Health Care from The Washington Independent - U.S. news and politics - washingtonindependent.com

The Year of Healthcare Reform?

Mike Lillis — Tue, 29 Jul 2008 15:58:21 GMT

Earlier this month, during the fiery debate over how to preserve payments to Medicare doctors, scores of Republicans did the unthinkable: Bucking the White House, the insurance industry and even party ideology, they joined the thin Democratic majority to scale back funding for private plans operating under the federal health-care program.

To health-policy observers, the move was a stunner. Congressional conservatives have long sought to curtail government's role in delivering health care by shifting more responsibility to the private sector. The GOP defections, which allowed Democrats their first major health policy-win in a decade, caused many commentators to suggest that Democrats' plans for broader health reform might find unexpected legs in 2009.

Illustration by: Matt Mahurin

"If the Democrats can win victories like this now," New York Times columnist Paul Krugman wrote on July 11, "they should be able to put a definitive end to the privatization of Medicare next year, when they're virtually certain to have a larger congressional majority and will probably hold the White House."

A host of health policy-experts, however, have another message: Not so fast. Trimming some Medicare payments for the sake of preserving the program, they argue, is far easier to accomplish than the sweeping expansions of federal coverage that many Democrats have proposed.

"Medicare naturally makes for strange bedfellows," Jacob Hacker, a political science professor a the University of California-Berkeley and the author of "The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream," wrote in an email. "Both conservatives and liberals have an interest in keeping the program's costs in line. The divisions are much deeper when it comes to expanding the role of government in health care -- and the political fight will be that much fiercer."

Others noted that the Democrats owe much to the looming elections for their Medicare victory. Faced with an enormous lobbying campaign from seniors and physician groups, they note, many Republicans voted largely to preserve their seats. This should not be mistaken for a change of heart on privatization, these experts say; rather, the Republicans' support was simply a political calculation. With that in mind, the experts predict, the same partisan battle will likely resurface next year -- making the Democrats' major health-reform successes highly uncertain.

At issue is the five-year old Medicare Advantage program, which delivers Medicare services through private insurance companies. In recent years, it has become a leading symbol of the ideological differences between each party's approach to health care. Republicans and other supporters argue that the private companies provide choice, treatments and efficiencies that Medicare cannot, while most Democrats and patient advocates say that removing the middle man would save Medicare much-needed resources.

The Congressional Budget Office has found that MA plans cost taxpayers roughly 12 percent more per beneficiary than traditional Medicare. For one particularly popular type of MA plan, called private fee for service, the divide is closer to 18 percent.

The Democratic proposal to stave off a scheduled 11 percent cut to Medicare physicians was expected to fail because it lopped $14 billion from the MA program over the next five years, mostly from private fee for service. But in a surprise vote, the House last month passed the bill 355 to 59, with 129 Republicans supporting the measure. Shortly afterward, the Senate -- with help from an ailing Sen. Edward M. Kennedy (D-Mass.) -- approved the bill 69 to 30. Eighteen Republicans lent their support.

Making good on earlier vows, President George W. Bush vetoed the bill over the MA cuts. But both chambers easily overrode the veto, with even more Republicans breaking with the White House than had done so originally. Some advocates say the vote is indication that the Democrats can take major strides toward universal coverage next year.

"We think it's more than possible," said Richard Kirsch, national campaign manager of Health Care for America Now, a liberal advocacy group. "We think it's likely."

There are others, however, who say passing MA cuts is no precursor of things to come. Robert Blendon, professor of health policy at Harvard University, said the credit should go to the lobbying efforts that successfully portrayed the opposition as anti-elderly. Faced with that, he said, many Republicans had little choice but to support the bill.

"Tactically, their position seemed politically indefensible in an election year," Blendon said. "The way the debate was framed made it very difficult to remain on that train, but I don't think the Republican leadership is giving up on their vision of what the Medicare program should look like."

Alexander Vachon, a Washington-based health-policy analyst, agreed, calling the Medicare vote an election year anomaly. "R[epublican]s were running from [the] Medicare bill like Indiana Jones with a big rock bearing down on him," Vachon wrote in an email. "Jones didn't care what rock was made of, just wanted to get out of the way. Ditto Rs."

What reforms are possible next year could hinge on the November election results. Democrats are expected to pick up seats in both chambers, but the question remains whether they'll gather the margins to have their way legislatively. Right now, it looks like they could pick up roughly six Senate seats -- not enough to break a Republican filibuster.

Meanwhile, Sen. Barack Obama (Ill.), the likely Democratic presidential nominee, has floated a sweeping health reform plan that aims to cover the nation's 47 million uninsured, computerize all medical records and eliminate unnecessary treatments. Obama claims the plan would save the average family of four $2,500 per year in premium costs.

But even if Obama does take the White House, Senate Republicans can kill proposals by rallying just 40 members in support of a filibuster.

That leaves next year's health reform questions largely unanswered. Some experts say that Democrats can use this year's victory to their advantage in 2009.

"Democrats should take away from the Medicare fight two big lessons," Hacker said. "They need to stick to their guns on the important principles, and they need to pressure moderate Republicans to break with the more conservative members of their party."

Advocates remain hopeful that this year's Medicare battle will embolden Democrats in similar fights to come.

"You couldn't characterize it in any way as a push against [privatization]," Paul Precht, director of policy for the Medicare Rights Center, said of the Republicans voting against MA. "But it does show that [Democrats] can play hardball and win, and that's an important lesson to take into the larger health-care debate."

A Bit More on That Surprise Kennedy Visit

Mike Lillis — Thu, 10 Jul 2008 16:51:14 GMT

Regarding yesterday's Senate passage of the Democrats' Medicare bill: If there was ever question about what force of nature compelled nine Republicans to switch their "no" votes of last month to "yes" votes yesterday, it's been put to rest. Here's a hint: It wasn't because they like the legislation.

There was some early speculation that ads run by seniors groups and the physicians' lobby over the July Fourth recess might have convinced the Republicans to join 129 of their House colleagues and support the bill. But according to today's New York Times, all nine flip-floppers ~~voted against the bill yesterday in the early stages of the vote~~ were prepared to vote against the bill Wednesday. It was only after the surprise arrival of Sen. Ted Kennedy (D-Mass.), who hasn't visited the Capitol since being diagnosed with brain cancer nearly eight weeks ago, that the Republicans recognized the bill had the final vote it needed for passage. Rather than going down with the ship, the nine switched their nays to yeahs.

So, technically, these nine supported the bill. But if they think the physicians' lobby didn't watch the process closely, they should probably think again.

As an interesting side-note, this is a different story than the one reported yesterday by The Dallas Morning News. It credited Texas Republican Sens. John Cornyn and Kay Bailey Hutchison with supplying "crucial support for the bill." Actually guys, that was Ted Kennedy.

Correction: An earlier version of this post reported that the nine Senate Republicans switched their vote on Wednesday, July 9 after the arrival of Sen. Ted Kennedy. In fact the nine senators voted only once -- in support of the bill -- after Kennedy's arrival.

With Kennedy's Arrival: Medicare Bill Is on Its Way to the White House

Mike Lillis — Wed, 09 Jul 2008 21:35:30 GMT

What a difference a week's vacation (and an extra Democrat) can make. Late last month, the Senate failed by one vote to reach the 60 required to take up a bill preventing a 10.6 percent cut to Medicare doctors. On Wednesday, the same chamber passed the same procedural step by a whopping 69 to 30 margin. The difference, it would seem, was not merely the heavy lobbying from powerful doctors' groups, nor the additional pressure from the wave of House Republicans that bucked the party to support the measure.

Rather, the difference was Ted Kennedy, the nine-term Massachusetts senator, who, suffering from brain cancer and in the midst of chemotherapy, surprised his upper chamber colleagues by showing up for the vote. (He'd missed the last one due to the illness.)

Recognizing that the bill would pass, a number of Republicans who had voted against the measure last month switched allegiances and supported the legislation this time around. For the record, they are: Tennessee Sens. Lamar Alexander and Bob Corker; Georgia Sens. Saxby Chambliss and Johnny Isakson; Texas Sens. John Cornyn and Kay Bailey Hutchison; and Sens. Mel Martinez (Fla.); Arlen Specter (Penn.) and John Warner (Va.).

Those 69 "yeahs," by the way, mean the bill not only passes the Senate, but it's veto-proof. Didn't see that one coming.

Medicare Pay Cut Bill Divides GOP

Mike Lillis — Wed, 09 Jul 2008 13:18:23 GMT

As Senate lawmakers prepare this week to tackle Democratic legislation to avert cuts to Medicare doctors, Republican leaders who oppose the bill face an unexpected challenge: abandonment by most House colleagues.

The bill has taken on a partisan air because the funding to prevent the physician pay cut would come largely by slicing a controversial program that delivers Medicare services through private insurance plans -- an initiative long popular with the Bush administration and congressional Republicans.

But in a shocking vote last month, the House approved the Democrats' bill by a veto-proof 355 to 59. Defying the GOP leadership, 129 Republicans supported the proposal. Senate Republicans held their ground a few days later, killing the bill by a slim one-vote margin. But the House defections -- as well as intense lobbying by physicians' groups over the Fourth of July recess -- have put additional pressure on Senate Republicans as the upper chamber takes up the bill again this week. The vote could come as early as Wednesday afternoon.

The House-versus-Senate dynamic is unusual from Republican lawmakers renowned for party unity. But with the GOP facing an ominous election cycle this year -- and with President George W. Bush tallying the lowest approval ratings in history -- many Republicans in tight races are taking a go-it-yourself attitude for their own job preservation.

Among the House Republican defectors, health policy experts say, the fear of being portrayed as harming Medicare patients trumped their support for the private insurance program -- called Medicare Advantage. Faced with a decision between party loyalty and preserving their political hides, many chose the latter.

"Why did they run to vote for the Medicare bill like brides at Filene's wedding dress sale?" Alexander Vachon, a Washington-based health-policy analyst, said in an email. "The obvious reason: Because they have to be reelected."

Senate Republicans are hardly immune to the trend. Indeed, five of the nine Republican senators who supported the Medicare bill last month face tough reelection bids this year. For some of the others, the political cost is already tangible.

In Texas, for example, the political arm of the Texas Medical Assn. pulled its reelection endorsement for first-term Republican Sen. John Cornyn in the wake of his vote against the bill. In California, Rep. Wally Herger (R) received so much flak from physicians that he immediately penned a letter explaining that he would, of course, have voted for the bill if he'd known it would pass.

"[I]f the bill comes back to the House for final approval, I intend to fully support it," Herger wrote the same day he voted against it.

But whether that pressure will be enough to alter the strategy of Senate Republicans this week remains to be seen. Robert Blendon, professor of health policy at Harvard University, said that voters' memories are short, leaving most Republican senators immune to the current pressures surrounding the Medicare bill. "Voting against it is not ideal if you're up for re-election," he said. "But if you're not up for re-election, it's not a story that's going to stick around for years."

Congress left Washington last month without blocking the scheduled 10.6 percent cut for physicians who treat seniors and the disabled under Medicare. That cut arrived July 1. The White House postponed any cut while Congress haggles over a compromise. But that moratorium ends on Friday. The impasse could carry drastic implications -- with some physicians threatening to drop services to Medicare patients if the cut remains.

At issue, however, is not whether the cut should be prevented, but how it should be offset. The Medicare Advantage program has enjoyed intense support from the Bush administration and congressional Republicans, who favor a larger role for private industry within the enormous federal health-care program. Bush has threatened to veto any significant cuts.

But Democrats, seniors groups and patient advocates have skewered Medicare Advantage as a giveaway to insurance companies at the expense of limited Medicare resources. The insurance industry says the extra costs are necessary to deliver extra services, like dental care not covered under traditional Medicare. But advocates say the federal government could provide the same care for much less. A number of independent cost analyses support the advocates' claims.

Reports from the Congressional Budget Office, for example, demonstrate that delivering services through the private plans costs, on average, about 12 percent more than delivering the same services through the regular program. Last year, the CBO estimated that capping Medicare Advantage payments at 110 percent of traditional Medicare costs would save $38 billion over five years and $95 billion over 10.

"We just feel we have to rein in the outrageous subsidies to the insurance industry," said Barbara Kennelly, president of the National Committee to Preserve Social Security and Medicare, a liberal advocacy group.

However the Senate votes this week, Bush's veto threat predicts the sides will be forced to reach some compromise over the Medicare Advantage cuts. Senate Finance Committee leaders Max Baucus (D-Mont.) and Charles Grassley (R-Iowa) had been concocting a compromise bill last month, that likely would have spared much of the Democrats' proposed Medicare Advantage cuts. But those negotiations ended following the surprising results of the House vote. "Frankly, we did not have an agreement," Baucus told reporters Monday, adding that the lopsided House vote "changed the dynamics dramatically."

In any event, Congress will be returning to the issue next year -- at the latest. The bill under consideration prevents physicians' cuts only through 2009, and a compromise might provide an even shorter fix. In the eyes of many observers, it's high-time Congress got to the root of the problem.

"Kicking it down the road six months or a year at a time just brings uncertainty to the whole process," said Joseph Antos, a health-policy analyst at the conservative American Enterprise Institute. "Just a little honesty would help every once in a while."

Economists: Health Cost Crisis Coming

Mike Lillis — Wed, 18 Jun 2008 00:45:48 GMT

In what is fast becoming a repetitive exercise, some of Washington's top economists warned lawmakers Tuesday that health-care spending threatens to devour the nation's economy unless Congress steps in with sweeping reforms.

The message is hardly news on Capitol Hill, where some policy-makers have sounded a similar alarm for years. But forecasting a fiscal doomsday is easier than convincing a divided Congress to prevent it. Indeed, despite the urgency of the health spending warnings, lawmakers agree that no major reforms are coming this election year.

Faced with pressure from the various interests within the powerful medical-services industry, lawmakers have instead continued a habit of throwing federal dollars into Medicare and Medicaid without regard to the effectiveness of treatments provided under those programs. Health-care experts say eliminating unnecessary care will be central to any health-policy overhaul, potentially saving hundreds of billions of dollars per year. But the politically thorny task of separating what works from what doesn't will likely take years, pushing real reform to the uncertain future.

Appearing before the Senate Finance Committee, Peter Orszag, director of the Congressional Budget Office, cautioned lawmakers that continued inaction will have dire economic consequences.

"Just like the subprime crisis came home to roost when it was unsustainable," Orszag said, "we are on an unsustainable path [in health-care spending], and bad things will happen." The economic troubles, he added, will "far exceed what we're facing today, unless we get at the heart of the problem."

Budget projections support the call for drastic health-policy reform. Spending on Medicare and Medicaid amounted to 4 percent of the gross domestic product, or GDP, in 2007. But that figure is expected to grow to 12 percent in 2050 and 19 percent in 2082, according to CBO projections.

The steep inflation is not limited to public-sector programs. In 2007, the nation's total health-care spending represented roughly 16 percent of GDP. At current rates of growth, however, that figure will jump to 25 percent in 2025 and 49 percent in 2082, CBO estimates.

"This course is clearly unsustainable," Orszag said.

Acting U.S. Comptroller General Gene Dodaro, who also appeared before the Senate panel, put those figures into some context. At current revenue rates, he said, in 2040 the entire federal budget would cover only Social Security, Medicare and interest on the debt. No funds would be available for education, transportation, defense or any other federal programs. "Now, obviously, this is not going to happen," Dodaro said, "but it illustrates the magnitude of the problem, and the size of the adjustments that are gonna have to take place."

Some effects are already tangible. Employees, for example, take home between $7,000 and $10,000 less each year because that money is consumed by employer-based health plans, Orszag said. State budgets are also being stretched, causing tuition hikes at public universities. "That is happening today," Orszag said.

Lawmakers say they recognize the crisis, but have been slow to act. Senate Finance Committee Chairman Max Baucus (D-Mont.) said Tuesday that, "if we fail to control health-care costs, it won't matter what else we do in the rest of the budget." But Baucus is in a tough spot. The clearest reform strategies -- including tax hikes, program cuts and increased costs to beneficiaries -- are also the least politically palatable. For that reason, Congress has tended to kick the trouble to be tackled another day.

"Our political system does not deal well with gradual, long-term problems," Orszag said.

The hearing came as Senate lawmakers, led by Baucus, are trying to push through legislation preventing doctors from receiving a 10.6 percent Medicare cut, slated to take effect July 1. The doctors' lobby has claimed that if the cut goes through, physicians will stop seeing Medicare patients -- a gamble no lawmaker wants to take.

But the news is not all bad. Orszag pointed out that there are vast regional payment discrepancies where significant savings probably lurks. At UCLA Medical Center, for example, the average cost to treat a Medicare patient in the last six months of life is $50,522. Meanwhile, the cost to treat the same patient at the Mayo Clinic is $26,330.

"There is no appreciable difference in quality," Orszag said, referring to the two renowned medical facilities. "The best medical care in the world should not cost twice as much as the best medical care in the world."

Orszag estimates that 30 percent of all health-care spending in the United States -- or roughly $700 billion per year -- goes for treatments that have no positive effect on the health of patients. Worse, Medicare pays blindly for these services. "Right now, we pay for more care rather than better care," Orszag said, "and that fundamentally has to change."

The steep, regional price discrepancies caught the attention of some Senate Finance Committee members, who would have to stand at the front lines of any congressional efforts to rein in health-care spending. "I'm not sure we should let people get away with that," Sen. Jay Rockefeller (D-W.V.) said, referring to the longer hospital stays and increased number of tests that are largely responsible for the cost difference.

Rockefeller said Congress has plenty of room to push physicians and other health-care providers to emphasize the quality of care above quantity. "We just tell them," he said, "And they'll hate it. And it'll be called socialism and all the rest of it -- and so be it."

But change won't come easily. That $700 billion doesn't go into a hole, it goes into the pockets of medical personnel nationwide. Eliminate a third of the dollars spent on medical services, and jobs will surely follow. In an already struggling economy, no one -- least of all a politician -- wants to bear responsibility for hiking unemployment, even if it's done for the sake of preserving Medicare.

For some observers, the delay is becoming more and more inexcusable.

Asked how quickly Congress should act, Orszag replied dryly: "Ten years ago would be the appropriate response to that question."

US Health Care: When Is a Crisis a Crisis?

Mike Lillis — Fri, 09 May 2008 17:30:00 GMT

A piece we ran this morning examines the current crisis in health care and the political barriers to fixing it. As the story points out, the U.S. spent about 16 percent of its gross domestic product -- or $2.1 trillion -- on health care in 2006. That raises the question: What do comparable countries spend on the same thing?

The quick answer: Not nearly as much. According to the Organization for Economic Cooperation and Development, which represents 30 developed-world democracies, Switzerland is second behind the U.S., spending 11.5 percent of its GDP on health care in 2004, the last year when comprehensive data are available. (By comparison, the U.S. spent 15.2 percent of GDP in the same year). Japan and the United Kingdom spent about half of what we did in 2004: 8.0 and 8.1 percent of GDP, respectively.

And that would be fine if the health benefits for all that health care spending were tangible. But it's simply not the case. With half the health care spending of America, for example, Japan's life expectancy is more than four years longer, according to the OECD. Infant mortality -- at 6.8 deaths per 1,000 live births -- is higher in the U.S. than in all the other OECD countries except Mexico and Turkey. And among the 26 countries reporting deaths from medical errors, the U.S. has the third-highest rate, behind Austria and Greece.

Also of dubious distinction, Americans die from preventable conditions at rates higher than citizens of all other industrialized nations, according to a 2008 study from the London School of Hygiene and Tropical Medicine. While researchers noted that the reasons for that trend are many, one contributor is the "comparatively poor performance of the U.S. health care system," the Health Affairs journal pointed out at the time.

Seems that sometimes, you don't get what you pay for.

Health Care Reform Waits

Mike Lillis — Fri, 09 May 2008 13:04:07 GMT

In 2004, Tommy Thompson, then-Health and Human Services secretary, approached his boss with a request. Observing that the nation's doctors and hospitals operate a tangled web of incompatible forms and technologies, Thompson asked President George W. Bush to create a universal system of electronic medical records that would follow patients around the country, eliminate redundant treatments and, according to some estimates, trim billions of dollars from the nation's annual health care tab. Thompson wanted the president to establish the system within 18 months.

"He came out for 10 years," Thompson said this week, "and as a result, we haven't been able to get there."

The anecdote, which Thompson told the Senate Finance Committee Tuesday, offers a glimpse of the obstacles facing health-reform advocates. With medical costs skyrocketing, employers increasingly dropping or trimming coverage, Medicare projected to go belly-up in a decade and the number of uninsured Americans tickling the 50 million mark, most observers contend the health-care system needs a complete overhaul. But such shakeups are rare in Washington, where special interests spend millions to keep things as they are, and the political will to confront industry is all but absent. Instead, lawmakers tend to dabble at the edges of problems until sweeping change becomes unavoidable. The health reform debate now seems to revolve around when that time will arrive.

Thompson said that 2009 brings a great opportunity to overhaul the system. He argued that, politically, big reform will be feasible with the arrival of a new administration, while, fiscally, it will be necessary because of Medicare's looming bankruptcy.

"It's the perfect storm," he said.

On Thompson's side, there is near-unanimous agreement that the health-care system is broken. Patient advocates, for example, decry the millions of uninsured; employers want a coverage model that won't nip their competitive edge over foreign companies, and doctors and hospitals want to spend less time wrangling with insurers over payments. Taken together, the troubles reveal a system in need of transformation. "One piece is not going to do it," Thompson said. "It is too broken."

Congressional lawmakers acknowledge as much. But identifying the problem is different than agreeing on the solution. Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee, which oversees Medicare and tax policy, conceded the "many difficult decisions" lawmakers face.

For that reason alone, few observers agree with Thompson that the reforms will arrive next year. David Walker, former head of the Government Accountability Office, argued that health care costs threaten to bankrupt the country if Congress fails to act, but an overhaul won't -- and shouldn't -- come overnight.

"It is possible to achieve some incremental reforms next year," said Walker, now president of the Peter G. Peterson Foundation, which aims to promote solutions to America's budget challenges, "but comprehensive reform will have to be done in stages over a number of years."

The health care debate arrives during an election year when polls reveal that the struggling economy and the war in Iraq are foremost on voters' minds. Donna Shalala, secretary of Health and Human Services under President Bill Clinton, however, called those polls "misleading."

"It seems very clear that when Americans talk about their economic concerns," she told Senate lawmakers, "they're talking about health care."

The three current presidential hopefuls have each unveiled ambitious health reform plans, though in each case, the details -- like how to pay for universal coverage -- have been kept purposefully vague to avoid criticism. Experts point to popular bipartisan proposals, like renewing the State Children's Health Insurance Program, as probable successes in 2009. But change on the scale that many say is needed to fix the entire system remains an idea for the more distant future.

"Taking something as big as health care, you're just asking for trouble if you try to do it in one fell swoop," said David Merritt, project director at the Center for Health Transformation, a right-leaning Washington-based policy organization. "Hillary Clinton can testify to that."

Merritt's reference was to the health care overhaul proposed in the first years of the Clinton administration. Facing well-heeled opposition from the insurance industry, among others, the plan went down in flames. Its failure was seen as a turning point for the administration, and is often cited as a central contributor to the Republican takeover of Congress in 1994.

In a 1995 issue of Health Affairs magazine, several architects of the Clinton proposal weighed in on the reasons for the plan's failure, and offered some advice to future administrations.

"We have seen that although the 'window of opportunity' might exist for major government action to address a particular policy issue, the tendency is for experts to overestimate the willingness of middle-class Americans to sacrifice and risk the uncertain consequences of major changes in their lives," wrote Robert J. Blendon, Mollyann Brodie, and John Benson, who had all worked on the Clinton plan.

"Thus, if substantial reform is to be achieved during these windows of opportunity, the legislation must be more modest in its reach than many reformers may see as desirable."

Reached by phone this week, Blendon said, "I haven't changed my mind a bit."

Blendon, a professor of health policy at Harvard University, pointed out an irony underlying the health-reform debate: While many Americans express dissatisfaction with the current system, many also harbor a fear of change. "Some of these reforms, while they might make great policy sense, won't have any legs when brought to the public," he said. "They are risk averse to a lot of changes in the health-care sector."

Instead, Blendon said, reform advocates in and out of Congress will probably have to wait a few more years until the crisis becomes the subject of more dinner-table conversations.

"Governments solve things when they perceive a crisis facing the middle class that they can't escape from," he said. "And then everyone says we should have done it 10 years ago. But it needs to be perceived as a real crisis and it needs to be on the front pages every day. Then you can really do big things."

Yet, all sides of the debate agree that the current system is a train-wreck -- and they have the statistics to back it up. In 2006, Americans spent roughly $2.1 trillion on health care, according to the Centers for Medicare and Medicaid Services -- roughly 16 percent of the nation's gross domestic product, or $7,000 for every man, woman and child in the country. Meanwhile, medical inflation (at 6.7 percent) is about twice that of overall inflation. Without legislative changes, the Congressional Budget Office projects that total health care spending will jump to 25 percent of GDP in 2025 and 37 percent in 2050.

Despite all the spending, 47 million Americans are uninsured.

"The problems are greater than the incremental solutions that Congress has tried to date," Baucus said in a statement.

Baucus faces a difficult task. From the left, liberal Democrats and patient advocates are pushing to increase the government's role in covering the uninsured while improving care for millions more. From the right, conservative Republicans and the numerous medical industries are urging more patient responsibility and privatization of care. The ultimate strategy will inevitably involve some compromise on everyone's part -- and a tangible crisis to bring it about.

As Peter Orszag, head of the Congressional Budget Office, told reporters last November: "The political system is not very good at dealing with gradual problems. It's good at dealing with crises."

The question remains when America's health-care system will be perceived as such.

Mending Mental Health Coverage?

Mike Lillis — Tue, 06 May 2008 12:43:35 GMT

For the estimated 60 million Americans suffering from mental illness, treatment can be an elusive and costly ordeal. Many health care plans don't cover mental care, and those that do usually provide lesser benefits for mental disorders than for physical ailments. Co-payments, for mental patients, are usually higher. In addition, the last major federal law tackling the problem is 12 years old.

Now Congress is hoping to fix some of that. Bills passed in both the House and Senate would require most employer-based health plans to eliminate the current pay discrepancies between coverage for mental and physical conditions. Supporters say that equating the two -- and thus establishing "parity" -- is long overdue. Helping their push, the stigma that's contributed to the legal discrimination has slowly faded as scientists uncover the biological and genetic causes of mental disorders.

"There is no shame in mental illness," House Speaker Nancy Pelosi (D-Cal.) said following passage of the House bill in March. "The great shame would be if Congress had not taken action."

But much work remains. Significant disparities between the Senate and House bills have forced sponsors into informal but delicate negotiations. The saga has aligned senators of both parties, the White House, business groups and the insurance industry -- all of whom support more business-friendly reforms -- against House lawmakers pushing for broader patient benefits.

The negotiations could prove a dilemma for House Democrats, who have increasingly shown an eagerness to stand firm on non-compulsory legislation in lieu of caving to the demands of industry and the administration. Led by Pelosi, Democrats in Congress's lower chamber have confronted the White House head-on over wiretapping legislation and a free trade deal with Columbia, for example -- in each case supporting the populist agenda that swept the party into power two years ago. The resulting stalemates seem to indicate that Democrats would be willing to kick these issues to next year, when the party is expected to command larger congressional majorities and, perhaps, control the White House.

Mental health advocates are optimistic the parity reforms will move this year -- and they have several things working in their favor. First, the Senate bill has broad bipartisan support, with Sen. Edward M. Kennedy (D-Mass.) a leading force behind it. Also, two long-time champions of parity -- Sen. Pete Domenici (R-N.M.) and Rep. Jim Ramstad (R-Minn.) -- are retiring at the end of the year, putting pressure on lawmakers in both chambers to honor their work by enacting reforms before they depart. Both lawmakers have personal investments in the the parity push: Domenici's daughter has schizophrenia, and Ramstad is a recovering alcoholic.

In the eyes of Washington's power-brokers, their cause hardly constitutes must-pass legislation, but with some momentum behind it, the parity legislation could be a rare instance of an election-year success.

Neither the House nor Senate bill forces insurers to cover mental treatments. But under both proposals, group health plans that opt to cover such care could no longer make the mental benefits more restrictive or costly than those for comparable medical and surgical treatments.

A 1996 law took a step in this direction, preventing insurers from applying different limits on annual or lifetime payments. But plans may still discriminate in other ways, like charging mental patients higher co-pays and restricting the number of days they can spend in the hospital.

Elizabeth Prewitt, government relations director for the National Assn. of State Mental Health Program Directors, which supports the House bill, said that roughly 67 percent of adults and 80 percent of children requiring mental health services go without -- a trend exacerbated by discriminatory insurance practices.

"If the patient has financial limitations," Prewitt said, "they often don't seek treatment at all."

Both the House and Senate bills apply only to group health plans covering 50 people or more.

In a controversial break from the Senate proposal, the House bill mandates that group plans "include benefits" for any condition contained in the American Psychiatric Assn.'s most recent reference guide for diagnosing mental ailments, called the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The manual lists serious conditions -- like schizophrenia, bipolar disorder and severe depression -- but also includes jet lag, caffeine addiction and sibling rivalry. Employers and insurance groups are quick to criticize the House bill for that provision, saying it will drive up costs and force employers to drop mental health coverage altogether.

"Nowhere else do you employ a professional manual to specify the conditions that have to be covered," said E. Neil Trautwein, a vice president at the National Retail Federation and leader of an ad hoc industry coalition lobbying the bill. "The practical effect is to require each and every thing in the DSM to be potentially subject to coverage."

The Senate proposal, in contrast, caters more to businesses, allowing the plans -- not the DSM -- to define their scope of coverage. Under both bills, however, insurers would pay only for those conditions they deem medically necessary. Supporters of the House bill contend that the medical necessity limitation makes much of the DSM criticism unjustified. Neither bill mandates mental health coverage. Yet business groups worry that the House language would drive coverage decisions into the courts.

"The issue is, how is the language in the House bill interpreted?" said Mohit Ghose, spokesman for America's Health Insurance Plans, a trade group. "What is the definition of medical necessity?"

As is often the case with congressional proposals, the debate hinges more on how the bill is perceived than on what it would do. Peter Newbould, director of congressional and political affairs at the American Psychological Assn., said the DSM provision doesn't deserve the scrutiny it's received.

"It's something that conservative senators latch on to -- perhaps supported by business and insurers -- and say, 'No, that's too much,'" Newbould said. "The problem is not the reality, it's the perception."

Newbould added, "Whether or not the DSM language is problematic misses the point that it's DOA in the Senate."

The White House has bolstered this Republican opposition. The administration issued a statement in March charging that the House bill "would effectively mandate coverage of a broad range of diseases and conditions and would have a negative effect on the accessibility and affordability of employer-provided health benefits."

Recognizing the political realities, Senate negotiators -- including Democrats -- have accepted the industry's compromise for the sake of passing reforms this year. Kennedy and Domenici have sent a newer version of their bill to House leaders. That bill moves closer to the House proposal but does not contain the DSM language. The question remains whether House leaders will accept the changes or hold out for a more patient-friendly bill.

All sides agree that time is short. With a new administration taking the helm next year, health care reform is expected to be among the top priorities of the new White House. Mental health advocates fear that the parity issue might lose priority in the shuffle.

"Time is of the essence," Newbould said. "If nothing gets done [this year], we'll get lost in the health care tornado that's soon coming in."

Taxpayers Fund Both Sides of Fight Over Bush's Illegal SCHIP Rules

Mike Lillis — Tue, 22 Apr 2008 15:31:26 GMT

Arriving too late to sneak into this morning's SCHIP story, one advocate's comments on the program's enrollment controversy reveal an interesting take on the saga. While the Bush administration hopes to limit program enrollment to the lowest-income kids, states are suing, both to keep higher-income youngsters on the rolls (if, like New Jersey, they already cover them) and to expand coverage to include wealthier kids (if, like New York, they don't).

Yet as Bruce Lesley, president of First Focus, a Washington-based children's health-care advocacy group, points out, this means that federal taxpayers are picking up the legal tab for the administration to defend its policy, while state taxpayers are picking up the legal tab to fight it. In both cases, Lesley says, those dollars would be better spent on kids than lawyers.

From a taxpayer perspective, HHS is forcing states into lawsuits to overturn this illegal action. Thus, you are paying with federal and state taxes … to battle your own money in court.

In other words, rather than HHS spending millions of dollars in legal expenses to try to prevent children from receiving health coverage, that money would be far better spent providing health coverage to children.

Report: Bush SCHIP Rules Illegal

Mike Lillis — Tue, 22 Apr 2008 10:30:00 GMT

The Bush administration has no plans to rescind controversial guidelines restricting enrollment in a popular children's health-care program, despite a recent legal finding that they were administered illegally.

The administration's position could leave the issue to the courts, where several states have already sued the White House over their right to expand coverage under the State Children's Health Insurance Program, or SCHIP. It could also lead to a showdown with Congress, though legislative efforts to expand SCHIP were twice vetoed by President George W. Bush last year. Perhaps with that in mind, congressional critics of the enrollment guidelines are clinging to the unlikely hope that the new legal opinion will inspire the administration to scrap the rules voluntarily.

The long-running debate over SCHIP highlights the sharp differences between the White House and a Democratic Congress over Washington's role in providing health care. With medical costs skyrocketing and employers dropping more and more coverage benefits, many lawmakers are pushing to expand that role into higher income brackets. The Bush administration has fought that push, claiming such expansions nibble away at private insurance markets.

In limbo are tens-of-thousands of kids whose health coverage hinges on their eligibility for the state-federal program.

At issue are controversial eligibility guidelines -- issued directly to state health officials in an Aug. 17 letter -- that prohibit states from using federal SCHIP funds to cover children in families earning more than 250 percent of the federal poverty level, or $53,000 for a family of four, until they have covered 95 percent of kids living under 200 percent of poverty, or $42,400. Supporters in and outside of the White House say the rules ensure that SCHIP dollars go to the lowest income kids.

But on Thursday, the Government Accountability Office challenged the guidelines, charging that the administration broke the law when it bypassed Congress in issuing them. Under a 12-year-old law, the GAO says, the changes have to be reviewed by both Congress and the GAO before they could take effect.

The legal opinion is being cheered by children's health-care advocates and state health officials. But they might not want to hold their breath waiting for change: The GAO opinion has no teeth, and the Bush administration has already issued a statement saying it will ignore it.

"GAO's opinion does not change the department's conclusion that the 8/17 letter is still in effect," Jeff Nelligan, spokesman for the Centers for Medicare and Medicaid Services, said in an Apr. 18 statement.

The issue boils down to a difference in legal interpretations. The Bush administration claims the Aug. 17 letter is just a non-binding statement of general policy -- a clarification of existing law. The GAO, on the other hand, argues that the letter constitutes a policy change significant enough to require congressional and GAO perusal under the Congressional Review Act.

"The August 17 letter from CMS to state health officials is a statement of general applicability and future effect designed to implement, interpret or prescribe law or policy with regard to [SCHIP]," GAO writes. "Accordingly, it is a rule under the Congressional Review Act. Therefore, before it can take effect, it must be submitted to Congress and the Comptroller General."

The Congressional Research Service, another nonpartisan investigative research body, reached a similar conclusion in a January report.

Meanwhile, a number of states have already felt the effects of the allegedly non-binding policy. State officials in both Wisconsin and Louisiana, for example, passed SCHIP expansions last year taking eligibility up to 300 percent of poverty, or $63,600 for a family of four. In both cases, the administration knocked that ceiling down to 250 percent. Researchers at Louisiana State University estimated the change prevented 6,000 kids from joining the program in Louisiana alone.

In New York, state officials passed an expansion pushing eligibility to 400 percent of poverty, or $84,800, but the administration rejected it, citing the Aug. 17 waiver. State officials say the change would allow for coverage of 70,000 more kids under the program.

New York has sued the administration, charging it did not have the authority to install the guidelines without congressional review. The GAO report bolsters that argument, though there's no indication that the court will reach its verdict in the near future.

Timeliness could pose a problem for states that currently cover kids living above 250 percent of poverty. The Bush administration has given states a year to comply with the conditions in the Aug. 17 directive. Afterward, states would have to drop those kids or pick up 100 percent of their health-care costs. With many state budgets already pinched due to the ailing economy, officials contend the latter option is virtually impossible.

That would force the issue to Congress, where critics of the Aug. 17 directive remain strangely hopeful that the administration will heed the GAO criticisms. "CMS now has a critical choice to make: rescind the rule or continue to spend taxpayer money defending a growing list of lawsuits it is unlikely to win," Sen. Jay Rockefeller (D-W.V.), who requested the GAO report, said in a statement.

"It would be in the best interest of all parties involved, but particularly children, if CMS voluntarily withdrew the August 17 letter," Rockefeller concluded.

That, however, could reopen the floodgates for state SCHIP expansions -- an unlikely scenario at the hands of an administration that threatened to veto any legislation confronting the expansion restrictions.

Hospital-Induced Fatalities Gets Public Airing

Matthew Blake — Wed, 16 Apr 2008 18:01:22 GMT

Today the House Committee on Oversight and Government Reform investigated the 6th leading cause of death in the U.S.: infections from hospital errors. Last year alone, a startling 100,000 people died from hospital-associated infections and almost 2 million suffered non-fatal health problems.

Democratic and Republican Committee members and witnesses shared their astonishment at the volume of deaths. Henry A. Waxman, (D-Calif.), committee chairman, noted that thousands of deaths can be prevented by elementary procedures like hospital personnel washing their hands and using clippers instead of a razor to remove hair before surgery. "You seem to be of one mind," Waxman said to the witnesses representing government and the medical profession. "Unlike other causes of death, this is one we know how to reduce."

Less clear is how much government can do to reduce them. Cynthia Bascatta, Director of Health Care Issues at the Government Accountability Office, said one way to alleviate the problem is to improve information-sharing between the Centers for Disease Control and other agencies under the Department of Health and Human Services. In fact, four different agencies are compiling their own data on hospital associated infections. As Arthur Allen reported for The Independent, former CDC scientists believe the agency's hospital infection program is increasingly dysfunctional.

Questions of competence aside, witnesses argued that government health agencies need to go back to basics. "The federal government spends a dollar on medical research for every penny on safety and the health-care industry," said Peter Pronovost, medical director at the Center for Innovation in Quality Patient Care at The John Hopkins University.

The most controversial solution to the hospital infection problem was returned to time and again by Rep. Tom Davis, the committee's ranking Republican. Davis wants to end reimbursements to hospitals that treat medicare patients who contracted hospital-associated infections. Hospital infections cost $5 billion a year, which Davis said creates a "perverse incentive," where the government pays the hospital to treat a problem the hospital caused.

Can any of these solutions be quickly implemented to curtail the hospital death epidemic? Hospital associated infections are a distressingly simple problem. But revisions in the government health care system during a lame duck Bush administration could be a bridge too far.

Dingell to Investigate 'Abortion' Search Ban

Mike Lillis — Tue, 15 Apr 2008 21:54:37 GMT

In the wake of news that a federally funded reproductive health database was programmed earlier this year to ignore searches containing the word "abortion," Congress has gotten in on the act.

Rep. John Dingell (D-Mich.) announced today that the House Energy and Commerce Committee, which he chairs, will investigate the manipulation of the Population Information Online database, run by The Johns Hopkins University and funded by the U.S. Agency for International Development. Reports indicate that university employees blocked "abortion" searches after USAID officials expressed concerns that two articles contained in the database centered on abortion advocacy.

POPLINE is the largest database of its kind in the world, holding roughly 360,000 articles and records related to reproductive health.

In letters to both Hopkins and USAID, Dingell announced his investigation into "the restriction of scientific inquiry," and asked leaders of both offices to provide details about how the decision was made.

I am concerned that the restriction of certain search terms in the POPLINE database is an ideological decision, and not in line with the spirit of free scientific inquiry intended by the creation of such a database. In addition I am concerned that such a complete restriction was mandated after only two specific items were identified as questionable by POPLINE's funding agency.

Dingell said he wants responses two weeks from today. But given this administration's track record on releasing internal documents, he might not want to hold his breath.

If That's the Dems' Grand Plan to Save Medicare, We're Done

Mike Lillis — Thu, 27 Mar 2008 17:18:56 GMT

It's an annual event as predictable as the blooming cherry blossoms: Every spring, the group assigned to diagnosis the fiscal health of Medicare delivers a grim report on the solvency of the program. And every year, certain members of Congress react with various degrees of alarm, indignation or incredulity -- and then do nothing.

The latest report arrived Wednesday, offering similar news to that delivered last April: In short, the Medicare trust fund -- the hospital insurance reserve to which working Americans contribute with every paycheck -- will begin paying out more than it receives this year, and will be exhausted by 2019.

The report led to the predictable partisan finger-pointing over who bears responsibility for the country's long-term budget woes. The White House said Congress hasn't done enough to enact the administration's budget-trimming proposals. Congressional Democratic leaders countered that the administration has opposed several of their own reform blueprints -- some with a veto.

But in the midst of the flurry, a statement from House Majority Leader Steny H. Hoyer (D-Md.) stuck out as even more absurd than the others. Here's Hoyer:

[T]he Democratic Majority in the House is committed to ensuring that the Medicare program continues to function effectively for beneficiaries, providers and taxpayers well into the future. That is why the House passed reforms -- as part of the Children's Health and Medicare Protection Act -- that would have extended Medicare solvency by two years.

Two years? Really? That's the Democrats' grand plan to save the program?

Don't break your hand patting yourself on the back, Mr. Hoyer. Some of us who are paying into that fund every month want it to be around beyond 2021.

White House Rules Clip Kids From SCHIP

Mike Lillis — Fri, 07 Mar 2008 18:36:23 GMT

Late one Friday evening last August, as the White House and congressional Democrats were embroiled in debate over the expansion of a popular children's health care initiative, the Bush administration quietly and unilaterally unveiled a dramatic policy change (pdf): States no longer could use federal dollars to expand their State Children's Health Insurance Programs (SCHIPs) until almost all the state's lowest-income children had coverage. State officials fumed, and Democratic leaders vowed to kill the changes. Yet roughly seven months later, the rules not only remain, but the White House has extended their reach to place even greater restrictions on kids' coverage. As a result, experts say, thousands of youngsters will be denied access to the program outright, while others must wait a year to enroll.

Central to the controversy is the partisan disagreement over the role of SCHIP in a modern America, where the price of health care is skyrocketing. Enacted in 1997, the program was designed to cover kids from families too wealthy to qualify for Medicaid, but too poor to afford their own insurance. Congress originally set the eligibility ceiling at 200 percent of poverty -- or currently $42,400 for a family of four -- but in light of rising health care costs and regional cost-of-living discrepancies, a number of states have expanded coverage to include higher-income children. Though the Bush administration had once encouraged those expansions, it now wants to rein them in.

The debate highlights the stark ideological differences between the two parties in their approach to health care, particularly the government's role in providing it. While most Democrats favor a robust expansion in federal health coverage -- even to include the uninsured of modest incomes -- the White House and its Republican supporters would transfer greater responsibility to private industry and individual patients. How wide is the chasm? House Democrats last year pushed for a $60 billion SCHIP expansion through 2012, while the administration proposed $5 billion (The issue remains unresolved.) Indeed, the administration's new SCHIP rules -- arriving in the form of a three-page letter to state health officials -- were created to prevent the state and federal program from encroaching on private insurance markets. The trouble is, health-care advocates argue, thousands of kids will lose out on coverage in the process.

The debate highlights the stark ideological differences between the two parties in their approach to health care, particularly the government's role in providing it.

In Louisiana, for example, where SCHIP covers kids living in families earning up to 200 percent of the federal poverty level, or $42,400 for a family of four, state officials passed legislation last year hiking that figure to 300 percent, or $63,600 for the same family. Citing its new guidelines, however, the White House rejected that proposal, and last week federal officials approved an altered plan with an eligibility ceiling of 250 percent of poverty, or $53,000 for a family of four.

The change leaves about 6,000 uninsured youngsters ineligible for the program, according to a December survey conducted by researchers at Louisiana State University. Kirby Goidel, director of LSU's Public Policy Research Lab and lead researcher behind the survey, said cost was the biggest reason parents cited for their kids' lack of insurance.

The news has left advocates torn between cheering the expansion and condemning the White House for preventing what might have been. "I'm grateful for the 250 percent," said Mary Joseph, director of the Children's Defense Fund of Louisiana. "But it's just frightening that [the administration] would come down here and drop all those rules and restrictions on us. We're leaving thousands of children on the side of the road."

The 300-percent proposal was approved by the state last year, when the Democratic government of former Gov. Kathleen Blanco held power. After Republican Gov. Bobby Jindal took office early this year, he appointed Alan Levine -- a one-time health agency appointee under former Florida Gov. Jeb Bush (R) -- as secretary of Louisiana's health department. Citing this changing of the guards, a number of observers suggested that elements of the revised plan reflect a difference in partisan priorities.

"We had a governor and a secretary standing firm over what they thought was in the best interest of children," said Sharon Pomeroy, policy coordinator at Agenda for Children, a New Orleans-based child advocacy group. "Now we've got a new governor and a new secretary, and they've got different ideas about what's in the best interest of children."

Other states have traveled similar roads. In Wisconsin, for example, state officials approved a plan setting a 300-percent eligibility ceiling, but the August guidelines knocked it down to 250 percent. In New York, lawmakers approved a plan taking SCHIP eligibility to 400 percent of poverty. When the administration rejected the proposal last year, the state filed a lawsuit, which is still pending.

Under the new federal guidelines, states wishing to cover children living above 250 percent of poverty must first cover 95 percent of kids living below 200 percent. State officials have equated that to a hard cap, because no state has achieved 95 percent coverage. Still, Louisiana has come close, covering 94.5 percent of that population, according to the LSU survey. It remains unclear, however, how the Centers for Medicare and Medicaid Services, which issued the rules, would determine whether states have complied with them.

Edward Schor, vice president of the Commonwealth Fund, a private health policy institute, said the August guidelines reflect the creativity of a White House frustrated in its failure to enact pet policies through the Democratic Congress. "What they're doing," Schor said, "is using this letter and other regulatory vehicles as a way to accomplish what they couldn't do through Congress."

There are other complaints from state officials and health advocates. The new guidelines, for example, were written specifically for SCHIP programs, but CMS has more recently decided to apply them to Medicaid as well. Also, while the rules set explicit restrictions on states wishing to cover beneficiaries living above 250 percent of poverty, the agency is now applying those same restrictions to kids living below that level. Families taking advantage of Louisiana's new expansion, for example, will have to pay monthly premiums, as well as co-payments for a variety of services afterwards.

Even more controversial, Louisiana kids wishing to move from private coverage into the expansion program must remain uninsured for one year before they are eligible -- a rule originally targeting only states proposing to cover kids living above 250 percent of poverty. Though certain exceptions exist -- such as when kids lose coverage because a parent dies or loses a job -- health advocates question the logic of leaving kids without coverage for so long.

Advocates are also attacking the administration model that Louisiana officials chose for its newly-approved expansion. While the state's SCHIP kids have historically had their services managed through Medicaid, the expanded program will be administered by the Office of Group Benefits, which handles health benefits of state employees. That change, kids' groups say, threatens the seamlessness that has been an asset of the program.

Bruce Lesley, president of the children's health group First Focus, said that keeping the program a part of Medicaid would be far more efficient and inexpensive than coordinating benefits, terminations and other interactions across agencies.

The Autism-Vaccine Connection: Reopened Can of Worms

Arthur Allen — Thu, 06 Mar 2008 19:45:26 GMT

At a news conference in Atlanta on Thursday (which I haven't seen, but read accounts of), the Atlanta parents of 9-year-old Hannah Poling revealed that in November, the vaccine court conceded their claim that vaccines caused her autism-like symptoms. At first glance, this case seems to contradict the scientific consensus that vaccines don't cause autism. Anti-vaccine groups are howling with glee about it. The decision requires some explanation, and it will take a bit of space.

The vaccine court, to back up, is part of the U.S. Court of Federal Claims. Congress set it up in 1988 amid a wave of costly lawsuits over the whole-cell pertussis vaccine, which has since been replaced. The idea of the court is to provide timely compensation to kids demonstrably injured by vaccines. If you want to sue a drug company for a vaccine reaction, you have to come here first. The court protects the drug companies from runaway juries, which helps keep litigation from driving pharma out of the not-terribly-profitable vaccine business.

People don't sue in vaccine court--they file claims, which the government can contest, or concede. In this peculiar little institution, Department of Justice lawyers represent the defendant, which is the Department of Health and Human Services. Special masters--administrative judges schooled in vaccine matters--rule on the cases.

Over the past decade, nearly 5,000 claims from parents with kids on the autism spectrum have flooded the court. To deal with these numbers, the court set up an Omnibus proceeding, similar to those established to deal with asbestosis claims. The court has been planning to run nine test cases out of the bunch. These test cases, which deal with various theories of how the vaccines might have caused autism, would then be used to resolve the thousands of other cases.

The first three test cases have been heard but not yet adjudicated. Poling was to have been one of the next test cases, but her lawyers withdrew the claim and settled on the side. It is extremely important to understand why they did this, because it gives an indication of how typical Poling's case is among the population of autistic kids with claims before the government.

It seems that Poling's case was withdrawn because it's very unusual, and therefore wouldn't be a good test case. Poling developed normally at first, her parents say, then suffered seizures and "autism-like symptoms" after getting five vaccinations when she was 19 months old. Some time later, doctors discovered that she had a mitochondrial disorder, a condition that occurs in about 1 in 4,000 kids and can bring about a range of problems.

Poling's symptoms started with a 102-degree fever a couple days after the shots. This may point to the live, attenuated viruses in the measles-mumps-rubella (MMR) or chickenpox vaccines she received as possible triggers of the reaction. Although this may be the first time that compensation for autism-like symptoms has been awarded by the court, encephalopathy--brain disease--is a rare, but recognized adverse event linked to the MMR shot. The court recognizes such cases, and compensates the children, a few times a year.

If this is the correct scenario, then we could assume Poling is an outlier whose case has nothing to do with the bulk of autism. Epidemiological studies have demonstrated (see Laura's post earlier today) without a doubt that the increased diagnosis of autism is not linked to thimerosal in vaccines or to the MMR shot, the two factors at play in the autism Omnibus.

That said, children with autism or autistic syndromes may have somewhat higher rates of mitochondrial disorders. These underlying conditions are more likely to be triggered by garden-variety infections than by vaccines. Yet there may be additional kids in the autism Omnibus who fit into this category. Whether the course of their problems fit as neatly as Poling's did remains to be seen.

In the past, the court has ruled in dozens of cases of a rare genetic disorder called tuberous sclerosis complex (TSC). Like mitochondrial disorders, this is a condition that often doesn't manifest itself until a child is several months to a few years old. Many parents of TSC children who suffered reactions and subsequent brain disorders following administration of the whole-cell pertussis vaccine--known as DTP--took them to the vaccine court in the 1980s and 1990s. Generally, they lost. The court determined that the underlying condition would have crippled the child regardless of the reaction to the DTP. But in some cases, they won. Incidentally, a small but significant portion of TSS children have "autistic-like symptoms."

To wrap up, this is probably an isolated case, but we won't know for a while. Clearly, though, the anti-vaccine forces, bolstered by the glitter of people like Jenny McCarthy and the wealth of donors like investment banker JB Handley, are going to play it for all they can.

Abortion Ban For American Indians Only

Mike Lillis — Wed, 05 Mar 2008 17:51:09 GMT

Following scant debate, the Senate last week approved an amendment to an Indian health care bill that would permanently prohibit the use of federal dollars to fund abortions for Native Americans except in rare cases. The move has prompted an outcry from women's health advocates -- who point out that a similar ban has existed on a temporary basis for years -- and from tribal groups, who are asking why Native American women should be subject to restrictions not applicable to other ethnic groups. Some charge that the Senate proposal is overtly racist.

The issue is a sensitive one in American Indian communities, where women are statistically more likely to be victims of rape or sexual assault than other American women -- but also where victims very rarely use the exceptions to the current federally funded abortion ban in the wake of those crimes. In the face of that discrepancy, advocates say, Congress should encourage victims to take advantage of the available services, not impose tighter restrictions.

The debate pits anti-abortion lawmakers on both sides of the aisle against health-care advocates who fear the latest move could set the stage for broader abortion prohibitions under federal programs outside the realm of Indian health services. In addition, there is the intrigue of scandal, for the sponsor of the controversial amendment, Sen. David Vitter (R-La.), made headlines last year for his earlier entanglement in a prostitution ring. Several abortion-rights sources suggested that Vitter -- who built his political career on family-values issues -- is trying to bolster his conservative credentials in the wake of that embarrassment.

The controversy swirls around a federal law -- known as the Hyde amendment -- that prohibits abortion coverage under Medicaid, Medicare and Indian Health Service programs. While the Hyde law must be renewed by Congress each year, the Vitter amendment -- which the Senate approved on Feb. 26 -- would apply Hyde's restrictions permanently to IHS beneficiaries. For that reason, tribal health advocates charge that the Vitter language treads on the sovereignty of Indian communities and places unique constraints on native women.

"It's a very racist amendment," said Charon Asetoyer, executive director of the Native American Women's Health Education Resource Center, "[because] it puts another layer of restrictions on the only race of people whose health care is governed primarily by the federal government. All women are subject to the Hyde amendment, so why would they put another set of conditions on us?"

Vitter's office did not return several calls and e-mails requesting comment.

A number of women's health groups have criticized the Vitter amendment as well, claiming it will have no practical effect on women's health services.

"Apart from being bad public health policy," Planned Parenthood said in a statement, "this language is duplicative of current law and serves only to politicize important legislation regarding comprehensive health care for Native Americans."

Though the Hyde amendment -- named for its sponsor, the late Illinois Rep. Henry Hyde (R ) -- first took effect in 1977, Congress must reapply it annually through the appropriations process. That, according to Vitter, puts the Hyde language "in a tenuous and precarious posture. It puts it up for debate and possible change of policy every year, every time we debate a new Health and Human Services appropriations bill. Therefore, it doesn't make the policy very solid, very secure, or very clear."

Vitter's amendment, attached last week to the Indian Health Care Improvement Act, would eliminate that uncertainty by codifying the Hyde amendment as a matter of authorization, not appropriation. "I suggest that would be a positive statement for life, for positive values for the future," he said on the Senate floor Jan. 22 -- the same day that thousands of anti-abortion marchers descended on Washington. A month later, the Senate approved Vitter's amendment by a vote of 52 to 42.

But critics say the creation of a second law governing IHS-funded abortion services might confuse the issue if inconsistencies are found between the two mandates. Indeed, certain elements of Vitter's amendment stray from the Hyde language. For example, while Hyde allows federally funded abortions for victims of incest at any age, Vitter specifies that the incest exception pertains only to minors.

Marlene Fried, a founding board member of the National Network of Abortion Funds, said the practical implications of that difference would be minimal. Still, she added, the change is significant as "another way of narrowing the [Hyde] exceptions."

The issue is especially charged because Native American women are more than three times as likely to suffer rape and sexual abuse as other women in the United States. Yet despite that statistic, only 25 abortions were performed at all IHS facilities between 1981 and 2001, according to figures gathered from the IHS by the Native American Women's Health Education Resource Center. (An IHS spokeswoman declined to release more recent IHS-funded abortion figures, suggesting that a reporter file a Freedom Of Information Act request.)

But, advocates say, Indian women continue to have the procedure off the reservation. "Native American women have abortions," Asetoyer said, "and anyone who tells you differently is out of touch with their community."

Susan Cohen, the director of government affairs at the Guttmacher Institute, a nonprofit reproductive health research group, said the Hyde restrictions don't prevent abortions, but they can delay them as low-income women are forced to save the money to fund the procedures out-of-pocket. That delay, Cohen added, can lead to dangerous complications. "Having later abortions is in no one's best interest," she said.

Meanwhile, some tribal advocates are concerned that the Vitter amendment might carry additional political significance, as the Senate bill now moves to the House for consideration. Several sources said the controversial amendment is potentially a poison pill for the overall bill, for House Democratic leaders have been loathe to codify the Hyde amendment.

Not that the issue is entirely partisan. A number of Democratic lawmakers voted to approve the Vitter provision last week, including Sens. Ken Salazar (Col.), Evan Bayh (Ind.), Robert Byrd (W.Va.), Robert Casey (Pa.), Tim Johnson (S.D.), Mary Landrieu (La.), Ben Nelson (Neb.), Mark Pryor (Ark.) and Majority Leader Harry Reid (Nev.). Of that group, Landrieu and Johnson are up for reelection this year in relative conservative states, with Landrieu facing a tight race.

Three Republicans -- Sens. Susan Collins (Me.), Olympia Snowe (Me.) and Arlen Specter (Pa.) -- voted against the amendment. All three have historic records of bucking their party on the abortion issue.

Vitter, for his part, voted against the final IHCIA bill on the same day that his amendment passed. The final bill was approved, however, by a count of 83 to 10.

The Looming Medicare Crunch

Mike Lillis — Mon, 03 Mar 2008 17:44:06 GMT

The New York Times' Robert Pear has been covering health care policy for years, and today he's got a nice succinct piece about the trouble facing Medicare and Medicaid. It's not a pretty picture. As Pear points out, the cost of the two programs last year was $627 billion, constituting 23 percent of all federal spending. In a decade that dollar figure will double, representing 30 percent of the budget.

Part of the projected increase is a consequence of the retiring Baby Boomers, the first of whom will be Medicare-eligible in 2011. But the more significant factor, experts say, is not the aging population but the rate of health inflation, which is leaping much more quickly than wages, federal revenues and the overall economy. This means that it's not the number of Medicare patients, but the rising cost to treat each one, that's the most significant problem facing the federal budget.

None of this is news. Nor is it difficult to understand why the nation's lawmakers have been slow to react: Politicians are in the business of being liked, and of the few available remedies, none will be popular. Congress will have to raise taxes, cut benefits or increase cost-sharing for beneficiaries. (Most likely, they will choose some combination of all three.)

The question is, when? Because even the presidential candidates -- for all their talk of health care reform -- have said little about how they would address the underlying spending crisis. As Pear writes:

[T]he need for cutbacks is not a popular theme for political candidates wooing voters who want more care at a lower cost.

The Democrats do not say, in any detail, how they would slow the growth of Medicare and Medicaid or what they think about the main policy options: rationing care, raising taxes, cutting payments to providers or requiring beneficiaries to pay more.
Nor do they say how they would overcome the health care industry lobby, which has blocked proposals for even modest reductions in Medicare payment rates.

Instead, scores of lawyers and lobbyists are continually urging Congress to expand Medicare coverage of specific drugs, medical devices, tests and procedures.

This silence, perhaps, is understandable in an election year. But folks who call themselves leaders will soon have some explaining as to why they put the pharmaceutical and device lobbies above the fiscal health of the country they're leaving for future generations. Because the longer they wait to act on health reforms, the more severe the shockwaves emanating from those reforms will be.

As Peter Orszag, director of the Congressional Budget Office, told lawmakers last year: "I think the best time to start is about 10 years ago."

FEMA Sticks to Guns on Temporary Housing

Suemedha Sood — Thu, 28 Feb 2008 14:50:05 GMT

Earlier this month, the Federal Emergency Management Agency and the Center for Disease Control confirmed a health problem that New Orleans residents have been talking about for almost two years. Studies in 2006 revealed that many government-issued trailers that city residents have lived in since Hurricane Katrina were toxic. Government agencies now verify that these Crescent City residents have been breathing formaldehyde fumes that exceed acceptable levels by anywhere from 5 to 60 times. Prolonged exposure to high levels of formaldehyde is known to cause respiratory illness, cancer, headaches, skin rashes, nausea and other health problems.

With this official announcement, many Katrina refugees find themselves displaced again. FEMA must now find replacements for its replacement housing. New Orleans housing experts interviewed by The Washington Independent say that FEMA is -- once again -- going about it in the wrong way.

According to non-profit housing experts, FEMA never really addressed the need for alternative housing for the hundreds of thousands of people who lost their homes in the storm. The agency relied on “temporary” housing -- meaning not-so-temporary stays in trailers, hotels, motels and apartments. Instead of using trailers, local housing experts say, the agency could have funded programs for alternative housing and publicly subsidized housing. Some developers who build community housing say that modular structures are the answer in a case like this.

Modular houses are factory-assembled houses built in sections -- delivered to a site and then built on foundations. The sections are assembled into a single building. The community housing developer Family Resources of New Orleans has advocated for modular housing, saying it is generally high quality, big enough for a family and relatively inexpensive.

"Modular housing is definitely an alternative to creating affordable housing," said Paula Pete, executive director of Family Resources. Family Resources was one of several groups competing for housing funds from FEMA. The group says it would have been able to build 100 modular homes on 12 acres for $13 million, but FEMA chose not to fund the project. With modular homes, says Pete, "There is an opportunity to create an alternative housing community."

Family Resources is one of the many non-profit housing groups saying that the trailer crisis is one example of FEMA's poor housing strategy. Trailers were meant to be temporary, or transitional, housing. Transitional housing for the homeless, for example, provides shelter for about three months; the longest stay might be 18 months. During that time, housing professionals shift people into more permanent homes. FEMA never did that. It offered "temporary" trailers for Katrina victims. But there was nothing temporary about them.

Now that the trailers must be evacuated because of toxicity, FEMA is moving people back into the emergency shelters -- hotels and motels. "Even though [FEMA is now] talking about moving people into hotels -- which have one room,'' Pete said, "that issue of housing should have been the first thing FEMA did."

FEMA says it is working hard to find shelter for those still in trailers. As of 2006, there were 101,174 displaced people in the trailers. On Feb. 1, about 38,297 families still lived in trailers and mobile homes. "Now that the testing results are out," said Alexandra Kirin, the FEMA spokesperson, "we're moving people more quickly. We're giving priority to people with chronic respiratory illnesses and then to anyone who calls with concerns."

FEMA may have been aware of the toxicity issue earlier. In July, Congress subpoenaed documents indicating that FEMA lawyers discouraged officials from pursuing reports about the toxic fumes. That is also roughly when the agency began evacuating trailers.

In early 2006, FEMA first received reports of trailer residents complaining about headaches and nosebleeds. In April 2006, the Sierra Club tested for formaldehyde and found dangerous levels. It wasn't until December 2007, however, that the CDC began testing. Now, the government says it will evacuate all trailers before the summer heat and humidity increase the dangers of formaldehyde.

The agency has been moving people to apartments, hotels and motels. But hotels and motels may not welcome a flood of homeless residents again, says homelessness outreach group the Outreach Center. After all, this time last year, hotels were forced to evict thousands of residents when FEMA ended its hotel subsidy program.

“I cringe to think,” said Keller, “of people having to leave their transitional housing [that] many waited up to a year to receive…to be uprooted and plunked down in ‘emergency shelter’ in hotels. We’re most concerned about the unseen individuals as well—the children as they get uprooted out of school and away from their friends once again.”

Some say public housing could be one answer. The National Low Income Housing Coalition has been calling on the federal government to expand the public housing program to make Section 8 vouchers widely available to Katrina victims. The Section 8 voucher program, created by the Dept. of Housing and Urban Development, provides subsidized housing for low-income families and individuals. "The administration continues to create new, complicated and complex programs," said the national housing organization in a press release, "rather than using existing housing programs which are proven effective and already in place, such as the Section 8 voucher program."

Section 8 vouchers are available now only to people who qualified before Hurricane Katrina hit. HUD provides "housing assistance" for all Katrina survivors, said the public affairs officer Patricia Campbell, but this is limited to help in paying rent. The rapidly increasing rents in New Orleans -- and the lack of apartments -- make HUD's rental assistance programs unsustainable options, says the National Low Income Housing Coalition. Before the hurricane, almost half the city's residents were renters. But the scarcity of rental housing after the destruction of Katrina has nearly doubled rents.

The Outreach Center talks about the lack of safe, affordable housing. “Many of these evacuees,” said Keller, “are elderly and disabled, or single mothers with children who couldn’t afford more than $200-$300 per month before the storms. Fair-market rents in this region are several hundred dollars above that—if you could even find units available.”

The continuing trailer evacuation makes the situation worse for the lowest income renters. It is with these renters in mind that the National Low Income Housing Coalition recommends transferring FEMA rental assistance households to Section 8 housing. Government subsidized housing will provide needed stability for many elderly and disabled residents, the advocacy group says.

But public housing comes with its own problems, says Pete of Family Resources. "There's legislation now in Congress calling for 3,000 housing vouchers," she said. "Even if we had 3,000 housing vouchers, we don't even have 3,000 houses."

Why We Need Universal Healthcare

Arthur Allen — Thu, 21 Feb 2008 21:54:49 GMT

Uninsured women are three times more likely than the well-insured to have their breast cancers diagnosed when it may be too late to cure them, according to a major study published this week by the American Cancer Society. Uninsured patients with colon cancer are twice as likely to be diagnosed in the late stages, it found. Previous, smaller studies have shown similar results, but this piece of research included 3.7 million patients -- about 75 percent of all U.S. cancer patients diagnosed between 1998 and 2004.

Both colorectal and breast cancers can be detected with routine screening, which is precisely what the uninsured don't get. Interestingly, the rate of late-stage diagnosis of ovarian and pancreatic cancers--two diseases that are difficult to detect early--was roughly the same in insured and uninsured patients.

The authors found that Medicaid does a bad job of getting people to doctors before their cancers have progressed; Medicaid patients were nearly as likely as the uninsured to be in Stage III or Stage IV of breast or colon cancer when diagnosis occurred. Hispanics and, especially, blacks, also are more likely to have their cancers diagnosed late, regardless of health insurance status. This points to "social and cultural factors which might limit access" for the poor, the authors write--things as simple as lack of transport and proximity to doctors, or as complex as lack of education, fear, stoicism and denial.

The study appeared in the Feb. 15 issue of Lancet Oncology; the abstract is linked here.

SARS -- The Culprit is Still At Large

Arthur Allen — Thu, 21 Feb 2008 19:43:19 GMT

Five years ago, an epidemic caused by a previously unknown coronavirus, known as severe acute respiratory syndrome (SARS), swept through China and then the world, killing 900 people and setting off a panic with billions in economic damage. Then, almost as suddenly as it sprang upon the unsuspecting world, SARS disappeared.

A few years later, I wrote in Slate that the virus would probably never return. Scientists had discovered that its main wild reservoir was a species of bats, I wrote. But the bat variety of SARS didn't effectively grow in people--it seemed to have mutated after infecting civet cats, a delicacy sold at many Chinese markets.After the epidemic, the Chinese slaughtered the civet cats and said they were closing the so-called "wet markets" at which wild game was sold live. It appeared the virus would

have no way of getting back into humans in a form that could hurt them. Wrong, according to a new study in the biology journal Cladistics (read definition of cladistics here).

The authors, led by Daniel Janies of Ohio State University, used genetic analysis to show that civets were not the first source of human infection. In fact, it was the other way around. Janies and his co-authors conducted an impressive comparison of the genomes of more than 150 coronavirus samples from people, bats, civets, pigs and other animals. The genomic fingerprint of SARS, according to this analysis, shows that bats transmitted the virus to humans. There had to be an intermediary between the two species, because of the poor infectivity of the bat-SARS in human lungs. But the middle-critter wasn't the civet, according to this analysis. "We still see missing links in the history of transfers of SARS from animals to humans," Janies said. "So at present there's no clear explanation about how the virus shifted from bat to human hosts."

The SARS phylogenetic tree--the graphic representation of how the virus evolved--shows that it traveled from bat to the intermediary to humans, and from humans to civets and pigs. In rare cases, late in the outbreak, civets transmitted it back to some people, according to the study, which appears in Cladistics volume 23.

What was the mysterious infector? Scientists are looking. But don't hold your breath.