A particular class of medication used to treat high blood pressure could protect older adults against memory decline and other impairments in cognitive function, according to a newly published study from Wake Forest University School of Medicine.
Research suggests that some of the drugs classified as angiotensin-converting enzyme (ACE) inhibitors, specifically those types of ACE inhibitors that affect the brain by crossing the blood-brain barrier, may reduce inflammation that could contribute to the development of Alzheimer's disease, a major cause of dementia.
The study appears in the current issue of Archives of Internal Medicine.
"High blood pressure is an important risk factor for Alzheimer's disease and vascular dementia," said Kaycee Sink, M.D., M.A.S., lead author of the study, geriatrician and an assistant professor of internal medicine - gerontology. "Our study found that all blood pressure medications may not be equal when it comes to reducing the risk of dementia in patients with hypertension."
Dementia is the broad term used to describe conditions in the brain that cause loss of brain function. There are several different causes of dementia, but Alzheimer's disease and strokes are two of the most common. People with dementia begin to lose their memory and may not be able to think well enough to do normal activities, such as getting dressed or eating, may lose their ability to solve problems or control their emotions, may experience personality changes and/or may become agitated or see things that are not there.
While memory loss is the hallmark of dementia, it does not, by itself, mean an individual has dementia. People with dementia have serious problems with two or more brain functions, such as memory and problem solving.
Someone is diagnosed with dementia every 70 seconds. It is estimated that the number of people in the United States living with dementia will increase to about 13 million by the year 2050. Therefore, delaying the onset of dementia, even by one year, would have a substantial impact on public health.
Hypertension, or high blood pressure, is a major contributor to the development of all types of dementia. Many of the estimated one in three U.S. adults who have hypertension are treated with ACE inhibitors, a class of drugs that help lower blood pressure by causing the blood vessels to relax and widen.
Some ACE inhibitors are known as "centrally-acting" because they can cross the blood-brain barrier, a specialized system of tiny blood vessels that protects the brain from harmful substances in the blood stream. Centrally-acting ACE inhibitors include captropril, fosinopril, lisinopril, perindopril, ramipril and trandolapril.
For the study, researchers analyzed data from the Cardiovascular Health Study, a long-term study of cardiovascular risk factors that involved 5,888 people over 65 years old from Forsyth County, N.C.; Sacramento County, Calif.; Pittsburgh, Pa.; and Washington County, Md.
The investigators specifically looked at 1,074 study participants who were free of dementia when they entered the study and who were being treated for hypertension. They evaluated whether exposure to ACE inhibitors in general - and to the centrally-active versus non-centrally active drugs - was related to dementia development and cognitive decline.
Compared to other classes of anti-hypertensive drugs, researchers found no association between exposure to ACE inhibitors as a class and the risk of dementia. There was a significant cognitive benefit, however, seen in those individuals treated with the centrally-active ACE inhibitors specifically.
The study found an association between taking centrally-active ACE inhibitors and lower rates of mental decline as measured by the Modified Mini-Mental State Exam, a test that evaluates memory, language, abstract reasoning and other cognitive functions. The research showed that participants who were exposed to ACE inhibitors that cross the blood-brain barrier saw an average 65 percent less cognitive decline per year of exposure compared to participants taking other blood pressure medications.
Researchers also found that non-centrally active ACE inhibitors were associated with an increased risk of dementia and the people taking them were more likely to develop difficulty performing daily activities. Specifically, participants who, for three years, took ACE inhibitors that do not cross the blood-brain barrier were at a 73 percent greater risk of developing dementia than were the individuals taking other anti-hypertensive drugs.
"ACE inhibitors have been shown to be beneficial to the heart and kidneys, and this study gives evidence that they may also be beneficial to the brain-at least the ones that are able to get into the brain," Sink said. "We already know it is important to treat high blood pressure and keep it under good control. But our study finds that some blood pressure medications, such as the ACE inhibitors that cross the blood brain barrier, may offer benefits to the brain that others do not. If a patient has an indication for an ACE inhibitor, it makes sense to choose one that crosses the blood brain barrier. This is quite different from the typical recommendations for physicians to avoid medications in older adults that get into the brain."
The research was supported by the National Heart, Lung and Blood Institute, the Wake Forest University Pepper Older Adults Independence Center, the Kulynych Center for Research in Cognition at Wake Forest University, the Hartford Geriatrics Health Outcomes Research Scholars Program, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.
Co-authors on the study were Xiaoyan Leng, Ph.D., Jeff Williamson, M.D., M.H.S., Stephen B. Kritchevsky, Ph.D., Hal Atkinson, M.D., Mike Robbins, Ph.D., and David C. Goff, Jr., M.D., Ph.D., all from the School of Medicine, Kristine Yaffe, M.D., from the University of California, Lewis Kuller, M.D., Dr.P.H., from the University of Pittsburgh, Sevil Yasar, M.D., from Johns Hopkins University, and Bruce Psaty, M.D., Ph.D., from the University of Washington.
Source
Wake Forest University Baptist Medical Center
Posted by Scott W. Yates, MD, MBA, MS, FACP
July 24, 2009
Businesses Worry About New Burdens
Executives across the country expressed concern Wednesday that
health-care bills being hammered out in Congress this week would place
onerous burdens on their businesses without doing enough to reduce their
swelling medical costs.
health-care bills being hammered out in Congress this week would place
onerous burdens on their businesses without doing enough to reduce their
swelling medical costs.
Small businesses were particularly vocal in decrying the emerging
legislation. They said they would be especially hard-hit by provisions
in a House bill introduced Tuesday that would place a surtax on those
earning over $350,000 and penalize companies that don't offer health
insurance to their employees with an 8% payroll tax. A key Senate bill
offered a softer version of that employer mandate but one many
businesses still found objectionable.
"It's going to cost jobs. It's pretty simple," said Bruce Josten,
executive vice president of the U.S. Chamber of Commerce, which
represents three million employers and opposes both the House and the
Senate bills. Chamber members have sent at least 50,000 letters to
lawmakers, and the group has bought advertisements in seven states whose
congressional representatives hold key votes.
Many employer groups have spent months pushing for an overhaul, hoping
it would lower their health-care costs and make it easier for small
businesses to buy coverage. But with the release of the House bill,
employer groups ramped up criticism, saying employers can't afford new
mandates.
In the Senate, the Health, Education, Labor and Pensions Committee
passed its health-overhaul bill Wednesday, making it the first of three
key bills to pass through committee. The House, after unveiling its bill
Tuesday, plans to begin publicly fine-tuning that plan in the next few
days.
The Senate Finance Committee, the only committee trying to work out a
bipartisan measure, is still hashing out details of its first draft.
Congressional leaders plan to merge the three bills into one measure
they hope to deliver to President Barack Obama by the fall.
Under the bills unveiled so far, the biggest change employers would face
is that all but the smallest ones would be required to provide their
workers with health insurance or pay a penalty. The House plan would
require companies with more than $400,000 in annual payroll that don't
provide health insurance to pay a penalty equal to 8% of their payroll.
The bill passed Wednesday by the Senate health committee places less
responsibility on employers for providing coverage. That measure would
require employers to pay up to $750 annually per worker if they don't
provide coverage or if they cover less than 60% of employees' premiums.
It would exempt firms with 25 or fewer workers.
Many businesses see the Senate Finance Committee bill as their last hope
to enact measures that would cut their costs without driving up their
expenses. Business groups have voiced support for an individual mandate,
improved health-information technology and an overhauled payment system
for doctors and hospitals, but not an employer mandate.
Mr. Josten of the Chamber of Commerce said that requiring employers to
help pay for health insurance would cause them to lower wages and reduce
their work force.
Wal-Mart Stores Inc., the nation's largest employer, has broken with the
retail industry by supporting an employer mandate and is encouraged by
that requirement in both bills, says spokesman Greg Rossiter, but he
added that the retail giant isn't yet able to throw its support behind
any particular piece of legislation. "We don't see enough cost savings
in the bills," he said.
Rodger Roeser, owner of Eisen Marketing Group, a public-relations firm
in Cincinnati, doesn't buy health care for his employees, since he
figures it would cost him up to $3,000 per month. To afford that, he
said he would have to lay off at least two of his 20 employees and
eliminate his company's policy of matching 401(k) contributions.
"You are looking at an instantaneous overhead increase," he said. "I
don't believe that providing health insurance should be, in any way,
shape or form, the responsibility of the employer. I pay you a fair
salary, and you can choose whether to get health insurance."
Not all businesses are opposed to the proposed legislation. Carl Camden,
chief executive of global temporary-staffing firm Kelly Services, hailed
the broad outlines of the Senate and House bills. Kelly Services
employed 650,000 temporary workers world-wide and brought in $5.5
billion in 2008 sales.
"Ideologically, it's a no-brainer for us. We have a collective
society-wide health-care financing problem and it's going to take a
collective society-wide solution to fix it," Mr. Camden said. "But on
the details, it's not a no-brainer."
Ron Bullock, who runs gear maker Bison Gear & Engineering Corp., of St.
Charles, Ill., bristles at the House proposal to tax wealthy Americans,
since some small businesses like his pay taxes at the individual rate.
Mr. Bullock, who provides insurance for his 215 employees, says the levy
is unfair, even though he wants a solution to his health costs, which
are rising at a rate of 10% a year.
Opinion: The Wall Street Journal
By AVERY JOHNSON and JANET ADAMY
-Jonathan D. Rockoff, Colleen DeBaise and Vanessa Fuhrmans contributed
to this article.
Posted by Scott W. Yates, MD, MBA, MS, FACP
July 21, 2009
Ten Questions on the Health-Care Overhaul
It is crunch time for health care. Lawmakers who are trying to fundamentally remake one-sixth of the U.S. economy say this might be the most complicated legislation they have undertaken.
Here are some basics that everyone can grasp -- and probably ought to, because the health bill, if it passes, will affect almost everyone.
1. What is the problem with health care, anyway? Is it as bad as they say?
The problem, as advocates for change see it, boils down to two big areas: high costs and lack of coverage. For some households and employers, the cost of care already is out of reach, and many more will struggle to afford it if costs keep escalating. Medicare is eating up a bigger share of government spending, and a growing number of bankruptcies and home foreclosures are linked to medical expenses.
Even though the U.S. spends $2 trillion a year for health care, some 46 million people don't have health coverage. To be sure, that oft-cited number from the Census Bureau is somewhat misleading because it includes illegal immigrants, healthy young adults who don't think they need insurance and poor people who are eligible for Medicaid.
Still, as the recession wears on, the number of uninsured appears to be rising. One study, by the left-leaning Center for American Progress Action Fund, found that as many as 14,000 people are losing their health insurance every day because of job cuts. Families who have insurance pay an additional $1,000 a year in premiums to effectively subsidize all the people who receive care but don't pay for it, according to a separate study by the liberal group Families USA and actuarial consultancy Milliman Inc.
2. Can Democrats and Republicans agree on anything?
Actually, yes. There is broad support for changing the way hospitals and doctors are paid so that they are compensated for the quality of care they provide, not the quantity of procedures they do. Democrats and Republicans also back the idea of creating online marketplaces where consumers and small businesses can comparison-shop for plans.
Both parties want to bar insurance companies from denying coverage to people who are already sick. The insurers are willing to make that concession, as long as lawmakers also require most people to carry insurance, since that would force young, healthy people into the insurance system.
It amounts to a twin mandate -- one on insurers to sell policies, and another on Americans to buy them. Although there are pockets of Republican opposition to the latter idea, both have enough bipartisan support to pass. These steps alone would represent big changes to the status quo.
3. Where are the main points of disagreement?
The sharpest divide between the two parties: Whether to create a government-run insurance plan (otherwise known as a "public plan") that would go up against private plans in online marketplaces. President Barack Obama says a public plan will keep private insurers honest. Republicans say it would give the government too much control over health care.
The other main battle, which doesn't break down as easily along party lines, is how to pay for a plan expected to cost at least $1 trillion over a decade. Many lawmakers think it makes sense to impose a tax on employer-provided health-care benefits, a perk that currently is tax-free.
Then they looked at the poll numbers. Many voters hate the idea of paying taxes on something that right now costs nothing. So Democrats have instead proposed raising taxes on the rich.
Congress also remains divided over whether to make employers (except really small ones) provide insurance. House Democrats propose that if companies don't offer insurance, they should contribute as much as 8% of their payroll spending toward helping workers buy insurance on their own. Republicans argue that companies will make up for it by cutting jobs and lowering wages.
4. What would a public plan look like?
The country already has a huge public plan -- Medicare, which covers the elderly and some other groups. It generally pays doctors and hospitals less than private insurers. Liberal Democrats would like to replicate it in the new marketplaces. They want the government directly to set premiums and services under the plan, perhaps with basic and premium options.
That isn't going to fly in this Congress, despite Democratic control of both chambers. Republicans are more opposed to having a government plan than Democrats are bent on having it. Conservatives figure the government would quickly drive private insurers out of business by undercutting them on price.
Two other scenarios have emerged as compromises. One is to hold off on creating the plan and instead impose heavy regulations on insurance companies aimed at making coverage accessible and affordable. If that doesn't work, then the government insurance plan would kick in after several years. The other idea is to create a batch of regional nonprofit insurance cooperatives to compete with private insurers. But many liberals consider that a far stretch from the original idea, since the government wouldn't run those plans.
One point that gets overlooked in the debate is that most people probably wouldn't even be eligible for the public plan. Only individuals without affordable employer-provided insurance and businesses that aren't big enough to buy reasonably priced plans on their own would qualify.
5. Why is the total price of the overhaul so expensive, especially considering that it is designed to bring down costs?
The cost mostly comes from giving people subsidies to buy insurance, and from expanding Medicaid, the federal-state insurance program for the poor, to cover more low-income Americans.
The theory is that once more Americans carry insurance, the entire health system will spend less money caring for them. Those people will have more access to care that prevents them from getting sick in the first place, and they would rely less on costly forms of treatment such as visiting the emergency room. But it could be years before that really reduces health costs, if it ever does.
President Obama often talks about more fundamental fixes for high costs, like paying for quality and blocking doctors from boosting their income with unnecessary tests. But Congress has limited power to change that.
6. What are the most likely ways to pay for the overhaul?
The White House has proposed about $950 billion in savings over 10 years to pay for the plan that include things like lower reimbursements to hospitals that treat Medicare patients. The wealthy are a natural target. One proposal is limiting itemized tax deductions for families who earn more than $250,000 annually, a campaign idea of the president. House Democrats want to impose a surtax on wealthy individuals. Less likely are new taxes on soda and sugary drinks, which many lawmakers see as politically unpopular.
7. Which industries are most likely to lose, and which to gain, from any overhaul?
Perhaps no industry stands to gain more from the changes than health insurers, who would get tens of millions of new customers because Americans would be required by law to carry health insurance. Pharmaceutical companies would sell more prescription drugs because more people would have coverage for drugs and access to doctors who prescribe them. Hospitals and doctors wouldn't have to provide as much free care as they do now.
But each of those groups also could take hits, particularly the health insurers if some kind of public option drives down their profit margins. The big losers would be retailers, restaurants and other businesses with low-income workers who provide little or no health insurance, since they would be forced to start paying for it.
Businesses that are too small to afford health insurance but not tiny enough to fall below the proposed $250,000 annual payroll cutoff that exempts them from providing coverage also could get squeezed by the legislation.
8. I already have insurance through my job - what happens to me?
Not too much at first. A handful of tax-free perks for the insured could get axed. For instance, lawmakers want to end the practice of allowing people to put money into so-called flexible spending accounts, which allow them to pay for everything from cosmetic dental work to surgery with tax-free dollars.
Longer term, a lot could change. For instance, your employer could drop coverage, preferring to pay the penalty for doing so and deflecting employees to Uncle Sam's plan. Cost-cutting efforts in other parts of the system could eventually affect employer-provided plans as well.
9. Politicians have tried for decades to push universal health insurance. Why did they always fail before? Why would this time be any different?
These efforts stretch back to the 1930s, when President Franklin Roosevelt proposed creating a compulsory health-insurance system for all Americans, run by the states. Doctors, worried it would hurt their pay, helped kill the measure, buoyed by opposition from business and labor groups. Other major health overhaul attempts, most notably President Bill Clinton's 1993-94 effort, died because powerful interest groups feared their members would either earn less or have to pay more under the new system.
What is different now is that major health and other interest groups are on board with the idea. Many insurers, hospitals, doctors and drug companies agree that the system is so flawed it isn't sustainable, and they see a bill as a chance to push through improvements like adopting electronic health records, broadening the use of data to show which treatments work best and reducing the threat of malpractice lawsuits. Employers see it as a chance to curb the sharply rising price of covering their workers. Almost no one is arguing that the system is fine the way it is. Mr. Obama's high popularity, coupled with wide Democratic margins in Congress, also grease the wheels for passing a bill.
10. What happens if the effort once again fails?
Lawmakers would likely scale back their plans and try to at least pass a measure that partially expands insurance coverage or helps stall the increase in health costs. But so many parts of the legislation are intertwined that they will be less effective, and perhaps impossible to achieve, if done piecemeal. Lawmakers might be reluctant to take up the controversial legislation ahead of congressional elections next year. So it would probably be several years before lawmakers tried again.
From the Wall Street Journal
by Janet Adamy
Posted by Scott W. Yates, MD, MBA, MS, FACP
Here are some basics that everyone can grasp -- and probably ought to, because the health bill, if it passes, will affect almost everyone.
1. What is the problem with health care, anyway? Is it as bad as they say?
The problem, as advocates for change see it, boils down to two big areas: high costs and lack of coverage. For some households and employers, the cost of care already is out of reach, and many more will struggle to afford it if costs keep escalating. Medicare is eating up a bigger share of government spending, and a growing number of bankruptcies and home foreclosures are linked to medical expenses.
Even though the U.S. spends $2 trillion a year for health care, some 46 million people don't have health coverage. To be sure, that oft-cited number from the Census Bureau is somewhat misleading because it includes illegal immigrants, healthy young adults who don't think they need insurance and poor people who are eligible for Medicaid.
Still, as the recession wears on, the number of uninsured appears to be rising. One study, by the left-leaning Center for American Progress Action Fund, found that as many as 14,000 people are losing their health insurance every day because of job cuts. Families who have insurance pay an additional $1,000 a year in premiums to effectively subsidize all the people who receive care but don't pay for it, according to a separate study by the liberal group Families USA and actuarial consultancy Milliman Inc.
2. Can Democrats and Republicans agree on anything?
Actually, yes. There is broad support for changing the way hospitals and doctors are paid so that they are compensated for the quality of care they provide, not the quantity of procedures they do. Democrats and Republicans also back the idea of creating online marketplaces where consumers and small businesses can comparison-shop for plans.
Both parties want to bar insurance companies from denying coverage to people who are already sick. The insurers are willing to make that concession, as long as lawmakers also require most people to carry insurance, since that would force young, healthy people into the insurance system.
It amounts to a twin mandate -- one on insurers to sell policies, and another on Americans to buy them. Although there are pockets of Republican opposition to the latter idea, both have enough bipartisan support to pass. These steps alone would represent big changes to the status quo.
3. Where are the main points of disagreement?
The sharpest divide between the two parties: Whether to create a government-run insurance plan (otherwise known as a "public plan") that would go up against private plans in online marketplaces. President Barack Obama says a public plan will keep private insurers honest. Republicans say it would give the government too much control over health care.
The other main battle, which doesn't break down as easily along party lines, is how to pay for a plan expected to cost at least $1 trillion over a decade. Many lawmakers think it makes sense to impose a tax on employer-provided health-care benefits, a perk that currently is tax-free.
Then they looked at the poll numbers. Many voters hate the idea of paying taxes on something that right now costs nothing. So Democrats have instead proposed raising taxes on the rich.
Congress also remains divided over whether to make employers (except really small ones) provide insurance. House Democrats propose that if companies don't offer insurance, they should contribute as much as 8% of their payroll spending toward helping workers buy insurance on their own. Republicans argue that companies will make up for it by cutting jobs and lowering wages.
4. What would a public plan look like?
The country already has a huge public plan -- Medicare, which covers the elderly and some other groups. It generally pays doctors and hospitals less than private insurers. Liberal Democrats would like to replicate it in the new marketplaces. They want the government directly to set premiums and services under the plan, perhaps with basic and premium options.
That isn't going to fly in this Congress, despite Democratic control of both chambers. Republicans are more opposed to having a government plan than Democrats are bent on having it. Conservatives figure the government would quickly drive private insurers out of business by undercutting them on price.
Two other scenarios have emerged as compromises. One is to hold off on creating the plan and instead impose heavy regulations on insurance companies aimed at making coverage accessible and affordable. If that doesn't work, then the government insurance plan would kick in after several years. The other idea is to create a batch of regional nonprofit insurance cooperatives to compete with private insurers. But many liberals consider that a far stretch from the original idea, since the government wouldn't run those plans.
One point that gets overlooked in the debate is that most people probably wouldn't even be eligible for the public plan. Only individuals without affordable employer-provided insurance and businesses that aren't big enough to buy reasonably priced plans on their own would qualify.
5. Why is the total price of the overhaul so expensive, especially considering that it is designed to bring down costs?
The cost mostly comes from giving people subsidies to buy insurance, and from expanding Medicaid, the federal-state insurance program for the poor, to cover more low-income Americans.
The theory is that once more Americans carry insurance, the entire health system will spend less money caring for them. Those people will have more access to care that prevents them from getting sick in the first place, and they would rely less on costly forms of treatment such as visiting the emergency room. But it could be years before that really reduces health costs, if it ever does.
President Obama often talks about more fundamental fixes for high costs, like paying for quality and blocking doctors from boosting their income with unnecessary tests. But Congress has limited power to change that.
6. What are the most likely ways to pay for the overhaul?
The White House has proposed about $950 billion in savings over 10 years to pay for the plan that include things like lower reimbursements to hospitals that treat Medicare patients. The wealthy are a natural target. One proposal is limiting itemized tax deductions for families who earn more than $250,000 annually, a campaign idea of the president. House Democrats want to impose a surtax on wealthy individuals. Less likely are new taxes on soda and sugary drinks, which many lawmakers see as politically unpopular.
7. Which industries are most likely to lose, and which to gain, from any overhaul?
Perhaps no industry stands to gain more from the changes than health insurers, who would get tens of millions of new customers because Americans would be required by law to carry health insurance. Pharmaceutical companies would sell more prescription drugs because more people would have coverage for drugs and access to doctors who prescribe them. Hospitals and doctors wouldn't have to provide as much free care as they do now.
But each of those groups also could take hits, particularly the health insurers if some kind of public option drives down their profit margins. The big losers would be retailers, restaurants and other businesses with low-income workers who provide little or no health insurance, since they would be forced to start paying for it.
Businesses that are too small to afford health insurance but not tiny enough to fall below the proposed $250,000 annual payroll cutoff that exempts them from providing coverage also could get squeezed by the legislation.
8. I already have insurance through my job - what happens to me?
Not too much at first. A handful of tax-free perks for the insured could get axed. For instance, lawmakers want to end the practice of allowing people to put money into so-called flexible spending accounts, which allow them to pay for everything from cosmetic dental work to surgery with tax-free dollars.
Longer term, a lot could change. For instance, your employer could drop coverage, preferring to pay the penalty for doing so and deflecting employees to Uncle Sam's plan. Cost-cutting efforts in other parts of the system could eventually affect employer-provided plans as well.
9. Politicians have tried for decades to push universal health insurance. Why did they always fail before? Why would this time be any different?
These efforts stretch back to the 1930s, when President Franklin Roosevelt proposed creating a compulsory health-insurance system for all Americans, run by the states. Doctors, worried it would hurt their pay, helped kill the measure, buoyed by opposition from business and labor groups. Other major health overhaul attempts, most notably President Bill Clinton's 1993-94 effort, died because powerful interest groups feared their members would either earn less or have to pay more under the new system.
What is different now is that major health and other interest groups are on board with the idea. Many insurers, hospitals, doctors and drug companies agree that the system is so flawed it isn't sustainable, and they see a bill as a chance to push through improvements like adopting electronic health records, broadening the use of data to show which treatments work best and reducing the threat of malpractice lawsuits. Employers see it as a chance to curb the sharply rising price of covering their workers. Almost no one is arguing that the system is fine the way it is. Mr. Obama's high popularity, coupled with wide Democratic margins in Congress, also grease the wheels for passing a bill.
10. What happens if the effort once again fails?
Lawmakers would likely scale back their plans and try to at least pass a measure that partially expands insurance coverage or helps stall the increase in health costs. But so many parts of the legislation are intertwined that they will be less effective, and perhaps impossible to achieve, if done piecemeal. Lawmakers might be reluctant to take up the controversial legislation ahead of congressional elections next year. So it would probably be several years before lawmakers tried again.
From the Wall Street Journal
by Janet Adamy
Posted by Scott W. Yates, MD, MBA, MS, FACP
July 17, 2009
Budget Blow for Health Plan
Congress's Chief Fiscal Watchdog Warns of Overhaul's Cost; Ammunition for Critics
Congress's chief budget scorekeeper cast a new cloud over Democratic efforts to overhaul the nation's health-care system, telling lawmakers Thursday that the main proposals being considered would fail to contain costs -- one of the primary goals -- and could actually worsen the problem of rapidly escalating medical spending.
"We do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount," Douglas Elmendorf, director of the Congressional Budget Office, told the Senate Budget Committee. "On the contrary, the legislation significantly expands the federal responsibility for health-care costs," he added.
When President Barack Obama and lawmakers set out earlier this year to revamp the health-care system, they had two main objectives: Expand access to health insurance and curb runaway costs, not just for the government but the economy as a whole.
But as House and Senate versions of the legislation have advanced, lawmakers have found it easier to embrace proposals expanding coverage than those cutting the long-term cost of care. Mr. Obama and other Democrats have made several compromises on cost savings to keep key players on board for the overall effort. For example, the White House has softened several threats to extract savings from the powerful pharmaceutical industry, despite the president's campaign pledge to take on drug makers.
Mr. Elmendorf's assessment carries significant weight in the health-care debate, since his nonpartisan organization is used to determine the official costs and impact of legislative proposals. One of his predecessors in charge of the CBO, Robert Reischauer, famously helped derail the last major push to broadly expand health care in 1994 when he testified that President Bill Clinton's proposal would cost far more than the White House had projected.
The CBO assessment quickly reverberated around Capitol Hill, where House and Senate Democratic leaders are struggling to secure votes to advance health legislation before a scheduled break in August. Some Democrats had already grown nervous about the health-care effort in recent days, after House Democrats said they would pay for their plan with a surtax on upper-income families -- a proposal that could cause trouble for some Democrats in Republican-leaning districts.
While most Democratic lawmakers embrace in principle Mr. Obama's goal of enacting sweeping changes this year, many have said they would only support a measure that clearly can contain health-care spending. In recent days, many of those lawmakers have threatened to oppose the proposals crafted by congressional leaders, saying the plans won't do enough on that front.
Mr. Elmendorf's comments gave them new ammunition to threaten opposition.
"We have to take steps to hold health-care costs to the rate of inflation, or we will never balance our federal budget again and health-insurance costs will continue to become less and less affordable for the American people," said Arkansas Democratic Rep. Mike Ross. Mr. Ross is a leading member of the Blue Dogs, a moderate faction of the party's caucus that counts more than 50 members and has a crucial say over whether health-care legislation will pass. Mr. Elmendorf's comments, he said, "only underscore what the Blue Dogs have been saying all along."
Rep. Jim Matheson, a moderate Democrat from Utah, suggested Mr. Elmendorf's assessment "is of great concern" and called for renewed focus on restraining spending. "If we don't reform the system to get costs under control, then nothing else matters," he said. "We're just putting more people into a broken system."
The testimony undercuts one of Mr. Obama's central arguments: that the initiative will control long-term costs for the government as well as ordinary Americans and businesses. Mr. Elmendorf did caution that making long-term assessments is difficult. "It is very hard to look out...and say very accurate things about growth rates," he said. But when asked whether bills moving through Congress would bring the health-care cost curve under control, he responded: "The cost curve is being raised."
The White House played down the significance of Mr. Elmendorf's remarks. Kenneth Baer, a spokesman for the Office of Management and Budget, said "the process is still ongoing" in terms of shaping legislation. He stressed that the Obama administration remains "confident that we will see a final bill that is both deficit-neutral and will reduce the rise in health-care cost growth in the years to come."
But it was clear that Mr. Elmendorf's remarks struck a nerve with House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid, who jointly appointed the economist to his post after the previous CBO director, Peter Orszag, was made White House budget director.
Ms. Pelosi, a California Democrat, complained that the CBO, in calculating the impact of health legislation, doesn't give "any credit" to certain proposals designed to reduce spending, such as preventive-care measures that backers of the bill say will reduce costs throughout the system.
In his appearance, Mr. Elmendorf suggested lawmakers could take steps to control costs. Among other things, he said Congress could reduce the tax subsidy that critics say encourages employers to offer large health-insurance policies. That idea was being considered by members of the Senate Finance Committee, but dropped after Senate Democratic leaders -- including Mr. Reid -- voiced concern. The proposal has been sharply opposed by labor unions, among other groups, that have big tax-advantaged plans.
On Thursday, Mr. Reid expressed disdain when asked by reporters about Mr. Elmendorf's suggestion. "What he should do is maybe run for Congress," the Nevada Democrat said.
Republicans were quick to trumpet the Elmendorf comments in their stepped-up campaign against the health-care effort. "The director of the Congressional Budget Office today confirmed that the Democrats' government-run plan will make health care more costly than ever, making clear that one of the Democrats' chief talking points is pure fiction," said Ohio Rep. John Boehner, the House Republican leader.
Mr. Elmendorf addressed his analysis generally to the main bills moving in the House and Senate. He suggested the analysis is evolving, noting the House bill was only released "two days ago." He made clear he wasn't referring to legislation being fashioned by the Senate Finance Committee, because leaders of that panel "have not yet released" that bill.
While the CBO storm may have set back the move for rapid action on health care, the effort also got an important boost Thursday when the American Medical Association offered support for the House proposal.
In a letter delivered to House Ways and Means Chairman Charles Rangel, a New York Democrat, the doctors' group expressed "appreciation and support" for the bill. Among other things, the AMA welcomed a provision that would put in place a new formula for payments to doctors under Medicare, avoiding deep cuts scheduled to take place next year and in future years.
Opinion: The Wall Street Journal
By: Greg Hitt
Posted by Scott W. Yates, MD, MBA, MS, FACP
Congress's chief budget scorekeeper cast a new cloud over Democratic efforts to overhaul the nation's health-care system, telling lawmakers Thursday that the main proposals being considered would fail to contain costs -- one of the primary goals -- and could actually worsen the problem of rapidly escalating medical spending.
"We do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount," Douglas Elmendorf, director of the Congressional Budget Office, told the Senate Budget Committee. "On the contrary, the legislation significantly expands the federal responsibility for health-care costs," he added.
When President Barack Obama and lawmakers set out earlier this year to revamp the health-care system, they had two main objectives: Expand access to health insurance and curb runaway costs, not just for the government but the economy as a whole.
But as House and Senate versions of the legislation have advanced, lawmakers have found it easier to embrace proposals expanding coverage than those cutting the long-term cost of care. Mr. Obama and other Democrats have made several compromises on cost savings to keep key players on board for the overall effort. For example, the White House has softened several threats to extract savings from the powerful pharmaceutical industry, despite the president's campaign pledge to take on drug makers.
Mr. Elmendorf's assessment carries significant weight in the health-care debate, since his nonpartisan organization is used to determine the official costs and impact of legislative proposals. One of his predecessors in charge of the CBO, Robert Reischauer, famously helped derail the last major push to broadly expand health care in 1994 when he testified that President Bill Clinton's proposal would cost far more than the White House had projected.
The CBO assessment quickly reverberated around Capitol Hill, where House and Senate Democratic leaders are struggling to secure votes to advance health legislation before a scheduled break in August. Some Democrats had already grown nervous about the health-care effort in recent days, after House Democrats said they would pay for their plan with a surtax on upper-income families -- a proposal that could cause trouble for some Democrats in Republican-leaning districts.
While most Democratic lawmakers embrace in principle Mr. Obama's goal of enacting sweeping changes this year, many have said they would only support a measure that clearly can contain health-care spending. In recent days, many of those lawmakers have threatened to oppose the proposals crafted by congressional leaders, saying the plans won't do enough on that front.
Mr. Elmendorf's comments gave them new ammunition to threaten opposition.
"We have to take steps to hold health-care costs to the rate of inflation, or we will never balance our federal budget again and health-insurance costs will continue to become less and less affordable for the American people," said Arkansas Democratic Rep. Mike Ross. Mr. Ross is a leading member of the Blue Dogs, a moderate faction of the party's caucus that counts more than 50 members and has a crucial say over whether health-care legislation will pass. Mr. Elmendorf's comments, he said, "only underscore what the Blue Dogs have been saying all along."
Rep. Jim Matheson, a moderate Democrat from Utah, suggested Mr. Elmendorf's assessment "is of great concern" and called for renewed focus on restraining spending. "If we don't reform the system to get costs under control, then nothing else matters," he said. "We're just putting more people into a broken system."
The testimony undercuts one of Mr. Obama's central arguments: that the initiative will control long-term costs for the government as well as ordinary Americans and businesses. Mr. Elmendorf did caution that making long-term assessments is difficult. "It is very hard to look out...and say very accurate things about growth rates," he said. But when asked whether bills moving through Congress would bring the health-care cost curve under control, he responded: "The cost curve is being raised."
The White House played down the significance of Mr. Elmendorf's remarks. Kenneth Baer, a spokesman for the Office of Management and Budget, said "the process is still ongoing" in terms of shaping legislation. He stressed that the Obama administration remains "confident that we will see a final bill that is both deficit-neutral and will reduce the rise in health-care cost growth in the years to come."
But it was clear that Mr. Elmendorf's remarks struck a nerve with House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid, who jointly appointed the economist to his post after the previous CBO director, Peter Orszag, was made White House budget director.
Ms. Pelosi, a California Democrat, complained that the CBO, in calculating the impact of health legislation, doesn't give "any credit" to certain proposals designed to reduce spending, such as preventive-care measures that backers of the bill say will reduce costs throughout the system.
In his appearance, Mr. Elmendorf suggested lawmakers could take steps to control costs. Among other things, he said Congress could reduce the tax subsidy that critics say encourages employers to offer large health-insurance policies. That idea was being considered by members of the Senate Finance Committee, but dropped after Senate Democratic leaders -- including Mr. Reid -- voiced concern. The proposal has been sharply opposed by labor unions, among other groups, that have big tax-advantaged plans.
On Thursday, Mr. Reid expressed disdain when asked by reporters about Mr. Elmendorf's suggestion. "What he should do is maybe run for Congress," the Nevada Democrat said.
Republicans were quick to trumpet the Elmendorf comments in their stepped-up campaign against the health-care effort. "The director of the Congressional Budget Office today confirmed that the Democrats' government-run plan will make health care more costly than ever, making clear that one of the Democrats' chief talking points is pure fiction," said Ohio Rep. John Boehner, the House Republican leader.
Mr. Elmendorf addressed his analysis generally to the main bills moving in the House and Senate. He suggested the analysis is evolving, noting the House bill was only released "two days ago." He made clear he wasn't referring to legislation being fashioned by the Senate Finance Committee, because leaders of that panel "have not yet released" that bill.
While the CBO storm may have set back the move for rapid action on health care, the effort also got an important boost Thursday when the American Medical Association offered support for the House proposal.
In a letter delivered to House Ways and Means Chairman Charles Rangel, a New York Democrat, the doctors' group expressed "appreciation and support" for the bill. Among other things, the AMA welcomed a provision that would put in place a new formula for payments to doctors under Medicare, avoiding deep cuts scheduled to take place next year and in future years.
Opinion: The Wall Street Journal
By: Greg Hitt
Posted by Scott W. Yates, MD, MBA, MS, FACP
Health Reform Requires Lawsuit Reform
Health Reform Requires Lawsuit Reform
But tort lawyers are the one special interest Democrats won't offend.
Containing health-care costs is impossible under the current legal structure. That fact has to be addressed if President Barack Obama is to create an affordable health-care system that is accessible to everyone.
Every incentive in the system now is to do more -- that's how doctors get paid and that's how doctors get protected from lawsuits. Billions of dollars are wasted in "defensive medicine." Bureaucracy built up over decades diverts resources from patient care to mindless compliance. Forms are everywhere.
The only path to affordable health care is a basic overhaul to realign incentives. The new ideas are out there -- for example, creating a reimbursement model that rewards effective care, and restoring trust in the reliability of justice by creating special health courts.
Overhaul, however, requires letting go of the old ways. Congress is perfectly willing to come up with new programs and introduce new taxes to pay for ever-rising health-care costs. But Congress seems unwilling to make hard choices.
Like a crash in slow motion, you can see Congress tumbling down toward the lowest common denominator -- a reform package that will do little to contain costs, but will offend the least number of special interests.
Studies have repeatedly demonstrated that the current ad hoc system of justice, with verdicts that vary widely from one jury to the next, has spawned a culture of legal fear and self protection. Studies also show that the system fails injured patients -- a claim takes an average of five years to resolve and nearly 60 cents out of every dollar spent in the malpractice system ends up going to lawyers or administrative costs.
That's why most of the important health-care constituencies, from the American Medical Association to AARP, favor creating pilot projects for special health courts. Mr. Obama has recently talked about the need "to explore a range of ideas about how to . . . scale back the excessive defensive medicine."
But one interest group hates the idea. You guessed which one. Sen. Mike Enzi (R., Wy.) discovered just how powerful the trial lawyers are when he proposed creating health court pilot projects. His proposal was only to permit experiments, not broad-scale tort reform, and it had been developed with Sen. Max Baucus (D., Mt.), chairman of the Finance Committee. But when Mr. Enzi offered this modest proposal, other members of the Senate Committee on Health, Education, Labor and Pensions killed the idea, declaring that the Constitution requires juries to be the ultimate decision maker in civil lawsuits.
That's not true. Special courts without juries are common in America and include courts for bankruptcy, tax disputes, workers compensation and more. America has a long history of using expert courts when there is a need for expertise and consistency. It's hard to imagine any area that needs consistent justice more than health care.
The senators weren't willing to discuss the merits of an expert court. The jury, as Sen. Sheldon Whitehouse (D., R.I.) put it, is "our protection against tyranny of the majority." But that's not true either, at least not for civil cases. In private lawsuits, juries have the limited role of deciding disputed issues of fact. "What is the object of the jury trial?," asked John Marshall in the debates over ratifying the Constitution. Marshall, the future chief justice of the U.S. Supreme Court, then answered his own question: "To inform the court of the facts." It is the judge who is tasked with drawing legal boundaries that determine who can sue for what. Those boundaries are precisely what's missing in deciding whether doctors have abided by accepted standards of care.
At the hearing, Mr. Whitehouse warned that "we take enormous risks as a country if we interfere with the institution of trial by jury." Actually, the enormous damage of unreliable justice is visible all around American society -- in playgrounds stripped of athletic equipment (contributing to the epidemic of obesity), in schools where disorder is the norm because of loss of teacher authority, and in a health-care system that squanders resources practicing unnecessary defensive medicine.
Fear is the tool not of leadership but of the status quo. It could hardly be easier to scare people into keeping programs and institutions the way they are. But that only delays the day of reckoning. Congress is mortgaging our children's future. Cost containment must be a goal. Protecting trial lawyers is not the solution.
Opinion: The Wall Street Journal
By: Philip K. Howard
Mr. Howard, a lawyer and author, is chairman of Common Good (www.commongood.org).
Posted by Scott W. Yates, MD, MBA, MS, FACP
But tort lawyers are the one special interest Democrats won't offend.
Containing health-care costs is impossible under the current legal structure. That fact has to be addressed if President Barack Obama is to create an affordable health-care system that is accessible to everyone.
Every incentive in the system now is to do more -- that's how doctors get paid and that's how doctors get protected from lawsuits. Billions of dollars are wasted in "defensive medicine." Bureaucracy built up over decades diverts resources from patient care to mindless compliance. Forms are everywhere.
The only path to affordable health care is a basic overhaul to realign incentives. The new ideas are out there -- for example, creating a reimbursement model that rewards effective care, and restoring trust in the reliability of justice by creating special health courts.
Overhaul, however, requires letting go of the old ways. Congress is perfectly willing to come up with new programs and introduce new taxes to pay for ever-rising health-care costs. But Congress seems unwilling to make hard choices.
Like a crash in slow motion, you can see Congress tumbling down toward the lowest common denominator -- a reform package that will do little to contain costs, but will offend the least number of special interests.
Studies have repeatedly demonstrated that the current ad hoc system of justice, with verdicts that vary widely from one jury to the next, has spawned a culture of legal fear and self protection. Studies also show that the system fails injured patients -- a claim takes an average of five years to resolve and nearly 60 cents out of every dollar spent in the malpractice system ends up going to lawyers or administrative costs.
That's why most of the important health-care constituencies, from the American Medical Association to AARP, favor creating pilot projects for special health courts. Mr. Obama has recently talked about the need "to explore a range of ideas about how to . . . scale back the excessive defensive medicine."
But one interest group hates the idea. You guessed which one. Sen. Mike Enzi (R., Wy.) discovered just how powerful the trial lawyers are when he proposed creating health court pilot projects. His proposal was only to permit experiments, not broad-scale tort reform, and it had been developed with Sen. Max Baucus (D., Mt.), chairman of the Finance Committee. But when Mr. Enzi offered this modest proposal, other members of the Senate Committee on Health, Education, Labor and Pensions killed the idea, declaring that the Constitution requires juries to be the ultimate decision maker in civil lawsuits.
That's not true. Special courts without juries are common in America and include courts for bankruptcy, tax disputes, workers compensation and more. America has a long history of using expert courts when there is a need for expertise and consistency. It's hard to imagine any area that needs consistent justice more than health care.
The senators weren't willing to discuss the merits of an expert court. The jury, as Sen. Sheldon Whitehouse (D., R.I.) put it, is "our protection against tyranny of the majority." But that's not true either, at least not for civil cases. In private lawsuits, juries have the limited role of deciding disputed issues of fact. "What is the object of the jury trial?," asked John Marshall in the debates over ratifying the Constitution. Marshall, the future chief justice of the U.S. Supreme Court, then answered his own question: "To inform the court of the facts." It is the judge who is tasked with drawing legal boundaries that determine who can sue for what. Those boundaries are precisely what's missing in deciding whether doctors have abided by accepted standards of care.
At the hearing, Mr. Whitehouse warned that "we take enormous risks as a country if we interfere with the institution of trial by jury." Actually, the enormous damage of unreliable justice is visible all around American society -- in playgrounds stripped of athletic equipment (contributing to the epidemic of obesity), in schools where disorder is the norm because of loss of teacher authority, and in a health-care system that squanders resources practicing unnecessary defensive medicine.
Fear is the tool not of leadership but of the status quo. It could hardly be easier to scare people into keeping programs and institutions the way they are. But that only delays the day of reckoning. Congress is mortgaging our children's future. Cost containment must be a goal. Protecting trial lawyers is not the solution.
Opinion: The Wall Street Journal
By: Philip K. Howard
Mr. Howard, a lawyer and author, is chairman of Common Good (www.commongood.org).
Posted by Scott W. Yates, MD, MBA, MS, FACP
Swine Flu Speading with ‘Unprecedented Speed,’ Says WHO
Swine Flu Speading with 'Unprecedented Speed'
The World Health Organization says it's going to stop counting cases of the new H1N1 flu is no longer needed to monitor the pandemic's level or nature of risk, according to a note posted on its website.
The virus is spreading with "unprecedented speed", wrote the WHO. "At this point, further spread of the pandemic, within affected countries and to new countries, is considered inevitable."
But countries need to continue to closely monitor "unusual events" like clusters of severe virus infections or unusual patterns of these serious cases. These signals might come from noticing an increase in the number of people staying home from work or school, or by an increase in emergency room visits.
On the H1N1 vaccine front, the WSJ notes that the manufacturing has been difficult. Novartis said that the yield is about 30% to 50% of what it normally gets for the seasonal flu vaccines, while Baxter told the WSJ that "yield optimization" — getting a lot of vaccine per batch — is a challenge.
Experts worry that the limited supply of vaccine will prompt a "global grab", where countries will try to protect their own citizens first, according to ABC News. This could be an issue for the U.S., which makes only 20% of the flu vaccine it uses.
"There's always a concern that when we have these international vaccine manufacturers that some of that vaccine for example might be embargoed or held back," William Schaffner, chairman of preventive medicine at Vanderbilt University Medical Center told ABC.
The CDC is hosting a call for reporters at noon Eastern time today. We'll listen in and report back on the key points.
From The Wall Street Journal Online
By: Shirley S. Wang
Posted by Scott W. Yates, MD, MBA, MS, FACP
The World Health Organization says it's going to stop counting cases of the new H1N1 flu is no longer needed to monitor the pandemic's level or nature of risk, according to a note posted on its website.
The virus is spreading with "unprecedented speed", wrote the WHO. "At this point, further spread of the pandemic, within affected countries and to new countries, is considered inevitable."
But countries need to continue to closely monitor "unusual events" like clusters of severe virus infections or unusual patterns of these serious cases. These signals might come from noticing an increase in the number of people staying home from work or school, or by an increase in emergency room visits.
On the H1N1 vaccine front, the WSJ notes that the manufacturing has been difficult. Novartis said that the yield is about 30% to 50% of what it normally gets for the seasonal flu vaccines, while Baxter told the WSJ that "yield optimization" — getting a lot of vaccine per batch — is a challenge.
Experts worry that the limited supply of vaccine will prompt a "global grab", where countries will try to protect their own citizens first, according to ABC News. This could be an issue for the U.S., which makes only 20% of the flu vaccine it uses.
"There's always a concern that when we have these international vaccine manufacturers that some of that vaccine for example might be embargoed or held back," William Schaffner, chairman of preventive medicine at Vanderbilt University Medical Center told ABC.
The CDC is hosting a call for reporters at noon Eastern time today. We'll listen in and report back on the key points.
From The Wall Street Journal Online
By: Shirley S. Wang
Posted by Scott W. Yates, MD, MBA, MS, FACP
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