History > 2009 > USA > Health (VIII)
A Public Health Plan, and Alternatives
December 1, 2009
Months to Live
for a Comfortable Death:
December 27, 2009
The New York Times
By ANEMONA HARTOCOLLIS
In almost every room people were sleeping, but not like
babies. This was not the carefree sleep that would restore them to rise and
shine for another day. It was the sleep before — and sometimes until — death.
In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream
on Long Island, the patients were sleeping because their organs were shutting
down, the natural process of death by disease. But at least one patient had been
rendered unconscious by strong drugs.
The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart
failure and kidney problems, was brought from home by his wife and son, who were
distressed to see him agitated, jumping out of bed and ripping off his clothes.
Now he was sleeping soundly with his mouth wide open.
“Obviously, he’s much different than he was when he came in,” Dr. Edward
Halbridge, the hospice medical director, told Mr. Oltzik’s wife. “He’s calm,
Mr. Oltzik’s life would end not with a bang, but with the drip, drip, drip of an
IV drug that put him into a slumber from which he would never awaken. That drug,
lorazepam, is a strong sedative. Mr. Oltzik was also receiving morphine, to kill
pain. This combination can slow breathing and heart rate, and may make it
impossible for the patient to eat or drink. In so doing, it can hasten death.
Mr. Oltzik received what some doctors call palliative sedation and others less
euphemistically call terminal sedation. While the national health coverage
debate has been roiled by questions of whether the government should be paying
for end-of-life counseling, physicians like Dr. Halbridge, in consultations with
patients or their families, are routinely making tough decisions about the best
way to die.
Among those choices is terminal sedation, a treatment that is already widely
used, even as it vexes families and a profession whose paramount rule is to do
Doctors who perform it say it is based on carefully thought-out ethical
principles in which the goal is never to end someone’s life, but only to make
the patient more comfortable.
But the possibility that the process might speed death has some experts
contending that the practice is, in the words of one much-debated paper, a form
of “slow euthanasia,” and that doctors who say otherwise are fooling themselves
and their patients.
There is little information about how many patients are terminally sedated, and
under what circumstances — estimates have ranged from 2 percent of terminal
patients to more than 50 percent. (Doctors are often reluctant to discuss
particular cases out of fear that their intentions will be misunderstood.)
While there are universally accepted protocols for treating conditions like flu
and diabetes, this is not as true for the management of people’s last weeks,
days and hours. Indeed, a review of a decade of medical literature on terminal
sedation and interviews with palliative care doctors suggest that there is less
than unanimity on which drugs are appropriate to use or even on the precise
definition of terminal sedation.
Discussions between doctors and dying patients’ families can be spare, even
cryptic. In half a dozen end-of-life consultations attended by a reporter over
the last year, even the most forthright doctors and nurses did little more than
hint at what the drugs could do. Afterward, some families said they were
surprised their loved ones died so quickly, and wondered if the drugs had played
Whether the patients would have lived a few days longer is one of the more
prickly unknowns in palliative medicine. Still, most families felt they and the
doctors had done the right thing.
Mr. Oltzik died after eight days at the hospice. Asked whether the sedation that
rendered Mr. Oltzik unconscious could have accelerated his death, Dr. Halbridge
said, “I don’t know.”
“He could have just been ready at that moment,” he said.
With their families’ permission, Dr. Halbridge agreed to talk about patients,
including Mr. Oltzik and Frank Foster, a 60-year-old security guard dying of
cancer. He said he had come to terms with the moral issues surrounding sedation.
“Do I consider myself a Dr. Death who is bumping people off on a regular basis?”
he asked. “I don’t think so. In my own head I’ve sort of come to the realization
that these people deserve to pass comfortably.”
An Uncomfortable Topic
For every one like Dr. Halbridge, there were other doctors who, when asked about
their experiences, would speak only in abstract and general terms, as if giving
a medical school lecture, and declined requests to arrange interviews with
families who had been through the process. It is a difficult subject to discuss.
The medical profession still treats its role as an art as much as a science,
relying on philosophical principles like the rule of double effect. Under this
rule, attributed to the 13th century Roman Catholic philosopher Thomas Aquinas,
even if there is a foreseeable bad outcome, like death, it is acceptable if it
is unintended and outweighed by an intentional good outcome — the relief of
unyielding suffering before death. The principle has been applied to ethical
dilemmas in realms from medicine to war, and it is one of the few universal
standards on how end-of-life sedation should be carried out.
At Metropolitan Hospital Center, a city-run hospital in East Harlem, Dr. Lauren
Shaiova, the chief of pain medicine and palliative care, has issued 20 pages of
guidelines for palliative sedation. The guidelines include definitions,
criteria, what to discuss with family and hospital workers and a list of drugs
to induce sleep, control agitation and relieve pain.
The checklist of topics to be discussed with the family includes whether to
offer intravenous food and water. Another checklist anticipates that some
hospital workers may be upset by the process, and recommends a discussion with
questions like: “Were you comfortable with the sedation of this patient? If not,
what were your concerns?”
But clarity, doctors say, is hardly the rule. In 2003, Dr. Paul Rousseau, then a
Veterans Affairs geriatrician in Phoenix, wrote an editorial in the Journal of
Palliative Medicine calling for more explicit guidelines and research. He noted
that some researchers include intermittent deep sleep in the category of
palliative sedation, while others limit it to continuous sedation, which he said
might explain some of the variance in estimates of how often it occurs.
And he proposed more systematic research into the types of medications used, how
long it takes for patients to die, and the feelings of family and medical staff.
Doctors at two prominent New York City hospitals, Beth Israel Medical Center and
NewYork-Presbyterian Hospital, freely discussed their policies on terminal
sedation, but were reluctant to allow a reporter to talk to patients or
families. The policy adopted by Beth Israel’s hospice endorses palliative
sedation to “carefully selected patients” at the end of life. The three-page
policy reviews legal, ethical and clinical considerations in broad strokes, but
refrains from providing names of drugs and checklists.
Dr. Russell Portenoy, chairman of pain medicine and palliative care at Beth
Israel, said the policy reflected the perceived perils of too much specificity.
The hospice ethics committee decided that every patient was different, he said,
and that “it was better to present a policy at this 10,000-foot level.”
The Metropolitan guidelines authorize certain drugs to induce palliative
sedation, or in conjunction with sedation for pain, delirium and agitation. The
sedation drugs are lorazepam, midazolam, phenobarbital and, in the intensive
care unit only, sodium thiopental.
For pain, the guidelines list opioid drugs, including morphine, methadone and
Doctors say that other drugs used for sedation are ketamine, an anesthetic and
sedative popular at rave parties, and propofol, an anesthetic, which was ruled,
with lorazepam, to have caused Michael Jackson’s death. In very high doses,
sodium thiopental is used as a sedative in the three-drug combination used for
There is one ethical guidepost for all the protocols: Terminal sedation should
not become so routine that the end of life is scheduled like elective surgery,
for the convenience of the doctor or the family, or because the patient’s care
is no longer economically viable.
Physicians occasionally feel pressure to turn up the medication, said Dr.
Pauline Lesage, Beth Israel’s hospice medical director. The pressure may come
from weary relatives, who say, in effect, “Now it’s enough; I just want him to
Sometimes the pressure is institutional. “You may be tempted to jump over
because, oh well, ‘I need the bed,’ or ‘That’s enough, I don’t see what we are
doing here,’ ” she explained.
The doctors resist pressure to deliberately hasten death, she said. “Otherwise
you see that you are jumping into a different field.”
Leo Oltzik was a lanky man with a piercing gaze, a draftsman who, among many of
his projects, worked on plans for the Second Avenue subway. In 57 years of
marriage, he and his wife, Eleanor, had a son and a daughter and hardly ever
They slept in the same bed, even after a railing had to be installed on one side
to keep Mr. Oltzik from jumping out. But around Thanksgiving, Mr. Oltzik became
too agitated for his wife and son to continue caring for him at home. “He was
fighting death,” Mrs. Oltzik said.
After three days of efforts to calm Mr. Oltzik in the hospice failed, Dr.
Halbridge told the family that he was going to try an IV drip. Mr. Oltzik was
connected to an intravenous bag of Ativan, a brand name of lorazepam, and he was
given Roxanol, a liquid morphine, for pain and shortness of breath. He lay in a
large room where the December sun washed over flowered curtain ruffs, plush
carpeting and lavender chairs. He looked as if he was sleeping, except to his
“That’s not him,” she said, pulling out a photograph from better times.
On the sixth day, the staff invited Mrs. Oltzik and their son into a cozy
meeting room, equipped with an overstuffed couch and chairs. They were joined by
Dr. Halbridge; Barbara Walsh, a nurse managing the hospice team; and Lynne
Kiesel, a medical social worker, who called the Oltziks’ daughter, Barbara
Ladin, in Florida, and put her on a speakerphone.
“We have these meetings to talk about how you’re doing, how he’s doing, and to
give you a chance to ask us questions,” Ms. Walsh began, then turned to Dr.
Halbridge, who signaled his profession with the stethoscope wrapped over his
dark blazer like a shawl.
“Our biggest challenge was to try to get him not to be so agitated,” Dr.
The staff had tried to calm him with various medications by mouth, without
success. “So we put him on an IV medication, which is dripping in at a
continuous rate,” he said.
The doctor pressed ahead, in a cheerful, upbeat voice, tinged with regret,
saying that the staff had to decide what was better for Mr. Oltzik in the long
run and wanted the family’s opinion. His blood pressure was falling, “which
implies that his body is slowing down, but he’s comfortable, and that’s what
we’re looking for,” Dr. Halbridge continued. (Low blood pressure can be a side
effect of Ativan and Roxanol, according to the drug manufacturers, as well as a
consequence of the dying process.)
Ms. Walsh added consolingly, “He really looks like he’s sleeping.”
She said, apologetically, that the hospice had tried to find a balance between
controlling Mr. Oltzik’s agitation and making him too sleepy.
“We did go to this IV as kind of a last measure, because we know that people do
get sleepy and may not be as responsive, and we know how hard that is for the
family to see,” she said.
Mr. Oltzik’s daughter zeroed in on the question that had been hanging over the
discussion: “This is the end?”
“Yes, pretty much,” Dr. Halbridge said, “because what we’re seeing is a man who
had a rather significant blood pressure on admission, and over the past day now,
and today again, his blood pressure is even lower. So we’re talking about a poor
prognosis and a shorter time.”
Mr. Oltzik’s son detected an almost imperceptible change in his mother. “Stay
calm,” he urged her.
Moments later, the social worker gently entered the discussion, saying, “You’ve
given him excellent care at home.”
“I worked very hard,” Mrs. Oltzik said.
Although throughout the half-hour meeting the staff had never explicitly asked
to continue sedating Mr. Oltzik, his daughter now gave them tacit permission:
“We understand that the inevitable is here, but we wish him to go in peace and
to find solace in that,” Ms. Ladin said.
When the conference was over, Mrs. Oltzik still seemed to be ruminating. As many
relatives do, she had hesitated over whether her husband should be given
nutrition and water through tubes, now that he could not feed himself. The
thought of someone dehydrating or starving is one of the most difficult
emotional burdens for families, and was the crux of the famous fight over Terri
Schiavo, a vegetative Florida woman whose husband wanted to let her die, but
whose parents did not.
Palliative care doctors generally agree that sedated patients do not feel pain
from dehydration or starvation, and that food and water may only prolong agony
by feeding the fatal disease.
Mrs. Oltzik had done some research, and decided that nutrition and water would
only burden her husband’s system. “The idea is now not to make him work harder,
but to be as peaceful and calm as he can,” she said. “Common sense dictates that
that would be the way to go.”
Much of the conversation had proceeded not in black and white like a legal
document, but in shades of gray. By the end, they all seemed to understand one
another, though ultimately Mrs. Oltzik would express some sadness at being
unable to interact with her husband.
The Family’s Dilemma
From Karen Foster’s perspective, watching her husband, Frank, die while sedated
was the least in a series of cruel blows. Mr. Foster, who arrived at the
Franklin hospice about the same time as Mr. Oltzik, had stoically hidden his
liver cancer from his family for years. As recently as October, he was still
driving, Mrs. Foster said; then he suddenly went downhill.
The night before Thanksgiving, her husband was acting bizarrely, and soon he was
admitted to the hospice, Mrs. Foster said. Dr. Halbridge put him on morphine for
pain and Ativan to calm his shortness of breath and anxiety. It was terminal
sedation, Dr. Halbridge said, but Mr. Foster’s liver was failing so rapidly that
no medication could have hastened his death.
Mrs. Foster sat stiffly at his bedside in a cloche hat and long coat, as if she
expected him to go any second. She said she was relieved that her husband was no
longer suffering. The sight of him sedated, his mouth open in a premonition of
death that some doctors call “the O sign,” was less shocking than the disease he
kept secret, she said.
But families sometimes push back. Marguerite Calixte, a day care worker, asked
Dr. Halbridge to wake her husband out of deep sedation — begun the day before
because he had trouble breathing — so she could say goodbye.
Her husband, Alix, who was 53, had trained as a nurse and had told her that if
he was going to die of his colon cancer, he wanted to die at home, with his wife
and their two teenage children.
On a Thursday night, Dr. Halbridge began decreasing the morphine drip, and by
the next morning, Mr. Calixte’s eyes fluttered open. “I’ve been talking to him,”
his wife said on Saturday, in Haitian cadences. “I say, ‘If you want to go home,
squeeze my hand tight.’ He keep doing it over and over.”
Ms. Walsh, the team manager, patiently gave Mrs. Calixte a lesson in how to take
care of her husband, but doubted that he would be able to go home on Monday, and
she was right.
He died that Saturday night, when his wife went home to have dinner with their
Mrs. Calixte believed the morphine was to blame. “He died quicker,” she said. “I
don’t know when it was going to be, but it wasn’t going to be now. The thing is,
he was going to suffer. I know that. But he wasn’t going to die so quick.”
Dr. Halbridge said there was “no way of knowing which would have taken him
sooner,” the medication or the disease. He said the conflict between his desire
to make Mr. Calixte comfortable and Mrs. Calixte’s wishes made the case “a tough
one, I admit.”
Teaching a Difficult Subject
The American Academy of Hospice and Palliative Medicine has endorsed “palliative
sedation to unconsciousness” and in 2008, the American Medical Association
issued a policy statement supporting palliative sedation, except when it is used
primarily for emotional distress. Even the United States Supreme Court, while
rejecting a constitutional right to physician-assisted suicide, has opened the
door to palliative sedation.
There is general agreement that “a patient who is suffering from a terminal
illness and who is experiencing great pain has no legal barriers to obtaining
medication, from qualified physicians, to alleviate that suffering, even to the
point of causing unconsciousness and hastening death,” Justice Sandra Day
O’Connor wrote in a 1997 case, Washington v. Glucksberg.
One provision of the House health care bill, which passed in November,
recognizes that palliative care may include treatment “furnished for the purpose
of alleviating pain or discomfort, even if such use may increase the risk of
death.” The bill — but not the Senate version, passed on Thursday — also allows
doctors to be reimbursed for discussions with patients about what treatments
they would want or decline. This gave rise to charges by some Republicans that
“death panels” would be convened to decide who deserves life-saving treatment.
Amid the furor, the bill was revised to make clear that patients would not be
forced to forgo treatment.
Terminal sedation remains touchy enough that last month, Dr. Lyla Correoso,
Bronx medical director of the Visiting Nurse Service of New York, and Dr.
Shaiova spoke with doctors, nurses, administrators and social workers at
Metropolitan Hospital about how to explain the process to families and
colleagues, so no one would feel guilty or betrayed.
The title of the lecture, projected on a giant PowerPoint screen, conveyed the
crux of the dilemma: “The Double Effect: Is it the Drug or the Disease?”
“Some people speculate that people are really covering up the fact that this is
really perhaps a type of euthanasia or maybe something else that’s really
afoot,” Dr. Correoso said. “You have to have good overall intent, and most
physicians, that’s what we’re here for — we’re here to do something good.”
She advocated setting “goalposts” in advance, by asking patients to stipulate
“the farthest line I’m not going to cross” — including sedation.
The most pointed questions came from a chaplain, Rabbi Isaac H. Mann. Was it
possible, he asked, that a person under deep sedation could still be feeling
pain, and how would the staff know?
“Yes,” Dr. Shaiova replied. But they often expressed pain through agitation or
grimacing, she said, adding, “Err on the side of treating them” with
The chaplain pressed for more clarity, even after the meeting had broken up. Was
she trying to say, he asked Dr. Correoso, that if morphine killed a patient,
“you wouldn’t mind?”
“Then you’ve already broken the principle of double effect,” Dr. Correoso
“The doctor knows that this can kill the patient,” Rabbi Mann insisted.
“The doctor doesn’t know,” Dr. Correoso said. Then she repeated a refrain often
heard in the world of palliative medicine: “It’s not easy to kill a patient.
People think it’s easy, but it’s really not. That’s why Dr. Kevorkian had to use
all that” combination of drugs.
The Gray Zone
On the day Dr. Shaiova and Dr. Correoso lectured on terminal sedation, they were
also consulting with a patient at Metropolitan Hospital who was dying of lung
cancer. The patient, Gloria Scott, 50, had learned of her cancer in June.
End-of-life treatment often has a kind of studied ambiguity to it, and such was
the case with Ms. Scott.
After she was moved to the hospice wing of Margaret Tietz Nursing and
Rehabilitation Center in Jamaica, Queens, she received fentanyl, a synthetic
opioid pain reliever, through an IV line that gave her the drug continuously,
and allowed her or a nurse or doctor to push a pump for more when she had
“breakthrough” pain. Under her right ear, she wore a scopolamine patch, used to
reduce secretions. Scopolamine has sedative and mood-altering properties, and
was once combined with morphine to induce “twilight sleep” for women giving
birth. Ms. Scott also had standing orders for Ativan, the sedative, and Haldol,
for delirium, two more drugs in the palliative sedation arsenal.
At first, though in pain, she was lively. She sat on the bed in the lotus
position, which eased her pain, and in her Betty Boop voice, punctuated by an
infectious giggle, she talked about her favorite Motown music and her plans to
get a business degree.
She fiercely resisted signing a “do not resuscitate” order, although she would
later change her mind. “I don’t know when is my last day,” she said. “I might
outlive one of you all.”
She asked her doctor at the hospice agency, Erik Carrasco, to keep the fentanyl,
which she had begun taking at the hospital, turned down low. Otherwise, she
said, “you sit here and you nod. I don’t want to be like that.”
Two weeks later, the change in Ms. Scott was marked. She was still alive but
dessicated and barely responded to visitors. Her companion, Milton Cruz, was
troubled by her “semi-dreamland” state, as he put it, but was shy about asking
In her last days, she lost the desire to eat or drink, though nurses continued
offering food and water, Dr. Carrasco said. The textbook survival time for
patients who stop eating and drinking is two weeks, Dr. Carrasco said, but he
said he had seen people last longer — elderly people who had survived the
Holocaust and “people who are waiting for someone, like a son.”
She died after 22 days. Dr. Shaiova said she did not consider Ms. Scott’s
sedation to be palliative or terminal sedation, because that was not her
doctor’s intention. Her body had sedated itself as a defense against the
disease, Dr. Shaiova said, and she had been on fentanyl long enough to develop
some tolerance, making it unlikely to have hastened her death.
“When you’re sick, you’re sick, and everything else is somewhere in the gray
zone, and that’s the problem,” Dr. Shaiova said.
Dr. Carrasco said that while the medication might have contributed to her
drowsiness, he believed she had died a natural death. “What I’ve been seeing
sometimes is you release the pain,” he said, “and even though you are using very
small amounts of morphine or narcotic, they relax and pass away.”
Even when everybody agrees that terminal sedation is a humane response to
unyielding suffering, many doctors seem to feel a prick of conscience.
“There should be ambivalence,” said Dr. Joseph J. Fins, chief of medical ethics
at Weill Cornell Medical College. “If it became too easy and you weren’t
ambivalent, then I would really start worrying about it. But the fact that
you’re worrying about it doesn’t mean you’ve done something wrong.”
In a 1996 paper in the Journal of Palliative Care that is still debated within
that community, Dr. J. Andrew Billings, a Harvard professor and palliative care
doctor at Massachusetts General Hospital, and Dr. Susan D. Block, a
psychiatrist, took on the moral ambiguity surrounding terminal sedation. They
argued that the main distinction between terminal sedation and euthanasia was
Terminal sedation would lead inexorably to death, but “not too quickly,” they
said. They derided the rule of double effect in this context as a
rationalization, a subtle cover-up, of what they called “slow euthanasia.”
Even a simple morphine drip, they said, could put patients into a stupor at the
right dose or when combined with other drugs or when concentrated by the
inefficiency of a damaged liver or kidneys.
“If the morphine drip becomes a code word for slow euthanasia,” they wrote,
“laypersons may be increasingly wary of the other uses of opioids.”
Both Dr. Billings, who is still at Harvard, and Dr. Block declined requests to
The authors did not endorse euthanasia, but their arguments have been used by
others looking to make the case for public acceptance of euthanasia, to the
dismay of some doctors who defend terminal sedation.
People who adopt this argument say, “We know what you’re really doing, it’s
crypto-euthanasia,” Dr. Fins said. “Polemics really have no place at the
Dr. Fins said he sometimes told families that terminal sedation was altruistic,
because they might be giving up an extra day or two “of communication with the
person you love in the service of that love.”
As for the argument that double effect is overly scholarly, Dr. Fins said: “I
can’t imagine a world at the end of life without double effect. We’d be highly
impoverished without it, and patients would suffer needlessly without it. We do
need our philosophical contrivances in order to be pragmatic physicians and
Ambivalent, Then Accepting
Mr. Oltzik died two days after the meeting between Dr. Halbridge and his family,
and Dr. Halbridge was frank in describing his treatment.
Asked if he would call it palliative sedation, Dr. Halbridge said, “This would
be called terminal sedation, almost.” He said he hesitated only because the word
“terminal” sounded negative and might make the family feel bad, when “it’s
really comfort care.” The terms “palliative” and “terminal” were
interchangeable, he said.
Speaking with considerable passion, he said he saw himself as the doctor who
would not “forsake” patients by telling them he could do nothing for them. If
there was no cure, he could at least offer comfort. “We are not gods who can
cure everything, and I think at some point in time you have to accept that,” he
said, “and to me, it’s the mark of an honest doctor who understands when that
time has come.”
The decision to administer terminal sedation was based on a review of the
patient’s history that convinced him that Mr. Oltzik was “terminally agitated,”
he said. “It means that he is entering the dying process and for whatever reason
— whether it’s physical, spiritual — something is interrupting the peaceful
passing, and to me, because it’s so uncomfortable for the family and for the
patient, that’s the time to medicate the patient and make them comfortable,
because no matter what you do, he’s not going to go back to the old Leo that he
He then told a self-deprecating joke about a doctor who gets to the gates of
heaven and demands to jump to the head of the line, only to be turned back by
St. Peter. But St. Peter opens the gates to someone else carrying a doctor’s
bag. “That’s God,” St. Peter explains. “He just thinks he’s a doctor.”
Young residents often challenge him, saying things like, “If I’m 105 years old,
I want to be fed, no matter what,” Dr. Halbridge said. His response is, “O.K.,
but did you ask your patient what he wants?”
Some patients are getting “multimillion-dollar workups” in the intensive care
unit, he said, but make their wishes known by pulling out tubes. “I think a
light bulb should go off in somebody’s head after the third time he pulls it
out. Am I going to change the outcome of this, and if I’m not, why am I doing
At one point, however, Mrs. Oltzik changed her mind.
“She was having second thoughts on that, and then she was saying, ‘I wonder if
we should cut back on his medication,’ ” Dr. Halbridge said.
She hoped for a last chance to communicate with her husband, but Dr. Halbridge
said he warned her that Mr. Oltzik was more likely to wake up agitated and
suffering. Dr. Halbridge did not want to feel like he was experimenting. “I have
a little bit of a problem with using the patient as kind of a guinea pig and
saying, ‘Well, the medication worked nicely, now we’ll take it away and see if
they bounce back the other way,’ ” he said.
Did he wake Mr. Oltzik? There was no need, Dr. Halbridge said: “He passed away
within a couple of minutes.”
A couple of weeks later, Mrs. Oltzik still felt a bit uneasy. “They had him so
heavily sedated that he was in a stupor,” she said. “I didn’t say goodbye to
him, which hurts me.”
But she did not fault the hospice team’s judgment. She could not think of any
other way to handle her husband’s agitation. As to whether his death had been
speeded up, even a tiny bit, she said philosophically, “There was no way of
Hard Choice for a
Comfortable Death: Sedation, NYT, 27.12.2009,
Senate Passes Health Care Overhaul on Party-Line Vote
December 25, 2009
The New York Times
By ROBERT PEAR
WASHINGTON — The Senate voted Thursday to reinvent the
nation’s health care system, passing a bill to guarantee access to health
insurance for tens of millions of Americans and to rein in health costs.
The 60-to-39 party-line vote, starting at 7:05 a.m. on the 25th straight day of
debate on the legislation, brings Democrats closer to a goal they have pursued
for decades and brings President Obama a step closer to success in his signature
domestic initiative. When the roll was called, with Vice President Joseph R.
Biden Jr. presiding, it was the first time the Senate had gathered for a vote on
Christmas Eve since 1895.
If the bill becomes law, it would be a milestone in social policy, comparable to
the creation of Social Security in 1935 and Medicare in 1965. But unlike those
programs, the initiative lacks bipartisan support. Only one Republican supported
a broadly similar bill that the House approved last month 220 to 215, and no
Republicans backed the Senate version.
After the vote, lawmakers and Mr. Obama wasted no time leaving for their holiday
break, well aware that their return to Washington would mean plunging into
negotiations to reconcile the measures passed by the two chambers.
If a deal can be struck, as seems likely, the resulting law would vastly expand
the role and responsibilities of the federal government. It would, as lawmakers
said repeatedly in the debate, touch the lives of nearly all Americans.
The bill would require most Americans to have health insurance, would add 15
million people to the Medicaid rolls and would subsidize private coverage for
low- and middle-income people, at a cost to the government of $871 billion over
10 years, according to the Congressional Budget Office.
The budget office estimates that the bill would provide coverage to 31 million
uninsured people, but still leave 23 million uninsured in 2019. One-third of
those remaining uninsured would be illegal immigrants.
Mr. Obama hailed the Senate action. “We are now incredibly close to making
health insurance reform a reality,” he said, before leaving the White House to
celebrate Christmas in Hawaii.
The president, who endorsed the Senate and House bills, said he would be deeply
involved in trying to help the two chambers work out their differences. But it
is unclear how specific he will be — if, for example, he will push for one type
of tax over another or try to concoct a compromise on insurance coverage for
Senator Olympia J. Snowe of Maine, a moderate Republican who has spent years
working with Democrats on health care and other issues, said she was “extremely
disappointed” with the bill’s evolution in recent weeks. After Senate Democrats
locked up 60 votes within their caucus, she said, “there was zero opportunity to
amend the bill or modify it, and Democrats had no incentive to reach across the
Like many Republicans, Ms. Snowe was troubled by new taxes and fees in the bill,
which she said could have “a dampening effect on job creation and job
preservation.” The bill would increase the Medicare payroll tax on high-income
people and levy a new excise tax on high-premium insurance policies, as one way
to control costs.
When the roll was called Thursday morning, the mood was solemn as senators
called out “aye” or “no.” Senator Robert C. Byrd, the 92-year-old Democrat from
West Virginia, deviated slightly from the protocol.
“This is for my friend Ted Kennedy,” Mr. Byrd said. “Aye!”
Senator Kennedy of Massachusetts, a longtime champion of universal health care,
died of brain cancer in August at age 77.
Senator Jim Bunning, Republican of Kentucky, did not vote.
The fight on Capitol Hill prefigures a larger political battle that is likely to
play out in the elections of 2010 and 2012, as Democrats try to persuade a
skeptical public of the bill’s merits, while Republicans warn that it will drive
up costs for those who already have insurance.
“Our members are leaving happy and upbeat,” said the Senate Republican leader,
Mitch McConnell of Kentucky. “The public is on our side. This fight is not
After struggling for years to expand health insurance in modest, incremental
ways, Democrats decided this year that they could not let another opportunity
slip away. As usual, lawmakers were deluged with appeals from lobbyists for
health care interests who have stymied similar ambitious efforts in the past.
But this year was different.
Lawmakers listened to countless stories of hardship told by constituents who had
been denied insurance, lost coverage when they got sick or seen their premiums
soar. Hostility to the insurance industry was a theme throughout the Senate
Senator Sherrod Brown, Democrat of Ohio, said insurance companies were often
“just one step ahead of the sheriff.” Senator Dianne Feinstein, Democrat of
California, said the industry “lacks a moral compass.” And Senator Sheldon
Whitehouse, Democrat of Rhode Island, said the business model of the industry
“deserves a stake through its cold and greedy heart.”
The bill would establish strict federal standards for an industry that, since
its inception, has been regulated mainly by the states. Under it, insurers could
not deny coverage because of a person’s medical condition; could not charge
higher premiums because of a person’s sex or health status; and could not
rescind coverage when a person became sick or disabled. The government would, in
effect, limit insurers’ profits by requiring them to spend at least 80 to 85
cents of every premium dollar on health care.
The specificity of federal standards is illustrated by one section of the bill,
which requires insurers to issue a benefits summary that “does not exceed four
pages in length and does not include print smaller than 12-point font.”
Another force propelling health legislation through the Senate was the
Democrats’ view that it was a moral imperative and an economic necessity.
“The health insurance policies of America, what we have right now is a moral
disgrace,” said Senator Tom Harkin, Democrat of Iowa. “We are called upon to
right a great injustice, a great wrong that has been put upon the American
Costs of the bill would, according to the Congressional Budget Office, be more
than offset by new taxes and fees and by savings in Medicare. The bill would
squeeze nearly a half-trillion dollars from Medicare over the next 10 years,
mainly by reducing the growth of payments to hospitals, nursing homes, Medicare
Advantage plans and other providers.
Republicans asserted that the cuts would hurt Medicare beneficiaries. But AARP,
the lobby for older Americans, and the American Medical Association ran an
advertisement urging senators to pass the bill, under which Medicare would cover
more of the cost for prescription drugs and preventive health services.
Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group,
said the bill appeared to be unstoppable. But she added: “We are not sure it
will be workable. It could disrupt existing coverage for families, seniors and
small businesses, particularly between now and when the legislation is fully
implemented in 2014.”
Senate Passes Health
Care Overhaul on Party-Line Vote, NYT, 25.12.2009,
Months to Live
Medical Costs of End-of-Life Care
December 23, 2009
The New York Times
By REED ABELSON
LOS ANGELES — The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s
most highly regarded academic hospitals, has earned a reputation as a place
where doctors will go to virtually any length and expense to try to save a
“If you come into this hospital, we’re not going to let you die,” said Dr. David
T. Feinberg, the hospital system’s chief executive.
Yet that ethos has made the medical center a prime target for critics in the
Obama administration and elsewhere who talk about how much money the nation
wastes on needless tests and futile procedures. They like to note that U.C.L.A.
is perennially near the top of widely cited data, compiled by researchers at
Dartmouth, ranking medical centers that spend the most on end-of-life care but
seem to have no better results than hospitals spending much less.
Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of
the U.C.L.A. Health System, says his hospital has started re-examining its
high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the
issue, the more they recognize a difficult truth: It can be hard, sometimes
impossible, to know which critically ill patients will benefit and which will
That distinction tends to get lost in the Dartmouth end-of-life analysis, which
considers only the costs of treating patients who have died. Remarkably, it pays
no attention to the ones who survive.
Take the case of Salah Putrus, who at age 71 had a long history of heart
After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was
referred to U.C.L.A. this year to be evaluated for a heart transplant.
Some other medical centers might have considered Mr. Putrus too old for the
surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said
his physician there, Dr. Tamara Horwich.
Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.”
They changed his medicines to reduce the amount of water he was retaining. They
even removed some teeth that could be a potential source of infection.
His condition improved so much that more than six months later, Mr. Putrus has
remained out of the hospital and is no longer considered in active need of a
Because Dartmouth’s analysis focuses solely on patients who have died, a case
like Mr. Putrus’s would not show up in its data. That is why critics say
Dartmouth’s approach takes an overly pessimistic view of medicine: if you
consider only the patients who die, there is really no way to know whether it
makes sense to spend more on one case than another.
According to Dartmouth, Medicare pays about $50,000 during a patient’s last six
months of care by U.C.L.A., where patients may be seen by dozens of different
specialists and spend weeks in the hospital before they die.
By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn.,
where doctors closely coordinate care, are slow to bring in specialists and aim
to avoid expensive treatments that offer little or no benefit to a patient.
“One of them costs twice as much as the other, and I can tell you that we have
no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A.
Medical,” Peter R. Orszag, the White House budget director and a disciple of the
Dartmouth data, has noted. “We can no longer afford an overall health care
system in which the thought is more is always better, because it’s not.”
By some estimates, the country could save $700 billion a year if hospitals like
U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final
year of life account for about a quarter of the program’s total spending.
Under the House health care legislation pending in Congress, the Institute of
Medicine would conduct a study of the regional variations in Medicare spending
to try to determine how to reward hospitals like Mayo for providing more
cost-effective care. Hospitals identified as high-cost centers might even be
penalized, perhaps receiving lower payments from the government. The Senate bill
calls only for studies of Medicare spending variations, so it will be up to
House-Senate negotiators to resolve the matter in the final legislation.
That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that
unless the distinction can be clearly drawn between excellence and excess in
medical care, efforts to cut wasteful spending could be little more than blunt
“There’s a real risk of doing harm here — real harm,” he said.
Indeed, U.C.L.A. and five other big California medical centers recently
published their own research results with a striking conclusion: for heart
failure patients, the hospitals that spend the most seem to save the most lives.
Testing the Thesis
Dr. Rosenthal remembers a pivotal meeting back in 2005 when he and officials at
the other California hospitals met with Dartmouth researchers to discuss their
“We were inspired,” Dr. Rosenthal recalled, saying he found himself agreeing
with much of the criticism aimed at his institution for its aggressive approach.
The Dartmouth analysis prompted Dr. Rosenthal to seek further data. He
collaborated with colleagues at U.C.L.A. and four other medical centers
affiliated with the University of California system, as well as Cedars-Sinai
Medical Center in Los Angeles, to design a study of why some hospitals spent so
much more on dying patients than others and what they got from their efforts.
To focus their analysis, the researchers chose to look only at a single category
of patients: elderly people with heart failure. The dead would be counted, as
Dartmouth does, but so would the living.
What they found seemed to contradict the Dartmouth thesis. The hospital that
spent the most on heart failure patients had one-third fewer deaths after six
months of an initial hospital stay.
The researchers did not disclose which of the six hospitals had the best
results. But for the doctors involved, the implications were clear: spending
more can sometimes save lives.
“It doesn’t look like it is all waste,” said Dr. Michael K. Ong, a U.C.L.A.
internist and health policy researcher who was one of the authors of the study,
which was recently published in the peer-reviewed medical journal Circulation:
Cardiovascular Quality and Outcomes.
Another of the authors was Dr. Michael A. Gropper, a critical care specialist at
the University of California, San Francisco. The Dartmouth research has
consistently portrayed his hospital as much more cost-effective in end-of-life
care than U.C.L.A. But the California study gave Dr. Gropper a new perspective.
“There’s no doubt that additional investments may be worthwhile,” he said.
Some other experts take a similar view.
“If you only look at the failures, you miss the benefit,” said Dr. Peter Bach,
an epidemiologist at Memorial Sloan-Kettering Cancer Center in Manhattan, who
has examined the medical histories of cancer patients who have died, including
women with early-stage breast cancer.
“No one in their right mind would tell you not to treat these women,” he said,
“even though some of them will die.”
The California researchers say they also found much less variation among the six
hospitals than the Dartmouth data would indicate after they took account of
significant differences among the patients the hospitals treat, including the
many patients who come to U.C.L.A. for a transplant, who are, by definition,
Over all, the California researchers found that the variation in spending among
the six hospitals was significantly less than the level reported by Dartmouth.
When looking at all patients hospitalized for heart failure, for example, the
variation in use of resources was 27 to 44 percent lower than when they looked
at only the patients who died. And that corresponded with a separate, informal
analysis of Medicare spending by the Congressional Budget Office, which after
adjusting for the severity of illness in patients and differences in prices
among regions, found less striking variations in spending.
A report from the Medicare Payment Advisory Commission released this month also
found less variation.
Dr. Rosenthal, who argues that there are also fundamental socioeconomic
differences between patients in the poorer sections of Los Angeles and those in
the Mayo Clinic’s small and solidly middle-class hometown of Rochester, Minn.,
was co-author of an op-ed article in The Los Angeles Times last summer making
that case. “Health care costs are significantly higher in areas of poverty,” he
The Dartmouth researchers tend to dismiss such counterarguments, saying their
conclusion — higher spending does not necessarily buy better patient outcomes —
is backed by decades of research. While more spending may have yielded benefits
among these six hospitals, a Dartmouth official said, hospitals generally have
not shown they deliver better results when they provide more care.
Still, Dr. Elliott S. Fisher, one of the lead investigators at the Dartmouth
Atlas Project, acknowledged that the California researchers’ analysis might be
better able than Dartmouth’s to identify cases in which more intensive care
might prove beneficial. “Sometimes more medical care is better,” he said, “but
the question is when.”
He says he believes that cost-effective hospitals with good medical outcomes
should be financially rewarded for their efforts and results. But he says that
public policy aimed primarily at penalizing high spenders would not be the
solution. “Simply reducing their prices,” he said, “won’t fix anything.”
‘Hail Mary Pass’
Just how hard it is to determine who will most benefit from expensive care is
clear in the case of George Klidaras, a 49-year-old stay-at-home father of two
who arrived by ambulance late at night in mid-June in need of a heart
His age might have made him a good candidate for the procedure. And so might his
overall state of health. He was lucidly answering doctors’ questions when he
arrived. And although he had suffered a stroke in his early 40s and had a
chronic heart condition, as recently as March, Mr. Klidaras had been living a
relatively normal life.
By the time Mr. Klidaras arrived at U.C.L.A., though, his heart had weakened
significantly. In the preceding weeks he had already received a pacemaker and
defibrillator, and his local cardiologist decided it was time to ask U.C.L.A. —
a highly regarded transplant center and regional magnet for cases beyond the
skill of many other hospitals — to tackle his case.
Coming to U.C.L.A. “was our Hail Mary pass,” said his wife, Andra, a postal
Mr. Klidaras’s lungs were damaged from a pulmonary embolism, and he had a high
white-blood-cell count — a possible sign of infection. So the first order of
business was to try to determine the source of infection so he would be well
enough to undergo surgery.
The flurry of activity in the intensive care unit was “overwhelming,” Ms.
Klidaras recalled. Her husband saw a dizzying array of specialists, including an
infectious disease doctor and a dermatologist after he developed a rash. “They
gave him every antibiotic and every test,” she said.
Mr. Klidaras spent nearly five weeks in the intensive care unit, at a cost of
about $10,000 a day and a total cost in the neighborhood of $300,000. And the
doctors never could stabilize his condition enough for the transplant surgery.
After the doctors told Ms. Klidaras there was nothing more they could do, she
told them not to resuscitate him if his heart stopped beating on its own. He
died July 20.
“Until the last week, I believed he was going to make it,” Mrs. Klidaras said.
“I wanted them to do everything they could to save him.”
Someone giving the strictest of reading to the Dartmouth doctrine might argue
that, given the outcome, the effort devoted to the Klidaras case was a futile
expenditure of time and money.
For U.C.L.A.’s doctors, deciding when enough is enough is not ultimately their
call. Even when they recommend against a patient’s getting another procedure or
test, it may be the patients and families who cannot let go.
When doctors, patients and families have trouble agreeing when to stop medical
treatment, the person typically called in is Dr. Neil S. Wenger, a practicing
physician who also serves as director of the U.C.L.A. Health System Ethics
“For someone to die who is in the clutches of medical care, decisions have to be
made,” Dr. Wenger said. “Otherwise, you don’t get to die a reasonable death.”
The decisions may include turning off life-prolonging technologies that were put
in place when there was still hope — the dialysis machine to keep the kidneys
functioning, the ventilator for the lungs — but now may be the only thing
keeping the patient alive.
Dr. Wenger often sees difficult family dynamics. He spent more than an hour
recently counseling the relatives of a woman with a traumatic head injury who
was unlikely to ever regain consciousness. When a family member suggested
stopping treatment, a sibling protested, saying, “You’re killing my sister.”
Such intense emotions are “extremely common,” Dr. Wenger said.
Doctors, too, often have trouble letting go.
Many acknowledge that the current payment system encourages more care, because
it rewards doctors for providing additional tests and procedures — not for
spending the hours sometimes necessary to guide patients and families through
the long, difficult process of deciding when to stop.
“The more tubes you put in, the more you get paid,” said Dr. Patrick T. Dowling,
chairman of the department of family medicine at U.C.L.A.
But the bigger challenge may be changing the “we’re not going to let you die”
culture at places like U.C.L.A.
Doctors at other leading medical centers, like the one at the University of
California, San Francisco, say one big difference among institutions is how
doctors and nurses talk with patients and families about their choices.
“It’s a cultural thing,” said Dr. Gropper. He says the doctors and nurses at the
San Francisco medical center take the time to keep talking with patients’
families and even other doctors when they seem reluctant to end treatments. “You
chip away at them,” he said.
At U.C.L.A., such palliative care — treatment devised to relieve pain and make
patients more comfortable, particularly at the end of life — was essentially an
afterthought until just a few years ago, when an internal task force recommended
that the hospital add it to its many other specialties. The hospital now has a
formal unit devoted to palliative care and is building up its expertise in the
field. Residents, in training to be doctors, are being taught how better to
discuss these issues with patients and their families.
Some doctors are resistant, particularly those with patients who had hoped for a
transplant but were removed from the list when it became clear they had no
realistic chance of recovery.
Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient
two years ago who got a liver transplant but developed serious complications
afterward and remained in the hospital for a year. “He had never, ever been told
that he would have to live with a ventilator and dialysis,” Dr. Ferrell said.
“He was never told that this is as good as it’s going to get.”
Dr. Ferrell talked with the patient about whether he might want to leave the
intensive-care unit to go home and receive hospice care. But when the surgeon
overseeing the case found out, he was furious.
“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr.
Ferrell. “Don’t ever come back.”
The patient chose to leave.
But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the
value of what he is trying to do.
“We’re not the bad guys,” he said. “We offer options.”
Weighing Medical Costs
of End-of-Life Care, NYT, 23.12.2009,
Smoking Rate Drops in Massachusetts, Drawing Attention
December 17, 2009
The New York Times
By ABBY GOODNOUGH
BOSTON — When Massachusetts started offering virtually free treatments to
help poor residents of the state stop smoking in 2006, proponents hoped the new
Medicaid program would someday reap benefits.
But state officials never expected it would happen so soon.
New state data show a steep drop in the smoking rate among poor people. When the
program , about 38 percent of poor Massachusetts residents smoked. By 2008, the
smoking rate for poor residents had dropped to about 28 percent, a decrease of
about 30,000 people in two and a half years, or one in six smokers, said Lois
Keithly, director of the state’s Tobacco Cessation and Prevention Program.
There are also indications that the drop has lowered rates of hospitalization
for heart attacks and emergency room visits for asthma attacks, she said.
The data has not yet been peer-reviewed. But the numbers have already grabbed
national attention, with several United States senators and antismoking
advocates using the data to push for similar new Medicaid coverage for tobacco
addiction in the national health care legislation.
Senators Richard J. Durbin of Illinois and Bernard Sanders of Vermont have
introduced an amendment that would do so, and the Senate could vote on it by the
weekend. If the amendment fails, Senator Tom Harkin of Iowa said he would try
another avenue: seeking an expansion through a conference committee that will
ultimately reconcile the House and Senate bills.
"We should be able to find an opening," Mr. Harkin said in an interview. "This
is one demonstrable way we can actually bend the cost curve and keep people
The Massachusetts program, part of the state’s landmark universal health care
law, covers almost the entire cost of counseling and prescription drugs for
Medicaid enrollees trying to quit smoking. Most states do not provide nearly as
much help for poor smokers.
The rate of smoking among Medicaid patients had not changed in a decade before
the program was introduced. It was much higher than the rate in the general
population, which stands at about 18 percent.
Under the current Senate health care bill, only pregnant women on Medicaid would
qualify for comprehensive smoking-cessation treatment, including drugs and
counseling. The bill passed by the House last month would provide broader
Medicaid coverage of such treatment, and antismoking groups are lobbying the
Senate to adopt that approach.
Massachusetts lawmakers wanted to cover stop-smoking treatments for Medicaid
enrollees, because the poor smoke at much higher rates than the general
Under the Massachusetts program, Medicaid recipients from age 18 to 64 are
eligible for 180 days of antismoking drugs, including Chantix and bupropion, and
16 counseling sessions per year. Co-payments do not exceed $3, Ms. Keithly said,
and preauthorization is usually not required.
The state spent a total of $11 million on the program during its first two
years, she said; the costs since July 2008 have not been tallied.
Insurance plans for higher-income residents provide less coverage for
smoking-cessation treatment, Ms. Keithly said, or none at all.
“This is really the gold standard,” she said.
Michael Siegel, a professor at Boston University’s School of Public Health, said
the main finding — a significant drop in the smoking rate of Medicaid recipients
— was “very compelling.”
State researchers also looked at the smoking rate for uninsured residents, who
also tend to be poor, over the same period and found it did not change.
“That’s something you need to see,” Dr. Siegel said, “because if they had just
found that the rate among Medicaid recipients dropped, it might be coincidental
or dropping among everyone.”
The researchers found that smokers who took advantage of the cessation program
had much lower rates of hospitalization for heart attacks and emergency room
visits for asthma attacks than before starting the treatment.
But Dr. Siegel and other researchers said those findings were not as persuasive
because the state had not used a control group.
“It’s intriguing but still quite preliminary,” said Nancy A. Rigotti, director
of the Tobacco Research and Treatment Center at Massachusetts General Hospital.
Still, Dr. Rigotti said, Congress should take the Massachusetts data seriously
as it debates health care reform. She said that pregnant women — the only
Medicaid recipients who would receive broad smoking-cessation benefits under the
Senate plan — are often advised to avoid stop-smoking drugs.
Senator Harkin said that even though the Congressional Budget Office has
predicted that covering smoking-cessation treatment for pregnant women alone
would save $100 million in health care costs over 10 years, concern about
up-front costs has made many senators reluctant to expand the benefits to all
“It’s very frustrating,” he said.
According to the American Lung Association, Massachusetts is among only six
states that offer extensive stop-smoking benefits for Medicaid recipients. The
others are Indiana, Minnesota, Nevada, Oregon and Pennsylvania. Massachusetts is
the only one of those states that has reported a significant drop in the smoking
rate for Medicaid patients; several experts said the others might not have
promoted their programs as aggressively or kept track of results.
Terry F. Pechacek, associate director for science for the Office on Smoking and
Health at the Centers for Disease Control in Atlanta, said he had reviewed the
Massachusetts data and found the numbers “shocking” given that smoking rates
around the nation have barely budged since 2004.
About 20.6 percent of Americans were smokers in 2008, the C.D.C. reported last
month, down from 20.9 percent in 2004. Smoking-related illnesses cost the
Medicaid system more than $22 billion a year, Dr. Pechacek said — about 11
percent of overall Medicaid expenditures.
“The fact is we need to expand it to everyone,” he said of the type of coverage
offered in Massachusetts.
Dr. Pechacek and others said that if the federal health care overhaul does
include smoking-cessation coverage, publicizing it will be as crucial to its
success as the cessation tools themselves.
“Even in the some of the states that offer wider coverage,” he said, “there’s
been minimal promotion. People have to know about a benefit for it to have an
Smoking Rate Drops in
Massachusetts, Drawing Attention, NYT, 17.12.2009,
Senate Grinds to A Halt on Healthcare
December 16, 2009
Filed at 2:53 p.m. ET
The New York Times
WASHINGTON (Reuters) - The slow-moving U.S. Senate debate on
healthcare reform ground to a complete halt on Wednesday, with Republicans
forcing the reading of a 767-page amendment as Democrats scrambled to finish
work this year.
Republican Senator Tom Coburn invoked his right to require an amendment by
independent Senator Bernie Sanders be read aloud by a Senate clerk -- a task
expected to take well into the night.
Republicans so far are united in opposition to a sweeping healthcare overhaul
that is President Barack Obama's top domestic priority, and have vowed to use
every tool possible to slow the debate.
The move did not dramatically disrupt the snail's pace of the Senate, which has
largely been in healthcare limbo awaiting cost estimates on provisions in a
manager's amendment to be offered in a few days by Senate Democratic leader
The proposed overhaul of the $2.5 trillion healthcare industry has been bogged
down in the Senate amid disputes among Democrats over costs, plans for the
government-run insurance program and how it would affect abortion.
Reid's amendment will make final adjustments designed to win the 60 Senate votes
needed to overcome Republican procedural hurdles. The Democrats have no margin
of error -- they control exactly 60 seats.
The Senate bill would extend coverage to 30 million uninsured Americans, provide
subsidies to help them pay for the coverage and halt practices like refusing
insurance to people with pre-existing medical conditions.
Coburn had threatened earlier in the debate to force the public reading of the
entire 2,074-page healthcare bill but relented before the Thanksgiving holiday.
This time he followed through after Democrats rejected his request that all
remaining amendments be filed for at least 72 hours and given a cost estimate by
budget analysts before they are considered.
He also asked Democrats to accept his amendment requiring certification that all
senators had read the bill and understood it before they voted on it.
'IMPOSSIBLE TO SAY THEY UNDERSTAND'
"I think it is impossible to certify that any senator fully understood. They may
read but not fully understand for a variety of reasons," Democratic Senator Max
Baucus said in rejecting the request.
Republican Senate leader Mitch McConnell has said he may use other procedural
means to slow the bill as Democrats try to reach a final vote before the
Reid must file his manager's amendment and three procedural motions to end
debate within the next few days, setting off a series of votes that will lead to
a vote on final passage.
Obama has pushed the Senate to finish the healthcare bill this year to keep the
issue from slipping into next year's congressional election campaigns.
The Senate bill would then be reconciled in early January with a version
approved by the House of Representatives on November 7, and each chamber would
have to pass it again.
House Speaker Nancy Pelosi told reporters on Wednesday she was still confident
the Congress could pass the final measure before Obama's State of the Union
address in late January.
But the Democratic House leader voiced exasperation with the Senate. "We should
have had a bill months ago," Pelosi said.
Union leaders including the executive body of the AFL-CIO, the largest U.S.
labor federation, met on Wednesday to discuss how to respond to Reid's decision
to accommodate moderates by eliminating proposals for a government-run insurance
option and an expansion of the Medicare health program for the elderly.
Those moves have angered liberals. Unions also have been unhappy with the
Senate's proposal to tax high-cost health insurance plans -- like those many
unions have -- to help pay for the overhaul.
"This afternoon, the executive board of the AFL-CIO is meeting to discuss the
most recent developments in the health care negotiations, what our position is
and what our next steps will be," AFL-CIO spokesman Eddie Vale said.
(Additional reporting by Thomas Ferraro and David Morgan;
editing by Paul Simao)
Senate Grinds to A
Halt on Healthcare, NYT, 16.12.2009,
Giving Psychiatric Drugs to Children
December 16, 2009
The New York Times
To the Editor:
Re “Poor Children
Likelier to Get Antipsychotics” (front page, Dec. 12):
I am the mother of a teenage boy who received a diagnosis of attention deficit
disorder and oppositional defiant disorder eight years ago and was prescribed
antipsychotic medication. Throughout the years, we have visited no fewer than
five psychiatrists and countless other therapists.
I would often question why my son was prescribed medications (at one point three
at a time) that failed to do as they promised. For example, the ones that were
designed to help him sleep at night did the reverse, and the ones to keep him
awake made him lethargic.
I decided that it was in my son’s best interest to take a break from the weekly
therapy and daily medication. Surprisingly, he functioned much better: His
sleeping patterns and appetite improved. He is now back on medication, but with
new therapists and with the parents’ considerations in mind.
Families like ours are often duped into believing that there aren’t options
other than medication, or should we refuse to comply, charges of neglect could
Ridgewood, N.Y., Dec. 14, 2009
To the Editor:
In discussing the “off label” use of antipsychotic medications to treat children
with attention deficit hyperactivity disorder and other disruptive behavior
disorders, the article did not mention that there are well-established,
effective, evidence-based treatment protocols for children with these diagnoses.
These programs use cognitive behavioral interventions with children, and, of at
least equal importance, provide parent training and coordination between family,
school and treatment provider. These treatment models are often used in
conjunction with medication, but may reduce or in some cases obviate the need
Effective use of these protocols requires coordination and follow-up with
teachers and parents, much of which is not currently reimbursable either by
private insurance or Medicaid.
New York, Dec. 14, 2009
The writer is director of the Child and Family Clinic-Plus Program of the
Riverdale Mental Health Association.
To the Editor:
As a practicing child psychiatrist for the last 22 years, I am not surprised
that poorer children on Medicaid are prescribed antipsychotic drugs at four
times the rate of middle-class children. Sadly, it is symptomatic of the general
trend in psychiatry over the last 15 years to “medicalize” complex behavioral
problems and label them with an overly simplistic medical diagnosis, like
bipolar disorder, implying that the right medication will solve the problem.
In a Medicaid population, the temptation for overwhelmed doctors and
understaffed clinics to succumb to a potentially quick fix with a readily
available treatment is often too compellingly expedient. If only the simple act
of writing a prescription could cure the emotional distress of children
subjected to the social ills of poverty.
Berkeley, Calif., Dec. 12, 2009
To the Editor:
We are parents of a 10-year-old son who is on Medicaid as a result of long-term
disability. He has been prescribed antipsychotics for more than five years. We
have tried numerous times to taper off the medication and instead focus on
counseling with various therapists.
After a few sessions with these therapists, we have been told either that his
disorder is not their specialty or that his situation is too complex. We have
always felt — and the study behind this article lends credence to our suspicions
— that the motivation for not offering long-term counseling was tied to the
reimbursement offered by his insurance.
We are fearful that the heavy reliance on medication is leaving our son ill
equipped to live independently when he becomes an adult. He and every other
child deserve to be provided the treatment that offers them the best chance to
be functioning members of society, and a pill is not always the answer.
Eau Claire, Wis., Dec. 12, 2009
To the Editor:
One of the reasons for the disparate use of medication has to do with the large
cohort of poor children and adolescents in residential treatment centers, foster
care, group homes and juvenile justice facilities. These institutions often do
not or cannot provide the kind of mental health services that ultimately would
help children face issues like profound rage and deep sadness that fuel
behaviors that are often frightening and violent, but not necessarily psychotic.
Because these institutions focus on controlling behavior instead of the more
time-consuming process of helping children identify and understand their
feelings, they are given drugs that, in the long run, do more harm than good.
This is not only a disservice to children who already face tremendous hurdles,
but will also ultimately increase the costs borne by Medicaid when it becomes
necessary to address the physical and psychological damage done by the use of
Dobbs Ferry, N.Y., Dec. 12, 2009
The writer is a psychoanalyst.
To the Editor:
Federal funding allocated to help treat and study psychiatric disorders pales in
comparison to that for other medical conditions. Research on cancer, heart
disease and infectious diseases receives three to four times the annual funding
of the National Institute of Mental Health. Within that small pool, childhood
psychiatric disorders are allocated an even smaller portion of funds.
Because of the limited funds, few children with psychiatric disorders are
treated by doctors with advanced training in this area. Rather, they are often
managed by family practitioners and pediatricians.
Can the same be said of children with cancer or heart disease? Doesn’t a child
with a serious psychiatric disorder deserve to be seen by a doctor with
specialized training just as children with cancer are? Sadly, the answer from
our current system of distributing medical funds is a resounding no.
Jonathan E. Posner
New York, Dec. 13, 2009
The writer is a child and adolescent psychiatrist.
Giving Psychiatric Drugs
to Children, NYT, 16.12.2009,
Poor Children Likelier to Get Antipsychotics
December 12, 2009
The New York Times
By DUFF WILSON
New federally financed drug research reveals a stark disparity: children
covered by Medicaid are given powerful antipsychotic medicines at a rate four
times higher than children whose parents have private insurance. And the
Medicaid children are more likely to receive the drugs for less severe
conditions than their middle-class counterparts, the data shows.
Those findings, by a team from Rutgers and Columbia, are almost certain to add
fuel to a long-running debate. Do too many children from poor families receive
powerful psychiatric drugs not because they actually need them — but because it
is deemed the most efficient and cost-effective way to control problems that may
be handled much differently for middle-class children?
The questions go beyond the psychological impact on Medicaid children, serious
as that may be. Antipsychotic drugs can also have severe physical side effects,
causing drastic weight gain and metabolic changes resulting in lifelong physical
On Tuesday, a pediatric advisory committee to the Food and Drug Administration
met to discuss the health risks for all children who take antipsychotics. The
panel will consider recommending new label warnings for the drugs, which are now
used by an estimated 300,000 people under age 18 in this country, counting both
Medicaid patients and those with private insurance.
Meanwhile, a group of Medicaid medical directors from 16 states, under a project
they call Too Many, Too Much, Too Young, has been experimenting with ways to
reduce prescriptions of antipsychotic drugs among Medicaid children.
They plan to publish a report early next year.
The Rutgers-Columbia study will also be published early next year, in the
peer-reviewed journal Health Affairs. But the findings have already been posted
on the Web, setting off discussion among experts who treat and study troubled
Some experts say they are stunned by the disparity in prescribing patterns. But
others say it reinforces previous indications, and their own experience, that
children with diagnoses of mental or emotional problems in low-income families
are more likely to be given drugs than receive family counseling or
Part of the reason is insurance reimbursements, as Medicaid often pays much less
for counseling and therapy than private insurers do. Part of it may have to do
with the challenges that families in poverty may have in consistently attending
counseling or therapy sessions, even when such help is available.
“It’s easier for patients, and it’s easier for docs,” said Dr. Derek H. Suite, a
psychiatrist in the Bronx whose pediatric cases include children and adolescents
covered by Medicaid and who sometimes prescribes antipsychotics. “But the
question is, ‘What are you prescribing it for?’ That’s where it gets a little
Too often, Dr. Suite said, he sees young Medicaid patients to whom other doctors
have given antipsychotics that the patients do not seem to need. Recently, for
example, he met with a 15-year-old girl. She had stopped taking the
antipsychotic medication that had been prescribed for her after a single
examination, paid for by Medicaid, at a clinic where she received a diagnosis of
Why did she stop? Dr. Suite asked. “I can control my moods,” the girl said
After evaluating her, Dr. Suite decided she was right. The girl had arguments
with her mother and stepfather and some insomnia. But she was a good student and
certainly not bipolar, in Dr. Suite’s opinion.
“Normal teenager,” Dr. Suite said, nodding. “No scrips for you.”
Because there can be long waits to see the psychiatrists accepting Medicaid, it
is often a pediatrician or family doctor who prescribes an antipsychotic to a
Medicaid patient — whether because the parent wants it or the doctor believes
there are few other options.
Some experts even say Medicaid may provide better care for children than many
covered by private insurance because the drugs — which can cost $400 a month —
are provided free to patients, and families do not have to worry about the
co-payments and other insurance restrictions.
“Maybe Medicaid kids are getting better treatment,” said Dr. Gabrielle Carlson,
a child psychiatrist and professor at the Stony Brook School of Medicine. “If it
helps keep them in school, maybe it’s not so bad.”
In any case, as Congress works on health care legislation that could expand the
nation’s Medicaid rolls by 15 million people — a 43 percent increase — the scope
of the antipsychotics problem, and the expense, could grow in coming years.
Even though the drugs are typically cheaper than long-term therapy, they are the
single biggest drug expenditure for Medicaid, costing the program $7.9 billion
in 2006, the most recent year for which the data is available.
The Rutgers-Columbia research, based on millions of Medicaid and private
insurance claims, is the most extensive analysis of its type yet on children’s
antipsychotic drug use. It examined records for children in seven big states —
including New York, Texas and California — selected to be representative of the
nation’s Medicaid population, for the years 2001 and 2004.
The data indicated that more than 4 percent of patients ages 6 to 17 in Medicaid
fee-for-service programs received antipsychotic drugs, compared with less than 1
percent of privately insured children and adolescents. More recent data through
2007 indicates that the disparity has remained, said Stephen Crystal, a Rutgers
professor who led the study. Experts generally agree that some characteristics
of the Medicaid population may contribute to psychological problems or
psychiatric disorders. They include the stresses of poverty, single-parent
homes, poorer schools, lack of access to preventive care and the fact that the
Medicaid rolls include many adults who are themselves mentally ill.
As a result, studies have found that children in low-income families may have a
higher rate of mental health problems — perhaps two to one — compared with
children in better-off families. But that still does not explain the four-to-one
disparity in prescribing antipsychotics.
Professor Crystal, who is the director of the Center for Pharmacotherapy at
Rutgers, says his team’s data also indicates that poorer children are more
likely to receive antipsychotics for less serious conditions than would
typically prompt a prescription for a middle-class child.
But Professor Crystal said he did not have clear evidence to form an opinion on
whether or not children on Medicaid were being overtreated.
“Medicaid kids are subject to a lot of stresses that lead to behavior issues
which can be hard to distinguish from more serious psychiatric conditions,” he
said. “It’s very hard to pin down.”
And yet Dr. Mark Olfson, a psychiatry professor at Columbia and a co-author of
the study, said at least one thing was clear: “A lot of these kids are not
getting other mental health services.”
The F.D.A. has approved antipsychotic drugs for children specifically to treat
schizophrenia, autism and bipolar disorder. But they are more frequently
prescribed to children for other, less extreme conditions, including attention
deficit hyperactivity disorder, aggression, persistent defiance or other
so-called conduct disorders — especially when the children are covered by
Medicaid, the new study shows.
Although doctors may legally prescribe the drugs for these “off label” uses,
there have been no long-term studies of their effects when used for such
The Rutgers-Columbia study found that Medicaid children were more likely than
those with private insurance to be given the drugs for off-label uses like
A.D.H.D. and conduct disorders. The privately insured children, in turn, were
more likely than their Medicaid counterparts to receive the drugs for
F.D.A.-approved uses like bipolar disorder.
Even if parents enrolled in Medicaid may be reluctant to put their children on
drugs, some come to rely on them as the only thing that helps.
“They say it’s impossible to stop now,” Evelyn Torres, 48, of the Bronx, said of
her son’s use of antipsychotics since he received a diagnosis of bipolar
disorder at age 3. Seven years later, the boy is now also afflicted with weight
and heart problems. But Ms. Torres credits Medicaid for making the boy’s mental
and physical conditions manageable. “They’re helping with everything,” she said.
Poor Children Likelier
to Get Antipsychotics, NYT, 12.12.2009,
Postpartum Depression Strikes Fathers, Too
December 8, 2009
The New York Times
By RICHARD A. FRIEDMAN, M.D.
The pregnancy was easy, the delivery a breeze. This was the couple’s first
baby, and they were thrilled. But within two months, the bliss of new parenthood
was shattered by postpartum depression.
A sad, familiar story. But this one had a twist: The patient who came to me for
treatment was not the mother but her husband.
A few weeks after the baby arrived, he had become uncharacteristically anxious,
sad and withdrawn. He had trouble sleeping, even though his wife was the one up
at night breast-feeding their new son. What scared her enough to bring him to my
office was that he had become suicidal.
Up to 80 percent of women experience minor sadness — the so-called baby blues —
after giving birth, and about 10 percent plummet into severe postpartum
depression. But it turns out that men can also have postpartum depression, and
its effects can be every bit as disruptive — not just on the father but on
mother and child.
We don’t know the exact prevalence of male postpartum depression; studies have
used different methods and diagnostic criteria. Dr. Paul G. Ramchandani, a
psychiatrist at the University of Oxford in England who did a study based on
26,000 parents, reported in The Lancet in 2005 that 4 percent of fathers had
clinically significant depressive symptoms within eight weeks of the birth of
their children. But one thing is clear: It isn’t something most people,
including physicians, have ever heard of.
At first, my patient insisted that everything was just fine. He and his wife had
been trying to conceive for more than a year. He was ecstatic at the prospect of
fatherhood, and he did not acknowledge feeling depressed or suicidal.
Suspicious of his rosy appraisal, I pushed a little.
It turned out that he had just taken a new high-pressure job in finance six
months before the birth of his son. Though he was reluctant to admit it, he
clearly had more than a little concern about his family’s financial future.
And he was anxious about his marriage and his new life. “We go out a lot with
friends to dinner and theater,” he said wistfully, as I recall. “Now I guess
that’s all going to end.”
He had spent the nine months of pregnancy in a state of excitement about being a
father without really registering what a life-transforming event it was going to
Unlike women, men are not generally brought up to express their emotions or ask
for help. This can be especially problematic for new fathers, since the prospect
of parenthood carries all kinds of insecurities: What kind of father will I be?
Can I support my family? Is this the end of my freedom?
And there is probably more to male postpartum depression than just social or
psychological stress; like motherhood, fatherhood has its own biology, and it
may actually change the brain.
A 2006 study on marmoset monkeys, published in the journal Nature Reviews
Neuroscience, reported that new fathers experienced a rapid increase in
receptors for the hormone vasopressin in the brain’s prefrontal cortex. Along
with other hormones, vasopressin is involved in parental behavior in animals,
and it is known that the same brain area in humans is activated when parents are
shown pictures of their children.
There is also some evidence that testosterone levels tend to drop in men during
their partner’s pregnancy, perhaps to make expectant fathers less aggressive and
more likely to bond with their newborns. Given the known association between
depression and low testosterone in middle-aged men, it is possible that this
might also put some men at risk of postpartum depression.
By far the strongest predictor of paternal postpartum depression is having a
depressed partner. In one study, fathers whose partners were also depressed were
at nearly two and a half times the normal risk for depression. That was a
critical finding, for clinicians tend to assume that men can easily step up to
the plate and help fill in for a depressed mother. In fact, they too may be
stressed and vulnerable to depression.
And there is the child to think about. Research has clearly shown that maternal
postpartum depression can impair the emotional and cognitive development of
infants. A father could well buffer the infant from some of the adverse effects
of maternal depression — but that is a tall order if he too is depressed.
Dr. Ramchandani, who also followed children for three and a half years after
birth, reported that they were affected differently depending on which parent
was depressed. Maternal postpartum depression was associated with adverse
emotional and behavioral effects in children regardless of sex; depression in
fathers was linked only with behavioral problems in boys. (The study did not
report on possible effects when both parents were depressed.)
As for my patient, he recovered within two months with the help of psychotherapy
and an antidepressant. Afterward, he summed up the situation in just 10 words:
“And I thought only women get this kind of thing.”
All too many doctors think so too.
Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical
Postpartum Depression Strikes Fathers, Too,
Millions in U.S. Drink Dirty Water, Records Show
December 8, 2009
The New York Times
By CHARLES DUHIGG
More than 20 percent of the nation’s water treatment systems have violated
key provisions of the Safe Drinking Water Act over the last five years,
according to a New York Times analysis of federal data.
That law requires communities to deliver safe tap water to local residents. But
since 2004, the water provided to more than 49 million people has contained
illegal concentrations of chemicals like arsenic or radioactive substances like
uranium, as well as dangerous bacteria often found in sewage.
Regulators were informed of each of those violations as they occurred. But
regulatory records show that fewer than 6 percent of the water systems that
broke the law were ever fined or punished by state or federal officials,
including those at the Environmental Protection Agency, which has ultimate
responsibility for enforcing standards.
Studies indicate that drinking water contaminants are linked to millions of
instances of illness within the United States each year.
In some instances, drinking water violations were one-time events, and probably
posed little risk. But for hundreds of other systems, illegal contamination
persisted for years, records show.
On Tuesday, the Senate Environment and Public Works committee will question a
high-ranking E.P.A. official about the agency’s enforcement of drinking-water
safety laws. The E.P.A. is expected to announce a new policy for how it polices
the nation’s 54,700 water systems.
“This administration has made it clear that clean water is a top priority,” said
an E.P.A. spokeswoman, Adora Andy, in response to questions regarding the
agency’s drinking water enforcement. The E.P.A. administrator, Lisa P. Jackson,
this year announced a wide-ranging overhaul of enforcement of the Clean Water
Act, which regulates pollution into waterways.
“The previous eight years provide a perfect example of what happens when
political leadership fails to act to protect our health and the environment,”
Ms. Andy added.
Water pollution has become a growing concern for some lawmakers as government
oversight of polluters has waned. Senator Barbara Boxer, Democrat of California,
in 2007 asked the E.P.A. for data on Americans’ exposure to some contaminants in
The New York Times has compiled and analyzed millions of records from water
systems and regulators around the nation, as part of a series of articles about
worsening pollution in American waters, and regulators’ response.
An analysis of E.P.A. data shows that Safe Drinking Water Act violations have
occurred in parts of every state. In the prosperous town of Ramsey, N.J., for
instance, drinking water tests since 2004 have detected illegal concentrations
of arsenic, a carcinogen, and the dry cleaning solvent tetrachloroethylene,
which has also been linked to cancer.
In New York state, 205 water systems have broken the law by delivering tap water
that contained illegal amounts of bacteria since 2004.
However, almost none of those systems were ever punished. Ramsey was not fined
for its water violations, for example, though a Ramsey official said that
filtration systems have been installed since then. In New York, only three water
systems were penalized for bacteria violations, according to federal data.
The problem, say current and former government officials, is that enforcing the
Safe Drinking Water Act has not been a federal priority.
“There is significant reluctance within the E.P.A. and Justice Department to
bring actions against municipalities, because there’s a view that they are often
cash-strapped, and fines would ultimately be paid by local taxpayers,” said
David Uhlmann, who headed the environmental crimes division at the Justice
Department until 2007.
“But some systems won’t come into compliance unless they are forced to,” added
Mr. Uhlmann, who now teaches at the University of Michigan law school. “And
sometimes a court order is the only way to get local governments to spend what
A half-dozen current and former E.P.A. officials said in interviews that they
tried to prod the agency to enforce the drinking-water law, but found little
“I proposed drinking water cases, but they got shut down so fast that I’ve
pretty much stopped even looking at the violations,” said one longtime E.P.A.
enforcement official who, like others, requested anonymity for fear of
reprisals. “The top people want big headlines and million-dollar settlements.
That’s not drinking-water cases.”
The majority of drinking water violations since 2004 have occurred at water
systems serving fewer than 20,000 residents, where resources and managerial
expertise are often in short supply.
It is unclear precisely how many American illnesses are linked to contaminated
drinking water. Many of the most dangerous contaminants regulated by the Safe
Drinking Water Act have been tied to diseases like cancer that can take years to
But scientific research indicates that as many as 19 million Americans may
become ill each year due to just the parasites, viruses and bacteria in drinking
water. Certain types of cancer — such as breast and prostate cancer — have risen
over the past 30 years, and research indicates they are likely tied to
pollutants like those found in drinking water.
The violations counted by the Times analysis include only situations where
residents were exposed to dangerous contaminants, and exclude violations that
involved paperwork or other minor problems.
In response to inquiries submitted by Senator Boxer, the E.P.A. has reported
that more than three million Americans have been exposed since 2005 to drinking
water with illegal concentrations of arsenic and radioactive elements, both of
which have been linked to cancer at small doses.
In some areas, the amount of radium detected in drinking water was 2,000 percent
higher than the legal limit, according to E.P.A. data.
But federal regulators fined or punished fewer than 8 percent of water systems
that violated the arsenic and radioactive standards. The E.P.A., in a statement,
said that in a majority of situations, state regulators used informal methods —
like providing technical assistance — to help systems that had violated the
But many systems remained out of compliance, even after aid was offered,
according to E.P.A. data. And for over a quarter of systems that violated the
arsenic or radioactivity standards, there is no record that they were ever
contacted by a regulator, even after they sent in paperwork revealing their
Those figures are particularly worrisome, say researchers, because the Safe
Drinking Water Act’s limits on arsenic are so weak to begin with. A system could
deliver tap water that puts residents at a 1-in-600 risk of developing bladder
cancer from arsenic, and still comply with the law.
Despite the expected announcement of reforms, some mid-level E.P.A. regulators
say they are skeptical that any change will occur.
“The same people who told us to ignore Safe Drinking Water Act violations are
still running the divisions,” said one mid-level E.P.A. official. “There’s no
accountability, and so nothing’s going to change.”
Griffin Palmer contributed reporting.
Millions in U.S. Drink Dirty Water, Records
Show, NYT, 8.12.2009,
Battle on Late-Term Abortions Shifts to a Clinic in Nebraska
December 4, 2009
The New York Times
By MONICA DAVEY
BELLEVUE, Neb. — The national battle over abortion, for decades firmly
planted outside the Kansas clinic of Dr. George R. Tiller, has erupted here in
suburban Omaha, where a longtime colleague has taken up the cause of late-term
Since Dr. Tiller was shot to death in May, his colleague, Dr. LeRoy H. Carhart,
has hired two people who worked at Dr. Tiller’s clinic and has trained his own
staff members in the technical intricacies of performing late-term abortions.
Dr. Carhart has also begun performing some abortions “past 24 weeks,” he said in
an interview, and is prepared to perform them still later if they meet legal
requirements and if he considers them medically necessary.
“There is a need, and I feel deeply about it,” said Dr. Carhart, visibly weary
after a day when eight patients had appointments at his clinic here.
The late-term abortions, coming after the earliest point when a fetus might
survive outside the womb, are the most controversial, even among some who favor
abortion rights. A few of Dr. Carhart’s employees quit when he told them of his
plans to expand the clinic’s work.
Opponents of abortion, who had devoted decades to trying to stop Dr. Tiller’s
business with protests and calls for investigations, are now turning their
efforts to stopping Dr. Carhart. Troy Newman, the president of Operation Rescue,
an anti-abortion group, said he had traveled from the group’s headquarters in
Wichita, Kan., to Nebraska six times in recent months, portraying this suburb of
fewer than 50,000 as a new battlefield in the abortion fight.
“We’re trying to get criminal charges against him, to get his license revoked,
and to get legislators there to look at the law,” Mr. Newman said of Dr.
State law in Nebraska bans abortions in cases when a fetus clearly appears to
have reached viability, except to “preserve the life or health of the mother.”
Abortion-rights advocates say the need exists for late-term abortions, in cases
of extraordinary genetic defects and other dire health circumstances, and some
had worried that only a few physicians would be willing to provide such care
after Dr. Tiller’s killing, an act prosecutors say was carried out by an
“He’s standing up, and so are some others,” Vicki Saporta, president of the
National Abortion Federation, said of Dr. Carhart.
A few other doctors have long performed late-term abortions, and some said both
the threats against them and their efforts at security had increased since Dr.
Dr. Carhart, 68, knew Dr. Tiller for years, and would make regular trips to his
clinic in Wichita to perform abortions there, as other physicians did. Though
Dr. Tiller’s clinic was not the only one in the country performing late-term
abortions, it was a focal point for controversy. Operation Rescue even moved its
headquarters to Wichita because of Dr. Tiller’s practice.
Dr. Carhart, who has been performing abortions since the 1970s, is no stranger
to the debate; he has been a litigant in two abortion-related cases decided by
the United States Supreme Courtover a particular method of abortion referred to
by critics as “partial-birth abortion.” And immediately after Dr. Tiller’s
killing, Dr. Carhart offered to continue operating his clinic, but the Tiller
family decided to close it.
Still, in the months since the killing, Dr. Carhart has made changes at his
clinic and to his lifestyle as he has openly moved to take up Dr. Tiller’s
Visitors to the clinic here must pass through a metal detector, new security
cameras scan outside the building and a security consultant is employed full
time. Dr. Carhart says he goes out publicly only on short, unscheduled trips and
rarely eats out (and when he does, he says he stays less than 30 minutes). Dr.
Carhart, an Air Force veteran, said his daughter was wed this fall on a nearby
military base, mainly for security and privacy.
“We do everything differently now,” he said.
Dr. Carhart declined to provide specifics on how late in a pregnancy he would be
willing to perform an abortion. Dr. Tiller performed them, in some cases, as
late as in the third trimester of pregnancy. Dr. Carhart’s fee schedule lists
prices for abortions up to 22 weeks and 6 days (at that point, $2,100 in cash or
$2,163 on a credit card), but notes that abortions after 23 weeks are available
“after consultation with our doctor,” and that abortions after the 27th week may
take four days.
At his clinic in the past, Dr. Carhart said, he had performed abortions up to
about 22 weeks into gestation — considered by some to be near the earliest point
at which a fetus can survive outside the womb, a notion known as viability and
one that is cited in many laws related to abortion.
Dr. Carhart’s opponents insist that late-term procedures violate state and
federal statutes as well as professional rules. They have approached officials
in Nebraska seeking an investigation. Mr. Newman, who had regularly called for
investigations into Dr. Tiller’s work but strongly denounced his killing, has
submitted a complaintabout Dr. Carhart to Jon Bruning, Nebraska’s attorney
general. In it, Mr. Newman accuses Dr. Carhart of using improper operating
procedures under shoddy conditions.
Representatives of Mr. Bruning would not comment on whether an investigation was
taking place. Marla Augustine, a spokeswoman for the State Department of Health
and Human Services, which regulates physicians, said Dr. Carhart had no formal
disciplinary actions on his record.
(In 1993, she said, he signed an assurance of compliance with the state,
promising not to do certain things, like talk on the phone during surgical
procedures, but the agreement says it did not mean he had admitted committing
any violations and was not considered a disciplinary action.)
Dr. Carhart, meanwhile, said he had heard nothing lately from state officials.
“Anybody can file a claim,” he said.
A brochure for his clinic shows a photograph of Dr. Carhart beside Dr. Tiller,
and says that the clinic dedicates “our services to women in honor of” Dr.
Tiller. Asked whether he feared a similar fate as Dr. Tiller’s, Dr. Carhart said
he had signed up for this life.
“They have never targeted me more,” he said of abortion opponents. “But to me,
the most dangerous response would be for me to stop what I am doing. The thought
that killing Tiller might also succeed in closing another clinic — that’s my
main reason for keeping open.”
Battle on Late-Term
Abortions Shifts to a Clinic in Nebraska, NYT, 4.12.2009,
Swine Flu, as of Now
The New York Times
So far, the
news about swine flu is better than expected. The pandemic may have reached its
peak and is heading downward in all regions of the country; weekly deaths from
swine flu have started to decline; the virus remains relatively mild; there seem
to be few claims of serious side effects from the vaccine; and despite
widespread complaints about shortages, vaccine supplies are steadily building
By mid-October, the latest estimates available, the swine flu had infected some
22 million Americans, sent roughly 98,000 to the hospital and killed roughly
3,900. Those numbers may sound high, but they are not apt to reach the levels of
harm caused by a normal flu season. One big unknown is whether we will see a
normal flu epidemic on top of the swine flu outbreaks or whether the swine flu
will crowd out the seasonal flu, which has barely been detected here.
Supplies of seasonal flu vaccine have also been running short. The five
companies licensed to make flu shots for this country had expected to make more
than 118 million doses, but manufacturing glitches and the need to convert
production to swine flu vaccine cut the supply of seasonal flu vaccine to 114
million doses. Even 118 million would not have been enough to meet demand that
was revved up this year by all the publicity surrounding the new swine flu. (The
vaccines are not interchangeable.)
Even as the swine flu seemed to be waning last week, health officials voiced
concerns that Thanksgiving travels and get-togethers could lead to new
outbreaks. And there were a few hints of troubling developments.
Some swine flu patients have developed serious bacterial infections in their
lungs, including pneumococcal infections that invade the blood and other
internal sites. The victims are mostly those with underlying chronic health
problems like asthma, diabetes, heart disease and other longstanding ailments.
There is a vaccine that can protect them from 23 strains of pneumococcal
infection, and health officials are urging adults with chronic conditions to get
it from their doctors now.
There have also been scattered reports of mutations in the swine flu virus that
cause harm deep in the lungs of some patients or make the virus resistant to one
of the standard drug treatments. However, neither mutation seems to be spreading
This is no time for Americans to let down their guard. The number of children
and teenagers killed by the flu continues to rise. Even if it is past its peak,
the swine flu will go on to infect many millions more before it disappears. And
if the swine flu follows the pattern of some previous pandemic strains, it could
return in a new wave early next year.
As of last Wednesday, some 61 million doses of the swine flu vaccine had been
used or were available to order, far less than needed to vaccinate the original
target groups of 159 million Americans. As vaccine supplies build up, those who
are at highest risk or could endanger others at high risk — pregnant women,
people caring for infants less than 6 months old, health care workers with
direct patient contact, children 6 months through 4 years old, and children 5
through 18 with chronic medical problems — would be wise to get immunized. So
would others deemed at some risk, like young adults and older adults with
The Swine Flu, as of Now, NYT, 1.12.2009,