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History > 2013 > USA > Health (III)



The Obamacare We Deserve


December 31, 2013
The New York Times


TODAY marks the beginning of health care coverage under the Affordable Care Act’s new insurance exchanges, for which two million Americans have signed up. Now that the individual mandate is officially here, let me begin with an admission: Obamacare is awful.

That is the dirty little secret many liberals have avoided saying out loud for fear of aiding the president’s enemies, at a time when the ideal of universal health care needed all the support it could get. Unfortunately, this meant that instead of blaming companies like Novartis, which charges leukemia patients $90,000 annually for the drug Gleevec, or health insurance chief executives like Stephen Hemsley of UnitedHealth Group, who made nearly $102 million in 2009, for the sky-high price of American health care, the president’s Democratic supporters bought into the myth that it was all those people going to get free colonoscopies and chemotherapy for the fun of it.

I believe Obamacare’s rocky start — clueless planning, a lousy website, insurance companies raising rates, and the president’s telling people they could keep their coverage when, in fact, not all could — is a result of one fatal flaw: The Affordable Care Act is a pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go. When right-wing critics “expose” the fact that President Obama endorsed a single-payer system before 2004, they’re actually telling the truth.

What we now call Obamacare was conceived at the Heritage Foundation, a conservative think tank, and birthed in Massachusetts by Mitt Romney, then the governor. The president took Romneycare, a program designed to keep the private insurance industry intact, and just improved some of its provisions. In effect, the president was simply trying to put lipstick on the dog in the carrier on top of Mitt Romney’s car. And we knew it.

By 2017, we will be funneling over $100 billion annually to private insurance companies. You can be sure they’ll use some of that to try to privatize Medicare.

For many people, the “affordable” part of the Affordable Care Act risks being a cruel joke. The cheapest plan available to a 60-year-old couple making $65,000 a year in Hartford, Conn., will cost $11,800 in annual premiums. And their deductible will be $12,600. If both become seriously ill, they might have to pay almost $25,000 in a single year. (Pre-Obamacare, they could have bought insurance that was cheaper but much worse, potentially with unlimited out-of-pocket costs.)

And yet — I would be remiss if I didn’t say this — Obamacare is a godsend. My friend Donna Smith, who was forced to move into her daughter’s spare room at age 52 because health problems bankrupted her and her husband, Larry, now has cancer again. As she undergoes treatment, at least she won’t be in terror of losing coverage and becoming uninsurable. Under Obamacare, her premium has been cut in half, to $456 per month.

Let’s not take a victory lap yet, but build on what there is to get what we deserve: universal quality health care.

Those who live in red states need the benefit of Medicaid expansion. It may have seemed like smart politics in the short term for Republican governors to grab the opportunity offered by the Supreme Court rulings that made Medicaid expansion optional for states, but it was long-term stupid: If those 20 states hold out, they will eventually lose an estimated total of $20 billion in federal funds per year — money that would be going to hospitals and treatment.

In blue states, let’s lobby for a public option on the insurance exchange — a health plan run by the state government, rather than a private insurer. In Massachusetts, State Senator James B. Eldridge is trying to pass a law that would set one up. Some counties in California are also trying it. Montana came up with another creative solution. Gov. Brian Schweitzer, a Democrat who just completed two terms, set up several health clinics to treat state workers, with no co-pays and no deductibles. The doctors there are salaried employees of the state of Montana; their only goal is their patients’ health. (If this sounds too much like big government to you, you might like to know that Google, Cisco and Pepsi do exactly the same.)

All eyes are on Vermont’s plan for a single-payer system, starting in 2017. If it flies, it will change everything, with many states sure to follow suit by setting up their own versions. That’s why corporate money will soon flood into Vermont to crush it. The legislators who’ll go to the mat for this will need all the support they can get: If you live east of the Mississippi, look up the bus schedule to Montpelier.

So let’s get started. Obamacare can’t be fixed by its namesake. It’s up to us to make it happen.


Michael Moore is a documentary filmmaker

whose 2007 film “Sicko” examined

the American health care industry.

    The Obamacare We Deserve, NYT, 31.12.2013,






Millions Gaining Health Coverage

Under Law


December 31, 2013
The New York Times


WASHINGTON — Millions of Americans will begin receiving health insurance coverage under the Affordable Care Act on Wednesday after years of contention and a rollout hobbled by delays and technical problems. The decisively new moment in the effort to overhaul the country’s health care system will test the law’s central premise: that extending coverage to far more Americans will improve the nation’s health and help many avoid crippling medical bills.

Starting Wednesday, health insurance companies can no longer deny coverage to people with pre-existing conditions and cannot charge higher premiums to women than to men for the same coverage. In most cases, insurers must provide a standard set of benefits prescribed by federal law and regulations. And they cannot set dollar limits on what they spend on “essential health benefits” for a policyholder.

Though this is a milestone for the law, it is unlikely to end the constant partisan battles that began even before its passage nearly four years ago. Late Tuesday, Justice Sonia Sotomayor temporarily blocked the Obama administration from forcing some religious-affiliated groups to provide coverage of birth control or face penalties.

Doctors, hospitals and pharmacists say consumers could initially experience some delays and difficulties as they try to use their new insurance.

“I feel a huge sense of relief,” said Katie R. Norvell, 33, a music therapist in St. Louis, who has been uninsured for three and a half years and has a pre-existing gynecological condition, endometriosis. She signed up Dec. 22 for a midlevel silver plan offered by Coventry Health Care, owned by Aetna, and has already begun making doctor’s appointments.

“With coverage,” she said, “I can be my best self. Health insurance won’t control my job choices.”

A series of last-minute changes in rules and deadlines for people to sign up and pay premiums have left less time for insurers to activate coverage and issue identification cards, adding to the uncertainty caused by the troubled rollout of the health exchange.

“There will be a lot of confusion,” said Brian D. Caswell, a former president of the Kansas Pharmacists Association, who owns a drugstore in rural Baxter Springs. “Many people will get insurance cards, but will not have a clue what’s covered, what’s not covered and what they are supposed to pay.”

Others may find their insurance companies have no record of their enrollment because the information was not sent by the online marketplaces where they signed up for coverage. Some of the newly insured may have trouble finding doctors who accept their health plans, many of which are restricting the number of providers in their networks to hold down premium costs.

And as newly insured consumers sort through details of their coverage, others will find that they are no longer insured by their old plans, which were canceled or discontinued because they did not comply with coverage requirements of the law. Of several million who received cancellation notices, most should be able to obtain other coverage, the Obama administration says.

Toby Mitchell, a self-employed recruiter in Napa, Calif., said she considered forgoing insurance when Kaiser Permanente canceled her longtime plan because it did not meet the requirements of the new law. But in the end, Ms. Mitchell, 60, decided to buy a bronze plan. Her monthly premiums will now be $575, compared with $288 on her old plan.

“I was really shocked,” she said. “It’s just painful because there are other things I’d rather do with that money, especially when it’s hard to see the value is there for me personally.”

Kathleen Sebelius, the secretary of health and human services, said Tuesday that more than 2.1 million people had selected private health plans, about half of them through the federal insurance exchange and half in marketplaces run by states. In addition, hundreds of thousands of Americans have enrolled in Medicaid, the government health insurance program for low-income people, which about half the states have decided to expand under the law.

Federal officials said they did not know how many subscribers were replacing insurance policies canceled because they did not meet coverage standards.

Subscribers will be entitled to coverage starting Wednesday if they pay the first month’s premium by the due date, Jan. 10 for many insurers.

Ana Yngelmo, a 37-year-old immigration lawyer in Kearny, N.J., said she would use her new insurance to start seeing a primary care doctor and to get her first mammogram. Ms. Yngelmo, who said she had been uninsured for 16 months, chose a platinum plan with generous coverage and no deductible. She qualified for a tax-credit subsidy that will lower her monthly premium to $350 — still expensive, she said, but worth it for peace of mind.

“For me, insurance is about those tragic situations where you need some terrible surgery or get cancer,” said Ms. Yngelmo, who recently started her own law practice. “I just want to make sure that in those situations, I can go to whichever doctor I want and it will be covered.”

In some states, doctors are preparing for an influx of newly insured patients. Dr. Michael J. Pramenko, a family doctor who is executive director of Primary Care Partners in Grand Junction, Colo., said his group had opened a satellite clinic, added several doctors and extended office hours in the expectation that “we will be seeing more patients.”

Cynthia Taueg, a vice president of the St. John Providence Health System in Warren, Mich., near Detroit, said she expected a gradual increase in patients because “a majority of the uninsured in our service area will be eligible for Medicaid” or for subsidized private insurance through the exchange.

Scott Keefer, a vice president of Blue Cross and Blue Shield of Minnesota, voiced a concern expressed by many insurers: Some consumers will go to doctors, hospitals and drugstores believing they have enrolled in a health plan, only to find that the company has no record of them.

That is what happened in January 2006 when a prescription drug benefit was added to Medicare. Many low-income people left pharmacies empty-handed after being told they would be responsible for co-payments of $100, $250 or more. Pharmacists extended credit to some customers. To help their residents, states paid drug claims that should have been paid by Medicare.

The Affordable Care Act is far more complicated, as it relies on a larger number of providers to deliver a much wider array of benefits.

Since the federal exchange opened Oct. 1, officials have grappled with problems in the quality of enrollment data. Insurers said the government initially provided them incorrect or incomplete information on some enrollees, and no information at all about some who enrolled online.

Insurers and government officials are taking steps to reduce confusion. Aetna, for example, has posted information on its website answering questions likely to bedevil consumers in the next few weeks. The insurance exchanges in California and Connecticut are about to run advertisements explaining the Jan. 10 premium deadline.

Peter V. Lee, the executive director of California’s insurance exchange, said that while logistical problems would surely pop up, they would matter less and less as people started using their benefits.

But John G. Lee, an insurance agent in Fredericksburg, Va., said that health insurance was a complicated product and that people did not always understand what they were buying online. He said he worried that consumers would be upset when they discovered that certain medicines were not covered by their plans, or that their doctors were excluded from the approved providers.

William Hannah of Cleveland, Ga., who has been uninsured for about 20 years, said he was looking forward to using his new coverage to see a specialist for lower back problems and numbness in his limbs. But Mr. Hannah said he had canceled the first plan he signed up for, from Blue Cross and Blue Shield of Georgia, after realizing it would not pay for treatment at the medical center closest to his home. He switched to a silver plan from Alliant Health Plans and qualified for a tax subsidy that will lower his premium costs to $56 a month.

“It’s very affordable to me, thanks to the tax credit,” said Mr. Hannah, 63, who said he had retired early to care for his ailing mother. “On the other hand, there’s the limitation of what the insurance companies are actually paying for and what institutions they are paying for.”

    Millions Gaining Health Coverage Under Law, NYT, 31.12.2013,






E.R. Costs for Mentally Ill Soar,

and Hospitals Seek Better Way


December 25, 2013
The New York Times


RALEIGH, N.C. — As darkness fell on a Friday evening over downtown Raleigh, N.C., Michael Lyons, a paramedic supervisor for Wake County Emergency Medical Services, slowly approached the tall, lanky man who was swaying back and forth in a gentle rhythm.

In answer to Mr. Lyons’s questions, the man, wearing a red shirt that dwarfed his thin frame, said he was bipolar, schizophrenic and homeless. He was looking for help because he did not think his prescribed medication was working.

In the past, paramedics would have taken the man to the closest hospital emergency room — most likely the nearby WakeMed Health and Hospitals, one of the largest centers in the region. But instead, under a pilot program, paramedics ushered him through the doors of Holly Hill Hospital, a commercial psychiatric facility.

“He doesn’t have a medical complaint, he’s just a mental health patient living on the street who is looking for some help,” said Mr. Lyons, pulling his van back into traffic. “The good news is that he’s not going to an E.R. That’s saving the hospital money and getting the patient to the most appropriate place for him,” he added.

The experiment in Raleigh is being closely watched by other cities desperate to find a way to help mentally ill patients without admitting them to emergency rooms, where the cost of treatment is high — and unnecessary.

While there is evidence that other types of health care costs might be declining slightly, the cost of emergency room care for the mentally ill shows no sign of ebbing.

Nationally, more than 6.4 million visits to emergency rooms in 2010, or about 5 percent of total visits, involved patients whose primary diagnosis was a mental health condition or substance abuse. That is up 28 percent from just four years earlier, according to the latest figures available from the Agency for Healthcare Research and Quality in Rockville, Md.

By one federal estimate, spending by general hospitals to care for these patients is expected to nearly double to $38.5 billion in 2014, from $20.3 billion in 2003.

The problem has been building for decades as mental health systems have been largely decentralized, pushing oversight and responsibility for psychiatric care into overwhelmed communities and, often, to hospitals, like WakeMed.

In North Carolina, the problem is becoming particularly acute. A recent study said that the number of mental patients entering emergency rooms in the state was double the nation’s average in 2010.

More than 10 years after overhauling its own state mental health system, North Carolina is grappling with the consequences of a lost number of beds and a reduction in funding amid a growing outcry that the state’s mentally ill need more help.

In Raleigh, where the Dorothea Dix Hospital — a state psychiatric institution that served the area for more than 150 years — was closed in 2012, mentally ill patients began trickling into hospital emergency rooms.

Hospitals, which cannot legally turn away any patient seeking care, say the influx of psychiatric patients is straining already busy E.R.'s and creating dangerous conditions.

This spring, University Medical Center of Southern Nevada in Las Vegas declared an “internal disaster,” shutting its doors to arriving ambulances for 12 hours, after mental patients filled up more than half of its emergency room beds. A suicidal patient took out a gun and shot herself in the head while in a hospital emergency room in New Mexico in January.

With a crisis facing states, communities and hospitals across the country, experts say no clear solution has emerged. St. Joseph’s Hospital Health Center in Syracuse created a separate psychiatric emergency department. Interim LSU Hospital in New Orleans opened a 10-bed mental health emergency room extension six years ago that is typically full.

But in Raleigh, the goal is slightly different: keep the psychiatric patients out of the hospital emergency room altogether.

The problem facing North Carolina and other states is a legacy of the 1960s, when warehousing of the mentally ill in large psychiatric hospitals was seen as inhumane.

The first wave of so-called deinstitutionalization was driven by new psychiatric drugs and by a 1963 law championed by President John F. Kennedy that provided federal funding for community-based mental health centers.

States began reducing the number of psychiatric beds. From a peak of more than 300 beds per 100,000 people in 1955, states had cut the number of beds to an average of 14 by 2010, according to research from the Treatment Advocacy Center, a nonprofit organization that promotes improved psychiatric care through better laws, policies and practices.

For decades, North Carolina resisted the broad mental health reforms. But in 2000, state lawmakers moved to overhaul the state’s mental health system, closing state facilities and pushing counseling and outpatient programs to local communities.

When the economy plummeted in 2008, North Carolina, like other states, reduced funding to community programs. In all, the state spends 20 percent less on community mental health services than it did a decade ago.

Today, North Carolina has only eight beds in state psychiatric hospitals per 100,000 people, the lowest ratio in the country.(North Carolina, like other states, has added beds in local community facilities but, even then, its total beds are down a quarter since 2001.)

Uninsured patients rarely receive individual therapy, only group sessions. And it can take up to three months to see a psychiatrist.

“Now, we are seeing some of the most acute, the most aggressive and the most chronic mental health patients, and we’re holding them longer,” said Janice Frohman, the director of WakeMed’s emergency department.

The effects of the upheaval in care of the mentally ill are playing out vividly at WakeMed. A private, nonprofit organization with 884 beds, WakeMed is struggling to find a way to meet the needs of increasing numbers of mentally ill patients while also controlling costs.

Hospital officials, along with their counterparts at the county and state level, support the pilot program but say it is one small step toward meeting a much bigger challenge.

WakeMed has treated an average of 314 patients a month whose primary diagnosis is some form of psychosis. That is up a third from two years ago.

On any given day, 25 to 50 mentally ill patients can be found throughout its halls.

Some linger in the busy emergency room bays, surrounded by the bright lights and the soft beeps of machines. Others are mixed into the hospital’s inpatient rooms.

The nurses on the ward wear small panic buttons on the lapels of their hospital coats. When asked when she last pressed her panic button, which immediately floods the ward with help to subdue a violent patient, Francine Moseley, a petite nurse smiles ruefully: It was just last night.

The panic calls happen about 25 times a month.

WakeMed, like Holly Hill, receives some money from a variety of sources to care for the patients, but it must pay for many other costs.

Last year, the hospital spent $2 million on so called sitters, who monitor the most aggressive patients 24 hours a day. When the county sheriff’s office became overwhelmed transporting patients to facilities up to three hours away, WakeMed hired a private transportation company.

The hospital now employs 14 behavioral health specialists and four patient service assistants who spend hours contacting care facilities in the hopes of finding an empty bed.

As the state’s mental health system became more fragmented, community leaders in Wake County have been trying to better coordinate care for patients who use the bulk of resources.

They are focusing on the “high users” — individuals who repeatedly call 911 or show up at emergency rooms.

There is the elderly man suffering from chronic pain who has been transported by ambulance to Raleigh emergency rooms 120 times in the last two years. A female patient with a history of mental illness called 911 nine times in June alone.

A little more than three years ago, Brent Myers, an emergency room physician, noticed that increasingly at the start of his shift more than half the beds were already full of patients needing mental health care, rather than physical care.

The head of Wake County Emergency Medical Services, Dr. Myers was also among a handful of paramedics in the county who are trying to expand the role of first responders. Seeing an opportunity to both accomplish that goal and help reduce the number of patients flowing into the hospital emergency room, he persuaded county and state officials to agree to an experiment.

Shortly thereafter, a group of Wake County paramedics began to be trained to perform mental health exams on patients in the field who are judged not to be in need of emergency medical care. By asking a series of questions, the paramedics are then able to evaluate a patient’s mental condition. While giving a patient the option of going to a local emergency room if they prefer, they also offer the choice of being taken to another facility that might be better suited to provide the kind of care they need.

Last year, more than half of the 450 patients identified with mental illness asked to go somewhere other than the emergency room.

Dr. Myers sees it as the start for connecting other types of patients with alternatives to hospital emergency rooms.

Emergency officials in many other areas are looking to replicate aspects of the Wake County program. But many states have laws and protocols that essentially dictate that patients may be transported by ambulance to only hospital emergency rooms. Moreover, Medicare and state Medicaid programs are largely unable to reimburse for transports to nonhospital facilities.

Still, Dr. Myers says there are bigger costs that can be squeezed out of the health care system by changing how emergency responders deal with high users, whether they be mentally ill patients or simply those suffering from chronic conditions like diabetes who could be better served by connecting with a home-health provider.

“Our next big step is to get into the community in a big way,” Dr. Myers said. “That’s where we’re headed.”

    E.R. Costs for Mentally Ill Soar, and Hospitals Seek Better Way, NYT, 25.12.2013,






Medicaid Expansion

Faces Major Logistical Challenges

Among the Homeless


November 24, 2013
The New York Times


CHICAGO — In a back room at the Franciscan House of Mary and Joseph, one of the largest homeless shelters in Chicago, a social worker named Sheena Ward guided Terry Cannon through a Medicaid application.

A wet cough punctuated Mr. Cannon’s often wry answers to Ms. Ward’s questions about his disability status, military service and marital history. “I have glaucoma, I’m going blind. I have lung disease, I’m dying,” he said. “How can they deny me? If they do, give me a couple years and I’ll be gone.”

Today, most state Medicaid programs cover only disabled adults or those with dependents, so Mr. Cannon and millions of other deeply impoverished Americans are left without access to the program. But starting Jan. 1, President Obama’s health care law will expand Medicaid coverage to adults with incomes under 138 percent of the federal poverty line, and enrollment is expected to increase by about nine million next year. Thousands of homeless people will be among the newly covered.

Housing advocates say they believe that the Medicaid expansion has the potential to reduce rates of homelessness significantly, both by preventing low-income Americans from becoming homeless as a result of illness or medical debt and by helping homeless people become eligible for and remain in housing.

“We really feel like this is the last piece of the puzzle that we need to end chronic homelessness,” said Steve Berg, the vice president for programs and policy at the National Alliance to End Homelessness.

But signing up homeless people for Medicaid is a huge logistical challenge, as housing advocates acknowledge. Homeless individuals often do not have an email address, phone number or permanent address. Many are unaware of the health care law or are skeptical of public programs.

Housing advocates and social workers across the country are now on a major push to inform impoverished and homeless people that they are eligible for Medicaid in the 25 states that are expanding the program and in the District of Columbia, and to enroll them.

For homeless people, experts said, the Medicaid expansion will mean more consistent treatment for medical conditions, including alcoholism, drug addiction, chronic pain and depression. For states and cities, they said, it will mean a more effective safety net, and perhaps even a cheaper one.

“You cannot successfully treat someone for diabetes if they’re living under a bridge,” said Ed Blackburn, the executive director of Central City Concern, a nonprofit agency in Portland, Ore. “And serious mental illness and chronic health conditions are barriers to getting housing.”

To help spread the word, Heartland Alliance, the nonprofit organization where Ms. Ward works, has stationed employees in soup kitchens, shelters and medical clinics to increase awareness and encourage enrollment. “They’re accustomed to a no,” Ms. Ward said of her homeless clients. “You really have to encourage them and let them know it’s their right to be covered.”

The conditions of homeless life can also make it difficult to enroll. At the House of Mary and Joseph, Julie Nelson, associate director of outreach, benefits and entitlements at Heartland Alliance, huddled with 48-year-old Marvin Cosper. “I heard about Obamacare,” he said, nodding, as Ms. Nelson walked him through the basics of the available plans.

But when she explained that it might take 60 days for him to be enrolled, he bristled. “I’m just passing through,” he said.

Mr. Cosper is a former drug addict and onetime crack cocaine dealer who has spent much of the past 20 years homeless, moving from state to state. “I was under the impression it was federal,” he said. “I thought it was federal, so whatever state you were in, you could use that card.”

“That’s a really good question,” Ms. Nelson said. “It goes state by state.” About half of states have opted out of the Medicaid expansion, a decision made possible by the Supreme Court’s 2012 ruling on the law.

Mr. Cosper decided to sign up for Medicaid anyway.

Another client, Donna Terrell, who is 54 and has been homeless for a decade, worked with Ms. Nelson to sort out whether she was enrolled already.

“I’m in limbo,” Ms. Terrell said, settling onto a cot with a plastic mattress in a room that would hold about 40 women that night. She said she had filled out the paperwork but had never received an enrollment card, ending up with $6,000 in medical bills instead. She and Ms. Nelson determined that Ms. Terrell did have coverage, but her card had been sent to a shelter that had shut down months before.

If the logistical challenges of signing up homeless people for Medicaid can be mitigated, housing advocates and social workers say, the Medicaid expansion could provide profound benefits for them, even though some experts caution that finding doctors who accept Medicaid will continue to be a challenge in many states.

Studies suggest that most chronically homeless Americans are uninsured. It can be logistically difficult for people with very low or nonexistent incomes to gain access even to charity care and free clinics, because getting there costs money and because clinics’ hours and ability to provide care are limited.

The Medicaid expansion is expected to greatly improve access to care for hundreds of thousands of homeless Americans, who would be able to see physicians and specialists, often at no cost.

It might also shift the burden of care from emergency rooms to doctors’ offices, with benefits for state budgets. Homeless people tend to use health care services in the most expensive ways, said Jennifer Ho, a senior adviser at the Department of Housing and Urban Development. “They show up when they’re sicker,” she said. “They stay longer. And it’s harder to discharge them because they don’t have a place to go.”

Housing advocates emphasized that the Medicaid expansion would not directly help homeless people find housing. But officials at federal agencies, national housing organizations and local nonprofit organizations pointed to several ways it could reduce rates of homelessness.

In addition to helping prevent homelessness due to medical debt or untreated illness, the expansion could free up money for nonprofit groups to spend on housing, rather than on health care, officials at the National Alliance to End Homelessness said.

The expanded coverage might also make it easier for homeless people to find and stay in housing. For instance, some housing units require prospective tenants to have Medicaid, Ms. Nelson said. Moreover, the expanded Medicaid program would “pay for services that help people become stable so that they can remain in housing,” said Karen Batia, the executive director of Heartland Alliance’s health outreach operations.

“It’s a means to an end,” said Ms. Ward, the social worker, adding that it would help organizations like Heartland “treat the person holistically.”

Some states might try to bring down medical costs by asking the federal government for waivers to spend Medicaid dollars on supportive housing, experts said.

But first, the challenge is expanding Medicaid to a fragile and hard-to-reach population.

    Medicaid Expansion Faces Major Logistical Challenges Among the Homeless,
    NYT, 24.11.2013,






Texas Women and Abortion Rights


November 20, 2013
The New York Times


In an alarming 5-to-4 ruling, the Supreme Court turned away an emergency application to block a new Texas law that is impeding access to safe and legal abortion care in the state. The ruling leaves in place an order by the United States Court of Appeals for the Fifth Circuit that allowed the law go into effect while it considers an appeal.

The Texas law requires doctors who perform abortions to have admitting privileges at a nearby hospital. A federal district judge, Lee Yeakel, ruled last month that this provision serves no medical purpose and improperly infringes on women’s reproductive rights. The requirement forces a third of Texas’ abortion doctors to stop offering the procedure. Judge Yeakel issued an injunction blocking the provision, which a three-judge panel of the appellate court promptly lifted.

The justices should have blocked the law as the appeal proceeds. The court’s 1992 decision in Planned Parenthood v. Casey forbids state regulations that have “the purpose or effect of placing a substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus” — a principle this provision clearly violates.

Justice Antonin Scalia, joined by Justices Clarence Thomas and Samuel Alito Jr. (Chief Justice John Roberts Jr. and Justice Anthony Kennedy did not join in the majority opinion but presumably voted to allow the law to go into effect), wrote that the plaintiffs had not met the “heavy” procedural burden of showing that the appeals court ruling was “a clear violation of accepted legal standards.” But as Justice Stephen Breyer rightly noted in his dissent, “The longer a given facility remains closed, the less likely it is ever to reopen even if the admitting privileges requirement is ultimately held unconstitutional.”

The Supreme Court’s procedural decision will affect thousands of women who would have sought abortions at the clinics no longer offering that service. The justices should follow their own precedent and strike down the admitting privileges rule if and when they are asked to directly consider its constitutionality.

    Texas Women and Abortion Rights, NYT, 20.11.2013,






Justices Reject Bid

to Block Texas Law on Abortions


November 19, 2013
The New York Times


WASHINGTON — The Supreme Court on Tuesday turned away an emergency application asking it to block a Texas law that requires doctors performing abortions to have admitting privileges at a nearby hospital.

The decision was effectively 5 to 4 and split along ideological lines.

The effect of the ruling, Justice Stephen G. Breyer wrote for the four dissenters, was to leave 24 counties in the Rio Grande Valley without abortion clinics. “It may,” he added, “substantially reduce access to safe abortions elsewhere in Texas.”

Justice Antonin Scalia, joined by Justices Clarence Thomas and Samuel A. Alito Jr., wrote that the challengers to the law had not met a heavy procedural burden in asking the Supreme Court to alter an appeals court’s provisional decision to let the law go into effect while it considers an appeal.

“Reasonable minds can perhaps disagree about whether the court of appeals should have granted a stay in this case,” Justice Scalia wrote. “But there is no doubt that the applicants have not carried their heavy burden of showing that doing so was a clear violation of accepted legal standards — which do not include a special ‘status quo’ standard for laws affecting abortion.”

Chief Justice John G. Roberts Jr. and Justice Anthony M. Kennedy also presumably voted to reject the application and allow the law to go into effect but did not join Justice Scalia’s opinion.

Abortion rights groups and clinics said the law served no medical purpose and was forcing a third of the state’s 36 abortion clinics to stop performing the procedure, preventing some 20,000 women a year from access to safe abortions.

State officials told the court that the law, which requires that doctors have hospital admitting privileges within 30 miles of where they perform abortions, protects public health by “fostering a woman’s ability to seek consultation and treatment for complications directly from her physician.”

The officials added that the impact of the law was modest, saying that more than 90 percent of women seeking abortions in the state will still live within 100 miles of an abortion clinic.

The law had been temporarily stalled when Wendy Davis, a Democratic state senator, mounted an 11-hour filibuster in the Republican-controlled Legislature. Ms. Davis is now running for governor.

The case may yet reach the justices. The United States Court of Appeals for the Fifth Circuit, in New Orleans, provisionally allowed the law to go into effect last month. The appeals court will hear arguments in the case in January, and either side may appeal its decision to the Supreme Court.

Justice Breyer wrote that the validity of the Texas law “is a difficult question.” He added that he expected the Supreme Court to agree to hear an appeal regardless of how the appeals court rules.

The appeals court’s ruling stayed one from Judge Lee Yeakel, a federal district judge in Austin, who had blocked the law. Judge Yeakel said the law’s “admitting-privileges provision is without a rational basis and places a substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus.”

Justice Breyer, joined by Justices Ruth Bader Ginsburg, Sonia Sotomayor and Elena Kagan, said Judge Yeakel’s ruling should have been allowed to stand while the appeal was considered.

At bottom, the two sides in Tuesday’s ruling differed about what it means to maintain the status quo while a case proceeds through the courts. Justice Scalia said that the status quo is upheld and federalism principles are vindicated when validly enacted state laws are allowed to stand while their constitutionality is definitively resolved.

Justice Breyer focused on the practical consequences for women in Texas seeking abortions.

“I would maintain the status quo” of allowing clinics in Texas to provide abortions, he wrote, “while the lower courts consider this difficult, sensitive and controversial legal matter.”

“The longer a given facility remains closed,” Justice Breyer wrote, “the less likely it is ever to reopen even if the admitting privileges requirement is ultimately held unconstitutional.”

    Justices Reject Bid to Block Texas Law on Abortions, NYT, 19.11.2013,






The Shame of American Health Care


November 17, 2013
The New York Times


Even as Americans struggle with the changes required by health care reform, an international survey released last week by the Commonwealth Fund, a research organization, shows why change is so necessary.

The report found that by virtually all measures of cost, access to care and ease of dealing with insurance problems, Americans fared poorly compared with people in other advanced countries. The survey covered 20,000 adults in the United States and 10 other industrial nations — Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and Britain, all of which put in place universal or near-universal health coverage decades ago. The United States spends far more than any of these countries on a per capita basis and as a percent of the national economy.

For that, it gets meager results. Some 37 percent of American adults went without recommended care, did not see a doctor when sick or failed to fill prescriptions in the past year because of costs, compared with 4 percent in Britain and 6 percent in Sweden. Nearly a quarter of American adults could not pay medical bills or had serious problems paying them compared with less than 13 percent in France and 7 percent or less in five other countries. Even Americans who were insured for the entire year were more likely than adults abroad to forgo care because of costs, an indication of how skimpy some insurance policies are.

When Americans got sick, they had to wait longer than people in most of the other countries to get help. Fewer than half were able to get same-day or next-day appointments with a doctor or nurse; one in four had to wait six days or longer. (Only Canada fared worse on both counts.) But Americans got quicker access to specialists than adults in all but two other countries.

The complexity of the American insurance system is also an issue. Some 32 percent of consumers spent a lot of time on insurance paperwork or in disputes with their insurer over denials of payment for services they thought were covered.

The Affordable Care Act was created to address these problems by covering tens of millions of uninsured people and providing subsidies to help many of them pay for policies; by setting limits on the out-of-pocket costs that patients must bear; and by requiring that all policies cover specified benefits.

Americans are understandably frustrated with the Obama administration’s failure to produce a functioning website. President Obama’s erroneous statements that all people who like their current insurance policies can keep them — not true for many people buying insurance in the individual market — has added to anger and misunderstanding. The reform law, however imperfect, is needed to bring the dysfunctional American health care system up to levels already achieved in other advanced nations.

    The Shame of American Health Care, NYT, 17.11.2013,






Alzheimer’s Anxiety


November 16, 2013
The New York Times


PHILADELPHIA — ALMOST every day I worry about whether my parents have Alzheimer’s. My dad is 86 and my mother is about to turn 80. Just because of their age they are at high risk for the disease, and I constantly wonder if their forgetfulness is “normal” or a sign of the worst.

All of us are afraid of Alzheimer’s. We worry about having a parent with it or getting it ourselves. Many believe they would rather die.

It is no wonder we fear the disease. Alzheimer’s gradually robs its victims of their identities. While many remain happy and unbothered by their forgetfulness, they inevitably become different people, living largely in whatever part of the past they can remember. Eventually, they have to be fed and taken to the bathroom — their existence ever constricting as they drift further and further from their former selves.

The personal effects are devastating, but so are the societal ones. In 1980, nearly three million Americans had dementia caused by Alzheimer’s. That number has since doubled. Some estimates show that, in the next 40 years, it will increase almost threefold, to 16 million. This is because the greatest risk factor for developing Alzheimer’s dementia is old age, and America is rapidly aging. One in nine Americans over 65 have the disease, and one in three over 85. This adds up to $200 billion a year in health care costs, not counting the tens of billions in unpaid care that families provide.

The costs of the disease, along with the uncertainty over both diagnoses and treatments, is scary, especially for can-do Americans. So it’s only natural that, in recent years, people have trumpeted the development of a new test that can measure the presence of beta-amyloid — the protein clumps in the brain that are one of the hallmarks of Alzheimer’s dementia. The patient is injected with a radioactive molecule that zeros in on beta-amyloid, and a positron emission tomography, or PET, scanner then detects the radioactivity.

In April 2012, the Food and Drug Administration approved Eli Lilly’s radioactive molecule for patients who are being evaluated for Alzheimer’s disease and other causes of cognitive decline that result in forgetfulness or disorientation.

In September, Medicare announced that it would pay for the test — which costs between $3,000 and $5,000 and is often not covered by private insurance — but only if the patient was part of a randomized, controlled trial, which is the only way to definitively determine the value of the scan.

Eli Lilly has objected to the ruling, contending that the test should be covered without restriction. And the Alzheimer’s Association, a leading research advocacy and patient support organization, has posted on its website, “Despite the concerns and complications, we believe it is valuable to the Alzheimer field — to the pursuit of better Alzheimer diagnostics, treatments and preventions — to have this product more widely available.”

But the Alzheimer’s Association isn’t entirely unbiased. Since 2008, it has received $1.6 million from Lilly. And in 2012 it received more than $4 million from all drug companies — many of which are selling Alzheimer’s drugs.

The question patients and their families should be asking is, what does this test really offer?

Let’s be clear: it does not cure the disease or affect symptoms. At best it identifies what might be causing a patient’s forgetfulness. But, at worst, it can get that diagnosis wrong. According to the company’s own post-mortem study of 59 terminally ill patients, false positives in scans for the presence of amyloid were reported in up to 3 percent of cases, while up to 20 percent of cases resulted in a false negative: patients were diagnosed as not having amyloid and thus Alzheimer’s, even when they did.

To make things more confusing, while colloquially called an “Alzheimer’s test,” the scan doesn’t diagnose Alzheimer’s dementia — it only determines the presence of amyloid. And our understanding of the connection between the two is shaky. While everyone who has Alzheimer’s also has amyloid, not everyone with amyloid has Alzheimer’s dementia. Almost a third of cognitively normal elderly people have these protein clusters in their brains. On the scan they would light up. But those patients don’t have Alzheimer’s dementia and we don’t know how likely they are to develop it in the future. Imagine the anguish of that error.

In fact, the only thing the scan can do is confirm that a patient’s cognitive problems are not caused by Alzheimer’s.

Even if it could diagnose Alzheimer’s, it probably wouldn’t make much difference to patients. Currently, there are five drugs on the market that treat dementia. None can cure the disease. None can change the downward trajectory of cognition. At best, they can relieve the symptoms of patients with moderate to severe Alzheimer’s for about six to 12 months. And let’s not forget these drugs all have side effects like fatigue, dizziness and pain.

Even those who advocated the general approval of the scan never argued that it would help patients decide whether or not to use medication: these drugs are not preventive; they are taken only by people who already have advanced Alzheimer’s dementia. As one expert who is collaborating with Lilly put it: “Having an amyloid scan is hugely helpful not in determining drug therapy but for other things” — like planning.

But today, individuals 55 or younger are likely to live past 80, which means they stand a good chance of getting Alzheimer’s dementia. We don’t need an expensive test to tell us that we should all be planning for the possibility of Alzheimer’s — investing in long-term care insurance, exercising and staying socially active.

Alzheimer’s disease is scary. But that is no reason for society to waste a lot of money on a test that really doesn’t help. It is a reason for a lot more research on Alzheimer’s, including Medicare’s randomized trial to evaluate the effectiveness of the test. This research will take time, but there is no other path forward.


Ezekiel J. Emanuel is an oncologist,

vice provost at the University of Pennsylvania

and contributing opinion writer.

    Alzheimer’s Anxiety, NYT, 16.11.2013,






Leonard Herzenberg,


Who Revolutionized Research

Dies at 81


November 10, 2013
The New York Times


Leonard Herzenberg was in his lab at Stanford University one day in the early 1960s laboriously counting cells under a microscope. His eyes hurt. “There’s got to be some kind of machine that can do this,” he remembered muttering.

He went on to develop precisely that — and in doing so helped revolutionize immunology, facilitate stem cell research and advance the treatment of cancer, H.I.V. infection and other illnesses.

Dr. Herzenberg, who died on Oct. 27 at 81 in Stanford, Calif., created a device that can pick out individual cells from a mass of trillions of them and then capture, sort and count them so they can be analyzed and used to fight disease.

Some likened his achievement to watching a parade of 10,000 men in drab suits, spotting the two wearing yellow ties and the three wearing pink ones, and then pulling the five out of line without anyone losing a step.

Today, more than 40,000 such devices are in operation around the world; virtually no significant medical lab is without one. In 2006, the Inamori Foundation presented Dr. Herzenberg with the Kyoto Prize, the Japanese equivalent of the Nobel Prize, in the category of advanced technology, calling his achievement “monumental.”

Dr. Irving Weissman, who was a student of Dr. Herzenberg’s and became one of the world’s leading stem cell researchers, said, “Without Len, tens of thousands of people now alive would not be.”

Dr. Herzenberg’s success was not his alone. At his side in the laboratory was Leonore Herzenberg, his wife of 60 years and a fellow researcher. “Len and Lee,” as everyone knew them, were known for holding brainstorming sessions with generations of young researchers, many of whom achieved international renown. Many of his most important papers listed her as an author.

“You can’t sort out which one did what,” Ms. Herzenberg said in an interview. “I swear it was magical.”

Leonard Herzenberg’s invention is called the fluorescence-activated cell sorter, known by the acronym FACS. (The generic name for it and similar devices is flow cytometer.) The FACS name was later trademarked by the medical devices manufacturer Becton, Dickinson and Company (also known as BD).

Dr. Herzenberg’s mission was always more medical than technical, although he liked fooling with gadgets. He used his cell sorter to become a leader in developing strains of antibodies — called monoclonal antibodies — that glom onto targeted viruses and bacteria.

He created the antibodies — actually armies of protein cells — by introducing a specific germ to human or animal tissue; the process prompted the body to form a multitude of antibodies geared specifically to attack that germ. He identified the antibodies by illuminating them with fluorescence — a process developed in the 1940s — enabling him to capture and clone them.

The technique permitted the creation of large numbers of pure, identical antibodies, which could be used for purposes as minute and delicate as plucking out exceedingly rare stem cells for study.

Dr. Herzenberg gave these living antibodies away — a generosity rare in today’s legalistic, profit-hungry scientific world — and they continue to be widely used.

His cell sorter, too, remains in wide use. Susan O. Sharrow, a biochemist with the National Cancer Institute, said in an email that the FACS “remains the gold standard” for such devices.

Leonard Arthur Herzenberg was born on Nov. 5, 1931, in the Flatbush section of Brooklyn, where he grew up. His father, William, was a clothing salesman; his mother, the former Ann Seidlitz, a legal secretary. Leonard read science books in elementary school and was doing experiments in his basement by high school.

He met Leonore Alderstein when they were students at Brooklyn College. At the time, he was nearing graduation; she, at 17, still had a few years to go. They decided to marry when both had graduated. Mr. Herzenberg, who had studied chemistry and biology, received his degree in 1952 and was accepted to continue his studies at the California Institute of Technology. The couple parted, but not for long. Loneliness and the weight of phone bills won out, and they married in 1953.

“Our parents thought we were too young, too innocent, too poor and too crazy,” Ms. Herzenberg wrote in the journal The Annual Review of Immunology in 2004. “They were probably right.”

In California, Ms. Herzenberg took courses at Pomona College and was allowed to audit graduate courses at Caltech. (It did not admit women then.) Also allowed to take tests, she got A’s, she said.

She was with Dr. Herzenberg at virtually every stage of his career — when he did postdoctoral research at the Pasteur Institute in Paris; when he was the first appointment to Stanford’s new genetics department in 1959. Indeed, most of their waking life was in the lab. She wrote papers on her own and papers with him, including some on the cell sorter.

Though she never earned a college degree, the University of Paris later named Ms. Herzenberg a doctor for her mountain of published work, and Stanford made her a full research professor.

In the early 1980s, the couple helped develop a blend of mouse and human antibodies that were acceptable to human immune systems. Royalties from the patent stand as the most profitable ever for Stanford. They also jointly supported human rights, education and health endeavors. A recipient of many awards, Dr. Herzenberg donated much of his prize money, including the $445,000 that came with the Kyoto award, to these initiatives.

Dr. Herzenberg, who lived in Stanford, died of complications of a stroke, his wife said.

In addition to her, he is survived by his daughters Jana Herzen and Berri H. Michel; his sons Eric and Michael; and four grandchildren.

Dr. Herzenberg’s idea for the FACS, which he named, evolved from his realization, shared by many, that microscopes were incapable of meeting the high-volume demands of minute biological research. He heard about work being done at Los Alamos National Laboratory in New Mexico by Dr. Mack J. Fulwyler on a device to sort particles in mouse lungs resulting from atomic bomb fallout. The Fulwyler device was the original cytometer, according to J. Paul Robinson, a Purdue University professor who has documented the technology’s history. Dr. Fulwyler gave Dr. Herzenberg his design plans.

By 1969, working with Stanford engineers and financing by the National Cancer Institute, Dr. Herzenberg had come up with his improved version of Dr. Fulwyler’s cytometer. Three years later, the Stanford team produced an even more sophisticated one, a laser-powered model using fluorescence. Similar inventions emerged in this period, including one created by Dr. Wolfgang Göhde in Germany in 1968, the first patented cytometer to use fluorescence.

But Dr. Herzenberg’s device ended up leading the pack because, as it evolved, it could address some of biology’s most complex problems, said Dr. Howard M. Shapiro, another expert in the field. Emphasizing that success has many fathers, Dr. Shapiro said that Dr. Herzenberg most clearly “passes the paternity test.”

    Leonard Herzenberg,
    Immunologist Who Revolutionized Research, Dies at 81,
    NYT, 10.11.2013,






After Mental Illness,

an Up and Down Life


November 9, 2013
The New York Times


TEMPE, Ariz. — IN 2005, a distraught mother rushed her 13-year-old son to the emergency room for a psychiatric evaluation. The boy was overwrought, consumed by anxiety. The physicians asked the standard questions: Did he want to kill or hurt himself or others? No, was his answer.

The boy’s name was Adam Lanza. In the years between that hospital visit and the day, last December, when he shot to death 26 people at a Connecticut elementary school, there is reason to believe he had guidance from well-meaning therapists, parents and teachers. These efforts were obviously ineffective. What went wrong?

Twenty years ago, I wrote a book about childhood mental illness that focused on the experiences of two struggling young people in Pittsburgh, Daniel and Meggan. At the time, this is what struck me most about the treatment of children and adolescents with mental health problems: Social workers and psychiatrists mostly tried their best but didn’t know what they were doing, really. The science was imprecise and the system was fractured.

Two decades later, we are now able to see inside the brain with startling precision, thanks to sophisticated imaging techniques. And we know a lot more about brain biology. But we have been unable to transform much of that knowledge into definitive treatments.

Caring for the mentally ill adult is challenging. Children are considerably more complicated, because they are constantly changing and developing. Adam Lanza may have been a totally different human being in 2005 from the one he was in 2012. Or he may have been the same person, displaying symptoms the experts did not then acknowledge or understand.

Recently, I’ve been thinking about Daniel and Meggan, and wondering what happened to them. Had they ended up hurting themselves or others? Had they been able to live productive and satisfying lives?

When I met Daniel, he was a scrawny 10-year-old with tight curly hair. He had a scar on his forehead, where a ceiling had collapsed on him during a fire in a rooming house where his family had stashed, ignored and frequently abused him. Daniel was suffering from post-traumatic shock syndrome and schizophrenia and, after being removed from his family, was staying at a residential treatment center — one of 13 places he lived before turning 18.

In contrast, Meggan came from an upper-middle-class background, but she, too, suffered through a series of placements. Her parents shuttled her from therapists to hospitals to special schools, seeking help for and insight into her unpredictable behavior. Exhausted and nearly bankrupt, they eventually gave up, voluntarily relinquishing custody of their daughter to the state. This was then a frequent choice for many desperate families.

A reversal of approach has taken place since Daniel’s and Meggan’s therapeutic gantlet, when nearly three-fourths of all mental health dollars for adolescents were devoted to institutional care. Today, mental health professionals are more focused on keeping families together. In some states, intervention teams are available to respond to children in crisis, at home or at school. Drop-in centers have been established to provide families a therapeutic timeout. But these and other Band-Aid approaches are employed sporadically, and often, according to the United States Government Accountability Office, they are administered by undertrained personnel. The system, to put it bluntly, is a mess.

Funding, obviously, is part of the problem. Fifteen million children in the United States now suffer from some mental health disorder, and the Centers for Disease Control and Prevention reports that their numbers have been rising since at least the mid-1990s. But at the same time, spending on mental health treatment as a share of overall health spending declined from more than 9 percent in the mid-1980s to 7.4 percent in 2004, where it remained through recent years.

Resources aren’t the only problem. Psychologists and psychiatrists are still befuddled by basic challenges, beginning with diagnoses, which, for children, can change as they develop. In the 1990s, Meggan was told she was bipolar, then, 10 years later, that she was a high-functioning autistic and, more recently, according to her mother, a borderline personality. She has given up listening to doctors. “I am myself,” she insists, “my own unique flavor of mental health — ‘Meggan’s Syndrome’ — which is pretty awesome!”

After diagnoses, there’s the problem of medication. Certainly the advent of anti-psychotic medications has helped improve the treatment of the mentally ill, but dosages are still largely based on trial and error. Many of these drugs lack a Food and Drug Administration recommendation for children and adolescents — but that doesn’t mean they aren’t given to them. Meggan and Daniel were both prescribed a cocktail of drugs as children, one of the first being the mood stabilizer Lithium. According to a 2012 study in JAMA Psychiatry, the rate of antipsychotic drugs administered to children between 1993 and 2009 — Abilify, Geodon, Seroquel and others — has increased by a factor of nearly eight (for adults, the rate has only doubled). And, according to the G.A.O., foster children receive these medications up to four times more often than kids in the general population.

Studies have demonstrated that talk therapy or talk therapy combined with medication is more effective than meds alone. But there aren’t enough qualified psychiatrists and psychologists to provide that therapy. Today there are around 7,400 child psychiatrists practicing in the United States (roughly one for every 2,000 patients), compared with 4,600 in 1992. By 2020 there will be around a thousand more, though the American Academy of Child and Adolescent Psychiatry estimates that we will need double the current number by then.

I hadn’t communicated with Meggan since the book was published, so this summer I set up an appointment to talk. Now 38, she is the same vivacious and manic Meggan, laughing, crying and contradicting herself. We talked in a conference room at the medical center where she now works — and where she was once an inpatient.

She’s had an “up and down” life, she told me. On the plus side, she’s a college graduate with a degree in biology and three children. But she feels lonely and isolated. She is going through a divorce, and about three years ago was cited for marijuana possession, the use of which prompted her parents to seek custody of her children. She stopped cold turkey, and the suit was settled privately. She often works seven days a week, but her parents continue to supplement her income.

Daniel and I had kept in touch sporadically. I knew he had been in jail a couple of times for petty crimes and that he had relocated to another state. He married and legally changed his first and last names, thinking that a new name would help him escape the trauma of his past. But painful memories plague him. Now 37, he weighs 267 pounds, at 5-foot-3, and is suffering from congestive heart failure.

Meggan and Daniel have demonstrated their ability to survive and their will to persevere. After much effort, Daniel taught himself to read on a basic level, by studying websites and sounding out and memorizing words. And he never relented in his efforts to find work. He is now employed as a part-time cashier at a Ponderosa Steakhouse, his first paying job. He and his wife continue to rely on disability payments, however.

Meggan has had setbacks and made harmful choices, but she is now a responsible mother and a breadwinner.

Just think what they could have achieved, had they not been held captive by a dysfunctional system. We must work harder to understand mental illness and to provide the resources that social-service professionals need, to ensure that lost children like Meggan and Daniel can achieve their full potential.


Lee Gutkind is the editor of Creative Nonfiction magazine

and a writer in residence at Arizona State University

who is working on a new book on childhood mental illness.

    After Mental Illness, an Up and Down Life, NYT, 9.11.2013,






Equal Coverage for the Mentally Ill


November 8, 2013
The New York Times


A struggle over decades to force insurers to cover mental health and addiction services on the same basis as medical and surgical costs is headed for success under new rules issued on Friday by the Obama administration. The rules will cover most Americans with health insurance, including those in many employer-sponsored plans, in other group plans, in some but not all Medicaid plans, and in policies bought on the individual markets.

The rules strengthen a 2008 law that required parity in coverage — but only when an insurer actually offered mental health and addiction benefits. It did not require such benefits. The new health care law, the Affordable Care Act, does require coverage for mental health and substance abuse as 1 of 10 essential benefits in any new health plans. Combined, the two complete the job of offering both parity and coverage.

What the new rule would mean in practice is that limits on the amount of co-payments and the number of doctor visits or hospital days cannot be less generous than those that apply to most medical and surgical benefits. The same would be true of other rules, like those requiring prior authorization.

The benefits for the American public could be substantial, bringing help to many people previously unable to get it because of the cost. About a quarter of Americans 18 and older have a diagnosable mental disorder in a given year, and 6 percent have a seriously debilitating disorder, according to the National Institute of Mental Health. Nearly 60 percent of the people with mental health conditions and 90 percent of those with substance abuse problems don’t get the treatment they need, according to the administration.

The administration hopes that making treatment available to the mentally ill will help reduce gun violence, including mass murders. Some backers of parity believe it will also help veterans suffering from stress disorders from the battlefield get easier access to mental health services.

The effect on costs is uncertain. Insurers fear that the expenses of high-cost inpatient treatment or long-term rehabilitation of patients suffering from mental health disorders or substance abuse will drive up insurance costs, but experts say the number of people receiving high levels of care will be too small to have a significant effect on overall costs. And in the long run, better care could cure enough people to save billions of dollars a year in medical costs, lost wages and reduced productivity associated with alcoholism and other addictions.

Still, it is too early to declare victory. The rules will need to be vigorously enforced by state insurance commissioners who already have their hands full trying to make the Affordable Care Act work. And more money may need to be invested in behavioral health clinics or other providers to meet the demand for services by people who suddenly have insurance to pay the bill. Merely having an insurance policy is no guarantee that a provider can be found to deliver the necessary care.

    Equal Coverage for the Mentally Ill, NYT, 8.11.2013,







Obama Yields to Criticism

of Health Law


November 7, 2013
The New York Times


WASHINGTON — President Obama bowed Thursday night to mounting criticism that he had misled the American people about the health care law, apologizing to people who were forced off their health insurance plans by the Affordable Care Act despite “assurances from me.”

In an interview with NBC News, Mr. Obama said that he did not do enough to ensure that the law did not force the termination of insurance policies that people like because they do not meet the law’s new coverage requirements.

“It means a lot to them. And it’s scary to them. And I am sorry that they, you know, are finding themselves in this situation, based on assurances they got from me,” Mr. Obama told Chuck Todd of NBC in an interview in the Diplomatic Room of the White House. “We’ve got to work hard to make sure that we hear them and that we’re going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this.”

For years, Mr. Obama has repeatedly said that Americans who were satisfied with their health insurance plans could keep them even after his health care program took full effect at the beginning of next year. “If you like your health plan, you will be able to keep your health plan,” he said in speeches and at campaign rallies and town hall meetings.

But hundreds of thousands of people across the country began receiving letters of cancellation from their insurance companies in recent weeks, prompting accusations that Mr. Obama lied about the impact of the health care law for political reasons.

“We know that lying to Congress is a crime, but unfortunately, lying to the American people is not,” Senator John Cornyn, Republican of Texas, said Wednesday during a congressional hearing on Capitol Hill.

In the NBC interview, Mr. Obama said he had not purposely misled anyone. He said it was always his intention that no one should lose a plan he wanted to keep. But he emphasized that most people who were forced off a current plan would be able to find new insurance that was cheaper and provided better coverage.

“I think we, in good faith, have been trying to take on a health care system that has been broken for a very long time,” Mr. Obama said. “And what we’ve been trying to do is to change it in the least disruptive way possible.”

He added that “they’re benefiting from more choice and competition.”

“But obviously, we didn’t do a good enough job in terms of how we crafted the law,” he said. “And, you know, that’s something that I regret. That’s something that we’re going to do everything we can to get fixed.”

Senator Mary L. Landrieu, Democrat of Louisiana, introduced legislation this week to force insurance companies to reissue the health plans they have been canceling by the thousands. And officials in several states have sought assurances from insurance companies that people will not be dropped until the federal health insurance website is working.

The president did not endorse those specific efforts and did not elaborate on how he intended to help people who were faced with paying higher premiums for a new insurance plan. Mr. Obama said the White House was looking at a “range of options” to help people whose policies had been canceled. And he said that he had “assigned my team to see what we can do to close some of the holes and gaps in the law.”

The decision to apologize on Thursday reflects the increasingly dire political position that the president is in after the troubled rollout of the health care marketplace, which was designed to get coverage for millions of uninsured Americans.

But the website’s failures were compounded by the cancellation letters by insurance companies, which gave new ammunition to the president’s Republican critics. The controversy has also worried many of the president’s Democratic allies on Capitol Hill who face re-election campaigns next year.

Mr. Obama said in the interview that he was “deeply frustrated” by the technical problems surrounding the website.

“I take responsibility for that; my team takes responsibility of that,” he said. “And we are working every single day, 24/7, to improve it. And it’s better now than it was last week. And it’s certainly a lot better than it was on Oct. 1.”

He also defended Kathleen Sebelius, the secretary of health and human services, from attacks by Republicans who have called for her to resign.

“You know, Kathleen Sebelius doesn’t write code; yeah, she wasn’t our I.T. person,” he said. “Ultimately, the buck stops with me. You know, I’m the president. This is my team. If it’s not working, it’s my job to get it fixed.”

Mr. Obama dodged questions about whether he might accept a delay in implementing parts of his health care law if the website was still not working by the end of this month. The administration has said that the online portal would be working for most people by then.

    Apologizing, Obama Yields to Criticism of Health Law, NYT, 7.11.2013,






Rules to Require Equal Coverage

for Mental Ills


November 8, 2013
The New York Times


WASHINGTON — The Obama administration on Friday will complete a generation-long effort to require insurers to cover care for mental health and addiction just like physical illnesses when it issues long-awaited regulations defining parity in benefits and treatment.

The rules, which will apply to almost all forms of insurance, will have far-reaching consequences for many Americans. In the White House, the regulations are also seen as critical to President Obama’s program for curbing gun violence by addressing an issue on which there is bipartisan agreement: Making treatment more available to those with mental illness could reduce killings, including mass murders.

In issuing the regulations, senior officials said, the administration will have acted on all 23 executive actions that the president and Vice President Joseph R. Biden Jr. announced early this year to reduce gun crimes after the Newtown, Conn., school massacre. In planning those actions, the administration anticipated that gun control legislation would fail in Congress as pressure from the gun lobby proved longer-lasting than the national trauma over the killings of first graders and their caretakers last Dec. 14.

“We feel actually like we’ve made a lot of progress on mental health as a result in this year, and this is kind of the big one,” said a senior administration official, one of several who described the outlines of the regulations that Kathleen Sebelius, the secretary of health and human services, will announce at a mental health conference on Friday in Atlanta with the former first lady Rosalynn Carter.

While laws and regulations dating to 1996 took initial steps in requiring insurance parity for medical and mental health, “here we’re doing full parity, and we’ve also taken steps to extend it to the people covered in the Affordable Care Act,” the senior official said. “This is kind of the final word on parity.”

With the announcement, the administration will make some news that is certain to be popular with many Americans at a time when Mr. Obama and Ms. Sebelius have been on the defensive for the bungled introduction of the insurance marketplaces created under the Affordable Care Act.

According to administration officials, the rule would ensure that health plans’ co-payments, deductibles and limits on visits to health care providers are not more restrictive or less generous for mental health benefits than for medical and surgical benefits. Significantly, the regulations would clarify how parity applies to residential treatments and outpatient services, where much of the care for people with addictions or mental illnesses occurs.

Any geographic or facility-type limitations would have to be comparable for medical and mental health benefits. For example, an administration official said, an insurer “can’t say you can only get substance-abuse treatment in state but you can go anywhere for medical/surgical.”

The regulations, which specifically put into effect the 2008 Mental Health Parity and Addiction Equity Act, would affect most Americans with insurance — roughly 85 percent of the population — whether their policies are from employer plans, other group plans, or coverage purchased in the market for individual plans.

The final parity rules do not apply to health plans that manage care for millions of low-income people on Medicaid. However, the administration has previously issued guidance to state health officials saying that such plans should meet the parity requirements of the 2008 law.

The parity law does not apply to Medicare, according to Irvin L. Muszynski, a lawyer at the American Psychiatric Association.

The rules have been awaited since the 2008 law by patient advocate groups. As it happened, the groups’ complaints about regulatory delays were the subject of a Senate hearing on Thursday. Interest picked up further last month as individuals could begin enrolling in the new insurance marketplaces, or exchanges, provided under Mr. Obama’s health care law.

Under that law,treatment for mental health and substance abuse is among 10 categories of benefits considered essential and thus mandatory in plans marketed in the new exchanges to individuals and small groups. Although many insurers already provide extensive mental health coverage, some have found ways to get around existing rules and to deny payment for treatment, or to otherwise limit the benefits.

Senator Richard Blumenthal, Democrat of Connecticut, said the five-year delay in issuing a final rule had real-world consequences. “In mental health, uncertainty kills,” he said. “If an individual poses a threat to himself or others, he cannot be told he will get the care he needs as soon as his insurance company decides what ‘parity’ means.”

Insurance companies have raised concerns about the expense involved in paying for the lengthy and intensive courses of treatment that the final regulations address. But experts have said the rules are not expected to significantly add to the cost of coverage because so few patients require these levels of care.

Mental health services are scarce in many parts of the country, particularly for children, so experts have questioned whether changes in the law will have much impact in practice.

Former Representative Patrick J. Kennedy of Rhode Island, a co-sponsor of the 2008 law, said the rules could particularly help veterans. “No one stands to gain more from true parity than the men and women who have served our country and now need treatment for the invisible wounds they have brought home from Iraq and Afghanistan,” he said.

Administration officials consulted closely with mental health groups. “What we are hearing is very positive,” said Andrew Sperling, a lobbyist at the National Alliance on Mental Illness, based on what he had been told of the final language.

Under the 2008 law, treatment limits — like restrictions on the number of doctor visits or days in a hospital — cannot be more restrictive for mental health benefits than for medical and surgical benefits. But interpretation of the law left much in question.

For example, Mr. Sperling said, policyholders can easily determine whether numerical limits on doctor visits are comparable in their plans for mental and medical health care. But, he said, it is more difficult to challenge “nonquantitative limits” — like some insurers’ requirements that people get their authorization before seeing a psychotherapist.

The provision of the rule that will seek to clarify the amount of transparency required of health plans “is important,” Mr. Sperling said. Patients advocates say they need to be able to see the criteria by which insurers find a particular service to be medically necessary, so policyholders can judge whether standards for mental health treatments are more restrictive.

Carol A. McDaid, the leader of a coalition of patients and providers of mental health and addiction services, said: “This is the beginning, not the end, of our work to make the vision of the law a reality. We have to make sure that the law and the rules are fully enforced.”

Insurers and business trade groups said they did not know enough about the rules to comment.

Dr. Paul Summergrad of Tufts University, president-elect of the American Psychiatric Association, said he hoped the final rules would end “the uniquely discriminatory form of prior authorization and utilization review” applied to emergency care for patients with mental illness.

A person who has a heart attack or pneumonia and goes to a hospital will routinely be admitted, with electronic notice sent to the insurer on the next business day, Dr. Summergrad said. By contrast, he said, if a person who is profoundly depressed and tried to commit suicide goes to a hospital, an emergency room doctor must call a toll-free telephone number, “present the case in voluminous detail and get prior authorization.”

State insurance commissioners will apparently have the primary responsibility for seeing that commercial insurers comply with the parity standards. They already have their hands full, however, enforcing new insurance market rules, and in some states insurance regulators are considered close to the industry.

“We need enforcement,” Mr. Kennedy said in an interview. “The notion of delegating this to the states, which are looking to the federal government for direction, is problematic.”

    Rules to Require Equal Coverage for Mental Ills, NYT, 8.11.2013,






This Is Why We Need Obamacare


November 2, 2013
The New York Times


THE biggest health care crisis in America right now is not the inexcusably messy rollout of Obamacare.

No, far more serious is the kind of catastrophe facing people like Richard Streeter, 47, a truck driver and recreational vehicle repairman in Eugene, Ore. His problem isn’t Obamacare, but a tumor in his colon that may kill him because Obamacare didn’t come quite soon enough.

Streeter had health insurance for decades, but beginning in 2008 his employer no longer offered it as an option. He says he tried to buy individual health insurance but, as a lifelong smoker in his late 40s, couldn’t find anything affordable — so he took a terrible chance and did without.

At the beginning of this year, Streeter began to notice blood in his bowel movements and discomfort in his rectum. Because he didn’t have health insurance, he put off going to the doctor and reassured himself it was just irritation from sitting too many hours.

“I thought it was driving a truck and being on your keister all day,” he told me. Finally, the pain became excruciating, and he went to a cut-rate clinic where a doctor, without examining him, suggested it might be hemorrhoids.

By September, Streeter couldn’t stand the pain any longer. He went to another doctor, who suggested a colonoscopy. The cheapest provider he could find was Dr. J. Scott Gibson, a softhearted gastroenterologist who told him that if he didn’t have insurance he would do it for $300 down and $300 more whenever he had the money.

Streeter made the 100-mile drive to Dr. Gibson’s office in McMinnville, Ore. — and received devastating news. Dr. Gibson had found advanced colon cancer.

“It was heartbreaking to see the pain on his face,” Dr. Gibson told me. “It got me very angry with people who insist that Obamacare is a train wreck, when the real train wreck is what people are experiencing every day because they can’t afford care.”

Dr. Gibson says that Streeter is the second patient he has had this year who put off getting medical attention because of lack of health insurance and now has advanced colon cancer.

So, to those Republicans protesting Obamacare: You’re right that there are appalling problems with the website, but they will be fixed. Likewise, you’re right that President Obama misled voters when he said that everyone could keep their insurance plan because that’s now manifestly not true (although they will be able to get new and better plans, sometimes for less money).

But how about showing empathy also for a far larger and more desperate group: The nearly 50 million Americans without insurance who play health care Russian roulette as a result. FamiliesUSA, a health care advocacy group that supports Obamacare, estimated last year that an American dies every 20 minutes for lack of insurance.

It has been a year since my college roommate, Scott Androes, died of prostate cancer, in part because he didn’t have insurance and thus didn’t see a doctor promptly. Scott fully acknowledged that he had made a terrible mistake in economizing on insurance, but, in a civilized country, is this a mistake that people should die from?

“Website problems are a nuisance,” Dr. Gibson said. “Life and death is when you need care and can’t afford to get it.”

The Institute of Medicine and the National Research Council this year ranked the United States health care system last or near last in several categories among 17 countries studied. The Commonwealth Fund put the United States dead last of seven industrialized countries in health care performance. And Bloomberg journalists ranked the United States health care system No. 46 in efficiency worldwide, behind Romania and Iran.

The reason is simple: While some Americans get superb care, tens of millions without insurance get marginal care. That’s one reason life expectancy is relatively low in America, and child mortality is twice as high as in some European countries. Now that’s a scandal.

Yet about half the states are refusing to expand Medicaid to cover more uninsured people — because they don’t trust Obamacare and want it to fail. The result will be more catastrophes like Streeter’s.

“I am tired of being the messenger of death,” said Dr. Gibson. “Sometimes it’s unavoidable. But when people come in who might have been saved if they could have afforded care early on, then to have to tell them that they have a potentially fatal illness — I’m very tired of that.”

Streeter met with a radiologist on Thursday and is bracing for an arduous and impoverishing battle with the cancer. There’s just one bright spot: He signed up for health care insurance under Obamacare, to take effect on Jan. 1.

For him, the tragedy isn’t that the Obamacare rollout has been full of glitches, but that it may have come too late to save his life.

    This Is Why We Need Obamacare, NYT, 2.11.2013,






As Drug Costs Rise,

Bending the Law Is One Remedy


October 22, 2013
The New York Times


Lee Higman, a 71-year-old artist from Bellevue, Idaho, who considers herself a law-abiding citizen, was shocked last month when she got a notice from the Food and Drug Administration telling her: “A mail shipment addressed to you from a foreign country is being held.”

The 90 tablets of Vagifem, prescribed by her physician, that she had ordered from a Canadian pharmacy had been impounded as an illegal drug at Los Angeles International Airport.

First marketed in 1988, Vagifem estrogen tablets are used by millions of women to relieve symptoms of menopause. There is no generic version available in the United States, and brand-name drugs are expensive here. So about five years ago, Mrs. Higman started ordering the tablets from Canada, where a year’s supply that would cost about $1,000 in the United States sells for under $100.

“The price went up. And we’d lost a lot on the stock market, and we’re living on fixed incomes,” Mrs. Higman, who is an artist, said in an interview. She and her husband, a writer, are covered by Medicare. In an e-mail to the Food and Drug Administration, she sought the release of the package, explaining, “When it became economically imperative I ordered it from Canada, a country with strict drug requirements.”

The high price of many prescription drugs in the United States has left millions of Americans telling white lies and committing fraud and other crimes to get their medicines. In response to a New York Times article about the costs, hundreds of readers shared their strategies, like having a physician prescribe twice the needed dose and cutting pills in half, or “borrowing” medicines from a friend or relative with better insurance coverage. But an increasingly popular — though generally illegal — route is buying the drugs from overseas.

The Canadian International Pharmacy Association, a 10-year-old group, said its members fill prescriptions for one million Americans each year. “It’s the Americans who are seeking us out,” said Tim Smith, the group’s general manager. “Clearly there’s a need.”

In surveys from 2011 by the Centers for Disease Control and Prevention, about 2 percent of adults and about 5 percent of the uninsured said they had bought prescription drugs from other countries. The figures most likely underestimated the practice because people may be reluctant to admit to doing something illegal, even though the law is rarely enforced in such cases.

The Food and Drug Administration says on its Web site that “in most circumstances it is illegal to import drugs into the U.S. for personal use” because the agency cannot guarantee they are safe and effective. The government also prohibits “reimportation” of drugs made in the United States because it cannot guarantee the medications were not tampered with or stored improperly.

The agency said it does not track the volume of such imports. However, it “typically does not object” to people buying imported medicine for personal use “under certain circumstances,” the agency said. Those include using the drug to treat a serious condition for which an effective alternative is unavailable in the United States and purchasing less than a three-month supply. But those ambiguous edicts have left patients wary.

Dr. Stephen Barrett, a retired psychiatrist and health care advocate in North Carolina, said he has saved thousands of dollars buying medicines from overseas in the past decade. “It may be technically illegal, but I don’t think anyone would ever get prosecuted,” he said, adding that such laws reflected “protectionism” for drug makers. Although the Obama administration initially proposed allowing some importation of drugs, the idea was dropped from the Affordable Care Act after intense opposition from the pharmaceutical industry.

Mr. Smith, of the Canadian pharmacy group, said members follow strict pharmacy and prescription protocols and dispense only medicines approved by Health Canada, which regulates them. Members also broker purchases from licensed pharmacies in other countries, like Britain and Australia, which may further reduce the costs. Package inserts in foreign languages must be translated into English.

He acknowledged that consumers must take care to ensure an online pharmacy is legitimate, noting that in 2011 his association sent hundreds of cease-and-desist letters to Web sites — some of which were not based in Canada and were not even pharmacies — that were fraudulently using the group’s certification seal.

Dr. Barrett said he uses Web sites like PharmacyChecker.com to screen online pharmacies and prefers products from English-speaking countries.

Some purchases from overseas pharmacies are identical to products sold in the United States. When a Food and Drug Administration compliance officer told Mrs. Higman that her order of Vagifem was held because it was an “unapproved” drug, she responded, “This drug might come from Turkey, however, it is in the same box, the same packaging, the same labels, the same manufacturer, Nordisk, as the outrageously priced Vagifem in the United States.”

Identical drugs sold in other countries may have different package inserts, slight variations in dose or different brand names. But that is frequently a function of patent law and business decisions by drug makers, rather than medical efficacy.

Diana Simonson, 42, a freelance computer programmer in Glens Falls, N.Y., said she started ordering her inhalers from Canada after she nearly died of an asthma attack in the United States, where she cannot afford her preventive treatments.

For decades, she was able to control her asthma with a steroid inhaler. But it was banned a few years ago because it contained a propellant that was deemed environmentally harmful. The replacement product cost $250 a month. “That was like another car payment — I couldn’t do it,” said Ms. Simonson, who has a high-deductible insurance policy through the Freelancers Union.

With an income of about $35,000 and a child to raise, she tried to do without. But at an air show with her 7-year-old son, she became so short of breath that she had to be rushed by ambulance to an emergency room.

The inhalers she gets from Canada every three months are the same brand, and by the same manufacturer, that she used to buy in the United States. But often they are produced in a third country, like Turkey or Malaysia.

Kristen Bailey of Colorado started ordering medicine by mail from India when she was given a diagnosis of Crohn’s disease after graduating from college in 2011 with no insurance. Her medicine retails for tens of thousands of dollars in the United States.

The process is simpler for patients who live near the border. Joshua Kalish, 70, of Silver City, N.M., said that before he was eligible for Medicare, he drove to Mexico to fill his prescriptions, calling it a “common practice.”

Mrs. Higman said she is also heading for the border. Despite her pleas, the Food and Drug Administration told her that her Vagifem tablets would be returned to Canada or destroyed.

To tide her over, she has spent $233 for two months of Vagifem at a local pharmacy. “Fortunately my children and grandchildren live in Seattle, so the next time we go over there, I’ll take a little trip up to Vancouver, British Columbia, to buy my medicine,” she said. “I’ll save enough money to get room service in a five-star hotel there and still have enough left to claim I saved a couple of bucks.”

    As Drug Costs Rise, Bending the Law Is One Remedy, NYT, 22.10.2013,






Out of Network,

Not by Choice,

and Facing Huge Health Bills


October 18, 2013
The New York Times


Once the cardiologist figured out why Raquel and Michael D’Andrea’s 9-week-old daughter was so frail and unable to eat, he immediately sent her to the hospital for heart surgery.

“He told us to go home, get packed and get to the hospital, where they will be waiting for us,” Ms. D’Andrea said. “That was very shocking, but we did it.”

There was little time to think about the intricacies of their insurance plan, but Ms. D’Andrea knew she had already selected a comprehensive plan a few years earlier. She gave her insurance card to the hospital staff, but her daughter, Sienna, was ultimately treated by several doctors who were not in their plan’s network.

“We assumed that because we showed them our insurance card and nobody had any objections, we were covered,” said Ms. D’Andrea, 35, of Farmingdale, N.Y. “But I also wasn’t in the mind-set to ask, or to have them stop doing heart surgery on her.”

Sienna left the hospital in early March, two weeks after a successful operation repaired her aorta. But she had a rough road ahead. She went home with a feeding tube in her nose.

And just a few weeks later, after vomiting through the night, she spent another 17 days in the hospital. As the family finally arrived back home in mid-April, piles of bills from out-of-network doctors started to roll in.

It’s not uncommon for patients who visit an in-network hospital to learn later that they’ve been treated by out-of-network providers, resulting in thousands of dollars in charges. And while the Affordable Care Act generally caps what consumers must spend out of pocket when using providers within their plan’s network, it doesn’t protect consumers from large bills from outside providers. Those providers may be free to charge the consumer for the balance of the bill that the insurer did not pay, known as “balance billing.”

“When the doctors work in the hospital, not for the hospital, which is often the case, they’re not obliged to join the same networks as the hospital,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “And patients generally have no say in selecting those doctors. Sometimes the patients don’t even see them — for instance, if their X-rays get sent to a radiologist or their tissue to a pathologist,” patients won’t even know the name of that doctor until the bill comes.”

This generally happens because the hospitals don’t always assign doctors to the patient. Individuals may begin treatment with a doctor who accepts their insurance. But if that doctor refers the patient to another specialist, or works with an anesthesiologist who isn’t in the network, the patient is likely to end up with a bill from that provider, said Gerard F. Anderson, director of the Center for Hospital Finance and Management at Johns Hopkins University Bloomberg School of Public Health. “About the only thing you can do is to go to a hospital where the M.D.’s are all hospital employees,” he added.

Some states limit the amount that out-of-network hospitals and doctors can charge above what insurance has covered, experts said, but there are no federal curbs on balance billing. The new health care law, does, however, offer some protections for people who need emergency care: insurers cannot charge more for co-payments and co-insurance for emergency services than they would charge when you use in-network providers. Insurers must also pay out-of-network emergency providers according to a standard schedule, in hopes of lessening the likelihood that patients will be left with enormous bills.

Still, there’s nothing in the law that stops health care providers from billing consumers for the balance, which is what often happens — and exactly what the D’Andrea family experienced. “This is not an issue that the Affordable Care Act fixes,” said Timothy S. Jost, a professor at the Washington and Lee University School of Law and expert on health care laws. “It is conceivable that the problem gets worse for some people if the Affordable Care Act encourages narrower networks, which some people think it might do.”

If consumers use providers within their network, their annual out-of-pocket costs will vary depending on the type of plan they choose (bronze, silver or gold, for example) and their household income. But the new law states that those expenses cannot exceed $6,350 for individuals and $12,700 for a family of two or more in 2014. (This is true for all plans bought on the exchange, and for many individual plans.)

So what sort of recourse do consumers have when they receive big bills from out-of-network providers? The first step is to make sure your insurance plan paid what it should have, since many plans provide some coverage for out-of-network services. And if you were treated for an emergency service (in an emergency room or an extension of it), make sure the insurer paid at least what they would have paid to an in-network provider, said Cheryl Fish-Parcham, deputy director of health policy at Families USA, a Washington consumer advocacy group. Consumers should also check to see if their state has any additional protections against balance billing. Finally, consumers should talk to their providers about reducing any remaining charges.

Consumers would do well to follow the lead of Ms. D’Andrea’s mother, Livia Cooper. The couple relied on her to deconstruct and analyze the reams of invoices that arrived in their mailbox — including a collection notice — since they were busy caring for Sienna.

Ms. Cooper spent countless hours poring over the bills, trying to make sense of it all. “It was so overwhelming,” said Ms. Cooper, who had to close the women’s boutique she ran with Ms. D’Andrea so they could focus on Sienna, who is now 9 months old. “We received department bills and there could be 60 invoices on one printout. You would have a bill for $8,100 from one department or $6,500 from another department. It was hard to figure out what was covered, what wasn’t covered and what was balance-billed.”

The billing service for the doctors initially wanted the D’Andreas to enroll in its budget plan, which Ms. Cooper refused to do before figuring what the couple actually owed. Her persistence ultimately paid off. She finally reached a supervisor in the billing department and explained that “we had insurance, were paying the co-insurance, co-payments and deductibles, and could not afford to pay any more than what we were obligated,” she said. She also pointed out that the providers were paid what they would have been paid if they were in the network.

As a result, many of their bills were reduced, and some were forgiven. The surgeon who repaired Sienna’s heart was in the plan’s network, for instance, but the assisting surgeon was not. And even though the insurer paid the assisting surgeon the same amount as the main surgeon, Ms. Cooper said that the couple was billed for $4,100, or the balance not covered by insurance. The billing department asked the couple to file an appeal with the insurer, which they did. As a result, the insurance company paid an additional $700 and the surgeon wrote off the balance.

Ms. D’Andrea and her husband, who operates a small entertainment and D.J. business and also refurbishes homes, ultimately paid about $10,000 in out-of-pocket expenses, Ms. Cooper estimates.

Since the couple’s current health plan will terminate at the end of the year, they are now trying to choose a plan on the New York exchange that includes Sienna’s doctors — another tedious process. “Sienna’s situation is such that it makes us very nervous,” said Ms. Cooper, who is helping the couple research various plans. “You don’t know who the doctors are on different plans because there are no lists.”

As my colleague Abby Goodnough reported earlier this week, many of the state-run exchanges do not have provider directories or search tools on their Web sites — at least not yet — so customers cannot easily check which doctors and hospitals are included in a particular plan’s network.

And even though the D’Andreas could not have known that out-of-network doctors were treating their daughter, it underscores how important it is to ensure all of their providers will be on the plan they ultimately choose. “Basically, if you’re out of network,” Ms. Cooper said, “you’re out of luck.”

    Out of Network, Not by Choice, and Facing Huge Health Bills,
    NYT, 18.10.2013,






The Soaring Cost of a Simple Breath


October 12, 2013
The New York Times


OAKLAND, Calif. — The kitchen counter in the home of the Hayes family is scattered with the inhalers, sprays and bottles of pills that have allowed Hannah, 13, and her sister, Abby, 10, to excel at dance and gymnastics despite a horrific pollen season that has set off asthma attacks, leaving the girls struggling to breathe.

Asthma — the most common chronic disease that affects Americans of all ages, about 40 million people — can usually be well controlled with drugs. But being able to afford prescription medications in the United States often requires top-notch insurance or plenty of disposable income, and time to hunt for deals and bargains.

The arsenal of medicines in the Hayeses’ kitchen helps explain why. Pulmicort, a steroid inhaler, generally retails for over $175 in the United States, while pharmacists in Britain buy the identical product for about $20 and dispense it free of charge to asthma patients. Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented.

“The one that really blew my mind was the nasal spray,” said Robin Levi, Hannah and Abby’s mother, referring to her $80 co-payment for Rhinocort Aqua, a prescription drug that was selling for more than $250 a month in Oakland pharmacies last year but costs under $7 in Europe, where it is available over the counter.

The Centers for Disease Control and Prevention puts the annual cost of asthma in the United States at more than $56 billion, including millions of potentially avoidable hospital visits and more than 3,300 deaths, many involving patients who skimped on medicines or did without.

“The thing is that asthma is so fixable,” said Dr. Elaine Davenport, who works in Oakland’s Breathmobile, a mobile asthma clinic whose patients often cannot afford high prescription costs. “All people need is medicine and education.”

With its high prescription prices, the United States spends far more per capita on medicines than other developed countries. Drugs account for 10 percent of the country’s $2.7 trillion annual health bill, even though the average American takes fewer prescription medicines than people in France or Canada, said Gerard Anderson, who studies medical pricing at the Bloomberg School of Public Health at Johns Hopkins University.

Americans also use more generic medications than patients in any other developed country. The growth of generics has led to cheap pharmacy specials — under $7 a month — for some treatments for high cholesterol and high blood pressure, as well as the popular sleeping pill Ambien.

But many generics are still expensive, even if insurers are paying the bulk of the bill. Generic Augmentin, one of the most common antibiotics, retails for $80 to $120 for a 10-day prescription ($400 for the brand-name version). Generic Concerta, a mainstay of treating attention deficit disorder, retails for $75 to $150 per month, even with pharmacy discount coupons. For some conditions, including asthma, there are few generics available.

While the United States is famous for break-the-bank cancer drugs, the high price of many commonly used medications contributes heavily to health care costs and certainly causes more widespread anguish, since many insurance policies offer only partial coverage for medicines.

In 2012, generics increased in price an average of 5.3 percent, and brand-name medicines by more than 25 percent, according to a recent study by the Health Care Cost Institute, reflecting the sky-high prices of some newer drugs for cancer and immune diseases.

While prescription drug spending fell slightly last year, in part because of the recession, it is expected to rise sharply as the economy recovers and as millions of Americans become insured under the Affordable Care Act, said Murray Aitken, the executive director of IMS Health, a leading tracker of pharmaceutical trends.

Unlike other countries, where the government directly or indirectly sets an allowed national wholesale price for each drug, the United States leaves prices to market competition among pharmaceutical companies, including generic drug makers. But competition is often a mirage in today’s health care arena — a surprising number of lifesaving drugs are made by only one manufacturer — and businesses often successfully blunt market forces.

Asthma inhalers, for example, are protected by strings of patents — for pumps, delivery systems and production processes — that are hard to skirt to make generic alternatives, even when the medicines they contain are old, as they almost all are.

The repatenting of older drugs like some birth control pills, insulin and colchicine, the primary treatment for gout, has rendered medicines that once cost pennies many times more expensive.

“The increases are stunning, and it’s very injurious to patients,” said Dr. Robert Morrow, a family practitioner in the Bronx. “Colchicine is a drug you could find in Egyptian mummies.”

Pharmaceutical companies also buttress high prices by choosing to sell a medicine by prescription, rather than over the counter, so that insurers cover a price tag that would be unacceptable to consumers paying full freight. They even pay generic drug makers not to produce cut-rate competitors in a controversial scheme called pay for delay.

Thanks in part to the $250 million last year spent on lobbying for pharmaceutical and health products — more than even the defense industry — the government allows such practices. Lawmakers in Washington have forbidden Medicare, the largest government purchaser of health care, to negotiate drug prices. Unlike its counterparts in other countries, the United States Patient-Centered Outcomes Research Institute, which evaluates treatments for coverage by federal programs, is not allowed to consider cost comparisons or cost-effectiveness in its recommendations. And importation of prescription medicines from abroad is illegal, even personal purchases from mail-order pharmacies.

“Our regulatory and approval system seems constructed to achieve high-priced outcomes,” said Dr. Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center. “We don’t give any reason for drug makers to charge less.”

And taxpayers and patients bear the consequences.

California’s Medicaid program spent $61 million on asthma medicines last year, paying more than $200 — not far from full retail price — for many inhalers. At the Breathmobile clinic in Oakland, the parents of Bella Buyanurt, 7, fretted about how they would buy her medications since the family lost Medicaid coverage. Barbara Wolf, 73, a retired Oakland school administrator covered by Medicare, said she used her inhaler sparingly, adding, “I minimize puffs to minimize cost.”


‘A Frustrating Saga’

Hannah and Abby Hayes were admitted to the hospital on separate occasions in 2005 with severe shortness of breath. Oakland, a city subject to pollution from its freeways and a busy seaport, has four times the hospital admission rate for asthma as elsewhere in California.

The asthma rate nationwide among African-Americans and people of mixed racial backgrounds is about 20 percent higher than the average.

Robin Levi, a Stanford-trained lawyer who works for Students Rising Above, a group that helps low-income students attend college, is black. Her husband, John Hayes, an economist, is white. Their daughters have allergic asthma that is set off by animals, grass and weeds, but they also get wheezy when they have a cold.

“That first year, I had to take a lot of time from my job to deal with the asthma drugs, the prices, arguing with insurers — it was a frustrating saga,” Ms. Levi said.

For decades, the backbone of treatment for asthma has centered on inhaled medicines. The first step is a bronchodilator, which relaxes the muscles surrounding small airways to open them. For people who use this type of rescue inhaler frequently, doctors add an inhaled steroid as a maintenance drug to prevent inflammation and ward off attacks. The two medicines are often mixed in a single combination inhaler for adults, and these products are especially pricey. In addition, many patients, particularly children, take pills as well as nasal sprays that calm allergies that set off the condition.

While on medication, neither Hayes girl has been in the hospital since her initial diagnosis. Their mother tweaks dosing, adding extra medicine if they have a cold or plan to ride horses.

For most patients, asthma medicines are life-changing. In economic terms, that means demand for the medicines is inelastic. Unlike a treatment for acne that a patient might drop if the price became too high, asthma patients will go to great lengths to obtain their drugs.

For pharmaceutical companies, that has made these respiratory medicines blockbusters: the two best-selling combination inhalers, Advair and Symbicort, had global sales of $8 billion and $3 billion last year. Each inhaler, typically lasting a month, retails for $250 to $350 in the United States.

Asked to explain the high price of inhalers, the two major manufacturers say the calculus is complicated.

“Our pricing is competitive with other asthma treatments currently on the market,” Michele Meixell, the United States spokeswoman for AstraZeneca, which makes Symbicort and other asthma drugs, said in an e-mail. She added that low-income patients without insurance could apply for free drugs from the company.

Juan Carlos Molina, the director of external communication for GlaxoSmithKline, which makes Advair, said in an e-mail that the price of medicines was “closely linked to this country’s model for delivery of care,” which assumes that health insurance will pick up a significant part of the cost. An average co-payment for Advair for commercially insured patients is $30 to $45 a month, he added.

Even with good insurance, the Hayeses expect to spend nearly $1,000 this year on their daughters’ asthma medicines; their insurer spent much more than that. The total would have been more than $4,000 if the insurer had paid retail prices in Oakland, but the final tally is not clear because the insurer contracts with Medco, a prescription benefits company that negotiates with drug makers for undisclosed discounts.


Patent Plays

Dr. Dana Goldman, the director of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California, said: “Producing these drugs is cheap. And yet we are paying very high prices.” He added that because inhalers were so effective at keeping patients out of hospitals, most national health systems made sure they were free or inexpensive.

But in the United States, even people with insurance coverage struggle. Lisa Solod, 57, a freelance writer in Georgia, uses her inhaler once a day, instead of twice, as usually prescribed, since her insurance does not cover her asthma medicines. John Aravosis, 49, a political blogger in Washington, buys a few Advair inhalers at $45 each during vacations in Paris, since his insurance caps prescription coverage at $1,500 per year. Sharon Bondroff, 68, an antiques dealer in Maine on Medicare, scrounges samples of Advair from local doctors. Ms. Bondroff remembers a time, not so long ago, when inhalers “were really cheap.” The sticker shock for asthma patients began several years back when the federal government announced that it would require manufacturers of spray products to remove chlorofluorocarbon propellants because they harmed the environment. That meant new inhaler designs. And new patents. And skyrocketing prices.

“That decision bumped out the generics,” said Dr. Peter Norman, a pharmaceutical consultant based in Britain who specializes in respiratory drugs. “Suddenly sales of the branded products went right back up, and since then it has not been a very competitive market.”

The chlorofluorocarbon ban even eliminated Primatene Mist inhalers, a cheap over-the-counter spray of epinephrine that had many unpleasant side effects but was at least an effective remedy for those who could not afford prescription treatments.

As drugs age and lose patent protection, the costs of treatment can fall significantly because of generic competition — particularly if a pill has only one active ingredient and is simple to replicate. When Singulair, a pill the Hayes girls take daily to block allergic reactions in the lungs, lost its patent protection last year, generics rapidly entered the market. The price of the drug has already dropped from $180 per month to as low as $15 to $20 with pharmacy coupons.

But sprays, creams, patches, gels and combination medicines are more difficult to copy exactly to make a generic that meets Food and Drug Administration standards. Each time a molecule is put in a new inhaler or combined with another medicine, the amount delivered into the lungs or through the skin may change, even though that often has an imperceptible effect on patients.

“Drug companies can switch devices and use different combinations, and it becomes quite difficult to demonstrate equivalence,” Dr. Norman said, adding that inhaler makers have exploited such barriers to increase sales of medicines long after the scientific novelty has passed.


Obstacles for Generics

A result is that there are no generic asthma inhalers available in the United States. But they are available in Europe, where health regulators have been more flexible about mixing drugs and devices and where courts have been quicker to overturn drug patent protection.

“The high prices in the U.S. are because the F.D.A. has set the bar so high that there is no clear pathway for generics,” said Lisa Urquhart of EvaluatePharma, a consulting firm based in London that provides drug and biotech analysis. “I’m sure the brands are thrilled.”

The F.D.A. acknowledges that the lack of inhaled generic medicines, as well as topical creams, has been costly for patients, but it attributes that to “difficult, longstanding scientific challenges,” since measuring drug activity deep into the lung is complicated, said Sandy Walsh, a spokeswoman for the agency. Dr. Robert Lionberger, the agency’s acting deputy director in the office of generic drugs, said that research into the development of generic inhaled medicines was the agency’s highest priority but that the effort had been stalled because of budget cuts imposed by Congress.

Even so, experts say, a significant problem is that none of the agencies that determine whether medicines come to market in the United States are required to consider patient access, affordability or need.

The Food and Drug Administration has handed out patents to reward drug makers for conducting formal safety and efficacy studies on old drugs that had not been so scrutinized. That transformed cheap mainstays of treatment like colchicine for gout and intravenous hydroxyprogesterone for preterm labor into high-priced branded products, costing $5 a pill and $1,500 per dose.

For its part, the United States patent office grants new protections for tweaks to drugs without weighing the financial impact on patients.

For example, with the patent for the older oral contraceptive Loestrin 24Fe about to expire, the company Warner Chilcott stopped making the pill this year and introduced a chewable version — with a new patent and an expensive promotional campaign urging patients and doctors to switch. While many insurance plans covered the popular older drug with little or no co-payment, they often exclude the new pills, leaving patients covering the full monthly cost of about $100. Patients complained that the new pills tasted awful and were confused about whether they could just be swallowed.

“Drug patents are easy to get, and the patent office is deluged,” said Dr. Aaron Kesselheim, a pharmaceutical policy expert at Harvard Medical School. “The F.D.A. approves based on safety and efficacy. It doesn’t see its role as policing this process.”

For asthma patients in the United States, the best the market has yielded are a few faux generics that are often only marginally cheaper than the brand-name versions. AstraZeneca, for example, has an agreement with Teva Pharmaceuticals, a generic manufacturer, to make an approved generic version of its Pulmicort Respules, an asthma medicine for home inhalation treatments. Teva paid AstraZeneca more than $250 million last year in royalties to make a generic, which sells for about $200 for a typical monthly dose, compared with close to $300 for the branded product.


Research vs. Marketing

There are good reasons drug companies are feeling threatened. In the last several years, some best-selling medicines, like Lipitor for high cholesterol and Plavix for blood thinning, have been largely replaced by cheap generics in a very competitive market. In 2012, that led to $29 billion in savings for patients, said Mr. Aitken of IMS, or $29 billion in lost revenues for drug makers. Eighty-four percent of prescriptions dispensed last year were for generic medications.

While drug companies generally remain highly profitable, recent trends have meant tough times for some companies, including Merck, whose profits crashed 50 percent this year primarily because the patent expired on its best-selling asthma pill, Singulair.

So AstraZeneca has recently spent millions of dollars in court pursuing several small drug companies for patent infringement after they announced a plan to make a true cheap generic version of Pulmicort Respules. Though a New Jersey judge sided with the generic manufacturers this spring, legal appeals by AstraZeneca will keep the generics off the market for the near future.

As insurance policies require patients to contribute more out of pocket for medicines, public pressure to curb prices has grown. This year, more than 100 top cancer specialists protested the rising prices of cancer treatments.

Drug companies have long argued that pharmaceutical pricing reflects the cost of developing and testing innovative new drugs, many of which do not pan out or make it to market.

“When there’s a really innovative product, you might be able to justify the price,” Dr. Kesselheim said. “But this is not generally the case.”

Critics counter that drug companies spend far more on marketing and sales than the 15 percent and 20 percent of their revenues that they devote to research and development.

In the United States, one of the few Western countries that allows advertising of prescription drugs to consumers, GlaxoSmithKline spent $99 million in advertising for Advair in 2012. Despite its financial woes, Merck spent $46.3 million to advertise its steroid spray, Nasonex, according to fiercepharma.com, a Web site that tracks the industry’s advertising.

Also, the focus of much pharmaceutical research in recent years has shifted from simple drugs for common diseases that would have widespread use to complicated molecules that would most likely benefit fewer patients but carry far higher price tags, in the realm of tens of thousands of dollars.

The newest offering for asthma is Novartis’s Xolair, which is given by injection in a doctor’s office every two weeks at a cost of up to $1,500, depending on the dose. Because the drug is so expensive and was deemed to have little or no benefit over inhalers for a vast majority of patients, the British government last year announced that it would not make it available through the National Health Service. It relented this year, agreeing to stock it for limited use, after the manufacturer offered a confidential discount.

In all other developed countries, governments similarly use a variety of tools to make sure that drug manufacturers sell their products at affordable prices. In Germany, regulators set drug wholesale and retail prices. Across Europe, national health authorities refuse to pay more than their neighbors for any drug. In Japan, the price of a drug must go down every two years.

Drug prices in the United States are instead set in hundreds of negotiations by hospitals, insurers and pharmacies with drug manufacturers, with deals often brokered by powerful middlemen called group purchasing organizations and pharmacy benefit managers, who leverage their huge size to demand discounts. The process can get nasty; if mediators offer too little for a given product, manufacturers may decide not to produce it or permanently drop out of the market, reducing competition.

With such jockeying determining supply, products can simply disappear and prices for vital medicines can fluctuate far more than they do for a carton of milk. After the price of Abby Hayes’s Rhinocort Aqua nasal spray rose abruptly, it was unavailable for many months. That sent her family scrambling to find other prescription sprays, each with a price tag over $150.

This year the price of Advair dropped 10 percent in France, but in pharmacies in the Bronx, it has doubled in the last two years.

In Georgia, Ms. Solod, the freelance writer, found the same thing. “Every time I get Advair, the price is different,” she said. “And the price always goes up. It never comes down.”

Twenty years ago, drugs that could safely be sold directly to patients typically moved off the prescription model as their patent life ended. That brought valuable medicines like nondrowsy antihistamines and acid reducers to drugstore shelves. But with profitable prescription products now selling for $100 per tiny bottle, there is little incentive to make the switch, since over-the-counter drugs rarely succeed if they cost more than $20.

As a result, a number of products that are sold directly to patients in other countries remain available only by prescription in the United States. That includes a version of the popular but expensive steroid nasal spray used by Abby Hayes, which is available over the counter in London for under $15 at the Boots pharmacy chain.

“Not only is the cost cheaper, but it doesn’t require a doctor’s visit to get it,” said Dr. Jan Lotvall, a professor of allergy and immunology at the University of Gothenburg in Sweden, where steroid nasal sprays are also available over the counter.

During this high pollen season, Abby had to cut short a gymnastics practice, and her sister, Hannah, missed one day of school because of breathing problems, the first time in many years. But with parents who can afford to get the medicine they require, both are now doing fine.

That is not true of two other sisters from Oakland whom their mother mentors. With treatment hard to access and drug prices high, Kemonni and Donzahnya Pitre, 19 and 17, simply suffer and struggle to breathe.

As Donzahnya, a high school senior, looked through the Fiske Guide to Colleges at the Hayeses’ kitchen table one day, she had an unusual selection criterion: “I worry about going to a college that’s surrounded by a lot of grass.”

    The Soaring Cost of a Simple Breath, NYT, 12.10.2013,






With New Abortion Restrictions,

Ohio Walks a Narrow Legal Line


October 9, 2013
The New York Times


CLEVELAND — Angela H., married with two children, became pregnant accidentally and, after medical complications during her last pregnancy and severe postpartum depression, said neither she nor her family was ready for another child.

Under a law that took effect in Ohio this month, the Cleveland abortion clinic she visited had to offer her a chance not only to view an ultrasound of the fetus but also to watch its beating heart, which she said she resented.

“It’s a hard decision for anybody to make,” she said of abortion, asking that her surname not be published out of privacy concerns. “To make it more difficult by passing these laws and making women feel guilty is terrible.”

Ohio has become a laboratory for what anti-abortion leaders call the incremental strategy — passing a web of rules designed to push the hazy boundaries of Supreme Court guidelines without flagrantly violating them. Many of the rules, critics say, are designed to discourage women from getting abortions or to hamper clinic operations, even forcing some to close.

The mandated discussion of fetal heartbeats is one of a cascade of abortion restrictions adopted in Ohio over the years, from a waiting period to curbs on the medication-induced abortions preferred by many women. The pace has quickened since John R. Kasich became governor in 2011, cementing Republican domination of state politics. Avowedly anti-abortion, Mr. Kasich said through a spokesman that he considered the restrictions he signed this year “reasonable.”

These laws have passed without the national drama provoked by far-reaching abortion bans that were approved, then overturned in court, in states like Arkansas and North Dakota. But taken together, they affect patients and clinics in myriad ways — in the view of the laws’ proponents, rightly making women think twice before ending a pregnancy and ensuring clinic safety or, in the view of opponents, imposing heartless obstacles and guilt on women who are seeking a legal procedure.

“In Ohio, the last few years have been fantastic if you support the pro-life movement,” said Mike Gonidakis, the president of Ohio Right to Life. His group has even lobbied against a more sweeping ban on early-term abortions, incurring the wrath of more restless abortion foes. But he says, “We’ve been able to craft pro-life laws that can withstand court scrutiny.”

On Wednesday, the American Civil Liberties Union filed a challenge in state court to the heartbeat mandate and other new restrictions, asserting that they were adopted in violation of the Ohio Constitution’s “single subject” rule because they were part of an unrelated budget bill.

More broadly, abortion-rights advocates call the incremental strategy, which has been refined by several national groups and pursued in a number of states, an insidious way to limit access to abortion and shame women who in many cases already have to walk past shouting protesters to enter clinics.

“If you can’t outlaw abortion outright, just make it harder and harder to get,” said Chrisse France, the executive director of Preterm, a large nonprofit abortion clinic on the East Side of Cleveland that performs about 4,900 abortions a year, mainly for low-income women. “They say they’re doing this to protect women’s health, but some of the laws are actually harmful, and some are just cruel.”

Conversations with patients at Preterm revealed diverse reactions to the mandated waiting period and counseling, but no sign that any women were changing course.

Madelyn Puterbaugh, 23, said that her birth control had failed and that it was “not the right time” for her to bear a child. She said she had turned down the chance to view the fetal heartbeat. “I didn’t look,” she said. “I thought I’d be too sad.”

She went ahead with the abortion, but said she had not minded the required 24-hour wait between the counseling and the procedure. “They gave me a lot to think about,” she said, “but it’s my choice.”

Ohio has long required abortion clinics to have a formal transfer agreement with a nearby hospital for emergency care, something physicians say is medically unnecessary because hospitals are required to treat emergency patients. Now, a new measure bars public hospitals from signing such agreements — a shift that could force two or three of the state’s remaining 11 clinics to close because they cannot find willing partners.

Other measures wrapped into the state budget bill this year, and signed by Governor Kasich, include a requirement that women seeking an abortion be told the probable odds that their pregnancy would go to full term if they changed their minds; a diversion of federal welfare money to so-called crisis pregnancy centers; new financing for rape-crisis centers on the condition that they provide no abortion referrals; and a tightening of parental consent requirements for minors.

To avoid passing money to Planned Parenthood, the state also ended competitive bidding for federal family planning grants, giving priority to public agencies. As a result, some nonprofit women’s health centers that have no connection to Planned Parenthood or abortion also face drastic cuts.

The newest rules follow a flurry of changes in 2011, when, among other things, the state banned abortions, except to save the mother’s life, once the fetus is viable. Fearing potential criminal charges, clinic doctors around the state have stopped performing abortions beyond the 22nd week of pregnancy, even in cases involving severe birth defects or serious medical conditions.

Since a federal court allowed it here in 2011 after years of litigation, Ohio has been the only state to require what doctors call an outdated, less safe and less effective regimen for medication abortions.

The law mandates adherence to the original Food and Drug Administration approval, which called for three times the drug dosage now standard and authorized the method only through seven weeks of pregnancy. As a result, while later studies showed them to be safe through nine weeks, medication abortions can no longer be offered in the eighth and ninth weeks of pregnancy.

Similar restrictions on medication abortion were passed this year in Texas and are under court challenge; they have been voided as unconstitutional barriers in North Dakota and in Oklahoma, which is seeking a review by the Supreme Court.

At Preterm, the annual number of nonsurgical abortions plummeted to 90 in 2012 from more than 600 in earlier years. But “there’s no evidence that this cut down on abortion,” said Ms. France, the clinic director. “Women just said, ‘Never mind, I’ll get a surgical abortion.’ ”

In Ohio, as elsewhere, abortions have declined over all in recent years, although there was a slight uptick to 25,473 reported procedures in 2012, with black women accounting for a growing share. Whether the new laws have significantly reduced the numbers or simply made abortions more fraught is disputed.

Mr. Gonidakis, of Ohio Right to Life, said he felt sure the measures had persuaded many women to change their minds and predicted that even more, when confronted with the fetal heartbeat and other information, would do so in the future.

“There are so many families waiting to adopt,” he added, offering an alternative that crisis pregnancy centers and others are increasingly promoting.

In the coming months, Mr. Gonidakis said, his organization plans to focus its lobbying on the easing of state adoption rules and an increase in tax breaks for adoptive parents.

But other anti-abortion groups and conservative legislators are pressing ahead with a proposal to ban abortion altogether once a fetal heartbeat is detectable, as early as six weeks into pregnancy.

    With New Abortion Restrictions, Ohio Walks a Narrow Legal Line,
    NYT, 9.10.2013,






California Expands Availability of Abortions


October 9, 2013
The New York Times


LOS ANGELES — Gov. Jerry Brown on Wednesday expanded access to abortion in California, signing a bill to allow nurse practitioners, midwives and physician assistants to perform a common type of the procedure, an aspiration abortion, during the first trimester.

Washington, Montana, Vermont and New Hampshire allow nurse practitioners to perform such abortions, which use a tube and suction, while several other states, including California, permit nonphysicians to provide drugs to terminate pregnancy.

But the new California law goes further, allowing a wider range of nonphysician practitioners to perform surgical abortions. While other states have passed a tide of laws restricting abortion access, California has gone against the political tide.

“We are trending in a different direction, and we’re very proud of it,” said Toni Atkins, the state assemblywoman who wrote the bill. “California has a strong history of support for reproductive health care for women.” She said women in rural parts of the state had trouble finding an abortion provider.

“This is an issue of accessibility,” Ms. Atkins said. “California is a very large state, and more than half the counties don’t have an abortion provider.”

Abortion opponents said the new law would endanger women’s health.

“This bill trivializes what is taking place with abortion,” said Brian Johnston, director of the National Right to Life’s Western regional office. “It will massively expand the number of abortions and at the same time reduce safety. For those who say they care about women’s health, they’re doing the opposite, reducing the medical standards for abortion.”

This is not the first time in recent years that California — where Democrats control all statewide offices and both houses of the State Legislature — has bucked national trends. Last year, while conservative state governments were enacting tougher qualifications for voting, Democrats passed a series of laws intended to make registration and voting easier than ever.

But on the issue of abortion, California is the only state this year to have expanded access to the procedure.

By contrast, 68 restrictions on abortion have been passed by states so far this year, according to Elizabeth Nash, the state issues manager for the Guttmacher Institute, a research organization that studies reproductive health issues.

“California is moving in a direction to protect reproductive health, as other states across the country are passing abortion restrictions,” Ms. Nash said. Supporters of the bill pointed to a state pilot program at the University of California, San Francisco, which found that nurse practitioners, certified midwife nurses and physician assistants were able to provide the procedure just as safely as surgeons.

During the pilot program, which began in 2007, some 8,000 aspiration abortions were provided by nondoctors. Complications rates for doctors and nondoctors were similar, below 2 percent in both cases.

“This is a very safe procedure, and we now have a very large study to show that this does not compromise safety,” said Dr. Tracy Weitz, who led the study. “Most people saying it compromises safety actually have an agenda to make abortion illegal, which we know from decades of experience actually makes abortion unsafe.”

“Hopefully this will give women more options early in their first trimesters, when we know abortion is safest,” Dr. Weitz added. “And the second trimester, when it is more complicated, will remain in the domain of physicians.”

Governor Brown announced his approval of the bill along with several others related to women’s health care, including one that brings construction standards for clinics that perform abortions in line with those of other primary-care clinics.

    California Expands Availability of Abortions, NYT, 9.10.2013,






Pent-Up Demand for Health Insurance


October 4, 2013
The New York Times


There were plenty of computer glitches when millions of Americans went online to check out their options for affordable insurance policies on the new health care exchanges that opened for business this week. It was frustrating, but it was also an indication of overwhelming interest that exceeded all predictions.

In the first three days, there were 8.6 million unique visitors to the federal government Web site for health care exchanges, far more than had ever signed on at one time to a popular Web site serving Medicare patients. In New York, the state-run exchange had an astonishing 30 million visits in the first two days, although a large share almost surely consisted of repeat visits by people who were blocked by balky computer systems.

Earlier surveys had shown that most Americans were unaware that the exchanges would open on Oct. 1 and ignorant of what the health care reform law could provide for them. Many thought it was still just a proposal, not a law. (Congressional Republicans who have shut down the government over their demands to defund and weaken health care reform may have inadvertently fanned interest in exchanges by putting them in the news.)

Neither federal nor state officials were willing to say how many people actually enrolled in a health plan the first week, but the numbers are surely low. People need time to ponder their choices, and the computer problems haven’t made it easy. But the start-up problems are sure to be smoothed out as enrollment for coverage in 2014 goes on for the next six months. As federal officials stress, this is not a sprint but a marathon.

The administration’s goal is to enroll some seven million uninsured Americans in health plans on the exchanges in 2014. They hope that 2.8 million will be young people between the ages of 18 and 34, whose participation is needed to help subsidize coverage for older and sicker people. Administration officials estimate that with about 14 million uninsured people in this age group, the plans will need to enroll one in five of them, a goal that should be reachable with an aggressive recruiting effort.

Polls show that most uninsured adults want health insurance and plan to get it; many will do so because the law requires them to obtain coverage or pay a penalty. The penalty an uninsured adult will have to pay is relatively low for 2014, only $95, but it rises to $325 for 2015 and to $695 for 2016.

In an astonishingly irresponsible campaign, conservative advocacy groups are urging college students and other young people to pay the penalty and forget the insurance. But even those who consider themselves “young invincibles” are vulnerable to catastrophic accidents or life-threatening infections.

Administration officials believe that enrollment will start slowly but will spike upward to meet the mid-December deadline for full-year coverage beginning on Jan. 1, 2014. They expect another spike in enrollment numbers near the March 31 deadline for coverage for the rest of 2014. In the end, people will enroll if they can find insurance that meets their medical needs and their budgets. There is good reason to believe they will.

    Pent-Up Demand for Health Insurance, NYT, 4.10.2013,






Reform Turns Real


October 3, 2013
The New York Times


At this point, the crisis in American governance has taken on a life of its own. Some Republicans are now saying openly that they want concessions in return for reopening the government and avoiding default, not because they have any specific policy goals in mind, but simply because they don’t want to feel “disrespected.” And no endgame is in sight.

But this confrontation did start with a real issue: Republican efforts to stop Obamacare from going into effect. It’s long been clear that the great fear of the Republican Party was not that health reform would fail, but that it would succeed. And developments since Tuesday, when the exchanges on which individuals will buy health insurance opened for business, strongly suggest that their worst fears will indeed be realized: This thing is going to work.

Wait a minute, some readers are saying. Haven’t many stories so far been of computer glitches, of people confronting screens telling them that servers are busy and that they should try again later? Indeed, they have. But everyone knowledgeable about the process always expected some teething problems, and the nature of this week’s problems has actually been hugely encouraging for supporters of the program.

First, let me say a word about the underlying irrelevance of start-up troubles for new government programs.

Political reporting in America, especially but not only on TV, tends to be focused on the play-by-play. Who won today’s news cycle? And, to be fair, this sort of thing may matter during the final days of an election.

But Obamacare isn’t up for a popular referendum, or a revote of any kind. It’s the law, and it’s going into effect. Its future will depend on how it works over the next few years, not the next few weeks.

To illustrate the point, consider Medicare Part D, the drug benefit, which went into effect in 2006. It had what was widely considered a disastrous start, with seniors unclear on their benefits, pharmacies often refusing to honor valid claims, computer problems, and more. In the end, however, the program delivered lasting benefits, and woe unto any politician proposing that it be rolled back.

So the glitches of October won’t matter in the long run. But why are they actually encouraging? Because they appear, for the most part, to be the result of the sheer volume of traffic, which has been much heavier than expected. And this means that one big worry of Obamacare supporters — that not enough people knew about the program, so that many eligible Americans would fail to sign up — is receding fast.

Of course, it’s important that people who want to sign up can actually do so. But the computer problems can and will be fixed. So, by March 31, when enrollment for 2014 closes, we can be reasonably sure that millions of Americans who were previously uninsured will have coverage under the Affordable Care Act. Obamacare will have become a reality, something people depend on, rather than some fuzzy notion Republicans could demonize. And it will be very hard to take that coverage away.

What we still don’t know, and is crucial for the program’s longer-term success, is who will sign up. Will there be enough young, healthy enrollees to provide a favorable risk pool and keep premiums relatively low? Bear in mind that conservative groups have been spending heavily — and making some seriously creepy ads — in an effort to dissuade young people from signing up for insurance. Nonetheless, insurance companies are betting that young people will, in fact, sign up, as shown by the unexpectedly low premiums they’re offering for next year.

And the insurers are probably right. To see why anti-Obamacare messaging is probably doomed to fail, think about whom we’re talking about here. That is, who are the healthy uninsured individuals the program needs to reach? Well, they’re by and large not affluent, because affluent young people tend to get jobs with health coverage. And they’re disproportionately nonwhite.

In other words, to get a description of the typical person Obamacare needs to enroll, just take the description of a typical Tea Party member or Fox News viewer — older, affluent, white — and put a “not” in front of each characteristic. These are people the right-wing message machine is not set up to talk to, but who can be reached through many of the same channels, from ads on Spanish-language media to celebrity tweets, that turned out Obama voters last year. I have to admit, I find the image of hard-line conservatives defeated by an army of tweeting celebrities highly attractive; but it’s also realistic. Enrollment is probably going to be just fine.

So Obamacare is off to a good start, with even the bad news being really good news for the program’s future. We’re not quite there yet, but more and more, it looks as if health reform is here to stay.

    Reform Turns Real, NYT, 3.10.2013,






A Population Betrayed


October 3, 2013
The New York Times


It is outrageous that millions of the poorest people in the country will be denied health insurance because of decisions made mostly by Republican governors and legislators. These people will neither qualify for their state’s Medicaid program for the poor nor for subsidized coverage on new insurance exchanges that are being established in every state by the health care reform law.

Their plight is a result of the Supreme Court’s decision last year that struck down the reform law’s mandatory expansion of Medicaid and made expansion optional. Every state in the Deep South except Arkansas has rejected expansion, as have Republican-led states elsewhere. These 26 states would rather turn down incredibly generous federal funds that would finance 100 percent of the expansion costs for three years and at least 90 percent thereafter than offer a helping hand to their most vulnerable residents.

As Sabrina Tavernise and Robert Gebeloff reported in The Times on Thursday, two-thirds of the country’s poor, uninsured blacks and single mothers and more than half of the uninsured low-wage workers live in those states. The reform law originally sought to help poor and middle-income people through two parallel mechanisms. One was a mandatory expansion of Medicaid (which in most states cover primarily children and their parents with incomes well below the poverty level) to cover childless adults and to help people with income levels above the poverty line. Those with slightly higher incomes would be eligible for federal subsidies to buy private policies on the new insurance exchanges.

That approach fell apart when 26 states decided not to expand Medicaid, at least for now. There is no provision in the law to provide health insurance subsidies for anyone below the poverty line because those people are supposed to be covered by Medicaid.

The Times report, based on an analysis of census data, found that eight million Americans who are impoverished and uninsured will be ineligible for help of either kind. To add to the insanity, people whose incomes initially qualify them for subsidies on the exchanges could — if their income fell because they lost a job — end up with no coverage at all.

There are no easy solutions to the difficulties wrought by the Supreme Court decision and the callousness of state officials who seized on that opening to victimize the poor.

States like New Hampshire, Ohio, Pennsylvania and Tennessee that are still flirting with the idea of expansion should do the right thing and expand. States that have adamantly refused to expand should relent and take the generous federal funds. And if Congressional Republicans ever give up on their obsession to destroy the health reform law, Congress could surely find ways to make certain that the people most in need of help get it.

    A Population Betrayed, NYT, 3.10.2013,






Millions of Poor Are Left Uncovered

by Health Law


October 2, 2013
The New York Times


A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states.

People shopping for insurance on the health exchanges are already discovering this bitter twist.

“How can somebody in poverty not be eligible for subsidies?” an unemployed health care worker in Virginia asked through tears. The woman, who identified herself only as Robin L. because she does not want potential employers to know she is down on her luck, thought she had run into a computer problem when she went online Tuesday and learned she would not qualify.

At 55, she has high blood pressure, and she had been waiting for the law to take effect so she could get coverage. Before she lost her job and her house and had to move in with her brother in Virginia, she lived in Maryland, a state that is expanding Medicaid. “Would I go back there?” she asked. “It might involve me living in my car. I don’t know. I might consider it.”

The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.

“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”

The disproportionate impact on poor blacks introduces the prickly issue of race into the already politically charged atmosphere around the health care law. Race was rarely, if ever, mentioned in the state-level debates about the Medicaid expansion. But the issue courses just below the surface, civil rights leaders say, pointing to the pattern of exclusion.

Every state in the Deep South, with the exception of Arkansas, has rejected the expansion. Opponents of the expansion say they are against it on exclusively economic grounds, and that the demographics of the South — with its large share of poor blacks — make it easy to say race is an issue when it is not.

In Mississippi, Republican leaders note that a large share of people in the state are on Medicaid already, and that, with an expansion, about a third of the state would have been insured through the program. Even supporters of the health law say that eventually covering 10 percent of that cost would have been onerous for a predominantly rural state with a modest tax base.

“Any additional cost in Medicaid is going to be too much,” said State Senator Chris McDaniel, a Republican, who opposes expansion.

The law was written to require all Americans to have health coverage. For lower and middle-income earners, there are subsidies on the new health exchanges to help them afford insurance. An expanded Medicaid program was intended to cover the poorest. In all, about 30 million uninsured Americans were to have become eligible for financial help.

But the Supreme Court’s ruling on the health care law last year, while upholding it, allowed states to choose whether to expand Medicaid. Those that opted not to leave about eight million uninsured people who live in poverty ($19,530 for a family of three) without any assistance at all.

Poor people excluded from the Medicaid expansion will not be subject to fines for lacking coverage. In all, about 14 million eligible Americans are uninsured and living in poverty, the Times analysis found.

The federal government provided the tally of how many states were not expanding Medicaid for the first time on Tuesday. It included states like New Hampshire, Ohio, Pennsylvania and Tennessee that might still decide to expand Medicaid before coverage takes effect in January. If those states go forward, the number would change, but the trends that emerged in the analysis would be similar.

Mississippi has the largest percentage of poor and uninsured people in the country — 13 percent. Willie Charles Carter, an unemployed 53-year-old whose most recent job was as a maintenance worker at a public school, has had problems with his leg since surgery last year.

His income is below Mississippi’s ceiling for Medicaid — which is about $3,000 a year — but he has no dependent children, so he does not qualify. And his income is too low to make him eligible for subsidies on the federal health exchange.

“You got to be almost dead before you can get Medicaid in Mississippi,” he said.

He does not know what he will do when the clinic where he goes for medical care, the Good Samaritan Health Center in Greenville, closes next month because of lack of funding.

“I’m scared all the time,” he said. “I just walk around here with faith in God to take care of me.”

The states that did not expand Medicaid have less generous safety nets: For adults with children, the median income limit for Medicaid is just under half of the federal poverty level — or about $5,600 a year for an individual — while in states that are expanding, it is above the poverty line, or about $12,200, according to the Kaiser Family Foundation. There is little or no coverage of childless adults in the states not expanding, Kaiser said.

The New York Times analysis excluded immigrants in the country illegally and those foreign-born residents who would not be eligible for benefits under Medicaid expansion. It included people who are uninsured even though they qualify for Medicaid in its current form.

Blacks are disproportionately affected, largely because more of them are poor and living in Southern states. In all, 6 out of 10 blacks live in the states not expanding Medicaid. In Mississippi, 56 percent of all poor and uninsured adults are black, though they account for just 38 percent of the population.

Dr. Aaron Shirley, a physician who has worked for better health care for blacks in Mississippi, said that the history of segregation and violence against blacks still informs the way people see one another, particularly in the South, making some whites reluctant to support programs that they believe benefit blacks.

That is compounded by the country’s rapidly changing demographics, Dr. Geiger said, in which minorities will eventually become a majority, a pattern that has produced a profound cultural unease, particularly when it has collided with economic insecurity.

Dr. Shirley said: “If you look at the history of Mississippi, politicians have used race to oppose minimum wage, Head Start, all these social programs. It’s a tactic that appeals to people who would rather suffer themselves than see a black person benefit.”

Opponents of the expansion bristled at the suggestion that race had anything to do with their position. State Senator Giles Ward of Mississippi, a Republican, called the idea that race was a factor “preposterous,” and said that with the demographics of the South — large shares of poor people and, in particular, poor blacks — “you can argue pretty much any way you want.”

The decision not to expand Medicaid will also hit the working poor. Claretha Briscoe earns just under $11,000 a year making fried chicken and other fast food at a convenience store in Hollandale, Miss., too much to qualify for Medicaid but not enough to get subsidies on the new health exchange. She had a heart attack in 2002 that a local hospital treated as part of its charity care program.

“I skip months on my blood pressure pills,” said Ms. Briscoe, 48, who visited the Good Samaritan Health Center last week because she was having chest pains. “I buy them when I can afford them.”

About half of poor and uninsured Hispanics live in states that are expanding Medicaid. But Texas, which has a large Hispanic population, rejected the expansion. Gladys Arbila, a housekeeper in Houston who earns $17,000 a year and supports two children, is under the poverty line and therefore not eligible for new subsidies. But she makes too much to qualify for Medicaid under the state’s rules. She recently spent 36 hours waiting in the emergency room for a searing pain in her back.

“We came to this country, and we are legal and we work really hard,” said Ms. Arbila, 45, who immigrated to the United States 12 years ago, and whose son is a soldier in Afghanistan. “Why we don’t have the same opportunities as the others?”

    Millions of Poor Are Left Uncovered by Health Law, NYT, 2.10.2013,






Psychotherapy’s Image Problem


September 29, 2013
The New York Times


PROVIDENCE, R.I. — PSYCHOTHERAPY is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

As well they should: for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.

So what explains the gap between what people might prefer and benefit from, and what they get?

The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices.

For the sake of patients and the health care system itself, psychotherapy needs to overhaul its image, more aggressively embracing, formalizing and promoting its empirically supported methods.

My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).

In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications.

Given the chronic nature of many psychiatric conditions, the more lasting benefits of psychotherapy could help reduce our health care costs and climbing disability rates, which haven’t been significantly affected by the large increases in psychotropic medication prescribing in recent decades.

Psychotherapy faces an uphill battle in making this case to the public. There is no Big Therapy to counteract Big Pharma, with its billions of dollars spent on lobbying, advertising and research and development efforts. Most psychotherapies come from humble beginnings, born from an initial insight in the consulting office or a research finding that is quietly tested and refined in larger studies.

The fact that medications have a clearer, better marketed evidence base leads to more reliable insurance coverage than psychotherapy has. It also means more prescriptions and fewer referrals to psychotherapy.

But psychotherapy’s problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.

There is a lot of organizational catching up to do. Groups like the American Psychiatric Association, which typically promote medications as treatments of first choice, have been publishing practice guidelines for more than two decades, providing recommendations for which treatments to use under what circumstances. The American Psychological Association, which promotes psychotherapeutic approaches, only recently formed a committee to begin developing treatment guidelines.

Professional psychotherapy organizations also must devote more of their membership dues and resources to lobbying efforts as well as to marketing campaigns targeting consumers, primary care providers and insurers.

If psychotherapeutic services and expenditures are not based on the best available research, the profession will be further squeezed out by a health care system that increasingly — and rightly — favors evidence-based medicine. Many of psychotherapy’s practices already meet such standards. For the good of its patients, the profession must fight for the parity it deserves.


Brandon A. Gaudiano is a clinical psychologist

and assistant professor of psychiatry and human behavior

at the Alpert Medical School at Brown University.

    Psychotherapy’s Image Problem, NYT, 29.9.2013,






The Violence in Our Heads


September 19, 2013
The New York Times


STANFORD, Calif. — THE specter of violence caused by mental illness keeps raising its head. The Newtown, Conn., school killer may have suffered from the tormenting voices characteristic of schizophrenia; it’s possible that he killed his mother after she was spooked by his strange behavior and tried to institutionalize him. We now know that Aaron Alexis, who killed 12 people at the Washington Navy Yard on Monday, heard voices; many observers assume that he, too, struggled with schizophrenia.

To be clear: a vast majority of people with schizophrenia — a disease we popularly associate with violence — never commit violent acts. They are far more likely to be the victims of violence than perpetrators of it. But research shows us that the risk of violence from people with schizophrenia is real — significantly greater than it is in the broader population — and that the risk increases sharply when people have disturbing hallucinations and use street drugs. We also know that many people with schizophrenia hear voices only they can hear. Those voices feel real, spoken by an external, commanding authority. They are often mean and violent.

An unsettling question is whether the violent commands from these voices reflect our culture as much as they result from the disease process of the illness. In the past few years I have been working with some colleagues at the Schizophrenia Research Foundation in Chennai, India, to compare the voice-hearing experience of people with schizophrenia in the United States and India.

The two groups of patients have much in common. Neither particularly likes hearing voices. Both report hearing mean and sometimes violent commands. But in our sample of 20 comparable cases from each country, the voices heard by patients in Chennai are considerably less violent than those heard by patients in San Mateo, Calif.

Describing his own voices, an American matter-of-factly explained, “Usually it’s like torturing people to take their eyes out with a fork, or cut off someone’s head and drink the blood, that kind of stuff.” Other Americans spoke of “war,” as in, “They want to take me to war with them,” or their “suicide voice” asking, “Why don’t you end your life?”

In Chennai, the commanding voices often instructed people to do domestic chores — to cook, clean, eat, bathe, to “go to the kitchen, prepare food.” To be sure, some Chennai patients reported disgusting commands — in one case, a woman heard the god Hanuman insist that she drink out of a toilet bowl. But in Chennai, the horrible voices people reported seemed more focused on sex. Another woman said: “Male voice, very vulgar words, and raw. I would cry.”

These observations suggest that local culture may shape the way people with schizophrenia pay attention to the complex auditory phenomena generated by the disorder and so shift what the voices say and how they say it. Indeed, that is the premise of a new patient-driven movement, more active in Europe than in the United States, which argues that if you treat unsettling voices with dignity and respect, you can change them.

The Hearing Voices movement encourages people who hear distressing voices to identify them, to learn about them, and then to negotiate with them. It is an approach that flies in the face of much clinical practice in the United States, where psychiatrists tend to assume that treating such voices as meaningful encourages those who hear them to give them more authority and to follow their commands.

Yet while there is no judgment from the scientific jury at this point, there is evidence that at least some people find that when they use the Hearing Voices approach, their voices diminish, become kinder and sometimes disappear altogether — independent of any use of drugs.

This evidence is strengthened by a recent study in London that taught people with schizophrenia to create a computer-animated avatar for their voices and to converse with it. Patients chose a face for a digitally produced voice similar to the one they were hearing. They then practiced speaking to the avatar — they were encouraged to challenge it — and their therapist responded, using the avatar’s voice, in such a way that the avatar’s voice shifted from persecuting to supporting them.

All of the 16 patients who received a six-week trial of that therapy found that their hallucinations became less frequent, less intense and less disturbing. Most remarkably, three patients stopped hearing hallucinated voices altogether, even three months after the trial. One of those three patients had heard voices incessantly for the prior 16 years.

The more we know about the auditory hallucinations of schizophrenia, the more complex voice-hearing seems and the more heterogeneous the voice-hearing population becomes. Not everyone will benefit from the new approaches. Still, they offer hope for those struggling with a grim disease.

Meanwhile, it is a sobering thought that the greater violence in the voices of Americans with schizophrenia may have something to do with those of us without schizophrenia. I suspect that the root of the differences may be related to the greater sense of assault that people who hear voices feel in a social world where minds are so private and (for the most part) spirits do not speak.

We Americans live in a society in which, when people feel threatened, they think about guns. The same cultural patterns that make it difficult to get gun violence under control may also be responsible for making these terrible auditory commands that much harsher.


T. M. Luhrmann is a professor of anthropology

at Stanford University and a contributing opinion writer.

    The Violence in Our Heads, NYT, 19.9.2013,






Antibiotic-Resistant Infections

Lead to 23,000 Deaths a Year,

C.D.C. Finds


September 16, 2013
The New York Times


Federal health officials reported Monday that at least two million Americans fall ill from antibiotic-resistant bacteria every year and that at least 23,000 die from those infections, putting a hard number on a growing public health threat. It was the first time that federal authorities quantified the effects of organisms that many antibiotics are powerless to fight.

The number of deaths is substantially lower than previous estimates, in part because researchers from the Centers for Disease Control and Prevention stripped out cases in which a drug-resistant infection was present but not necessarily the cause of death. Infectious disease doctors have long warned that antibiotic resistance — in which bacteria develop defenses against antibiotics used to kill them — threatens to return society to a time when people died from ordinary infections.

“They have come up with hard numbers where it has been only guesswork,” said Dr. Stuart B. Levy, a professor of microbiology at Tufts University and the president of the Alliance for the Prudent Use of Antibiotics. “This sets a baseline we can all believe in.”

In 2007, the C.D.C. estimated that about 100,000 people died every year of infections they developed while in hospitals. Most of those infections were believed to be resistant to some antibiotics, but not necessarily the most widely used ones. And it was unclear how many of the deaths were caused by the drug-resistant infections. Monday’s report quantifies that.

Dr. Steven L. Solomon, the director of the C.D.C.’s office of antimicrobial resistance, acknowledged that the report underestimated the numbers, but said that was by design. Researchers were instructed to be conservative and to base their calculations only on deaths that were a direct result of a drug-resistant bacterial infection.

“This is a floor,” Dr. Solomon said. “We wanted the cleanest number, the least subjective number.”

One point of contention has been the extent to which industrial-scale animal farming contributes to the problem of antibiotic-resistant infections in humans. The government has estimated that more than 70 percent of antibiotics in the United States are given to animals. Companies use them to prevent sickness when animals are packed together in ways that breed infection. They also use them to make animals grow faster, though federal authorities are trying to stop that.

The report said that “much of antibiotic use in animals is unnecessary and inappropriate and makes everyone less safe.” It also said that about half of antibiotic use in people is inappropriate.

The 114-page report counts infections from 17 drug-resistant bacteria and one fungus, pathogens that Dr. Solomon said caused an overwhelming majority of drug-resistant bacterial infections in the country. It drew on data from five disease-tracking systems, including a major count of bacterial infections reported in hospitals in 10 different areas across the country. The count of deaths was based on mathematical models — one for each resistant organism.

One particularly lethal type of drug-resistant bacteria, known as CRE, has become resistant to nearly all antibiotics on the market. It is still relatively rare, causing just 600 deaths a year, but researchers have identified it in health care facilities in 44 states.

“We are getting closer and closer to the cliff,” said Dr. Michael Bell, a C.D.C. official who presented the data.

Infections from one of the most pervasive types of drug-resistant bacteria tracked in the report, MRSA, have been declining. Invasive MRSA infections in hospitals went down by more than half from 2005 to 2011, according to a paper published Monday in the journal JAMA Internal Medicine. However, the number of invasive MRSA infections picked up outside health care settings has not changed much, and researchers pointed out that the number of those types of infections has for the first time outstripped the number acquired in hospitals.

“This is a really big switch,” said Eli Perencevich, an infectious disease epidemiologist at the University of Iowa.

Hospitals have taken steps to prevent drug-resistant infections, but less is known about preventing infections outside hospitals, clinics and nursing homes. There has been little research, for example, on the extent to which antibiotic use on industrial farms contributes to resistant germs in people. The farm animal industry has been reluctant to allow data collection, and very few studies of the link have been done.

In a separate study in JAMA Internal Medicine on Monday, researchers from the Johns Hopkins Bloomberg School of Public Health sifted through health records of more than 440,000 people in the Geisinger Health System, which operates a network of clinics and hospitals in Pennsylvania, and found that patients who lived near farms and areas where manure was dumped were 38 percent more likely to develop a MRSA infection, particularly of soft tissue or skin, researchers found.

Some researchers not involved in the study said it offered evidence that living near farms increased one’s chances of developing a MRSA infection. But the study did not test farm animals or soil for MRSA, nor did it find evidence of the type of MRSA that is typically associated with farm animals, and others said the infections might have been caused by something other than antibiotics on farms.

    Antibiotic-Resistant Infections Lead to 23,000 Deaths a Year, C.D.C. Finds,
    NYT, 17.09.2013,






Stephen Crohn,

Who Furthered AIDS Study,

Dies at 66


September 14, 2013
The New York Times


His boyfriend was dying of a disease without a name.

Beginning in 1978, Stephen Crohn cared for Jerry Green, a handsome gymnast, as he lost 30 pounds, went blind and was ravaged by the kinds of infections that rarely harmed otherwise healthy people.

Mr. Green was one of the first people to die of the disease that became known as AIDS. In the ensuing years, scores of Mr. Crohn’s friends died of it. He had taken no special precautions, and he had been as sexually active as his friends.

But he never got sick.

Mr. Crohn’s resistance helped lead to a deeper understanding of H.I.V., the virus that causes AIDS, and treatments, simply by staying alive and working with doctors to help figure out why he was.

“What he contributed to medical knowledge is really quite extraordinary,” said Dr. Bruce D. Walker, the director of the Ragon Institute of Massachusetts General Hospital, M.I.T. and Harvard.

Mr. Crohn died on Aug. 23 in New York City at 66. The cause was suicide, his sister Amy Crohn Santagata said on Friday in confirming the death, which was not announced at the time.

Mr. Crohn’s immune system and its quirks earned him unsought renown. In 1996, the British newspaper The Independent called him “The Man Who Can’t Catch AIDS,” and he told his story in documentary films and newspaper interviews around the world.

Mr. Crohn had first come to the attention of Dr. Bill Paxton, then a scientist at the Aaron Diamond AIDS Research Center in New York. Dr. Paxton had been looking for gay men who seemed resistant to infection. Working with Dr. David Ho, now the chief executive of the Diamond Center, Dr. Paxton exposed Mr. Crohn’s cells, and those of another promising volunteer, to H.I.V.

“I couldn’t infect the CD4 cells,” he said in an interview. “I’d never seen that before.”

The CD4 white blood cells, which H.I.V. normally penetrates to start the process of disease, locked out the virus. Even at H.I.V. concentrations thousands of times greater than would be encountered outside a test tube, nothing happened.

Years later, researchers isolated the cause. H.I.V. gets into cells by fitting into two receptors on CD4 cells. But thanks to a genetic defect, the second receptor on Mr. Crohn’s CD4 cells was flawed. The malfunctioning receptor, CCR5, had no negative effect on his health and kept H.I.V. from getting in. As he put it in a “Nova” documentary on PBS: “It’s like a key — the virus comes with this. It’s looking for a two-holed keyhole. I don’t have one of the holes. Period. It’s never going to attach to me.”

The genetic anomaly, known as the delta 32 mutation, which produces the flawed receptor, is found in less than 1 percent of the population.

Stephen Lyon Crohn was born on Sept. 5, 1946, in Manhattan to Richard Crohn (who also had the gene) and the former Janet Goren. He was raised in Dumont, N.J., and was educated at New York University, City College of New York and the Art Students League of New York. He lived in Saugerties, N.Y.

Besides Ms. Santagata, Mr. Crohn is survived by two other sisters, Carla Crohn Friedman and Judith Bloom, as well as many nieces and nephews.

Mr. Crohn was an artist and worked as a freelance editor for Fodor’s Travel. His paintings, mainly abstract works that evoked landscapes, were exhibited in New York, San Francisco and elsewhere.

“My brother saw all his friends around him dying, and he didn’t die,” Ms. Santagata said. “He went through a tremendous amount of survivor guilt about that and said to himself, ‘There’s got to be a reason.’ ”

“He was quite extraordinary, and then also quite ordinary,” she said.

Mr. Crohn was the great-nephew of Burrill B. Crohn, a leading gastroenterologist who first described the disease that carries his name.

Mr. Crohn felt he was carrying on “his family’s tradition” by helping researchers, said Dr. Paxton, now a professor of infection and immunity at the University of Liverpool Institute of Infection and Global Health.

The research based on Mr. Crohn’s immune system has led to advances in fighting H.I.V. A drug that blocks the CCR5 receptor, maraviroc, is now used to keep infection from spreading in patients who have contracted the virus. And in 2006, an AIDS patient in Berlin was effectively cured of the disease after receiving bone marrow transplants from a matching donor who had the delta 32 mutation.

“This is a classic case of medical science learning from patients,” said Dr. Walker of the Ragon Institute. “Most of the immunology we know comes from studying other animal models,” he said. “We need to study humans who have real diseases.”

He explained, “You take the extreme examples and try to see how those people are different from the average person with the disease.”

So, he said, Dr. Paxton and colleagues asked, “How is Steve different from the average person with H.I.V. infection? And bingo, they found it.”

Dr. Paxton and Mr. Crohn remained friends. “He was the type of guy who walks into the room, and it lights up,” he said. “I was going to call him this weekend.”

    Stephen Crohn, Who Furthered AIDS Study, Dies at 66, NYT,  14.9.2013,






Wrestling With Dying Hospitals


August 11, 2013
The New York Times


Think about New York City and public health, and the mind instantly goes to soda cups and cigarette bans, to Mayor Michael Bloomberg’s 12-year campaign of behavioral modification to make his fellow citizens ditch their bad habits. But eating better is not the only way to a healthier city, especially when so many New Yorkers lack access to decent health care in their own neighborhoods.

On that, the Democratic candidates agree about the need for more primary and preventive care and far less reliance on the emergency room. One candidate, Bill de Blasio, has taken on that problem with a plan to save dying community hospitals in his home borough, Brooklyn.

Mr. de Blasio was arrested last month, protesting plans by the State University of New York to close Long Island College Hospital in Cobble Hill, which has hemorrhaged money and patients for years.

Mr. de Blasio has made fighting hospital closings a crusade, and his office sued to block the shutdown, arguing that it lacked proper review and would rob the community of needed services. A court order is keeping the hospital open for now, though it has only a handful of patients and no apparent future.

It’s easy to dismiss Mr. de Blasio’s arrest as a way to broadcast his solidarity with 1199 S.E.I.U., the health care workers’ union, which has endorsed him. But he has elevated an important issue on which Mr. Bloomberg long ago checked out. Struggling community hospitals, including the two on the brink of extinction — Long Island College Hospital and Interfaith Medical Center in Bedford-Stuyvesant, which is in bankruptcy court — have been badly managed and are ill equipped to survive in a changing marketplace. Many are disappearing under mountains of debt and need to be either rescued or reinvented.

Mr. de Blasio is proposing to try to do both, through a new entity, a Brooklyn Health Authority, run jointly by the city and state, with the power to modernize hospital systems boroughwide, coordinate the spending of health care dollars and set higher standards of care. He argues that haphazardly closing hospitals without a plan to transform the system would be disastrous in the short run, especially for emergency and psychiatric care. Long Island College Hospital and Interfaith, as Nina Bernstein reported in The Times, serve a swath of the city where 250,000 people live, many of them poor and uninsured.

Mr. de Blasio’s plan hinges on New York State getting a federal waiver to keep $10 billion in savings it has wrung from Medicaid to invest in health reforms statewide. It also requires approval by lawmakers in Albany, who may resist creating a new authority with the teeth to compel mergers and contain costs.

Mr. de Blasio’s answer may not be perfect or ultimately achievable. His rival Christine Quinn agrees that Long Island College Hospital should stay open and that getting the Medicaid waiver is the key to financing needed innovations in health care, but she doesn’t think Mr. de Blasio has the whole answer. She says a solution is needed citywide, not just in Brooklyn, and is wary of passing on this huge task to a newly invented bureaucracy.

Institutions like Long Island College Hospital cannot remain as they have been. It’s encouraging that the candidates at least agree that the city’s weak hospitals must have the focused attention of the next mayor.

    Wrestling With Dying Hospitals, NYT, 11.8.2013,






Radical Life Extension


August 7, 2013
The New York Times


The United States — and indeed the world — is straining under the weight of an aging population, and that strain is only expected to grow.

Life expectancy at birth in this country at the turn of the 20th century was nearly 50 years. According to the United States Census Bureau, it’s now over 78. And by 2050, it’ll be over 80. Others estimate it could be even higher.

A 2009 report by the MacArthur Research Network on an Aging Society estimated that by 2050 “life expectancy for females will rise to 89.2-93.3 years and to 83.2-85.9 years for males.”

One of the authors of the study, S. Jay Olshansky, a professor at the School of Public Health at the University of Illinois, Chicago, said at the time: “The economic implications for the U.S. economy are huge. We estimated we would be spending $3.2 to $8.3 trillion more in today’s dollars than currently projected.”

The Census Bureau projects that the number of Americans over 65 will more than double by 2060.

And this top-heavy population pyramid may only become more warped. A 2009 study published in The Lancet predicts that more than half of babies born in 2000 in “countries with long life expectancies” will live past 100 years old.

All of this raises tricky economic and ethical questions about how a society survives and prospers when so many of its citizens are beyond what we currently conceive as working-age, and live longer in the twilight, when disease ravages the mind and body, and people are more likely to be dependent than independent.

For instance, think of the raging debates we are now having about entitlements in light of a rapidly aging population. How can they be shored up? Can they survive as currently constructed?

Think of the pension problems that cities like Detroit are experiencing. Will those pension liabilities become even more unsustainable as more people grow older?

Having examined Americans’ feelings about living substantially longer lives, the Pew Research Center released a report on Tuesday titled “Living to 120 and Beyond: Americans’ View on Aging, Medical Advances and Radical Life Extension.”

Most Americans hadn’t heard of radical life extension, but as the report explained, it’s the prospect — raised by scientists, bioethicists and other experts — “that advances in biotechnology and other fields could slow down or turn back the biological clock and allow many humans to live to 120 years or beyond.”

When asked if they’d like to live to be 120, most Americans said no, but most said that their ideal life span was between 79 and 100 years old, higher than the current average life expectancy.

Half thought treatments allowing people to live to be 120 would be bad for society, while 4 in 10 thought they would be good. Two-thirds thought that the treatments prolonging life would strain natural resources.

But aside from the economic and scarcity issues, there are ethical and theological issues.

Pew points out that longer life spans could have real effects on relationships and family structures, calling into question how and when people considered marriage and childbearing and care for the elderly.

And as they explain: “There are many ethical issues, too. At a very basic level, some fear life extension could fundamentally alter people’s sense of what it means to be human — and not for the better.”

How do people value life when death is increasingly delayed?

Before Cardinal Joseph Ratzinger became Pope Benedict XVI, he led a theological commission that wrote: “Disposing of death is in reality the most radical way of disposing of life.”

That’s one religious view, although there are many others.

The point is that we are living longer and our life expectancies are predicted to keep rising. This presents real challenges for us as a society and an economy.

    Radical Life Extension, NYT, 7.8.2013,






Brooklyn Hospital Closings

a Blow to Psychiatric Care


August 1, 2013
The New York Times


Two years ago, a group appointed by Gov. Andrew M. Cuomo warned that Brooklyn would suffer a series of free-falling hospital bankruptcies and closings unless health care in the borough was restructured, with harsh consequences for a place where more than one in five of the 2.5 million residents live below the poverty line.

Now the imminent closing of Interfaith Medical Center, a hospital in Bedford-Stuyvesant that is among the largest providers of acute psychiatric care in Brooklyn, is threatening the borough with a severe shortage of inpatient mental health care, other hospital officials said. With the Coney Island Hospital psychiatric emergency department still out of commission after Hurricane Sandy, the loss of the 120 psychiatric beds at Interfaith, which also handles about 67,000 outpatient psychiatric visits a year, is going to create a crisis, hospital officials said.

The latest developments underscore how prescient the Cuomo group was, and also how little success it had in forestalling the crisis. Few of its recommendations have been acted upon, including the merging of several of the hospitals and a change in state law to loosen restrictions on private ownership.

“Not only is this a bad situation for patients,” said Pamela Brier, the chief executive of Maimonides Medical Center, reflecting on the abrupt loss of Interfaith on the heels of the shuttering of Long Island College Hospital in Cobble Hill, “but it has to be considered a harbinger of more to come.”

Maimonides, now widely considered one of the only financially solid private hospitals in Brooklyn, has been operating its psychiatric beds at capacity or above since the storm, which knocked out several of the city’s largest psychiatric hospitals, disrupted outpatient services and flooded scores of coastal nursing homes and adult homes, where many mentally ill people had found housing of last resort.

Though more attention and protest has been focused on the loss of acute-care medical beds and the emergency room at Long Island College Hospital and Interfaith, which together serve more than 250,000 people, the disappearance of Interfaith’s 160 so-called behavioral health beds, including 40 detox and rehabilitation slots, may have more far-reaching repercussions, veterans of the mental health system said.

The state recently announced a plan to downsize its own roster of mental hospitals, to 15 from 24. The state’s Medicaid redesign plan calls for more outpatient services and supportive housing to prevent mental health crises that require hospitalization. But such resources take time and money to create, and are in short supply.

Dr. Nirav R. Shah, the state health commissioner, was traveling and unavailable to discuss the issue on Thursday, according to Bill Schwarz, a spokesman. Mr. Schwarz later sent an e-mail statement from Dr. Shah, saying the department, along with the State Office of Mental Health and the State Office of Alcoholism and Substance Abuse Services, “are committing extensive, collective efforts to assist Interfaith Medical Center in its efforts to develop a comprehensive closure plan that will ensure the health care needs of all current patients as well as those in the community are met.”

The schedule calls for the closing to begin on Aug. 15, the date of a hearing in bankruptcy court in which Interfaith will seek approval for the shutdown. By mid-September, all inpatient services would end, and by mid-November, outpatient services would cease.

“Closing hospitals is not a health policy,” said Bill de Blasio, the public advocate and a Democratic candidate for mayor who has made Brooklyn’s health care crisis a central issue of his campaign. “If we don’t stop this crisis at Interfaith, we’ll face it at Brookdale. If we don’t stop it there, we’ll face it at Kingsbrook, and the list goes on. “

Mr. de Blasio’s plan for health care in Brooklyn, issued last week, includes creating a Brooklyn health care authority, its members appointed by the mayor and the governor, with the power to reshape the delivery of care to better serve community needs, change leadership of hospitals and expedite mergers. The authority would have control over money that the state is seeking from a federal Medicaid waiver, including funds to stabilize safety-net hospitals.

That federal waiver application could bring up to $10 billion statewide, but it has yet to be approved. Christine C. Quinn, the City Council speaker and a mayoral candidate, issued a letter on Thursday urging federal officials to approve it.

“In New York City, we are faced with a crisis in our health care delivery system,” she wrote. “The $10 billion waiver would not only allow the state to invest in innovative models of health care delivery, but it would also allow our hospitals to continue providing the care that saves the lives of our residents.”

Stephen Berger, an investment banker who has long advised the state on health policy, said the waiver money was one step toward a solution, and that parts of the de Blasio plan were worth serious discussion, particularly the city-and-state collaboration.

“What’s happening in Brooklyn is a massive tragedy,” Mr. Berger said. “We have no way to keep alive institutions that are fundamentally financially broke and losing dollars.”



This article has been revised

to reflect the following correction:

Correction: August 5, 2013

An article on Friday about the effect of the impending closure of Interfaith Medical Center in Brooklyn misstated the status of another hospital, Coney Island Hospital, which suffered damage from Hurricane Sandy. Coney Island’s psychiatric emergency department remains closed, but other parts of the hospital, including its inpatient psychiatric beds, are open; it is not the case that the entire hospital is closed.

Brooklyn Hospital Closings a Blow to Psychiatric Care,




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