History > 2009 > USA > Health (IV)
Overseas, Under the Knife
Leads Cancer Researchers
to Play It Safe
June 28, 2009
The New York Times
By GINA KOLATA
Among the recent research grants awarded by the National Cancer Institute is
one for a study asking whether people who are especially responsive to
good-tasting food have the most difficulty staying on a diet. Another study will
assess a Web-based program that encourages families to choose more healthful
Many other grants involve biological research unlikely to break new ground. For
example, one project asks whether a laboratory discovery involving colon cancer
also applies to breast cancer. But even if it does apply, there is no treatment
yet that exploits it.
The cancer institute has spent $105 billion since President Richard M. Nixon
declared war on the disease in 1971. The American Cancer Society, the largest
private financer of cancer research, has spent about $3.4 billion on research
grants since 1946.
Yet the fight against cancer is going slower than most had hoped, with only
small changes in the death rate in the almost 40 years since it began.
One major impediment, scientists agree, is the grant system itself. It has
become a sort of jobs program, a way to keep research laboratories going year
after year with the understanding that the focus will be on small projects
unlikely to take significant steps toward curing cancer.
“These grants are not silly, but they are only likely to produce incremental
progress,” said Dr. Robert C. Young, chancellor at Fox Chase Cancer Center in
Philadelphia and chairman of the Board of Scientific Advisors, an independent
group that makes recommendations to the cancer institute.
The institute’s reviewers choose such projects because, with too little money to
finance most proposals, they are timid about taking chances on ones that might
not succeed. The problem, Dr. Young and others say, is that projects that could
make a major difference in cancer prevention and treatment are all too often
crowded out because they are too uncertain. In fact, it has become lore among
cancer researchers that some game-changing discoveries involved projects deemed
too unlikely to succeed and were therefore denied federal grants, forcing
researchers to struggle mightily to continue.
Take one transformative drug, for breast cancer. It was based on a discovery by
Dr. Dennis Slamon of the University of California, Los Angeles, that very
aggressive breast cancers often have multiple copies of a particular protein,
HER-2. That led to the development of herceptin, which blocks HER-2.
Now women with excess HER-2 proteins, who once had the worst breast cancer
prognoses, have prognoses that are among the best. But when Dr. Slamon wanted to
start this research, his grant was turned down. He succeeded only after the
grateful wife of a patient helped him get money from Revlon, the cosmetics
Yet studies like the one on tasty food are financed. That study, which received
a grant of $100,000 over two years, is based on the idea that since obesity is
associated with an increased risk of cancer, understanding why people have
trouble losing weight could lead to better weight control methods, which could
lead to less obesity, which could lead to less cancer.
“It was the first grant I ever submitted, and it was funded on the first try,”
said the principal investigator, Bradley M. Appelhans, an assistant professor of
basic medical sciences and psychology at the University of Arizona. Dr.
Appelhans said he realized it would hardly cure cancer, but hoped that “it will
provide knowledge that will incrementally contribute to more effective cancer
Even top federal cancer officials say the system needs to be changed.
“We have a system that works over all pretty well, and is very good at ruling
out bad things — we don’t fund bad research,” said Dr. Raynard S. Kington,
acting director of the National Institutes of Health, which includes the cancer
institute. “But given that, we also recognize that the system probably provides
disincentives to funding really transformative research.”
The private American Cancer Society follows a similarly cautious path. Last
year, it awarded $124 million in new research grants, with some money coming
from large donors but most from events like walkathons and memorial donations.
Dr. Otis W. Brawley, chief medical officer at the cancer society, said the whole
cancer research effort remained too cautious.
“The problem in science is that the way you get ahead is by staying within
narrow parameters and doing what other people are doing,” Dr. Brawley said. “No
one wants to fund wild new ideas.”
He added that the problem of getting money for imaginative but chancy proposals
had worsened in recent years. There are more scientists seeking grants — they
surged into the field in the 1990s when the National Institutes of Health budget
doubled before plunging again.
That makes many researchers, who need grants not just to run their labs but also
sometimes to keep their faculty positions, even more cautious in the grant
proposals they submit. And grant review committees become more wary about giving
scarce money to speculative proposals.
Philanthropies, which helped some researchers try outside-the-box ideas, are now
having financial problems. And advances in technology have made research more
“Scientists don’t like talking about it publicly,” because they worry that their
remarks will be viewed as lashing out at the health institutes, which supports
them, said Dr. Richard D. Klausner, a former director of the National Cancer
But, Dr. Klausner added: “There is no conversation that I have ever had about
the grant system that doesn’t have an incredible sense of consensus that it is
not working. That is a terrible wasted opportunity for the scientists, patients,
the nation and the world.”
A Big Idea Without a Backer
For 25 years, Eileen K. Jaffe received federal grants to run her lab. As a
senior scientist at the Fox Chase Cancer Center, with a long list of published
papers in prestigious journals, she is a respected, established researcher.
Then Dr. Jaffe stumbled upon results that went against textbook explanations,
suggesting that it might be possible to find an entirely new class of drugs that
could disable proteins that fuel cancer cells. Now she wants to find chemicals
that might be developed into such drugs.
But her grant proposal was rejected out of hand by the institutes of health, not
even discussed by a review panel. She had no preliminary data showing that the
idea was likely to work, something reviewers always want to see, and the idea
was just too unprecedented.
Dr. Jaffe epitomizes the scientist who realizes that if she were to
single-mindedly pursue her unorthodox idea, her “career may be ruined in the
process,” in the words of Dr. Brawley of the American Cancer Society.
Dr. Jaffe is just conceiving her project; it is much to soon to know whether it
will result in a revolutionary drug. And even if she does find potential new
drugs, it is not clear that they will be effective. Most new ideas are difficult
to prove, and most potential new drugs fail.
So Dr. Jaffe was not entirely surprised when her grant application to look for
such cancer drugs was summarily rejected.
“They said I don’t have preliminary results,” she said. “Of course I don’t. I
need the grant money to get them.”
Dr. Young, chancellor at Fox Chase, said Dr. Jaffe’s situation showed why people
with bold new ideas often just give up.
“You can’t prove it will work in advance,” he said. “If you could, it wouldn’t
be a high-risk idea.”
It is a long haul, Dr. Jaffe knows. And she has already had to downsize her lab.
But, she said, she will persist.
Angels Outside Government
At the Dana-Farber Cancer Institute in Boston, Dr. Ewa T. Sicinska knew she
would have a similar problem with her research. She wanted to grow human cancers
in mice. Unlike Dr. Jaffe, though, Dr. Sicinska did not even apply for
It is not that the project was unimportant.
“Rather than have to start a human clinical trial to test new drugs, we want to
test them first in mice with real human tumors,” said Dr. George D. Demetri, who
leads the research group supporting Dr. Sicinska.
Researchers have studied mouse cancers but, they acknowledge, they are just not
the same as human cancers — they are much easier to treat, and drugs that cure
mice often do nothing in people. So, over the years, scientists have tried to
implant human cancer cells in mice, but with little success.
“Everyone told us that if you take tumors out of patients and put them in mice,
they don’t grow,” Dr. Demetri said. The tumor cells usually were put in a
plastic dish before being implanted in mice. “We said — wait a minute. The cells
are not growing in the plastic dish. They probably are dying. What if we bypass
With that idea in mind, Dr. Demetri, convinced it was too speculative to get
federal money, tapped an unusual source, the Ludwig Fund. Endowed by Daniel K.
Ludwig, one of the world’s richest men in the 1960s and 1970s, the fund supports
unfettered cancer research at six medical centers in the United States,
including Dana-Farber, to be used at the institutes’ discretion. That put Dr.
Sicinska in a very different position from that of Dr. Jaffe. She could try
something chancy without a grant.
Dr. Sicinska used a quarter of a million dollars of Ludwig money for this
project, buying mice without immune systems, which meant they could not reject
human tumors, and housing them in a germ-free basement lab. She spent months
learning to implant tumors in the mice and enlisted geneticists to study the
implanted tumors, making sure they did not mutate beyond recognition.
She spends her days in the lab, using a miniature ultrasound machine to scan the
mice, hairless creatures with prominent ears. Four types of sarcomas — cancers
of fat, muscle or bone — are growing in them and look genetically identical to
the tumors removed from patients.
Dr. Elias A. Zerhouni, former director of the National Institutes of Health,
said he was not sure that a grant for the project would have been turned down.
The N.I.H., he said, does finance research on mouse models for human cancer.
But Dr. Demetri said he did not apply “because we have lots of experience in
what’s fundable.” His mouse work, he said, is exploratory, and he cannot predict
what he will find or when. He certainly could not lay out a road map of what he
would do and promise results in a few years.
Studies With a Different Goal
Researchers like Dr. Appelhans, who is studying weight control and tasty foods,
do not expect to change the outlook for cancer patients anytime soon. But, they
say, that does not mean their work is unimportant.
Dr. Appelhans will study 85 overweight or obese women, measuring how much the
tastes and textures of food drive their eating. Then they will be given a weight
loss diet and nutritional counseling. Dr. Appelhans will ask whether those who
are most tempted by the tastes and textures also have the most trouble following
As for the grant to assess a Web-based program to improve food choices, it is
predicated on studies indicating that what people eat in childhood and
adolescence may have an impact on cancer risk in middle and old age, said the
grant recipient, Karen Weber Cullen, associate professor of pediatrics at Baylor
College of Medicine. Some studies have found that people who reported having
eaten fruits and vegetables when they were younger and maintaining a healthy
weight were less likely to have cancer.
Of course, it would not be feasible to follow participants for 30 or 40 years to
see if their cancer risk was altered, Dr. Cullen noted. But, she added, “we try
to achieve improvements in diet and physical activity behaviors that become
permanent and will make a difference in later years.”
In the study asking whether a molecular pathway that spurs the growth of colon
cancer cells also encourages the growth of breast cancer cells, the principal
investigator ultimately wants to find a safe drug to prevent breast cancer. She
received a typical-size grant of a little more than $1 million for the five-year
The plan, said the investigator, Louise R. Howe, an associate research professor
at Weill Cornell Medical College, is first to confirm her hypothesis about the
pathway in breast cancer cells. But even if it is correct, the much harder
research would lie ahead because no drugs exist to block the pathway, and even
if they did, there are no assurances that they would be safe.
Dr. Howe said she hoped that she would find such drugs, or that companies would.
Then she wants to develop a way to selectively deliver the drugs to precancerous
breast cells. If it all works and the treatment is safe, women with precancerous
conditions could avoid developing cancer.
Dr. Howe has reviewed grants for the cancer institute herself, she said, and
realizes that, among other things, those that get financed must have “a novel
hypothesis that is credible based on what we know already.”
Trying to Change the System
The National Institutes of Health has started “pilot experiments” to see if
there is a better way of getting financing for innovative projects, its acting
director, Dr. Kington, said.
They include “pioneer awards,” begun in 2004 for “ideas that have the potential
for high impact but may be too novel, span too diverse a range of disciplines or
be at a stage too early to fare well in the traditional peer review process.”
But only 3 percent to 5 percent of the applicants get funded. Now the institutes
have decided to set aside up to $25 million for “transformative R01 grants,”
described as “proposing exceptionally innovative, high risk, original and/or
unconventional research with the potential to create or overturn fundamental
About 700 proposals have come in, but only a small number are expected to be
financed, according to Dr. Keith R. Yamamoto, a molecular biologist and
executive vice dean of the school of medicine at the University of California,
San Francisco, and co-chairman of the committee that reviewed the proposals last
“From reading the applications so far, there are really some fantastic things,”
Dr. Yamamoto said.
There also is new money from the federal economic stimulus package passed by
Congress, which gives the National Institutes of Health $200 million for
“challenge grants” lasting two years or less.
But the N.I.H. has received about 21,000 applications for 200 challenge grants,
and researchers who have applied concede there is not much hope.
“I did submit one of these challenge grants recently, like the rest of the
lemmings,” said Dr. Chi Dang, professor of medicine, cell biology, oncology and
pathology at the Johns Hopkins University School of Medicine. But, he added,
“there are many, many more applications than slots.”
Some experienced scientists have found a way to offset the problem somewhat.
They do chancy experiments by siphoning money from their grants.
“In a way, the system is encrypted,” Dr. Yamamoto said, allowing those in the
know to wink and do their own thing on the side.
Great discoveries have been made with N.I.H. financing without manipulating the
system, Dr. Klausner said.
“But,” he added, “I actually believe that by and large it is despite, rather
than because of, the review system.”
Grant System Leads
Cancer Researchers to Play It Safe, NYT, 28.6.2009,
Swine Flu Cases in the U.S.
Pass a Million, Officials Say
June 27, 2009
The New York Times
By DONALD G. McNEIL Jr.
Swine flu has infected more than a million Americans, federal health
officials said Friday, and is infecting thousands more every week even though
the annual flu season is well over.
That total of those who have already been infected is “just a ballpark figure,”
said Dr. Anne Schuchat, director of respiratory diseases at the Centers for
Disease Control and Prevention, adding, “We know we’re not tracking every single
one of them.”
Only a tiny fraction of those million cases have been tested, Dr. Schuchat said.
The estimate is based on testing plus telephone surveys in New York City and
several other locales where the new flu has hit hard.
A survey in New York City, she said, showed that almost 7 percent of those
called had had flu symptoms during just three weeks in May when the flu was
spreading rapidly through schools. If that percentage of the city has had it,
then there have been more than 500,000 cases in the city alone, though most have
been mild enough that doctors recommended nothing more than rest and fluids.
The flu has now spread to many areas of the country, Dr. Schuchat noted, and the
C.D.C. has heard of outbreaks in 34 summer camps in 16 states.
About 3,000 Americans have been hospitalized, she said, and their median age is
quite young, just 19. Of those, 127 have died.
The median age for deaths is somewhat higher, at 37, but that number is pushed
up because while only a few elderly people catch the new flu, about 2 percent of
them die as a result.
Of those who die, Dr. Schuchat said, about three-quarters have some underlying
condition like morbid obesity, pregnancy, asthma, diabetes or immune system
problems. Even those victims, she said, “tend to be relatively young, and I
don’t think that they were thinking of themselves as ready to die.”
The new flu has now reached more than 100 countries, according to the World
Health Organization. The world’s eyes are on the Southern Hemisphere, which is
at the beginning of its winter, when flu spreads more rapidly. Australia, Chile
and Argentina are seeing a fast spread of the virus, mostly among young people,
while one of the usual seasonal flus, an H3N2, is also active.
Five American vaccine companies are working on a swine flu vaccine, Dr. Schuchat
said. The C.D.C. has estimated that once the new vaccine is tested for both
safety and effectiveness, no more than 60 million doses will be available by
September. That means difficult decisions will have to be made about whom to
give it to first.
Swine Flu Cases in the
U.S. Pass a Million, Officials Say, NYT, 27.6.2009,
Where Can the Doctor Who’s Guided
All the Others Go for Help?
June 23, 2009
The New York Times
By ELISSA ELY, M.D.
Psychiatry is a relatively safe profession, but it has a hazard that is not
apparent at first glance: if you are in it long enough, there may be no one to
talk to about your own problems.
It is not that way when you start out. Most psychiatric residents spend a good
deal of time in therapy with a senior psychiatrist, for a number of reasons —
not least, that it is the most intimate way to learn technical magic. Books
teach the same thing to everyone who reads them. But no one forgets the
crystalline remark their therapist made just to them, and how they viewed
themselves differently ever after.
At a certain point, though, you stop being the student and become the teacher.
You settle into the details of a career — hospital, research, private practice.
Roots go down, time passes. Eventually, younger psychiatrists begin to approach
you. Now you are the generation above, saving early-morning slots for residents
before they head off to clinic and class. You lower fees and accommodate their
hurtling, insane schedules. You remember how it was.
But no amount of wisdom prevents personal frailty. You are never too old for
your own problems. Yet when you are the professional others go to, where do you
bring your sorrows and secret pain?
Sometimes the situation is clear. During my training there was a formidable
psychiatrist who disappeared periodically. Everyone knew she was being
hospitalized for a recurrent manic psychosis, and that she would be back to
intimidate the trainees as soon as medications had stabilized her.
There was an oddness about it, but no dishonor. Actually, her illness made her
more impressive. We are taught to explain that mental illness has a biological
component responsive to medical treatment, just like diabetes or heart disease.
Her example brought conviction to our tone.
In my residency, I moonlighted in a medication clinic where an elderly
psychiatrist was being treated for a dementia he did not recognize. He could not
remember simple requests, raised his cane to strangers, screamed at family
members; his wife met with me separately and told me she was ready to leave him.
Carefully writing “Dr.” on the top line of each of his prescriptions, I felt
undersized and overregarded. Yet he took the pills without question and showed a
fatherly interest in my career. Years later, I thought maybe his wife had chosen
a student deliberately. My junior status allowed him to maintain his senior
Often, though, the situation is not straightforward, and medication is not the
problem. Life is. Maybe we are overcome, maybe ashamed, maybe despairing.
Self-revelation — the nakedness necessary in therapy — is hard when you have
been a model to others.
“In my situation, it would be difficult to find someone,” Dr. Dan Buie, a
beloved senior analyst in Boston, told me. It is not that psychiatrists aren’t
waiting in wing chairs all over the city. It is that so many of them are former
students and former patients. One generation of psychiatrists grows the next
through teaching and treatment.
Surrendering that professional identity to become a patient reverses a kind of
natural order. “You can’t be a simple patient,” Dr. Buie said. “Anyone I’d go
to, I’ve known.” To avoid it, some travel to other cities for therapy (probably
passing colleagues in trains heading in the other direction).
There is also the factor of experience. It is one thing if my internist is
younger than I; she is closer to the bones of medicine, and with any luck we can
get to know each other for years before serious illness requires more intimate
contact. It is another thing if my therapist is younger than I.
“It would be a big mistake not to turn to someone,” Dr. Buie went on, “but I
might have some trouble going to younger colleagues. It’s hard to understand the
issues that come up in the course of a life cycle unless you’ve lived it
Dr. Rachel Seidel, a psychoanalyst and psychiatrist in Cambridge, said that when
people feel vulnerable, “we want someone with more insight than we have.”
“It’s a paradox,” she added. “Do I have to have gone through what you’ve gone
through in order to be empathic to you? And yet, I’d have a preference for
someone who’s been around longer.”
Some look laterally for help. Peer supervision is a well-known form of risk
management; presenting troubling professional cases to colleagues prevents folly
and mistakes at any age.
“I use a couple of peers,” said Dr. Thomas Gutheil, professor of psychiatry at
Harvard Medical School. “Then they use me. It’s the reciprocity that’s key — you
feel the comfort of telling everything about yourself when you know the reverse
is also true.”
Other solutions are even closer. The playwright Edward Albee once wrote that it
can be necessary to travel a long distance out of the way in order to come back
a short distance correctly. The best source of help can be the nearest source of
all. An elderly luminary at the Boston Psychoanalytic Society and Institute
listened without comment when asked: Whom does he — the doctor others seek out
for help — seek out for help himself? He wasted no words.
“My wife,” he said crisply.
Elissa Ely is a psychiatrist in Boston.
Where Can the Doctor
Who’s Guided All the Others Go for Help?, NYT, 23.6.2009,
Agreement With Drug Companies
June 22, 2009
Filed at 1:04 p.m. ET
By THE ASSOCIATED PRESS
The New York Times
WASHINGTON (AP) -- President Barack Obama on Monday welcomed the
pharmaceutical industry's agreement to help close a gap in Medicare's drug
coverage, calling the pact a step forward in the push for overhaul of the
nation's health care system.
Obama said that drug companies have pledged to spend $80 billion over the next
decade to help reduce the cost of drugs for seniors and pay for a portion of
Obama's health care legislation. The agreement with the pharmaceutical industry
would help close a gap in prescription drug coverage under Medicare.
''This is a significant breakthrough on the road to health care reform, one that
will make a difference in the lives of many older Americans,'' Obama said in the
White House's Diplomatic Room.
He was joined by Sen. Max Baucus, D-Mont., the chairman of the Senate Finance
Committee who struck the deal with the White House; Sen. Chris Dodd, D-Conn.,
and Barry Rand, head of the senior citizens' advocacy group AARP. Notably absent
was a representative from the pharmaceutical association.
''It was always designed to be an AARP event,'' said Ken Johnson, spokesman for
the association. ''We don't think we should have been invited to it.''
Johnson said Billy Tauzin, the group's president and a former Republican
congressman from Louisiana, will attend a town hall meeting on health care that
Obama is staging at the White House on Wednesday.
Johnson said there are other parts to the agreement that have still not been
completed, but he declined to provide details.
''There are a lot of discussions going on right now, there are a lot of moving
pieces, there are a lot of elements to it that have not been finalized,''
The president used the opportunity to make his sternest call yet for action,
saying the drug agreement is one piece of ''health care reform I expect Congress
to enact this year.''
Obama said the move on Medicare will help correct an anomaly in the program that
provides a prescription drug benefit through the government health care program
for the elderly and disabled. Under the deal, drug companies will pay part of
the cost of brand name drugs for lower and middle-income older people in the
so-called ''doughnut hole.'' That term refers to a feature of the current drug
program that requires beneficiaries to pay the entire cost of prescriptions
after initial coverage is exhausted but before catastrophic coverage begins.
Obama said some Medicare beneficiaries will find at least a 50 percent discount
on prescription drugs. Obama says drug companies stand to benefit when more
Americans can afford prescription drugs.
The drug companies' investment would reduce the cost of drugs for seniors and
pay for a portion of Obama's proposed revamping of health care.
''This is an early win for reform,'' Rand said.
Under the agreement, part of the $80 billion would be used to halve the cost of
brand name drugs for Medicare recipients when they are in a coverage gap of the
program. AARP, which represents 40 million older Americans, has long lobbied to
eliminate that coverage gap completely.
The deal would affect about 26 million low- and middle-income recipients of the
program's enrollees, AARP said. It would apply to brand name and biologic drugs,
but not generics, the group said, and likely take effect in July 2010, assuming
drug overhaul legislation becomes law.
Under Medicare's Part D prescription drug program, recipients pay about 25
percent of the cost of their drugs until they and the government have paid
At that point, beneficiaries must cover the full cost of drugs until they have
spent $4,350 from their own pockets. When they reach that amount, Medicare's
catastrophic drug benefit takes effect, and recipients only pay 5 percent of
their drugs' costs until the end of the year.
Associated Press Writer Alan Fram contributed to this report.
Agreement With Drug Companies, NYT, 22.6.2009,
A Public Health Plan
June 21, 2009
The New York Times
As the debate on health care reform unfolds, no issue has caused such
partisan rancor — and spawned such misleading rhetoric — as whether to create a
new public insurance plan to compete with private plans.
The nation already has several huge public plans, including Medicare for the
elderly (once reviled by conservatives, it is now only short of the flag in its
popularity) and Medicaid for the poor.
Now the issue is whether to establish a new public plan to encourage more
competition among health insurers and provide Americans with an alternative.
Most Democrats and some Republicans have already accepted the need to create one
or more health insurance exchanges where individuals without group coverage and
possibly small businesses could buy insurance policies. Some proponents hope
that big businesses could enroll their workers as well.
An exchange would give the government (federal or state) a lot more power over
insurers that choose to participate in order to tap a vast new market of
previously uninsured people. It would determine the range of benefits that all
participating plans would have to offer. It would presumably require those plans
to accept all applicants, regardless of “pre-existing conditions.”
What Republicans are adamantly opposed to is the idea of adding a public plan to
that exchange. They portray it as a “government takeover” of the health care
system, or even as socialized medicine. Those are egregious
There is no serious consideration in Congress of a single-payer governmental
program that would enroll virtually everyone. Nor is there any talk of extending
the veterans health care system, a stellar example of “socialized medicine,” to
the general public.
The debate is really over whether to open the door a crack for a new public plan
to compete with the private plans. Most Democrats see this as an important
element in any health care reform, and so do we.
A public plan would have lower administrative expenses than private plans, no
need to generate big profits, and stronger bargaining power to obtain discounts
from providers. That should enable it to charge lower premiums than many private
It would also provide an alternative for individuals who either can’t get
adequate insurance from private insurers or don’t trust the private insurance
industry to treat them fairly. And it could serve as a yardstick for comparing
the performance of private plans and for testing innovative coverage schemes.
Unfortunately, many Senate Democrats are so desperate to find a political
compromise with Republicans — or so bullied by the rhetoric — that they are in
danger of gravely weakening a public plan, or eliminating it entirely. That
would be a mistake.
Here is a look at the main proposals now under consideration:
THE MOST ROBUST This approach, favored by many analysts, would allow the new
public plan to piggy-back on the rate-setting powers of Medicare. As a result,
it is the one most feared by Republicans, the insurance industry and doctors and
hospitals. Any doctors who wanted to participate in Medicare, as virtually all
do, would also have to participate in this plan and would have to accept the
same payment rates as Medicare provides.
With lower costs, it would be cheaper for consumers, charging its members
premiums as much as 20 to 30 percent lower than premiums for comparable private
coverage, a boon to hard-pressed families.
It would also shave hundreds of billions of dollars from the amount needed to
cover the uninsured — a crucial advantage as Congress scrambles to finance the
The risk is that if this plan, given its power, were too stingy, it might drive
some financially stressed hospitals into bankruptcy. The hope is that the
downward pressure on reimbursements might force them to innovate and find big
Republicans and private insurers fear, with some reason, that such an
inexpensive public plan would entice or drive tens of millions of Americans away
from private insurance, especially if big employers were allowed to enroll their
workers in an exchange. The challenge is to craft rules to discourage employers
from simply dropping their own subsidies entirely.
The prospect of competing with a government plan terrifies the private insurers.
But in our judgment, if that many Americans were to decide that such a plan is a
better deal for them and their families, that would be a good thing. Innovative
private plans that already deliver better services at lower costs would survive.
Inefficient private plans would wither.
In an effort to address some of these fears, Senator Jay Rockefeller has
introduced a bill that would use Medicare provider payment rates for only the
first two years and let doctors opt out after three years while remaining in
Medicare. That would get the new public plan off to a good start, after which it
would compete on its own.
LIGHTER VERSIONS Other proposals are circulating that would level the playing
field with private plans. They would require the public plan to hold the same
reserves as private plans and sustain itself from premium income without drawing
on the federal treasury. It would probably pay providers higher rates than
Medicare but lower rates than most private plans. Its administrative costs would
be far lower, allowing it to offer lower premiums. These more modest versions
could be worth having, but they would save individuals and the health care
system far less money.
STATE-BASED PLANS A bipartisan group, led by three former Senate leaders —
Republicans Bob Dole and Howard Baker and Democrat Tom Daschle — has proposed
leaving it to states to create public plans if they wish. The federal government
would be able to step in after five years if a state has failed to establish an
exchange with affordable insurance options. That looks like a formula for delay
COOPERATIVES Propelled by a belief that no public plan could survive a
Republican filibuster, Senator Kent Conrad, Democrat of North Dakota, has
proposed instead setting up private nonprofit cooperatives — run for the benefit
of their members rather than stockholders — to compete with profit making
The presumed advantage of this approach is that cooperatives might be able to
charge lower premiums because they would not have to earn large profits. Their
performance, too, would be a yardstick against which to measure whether profit
making plans are charging fair premiums.
Health care cooperatives have existed at the local or regional level for decades
in this country. Many have gone belly up. A few still provide high quality care
at reasonable prices. Given sufficient size, seed money and negotiating power, a
cooperative organization could help transform the health care system. But
Republicans seem unlikely to accept a strong national organization, so creation
of cooperatives is apt to be local and spotty. They would be unlikely to deliver
as much savings as a large public plan.
TIGHT REGULATION Right from the start of the debate, some experts have suggested
that much tighter regulation of the new insurance exchange could achieve many of
the goals of a public plan.
Regulators could insist that insurers not exclude people with pre-existing
conditions or charge them higher premiums. The exchange could offer customers a
menu of private plans and be modeled on the federal program that serves Congress
and other government personnel. Several European countries, including Germany,
provide better health care at lower cost than the United States without relying
on a public plan. And the near-universal coverage in Massachusetts was achieved
without a public plan option.
We continue to believe that a public plan would be desirable. Surveys by the
Commonwealth Fund have found that Medicare beneficiaries report fewer problems
obtaining medical care, less financial hardship due to medical bills, and higher
satisfaction with their coverage than do workers insured by private employers.
If Senate Republicans block a public plan, much tighter regulation will be
essential to guarantee affordable private coverage for millions of Americans.
A Public Health Plan,
House Unveils Health Bill,
Minus Key Details
June 20, 2009
The New York Times
By ROBERT PEAR
and DAVID M. HERSZENHORN
WASHINGTON — House Democrats on Friday answered President Obama’s call for a
sweeping overhaul of the health care system, unveiling a bill that they said
would cover 95 percent of Americans. But they said they did not know how much it
would cost and had not decided how to pay for it.
The proposal would establish a new public health insurance plan to compete with
private plans. Republicans and insurance companies strenuously oppose such an
entity, saying it could lead to a government takeover of health care. The draft
bill would require all Americans to carry health insurance. Most employers would
have to provide coverage to employees or pay a fee equivalent to 8 percent of
their payroll. The plan would also end many insurance company practices that
deny coverage or charge higher premiums to sick people.
“Health insurance for most American families is just one big surprise,” said
Representative George Miller of California, the chairman of the Education and
Labor Committee. “When you go to use it, you find out it’s not quite as it’s
represented, and you spend hours on the phone with exclusions and discussions
and referrals to other legal documents that you didn’t have at the time you
The 852-page House bill, as expected, is more expansive than the legislation
taking shape in the Senate, where work on the issue bogged down this week after
early cost estimates came in far higher than expected. The initial price tag for
a measure drafted by the Senate Finance Committee, for example, was $1.6
trillion over 10 years.
Similar sticker shock could hit House members when they see the cost of their
bill, which incorporates many ideas from health policy experts about how to fix
the health system.
Industry critics of the emerging Senate bill are likely to have even more
objections to the House version, but House Democratic leaders can probably push
their measure through on a party-line vote.
Under the House bill, health insurance would be regulated by a powerful new
federal agency, headed by a presidential appointee known as the health choices
The draft bill was unveiled by three committee chairmen — Mr. Miller; Henry A.
Waxman of California, chairman of the Energy and Commerce Committee; and Charles
B. Rangel of New York, chairman of the Ways and Means Committee. The chairmen,
all first elected in the 1970s, have worked together in secret for months to
develop a single bill.
The proposal would expand Medicaid eligibility, increase Medicaid payments to
primary care doctors and gradually close a gap in Medicare coverage of
prescription drugs known as a doughnut hole. The bill would also reverse deep
cuts in Medicare payments to doctors scheduled to occur in the next five years.
Taken together, these provisions could significantly drive up the bill’s cost.
The bill would impose a new “tax on individuals without acceptable health care
coverage.” The tax would be based on a person’s income and could not exceed the
average cost of a basic health insurance policy. People could be exempted from
the tax “in cases of hardship.”
Asked why there was no cost estimate for the bill, the House Democratic leader,
Steny H. Hoyer of Maryland, said: “Until we have a final product, we are
reluctant to ask the Congressional Budget Office for a score. But whatever we do
will be fully paid for.”
House Democrats pledged to offset the cost of their legislation by reducing the
growth of Medicare and imposing new, unspecified taxes.
Republicans, who had no role in developing the bill, denounced it as a blueprint
for a vast increase in federal power and spending.
“Families and small businesses who are already footing the bill for Washington’s
reckless spending binge will not support it,” said the House Republican leader,
John A. Boehner of Ohio, who raised the specter of federal bureaucrats’ making
medical decisions for millions of people.
Business groups also were not pleased. “There is enough to see here already to
know that we would be compelled to oppose this bill,” said E. Neil Trautwein, a
vice president of the National Retail Federation.
But John J. Sweeney, president of the A.F.L.-C.I.O., praised the House bill,
saying it provided “a road map for what health care reform should look like.”
The House chairmen described their bill as a starting point in a battle that
would dominate Congress this summer and ultimately involve the full range of
interest groups in Washington. The three House committees plan to hold as many
as six hearings on the bill next week. Mr. Waxman said lawmakers were committed
to considering all ideas, even a proposal to tax some employer-provided health
benefits, which he opposes.
The House bill shows what Democrats mean when they speak of a “robust” public
Under the bill, the public plan would be run by the Department of Health and
Human Services and would offer three or four policies, with different levels of
benefits. The plan would initially use Medicare fee schedules, paying most
doctors and hospitals at Medicare rates, plus about 5 percent. After three
years, the health secretary could negotiate with doctors and hospitals.
But the bill says, “There shall be no administrative or judicial review of a
payment rate or methodology” used to pay health care providers in the public
Scott P. Serota, president of the Blue Cross and Blue Shield Association, said,
“A government-run plan that pays based on Medicare rates, for any period of
time, is a recipe for disaster.”
The bill would limit what doctors could charge patients in the public insurance
plan, just as Medicare limits what doctors can charge beneficiaries.
In setting payment rates for doctors and hospitals under the public plan, the
bill says, the government should try to reduce racial and ethnic disparities and
“geographic variation in the provision of health services.”
The public plan would receive an unspecified amount of start-up money from the
federal government. After that, it would have to be self-sustaining.
The bill would require drug companies to finance improvements in the Medicare
drug benefit. Drug companies would have to pay rebates to the government on
drugs dispensed to low-income Medicare beneficiaries.
The bill would expand Medicaid to cover millions of people with incomes below
133 percent of the poverty level ($14,400 for an individual, $29,330 for a
family of four). The cost would be borne by the federal government.
The government would also offer subsidies to make insurance more affordable for
people with incomes from 133 percent to 400 percent of the poverty level
($43,300 for an individual, $88,200 for a family of four).
House Unveils Health
Bill, Minus Key Details, NYT, 20.6.2009,
The Rationing of U.S. Medical Care
June 19, 2009
The New York Times
To the Editor:
David Leonhardt (“Limits
in a System That’s Sick,” Economic Scene, June 17) makes no mention of the
most egregious form of medical care rationing — the decisions by insurance
companies to pay or not to pay for medical procedures, decisions that are
routinely based on cost rather than on sound medical practice.
Health care reform will get nowhere until the public understands that the
insurance companies are the ones currently making the rationing decisions. The
objection to a government-run plan — that it would compromise the relationship
of doctor and patient — overlooks the fact that the relationship is already
severely compromised by the insurance companies.
Whately, Mass., June 17, 2009
To the Editor:
Let’s not forget that health care is also already rationed by socioeconomic
status: the very poor are covered by government plans, and the very rich can
afford whatever treatment they want. It’s we folks in the middle who are left
holding the bag.
Berkeley, Calif., June 17, 2009
To the Editor:
David Leonhardt is correct that health care in the United States is rationed.
Our present system reflects a flawed value system of society that does not
recognize the value of the time, judgment and advice of a fully trained
primary-care physician. Payment is for actions taken. This is different from the
other learned professions.
Thoughtful, conscientious evaluation and management require more time and fewer
actions than third parties pay for. This changes good primary-care doctors into
referral centers to specialists. Paying for time and not just actions is a
prerequisite for meaningful reform.
The cultural desire to know what is wrong immediately is another cause of higher
costs. Immediacy requires myriad tests and imaging done quickly. Careful
observation for a time can be just as effective, safer and less costly. Another
prerequisite for lowering costs is for our national culture to develop some
Marcus M. Reidenberg
New York, June 17, 2009
The writer, a medical doctor, is a professor of pharmacology, medicine and
public health at Weill Cornell Medical College.
To the Editor:
“Doctors and the Cost of Care” (editorial, June 14) unfairly blames “profligate
physician behavior” for high medical spending in the United States. Contrary to
what the Dartmouth researchers claimed, regions with high Medicare per capita
spending are not necessarily wasting money.
Medicare spending per capita is an inaccurate proxy for overall medical
spending. Atul Gawande, in his New Yorker article cited in the editorial, relies
on the Dartmouth Medicare data to identify McAllen, Tex., as the town with the
highest per capita medical spending next to Miami.
But there are reasons other than physician behavior that explain Medicare costs
in McAllen. It is a border town and cares for many newcomers who are uninsured
and can’t pay. Therefore costs are shifted to insurance programs like Medicare.
In addition, to the extent actual medical spending per capita is high in
McAllen, Dr. Gawande points out other reasons. McAllen’s population drinks 60
percent more than average and has a 38 percent obesity rate.
Most doctors put their patients first, and many doctors provide free treatment
when a patient cannot pay. What a shame doctors are being vilified in the name
of reform. Betsy McCaughey
New York, June 15, 2009
The writer is chairwoman of the Committee to Reduce Infection Deaths and a
former lieutenant governor of New York State.
To the Editor:
I was disturbed to see your editorial suggest that the blame for “ever rising
premiums” falls primarily on physicians. Let’s give credit where credit is due.
Between 2000 and 2007, the 10 largest publicly traded insurance companies
increased their profits 428 percent, from $2.4 billion to $12.9 billion,
according to Securities and Exchange Commission filings.
During the same period, the number of insurers fell by nearly 20 percent,
largely because of a huge wave of mergers that led to stunning consolidation.
And premiums increased by more than 87 percent, rising four times faster than
the average American’s wages.
Today, 95 percent of American insurance markets qualify as tight oligopolies. As
in so many industries, blind reliance on free-market forces has failed the
Clearly, doctors bear a responsibility to curb costs. But the real culprits are
the middlemen who, after years of lax regulation, now have such a tight grip on
the market that they can — and do — charge whatever they want.
David A. Balto
Washington, June 14, 2009
The writer is a senior fellow with the Center for American Progress.
To the Editor:
Since its founding, Mayo Clinic has paid physicians with salaries to avoid
financial conflicts of interest in clinical decision-making, and to promote
multi-disciplinary coordination of care. Less well known, but important to
Mayo’s early growth, was its principle of billing based on patients’ means.
Using a sliding scale, wealthier patients paid more than poorer patients did for
the same care. Such means adjustment increased patient volumes, which
strengthened Mayo’s expertise and efficiency, benefiting rich and poor alike.
Health reform warrants similar means-adjustment principles. Consumer-owned
cooperatives could buy high-deductible, low-premium insurance policies, and pay
below-deductible bills, using means-adjusted withdrawals from participants’
health savings accounts. Such a plan would improve outcomes and value more
effectively than bureaucratic price-setting would.
Randall C. Walker
Rochester, Minn., June 15, 2009
The writer is a medical doctor at the Division of Infectious Diseases, Mayo
Clinic College of Medicine.
The Rationing of U.S.
Medical Care, NYT, 19.6.2009,
Report on Gene for Depression
Is Now Faulted
June 17, 2009
The New York Times
By BENEDICT CAREY
One of the most celebrated findings in modern psychiatry — that a single gene
helps determine one’s risk of depression in response to a divorce, a lost job or
another serious reversal — has not held up to scientific scrutiny, researchers
The original finding, published in 2003, created a sensation among scientists
and the public because it offered the first specific, plausible explanation of
why some people bounce back after a stressful life event while others plunge
into lasting despair.
The new report, by several of the most prominent researchers in the field, does
not imply that interactions between genes and life experience are trivial; they
are almost certainly fundamental, experts agree.
But it does suggest that nailing down those factors in a precise way is far more
difficult than scientists believed even a few years ago, and that the original
finding could have been due to chance. The new report is likely to inflame a
debate over the direction of the field itself, which has found that the genetics
of illnesses like schizophrenia and bipolar disorder remain elusive.
“This gene/life experience paradigm has been very influential in psychiatry,
both in the studies people have done and the way data has been interpreted,”
said Dr. Kenneth S. Kendler, a professor of psychiatry and human genetics at
Virginia Commonwealth University, “and I think this paper really takes the wind
out of its sails.”
Others said the new analysis was unjustifiably dismissive. “What is needed is
not less research into gene-environment interaction,” Avshalom Caspi, a
neuroscientist at Duke University and lead author of the original paper, wrote
in an e-mail message, “but more research of better quality.”
The original study was so compelling because it explained how nature and nurture
could collude to produce a complex mood problem. It followed 847 people from
birth to age 26 and found that those most likely to sink into depression after a
stressful event — job loss, sexual abuse, bankruptcy — had a particular variant
of a gene involved in the regulation of serotonin, a brain messenger that
affects mood. Those in the study with another variant of the gene were
significantly more resilient.
“I think what happened is that people who’d been working in this field for so
long were desperate to have any solid finding,” Kathleen R. Merikangas, chief of
the genetic epidemiology research branch of the National Institute of Mental
Health and senior author of the new analysis, said in a phone interview. “It was
exciting, and some people thought it was the finding in psychiatry, a major
The excitement spread quickly. Newspapers and magazines reported the finding.
Columnists, commentators and op-ed writers emphasized its importance. The study
provided some despairing patients with comfort, and an excuse — “Well, it is in
my genes.” It reassured some doctors that they were medicating an organic
disorder, and stirred interest in genetic testing for depression risk.
Since then, researchers have tried to replicate the gene finding in more than a
dozen studies. Some found similar results; others did not. In the new study,
being published Wednesday in The Journal of the American Medical Association,
Neil Risch of the University of California, San Francisco, and Dr. Merikangas
led a coalition of researchers who identified 14 studies that gathered the same
kinds of data as the original study. The authors reanalyzed the data and found
“no evidence of an association between the serotonin gene and the risk of
depression,” no matter what people’s life experience was, Dr. Merikangas said.
By contrast, she said, a major stressful event, like divorce, in itself raised
the risk of depression by 40 percent.
The authors conclude that the widespread acceptance of the original findings was
premature, writing that “it is critical that health practitioners and scientists
in other disciplines recognize the importance of replication of such findings
before they can serve as valid indicators of disease risk” or otherwise change
Dr. Caspi and other psychiatric researchers said it would be equally premature
to abandon research into gene-environment interaction, when brain imaging and
other kinds of evidence have linked the serotonin gene to stress sensitivity.
“This is an excellent review paper, no one is questioning that,” said Myrna
Weissman, a professor of epidemiology and psychiatry at Columbia. “But it
ignored extensive evidence from humans and animals linking excessive sensitivity
to stress” to the serotonin gene.
Dr. Merikangas said she and her co-authors deliberately confined themselves to
studies that could be directly compared to the original. “We were looking for
replication,” she said.
Report on Gene for
Depression Is Now Faulted, NYT, 17.6.2009,
Health Care Rationing Rhetoric
June 17, 2009
The New York Times
By DAVID LEONHARDT
More to the point: Rationing!
As in: Wait, are you talking about rationing medical care? Access to medical
care is a fundamental right. And rationing sounds like something out of the
Soviet Union. Or at least Canada.
The r-word has become a rejoinder to anyone who says that this country must
reduce its runaway health spending, especially anyone who favors cutting back on
treatments that don’t have scientific evidence behind them. You can expect to
hear a lot more about rationing as health care becomes the dominant issue in
Washington this summer.
Today, I want to try to explain why the case against rationing isn’t really a
substantive argument. It’s a clever set of buzzwords that tries to hide the fact
that societies must make choices.
In truth, rationing is an inescapable part of economic life. It is the process
of allocating scarce resources. Even in the United States, the richest society
in human history, we are constantly rationing. We ration spots in good public
high schools. We ration lakefront homes. We ration the best cuts of steak and
Health care, I realize, seems as if it should be different. But it isn’t.
Already, we cannot afford every form of medical care that we might like. So we
We spend billions of dollars on operations, tests and drugs that haven’t been
proved to make people healthier. Yet we have not spent the money to install
computerized medical records — and we suffer more medical errors than many other
We underpay primary care doctors, relative to specialists, and they keep us
stewing in waiting rooms while they try to see as many patients as possible. We
don’t reimburse different specialists for time spent collaborating with one
another, and many hard-to-diagnose conditions go untreated. We don’t pay nurses
to counsel people on how to improve their diets or remember to take their pills,
and manageable cases of diabetes and heart disease become fatal.
“Just because there isn’t some government agency specifically telling you which
treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan,
head of Medicare in the Bush administration, says, “that doesn’t mean you aren’t
getting some treatments.”
Milton Friedman’s beloved line is a good way to frame the issue: There is no
such thing as a free lunch. The choice isn’t between rationing and not
rationing. It’s between rationing well and rationing badly. Given that the
United States devotes far more of its economy to health care than other rich
countries, and gets worse results by many measures, it’s hard to argue that we
are now rationing very rationally.
On Wednesday, a bipartisan panel led by four former Senate majority leaders —
Howard Baker, Tom Daschle, Bob Dole and George Mitchell — will release a solid
proposal for health care reform. Among other things, it would call on the
federal government to do more research on which treatments actually work. An
“independent health care council” would also be established, charged with
helping the government avoid unnecessary health costs. The Obama administration
supports a similar approach.
And connecting the dots is easy enough. Armed with better information, Medicare
could pay more for effective treatments — and no longer pay quite so much for
health care that doesn’t make people healthier.
Mr. Baker, Mr. Daschle, Mr. Dole and Mr. Mitchell: I accuse you of rationing.
There are three main ways that the health care system already imposes rationing
on us. The first is the most counterintuitive, because it doesn’t involve
denying medical care. It involves denying just about everything else.
The rapid rise in medical costs has put many employers in a tough spot. They
have had to pay much higher insurance premiums, which have increased their labor
costs. To make up for these increases, many have given meager pay raises.
This tradeoff is often explicit during contract negotiations between a company
and a labor union. For nonunionized workers, the tradeoff tends to be invisible.
It happens behind closed doors in the human resources department. But it still
Research by Katherine Baicker and Amitabh Chandra of Harvard has found that, on
average, a 10 percent increase in health premiums leads to a 2.3 percent decline
in inflation-adjusted pay. Victor Fuchs, a Stanford economist, and Ezekiel
Emanuel, an oncologist now in the Obama administration, published an article in
The Journal of the American Medical Association last year that nicely captured
the tradeoff. When health costs have grown fastest over the last two decades,
they wrote, wages have grown slowest, and vice versa.
So when middle-class families complain about being stretched thin, they’re
really complaining about rationing. Our expensive, inefficient health care
system is eating up money that could otherwise pay for a mortgage, a car, a
vacation or college tuition.
The second kind of rationing involves the uninsured. The high cost of care means
that some employers can’t afford to offer health insurance and still pay a
competitive wage. Those high costs mean that individuals can’t buy insurance on
The uninsured still receive some health care, obviously. But they get less care,
and worse care, than they need. The Institute of Medicine has estimated that
18,000 people died in 2000 because they lacked insurance. By 2006, the number
had risen to 22,000, according to the Urban Institute.
The final form of rationing is the one I described near the beginning of this
column: the failure to provide certain types of care, even to people with health
insurance. Doctors are generally not paid to do the blocking and tackling of
medicine: collaboration, probing conversations with patients, small steps that
avoid medical errors. Many doctors still do such things, out of professional
pride. But the full medical system doesn’t do nearly enough.
That’s rationing — and it has real consequences.
In Australia, 81 percent of primary care doctors have set up a way for their
patients to get after-hours care, according to the Commonwealth Fund. In the
United States, only 40 percent have. Over all, the survival rates for many
diseases in this country are no better than they are in countries that spend far
less on health care. People here are less likely to have long-term survival
after colorectal cancer, childhood leukemia or a kidney transplant than they are
in Canada — that bastion of rationing.
None of this means that reducing health costs will be easy. The
comparative-effectiveness research favored by the former Senate majority leaders
and the White House has inspired opposition from some doctors, members of
Congress and patient groups. Certainly, the critics are right to demand that the
research be done carefully. It should examine different forms of a disease and,
ideally, various subpopulations who have the disease. Just as important,
scientists — not political appointees or Congress — should be in charge of the
But flat-out opposition to comparative effectiveness is, in the end, opposition
to making good choices. And all the noise about rationing is not really a
courageous stand against less medical care. It’s a utopian stand against better
Health Care Rationing
Rhetoric Overlooks Reality, NYT, 17.6.2009,
as Obama Pushes Health Issue
June 16, 2009
The New York Times
By ROBERT PEAR
and JACKIE CALMES
WASHINGTON — President Obama went before a convention of receptive but wary
doctors on Monday to make the economic case for a health care overhaul, both for
the nation and for the physicians’ own bottom lines.
But as the president spoke at the annual conference of the American Medical
Association in Chicago, it became clear that one of the major health plans on
the table would cost at least $1 trillion over 10 years yet leave tens of
millions of people uninsured.
Congress is wrestling with how to pay for Mr. Obama’s vision to extend health
care to all Americans, and some lawmakers are considering tax increases and
spending cuts different from the ones he has proposed. House Democrats, for
example, are weighing a tax on soft drinks and a value-added tax, a broad-based
consumption tax similar to the sales taxes many states levy.
An analysis released Monday by the nonpartisan Congressional Budget Office
raised the hurdles for draft legislation in the Senate just as its Health,
Education, Labor and Pensions Committee planned to begin voting on Wednesday.
The office concluded that a plan by the committee’s Democratic leaders, Senators
Edward M. Kennedy of Massachusetts and Christopher J. Dodd of Connecticut, would
reduce the number of uninsured only by a net 16 million people. Even if the bill
became law, the budget office said, 36 million people would remain uninsured in
That finding came as a surprise. Robert D. Reischauer, an economist who headed
the budget office when Congress tackled the health care issue in the Clinton
administration, said that if so many people remained uninsured, it might not be
feasible to cut special federal payments to hospitals that serve many low-income
Mr. Obama said Saturday that the government could save $106 billion over 10
years by cutting such hospital payments as more people gained coverage.
Senator Orrin G. Hatch of Utah, a senior Republican on both committees drafting
health legislation, said he found the office’s numbers stunning. He calculated
that the Kennedy bill would cost taxpayers $62,500 per uninsured person over the
Mr. Obama took the cost issue head on in Chicago. “The cost of inaction is
greater,” he told the doctors, because rising health care prices are “an
escalating burden on our families and businesses” and “a ticking time bomb for
the federal budget.”
Opening a week in which health care will dominate attention in Congress, the
president’s speech on Monday was the latest example of an oft-used ploy to press
his case: appearing before skeptical audiences, confident of his powers of
persuasion but willing as well to say what his listeners do not want to hear.
Mr. Obama spoke just days after the A.M.A. had signaled opposition to his
proposal for a public health insurance plan to compete with private insurers as
part of a menu of choices, much like the one for members of Congress.
“The public option is not your enemy,” Mr. Obama said. “It is your friend, I
believe.” Saying it would “keep the insurance companies honest,” the president
dismissed as “illegitimate” the claims of critics that a public insurance option
amounts to “a Trojan horse for a single-payer system” run by the government.
Mr. Obama twice referred to the use of such “fear tactics” about “socialized
medicine” in past legislative battles, without pointing out that the A.M.A., a
traditionally Republican-leaning group, was among those using the charge, as in
the mid-1960s debate over creating Medicare for people 65 and older.
Mr. Obama drew repeated applause, and even some standing ovations, when he
called for incentives to get more medical students to go into primary care
instead of the more lucrative specialty practices, and when he pledged to work
with doctors to reduce their often unnecessary “defensive medicine” to avoid
malpractice lawsuits. But scattered boos met his follow-up remark that he
opposed any cap on malpractice awards.
The president’s emphasis on reducing health care costs over expanding insurance
coverage, which dates to his campaign, reverses Democrats’ priorities of recent
years. Obama advisers say the focus on cost savings has appeal for all
Americans, not just the uninsured. Some advisers, including veterans of the
Clinton administration, say President Bill Clinton’s emphasis on covering the
uninsured helped doom his health care plan in 1994.
“We have made cost control a coequal objective, just as important as the
expansion of insurance coverage, which has traditionally been the dominant goal
for Democrats,” said Rahm Emanuel, the White House chief of staff. “The entire
discussion has to be centered on controlling or reducing costs.”
That rationale has been Mr. Obama’s answer to those who, after his election,
predicted that he would have to shelve his campaign promise to overhaul health
care to attend instead to an economy in crisis. “If we fail to act, premiums
will climb higher, benefits will erode further, the rolls of the uninsured will
swell to include millions more Americans, all of which will affect your
practice,” he told the A.M.A. members.
The practical problem for Mr. Obama is that by all accounts, the savings and
efficiencies he envisions will not occur quickly, certainly not in the 10-year
time frame of budget scorekeeping for purposes of passing legislation.
The budget office estimated that 39 million people would get coverage through
new “insurance exchanges.” But at the same time, it said, the number of people
with employer-provided health insurance would decline by 15 million, or about 10
percent, and coverage from other sources would fall by 8 million.
In effect, the office said, millions of people would get a better deal if they
bought insurance through an exchange because they could qualify for federal
subsidies not available if they stayed in their employers’ health plans.
Subsidies are expected to average $5,000 to $6,000 a person.
Mr. Obama assured skeptics in the audience: “You did not enter this profession
to be bean counters and paper pushers. You entered this profession to be
healers. And that’s what our health care system should let you be.”
On Wednesday, leaders of the Senate Finance Committee hope to unveil what will
be the one bipartisan measure in Congress.
Democrats on three House panels continue to meet privately to seek consensus on
a single plan. Democrats on the House Ways and Means Committee said they were
trying to decide whether to finance coverage of the uninsured with one
broad-based tax, like the value-added tax, or a combination of smaller taxes.
The value-added tax, common in other countries, is collected in stages from each
business that contributes to the production and sale of consumer goods.
Economists say a 5 percent VAT could have raised $285 billion last year.
But a VAT could violate Mr. Obama’s campaign pledge not to raise taxes on
households with incomes under $250,000 a year.
Cost Concerns as Obama
Pushes Health Issue, NYT, 16.6.2009,
Many in Congress
Hold Stakes in Health Industry
June 14, 2009
The New York Times
By JACKIE CALMES
WASHINGTON — As President Obama and Congress intensify the push to overhaul
health care in the coming week, the political and economic force of that
industry is well represented in the financial holdings of many lawmakers and
others with a say on the legislation, according to new disclosure forms.
The personal financial reports, due late last week from members of Congress,
show that many lawmakers hold investments in insurance, pharmaceutical and
prescription-benefit companies and in hospital interests, all of which would be
affected by the administration’s overhaul of health care.
The lawmakers’ stakes are impossible to quantify because the reports ask for
ranges of value for each asset, and because many officials’ holdings are in
stock index and mutual funds. The Senate majority leader, Harry Reid of Nevada,
for example, has interests in a stock index fund for the health care sector of
more than $50,000 and up to $100,000.
Representative Dave Camp of Michigan, the senior Republican on the Ways and
Means Committee, one of three panels in the House with jurisdiction over health
care, reported at least tens of thousands of dollars in health-related
interests, including the medical technology giant Medtronic, the drug maker
Wyeth and the insurance company Aetna.
In Congress, as members and aides of the three House committees continue to meet
privately, the Senate health committee will begin publicly drafting and voting
on its bill as soon as Tuesday. Later in the week, the Democratic chairman and
senior Republican of the Senate Finance Committee, Max Baucus of Montana and
Charles E. Grassley of Iowa, are expected to unveil a bipartisan plan.
Neither Mr. Baucus, from a ranching family, nor Mr. Grassley, a farmer, have
major health-related holdings, their reports show.
Senator Edward M. Kennedy of Massachusetts, chairman of the health committee,
has much of his wealth in blind trusts.
Senator Christopher J. Dodd, Democrat of Connecticut, leads the health committee
in consultation with Mr. Kennedy. Mr. Dodd’s wife, Jackie Clegg Dodd, is a
member of the board and a shareholder in several health-related companies,
including Cardiome Pharma, Javelin Pharmaceuticals and Brookdale Senior Living.
Senator Tom Coburn of Oklahoma, a Republican on the health committee, is an
obstetrician with income from his clinic in Muskogee. The wife of Representative
Wally Herger of California, the senior Republican on the health subcommittee of
the Ways and Means panel, works for Catholic Healthcare West, while the wife of
Representative Joe L. Barton of Texas, the top Republican on the House Energy
and Commerce Committee, works for JPS Health Network.
Mr. Obama’s chief adviser on health care, Nancy-Ann DeParle, also filed
disclosure forms with the White House. Ms. DeParle, who served in the Clinton
administration, went on to lucrative positions on the boards of health companies
and as director of a private-equity firm with health investments, earning more
than $2 million from 2008 to this year, according to forms signed on May 13.
The companies included Medco Health Solutions, a pharmacy benefits manager;
Boston Scientific, a device maker; Cerner, a provider of medical information
technology; and DaVita, an operator of dialysis services.
A handwritten note on the forms, dated June 4, says that “all conflicting assets
have been divested.” Ms. DeParle is the wife of a reporter for The New York
Times, Jason DeParle.
Janie Lorber, Ashley Southall and Jack Styczynski contributed reporting.
Many in Congress Hold
Stakes in Health Industry, NYT, 13.6.2009,
Paying for Health Care Reforms
June 14, 2009
The New York Times
By SHERYL GAY STOLBERG
and ROBERT PEAR
WASHINGTON — The White House said Saturday that President
Obama intends to pay for his health care overhaul partly by cutting more than
$200 billion in expected reimbursements to hospitals over the next decade — a
proposal that is likely to provoke a backlash from cash-strapped medical
institutions around the country.
Mr. Obama has insisted that his plan will not add to the federal deficit, and he
had already set aside in his budget what he calls a $635 billion “down payment”
toward the overall 10-year cost of the overhaul, which is expected to top $1
trillion. But Republicans and some Democratic legislators have been pressing him
for details on how he would cover the rest. On Saturday, he used his weekly
Internet and radio address to do so.
Mr. Obama said he had identified “an additional $313 billion in savings that
will rein in unnecessary spending and increase efficiency and the quality of
care,” bringing the total to nearly $950 billion. He did not offer a specific
breakdown, but advisers said that in addition to the more than $200 billion in
lowered hospital reimbursements, the president expects $75 billion in savings
over 10 years by getting better prices for prescription drugs, and $22 billion
in other savings.
“These savings will come from common sense changes,” Mr. Obama said in his
address. “For example — if more Americans are insured, we can cut payments that
help hospitals treat patients without health insurance.”
He added: “If the drug makers pay their fair share, we can cut government
spending on prescription drugs. And if doctors have incentives to provide the
best care instead of more care, we can help Americans avoid the unnecessary
hospital stays, treatments, and tests that drive up costs.”
Saturday’s announcement comes amid an intense push by the White House to sell
Mr. Obama’s health care plan, his highest legislative priority. Broadly
speaking, Mr. Obama wants to extend coverage to the nation’s 45 million
uninsured, preserve consumer choice and cut rising health care costs. He has
argued that fixing the nation’s broken health care system is crucial to the
economic health of the United States.
But as Congress contemplates the details of the legislation, the question of how
to pay for the plan is among the thorniest it will face. Already, one of Mr.
Obama’s early proposals — limiting tax deductions for high income people — has
run into major roadblocks on Capitol Hill. By providing details in his weekly
address on Saturday, Mr. Obama may be hoping to give lawmakers the political
leeway to adopt other cost-saving measures.
The administration expects to achieve the lowered hospital payments in two major
ways, by slowing the growth of reimbursements. First, said Mr. Obama’s budget
director, Peter M. Orszag, payments to hospitals will be reduced to try to
encourage them to work more productively and efficiently.
Mr. Orszag said hospitals could figure out ways of treating patients “more
effectively, through health information technology, a nurse coordinator instead
of an unnecessary specialist,” for example. These “productivity adjustments”
would account for $110 billion in savings.
Second, the administration expects to lower payments to hospitals that treat
large numbers of low-income patients. Medicare and Medicaid make special extra
payments to these hospitals, but Mr. Orszag said those payments will become less
necessary over time, as more of the nation’s 45 million uninsured acquire
coverage through the new program. This would account for $106 billion in
But hospital administrators, already nervous about lowered reimbursements, are
likely to oppose such cuts. Less than 24 hours before Mr. Obama’s radio address,
the president of the American Hospital Association, Richard J. Umbdenstock,
issued a call to action to his members across the country, warning that Congress
might cut provider payments.
Mr. Umbdenstock asked hospitals to "push back" against the proposed cuts.
"Payment cuts are not reform," he said, denouncing "blunt cuts that cripple
hospitals’ ability to do better for their patients."
Dr. Patricia A. Gabow, chief executive of the Denver Health and Hospital
Authority, which operates a 477-bed public hospital, said it would be "pretty
risky" for Congress to cut payments to safety net hospitals before knowing
whether new legislation actually reduced the amount of uncompensated care they
"What about homeless people, the chronically mentally ill, substance abusers and
people with low literacy?” Dr. Gabow asked. "You think they will be using the
federal health insurance exchange to enroll in insurance plans? I don’t think
Kenneth E. Raske, president of the Greater New York Hospital Association, said
the proposed cuts could be "devastating to hospitals that serve inner-city
Mr. Raske noted that none of the major proposals in Congress would provide
health insurance to illegal immigrants, and many of them would still be unable
to pay their hospital bills. In addition, he said, the federal payments will
still be needed because "Medicaid woefully underpays for outpatient clinics” and
other services in some states, including New York.
Five Congressional committees are working at a feverish pace to meet the
president’s goal of passing a health care bill that he can sign by October.
The Democratic chairman of the Finance Committee, Senator Max Baucus of Montana,
intends to unveil his plan this week. Aides said it would include a proposal to
tax some employer-provided health benefits, a notion that Mr. Obama sharply
criticized during his campaign for the White House. Workers might, for example,
have to pay income tax on the value of family coverage exceeding $15,000 a year.
Labor unions, many employers and many House Democrats oppose such a tax, saying
it would destabilize the employer-based system of health insurance on which
millions of Americans depend.
The Congressional Joint Committee on Taxation said a proposal like Mr. Baucus’s
could raise more than $400 billion over 10 years. Mr. Obama did not mention
taxing health benefits in his Saturday address.
Paying for Health Care Reforms, NYT, 14.6.2009,
Disease of Rich
Extends Its Pain to Middle Class
June 13, 2009
The New York Times
By ANDREW POLLACK
Lonnie Matthews, a retired building maintenance engineer in Burlington, N.C.,
has something in common with King Henry VIII, Sir Isaac Newton and Benjamin
Franklin. He has gout.
Often called the “disease of kings” because of its association with the rich
foods and copious alcohol once available only to aristocrats, gout is staging a
middle-class comeback as American society grows older and heavier.
The rising tide of gout — an extremely painful arthritis of the big toe and
other joints — is leading the pharmaceutical industry to rediscover what it had
considered a disease of the past. Companies are now racing to improve upon
decades-old generic drugs that do not work well for everyone.
Already this year the Food and Drug Administration has approved the first new
gout drug in more than 40 years, a product called Uloric from Takeda
Another new drug, Krystexxa, made by Savient Pharmaceuticals of East Brunswick,
N.J., will be reviewed for possible approval by an F.D.A. advisory committee on
And several other companies are testing drugs in clinical trials.
“It’s kind of like the forgotten disease,” said Barry D. Quart, chief executive
of one of those companies, Ardea Biosciences of San Diego.
Ardea discovered accidentally that an AIDS drug it was developing might work
against gout. Now the company has shifted its focus to gout, envisioning annual
sales of $1 billion if its drug is successful.
That would mean a huge increase in spending on gout medicines, which had sales
of only $53.4 million last year, according to IMS Health, a health care
information company. Uloric, the drug from Takeda, sells a daily pill for at
least $4.50 compared with 10 to 50 cents for the most commonly used generic,
It is estimated that two million to six million Americans have gout. Although
the disease becomes more common as people age, some men develop gout in their
40s and 50s, or even younger. It is three to four times as common in men as in
women, in part because estrogen is thought to protect premenopausal women from
Various studies suggest that the number of cases in this country has as much as
doubled in the last three decades.
“We have accumulated a lot of people with severe disease,” said Dr. Robert A.
Terkeltaub, section chief of rheumatology at the Veterans Affairs Medical Center
in San Diego and a consultant to some of the companies developing gout drugs.
And the typical case these days, is “not going to be someone who looks like
Henry VIII,” he said. “Now it’s going to be some 80-year-old lady with
congestive heart failure.”
One of the severe cases is Mr. Matthews, who had controlled his disease for many
years with the generic allopurinol. But when he developed renal problems in
2006, he stopped taking allopurinol because it can be harmful to those with bad
kidneys. After that, Mr. Matthews was bedridden or in a wheelchair and in such
excruciating pain in many of his joints that he said he contemplated suicide.
“It was like having a toothache so bad you can’t stand it, all over your body,”
Mr. Matthews, 76, says he found relief as a participant in a clinical trial of
Savient’s Krystexxa, the drug now up for review by the F.D.A.
Gout is caused by the buildup of a chemical called uric acid in the blood. Uric
acid is formed by the breakdown of purines, which are components of DNA, RNA and
some other important molecules in the body.
Some types of meat and fish, as well as beer, are particularly rich in purines
and can raise the risk of gout. There is also evidence that sugary soft drinks
raise the risk.
When uric acid levels get too high, the chemical can form needlelike crystals
that accumulate in joints.
In the early stages of the disease, gout attacks, which can last several days
and are excruciating, occur only rarely. But over time, the frequency increases
and people can develop disfiguring and disabling lumps of the chalky white
crystals, called tophi. Michael Clayton of Atlanta, who has severe gout, said he
had to quit a job as general manager of a restaurant after customers complained
about the tophi on his hands, which sometimes oozed liquid resembling Wite-Out.
Many doctors and patients treat only gout attacks. They use either pain
relievers like naproxen, steroids or colchicine — a crocus plant derivative that
has been used for centuries.
Many of the new drugs lower uric acid levels in the blood, meaning they can
prevent gout attacks and keep the disease under control.
A problem in getting doctors to prescribe chronic treatment for gout is that
many patients are reluctant to admit they have the disease because of its
association with gluttony.
“It’s part of society’s view of gout that this is something self-inflicted,”
said Dr. N. Lawrence Edwards, professor of medicine at the University of
So the industry is trying to spread the word that genetics and other factors,
not just diet, contribute to gout. Takeda and Savient bankroll the Gout and Uric
Acid Education Society, which is led by Dr. Edwards and was formed in 2005 to
raise awareness of the disease.
Another reason that gout is shedding its image as a disease of the past is
preliminary evidence — though still far from proof — that high uric acid levels
might also contribute to modern-day ills like hypertension, obesity, heart
disease, kidney impairment and diabetes.
In one small study published last year, treatment with allopurinol reduced high
blood pressure in adolescents.
Right now, it is estimated that 15 million to 20 million Americans have elevated
uric acid levels, known as hyperuricemia. But they do not have gout symptoms and
are therefore not treated.
If further studies prove that high uric acid levels contribute to other
diseases, though, then “hyperuricemia” could be defined as a disease in its own
right and millions of people might one day take drugs to lower uric acid levels,
much as they now do to lower cholesterol.
Paul Hamelin, president of Savient, said, “There’s a huge amount of ground that
nobody’s ever plowed yet.”
Disease of Rich Extends
Its Pain to Middle Class, NYT, 13.6.2009,
Senate Votes to Impose
U.S. Regulation on Tobacco
June 12, 2009
The New York Times
By DUFF WILSON
WASHINGTON — The Senate voted overwhelmingly Thursday to impose federal
regulation on cigarettes and other forms of tobacco, passing a landmark bill to
empower the Food and Drug Administration to control products that eventually
kill half their regular users.
The legislation, with only minor differences from a version the House passed in
April by a nearly 3-to-1 ratio. A White House spokesman, Reid H. Cherlin, said
on Thursday that President Obama, who was a co-sponsor of the bill when he was
in the Senate, would sign the legislation when it reached his desk.
An estimated one in five people in this country smoke, and more than 400,000 of
them die each year from smoking-related disease. But for decades, even after the
surgeon general’s 1964 report declaring cigarettes a health hazard,
Congressional efforts to regulate tobacco had met stiff opposition from
lawmakers from tobacco-growing states and their political allies.
And when the F.D.A. tried on its own to start regulating nicotine as a drug, the
Supreme Court struck down that effort in 2000, saying the agency could not take
such a step without Congressional authority. Cigarettes remained less regulated
than cosmetics or pet food.
But with broad bipartisan support in both the Senate and House, and a campaign
pledge by Barack Obama to sign such legislation if he became president, the
anti-tobacco forces came into alignment.
“This long-overdue grant of authority to F.D.A. to regulate tobacco products
means that the agency can finally take the actions needed to protect our people
from the most deadly of all consumer products,” Edward M. Kennedy, the
Massachusetts Democrat who was chief sponsor of the legislation in the Senate,
said in a statement from home, where he is receiving treatment for a brain
The Family Smoking Prevention and Tobacco Control Act, as it is called, would
empower the F.D.A. to set standards for cigarettes, regulating chemicals in
cigarette smoke and outlawing most tobacco flavorings. It could also study
whether to also ban menthol. Flavorings are considered a lure to first-time
smokers, especially the young. Menthol is used by three-quarters of black
smokers, who also have a disproportionate share of lung cancer.
The law would also further restrict marketing and advertising of tobacco
products. Colorful advertising and store displays will be replaced by
black-and-white-only text as part of restrictions aimed at reducing the appeal
to youth to try smoking. Cigarette makers will be required to stop using terms
like “light” and “low tar” by next year and to place large and graphic health
warnings on their packages by 2012.
But while the F.D.A. could mandate a reduced level of nicotine, an addictive
chemical, the law expressly says the agency cannot ban it. Public health
advocates say outlawing nicotine would force addicts would turn to a black
market or other sources.
Still, health advocates predict that F.D.A. product standards could eventually
reduce some of the 60 carcinogens and 4,000 toxins in cigarette smoke, or make
them taste so bad they deter users.
“This is a bill not for a one-year or two-year splash, but for a long-term
impact,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids,
a Washington advocacy group that took a lead in coordinating support for the
legislation. The Altria Group, the parent company of Philip Morris, whose
Marlboro brand helps make it the nation’s leading tobacco seller, endorsed the
F.D.A. legislation and negotiated some of its crucial provisions with Congress.
The Congressional Budget Office had estimated that the F.D.A. legislation would
reduce youth smoking by 11 percent and adult smoking by 2 percent over the next
decade beyond the declines that had already resulted from public education,
higher taxes and smoke-free indoor space laws.
At least partly because of such other efforts, cigarette smoking has declined
measurably over the last decade: in 2005, about 21 percent of adults in the
United States were smokers, compared with about 25 percent in 1995.
Reynolds America and Lorillard, the second- and third-largest companies, opposed
the legislation and criticized it as being intended to protect Philip Morris’s
market dominance by restricting advertising and new products.
But Brendan McCormick, a spokesman for Philip Morris’s parent, Altria, argued
that previous marketing restrictions, like the television advertising ban
imposed in 1971, had not frozen companies’ market shares. He said his company
supported “federal regulation and the benefits it will bring to tobacco
consumers and the greater predictability and stability we think it will bring to
the tobacco industry.”
There are only minor differences between the Senate bill and the one the House
passed in April — the main one involving the size of the graphic warnings on
cigarette packs, which would be bigger under the Senate version.
Henry A. Waxman, the California Democratic who was chief sponsor of the House
bill, said in an interview that he hoped the House could simply pass the Senate
version of the bill next week to send quickly to the President.
“I would prefer we do that,” Mr. Waxman said, adding that it was still possible
to call a conference committee instead to negotiate the minor differences. But
that process, he said, could delay action and risk another Senate filibuster of
the type that was broken Monday in a crucial vote of 61 Senators, two more than
needed to proceed to final action. That filibuster had been mounted by Richard
M. Burr, Republican of North Carolina, the nation’s leading tobacco-growing
state. Only one Democrat — Kay Hagan, also of North Carolina — had voted to
uphold the filibuster.
On Tuesday, the Senate voted 60 to 36 against a substitute bill by Mr. Burr and
Ms. Hagan to promote smokeless and other “reduced risk” products rather than
strictly regulate all new tobacco products.
Under the law, new products could be approved only if makers could demonstrate
health benefits to society as a whole — meaning the products would not induce
too many nonsmokers or would-be quitters to try them, rather than abstaining.
Another crucial procedural vote Wednesday passed 67-30, cutting off amendments.
And the final action Thursday came on a 79 to 17 vote, with Ms. Hagan of North
Carolina the only Democrat voting against it.The voting reflected a political
shift from years past, when tobacco state senators could count on support from
other Southern conservatives.
John Cornyn of Texas, who is chairman of the Senate Republican campaign
committee, co-sponsored the tobacco bill and voted against the filibuster. “This
is a rarity these days in Washington,” Mr. Cornyn said in debate Tuesday. “It is
actually a bipartisan bill.”
Michael B. Enzi of Wyoming, the ranking Republican on the Senate health
committee, also supported the tobacco legislation. “Smoking killed my dad and my
mom and my mother-in-law, and second-hand smoking conclusively affected me,” he
said during the Senate debate. “So this isn’t political. This is about the
health of all Americans.”
Although tobacco companies have also lost a series of recent rulings in court,
tobacco industry financial analysts say federal regulation, higher taxes and
court verdicts are all manageable because the companies, with a market of
addicted customers, can raise prices to remain profitable.
A Goldman Sachs analyst, Judy Hong, wrote in a report to investors last week,
“Some of the new remedies may be unpleasant but not financially disabling to the
Under the law, tobacco regulation would be introduced in stages. First, the
F.D.A. would hire a director and staff and find space for a new Tobacco Center,
to be financed by industry fees. The projected budget is $85 million the first
year, $450 million by the third year and more than $700 million in 10 years. A
scientific advisory committee would be set up by next year.
New marketing restrictions next year would include a ban on all outdoor
advertising of tobacco within 1,000 feet of schools and playgrounds.
The Association of National Advertisers, a trade organization, says the
legislation’s “massive crushing and unprecedently broad advertising
restrictions” violate First Amendment protections for commercial speech. A court
challenge is probable.
While cigarette consumption has declined in most Western countries, it is
growing in Asia and Eastern Europe. An estimated 1.3 billion people now smoke
worldwide, according to the World Lung Foundation.
“The unfortunate thing,” Nancy Brown, president of the American Heart
Association, said in an interview, “is the bad American habit is now being
exported to other countries.”
Senate Votes to Impose
U.S. Regulation on Tobacco, NYT, 12.6.2009,
Regulating Tobacco Industry
Is a Recent Concept
June 12, 2009
The New York Times
By DUFF WILSON
Smoking has a long history of addiction, disease and deaths, but government
efforts to control it have come relatively recently.
Tobacco began spreading around the world after Christopher Columbus first
encountered Native Americans, who smoked and chewed the leaf. Not until the 20th
century, though, did cigarettes became the main form of tobacco consumption —
and the most lethal legal products on the market.
Their popularity grew rapidly in this country after giveaways to American
soldiers in World Wars I and II, and the introduction of sophisticated marketing
campaigns. And notwithstanding decades of industry denials, smoking-related
cancer and lung disease started rising apace.
In the early 1950s the medical researcher Dr. Ernst L. Wynder published landmark
studies linking smoking to lung cancer and showing that tars from tobacco smoke
could cause skin cancer when brushed on mice.
Steps on the path to federal regulation include the first surgeon general’s
report on smoking, in 1964. Congress banned smoking on most airplane flights
starting in 1988.
In 1994, the chief executives of the nation’s seven largest tobacco companies
appeared at a House hearing overseen by Henry A. Waxman, Democrat of California,
and swore under oath that tobacco was not addictive and did not cause cancer.
The six-hour hearing, carried live on national television, was considered a
turning point in public perception of the tobacco industry.
“We had hearings on tobacco for decades,” Mr. Waxman, chief sponsor of the House
version of the tobacco legislation, said in an interview Wednesday. “But it was
not until 1994, after tobacco executives testified and lied to us, saying
cigarettes weren’t harmful, nicotine wasn’t addictive, they didn’t manipulate
the nicotine and of course they didn’t target kids — it wasn’t until after that
that we started getting the inside information from tobacco companies and found
the opposite was true.”
In 1998, seven tobacco companies agreed to a “master settlement agreement” with
46 states to resolve suits for $206 billion and to change marketing practices,
including those appealing to youth. But subsequently, cigarette companies nearly
doubled their marketing expenditures, peaking at $15.1 billion in 2003, and
increased advertising in stores.
Last month, the federal appeal court in Washington upheld a landmark
racketeering verdict against five major tobacco companies in a lawsuit filed in
1999 by the Department of Justice. The appeals court, saying consumer fraud
continues to this day, ordered the companies to publish “corrective statements”
about health risks.
The F.D.A. has previously tried on its own to regulate tobacco, most recently in
1996 when it asserted that cigarettes were medical devices and nicotine a drug.
Philip Morris and other tobacco companies sued, and the Supreme Court ruled by a
5-4 vote that the F.D.A. lacked specific Congressional authority.
Since then, the Senate and House have each voted to give the F.D.A. that
authority, but in different years. And President Bush had threatened to veto
But President Obama, who himself has admitted difficulty quitting smoking, has
promised to sign it into law.
Industry Is a Recent Concept, NYT, 12.6.2009,
Overseas, Under the Knife
June 10, 2009
The New York Times
By ARNOLD MILSTEIN,
MARK D. SMITH
and JEROME P. KASSIRER
ONE consequence of the high cost of medical care in the United States has
been the rise of medical tourism. Every year, thousands of Americans undergo
surgery in other countries because the allure of good care at half the price is
too good to pass up.
Average total fees at well-regarded hospitals like Apollo and Wockhardt in India
are 60 percent to 90 percent lower than those of the average American hospital,
according to a 2007 study by the consulting group Mercer Health and Benefits
(where Dr. Milstein is affiliated). Even compared with low-cost American
hospitals, the offshore fees are 20 percent to 50 percent lower.
Most medical travelers seek cosmetic procedures like facelifts and liposuction,
but an increasing number have high-risk operations like heart surgery and joint
replacement in places like India, Singapore and Thailand.
Is this a good idea? The only way to know is to find out how foreign hospitals
and surgeons compare with their American counterparts.
Which Americans consider this option? Typically, they are people who have either
no health insurance or meager coverage. Though not poor enough to qualify for
Medicaid, they cannot afford a good health plan. But lately, even some people
with good coverage have been encouraged to take advantage of cost savings
A few pioneering American insurers like Blue Cross Blue Shield of South Carolina
and self-insured employers like the Hannaford Brothers supermarket chain sent
American doctors to evaluate foreign hospitals. Favorably impressed, they now
offer payment for travel expenses and cash incentives as high as $10,000 for
choosing offshore hospitals.
For very costly operations like open heart surgery or hip joint replacement,
savings far exceed these payments. That is not to say that offshore surgery
could substantially lower health care costs. Less than 2 percent of spending by
American health insurers goes to the kind of non-urgent procedures that
Americans seek overseas.
Other negatives are obvious: people having surgery done halfway around the world
are far from their regular doctors as well as friends and family. Consider,
also, what happens if an American abroad falls victim to negligent care.
Arranging transfer to another hospital may be difficult — and malpractice suits
typically face longer odds and smaller payments than in the United Sates. To
mitigate these problems, some insurers and free-standing medical travel services
offer coordination with American doctors, local concierge services and
supplementary medical malpractice insurance.
There is reason to think the quality of care at some foreign hospitals may be
comparable to quality in the United States. More than 200 offshore hospitals
have been accredited by the Joint Commission International, an arm of the
organization that accredits American hospitals. Many employ English-speaking
surgeons who trained at Western medical schools and teaching hospitals.
So should offshore surgery be welcomed as a modest way to make American health
care more affordable? We can’t know until we can directly compare the outcomes
with those of American surgery. To begin, we must adopt a uniform way for
American hospitals and surgeons to report on the frequency of short-term
Medicare could do this by requiring that all participating hospitals and
surgeons count pre-surgical risk factors and post-surgical complications during
hospitalization and for 30 days afterward, when most short-term problems become
evident. The system used for many years by Veterans Affairs hospitals to reduce
surgical complications is the best option for this, since it is available to all
American doctors through the American College of Surgeons. So far, however, only
a small minority of surgeons participate in this or any other valid national
system of reporting surgical outcomes.
Patients and their surgeons also need comparable measurements of long-term
success. Medicare should lead by adopting Sweden’s method of monitoring hip
joint replacement outcomes. It tracks, for example, a patient’s ability to walk
without pain six years after surgery.
Finally, Medicare should invite accredited offshore hospitals and their
affiliated doctors to participate in all of its comparative performance
reporting systems. Beyond informing Americans contemplating treatment abroad,
such comparisons would allow us to learn if our care is the world’s best — and
to accelerate our improvement efforts if it is not.
Arnold Milstein is a doctor specializing in health care improvement. Mark D.
Smith is an internist and the chief executive of a health care foundation.
Jerome P. Kassirer is a professor at Tufts University School of Medicine.
Overseas, Under the Knife, NYT, 9.6.2009,
Paying for Universal Health Coverage
June 7, 2009
The New York Times
For Congress and the administration to keep the promise of comprehensive
health care reform, they will have to find the political will to pay for
universal coverage and other investments that are needed right away but will not
produce quick savings. The cost could reach $1.5 trillion over the next decade.
President Obama, who had already proposed some $634 billion in new taxes and
spending cuts, endorsed additional ideas last week. But Congressional Democrats
will almost certainly need to come up with a lot more money — and that is likely
to mean new taxes.
There are at least two easy ways to duck the problem should Congress choose to
be imprudent. One way out would be to abandon the goal of universal coverage
until after costs have been controlled. That would be unfair to the 46 million
uninsured Americans, who often suffer health damage because they are reluctant
to seek treatment until their plight becomes desperate.
Another way out would be to finance universal coverage by adding to the deficit,
the path that George W. Bush took to pay for his tax cuts for the wealthy. With
deficits already at high levels, Mr. Obama has reasonably insisted that health
care reforms have to be “deficit neutral” over a 10-year period, meaning that
any upfront costs must be fully paid for through cost reductions or new revenues
by the end of a decade.
Mr. Obama’s budget experts have proposed short-term savings of more than $300
billion in the Medicare and Medicaid programs. They would eliminate unjustified
subsidies given to private plans that participate in Medicare and reduce
payments to home health care providers, drug companies and many hospitals.
Last week, Mr. Obama said he would work with the Senate to find $200 billion to
$300 billion more in Medicare and Medicaid savings. He endorsed one way to
ensure that cuts would actually be made — saying he was open to giving an
obscure panel, the Medicare Payment Advisory Commission, enormous power to set
Medicare payment rates. That would insulate Congress from lobbying by every
group whose income might be reduced.
Mr. Obama said he was receptive to proposals that would require most Americans
to take out health insurance and most employers, except for small businesses, to
share the cost. Both would pump money into the system and help defray the costs
Virtually all experts agree that more revenues will be needed. Mr. Obama’s
proposal to limit itemized deductions by wealthy Americans met with a cool
reception but ought to remain on the table. Significant money could be raised by
increasing taxes on sugared drinks, alcohol, tobacco and other products that are
bad for one’s health. But more taxes will probably be needed.
Even the liberal-leaning Center on Budget and Policy Priorities suggested last
week that Congress is unlikely to be able to pay for universal coverage unless
it takes the unpopular step of limiting the tax exclusion for the value of the
health insurance provided by an employer. It is the nation’s costliest tax
subsidy, and some experts believe it encourages overuse of medical services.
Congress has heavy lifting ahead. It must foster reforms that are apt to reduce
costs in the long-run (past the 10-year mark) and find a mix of short-term
savings and tax increases to put us on course without driving up the deficit.
Paying for Universal
Health Coverage, NYT, 7.6.2009,
Obama Urges Effort on Health Care
June 7, 2009
The New York Times
By HELENE COOPER
WASHINGTON — President Obama, signaling the start of his
health care push, called on Congress and his government to tackle “the root
causes of skyrocketing health care costs.”
In his weekly radio and Internet address on Saturday morning, Mr. Obama said
that he wants to see health care reform that is built around lowering costs,
improving quality and coverage and protecting consumer choice.
“That means if you like the plan you have, you can keep it,” the president said.
“If you like the doctor you have, you can keep your doctor, too. The only change
you’ll see are falling costs as our reforms take hold.”
Just how he plans to achieve that remains up in the air; the address was long on
broad goals and short on specifics. Mr. Obama said that he had made it clear to
Congress that health reform should not add to the budget deficit.
“We’ll work with Congress to fully cover the costs through rigorous spending
reductions and appropriate additional revenues,” Mr. Obama said. “We’ll
eliminate waste, fraud and abuse in our health care system, but we’ll also take
on key causes of rising costs — saving billions while providing better care to
the American people.”
Mr. Obama has been gearing up for a battle over health care reform since he took
office, convening a health care summit and inviting industry leaders to the
White House, where they publicly pledged to cut $2 trillion in health care costs
over the next decade.
“Simply put, the status quo is broken,” Mr. Obama said in the address. “We
cannot continue this way. If we do nothing, everyone’s health care will be put
in jeopardy. Within a decade, we’ll spend one dollar out of every five we earn
on health care — and we’ll keep getting less for our money.”
The address came as Mr. Obama neared the end of his trip abroad. On Saturday he
was in France, attending the commemoration ceremonies surrounding the 65th
anniversary of D-Day.
Obama Urges Effort on
Health Care, NYT, 7.6.2009,
Senators Set to Visit White House
to Discuss Health Care
June 2, 2009
The New York Times
By SHERYL GAY STOLBERG
and ROBERT PEAR
WASHINGTON — President Obama will meet with influential Senate Democrats on
Tuesday to discuss overhauling health care, as the White House releases a report
asserting that revamping the system would increase the income of a typical
family of four by $2,600 in 2020, and by $10,000 in 2030.
The Democrats on two Senate committees that are drafting health legislation have
been invited to the White House to meet with Mr. Obama, hours before he leaves
for the Middle East and Europe. As part of a push to secure Congressional
passage of a bill this year, the administration will also make the case on
Tuesday that reforming health care is critical to fixing the economy.
“If we don’t do this we’re going to be facing a real mess 30 years from now,”
Christina Romer, the chairwoman of the White House Council of Economic Advisers,
told reporters Monday on a conference call to discuss her new report, “The
Economic Case for Health Care Reform.”
Also, six health care organizations followed up Monday on a commitment they made
last month to Mr. Obama to trim $2 trillion in health care costs over 10 years.
The groups, representing doctors, hospitals, drug companies and a labor union,
proposed eliminating unnecessary medical tests and procedures, slashing red tape
and better managing chronic diseases.
They said the potential savings could be $1 trillion to $1.7 trillion over 10
Health care spending in the United States accounts for 18 percent of the gross
domestic product, according to the White House report, and is expected to rise
sharply, to as much as 28 percent in 2030 and 34 percent in 2040. The
administration says it can slow the growth of health spending even as it expands
coverage to the more than 45 million people who are now uninsured.
Republicans are doubtful. Referring to the health care groups’ proposals,
Senator Charles E. Grassley of Iowa, the senior Republican on the Finance
Committee, said Monday, “I’m skeptical that these proposals will add up to
anywhere near $2 trillion.”
The House Republican leader, Representative John A. Boehner of Ohio, called the
White House report “nothing more than smoke and mirrors,” and said the
administration had not offered a credible plan to expand coverage “without
raising taxes or rationing care.”
The White House report — 51 pages, with charts, graphs and algebraic formulas —
estimated that slowing the growth rate of health care spending by 1.5 percent a
year would increase economic output by more than 2 percent in 2020 and nearly 8
percent in 2030. The report also states that revamping the health care system
would “prevent disastrous increases in the federal budget deficit.”
The 1.5 percent figure was cited as a goal by the six organizations that
proposed cost savings to the president. Each submitted recommendations, though
it was not clear how much each was willing to sacrifice.
The Pharmaceutical Research and Manufacturers of America, representing drug
companies, advocated greater use of certain prescription drugs, like medicines
for high blood pressure — a move it said could save lives and money by keeping
people healthier and reducing hospital admissions.
Doctors, represented by the American Medical Association, promised to try to
curb the overuse of imaging services, like magnetic resonance imaging of the
knee and the shoulder, and to reduce surgeries that might not be necessary, like
Caesarean section deliveries and angioplasties in patients with stable coronary
The Service Employees International Union said Medicaid and Medicare could save
money by encouraging the use of home care services, instead of nursing homes.
The union recommended that the federal government temporarily increase Medicaid
payments to the states for home- and community-based services.
America’s Health Insurance Plans, representing insurers, vowed to establish
standard claim forms and Web sites that allowed doctors to communicate more
easily with insurers.
Congress may try to put some proposals into legislation, to help offset the
costs of providing coverage for millions of the uninsured. This week, the
chairmen of the two relevant Senate committees are finishing legislation to be
considered by their panels this month.
Senators Set to Visit
White House to Discuss Health Care Overhaul, NYT, 2.6.2009,
Cigarettes Without Smoke,
June 2, 2009
The New York Times
By KATIE ZEZIMA
FALL RIVER, Mass. — During 34 years of smoking, Carolyn Smeaton has tried
countless ways to reduce her three-pack-a-day habit, including a nicotine patch,
nicotine gum and a prescription drug. But stop-smoking aids always failed her.
Then, having watched a TV infomercial at her home here, Ms. Smeaton tried an
electronic cigarette, which claimed to be a less dangerous way to feed her
addiction. The battery-powered device she bought online delivered an odorless
dose of nicotine and flavoring without cigarette tar or additives, and produced
a vapor mist nearly identical in appearance to tobacco smoke.
“I feel like this could save my life,” said Ms. Smeaton, 47, who has cut her
tobacco smoking to a pack and a half daily, supplemented by her e-cigarette.
That electronic cigarettes are unapproved by the government and virtually
unstudied has not deterred thousands of smokers from flocking to mall kiosks and
the Internet to buy them. And because they produce no smoke, they can be used in
workplaces, restaurants and airports. One distributor is aptly named Smoking
The reaction of medical authorities and antismoking groups has ranged from calls
for testing to skepticism to outright hostility. Opponents say the safety claims
are more rumor than anything else, since the components of e-cigarettes have
never been tested for safety.
In fact, the Food and Drug Administration has already refused entry to dozens of
shipments of e-cigarettes coming into the country, mostly from China, the chief
maker of them, where manufacture began about five years ago. The F.D.A. took
similar action in 1989, refusing shipments of an earlier, less appealing
version, Favor Smoke-Free Cigarettes.
“These appear to be unapproved drug device products,” said Karen Riley, a
spokeswoman for the agency, “and as unapproved products they can’t enter the
But enough of the e-cigarettes have made their way into the country that they
continue to proliferate online and in the malls.
For $100 to $150 or so, a user can buy a starter kit including a battery-powered
cigarette and replaceable cartridges that typically contain nicotine (though
cartridges can be bought without it), flavoring and propylene glycol, a liquid
whose vaporizing produces the smokelike mist. When a user inhales, a sensor
heats the cartridge. The flavorings include tobacco, menthol and cherry, and the
levels of nicotine vary by cartridge.
Propylene glycol is used in antifreeze, and also to create artificial smoke or
fog in theatrical productions. The F.D.A. has classified it as an additive that
is “generally recognized as safe” for use in food. But when asked whether
inhaling it was safe, Dr. Richard D. Hurt, director of the Nicotine Dependence
Center at the Mayo Clinic, said, “I don’t think so, but I’m not sure anyone
knows for sure.”
Of the e-cigarettes themselves, Dr. Hurt added: “We basically don’t know
anything about them. They’ve never been tested for safety or efficacy to help
people stop smoking.”
Public health officials also worry that the devices’ fruit flavors, novelty and
ease of access may entice children.
“It looks like a cigarette and is marketed as a cigarette,” said Jonathan P.
Winickoff, an associate professor at the Massachusetts General Hospital for
Children and chairman of the American Academy of Pediatrics Tobacco Consortium.
“There’s nothing that prevents youth from getting addicted to nicotine.”
Sales and use of electronic cigarettes are already illegal on safety grounds in
Australia and Hong Kong, and some other countries regulate them as medicinal
devices or forbid their advertising. So far the United States has focused only
on stopping them at the border, although Senator Frank R. Lautenberg, Democrat
of New Jersey, has asked the drug agency to take them off the market until they
can be tested.
Distributors of electronic cigarettes fear that a bill making its way through
Congress that would give the F.D.A. the authority to regulate tobacco could be
used to put them out of business as well. The bill has passed the House and
could be taken up by the Senate this week.
The only American study of electronic cigarettes, now under way at Virginia
Commonwealth University and financed by the National Cancer Institute, deals not
with the kind of safety questions raised by propylene glycol but rather with the
amount of nicotine processed by the bodies of the products’ users.
Another study, conducted this year at the University of Auckland in New Zealand
and financed by Ruyan, an electronic cigarette company, shows that users
typically receive 10 percent to 18 percent of the nicotine delivered by a
Smoking Everywhere, a Florida-based distributor of electronic cigarettes, sued
the F.D.A on April 28, claiming that the agency did not have jurisdiction to
refuse the imported devices.
“The F.D.A. has the power to regulate Nicorette gum and the like because it is
marketed as a smoking cessation product,” said Kip Schwartz, a lawyer for
Smoking Everywhere. But the company says its products are a cigarette
alternative for adult enjoyment and make no claims to help smokers quit, Mr.
Matt Salmon, a spokesman for the Electronic Cigarette Association, which
represents six distributors, said e-cigarettes delivered nothing more than a
mixture of nicotine and water vapor and emitted “no carcinogens.” The
association declined to give sales figures, but said that “hundreds of
thousands” of people used the products and that the average age of those users
was the mid-40s.
“It’s a really good alternative for people who smoke tobacco,” Mr. Salmon said.
Edwin Schwab, who quit smoking regular cigarettes last year after trying
e-cigarettes, likes them so much he has started selling them at a mall kiosk in
Mr. Schwab took his e-smoke along when he went out one night, he said, “and when
everyone was smoking outside in the cold, I just stood in the warm bar,
Smoke, or Regulation, NYT, 2.6.2009,
Kan. Doctor Refused to Quit:
'I Know They Need Me'
June 2, 2009
Filed at 5:12 a.m. ET
By THE ASSOCIATED PRESS
The New York Times
To some he was an unflinching hero, to others a remorseless villain. As a
late-term abortion doctor, George Tiller knew he had chosen a dangerous career,
one that made him a lightning rod. His clinic was a fortress, his days marred by
threats, but he refused to give up what he saw as his life's mission.
''He never wavered,'' says Susie Gilligan, who knew Tiller as part of her work
in the Feminist Majority Foundation. ''He never backed away. He had incredible
strength. When you spoke to him, he was a soft-spoken man, a very gentle man. He
said, 'This is what I have to do. Women need me. I know they need me.'''
Tiller, 67, whose Wichita, Kan., clinic had been the target of anti-abortion
protests for more than two decades, was fatally shot Sunday while serving as an
usher at his church. The suspect, identified by police as Scott Roeder, was
taken into custody three hours later. He was booked without bail on one count of
first-degree murder and two counts of aggravated assault.
As one of a few doctors across the nation to perform third-trimester abortions,
Tiller had survived an earlier shooting, his clinic was bombed, his home
picketed. He hired a Brink's armored truck to take him to work for several
weeks, he had federal marshals protecting him for 30 months. He built a new
surgical center without windows and he was known to wear a bulletproof vest,
sometimes even to church.
Through it all, he stood defiant.
When a pipe bomb heavily damaged his clinic in the mid 1980s, he hung a sign
outside the rubble saying: ''Hell, No. We Won't Go!'' He offered a $10,000 award
-- which was never collected.
When thousands of protesters gathered at the Women's Health Care Services clinic
in 1991 for the 45-day ''Summer of Mercy'' demonstration staged by Operation
Rescue, he was again unbowed.
''I am a willing participant in this conflict,'' he said at the time. ''I choose
to be here because I feel that it is the moral, it is the ethical thing to do.''
He told The Wichita Eagle newspaper in 1991 that prayer and meditation helped
him through hard times. ''If I'm OK on the inside,'' he said, ''what people say
on the outside does not make much difference.''
When a woman passing out anti-abortion literature shot him in both arms outside
the clinic two years later, he briefly pursued her by car, recalls Peggy Bowman,
his former spokeswoman. ''He didn't even know he was shot and all of a sudden he
saw this blood (and figured), 'I probably shouldn't spend my time chasing this
woman,''' she says.
Tiller suffered minor wounds -- and was back at the clinic the next day. (That's
when he hired the armored truck.)
This spring, Tiller was acquitted of misdemeanor charges of violating Kansas
restrictions on late-term abortions. Shortly after, the state's medical board
announced it was investigating allegations against him that were nearly
identical to those a jury had rejected.
Tiller's outspokenness rankled his critics, who decried as a publicity stunt his
offer several years ago to provide free abortions on the anniversary of the Roe
vs. Wade Supreme Court decision that legalized abortion. He said at the time at
least 32 low-income women signed up for the free first-trimester abortions.
Abortion opponents also claimed Tiller's large financial involvement in Kansas
politics thwarted prosecutions against him. They routinely blamed Tiller's
''corrupt influences in the government'' whenever legislation strengthening
state abortion laws failed to pass the Legislature or was vetoed by the
While anti-abortion activists have condemned Tiller's death, Randall Terry,
founder of Operation Rescue -- who also said the gunman was wrong -- told the
National Press Club on Monday the doctor was ''a mass murderer and,
horrifically, he reaped what he sowed.''
Tiller, a former Navy flight surgeon, hadn't planned to be an abortion doctor.
He hoped to become a dermatologist.
But when his father, also a doctor, died in a plane crash (his mother, sister
and brother-in-law also were killed), he took over the family practice. He soon
learned the elder Tiller had performed abortions.
''In reading through some of his records, he realized his father had done
abortions when they were illegal,'' says Bowman, his former spokeswoman. ''At
first, he was really shocked. Then in going through those charts, he totally
began to understand the importance of this service.''
Friends and colleagues say Tiller, a father of four and grandfather of 10, was a
strong-willed, unassuming man who was quick with a hug or a joke. He decorated
his office with family photos. He cherished rituals; he raised American flags in
his clinic parking lot after the 1991 protests were over and later gave them to
''He was never riled, he was always calm and cool,'' says Eleanor Smeal,
president of the Feminist Majority Foundation. ''He was a very serious man, but
a very good-natured one.''
In a 2008 speech to a young women's leadership conference sponsored by the
foundation, he said he was on a hit list in 1994, leading to federal protection.
His wife was stalked, he said, and the names of his vendors were made public on
''But the good news,'' he said, ''is we still live in the United States of
America'' and Roe vs. Wade allows women the opportunity to terminate
Dr. Susan Robinson, a California obstetrician-gynecologist who calls Tiller her
mentor, recalls one day when she asked him: ''How can you stand it being in a
pressure cooker?' He said, 'If it it's none of my business, I don't get
involved. If it doesn't matter, I don't get involved. If there's nothing I can
do about it, I don't get involved.' ''
But it was clear his work had taken a toll. Willow Eby, who worked as a
volunteer escort at the clinic, remembers a conference she attended last year
for abortion providers where he talked about his work.
''He explained that this would take your youth, it would take your energy, it
would wear you down,'' she recalls. ''But he said he would not let down the
women who needed him badly.''
Tiller once said his ''gifts of understanding'' helped him bring a service to
women that aided them in fulfilling their dreams of a happy, healthy family. It
was important, he said, that women have a choice when dealing with technology
that can diagnose severe fetal abnormalities before a baby is born.
''Prenatal testing without prenatal choices is medical fraud,'' he declared.
Colleagues said Tiller's office walls were lined with letters from patients
expressing their thanks.
One woman who turned to him was Miriam Kleiman, of northern Virginia. Nine years
ago, a routine sonogram revealed her 29-week-old fetus had major brain
abnormalities that prevented the baby's heart and lungs from functioning
Doctors told her the baby would die in utero or soon after birth. Kleiman's
doctors told her a third trimester abortion was not possible.
Kleiman says she could not bear a two-month death watch. ''There was a baby
dying inside of me, and it wasn't if, but when,'' she says.
After desperate pleas, she says, a doctor scribbled Tiller's name on a scrap of
paper. She and her husband flew to Wichita and drove through a gauntlet of
protesters to the fortress-like clinic.
She remembers Tiller and his staff as kind and compassionate. She had the
abortion and brought home her baby to be buried.
Kleiman, who now has two sons, says she cried when she heard of Tiller's death
while watching her son's soccer game.
''I fear,'' she says, ''that other people might not have this option in the
future -- to have a medical option that was safe, that was legal and allowed us
to say goodbye with dignity.''
Associated Press writers Roxana Hegeman in Wichita and Sam Hananel in
Washington, D.C., contributed to this report and Rhonda Shafner in New York
Kan. Doctor Refused to
Quit: 'I Know They Need Me', NYT, 2.6.2009,
Abortion Doctor Slain by Gunman
in Kansas Church
June 1, 2009
The New York Times
By JOE STUMPE and MONICA DAVEY
WICHITA, Kan. — George Tiller, one of only a few doctors in the nation who
performed abortions late in pregnancy, was shot to death here Sunday in the
foyer of his longtime church as he handed out the church bulletin.
The authorities said they took a man into custody later in the day after pulling
him over about 170 miles away on Interstate 35 near Kansas City. They said they
expected to charge him with murder on Monday.
The Wichita police said there were several witnesses to the killing, but law
enforcement officials would not say what had been said, if anything, inside the
foyer. Officials offered little insight into the motive, saying that they
believed it was “the act of an isolated individual” but that they were also
looking into “his history, his family, his associates.”
A provider of abortions for more than three decades, Dr. Tiller, 67, had become
a focal point for those around the country who opposed it. In addition to
protests outside his clinic, his house and his church, Dr. Tiller had once seen
his clinic bombed; in 1993, an abortion opponent shot him in both arms. He was
also the defendant in a series of legal challenges intended to shut down his
operations, including two grand juries that were convened after citizen-led
On Sunday morning, moments after services had begun at Reformation Lutheran
Church, Dr. Tiller, who was acting as an usher, was shot once with a handgun,
the authorities said. The gunman pointed the weapon at two people who tried to
stop him, the police said, then drove off in a powder-blue Taurus. Dr. Tiller’s
wife, Jeanne, a member of the church choir, was inside the sanctuary at the time
of the shooting.
The police in Wichita described the man who was detained as a 51-year-old from
Merriam, a Kansas City suburb, but declined to give his name until he was
charged. The Associated Press reported that a sheriff’s official from Johnson
County, Kan., where the man was taken into custody, identified him as Scott
The killing of Dr. Tiller is likely to return the issue of abortion to center
stage in the nation’s political debate. Until recently, President Obama, who
supports abortion rights, had largely sought to avoid the debate. Last month, he
confronted the issue in a commencement speech at the University of Notre Dame,
an appearance that drew protests because of his views. During the speech, he
appealed to each side to respect one another’s basic decency and to work
together to reduce the number of unwanted pregnancies.
Mr. Obama issued a statement after Dr. Tiller’s killing, saying, “However
profound our differences as Americans over difficult issues such as abortion,
they cannot be resolved by heinous acts of violence.”
Advocates of abortion rights denounced the killing, saying it would send a
renewed, frightening signal to others who provide abortions or work in clinics
and to women who may consider abortions. Some described Dr. Tiller as one of
about only three doctors in the country who had, under certain circumstances,
provided abortions to women in their third trimester of pregnancy, and said his
death would mean that women, particularly in the central United States, would
have few if any options in such cases.
“This is a tremendous loss on so many levels,” said Peter B. Brownlie, president
of Planned Parenthood of Kansas and Mid-Missouri, who had known Dr. Tiller for
Opponents of abortion, including those here who have been most vociferous in
their protests of Dr. Tiller and his work, also expressed outrage at the
shooting and said they feared that their groups might be wrongly judged by the
Troy Newman, the president of Operation Rescue, an anti-abortion group based in
Wichita, said he had always sought out “nonviolent” measures to challenge Dr.
Tiller, including efforts in recent years to have him prosecuted for crimes or
investigated by state health authorities.
“Operation Rescue has worked tirelessly on peaceful, nonviolent measures to
bring him to justice through the legal system, the legislative system,” Mr.
Newman said, adding, “We are pro-life, and this act was antithetical to what we
By late Sunday, Mr. Newman said, some were already suggesting that there were
links between the suspect and Operation Rescue. Someone named Scott Roeder had
made posts to the group’s blog in the past, Mr. Newman said, but “he is not a
friend, not a contributor, not a volunteer.”
Dr. Tiller’s death is the first such killing of an abortion provider in this
country since 1998, when Dr. Barnett Slepian was shot by a sniper in his home in
the Buffalo area. Dr. Tiller was the fourth doctor in the United States who
performed abortions to be killed in such circumstances since 1993, statistics
from abortion rights’ groups show.
Although most of the deadly violence occurred in the 1990s, advocates said,
abortion clinics and doctors have continued to be the targets of intense,
sometimes threatening protests. Some said they feared that Dr. Tiller’s death
might signal a return to the earlier level of violence. At some clinics on
Sunday, administrators were reviewing their security precautions.
Adam Watkins, 20, one of the church members, told The A.P. he was seated in the
middle of the congregation when he heard a small pop at the start of the
service. An usher came in and told the congregation to remain seated, and then
escorted Mrs. Tiller out. “When she got to the back doors, we heard her scream,”
Mr. Watkins said.
Dr. Tiller had long been at the center of the abortion debate here, one that
rarely seemed to quiet much in this southern Kansas city of about 358,000.
In 1993, Rachelle Shannon, from rural Oregon, shot Dr. Tiller in both arms. Two
years earlier, during Operation Rescue’s “Summer of Mercy” protests, thousands
of anti-abortion protesters tried to block off the clinic, the site of a bombing
Friends of Dr. Tiller also described regular incidents of vandalism at the
clinic, and a barrage of threats to him and his family — threats they say had
concerned him deeply for years.
Family members, including 4 children and 10 grandchildren, issued a statement
through Dr. Tiller’s lawyer, which read in part: “George dedicated his life to
providing women with high-quality health care despite frequent threats and
violence. We ask that he be remembered as a good husband, father and grandfather
and a dedicated servant on behalf of the rights of women everywhere.”
In recent years, Dr. Tiller had also been the focus of efforts by anti-abortion
groups and others — including a former state attorney general, Phill Kline — who
wished to see him prosecuted for what they considered violations of state law in
cases of late-term abortions.
Two grand juries, summoned by citizen-led petition drives, looked into Dr.
Tiller’s practices, including questions of whether he met a state law
requirement that abortions at or after 22 weeks of pregnancy be limited to
circumstances where a fetus would not be viable or a woman would otherwise face
“substantial and irreversible impairment of a major bodily function” — words
whose interpretation were at the root of much debate.
This year, Dr. Tiller was acquitted in a case that raised questions about
whether he was too closely tied to a doctor from whom he sought second opinions
in abortion cases. As recently as this spring, the State Board of Healing Arts
was investigating a similar complaint against him.
Joe Stumpe reported from Wichita, Kan.,
and Monica Davey from Chicago.
Abortion Doctor Slain by
Gunman in Kansas Church, NYT, 1.6.2009,