History > 2011 > USA > Health (V)

Sex Education Gets Directly to Youths,

via Text

December 30, 2011
The New York Times
By JAN HOFFMAN

While heading to class last year, Stephanie Cisneros, a Denver-area high school junior, was arguing with a friend about ways that sexually transmitted diseases might be passed along.

Ms. Cisneros knew she could resolve the dispute in class — but not by raising her hand. While her biology teacher lectured about fruit flies, Ms. Cisneros hid her phone underneath her lab table and typed a message to ICYC (In Case You’re Curious), a text-chat program run by Planned Parenthood of the Rocky Mountains.

Soon, her phone buzzed. “There are some STDs you can get from kissing but they are spread more easily during sex,” the reply read. “You can get a STD from oral sex. You should use a condom whenever you have sex.”

Ms. Cisneros said she liked ICYC for its immediacy and confidentiality. “You can ask a random question about sex and you don’t feel it was stupid,” said Ms. Cisneros, now a senior. “Even if it was, they can’t judge you because they don’t know it’s you. And it’s too gross to ask my parents.”

Sex education is a thorny subject for most school systems; only 13 states specify that the medical components of the programs must be accurate. Shrinking budgets and competing academic subjects have helped push it down as a curriculum priority. In reaction, some health organizations and school districts are developing Web sites and texting services as cost-effective ways to reach adolescents in the one classroom where absenteeism is never a problem: the Internet.

In Chicago, teenagers can subscribe to Sex-Ed Loop, a program endorsed by the district that includes weekly automated texts about contraception, relationships and disease prevention. Through Hookup, California teenagers can text their ZIP codes to a number and receive locations for health clinics.

Many services, like Sexetc.org, a national site run by and for teenagers, offer both privacy and communities where adolescents can learn about sexuality and relationships, particularly on mobile devices, eluding parental scrutiny. Services offer links to blogs, interactive games, moderated forums, and Facebook and Twitter pages.

The messages, rendered in teenspeak, can be funny and blunt: for Real Talk, a technology-driven H.I.V. prevention program run by the AIDS Council of Northeastern New York, teenagers made a YouTube video, shouting a refrain from a rap song, “Sport Dat Raincoat,” during which a girl carrying an umbrella is pelted with condoms.

“When we ask young people what is the No. 1 way they learn about sex, they say, ‘We Google it,’ ” said Deb Levine, executive director of ISIS Inc., an Oakland, Calif.,-based nonprofit organization that administers texting services and checks content for medical accuracy. “But most of the time, the best information is not coming up in those searches.”

Quantifying services is difficult. But Ms. Levine, who hosts Sex::Tech, a conference about sexual health programs for youth, said that requests to make presentations about online or mobile services had soared. Typically, she receives between 40 and 50 applications. This year, she received about 120.

Unlike classroom lessons, which are supposed to follow local, state or federal guidelines, Internet programs have no independent standards. And proponents of abstinence-based sexual education argue that these digital services presume that sexual activity among teenagers is the norm, and do not spend enough time on alternatives.

“They are only focusing on the risk-reduction model,” said Valerie Huber, executive director of the National Abstinence Education Association, which hopes to kick off its online service for teenagers next year.

Those who run digital programs say they simply want teens to have accurate information, to help them make good decisions. Even though popular culture is saturated with sex, facts and advice can be hard to find.

Few disagree about the need for more education. Although the teenage birth rate dropped 9 percent in 2010 from 2009, the United States still has one of the highest rates among developed countries, according to the Centers for Disease Control and Prevention. Rates of syphilis, gonorrhea and chlamydia among American teenagers continue to rise.

Most online services receive grants from philanthropies, like the Ford Foundation, and health and education agencies on the state and federal level. Classroom content is largely controlled by school districts, but it is a low priority in many areas. Chicago, for example, does not have a mandated sex education curriculum, although teachers are encouraged to include material in science or physical education classes. School officials see programs like Sex-Ed Loop, which began in September, as vital.

Mary Beth Szydlowski, the H.I.V. education prevention specialist for Chicago schools, said that Sex-Ed Loop not only reinforces what students learn in class but can reach all teenagers, including dropouts. It is managed by the Illinois Caucus for Adolescent Health, which enlists Chicago teenagers to create the text messages as well as blog posts and testimonial videos for its site.

Juan Chavez, 19, a sophomore at DePaul University, remembers sex education during ninth-grade health class as awkward.

“The teacher had been a nutrition major,” Mr. Chavez said. “He was really uncomfortable. He just said, ‘I don’t believe you guys should be having sex, so I’ll just say this because I have to.’ ”

Now, through the Illinois Caucus for Adolescent Health, Mr. Chavez texts and blogs, with a focus on gay teenagers, about such subjects as what to do if a condom breaks, which clinics are gay-friendly and where to find low-cost lubricants — “things people need to know on the fly,” he said.

Parents who fear that sex education will encourage a child to experiment are misguided, said Elizabeth Schroeder, executive director of Answer, a national sex education organization that oversees Sexetc. Studies show the opposite is true, she said.

But making sure that Web-surfing teenagers find these programs, rather than pornographic sites, has been challenging.

Leslie Kantor, vice president for education at Planned Parenthood Federation of America, said it was expanding its chat program, which teenagers can use with handheld devices or online. The organization is trying, she said, to embed material with search terms used by teenagers.

“How do I write content that says ‘sex’ 80,000 times so our page will pop up in a kid’s search on Google near the top?” she said.

When it comes to marketing, programs are increasingly relying on the customer: teenagers.

Real Talk held a classroom contest to see which student could send the most texts containing this prevention message: “ROFL!!!” (Translation: rolling on the floor laughing). “STDs and HIV can spread as fast as this message. Still laughing? Pass on the message not HIV/STDs. 518-HIV-TEST.” Within an hour, the message had been sent to nearly 450 phones.

    Sex Education Gets Directly to Youths, via Text, NYT, 30.12.2011,
    http://www.nytimes.com/2011/12/31/us/sex-education-for-teenagers-online-and-in-texts.html

Online Merchants Home in on Imbibing Consumers

December 27, 2011
The New York Times
By STEPHANIE CLIFFORD

After enjoying a few drinks, some people go dancing. Others order food. And for some, it’s time to shop online.

“I have my account linked to my phone, so it’s really easy,” said Tiffany Whitten, of Dayton, Ohio, whose most recent tipsy purchase made on her smartphone — a phone cover — arrived from Amazon much to her surprise. “I was drunk and I bought it, and I forgot about it, and it showed up in the mail, and I was really excited.”

Shopping under the influence has long benefited high-end specialty retailers — witness the wine-and-cheese parties that are a staple of galleries and boutiques. Now the popularity of Internet sales has opened alcohol-induced purchases to the masses, including people like Ms. Whitten, who works in shipping and receiving and spent just $5 on the cat-shaped phone cover.

Chris Tansey, an accountant in Australia, went shopping online after drinking late one night (to be precise, it was well into the morning). By the end of the session, he had bought a $10,000 motorcycle tour of New Zealand.

“The hang-ups of spending your hard-earned cash are so far removed from your life when you’ve had a bottle of wine,” Mr. Tansey said in an e-mail. The New Zealand trip was terrific, he said. But a pair of $3 sunglasses on eBay “turned out to be horrible fakes, with $17 of postage that I obviously didn’t see with beer goggles.”

Online retailers, of course, can never be sure whether customers are inebriated when they tap the “checkout” icon. One comparison-shopping site, Kelkoo, said almost half the people it surveyed in Britain, where it is based, had shopped online after drinking.

But while reliable data is hard to come by, retailers say they have their suspicions based on anecdotal evidence and traffic patterns on their Web sites — and some are adjusting their promotions accordingly.

“Post-bar, inhibitions can be impacted, and that can cause shopping, and hopefully healthy impulse buying,” said Andy Page, the president of Gilt Groupe, an online retailer that is adding more sales starting at 9 p.m. to respond to high traffic then — perhaps some of it by shoppers under the influence.

On eBay, the busiest time of day is from 6:30 to 10:30 in each time zone. Asked if drinking might be a factor, Steve Yankovich, vice president for mobile for eBay, said, “Absolutely.” He added: “I mean, if you think about what most people do when they get home from work in the evening, it’s decompression time. The consumer’s in a good mood.”

Nighttime shopping is growing over all. ChannelAdvisor, which runs e-commerce for hundreds of sites, says its order volumes peak about 8 p.m., and that shoppers are placing orders later and later: in 2011, the number of orders placed from 9 to midnight increased compared with previous years.

A recent array of nighttime offers sent to a shopper’s e-mail inbox included: from 6 to 9 p.m., a limited-quantity sale on fashions at Neiman Marcus; at 7:38 p.m., a promotion for three-day stays at Loews hotels; at 8:44 p.m., a promotion by Gilt for macaroons and faux-fur blankets; and at 2:23 a.m., an offer by Saks for a $2,000 gift card with purchase.

At QVC, the television shopping channel, traffic and viewers rise around noon, then quiet down until after 7 p.m. Then items like cosmetics and accessories sell briskly. “Call them girl treats — they seem to attract a really strong following once you get past dinnertime,” said Doug Rose, senior vice president for multichannel programming and marketing for the company. “You can probably come to your own conclusion as to what’s motivating her.”

Still, the nighttime spike requires delicacy among retailers: for reasons of propriety, they do not want to be seen as encouraging drunken shopping, and many people who inadvertently buy products in that state would most likely return them at high rates. On the other hand, a happy customer can lead to higher sales.

“In a shopping context, alcohol would lift people’s moods and make them feel more relaxed,” said Nancy Puccinelli, an associate fellow at the Oxford’s Saïd Business School who studies consumer behavior. “If we see a product and we feel good, we will evaluate the product more positively.”

Alcohol-fueled purchases, however, could lead to problems, she said. Even with online retailers storing credit card information and offering one-click checkout, alcohol reduces working memory, which means “at the time of purchase, you wouldn’t have the cognitive ability to think through. If you think about a sweater: is this the right size, is it the right color,” she said.

Kristin A. Kassaw, a professor of psychiatry and behavioral science at Baylor, said online shopping while drunk could have serious financial consequences.

“When you’re loading things you can’t feel or touch into this fake cart, you don’t have a sense of, ‘I’m buying all this stuff, I’m buying too much.’ It takes you away from the actual spending-money experience,” she said.

In actual stores, despite the longer hours around the holidays, intoxicated shoppers seem to be rare — but when they do appear, they can be quite disruptive.

On Thanksgiving night around 11 p.m., a shopper at a Walmart in Florence, Ala., was stumbling in the aisles and grabbing onto items; police officers shot him with a stun gun and charged him with public intoxication. At a Best Buy in Lufkin, Tex., a drunken man disappeared into a bathroom around 4 a.m. on Black Friday and tried to flush a cable down the toilet, apparently to avoid being caught shoplifting.

And in Scarborough, Me., early on the Friday after Thanksgiving, a man was arrested as he drove out of a Cabela’s parking lot, where he had ostensibly been drinking all night as he waited for the store to open.

Amanda Schuster, a wine-and-spirits writer and consultant in Brooklyn, says she never shops in actual stores after drinking, but she finds it hard to resist the Web. “It feels productive in a way — like I didn’t just come home drunk and pass out, I went home and did something,” she said.

That something tends to be buying used CDs at Amazon. When an unexpected package shows up, “I try to backtrack a little bit, and I look in to my purchasing history, and I’m like, oh, yeah,” she said.

Regrets? She has a few.

“When did I get ‘Heart’s Greatest Hits’?” she said.

    Online Merchants Home in on Imbibing Consumers, NYT, 27.12.2011,
    http://www.nytimes.com/2011/12/28/business/
    online-retailers-home-in-on-a-new-demographic-the-drunken-consumer.html

Looking for a Place to Die

December 21, 2011
The New York Times
By THERESA BROWN

Pittsburgh

THE patient was a fairly young woman and she’d had cancer for as long as her youngest child had been alive. That child was now walking and talking and her mother’s cancer had spread throughout her body to the point where there were no more curative options. Aggressive growth of the disease in her brain had stripped her of her personality and her memories.

She had another child, too, a few years older, and a husband whose drawn eyes and tense frame bore the strain of trying to keep it all together. Extended family lived far away and couldn’t be brought closer. The husband and kids lived more than an hour’s drive from the hospital.

No one could say for sure how long she would live, but continued hospital care was clearly pointless. Nor could she go home: she needed more attention than her family could provide. Everyone — her physician, the husband, the palliative care team, we nurses — agreed she needed inpatient hospice care, and that it should be provided close to home.

The problem was, she had no place to go. There was a hospice facility near her house, but it would accept her only if she would die within six days.

I’ve run up against these kinds of time limits before in my work as an oncology nurse. There’s a certain logic to it: hospice insurance benefits are ideally used to cover the costs of end-of-life care in patients’ homes, for up to six months, while periods of inpatient care are for the “short term.” And although patients do die in inpatient hospices, part of the mission of hospice is allowing patients to remain at home instead of in a hospital; hence the turn away from inpatient care, which is costly and often intrusive.

But that leaves people like this patient — more than a few days away from death, unable to be adequately cared for at home and unable to afford to pay out-of-pocket for a facility — struggling to find a place to die.

Dying at home was neither safe nor compassionate for this patient. She needed constant supervision: she would struggle to sit up and moan in frustration, or lurch dangerously over the side of the bed. Her speech was more sounds than words, and she had no control over her bowels or bladder.

Her husband looked as if he might fold in on himself at any minute, and he’d already borne the burden of care for a long time. Though I didn’t know for sure, it’s likely that his insurance couldn’t guarantee continuous nursing care in the home as a covered expense. And the patient’s children had already lost so much of their mother; she no longer even recognized them. Did they need to witness her final deterioration up close at home?

Home was not the only option. She could have stayed in the hospital and pursued aggressive care. Indeed, if her physician or a family member had said “do everything,” meaning keep her alive as long as possible through intravenous medications and hydration and, ultimately, sending her to the intensive care unit on a ventilator, it would have cost thousands of dollars but, paradoxically, most insurance companies would have considered it a legitimate care option.

Doing everything possible to extend her life wouldn’t have benefited her or her family, though. Roughly a third of family members of I.C.U. patients show symptoms of post-traumatic stress, according to research by the French intensive-care expert Elie Azoulay and his collaborators. If a loved one dies in intensive care after discussions about advance directives and patient wishes — that is, after the family has been made fully aware of the finality of the situation — the psychological fallout is even greater, approaching 80 percent. We do not always aid the living by inflicting high-tech ministrations on the almost-dead.

In other words, inpatient hospice care made sense medically, financially and psychologically for this patient, but the system simply wouldn’t allow it.

The only option, then, was for me to convince the hospice staff that she would die within six days. I spoke with the inpatient coordinator, the administrator and the hospice admissions nurse, who came to the hospital floor to assess the patient.

My explanations were precise: “She’s on an antibiotic now, but that’ll stop in hospice so she could go septic. Her kidney function is already diminished; kidney failure is only a matter of time. She has periods of difficulty breathing, and hospice won’t have the respiratory support she’ll need, but you can give her morphine to stop the air hunger.”

All of us will at some point come to this pass; we will all need a place to die. It’s not easy to think about, but it is true. We can turn away from that hard fact, try to stall death, even bend it to our will for a little while in the I.C.U. Or we can face that most difficult of life’s trials and ask ourselves how to make it easier.

With this patient I ended up being persuasive enough, and she got her inpatient admission. Was she dead in six days? Probably; I don’t know for sure. What I do know is that her sad husband and two young children, who would never really know their mother, had a chance to grieve and say goodbye in the most humane way possible for them.

Theresa Brown, an oncology nurse, is a contributor to The New York Times’s

Well blog and the author of “Critical Care: A New Nurse Faces Death,

Life and Everything in Between.”

    Looking for a Place to Die, NYT, 21.12.2011,
    http://www.nytimes.com/2011/12/22/opinion/looking-for-a-place-to-die.html

For Illegal Immigrant, Line Is Drawn at Transplant

December 20, 2011
The New York Times
By NINA BERNSTEIN

Without treatment to replace his failing kidneys, doctors knew, the man in Bellevue hospital would die. He was a waiter in his early 30s, a husband and father of two, so well liked at the Manhattan restaurant where he had worked for a decade that everyone from the customers to the dishwasher was donating money to help his family.

He was also an illegal immigrant. So when his younger brother volunteered to donate a kidney to restore him to normal life, they encountered a health care paradox: the government would pay for a lifetime of dialysis, costing $75,000 a year, but not for the $100,000 transplant that would make it unnecessary.

For nearly two years, the brothers and their supporters have been hunting for a way to make the transplant happen. Their journey has taken them through a maze of conflicting laws, private insurance conundrums and ethical quandaries, back to the national impasse between health care and immigration policies.

The waiter’s boss sought private insurance, she and the brothers said, speaking on the condition that their names be withheld for fear of provoking immigration authorities. The Catch-22: for the first year, the waiter, called Angel, would get no coverage for his “pre-existing condition,” nor would he receive the dialysis that keeps him alive and able to work four days a week.

Doctors sought a transplant center that would take him. Hospitals in the city receive millions of taxpayer dollars to help offset care for illegal immigrants and other uninsured patients. But at one hospital, administrators apparently overruled surgeons willing to waive their fees. At another, Angel was told to come back when he had legal status or $200,000.

A last resort is a return to Mexico, where the operation costs about $40,000. But to pay off the necessary loans, Angel and his brother, a deli worker, would have to sneak back in through the desert. If they failed, they would be cut off from their children in Brooklyn, who are United States citizens.

“As a physician, it puts you in a real ethical dilemma,” said Dr. Eric Manheimer, Bellevue’s medical director, noting that a transplant would sharply reduce Angel’s risk of death from complications. “The ultimate irony is it’s cheaper to put in a transplant than to dialyze someone for the rest of their life.”

Bellevue performs no transplants but, as a trauma center, often supplies organs harvested, with family consent, from illegal immigrants fatally injured at work.

“Here’s the paradox: he could donate, but he can’t receive,” Dr. Manheimer said, calling the imbalance troubling. Organ registries do not record illegal status, but a study estimated that over a 20-year period noncitizens donated 2.5 percent of organs and received fewer than 1 percent.

To those focusing on immigration enforcement, however, the inequity runs the other way. “They should not get any benefit from breaking the law, especially something as expensive as organ transplants or dialysis,” said Representative Dana T. Rohrabacher, Republican of California, who contends that care for illegal immigrants is bankrupting American health care and has sought to require that emergency rooms report stabilized patients for deportation unless they prove citizenship or legal residence.

“If they’re dead, I don’t have an objection to their organs being used,” Mr. Rohrabacher added. “If they’re alive, they shouldn’t be here no matter what.”

To Ruth Faden, the director of the Johns Hopkins Berman Institute of Bioethics, the brothers’ case, like the transplant statistics, illustrates how quickly firm principles on both sides unravel in practice.

“We tie ourselves up in knots,” she said, “because we’ve accepted as a country and in international human rights law that if someone shows up in extremis in your emergency room, the nurses and doctors and technicians are morally obligated, and legally obligated, to provide that life-saving care.”

How to begin refusing care, she added, becomes a dilemma for “real people in real time.”

The sudden onset of the waiter’s illness in January 2010 left no time to spare. At Bellevue, he underwent surgery to implant a temporary venous catheter in his neck, to cleanse his blood of lethal toxins. The cause of his renal disease is most likely genetic: when he was 8 — about the age of his own sons now — his father died of kidney failure.

Through quirks of legislative history, nearly everyone with end-stage renal disease in the United States, regardless of income, is covered under federal Medicare for dialysis and transplantation, except illegal immigrants. But regardless of a patient’s immigration status, hospitals can be reimbursed for emergency care by Medicaid, the federal and state insurance program for the needy.

Unlike most states, New York, California and North Carolina define outpatient dialysis as an emergency measure. Studies show such regular dialysis is cheaper, with fewer life-threatening complications, than waiting until toxin levels require hospital treatment.

“What do I have to do to become normal?” Angel remembers asking. The medical answer was clear: a transplant, and anti-rejection drugs costing about $10,000 a year. But news that his brother and sister were compatible donors came with a blunt warning, the waiter recalled: “As long as you don’t have your papers, you won’t get a transplant.”

Like many Mexican New Yorkers, Angel has relatives who migrated years ago without visas and are now citizens. An uncle still works for the restaurateur who helped him legalize. But immigration rules have changed, eliminating such paths.

“My boss, she tried to help me,” said the waiter, who supported his mother and half-siblings from the age of 16, and worked his way up from busboy, paying taxes, mastering English and learning enough French to counsel diners on the wine list. “We find no way.”

His boss kept hunting. “He deserves every break he can get,” she said.

They consulted lawyers at LegalHealth, which counsels low-income patients. Randye Retkin, the director, said the waiter was one of a dozen patients in need of transplants who were referred to the nonprofit program by hospitals last year because of immigration barriers.

For many there is no remedy, Ms. Retkin said. She cited a Mexican mother of two who died without the small-bowel transplant she needed, just as lawyers won a yearlong legal battle for Medicaid to pay for it.

The waiter turned to the Mexican consulate, which appealed to Dr. Manheimer. The doctor said he persuaded surgeons at NYU Langone Medical Center to waive their $20,000 fees, but administrators would not absorb the rest. The hospital declined to comment.

Two other doctors, Hector J. Castro, a critical care specialist, and Kann H. Patel, a hematologist, sent Angel to Mount Sinai Medical Center. But there a financial transplant counselor told him he would have to pay double the typical cost in advance, to cover any complications.

“Personally, I’m troubled by it,” said Dr. Sander Florman, who directs the Recanati/Miller Transplantation Institute at Mount Sinai. “We’re looking at human beings.”

But Dr. Florman confirmed that the waiter’s experience reflected policies at the hospital. “Our general approach is we’re not the immigration police,” he said. “On the other hand, there has to be a mechanism to pay for it.”

Mount Sinai officials say they provided $67.3 million in uncompensated care last year, and received $25 million from the state to offset such costs. “Mount Sinai struggles each day to balance its limited resources with its strong commitment to provide compassionate medical care,” it said in a statement, noting that kidney transplantation, unlike dialysis, is not an emergency procedure under Medicaid.

For nearly everyone else, however, there is a Medicare option. Scholars trace the unusual program, now costing $40 billion a year, to a 1962 Life magazine article titled “They Decide Who Lives, Who Dies,” about laymen at a Seattle hospital who judged which patients would get scarce treatment on the first “artificial kidney machine.” The outcry that followed is often credited for the birth of bioethics and for the 1972 law guaranteeing coverage.

That law did not mention citizenship, said Dr. Scott Sanoff, who teaches medicine at the University of Virginia, but later restrictions, and murky state-by-state variations in Medicaid, left decisions on illegal immigrants’ access to care to each medical center, often without any payment mechanism. The life-and-death nature of the decisions has been obscured, he added: In the case of Angel, “his life expectancy could be more than doubled with the transplant compared to dialysis.”

The waiter now shuttles between a basement dialysis center, the restaurant and his family’s cramped but well-kept walk-up. There, as their children clustered nearby, his brother, 26, said they would not give up.

“He’s more than my brother, he’s like my father,” he said. “If I can give him life, I have to.”

    For Illegal Immigrant, Line Is Drawn at Transplant, NYT, 20.12.2011,
    http://www.nytimes.com/2011/12/21/nyregion/illegal-immigrants-transplant-cheaper-over-life-isnt-covered.html

Seeing Terror Risk, U.S. Asks Journals to Cut Flu Study Facts

December 20, 2011
The New York Times
By DENISE GRADY and WILLIAM J. BROAD

For the first time ever, a government advisory board is asking scientific journals not to publish details of certain biomedical experiments, for fear that the information could be used by terrorists to create deadly viruses and touch off epidemics.

In the experiments, conducted in the United States and the Netherlands, scientists created a highly transmissible form of a deadly flu virus that does not normally spread from person to person. It was an ominous step, because easy transmission can lead the virus to spread all over the world. The work was done in ferrets, which are considered a good model for predicting what flu viruses will do in people.

The virus, A(H5N1), causes bird flu, which rarely infects people but has an extraordinarily high death rate when it does. Since the virus was first detected in 1997, about 600 people have contracted it, and more than half have died. Nearly all have caught it from birds, and most cases have been in Asia. Scientists have watched the virus, worrying that if it developed the ability to spread easily from person to person, it could create one of the deadliest pandemics ever.

A government advisory panel, the National Science Advisory Board for Biosecurity, overseen by the National Institutes of Health, has asked two journals, Science and Nature, to keep certain details out of reports that they intend to publish on the research. The panel said conclusions should be published, but not “experimental details and mutation data that would enable replication of the experiments.”

The panel cannot force the journals to censor their articles, but the editor of Science, Bruce Alberts, said the journal was taking the recommendations seriously and would probably withhold some information — but only if the government creates a system to provide the missing information to legitimate scientists worldwide who need it.

The journals, the panel, researchers and government officials have been grappling with the findings for several months. The Dutch researchers presented their work at a virology conference in Malta in September.

Scientists and journal editors are generally adamant about protecting the free flow of ideas and information, and ready to fight anything that hints at censorship.

“I wouldn’t call this censorship,” Dr. Alberts said. “This is trying to avoid inappropriate censorship. It’s the scientific community trying to step out front and be responsible.”

He said there was legitimate cause for the concern about the researchers’ techniques falling into the wrong hands.

“This finding shows it’s much easier to evolve this virus to an extremely dangerous state where it can be transmitted in aerosols than anybody had recognized,” he said. Transmission by aerosols means the virus can be spread through the air via coughing or sneezing.

Ever since the tightening of security after the terrorist attacks on Sept. 11, 2001, scientists have worried that a scientific development would pit the need for safety against the need to share information. Now, it seems, that day has come.

“It’s a precedent-setting moment, and we need to be careful about the precedent we set,” Dr. Alberts said.

Both studies of the virus — one at the Erasmus Medical Center in Rotterdam, in the Netherlands, and the other at the University of Wisconsin-Madison — were paid for by the National Institutes of Health. The idea behind the research was to try to find out what genetic changes might make the virus easier to transmit. That way, scientists would know how to identify changes in the naturally occurring virus that might be warning signals that it was developing pandemic potential. It was also hoped that the research might lead to better treatments.

Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, said the research addressed important public health questions, but added, “I’m sure there will be some people who say these experiments never should have been done.”

Dr. Fauci said staff members at the institutes followed the results of the research and flagged it as something that the biosecurity panel should evaluate.

The lead researcher at the Erasmus center, Ron Fouchier, did not respond to requests for an interview. The center issued a statement saying that researchers there had reservations about the panel’s recommendation, but would observe it.

The Wisconsin researcher, Yoshihiro Kawaoka, was out of the country and “not responding to queries,” according to a spokesman for the university. But the school said its researchers would “respect” the panel’s recommendations.

David R. Franz, a biologist who formerly headed the Army defensive biological lab at Fort Detrick, Md., is on the board and said its decision to intervene, made in the fall, was quite reasonable.

“My concern is that we don’t give amateurs — or terrorists — information that might let them do something that could really cause a lot a harm,” he said in an interview.

“It’s a wake-up call,” Dr. Franz added. “We need to make sure that our best and most responsible scientists have the information they need to prepare us for whatever we might face.”

Amy Patterson, director of the office of biotechnology activities at the National Institutes of Health, in Bethesda, Md., said the recommendations were a first.

“The board in the past has reviewed manuscripts but never before concluded that communications should be restricted in any way,” she said in a telephone interview. “These two bodies of work stress the importance of public health preparedness to monitor this virus.”

Ronald M. Atlas, a microbiologist at the University of Louisville and past president of the American Society for Microbiology, who has advised the federal government on issues of germ terrorism, said the hard part of the recommendations would be creating a way to move forward in the research with a restricted set of responsible scientists.

He said that if researchers had a better understanding of how the virus works, they could develop better ways to treat and prevent illness. “That’s why the research is done,” he said.

The government, Dr. Atlas added, “is going to struggle with how to get the information out to the right people and still have a barrier” to wide sharing and inadvertently aiding a terrorist. “That’s going to be hard.”

Given that some of the information has already been presented openly at scientific meetings, and that articles about it have been sent out to other researchers for review, experts acknowledged that it may not be possible to keep a lid on the potentially dangerous details.

“But I think there will be a culture of responsibility here,” Dr. Fauci said. “At least I hope there will.”

The establishment of the board grew out of widespread fears stemming from the 2001 terrorist attacks on the United States and the ensuing strikes with deadly anthrax germs that killed or sickened 22 Americans.

The Bush administration called for wide controls on biological information that could potentially help terrorists. And the scientific community firmly resisted, arguing that the best defenses came with the open flow of information.

In 2002, Dr. Atlas, then the president-elect of the American Society for Microbiology, objected publicly to “anything that smacked of censorship.”

The federal board was established in 2004 as a compromise and is strictly advisory. It has 25 voting members appointed by the secretary of health and human services, and has 18 ex officio members from other federal agencies.

Federal officials said Tuesday that the board has discussed information controls on only three or four occasions. The first centered on the genetic sequencing of the H1N1 virus that caused the 1918 flu pandemic, in which up to 100 million people died, making it one of the deadliest natural disasters in human history.

“We chose to recommend publication without any modifications,” Dr. Franz, the former head of the Army lab, recalled. “The more our good scientists know about problems, the better prepared they are to fix them.”

This fall, federal officials said, the board wrestled with the content of H5N1 papers to Science and Nature, and in late November contacted the journals about its recommendation to restrict information on the methods that the scientists used to modify the deadly virus.

“The ability of this virus to cross species lines in this manner has not previously been appreciated,” said Dr. Patterson of the National Institutes of Health. “Everyone involved in this matter wants to do the proper thing.”

    Seeing Terror Risk, U.S. Asks Journals to Cut Flu Study Facts, NYT, 20.12.2011,
    http://www.nytimes.com/2011/12/21/health/fearing-terrorism-us-asks-journals-to-censor-articles-on-virus.html

U.S. Requests Bird Flu Paper Redactions

December 20, 2011
The New York Times
By THE ASSOCIATED PRESS

WASHINGTON (AP) — The U.S. government asked scientists Tuesday not to reveal all the details of how to make a version of the deadly bird flu that they created in labs in the U.S. and Europe.

The lab-bred virus, being kept under high security, appears to spread more easily among mammals. That's fueled worry that publishing a blueprint could aid terrorists in creating a biological weapon, the National Institutes of Health said.

But the NIH said it was important for the overall findings to be published in scientific journals, because they suggest it may be easier than previously thought for bird flu to mutate on its own and become a greater threat.

"It's very important research," NIH science policy director Dr. Amy Patterson told The Associated Press. "As this virus evolves in nature, we want to be able to rapidly detect . . . mutations that may indicate that the virus is getting closer to a form that could cross species lines more readily."

Bird flu, known formally as H5N1 avian influenza, occasionally infects people who have close contact with infected poultry, particularly in parts of Asia. It is highly deadly when it does infect people because it's different from typical human flu bugs. The concern is that one day it may begin spreading easily between people.

The NIH paid for two research projects, at the Erasmus University Medical Center in the Netherlands and at the University of Wisconsin, to better understand what might fuel the virus' ability to spread. The NIH said researchers genetically engineered bird flu that could spread easily among ferrets — animals whose response to influenza is similar to humans.

So the government's biosecurity advisers — the National Science Advisory Board for Biosecurity — reviewed the research as it was submitted to two scientific journals, Science and Nature. Following the board's recommendation, the Department of Health and Human Services asked the researchers and journal editors not publish the full genetic information that could enable someone to copy the work.

Patterson said publishing the general findings, however, could help scientists better monitor bird flu's natural evolution and spur further research into new treatments. The government will set up a way for scientists who are pursuing such work to be given the unpublished genetic details, she said.

Patterson said researchers were making changes in their scientific reports.

But in a statement, Science editor-in-chief Dr. Bruce Alberts said his journal "has concerns about withholding potentially important public health information from responsible influenza researchers" and was evaluating how best to proceed.

Nature's editor-in-chief, Dr. Philip Campbell, called the recommendations unprecedented.

"It is essential for public health that the full details of any scientific analysis of flu viruses be available to researchers," he said in a statement. The journal is discussing how "appropriate access to the scientific methods and data could be enabled."

    U.S. Requests Bird Flu Paper Redactions, NYT, 20.10.2011,
    http://www.nytimes.com/aponline/2011/12/20/health/AP-US-MED-Bird-Flu.html

Exonerated of Murder, Texan Seeks Inquiry on Prosecutor

December 19, 2011
The New York Times
By JOHN SCHWARTZ and BRANDI GRISSOM

AUSTIN, Tex. — A Texas man wrongfully convicted in 1987 of murdering his wife is scheduled to be officially exonerated on Monday.

That is no longer so unusual in Texas, where 45 inmates have been exonerated in the last decade based on DNA evidence. What is unprecedented is the move planned by lawyers for the man, Michael Morton: they are expected to file a request for a special hearing to determine whether the prosecutor broke state laws or ethics rules by withholding evidence that could have led to Mr. Morton’s acquittal 25 years ago.

“I haven’t seen anything like this, ever,” said Bennet L. Gershman, an expert on prosecutorial misconduct at Pace University in New York. “It’s an extraordinary legal event.”

The prosecutor, Ken Anderson, a noted expert on Texas criminal law, is now a state district judge. Through a lawyer, he vigorously denied any wrongdoing in Mr. Morton’s case.

Mr. Morton, who was a manager at an Austin supermarket and had no criminal history, was charged with the beating death of his wife, Christine, in 1986. He had contended that the killer must have entered their home after he left for work early in the morning. But Mr. Anderson convinced the jury that Mr. Morton, in a rage over his wife’s romantic rebuff the previous night — on Mr. Morton’s 32nd birthday — savagely beat her to death.

Mr. Morton was sentenced to life in prison. Beginning in 2005, he pleaded with the court to test DNA on a blue bandanna found near his home shortly after the murder, along with other evidence.

For six years, the Williamson County district attorney, John Bradley, fought the request for DNA testing, based on advice from Judge Anderson, his predecessor and friend. In 2010, however, a Texas court ordered the DNA testing, and the results showed that Mrs. Morton’s blood on the bandanna was mixed with the DNA of another man: Mark A. Norwood, a felon with a long criminal history who lived about 12 miles from the Mortons at the time of the murder. By then, Mr. Morton had spent nearly 25 years in prison.

Mr. Norwood has been arrested and charged in Mrs. Morton’s death and is a suspect in a similar murder from 1988.

The filing by Mr. Morton’s lawyer, John Raley, and attorneys from the Innocence Project, a group based in New York that represents prisoners seeking exoneration through DNA testing, is asking for what is known as a “court of inquiry.” The lawyers did not share the document with reporters but answered questions about it.

They will ask the court to determine that there is probable cause to believe that Mr. Anderson withheld reports that the judge in the 1987 trial had ordered him to turn over. The judge had demanded the documents to determine whether they might help Mr. Morton’s case. Finding nothing exculpatory in the small number of documents he was provided by the prosecutor, the judge ordered the record sealed.

In August, however, a different judge ordered the record unsealed, and Mr. Morton’s lawyers discovered that Mr. Anderson had provided only a fraction of the available evidence. Missing from the file was the transcript of a telephone conversation between a sheriff’s deputy and Mr. Morton’s mother-in-law in which she reported that her 3-year-old grandson had seen a “monster” — who was not his father — attack and kill his mother.

Also missing were police reports from Mr. Morton’s neighbors, who said they had seen a man in a green van repeatedly park near their home and walk into the woods behind their house. And there were even reports, also never turned over, that Mrs. Morton’s credit card had been used and a check with her forged signature cashed after her death.

In October, Judge Sid Harle of Bexar County District Court freed Mr. Morton based on the DNA evidence and authorized an unusual process allowing his defense lawyers to investigate the prosecutor’s conduct in the original trial. The lawyers questioned the lead sheriff’s investigator, an assistant district attorney who worked with Mr. Anderson and the former prosecutor himself.

In their accounts, the witnesses said Mr. Anderson had firmly controlled every detail of the prosecution. In his own two-day deposition, however, Judge Anderson said he recalled few details of the case and asserted that he had done nothing wrong. He said that he had interpreted the judge’s order to disclose the reports as a narrow demand for the initial documents from the investigation and that he felt “sick” over Mr. Morton’s wrongful imprisonment.

If the court of inquiry ends with a finding that Mr. Anderson committed serious acts of misconduct by concealing material evidence, it could lead to disciplinary action by the state bar association and possibly even a criminal prosecution.

Experts, however, are skeptical that Judge Anderson could face serious punishment or disbarment, even if the court were to decide that he had committed malfeasance. Susan R. Klein, a professor at the University of Texas Law School who specializes in criminal issues and prosecutorial ethics, said that such actions would be “incredibly unusual,” particularly after the Supreme Court’s decision this year dismissing a $14 million civil jury award against a Louisiana prosecutor, Harry Connick Sr., for his failure to turn over evidence that ultimately led to an exoneration.

While withholding material evidence intentionally can get a lawyer disbarred, Ms. Klein said, “It’s extremely unlikely.” In the court filing, Mr. Morton’s lawyers argue that the amount of time that has passed since the trial may not be a bar to criminal prosecution if Mr. Anderson is found to have violated a court order; they argue that there may be no statute of limitations for contempt of court under state law.

Mark Dietz, a lawyer for Judge Anderson, said that he had asked for, but had not received, the report that Mr. Morton’s lawyers plan to file on Monday. He said he worried that the report would inaccurately reflect what happened in 1987. Mr. Dietz questioned whether Judge Harle had jurisdiction to order a court of inquiry, and in a letter to Barry C. Scheck, the co-founder of the Innocence Project, wrote that while his client welcomed “positive discussion about criminal justice reforms,” “false and defamatory statements regarding Mr. Anderson’s conduct as a prosecutor in the Morton case have no proper place in that discussion.”

In an interview, Mr. Scheck said he hoped the court of inquiry proceeding would result in changes in law and policy that could promote greater fairness in criminal cases. Previous high-profile exonerations, he said, have led to new laws that improved access to DNA testing after conviction and provided generous compensation to those who were wrongfully convicted.

“This is one of those catalytic, iconic cases that leads to reform,” he said.

 

John Schwartz reported from New York, and Brandi Grissom from Austin. Ms. Grissom writes for The Texas Tribune, which produces a twice-weekly local section in the Texas editions of The New York Times.

    Exonerated of Murder, Texan Seeks Inquiry on Prosecutor, NYT, 19.12.2011,
    http://www.nytimes.com/2011/12/19/us/texas-man-seeks-inquiry-after-exoneration-in-murder.html

Life Goes On, and On ...

December 17, 2011
The New York Times
By JAMES ATLAS

A FRIEND calls from her car: “I’m on my way to Cape Cod to scatter my mother’s ashes in the bay, her favorite place.” Another, encountered on the street, mournfully reports that he’s just “planted” his mother. A third e-mails news of her mother’s death with a haunting phrase: “the sledgehammer of fatality.” It feels strange. Why are so many of our mothers dying all at once?

As an actuarial phenomenon, the reason isn’t hard to grasp. My friends are in their 60s now, some creeping up on 70; their mothers are in their 80s or 90s. Ray Kurzweil, the author of “The Singularity Is Near: When Humans Transcend Biology,” believes that we’re close to unlocking the key to immortality. Perhaps within this century, he prophesies, “software-based humans” will be able to survive indefinitely on the Web, “projecting bodies whenever they need or want them, including virtual bodies in diverse realms of virtual reality.” Neat, huh? But for now, it’s pretty much dust to dust, the way it’s always been — mothers included. (Most of our fathers are long gone, alas. Women live longer than men.)

It’s the ones who aren’t dead who should baffle us. My own mother, for instance, still goes to the Boston Symphony and attends a weekly current events class at Brookhaven, her “lifecare living” center (can’t we find a less technocratic word?) near Boston. She writes poems in iambic pentameter for every occasion. At 94, she’s hardly anomalous: there are plenty of nonagenarians at Brookhaven. Ninety is the new old age. As Dr. Muriel Gillick, a specialist in geriatrics and palliative care at Harvard Medical School, says, “If you’ve made it to 85 then you have a reasonable chance of making it to 90.” That number has nearly tripled in the last 30 years. And if you get that far... it’s been estimated that there will be eight million centenarians by 2050.

It won’t end there. Scientists are closing in on the mechanism of what are called “senescent cells,” which cause the tissue deterioration responsible for aging. Studies of mice suggest that targeting these cells can slow down the process. “Every component of cells gets damaged with age,” Leonard Guarente, a biology professor at M.I.T., explained to me. “It’s like an old car. You have to repair it.” We’re not talking about immortality, Professor Guarente cautions. Biotechnology has its limits. “We’re just extending the trend.” Extending the trend? I can hear it now: 110 is the new 100.

Is this a good thing or a bad thing? On the debit side, there’s the ... debit. The old-age safety net is already frayed. According to some estimates, Social Security benefits will run out by 2037; Medicare insurance is guaranteed only through 2024. These projected shortfalls are in part the unintended consequence of the American health fetish. The ad executives in “Mad Men” firing up Lucky Strikes and dosing themselves with Canadian Club didn’t have to worry. They’d be dead long before it was time to collect.

Then there’s the question of whether reaching 5 score and 10 is worth it — the quality-of-life question. Who wants to end up — as Jaques intones in “As You Like It” — “sans teeth, sans eyes, sans taste, sans everything”? You may live to be as old as Methuselah, who lasted 969 years, but chances are you’ll feel it.

Worse — it’s no longer a rare event — you can outlive your children. Reading the obituary of Christopher Ma, a Washington Post executive who had been a college classmate of mine, I was especially sad to see that Chris was survived by his wife, a daughter, a son, a brother, two sisters and “his mother, Margaret Ma of Menlo Park, Calif.” Can anything more tragic befall a parent than to be predeceased by a child?

These are the perils old people suffer. What about us, the boomers, now ourselves elderly children? One challenge my entitled generation faces is that many of our long-lived parents are running through their retirement money, which leaves the burden of supporting them to us. (To their credit, it’s a burden that often bothers our parents, too.) And the cost of end-stage health care is huge — a giant portion of all medical expenses in this country are incurred in the last months of life. Meanwhile, our prospects of retirement recede on the horizon.

Also, elder care is stressful and time consuming. The broken hips, the trips to the E.R., the bill paying and insurance paperwork demand patience. A paper titled “Personality Traits of Centenarians’ Offspring” suggests this cohort scores high marks “extraversion, openness, agreeableness and conscientiousness.” But even the well-adjusted find looking after old parents tough.

In the mid-’80s, when the idea of the “sandwich generation” was born — boomers saddled with the care of aging parents while raising their own children — it seemed like a problem we would eventually outgrow. Twenty-five years later, we’re still sandwiched, and some of those caught in the middle feel the squeeze.

So what’s the good part? Time spent with an elderly parent can offer an opportunity for the resolution of “unfinished business,” a chance to indulge in last-act candor. A college classmate writes in our 40th-reunion book of ministering to her chronically ill mother and being “moved by how the twists and turns of complicated health care have deepened our relationship.” I hear a lot about late-in-life bonding between parent and child.

My mother needs a minor operation. “I’ve outlasted my time,” she says as she’s wheeled into surgery. “Anyway, you’re too old to have a mother.” Thanks, Ma. What about Rupert Murdoch? His mother is 102. Also, if I’m too old to have a mother, why do I still feel like a child?

Two weeks later, Mom comes to Vermont to recuperate. My father, who died a decade ago at 87, is buried in the field behind our house (hope this is legal). His gravestone reads “Donald Herman Atlas 1913-2001,” and it has an epitaph from his favorite poet, T. S. Eliot, carved in italics: “I grow old ... I grow old .../ I shall wear the bottoms of my trousers rolled.” Mom likes to visit him there. Standing over Dad’s grave, she carries on a dialogue of one. “I thought I’d have joined you by now, Donny, but I’m a tough old bird.” As she heads back up to the house, she turns and waves. “À bientôt.” See you soon.

Not so fast, Mom. I still have issues.

 

James Atlas is the author of “My Life in the Middle Ages: A Survivor’s Tale.”

    Life Goes On, and On ..., NYT, 17.12.2011,
    http://www.nytimes.com/2011/12/18/opinion/sunday/old-age-life-goes-on-and-on.html

Health Care Law Will Let States Tailor Benefits

December 16, 2011
The New York Times
By ROBERT PEAR

WASHINGTON — In a major surprise on the politically charged new health care law, the Obama administration said Friday that it would not define a single uniform set of “essential health benefits” that must be provided by insurers for tens of millions of Americans. Instead, it will allow each state to specify the benefits within broad categories.

The move would allow significant variations in benefits from state to state, much like the current differences in state Medicaid programs and the Children’s Health Insurance Program.

By giving states the discretion to specify essential benefits, the Obama administration sought to deflect one of the most powerful arguments made by Republican critics of President Obama’s health care overhaul — that it was imposing a rigid, bureaucrat-controlled health system on Americans and threatening the quality of care. Opponents say that the federal government is forcing a one-size-fits-all standard for health insurance and usurping state authority to regulate the industry.

This criticism has inspired legal challenges to the new law — with the Supreme Court set to decide next year whether the government can require Americans to buy health insurance — and helps explain why public opinion of the law remains deeply divided.

The law is looming as a central issue in the 2012 presidential race, with Republican presidential candidates being evaluated on the strength of their opposition to it. The announcement by the administration follows its decision this year to jettison a program created in the law to provide long-term care insurance, a move that disappointed liberal backers of the program championed by the late Senator Edward M. Kennedy.

The action Friday prompted questions among supporters of the new health care law. Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, said, “The new bulletin perpetuates uncertainty about what benefits an insurer will be required to cover under the Affordable Care Act.” From the consumer’s point of view, Professor Jost added, “I wish the Department of Health and Human Services had signaled that there would be more uniformity and less flexibility.”

Chris Jacobs, a health policy analyst for Senate Republicans, said the new policy “gives states the flexibility to impose more benefit mandates, not fewer,” and would lead to higher insurance premiums, contrary to what Mr. Obama promised in the 2008 campaign.

The new law lists 10 categories of “essential health benefits” that must be provided by insurance offered in the individual and small-group markets, starting in January 2014. These include preventive care, emergency services, maternity care, hospital and doctors’ services, and prescription drugs.

Kathleen Sebelius, the secretary of health and human services, had been expected to provide details of what services and benefits must be provided in each category. Instead, in an insurance bulletin issued Friday, Ms. Sebelius said the federal government would respect the states’ role, giving them “the flexibility to design coverage options that meet their unique needs.”

Under this approach, each state would designate an existing health insurance plan as a benchmark. The benefits provided by that plan would be deemed essential, and all insurers would have to provide benefits of the same or greater value. Plans could modify coverage within a benefit category so long as they did not reduce the value of coverage.

Each state would choose one of the following health insurance plans as a benchmark:

¶ One of the three largest small-group plans in the state.

¶ One of the three largest health plans for state employees.

¶ One of the three largest national health insurance options for federal employees.

¶ The largest health maintenance organization operating in the state’s commercial insurance market.

While working on health care legislation in 2009 and 2010, Congress spent many hours debating how to balance the goals of comprehensive benefits and affordable coverage.

Sherry A. Glied, an assistant secretary of health and human services, said the administration’s approach “builds off the experience of today’s marketplace and will minimize disruption to it.”

Steven B. Larsen, deputy administrator of the federal Centers for Medicare and Medicaid Services, said, “The state is always in control of what the essential benefits package is in that state.”

In recent months, federal health officials have taken a number of steps that could help inoculate Mr. Obama against charges that he was foisting a rigid, inflexible model of health care on the nation.

Several states have received temporary waivers from tough new federal standards that require insurers to spend more of each premium dollar for the benefit of consumers. Federal officials have also provided temporary exemptions from some provisions of the law for some employers and labor unions offering bare-bones coverage.

The new law says that the scope of essential health benefits must be “equal to the scope of benefits provided under a typical employer plan.” But the law itself specifically requires some benefits not widely available in employer-sponsored health plans, like “habilitative services” for people with conditions like autism or cerebral palsy.

Under the new law, each state is supposed to have an insurance exchange or marketplace where consumers can compare options and buy insurance. Health plans must offer the essential benefits, regardless of whether the coverage is sold inside or outside the exchange.

The government will offer subsidies to help low-income people buy insurance through exchanges. The subsidies will help cover the cost of essential benefits. States can require insurers to provide additional benefits, but states will have to pay much of the extra cost.

The law also says that the definition of essential benefits must not “discriminate against individuals because of their age, disability or expected length of life.”

Sara Rosenbaum, a professor of health law and policy

at George Washington University,

said the new bulletin “does not offer any guidance on this crucial part of the law.”

    Health Care Law Will Let States Tailor Benefits, NYT, 16.12.2011,
    http://www.nytimes.com/2011/12/17/health/policy/health-care-law-to-allow-states-to-pick-benefits.html

Gingrich Push

on Health Care Appears at Odds With G.O.P.

December 16, 2011
The New York Times
By JIM RUTENBERG and MIKE McINTIRE

Shortly before the passage of President Obama’s stimulus bill in 2009, Newt Gingrich’s political committee put out a video of Mr. Gingrich denouncing it as a “big politician, big bureaucracy, pork-laden bill.”

“It should be stopped,” he said.

But at the same time, Mr. Gingrich was cheering a $19 billion part of the package that promoted the use of electronic health records, something that benefited clients of his consulting business. “I am delighted that President Obama has picked this as a key part of the stimulus package,” he told health care executives in a January 2009 conference call.

After the bill was passed a month later, Mr. Gingrich’s consultancy, the Center for Health Transformation, joined two of its clients, Allscripts and Microsoft, in an “Electronic Health Records Stimulus Tour” that traveled the country, encouraging doctors and hospitals to buy their products with the billions in new federal subsidies. “Get Engaged, Get Incentives,” one promotion read.

As Mr. Gingrich runs for president, he is working to appeal to Republican primary voters suspicious of big-government activism, especially in the realm of health care. But interviews and a review of records show how active Mr. Gingrich has been in promoting a series of recent programs that have given the government a bigger hand in the delivery of health care, and at the same time benefited his clients.

During the Bush administration, he was a leading Republican advocate for the costly expansion of Medicare, which many in his party now regret. And he and his center pushed some policies that are reflected in Mr. Obama’s health care record — a record Mr. Gingrich regularly criticizes on the campaign trail. All the while, his center functioned as a sort of high-priced club where companies joined him in working the corridors of power in Washington and in state capitals.

Mr. Gingrich did not respond to questions for this article. But a spokeswoman for the center said in an e-mail that Mr. Gingrich was a health care “visionary” who, for instance, supported electronic health records “BEFORE it ever came up for discussion by the president or anyone else.”

Mr. Gingrich’s chief Republican rival, Mitt Romney, has found himself on the defensive among conservatives for signing a universal health care law when he was governor of Massachusetts. But Mr. Gingrich has his own history with health care policy, part of which puts him at odds with many Republican voters.

Mr. Gingrich’s ideas and the interests of his clients are often intertwined. When President George W. Bush and some Congressional Republicans were seeking to block renewal of the State Children’s Health Insurance Program in 2007, Mr. Gingrich met with his former conservative House colleagues, arguing that inaction could unfairly harm children. At the time his center was being paid hundreds of thousands of dollars a year by major drug makers and insurers, groups that would have been harmed by a lapse in the program.

When he urged Republicans to support the Bush administration’s expansion of Medicare’s prescription drug benefit, he worked to ensure that it would cover new diabetes treatments sold by Novo Nordisk, a Danish drug company and a founding member of Mr. Gingrich’s center.

More broadly, he has indicated his agreement with the most controversial aspect of President Obama’s heath care plan, the requirement that every American buy health insurance. Although he now says he is opposed to the so-called individual mandate, in a May 2009 conference call — previously unreported — he told health care executives, “We believe there should be must-carry; that is, everybody should have health insurance, or if you’re an absolute libertarian, we would allow you to post a bond.”

Mr. Gingrich also worked with former Senator Tom Daschle, an early health policy adviser to Mr. Obama, to write a forward to the center’s book on the expansion of electronic health records. “It’s fair to say he was supportive of the goals of health care reform,” Mr. Daschle wrote in a brief e-mail exchange. “And I felt that we were in agreement on some of the principles.”

Mr. Gingrich has defended his support for the prescription drug benefit, and other health care spending, by saying that present costs will be more than offset by future savings. And a spokeswoman for his company, the Center for Health Transformation, Susan Meyers, reiterated Mr. Gingrich’s assertion that he does not lobby. But his dealings with Novo Nordisk show how his center’s policy advocacy could blend with the narrower objectives of its paying members.

Separate from its $200,000-a-year charter membership in the center, Novo Nordisk, the world’s largest producer of insulin, hired Mr. Gingrich to help “position itself as a thought leader” in an initiative to raise awareness of diabetes. A research document prepared in 2003 by the Gingrich Group, a consulting firm related to the health care center, noted that in improving treatment, the company wished to also emphasize insulin-delivery devices that “offer better financial return for Novo.”

Mr. Gingrich’s health center went on to help Novo Nordisk create a national diabetes campaign, and worked to shape government policies toward the disease. According to a presentation by a Gingrich aide to health care executives in 2004, the center was “working to insure” that Medicare covered insulin products manufactured by Novo Nordisk, and Mr. Gingrich planned to meet with members of Congress “to help them develop priorities” on fighting diabetes.

In its annual report to shareholders, Novo Nordisk listed its work with Mr. Gingrich under the category of public-policy activities, noting: “Such activities are often referred to as lobbying.”

But a Novo Nordisk spokesman, Ken Inchausti, said Mr. Gingrich actually did no lobbying for the firm.

“He was providing us with guidance and strategic advice on how best we could inform policy makers,” Mr. Inchausti said, adding that Mr. Gingrich had valuable insights because of his work on diabetes while in Congress.

The devices were ultimately covered. Dr. Mark McClellan, President Bush’s administrator of Medicare and Medicaid Services at the time, said that he did not remember Mr. Gingrich specifically bringing up diabetes issues, but that he had various interactions with Mr. Gingrich.

“A lot of people including Newt had some views and some clients who cared about the issues that we were dealing with,” he said. “I do remember having a lot of discussions about what should and shouldn’t be covered.”

Mr. Gingrich also worked with Dr. McClellan and other Bush administration health officials on electronic records.

“Newt and I had many conversations,” said Dr. David J. Brailer, the Bush administration’s national health technology coordinator. “Because of Newt’s involvement, you dealt with a significant amount of creativity — they had a lot of creative ideas of how it could work and how it should work.”

Over the years, Mr. Gingrich accumulated more and more clients with an interest in building a national electronic health records system: Allscripts, Siemens, Microsoft and GE Healthcare.

Certainly, his belief in the importance of electronic health records fit with his futurist bent. Huge advances in technology, the argument goes, can enable doctors from different hospitals, different fields and even in different states to work off a single electronic file that would include every medical decision and diagnosis in a given patient’s history. Mr. Gingrich was among leaders of both parties who argued that the technology would save lives and billions of dollars while also providing a huge database of results to judge the efficacy of treatments.

Mr. Gingrich found common cause with Hillary Rodham Clinton, then a senator from New York; Mr. Daschle, with whom he wrote the introduction to the center’s book, “Paper Kills 2.0”; and Senator Sheldon D. Whitehouse, Democrat of Rhode Island.

Shortly before Mr. Obama’s election in 2008, Mr. Whitehouse and Mr. Gingrich wrote an opinion article in The Washington Times calling for a national, electronic health information system. They also called for the creation of a “comparative effectiveness institute” that could use the network to “collect and understand the best practices of the country’s best providers of care.” Such an institute, they wrote, “could not only educate other providers on how to improve, but also inform policy makers on how to design policy that promotes these best practices.”

When President Obama proposed spending tens of billions on developing just such a system, Mr. Gingrich wrote in The New York Post in mid-January 2009, “The president-elect should be applauded for making this vital priority a key part of his economic stimulus plan.”

Mr. Gingrich’s chief health aide, David Merritt, was invited to testify before a Senate panel on privacy issues related to the creation of the system. During that testimony, Mr. Merritt told the senators, among them Mr. Whitehouse, that while protecting privacy was important, “I think that as we move forward with comparative effectiveness and evidence-based medicine, we need as much data as possible.”

When the bill passed, providing more than $19 billion in incentives and grants to help health care providers buy electronic systems, the center and its health technology clients were in a celebratory mood. In presentations to investors, the Allscripts chief executive, Glen Tullman, called it “the most expansive opportunity in our company’s history,” and “more money coming into a segment than we’ve ever seen.”

In order for Allscripts and other health care systems makers to benefit from incentives and grants, they would need to make sure potential customers knew they were eligible for the cash. And so, joining with industry partners — including another center client, Microsoft — it embarked on an “E.H.R. Stimulus Tour,” visiting cities and providing Webcasts.

In one of the Webcasts, Mr. Merritt joined with Mr. Tullman and the Allscripts marketing chief to walk through the stimulus bill incentives.

When The Wall Street Journal editorial board, in January 2009, criticized the bill for creating a Federal Coordinating Council for Comparative Effectiveness Research, the center was there to defend it. The Journal argued that eventually “the comparative effectiveness outfit will start to ration care to control costs.” In a statement for the center, Mr. Merritt had said that while those fears were understandable, “that argument is not currently justifiable in the specific language of the bill.”

The following August, however, the coordinating council came in for added scrutiny as conservative health care opponents rallied against its creation in angry town-hall-style meetings and online, playing into fears of “death panels.”

Around the same, Mr. Gingrich reversed his call for a “comparative effectiveness institute.”

“In our country, the road to dehumanizing, bureaucratic health care rationing,” Mr. Gingrich wrote in Human Events, a conservative publication, that August, “begins with something called comparative effectiveness research.”

    Gingrich Push on Health Care Appears at Odds With G.O.P., NYT, 16.12.2011,
    http://www.nytimes.com/2011/12/16/us/
    politics/gingrichs-health-care-policy-history-at-odds-with-gop.html

Free the F.D.A.

December 13, 2011
The New York Times
By DANIEL CARPENTER

Cambridge, Mass.

THE unilateral decision last week by Kathleen Sebelius, the secretary of health and human services, to block the Plan B One-Step contraceptive pill from being sold to adolescents without a prescription is shocking in more ways than one.

Not only was it unexpected, but for the first time in American history, a cabinet secretary — and by extension, a president — has overruled a drug-approval decision by the Food and Drug Administration.

The precedent risks placing the real power for drug approval not just with a cabinet secretary, but with the White House itself. The only solution, then, is to make the F.D.A. truly independent. Americans have already done this, through the Federal Reserve, to protect our money supply from political meddling; it’s time to do it for drugs.

True, Ms. Sebelius’s decision was entirely legal: the federal Food, Drug and Cosmetic Act of 1938 gives authority to “the secretary” in the department in which the F.D.A. resides. And F.D.A. rulemaking — the creation of new regulations that govern not a specific case but a range of activities, like rules for testing or the way drug companies synthesize their compounds — has long been overseen by high officials, not least by the president’s Office of Management and Budget and, before that, by the secretary of health and human services and her predecessors in previous departments with different names.

But the decision nevertheless sets a radical precedent. The key part of the Food, Drug and Cosmetic Act holds that no drug can be sold in interstate commerce without prior approval by the F.D.A. And until last Wednesday, the decision of the F.D.A. commissioner was final. That power still rests with the federal government, but as a result of last Wednesday’s decision, it now arguably rests in the White House.

That’s not just a symbolic change; it could have drastic effects on regulatory policy. The F.D.A. entrusts drug-review decisions to its scientists. In its first few decades, the F.D.A. collaborated with scientific societies to develop technical standards for evaluating drugs, standards that have now been emulated worldwide.

After the thalidomide tragedy of the early 1960s, in which a newly hired medical officer refused to approve the drug in spite of tremendous pressure (it was instead distributed through a clinical testing program), the F.D.A. and the Department of Health and Human Services began to codify these “subdelegation” patterns — that is, giving final say to the F.D.A. — into federal regulation. Federal courts have uniformly upheld these arrangements: they have the sanction of law as well as of scientific practice.

The possibilities opened by this decision are frightening. A radical pro-business secretary could now, in principle, bypass the clinical trial system and the F.D.A. approval process and decide to approve a drug. A different secretary, one distrustful of the pharmaceutical industry, could stop a drug despite strong scientific support behind it.

As a result, other countries might easily decide that American drug approval no longer carries scientific weight, hurting our companies’ exports and the international fight against infectious diseases.

The solution is to do something that many F.D.A. watchers have been proposing for at least a decade: Take the F.D.A. out of the Department of Health and Human Services and make it an independent agency, like the Fed.

Such an arrangement would give the commissioner a fixed term of six years, dischargeable only for cause. In the same way the president can’t overrule Fed decisions on interest rates, there would be no president or cabinet to overrule the F.D.A.’s decision to approve or deny a drug. (Of course, the Administrative Procedure Act would still apply, and these decisions would still be reviewable on procedural grounds, as they are now, in court.)

To be sure, an extreme micromanaging president might, in theory, be able to request the resignation of his F.D.A. commissioner to apply political pressure. But with an independent agency he would not be able to hide behind his cabinet secretaries, as President Obama did.

Critics of this idea will point out that the F.D.A. is equipped to review drugs from a health and safety point of view, not from a moral one. This is a reasonable point. But it doesn’t follow that the secretary or president should have a blanket veto over its decisions. Congress could easily establish a law providing for separate bioethical review.

At the very least, President Obama and Ms. Sebelius need to clarify what their precedent entails. If they don’t, we can expect to see lobbies from all corners of society — drug companies themselves, safety advocates, groups of doctors and patients — walk directly away from an F.D.A. decision they don’t like and take their cases to the White House.

We would never allow this sort of second-guessing when it comes to our financial health. We should have the same standards when it comes to our public health.

 

Daniel Carpenter is a professor of government at Harvard

and the author of “Reputation and Power:

Organizational Image and Pharmaceutical Regulation at the F.D.A.”

    Free the F.D.A., NYT, 13.12.2011,
    http://www.nytimes.com/2011/12/14/opinion/free-the-fda.html

Clive Robbins,

Developer of a Method of Music Therapy, Dies at 84

December 12, 2011
The New York Times
By MARGALIT FOX

Clive Robbins, a developer of an influential brand of music therapy designed to help people with various disabilities meet the physical, mental and social challenges that are facts of everyday life, died on Wednesday at his home in Jersey City. He was 84.

His death was announced by the Nordoff-Robbins Center for Music Therapy at New York University. Alan Turry, the center’s managing director, said that Mr. Robbins had been ill with cancer and heart disease for some time.

With his wife, Carol, Mr. Robbins established the center in 1989 and was its founding director. Part of the university’s graduate program in music therapy, the center is responsible for professional training, clinical care and research, rooted in the particular brand of music therapy conceived by Mr. Robbins and Paul Nordoff more than 50 years ago.

Mr. Robbins, a British-born special-education teacher, and Mr. Nordoff, an American pianist and composer, first joined forces in England in the late 1950s. Their aim was to design a therapy, centered on music, that would help hard-to-reach children acquire linguistic and social skills.

Known as Nordoff-Robbins music therapy, their method is now used by hundreds of therapists around the world to treat people of all ages. The conditions treated include autism, mental retardation, psychiatric illnesses, stroke, Alzheimer’s disease and physical and learning disabilities.

Today there are also Nordoff-Robbins centers in London; Seoul, South Korea; and Kingswood, Australia.

The Nordoff-Robbins method takes as its philosophical starting point the belief that responsiveness to music lives in everyone, that music has deep power as a communicative tool and that the experience of two people making music together is an inherently empathetic one.

Where other schools of music therapy might integrate music into more traditional treatment, like talk therapy, in the Nordoff-Robbins approach the music is not so much an adjunct to therapy as it is the stuff of therapy itself.

Nordoff-Robbins therapists, who are skilled musicians and accomplished improvisers, use music to mirror a patient’s emotional state throughout a session. Joy, anger, sadness and the shifts among them — as well as physical behaviors like the repetitive movements made by an autistic child — can be immediately reflected in the changing melodic lines, rhythms and tempos the therapist plays on the piano or guitar.

Patients are encouraged to participate in the music-making — beating drums, strumming guitars, singing — which enhances verbal, social and physical skills.

“We are so full of rhythm and pitch,” Mr. Robbins told the newspaper The Australian in 2007, “so it’s very natural for us to move into music. Some of us like music that’s heavy with pulse: that makes us feel solid. Others like music that’s light and playful; some like romantic music or thoughtful music. We can find in music an extension of our own needs.”

The Nordoff-Robbins method neither aims nor promises to cure its patients. Rather, as Mr. Robbins explained in a 1994 interview with the CBS News program “America Tonight,” “We try to unfold the abilities we can reach and develop them, so the child has more equipment for living.”

A baker’s son, Clive Edward Robbins was born on July 23, 1927, in Birmingham, England. At 14 he began piano lessons, and at 16, during World War II, he joined the Royal Air Force. After the war, he began his career as a special-education teacher in England.

He and Mr. Nordoff were close collaborators for nearly two decades, writing and lecturing, training teachers, treating patients and helping establish Nordoff-Robbins programs around the world. Mr. Nordoff died in 1977.

Mr. Robbins, whose marriage to his first wife, Mildred, ended in divorce, married Carol Matteson, also a music therapist, in 1975. They spent the next several years at the New York State School for the Deaf in Rome, N.Y., where they developed an innovative curriculum that let even children with very little residual hearing learn, appreciate and express themselves through music.

Carol Robbins died in 1996. Mr. Robbins is survived by his third wife, the former Kaoru Mochizuki, a music therapist whom he married in 1998; a son and daughter from his first marriage, Toby and Jenny; a half-brother; seven grandchildren; and two great-grandchildren.

Mr. Robbins, who continued to treat patients almost until the end of his life, lived for years, quite contentedly, with tinnitus, an occupational hazard.

“Too many children had breakthroughs on the cymbals,” he told The New Zealand Herald in 2007. “They were having a terrific time and I didn’t want to stop them.”

    Clive Robbins, Developer of a Method of Music Therapy, Dies at 84, NYT, 12.12.2011,
    http://www.nytimes.com/2011/12/13/nyregion/
    clive-robbins-developer-of-influential-method-of-music-therapy-dies-at-84.html

To Fix Health, Help the Poor

December 8, 2011
The New York Times
By ELIZABETH H. BRADLEY and LAUREN TAYLOR

New Haven

IT’S common knowledge that the United States spends more than any other country on health care but still ranks in the bottom half of industrialized countries in outcomes like life expectancy and infant mortality. Why are these other countries beating us if we spend so much more? The truth is that we may not be spending more — it all depends on what you count.

In our comparative study of 30 industrialized countries, published earlier this year in the journal BMJ Quality and Safety, we broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money — far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

What’s more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.

Our study found that countries with high health care spending relative to social spending had lower life expectancy and higher infant mortality than countries that favored social spending. While the stagnating life expectancy in the United States remains at 78 years, in many European countries it has leapt to well over 80 years, and several countries boast infant mortality rates approximately half of ours. In a national survey conducted by the Robert Wood Johnson Foundation, four out of five physicians agreed that unmet social needs led directly to worse health.

Unfortunately, instead of learning from countries like Sweden and France, we prefer the frantic scramble to recover money from one part of the health care system only to reallocate it toward retreads of previously failed reforms. We pretend that the fresh schemes are innovative, but they are usually long on promises, short on details and often marked with an annoying acronym: H.M.O., F.S.A., A.C.O. and so forth.

It’s time to think more broadly about where to find leverage for achieving a healthier society. One way would be to invest more heavily in social services. This may be difficult for many Americans to swallow as it suggests a potentially expanded role for government. Out of respect for individuals’ rights, our current social programs are mostly opt-in, leaving holes for the undocumented, uneducated and unemployed to slip through cracks and become acutely ill. Emergency rooms, though, are not allowed to opt out of providing these people extraordinarily expensive medical treatment before discharging them back to wretched conditions and their inevitable return to the E.R.

The impact of sub-par social conditions on health has been well documented. Homelessness isn’t typically thought of as a medical problem, but it often precludes good nutrition, personal hygiene and basic first aid, and it increases the risks of frostbite, leg ulcers, upper respiratory infections and trauma from muggings, beatings and rape. The Boston Health Care for the Homeless Program tracked the medical expenses of 119 chronically homeless people for several years. In one five-year period, the group accounted for 18,834 emergency room visits estimated to cost $12.7 million.

We can learn from the star pupils in our analysis. Other countries have created government ministries that marry health and social care. Earlier this year, the Department of Health in Britain released plans to create health and well-being boards comprising local government representatives, primary care physicians, hospital administrators, children and adult-services specialists and public health directors, who will coordinate care for their constituencies across the health and social care spectrum. We should think expansively about how to construct similar programs that enable much needed integration of these mutually dependent sectors. The Department of Veterans Affairs is leading the way, with programs called “stand downs” that simultaneously address the health and social needs of retired service members.

It is Americans’ prerogative to continually vote down the encroachment of government programs on our free-market ideology, but recognizing the health effects of our disdain for comprehensive safety nets may well be the key to unraveling the “spend more, get less” paradox. Before we spend even more money, we should consider allocating it differently.

 

Elizabeth H. Bradley is professor of public health at Yale

and faculty director of its Global Health Leadership Institute,

where Lauren Taylor is a program manager.

    To Fix Health, Help the Poor, NYT, 8.12.2011,
    http://www.nytimes.com/2011/12/09/opinion/to-fix-health-care-help-the-poor.html

A Decade of Progress on AIDS

November 30, 2011
The New York Times
By BONO

I’LL tell you the worst part about it, for me.

It was the look in their eyes when the nurses gave them the diagnosis — H.I.V.-positive — then said there was no treatment. I saw no anger in their expression. No protest. If anything, just a sort of acquiescence.

The anger came from the nurses, who knew there really was a treatment — just not for poor people in poor countries. They saw the absurdity in the fact that an accident of geography would deny their patients the two little pills a day that could save their lives.

This was less than a decade ago. And all of us who witnessed these dedicated African workers issuing death sentence after death sentence still feel fury and shame. AIDS set off an almost existential crisis in the West. It forced us to ask ourselves the big, uncomfortable questions, like whether capitalism, which invented the global village and kept it well stocked with stuff, could also create global solutions. Whether we were interested in charity... or justice.

The wanton loss of so many lives in Africa offended the very idea of America: the idea that everyone is created equal and that your destiny is your own to make. By the late 1990s, AIDS campaigners in the United States and around the world teamed up with scientists and doctors to insist that someone — anyone — put the fire out. The odds against this were as extreme as the numbers: in 2002, two million people were dying of AIDS and more than three million were newly infected with H.I.V. Around 50,000 people in the sub-Saharan region had access to treatment.

Yet today, here we are, talking seriously about the “end” of this global epidemic. There are now 6.6 million people on life-saving AIDS medicine. But still too many are being infected. New research proves that early antiretroviral treatment, especially for pregnant women, in combination with male circumcision, will slash the rate of new H.I.V. cases by up to 60 percent. This is the tipping point we have been campaigning for. We’re nearly there.

How did we get here? America led. I mean really led.

The United States performed the greatest act of heroism since it jumped into World War II. When the history books are written, they will show that millions of people owe their lives to the Yankee tax dollar, to just a fraction of an aid budget that is itself less than 1 percent of the federal budget.

For me, a fan and a pest of America, it’s a tale of strange bedfellows: the gay community, evangelicals and scruffy student activists in a weird sort of harmony; military men calling AIDS in Africa a national security issue; the likes of Nancy Pelosi, Barbara Lee and John Kerry in lock step with Bill Frist and Rick Santorum; Jesse Helms, teary-eyed, arriving by walker to pledge support from the right; the big man, Patrick Leahy, offering to punch out a cranky Congressional appropriator; Jeffrey Sachs, George Soros and Bill Gates, backing the Global Fund to Fight AIDS, Tuberculosis and Malaria; Rupert Murdoch (yes, him) offering the covers of the News Corporation.

Also: a conservative president, George W. Bush, leading the largest ever response to the pandemic; the same Mr. Bush banging his desk when I complained that the drugs weren’t getting there fast enough, me apologizing to Mr. Bush when they did; Bill Clinton, arm-twisting drug companies to drop their prices; Hillary Rodham Clinton, making it policy to eradicate the transmission of H.I.V. from mother to child; President Obama, who is expected to make a game changing announcement this World AIDS Day to finish what his predecessors started — the beginning of the end of AIDS.

And then there were the everyday, every-stripe Americans. Like a tattooed trucker I met off I-80 in Iowa who, when he heard how many African truck drivers were infected with H.I.V., told me he’d go and drive the pills there himself.

Thanks to them, America led. Really led.

This was smart power. Genius, really. In 2007, 8 out of the 10 countries in the world that viewed the United States most fondly were African. And it can’t be a bad thing for America to have friends on a continent that is close to half Muslim and that, by 2025, will surpass China in population.

Activists are a funny lot. When the world suddenly starts marching in step with us, we just point out with (self-)righteous indignation all that remains to be done. But on this World AIDS Day I would like you to stop and consider what America has achieved in this war to defend lives lived far away and sacred principles held closer to home.

The moonshot, I know, is a tired metaphor; I’ve exhausted it myself. But America’s boldest leap of faith is worth recalling. And the thing is, as I see it, the Eagle hasn’t landed yet. Budget cuts ... partisan divisions ... these put the outcome in jeopardy just as the science falls into place. To get this far and not plant your flag would be one of the greatest accidental evils of this recession.

Bono is the lead singer of the band U2

and a founder of the advocacy group ONE and the (Product)RED campaign.

    A Decade of Progress on AIDS, NYT, 30.11.2011,
    http://www.nytimes.com/2011/12/01/opinion/a-decade-of-progress-on-aids.html

DNA Sequencing Caught in Deluge of Data

November 30, 2011
The New York Times
By ANDREW POLLACK

BGI, based in China, is the world’s largest genomics research institute, with 167 DNA sequencers producing the equivalent of 2,000 human genomes a day.

BGI churns out so much data that it often cannot transmit its results to clients or collaborators over the Internet or other communications lines because that would take weeks. Instead, it sends computer disks containing the data, via FedEx.

“It sounds like an analog solution in a digital age,” conceded Sifei He, the head of cloud computing for BGI, formerly known as the Beijing Genomics Institute. But for now, he said, there is no better way.

The field of genomics is caught in a data deluge. DNA sequencing is becoming faster and cheaper at a pace far outstripping Moore’s law, which describes the rate at which computing gets faster and cheaper.

The result is that the ability to determine DNA sequences is starting to outrun the ability of researchers to store, transmit and especially to analyze the data.

“Data handling is now the bottleneck,” said David Haussler, director of the center for biomolecular science and engineering at the University of California, Santa Cruz. “It costs more to analyze a genome than to sequence a genome.”

That could delay the day when DNA sequencing is routinely used in medicine. In only a year or two, the cost of determining a person’s complete DNA blueprint is expected to fall below $1,000. But that long-awaited threshold excludes the cost of making sense of that data, which is becoming a bigger part of the total cost as sequencing costs themselves decline.

“The real cost in the sequencing is more than just running the sequencing machine,” said Mark Gerstein, professor of biomedical informatics at Yale. “And now that is becoming more apparent.”

But the data challenges are also creating opportunities. There is demand for people trained in bioinformatics, the convergence of biology and computing. Numerous bioinformatics companies, like SoftGenetics, DNAStar, DNAnexus and NextBio, have sprung up to offer software and services to help analyze the data. EMC, a maker of data storage equipment, has found life sciences a fertile market for products that handle large amounts of information. BGI is starting a journal, GigaScience, to publish data-heavy life science papers.

“We believe the field of bioinformatics for genetic analysis will be one of the biggest areas of disruptive innovation in life science tools over the next few years,” Isaac Ro, an analyst at Goldman Sachs, wrote in a recent report.

Sequencing involves determining the order of the bases, the chemical units represented by the letters A, C, G and T, in a stretch of DNA. The cost has plummeted, particularly in the last four years, as new techniques have been introduced.

The cost of sequencing a human genome — all three billion bases of DNA in a set of human chromosomes — plunged to $10,500 last July from $8.9 million in July 2007, according to the National Human Genome Research Institute.

That is a decline by a factor of more than 800 over four years. By contrast, computing costs would have dropped by perhaps a factor of four in that time span.

The lower cost, along with increasing speed, has led to a huge increase in how much sequencing data is being produced. World capacity is now 13 quadrillion DNA bases a year, an amount that would fill a stack of DVDs two miles high, according to Michael Schatz, assistant professor of quantitative biology at the Cold Spring Harbor Laboratory on Long Island.

There will probably be 30,000 human genomes sequenced by the end of this year, up from a handful a few years ago, according to the journal Nature. And that number will rise to millions in a few years.

In a few cases, human genomes are being sequenced to help diagnose mysterious rare diseases and treat patients. But most are being sequenced as part of studies. The federally financed Cancer Genome Atlas, for instance, is sequencing the genomes of thousands of tumors and of healthy tissue from the same people, looking for genetic causes of cancer.

One near victim of the data explosion has been a federal online archive of raw sequencing data. The amount stored has more than tripled just since the beginning of the year, reaching 300 trillion DNA bases and taking up nearly 700 trillion bytes of computer memory.

Straining under the load and facing budget constraints, federal officials talked earlier this year about shutting the archive, to the dismay of researchers. It will remain open, but certain big sequencing projects will now have to pay to store their data there.

If the problem is tough for human genomes, it is far worse for the field known as metagenomics. This involves sequencing the DNA found in a particular environment, like a sample of soil or the human gut. The idea is to take a census of what microbial species are present.

E. Virginia Armbrust, who studies ocean-dwelling microscopic organisms at the University of Washington, said her lab generated 60 billion bases — as much as 20 human genomes — from just two surface water samples. It took weeks to do the sequencing, but nearly two years to then analyze the data, she said.

“There is more data that is infiltrating lots of different fields that weren’t particularly ready for that,” Professor Armbrust said. “It’s all a little overwhelming.”

The Human Microbiome Project, which is sequencing the microbial populations in the human digestive tract, has generated about a million times as much sequence data as a single human genome, said C. Titus Brown, a bioinformatics specialist at Michigan State University.

“It’s not at all clear what you do with that data,” he said. “Doing a comprehensive analysis of it is essentially impossible at the moment.”

Other scientific fields, like particle physics and astronomy, handle huge amounts of data. In those fields, however, much of the data is generated by a few huge accelerators or observatories, said Eugene Kolker, chief data officer at Seattle Children’s Hospital.

“In the life sciences, anyone can produce so much data, and it’s happening in thousands of different labs throughout the world,” he said.

Moreover, DNA is just part of the story. To truly understand biology, researchers are gathering data on the RNA, proteins and chemicals in cells. That data can be even more voluminous than data on genes. And those different types of data have to be integrated.

“We have these giant piles of data and no way to connect them” said H. Steven Wiley, a biologist at the Pacific Northwest National Laboratory. He added, “I’m sitting in front of a pile of data that we’ve been trying to analyze for the last year and a half.”

Still, many say the situation will be manageable. Jay Flatley, chief executive of Illumina, the leading supplier of sequencing machines, said he did not think information handling was a bottleneck or that it was causing people to hold off on buying new sequencers.

Researchers are increasingly turning to cloud computing so they do not have to buy so many of their own computers and disk drives.

Google might help as well.

“Google has enough capacity to do all of genomics in a day,” said Dr. Schatz of Cold Spring Harbor, who is trying to apply Google’s techniques to genomics data. Prodded by Senator Charles E. Schumer, Democrat of New York, Google is exploring cooperation with Cold Spring Harbor.

Google’s venture capital arm recently invested in DNAnexus, a bioinformatics company. DNAnexus and Google plan to host their own copy of the federal sequence archive that had once looked as if it might be closed.

The amount of data stored for a human genome will drop sharply. Sequencers produce huge amounts of raw data that then has to be analyzed and processed by software to produce the result.

With the field still young, many researchers store all the raw data, so it can be re-analyzed if better software is developed in the future.

In uncertain times, “scientists cling to their data,” said David J. Dooling, assistant director of the genome institute at Washington University in St. Louis.

But there is now so much raw data that it is becoming not feasible to re-analyze it. So researchers will increasingly store just the final results. In the case of human genomes, they might store even less — only the difference between a particular genome and some reference genome.

Professor Brown of Michigan State said: “We are going to have to come up with really clever ways to throw away data so we can see new stuff.”

    DNA Sequencing Caught in Deluge of Data, NYT, 30.11.2011,
    http://www.nytimes.com/2011/12/01/business/dna-sequencing-caught-in-deluge-of-data.html

Gingrich Gave Push to Clients, Not Just Ideas

November 29, 2011
The New York Times
By MIKE McINTIRE and JIM RUTENBERG

Newt Gingrich is adamant that he is not a lobbyist, but rather a visionary who traffics in ideas, not influence. But in the eight years since he started his health care consultancy, he has made millions of dollars while helping companies promote their services and gain access to state and federal officials.

In a variety of instances, documents and interviews show, Mr. Gingrich arranged meetings between executives and officials, and salted his presentations to lawmakers with pitches for his clients, who pay as much as $200,000 a year to belong to his Center for Health Transformation.

When the center sponsored a “health transformation summit” at the Florida State Capitol in March 2006, lawmakers who attended Mr. Gingrich’s keynote speech inside the House chamber received a booklet promoting not just ideas but also the specific services of two dozen of his clients. Executives from some of those companies sat on panels for discussions that lawmakers were encouraged to attend after Mr. Gingrich’s address.

Gerard White, president of Clearwave, which paid about $50,000 to become a center member, used the occasion to pitch his company’s system for managing patient medical data. “It was a way for companies who were part of Newt’s group to say to health officials in Florida, ‘Hey, here are some exciting things we’re doing,’ ” Mr. White said.

Mr. Gingrich and his aides have repeatedly emphasized that he is not a registered lobbyist, an important distinction in their effort to position him as an outsider who will transform the ways of Washington. They say that he has never taken a position for money and that corporations have signed on with him because of the strength of his ideas.

“You have somebody who knows what he believes in, he can effectively communicate it, and he’s successful in doing it,” said his spokesman, R. C. Hammond. “God bless America.”

Yet if Mr. Gingrich has managed to steer clear of legal tripwires, a review of his activities shows how he put his influence to work on behalf of clients with a considerable stake in government policy. Even if he does not appear to have been negotiating legislative language, he and his staff did many of the same things that registered lobbyists do.

The center’s own records — kept in a restricted section of its Web site, but found by The New York Times in an unsecured archived version of the site — contain several previously unreported examples.

Two years before the Florida “summit,” Mr. Gingrich made a presentation to Republican lawmakers in Georgia, promoting the work of his member companies by citing specific benefits if they were hired. For example: “VitalSpring could save the State Employee Program over $20 million a year.”

Minutes of a members-only conference call from March 2004 said the center had “arranged joint meetings” for members to present their work on electronic health records to top federal officials, noting that Mr. Gingrich “reported very positive feedback overall from these meetings.”

He also pressed for passage of a federal bill to increase the use of electronic health records, collaborating with one of its co-sponsors, Representative Patrick J. Kennedy of Rhode Island, and Senator Hillary Rodham Clinton of New York, both Democrats. After appearing at a press briefing on the issue with Mrs. Clinton in 2005, he stated flatly on Fox News: “We’re launching a bill.”

Mr. Gingrich’s ability to reach leaders like Mrs. Clinton was a selling point for the center. A PowerPoint presentation for prospective members advertised its “contacts at the highest levels” of federal and state government. Paying $200,000 a year for the top-tier membership, it said, “increases your channels of input to decision makers” and grants “access to top transformational leadership across industry and government.”

In asserting that Mr. Gingrich has never engaged in lobbying, his aides say lawyers have thoroughly vetted all of his activities. Randy Evans, a Georgia lawyer who has represented Mr. Gingrich since his days as House speaker, said none of Mr. Gingrich’s clients paid him to adopt a position that he did not already have.

“That matters a lot,” Mr. Evans said, “because there was never a point where we identified a client’s position first and decided, ‘O.K., that’s where we’re going.’ His vision always came first.”

Mr. Evans said that when Mr. Gingrich appeared to be promoting the services of his clients before state lawmakers, he was merely citing examples to buttress his ideas, and that the companies “weren’t paying him to do that.” Mr. Gingrich would also include examples from firms that were not center members, he said.

Any interactions Mr. Gingrich had with members of Congress or federal officials on matters important to his clients “followed specific protocols and procedures” that the center designed to ensure he stayed within the law, Mr. Evans said.

“It would be absolutely false to say that he lobbied at any point,” Mr. Evans said.

As his campaign for the Republican presidential nomination has gained traction in recent weeks, Mr. Gingrich has said he expects increased scrutiny of his business activities since leaving Congress in 1999. Those activities, which primarily involve the Center for Health Transformation and his original consulting firm, the Gingrich Group, have made him wealthy. The consultancy and center earned a combined $55 million over the last 10 years, according to a Gingrich Group representative.

From the moment he entered private life, Mr. Gingrich seemed determined to avoid being tagged as a lobbyist, which can be a kiss of death for anyone contemplating a presidential run. An early consulting contract, with a plastics company in 2001, contained language that would become standard: He “does not provide lobbying services of any kind.”

“He made it very clear to us that he does not lobby, but that he could direct us to the right places in Washington and elsewhere,” said Paul Branagan, who was president of Millennium Plastics when it hired Mr. Gingrich for $7,500 a month plus stock options.

As his policy interests increasingly focused on health care, Mr. Gingrich created the center, which he portrays as a think tank promoting innovative ways to improve health care delivery and save money. Companies and trade groups pay annual fees ranging from $20,000 to $200,000, with higher-paying members gaining more direct access to Mr. Gingrich.

Many of the ideas he has pushed involve the increased use of information technology, and companies specializing in that are well represented on the center’s roster. They also figured prominently in an early center initiative, teaming up in 2003 with the conservative Georgia Public Policy Foundation to promote changes in health care in Mr. Gingrich’s home state.

At his discussion with Georgia House Republicans in 2004, Mr. Gingrich gave examples of companies whose services could “both improve health and start saving money,” according to the center’s summary of his presentation. His talk included a handout listing mostly members of the center, their contact information and a description of their services.

Kelly McCutchen, the policy foundation’s president, said that Mr. Gingrich was good at convincing state lawmakers of the merits of modernizing health care, and that citing cutting-edge companies was effective.

“He does cite examples in his presentations,” Mr. McCutchen said. “But everybody cites examples. Is there a quid pro quo? Can you prove that a company is paying someone to lobby a position, or are they just supporting them because they like the educational work they’re doing? I’ll let others decide that.”

In Washington, Mr. Gingrich’s push for electronic health records illustrated how his own policy advocacy and his ties to former Congressional colleagues made him a sought-out consultant for companies like Astra Zeneca and Siemens. Mr. Gingrich hailed HealthTrio, one of the center’s “founding charter members,” during a hearing held in 2003 by Senator Larry Craig, Republican of Idaho. Telling the senator that HealthTrio’s chief executive had helped design the electronic records program in the United Kingdom, Mr. Gingrich said the company “estimates we could have an electronic health record for every American for about 10 cents per month, per person.”

The center later arranged for HealthTrio and I.B.M. to meet with senior federal health officials and congressional leaders “to review the U.K. approach and how it might be applied in the U.S.,” according to center records.

Some of the ideas promoted by the center found their way into the electronic health records legislation proposed by Mr. Kennedy, which was prepared with input from Mr. Gingrich. Mr. Kennedy said that he had known Mr. Gingrich from their days in the House, and that they had found a common interest in the issue.

“We worked together because it usually got people’s attention,” Mr. Kennedy said in an interview. “When there was a Kennedy and a Gingrich, it got people to think, ‘Hey, if this is above partisanship, let me take another look at it.’ ”

A Congressional staff member involved in the legislation, who requested anonymity to discuss internal deliberations, said Mr. Gingrich had frequently cited the work of companies he identified as “members” of his center. But the staff member said it was not initially clear to him that they were paying the former House speaker. “It was a year before I even realized that the Center for Health Transformation was even a for-profit company, because it didn’t sound like one,” he said.

    Gingrich Gave Push to Clients, Not Just Ideas, NYT, 29.11.2011,
    http://www.nytimes.com/2011/11/30/us/politics/gingrich-gave-push-to-clients-not-just-ideas.html

Matthew P. Sapolin,

Who Led Bloomberg’s Office for Disabled, Dies at 41

November 29, 2011
The New York Times
By ELIZABETH A. HARRIS

Matthew P. Sapolin, the Bloomberg administration’s disabilities commissioner, died of cancer on Tuesday. He was 41.

Mr. Sapolin, whose death was confirmed by the mayor’s office, had served as commissioner for the Mayor’s Office for People With Disabilities since the post was created in 2006. In that role, he pushed to make New York City’s building code more accommodating to people with disabilities, created a mentoring program and led an effort to freeze rents for some disabled New Yorkers.

Mr. Sapolin was also blind. Friends and colleagues said that while Mr. Sapolin’s blindness informed his life, it did not narrow it. He was an accomplished wrestler, a versatile musician, a formidable chess player and an occasional skier.

“His mother told him, you go to school and you’ll learn, and that’s it,” said Carol Robles-Román, deputy mayor for legal affairs. “You’re going to school with everybody else, and they’re going to treat you like everybody else.”

Mayor Michael R. Bloomberg appointed Mr. Sapolin executive director of the Office for People With Disabilities in 2002. Four years later, Mr. Bloomberg decided to elevate the job to the level of commissioner, and Mr. Sapolin rose with it.

At age 5, Mr. Sapolin lost his sight to bilateral retinoblastoma, a cancer that affects the optic nerve. Mr. Bloomberg’s office said he had battled cancer ever since, and it was that disease that killed him, a rare form called leiomyosarcoma.

Mr. Sapolin was the captain of his high school wrestling team in Islip, N.Y., the town where he was born. He went on to be co-captain of the wrestling team at New York University. In 1992, he was profiled in Sports Illustrated when he had the Division III nationals within reach, competing against sighted wrestlers.

“I think what strikes me is what a fighter he was,” Ms. Robles-Román said. “He was tenacious and he was an advocate to the nth degree, but he was always professional, collaborative and collegial. Those words don’t necessarily go together, but in Matt’s case, they really did.”

Mr. Sapolin continued to go to work for Mr. Bloomberg — who would sometimes joke that Mr. Sapolin’s golden retriever guide dog had a habit of shedding on his suits — as recently as last week, said Jason Mischel, his deputy and general counsel.

“Between the office and his apartment on the Upper West Side,” Mr. Mischel said, “he would run into three or four people who would come up to him and say ‘Hey, commissioner, do you remember me?’ And he would know them by the sound of their voice.”

Mr. Sapolin is survived by his wife, Candra, and their two children, Trevor and Toscany.

    Matthew P. Sapolin, Who Led Bloomberg’s Office for Disabled, Dies at 41, NYT, 29.11.2011,
    http://www.nytimes.com/2011/11/30/nyregion/matthew-p-sapolin-who-led-bloombergs-office-for-disabled-dies-at-41.html
 

Finding Purpose After Living With Delusion

November 25, 2011
The New York Times
By BENEDICT CAREY

ATHENS, Ohio — She was gone for good, and no amount of meditation could resolve the grief, even out here in the deep quiet of the woods.

Milt Greek pushed to his feet. It was Mother’s Day 2006, not long after his mother’s funeral, and he headed back home knowing that he needed help. A change in the medication for his schizophrenia, for sure. A change in focus, too; time with his family, to forget himself.

And, oh yes, he had to act on an urge expressed in his psychotic delusions: to save the world.

So after cleaning the yard around his house — a big job, a gift to his wife — in the coming days he sat down and wrote a letter to the editor of the local newspaper, supporting a noise-pollution ordinance.

Small things, maybe, but Mr. Greek has learned to live with his diagnosis in part by understanding and acting on its underlying messages, and along the way has built something exceptional: a full life, complete with a family and a career.

He is one of a small number of successful people with a severe psychiatric diagnosis who have chosen to tell their story publicly. In doing so, they are contributing to a deeper understanding of mental illness — and setting an example that can help others recover.

“I started feeling better, stronger, the next day,” said Mr. Greek, 49, a computer programmer who for years, before receiving medical treatment, had delusions of meeting God and Jesus.

“I have such anxiety if I’m not organizing or doing some good work. I don’t feel right,” he said. “That’s what the psychosis has given me, and I consider it to be a gift.”

Doctors generally consider the delusional beliefs of schizophrenia to be just that — delusional — and any attempt to indulge them to be an exercise in reckless collusion that could make matters worse. There is no point, they say, in trying to explain the psychological significance of someone’s belief that the C.I.A. is spying through the TV; it has no basis, other than psychosis.

Yet people who have had such experiences often disagree, arguing that delusions have their origin not solely in the illness, but also in fears, longings and psychological wounds that, once understood, can help people sustain recovery after they receive treatment.

Now, these psychiatric veterans are coming together in increasing numbers, at meetings and conferences, and they are writing up their own case histories, developing their own theories of psychosis, with the benefit of far more data than they have ever had before: one another’s stories.

“It’s a thrilling time, because people with lived experience are beginning to collaborate in large numbers,” said Gail A. Hornstein, a psychologist at Mount Holyoke College and author of “Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness.” “They are developing their own theories, their own language about what their experiences means from the inside.”

Mr. Greek is one of the most exceptional, having built a successful life and career despite having schizophrenia — and, he says, because of it. He manages the disorder with medication, personal routines, and by minding the messages in his own strange delusions.

“Schizophrenia is the best thing that ever happened to me,” he said. “I know a lot of people with the diagnosis don’t feel that way, but the experience changed me, for the better. I was so arrogant, so narcissistic, so self-involved, and it humbled me. It gave me a purpose, and that purpose has been very much a part of my recovery.”

 

The Village Eccentric

Like many idealistic undergraduates, Mr. Greek arrived at Ohio University in Athens on a mission. Only, like many undergrads, he wasn’t completely sure what it was.

“To discover a psychological code that people should live by, to create world peace,” he said. “Something like that.”

The town was ready to listen, regardless. It was the fall of 1981, and Athens still had one sandal planted in the 1960s; communes thrived in the Appalachian foothills to the north, and big ideas were in the air, at least in the streets and bars near campus, where professors and students gathered.

One stood out. “You can’t imagine how intense he was back then,” said June Holley, a friend and business consultant in Athens. “He had this long, very thick, curly chestnut hair and wild eyes; he looked like a lion. He could be loud, and I think a lot of people just didn’t want to deal with it.”

Local residents gave him the sidewalk, avoided eye contact, and generally accepted him as one variety of village lunatic — in a town with a rich history of them.

He knew the role, at some level. The son of a college math professor and a lawyer, progressives both, Milton Thomas Greek grew up in Roanoke, Ill., and neighboring Benson, about two hours southwest of Chicago. He declared himself an atheist early and often, which in a devout Christian community was one way to stir the air — and the boys who ruled the schoolyard.

“They told me I was damned — damned! — and came after me,” Mr. Greek said. “Now I see that it was just an excuse, like picking on the fat kid for being fat, or the nerd for being a nerd. But at the time I thought it was all about religion.”

He did not discover the secret to world peace and, by senior year, was in a troubled marriage, and began seeing and hearing things others did not. One day he saw a homeless man in the Athens bus station with eyes “like landscapes that went back into the man’s head infinitely far, stretching on for eternity.” God’s eyes; who else?

Later, he was hitchhiking, and a man with long hair and sandals pulled over to offer a ride, his eyes rippling with the same eternal light as the street person’s. Jesus? It had to be (“I’d already met God, so it made sense.”) The man said something about a small town in the woods, and Mr. Greek thought that that town had to be heaven.

His marriage collapsed. His friends stopped calling. He was back at home in Illinois when a doctor finally gave him a diagnosis — schizophrenia — and prescribed medication.

It seemed like a charade, from start to finish. The doctor never asked what he thought his hallucinations meant, or whether the strange thoughts were linked to experiences in his life. He stopped taking the pills.

“I became very suicidal,” he said. “I had no idea what’s happening to me during this entire time. I had been this big atheist, but here I am thinking that the rapture is about to start and that I’m the Antichrist — all this religious imagery.”

 

Why?

The answer was obvious and ultimately liberating, but he had to spend a long time wandering in the woods — literally — to find it.

It was 1984, he had begged his way back into Ohio University for graduate studies in sociology, still lost in his own mind, his thoughts turning darker by the day. He was alienating classmates, professors, friends.

About the only exception was Ms. Holley, a graduate student some 15 years his senior who enjoyed his company, and one day he decided to visit the commune where she lived, with her family and several other families. It took him two days to find it, the first spent wandering the misty woods until dark in a waking, delusional dream, and the second stumbling into a clearing just off Hooper Ridge Road, where Ms. Holley and her friends took him in.

Over the next several months they sat with him, accepted him as a member of the tribe, and encouraged his mission to improve the world at face value. And save his life they probably did, in part by suggesting that he seek help.

It was Ms. Holley who delivered the message. “I trusted her completely, so when she said I was hallucinating — when she used the word ‘hallucination’ — I knew it was true,” Mr. Greek said. “I would have to give the medication another try.”

He was lucky. It worked, blunting the psychosis enough that he was able to complete a programming course and find work, first in Illinois and later back in Athens at Ohio University’s Information Technology department. In time he found something more: During a snowstorm in 1996, Mr. Greek knocked on the door of a neighbor he had seen around Athens, a single mother with two teenage children, carrying a full-time job plus graduate classes, who was at that very moment (he would learn later) praying for something to get her through the winter.

The man at the door did not exactly look like a savior, in his beat-up jeans and unruly hair, his soft eyes and half-smile. But he offered to cook dinner — stir fry — on a day when the fridge was nearly empty.

The two neighbors became friendly, then close, and finally fell for each other. Neither can say exactly when it happened, but she remembers looking out her window one day to see Mr. Greek pull up to his apartment across the street, his old Honda coughing white smoke. He popped the hood and backed away from the car in slow motion, staring at the engine, then turned abruptly toward his apartment — and vanished, falling face-first into some bushes. “I thought, ‘Well, O.K., he’s got something,” she said. “I’m not sure what. Absentmindedness, maybe?”

They married in 2003 (Mr. Greek’s wife, an artist, asked that her name not appear in this article, for her own privacy), and she helped him fit his religious delusions, now controlled by medication, into a coherent personal story that has guided his day-do-day life.

The frightening voices and ominous signs saying that he was damned were no more than embodiments of his very real childhood terror of being cast out, as the schoolyard boys threatened. His search for heaven on earth was in part an attempt to escape that fate, to find a secure place. But it also dramatized a longing to put the world right, a mission that may have started as vain fantasy, but in time became an emotional imperative, a need to commit small acts of kindness, like cooking dinner for a snowed-in neighbor.

 

A Regimen for Coping

“He has this long list of causes that he’s extremely passionate about, and he has strong opinions about almost everything, but he’s also very sensitive to his relations with people and open to other philosophies,” said Melissa Van Meter, who has worked with Mr. Greek at the university and holds very different political views. “It has just impressed me that he could handle so much personally and do so well professionally.”

“When I began to see the delusions in the context of things that were happening in my real life, they finally made some sense,” Mr. Greek said. “And understanding the story of my psychosis helped me see what I needed to stay well.”

Mr. Greek’s regimen combines meditation, work and drug treatment with occasional visits to a therapist and a steady diet of charitable acts. Some of these are meant to improve the community; others are for co-workers and friends, especially those dealing with a psychiatric diagnosis.

To help others experiencing psychotic delusions, he relies on his own theory of what delusions may mean. In an analysis of 20 delusional experiences, all described by sufferers in the first person, Mr. Greek identifies four story lines.

Among them are the rescuer (on a mission to save a particular group); the self-loathing person (lost in a sense of extreme worthlessness); the visionary (on a journey to spiritual realms to bring back truth); and the messianic (out to transform the world through miracles, or contact with deities) — the last of which is his own psychosis story.

Each, in Mr. Greek’s reading, grows out of a specific fear or trauma, whether isolation, abuse or family dysfunction, in the same way his own delusional story symbolized a fear of being a social reject. He is preparing the study for publication in a psychiatric journal and has put much of his thinking into a manual for families dealing with psychosis, called “Schizophrenia: A Blueprint for Recovery.”

Mr. Greek’s analysis of the story lines in psychosis is certainly not the first of its kind, nor the most comprehensive. Psychiatrists, psychologists, therapists and brain scientists have spun out hundreds of ideas about what goes on during a delusion.

But until recently patients themselves — that is, nonprofessionals who have lived with hallucinations and delusions — had little more than their own strange story to study, in any detail. Now they have dozens, and Mr. Greek is one of a small number of such “native” theorists who argue that the content of a delusion should not be ignored but engaged, carefully, once a person has his or her hallucinations under control.

 

Underlying Needs

“By exploring a person’s anomalous beliefs and experiences, we are better able to understand the underlying feeling and needs that give fuel to these experiences,” said Paris Williams, a psychologist who has struggled with psychosis and recently published a doctoral dissertation analyzing the content of six people’s delusions, which has informed Mr. Greek’s work.

For instance, said Dr. Williams, who is working on a book called “Rethinking Madness,” “we can find ways to make them feel safe when they believe they are being persecuted by malevolent forces, or find ways to help them feel empowered when they experience demanding voices.”

One place Mr. Greek feels safe is in a clearing in the woods behind his house, where on a recent afternoon he disappeared wearing a tie-dyed shirt and old jeans with the knees worn completely through. He practices mindfulness meditation here, tuning in to the rhythms of life that usually pass unnoticed.

Back at home, he runs thoughts and perceptions by his wife. “He says things like, ‘Is that a marching band I’m hearing, or am I just hallucinating?’ ” she said. “I’ll say, ‘Uh no, I don’t hear a band, Milt,’ and he’s fine.”

And he visits a therapist when stress levels are running very high. The therapist has given him diagnoses of schizophrenia and “mood disorder, not otherwise specified,” according to his medical records, and she treats him in sessions and with an antipsychotic drug, adjusting the dosage up or down depending on his mood.

Since his mother’s death, Mr. Greek and his wife have taken several more emotional blows, with other close relatives dying. He has been especially stretched, between his work, various community projects, and traveling to speak, often to police groups about how to understand psychotic thinking when dealing with people on the street.

It was too much, and in August he visited his therapist again, and soon after made a deal with his wife. “She and I signed a contract identifying and limiting volunteer work I will do next year,” he said in an e-mail. “I am being coached on how to say no.”

The world is not yet saved from itself, nor for that matter is Athens. But even a messianic rescuer needs a day off, if only to come back stronger the next.

    Finding Purpose After Living With Delusion, NYT, 25.11.2011,
    http://www.nytimes.com/2011/11/26/health/man-uses-his-schizophrenia-to-gather-clues-for-daily-living.html

Health Care and the States

November 22, 2011
The New York Times


In reviewing the constitutionality of health care reform, the Supreme Court said it would consider the legality of the Medicaid expansion included in the reform law. The question seems narrow, but it could have significant implications for redefining Congress’s spending power.

The only appellate court that even addressed this question, the United States Court of Appeals for the 11th Circuit, rejected the constitutional challenge. Having taken up the question, the Supreme Court should affirm that ruling. It would be a serious mistake for the court to use this case to restrict Congress’s authority by placing any additional requirements for the commitment of federal money.

The Constitution’s spending clause gives Congress the power to pay debts and “provide for the common defense and general welfare” of the country. In 1987, the Supreme Court held that when Congress provides money to a state, it has broad power to require states to meet conditions related to the money — as long as the spending serves the general welfare and meets other restrictions.

The health care reform law does just that. In expanding the number of people eligible for Medicaid and raising the minimum coverage, it requires states to pay for 10 percent of the added cost or else lose all federal financing for Medicaid. As the 11th Circuit said, Congress made clear when Medicaid was passed in 1965 that it reserved the right to change the program. It has done so many times without any court striking down any change as coercive.

The health law gives states until 2014 to decide whether they will adopt the expansion and develop new budgets to finance a program replacing Medicaid. “If states bear little of the cost of expansion,” the appeals court said, then “the idea that states are being coerced into spending money in an ever-growing program seems” overblown.

The coercion argument, which is a favorite of states’ rights proponents, rests on the premise that Congress’s power under the spending clause is by definition quite limited. That erroneous idea held sway on the Supreme Court in the 1930s before it was discredited. If it accepts the coercion argument now, the Supreme Court would basically usurp Congress’s authority to determine the nature and scope of federal spending for the general welfare.

This issue matters because a lot of major federal laws carry conditions that apply to the states and other institutions. For example, any state receiving federal funds — whether for agriculture or housing — is prohibited from discriminating on race, color or national origin under the Civil Rights Act. Likewise, any education institution that accepts federal funds cannot discriminate based on gender under Title IX of the federal education law. While some forms of discrimination are prohibited by the Constitution, these federal statutes impose additional duties of enforcement and spell out penalties for not complying.

Curbing Congress’s power to impose conditions on the disbursement of federal money would upend settled precedent. Such a move by the court would invite litigation and uncertainty that would harm all governments, federal and state.

    Health Care and the States, NYT, 22.11.2011,
    http://www.nytimes.com/2011/11/23/opinion/health-care-reform-and-the-states.html

Low-Tax Cigarettes, Made in Store, Draw City Lawsuit

November 21, 2011
The New York Times
By SAM ROBERTS

Sometimes a cigar is just a cigar, as Freud supposedly said, but when is a cigarette a cigarette?

The city filed suit last week against a “roll your own” cigarette shop in Chinatown and a related one on Staten Island, where a pack of cigarettes can cost less than $5, because the stores are not collecting cigarette taxes. The stores, both called Island Smokes, do not sell packs of Marlboros and Newports. Instead, they sell loose tobacco and cigarette papers, and have machines that let customers fabricate their own cigarettes.

Such stores operate in a legal gray area, arguing that because they do not sell prepackaged cigarettes, they are subject only to taxes on loose tobacco, which are far less. But according to the city, the shops are effectively selling cigarettes and should be forced to charge the full state and city taxes — currently $5.85 per pack, which has pushed the cost of most packs in New York City to more than $10.

“By selling illegally low-priced cigarettes,” said the city’s lawsuit, filed in Federal District Court in Manhattan, “defendants not only interfere with the collection of city cigarette taxes, they also impair the city’s smoking cessation programs and impair individual efforts at smoking reduction, thereby imposing higher health care costs on the city and injuring public health.”

Jonathan Behrins, a lawyer for the companies that own the shops, said Monday that the stores were not obligated to charge cigarette taxes because “we are not producing cigarettes for resale.”

“We are selling the contents that produce the cigarette,” he said, “and it’s up to the user to make them.”

Mr. Behrins acknowledged that employees sometimes assist customers by “demonstrating” the equipment, but likened the whole process to “making your own beer.”

The city offered a much different analogy.

“When you go to a salad bar, they sell you a salad, not a salad assembly process,” said Eric Proshanksy, deputy chief of the corporation counsel’s affirmative litigation division. “When customers walk out of these stores, they have finished cigarettes and they bought them in those stores. The stores also have signage that calls them a discount cigarettes shop.”

Inside the Island Smokes on Eldridge Street in Chinatown, plastic bins contain different styles of loose tobacco — menthol, double menthol, ultra light and more. More than a dozen machines are spread out in two rooms.

On Monday an employee showed a first-time buyer how the machines work. The customer attaches an empty paper tube to the machine and punches a “load” button; after the cigarette is full, it must be placed in another machine resembling an electric pencil sharpener that seals the ends. The pack cost $6, including the small tin box that holds the finished cigarettes; a refill is $4.50.

One man entered and asked if he could buy a pack of Newports. When told that Island Smokes sold only its own tobacco and that customers had to roll their own cigarettes, the man promptly left.

Customers who were rolling cigarettes swore by the shop’s products, which are advertised as “all natural.”

“It’s such a better, cheaper alternative,” said Veronica Raccuia, 20. The store says its tobacco does not contain additives found in premade cigarettes. “You don’t taste all the chemicals,” she said.

Customers were frustrated to learn of the city’s lawsuit against the shop, saying it was simply another measure intended to regulate people’s lives.

“The government is so money-hungry they’ll do anything to get rid of whoever they’re not getting money from,” Ms. Raccuia said.

“Just leave people alone,” she added. “In this economy, no one can barely afford food, let alone a pack of $15 cigarettes.”

 

Tim Stelloh contributed reporting.

    Low-Tax Cigarettes, Made in Store, Draw City Lawsuit, 21.11.2011,
    http://www.nytimes.com/2011/11/22/nyregion/roll-your-own-cigarette-shops-sued-by-new-york-city-in-tax-dispute.html

Fixing Medicare

November 20, 2011
The New York Times

There is no way to wrestle down the deficit without reining in Medicare costs. Ensuring that the program provides quality health care coverage to millions of older and disabled Americans is essential. These goals are not incompatible, but they require a judicious approach to policy making that is depressingly absent in Washington.

Medicare is nothing less than a lifeline for 49 million older and disabled Americans. It helps pay for care in a wide range of settings, including hospitals, nursing homes, outpatient clinics, doctors’ offices, hospices and at home, as well as for prescription drugs.

It is also hugely costly. The federal government spent about $477 billion in net Medicare outlays in fiscal year 2011 — 13 percent of its total spending. By 2021, it is projected to spend $864 billion — or 16 percent of the total — according to figures derived by the Kaiser Family Foundation. That rate of growth is not sustainable indefinitely.

Unfortunately, many politicians seem less interested in coming up with ways to fix Medicare than in how they might impose their ideology on the program or leverage the issue for their next political campaign. Members of both parties need to define more clearly for the public what Medicare’s true problems are and how they propose to address them. Here are some of the major issues:

NEAR-TERM COSTS There are three key drivers of Medicare spending: the spiraling cost of all health care as new technologies and treatments are developed; much greater use of medical services by the typical beneficiary; and an aging population. By 2020, the number of enrollees will increase to 64 million.

The current rancorous debate in Washington is focused on finding big immediate cuts to slow Medicare spending. We are skeptical that this can be done quickly without wreaking major havoc.

The health care reform law enacted last year calls for cutting more than $400 billion from Medicare over the next decade, primarily by slowing the rate of growth in payments to health care providers and phasing out unjustified subsidies to private Medicare Advantage plans that insure roughly a quarter of all enrollees. Republican leaders, who denounced those cuts in 2010, have since embraced Representative Paul Ryan’s proposal, which adopts virtually all of the same reductions. Even these will be difficult to achieve without driving out providers, according to the government’s nonpartisan budget analysts.

There is time to get this right. Since January 2010 the growth in Medicare spending has actually slowed to an annual rate of about 4 percent, less than half the annual rate for the previous decade. No one is quite sure why, but one theory holds that hospitals are scrambling to squeeze a lot of fat out of the system even before the health care reforms pressure them to do it.

LONGER-TERM SAVINGS The only way to make Medicare sustainable is to have it grow at the same rate as the economy that provides the tax base to support it. In recent years, Medicare spending has been growing faster than gross domestic product, by roughly 1.7 to 2 percentage points.

Policy experts of varied political stripes have proposed a host of ways to eliminate excess spending without harming beneficiaries or the medical system. Some would charge higher Medicare premiums for those able to afford them, or raise the age of eligibility, or increase cost-sharing by beneficiaries to deter unnecessary use of medical care. All such proposals have strengths and weaknesses that need to be carefully analyzed.

A more radical proposal, championed primarily by Republicans, is to stop providing Medicare payments for specified benefits no matter the cost and instead give beneficiaries a set amount of money to buy private insurance policies that might not provide the same benefits. These so-called premium-support or voucher plans come in many flavors — some good, some bad — and would need to be carefully vetted. The most extreme version, proposed by Representative Ryan, would save the federal government a lot of money mainly by shifting big costs to beneficiaries and driving up costs for the rest of the health care system.

FEE-FOR-SERVICE Experts across the political spectrum agree that Medicare’s system for paying health care providers is a big part of its spending problem. The traditional Medicare program pays doctors separate fees for each of 7,000 different services, such as a diagnostic test, office visit or surgical procedure. This encourages excess use of medical tests and procedures because the doctors get more income as their services proliferate and the patient has little reason to question whether another M.R.I. so soon after the last one is really necessary.

The solution, most experts agree, is to have Medicare pay doctors and other health care providers fixed sums to manage a patient’s care and then let the doctors decide which services are truly necessary. Close monitoring would be needed to ensure that doctors don’t deny medically important services to improve their bottom lines.

The reform law is making a start with pilot programs and modest changes in payment policies to encourage coordinated care management. More vigorous action is needed. This can be done by strengthening provisions in the reform law (unless the Republicans succeed in repealing it) or by adding additional measures that gain bipartisan approval.

BENEFITS Medicare reform should not just be about saving money. Medicare’s coverage has some glaring gaps that need fixing. There is no provision for long-term care in nursing homes or at home, forcing many middle-class people to impoverish themselves to qualify for Medicaid. And patients can be socked with very high or very low rates of cost-sharing depending on whether care is delivered in a hospital, nursing home, by a doctor or at home. This crazy-quilt pattern confuses patients about the costs they will have to pay and almost certainly complicates and drives up the costs of administering the program.

•

At this point, the supercommittee looks close to implosion. But the last time Washington tried for a quick fix of Medicare, in 1997, it did not turn out well. Congress devised a flawed formula that was supposed to hold down payments to doctors. Instead, many doctors simply expanded the number of services delivered to keep their incomes high, while Congress — after being lobbied — has postponed the payment cuts year after year. To catch up with the formula, Congress would have to cut physician reimbursements by 29 percent next year. That obviously shouldn’t happen and won’t.

That cautionary tale is in no way an argument for inaction. It is an argument for serious, unhurried analysis in a less polarized climate. That is the only way to fix this vital program.

    Fixing Medicare, NYT, 20.9.2011,
    http://www.nytimes.com/2011/11/21/opinion/fixing-medicare.html

The Smokers’ Surcharge

November 16, 2011
The New York Times
By REED ABELSON

More and more employers are demanding that workers who smoke, are overweight or have high cholesterol shoulder a greater share of their health care costs, a shift toward penalizing employees with unhealthy lifestyles rather than rewarding good habits.

Policies that impose financial penalties on employees have doubled in the last two years to 19 percent of 248 major American employers recently surveyed. Next year, Towers Watson, the benefits consultant that conducted the survey, said the practice — among employers with at least 1,000 workers — was expected to double again.

In addition, another survey released on Wednesday by Mercer, which advises companies, showed that about a third of employers with 500 or more workers were trying to coax them into wellness programs by offering financial incentives, like discounts on their insurance. So far, companies including Home Depot, PepsiCo, Safeway, Lowe’s and General Mills have defended decisions to seek higher premiums from some workers, like Wal-Mart’s recent addition of a $2,000-a-year surcharge for some smokers. Many point to the higher health care costs associated with smoking or obesity. Some even describe the charges and discounts as a “more stick, less carrot” approach to get workers to take more responsibility for their well-being. No matter the characterizations, it means that smokers and others pay more than co-workers who meet a company’s health goals.

But some benefits specialists and health experts say programs billed as incentives for wellness, by offering discounted health insurance, can become punitive for people who suffer from health problems that are not completely under their control. Nicotine addiction, for example, may impede smokers from quitting, and severe obesity may not be easily overcome.

Earlier this year, the American Cancer Society and the American Heart Association were among groups that warned federal officials about giving companies too much latitude. They argued in a letter sent in March that the leeway afforded employers could provide “a back door” to policies that discriminate against unhealthy workers.

Kristin M. Madison, a professor of law and health sciences at Northeastern University in Boston, said, “People are definitely worried that programs will be used to drive away employees or potential employees who are unhealthy.”

Current regulations allow companies to require workers who fail to meet specific standards to pay up to 20 percent of their insurance costs. The federal health care law raises that amount to 30 percent in 2014 and, potentially, to as much as half the cost of a policy.

When Wal-Mart Stores, the nation’s largest employer, recently sought the higher payments from some smokers, its decision was considered unusual, according to benefits experts. The amount, reaching $2,000 more than for nonsmokers, was much higher than surcharges of a few hundred dollars a year imposed by other employers on their smoking workers.

And the only way for Wal-Mart employees to avoid the surcharges was to attest that their doctor said it would be medically inadvisable or impossible to quit smoking. Other employers accept enrollment in tobacco cessation programs as an automatic waiver for surcharges.

“This is another example of where it’s not trying to create healthier options for people,” said Dan Schlademan, director of Making Change at Walmart, a union-backed campaign that is sharply critical of the company’s benefits. “It looks a lot more like cost-shifting.”

Wal-Mart declined to make an official available for an interview and provided limited answers to questions through an e-mail response. “The increase in premiums in tobacco users is directly related to the fact that tobacco users generally consume about 25 percent more health care services than nontobacco users,” said Greg Rossiter, a company spokesman.

Wal-Mart requires an employee to have stopped smoking to qualify for lower premiums. The company, which has more than one million employees, started offering an antismoking program this year, and says more than 13,000 workers have enrolled.

Some labor experts contend that employers can charge workers higher fees only if they are tied to a broader wellness program, although federal rules do not define wellness programs.

Employers cannot discriminate against smokers by asking them to pay more for their insurance unless the surcharge is part of a broader effort to help them quit, said Karen L. Handorf, a lawyer who specializes in employee benefits for Cohen Milstein Sellers & Toll in Washington.

Many programs that ask employees to meet certain health targets offer rewards in the form of lower premiums. At Indiana University Health, a large health system, employees who do not smoke and achieve a certain body mass index, or B.M.I., can receive up to $720 a year off the cost of their insurance. “It’s all about the results,” said Sheriee Ladd, a senior vice president in human resources at the system.

Initially the system also rewarded employees who met cholesterol and blood glucose goals, but after workers complained that those hurdles seemed punitive, Indiana shifted its emphasis a bit.

Workers who do not meet the weight targets can be eligible for lower premiums if a doctor indicates they have a medical condition that makes the goal unreasonable, Ms. Ladd said. “There are not many of those who come forward, but it’s available,” she said, adding that workers must be nonsmoking to get the other discount. About 65 percent of roughly 16,000 workers receive a discount.

Some benefits consultants say companies may be increasingly willing to test the boundaries of the law because there has been little enforcement, even though there is a provision requiring employers to accommodate workers with medical conditions limiting their ability to meet certain standards. “They are thumbing their nose at the accommodation provision,” said Michael Wood, a consultant at Towers Watson.

Still, “The employer is going to win not by cost-shifting but by getting people to stop smoking,” said Barry Hall, an executive at Buck Consultants, which advises employers.

Some versions of tougher standards have already been abandoned. The UnitedHealth Group, for example, had introduced a health plan called Vital Measures, which allowed workers to reduce the size of their deductible by meeting various health targets, but discontinued the offering three years ago because of insufficient demand, according to a spokesman. The insurer now offers plans that allow employees to earn rewards by either achieving health targets or participating in a coaching program to improve their health.

Wal-Mart’s decision to start charging smokers more for insurance came abruptly, according to some employees who say they had no chance to quit or consult a doctor. Jerome Allen, who works for Wal-Mart in Texas, says he realized he was paying $40 a month more as a smoking surcharge only when he saw a printout of his insurance coverage.

“Forty dollars is a lot of money,” said Mr. Allen, 63, who works part time. He says he has now quit smoking.

Wal-Mart says it mailed information about benefits changes weeks in advance of the enrollment deadline.

Under Wal-Mart’s programs, employees who want to enroll in some of the company’s more generous plans, which offer lower deductibles and out-of-pocket maximums, can pay as much as $178 a month, or more than $2,000, a year more if they smoke.

Many other companies charge smokers a smaller, flat amount, and have kept any financial penalties under the 20 percent threshold set by the federal rules, according to benefits experts. Target, a Wal-Mart competitor, does not charge smokers more for insurance, while Home Depot charges a smoker $20 a month. PepsiCo requires smokers to pay $600 a year more than nonsmokers unless they complete an antismoking program.

Some critics say Wal-Mart’s surcharge may have the effect of forcing people to opt for less expensive plans or persuade them to drop coverage altogether. Dr. Kevin Volpp, the director of the Center for Health Incentives and Behavioral Economics at the Leonard Davis Institute at the University of Pennsylvania, pointed out that surcharges and stringent health targets might wind up endangering those whose health was already at high risk. “There is this potentially very significant set of unintended consequences,” he said.

    The Smokers’ Surcharge, NYT, 16.11.2011,
    http://www.nytimes.com/2011/11/17/health/policy/smokers-penalized-with-health-insurance-premiums.html

Oregon Tests iPads as Aid to Disabled Voters

November 16, 2011
The New York Times
By KATHARINE Q. SEELYE

Could the iPad someday supplant the voting machine?

Oregon last week became the first state in the country to use iPads to allow people with disabilities to vote, and it intends to use them again for another election in January. Several other states are expected to follow suit with iPads or other tablets, possibly as early as for next year’s presidential election.

In a special primary election in five counties in Oregon, 89 people with disabilities marked their ballots on an iPad. They did not actually cast their votes online — Internet voting is an idea whose time has not yet come, several elections officials said.

Rather, these voters used iPads, brought to their homes or nursing homes by election workers, to call up their ballots, mark them on-screen and print them out on a portable wireless printer. The voters or assistants then either mailed in the printed ballots or dropped them off at election stations.

One woman, who has impaired vision, was able to enlarge the print on her ballot so that she could see the names of candidates. A man with arthritis who could not hold a pen was able to touch the screen with his finger and mark his ballot.

“The goal was to make voting accessible and convenient for voters with disabilities, and the iPad does exactly that,” said Kate Brown, Oregon’s secretary of state.

For the Jan. 31 election, she said, voters with disabilities will have even more iPad options: those who cannot use their hands, for example, can use a tube to activate software that lets them call up the ballot and mark it. They will be able to attach their own joysticks or paddles. The iPad can also translate the ballot for those who do not speak English, and read it out to the blind.

Ms. Brown said that the state tried out several different tablets and devices at a conference this year and found that people with disabilities preferred the iPad.

Jim Dickson, vice president for government affairs at the American Association of People With Disabilities, commended Oregon’s experiment. “Is the iPad perfect?” he said. “No. But it is an important step forward.” One challenge is that the visually impaired cannot read the printouts of their ballots to verify them.

Election workers found the iPad and wireless printers more convenient than the computer stations that they had previously dragged to homebound voters.

Ms. Brown said that if the experiment went as well in January — when voters in five counties will choose a replacement for Representative David Wu, a Democrat who resigned after a sex scandal — she expected to expand the program statewide.

Other states are interested, too. “It’s definitely a direction we’re moving in,” said Shane Hamlin, co-director of elections for Washington State, although he said it was too early to say whether tablet voting might be available to all voters or just those with disabilities.

But he said that in the long run, voting by iPad or a similar device could save money, considering the costs of maintaining, storing and updating regular voting machines.

Lori J. Steele, chief executive officer of Everyone Counts, the California company that developed the software used by Oregon, said she expected that a half-dozen states would be using iPads or similar tablets for people with disabilities in next year’s presidential election.

“Oregon is the model for what states could and will be doing in the next few years,” she said. “I can see the transformation as old equipment becomes obsolete.”

    Oregon Tests iPads as Aid to Disabled Voters, NYT, 16.11.2011,
    http://www.nytimes.com/2011/11/17/us/oregon-tries-out-voting-by-ipad-for-disabled.html

Health Reform and the Supreme Court

November 14, 2011
The New York Times

The Supreme Court’s decision to review the constitutionality of health care reform means it will be issuing a ruling in the middle of the 2012 presidential campaign. This can be a highly politicized court, and, for the public good and its own credibility, it must resist that impulse.

If the court follows its own precedents, as it should, this case should not be a close call: The reform law and a provision requiring most people to obtain health insurance or pay a penalty are clearly constitutional.

The court agreed to hear appeals from a ruling by the United States Court of Appeals for the 11th Circuit, which struck down the individual mandate to buy health insurance but left other parts of the law standing. Opponents of the law contend that Congress went beyond its authority in the reform measure. But Congress, under the commerce clause, plainly has the power to regulate the national health care market.

Almost everyone needs health care at some point, and if uninsured people are unable to pay steep medical bills they will get charity care that shifts the costs to others, whose insurance premiums go up to cover the cost of the free riders. There is no denying the health care market is interconnected and that individuals’ decisions to purchase insurance — or not — affects the whole system.

Republican-appointed judges on two appellate courts have found the insurance mandate constitutional. They have cogently pointed out that past Supreme Court decisions have upheld federal laws that were much more intrusive on personal liberty and involved activities less clearly relevant to interstate commerce. These include rulings on laws that prohibit a farmer growing wheat for his own family’s use and a woman growing marijuana for her own medicinal use. There is also no doubt that Congress has the authority to set minimum-wage rates and other laws that affect an individual’s economic decisions. As Judge Laurence Silberman of the United States Court of Appeals for the District of Columbia Circuit wrote last week in upholding the health reform law, “the right to be free from federal regulation is not absolute, and yields to the imperative that Congress be free to forge national solutions to national problems, no matter how local — or seemingly passive — their individual origins.”

In addition to reviewing the mandate, the Supreme Court will also consider three other questions: whether other parts of the law are voided if the mandate is struck down; whether a decision must be put off until 2015 when the first penalties by noncompliant individuals would be paid; and whether Congress can require states to expand Medicaid programs in 2014.

If the justices were to strike down the mandate, they would have to consider whether that provision can be eliminated without excising some or all of the rest of the law. Without the mandate, it will be difficult for health insurers to accept all applicants and charge them premiums without regard to their health status. But there is no constitutional reason to strike down those other popular insurance reforms.

The reform law’s expansion of Medicaid coverage to many individuals who are not now covered also has been challenged by the states as unconstitutional coercion because they claim to have no option but to comply. In rejecting that argument, the 11th Circuit noted that the federal government would bear most of the costs of the program’s expansion. Moreover, it found that the states had ample powers to develop alternative programs if they want to drop out of Medicaid.

All of these issues are best resolved in the political system, not the courts. The Supreme Court ought to show judicial restraint, adhere to precedent and uphold the constitutionality of health care reform.

    Health Reform and the Supreme Court, NYT, 14.11.2011,
    http://www.nytimes.com/2011/11/15/opinion/health-reform-and-the-supreme-court.html

Justices to Hear Health Care Case as Race Heats Up

November 14, 2011
The New York Times
By ADAM LIPTAK

WASHINGTON — The Supreme Court on Monday agreed to hear a challenge to the 2010 health care overhaul law, President Obama’s signature legislative achievement, setting the stage for oral arguments by March and a decision in late June as the 2012 presidential campaign enters its crucial final months.

The decision to hear the case prompted confident assertions from each side that it was sure to prevail, and gave rise to calculations about the complicated political impact of possible rulings.

The range of issues the court agreed to address amounted to a menu of possible resolutions: the justices could uphold the law, strike down just its most controversial provision or some or all of the rest of it, or duck a definitive decision entirely as premature.

Whatever the outcome, the tensions running through the case — between the 26 states challenging the law and the federal government, and between Mr. Obama and the Supreme Court led by Chief Justice John G. Roberts Jr. — are likely to give rise to both a political and constitutional blockbuster.

The court’s decision to step in had been expected, but Monday’s order answered many questions about just how the case would proceed. Indeed, it offered a road map toward a ruling that will help define the legacy of the Roberts court while focusing renewed political attention on the law that has sharply divided Republicans and Democrats.

The court scheduled five and a half hours of arguments instead of the usual one, a testament to the importance of the case, and the court’s ruling a few months later will present opportunities and challenges for the presidential contenders as well as for candidates in the battle for control of Congress.

It is hardly clear, for instance, that a Supreme Court ruling upholding the law would help only Mr. Obama, as opponents of the law might redouble their efforts to elect candidates committed to repealing it. And a decision striking down the law might allow Mr. Obama to court voters unhappy with the Supreme Court’s decisions as he did in cases like Citizens United, which allowed unlimited campaign spending from corporations and unions. Appeals from three courts had been vying for the justices’ attention, presenting an array of issues beyond the central one of whether Congress has the constitutional power to require people to purchase health insurance or face a penalty through the so-called individual mandate.

The Supreme Court agreed to hear appeals from just one decision, from the United States Court of Appeals for the 11th Circuit, in Atlanta, the only one so far striking down the mandate. The decision, from a divided three-judge panel, said the mandate overstepped Congressional authority and could not be justified by the constitutional power “to regulate commerce” or “to lay and collect taxes.”

The appeals court went no further, though, severing the mandate from the rest of the law.

On Monday, the justices agreed to decide not only whether the mandate is constitutional but also, if it is not, how much of the balance of the law, the Patient Protection and Affordable Care Act, must fall along with it.

But even the Obama administration has said that the mandate is “absolutely intertwined” with two other provisions — one forbidding insurers to turn away applicants, and the other barring them from taking account of pre-existing conditions.

In a statement issued soon after the decision, the administration reaffirmed its position that the Constitution permitted Congress to enact the mandate.

“We know the Affordable Care Act is constitutional and are confident the Supreme Court will agree,” said Dan Pfeiffer, the White House communications director.

Pam Bondi, Florida’s attorney general, said she welcomed the court’s prompt action in agreeing to review the 11th Circuit’s decision, in which her state was the lead plaintiff.

“Throughout this case,” Ms. Bondi said, “we have urged swift judicial resolution because of the unprecedented threat that the individual mandate poses to the liberty of Americans simply because they live in this country.”

Representative Nancy Pelosi of California, the House Democratic leader, said a decision upholding the law would mean that “Americans will benefit from lower health care costs and greater access to high-quality medical care.”

But leading opponents of the law said they were confident they would triumph.

“It is high time for the high court to strike down this unconstitutional, unworkable and unpopular law,” said Randy E. Barnett, a law professor at Georgetown.

The 11th Circuit did rule against Florida and the other states on one of their other central arguments, rejecting a challenge to the law’s expansion of the Medicaid program.

The Supreme Court also agreed to hear an appeal from that ruling.

The states, represented by Paul D. Clement, a former United States solicitor general, argued that Congress had exceeded its constitutional authority by expanding the eligibility and coverage thresholds that states must adopt to remain eligible to participate in Medicaid.

The problem, Mr. Clement wrote, was that “Congress did not tie its new conditions only to those additional federal funds made newly available under” the Affordable Care Act. “It instead made the new terms a condition of continued participation in Medicaid, thereby threatening each state with the loss of all federal Medicaid funds — on average, more than a billion dollars per year — unless it adopts the act’s substantial expansions of state obligations.”

The justices also said they would consider an intriguing threshold issue that could conceivably postpone any definitive ruling on the mandate until 2015.

In September, a divided three-judge panel of the United States Court of Appeals for the Fourth Circuit, in Richmond, Va., ruled that it was premature to decide the case in light of the Anti-Injunction Act, a federal law that bars suits “for the purpose of restraining the assessment or collection of any tax.” The Supreme Court had interpreted the term “tax” very broadly for purposes of the law.

If the Fourth Circuit ruling is correct, individuals may not challenge the individual mandate until the first penalty is due in April 2015.

On Nov. 8, a dissenting judge on the United States Court of Appeals for the District of Columbia Circuit also endorsed that position.

The administration had initially pressed but later abandoned the argument.

In the Supreme Court, the Justice Department suggested that the court consider the issue and perhaps appoint a lawyer to present arguments in favor of it, as the court occasionally does when the parties agree on a significant issue that could alter the outcome of the eventual decision. The court did not say on Monday whether it would make such an appointment, but the prospect seems likely.

The justices will hear two hours of argument on whether Congress overstepped its constitutional authority, 90 minutes on whether the mandate may be severed from the balance of the law if Congress did go too far, and an hour each on the Medicaid and Anti-Injunction Act questions.

In all, the Supreme Court agreed to hear three appeals, two from challengers to the law and a third from the Obama administration.

The appeals involving the 26 states is known as Florida v. Department of Health and Human Services, No. 11-400. A second challenge, from a business group and two individuals, is called National Federation of Independent Business v. Sebelius, No. 11-393. The federal government’s appeal is Department of Health and Human Services v. Florida, No. 11-398.

There was no indication in Monday’s order that any of the justices had decided to disqualify themselves from the case. Such a notation is customary when justices have decided not to participate.

There have been calls for Justice Clarence Thomas to step aside, based on activities of his wife, Virginia, in groups opposed to the law. Others have said Justice Elena Kagan should not hear the case if she had any involvement in the health care lawsuits when she was United States solicitor general. But she apparently took pains to avoid working on them.

    Justices to Hear Health Care Case as Race Heats Up, NYT, 14.11.2011,
    http://www.nytimes.com/2011/11/15/us/supreme-court-to-hear-case-challenging-health-law.html

The Tobacco Horror Show

November 14, 2011
9:00 pm
The New York Times
By STANLEY FISH

I’m sure you’ve noticed those TV ads for pharmaceutical products that include an incredibly long list of side effects and possible hazards recited by a cheerful voice as men and women are shown living the happy lives made possible by a drug that can inflict on them everything from bloating and joint pain to death. This combination of positive and negative communications is mandated by the government requirement that drug manufacturers must disclose all the risk factors attending the product they are hawking.

The result is what one might call the “battle of information.” The drug companies are providing information about the benefits of their product, and under duress (it would not be their choice to do this) they are also providing information about the dangers of that same product. It is their hope that the positive message will have more impact than the negative one, and that hope is supported by the fact that they get to tell their happy story in images (look what this drug can do for you), while the other, distressing story (hear what this drug can do to you) is conveyed by words. The companies are counting on the fact that not all information-delivery systems are equal and, as the old proverb goes, a picture is worth a thousand words.

The same dynamics are on display in a case decided on Nov. 7 in the United States District Court for the District of Columbia, but the positions are reversed: it is the government that is deploying images and the drug companies — in this case tobacco companies — that are standing up for words.
FDA, via/European Pressphoto AgencyAn example of an ad campaign warning people about smoking.

The case — R. J. Reynolds et al v. United States Food and Drug Administration — concerns the F.D.A.’s plan to augment the textual warnings on cigarette packages with graphic color images, including diseased lungs, a cadaver on an autopsy table and a man blowing smoke from a hole in his throat. The tobacco companies requested an injunction on the implementation of the plan until certain constitutional matters could be resolved in the courts. They argued that the “mandatory graphic images unconstitutionally compel speech”; for were they in place every cigarette package would be a “mobile billboard” for a message the companies did not choose to proclaim, but one they were required to display and, in effect, pay for. (This of course would not be materially different from the list of risk factors drug manufacturers are required to insert in ads they pay for.)

The companies also claim that “the purpose and effect of the warnings is to drown out Plaintiff’s own constitutionally protected speech and replace it with the Government’s emotionally-charged anti-smoking message.” “Emotionally-charged” is the key phrase here. The companies do not object to particular images, but to the use of images at all because they speak to the emotions and, in this instance, are “designed to shock, disgust and frighten” rather than “provide purely factual and uncontroversial information.”

But is the producing of an effect, even of an effect that is visceral, unrelated to the communication of information? Maybe yes if we’re talking about a horror movie where the eliciting of shock, disgust and fear is the entire point. That’s what people go to horror movies for — to experience an emotional rollercoaster that is unattached to any cognitive message.

In the case of the tobacco warnings, however, the emotions intentionally produced by the graphic images bring a cognitive message home. It is in fact a horror-message — if you smoke, all kinds of horrible things are likely to happen to you — and it is the government’s judgment, expressed in its brief, that the print warnings we are now accustomed to have become “stale” and no longer “convey [the] relevant information in an effective way,” no longer, that is, convey the message.

Of course, the tobacco industry has lived with print warnings for a long time and is fully aware of how humdrum they have become. What alarms them is the specter (another kind of horror show) of warnings that might really convey the relevant information effectively. What alarms them is not that the proposed images distort the truth, but that they tell it. “Ultimately,” the government’s brief concludes, “plaintiff’s objection to the pictorial health warnings is not that they are false, but that they are true.”

Given that the conveying of true information about the risks of a legal product has been held constitutional even when the government burdens a manufacturer’s delivery of its message, one would have expected the government to prevail. But is does not. Judge Richard J. Leon issued the injunction sought by the tobacco companies and gave as a reason the illegitimacy of images as conveyers of information: “[T]he government’s emphasis on the images’ ability to provoke emotion strongly suggests that the government’s actual purpose is not to inform, but rather to advocate a change in consumer behavior.” And again, “the graphic warnings cross the line from information to advocacy.”

This is wrong in both directions. Images can inform and the bare recital of information can advocate by appealing to the emotions. The line Leon wants to draw is, at best, a blurry one, as is his contrast (borrowed from the plaintiff’s brief) between images “calculated to provoke the viewer to quit” and “disseminating purely factual and uncontroversial information.” It takes only a second’s thought to undermine the contrast. Is the factual and uncontroversial assertion that “ smoking can kill you” (one of the new print warnings) without persuasive intent or effect? “Oh, I just thought I’d tell you that smoking kills and can harm your children. Nothing hortatory on my mind, just sayin’.” And just as the information that smoking kills is offered with the intention to “provoke” the informee to quit, so is the image of a cadaver on a slab offered with the intention of conveying a piece of factual and uncontroversial information — smoking kills.

Leon regards that image as non-factual and therefore controversial because, he says, the government does not offer “a single shred of evidence to support the proposition that smoking causes autopsies.” But the proposition is not that smoking causes autopsies, it’s that smoking causes death, and there’s plenty of evidence of that. In order to draw from the image the conclusion he wants to reach, Leon must read it in an obtusely literal way as claiming that every time a cadaver lies on an autopsy table it has been brought there by smoking.

The claim, however, is at once narrower in scope and less controversial, in fact not controversial at all: if you continue smoking, one of the things likely to happen is that you’ll end up on a slab. The image of the cadaver stands in for death, for the proposition that smoking kills. It is an example of metonymy, a figure of speech in which a thing or concept — in this case death — is not presented directly but by reference to something — the condition of being in a morgue — with which it is closely associated. As a figure of speech, metonymy operates at a remove from the object it points us to; it requires an inference. But the inference, once made (and it is no trick at all to make it), puts us in direct and forceful contact with an uncontroversial fact.

If Leon’s objection to the image were taken seriously, if assertions of fact could be made only in the absence of figures of speech — no metonymies, allusions, metaphors, comparisons, similes, patterned repetitions and a thousand other deviations from an impossible literalism — the account of even a single fact would fill 300 pages. As John McEnroe is fond of saying, “you cannot be serious.”

But apparently Judge Leon is serious and one can only wonder why. The answer given on some left-wing blogs is that he is in the pocket of the tobacco industry. But a more generous and analytic answer might point to a very old philosophical/theological tradition in which he enrolls himself, perhaps unwittingly. That tradition is marked by two related oppositions. The first opposes the verbal to the visual and stigmatizes the latter as the medium of deception and false appearances. Aristotle’s distrust of spectacle (opsis) founds an anti-theatrical prejudice that finds a high (or low) watermark in Stephen Gosson’s “School of Abuse” (1579) and Ben Jonson’s invectives against the set designer Inigo Jones. The theological counterpart to this prejudice is derived from the second commandment (“thou shalt not make unto thee any graven image”) and 1 John 2:16: “For all that is in the world, the lust of the flesh, and the lust of the eyes, and the pride of life is not from the Father, but is from the world.” The fruits of these texts can be seen in the periodic eruption of iconoclastic frenzy.

The second opposition in the tradition is located within the realm of the verbal itself. The literal, identified with pure observation and description, is opposed to the rhetorical, identified (again) with deception and with a surrender to the lure of surfaces and to base emotional appeals.

Either singly or in combination, the two binaries — words vs. images and literal, information-bearing words vs. words aiming to persuade — have led to a search for what Thomas Kuhn has called a “neutral observation language,” a super-literal language uninflected and uninfected by the distortions of any human, or as Leon terms it, “subjective” perspective. Although there have been innumerable attempts to come up with such a language — from the efforts to recover the language of Eden, to the linguistic reforms (no figures of speech) proposed by England’s Royal Society in the 17th century, to the 20th century logical positivists, to the construction of artificial languages with universalist ambitions like Esperanto — it has never been found and never will be found. One could say, then, that Judge Leon’s reasoning and the decision it leads to are based on a linguistic mirage, a will o’ the wisp, although the damage the decision might allow to be done, if it is upheld, is no mirage at all.

    The Tobacco Horror Show, NYT, 14.11.2011?
    http://opinionator.blogs.nytimes.com/2011/11/14/the-tobacco-horror-show/

Evelyn H. Lauder,

Champion of Breast Cancer Research,

Dies at 75

November 12, 2011
The New York Times
By CATHY HORYN

Evelyn H. Lauder, a refugee of Nazi-occupied Europe who married into an illustrious family in the beauty business and became an ardent advocate for breast cancer awareness, raising millions for research, died on Saturday at her home in Manhattan. She was 75.

The cause was nongenetic ovarian cancer, said Alexandra Trower, a spokeswoman for the Estée Lauder Companies.

As the wife of Leonard A. Lauder, the chairman emeritus of the Estée Lauder Companies, and as the daughter-in-law of the company’s formidable matriarch, Estée Lauder, Evelyn Lauder had to establish her own place in a family as complex as it was competitive.

Mrs. Lauder frequently told the story of how, early in her marriage, she returned to the couple’s apartment to find that Estée had rearranged the furniture more to her liking. When Evelyn and Leonard were dating — it was only their second date — Estée implored her to stay and be the hostess for a birthday party she was giving her son.

“So I stayed,” Mrs. Lauder said in an interview in 2008. “What could I do? She was like a steamroller.”

Yet it was clear that Estée was crazy about the young woman, and soon after Evelyn’s marriage, in 1959, she joined the family cosmetics company, then a small enterprise, pitching in wherever she was needed.

“I was very strong,” she said. “Having had a childhood like the one I had, I was much more tough than a lot of people. I was one of the few people who spoke my mind to Estée.”

Mrs. Lauder learned she had breast cancer in 1989 and soon became a strong voice on behalf of women’s health, though she was always reluctant to discuss her own condition. “My situation doesn’t really matter,” she told a reporter in 1995.

She was a creator of the Pink Ribbon campaign, a worldwide symbol of breast health, and in 1993 she founded the Breast Cancer Research Foundation, which has raised more than $350 million.

In 2007 she received a diagnosis of ovarian cancer, which developed independently of her breast cancer, Ms. Trower said.

Evelyn Hausner was born on Aug. 12, 1936, in Vienna, the only child of Ernest and Mimi Hausner. Her father, a dapper man who lived in Poland and Berlin before marrying the daughter of a Viennese lumber supplier, owned a lingerie shop. In 1938, with Hitler’s annexation of Austria, the family left Vienna, taking a few belongings, including household silver, which Ernest Hausner used to obtain visas to Belgium.

The family eventually reached England, where Evelyn’s mother was immediately sent to an internment camp on the Isle of Man. “The separation was very traumatic for me,” Mrs. Lauder said. Her father placed her in a nursery until her mother could be released and he could raise money. In 1940, the family set sail for New York, where her father worked as a diamond cutter during the war.

In 1947, he and his wife bought a dress shop in Manhattan called Lamay. Over time they expanded it to a chain of five shops.

Mrs. Lauder grew up on West 86th Street and attended Public School 9. During her freshman year at Hunter College, she met Leonard Lauder on a blind date. Already graduated from college and training to be a naval officer, Mr. Lauder had grown up on West 76th Street, though in a sense it was a world apart. “He was the first person who took me out to dinner in a restaurant,” she recalled. They married four years later at the Plaza Hotel.

Though always at home by 4 p.m. when her two children were little, Mrs. Lauder said she never considered being a stay-at-home mom, in spite of the family’s growing wealth. “I couldn’t bear it,” she said. “I grew up with a working mother.” Mrs. Lauder was also a public school teacher for several years.

She held many roles at Estée Lauder, including creator of training programs and director of new products and marketing. In 1989, the year of her breast cancer diagnosis, she became the senior corporate vice president and head of fragrance development worldwide.

Mrs. Lauder is survived by her husband; her sons, William and Gary; and five grandchildren.

Though Mrs. Lauder, an avid photographer, had a home in Colorado and a penthouse on Fifth Avenue lined with modern art, she and her husband liked to retreat to a plain cabin in Putnam County, N.Y., where Mrs. Lauder might serve guests German food she had prepared.

Asked once how she felt about working with her husband in the early days, she replied, “Working with Leonard was a riot.” Indeed, she joked that he had such a sense of business, without family favoritism, that getting an appointment with him was sometimes tough. “It would take me much longer to get a date with him,” she said, “than someone who didn’t have his name.”

    Evelyn H. Lauder, Champion of Breast Cancer Research, Dies at 75, NYT, 12.11.2011,
    http://www.nytimes.com/2011/11/13/nyregion/evelyn-h-lauder-champion-of-breast-cancer-research-dies-at-75.html

Seeking a Cure for Troubled Hospitals in Brooklyn

November 9, 2011
The New York Times
By NINA BERNSTEIN

When the pain in his groin was too great to bear, Ralph Hutchins, who works as a mover, headed to the crowded emergency room at the nearest hospital one recent Tuesday, his life at risk. Tanya Boynton, a mother of four who works 12-hour shifts, hobbled into another emergency room from a homeless shelter, afraid illness would end her job.

They needed care in the heart of Brooklyn, not far from the world’s richest concentration of premier hospitals. Only a few private hospitals have survived in neighborhoods like Bedford-Stuyvesant, Brownsville and Bushwick to serve poor patients like them. Now all are in such dire financial shape that a small group of veteran health care planners appointed by Gov. Andrew M. Cuomo is debating last-ditch measures to save them.

For decades, the fallback solution in American cities has been to close such hospitals.

But one of the actions being considered by the group may be even more radical: expunge the hospitals’ debt of more than $1 billion, partly at taxpayer expense, and then let large for-profit companies take over the facilities and restructure patients’ care. Experts say what ultimately becomes of the hospitals could make them a model, or a disastrous experiment, in the delivery of health care to the poor.

The proposals are still being drafted but are already generating concern among public health advocates, who worry that the changes would shred a frayed medical safety net and send the poorest and uninsured patients to other overwhelmed hospitals, especially to three public hospitals that are at capacity and facing new budget cuts.

Proponents say this fear is unfounded. But it runs deep in New York State, which added a right to health care to its constitution during the Great Depression, and is the only state that still prevents large companies and their stockholders from owning hospitals.

“If we don’t figure out a way to redesign the system, we’re going to have free-fall bankruptcies not only in Brooklyn, but all over the state,” said Stephen Berger, chairman of Mr. Cuomo’s Brooklyn Work Group. Its recommendations are due this month.

Brooklyn shows the acute stage of a problem that has vexed the nation for years: how to sustain delivery of major medical care to the poor. After the crack and H.I.V. epidemics of the 1980s, either shrinking hospitals with empty beds or letting them fail was seen as a way to make the system more efficient. But as big cities lost more than half their hospitals, closings were concentrated in places like central Brooklyn, where the bed-to-population ratio is now below state and national averages and busy hospitals are struggling financially despite high occupancy rates.

Kings County Hospital Center, Woodhull Medical and Mental Health Center and the State University of New York Downstate Medical Center, the three public hospitals in the area, could shoot up to as much as 130 percent of capacity and face a third more emergency room visits if even one or two of the most vulnerable private hospitals closed, according to a study submitted to the Berger group by the union representing interns and residents at public and private hospitals.

Alan Aviles, the president of New York City’s public hospital system, said it was making contingency plans for such a flood but could not go it alone, particularly since the collapse of the city’s Roman Catholic hospital network.

“We have to make sure that we still have voluntary safety net hospitals that are capable of sharing in that effort,” he said, noting that city hospitals already provided 75 percent of all outpatient care to the uninsured.

To stay healthy, experts say, even nonprofit private hospitals need a 3 percent profit margin. Only two of Brooklyn’s 10 private hospitals are doing that well, and of the five considered endangered — Interfaith Medical Center, Wyckoff Heights Medical Center, Brookdale University Hospital and Medical Center, Kingsbrook Jewish Medical Center and Brooklyn Hospital Center — some are hemorrhaging money.

Questions about mismanagement hang over some of these institutions, but analysts agree on the basic problem: Most of their patients rely on Medicaid, the government insurance program for the needy, which has been repeatedly cut as eligibility expanded.

There is no confidence that the national health care overhaul will help. Indeed, federal cuts expected through 2013 will disproportionately hurt the same hospitals. In neighborhoods with mainly black and Latino residents, in a borough of 2.5 million where more than one in five residents live below the poverty line and two in five receive Medicaid, the five endangered hospitals account for 83,000 admissions, 325,000 emergency room visits and 760,000 clinic visits a year.

The case of Mr. Hutchins, who showed up at Wyckoff, illustrates the strain. It was the third time in two months he sought help, he said. This time, at his insistence, the hospital admitted him.

Surgery revealed a strangulated hernia so far gone that cutting out life-threatening infected tissue left an open wound, he said.

Cost efficiency demanded speedy discharge; last year, Medicaid cut by 31 percent what it would pay for a case like his. But before Mr. Hutchins could be released, the hospital had to get him a portable wound pump.

At hospitals that pay suppliers promptly, administrators say, the device typically gets same-day delivery. At Wyckoff, it took a week.

Wyckoff’s general counsel, David Hoffman, said the hospital was like a homeowner with an underwater mortgage. Its buildings are worth a fraction of the $88 million it owes on a $140 million state loan, used in 1994 to rebuild. Its reserves are gone.

Such hospitals have not benefited from recent gentrification in Brooklyn. Affluent newcomers typically keep ties with their Manhattan doctors, who send them to hospitals there with the prestige to get top dollar from private insurance plans.

In 1980, Brooklyn had 26 hospitals; now it has 15, and 41 percent fewer acute-care beds — 2.3 beds per 1,000 residents, compared with Manhattan’s 4.7, the state’s 3.1 and the nation’s 2.6.

That pattern has played out nationwide, said Alan Sager, a professor of health policy and management at Boston University who has analyzed decades of hospital closings in 52 cities.

Professor Sager found that what best predicted that a hospital would be closed was not inefficiency, but location in a minority neighborhood, and for-profit hospitals were likeliest to close.

Proposals to save the Brooklyn survivors include a federal waiver that could redirect state Medicaid savings to so-called safety net hospitals, and a push for additional mergers. Another idea is making one or more of the hospitals a free-standing emergency department, a concept being tried at the defunct St. Vincent’s Hospital in Greenwich Village.

The proposal requiring the most salesmanship, and possibly a change in law, would leave taxpayers, bondholders and other creditors to absorb the hospitals’ net debt and then invite investors into a reformulated health care network.

Steven Moore, an executive with PricewaterhouseCoopers, the consultants invited by Mr. Berger to sketch out this proposal, likened Brooklyn’s indebted hospitals to banks with toxic assets, and suggested a bailout first. “Our premise is you have to design a system that will attract private capital,” Mr. Moore said. “Private capital is more efficient, it demands productivity, it demands creativity, it demands innovation.”

It also demands profits. Many experts doubted the proposal’s contention that 20 percent to 30 percent waste could be safely carved from Medicaid spending in Brooklyn to yield a reliable return of about 7 percent.

At the Greater New York Hospital Association, the lobbying group for hospitals, board members worried about people without insurance, particularly the city’s many illegal immigrants. Getting rid of toxic assets — hospitals’ debt — would not solve the problem of patient mix and revenue, said Kathleen Shure, an association executive, and “the board fears that it will end up in for-profit entities getting rid of ‘toxic populations.’ ”

Mr. Berger, an investment banker and veteran of health commissions, is impatient with such objections. “Health care is not hospitals,” he said. “Health care is an integrated system, a network,” one that requires new patterns of investment.

By law, hospitals must provide emergency care. But it is unclear what that might mean in a reformulated for-profit system, particularly for people in pain who damage the bottom line, like Ms. Boynton, 40, who limped into Interfaith with what turned out to be an acute attack of gout the same day Mr. Hutchins went to Wyckoff.

She would have preferred the Bronx clinic in her Medicaid managed-care plan, but her family had been evicted from its Bronx apartment after the landlord failed to make repairs required for a housing subsidy. At Interfaith, she got a three-day prescription that put her back on her feet and commuting, from a Brooklyn homeless shelter to her $300-a-week job at a home goods store on the Upper West Side of Manhattan.

Mr. Hutchins, 50, now discharged, is also on the mend. The hospital’s prognosis is more guarded.

“We stay open at the grace and generosity of our vendors,” said Mr. Hoffman, Wyckoff’s general counsel. “They know it will eventually get better, because we have to have hospitals. Otherwise, we’ll have sick and dying people lying in the streets, and nobody wants that.”

    Seeking a Cure for Troubled Hospitals in Brooklyn,, NYT, 9.11.2011,
    http://www.nytimes.com/2011/11/10/nyregion/strained-brooklyn-hospitals-are-subject-of-cuomo-study-group.html

Study Debunks Operation to Prevent Strokes

November 8, 2011
The New York Times
By DENISE GRADY

An operation that doctors hoped would prevent strokes in people with poor circulation to the brain does not work, researchers are reporting. A $20 million study, paid for by the government, was cut short when it became apparent that the surgery was not helping patients who had complete blockages in one of their two carotid arteries, which run up either side of the neck and feed 80 percent of the brain.

The surgery was a bypass that connected a scalp artery to a deeper vessel to improve blood flow to the brain.

The new study, published on Wednesday in The Journal of the American Medical Association, is the second in recent months to find that a costly treatment, one that doctors had high hopes for, did not prevent strokes. In September, researchers reported that stents being used to prop open blocked arteries deep in the brain were actually causing strokes. That study was also cut short.

Both the stents and the bypass operation seemed to make sense medically, and doctors thought they should work. Their failure highlights the peril of assuming that an apparent improvement on a lab test or X-ray, like better blood flow or a wider artery, will translate into something that actually helps patients, warned an editorial that accompanied the new findings. Only rigorous studies can tell for sure.

The editorial writer, Dr. Joseph P. Broderick, chairman of neurology at the University of Cincinnati College of Medicine, also cautioned that other stroke treatments were being used without sufficient study, particularly devices to remove clots. Dr. Broderick said doctors liked new technology, were paid well to use it and tended to believe in what they were doing, even without data.

The bypass operations were performed at 49 hospitals in the United States and Canada. All the patients given the surgery had had a stroke or transient ischemic attack (sometimes called a mini-stroke) during the previous 120 days, and were at high risk for another stroke. About 24,000 people a year in the United States were thought to be candidates for the operation.

But the study found that people who had the surgery, plus a strict regimen of drugs to lower their risk of stroke, fared no better than those who received the drugs alone. The drugs work by preventing blood clots and lowering cholesterol and blood pressure.

The surgery costs about $40,000, probably 10 times the price of a year’s worth of medicine to reduce the risk of stroke, according to Dr. William J. Powers, the lead author of the study and chairman of neurology at the University of North Carolina in Chapel Hill. But a successful operation would have been well worth the cost, Dr. Powers said, because it is even more expensive to take care of people who have suffered severe strokes.

Dr. David Langer, a brain surgeon and associate professor at the Hofstra North Shore-Long Island Jewish School of Medicine, said the study was well done and important.

“Surgeons don’t want to be doing bad operations,” Dr. Langer said. “Whenever you have a paper like this, we’re all disappointed, because we like to operate. But in the end it’s a good thing.”

Dr. Langer predicted that the new information would lead to a reduction in the use of the bypass operation but would not wipe it out entirely because some patients, different from those in the study, could still be helped by it.

The new research was an effort to improve on an earlier study, published in 1985, which also found that the bypass operation did not work. Those results led Medicare to stop covering the operation for people with blocked carotids.

But many doctors had seen individual patients who seemed better after the surgery, and researchers wondered if the earlier study might have included too few high-risk patients who really might be helped by the surgery.

So this time, researchers used a sophisticated scanning technique to identify the 30 percent of patients with blockages who also had extremely low blood flow to the brain, a condition that a French researcher named “misery perfusion.” Only people with the lowest flow were included in the study; 97 received surgery and drugs, and 98 drugs alone. The researchers then monitored strokes.

After two years, there was no statistical difference between the two groups. In the surgery group, 21 percent had strokes, compared with 22.7 percent in the medicine-only group. A statistical analysis found that no benefit was likely to emerge even if the study went on, so it was stopped. The original plan would have treated about 180 more patients and cost an additional $10 million to $15 million, Dr. Powers said.

“I’ve probably put 30 years of my life into this question,” he said, but added that stopping the study was the right decision “if there is literally no chance we’re going show the surgery works.”

Tests showed that technically the operation did what it was supposed to do: it improved blood flow to the brain. So why weren’t patients who had the surgery better off? It was because the operation itself caused strokes: 14.4 percent of the surgical patients had a stroke within a month of the operation, compared with a stroke rate of only 2 percent in the nonsurgical group during their first month in the study.

After the first month, surgical patients actually did have fewer strokes than would have been expected without the surgery — but any advantage was canceled out by the high stroke rate during that first month.

Dr. Powers said that the researchers pored over their data to see if they could find some clue to predict which patients would be most likely to have strokes soon after the surgery.

“We looked at 50 different factors to see if we could identify those people, and we couldn’t,” he said.

He said that the idea that patients could be helped by improved blood flow was still valid — but that researchers had to find a safer way to do it.

It was a letdown to find out that the operation did not work, Dr. Powers said.

“I like to tell myself that what was important was to get the answer,” he said. “Do I wish it had worked? Of course, because what we really want to do here is take better care of people. It’s a disappointment that after all this work we’re still no better at helping these people.”

    Study Debunks Operation to Prevent Strokes, NYT, 8.11.2011,
    http://www.nytimes.com/2011/11/09/health/research/surgery-to-prevent-strokes-is-found-ineffective.html

Court Blocks Graphic Labels on Cigarette Packs

November 7, 2011
The New York Times
By DUFF WILSON

A federal judge on Monday blocked a Food and Drug Administration requirement that tobacco companies put big new graphic warning labels on cigarette packages by next September.

In a preliminary injunction, Judge Richard J. Leon of United States District Court in Washington ruled that cigarette makers were likely to win a free speech challenge against the proposed labels, which include staged photos of a corpse and of a man breathing smoke out of a tracheotomy hole in his neck.

The judge ruled that the labels were not factual and required the companies to use cigarette packages as billboards for what he described as the government’s “obvious anti-smoking agenda!”

The 29-page ruling was a setback for Congressional and F.D.A. efforts to bolster the warnings on tobacco packages. The agency has said they are the most significant change to health warnings in 25 years.

The Justice Department is reviewing the ruling, a spokesman, Charles S. Miller, said. The F.D.A. declined to comment, a spokeswoman said.

If the ruling is appealed — as both sides expect — it would join a different federal judge’s ruling on similar issues on appeal and raise the possibility that the issue will be decided by the United States Supreme Court.

Floyd Abrams, a New York lawyer and First Amendment specialist who argued the case for Lorillard Tobacco of Greensboro, N.C., praised the ruling. He said the companies had just objected to “grotesque” images, but not to new words of warning.

“It’s basically rooted in the notion that compelled speech by the government is presumptively unconstitutional,” Mr. Abrams said. “The only exception that could fit here is the one which says that the government can require warnings to be placed on products including tobacco products, but that the warnings must be factual and uncontroversial in nature.”

Five tobacco companies had challenged the selection of nine specific graphic warnings as an unconstitutional intrusion on commercial free speech. The judge agreed with them on almost every point, saying the companies would suffer irreparable harm if the provision were enforced before it was fully decided in courts, a process that is likely to take years.

“It is abundantly clear from viewing these images that the emotional response they were crafted to induce is calculated to provoke the viewer to quit, or never to start, smoking: an objective wholly apart from disseminating purely factual and uncontroversial information,” Judge Leon wrote.

“At first blush, they appear to be more about shocking and repelling than warning,” Judge Leon added in a footnote.

Antismoking activists called on the Justice Department to appeal immediately.

“This ruling presents a direct and immediate threat to public health,” Charles D. Connor, president and chief executive of the American Lung Association, said in a statement. “The tobacco industry’s efforts to halt the replacement of cigarette warning labels that are 25 years old, ineffective and hidden on the side of packages, will result in more lives lost to tobacco.”

Matthew L. Myers, a lawyer and president of the Campaign for Tobacco-Free Kids, a Washington advocacy group, said Judge Leon had sympathized with tobacco companies during oral arguments.

“The government has been expecting this decision and will appeal,” Mr. Myers said. “In addition, many of the same issues are now pending before a panel of the United States Court of Appeals for the Sixth Circuit because a federal judge in Kentucky reached a decision different than Judge Leon’s decision today.”

In that case, Judge Joseph H. McKinley Jr. ruled the cigarette makers could be forced to put graphic images and warnings on the top half of their packages, as Congress required. But Judge Leon noted that Judge McKinley had not seen the actual proposed images.

Judge Leon was appointed to the bench in 2002 by President George W. Bush. Last year, Judge Leon also ruled against the F.D.A. over e-cigarettes, an electronic device that looks like a cigarette and delivers nicotine, saying they should be regulated as tobacco products rather than under the stricter regimen as drug delivery devices. The government has not appealed that case.

The Family Smoking Prevention and Tobacco Control Act of 2009 gave the F.D.A. authority for the first time to regulate tobacco products. It included a provision directing the F.D.A. to require larger, graphic warning labels covering the top half of the front and back of cigarette packs by Sept. 22, 2012, as well as 20 percent of print advertising.

The F.D.A. had studied 36 images and narrowed them down to nine after surveys of effectiveness. The photos are similar to some included with cigarettes in Canada. But the tobacco companies argued, and the judge agreed, that the F.D.A. could not prove the images would make a statistically significant difference in smoking rates in the United States.

“We are pleased with the judge’s ruling and look forward to the court’s final resolution of this case,” Bryan D. Hatchell, a spokesman for R.J. Reynolds Tobacco of Winston-Salem, N.C., makers of Camel cigarettes, said after the ruling.

Other plaintiffs in the suit are Commonwealth Brands, the Liggett Group, and Santa Fe Natural Tobacco. The Altria Group, parent company of Philip Morris, makers of the dominant brand of Marlboro cigarettes, did not join the lawsuit. Altria was also the only major cigarette maker to support the new legislation.

    Court Blocks Graphic Labels on Cigarette Packs, NYT, 7.11.2011,
    http://www.nytimes.com/2011/11/08/health/policy/court-blocks-graphic-labels-on-cigarette-packs.html

In State Care, 1,200 Deaths and Few Answers

November 5, 2011
The New York Times
By DANNY HAKIM and RUSS BUETTNER

For James Michael Taylor, an evening bath became a death sentence.

Mr. Taylor, who was 41 and a quadriplegic, had little more ability than a newborn baby to lift his head. Bathing him required the constant attention of a staff member at the group home for the developmentally disabled where he lived, near Schenectady, N.Y.

One summer night in 2005, a worker lowered Mr. Taylor into the tub, turned on the water and left the room. Over the next 15 minutes, the water slowly rose over his head. He drowned before anyone returned.

Joan Taylor, his mother, remembers the words her husband said as dirt was shoveled onto their son’s grave.

“This is the last time they’re going to dump on you,” he told his dead son.

James Taylor’s death was no aberration.

In New York, it is unusually common for developmentally disabled people in state care to die for reasons other than natural causes.

One in six of all deaths in state and privately run homes, or more than 1,200 in the past decade, have been attributed to either unnatural or unknown causes, according to data obtained by The New York Times that has never been released.

The figure is more like one in 25 in Connecticut and Massachusetts, which are among the few states that release such data.

What’s more, New York has made little effort to track or thoroughly investigate the deaths to look for troubling trends, resulting in the same kinds of errors and preventable deaths, over and over.

The state does not even collect statistics on specific causes of death, leaving many designated as “unknown,” sometimes even after a medical examiner has made a ruling.

The Times undertook its own analysis of death records and found disturbing patterns: some residents who were not supposed to be left alone with food choked in bathrooms and kitchens. Others who needed help on stairs tumbled alone to their deaths. Still others ran away again and again until they were found dead.

Mr. Taylor was hardly the only resident to drown in a bathtub. Another developmentally disabled man at a house run by the same nonprofit organization drowned in a tub four months earlier.

Through a Freedom of Information request to the State Commission on Quality of Care and Advocacy for Persons With Disabilities, The Times obtained data for all 7,118 cases of developmentally disabled people — those with conditions like cerebral palsy, autism and Down syndrome — who died while in state care over the past decade.

The data from the agency, which is responsible for overseeing treatment for the developmentally disabled, included only the broad “manner” in which people died — by homicide or suicide, accidents or natural causes.

By far the biggest category, other than natural causes, was “unknown,” accounting for 10 percent of all deaths in the system.

The records suggested problems in care may be contributing to those unexplained deaths. The average age of those who died of unknown causes was 40, while the average age of residents dying of natural causes was 54.

The Times reviewed the case files of all the deaths not resulting from natural causes that the commission investigated over the past decade and found there had been concerns about the quality of care in nearly half of the 222 cases.

The records also showed that problems leading to deaths rarely resulted in systemwide steps, like alerts to all operators of homes, to prevent mistakes from recurring. Responses were typically limited to the group home where a resident died.

At homes operated by nonprofit organizations, low-level employees were often fired or disciplined, but repercussions for executives were rare. At state-run homes, it is also difficult to take action against caregivers, who are represented by unions that contest disciplinary measures.

New York relies heavily on the operators of the homes to investigate and determine how a person in their care died and, in a vast majority of cases, accepts that determination. And the state has no uniform training for the nearly 100,000 workers at thousands of state and privately run homes and institutions.

The value of analyzing death records for problems in care that could be prevented through alerts or training has been well established, and is encouraged by the federal Government Accountability Office. Officials in Connecticut, for example, noticed four choking deaths in 2006, the first year the state published such data. They developed a statewide program — two days of initial training and a refresher course every two years thereafter. The state has had just one choking death since 2007. New York has had at least 21 during that same period.

“It’s incredibly important,” said Terrence W. Macy, commissioner of the Department of Developmental Services in Connecticut. “If everybody knows you study it this hard and you have this level of detail, it’s going to have an impact.”

There is no question that it can be extremely challenging to care for the developmentally disabled, a population that includes some people who are fragile and immobile and others who are unruly and inclined toward violence. But the problems in the New York system appear especially troubling given that the state spends $10 billion a year caring for the developmentally disabled — more than California, Texas, Florida and Illinois combined — while providing services to fewer than half as many people as those states do.

Lawsuits are relatively rare after the deaths of developmentally disabled people in New York, in part because economic damages are difficult to prove, given that the victims are seldom employed. And sometimes families are simply grateful to the group home for years of care for their relative.

This year, Gov. Andrew M. Cuomo forced the commissioners of the two agencies that oversee the developmentally disabled to resign amid a Times investigation of group home workers who were beating and abusing residents.

In interviews, the officials who replaced them acknowledged problems with how the state tracks and seeks to prevent untimely deaths.

Courtney Burke, the commissioner of the Office for People With Developmental Disabilities, which operates and oversees thousands of group homes, acknowledged that her agency suffered from a lack of transparency and what she called “a culture of nonreporting.”

“One of the things I’m seeking to do,” she said last month, “is have better data on those deaths.”

 

A Recurring Problem

One evening last year, a large piece of London broil was left marinating in the refrigerator of a state-run group home in the hamlet of Golden’s Bridge, in Westchester County.

The kitchen was supposed to be locked overnight. As in many homes for the developmentally disabled, residents known to be at risk for choking were not allowed to be left alone with food. But the kitchen was open during the early morning of June 5, 2010. No one noticed as Cynthia Dupas left her bedroom, opened the refrigerator and bit off a chunk of raw beef. She collapsed outside her bedroom and died. She was 51.

Hers was hardly an isolated case. A quarter of the 222 death files reviewed by The Times involved a person choking to death. And given the state’s poor recordkeeping, the actual number of choking deaths is likely larger. The deaths often occur when residents try to eat food too quickly; physical limitations also play a role. Some of the fatalities came in quick succession:

At a home near the Finger Lakes in 2001, a resident died after stuffing down a steak that was left on the kitchen counter after dinner, in violation of safety guidelines for several residents.

Four months later, Maxwell Chanels died at a Schenectady-area group home after being left alone to eat a steak. A nonprofit group that cared for Mr. Chanels during the day had determined he was a choking risk who required mealtime supervision, but a second nonprofit agency that ran the group home where he lived had no such protections in place. He was 66.

Less than two weeks later, Virgil Macro was served a breakfast that had not been prepared according to a meal plan devised to keep him from choking. Staff members at his Dutchess County group home also failed to supervise him while he ate. He was 39.

In each case, the response suggested by the Commission on Quality of Care was mostly limited to the place where the death occurred. Workers who made mistakes were disciplined. Some employees in the home, or the local area, were retrained.

But other states take broader action.

In 2006, Ohio officials recognized an increase in choking deaths and issued a statewide alert.

A year later, California officials noticed a similar rise in one part of the state and began an educational program that reduced deaths.

A lack of standards and accepted definitions of basic terms also leads to deadly confusion.

Terms like “bite-size” and “chopped,” which are key to defining what is safe for a person to eat, can be left open to interpretation by the staff at a given institution or group home.

The Commission on Quality of Care regularly asks individual homes to revisit those definitions, but the state has not resolved varying interpretations.

In contrast, Connecticut’s training materials, which the state credits with sharply reducing choking deaths, precisely define such terms with photographs and dimensions.

State officials in New York cannot even agree on how many people are dying. The Office for People With Developmental Disabilities says 933 people in state care died in 2009. The Commission on Quality of Care says 757 did. Neither agency could explain the discrepancy.

Outside experts said they were particularly puzzled that records maintained by the state would list the cause as “unknown” in more than 700 deaths over the past decade, and wondered how hard state officials had tried to determine what happened.

Bruce Simmons was one of the many people the state had listed as dead of unknown causes. But a review of the records from the state’s own investigation reveals what occurred. He lived in a group home in Cortland, N.Y., which kept him under tight supervision around food because of his history of stealing food and choking. But the nonprofit group that took care of him during the day decided that was not necessary, and he choked to death in November 2008. He was 52.

 

Lapses in Fire Safety

All that is left of the house at 1534 State Route 30 in the Adirondack town of Wells is a grassy field and an empty driveway.

More than two and a half years ago, the house, home to nine developmentally disabled residents, burned to the ground, killing four of them.

The fire revealed shortcomings in staff training and safety standards. And the home’s evacuation plans were based on unrealistic expectations that developmentally disabled residents would be able to flee in an emergency.

Large institutions for the developmentally disabled are built much like hospitals, with extensive fire safety measures. The group home had some safety features, like sprinklers in parts of the house, but was permitted to meet building codes akin to those of homes with able-bodied residents who know they should flee from a fire.

Yet though the Wells fire took place in March 2009, the state has not undertaken a broad review of whether group homes, which now care for a vast majority of the state’s developmentally disabled, have appropriate safety modifications to protect residents who often do not understand that they are in danger.

The fire at the house, known as Riverview, occurred in the early morning, starting in a trash can on a screen porch and spreading rapidly up vinyl siding into the attic of the L-shaped, one-story residence.

An automatic alarm call was made at 5:25 a.m. to a monitoring company. The protocol established by the Office for People With Developmental Disabilities required that the company call the group home before notifying the Fire Department, which wasted minutes and violated state fire standards. By 5:30, the local fire company was dispatched, alerting Ken Hoffman, a firefighter who lived across the street and rushed over to help.

When Mr. Hoffman arrived, all nine residents were still inside, but he and two staff members helped most of them evacuate. Then one resident fell, distracting the two staff members as three residents wandered back into the burning house, according to state records.

There were further complications. The state had not informed local fire officials about the presence of the group home, leaving them ill prepared.

“There was no contact,” said Peter Byrne, a Rockland County fire safety official who was on the panel of experts convened by the state after the fire. “If I roll into a single-family dwelling at 2 or 3 in the morning, I’m expecting mom, dad and 2.3 kids, whatever the average is, not 11 challenged individuals.”

Credible investigations were performed — one by a local grand jury, one by the State Office of Fire Prevention and Control, and another by the panel that included Mr. Byrne.

But a follow-up review undertaken by the two agencies most responsible for the developmentally disabled — the Office for People With Developmental Disabilities and the Commission on Quality of Care — included questions like whether residents’ day-to-day medical care needs were being met.

The questions “were not germane to the fundamental questions posed by the Wells fire — what was the cause of the fire and what can we do in the future to prevent such fires from occurring in such a tragic manner,” Roger Bearden, the new head of the commission, said in an interview.

Like most group homes in New York, the Riverview house was required to meet residential building codes, which are less than stringent.

There were no sprinklers in the attic at the house, or on the screen porch where the fire started. Records showed that the building’s original plans required fire retardant materials on the porch ceiling and that a planned barrier wall in the attic was abandoned during construction.

While the house was required to meet standards from the National Fire Protection Association, an interview with a top association official suggests that while the standards are open to interpretation, the house could have been more robustly protected.

“There’s been an unresolved question about why a sprinkler wasn’t provided on that porch area,” said Robert E. Solomon, a fire safety expert at the association who served on the state panel.

“Our standards would have probably put a sprinkler on that porch area where that fire occurred,” he said, which could have prevented the fire from spreading.

The Riverview case also underscores widespread problems in how fire drills at group homes have been conducted. The Times reported in March that a whistle-blower warned a senior state official in 2008 that drill records were being routinely faked or implausibly speedy evacuation times were being claimed. State investigators found that was the case at the Riverview house.

The staff also seemed unprepared; time was spent battling the fire with an extinguisher instead of evacuating residents. The grand jury convened by the district attorney of Hamilton County noted that fires were common in group homes, adding, “It would be a grave mistake to view Riverview’s tragedy as an isolated incident.”

Some steps have been taken since the fire: tighter rules guiding new construction, bringing in outside supervisors for fire drills and outside experts for inspections. But Ms. Burke’s agency did not say when it would review whether other homes in the system might also be lacking fire safety features sufficient enough for developmentally disabled residents.

After several weeks of inquiries from The Times, Ms. Burke said she would reconvene the state panel that investigated the fire. Mr. Hoffman said he could not shake the memory of the fire.

“It’s still something that comes back to my mind on a weekly basis,” he said. “We lost four neighbors that night.”

 

A System’s Failure

No one told Joan Taylor, after her son James died in August 2005, that there had been a similar bathtub drowning four months earlier.

Or that the other drowning, like her son’s, took place at a group home operated by a local chapter of the New York State ARC, the nation’s largest nonprofit organization serving the developmentally disabled.

In both cases, there had been concerns that ARC had too few staff members to supervise the developmentally disabled residents.

Dalton Lacomb died at the ARC home in Malone, N.Y., in April 2005, after being left alone in a bath for up to 20 minutes. The house had 11 residents and one overnight staff member on duty. The state recommended hiring more employees, but backed off after discussions with ARC management.

The death “wasn’t related to staffing levels,” Lester G. Parker, executive director of the Adirondack ARC, which oversees the Malone house, said in an interview. “It was related to a staff person clearly and significantly neglecting their duties.”

Mrs. Taylor had pushed for an increase in staffing at her son’s group home near Schenectady, where three workers looked after eight severely developmentally disabled residents.

ARC officials in Schenectady declined to comment. After Mr. Taylor drowned, the organization’s only significant response was to fire his caregiver.

“The guy who left James unattended is the scapegoat, and the agency really took no responsibility from the top,” Mr. Taylor’s sister, Patricia Taylor, said.

Marc Brandt, ARC’s statewide leader, acknowledged that no broad changes were enacted after the drownings, but said it was up to the state, not his organization, to take action.

“If they see anything that is wrong, they’ve always let us know,” he said.

Mr. Taylor’s mother has been a fierce advocate for people with developmental disabilities for decades.

Mrs. Taylor, 86, started a parent group, lobbied in Albany and was appointed to the capital-area Board of Visitors of the Office for People With Developmental Disabilities. She is most proud of helping get legislation passed in 2002 that gave parents control over end-of-life decisions for the developmentally disabled. “I was insulted I couldn’t make that decision for my son, who I wanted to die with dignity,” she said.

On a recent day, as Mrs. Taylor sat on the back porch of her apartment at a retirement home in Saratoga Springs, wearing tennis shoes and shorts, she leafed through the guestbook from her son’s funeral, filled with 300 signatures, including those of local elected officials.

“I don’t know if my kid died with dignity or not,” she said.

She grew up on Long Island and trained as a nurse; her late husband, Robert, was an engineer with General Electric. She knew something was wrong with James, their youngest child, when he was still a baby. Suspecting he could not hear, she slammed cupboard doors near their infant son, and he did not flinch.

She got a much greater shock after a doctor told her, “Your son is mentally retarded.”

Doctors recommended that he be institutionalized. Mrs. Taylor resisted, but she had five other children. Dealing with James, her sixth child — quadriplegic, sleepless and with the intellectual capacity of a 3-month-old — filled her days and nights.

Eventually, she felt she had no choice.

“I will never forget that day,” Mrs. Taylor once wrote in an essay. “My husband and I woke up that morning both fighting back the tears. I dressed James in his very best suit and we drove the 30 miles back to the institution and left him there.”

“We both cried all the way home,” she said. “I thought it was the worst day of my life.”

She has done advocacy work with ARC and Mr. Brandt over the years, and calls him “a saint,” but she is angry about what happened to her son.

Her daughter said it was because of her mother’s advocacy work that Mr. Taylor’s death received attention.

She worries about the developmentally disabled who die and have no family around to push for answers for them.

“These deaths are marginalized because these sort of people are not valued by society,” Patricia Taylor said.

When she was in the fourth grade, she dreamed of taking her brother and running away with him, protecting him. She finds it hard to accept that no one was able to protect him after he grew up.

“I believe that God put these people here for a purpose, because if we didn’t have them to look after, we would lose our humanity,” she said. “How would we know compassion? It says in the Bible, do ye so unto the least of my brothers. I think that’s what it’s all about.”

    In State Care, 1,200 Deaths and Few Answers NYT, 5.11.2011,
    http://www.nytimes.com/2011/11/06/nyregion/at-state-homes-simple-tasks-and-fatal-results.html

Ricky Wyatt, 57, Dies; Plaintiff in Landmark Mental Care Suit

November 3, 2011
The New York Times
By DOUGLAS MARTIN

Ricky Wyatt was a rambunctious Alabama teenager who had broken windows, overturned a school desk or two, and been in and out of group homes. His probation officer decided he needed to be committed to a mental institution. His aunt, his legal guardian, agreed.

So Ricky found himself at 14 in a crowded and understaffed hell, the Bryce State Hospital in Tuscaloosa, Ala. Among more than 5,000 patients, he was the youngest by a decade. Though he was never found to have any illness, he was given large doses of Thorazine and other psychoactive drugs regularly.

Mr. Wyatt, who died on Tuesday at 57, became the lead plaintiff in a landmark class-action federal lawsuit protesting conditions in the hospital. The suit led to a judgment in 1971 that gave the federal government control of Alabama’s mental institutions and set national guidelines for mental care that came to be called the Wyatt Standards.

“The enormity of what this case accomplished cannot be overstated,” Judge Myron Thompson of Federal District Court in Montgomery, Ala., said when he returned Alabama’s mental health system to state control in 2003. “The principles of humane treatment of people with mental illness and mental retardation embodied in this litigation have become part of the fabric of law in this country and, indeed, international law.”

James Tucker, the legal director of the Alabama Disabilities Advocacy Program, said Mr. Wyatt had died in a Tuscaloosa hospital. He did not know the cause, he said.

Ricky J. Wyatt was born in Tuscaloosa in 1954 and reared by his great-grandmother because his mother, Sylvia Hunter, “got in trouble,” he said in 2009 in an interview with Listen, an Alabama Department of Mental Health newsletter. Sylvia Hunter was in prison for forgery when the landmark suit was filed on his behalf, she told The Decatur Daily, an Alabama newspaper.

Ricky described himself as a “hell-raiser” who had been sent to reform school. While he was living at a children’s home, he said, his probation officer decided he needed to be committed to Bryce and his aunt, Mildred Rawlins, beset with problems of her own, agreed.

Paul Davis, a journalist who covered the case, wrote in Law and Psychology Review in January this year that Alabama law had made it easy to put people in mental institutions at the time. “If Aunt Bessie regularly burned the biscuits, or if Grandma Smith said the same things over and over again, a relative could simply go to a doctor and tell him their kin needed to go to the mental hospital,” he said. In a sense, Ricky was coming home when he was committed to Bryce. He counted 56 relatives who had worked there, starting with his great-great-grandfather. Mildred Rawlins worked there. Ricky played there as a child.

Being a patient was different. Ricky, 15 at the time of the trial, testified that he had been made to sleep on wet floors and locked in a cell-like room. He told of supervisors making people fight so they could bet on the winners. He was awakened by being poked with a broom. Hot water was thrown on him, he said. He was placed in a rehabilitation program for drugs and alcohol, though he had used neither.

“The worst thing was that I knew there was nothing wrong with me,” he told Listen.

The lawsuit began after the hospital laid off workers, leaving only one nurse for every 250 patients. Workers, including his aunt, decided to file a class-action suit and asked Ricky to be its human face.

Judge Frank M. Johnson Jr., who had earlier ordered that Alabama’s schools and prisons be placed under federal control on civil rights grounds, heard the case. He threw out the issue of the layoffs, saying the state had the right to hire and fire. But he let the claim of patient mistreatment go forward.

Judge Johnson’s ruling required humane treatment of patients, sufficient staffing, individualized treatment plans and as little reduction in patient freedom as practicable. It set 35 specific standards in areas like diet and nutrition.

Mr. Wyatt’s survivors include his mother; his sister, Kathy King; and his brother, Ronnie.

After the case, Mr. Wyatt found jobs in Florida and other states. He fell from a ladder while working as a painter and afterward used a walker or a wheelchair. He lived his last years in a trailer next door to his mother’s house in Cottondale, Ala.

When federal control of Alabama’s mental health programs ended on Dec. 5, 2003, there were 1,500 patients in state institutions, compared with more than 10,000 when it began. The next day, Mr. Wyatt visited Bryce. “It changed so much I couldn’t believe it,” he said.

    Ricky Wyatt, 57, Dies; Plaintiff in Landmark Mental Care Suit, NYT, 3.11.2011,
    http://www.nytimes.com/2011/11/04/health/ricky-wyatt-57-dies-plaintiff-in-landmark-mental-care-suit.html

Glaxo to Pay $3 Billion in Avandia Settlement

November 3, 2011
The New York Times
By DUFF WILSON

The British drug company GlaxoSmithKline said Thursday that it has agreed to pay $3 billion to settle United States government civil and criminal investigations into its sales practices.

The settlement is the largest yet in a wave of cases brought against pharmaceutical companies for illegal marketing of drugs, passing the previous record of $2.3 billion paid by Pfizer in 2009. In recent years, drug companies have been the major targets of federal fraud investigations that cost Medicare and Medicaid tens of billions of dollars.

The cases against GlaxoSmithKline include illegal marketing of Avandia, a diabetes drug that was severely restricted last year after it was linked to heart risks. Company whistleblowers and federal prosecutors said the company had paid doctors and manipulated medical research to promote the drug.

The company had already set aside money for the settlement, which analysts said would remove legal uncertainty. GlaxoSmithKline stock was up 1.57 percent to $43.95 a share in morning trading.

“This is a significant step toward resolving difficult, long-standing matters which do not reflect the company that we are today,” Andrew Witty, chief executive of GlaxoSmithKline, said in a statement. “In recent years, we have fundamentally changed our procedures for compliance, marketing and selling in the U.S. to ensure that we operate with high standards of integrity and that we conduct our business openly and transparently.”

The statement said that GlaxoSmithKline’s “agreement in principle with the U.S. government” would be finalized next year.

The company had set aside $3.4 billion in January — eliminating its fourth quarter profit — to pay for investigations and product liability cases over Avandia. Glaxo also took a $2.3 billion charge last year to settle civil lawsuits over Avandia.

The company statement said it has made “fundamental changes” to marketing policies in the United States since 2008, including a bonus payment system for sales people using quality measurements rather than sales targets.

In a note to investors, Brian Bourdot, an analyst at the investment bank Barclays Capital, called the settlement an important step for Glaxo, but noted that the company “remains involved in other legal disputes, including alleged violations of the Foreign Corrupt Practices Act.”

“We regard such disputes as an innate risk for large multinational pharmaceutical companies,” he added.

Glaxo’s other cases include a nationwide investigation of the company’s sales and marketing practices for nine drugs from 1997 to 2004, led by the United States attorneys in Colorado and Massachusetts, and a Department of Justice investigation into Medicaid pricing practices.

Other large drug company settlements, aside from Pfizer’s payment over illegal marketing of the painkiller Bextra and other drugs, include Eli Lilly’s payment of $1.4 billion in 2009 over claims it marketed Zyprexa, an antipsychotic drug, for unapproved uses by elderly patients with dementia; and Abbott Laboratories’ announcement last week that it would pay $1.3 billion to settle claims it had illegally marketed the epilepsy drug Depakote.

This article has been revised to reflect the following correction:

Correction: November 3, 2011

An earlier version of this article described the drug Avandia incorrectly. It is a diabetes drug, not a painkiller.

    Glaxo to Pay $3 Billion in Avandia Settlement, NYT, 3.10.2011,
    http://www.nytimes.com/2011/11/04/business/glaxo-to-pay-3-billion-in-avandia-settlement.html

Morris Chafetz, 87, Dies; Altered View of Alcoholism

October 21, 2011
The New York Times
By WILLIAM GRIMES

Dr. Morris E. Chafetz, who played an important role in changing the public perception of alcoholism from social crime or personal failing to a disease requiring treatment, died on Oct. 14 at his home in Washington. He was 87.

The cause was suicide, his son Marc said. Dr. Chafetz’s wife of more than 60 years, the former Marion Donovan, died the previous day at an assisted-living facility in Bethesda She was 86.

Dr. Chafetz (pronounced CHAFE-etz), the first director of the National Institute on Alcohol Abuse and Alcoholism, became a leading spokesman for the problems of alcoholism and its treatment purely by accident. After he finished his training as a psychiatrist at Harvard Medical School and Massachusetts General Hospital in 1954, there was only one job available: starting an alcohol treatment center that the state had just provided money to create.

No other psychiatrist would take the job. Dr. Chafetz did so only reluctantly.

“I did not think much of alcoholic people,” he told the journal Alcohol Health and Research World in 1995. “I did not like them; I just was not the least bit interested in them.”

He quickly changed his opinion.

“It only took me a few months of listening to these patients to recognize my prejudices and the prejudices of others,” he said. “I realized that this issue reflected every social health policy problem being faced by the country.”

In 1970 Dr. Chafetz was invited by Elliot L. Richardson, the secretary of health, education and welfare under President Richard M. Nixon, to work on alcoholism issues at the National Institute of Mental Health.

Behind the scenes, he lobbied for the creation of a new federal agency devoted to the problems of alcoholism. When Congress approved legislation for the National Institute on Alcohol Abuse and Alcoholism to coordinate all federal programs dealing with the issue, he was offered the job of director.

This time, he jumped at the opportunity.

“Who gets the chance to start a federal agency in their area of expertise, the field they have studied for years?” he said. “It really was the greatest five years of my life.”

Dr. Chafetz started in 1970 with an annual budget of $6.5 million. By 1975, when he left, the budget was $214 million, which supported grants for programs in the United States and abroad to educate the public about alcoholism and to support its prevention and treatment.

“Having experienced the extent of my own prejudices and my own ignorance of the issue, I was bound and determined to turn the country around and to treat alcoholics as ill human beings who needed treatment, not as bad people who should be ignored and neglected,” Dr. Chafetz told Alcohol Health and Research World.

“I remember saying in one of my first speeches that alcoholism was America’s most treatable untreated illness, and I still feel that way,” he said.

Morris Edward Chafetz was born on April 20, 1924, in Worcester, Mass. His parents were Jewish emigrants from what is now Belarus, and his father worked as a dry-goods salesman.

After earning a bachelor’s degree from Tufts in 1944, he served in the Army, then returned to Tufts for his medical degree, which he received in 1948.

He met his wife at a school dance and married her in 1946. In addition to his son Marc, of Washington, he is survived by two other sons, Gary, of Cambridge, Mass., and Adam, of Potomac, Md.; a brother, Samuel, of Worcester; and six grandchildren.

Dr. Chafetz regarded alcoholism as a complex interplay of social and psychological factors, and he often argued that presenting wine, beer and spirits as a normal part of life, rather than alluringly illicit substances, might encourage responsible drinking.

On one occasion, he proposed that schools teach children how to drink responsibly, starting with heavily diluted sherry in grade school. “Alcohol is here to stay, and people must learn to develop a healthy attitude toward it,” he told a professional conference held by the New York Academy of Sciences in 1966.

He emphasized scientific findings showing the health benefits of moderate drinking, opposed total abstinence as a social ideal and promoted the Mediterranean approach to alcohol consumption: in company, with food and never with the goal of intoxication.

These views were reflected in his books “Liquor: The Servant of Man” (1965), “Why Drinking Can Be Good for You” (1965) and “Drink Moderately and Live Longer: Understanding the Good of Alcohol” (1995), written with his wife.

After leaving the alcoholism institute, Dr. Chafetz became the president of the Health Education Foundation, a charitable organization supported by the public and the liquor industry. In 1982, President Ronald Reagan appointed him chairman of the education and prevention committee of the Presidential Commission on Drunk Driving.

He wrote many books on alcoholism and its treatment, including “Alcoholism and Society” (1962, written with Harold W. Demone), “The Alcoholic Patient: Diagnosis and Management” (1983) and “The Encyclopedia of Alcoholism” (1982, written with Robert O’Brien).

    Morris Chafetz, 87, Dies; Altered View of Alcoholism, NYT, 21.10.2011,
    http://www.nytimes.com/2011/10/21/us/morris-chafetz-87-dies-altered-view-of-alcoholism.html

Wal-Mart Cuts Some Health Care Benefits

October 20, 2011
The New York Times
By STEVEN GREENHOUSE and REED ABELSON

After trying to mollify its critics in recent years by offering better health care benefits to its employees, Wal-Mart is substantially rolling back coverage for part-time workers and significantly raising premiums for many full-time staff.

Citing rising costs, Wal-Mart, the nation’s largest private employer, told its employees this week that all future part-time employees who work less than 24 hours a week on average will no longer qualify for any of the company’s health insurance plans.

In addition, any new employees who average 24 hours to 33 hours a week will no longer be able to include a spouse as part of their health care plan, although children can still be covered.

This is a big shift from just a few years ago when Wal-Mart expanded coverage for employees and their families after facing criticism because so many of its 1.4 million workers could not afford or did not qualify for coverage — rendering many of them eligible for Medicaid.

Under pressure from states saddled with rising Medicaid costs and from labor unions and community groups, Wal-Mart had agreed to offer part-time employees, even those averaging less than 24 hours a week, health care insurance after a year on the job, shaving a year off the eligibility requirement. Wal-Mart also said that it was offering health plans that cost its employees about $250 a year for family coverage.

At the time, the moves were considered a departure from some of its major rivals and large employers, more than half of whom offer no company-sponsored health plan for part-time workers.

On Thursday, the company would not say what percentage of its work force was part time or worked fewer than 24 hours a week. Greg Rossiter, a Wal-Mart spokesman, said the decision to deny coverage to new part-time employees resulted from the company’s revamping of its health care offerings in light of rising costs.

“Over the last few years, we’ve all seen our health care rates increase and it’s probably not a surprise that this year will be no different,” Mr. Rossiter said. “We made the difficult decision to raise rates that will affect our associates’ medical costs. The decisions made were not easy, but they strike a balance between managing costs and providing quality care and coverage.”

The company said the changes were not a result of the new federal health care law. But the higher rates along with steep spikes in premiums for other plans this year are likely to stoke the national debate over the year-old legislation that has pitted President Obama and Democrats against Republicans opposed to the changes. Challenges to the law by several states are now before the Supreme Court.

These moves are also occurring in a postrecession period when Wal-Mart has been struggling to regain its footing after months of disappointing or flat sales. And with unemployment still hovering around 9 percent, employers may feel less compelled to offer expansive benefits to people desperate for work.

Nationwide, employer-sponsored health premiums are up 9 percent, and increases of 5 percent or more are predicted for next year, with workers shouldering higher burdens on premiums and deductibles.

In 2009, Wal-Mart said 52 percent of its employees obtained health coverage through it, but on Thursday it declined to give the percentage.

Documents on Wal-Mart’s health and other benefit offerings were obtained by The New York Times from the Organization United for Respect at Walmart, a union-backed group of Wal-Mart employees that is seeking to pressure the company to improve wages and benefits.

In Wal-Mart’s 2012 health offerings, premiums will increase for some plans by more than 40 percent, although many of their workers pay relatively low premiums in comparison to more generous plans offered by other employers. But many Wal-Mart employees complain that their low premiums are accompanied by high deductibles that sometimes exceed 20 percent of their annual pay.

Wal-Mart’s new health offerings will require many employees who smoke to pay a significant penalty. They will be required to pay an extra $10 to $90 each pay period — $260 to $2,340 a year — if they want health coverage.

Several other large employers have begun charging higher premiums to employees who smoke, according to Mercer, a benefits consulting firm. Among the largest employers, about 28 percent vary their premiums based on tobacco use.

Mr. Rossiter defended the penalty for smokers, saying, “Tobacco users generally consume about 25 percent more health care services than nontobacco users.”

In its health care brochures, Wal-Mart told its employees that diseases caused by tobacco result in $96 billion in extra health care costs nationwide. And it noted that some other prominent companies, including Home Depot, Macy’s and PepsiCo, charge smokers more as part of their health plans.

Tammy Yancey, a $9.50-an-hour gas attendant at a Sam’s Club in Pinellas Park , Fla., complained that she would no longer be able to afford health insurance from the company. Ms. Yancey, a smoker, said her premiums would jump to $127.90 every two weeks — or $3,325 a year — up from $53.80 at present, when she earns $12,000 a year from her job.

“I won’t be able to afford the insurance,” she said. “And I really can’t go without insurance because I have a heart problem.”

Dan Schlademan, director of Making Change at Walmart, a union-backed campaign, condemned the changes.

“No wonder people are protesting in the streets,” he said. “This is another example of corporations putting profits ahead of what’s good for everyday Americans. It’s outrageous and damaging to many hard-working families that the biggest corporation in America is increasing health care costs for many employees by 40 percent.”

Wal-Mart says that its health care plans are affordable and competitive compared with those of its competitors. “We are proud to be among a few companies that continue to offer an affordable associate-only medical option for about a dollar per day or $15 per pay period,” Mr. Rossiter said. He noted that many companies offer health plans that start at $75 a week or more for each two-week pay period.

Companies frequently do not offer coverage to part-time workers. About 42 percent of large employers offer benefits to part-time employers, according to the 2011 survey by the Kaiser Family Foundation, which tracks changes in benefits. And some of Wal-Mart’s competitors, like Home Depot, do not offer their part-time workers the same health plans they offer full-time workers. Instead, those employees can enroll in plans that sharply limit the amount of coverage.

Wal-Mart also significantly reduced the amount of money it contributes to the savings accounts workers can use to pay for medical bills that are not covered under their plan. Last year, the company put $1,000 into accounts for families but it will cut the amount by half for next year to just $500. Companies typically put more money into these accounts as a way of encouraging employees to choose these plans, which cost employers less than traditional policies.

While Wal-Mart defends its decision to reduce these contributions, few companies have made similar cuts, according to Mercer. Companies are continuing to try to do what they can to encourage employees to enroll in these plans, said Beth Umland, who oversees the company’s benefits research.

Barbara Collins, a sales associate at the Wal-Mart in Placerville, Calif., said that the premiums for the H.M.O. plan for herself and her 5-year-old son would rise to $18 every two weeks from $10. Her big concern, she said, was that her deductible would jump to $5,000 a year, from $1,000 — a daunting amount considering she earns $19,000 a year. “I don’t know how I’ll be able to afford it if I go to a doctor or to physical therapy,” she said.

    Wal-Mart Cuts Some Health Care Benefits, NYT, 20.10.2011,
    http://www.nytimes.com/2011/10/21/business/wal-mart-cuts-some-health-care-benefits.html

Massachusetts Tries to Rein in Its Health Cost

October 17, 2011
The New York Times
By ABBY GOODNOUGH and KEVIN SACK

BOSTON — On the Republican campaign trail, the health care debate has focused on the mandatory coverage that Mitt Romney signed into law as governor in 2006. But back in Massachusetts the conversation has moved on, and lawmakers are now confronting the problem that Mr. Romney left unaddressed: the state’s spiraling health care costs.

After three years of study, the state’s legislative leaders appear close to producing bills that would make Massachusetts the first state — again — to radically revamp the way doctors, hospitals and other health providers are paid.

Although important details remain to be negotiated, the legislative leaders and Gov. Deval Patrick, all Democrats, are working toward a plan that would encourage flat “global payments” to networks of providers for keeping patients well, replacing the fee-for-service system that creates incentives for excessive care by paying for each visit and procedure.

“We have shown the nation how to extend care to everybody,” Mr. Patrick said in an interview, “and we’ll be the place to crack the code on costs.”

Those who led the 2006 effort to expand coverage readily acknowledge that they deferred the more daunting task of cost control for another day. It was assumed then that the politics would pit doctors, hospitals, insurers, employers and consumers against one another, and obliterate the fragile coalition behind the groundbreaking coverage law.

Predictably, the plan did little to slow the growth of health costs that already were among the highest in the nation. A state report last year found that per capita health spending in Massachusetts was 15 percent above the national average. And from 2007 to 2009, private health insurance premiums rose between 5 and 10 percent annually, according to another state study.

Yet the plan, which generated fresh attacks on Mr. Romney in a recent New Hampshire debate and a blistering Internet ad by Gov. Rick Perry of Texas, has largely succeeded in providing nearly universal coverage. Only 2 percent of residents and a fraction of 1 percent of children in Massachusetts are uninsured. The law’s popularity has given state leaders added incentive to make it financially sustainable.

But the process has been painstakingly slow. It started in 2008, when the Legislature appointed a commission to study changes in the medical payment system. A year later, the commission recommended the broad outlines of a global payment plan that essentially calls for teams of providers to be put on a budget for each patient’s care.

The networks would receive an annual fee for the care of each patient, with higher payments for patients deemed to be greater health risks and with bonuses for high-quality care. In theory, the healthier these so-called accountable care organizations can keep their patients, the more reimbursement they can pocket as profit. Insurers are already required to accept all applicants in Massachusetts, as will be the case nationally, in 2014, if the new federal health care law survives its legal and political challenges.

In February, three months after Mr. Patrick’s re-election, he submitted a bill that would impose a global payment system for most state employees, Medicaid recipients and others with state-subsidized health insurance — roughly one in four residents.

His plan would set parameters to help private insurers and providers follow suit, in the hope that they would gradually gravitate to global payments, without coercive legislation. And it would give the state’s insurance commissioner broader authority to reject premium increases deemed excessive, with an added goal of holding down hospital costs.

Lawmakers in each chamber have struggled to draft their own proposals, which they hope to bring to a vote by early next year. In the House, one idea is to move health care providers to a global payment system within three years, with a goal of keeping health care spending increases to about 3.9 percent a year after that — roughly the typical growth in the state’s gross domestic product.

But State Representative Steven Walsh, House chairman of the Joint Committee on Health Care Financing, said it would be crucial to move slowly, adding that it could take 15 years “to squeeze all the inequities out of the system.”

Because medical spending is driven not just by volume but also by pricing, a major question has been whether global payments alone will have much effect. It may be equally important, Mr. Patrick and others argue, to rein in the ability of the state’s most prestigious teaching hospitals and physicians’ groups to negotiate high rates of reimbursement.

A series of news media and government investigations have revealed that large, high-status providers, like Partners HealthCare System, which owns the Harvard-affiliated Massachusetts General and Brigham & Women’s hospitals, command substantially higher reimbursement from insurers than other entities.

In reports the last two years, Attorney General Martha Coakley, a Democrat, has concluded that differences in payments to hospitals cannot be explained by variations in their quality, the mix of their patients or the costs of academic medicine. Last month, the House majority leader, Representative Ronald Mariano, introduced a bill that would force insurers to narrow the inequities in payments.

Mr. Patrick said the state needed to help struggling hospitals by raising Medicaid reimbursement rates. But he also cited his insurance commissioner’s recent denials of premium increases as the kind of pressure needed to keep prices down. “I think having the authority that we have in respect to the insurers has been a very, very important tool,” Mr. Patrick said, “and we need similar authority with the hospitals.”

Massachusetts has had a model for global payments since 2009, when Blue Cross Blue Shield of Massachusetts, the state’s biggest health insurer, began experimenting with an “alternative quality contract” that pays groups of doctors and hospitals a set fee to work as a team in caring for patients. The plans cover about 613,000 people, or roughly two-thirds of Blue Cross members in health maintenance organizations, but none of those in preferred provider organizations.

This month, in an important advance, Partners HealthCare joined the program, with incentives to keep cost growth below the Blue Cross average.

“It’s a big deal,” said Stuart Altman, a health economist at Brandeis, “because they’re the biggest player in town and it sort of solidifies that this will be one of the major changes in the system and that it’s likely to be around for a while.”

Under market and political pressure, Partners also agreed to renegotiate its contract with Blue Cross Blue Shield and accept lower reimbursements, which is expected to save $240 million over three years. Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, said payments to Partners would increase at about 2 percent a year rather than the previously anticipated 5 percent to 6 percent.

The politically powerful hospitals clearly hope to persuade lawmakers that price controls are not needed. “This contract is evidence that at Partners, we think the market is working to address affordability,” said a company spokesman, Rich Copp.

Mr. Patrick said such experiments were important, but did not go far enough. “We still need a bill because we’ve got to have scale,” he said. “It can’t be one-offs.”

Initial resistance is also expected from doctors. The most recent annual work force study by the Massachusetts Medical Society found that nearly 60 percent of physicians — and higher rates of specialists — said they were not likely to join a voluntary global payment system.

But Mr. Walsh said that doctors and other stakeholders were becoming more comfortable with the idea. “It’s not seen as a foreign approach anymore,” he said.

 

Abby Goodnough reported from Boston, and Kevin Sack from Atlanta.

    Massachusetts Tries to Rein in Its Health Cost, NYT, 17.10.2011,
    http://www.nytimes.com/2011/10/18/us/massachusetts-tries-to-rein-in-its-health-care-cost.html

Eating Disorders a New Front in Insurance Fight

October 13, 2011
The New York Times
By ANDREW POLLACK

People with eating disorders like anorexia have opened up a new battleground in the insurance wars, testing the boundaries of laws mandating equivalent coverage for mental illnesses.

Through claims and court cases, those with severe cases of anorexia or bulimia are fighting insurers to pay for stays in residential treatment centers, arguing that the centers offer around-the-clock monitoring so that patients do not forgo eating or purge their meals.

But in the last few years, some insurance companies have re-emphasized that they do not cover residential treatment for eating disorders or other mental or emotional conditions. The insurers consider residential treatments not only costly — sometimes reaching more than $1,000 a day — but unproven and more akin to education than to medicine. Even some doctors who treat eating disorders concede there are few studies proving that residential care is effective, although they believe it has value.

“We’ve seen an increase in denials,” said Kathleen MacDonald, education and prevention coordinator for the Gail R. Schoenbach FREED Foundation, an advocacy group for those with eating disorders. “Now, I go to bed every night and I can’t answer all the e-mails I get. It’s heartbreaking.”

Both sides are closely watching the consequences of a major decision by the United States Court of Appeals for the Ninth Circuit, which ruled in August that insurers in California must pay for residential treatment for eating disorders and other serious mental illnesses under the state’s mental health parity law.

In the last decade or so, many states enacted similar laws, and, in 2008, so did the federal government. The laws generally require that coverage for mental and behavioral disorders be equivalent to that for physical ailments like diabetes or a broken bone.

But equivalence, or parity, can be tricky to define, and the appeals court ruling is one of the first by a high federal court to interpret the concept.

Blue Shield of California, the defendant in the lawsuit, is already seeking to have the case reheard, arguing that the decision could force insurers to pay for unlimited amounts of treatment, raising insurance costs.

While the ruling applies only to California’s law, some experts think it will influence courts, state agencies and insurers elsewhere.

“You’ll see it bleed over,” said Scott Petersen, a lawyer in Salt Lake City who often represents insurance companies in parity cases.

In New Jersey, Aetna, Horizon and AmeriHealth have agreed to end limits on the number of days of residential treatment they will cover for eating disorders, according to Bruce Nagel, a lawyer who sued the insurers under the state’s parity law.

The Parity Implementation Coalition, a group monitoring the federal parity law, has filed about 150 complaints about possible violations, according to Dr. Henry Harbin, a psychiatrist and adviser to the group. Some cases involve denial for residential treatment for substance abuse or mental illnesses by plans offered by companies like Wal-Mart and Coca-Cola Bottling.

An estimated 11 million Americans, mostly young women, suffer from eating disorders, the most serious being anorexia nervosa, in which people starve themselves, and bulimia nervosa, in which they engage in binge eating followed by purging. These disorders, particularly anorexia, have the highest fatality rate of any psychiatric disorder.

The advocates for those with eating disorders, who often cooperate or get financing from residential treatment centers, estimate there are about 75 such facilities for those specific illnesses, and many others for substance abuse and for emotionally or psychologically disturbed children.

Sam Menaged, founder and president of the Renfrew Center, which is based in Philadelphia and is one of the oldest and largest residential treatment centers for eating disorders, said only 60 percent of insurers covered the therapy and that hundreds of people were turned away from Renfrew each year.

The Blue Cross Blue Shield plan for federal employees added language to policies at the beginning of this year specifying that residential treatment for any condition would not be covered. Two months later, citing that change in policy, the Remuda Ranch closed its eastern center for eating disorders, which was in Milford, Va.

Executives at the federal plan said that residential treatment had never been covered and that the new language merely made that more explicit.

Yet Samantha Ascanio, 23, of Gaithersburg, Md., said the plan had covered her four previous stays at a residential center but denied payment this year. She instead enrolled in outpatient programs that lasted more than six months.

Most plans offered to California state employees also added language this year clarifying that residential treatment was not covered.

Advocates and some doctors who treat eating disorders say that hospitalization, which insurers typically cover, might stabilize a patient and restore weight but does not generally treat the underlying psychological issues. Outpatient treatment, which might also be covered, does provide counseling but not round the clock. Residential treatment, they say, occupies a vital niche between those two.

“I don’t think I would be alive today if I hadn’t gone there,” said Jeanene Harlick, who was the plaintiff in the recent California case.

Ms. Harlick, who is 37 and lives in San Mateo, Calif., stayed at the Castlewood Treatment Center in St. Louis from April 2006 through January 2007 to treat her anorexia. She was 35 percent below her ideal weight when she checked in and, within a month, needed a feeding tube.

With Blue Shield declining to pay, Ms. Harlick’s parents borrowed hundreds of thousands of dollars against their home.

Residential treatment can cost from hundreds of dollars to well over $1,000 a day, and even though a daily rate is generally lower than a hospital’s, patients often stay much longer — for weeks or months. Insurers also say that few standards exist for these types of centers.

“There’s a wide variation in licensing across the country,” said Jena L. Estes, vice president for the federal employee program at the Blue Cross and Blue Shield Association. “There’s a lack of oversight of many of those residential treatment centers.”

Ira Burnim, legal director of the Bazelon Center for Mental Health Law, which litigates for better mental health treatments, said that while he was not familiar with eating disorders, “study after study” had shown that residential centers for other mental or emotional disorders were not as effective as treatment at home.

Dr Anne E. Becker, president of the Academy of Eating Disorders and director of the eating disorders program at Massachusetts General Hospital, said that despite a paucity of studies, “There’s no question that residential treatment is life-saving for some patients.”

Some insurers say that there is no treatment for physical illnesses that is equivalent to residential treatment for mental illnesses, and therefore residential treatment does not have to be paid for under parity laws.

Ms. Harlick’s lawyer, Lisa S. Kantor, argued that residential treatment centers were equivalent to skilled nursing facilities, which Blue Shield did cover.

Adam Pines, a lawyer for Blue Shield, countered that residential treatment was more akin to assisted living, which the insurer did not cover.

The Ninth Circuit Appeals judges, based in San Francisco, ruled that residential treatment was medically necessary for eating disorders, and therefore had to be covered under the state’s parity law, even if no exact equivalent existed on the physical disease side.

“Some medically necessary treatments for severe mental illness have no analog in treatments for physical illnesses,” the three-judge panel wrote. “For example, it makes no sense in a case such as Harlick’s to pay for 100 days in a skilled nursing facility — which cannot effectively treat her anorexia nervosa — but not to pay for time in a residential treatment facility that specializes in treating eating disorders.”

In Blue Shield’s request for a rehearing, it argued that the decision would require insurers to pay for treatment of mental conditions “without substantive limits.” That would mean better coverage for mental illnesses than for physical illnesses, which would be inconsistent with parity, the company said, adding that it would also increase costs “to the point where some employers may simply forgo offering plans to their employees.” Even if policies cover residential treatment, an insurer could still deny reimbursement on the ground that the treatment is not medically necessary for a particular patient.

Katie Bird of St. Paul sought residential treatment last year, saying she had been exercising vigorously while consuming no more than a single hot chocolate on some days. As a result, she said, she experienced heart palpitations and frequently passed out while trying to care for her 3-year-old daughter.

She said her insurer, United Behavioral Health, would not pay the $200,000 it cost for her four months of residential treatment because her weight was not low enough. She sued and reached a confidential settlement.

It is still unclear how much money Ms. Harlick and her parents will recover from Blue Shield.

Ms. Harlick, who lost her job and insurance and is now on disability while studying social work in graduate school, said she hoped the court decision would show people that eating disorders were not just matters of weight and appearance, but serious diseases.

“I just feel like this ruling gives a little more legitimacy to the reality of what this illness is,” she said.

    Eating Disorders a New Front in Insurance Fight, NYT, 13.10.2011,
    http://www.nytimes.com/2011/10/14/business/ruling-offers-hope-to-eating-disorder-sufferers.html

Killing Medicaid the California Way

October 13, 2011
The New York Times
By BRUCE C. VLADECK and STEPHEN I. VLADECK

VIRTUALLY all of the debate over the health care legislation enacted last year has focused on the constitutionality of the individual mandate, the requirement that, by 2014, nearly all Americans either purchase health insurance or pay a fine if they fail to do so. The Supreme Court now seems likely to decide the fate of the mandate, perhaps as early as June.

But last week the court also heard oral arguments in another case that could, indirectly, have a far greater impact on whether the act can meet the goal of expanding health care access by broadening eligibility for Medicaid, by 2014, to 15 million people.

One of the central substantive requirements of the Medicaid program, which serves more than 50 million poor and disabled Americans, is what’s known as the equal access mandate, which requires states to set the rates at which they reimburse Medicaid providers at levels sufficient to ensure an adequate supply of providers. As both Congress and the executive branch have understood since Medicaid’s creation in 1965, there would be little incentive for providers to participate in Medicaid if their payments were too far below market levels.

Nevertheless, in response to vast budget shortfalls, the California Legislature in 2008 enacted an across-the-board 10 percent cut in reimbursement levels for Medi-Cal, the state Medicaid program. Three groups of Medicaid beneficiaries and providers sued the state, arguing that the categorical reduction was inconsistent with, and therefore pre-empted by, the equal access mandate. On the merits, three federal appellate panels agreed and halted the rate reduction.

In the case it heard last week, Douglas v. Independent Living Center of Southern California, the Supreme Court will not resolve whether those decisions were correct: the incompatibility between California’s rate reduction and the equal access mandate appears to be settled. Instead, the justices agreed to consider a technical but critical question: whether private parties, be they Medicaid beneficiaries or providers, may even bring such suits in the first place.

When Medicaid was enacted, the possibility of private suits to enforce its provisions could be taken for granted. In the past decade, however, the Supreme Court has held federal statutes to an increasingly restrictive standard in deciding whether or not they may be privately enforced. The result has been clear: most of the lower courts facing the issue in recent years have held that the equal access provision can no longer be enforced in suits by beneficiaries or providers.

But if beneficiaries or providers can’t enforce the equal access provision, who will? The answer, according to both California and the Obama administration, which filed an amicus brief in support of California in the Douglas case, is the United States Department of Health and Human Services. What they fail to acknowledge, however, is that the department utterly lacks the financial, legal, logistical and political wherewithal to enforce the provision. (We helped write an amicus brief in support of the plaintiffs.)

First, the department doesn’t have the resources to oversee compliance with the equal access provision. As Justice Anthony M. Kennedy pointed out at the oral argument last week, only 500 employees supervise nearly $400 billion in Medicaid expenditures. Indeed, the department’s budget for the administration of Medicaid declined by 44 percent between the 2008 and 2010 fiscal years, even as Medicaid costs have kept rising.

Second, even if the department sought to expand enforcement of the equal access provision, it would encounter the additional hurdle that its enforcement budget — unlike the bulk of the Medicaid program — depends on annual appropriations. Medicaid must compete annually with the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control and Prevention and other agencies.

Third, even with proper funding, the department has repeatedly admitted that its authority to enforce the equal access provision and to provide remedies for violations is limited, practically and legally. When states fail to comply with the equal access mandate, the department’s options are either to reject a state Medicaid plan up front or withdraw financing after the fact — both of which punish Medicaid beneficiaries at least as much as they punish the offending states. As a result, the department has focused instead on trying to cajole rather than coerce states into complying.

Despite these reservations, only Justice Kennedy seemed outwardly concerned during last week’s oral argument in Douglas about whether exclusive federal enforcement could be effective. If the rest of the justices hold that the equal access provision cannot be privately enforced, that will open the door for other states with budget shortfalls to enact similar across-the-board cuts in Medicaid reimbursement rates. From there, it would be only a matter of time before providers abandoned Medicaid beneficiaries for private consumers en masse, thereby vitiating the animating purpose of the Medicaid program.

Of course, even if the justices rule for California, Congress is free to respond by clarifying that Medicaid beneficiaries or providers should be able to enforce the equal access provision. But given the politics of the moment, and the reality that violating the equal access mandate saves money for states and the federal government, a true legislative fix seems unlikely.

Thus, even as it vigorously defends the constitutionality of the individual mandate, the Obama administration may be complicit in eviscerating Medicaid — and setting back the broader goal of ensuring that all Americans have access to quality health care.

 

Bruce C. Vladeck was the administrator of Medicare and Medicaid from 1993 to 1997. Stephen I. Vladeck is a professor of law at American University.

    Killing Medicaid the California Way, NYT, 13.10.2011,
    http://www.nytimes.com/2011/10/14/opinion/killing-medicaid-the-california-way.html

A Voice, Still Vibrant, Reflects on Mortality

October 9, 2011
The New York Times
By CHARLES McGRATH

HOUSTON — Christopher Hitchens, probably the country’s most famous unbeliever, received the Freethinker of the Year Award at the annual convention of the Atheist Alliance of America here on Saturday. Mr. Hitchens was flattered by the honor, he said a few days beforehand, but also a little abashed. “I think being an atheist is something you are, not something you do,” he explained, adding: “I’m not sure we need to be honored. We don’t need positive reinforcement. On the other hand, we do need to stick up for ourselves, especially in a place like Texas, where they have laws, I think, that if you don’t believe in Jesus Christ you can’t run for sheriff.”

Mr. Hitchens, a prolific essayist and the author of “God Is Not Great: How Religion Poisons Everything,” discovered in June 2010 that he had Stage 4 esophageal cancer. He has lately curtailed his once busy schedule of public appearances, but he made an exception for the Atheist Alliance — or “the Triple A,” as he called it — partly because the occasion coincided almost to the day with his move 30 years ago from his native England to the United States. He was already in Houston, as it happened, because he had come here for treatment at the MD Anderson Cancer Center, where he has turned his 12th-floor room into a temporary library and headquarters.

Mr. Hitchens is gaunt these days, no longer barrel-chested. His voice is softer than it used to be, and for the second time since he began treatment, he has lost most of his hair. Once such an enthusiastic smoker that he would light up in the shower, he gave up cigarettes a couple of years ago. Even more inconceivable to many of his friends, Mr. Hitchens, who used to thrive on whiskey the way a bee thrives on nectar, hasn’t had a drink since July, when a feeding tube was installed in his stomach. “That’s the most depressing aspect,” he said. “The taste is gone. I don’t even want to. It’s incredible what you can get used to.”

But in most other respects Mr. Hitchens is undiminished, preferring to see himself as living with cancer, not dying from it. He still holds forth in dazzlingly clever and erudite paragraphs, pausing only to catch a breath or let a punch line resonate, and though he says his legendary productivity has fallen off a little since his illness, he still writes faster than most people talk. Last week he stayed up until 1 in the morning to finish an article for Vanity Fair, working on a laptop on his bedside table.

Writing seems to come almost as naturally as speech does to Mr. Hitchens, and he consciously associates the two. “If you can talk, you can write,” he said. “You have to be careful to keep your speech as immaculate as possible. That’s what I’m most afraid of. I’m terrified of losing my voice.” He added: “Writing is something I do for a living, all right — it’s my livelihood. But it’s also my life. I couldn’t live without it.”

Mr. Hitchens’s newest book, published last month, is “Arguably,” a paving-stone-sized volume consisting mostly of essays finished since his last big collection, “Love, Poverty and War,” which came out in 2004. The range of subjects is typically Hitchensian. There are essays — miniature pamphlets, almost — on political subjects and especially on the danger posed to the West by Islamic terrorism and totalitarianism, a subject that has preoccupied Mr. Hitchens since 2001. But there are just as many on literary figures; there’s a paean to oral sex, and there are little rants about unruly wine waiters, clichés and the misuse of “fuel” as a verb. The book’s epigraph is from Henry James’s novel “The Ambassadors”: “Live all you can: It’s a mistake not to.” And in an introduction Mr. Hitchens writes: “Some of these articles were written with the full consciousness that they might be my very last. Sobering in one way and exhilarating in another, this practice can obviously never become perfected.”

In his hospital room he suggested that an awareness of mortality was useful for a writer but ideally it should remain latent. “I try not to dwell on it,” he said, “except that once in a while I say, O.K., I’m not going to make that joke, I’m not going to go for that chortle. Or if I have to choose between two subjects, I won’t choose the boring one.”

He added, talking about an essay on Philip Larkin that made it into “Arguably”: “I knew the collection was going to come out even if I did not, and I was very pleased when I finished that one, because of the way it ends: ‘Our almost-instinct almost true:/ What will survive of us is love.’ I remember thinking, if that’s the last piece I write, that will do me.” After a moment he went on: “The influence of Larkin is much greater than I thought. He’s perfect for people who are thinking about death. You’ve got that old-line Calvinist pessimism and modern, acid cynicism — a very good combo. He’s not liking what he sees, and not pretending to.”

His main regret at the moment, Mr. Hitchens said, was that while he was keeping up with his many deadlines — for Slate, The Atlantic and Vanity Fair — he didn’t have the energy to also work on a book. He had recently come up with some new ideas about his hero, George Orwell, for example — among them that Orwell might have had Asperger’s — and he said he ought to include them in a revised edition of his 2002 book, “Why Orwell Matters.” He had also thought of writing a book about dying. “It could be called ‘What to Expect When You’re Expecting,’ ” he said, laughing.

Turning serious, he said, “I’ve had some dark nights of the soul, of course, but giving in to depression would be a sellout, a defeat.” He added: “I don’t know why I got so sick. Maybe it was the smokes, or maybe it’s genes. My father died of the same thing. It’s pointless getting into remorse.”

On balance, he reflected, the past year has been a pretty good one. He won a National Magazine Award, published “Arguably,” debated Tony Blair in front of a huge audience and added two states to the list of those he has visited. “I lack only the Dakotas and Nebraska,” he said, “though I may not get there unless someone comes up with some ethanol-based cancer treatment in Omaha.”

Mr. Hitchens has an extensive support network that includes his wife, Carol Blue, and his great friends James Fenton and Martin Amis. Mr. Amis is known for being cool and acerbic, but as he kissed and embraced Mr. Hitchens last week, visiting on the way to a literary festival in Mexico, his affection for his friend was unmistakable. “Hitch’s buoyancy is amazing,” he said later. “He has this great love of life, which I rather envy, because I think I may be deficient in that respect. It’s an odd thing to say, but he’s almost like a Tibetan monk. It’s as if he’d become religious.”

    A Voice, Still Vibrant, Reflects on Mortality, NBYT, 9.10.2011,
    http://www.nytimes.com/2011/10/10/books/christopher-hitchens-on-writing-mortality-and-cancer.html

Report on Medicare Cites Prescription Drug Abuse

October 3, 2011
The New York Times
By ROBERT PEAR

WASHINGTON — Medicare is subsidizing drug abuse by thousands of beneficiaries who shop around for doctors and fill prescriptions for huge quantities of painkillers and other narcotics far exceeding what any patient could safely use, Congressional investigators say in a new report.

The investigators, from the Government Accountability Office, said Medicare officials had been slow to recognize and act on the evidence of abuse, which is to be presented at a Senate hearing on Tuesday.

“Our analysis found that about 170,000 Medicare beneficiaries received prescriptions from five or more medical practitioners” for 14 types of drugs that are frequently abused, said Gregory D. Kutz, director of forensic audits and special investigations at the accounting office.

The medications were obtained through Part D of Medicare, which provides coverage for prescription drugs. The drugs most commonly abused by Medicare beneficiaries included powerful prescription painkillers like oxycodones and hydrocodone products. Oxycodones include OxyContin and Percocet.

In one case described in the report, a Medicare beneficiary in Georgia received a 150-day supply of oxycodone in just 27 days by obtaining seven prescriptions from four doctors. Over the course of a year, the woman received prescriptions for a total of 3,655 oxycodone pills (a 1,679-day supply) from 58 different prescribers, and she filled them at more than 40 pharmacies.

In another case, a California man received prescriptions for a total of 1,397 fentanyl patches and pills (a 1,758-day supply) from 21 different prescribers in a year. In a third case, a Texas beneficiary received prescriptions for a total of 4,574 hydrocodone pills (a 994-day supply) from 25 different doctors.

Senator Thomas R. Carper, Democrat of Delaware, said: “Federal dollars intended to address the health needs of the elderly and the poor are instead being used to feed addictions or to pad the wallets of drug dealers. This is clearly unacceptable.”

Mr. Carper called the hearing as chairman of a Homeland Security and Governmental Affairs subcommittee.

The accounting office said prescription drug abuse threatened the health of beneficiaries and increased costs to taxpayers. “Medicare beneficiaries may be seeking several medical practitioners to support and disguise an addiction” or to obtain drugs that they can sell to others, the report said.

In many cases, doctors said they did not know that their patients were receiving prescriptions from other physicians.

When told that one of his Medicare patients had received prescriptions for a 994-day supply of hydrocodone pills from 25 different prescribers in one year, a Texas doctor told investigators that “it was medically unnecessary and possibly dangerous to consume the amount of narcotics obtained by the beneficiary.”

The auditors recommended that Dr. Donald M. Berwick, administrator of the federal Centers for Medicare and Medicaid Services, consider limiting patients who abuse prescription drugs to one prescriber or one pharmacy.

Medicare officials said they were reluctant to make that change. While acknowledging possible overuse of drugs by some beneficiaries, they said they did not want to jeopardize patients’ access to care.

“High utilization of pain medications is not necessarily an indication of abuse, but could be an indication of poorly coordinated care in the treatment of pain symptoms,” the Medicare agency said in a written response to the accountability office.

The Medicare drug benefit is managed by private insurance companies under contract with the government.

Jonathan D. Blum, deputy administrator of the Centers for Medicare and Medicaid Services, said prescriptions for painkilling medications known as opiates had increased sharply. Medicare drug plans provided nearly 57 million opiate prescriptions last year, up from nearly 46 million in 2007, an increase of 24 percent, he said.

Mr. Blum said greater use of electronic health records and the electronic transmission of prescriptions to drugstores could reduce fraud and abuse by making it easier to keep track of patients’ medication history. In addition, he said, insurers could step up the review of claims to identify patterns of “gross overuse or inappropriate or medically unnecessary care.”

In a memorandum to insurers last week, Cynthia G. Tudor, director of Medicare’s drug benefit group, asked them to suggest how Medicare could “more successfully exert control over payment for inappropriate overutilization of drugs.”

Even if an insurer detects misuse of prescription drugs and takes action to stop it, a beneficiary can often get medications by enrolling in a prescription drug plan offered by another insurance company.

Medicare officials told investigators that prescription drug plans could not share information on beneficiaries. As a result, the report said, patients can bypass restrictions “merely by switching prescription drug plans.”

    Report on Medicare Cites Prescription Drug Abuse, NYT, 3.10.2011,
    http://www.nytimes.com/2011/10/04/health/policy/04medicare.html

Canadian-Born Scientist

Dies 3 Days Before Winning Nobel Prize in Medicine

October 3, 2011
The New York Times
By THE ASSOCIATED PRESS

STOCKHOLM (AP) — A cell biologist was awarded the Nobel Prize in medicine on Monday for his discoveries about the immune system but hours later his university said that he had been dead for three days.

The Nobel committee had been unaware of Canadian-born Ralph Steinman's death and it was unclear whether the prize would be rescinded because Nobel statutes don't allow posthumous awards.

Steinman, 68, who shared the 10 million kronor ($1.5 million) prize with American Bruce Beutler and French scientist Jules Hoffmann, died on Sept. 30 of pancreatic cancer, according to Rockefeller University. It said Steinman's life had been extended with immunotherapy based on the discovery for which he won the Nobel Prize.

In the 1970s, Steinman found dendritic cells that help regulate adaptive immunity, an immune system response that purges invading microorganisms from the body.

Beutler and Hoffmann were cited for their discoveries in the 1990s of receptor proteins that can recognize bacteria and other microorganisms as they enter the body, and activate the first line of defense in the immune system, known as innate immunity.

"I am very touched. I'm thinking of all the people who worked with me, who gave everything," Hoffmann said by telephone to a news conference in Paris. "I wasn't sure this domain merited a Nobel."

The trio's discoveries have enabled the development of improved vaccines against infectious diseases. In the long term they could also yield better treatments of cancer, rheumatoid arthritis, type 1 diabetes, multiple sclerosis, and chronic inflammatory diseases, prize committee members said.

Since 1974, the Nobel statutes don't allow posthumous awards unless a laureate dies after the announcement but before the Dec. 10 award ceremony. That happened in 1996 when economics winner William Vickrey died a few days after the announcement.

Nobel officials said they believed it was the first time that a laureate had died before the announcement without the committee's knowledge.

"I think you can safely say that this hasn't happened before," Nobel Foundation spokeswoman Annika Pontikis told the AP.

Before the statues were changed in 1974 two Nobel Prizes were given posthumously. In 1961 U.N. Secretary General Dag Hammarskjold was awarded the Nobel Peace Prize less than a month after he died in a plane crash during a peace mission to Congo. Swedish poet Erik Axel Karlfeldt won the Nobel Prize in literature in 1931, although he had died in March the same year.

Nobel committee member Goran Hansson said the medicine committee didn't know Steinman was dead when it chose him as a winner and was looking through its regulations.

"It is incredibly sad news," Hansson said. "We can only regret that he didn't have the chance to receive the news he had won the Nobel Prize. Our thoughts are now with his family."

The discoveries have helped scientists understand why the immune system sometimes attacks its own tissues, paving the way for new ways to fight inflammatory diseases.

"They have made possible the development of new methods for preventing and treating disease, for instance with improved vaccines against infections and in attempts to stimulate the immune system to attack tumors," the committee said.

No vaccines are on the market yet, but Hansson told The Associated Press that vaccines against hepatitis are in the pipeline.

"Large clinical trials are being done today," he said.

Beutler, 53, is professor of genetics and immunology at The Scripps Research Institute in San Diego, California. Hoffmann, 70, headed a research laboratory in Strasbourg, France, between 1974 and 2009 and served as president of the French National Academy of Sciences between 2007-2008.

Steinman had been affiliated with Rockefeller University in New York since 1970, and headed its Center for Immunology and Immune Diseases.

"We are all so touched that our father's many years of hard work are being recognized with a Nobel Prize," Steinman's daughter, Alexis Steinman, said in the Rockefeller University statement. "He devoted his life to his work and his family, and he would be truly honored."

Hoffmann's discovery came in 1996 during research on how fruit flies fight infections. Two years later, Beutler's research on mice showed that fruit flies and mammals activate innate immunity in similar ways when attacked by germs.

Steinman's discovery dates back to 1973, when he found a new cell type, the dendritic cell, which has a unique capacity to activate so-called T-cells. Those cells have a key role in adaptive immunity, when antibodies and killer cells fight infections. They also develop a memory that helps the immune system mobilize its defenses next time it comes under a similar attack.

The medicine award kicked off a week of Nobel Prize announcements, and will be followed by the physics prize on Tuesday, chemistry on Wednesday, literature on Thursday and the Nobel Peace Prize on Friday. The winners of the economics award will be announced on Oct. 10.

The coveted prizes were established by wealthy Swedish industrialist Alfred Nobel — the inventor of dynamite — except for the economics award, which was created by Sweden's central bank in 1968 in Nobel's memory. The prizes are always handed out on Dec. 10, on the anniversary of Nobel's death in 1896.

Last year's medicine award went to British professor Robert Edwards for fertility research that led to the first test tube baby.

___

Associated Press writer Malin Rising contributed to this report.

    Canadian-Born Scientist Dies 3 Days Before Winning Nobel Prize in Medicine, NYT, 3.10.2011,
    http://www.nytimes.com/aponline/2011/10/03/world/AP-Nobel-Medicine.html