HealthLawProf Blog

New U.S. Rule Pares Outpatient Medicaid Services

The New York Times reports that in the first of an expected avalanche of post-election regulations, the Bush administration on Friday narrowed the scope of services that can be provided to poor people under Medicaid's outpatient hospital benefit.  Robert Pear writes,

In the first of an expected avalanche of post-election regulations, the Bush administration on Friday narrowed the scope of services that can be provided to poor people under Medicaid’s outpatient hospital benefit.

Public hospitals and state officials immediately protested the action, saying it would reduce Medicaid payments to many hospitals at a time of growing need.

The new rule conflicts with efforts by Congressional leaders and governors to increase federal aid to the states for Medicaid as part of a new economic action plan.

President-elect Barack Obama has endorsed those efforts. At a news conference on Friday, he said that legislation to stimulate the economy should include “assistance to state and local governments” so they would not have to lay off workers or increase taxes.

In a notice published Friday in the Federal Register, the Bush administration said it had to clarify the definition of outpatient hospital services because the current ambiguity had allowed states to claim excessive payments.

“This rule represents a new initiative to preserve the fiscal integrity of the Medicaid program,” the notice said.

But John W. Bluford III, the president of Truman Medical Centers in Kansas City, Mo., said: “This is a disaster for safety-net institutions like ours. The change in the outpatient rule will mean a $5 million hit to us. Medicaid accounts for about 55 percent of our business.”

Alan D. Aviles, the president of the New York City Health and Hospitals Corporation, the largest municipal health care system in the country, said: “The new rule forces us to consider reducing some outpatient services like dental and vision care. State and local government cannot pick up these costs. If anything, we expect to see additional cuts at the state level.”

Carol H. Steckel, the commissioner of the Alabama Medicaid Agency, said the rule would reduce federal payments for outpatient services at two large children’s hospitals, in Birmingham and Mobile.

Richard J. Pollack, the executive vice president of the American Hospital Association, said these concerns were valid.

“The new regulation,” Mr. Pollack said, “will jeopardize important community-based services, including screening, diagnostic and dental services for children, as well as lab and ambulance services.”

Herb B. Kuhn, the deputy administrator of the Centers for Medicare and Medicaid Services, defended the rule.

“We are not trying to deny services,” Mr. Kuhn said. “We want to pay for them more accurately and appropriately. Payments for some services were way higher than they should be.”

The rule narrows the definition of outpatient hospital services to exclude those that could be provided and covered outside a hospital.

In May, the White House said it wanted to avoid the rush of “midnight regulations” that had occurred at the end of other administrations. But Bush administration officials said this week that they still intended to issue, or relax, many economic, environmental, health and safety rules before they leave office on Jan. 20.

Medicaid, financed jointly by the federal government and the states, provides health insurance to more than 50 million low-income people. Services can often be billed at a higher rate if they are performed in the outpatient department of a hospital rather than in a doctor’s office or a free-standing clinic. Hospitals generally have higher overhead costs.

Matt D. Salo, a health policy specialist at the National Governors Association, said, “The new rule is consistent with the administration’s effort to squeeze, shrink and flatten Medicaid spending.”

In a recent letter, the governors urged Congress to increase the federal share of Medicaid for at least two years. With state tax revenues plunging, many governors are considering cuts in Medicaid and other programs. Such cuts, they say, would further depress economic activity.

Ann Clemency Kohler, the executive director of the National Association of State Medicaid Directors, said: “The new rule is a pretty sweeping change from longtime Medicaid policy. Since the beginning of the program, states have been allowed to define hospital outpatient services. We have to question why the rule is being issued now, three days after the election, with a new administration coming in.”

The rule was proposed in September 2007. It takes effect on Dec. 8, six weeks before Mr. Bush leaves office.

Ms. Kohler said the rule would cut “money going to the states, to safety net providers, at a time when states are really being stressed.”

“More and more people are coming onto Medicaid,” she said. “People are losing their jobs and running out of unemployment benefits. Some employers can no longer afford to provide health insurance to their workers.”

In the last 18 months, Congress has imposed moratoriums on six other rules that would have cut Medicaid payments. But the administration says Congress did not block the rule issued on Friday.

Larry S. Gage, the president of the National Association of Public Hospitals, said, “We will urge Congress to extend the moratorium to this rule, and we will ask the Obama administration to withdraw it.”

Army General Defies Culture of Silence on Mental Health

The Washington Post reports on an Army General who spoke out from the culture of silence on mental health by seeking treatment and advocating for others to do the same.  Pauline Jelinek writes,

It takes a brave soldier to do what Army Maj. Gen. David Blackledge did in Iraq.

It takes as much bravery to do what he did when he got home.

Blackledge got psychiatric counseling to deal with wartime trauma, and now he is defying the military's culture of silence on the subject of mental health problems and treatment.

"It's part of our profession ... nobody wants to admit that they've got a weakness in this area," Blackledge said of mental health problems among troops returning from America's two wars.

"I have dealt with it. I'm dealing with it now," said Blackledge, who came home with post-traumatic stress. "We need to be able to talk about it."

As the nation marks Veterans Day on Tuesday, thousands of troops are returning from Iraq and Afghanistan with anxiety, depression and other emotional problems.

As many as one-fifth of the more than 1.7 million who have served in the wars are estimated to have symptoms. In a sign of how tough it may be to change attitudes, roughly half of those who need help are not seeking it, studies have found.

Despite efforts to reduce the stigma of getting treatment, officials say they fear generals and other senior leaders remain unwilling to go for help, much less talk about it, partly because they fear it will hurt chances for promotion.

That reluctance is also worrisome because it sends the wrong signal to younger officers and perpetuates the problem leaders are working to reverse.

"Stigma is a challenge," Army Secretary Pete Geren said Friday at a Pentagon news conference on troop health care. "It's a challenge in society in general. It's certainly a challenge in the culture of the Army, where we have a premium on strength, physically, mentally, emotionally."

Adm. Mike Mullen, chairman of the Joint Chiefs of Staff, asked leaders this year to set an example for all soldiers, sailors, airmen and Marines: "You can't expect a private or a specialist to be willing to seek counseling when his or her captain or colonel or general won't do it."

Brig. Gen. Loree Sutton, an Army psychiatrist heading the defense center for psychological health and traumatic brain injury, is developing a campaign in which people will tell their personal stories. Troops, their families and others also will share concerns and ideas through Web links and other programs. Blackledge volunteered to help, and next week he and his wife, Iwona, an Air Force nurse, will speak on the subject at a medical conference.

Continue reading "Army General Defies Culture of Silence on Mental Health"

At the End of Life, a Delicate Calculus

The New York Times reports on Tuesdays election, where Washington State joined Oregon as the second in the nation to allow physicians to prescribe lethal doses of medication to terminally ill men and women who want to hasten their own deaths.  Jane Gross writes,

The Washington State proposition, Initiative 1000 (PDF), passed by a margin of 59 to 41 percent, and like the Oregon measure, which withstood several legal challenges, contains many safeguards intended to prevent hasty and ill-considered decisions. Patients requesting this assistance must be mentally competent, residents of the state, have six months or less to live according to two physicians, wait 15 days after their initial request and then repeat that request both orally and in writing. They must be capable of administering the lethal medication themselves and agree to counseling if their physicians request it. In addition, these patients also must be informed by their health care providers of other feasible alternatives.

In the view of Dr. Timothy E. Quill, director of the palliative care program at the University of Rochester, these options have expanded and gained acceptance in medical circles over the past decade. In 1997, in two important cases (Dr. Quill was a plaintiff in one), the U.S. Supreme Court ruled there was no constitutional right to physician-assisted suicide and upheld a prohibition against it. But in the same ruling, the justices conceded that terminally ill patients are entitled to aggressive pain management, even if high doses of opiates or barbiturates have the “double effect” of hastening death.

That seemed a footnote at the time to the larger issue, but it arguably cracked open the door to those other feasible options, which Dr. Quill and other end-of-life experts refer to as “last resorts” in jurisdictions where it is a crime for physicians to assist in dying.

Dr. Quill’s views on physician-assisted death — a term preferred by many palliative care doctors and right-to-die organizations — are outlined in two essays published by the Hastings Center, the nation’s oldest bioethics research institute. One, entitled “Physician-Assisted Death in the United States: Are the Existing ‘Last Resorts’ Enough?” appeared in the center’s bimonthly report this fall. The other, intended to be a resource for policymakers, political candidates and journalists, is one of 36 topics framed and amplified in the center’s more recent “Bioethics Briefing Book.”

In these articles, Dr. Quill enumerated “last resort” options in the order he advises they be considered, both because of what is involved in each practice and because of the degree of acceptance among ethicists, legal experts and the general public. The essays were written, obviously, before the voting in Washington State. Dr. Quill considered it “a good time to review areas of progress in palliative and end-of-life care and consider whether [laws or ballot measures of this type] are either necessary or desirable.”

He concluded with a cautious “yes” but makes a compelling case that adding physician-assisted death to the repertoire is not, for him, the singular solution it was when he made history by publishing an account in a medical journal about his own role in a patient’s death.

First and foremost, Dr. Quill and others say, all terminally ill patients should have access to state-of-the art palliative care, both to relieve pain and other symptoms and to provide emotional support to patients and families. Often delivered as part of hospice, palliative care has come of age in the last decade: it is now a board-certified sub-specialty, Dr. Quill noted, offered in a growing number of teaching and community hospitals.

Dr. Quill recommended that a palliative care consultation be mandatory before anyone considers the following “last resorts,” which he listed from least controversial to most:

1. In the rare cases where pain and suffering remain intractable, despite top-notch palliative care, the next option should be pain management so aggressive that it may well hasten death, although that is not the primary intention. This is the doctrine of “double effect,” articulated by the U.S. Supreme Court’s decision in 1997 and relatively uncontroversial.

2. Rarely challenged, too, is a patient’s right to forgo life-sustaining therapies or discontinue them once begun. This likely would include feeding tubes, ventilators and other life-support machinery. But it could also include chemotherapy, blood pressure medication, insulin or garden-variety antibiotics. The legal and ethical argument here is that we all have the right to autonomy and bodily integrity, and to control what is done or not done to us.

3. Also considered by some to be a matter of bodily integrity is V.S.E.D., short for “voluntarily stopping eating and drinking.” Dr. Quill believes this is “more morally complex” choice than the second option, because over the last decade the practice has expanded beyond those with end-stage cancer or Alzheimer’s disease — who often lose interest in food or forget how to eat and drink — to people who are not “actively dying” but nevertheless have had enough of disability or dependence. V.S.E.D. requires “considerable resolve,” Dr. Quill said, because thirst can be persistent and death can take as long as three weeks. Physicians do not “assist” these patients but support them with symptom relief for dry mouth or sedation in the event of delirium or other complicating discomforts.

4. The “last, last resort,” and by far the most controversial of the legal methods, is sedation to the point of unconsciousness, also known as palliative or terminal sedation. Endorsed earlier this year by the American Medical Association’s Council on Ethical and Judicial Affairs, it involves an explicit decision to render a patient unconscious if pain can be controlled no other way. Food and fluid may be discontinued, and in one to three days the patient dies of dehydration.

According to data from Oregon, 341 people have died in 11 years as a result of lethal doses of medication provided by a physician. That amounts to 1 in 1,000 deaths overall per year, according to the state health department, although 1 in 50 dying patients have discussed the possibility with their doctors and one in six with their families. “Most patients will be reassured by the possibility of an escape,” Dr. Quill said, “and will never need to activate that escape.”

By contrast, when physician-assisted death is a covert operation, far more people seem to grab the chance. Data on this secret but apparently widespread practice is hard to collect, because physicians can be charged and prosecuted for a crime. But in the mid-1990s a team of researchers, Dr. Quill among them, tried to investigate the question using techniques that protected anonymity. The researchers found that between 1 and 2 percent of deaths per year had been aided, illegally, by physicians through assisted suicide or euthanasia — 10 to 20 times the rate observed in Oregon since legalization of this practice.

Hospitals See Drop in Paying Patients

The New York Times reports that in another sign of the economy’s toll on the nation’s health care system, some hospitals say they are seeing fewer paying patients even as greater numbers of people are showing up at emergency rooms unable to pay their bills.  Reed Abelson writes,

While the full effects of the downturn are likely to become more evident in coming months as more people lose their jobs and their insurance coverage, some hospitals say they are already experiencing a fall-off in patient admissions.

Some patients with insurance seem to be deferring treatments like knee replacements, hernia repairs and weight-loss surgeries — the kind of procedures that are among the most lucrative to hospitals. Just as consumers are hesitant to make any sort of big financial decision right now, some patients may feel too financially insecure to take time off work or spend what could be thousands of dollars in out-of-pocket expenses for elective treatments.

The possibility of putting off an expensive surgery or other major procedure has now become a frequent topic of conversation with patients, said Dr. Ted Epperly, a family practice doctor in Boise, Idaho, who also serves as president of the American Academy of Family Physicians. For some patients, he said, it is a matter of choosing between such fundamental needs as food and gas and their medical care. “They wait,” he said.

The loss of money-making procedures comes at a difficult time for hospitals because these treatments tend to subsidize the charity care and unpaid medical bills that are increasing as a result of the slow economy.

“The numbers are down in the past month, there’s no question about it,” said Dr. Richard Friedman, a surgeon at Beth Israel Medical Center in New York, although he said it said it was too early to call the decline a trend.

But many hospitals are responding quickly to a perceived change in their circumstances. Shands HealthCare, a nonprofit Florida hospital system, cited the poor economy and lower patient demand when it announced last month that it would shutter one of its eight hospitals and move patients and staff to its nearby facilities.

The 367-bed hospital that is closing, in Gainesville, lost $12 million last year, said Timothy Goldfarb, the system’s chief executive. “We cannot carry it anymore,” he said.

Some other hospitals, while saying they have not yet seen actual declines in patient admissions, have tried to curb costs by cutting jobs in recent weeks in anticipation of harder times. That includes prominent institutions like Massachusetts General in Boston and the University of Pittsburgh Medical Center, as well as smaller systems like Sunrise Health in Las Vegas.

“It’s safe to say hospitals are no longer recession-proof,” said David A. Rock, a health care consultant in New York.

A September survey of 112 nonprofit hospitals by a Citi Investment Research analyst, Gary Taylor, found that overall inpatient admissions were down 2 to 3 percent compared with a year earlier. About 62 percent of the hospitals in the survey reported flat or declining patient admissions.

Separately, HCA, the Nashville chain that operates about 160 for-profit hospitals around the country, reported flat admissions for the three months ended Sept. 30 compared with the period a year earlier, and a slight decline in inpatient surgeries.

Many people are probably going to the hospital only when they absolutely need to. “The only way they are going to tap the health care system is through the emergency room,” Mr. Taylor said.

And now, as the economy has slid more steeply toward recession in recent weeks, patient admissions seem to have declined even more sharply, some hospital industry experts say. “What we have not seen through midyear this year is the dramatic slowdown in volume we’re seeing right now,” said Scot Latimer, a consultant with Kurt Salmon Associates, which works closely with nonprofit hospitals.

While the drop-off in patient admissions may still seem relatively slight, hospital executives and consultants say it is already having a profound impact on many hospitals’ profitability. As fewer paying customers show up, there has been a steady increase in the demand for services by patients without insurance or other financial wherewithal, many of whom show up at hospital emergency rooms — which are legally obliged to treat them.

“It’s disproportionately affecting the bottom line,” Mr. Latimer said.

Continue reading "Hospitals See Drop in Paying Patients"

D.C. Hospital Sues to Remove 12 Year Old Boy From Life Support

The Washington Post reports that the parents of a 12-year-old boy are trying to prevent a hospital from taking him off life support because they say their faith does not define death as cessation of brain function alone.  Del Quentin Wilber writes,

The family of a 12-year-old New York boy is entangled in a legal fight with Children's National Medical Center over whether doctors can cease life support because they believe he is brain-dead.

The dispute involves Motl Brody of Brooklyn, who was diagnosed with a severe form of brain cancer. The boy has been under the care of the Northwest Washington hospital for about six months. His tumor grew progressively worse, and doctors there pronounced him dead Tuesday night after tests showed no signs of brain activity.

His parents, Eluzer and Miriam Brody, are trying to prevent the hospital from taking him off life support because they say their faith does not define death as cessation of brain function alone. The parents, Orthodox Jews, have retained a lawyer who says that the boy's circulatory and respiratory systems are functioning, although with mechanical and other assistance.

"Under Jewish law and their faith, there is no such thing as brain death," said the parents' attorney, Jeffrey Zuckerman. "Their religious beliefs are entitled to respect."

The hospital has taken the dispute to D.C. Superior Court. In filings, the hospital extended its sympathy to the family but said the boy should no longer be on its equipment, saying that "scarce resources are being used for the preservation of a deceased body."

Under D.C. law, doctors can declare patients dead if there is no brain activity. The hospital wants a court order, over the parents' objections, that affirms its plan to disconnect the boy from a ventilator and to discontinue intravenous medications that keep his heart beating.

But Zuckerman says that doing so would infringe upon religious freedom.

The case is awaiting a ruling from Judge William Jackson.

"This child has ceased to exist by every medical definition," Sophia Smith, one of the boy's physicians, wrote in court papers, adding that she and her staff members are "distraught at what is providing futile care to the earthly remains of a former life."

"There is no activity in any portion of his brain, including the brain stem," she wrote. "Ethically, there is no appropriate treatment except removal of the ventilator and of the drugs."

A spokeswoman for the hospital, Emily Dammeyer, declined to comment on the case yesterday, citing patient privacy rules.

In court papers, the hospital's lawyers wrote that doctors have no choice but to stop life support or risk fines and other sanctions. They added that the hospital tried to find other facilities to take the boy but that none would admit him because he is brain-dead.

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First-Ever Mapping of Cancer Patient's Genome

The Washington Post reports that researchers have decoded the complete DNA sequence of a person with leukemia and discovered earlier unknown mutations associated with the blood cell cancer.  Ed Edelson writes,

In a genetics first, researchers report that they have decoded the complete DNA sequence of a person with acute myelogenous leukemia.

There were some surprises -- eight previously unknown mutations, along with two already identified genetic alterations, were associated with the blood cell cancer.

But more importantly, it is now possible to detect individual genetic differences for each case of cancer, said study senior author Richard K. Wilson, director of the Washington University Genome Sequencing Center, in St. Louis.

"We found mutations in genes that make a lot of sense when normal cells become cancer cells," Wilson explained. "That they seem to be fairly unique to this particular patient says on the one hand that this is a complicated disease. But the complications validate our approach -- we have to look at a number of patients to see not only what is different but what they have in common."

The feat brings the routine use of genomic screens for cancer patients a little closer, one expert said.

"Technically, this is a great achievement," added Richard Gibbs, director of the Human Genome Sequencing Center at Baylor College of Medicine, in Houston. "This really is a new era, based on genome studies. There is real clinical applicability, and that is what's remarkable about it."

The findings were reported in the Nov. 6 issue of Nature.

The Washington University center has already started genetic sequencing of a second person with acute myelogenous leukemia (AML), which Wilson said was chosen in part because "it is a cancer type that is extremely aggressive, with no good cure. We have seen some pretty good treatments for other cancers, but this one lags behind."

"The second [patient genome] is already in progress," he said, adding that the examination of the genomes of other patients is already underway.

While it cost millions of dollars and years to complete the first map of a single human genome, in 2003, such feats are now becoming routine because of "a new wave of technologies," Wilson noted. "It miniaturizes and parallelizes, so we can do lots of things in parallel on one platform. We used to be able to look at 100 DNA sequences per sample. Now we can look at 100 million per sample."

The genome laid out in theNaturestudy is that of a woman in her 50s who died of AML. The current picture is that mutations that turn a cell cancerous occur in sequence, each one pushing the cell closer to uncontrolled, malignant growth. Nine of the mutations in the woman's case were found in all tumor cells. The tenth was not present in all, and so it is believed to be the last one that occurred, possibly the tipping point that caused the cancer.

The complexity of the genetic changes linked to this one case of AML should not be viewed as discouraging, Gibbs said. "I don't think there is reason for pessimism," he said. "It is complicated, but that doesn't mean we're not going to understand it."

New technology may someday make it possible to perform genome sequencing forallcancer patients who need it, Gibbs said. "In the past, our ability to get the information has been questioned," he said. "When it was $10 million a shot, that was one thing. If it costs $5,000 or $10,000 per case, there is no argument about getting the information."

The Baylor center is carrying out similar genome studies for several forms of cancer, Gibbs said, including the brain tumor glioblastoma, lung cancer and pancreatic malignancies. And at Washington University, whole-genome studies are planned for breast and lung cancers, Wilson noted.

Obama Makes History: "Yes, We Can"

The Washington Post reports on last night's election.  The U.S. decisively elects its first African American President and the democrats expand control of Congress.  Robert Barnes and Michael D. Shear write,

Sen. Barack Obama of Illinois was elected the nation's 44th president yesterday, riding a reformist message of change and an inspirational exhortation of hope to become the first African American to ascend to the White House.

Obama, 47, the son of a Kenyan father and a white mother from Kansas, led a tide of Democratic victories across the nation in defeating Republican Sen. John McCain of Arizona, a 26-year veteran of Washington who could not overcome his connections to President Bush's increasingly unpopular administration.

Standing before a crowd of more than 125,000 people who had waited for hours at Chicago's Grant Park, Obama acknowledged the accomplishment and the dreams of his supporters.

"If there is anyone out there who still doubts that America is a place where all things are possible, who still wonders if the dream of our founders is alive in our time, who still questions the power of our democracy, tonight is your answer," he said just before midnight Eastern time.

"The road ahead will be long. Our climb will be steep. We may not get there in one year or even one term, but America, I have never been more hopeful than I am tonight that we will get there. I promise you: We as a people will get there."

The historic Election Day brought millions of new and sometimes tearful voters, long lines at polling places nationwide, and celebrations on street corners and in front of the White House. It ushered in a new era of Democratic dominance in Congress, even though the party's quest for the 60 votes needed for a veto-proof majority in the Senate remained in doubt early today. In the House, Democrats made major gains, adding to their already sizable advantage and returning them to a position of power that predates the 1994 Republican revolution.

Democrats will use their new legislative muscle to advance an economic and foreign policy agenda that Bush has largely blocked for eight years. Even when the party seized control of Congress two years ago, its razor-thin margin in the Senate had allowed Republicans to hinder its efforts.

McCain congratulated Obama in a phone call shortly after 11 p.m. and then delivered a gracious concession speech before his supporters in Phoenix. "We have had and argued our differences," he said of his rival, "and he has prevailed."

"This is an historic election, and I recognize the special significance it has for African Americans and the special pride that must be theirs tonight," McCain said.

Obama became the first Democrat since Jimmy Carter in 1976 to receive more than 50 percent of the popular vote, and he made good on his pledge to transform the electoral map.

He overpowered McCain in Ohio, Florida, Virginia and Pennsylvania -- four states that the campaign had spent months courting as the keys to victory. He passed the needed 270 electoral votes just after 11 p.m., with victories in California and Washington state.

The Democrat easily won most of the Northeast, the Rust Belt, the West Coast and mid-Atlantic states that normally back Democrats. By midnight, he appeared to be running strong in North Carolina, Indiana, Missouri and Montana, each of which was too close to call.

Continue reading "Obama Makes History"

Obama's Victory Speech

If you couldn't stay up late last night for Obama's victory speech or just want to hear or read it again, the New York Times has provided the clip and transcription.

Watch Obama's Victory Speech

Biden Sees Vice President's Role as 'Adviser in Chief,' Aides Say

The Washington Post reports on the new Vice President, Joseph Biden. Perry Bacon Jr. writes,

Vice President-elect Joseph R. Biden Jr. sees his role in Barack Obama's administration as "adviser in chief," using his decades of experience in the Senate to offer the president candid input on domestic and foreign policy issues, according to Biden aides.

But Biden, a twice-failed presidential candidate, will not use the post in a way many vice presidents have: to make a play for the Oval Office. He has said publicly that he does not intend to run for the presidency again.

Although Vice President Cheney has performed a similar role in the Bush administration, advising the president on key issues, meeting with congressional leaders and eschewing his own presidential run, Biden intends to operate differently. In the vice presidential debate last month, Biden called Cheney "the most dangerous vice president we've had probably in American history," and he has criticized Cheney for excessive secrecy and holding too much power in the Bush White House.

"There will be cc's and not bcc's," said Antony Blinken, a top Biden adviser, referring to the practice in the current administration in which Cheney aides receive e-mails on key matters, but without other recipients knowing the vice president's staff is involved. "There is not going to be a shadow operation."

Biden aides said the senator from Delaware does not intend to take on a defining issue, as Al Gore sought to do with his "reinventing government" initiative, which aimed to improve the efficiency of the federal bureaucracy. Biden's team says such a project distracts from a vice president's ability to serve as a general adviser to the president.

Instead, they said, he is likely to take on special projects. They cited as an example Gore's work in the Clinton administration in helping negotiate an agreement with the Russian government to stop it from selling weapons to Iran.

Biden plans to spend much of his time working with his former congressional colleagues, possibly attending some of the weekly lunches hosted by Senate Democrats, looking to gain support from key lawmakers before Obama officially announces proposals to the public so he is aware of concerns from both Democrats and Republicans before they become major problems.

"I'm confident I'll be spending a fair amount of time" working with Congress, Biden said at a news conference in Ohio a few days before the election. "I really have genuine relationships with Republican leaders in the House and the Senate. . . . I've never once misled any of my colleagues, Democrat or Republicans."

But it is not clear how much impact Biden could actually have in getting bills passed. His closest friends on the GOP side, such as Sen. Richard G. Lugar (Ind.) and Sen. Arlen Specter (Pa.), are moderate Republicans who may not be able to win over their more conservative colleagues. And Biden's and Obama's generally liberal views diverge sharply from those of many Republicans in the House and the Senate.

Because of his foreign policy expertise -- he has been serving as chairman of the Senate Foreign Relations Committee -- he expects to weigh in on key security matters. Obama assured him that he would be consulted on all major issues, but Biden has pledged to stay out of the way of the secretary of state.

"Every major decision he'll be making, I'll be sitting in the room to give my best advice," Biden said in the vice presidential debate.

David Wade, Biden's campaign spokesman, said Obama reached out to Biden, once he dropped out of the presidential race in January, for advice on issues. The two have spoken at least every other day since Obama tapped him to be his running mate.

But Biden may have a tough time becoming Obama's top counselor. His relationship with Obama is not longstanding: They met when Obama was running for Senate in 2004.

The president-elect chats often with his lead political adviser, David Axelrod, whom he has known for more than a decade and with whom he has a much closer relationship than with Biden. And whomever Obama picks as his chief of staff will hold major sway as well.

"It can be a senior adviser-in-chief role, and I think Al Gore had that," said Charles Burson, who served as Gore's chief of staff in the last two years of the Clinton administration. "Whether or not Biden has that role goes back to the chemistry between he and President Obama."

The Value of Voting, Beyond Politics

The New York Times discusses that although psychologists and neuroscientiests have tried to determine how people make voting decisions by taking brain scans and comparing how certain messages or images activate emotion centers, none of this has helped predict people's behavior in elections any more than a half-decent phone survey.  Benedict Carey writes,

For those who love the civic cheer and lukewarm coffee of their local polling place, an absentee ballot has all the appeal of a tax form. The paperwork, the miniature type, the search (in some states) for a notary public: it’s a tedium bath, and Pam Fleischaker, a lifelong Democrat from Oklahoma City, had every reason to take a pass this year.

Ms. Fleischaker, 62, was in New York recovering from a heart transplant, for one. And in her home state, the Democratic candidate, Senator Barack Obama, was polling hopelessly behind his opponent, Senator John McCain. She mailed in her absentee packet anyway, and hounded her two children, also in New York, to do the same.

“That one vote isn’t going to be decisive makes no difference to me,” Ms. Fleischaker said in a telephone interview last week. “Your vote is your voice, and there’s more power in it than in most of the things we do. It’s a lost pleasure, the feeling of that power.”

In recent years psychologists and neuroscientists have tried to get a handle on how people make voting decisions. They have taken brain scans, to see how certain messages or images activate emotion centers. They have spun out theories of racial bias, based on people’s split-second reactions to white and black faces. They have dressed up partisan political stereotypes in scientific jargon, describing conservatives as “inordinately fearful and craving order,” and liberals as “open-minded and tolerant.”

None of which has helped predict people’s behavior in elections any more than a half-decent phone survey. The problem is not only sketchy science, some experts say; it’s that researchers don’t agree on the answer to a more fundamental question: Why do people vote at all?

“There’s a longstanding literature looking at why any rational person would vote, when the chances of actually influencing an election are about the same as getting hit by lightning,” said John Londregan, a professor of politics and international affairs at Princeton. “In most theoretical models, it’s hard to get a predicted turnout above one. That is, one voter.”

Yet new models have done better, predicting elections with turnouts closer to the nation’s average of about 50 percent of eligible voters. They have also revealed some of the basic motives underlying both personal and group decisions about when to vote and why.

Casting a ballot clearly provides a value far higher than its political impact. The benefit may include side payments — say, the barbecues and camaraderie of a campaign, or the tiny possibility that a single vote may be decisive.

But recent research suggests that it has more to do with civic duty and the maintenance of moral self-image. In a series of experiments, researchers from Northwestern University and the University of California, Berkeley, have had study participants play a simple election game involving monetary rewards. A group of designated voters cast their vote for Choice A, an equal distribution of money among voters and nonvoters in the study; or B, a payout to be split only among the designated voters — a smaller group, so a higher amount. It cost money to vote, and participants could abstain at no cost.

The study authors, led by Sean Gailmard at Berkeley, called Choice A “ethical” and Choice B “selfish.” They found that ethical voting ran highest, at about 20 percent, when individual votes were least likely to affect the outcome. Selfish voting ran highest, also about 20 percent, when individuals’ choices were most likely to change the outcome.

This finding could explain why people might vote against a local tax increase but for a Congressional candidate who was likely to raise their income taxes: their vote carries far less value in a national race than in a local one.

This study and others also imply that there is a core of voters who not only turn out at the polls but also cast their ballot for the candidate or proposal they believe represents the larger good. This makes sense to those who study the evolution of group behavior. Small communities often have a scattering of people who stand up and do the right thing; their compensation is the private knowledge that they are willing to pay some cost to do what they believe is right, even if that price amounts to standing out in the cold for 15 minutes waiting to pull a lever.

“It may be a form of identity construction for individuals,” Dr. Gailmard wrote in an e-mail message. “Or it could be a duty to do the right thing, or a social norm.”

Continue reading "The Value of Voting, Beyond Politics"

Court Blocks White House Push on Medicare Expenses

The New York Times reports that a federal court has blocked the Bush administration’s effort to save money on Medicare by paying for only the least expensive treatments for particular conditions.  Robert Pear writes,

Congress sets Medicare payment rates and never intended to give officials broad discretion to alter them, the court said in an important test case on Oct. 16.

The case, just now being scutinized by Medicare officials and consumer advocates, involved drugs used to treat chronic obstructive pulmonary disease.

Judge Henry H. Kennedy Jr. of Federal District Court here said the policy of paying for only “the least costly alternative” was not permitted under the Medicare law.

The administration’s position would give the health and human services secretary “enormous discretion” to determine the amount paid for every item and service covered by Medicare, without reference to the detailed formulas set by Congress, Judge Kennedy said. “This flies in the face of the detailed statutory provisions,” he added.

Over the years, Medicare officials have often tried to adopt regulations that allow them to consider cost in deciding whether the program should cover various goods and services. Health care providers, manufacturers and some patients’ advocates have resisted these efforts, saying that coverage decisions should be made based on clinical effectiveness and not cost.

“We are disappointed with the ruling and continue to believe that our policy is supported by the statute,” Peter L. Ashkenaz, a spokesman for the federal Centers for Medicare and Medicaid Services, said Monday. “We are still considering our options and next steps.”

Federal health officials said the decision would make it more difficult to rein in Medicare costs.

Judge Kennedy found that Medicare and some of its contractors had unlawfully limited payments for DuoNeb, an inhalation drug taken through a nebulizer, which turns the medicine into a fine mist.

The drug, made by Dey, a unit of Mylan Inc., makes breathing easier by opening up the bronchial tubes. A single dose provides a combination of two commonly prescribed bronchodilators, albuterol and ipratropium.

Congress set forth the touchstone for Medicare coverage in a 1965 law that created the program. The law generally prohibits payment for items and services that are “not reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.”

If an item is covered, the payment rate is specified in other parts of the law.

The Bush administration argued that Medicare officials had the right to decide whether the expense incurred for a given item, not just the item itself, was “reasonable and necessary.”

Judge Kennedy said this argument “does not make sense” because Congress went to great lengths to establish payment rates.

Similar disputes have come up over other treatments.

Another pharmaceutical company, Sepracor, has for years challenged the government’s authority to use the “least costly alternative” as a basis for setting reimbursement rates for Xopenex, prescribed for asthma and chronic obstructive pulmonary disease.

In a friend-of-the-court brief, Sepracor said that Congress had set the payment rate at 106 percent of the average sales price. “Congress consciously chose to entrust the amount of reimbursement to the market, not to a government agency or its contractors,” the company said in its brief.

Patrick Morrisey, a lawyer representing Sepracor, said, “If you extend the agency’s logic to its natural conclusion, Congress would never need to pass any payment laws and policies.”

Scott T. Williams, vice president of Men’s Health Network, an education and advocacy group, welcomed the court decision. Mr. Williams said the decision would be “a springboard to help ensure that prostate-cancer patients have access to drugs like Lupron and Zoladex, rather than being forced to use the least costly alternative products.”

Mr. Williams said that if Medicare paid for only the least costly drugs, low-income and minority patients might not have access to more expensive treatments deemed appropriate by their doctors.

Lean Economy, Fatty Diet

The Los Angeles Times reports that when money's tight, many people switch to cheap, unhealthful processed foods.  Karen Ravn writes,

Prices are way down on the stock market and way up at the grocery store. Just thinking about it could make you lose your appetite -- or, alternatively, give you a serious craving for some comfort food. Indeed, as the economy flags, sags and drags, there's talk that it could affect the way people eat, and even how much they weigh.

You might imagine that high food prices could put the nation on a diet as people, strapped for cash, tighten their belts and eat less. Forget that idea. Many nutrition experts fear that soaring food prices will have the opposite effect -- fatten up the nation.

They point to science showing that price changes can make people change what they buy as well as how much. As the price of one food goes up, people not only buy less of it, but they also sometimes buy other, cheaper food in its place. And cheaper foods tend to have more calories than those with a higher price tag. For instance, as the price of oranges goes up, people don't buy as many oranges. And some may decide to buy cookies instead. Today, "people are eating cheap, unhealthy food who never thought they would be," says Adam Drewnowski, director of the Center for Obesity Research at the University of Washington in Seattle.

It's no accident that high-calorie foods (chips, dips, cookies, candy) are generally cheaper than low-calorie foods (broccoli, asparagus, peaches, blueberries). Processed foods are cheaper to produce, ship and store. As researchers note, this is partly due to agricultural policies, which could be changed, and partly due to the nature of the foods themselves, which can't.

"You can see how this situation could fuel both under-nutrition and over-nutrition," says Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University in New Haven, Conn.

But despite the fact that a diet could easily get derailed during these lean economic times, it doesn't have to be that way. In a related story, we provide some simple tips to help you stay on track and eat cheaply -- and healthfully.

Price of eating right

Drewnowski has been arguing for years that healthful eating isn't just a matter of choosing the right foods. It's also a matter of being able to afford those choices. "Simply put," he writes for an upcoming publication of the University of Washington's School of Public Health, "fats and sweets cost less, whereas healthier diets cost more."

He has data to back that up. In a 2004 paper published in Nutrition Today, he and co-author Anne Barratt-Fornell, a cancer and health information consultant at the University of Michigan Comprehensive Cancer Center Ann Arbor, assessed 200 foods being sold in a Seattle supermarket and found that, in general, the more "energy dense" a food is -- i.e. the more calories it contains per unit weight -- the less it costs per calorie. In other words, customers got more caloric bang for their buck if they bought foods full of fat, sugar and starch than if they bought foods full of vitamins, minerals and fiber.

At 2003 retail prices, shoppers could have bought all the calories they needed to get through a day for less than $1 if they bought them solely in the form of refined grains, added sugars and added fats. At the other extreme, a day's worth of calories would have cost several hundred times more if buyers got them all from fresh salmon, arugula and raspberries. (The sugar in fresh raspberries, for instance, costs about 100 times as much as the plain old refined sugar that comes in a bag.)

The price difference between low- and high-calorie foods seems to be growing, according to a 2007 study in the Journal of the American Dietetic Assn. by Drewnowski and Pablo Monsivais, a research analyst at the Center for Public Health Nutrition at the University of Washington. Using retail figures from major supermarket chains in the Seattle area, the researchers compared the prices of 372 foods and beverages in 2004 and 2006.

The average price increase was 7.9%. But the increase was not uniform. After dividing all the solid foods into five levels -- from highest in calories per gram to lowest -- the researchers found that prices of the foods most dense in calories had actually dropped slightly, by an average of 1.8%. But prices of the lowest-calorie foods had gone up by an average of 19.5%.

Drewnowski doesn't have any later figures, but he speculates that "those trends are probably worse now."

Shopping patterns

Researchers have studied consumers' behavior in situations where the prices of high-calorie foods stay constant but the prices of low-calorie foods go up (and vice versa).

For example, a team from the State University of New York at Buffalo studied the grocery shopping patterns of 47 mothers ages 25 to 50 in a laboratory set up to simulate a grocery store. The mothers chose their "purchases" from cards representing 60 different foods -- half considered healthful and low-calorie, and half unhealthful and high-calorie -- with pictures on the front and nutritional information on the back. "Prices" of the foods were displayed too, and varied in different segments of the study.

When prices were raised, the study found, moms bought less of both the low- and high-calorie foods. That's consistent with the idea that rising prices these days could lead people to buy less food.

If that were to happen, it could have some very negative consequences, of course, including hunger and malnutrition. On the plus side, it might help to ease the nation's obesity problem.

That's a nice thought. But for it to actually happen, overweight people would need to cut back on eating high-calorie food -- and that is not what the study found.

"Leaner, perhaps more health-conscious mothers," the authors wrote, were sensitive to price increases for high-calorie foods -- they bought fewer of them when their prices went up and sometimes even switched to foods lower in calories whose prices had not increased.

Continue reading "Lean Economy, Fatty Diet"

12 Things You Should Know About Aspirin

US News offers twelve benefits and limitations of taking aspirin.  Sarah Baldauf writes,

Aspirin, that old standard in everyone's medicine chest, can really pack a wallop. So much so that the American Heart Association has long recommended aspirin therapy for people who've had a heart attack, stroke caused by blood clot, unstable angina, or "ministrokes." The AHA also notes that even people who have not experienced such an event but who are at increased risk because of family history, say, may also stand to gain from aspirin therapy.

We're certainly familiar with our aspirin: About 60 percent of people ages 65 and older pop aspirin at least once a week. But this cheap, over-the-counter pill is not benign, and regular use should be discussed with a doctor. And beware marketing claims. Bayer was sent warning letters by the Food and Drug Administration today for touting two products—Bayer Women's Low Dose Aspirin + Calcium (Bayer Women's) and Bayer Aspirin with Heart Advantage (Bayer Heart Advantage)—for making unproved health claims.

Along with its benefits, aspirin has limitations, too. A roundup of recent research suggests taking aspirin regularly may do the following:

1) Cut pre-eclampsia risk during pregnancy. A research review published in The Lancet in 2007 suggests that pregnant women who took aspirin or other antiplatelet drugs were 10 percent less likely to develop the disorder that involves high blood pressure and potentially serious complications for mother and fetus. Aspirin therapy during pregnancy should definitely be discussed with an obstetrician.

2) Reduce risk of developing colorectal cancers. The journal Gastroenterology published a study earlier this year that found a significantly lowered risk of developing the cancers in men with regular, long-term aspirin (and other nonsteroidal anti-inflammatory) use. The benefits, however, were not evident until individuals had amassed a total of five consistent years of regular use. Also, the dose with the biggest benefit—325-mg pills more than 14 times each week—is greater than typically recommended.

3) Lower a woman's risk of breast cancer. A research review published this month in the Journal of the National Cancer Institute found a 13 percent relative risk reduction in women who used aspirin regularly compared with those who did not. The findings found an overall reduced risk of 12 percent for regular use of NSAIDs in general. Previous research on breast cancer risk and NSAID use has shown conflicting results.

4) Throw off test results for prostate cancer. In an issue of this month's journal Cancer, researchers reported that men who used aspirin and other NSAIDs regularly had about 10 percent lower levels of the prostate marker prostate-specific antigen. The researchers suggest this may hinder the detection of prostate cancer in regular users.

Continue reading "12 Things You Should Know About Aspirin"