Obama has named health-care reform his top domestic priority and talked about its prognosis from Italy on Friday.

“We’re closer to that significant reform than at any time in recent history,” Obama said. “That doesn’t make it easy. It’s hard….There are going to be some tough negotiations in the days and weeks to come, but I’m confident that we’re going to get it done.”

Financing remains a key sticking point in negotiations.

Earlier in the week, in the wake of polling that showed Americans skittish about a new tax on employer health benefits beyond a certain threshold, top Democrats appeared to be backing away from plans to tap this financing mechanism. The tax exclusion represents one of the biggest sources of potential funding for comprehensive reform, depending on how it’s structured and how many workers would be affected. The Senate Finance Committee’s bill estimated it would bring in $320 billion over 10 years. See last week’s Vital Signs on how a tax on health benefits may affect you.

The scramble to patch together alternative financing went into high gear, with lawmakers reportedly considering an income tax surcharge on wealthy individuals, a Medicare tax on capital gains and dividends and other ideas. Democrats are aiming to keep the cost of health reform at or below $1 trillion over 10 years.

On Tuesday, White House Chief of Staff Rahm Emanuel seemed to ignite a rally in health insurer stocks by hinting to the Wall Street Journal the administration would be open to compromise in the hotly contested public plan option that many Democrats favor to spur competition among private health insurers and bring down costs. This week’s Vital Signs discusses what’s at stake with a public plan option.

On Wednesday, the Obama administration announced that hospitals agreed to contribute savings of $155 billion over 10 years toward the cost of covering the 46 million uninsured. Read more on the deal.

The American Hospital Association praised the deal.

“We are pleased to see restrictions on physician self-referral to hospitals in which they have an ownership interest, proposals to simplify administrative red tape and no cuts to funding that teaching hospitals rely upon to train the next generation of physicians,” the AHA said in a prepared statement.

On Thursday, a group of fiscally conservative House Democrats in the so-called Blue Dog Coalition sent a letter to party leaders demanding changes in draft legislation the leaders wanted to vote on before the August recess, raising doubts about the ability to achieve that timing, according to the Associated Press. Lawmakers in the Senate appear to be slowing the process as well.

In a dramatic reversal on Tuesday, Wal-Mart, the world’s largest private employer, said in a letter to President Obama that it now supports a requirement that employers provide health insurance to their workers or pay into a fund as part of comprehensive health reform. This strategy is known as the employer mandate. The move suggests the retailing giant wants a level playing field among its competitors more than it wants to continue fighting what appears to be an uphill public-relations battle over providing benefits. Businesses that have reflexively opposed a mandate may now have to think twice.

Wal-Mart came under fire several years ago for providing its workers with skimpy benefits or often none at all. In many cases, workers who didn’t have company-provided health insurance were getting coverage through Medicaid, the government program for poor and low-income workers, prompting the state of Maryland to challenge Wal-Mart’s policies in a high-profile case.

In a statement on its Web site, Wal-Mart says it supports “shared responsibility” and an employer mandate that’s “broad and fair.” In exchange it said it wants health reform to control costs.

“We believe the mandate should cover as many businesses as possible, and cover part-time as well as full-time employees,” the statement said. Read the full text here.

The letter also was signed by leaders of the Service Employees International Union and the Center for American Progress.

On Wednesday, Obama held his third town hall meeting, this time in Annandale, Va., to press his case for health reform. About 200 people attended, most of whom support his health-care agenda.

On Thursday, the Senate’s health committee released a revamped version of its health-reform bill. This one has an estimated price tag that’s dramatically reduced to $611 billion over 10 years and would cover 97% of Americans. Earlier, the Congressional Budget Office scored a previous version of the bill that was incomplete. More details are available now. The bill, called the Affordable Health Choices Act, has provisions for an employer mandate and the option for a government health plan to compete with private insurers. Expect analysts to weigh on the measures and other congressional committees to accelerate their draft legislation in an effort to meet Obama’s goal of having a final bill on his desk by mid-October.

Will Americans who like their health plans be able to keep them as Obama said? Will families be able to see their annual premiums decline by $2,500 in a few years as promised?

On Monday, President Obama announced that drug companies had agreed to discount the cost of brand-name drugs to the tune of $80 billion for Medicare beneficiaries so fewer of them would fall into the coverage gap known as the doughnut hole. Senior-advocacy group AARP hailed the move, which was contingent on comprehensive health reform. The announcement suggested the Pharmaceutical Research and Manufacturers Association was trying to preempt potentially onerous regulation that may have come about if the group hadn’t voluntarily offered to reduce costs.

Obama also signed a landmark tobacco bill that gives the federal government sweeping new authority to regulate the manufacturing, marketing and advertising of cigarettes and tobacco products. Smoking causes 400,000 Americans to die every year.

In a Tuesday press conference, Obama defended his health plan and pushed back after two insurance industry groups sent a letter to the Senate Health, Education, Labor and Pensions committee urging it to drop the public plan option many Democrats want, which would compete with private insurers in an effort to make them more efficient.

“A government plan option – in any form – is unnecessary to achieve comprehensive reform and would have devastating consequences on the health insurance coverage that employers and individuals currently have, the federal budget deficit and existing provider systems,” said the letter from America’s Health Insurance Plans and the Blue Cross Blue Shield Association.

“If private insurers say that the marketplace provides the best quality health care; if they tell us that they’re offering a good deal, then why is it that the government, which they say can’t run anything, suddenly is going to drive them out of business? That’s not logical,” Obama said during the press conference.

On Wednesday, private insurers came under fire after a report from the Senate Commerce Committee found that companies underpaid doctors and hospitals in millions of insurance claims that were for out-of-network care. Insurers also left consumers in the dark on how they calculate “reasonable and customary” charges for such care, the report said. Lack of information has been a major obstacle to encouraging consumers to “shop around” for better prices for health services, a key feature in many conservative lawmakers’ health-care preferences.

In a separate development Wednesday that underscored the financial challenges of the Medicare program, the Departments of Justice and Health and Human Services announced they had indicted 53 doctors, health-care executives and beneficiaries for allegedly submitting more than $50 million in false Medicare claims in Detroit.

On Wednesday night, ABC News broadcast a town hall meeting where President Obama took questions related to his health-reform goals. Topics ranged from concern over whether the government would intervene in costly, sensitive end-of-life treatments to whether a public plan option and health insurance exchange would lead more employers to drop coverage. The public plan option proved surprisingly popular in a poll released last weekend, with 72% of 900 adults saying they supported a government-administered insurance plan that would compete with private insurers for customers, according to a CBS News/New York Times survey. Twenty percent opposed the idea.

Obama also signaled he may be open to taxing the value of employer-sponsored health benefits above a certain threshold, something he opposed during the campaign. The tax exclusion that now exists to make job-based benefits tax-free to workers is a potentially lucrative source of funding that could be used to expand coverage to the 46 million uninsured.

On Thursday, Senate Finance Committee Chairman Max Baucus expressed optimism about the progress of health-reform efforts, saying U.S. senators had found a way to cut the cost of a comprehensive bill to below $1 trillion over 10 years. Read the story. Shares of health-care companies closed higher Thursday on the news.

On Saturday, the Internet-organizing savvy Obama used to such advantage in his campaign is set to go to work on his health-care agenda as volunteers across the country take part in the first National Health Care Day of Service, designed to expose them to a cross section of the medical delivery system.

After years of slow, incremental changes to the health-care system, this week’s legislative and political process to enact comprehensive reform moved with uncharacteristic swiftness until hitting some familiar speed bumps. Here’s a recap of some of the highlights:

On Monday, President Obama won kudos from America’s largest doctors’ group for appealing to their higher calling in a speech he delivered to the American Medical Association, which has traditionally opposed systemic changes such as the creation of Medicare in the 1960s. Obama called for increasing financial incentives for medical students to enter primary care. He also asked for doctors’ support in controlling costs.

“If we do not fix our health-care system, America may go the way of GM; paying more, getting less, and going broke,” Obama said. Read text of Obama’s health-care speech.

For more on why 2009 may be do or die for Obama’s health-care hopes, read the Capitol Report.

This week’s Vital Signs column explores how doctors are critical to reform. AMA member Dr. Ted Epperly, president of the American Academy of Family Physicians and a family doctor in Boise, Idaho, said Obama’s speech was well-received among doctors. He summed up the crux of the problem of distorted financial incentives by saying, “In a market which incentivizes you for doing things to people, you get what the market pays you to do: Volume over value and quantity over quality. If your only tool is a hammer then everything looks like a nail.”

On Monday evening, the Congressional Budget Office released a preliminary, partial “scoring” of a Senate committee’s incomplete health-reform bill that disappointed its proponents and emboldened its opponents. CBO said the bill would cost more than $1 trillion over 10 years but still leave millions uninsured. That sent many Democrats back to the drawing board even though provisions such as an employer mandate and public health insurance option weren’t yet included in the scoring. It also set off a debate about how much could be cut from the bill without jeopardizing the aim of extending affordable coverage and containing health costs in the long run, and how much bipartisanship was necessary given the make-up of Congress. On Friday, Sen. Christopher Dodd vowed to forge ahead with the bill.

Battle lines soon hardened. On Tuesday, the AMA “clarified” its position on a public insurance plan option after press reports suggested it outright opposed any public plan. The AMA said it supports putting consumer-owned cooperatives in charge of an alternative to private insurance, a plan that’s championed by centrist Democrats as a compromise on one of the most controversial elements. Other Democrats remain committed to the original model.

On Wednesday, the U.S. Chamber of Commerce took aim at the Senate draft bill. “The creation of a government public plan option would inevitably result in a government-run health-care system,” the Chamber’s Bruce Josten said in a prepared statement. “We believe that market-driven health reforms are the best approach to reducing costs, promoting efficiency, wellness, and quality of care.” Still, the group said it still believed health reform could be achieved this year.

Another big lobby group, America’s Health Insurance Plans, also said it wants to help bring health reform in 2009. But it remains vehemently opposed to a public plan option that would compete with private insurers.

On Wednesday, Secretary of Health and Human Services Kathleen Sebelius told the Associated Press that covering the uninsured could take years even if legislation passes this year. She said Obama doesn’t want to put insurers out of business but wants to make them more efficient.

“I think there is a lot of understanding that the private market has really failed to provide affordable coverage to Americans,” Sebelius told the AP.

Also on Wednesday, former Senate majority leaders Tom Daschle, a Democrat, and Republicans Bob Dole and Howard Baker released a proposal to enact universal health insurance that they say won’t drive the federal government deeper in debt.

Adding fuel to the fire, a report released Thursday from PricewaterhouseCoopers found employers can expect a 9% jump in health-care costs in 2010, down only slightly from a 9.2% rise this year. See video interview.

On Friday, three House committees unveiled their single health-reform proposal that’s been months in the making and promises to cover 95% of Americans while holding down costs. Read the story.

By the end of the week, speculation that health-reform efforts were weakening bolstered shares of publicly traded health insurers on Friday. See MarketWatch First Take.

“It provides some protection for people, but it’s also a very risky investment, which is probably why the take-up has been low,” said Diane Rowland, executive vice president of the nonprofit, nonpartisan Kaiser Family Foundation. “There are lots of concerns about making a prudent purchase.”

The default alternative to LTCI is private pay, where family members absorb the cost of whatever care is needed. But those costs add up quickly, considering that home health services run $29 an hour, assisted living facilities cost $36,000 a year and nursing homes run about $70,000 a year on average, according to the Kaiser Family Foundation. Several states offer a partnership program with Medicaid that allows people with long-term care insurance to exempt a certain amount of their assets before qualifying for the program. (Medicaid typically requires spending everything before becoming eligible for government-sponsored nursing home care.)

This week, Sen. Ted Kennedy outlined a proposal for a voluntary, public long-term care insurance program as part of his health-reform bill. See my Vital Signs column for more on the prospects for long-term care reform.

LTCI is structured differently than health insurance. Among its most common features are:

Elimination period — The amount of time you have before a long-term care policy starts paying benefits. These are typically 60 or 90 days, often to coordinate with Medicare’s endpoint after an acute medical event. The elimination period is the LTC equivalent of a deductible.

Duration — The number of years the policy is in force. Three- to six years should cover the majority of people, said Bruce Chernof, president of the SCAN Foundation, a group advancing a continuum of quality care for seniors, based in Long Beach, Calif.

Inflation protection — To keep up with the rising cost of goods and services. This is essential for the product to offer a meaningful benefit when you’ll need it, said Howard Gleckman, author of “Caring for our Parents.”

Provisions for advances in care — Establishes flexibility to account for services that may dominate in the future.

Scope of benefits — Scrutinize the contract to make sure a host of desired benefits are covered, such as home care, adult day care, assisted living and possibly respite care so family caregivers can get a much-needed break. “You’ve got to purchase a product with flexibility,” Chernof said. “You don’t want to just be stuck with a nursing home benefit if you want to stay at home.”

Unlike health insurance, there’s no concern about using in-network services to avoid being charged extra for tapping out-of-network ones, said Beth Ludden a senior vice president for Genworth, one of the largest sellers of LTCI, based in Richmond, Va.

The share of premiums that workers pay for their employer-sponsored health insurance has been relatively constant in the last eight years. But it doesn’t feel that way for the many people who’ve been stung by higher cost-sharing. That’s because the absolute dollar amounts they’re responsible for paying have been going up, said Gabel, a senior fellow at the University of Chicago’s National Opinion Research Center. The result: A growing number of underinsured people, especially among those who are sick and lower-income. Patients with breast cancer have been particularly hard hit. See the story for more details.

The report, published this week as a Web exclusive in Health Affairs, underscores the financial conundrums surrounding comprehensive health reform, an effort the Obama administration is ramping up this week as it tries with Congress to forge a bill by the end of the July. See White House report.

On one hand, some employers are forcing workers to shoulder more of the cost in hopes that seeing the true tab for services will deter them from overspending on health care of questionable value. Proponents of this approach, including conservative economists, emphasize giving consumers more “skin in the game.” But shifting more financial responsibility to them ends up pushing more people onto the rolls of the uninsured or leaves them dangerously underinsured, consumer advocates argue.

So who’s right?

“They’re both right,” Gabel said.

The study suggests the need to make difficult trade-offs that few people want to discuss, he said.

“It says to me that if we don’t get really serious about controlling expenses — and serious means there has to be bitter medicine — then not only is health care going to become unaffordable to families, but health reform is going to be unsustainable.”

“If we’re going to be controlling health-care costs, we have to provide financial rewards for consumers who make cost-effective decisions, which means we have to stop subsidizing higher-cost plans. We can’t pay for [medical] technology that’s five times as expensive and works no better,” Gabel said. “We have to fundamentally change the set of incentives that everyone involved faces.”

Once I finally bought one and tried it, I discovered what many working moms already have: That pumping milk allows me to store it so that someone other than me can feed my child without sacrificing the vaunted health benefits of breast milk. That means my husband or another caregiver can step in when I’m not there. But I’m hardly off the hook, time-wise. At regular intervals around the clock I’m tethered to a machine to keep the so-called liquid gold flowing. That’s part of the deal and it’s non-negotiable, setting up lots of conflicts between the dual pull of career and family, not to mention the need for sleep.

Millions of women can attest to the trade-offs. Some grow to love pumping for the chance to continue feeling close to their babies during the work day until they can get home to breastfeed. Others merely tolerate the task. Just as many likely loathe it, or feel a combination of all three depending on how much stress they’re under at the time.

For many of us, expressing milk isn’t something about which we can seek counsel from our own mothers. Among some earlier generations, infant formula was the standard. And as a mass-market consumer product, efficient pumps have only arrived on the scene relatively recently — in the last 15 years or so. Plus, women haven’t been in the work force en masse for long. As late as the 1970s they often left their jobs early in their pregnancies and resumed working when their children were school-age, if at all. That’s in stark contrast to today, when more than 56% of women with kids under age one are in the labor force, according to the Bureau of Labor Statistics. Many mothers are major family breadwinners, especially as men have lost about 80% of the jobs during this recession. And more than a few working moms are hauling breast pumps with them, whether they have to pump in bathrooms, airports, cars or private offices.

The decision to pump milk is as much a financial one as a health-oriented and emotional one. While the alternative of purchasing infant formula can be pricey, buying or renting a breast pump is hardly cheap either. In San Francisco, renting a hospital-grade pump can set you back $75 a month, excluding accessories and cleaning fees. And some of the popular personal-use electric double pumps go for $300 to $400, not counting supplies like steam-cleaning bags and replacement or extra parts.

Mixed messages

The trials, tribulations and health benefits of breastfeeding have been burning up the blogs in the last few months. New York Times blogger Judith Warner wrote a contrarian piece headlined “Ban the Breast Pump” in which she questioned the wisdom of placing such a strong emphasis on expressing milk instead of making it easier for women to have the kind of extended maternity leave necessary to continue breastfeeding the old-fashioned way. Then the Washington Post health blog chimed in with “Another Reason to Breastfeed,” which looked at a study that found mothers who nurse their babies for more than a year over their lifetimes were 10% less likely to develop heart disease or suffer a heart attack or stroke compared with their counterparts who never breastfed. Finally, Slate’s XX Factor blog reported on a study that found that working women who breastfed longer than six months had lower earnings over time compared with mothers who breastfed for a shorter duration and those who used formula.

Which brings me to this week’s Vital Signs. It offers tips for working moms who want to pump milk during the work day. Last week’s column examined the broader phenomenon of how women often find it difficult to meet their breastfeeding goals even in the best of employment and personal-motivation circumstances. Their experiences collide with the growing public-health call for new moms to continue nursing their babies for at least the first year to reap the maximum health benefits for both mother and child.

Putting pumping to the test

As for me, I’m still breastfeeding — four months in now, with one month of pumping at work under my belt. But I’ll continue to weigh its health benefits against the stress that’s required to keep it up while holding down a full-time job. If it gets out of balance and I start obsessing about ounces per day, worrying about lost productivity at work or struggling to remember all the pieces I need to transport and keep clean instead of enjoying my time with my baby, I’ll know something has to change. I’ll also measure my effort against how I’d feel if the standard medical advice were somehow shown to be unsound. Would I regret all those workday interruptions and middle-of-the-night pumping sessions if new scientific information suggested the benefits of breast milk were overstated?

Now I want to hear from you. Does your employer offer a mother’s room for breastfeeding moms, and do you or your colleagues take advantage of it? How do you working moms make pumping work for you? At what point is it not (or no longer) worth the effort?

More than half of family doctors report seeing fewer patients since the recession began in January 2008, according to the American Academy of Family Physicians (AAFP), which surveyed 505 of its members. Nine out of 10 said their patients have expressed concern over their ability to pay for needed health care in recent months. Nearly 60% said they’ve seen an uptick in appointment cancellations, and about the same amount report they’ve seen more health problems result from patients forgoing needed preventive care such as colonoscopies, mammograms and pap smears.

As unemployment rises and people lose health coverage along with their jobs, nearly three in four family doctors say they’ve seen more uninsured patients visiting their offices, and two-thirds say they’ve responded to the tough times by doing things like increasing charity care, discounting their fees, providing free screenings or moving patients to cheaper generic drugs from costly brand-name ones.

In a prepared statement, Dr. Ted Epperly, president of the AAFP, took the opportunity to promote primary care as lawmakers in Washington start considering health-reform legislation, which President Obama wants to enact this year. Many experts agree that the nation’s primary-care network of family doctors, pediatricians and internists needs better support, especially as baby boomers age.

“The AAFP supports health-care coverage for all Americans regardless of their employment status or socioeconomic status,” Epperly said. “To achieve that goal and provide better care for all Americans in a cost-efficient manner, we must move toward a health-care system based on enhanced primary care.”

Outpatient care hit by slow payments

Many health-care providers are facing delayed payments, though the reasons aren’t entirely clear.

Payments for home health-care services took almost 34 days to receive last year, up from about 30 days in 2007, according to Sageworks, a financial-information firm that tracks private companies, based in Raleigh-Durham, N.C. Thirty-four days also was the norm last year for nursing-care facilities, which are typically reimbursed by Medicare and private insurance companies. That’s up only slightly from 2007. Doctors’ and dentists’ offices saw the least change in accounts-receivable days.

Outpatient care centers took the biggest hit to cash flow, Sageworks found. The category that includes family-planning centers, mental health and substance-abuse treatment, kidney dialysis, and freestanding ambulatory surgical and emergency centers saw its collection period double to 40 days in 2008 from 20 days the year earlier.

Lindsay Mangus, who does public relations for Sageworks, said its number-crunchers can’t be sure of causes and effects to explain the sudden jump in the outpatient category’s collection time. But a likely scenario is that more patients have lost insurance or don’t have enough of it.

“Accidents and emergency health conditions occur all the time, but due to the recession Americans have a lot less disposable income,” Mangus said. “They just don’t have the necessary funds on hand to make prompt payments.”

Some medical conditions don’t wait for bank accounts to rebound.

“If you’re having a heart attack you still have to have treatment,” she said. “You don’t have a choice in the matter.”

Of course, the news about health during the recession isn’t all bad. Research also suggests people pull back on expensive, harmful habits such as smoking and drinking alcohol to excess. One study released last year found that fewer people die in car crashes during economic downturns because they drive less often, and they slow down and take shorter trips when they do drive.

Labor and delivery comprise one of the most predictable and expensive health events for women of childbearing age. Yet forecasting the out of pocket costs remains a difficult challenge for even the most insurance-savvy. Thursday’s Wall Street Journal ran a story detailing reporter Anna Wilde Mathews’ quest to make sense of the bills before and after the birth of her son. An accompanying piece provides some practical tips. I also wrote about questions parents-to-be should ask, especially if they have a consumer-driven health plan, in an archived Vital Signs column from 2007.

After my daughter’s traditional birth in January, I was delighted to discover that my estimate, made with incomplete information garnered from my health insurer’s Web site, came close to my actual total costs. But that was only after I found $1,000 worth of erroneous bills and data input problems that initially inflated the costs. It was hardly straightforward and took more time than I would have liked, but following the numbers paid off. (And if your pregnancy spans two calendar years, as many do, getting an accurate estimate also can help by allowing you to sock away an appropriate amount of pretax money in a flexible spending account for medical expenses.)

I started by running a zip code-based search for average delivery costs in my area on my insurer’s member Web site while I was pregnant. My exact hospital wasn’t listed, but the exercise gave me an idea of what kind of charges it might submit for a traditional or caesarian birth. From there I just plugged in my coinsurance rate and called to doublecheck my coverage to see how doctors’ fees and anesthesiologists were factored in. (I also found out at that time that my daughter would have her own deductible on top of my own. Another thing to consider.)

Overall, the hospital did a good job of cocooning the three of us in its protective custody as we embarked on life with a newborn. From the triage unit to the labor/delivery/recovery room to the postpartum wing, I was struck by how many people — many of them nurses — were attending to our needs around the clock so my body could heal and the new family could bond. It was a remarkably busy and wonderful transition.

When the bills started rolling in, I monitored my claims online and noticed a double charge for my hospital room and board fees. I called the insurer to investigate. It turned out the charge had been reprocessed and my online record hadn’t reflected the change. Compounding matters was the sheer number of vendors I had to track, from the audiologist who ran the baby’s hearing test to the new pediatric group to the hospital food service. Some of the health-care workers billed me directly instead of submitting claims to my insurance, ensuring more follow-up phone calls to protect my credit.

Among the most confusing bills were those from the hospital itself, which billed for thousands of dollars under the nebulous category of “hospital incidentals.” The total charge for my daughter’s birth before factoring in the insurer’s negotiated rates was similar to that mentioned in the WSJ story — around $38,000. Amazing that with such a big tab the hospital didn’t automatically send an itemized list of charges so I could see exactly what I was paying for. Instead the bills came in piecemeal and with vague and similar-sounding charges. If there’s one tip I can pass on it’s this: Pick up the phone, ask questions and don’t give up. For better or for worse, it’s your responsibility to decipher your health-care bills and guard your pocketbook.

Instead of promoting the idea of school closures, the CDC wants to focus on early identification of affected people so that “students, faculty and staff with symptoms of influenza [are] out of schools and childcare facilities during their period of illness and recuperation, when they are potentially infectious to others.”

“When influenza becomes common in a community, it is unlikely that actions such as closing schools or daycare facilities are effective when it comes to slowing or stopping the spread of influenza viruses,” according to a CDC statement. “Instead, such measures bring significant cost — such as interrupting student learning — without a significant public-health benefit. In addition, we have learned that the disease currently being caused by this novel flu virus appears to be similar with that typically caused by seasonal influenza. Although many people may get sick, the available data do not indicate we are facing an unusually severe influenza virus.”

As of Wednesday, there were 1,487 probable and confirmed swine flu or H1N1 cases in 44 states, Dr. Richard Besser, acting director of the Centers for Disease Control and Prevention, said during a briefing. The median age of patients is 16, with a range of three months to 81 years. Two people have died from the virus in the U.S. and 35 have been hospitalized. The median age of hospitalized patients is 15 but ranges from eight months to 53 years old.

Besser said he expects to see more illness result from the new strain of flu and urged people not to become complacent just because drastic measures such as lengthy school closures are no longer being employed.

“We are continuing to see virus spread in the United States and around the globe,” he said. “The majority of the confirmed cases in this country are in younger people. And it’s important that people have respect for this virus, because it does cause severe disease, hospitalization and death.”

People seem to be taking the CDC’s hand hygiene recommendation to heart. Fifty-nine percent of more than 1,000 adults surveyed by the Harvard School of Public Health last week said they’re washing their hands or using hand sanitizers more frequently since the outbreak began. One in four say they’re avoiding places where large groups of people gather, such as sporting events, malls and public transit. Only 4% of parents said they kept their kids home from school or day care. More than half of Americans are concerned they or someone in their immediate family may come down with swine flu in the next 12 months, the poll found.

Many questions remain unanswered. Among them: Whether the virus will have a mild first wave in spring, only to be followed by a second wave in the fall that proves far deadlier after the bug has had a chance to mutate and adapt. Such a scenario occurred during the Spanish flu pandemic of 1918, which killed half a million Americans and at least 21 million people worldwide.

“As the [seasonal] flu season starts in the southern hemisphere, what takes place there is going to be incredibly important,” Besser said. “How does the virus compete with other viruses that are circulating in the community, does it change, does it mutate? If so, in what way?”