July 12, 2008
White House Vows Veto of Medicare Bill
Writing for the Los Angeles Times, Nicole Gaouette reports on the continued tension over the Senate's approval of the Medicare Bill, which would avert fee cuts to doctors who treat patients under the federal program. Gaouette writes,
The White House on Thursday [July 10, 2008] renewed a vow to veto popular legislation that would avert imminent fee cuts to doctors who treat patients under the federal Medicare program.
The threat came even as Democratic leaders confidently predicted that enough Republicans would side with them to ensure that the bill, which affects 44 million seniors and an additional 9 million military personnel, will become law.
If President Bush does not reconsider a veto, "rest assured that we will make very sure that this bill becomes law through a veto override," said House Speaker Nancy Pelosi (D-San Francisco).
While Democrats and the White House jousted, groups representing seniors pressed the administration to reconsider its veto threat and urged the bill's Republican supporters to help lobby the White House as well.
The Medicare Improvements for Patients and Providers Act would cover the fee cut by taking money from private healthcare insurers. These companies offer Medicare to about 20% of the program's beneficiaries.
Democrats noted that the private insurers charge more than traditional Medicare does, and that the only group to oppose the bill represented private insurers. Republicans countered that private insurers offer seniors more choice.
"Taking choices away from seniors in order to pay for the reimbursement for physicians is the wrong way to pass this bill," said White House spokesman Tony Fratto.
"Does the president still intend to veto this bill?" he asked rhetorically. "The answer is yes."
The American Medical Assn. has found that up to 60% of doctors will begin limiting the number of Medicare patients they see if the reimbursement cut goes into effect July 15. Small annual cuts were part of a 1990s deficit-reduction law, but Congress has almost always waived them. This year, their cumulative effect has risen to 10.6%. Republicans and Democrats agree that the cuts should end, but not on how to do it.
"If the president vetoes the bill, he's taking away the ability of patients to see their physicians, and the ultimate choice is whether a physician is able to see patients," said Dr. James Rohack, the AMA's president-elect.
Rohack said seniors and military families in rural areas would be most affected by the cut in reimbursements.
The military healthcare system, Tricare, bases its reimbursement rates on Medicare, and military groups have said they fear that fewer doctors will be willing to treat active and retired military personnel and their families if Bush vetoes the bill.
The bill passed the Senate in a dramatic vote Wednesday, propelled by the surprise appearance of Sen. Edward M. Kennedy (D-Mass.), who is recovering from surgery for brain cancer. What many expected to be a close vote became a 69-30 rout as one Republican after another -- 18 in all -- lined up to support a bill that had failed by one vote a month earlier.
An identical bill passed the House in June by an overwhelming 355-59 vote. Overriding a veto requires a two-thirds majority of those present and voting in both the House and the Senate.
Suit Alleges Inadequate Care of Hepatitis C Outbreak in California Prisons
The Los Angeles Times reports on a federal class-action lawsuit alleging that the California Department of Corrections and Rehabilitation is wrongly excluding thousands of inmates from proper diagnostic testing and treatment. Up to 40% of the 171,000 inmates in state prisons may be infected by hepatitis C. Patrick McGreevy writes,
California prison officials are failing to adequately treat an outbreak of hepatitis C that has infected thousands of inmates, a federal class-action lawsuit alleged Tuesday [July 8, 2008].
The lawsuit was filed in Los Angeles on behalf of inmates including Kevin Jackson, who is at the California State Prison at Solano and alleges that he has not received proper treatment since being diagnosed with the disease in August 2007.
Up to 40% of the 171,000 inmates in state prisons may be infected with hepatitis C, said Shawn Khorrami, an attorney for Jackson.
The lawsuit alleges that the California Department of Corrections and Rehabilitation is wrongly excluding thousands of inmates from liver biopsies and antiviral treatments and allowing their diseases to progress to more advanced stages of liver damage. Khorrami said the lack of proper diagnostic testing and treatment further spreads the disease among inmates.
"The Department of Corrections is playing judge, jury and executioner and doling out a punishment that no court would allow," Khorrami said. "This is unacceptable, inhumane and constitutes cruel and unusual punishment."
The lawsuit against Robin Dezember, director of the Division of Correctional Health Care Services for the prison system, is the latest in a string of legal challenges alleging that officials have failed to provide adequate medical care to inmates.
In response to previous litigation alleging substandard treatment of chronic diseases, the federal court appointed J. Clark Kelso as a receiver authorized to take control of and overhaul healthcare in the prison system. Kelso has been pressuring the state to spend billions of additional dollars to upgrade medical treatment for inmates, including the addition of 10,000 hospital beds in the prison system.
As a result, the receiver believes that the lawsuit is redundant, spokesman Luis Patino said.
"This lawsuit is seriously flawed," he said. "I can't imagine how many times the same class is going to sue the same agency for the same reason."
Kelso is aware of the problem with treating hepatitis C and "it is already being fixed," Patino said.
However, Khorrami said the receiver has not made enough progress in addressing the epidemic, which has the potential to affect the general public as infected prisoners are released into their communities.
July 11, 2008
States Moving Toward Comprehensive Health Care Reform
With the problem of the uninsured continuing to grow, states have taken the lead in developing proposals to reform their health care systems with the goal of significantly increasing the number of people with health care coverage. Three states, Maine, Massachusetts and Vermont, have enacted and are implementing reform plans that seek to achieve near universal coverage of state residents. Many other governors and legislators have announced comprehensive reform proposals or have established commissions charged with developing recommendations on how to expand coverage. As of July 2008, three states have enacted and fourteen states are moving toward comprehensive reform.
With Nudge by Kennedy, Medicare Bill Passes
The Washington Post reports on the recent approval of the Medicare Bill due in part to Senator Kennedy's encouragement. Paul Kane writes,
The legislation was approved by a veto-proof margin, 69 to 30, after falling one vote shy of passage less than two weeks ago. Kennedy cited that close vote, and his potential to make a difference, as the reason for his reappearance…
Kennedy cast his vote to prevent a 10.6 percent cut in payments to doctors who treat Medicare patients. On June 26, just 59 senators voted in favor of the legislation, which needed 60 votes to overcome Republican objections to the bill. Kennedy was not present for that vote.
The cuts in that program, which supporters say benefits elderly patients in rural communities, would allow Democrats to postpone the pay cut to doctors for 18 months but would cost the insurers $14 billion over five years.
Yesterday, attended a luncheon of Senate Republicans just hours before the vote, speaking against the Medicare legislation and assuring senators that Bush would veto the bill, according to sources familiar with the meeting.
Despite Cheney's lobbying, 18 Republicans supported the measure -- twice as many as last time. All 49 Democrats and both independents voted for it.
Democrats credited Kennedy's vote as the moment when some Republicans realized the bill would be approved, offering them a last chance to side with physicians. "Once we hit 60, it became a lot more," said (D-Ill.)…
Since the initial vote, Republicans had come under intense pressure from the , which aired advertisements in states where such Republicans as who opposed the provision, were facing reelection. The Texas chapter of the AMA withdrew its endorsement of Cornyn after his first vote. Yesterday, he switched sides.
The Medicare fee reductions are based on a funding formula more than a decade old that requires payment cuts to doctors whenever the growth rate in Medicare costs climbs above the growth in the gross domestic product.
Soaring health-care costs have caused regular payment cuts, but Congress has postponed them. The current reduction took effect July 1, but the government has said it would delay processing claims until early next week.
July 10, 2008
Animal Rights in Spain
William Saletan has a brief piece discussing recent legislation in Spain that makes it illegal to "kill or deprive of liberty" Great Apes. He is rather critical and writes,
The resolution, approved last week by a parliamentary committee with broad support, urges the government to implement the agenda of the Great Ape Project, an organization whose founding declaration says apes "may not be killed" or "arbitrarily deprived of their liberty." No more routine confinement. According to Reuters, the proposal would commit the government to ending involuntary use of apes in circuses, TV ads, and dangerous experiments. . . .
If the idea of treating chimps like people freaks you out, join the club. Creationists have been fighting this battle for a long time. They realized long ago that evolution threatened humanity's special status. Maybe you thought all this evolution stuff was just about the past. Surprise! Once you've admitted chimps are your relatives, you have to think about treating them that way. That's why, when the Spanish proposal won approval last week, GAP's leader in Spain called it a victory for "our evolutionary comrades."
Opponents view the resolution as egalitarian extremism. Spain's conservative party frets that it would grant animals the same rights as people. Spanish newspapers and citizens complain that ape rights are distracting lawmakers from human problems. Wesley Smith, my favorite anti-animal-rights blogger, sees the resolution as the first step in a campaign to "elevate all mammals to moral equality with humans." Ultimately, Smith warns, "Animal rights activists believe a rat, is a pig, is a dog, is a boy." . . .
GAP is scientifically honest. And science doesn't show mental parity between great apes and human adults. What it shows, as the group's president acknowledges, is that great apes "experience an emotional and intellectual conscience similar to that of human children." Accordingly, the Spanish proposal doesn't treat apes like you or me. It treats them like "humans of limited capacity, such as children or those who are mentally incompetent and are afforded guardians or caretakers to represent their interests." . . . .
Opening your mind to science-based animal rights doesn't eliminate inequality. It just makes the inequality more scientific. A rat can't match a pig, much less a boy. In fact, as a GAP board member points out, "We are closer genetically to a chimp than a mouse is to a rat."
George Orwell wrote the cruel finale to this tale 63 years ago in Animal Farm: "All animals are equal. But some animals are more equal than others." That wasn't how the egalitarian uprising in the book was supposed to turn out. It wasn't how the animal rights movement was supposed to turn out, either.
Reuters reports on the legislation and states,
Spain's parliament voiced its support on Wednesday for the rights of great apes to life and freedom in what will apparently be the first time any national legislature has called for such rights for non-humans. Parliament's environmental committee approved resolutions urging Spain to comply with the Great Apes Project, devised by scientists and philosophers who say our closest genetic relatives deserve rights hitherto limited to humans.
"This is a historic day in the struggle for animal rights and in defense of our evolutionary comrades, which will doubtless go down in the history of humanity," said Pedro Pozas, Spanish director of the Great Apes Project. . . .
The new resolutions have cross-party or majority support and are expected to become law and the government is now committed to update the statute book within a year to outlaw harmful experiments on apes in Spain.
For more information about the legislation and the rationale behind it, click here.
AMA Apologizes for Discrimination
The country's largest medical association issued a formal apology today for its historical antipathy toward African American doctors, expressing regret for a litany of transgressions, including barring black physicians from its ranks for decades and remaining silent during battles on landmark legislation to end racial discrimination. The apology marks one of the rare times a major national organization has expressed contrition for its role in the segregation and discrimination that black people have experienced in the United States.
The American Medical Association (AMA) issued the apology after assembling a panel of experts to analyze the history of the racial divide in medicine. The independent panel has produced a report, due to be published in the July 16 Journal of the American Medical Association, which explores the longstanding historical discrimination.
"The apology is important because a heritage of discrimination is evident in the under-representation of African Americans in medicine generally and in the AMA in particular," said the report's lead author, Robert B. Baker, professor of philosophy at Union College in Schenectady, New York and director of the Union Graduate College-Mount Sinai School of Medicine Bioethics Program. "Patterns of segregated medicine still haunt American health care. The legacy of these decisions affects minority patients on a daily basis." . . .
The panel noted that the AMA permitted state and local medical associations to exclude black physicians, effectively barring these doctors from the national organization. In the early 20th century, the organization listed black doctors as "colored" in its national physician directory. In addition, the AMA was silent during debates over the landmark Civil Rights Act of 1964, and, for years, declined to join efforts to force hospitals built with federal funds to not discriminate . . . .
Richard Allen Williams, a clinical professor of medicine at the University of California at Los Angeles and the president of the Minority Health Institute, said the apology is "an excellent gesture of goodwill." "I applaud the AMA for doing this. In the current climate of health care, it is a very timely gesture," he said. "Less than 5 percent of physicians are African Americans, and that needs to be changed. This cannot be changed by African American physicians alone, and we all need to move forward together.". . .
July 9, 2008
Goodbye to the Primacy Care Physician: A Health Care Crisis ...
Salon.com reports on the "passing" of the primary care/family doctor. Robert Burton writes about the shortage of primary care physicians in the United States and what this means for our health care system as well as noting how the shortage is being partially solved by the hiring of doctors from countries that cannot afford to lose those professionals
. . . The current healthcare debate about accessibility and affordability reminds me of a committee of well-intended E.R. doctors furiously debating the optimal cost, shape and efficiency of various tourniquets, while a casualty victim slowly bleeds to death. Better and more widespread and affordable health insurance won't be of value if you can't find a primary care provider willing and happy to treat you.
Make no mistake: Primary care is the backbone of a good medical system. No matter how great our latest medical technologies, most of our illnesses are best screened or handled by the family practitioner. You don't need a gastroenterologist to treat an ulcer or irritable bowel. You don't need a pulmonologist to treat most cases of asthma and emphysema. And you don't need an orthopedist for most aches and pain. . . .
But primary care physicians -- those trained in family medicine and general internal medicine -- are an endangered species. It's only a bit of hyperbole to say that, if the trend continues, the family doctor will become a fond memory, a nostalgic reminder that the medical system once had a more human face and sense of community . . . .
Currently, roughly 200,000 family practitioners and general internists practice in the U.S. One-third are over 55 and are likely to retire within five to 10 years. Meanwhile, an alarmingly low percentage of students are choosing to become primary care physicians. . . .
To underscore the general lack of recognition of the declining appeal of a primary care practice, consider that in 1976, a Department of Health and Human Services Advisory Committee predicted a surplus of 145,000 primary care physicians by the year 2000. And yet, in 2004, revised estimates suggested that by 2020 there will be a shortage of 90,000 to 200,000 physicians. . . .
This physician distribution is also geographic: Only 11 percent of the primary care physician workforce has opted to serve the 20 percent of Americans who live in non-metropolitan or rural areas. The smaller the community, the more dismal are the prospects of attracting a physician. Many communities are desperate for any warm medical body.
As a consequence of this overall shortage and distribution, more primary care positions are being taken by foreign medical school graduates. Nearly half of the internal medicine and primary care residency slots are now filled by foreign graduates; one in four new practicing physicians in the U.S. is an international medical graduate. . . .
A further ignored issue is how to supervise the education of those trained elsewhere. U.S. medical schools are subject to strict regulation. We don't have a similar mechanism for observing foreign training. Here's a scary set of statistics. According to a New York Times article by Leana Wen, M.D., Rhodes scholar and Global Health Fellow at the World Health Organization in Geneva, "Lower-income countries supply between 40 to 75 percent of U.S.-based, foreign-trained doctors." During a recent tour of the medical schools of three African countries, Wen was astounded to find that none of the students had been supplied with medical textbooks.
Earlier this year in the New England Journal of Medicine, Dr. Ranjana Srivastava, a medical oncologist and internist in Melbourne, Australia, wrote of his experiences tutoring foreign medical graduates, who are trying to obtain a medical credential in Australia. It's a moving description of foreign doctors' plight. Srivastava acknowledges the overwhelming cultural disadvantages the doctors face in crossing the "bridge" to standard Western practice. "I have observed over the years that most foreign doctors receive little encouragement, advice, or collegiality from a medical hierarchy engrossed in its own needs," he writes. And some days, he confesses, "their needs are much larger than I had ever imagined or feel equipped to handle.". . . .
In 2005, British Medical Association chairman James Johnson described the siphoning off of African-trained physicians to the U.K. as morally indefensible, as reported by the BBC. The examples are startling. In Zambia, only 50 out of 600 doctors trained since independence are still practicing in the country. Three-quarters of Zimbabwe's doctors have left since the early 1990s. More than half of all Ghana's doctors have left the country. Yes, our primary concern is providing adequate medical care in the U.S.. But we also need to be aware of how our solutions create shortages elsewhere and have obvious global implications.
In addition to how to best provide universal health coverage in the U.S., we need real debate about how we want our medicine to be delivered. Even if we were to arrive at a perfect solution, it would be six to eight years before these changes affected present primary care physician demographics. The answers aren't obvious and require real innovative thought. We need to restore family practice to a level of desirability that will attract the smart and the compassionate. Otherwise we can count on a dramatic rise in two-tier medicine, continuing geographic mal-distribution of medical care and an increasing reliance upon the physicians of other countries and lesser trained medical personnel to bail us out. Not a pretty picture and not a great stump speech for a political candidate, yet a brewing disaster we cannot continue to ignore.
Medicare Reform Discussion
Today, the Diane Rehm show discusses the Medicare Reform bill currently stuck in Congress. The brief overview states,
Senate Republicans are under pressure to pass legislation reversing scheduled pay cuts for doctors who care for Medicare patients. The White House has threatened a veto. An update on the latest efforts to rein in Medicare costs and reform battles ahead over entitlement spending.
Guests include: Ron Pollack, executive director of Families USA; Stephen Moore, member of the Wall Street Journal's editorial board and former President of the Club for Growth; Julie Rovner, health policy correspondent for National Public Radio, author of "Health Care Policy and Politics A-Z," and contributing editor for National Journal's CongressDaily.
Should be an interesting discussion. If you miss it, the podcast will be available later.
July 8, 2008
FDA Responds to Antibiotic Risks
The Washington Post reports on today's news that the FDA has issued an urgent warning concerning the cipro and other similar antibiotics. The risk is that a tendon rupture could occur requiring extensive surgery. Although some tendon injuries occurred without any warning, the FDA advised that if a patient experiences inflammation, the use of such drugs should be discontinued.
Ad Buys and Organizing for Health Care Reform
Ezra Klein provides the latest ad promoting health care reofrm from the new organization Health Care for America Now. He reports that the supporters of health reform have learned many lessons from their failures during the Clinton administration. He writes,
. . . . . So it's of both enormous practical and symbolic significance that, in 2008, the first major health reform coalition with serious money and a genuine pressure plan is on the left. Health Care for American Now is a joint venture founded by a Who's Who of progressive organizations. The primary partners -- which is to say, those who put up $500,000 to join -- are include The American Federation of State, County and Municipal Employees, Americans United for Change, Campaign for America’s Future, Center for American Progress Action Fund, Center for Community Change, MoveOn.org, National Education Association, National Women’s Law Center, Planned Parenthood Federation of America, Service Employees International Union, United Food and Commercial Workers, and USAction. Within that list are old guard groups like Labor and new wave organizations like MoveOn. Both Change to Win and the AFL-CIO are represented. Standing behind them are a much larger list of coalition partners that include the American Nurses Association, the American Academy of Pediatrics, and the National Women's Law Center. It's about as broad a progressive coalition as you can imagine, and exactly what didn't exist in 1994.
But the biggest, broadest coalition imaginable isn't of much use if it doesn't have money behind it. This one does. $40 million, to be exact, and given the lineup, there could be more coming if the campaign is effective. The YouTube atop this post comes is their first ad, which is backed by a $1.5 million buy. Beyond national media, they'll also be hiring hundreds of organizers and centering them in swing districts and in the communities of wavering congressmen. Yesterday, the Huffington Post reported that they'd pay particular attention to Blue Dog Democrats, but today, Richard Kirsch, the campaign director, denied that report (which doesn't mean it isn't true), and said, “We’re going to be talking to every member in the country. We’re asking every member of Congress in the country which side they stand on."That's the campaign's primary question: Which side? As Kirsch puts it, " Are you on the side of quality affordable health care? Or on the side of being left alone to fend for yourself in the complicated, bureaucratic, private insurance market?" Private insurers are the enemy here: They're the villains named in the ads, invoked from the podium, assaulted in the images. The poster behind the stage -- a blow-up of the first print ad -- asked, "Trust the insurance companies to fix the health care mess?" The answer? "Not on your life." Indeed, the campaign's second principle, after a "truly inclusive and accessible health care system where no one is left out," is "a choice of a private insurance plan, including keeping the insurance you have if you like it, or a public insurance plan without a private insurer middleman."
All of which is to say, this year, the Left is organizing first. They're raising money first. They're mounting a grassroots strategy first. They're building the pressure coalitions first. . . . It may, of course, prove insufficient. But unlike in 1994, it won't be non-existent. And that's a huge, and promising, difference.
July 7, 2008
Medicare Vote This Week
Robert Pear of the New York Times writes about the Medicare pay cuts and the impact the failure to enact a new Medicare funding bill has had on doctors. He reports,
Congress returns to work this week with Medicare high on the agenda and Senate Republicans under pressure after a barrage of radio and television advertisements blamed them for a 10.6 percent cut in payments to doctors who care for millions of older Americans. The advertisements, by the American Medical Association, urge Senate Republicans to reverse themselves and help pass legislation to fend off the cut.
How to pay doctors through the federal health insurance program is an issue that lawmakers are forced to confront every year because of what is widely agreed to be an outdated reimbursement formula. But the dispute, which showcases the continued potency of health care issues, has reached a new level of urgency this year. Some doctors are reassessing their participation in the program and powerful interests on all sides are in a lobbying frenzy.
Just before the Fourth of July recess, the House passed a bill to prevent the Medicare pay cut by a vote of 355 to 59. In the Senate, Republicans blocked efforts to take up the bill, so the cut took effect on July 1, as required by the formula. But the Bush administration has delayed processing of new claims to give Congress time to come up with a compromise. Senator Harry Reid of Nevada, the majority leader, said he planned to force another vote this week, and Democrats pressed their case over the weekend in their national radio address.
Democrats need just one more vote to pass the bill, and they hope to win over Republicans who were hit by advertisements over the recess. . . . But President Bush has vowed to veto the bill, so the fight — and the uncertainty — could continue for weeks. Mr. Bush and many Republicans oppose the bill because it would finance an increase in doctors’ fees by reducing federal payments to insurance companies that offer private Medicare Advantage plans as an alternative to the traditional government-run Medicare program. . . .
As the maneuvering goes on in Washington, doctors around the country have begun to reassess their participation in Medicare. Dr. David D. Richardson, 40, an ophthalmologist in Los Angeles County, closed his practice last week to all but emergency patients and those needing surgery. “I love practicing medicine,” Dr. Richardson said, “but I would lose more money by keeping my office open than by pulling it back to a skeleton crew. Just like a physician in the emergency room, I try to reduce the hemorrhaging.”
In Topeka, Kan., Dr. Kent E. Palmberg, senior vice president and chief medical officer of the Stormont-Vail HealthCare system, said its 70 primary care doctors were “no longer accepting new Medicare patients as of July 1 because of the draconian cut in Medicare reimbursement.”
Dr. Gerald E. Harmon, a family doctor in Pawleys Island, S.C., said he decided last week that he would not take new Medicare patients “until further notice.” “This is not what we enjoy doing,” says a notice in his waiting room. “It is what we must do to maintain financial viability.” . . .
The Problem of the Underinsured
Ezra Klein posts a review of the Commonwealth Fund's latest study on the number of underinsured in the United States. The Commonwealth Fund finds that nearly 14% of the American public do not have sufficient health insurance. Ezra Klein discusses why underinsurance is a problem and some fo the findings of the Commonwealth Fund. He writes,
We talk a lot about those without any coverage, but a fair portion are hurtling through life with all the protection afforded by a rusted, rattling Kia. In some ways, these underinsured can be worse off than the uninsured, as they think, and even act, like they have coverage, only to find themselves financially ruined or totally betrayed when a medical calamity hits. . . .
The Commonwealth Fund estimates that about 14 percent of the population was underinsured in 2007. That sounds about right, and it's a useful reminder that insurance isn't binary, wherein you have it or you don't. Rather, it exists on a continuum, with some folks being totally insured, some folks being half insured and half uninsured, some folks being totally uninsured but having access to emergency rooms, and so forth. This is how American rationing actually manifests. . . .
Click here for a helpful graphic view of this data.
Ian Welch at Firedoglake posts a brief overview of CalorieLab showing the latest results of their survey ranking states based on weight of residents. You can click on the CalorieLab link to review a map showing where various states rank. Colorado was the leanest state. Overall, it does not look good for those who were hoping to reverse the increase in illnesses associated with weight gain. He writes,
CalorieLab has out their annual "fattest States" and it's no surprise. Folks just keep getting fatter, so much so that they had to change the categories slightly so it wasn't a wash of red, fat, states.
American obesity is something that's really noticeable if you're from out of country. Not that Canada doesn't have its own fatness epidemic, but as in so many things, we just aren't the leaders in the field. Americans are, well, fat. And even Americans who aren't fat are mostly overweight. In fact the numbers on that map really understate things, what I find shocking is that when they add up obese (BMI >30) and overweight (25 to 29.9) there's no State in the union that isn't over 50%. Mississipi, the worst, weighs in at 69.1% combined.
Sure, you can weasel this a bit. BMI does have some problems, and we're all good progressives here who don't like to judge people based on the fact that their packing a few extra pounds *cough*. But it does measure something, and more to the point, it just keeps going up, year in, year out and it has for decades. Americans, or Canadians for that matter, just weren't this fat 30 years ago. . . .
Mr. Welch then provides his three reasons for the increasing size of Americans and believes that the trend can be reversed. He writes,
The first fact I'd push on is the farm bill and the way it subsidizes things like corn syrup production, so that the empty calories in the center aisles of grocery stores; the calories that are bad for you, are much cheaper than healthy lean meat and vegetable calories. . ..
The second problem is the "cult of the car" combined with the "burbification of America". . . .
If I were going to pick a third, it would be that people are never really taught how to exercise. Phys.ed gets cut back every year, but those programs that do exist tend to concentrate on team sports instead of teaching students how to do basic strength, cardio and flexibility training—a skill which they could use for life. . . .