairwoman of the committee, said she would introduce the legislation within weeks. “It’s a big priority for me, other members and the administration,” she said.

While Democrats have coalesced around the idea of denying sweets to schoolchildren, many students are not keen. When Asthtyn Bowling, a 16-year-old junior at Orange County High School in Orange, Va., was told of the looming ban, she was shocked.

“That would be terrible!” she said.

The legislation would reauthorize the government’s school breakfast and lunch programs. It aims to transform the eating habits of many of the nation’s children and teenagers, but some school officials say it will further crimp already strained budgets.

In addition to banning sugary treats, the new rules would require many schools to offer more nutritious options, which could be expensive. The administration has proposed spending $1 billion more each year on the $18 billion meals program, but the increase may not be enough to cover the extra costs.

The National PTA and a host of health and medical advocacy groups support the legislation, but local school officials are lukewarm.

“Our feeling is that school boards are acutely aware of the importance of ensuring that children have access to healthy and nutritious food,” said Lucy Gettman of the National School Boards Association.

The bill would exempt bake sales, parties and other occasional offerings of sweets. But drawing the line between routine and unusual can get tricky.

“What do you do about the Spanish club buying Kit Kat bars and selling them in the cafeteria?” asked Doug Davis, director of food service for the City of Burlington Public Schools in Vermont.

The National School Lunch Program serves 31 million children in more than 100,000 schools. It was started in 1946 to ensure that children get enough to eat after health problems related to malnutrition were found in an alarming number of World War II draftees. Now, health officials are also worried that children are eating too much of the wrong foods. About two-thirds of the nation’s adults and a third of its children are overweight — double the rates of 1980.

Junk food has long been banned from official school breakfast and lunch programs, but many schools offer fatty foods and sweets outside of these programs or have vending machines with sodas and candy, with the money often used to finance sports or other extracurricular programs. The legislation would require that all school offerings comply with strict new nutritional guidelines.

Many schools have changed their offerings. Five years ago, fewer than a third of the nation’s school districts put limits on students’ access to candy and sugary drinks. That share jumped to two-thirds by 2008, according to a survey by the Centers for Disease Control and Prevention.

Dr. William H. Dietz, an obesity researcher at the disease centers, said that changing school food policies had already helped.

“There’s been a plateau in childhood obesity, and I think one of the reasons is that things are different in schools,” he said.

Industry opposition to the new legislation has softened in part because the Coca-Cola Company and PepsiCo now sell far more than Coke and Pepsi. So instead of having to yank vending machines from schools, the companies could replace offerings with bottled water or juice.

Kevin Keane, senior vice president of the American Beverage Association, said that companies had been voluntarily taking high-calorie drinks out of schools. But, he said, the industry does not favor a federal ban.

Orange County High School has vending machines with Pepsi, Mountain Dew and Dr Pepper, but even more popular among students is a candy cart wheeled into the school’s central hallway three times a day by Betty Almond, a school secretary.

The cart is laden with Pop-Tarts, Skittles and Reese’s Peanut Butter Cups, and Mrs. Almond and helpers barely keep up with demand from students on their way to class. Sales are between $400 and $500 a week, which Mrs. Almond uses to buy uniforms and equipment for school sports teams. Her most recent project was to outfit the wrestling team, on which her grandson competes.

“The football team wants me to buy them a seven-man sled, but with this new legislation, they’ll never get it,” she said sadly.

Principal Gene Kotulka said he planned to write his congressman to complain about a ban.

“It’s not so much the money as the service it offers to the kids,” said Mr. Kotulka, who has a Santa Claus belly and is known as “Poppa K” to students. “I’d like to give our kids all the opportunities I can.”

At a meeting in his office to discuss food offerings, Bette Winter, director of the Orange County schools wellness committee, suggested that selling candy to students was not a good lesson.

“What’s the best way to teach children? By example, no?” she asked.

But Mr. Kotulka responded that it was parents’ responsibility to forbid children at risk of obesity to buy candy.

Whether the new rules will change eating habits is unknown, but Mrs. Almond’s candy cart became popular only after the school cafeteria got rid of its own sweets two years ago.

Edgar Coker, an 18-year-old senior, buys Pop-Tarts from Mrs. Almond every afternoon for 50 cents. “If I couldn’t buy it here, I’d bring it from home,” he said.

But Denise Snow, the school cafeteria manager, said that children can be taught to eat better. “When we went to whole-wheat pizza, the kids fussed for a while and we lost some of them,” Ms. Snow said. “But now they don’t say a thing, and pretty much everyone is back to eating them.”

    A Federal Effort to Push Junk Food Out of Schools, NYT, 8.2.2010, http://www.nytimes.com/2010/02/08/health/nutrition/08junk.html

For Some Survivors, Polio Won’t Fade Into the Past

February 3, 2010
The New York Times
By KIRK JOHNSON

SALT LAKE CITY — The polio virus, and its reign of terror in the American psyche, is faded history now. After a vaccine was introduced in the mid-1950s, millions of people sighed, turned the page and moved on. Many polio victims, often struck in childhood, tried to leave the story behind and forget, too.

“I worked alongside people who didn’t even notice my limp,” said Ronald S. Hanson, 78, a retired banker here who got polio at age 6, stunting his right leg but leaving him, he said, determined to live a normal life. “I didn’t want them to notice.”

So when Becky Lloyd, a researcher at the American West Center of the University of Utah, started an oral history project on polio last fall, she imagined weaving a tapestry of memory — a filling in of details about quarantines and rehabilitation units and hospital wards, with their rows of iron-lung breathing machines that became the most chilling symbols of the disease’s attack. Polio cases peaked in the United States in 1952.

But Ms. Lloyd soon found that polio’s past was not dead and gone. It was not even past. In all the early interviews, people talked about an after-echo legacy of the disease called post-polio syndrome that had come back to hit them in their 60s and 70s. Survivors who had battled through braces and operations decades ago wanted to talk about the present, Ms. Lloyd said, and the new battlefield they faced.

“Thirty, 40 or 50 years later, it’s like they’re getting the disease again,” Ms. Lloyd said.

Post-polio syndrome, first recognized by science in the 1980s, is not technically a disease — no bacteria or virus causes it, for example, like polio itself. Rather it is more like a car’s transmission breaking down after too many years of wear and tear on the gears: battered muscles and nerves that are pushed through a lifetime of strain to overcome and compensate for polio’s debilitating effects simply wear out sooner, doctors say.

And now the advancing age of the polio generation — an estimated 750,000 people in the United States — is compounding post-polio’s reach.

About two-thirds of polio survivors are over the age of 64, according to Lawrence C. Becker, the author of a study by Post-Polio Health International, an advocacy group. As many as 60 percent, by some estimates, will experience a post-polio aftershock, moving into an old age that few had prepared for.

Some polios, as survivors call themselves, say that post-polio has refocused their minds on how the virus shaped their lives — and sharpened their bittersweet memories.

“For years, I wouldn’t allow myself to think of polio,” said Virginia Lewis Hall, a retired teacher who grew up in a small town south of Salt Lake City and caught the disease at age 3, in 1949. “I always said, ‘I’ll just tough it out.’ ”

Ms. Hall, 63, said the effects of post-polio, particularly a deterioration of the breathing muscles, which forced her to take an early retirement and requires her to be on oxygen most of the time, have deepened her understanding of the mantra her parents taught her growing up: that she could choose any road she wanted in life, but that her journey would be different because of the disease.

In an interview over her kitchen table, Ms. Hall held up a photograph, taken when she was 5 and recovering from bone surgery, encased in a white plaster body cast from neck to toe, legs stiffened and splayed by a rod between her ankles. In the picture, her older brother, John, in a chest-cast himself from a polio operation (he died of respiratory complications at age 52) holds her up from behind. Huge grins illuminate their faces.

“My dad built a stand so I could stand up — it could hold me, and I could draw, and I could paint,” Ms. Hall said, describing her nine months in the cast. A love of art took root as she stood, otherwise immobilized but free to let her imagination roam. Today, water-color landscapes painted in retirement line the walls of her home.

Part of the problem for aging polio survivors is that, like World War II veterans or Holocaust survivors, their numbers are shrinking every year, which means that money for scientific research into post-polio is drying up, too.

Doctors with hands-on polio experience, like Jacquelin Perry — 91 and still practicing at a rehabilitation center in California — are disappearing even faster.

Dr. Perry began working with polio during World War II, when she was a physical therapist for the Army, and she has seen some patients continually for 50 years or more, creating lifelong charts of their progress, and in many cases, she said, their decline.

Her conclusion about polio and age is that the people who worked hardest to overcome disability have in many cases been hit hardest by its second-wave attack, as over-used muscles and nerves gave out after decades of strain. Her observation is backed up by numerous studies.

“It’s overuse,” Dr. Perry said in a telephone interview. “The people who tried hardest to be normal, and pushed hardest, have been hit more with post-polio.”

Some polio survivors call that the “Type A” problem. Overcoming polio, they say, required immense work, if not obsession, to adapt undamaged muscles and nerves to carry the load. Mr. Hanson, for example, the retired banker, said his left knee, unaffected by polio but burdened for years from carrying most of his body weight, gave out about 11 years ago and had to be replaced. The polio-damaged right leg, meanwhile, became even weaker.

“We’ve followed a lifetime of saying, ‘Push hard, keep going forward,’ ” said Prof. Fernando Torres-Gil, a polio survivor and director of the Center for Policy Research on Aging at the University of California, Los Angeles. “But now that’s an impediment to successful aging.”

Some people who have participated in the Utah project say that rethinking polio’s path — and accepting that post-polio could shape the rest of their days — has given them strength.

“I feel more in control,” said Fran Broadhead, 78, who got polio at age 6, in Alberta, before moving to Montana and later Utah.

Ms. Broadhead, whose childhood illness was relatively mild — she was up and playing with friends a year later — said she thought the weakness and fatigue that began hitting her in the last decade were mostly from polio. It is not a question her doctors can help answer, she said, since post-polio is rarely a formal diagnosis.

“It makes it easier for me to accept what I’m going through,” she said, “and to teach myself to adapt.”

    For Some Survivors, Polio Won’t Fade Into the Past, NYT, 3.2.2010, http://www.nytimes.com/2010/02/03/health/03polio.html

Critical Care: The Decline of St. Vincent’s Hospital

February 3, 2010
The New York Times
By ANEMONA HARTOCOLLIS

For more than 150 years, St. Vincent’s Hospital Manhattan was a beacon in Greenwich Village, serving poets, writers, artists, winos, the poor and the working-class and gay community.

It treated victims of calamities, from the cholera epidemic of 1849 to the sinking of the Titanic, the 9/11 terrorist attack and, just last year, the Hudson River landing of US Airways Flight 1549. The poet Edna St. Vincent Millay got her middle name from the hospital, which saved her uncle’s life in 1892 after he was accidentally locked in the hold of a ship for several days without food or water.

But last week, in what could mean the death knell of the last Roman Catholic general hospital in New York City, a big chain of hospitals proposed to take over St. Vincent’s, shut down its inpatient beds and most of its emergency room services, and convert it into an outpatient center tied into the chain’s own hospitals uptown and across town to the east.

How St. Vincent’s went from a cherished neighborhood amenity to a relic of times past is a chronicle of mismanagement compounded by the economics of the health care industry, changes in the fabric of a historic neighborhood and the low profit potential in religious work.

It was once part of the Roman Catholic social and political machine in New York City, a cradle-to-grave embrace of parishioners who were born in a Catholic hospital, educated in parochial schools, married in the church and given last rites by a priest.

Last week, a day after the announcement of the proposed takeover, members of the Sisters of Charity, the Catholic order that founded the hospital in 1849, gathered in a noon Mass at St. Vincent’s and vowed to fight. “We are not going away,” said Sister Jane Iannucelli, vice chairwoman of the hospital board, standing in the light of the stained glass windows.

“One of the things that’s so crucial to the Sisters of Charity is serving the poor,” she said after the Mass.

It was that very calling, some industry executives suggested, that may have helped make the hospital obsolete.

“Helping the poor is indeed the mission and the cause célèbre,” said Kenneth E. Raske, president of the Greater New York Hospitals Association, a trade group. “Therein lies the dilemma.”

While other hospitals emphasize high-tech care and rush to invest in the fancy equipment and celebrity doctors that attract patients with the means to pay for them, St. Vincent’s stuck to its motto of “compassionate care,” rooted in its origins as a place that trained nurses and that was under the auspices of nuns.

As the Village changed, becoming home to middle-class and affluent families, by many accounts St. Vincent’s failed to change with it. In 2007, several years after an ill-fated merger with other Catholic hospitals, St. Vincent’s management proposed to begin selling off its maze of outdated buildings around Seventh Avenue and 12th Street to build a new, state of the art high-rise building across the street, to be designed by Pei Cobb Freed & Partners Architects, famous for cutting-edge projects like the glass pyramid expansion of the Louvre museum in Paris and the John Hancock Tower in Boston.

But some said it was too late. In an indication of how St. Vincent’s reputation had fallen in the neighborhood, during a fierce debate over whether to demolish a low-rise modernist building to make way for the new hospital, the actors Susan Sarandon and Tim Robbins suggested that St. Vincent’s no longer served the neighborhood well.

“I would not want to bring my children there,” Ms. Sarandon declared at a landmarks preservation hearing.

At the height of the AIDS epidemic, St. Vincent’s ministered to those affected, and was bursting at the seams. But by the 1990s, drugs and public awareness helped bring AIDS under control, and the Village’s wealthy newcomers were choosing other hospitals.

From 1996 to 2007, the most recent year for which figures are available, the number of patients the hospital admitted went down by 10 percent, while the city rate was flat, state records show.

And its emergency room volume has been growing faster than the citywide rate, suggesting that it has the worst of both worlds — more emergency room patients and fewer inpatient admissions, which are where the money is.

Many of St. Vincent’s emergency room patients reported no ZIP code, indicating that they may be homeless, not surprising since St. Vincent’s is a major city contractor for homeless services, and hospital administrators said that homeless people from all over the city find their way there for treatment.

In short, many of the patients who frequent St. Vincent’s are part of the old Village rather than the new Village, as was clear from a tour of the emergency room last week. The room was electric with activity, every bed filled. Many of the patients were elderly, from Chinatown, or grizzled remnants of the Village’s old working class. Nuns from Mother Theresa’s order hovered about.

The room, like other parts of the hospital, had a quaint, homey feeling, comfortable but more like a place Marcus Welby might have taken his patients rather than the overly caffeinated environment of “House.”

“There’s a sense we’re here for the mission, and it truly permeates,” said Dr. Eric Legome, the chairman of emergency medicine.

Despite 62,000 emergency visits, nearly 1,800 births, almost 22,000 hospital admissions and 263,000 outpatient visits a year, according to St. Vincent’s officials, the hospital is bleeding red ink, and has been for years.

Hospital officials, who asked not to be named because of the sensitivity of negotiations with Continuum Health Partners, the chain that has offered to take over the hospital, said the hospital was close to having to declare bankruptcy for the second time since 2005. It is about $700 million in debt.

Officials blamed a high rate of poor and uninsured patients as well as federal Medicare cuts, state Medicaid cuts and the hospital’s inability to negotiate favorable contracts with health insurance companies, claiming their fees were 30 percent below the market rate.

Catholic hospitals in some parts of the country continue to thrive, but the New York City hospital field is much different from what it was 100 years ago; New Yorkers with health insurance now can choose from a number of prestigious hospitals.

To remain competitive, in 2000 St. Vincent’s merged with several other Catholic hospitals to form St. Vincent Catholic Medical Centers.

Along with the flagship hospital in the Village, it ran seven other hospitals: Bayley Seton and St. Vincent’s on Staten Island; Mary Immaculate, St. John’s and St. Joseph’s in Queens, St. Mary’s in Brooklyn and St. Vincent’s in Westchester. It was also affiliated with St. Vincent’s Midtown, formerly St. Clare’s, in Midtown Manhattan.

The merger was conceived as a way to streamline management and give the hospitals pricing leverage, but it was troubled from the beginning. After closings and sales, the network was left with just one New York City hospital, the flagship; a psychiatric and substance abuse treatment hospital in Westchester; and several nursing homes and other outpatient facilities. Some of St. Vincent’s high debt was inherited from the closed hospitals.

Over the last few years, St. Vincent’s has tried to polish its image, recruiting the Giants quarterback Eli Manning and former Mayor Rudolph W. Giuliani to raise money and attract customers.

It has traditionally been one of the beneficiaries of the Alfred E. Smith Foundation Dinner, an annual charity roast at the Waldorf-Astoria, where John McCain and Barack Obama traded jabs just before the 2008 election. The hospital’s chairman is Alfred E. Smith IV, a prominent Wall Street investment banker and the great-grandson of the New York governor who ran for president in 1928. Mr. Smith did not respond to a request for an interview.

In 2004, St. Vincent’s turned over management to Speltz & Weis, the first in a series of turnaround consultants, paying the firms millions of dollars a year to run the hospital and also hiring the firms’ officials as hospital executives. The system filed for Chapter 11 bankruptcy protection in early July 2005, when it appeared, according to court papers filed by hospital creditors, that it would be unable to make its payroll.

In a lawsuit filed in 2007, some of the hospital’s creditors painted a picture of a hospital system trapped between unscrupulous consultants and a passive or gullible board. The lawsuit accused David E. Speltz and Timothy C. Weis, its former chief executive and chief financial officer, of delaying the bankruptcy organization while they and their consulting firm collected millions of dollars in fees.

The lawsuit accused them of hiring high-priced independent contractors, who kicked back fees, instead of using hospital employees to do work. And it says they leveraged their positions with the hospital to negotiate the sale of their consulting company to Huron Consulting Group, in Chicago, also a defendant in the case.

From 2004 until the lawsuit was filed, St. Vincent’s paid Speltz & Weis, which was based in New Hampshire, $30.8 million and Huron $1.2 million in fees and expenses, according to court papers.

Among the expenses were a personal membership in a private university club, trips to New York for spouses, hundreds of dinners in Manhattan restaurants, opera tickets, groceries, dry cleaning and laundry, as well as travel and housing fees for consultants from outside New York, according to court papers.

Lawyers for Mr. Speltz and Mr. Weis did not return calls for comment. But they said in court papers that the creditors had written a “revisionist” history of events that unfairly blamed their clients for a bankruptcy that was actually caused by a $60 million shortfall in accounts receivable that had not been detected by auditors. Their firm had to bring in contractors for important jobs because previous St. Vincent’s managers had unwisely eliminated key positions, the lawyers said. The lawsuit is headed for mediation.

The current chief executive, Henry J. Amoroso, is its fourth since 2004. He did not respond to requests for comment. St. Vincent’s board announced recently that it had retained another crisis management firm, Grant Thornton.

Sister Iannucelli, the vice chairwoman, acknowledged that the hospital was on the precipice. “We have had enough money to pay our salaries,” she said, but added, “The cash flow has gotten tighter and tighter, and yes, we are in a very vulnerable position.”

She said that while the board was considering Continuum’s offer, because it needs a partner to continue to operate, it was also hoping other potential partners might step forward.

Last Thursday night, more than 500 people crowded into a basement meeting room at Our Lady of Pompeii Church on Carmine Street to protest the proposed takeover. One man, Mark Leonard, spoke of how a nurse offered to come to his house and baby-sit after he took home his very fragile twins from the St. Vincent’s intensive care unit.

“You guys must be exhausted,” he remembered the nurse calling to say. “You need a night out with your wife.”

Nancy Spannbauer, a program director for the Penn South senior citizens’ program in Chelsea, told how she had been in the home of a 91-year-old woman a few days earlier, while a doctor tried to get the woman to go to the hospital.

“Eventually she gave in,” Ms. Spannbauer said. “And she said, ‘Well, I suppose if I have to, I’ll only go to St. Vincent’s.’ ”

Colin Moynihan contributed reporting.

    Critical Care: The Decline of St. Vincent’s Hospital, NYT, 3.2.2010, http://www.nytimes.com/2010/02/03/nyregion/03vincents.html

Doctor’s Killer Puts Abortion on the Stand

January 29, 2010
The New York Times
By MONICA DAVEY

WICHITA, Kan. — Scott Roeder, the man charged with murder in the shooting of George R. Tiller, one of the few doctors in the country to perform late-term abortions, took the witness stand in his own defense on Thursday, and said that, yes, he did it.

Yes, he bought a gun. Yes, he took target practice. Yes, he had learned about Dr. Tiller’s habits, his home address, his security precautions. And, yes, he shot Dr. Tiller last May 31 as Dr. Tiller stood inside his church.

“That is correct, yes,” Mr. Roeder told the jurors, in a calm, matter-of-fact voice.

But there was a twist.

Lawyers for Mr. Roeder, who provided the only testimony for the defense in a trial that has spanned several weeks, are hoping that jurors will consider Mr. Roeder’s motive: his growing opposition to abortion, which he deemed criminal and immoral, and his mounting sense that laws and prosecutors and other abortion opponents were never going to stop Dr. Tiller from performing them.

“I did what I thought was needed to be done to protect the children. I shot him,” he testified, adding at another point, “If I didn’t do it, the babies were going to die the next day.”

Was he remorseful? No, Mr. Roeder said without emotion. After the killing, he said, he felt “a sense of relief.”

And so, in a way, the hearing here, watched intensely by all sides of the abortion debate, turned into precisely what the presiding judge had said all along that it ought not to be — a trial over abortion. Judge Warren Wilbert has wrestled with requests from the prosecution and the defense over how to permit Mr. Roeder to mount a murder defense without allowing him to turn the case into a public forum on abortion.

But even with his pointed testimony, based on a ruling late Thursday by Judge Wilbert, Mr. Roeder continues to face a difficult legal hurdle in beating back a charge of first-degree murder.

Judge Wilbert ruled that he would not instruct the jury to consider a lesser charge when they begin deliberations on Friday. Mr. Roeder has pleaded not guilty to murder, but defense lawyers had argued that his beliefs about abortion might warrant a voluntary manslaughter conviction if jurors concluded that Mr. Roeder possessed, as Kansas law defines it, “an unreasonable but honest belief that circumstances existed that justified deadly force.”

Seated on the witness stand, facing a tiny courtroom gallery that included Dr. Tiller’s widow, Jeanne, abortion opponents from other parts of the country, and national abortion rights supporters, Mr. Roeder seemed quiet, almost lawyerly, in his responses to inquiries about the killing, in which Dr. Tiller was shot in the forehead, the gun pressed to his skin.

Mr. Roeder, 51, of Kansas City, Mo., told jurors that he had a growing sense of his own faith and opposition to abortion in the 1990s after watching “The 700 Club,” the evangelist Pat Robertson’s television talk show. Mr. Roeder’s views on religion and abortion, he said, went “hand in hand.”

Mr. Roeder acknowledged under cross-examination that he had, as early as 1993, thought about killing Dr. Tiller. A year before the shooting, he said, he had gone to Dr. Tiller’s church with a gun intending to shoot him. (Dr. Tiller was not there that day, he said.) And he said he considered other alternatives: cutting off Dr. Tiller’s hands with a sword, shooting him from a distance with a rifle, or finding him at his house.

Of his decision to go to the church, he said, “It was the only window of opportunity I saw that he could be stopped.”

Abortion opponents here, including some who have served time in jail for abortion clinic violence, praised Mr. Roeder for his testimony. But some complained bitterly that Judge Wilbert had severely limited the defense by barring the testimony of Phill Kline, a former Kansas attorney general who had unsuccessfully pursued criminal investigations against Dr. Tiller and by preventing jurors from considering some conviction short of murder.

Abortion rights supporters, meanwhile, called Mr. Roeder’s statements deeply chilling, and said they mandated nothing short than a first-degree murder conviction, which could carry a life sentence. “It should send a message that there is no justification for this,” said Vicki Saporta, the president of the National Abortion Federation, who sat in the court.

Over four days, prosecutors laid out a case that rarely dealt with abortion, but stuck instead to dates and times and forensic and witness evidence implicating Mr. Roeder in the Tiller shooting. Abortion rights supporters said that was as it should be: this was murder, plain and simple.

By the middle of the week, the courthouse had drawn some of the most outspoken members of the abortion debate from around the country.

“George Tiller shed the blood of 60,000 innocent children,” Randall Terry, the founder of Operation Rescue, told reporters. Mr. Terry (who is in a legal dispute over the use of the group’s name with Operation Rescue’s current president, Troy Newman) said that he was neither condoning nor condemning Mr. Roeder’s actions, but that people should remember the children.

Days after Mr. Roeder’s arrest, the United States Department of Justice announced it was investigating Dr. Tiller’s death to determine whether there was anyone else involved in the plot. On Thursday, Mr. Roeder acknowledged that he has friends who, like him, believe that the killing of abortion doctors is justifiable. One such friend, Shelley Shannon, was imprisoned for shooting Dr. Tiller in both arms in 1993. Still, Mr. Roeder said on Thursday, he acted alone.

Justice Department representatives are “actively monitoring” Mr. Roeder’s case, a department spokesman said, adding, “Our investigation into the murder of Dr. Tiller is open and ongoing.”

Guided by lawyers, Mr. Roeder methodically described the morning of the shooting — how he had fired the gun inside the church, driven away from Wichita, hidden the gun in a small town, and picked up a snack, a pizza. In the days after the killing, Dr. Tiller’s family announced that it would close the abortion clinic, the only one in Wichita.

So, Nola Foulston, the prosecutor asked him, do you feel you have successfully completed your mission?

“He’s been stopped,” Mr. Roeder said.

But do you feel you have successfully completed your mission, she asked again.

“Yes,” he said.

 

Emma Graves Fitzsimmons contributed reporting from Chicago.

    Doctor’s Killer Puts Abortion on the Stand, NYT, 29.1.2010, http://www.nytimes.com/2010/01/29/us/29roeder.html

After Long Decline, Teenage Pregnancy Rate Rises

January 27, 2010
The New York Times
By TAMAR LEWIN

After more than a decade of declining teenage pregnancy, the pregnancy rate among girls ages 15 to 19 increased 3 percent from 2005 to 2006 — a turnaround likely to intensify the debate over federal financing for abstinence-only sex education.

The teenage abortion rate also crept up for the first time in more than a decade, rising 1 percent from 2005 to 2006, according to an analysis by the Guttmacher Institute, a nonpartisan nonprofit research group.

“It’s very disturbing,” said Sarah Brown, of the National Campaign to Prevent Teen and Unplanned Pregnancy. “We had over a decade of progress on a very serious problem, and I worry that we’ve ground to a halt. I think there are a lot of different factors at play, from less use of contraception, maybe because of less fear of AIDS, to our anything-goes culture, where it’s O.K. to get pregnant and have a baby in your teens.”

While teenage pregnancy rates for whites remain far lower than for blacks and Hispanics, the pregnancy rates increased for all three groups.

As previously reported, births to young women ages 15 to 19 — a statistic that is available more quickly than pregnancy and abortion data — rose from 2005 to 2006, and again from 2006 to 2007.

Since the teenage pregnancy rate is made up of births, abortions and miscarriages, it is likely that the teenage pregnancy rate rose from 2006 to 2007, as well.

But several experts said it was too soon to predict whether teenage pregnancy and birth rates would continue to rise, and revert to the record high levels of the 1980s and early 1990s.

The Guttmacher analysis examined federal data on teenage sex, births and abortion, along with the institute’s own abortion statistics.

While it is difficult to pinpoint precisely how different factors influence teenage sexual behavior, some experts speculate that the rise in teenage pregnancy might be partly attributable to the $150 million a year of federal financing for sex education that emphasized abstinence until marriage, avoiding all mention of the possible benefits of contraception.

“This new study makes it crystal clear that abstinence-only sex education for teenagers does not work,” said Cecile Richards, the president of the Planned Parenthood Federation of America.

The Clinton administration began financing abstinence-only programs as part of welfare reform, but such programs got a large boost in the Bush administration.

The Obama administration has moved away from abstinence-only programs, creating a new teenage-pregnancy initiative in which most financing will go to programs that have been shown to prevent pregnancy, with some experimental approaches.

Meanwhile, there are continuing efforts to reinstate financing for abstinence-only education as part of the health-reform legislation.

Lawrence Finer, director of domestic research for the Guttmacher Institute, said there was evidence that adolescent use of contraceptives had plateaued, or declined, adding that it was “an interesting coincidence” that this had happened just as the focus on abstinence-only education had left fewer students getting comprehensive sex education.

Advocates of abstinence-only education, however, had a different view.

“While this recent uptick is certainly disconcerting, it would be disingenuous to try to ascribe it abstinence education or any other single factor,” said Valerie Huber, executive director of the National Abstinence Education Association. “The overly sex-saturated culture certainly plays a part, with teen sex communicated almost as an expected rite of passage, without consequences, and that’s a dangerous message for young people, who tend to be risk-takers anyway.”

According to the Guttmacher analysis, the teenage pregnancy rate declined 41 percent from its peak, in 1990, when there were 116.9 pregnancies per 1,000 women aged 15 to 19, and 2005, when there were only 69.5 per 1,000. In 2006, the rate rose to 71.5 pregnancies for 1,000 women.

Teenage birth and abortion rates also declined in that period, with births dropping 35 percent from 1991 to 2005 and teenage abortion declining 56 percent between its peak, in 1988, and 2005.

    After Long Decline, Teenage Pregnancy Rate Rises, NYT, 27.1.2010, http://www.nytimes.com/2010/01/27/us/27teen.html

Lawrence Garfinkel, Dies at 88; Fought Smoking

January 27, 2010
The New York Times
By DENISE GRADY

Lawrence Garfinkel, an epidemiologist with the American Cancer Society who helped design landmark studies that linked smoking to lung cancer, died Thursday in Seattle. He was 88.

The cause was cardiovascular disease, his son Martin said.

Mr. Garfinkel became a leader in cancer epidemiology despite having no formal education in the field. His college degrees were in statistics: a bachelor’s from the City College of New York and a master’s from Columbia.

“He started as a statistical clerk at the cancer society,” his son said. “He was a recent veteran, just looking for work. It was a temporary job, and he stayed for 43 years.”

Hired in 1947, Mr. Garfinkel learned epidemiology on the job. His mentor was Dr. E. Cuyler Hammond, an epidemiologist and the director of the statistical research section.

Scientists had begun to suspect that smoking might cause lung cancer, but large studies were needed to find out for sure. Mr. Garfinkel helped Dr. Hammond and Dr. Daniel Horn conduct a study in the 1950s that tracked nearly 188,000 men for 44 months. Its conclusion became a milestone in epidemiology: Smokers had a marked increase in lung cancer risk.

The grim evidence began to turn the medical profession against tobacco and inspired public health campaigns against smoking. The tobacco industry fought back, picking over studies for flaws and questioning the researchers’ objectivity.

But the epidemiologists had just begun to work. Mr. Garfinkel and Dr. Hammond started an even bigger project in 1959, the Cancer Prevention Study I, which enrolled a million men and women.

A study begun in 1982, by Mr. Garfinkel and Dr. Steven D. Stellman, had 1.2 million participants. This research confirmed the earlier indictment of tobacco, and captured the steep rise in lung cancer among women who had taken up smoking.

“Those studies have been extraordinarily valuable in that they were a major impetus for tobacco control in the United States,” said Dr. Michael Thun, the vice president of epidemiology and surveillance research at the cancer society.

The studies also gathered data on obesity, alcohol, medications, hormones, occupational exposures, reproductive issues, other cancers and chronic diseases. Researchers are still using that information, said Dr. Stellman, a clinical professor of epidemiology at the Mailman School of Public Health at Columbia University.

Mr. Garfinkel and Dr. Hammond also worked with Dr. Oscar Auerbach, a pathologist who studied tissue from deceased smokers and showed that the degree of precancerous change depended on how much and how long they had smoked. The pathology findings bolstered the statistical correlations from the earlier studies by providing physical evidence of what smoke could do to the lungs.

Mr. Garfinkel became head of epidemiology at the cancer society in 1979, retired in 1990 and worked as a volunteer until 2003.

When Mr. Garfinkel retired, Dr. Richard D. Klausner, who was then the director of the National Cancer Institute, said, “Few individuals have contributed as much to our present-day knowledge about the disease consequences of smoking.”

Although Mr. Garfinkel contributed to 147 articles in scientific journals, colleagues say he never flaunted his achievements. “He carried with him the fact that he was the product of two poor immigrants, one of whom never learned to read,” his son said.

Lawrence Garfinkel was born on Jan. 11, 1922, on the Lower East Side of Manhattan, and grew up in the South Bronx. His parents were from Galicia, now in southeast Poland.

Mr. Garfinkel finished high school at 15 and went to college at night while working days in the garment district. He studied while riding the subway.

After the attack on Pearl Harbor, Mr. Garfinkel joined the Army and was wounded by shrapnel in France. After months in a hospital, he received a medical discharge. He went back to school, but because he had to work, it took him 10 years to earn his bachelor’s degree.

His wife, the former Celia Kleinbaum, whom he married in 1948, died in 1993. In addition to his son Martin, of Seattle, he is survived by his brothers Harold, of Margate, Fla., and Melvin, of Farmington, Conn.; another son, Herb, of San Francisco; and two grandchildren.

Mr. Garfinkel “indoctrinated his family” on the dangers of smoking, Martin Garfinkel said, recalling that when he was 10 his father gave him a deceased smoker’s blackened, cancerous lung in a jar of formaldehyde.

“I put it in my room on a shelf with my baseball glove,” he said. “It did the trick. I never smoked.”

    Lawrence Garfinkel, Dies at 88; Fought Smoking, NYT, 27.1.2010, http://www.nytimes.com/2010/01/27/health/27garfinkel.html

Ruth P. Smith, Abortion-Rights Pioneer, Dies at 102

January 27, 2010
The New York Times
By MARGALIT FOX

Ruth Proskauer Smith, a longtime reproductive rights advocate who helped found what is now Naral Pro-Choice America, died Friday at her home in Manhattan. She was 102.

Her son, Anthony Smith, confirmed the death.

In 1969, Mrs. Smith and 11 others formed the first steering committee of the National Association for the Repeal of Abortion Laws, as the organization was then known. (In 1973, after the Supreme Court’s decision in Roe v. Wade made abortion legal nationwide, the group’s name was changed to the National Abortion Rights Action League; it adopted its present name in 2003.)

In recent years, Mrs. Smith remained involved with Naral Pro-Choice New York, an affiliate of the national body. She was also active in the right-to-die movement, advocating that physician-assisted suicide be legally available to terminally ill people.

Ruth Proskauer was born on Aug. 14, 1907, in Deal, N.J., and reared in Manhattan. Hers was a distinguished family: her father, Judge Joseph M. Proskauer, served on the New York State Supreme Court before becoming a partner in the law firm now known as Proskauer Rose. Her mother, the former Alice Naumburg, helped found the Euthanasia Society of America, a right-to-die group. As a young woman, Ruth received her first public-speaking lesson from Gov. Alfred E. Smith, to whom her father was a close adviser.

Ruth Proskauer earned a bachelor’s degree from Radcliffe in 1929, followed by a master of fine arts from Radcliffe in 1932. She became a fieldworker for the Planned Parenthood League of Massachusetts in the 1940s and was later its executive secretary. Afterward, she held high positions with several national reproductive rights organizations.

In 1932 she married Theodore Smith; the marriage ended in divorce. Besides her son, Anthony, of Manhattan, Mrs. Smith is survived by a daughter, Gael S. Arnold, of Washington; six grandchildren; and seven great-grandchildren.

For the past two decades, until after her 102nd birthday, Mrs. Smith led a regular seminar on the Supreme Court at Quest, an educational program for retired professionals affiliated with the Center for Worker Education of the City College of New York.

    Ruth P. Smith, Abortion-Rights Pioneer, Dies at 102, NYT, 27.1.2010, http://www.nytimes.com/2010/01/27/nyregion/27smith.html

Letters

Looking at Ways to Treat Depression

January 12, 2010
The New York Times

To the Editor:

Re “The Wrong Story About Depression” (Op-Ed, Jan. 9):

Judith Warner is correct that antidepressants are frequently prescribed by primary-care doctors, often for the minor and moderate depressions referred to in the study getting recent media attention.

Depressions respond to psychotherapy. Ms. Warner is also correct that the effectiveness of this treatment very much depends on the individual practitioner. The practitioner can be a psychiatrist, a psychologist or a social worker.

The advantage of an evaluation by a well-trained psychiatrist is that the medical and drug-induced causes of depression can be better ruled out, and a judgment can be made whether the condition is of significant severity where the benefits of the addition of medication outweigh the risks.

Unfortunately, as with other fields, attempts to determine who are the best (performance measurements, published rankings, word of mouth) all have their flaws. There are many people suffering from severe depression, and we have to do a much better job ensuring that they get the best possible care.

Jeffrey B. Freedman

New York, Jan. 9, 2010

The writer, a psychiatrist, is immediate past president of the New York County district branch of the American Psychiatric Association.

•

To the Editor:

I am one of those people referred to by Judith Warner who have been prescribing and studying antidepressants — in my case, for 30 years. Every point made by Ms. Warner is dead-on:

Antidepressants do work for people who are really depressed; they don’t for people who aren’t. Depression is frequently diagnosed in people who don’t have it, and frequently not diagnosed in those who do.

Medications that work for depression are commonly misused, and types of psychotherapy that work for depression are commonly not used at all. The reasons for this state of affairs include mistrust of authority, stigma, big-stakes health care economics, cross-discipline rivalries and simplistic thinking (within the mental health care field as well as the general public).

The excesses of the media and the perverse incentives of our current health care delivery system make things worse.

I am, sadly, less hopeful than Ms. Warner that health care reform will help rectify things. I am more hopeful that advances in our understanding of depression itself will enable us to more accurately diagnose it, so that individuals in distress, whether from depression or other problems, get the help they actually need. Lawrence H. Price

Providence, R.I., Jan. 9, 2010

The writer, a psychiatrist, is professor of psychiatry and human behavior at Brown University and clinical director and director of research at Butler Hospital.

•

To the Editor:

In her article about treatments for depression, Judith Warner cites a group of psychologists who said that “relatively few psychologists learn or practice” interventions that these researchers deemed “effective.”

Research since the 1970s has consistently established the effectiveness of psychotherapy for treatment of conditions like depression when the therapy is conducted by a highly trained person who holds to a philosophy of psychotherapy (the philosophy does not much matter, as long as the therapist has one).

The more recent debate about “evidence-based” therapies is an old one in the psychological world, pitting our competent researchers against clinicians.

While researchers can investigate treatments in laboratory conditions, few clients fit into simple categories. Try applying an “evidence-based treatment” for a depressed, sexually abused child from a divorced family in which one parent is alcoholic and the child has a learning disability. Such clients do not tend to show up for laboratory studies and don’t tend to respond to simple bromides.

It is also untrue that psychologists do not learn about evidenced-based treatments. Nearly all psychologists in all states must take continuing education and are thereby exposed to the current research about psychological conditions and treatments. The best clinicians practice flexibility in approach, depending on the needs of their patients.

James Brush

Cincinnati, Jan. 9, 2010

The writer, a child and adolescent psychologist, is a former president of the Ohio Psychological Association.

•

To the Editor:

The article by Judith Warner as well as the original study on depression are likely to do harm to many Americans with depression. For decades, it has been recognized that the recognition and treatment of depression require that primary-care physicians both screen for and, when appropriate, treat depression. This treatment may take many forms, including the use of pharmacologic agents.

Many of those who need treatment have no access to psychiatrists because of geographical distribution, restrictive insurance coverage, cost or a perceived stigma to being cared for by a psychiatrist. Thus, distortion or misinterpretation of the evidence about the treatment of depression will result in those who desperately need help not obtaining it.

My colleagues and I spent many years in convincing family physicians and others that chronic depression is an important and treatable disease. Yes, some of the financing was from the pharmaceutical industry, but much of it came from federal agencies and others whose sole motivation was the health of the public. Because of this, we have made significant gains in the treatment of depression. Neil Brooks

Vernon, Conn., Jan. 10, 2010

The writer is a former president of the American Academy of Family Physicians.

•

To the Editor:

Judith Warner hits the nail on the head: the more accurate story about mental health treatment is the lack of parity with the diagnosis and treatment of other illnesses like cancer, diabetes and rheumatoid arthritis.

People with emotional problems suffer stigma and are vulnerable to fragmented systems of care, and the pressure to prescribe as a quick fix for complex problems. Cost-effective, evidenced-based treatments in which judicious use of medication is combined with counseling reduce crippling symptoms and expand quality of life.

Whether or not we enable those with mental illness to recover dreams damaged by their disease remains an ethical challenge. Sue Matorin

New York, Jan. 11, 2010

The writer is a social worker in the department of psychiatry, Weill Cornell Medical College.

    Looking at Ways to Treat Depression, NYT, 12.10.2010, http://www.nytimes.com/2010/01/12/opinion/l12warner.html

Op-Ed Contributor

The Wrong Story About Depression

January 9, 2010
The New York Times
By JUDITH WARNER

Washington

“STARTLING results,” promised the CNN teasers, building anticipation for a segment on this week’s big mental health news: a study led by researchers at the University of Pennsylvania indicating that the antidepressants Paxil and imipramine work no better than placebos (“than sugar pills,” said CNN) for people with mild to moderate depression.

Happy pills don’t work, the story quickly became, even though, boiled down to that headline, it was neither startling nor particularly true.

It sounded true. After all, any number of experts have argued that antidepressants — and selective serotonin reuptake inhibitors like Paxil in particular — are overhyped and oversold. And after years of hearing about shady practices within the pharmaceutical industry, and of psychiatrists who enrich themselves in the shadows by helping the industry market its drugs, we are primed to believe stories of psychiatric trickery.

Yet in all the excitement about “startling” news and “sugar pills,” a more nuanced and truer story about mental health care in America was all but lost.

That story begins to take shape when you consider what the new study actually said: Antidepressants do work for very severely depressed people, as well as for those whose mild depression is chronic. However, the researchers found, the pills don’t work for people who aren’t really depressed — people with short-term, minor depression whose problems tend to get better on their own. For many of them, it’s often been observed, merely participating in a drug trial (with its accompanying conversation, education and emphasis on self-care) can be anti-depressant enough.

None of this comes as news to people who have been prescribing or studying antidepressants over the past 20 years. Neither is it all that likely to change the practice of treating depression — at least as it’s carried out by responsible doctors.

After all, people who are depressed for the first time, or have been depressed for only a short time, or are upset after a personal setback, aren’t considered ideal candidates for immediate drug therapy. And, contrary to popular belief, there’s no evidence that most psychiatrists regularly prescribe pills straight off to people who can get better by reading about depression, exercising or doing nothing. What numbers do exist, said Peter Kramer, who has written extensively on antidepressant use in books like “Listening to Prozac,” indicate that relatively few people with minimal depression leave psychiatrists’ offices with a prescription.

That people have come to believe otherwise may be in part because most patients with depression are treated by general practitioners, not psychiatrists. Studies have shown that these primary care doctors don’t strenuously enough screen their patients for depression before prescribing drugs, or closely monitor their care afterward.

And here the truer story about mental health care in America begins to unfold. The trouble is not that the drugs don’t work; it’s that the care is not very good.

Inadequate treatment by nonspecialists is only a piece of the problem. In fact, most Americans with depression, rather than being overmedicated, are undertreated or not treated at all. This might have been big news this week, too, had anyone noticed another academic study, a survey of nearly 16,000 people published this month in The Archives of General Psychiatry, which looked more broadly at the picture of depression in America. The survey found that those who did get care were given psychotherapy more often than drugs. That finding might give heart to those who would prefer to see more alternatives to psychiatric drugs — if it weren’t for the fact that so much psychotherapy is so bad.

In 2008, a team of psychologists brought this point home in blunt terms in the journal Psychological Science in the Public Interest. “Despite the availability of highly effective interventions,” they wrote, “relatively few psychologists learn or practice these interventions.”

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

It is a societywide concern that a co-author of the new antidepressants study readily acknowledges. “What we reported on was a very small piece of a very large problem,” Robert J. DeRubeis, a professor of psychology at the University of Pennsylvania, told me. “Those kinds of things are not being sorted out in this country because there’s no system. Nobody’s asking these questions.”

With health care reform almost certainly on the horizon, perhaps now we can hope they will start asking.

Judith Warner, a former columnist at nytimes.com, is the author of the forthcoming “We’ve Got Issues: Children and Parents in the Age of Medication.”

    The Wrong Story About Depression, NYT, 9.1.2010, http://www.nytimes.com/2010/01/09/opinion/09warner.html

Obama Urges Quick Action on Health Overhaul

January 10, 2010
The New York Times
By JEFF ZELENY

WASHINGTON — President Obama said Saturday that Americans would see immediate benefits from a landmark overhaul of the nation’s health insurance system, and he urged Congress to reconcile swiftly differences on the legislation so it could be signed into law in the coming weeks.

“Once I sign health insurance reform into law, doctors and patients will have more control over their health care decisions, and insurance company bureaucrats will have less,” Mr. Obama said. “All told, these changes represent the most sweeping reforms and toughest restrictions on insurance companies that this country has ever known.”

In his weekly Saturday address, Mr. Obama highlighted elements of the plan that would take effect soon after enactment of the bill.

He said people with pre-existing illnesses would be able to buy affordable insurance, children with pre-existing conditions would no longer be denied coverage and small-business owners who could not afford to cover employees would receive tax credits to buy insurance.

“What every American should know is that once I sign health insurance reform into law, there are dozens of protections and benefits that will take effect this year,” Mr. Obama said.

Most of the proposed changes in the bill would not take effect until 2014, but the president used his weekly address to try to raise the urgency for the legislation.

The competing versions of the plan in the House and Senate would require most Americans to get health insurance and would provide subsidies for those who could not afford it.

But significant differences remain over how to accomplish that goal, including what taxes would be raised.

In his address, the president said the health insurance overhaul was needed to improve the economic fortunes for the nation’s middle class.

“We need to rebuild our economy in such a way that our families can feel a measure of security again,” Mr. Obama said.

    Obama Urges Quick Action on Health Overhaul, NYT, 10.1.2010, http://www.nytimes.com/2010/01/10/health/policy/10address.html

Editorial

Health Reform, the States and Medicaid

January 10, 2010
The New York Times

The country needs health care reform, and Congress should move quickly to pass legislation. But as House and Senate leaders work to forge a consensus bill for final approval, they should look for ways to lessen the Medicaid burden on hard-pressed state budgets — and ensure that relief is fairly apportioned.

One of the important goals is to extend coverage to more low-income Americans. The bills quite sensibly require the states to expand Medicaid and offer them generous federal support to do so. Even then, the states — whose Medicaid budgets are already badly stretched — will have to put up substantial money of their own.

Ideally, Congress should find some way to get more money to state Medicaid programs. But if that proves politically impossible, as seems likely, the states will have to bear part of the additional burden in what is, after all, a shared national enterprise. Their poorer citizens will benefit greatly.

HOW DOES MEDICAID WORK?The program currently pays for health care and nursing home care for 50 million poor Americans. In fiscal year 2008, the federal government paid about 57 percent of the total $354 billion cost, with the states picking up the rest. Both bills would broaden eligibility, and their requirement that everyone obtain insurance should also push more currently eligible people to sign up. That is a good thing.

It is important to remember that under the reform bills, all of these people would gain access to health insurance — either through Medicaid or through federally subsidized private insurance plans. Medicaid is a better deal for poor people because it typically charges much less in co-payments and premiums for a better package of benefits than private insurers are apt to provide. From an overall budgetary standpoint, Medicaid is also the cheapest way to insure people since it reimburses hospitals, doctors and other providers at a lower rate than private insurers do.

The issue here is how much the states can and should pay for expanding Medicaid rolls.

HOW WOULD IT CHANGE? Right now the states differ considerably on who is eligible for Medicaid. (Only a few states extend much coverage to poor, childless adults.) Both the House and the Senate versions would require the states to cover all poor people under age 65. The House version would set an income ceiling of 150 percent of the federal poverty level, or $33,000 for a family of four. The Senate bill would expand coverage only up to 133 percent of the federal poverty level, or $29,300 for a family of four. Our own preference would be to choose the higher ceiling for the benefit of more people.

WHO PAYS? AND HOW MUCH? To ease the additional burden on the states, under both bills the federal government would pick up the entire tab for newly eligible enrollees for the first two or three years. After that the states would have to pick up part of the cost.

The amount of federal support would differ for two categories of people. For those new enrollees who could have been covered under the state’s existing rules — but never enrolled — the federal government would pay its usual share, which varies depending on a state’s per capita income. In fiscal year 2008, the federal government paid three-quarters of the program’s costs in Mississippi but only half the cost in New York and California.

But for all “newly eligible” enrollees — those who were not covered by a state’s previous rules — the states would get a greatly enhanced match. That is appropriate since the goal is to enroll a lot more people. The House would have the federal government pay 91 percent of the costs of these newly eligible in every state. The Senate would pay 82 to 95 percent of the cost, depending on a state’s per capita income. We believe that per capita income is a poor measure of how much help a state needs, especially in states like New York and California, where a veneer of very-high-income people can skew the average income upward. The House approach seems fairer.

A BIGGER DISPARITY. While both bills would provide enhanced matches for “newly eligible” Medicaid recipients, they have very different definitions of “new.” The House would count people who are already covered by Medicaid under so-called waiver programs, which are considered demonstration projects. The Senate bill would not.

That may sound arcane, but it could make a huge difference. New York, which has large numbers of people in waiver programs, estimates that the Senate bill would cost it an additional $1 billion a year, while the House bill could actually save the state close to $4 billion a year. While good news for New York, that seems unfair.

California, a state in comparable if not worse budgetary distress, would get no such relief for its previous expansions of Medicaid because they were mostly achieved through amendments to its state Medicaid plan, not the waiver process. State officials calculate that the reform bills would require it to put up $3 billion to $4 billion a year to cover additional enrollees.

Instead of paying more for people already on the rolls, Congress should try to provide an enhanced share to all states for all new Medicaid enrollees, whether or not they were previously eligible.

WHAT ABOUT THE LAGGARDS? Texas, a state that currently has far less generous Medicaid coverage, illustrates the problems that can confront even a laggard state. While it will get substantial federal help to pay for its “newly eligible” citizens, it estimates that it would still have to spend $20 billion to $24 billion over a decade to expand its Medicaid rolls.


•

There is no perfect answer to these problems other than providing a lot more federal money for Medicaid expansion. So far the Senate has provided extra money to win the votes of key senators, most notoriously by granting Nebraska full federal funding in perpetuity for all newly eligible people it enrolls. Ideally, that should be done for all states, as Senator Ben Nelson, under fire for his special deal, has recently suggested.

That is not apt to happen. But surely Congress could find at least a little more money to ease the problems of California and other states that have already expanded their Medicaid rolls and now face crushing deficits.


•

This editorial is a part of a continuing series by The New York Times that is providing a comprehensive examination of the policy changes and politics behind the debate over health care reform.

    Health Reform, the States and Medicaid, NYT, 10.1.2010, http://www.nytimes.com/2010/01/10/opinion/10sun1.html

Popular Drugs May Help Only Severe Depression

January 6, 2010
The New York Times
By BENEDICT CAREY

Some widely prescribed drugs for depression provide relief in extreme cases but are no more effective than placebo pills for most patients, according to a new analysis released Tuesday.

The findings could help settle a longstanding debate about antidepressants. While the study does not imply that the drugs are worthless for anyone with moderate to serious depression — many such people do seem to benefit — it does provide one likely explanation for the sharp disagreement among experts about the drugs’ overall effectiveness.

Taken together, previous studies have painted a confusing picture. On one hand, industry-supported trials have generally found that the drugs sharply reduce symptoms. On the other, many studies that were not initially published, or were buried, showed no significant benefits compared with placebos.

The new report, appearing in The Journal of the American Medical Association, reviews data from previous trials on two types of drugs and finds that their effectiveness varies according to the severity of the depression being treated.

Previous analyses had found a similar pattern. But the new study is the first to analyze responses from hundreds of people being treated for more moderate symptoms, as are most people who seek care.

“I think the study could dampen enthusiasm for antidepressant medications a bit, and that may be a good thing,” said Dr. Erick H. Turner, a psychiatrist at Oregon Health and Science University. “People’s expectations for the drugs won’t be so high, and doctors won’t be surprised if they’re not curing every patient they see with medications.”

But Dr. Turner added, “The findings shouldn’t dampen expectations so much that people refuse to even try medication.”

A team of researchers, including psychologists who favor talk therapy and doctors who consult widely with drug makers, performed the new analysis, using government grants. The group evaluated six large drug trials, including 728 men and women, about half of them with severe depression and half with more moderate symptoms.

Three of the trials were of Paxil, from GlaxoSmithKline, a so-called S.S.R.I., and the other three were of imipramine, an older generic drug from the class known as tricyclics. The team, led by Jay C. Fournier and Robert J. DeRubeis of the University of Pennsylvania, found that compared with placebos, the drugs caused a much steeper reduction in symptoms of severe depression (cases scoring 25 or higher on a standard scale of severity, putting them in the top quarter of the sample). Patients with scores of less than 25 got little or no added benefit from the medications.

“We were able to give an overall estimate of effectiveness for the first time in this more moderate severity range, from 14 to 20 on the scale, in which there’s no question that doctors would likely consider prescribing medication,” Dr. DeRubeis said.

His co-authors included Steven D. Hollon and Dr. Richard C. Shelton of Vanderbilt University, Sona Dimidjian of the University of Colorado, Dr. Jan Fawcett of the University of New Mexico and Dr. Jay D. Amsterdam of Penn.

The effects of other popular S.S.R.I.’s like Lexapro and Prozac are not likely to be much different than those of Paxil, experts said.

Dr. DeRubeis and others said antidepressants’ inability to outperform placebos against moderate symptoms stemmed partly from the sustained attention that patients in drug trials received from top doctors — which itself can help relieve symptoms, drug or no drug. For some people, too, the drugs’ side effects may cancel any benefit.

“The message for patients with mild to moderate depression,” Dr. DeRubeis said, “is, ‘Look, medications are always an option, but there’s little evidence that they add to other efforts to shake the depression — whether it’s exercise, seeing the doctor, reading about the disorder or going for psychotherapy.’ ”

    Popular Drugs May Help Only Severe Depression, NYT, 6.1.2010, http://www.nytimes.com/2010/01/06/health/views/06depress.html

Adult Learning | Neuroscience

How to Train the Aging Brain

January 3, 2010
The New York Times
By BARBARA STRAUCH

I LOVE reading history, and the shelves in my living room are lined with fat, fact-filled books. There’s “The Hemingses of Monticello,” about the family of Thomas Jefferson’s slave mistress; there’s “House of Cards,” about the fall of Bear Stearns; there’s “Titan,” about John D. Rockefeller Sr.

The problem is, as much as I’ve enjoyed these books, I don’t really remember reading any of them. Certainly I know the main points. But didn’t I, after underlining all those interesting parts, retain anything else? It’s maddening and, sorry to say, not all that unusual for a brain at middle age: I don’t just forget whole books, but movies I just saw, breakfasts I just ate, and the names, oh, the names are awful. Who are you?

Brains in middle age, which, with increased life spans, now stretches from the 40s to late 60s, also get more easily distracted. Start boiling water for pasta, go answer the doorbell and — whoosh — all thoughts of boiling water disappear. Indeed, aging brains, even in the middle years, fall into what’s called the default mode, during which the mind wanders off and begin daydreaming.

Given all this, the question arises, can an old brain learn, and then remember what it learns? Put another way, is this a brain that should be in school?

As it happens, yes. While it’s tempting to focus on the flaws in older brains, that inducement overlooks how capable they’ve become. Over the past several years, scientists have looked deeper into how brains age and confirmed that they continue to develop through and beyond middle age.

Many longheld views, including the one that 40 percent of brain cells are lost, have been overturned. What is stuffed into your head may not have vanished but has simply been squirreled away in the folds of your neurons.

One explanation for how this occurs comes from Deborah M. Burke, a professor of psychology at Pomona College in California. Dr. Burke has done research on “tots,” those tip-of-the-tongue times when you know something but can’t quite call it to mind. Dr. Burke’s research shows that such incidents increase in part because neural connections, which receive, process and transmit information, can weaken with disuse or age.

But she also finds that if you are primed with sounds that are close to those you’re trying to remember — say someone talks about cherry pits as you try to recall Brad Pitt’s name — suddenly the lost name will pop into mind. The similarity in sounds can jump-start a limp brain connection. (It also sometimes works to silently run through the alphabet until landing on the first letter of the wayward word.)

This association often happens automatically, and goes unnoticed. Not long ago I started reading “The Prize,” a history of the oil business. When I got to the part about Rockefeller’s early days as an oil refinery owner, I realized, hey, I already know this from having read “Titan.” The material was still in my head; it just needed a little prodding to emerge.

Recently, researchers have found even more positive news. The brain, as it traverses middle age, gets better at recognizing the central idea, the big picture. If kept in good shape, the brain can continue to build pathways that help its owner recognize patterns and, as a consequence, see significance and even solutions much faster than a young person can.

The trick is finding ways to keep brain connections in good condition and to grow more of them.

“The brain is plastic and continues to change, not in getting bigger but allowing for greater complexity and deeper understanding,” says Kathleen Taylor, a professor at St. Mary’s College of California, who has studied ways to teach adults effectively. “As adults we may not always learn quite as fast, but we are set up for this next developmental step.”

Educators say that, for adults, one way to nudge neurons in the right direction is to challenge the very assumptions they have worked so hard to accumulate while young. With a brain already full of well-connected pathways, adult learners should “jiggle their synapses a bit” by confronting thoughts that are contrary to their own, says Dr. Taylor, who is 66.

Teaching new facts should not be the focus of adult education, she says. Instead, continued brain development and a richer form of learning may require that you “bump up against people and ideas” that are different. In a history class, that might mean reading multiple viewpoints, and then prying open brain networks by reflecting on how what was learned has changed your view of the world.

“There’s a place for information,” Dr. Taylor says. “We need to know stuff. But we need to move beyond that and challenge our perception of the world. If you always hang around with those you agree with and read things that agree with what you already know, you’re not going to wrestle with your established brain connections.”

Such stretching is exactly what scientists say best keeps a brain in tune: get out of the comfort zone to push and nourish your brain. Do anything from learning a foreign language to taking a different route to work.

“As adults we have these well-trodden paths in our synapses,” Dr. Taylor says. “We have to crack the cognitive egg and scramble it up. And if you learn something this way, when you think of it again you’ll have an overlay of complexity you didn’t have before — and help your brain keep developing as well.”

Jack Mezirow, a professor emeritus at Columbia Teachers College, has proposed that adults learn best if presented with what he calls a “disorienting dilemma,” or something that “helps you critically reflect on the assumptions you’ve acquired.”

Dr. Mezirow developed this concept 30 years ago after he studied women who had gone back to school. The women took this bold step only after having many conversations that helped them “challenge their own ingrained perceptions of that time when women could not do what men could do.”

Such new discovery, Dr. Mezirow says, is the “essential thing in adult learning.”

“As adults we have all those brain pathways built up, and we need to look at our insights critically,” he says. “This is the best way for adults to learn. And if we do it, we can remain sharp.”

And so I wonder, was my cognitive egg scrambled by reading that book on Thomas Jefferson? Did I, by exploring the flaws in a man I admire, create a suitably disorienting dilemma? Have I, as a result, shaken up and fed a brain cell or two?

And perhaps it doesn’t matter that I can’t, at times, recall the given name of the slave with whom Jefferson had all those children. After all, I can Google a simple name.

Sally.

Barbara Strauch is The Times’s health editor; her book “The Secret Life of the Grown-Up Brain” will be published in April.

    How to Train the Aging Brain, NYT, 3.1.2010, http://www.nytimes.com/2010/01/03/education/edlife/03adult-t.html

Guidance Counselor | Health

Going Viral

January 3, 2010
The New York Times
By JULIE BOSMAN

THE tiny, rectangular rooms with twin beds separated by only a few feet. The buffet-style dining halls. The communal bathrooms, whose patrons sometimes pad around carelessly in bare feet. There are few living arrangements, doctors say with a shudder, that are more fraught with contamination possibilities than the college dorm. “I would call them a public health challenge, to say the least,” says Dr. Margaret Spear, the director of university health services at Penn State, where roughly two-thirds of the students live in dorms.

Dorms have been the target of anti-flu efforts since last spring, when worries about swine flu were at a fever pitch. Colleges have papered walls with posters about hand washing and vaccination, installed freestanding Purell dispensers in entryways and set up rooms where sick students can stay in isolation.

Though some health experts have speculated that swine flu peaked in the fall, college officials are still worried about a wave of the virus in early 2010. Another nagging concern is seasonal flu, which typically occurs in January and February, as well as that year-round freshman plague, mononucleosis; then there’s meningitis, which peaks in late winter and early spring.

“Our busiest quarter is always right after the winter break, when students return,” says Dr. Drew Malloy, the medical director of the student health center at the University of California, Santa Cruz.

That’s because students bring germs back to campus after the holidays. Administrators warn: Take extra precautions as you return to school, especially this term with that potential third wave.

 

THE DORM IS A PETRI DISH

Doctors say that the combination of unsanitary conditions and close quarters is to blame for the quick spread of illness in dorms. The tight living makes it almost impossible for flu patients to stay the recommended six feet away from other people.It’s an extreme example, says Dr. Mark S. Dworkin, a professor of epidemiology and biostatistics at the University of Illinois, Chicago, but a similar dynamic plays out at prisons, barracks and refugee camps.

“Crowd people together and deny them access to good sanitation and personal hygiene, and the result is an outbreak of dysentery, typhoid fever or infestation with the human body louse,” he says. “Put army troops in barracks and stress them out and the result has been meningitis and influenza outbreaks. So the dormitory is just an example of the same concept.”

Think of shared bathrooms, dining halls and lounge areas. “When you get a whole group of students together in one building, the sanitation might not be the best,” says Bill Purdy, the executive director of student health at Duke University, where most of the 6,500 undergraduates live in dorms. “Mom’s not around, and their room is not as clean as it was at home.”

 

WASH HANDS, SANITIZE, REPEAT

Last fall, many students were unfazed by the threat of swine flu: according to a Washington Post/ABC News poll, nearly 7 of 10 people in the 18 to 29 age group said they did not intend to get vaccinated. But there were also shortages in the fall. Now the vaccine is expected to be more available, and many colleges will be distributing it for the first time at the beginning of this semester.

Lifestyle choices matter, too. College students are already vulnerable to illness, thanks to stress and physical exertion from staying up late, along with unhealthy habits like smoking and drinking in excess. Rensselaer Polytechnic Institute in Troy, N.Y., tried to ward off the spread of illness — and the sharing of plastic ware — by asking students to stop playing the drinking game beer pong.

“Stress plays a role,” says Dr. Rachel Bergeson, the director of student health services at Stony Brook University. “Drinking, of course, lowers the immune response. And not getting enough sleep lowers the immune response.”

It should be easier to practice basic hygiene these days, too, with newly installed hand-sanitizer dispensers in lobbies, hallways and bathrooms on many campuses. (Frequent and long washing of hands is effective prevention, doctors say, as is keeping hands away from the face.) Eckerd College in St. Petersburg, Fla., has set up hand-washing stations at large events. Other campuses have increased the cleaning of door handles, handrails, computer keyboards and elevator buttons, which can harbor viruses. At Tulane, health administrators have even considered the furniture, recommending arranging beds so roommates sleep facing opposite directions. “Then they will cough in opposite directions too,” says Dr. Maureen Lichtveld, head of Tulane’s flu emergency task force.

 

IF YOU GET SICK, ISOLATE

Some hard-charging, Type-A students might find it difficult to slow down and rest.At Wellesley, administrators try to check on students who have the flu with a phone call to discuss their health, says Dr. Vanessa Britto, the director of the health service. “We kind of chuckle after we’ve had the 10-minute discussion over the phone with someone, going over the whole thing about self-isolation, and you’re sort of wrapping up the conversation and they say, ‘So can I go to class tomorrow?’ ” Dr. Britto says. “And then we start over.”

To ease the pressure, Wellesley has relaxed policies on attendance for sick students, instructing professors not to require doctors’ notes for absences or to penalize students for missing class. Duke has done the same. Many colleges urge students to go home to their families, if possible. For those who stay, contacting the student health center usually results in an array of services, including a “flu kit” with information and over-the-counter medication, and perhaps alternative housing, with free meals delivered to the room.

Guidelines from the Centers for Disease Control and Prevention (www.cdc.gov/h1n1flu/institutions/guidance/) advise the sick to isolate themselves until 24 hours after their fevers subside, in the absence of fever-reducing medications.

Colleges say they will continue to move sick students out of their residence halls. Mount Holyoke College has about 60 “isolation spaces” scattered around campus. The college has seen about 115 cases of flu, but almost half of the sick students have gone home to their families to recover.

At Emory University, sick students can stay at a separate residence hall. Through mid-December, the school had seen about 700 cases of flulike illness; at its high, more than 50 students were in the special dorm. Stricken students retained a sense of humor. They named it Camp Swine.

 

P.S.: OTHER SCARY DORM DISEASES

The basic rules of flu prevention — good hygiene, hand washing, sanitizing — apply to those two other contagions accelerated by dorm life, mono and meningitis.

By some estimates, one of every 200 college students each year will acquire the herpes virus that causes mononucleosis.

“Of course, it’s often called the kissing disease, which tells you how it spreads,” says Dr. Lichtveld of Tulane. “But since it’s spread primarily through saliva, there is also risk with sharing glasses and sharing drinks.” The virus produces fever, swollen glands, loss of appetite and fatigue. “It makes you very tired, because your immune system is really in overdrive responding to it,” she says. Malaise and fatigue can go on for weeks or months, which will interrupt coursework.

Freshmen in particular are at increased risk for meningitis, spread through coughing, sneezing or direct contact with an infected person. In recent years, the risk has subsided as vaccination for young adults has become more routine. More than 20 states have laws meant to control meningitis on campus, and many colleges require proof of immunization before a student moves into a dorm. Still, according to the American College Health Association, 100 to 125 cases of meningococcal disease, a form of bacterial meningitis, occur on campus yearly. Five to 15 students — who could have been vaccinated — will die.

 

Julie Bosman is a Metro reporter for The Times.

    Going Viral, NYT, 3.1.2010, http://www.nytimes.com/2010/01/03/education/edlife/03guidance-t.html

Letters

How Hospitals Care for the Dying

January 2, 2010
The New York Times

To the Editor:

Re “Weighing the Medical Costs of End-of-Life Care” (“Months to Live” series, front page, Dec. 23):

As you report, the Ronald Reagan U.C.L.A. Medical Center has comparatively high costs for patient care. Among its explanations is a familiar refrain: our community’s patients are sicker.

While that may be true when the center is judged against the Mayo Clinic in Rochester, Minn., it does not explain the differences when compared with others serving indigent populations.

For example, the Dartmouth Atlas found that the average number of intensive-care-unit bed days in the last six months of life at U.C.L.A. was 11.4, while the figure was 4.3 at Johns Hopkins Hospital in Baltimore and 2.8 at Massachusetts General Hospital in Boston.

You say that when researchers looked “at all patients hospitalized for heart failure” at the center, “the variation in use of resources was 27 to 44 percent lower than when they looked at only the patients who died.” While it is proper to also look at the costs for patients who survived, this variation still does not explain the discrepancy.

It is not just hospital days that are excessive. According to a California HealthCare Foundation study of Medicare patients, when compared with patients at University of California San Francisco Medical Center, those at U.C.L.A. had 71 percent more doctor visits. and 37 percent more frequent referrals to 10 or more different doctors.

As we enter an era where more Americans have health coverage, we must make quality care affordable. Offering excuses and failing to learn from best practices are not acceptable options.

Joel Shalowitz
Evanston, Ill., Dec. 24, 2009

The writer, an internist, is director of Health Industry Management at the Kellogg School of Management, Northwestern University.

•

To the Editor:

Dr. David T. Feinberg, chief executive of the U.C.L.A. Medical Center, promises that if you go to his hospital, “we’re not going to let you die.” Why would a well-intentioned doctor say this to potential patients, violating the most fundamental ethical standards of informed consent?

Guaranteeing hospitals and doctors almost limitless Medicare dollars for intensive-care interventions, however burdensome and unlikely to succeed, may be a quintessentially American affirmation of the sanctity of human life — even if the same resources could be improving the education of our children. But today’s Medicare rewards dishonesty about death.

Since the vast majority of Americans would prefer to die peacefully at home, this deprives patients and families of the possibility of informed choice about their last sacred moments together. This is un-American and worse than expensive — it is morally unconscionable.

Lachlan Forrow
Boston, Dec. 24, 2009

The writer, an internist, is director of the Ethics and Palliative Care Programs at Beth Israel Deaconess Medical Center and chairman of the Massachusetts Expert Panel on End of Life Care.

•

To the Editor:

I read your article with gratitude, because it portrays an issue that goes a layer deeper than the questions of who is covered and how much that costs.

As a neonatal intensive-care nurse, I see the push and pull between heroism and futility daily. There is often no way to know which treatments will make a difference and which will prolong suffering, and this undeniably contributes to our staggering medical spending.

Though we are far from an answer to this problem, asking the right questions is a first step.

Rebecca Armstrong
Brooklyn, Dec. 23, 2009

•

To the Editor:

In a medical world that most often seeks to prolong life, it can be challenging to discuss end-of-life care. In our years of educating doctors, we have learned the value of acknowledging the complex concerns all parties bring to the question of when enough is enough.

It is critical to recognize when more may not be better, but it is equally important that decisions about extending or limiting care at the end of life be made in the context of compassionate and trusting relationships.

David Browning
Newton, Mass., Dec. 24, 2009

The writer is a medical educator at the Education Development Center and the Institute for Professionalism and Ethical Practice at Children’s Hospital Boston.

•

To the Editor:

Your article focuses on quantity of life versus cost, but what about the suffering of the patient and family?

During her first year, my daughter Erica was treated at the U.C.L.A. Medical Center. From birth she suffered from severe neurological defects, causing her great physical pain. My husband and I, daily witnesses to her suffering, decided to seek pediatric hospice care.

U.C.L.A. refused to consider a hospice referral, so we decided to transfer Erica to Children’s Hospital Los Angeles, which serves a less affluent population, and where the doctors supported a transfer to hospice care.

The results were dramatic. Her care focused on pain relief over survival, and Erica had the happiest six months of her life. She died at home, in our arms — perhaps a few months earlier than if we had kept her at U.C.L.A., at lower cost and, most important to us, with much less pain and suffering.

Fiona A. Harrison
Pasadena, Calif., Dec. 24, 2009

•

To the Editor:

Dr. Neil S. Wenger, director of the U.C.L.A. Health System Ethics Center, says: “For someone to die who is in the clutches of medical care, decisions have to be made.” But those decisions need not be made in the hospital.

During my practicing years as a geriatrician, I helped ill (sometimes terminally ill) patients and families make such decisions in my office.

Making end-of-life decisions while sick in the hospital is akin to making decisions on what to eat while hungry in the grocery store.

Pankaj Gupta
New York, Dec. 24, 2009

The writer, a geriatrician, is medical director of a managed care company.

•

To the Editor:

Most dying patients want to know their prognosis and what options are available. They want to devise, with their doctors’ help, goals of care after learning about the risks and benefits.

When end-of-life discussions occur, costs decrease because, armed with information, far more patients decide to forgo aggressive, costly treatments that often cause unnecessary suffering.

Research has shown that twice as many patients who have had discussions with their doctors have “do not resuscitate” orders, are much less likely to have mechanical ventilators, and are far more likely to enroll in hospice programs for more than a week.

More doctors and patients need to have these important end-of-life discussions.

David C. Leven
Executive Director
Compassion and Choices of New York
Pelham, N.Y., Dec. 24, 2009

    How Hospitals Care for the Dying, NYT, 2.1.2010, http://www.nytimes.com/2010/01/02/opinion/l02hospitals.html

U.S. Reaction to Swine Flu: Apt and Lucky

January 2, 2010
The New York Times
By DONALD G. McNEIL Jr.

Although it is too early to write the obituary for swine flu, medical experts, already assessing how the first pandemic in 40 years has been handled, have found that while luck played a part, a series of rapid but conservative decisions by federal officials worked out better than many had dared hope.

The outbreak highlighted many national weaknesses: old, slow vaccine technology; too much reliance on foreign vaccine factories; some major hospitals pushed to their limits by a relatively mild epidemic.

But even given those drawbacks, “we did a lot of things right,” concluded Dr. Andrew T. Pavia, chairman of the pandemic flu task force of the Infectious Diseases Society of America.

Federal officials deserve “at least a B-plus,” said Dr. William Schaffner, chairman of preventive medicine at Vanderbilt University’s medical school.

Even Dr. Peter Palese, a leading virologist at Mount Sinai Medical School, who can be a harsh critic of public policies he disagrees with, called the government’s overall response “excellent.”

About 10,000 people had died by mid-November, the Centers for Disease Control and Prevention estimated; the pandemic seems unlikely to reach even the lower end of a forecast of 30,000 to 90,000 deaths made in August by the President’s Council of Advisers on Science and Technology.

The virus and the vaccine cooperated. While the former proved highly transmissible in children, it was only rarely lethal, remained susceptible to drugs and has not thus far mutated into an unpredictable monster. Vaccine supply was a problem, but one small dose was enough. (By contrast, an experimental avian flu vaccine protected people only when it was six times as strong.)

For that reason, the relatively cautious decisions by the nation’s medical leadership contained the pandemic with minimal disruption to the economy.

For example, in the early days, they ignored advice to close the Mexican border and pre-emptively shut school systems. They released part of the national Tamiflu stockpile, but did not give it to millions of healthy people prophylactically, as Britain did. They ordered vaccine made with a 50-year-old egg technology rather than experimental methods. They bought adjuvants — chemical “boosters” — that could have stretched the first 25 million vaccine doses into 100 million, but did not use them for fear of triggering a backlash among Americans made nervous by the messages of the antivaccine movement.

To alert the public without alarming it, a stream of officials — from doctors in the navy blue and scrambled-eggs gold of the Public Health Service to a somber President Obama in the White House — offered updates, at least twice a week for months.

It is now clear that this is the least lethal modern pandemic. The flu appears to kill about one of every 2,000 people who get it, American researchers say. (British researchers found half that death rate.) By contrast, the Spanish flu of 1918 killed about 50 of every 2,000, and the 1957 and 1968 pandemics killed about 4 of every 2,000.

The flu has reached more than 200 countries and is still peaking in places like Eastern Europe and Russia. Even though there was no vaccine yet, it killed fewer than expected during the Southern Hemisphere’s winter, June through August.

Officials in the United States conceded that some mistakes were made.

For example, they could have spotted the new virus earlier if there had been better cooperation with Mexico. In late April, the United States isolated it in samples from Texas and California just as Canadian officials were testing Mexican ones. The outbreak probably began in rural Mexico in January, but was spotted only when thousands fell ill in late March or early April in Mexico City.

The C.D.C. tests viruses in Southeast Asia, where new flus are usually born. “This time,” said Dr. Thomas R. Frieden, the C.D.C. director, “one happened to emerge in a place where we don’t have a surveillance system.”

Also, the government predicted in early summer that it would have 160 million vaccine doses by late October. It ended up with less than 30 million, leading to a public outcry and Congressional investigations.

“Imagine if they’d managed the expectations better,” said Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “If they’d said, ‘We won’t have any till December,’ and had some in October, they would have looked like heroes.”

Robin Robinson, chief of vaccine purchasing for the Department of Health and Human Services, was the most overly optimistic. In an interview, Dr. Robinson said he had actually tried to be conservative, assuming that manufacturers would get 1.4 doses per egg, when they typically got two or more.

Until the eggs could be tested in August, “we didn’t know that we had one of the poorest-producing viruses in the last 50 years,” he said. Good batches had 0.6 doses per egg, he said, bad ones had 0.2.

If he had it to do over again, he said, “I’d factor in the worst-case scenario — which was 2009.”

Another controversial decision — sending a few early vaccine doses to Wall Street firms like Goldman Sachs and Citibank — was more of a bad public relations move than a bad public health one, experts said. That choice was made by the New York City Health Department, “and we made the decision not to second-guess local health authorities,” Kathleen Sebelius, secretary of health and human services, said in an interview.

The government allotted vaccine to states based on population size. Some local health officials had thousands line up in parking lots for shots, some sent teams into schools and some relied on private doctors.

Distribution of the vaccine could have been focused more precisely, experts said, directing it to hospitals first, or to doctors treating children and pregnant women, or to cities with big outbreaks.

“I still think sending it out on a per capita basis was the fairest and most equitable way,” Ms. Sebelius said.

The early combination of fears about the vaccine and anger over shortages, said Dr. Paul Offit, chief of infectious diseases at Children Hospital of Philadelphia, reminded him of an old Borscht Belt joke: “The food at this resort is so terrible,” one patron complains. “Yes,” agrees her companion. “And such small portions!”

One real triumph, several experts said, was how little damage misinformation did. In 1976, many people refused shots after three elderly Pittsburgh residents died shortly after getting theirs; it took the C.D.C. five days to explain that it was just a coincidence.

This time, many rumors arose but were quickly debunked: That thousands had died in Mexico. That the virus had circulated in the Midwest for a decade, undetected. That it had escaped from a laboratory. That seasonal flu shots made catching swine flu more likely. That flu shots did not work or caused autism. That the administration would make them mandatory. That Tamiflu resistance was widespread in Northern California. That a flu shot had disabled a Washington Redskins cheerleader, or that she was cured by chelation therapy by a doctor associated with the antivaccine movement. That mutant killer flu strains were circulating in Argentina or Ukraine or North Carolina.

The debunking succeeded, Dr. Osterholm said, “despite the fact that there are many fewer reporters who understand medical issues than there used to be.”

This time, both the C.D.C. and the World Health Organization responded quickly to almost every rumor. At the epidemic’s height, they held several news conferences a week, taking questions by phone from all over the world.

They also invited dozens of reporters to daylong seminars on influenza at C.D.C. headquarters in Atlanta and to exercises around the country led by the former anchorman Forrest Sawyer, at which they debated, for example, whether a miscarriage by one woman after getting a flu shot was a big scoop or a nonstory.

Remaining to be seen is what effect the pandemic has had on Americans’ feelings about vaccines.

Dr. Frieden said he thought a victory over the antivaccine movement had been scored. Nearly 60 million people have been vaccinated, including many pregnant women and children, with no surge in side effects.

John P. Moore, an AIDS researcher at Weill Cornell Medical College, was less sure. Dr. Moore, who spent years fighting AIDS denialism, has called skepticism about flu vaccine “an unholy alliance of the left and right” because it joined the liberal natural-medicine proponents with anti-big-government conservatives.

“It’s hard to say if it hurt or helped,” Dr. Moore said, pointing out that polls still show a large minority of Americans rejecting the vaccine. “As with AIDS, people have to die before others understand the consequences of ignoring science-based medicine.”

    U.S. Reaction to Swine Flu: Apt and Lucky, NYT, 2.1.2010, http://www.nytimes.com/2010/01/02/health/02flu.html