April 25, 2008
I am surprise there is much of a debate but apparently Congress is still wondering whether it is worth the many millions (ok, 1.3 billion and counting) dollars to continue to support abstinence-only sex education. The LA Times reports,
Continued federal funding of abstinence-only sex education in public schools was debated before a House committee Wednesday amid questions about whether the government should sponsor a program that many experts say doesn't work. Most of the 11 witnesses who appeared before the House Committee on Oversight and Government Reform advocated instead for comprehensive programs that include information about how teenagers can protect themselves from pregnancy or disease if they choose to engage in sexual activity. "The concern that many of us have with abstinence-only programs is the idea that one size fits all," said Rep. Eleanor Holmes Norton (D-D.C.), a member of the panel. . . .
Proponents of abstinence education argued that society should set high standards for teenage sexual behavior. They would prefer, they said, that programs focus on the emotional, physical and societal repercussions of sex outside of marriage.
But several witnesses emphasized that despite 11 years of federally funded abstinence programs, at a cost of more than $1.3 billion, teens are still having sex and becoming infected with sexually transmitted diseases. Those who support comprehensive plans said teens should get the information they need to protect themselves. A study released in December by the Centers for Disease Control and Prevention showed a rise in the teenage pregnancy rate in 2006, the first such increase in 15 years. Between 1991 and 2005, the rate dropped 34%. When the government began funding abstinence-only sex education in 1996, 49 of 50 states signed up for such programs. California did not, and it has never sought such funding. Currently, only 33 states receive federal funds for the programs.
"Seventeen states have now said they will not accept funding," said Dr. Georges Benjamin, director of the American Public Health Assn. "For a health department to give up funding is a very important fact." "Some states have looked at the federal requirements as the federal government telling them they had to only do it one way, and they didn't like it," said the committee chairman, Rep. Henry A. Waxman (D-Beverly Hills).
The federal government funds sex education programs that align to several requirements, including exclusively teaching that abstinence is the only way to avoid out-of-wedlock pregnancies and sexually transmitted infections and that sexual relations are acceptable only within a married, monogamous relationship. . . .
An October 2006 report by the Government Accountability Office found errors in the accuracy of information provided in some abstinence programs. The study was unable to reach any conclusions about the effectiveness of abstinence programs.
Another study, released Tuesday by the Heritage Foundation, a Washington-based conservative policy research center, reviewed 15 programs focused on abstinence education and found that in 11 of them, teenage sexual activity was significantly delayed or reduced. Several witnesses at the hearing questioned whether that study had been properly reviewed before publication.
Genetic Discrimination Bill Passes Senate
The Genetic Information Anti-Discrimination Act (GINA) passed the Senate yesterday. The House is epxected to approved GINA quickly and President Bush has indicated he will sign it. The New York Times reports,
People learning through genetic testing that they might be susceptible to devastating diseases wouldn't also have to worry about losing their jobs or their health insurance under anti-discrimination legislation the Senate passed Thursday. The 95-0 Senate vote sends the Genetic Information Nondiscrimination Act back to the House, which could approve it early next week. President Bush supports the legislation.
The bill, described by Sen. Edward Kennedy as ''the first major new civil rights bill of the new century,'' would bar health insurance companies from using genetic information to set premiums or determine enrollment eligibility. Similarly, employers could not use genetic information in hiring, firing or promotion decisions. . . .
Genetic testing could lead to early, lifesaving therapy for a wide range of diseases with hereditary links such as breast and prostate cancer, diabetes, heart disease and Parkinson's disease. ''But right now the ability to realize those goals is somewhat limited'' because of patients' fears that the information will be used against them, said Dr. David Herrington, a professor of cardiology at Wake Forest University and spokesman on genetic issues for the American Heart Association. The legislation ''will help them both be more willing to participate in research and avail themselves of the benefits of genetic testing.''
Congressional efforts to set federal standards to protect people from genetic discrimination go back more than a decade, to a time when there were only a small number of genetic tests. But now, with the mapping of the human genome in 2003, people have access to far more information about their hereditary disposition to such crippling afflictions as cystic fibrosis, Huntington's disease or Lou Gehrig's disease.
Bill sponsors said that has increased the likelihood that a prospective health insurance company or employer will reject a person because of concerns that person will suffer a costly disease in the future. . . .
A compromise worked out earlier this week tightens language to ensure there is a ''firewall'' between the part dealing with health plans and the section regarding employment, so as to discourage inappropriate claims. It also makes clear that, while individuals are protected from discrimination based on genetic predisposition, insurance companies still have the right to base coverage and pricing on the actual presence of a disease. ''We certainly improved the bill from a liability standpoint,'' said Coburn, an obstetrician. He said he was an adamant supporter of the legislation ''if it is not designed to feed the trial lawyers.'' . . .
April 24, 2008
Knowledge Concerning Medicare Part D's Cost Sharing
The Journal of the American Medical Association has posted the results of a recent study concerning the knowledge of Medicare Part D participants about various cost sharing aspects of this program. The abstract describes the study and the results,
Design, Setting, and Participants Telephone interviews were conducted in 2007 in a stratified random sample of community-dwelling Kaiser Permanente-Northern California Medicare Advantage beneficiaries aged 65 years or older, with a gap in coverage if they exceeded $2250 in drug costs (N = 1040; 74.9% response rate). Half were selected to have reached the gap in 2006. In the source population of Medicare Advantage Prescription Drug plan beneficiaries, 8% entered the coverage gap in 2006. Models were adjusted for individual characteristics and weighted for sampling proportions. . . . . .
Results An estimated 40% (95% confidence interval [CI], 35%-45%) of beneficiaries were aware that their drug plan in 2006 included a coverage gap; knowledge of the gap was greater among individuals who reached the gap during the year. Approximately 36% (95% CI, 32%-41%) of beneficiaries reported at least 1 of the following responses to drug costs: cost-coping behavior (26%), reduced adherence (15%), or experiencing financial burden (7%). In multivariate analyses, beneficiaries with lower household income more frequently reported cost responses (difference of 14.5 percentage points for < $40 000/y vs $40 000/y [95% CI, 3.6-25.4 percentage points]). Compared with beneficiaries who were unaware of having a coverage gap, those who were aware more frequently reported any cost response (difference of 11.3 percentage points [95% CI, 0.8-21.9 percentage points]), but had fewer reports of borrowing money or going without necessities (difference of 5.5 percentage points [95% CI, 1.1-10.0 percentage points]).
Conclusions Beneficiaries in this Medicare Advantage plan have limited knowledge of Part D cost sharing and often report behavioral responses to drug costs. Limited knowledge is associated with fewer reports of cost responses overall, but more reports of financial burden.
Growing Heart Cells
National Public Radio's Morning Edition reported on a new development in the embryonic stem cell research arena. Here is a brief overview:
A team of scientists in Canada has developed an efficient way to produce heart cells from human embryonic stem cells, a significant step for potential organ repair. But the study must move to trials with laboratory animals before the cells can be used with human patients.
Although the cells are not quite ready for use in human patients, the story reported that the scientists believe that these cells can be used to test heart medications before those medications are tested in humans.
April 23, 2008
Preconception Diet and Sex of Baby
The Associated Press reports on a study completed in England showing that women may be able to influence their sex of their child through their preconception diet. CNN.com picks up the story and states,
Women can influence the gender of their child with what they eat before they conceive, according to new research that lends scientific support to age-old superstitions about pregnancy.
The study of 740 women showed that higher calorie intake led to a higher probability of a male birth. The discovery shows higher calorie intake prior to conception can significantly increase the chances of having a son while women on restricted diets are more likely to produce daughters.
Scientists at Britain's Oxford and Exeter Universities, who studied eating habits of 740 women during their first-time pregnancies, say that their findings seem to back certain traditional links between diet and gender while disproving others. . . .
"If you want a boy, eat a healthy diet with a high calorie intake, including breakfast," she told New Scientist magazine. "Of women eating cereals daily, 59 percent had boys, compared with only 43 percent who bore boys in the group eating less than a bowlful per week."
The researchers said that a higher calorie intake prior to conception can increase the chances of having a son from ten to 11 boys in every 20 births, according to the study published in the Proceeding of the Royal Society B.
They said it could explain why male births in richer countries are experiencing a slight reduction.
Genetic Discrimination and Congress
The New York Times reports today on Congress' efforts to confront genetic discrimination. Andrew Pollack reports,
Congress reached an agreement clearing the way for a bill to prohibit discrimination by employers and health insurers on the basis of genetic tests. Senator Tom Coburn, an Oklahoma Republican who had been almost single-handedly holding up action on the bill, said in an interview Tuesday that most of his concerns had been resolved and predicted that the bill would pass soon. Senator Edward M. Kennedy, who is chairman of the Senate Health Committee, said a bipartisan agreement had been reached to move the bill to the Senate floor.
Proponents say the new law, more than a dozen years in the making, would help usher in an age of genetic medicine, in which DNA tests might help predict if a person is at risk of a disease, allowing action to be taken to prevent it.
Some of the tests already exist, like one for breast cancer risk, and new ones are being introduced almost every month. But backers of the legislation say many people are afraid of taking such tests because they fear the results would be used to deny them employment or health insurance. “This bill removes a significant obstacle to the advancement of personalized medicine,” said Edward Abrahams, the executive director of the Personalized Medicine Coalition. His group is an organization of drug and diagnostic companies, academic institutions and patient groups that advocate using genetic information to choose the most appropriate treatment for each patient.
The agreement would end a 13-year odyssey for the bill, first proposed in 1995 by Louise Slaughter, a House Democrat from western New York, who has been promoting it ever since.
The bill, called the Genetic Information Nondiscrimination Act, or GINA, has had broad support in Congress but has never managed to pass both houses in the same session.
It passed the Senate by votes of 95 to 0 in 2003 and 98 to 0 in 2005 but was kept from a vote in the House by Republican leadership. Last year, with Democrats newly in control, the House approved the bill 420 to 3. But this year Senator Coburn had placed a hold on the bill, preventing the Senate from voting on it.
One of Senator Coburn’s main concerns was that the bill might subject employers to civil rights lawsuits stemming from disputes over medical coverage. And employers that also finance their own health insurance, he said, might be sued twice. “We would have created a trial lawyers’ bonanza,” he said. Senator Coburn, a medical doctor, had called for a “firewall” between the employer and insurance sections of the bill. “We withstood all the criticism we got from lots of people, and now we got it fixed,” he said. . . .
GINA would make it illegal for health insurers to raise premiums or deny coverage based on genetic information, and would prohibit employers from using such information for decisions on hiring, firing, promotions or job assignments. Genetic information, for the law’s purposes, would include not only tests that determine variations in a person’s DNA, but also a family history of a particular disease. But GINA does not prohibit discrimination once someone already has a disease, and some experts said such protection would have to be the next step. . . .
Some experts, while welcoming the bill, said it did not go far enough.
Mark A. Rothstein, director of the bioethics institute at the University of Louisville School of Medicine, said GINA did not cover life insurance and long-term care insurance and that there already were legal ways for prospective employers to gain a job candidate’s health information. “GINA promises more than it delivers,” he said.
Growing Body Parts
In Slate.com, William Saleton reports on the latest military advance - growing body parts. He writes,
The regeneration of lost body parts has just moved from science fiction to U.S. military policy. Yesterday the Department of Defense announced the creation of the Armed Forces Institute of Regenerative Medicine, which will go by the happy acronym AFIRM. According to DOD's news service, AFIRM will "harness stem cell research and technology … to reconstruct new skin, muscles and tendons, and even ears, noses and fingers." The government is budgeting $250 million in public and private money for the project's first five years. NIH and three universities will be on the team. . . .
If you've been following Human Nature for the past three years, you know that tissue regeneration is well underway. The military has been working on regrowing lost body parts using extracellular matrices. Scientists in labs have grown blood vessels, livers, bladders, breast implants, and meat. This year they announced the production of beating, disembodied rat hearts. At yesterday's press conference, Army Surgeon General Eric Schoomaker explained that our bodies systematically generate liver cells and bone marrow and that this ability can be redirected through "the right kind of stimulation." . . . .
The wars in Iraq and Afghanistan, waged in large part through improvised explosive devices, have produced nearly 1,000 U.S. military amputees. Many other service members have lost eyesight or suffered burns or spinal-cord damage. We all want to help these young people recover. We've seen inspiring stories of doctors outfitting them with prosthetic limbs. If only we could make them truly whole again. And now we can.
At the press conference, Schoomaker displayed pictures of a wounded Marine whose disfigured features could be restored only through tissue regrowth. He vowed to "redefine the Army and military medicine." The Defense Department's assistant secretary for health declared a goal of "getting these people up to where they are functioning and reintegrated, employed, [and] able to help their families and be fully participating members of society."
It's a familiar and worthy goal. And it has to be, because in the larger context of human history, its job is to ease us across the mind-blowing threshold of human regeneration. If my daughter loses a tooth, she may be able to grow it back. If my son loses a finger, the work pioneered by AFIRM early in his life may be able to help him.
Warfare will never be the same again, either. American military medicine is already saving the lives of soldiers who would have died in previous conflicts. Yesterday's death is today's wound. Now we're raising the ante: Today's permanent wound will be tomorrow's bad memory. Blow off our fingers, and we'll grow them back.
Further down the road, other possibilities will emerge. If we can restore a soldier's original muscle strength, we can probably add to it. The military is already encouraging soldiers to get LASIK, which improves some people's eyesight beyond 20/20. It's hard to believe we won't continue to improve that surgery and systematize it across the armed forces. Most of us civilians will face these revolutions when we're ready. By then, like AFIRM, they'll already be here.
April 22, 2008
Life Expectancy Drops for American Women
The Washington Post reports today on an unexpected drop in American women's life expectancy in a study conducted by PLoS Medicine. The study also shows a smaller decline in life expectancy for men as well. David Brown writes,
For the first time since the Spanish influenza of 1918, life expectancy is falling for a significant number of American women. In nearly 1,000 counties that together are home to about 12 percent of the nation's women, life expectancy is now shorter than it was in the early 1980s, according to a study published today.
The downward trend is evident in places in the Deep South, Appalachia, the lower Midwest and in one county in Maine. It is not limited to one race or ethnicity but it is more common in rural and low-income areas. The most dramatic change occurred in two areas in southwestern Virginia (Radford City and Pulaski County), where women's life expectancy has decreased by more than five years since 1983.
The trend appears to be driven by increases in death from diabetes, lung cancer, emphysema and kidney failure. It reflects the long-term consequences of smoking, a habit that women took up in large numbers decades after men did, and the slowing of the historic decline in heart disease deaths. It may also represent the leading edge of the obesity epidemic. If so, women's life expectancy could decline broadly across the United States in coming years, ending a nearly unbroken rise that dates to the mid-1800s.
"I think this is a harbinger. This is not going to be isolated to this set of counties, is my guess," said Christopher J.L. Murray, a physician and epidemiologist at the University of Washington who led the study. It is being published in PLoS Medicine, an open-access journal of the Public Library of Science. Said Elizabeth G. Nabel, director of the National Heart, Lung and Blood Institute of the National Institutes of Health: "The data demonstrate a very alarming and deeply concerning increase in health disparities in the United States." The study found a smaller decline, in far fewer places, in the life expectancy of men in this country. In all, longevity is declining for about 4 percent of males. The phenomenon appears to be not only new but distinctly American. "If you look in Western Europe, Australia, Japan, New Zealand, we don't see this," Murray said. . . .
Life expectancy is not a direct measure of how long people live. Instead, it is a prediction of how long the average person would live if the death rates at the time of his or her birth lasted a lifetime. For that reason, life expectancy can dip or rise abruptly. The death rate from the Spanish flu was so high, especially among the young, that life expectancy fell by about seven years in 1918. But it rebounded quickly when the epidemic was over. . . .
In the study, Murray and collaborators at the Harvard School of Public Health examined mortality and cause-of-death data for the United States from 1961 through 1999. They divided the country into 2,068 units, including cities, counties or combinations of counties . . . .
April 21, 2008
Illinois Court Rules on Sterilization of Mentally Disabled Woman
The Chicago Tribune reports on a recent decision by the Illinois Appellate Court that denied a request to sterilize a mentally disabled woman against her will. Michael Higgins writing for the Tribune states,
Disability rights advocates and medical ethicists praised a precedent-setting ruling Friday by the Illinois Appellate Court denying a bid to sterilize a mentally disabled woman against her will.
The woman, identified only as K.E.J. in court records, isn't capable of raising a child on her own, but her guardian failed to prove that sterilization would be in her best interests, a three-judge panel in Chicago ruled unanimously.
"Tubal ligation is a particularly drastic means of preventing a mentally incompetent ward from becoming pregnant," Judge Joseph Gordon wrote in the 36-page opinion. There are "less intrusive and less psychologically harmful [birth-control] alternatives."
The ruling was the first appellate opinion on the issue in Illinois. "It's extraordinarily significant" because it guarantees the disabled a court hearing, said Katie Watson, a Northwestern University professor who wrote a friend-of-the-court brief in the case on behalf of about two dozen medical ethicists. "In the past, this was a decision that could be made between a guardian and a doctor," she said. "The decision must be moved into the light." The ruling means a guardian must go through some "significant legal hoops" before a court will order sterilization, said the woman's attorney, John Whitcomb of Equip for Equality, a disability rights group. . . .
Thanks to Cara at Feministe for the link.
Health Care Stories
RoCali at Daily Kos shares his health care story and asks that others write in to share their stories as well. The goal is to educate those individuals who still seem to believe that people without health insurance or who become ill are somehow at fault for any failures of the health care system to provide coverage. RoCali writes,
Here's one story of how living the American dream became a tale of waking up in the American medical insurance nightmare. This is only one story of millions that are developing right now and the millions that are yet to evolve. I know many of you have your own tale and I would be grateful if you would share it. Sometimes we start feeling that maybe this was our fault, that we alone got sucked down into this morass, buying into the hype that if we had been smarter or more industrious we could have avoided this. Let's remind ourselves that we are not some aberrent failure, but rather we got caught in a broken system.
About 15 years ago, I was 35, working in a local law firm, raising two children, and had a home in a nice family neighborhood. One day, I woke up not feeling so well. It's that simple when I look back, to recognize the starting point at which my life began to veer off the path I had so carefully laid. I felt tired and achey. A couple of days later, a terrible pain started in my back and after a few hours, my fever spiked to 106. I was admitted to the hospital, delirious. It seemed like no big deal to me when it was determined I had a severe kidney infection. I was in the hospital for a couple of weeks, yet when I was released I still had an infection, although I was stable. I had begun a ten year battle to rid my body of a super-infection. As happens in dominoes and houses of cards, things began to fall in a pattern.
My super-infection battle encompassed repeated bouts of pneumonia, kidney infections, and bizarre systemic infections. Then came the diagnosis of an auto-immune disorder, followed by muscle and nerve problems in my shoulders, and then joint problems in my hands, feet, and knees. Recently, after breaking my back and some ribs, it was determined that I have severe osteoporosis, just weeks before my 50th birthday. Over these years, I had numerous hospitalizations, surgeries, treatments, therapies, and incurred massive medical bills. When I first lost my job, I was relieved that my spouse's insurance would cover me. That insurance left with my spouse, who tired of the stress right after we went bankrupt seven years ago.
The only asset I managed to save between bankruptcy and divorce was the home my children were raised in. I had to sell it about four years ago when my COBRA insurance ran out and I was forced to turn to HIPPA for medical insurance coverage. HIPPA was the only program I could find for a middle aged woman with extensive pre-existing conditions. The premiums were more than double my COBRA payments, with less coverage and much higher deductibles and co-pays. Each year, HIPPA has lowered my coverage and/or increased my out-of-pocket expenses. From the equity I garnered when selling my home, I can cover another ten months, possibly, of premiums and co-pays. I'm still only able to work a few hours a week and that is not likely to change in the immediate future. At times, I have tried to increase my working hours, only to suffer serious health deteriorations shortly after, setting me back months or even years. My retirement accounts have long since been spent. My health care premiums for this are now over $600 per month. My co-pays for medication alone are about $630 per month at this time. Without insurance, the costs of just my medications exceed $3,000 per month, so letting health insurance go is not a palatable option.
Please, don't misunderstand me. I am not laying all these personal details out so someone will say, "oh, how sad." The point I'm attempting to make here is how easily this can happen, in the blink of an eye, to any of us. No matter how hard you work, how smart you are, or what great physical shape you keep yourself in, all it takes is an unfortunate moment and the landscape of your life is dramatically altered. I'm spending my days being grateful I've managed thus far, unlike so many of my fellow citizens who could not keep up and have fallen by the wayside, some to their death. I am truly one of the lucky ones. I have had a supportive family and sufficient assets to bring me through thus far. But so many of our neighbors, friends, and co-workers have not been as fortunate as I. They had nothing to fall back on, they are alone, they are in pain, they are ill, they are frightened, and they see no place left to turn. . . . .
In the wealthy and powerful nation called America, the divide between classes continues to grow. Many of those that live on the better side of that divide are woefully ignorant of the plight of the other side. The growing divide is particularly evident in matters of health. While our nation claims the best medical technology and advances, that is little comfort to the large number of citizens that cannot afford such miraculous treatment. It's a bit like holding a loaf of bread just beyond the starving person's reach, tantalizing, frustrating, and often breeding despair. Yet a certain segment of our population remains oblivious. Their attention is garnered only when their pocketbook is directly affected by taxation or when the unthinkable happens to even them. They also do not realize the subtle ways this disaster costs them on a daily basis, through increased costs, decreased production in the workplace, and other long-reaching effects of a lack of adequate medical care on a large populace.
Please, share your story with me. Let's join our voices together until even the other side of the divide cannot help but hear and acknowledge the tumult. Every time we step in the voting booth, we need to remember the millions of voices asking, not for charity, but begging for a fair shake. We also need to remember the voices that have been silenced and we bear the responsibility for speaking out in their names. Disparity thrives best in shadow and silence. Let us throw the light on this issue and raise our collective voices, if not for ourselves, for those who can't.
April 20, 2008
Plastic Bottles/BPA Update
The New York Times updates the recent concern Congress and the Canadian government have shown over the use of BPA (bisphenol-A) in many plastic children's items - including baby bottles and other products that children put in their mouths. Ian Austin provides this information,
The Canadian government moved Friday to ban polycarbonate infant bottles, the most popular variety on the market, after it officially declared one of their chemical ingredients toxic. The action, by the departments of health and environment, is the first taken by any government against bisphenol-a, or BPA, a widely used chemical that mimics a human hormone. It has induced long-term changes in animals exposed to it through tests.
Also on Friday, Senator Charles E. Schumer, Democrat of New York, said he intended to introduce on Monday a bill that would ban many uses of BPA-related plastics. It would prohibit them in all children’s products, including nonfood items they may put in their mouths, as well as in any product used to contain food or beverages. . . .
But in Washington, Steven G. Hentges, the head of the American Chemical Council’s polycarbonate group, told reporters in a teleconference: “We do not think that bans on bisphenol-a are based on science.” Shannon Jenest, a spokeswoman for Philips Avent, which makes bottles from polycarbonate and other materials, said she “wouldn’t see us challenging” the Canadian health department. . . .
Most of Canada’s major retailers, including the Canadian units of Wal-Mart and Sears, have rushed to remove food-related BPA products from their stores. The country’s largest druggist, Shoppers Drug Mart, took the step at its 1,080 stores on Friday.
Senator Schumer said in an interview that he was prompted to act by the Canadian announcement and a report from the United States Department of Health and Human Services this week, which endorsed a scientific panel’s finding that there was “some concern” about the health effects of the chemical. “It’s better to be safe than sorry,” he said. “There are alternatives.” Senator Schumer added that his bill would give industry a substantial amount of time to switch to other plastics.
Children's Health Care Update - Some Good News
The New York Times reports that the Bush Administration has suffered a setback in its attempt to restrict the States ability to expand the availability of SCHIP funds to middle-income families. President Bush had issued an August 17th Directive placing rather difficult to meet preconditions on the States before the States could expand their SCHIP programs. Robert Pear writes,
The Bush administration violated federal law last year when it restricted states’ ability to provide health insurance to children of middle-income families, and its new policy is therefore unenforceable, lawyers from the Government Accountability Office said Friday.
The ruling strengthens the hand of at least 22 states, including New York and New Jersey, that already provide such coverage or want to do so. And it significantly reduces the chance that the new policy can be put into effect before President Bush leaves office in nine months.
At issue is the future of the State Children’s Health Insurance Program, financed jointly by the federal government and the states. Congress last year twice passed bills to expand the popular program, and Mr. Bush vetoed both. State officials of both parties say the policy, set forth in a letter to state health officials on Aug. 17, has stymied their efforts to cover more children at a time when the number of uninsured is rising and more families are experiencing economic hardship.
In a formal legal opinion Friday, the accountability office said the new policy “amounts to a marked departure” from a longstanding, settled interpretation of federal law. It is therefore a rule and, under a 1996 law, must be submitted to Congress for review before it can take effect, the opinion said. But Jeff Nelligan, a spokesman for the federal Centers for Medicare and Medicaid Services, said, “G.A.O.’s opinion does not change our conclusion that the Aug. 17 letter is still in effect.” The letter told states what steps they needed to take to be sure the children’s health program would not displace or “crowd out” private coverage under group health plans. The White House cited the policy as a justification for rejecting a proposal by New York State to cover 70,000 additional youngsters.
What happens next is not clear. New York, New Jersey and several other states have filed lawsuits challenging the Bush administration policy. In addition, Congress may consider legislation to suspend the directive. . . .
The 1996 law, the Congressional Review Act, was enacted to keep Congress informed about the rule-making activities of federal agencies. If Congress objects to a new rule, it can pass “a joint resolution of disapproval,” which the president can sign or veto. Under the Aug. 17 directive, states cannot expand the Children’s Health Insurance Program to cover youngsters with family incomes over 250 percent of the federal poverty level ($53,000 for a family of four) unless they can prove that they already cover 95 percent of eligible children below twice the poverty level ($42,400). Moreover, in such states, children who lose or drop private coverage must be uninsured for 12 months before they can enroll in the Children’s Health Insurance Program, and co-payments in the public program must be similar to those in private plans. . . .
The Justice Department contends that the letter is “merely a general statement of policy with nonbinding effect,” But Gary L. Kepplinger, general counsel of the accountability office, said administration officials had treated it as “a binding rule.”