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New Online Tool Helps Women Track Menopause Symptoms

Tue, 22 May 2012 10:04:00 EDT

Wyeth's Prempro, a menopause treatment, is displayed on the shelf at a pharmacy in Cambridge, Mass., in 2006.

A full 72 percent of women experiencing menopausal symptoms have not received treatment for them, according to a new survey by the Endocrine Society. The poll, conducted in mid-April, also found that 60 percent of women exhibiting symptoms of menopause have not talked to their primary health providers about possible treatment.

The statistics prompted the Endocrine Society and its Hormone Health Network to develop a so-called Menopause Map -- an interactive online quiz that helps women and their doctors discuss what treatment options (hormonal or nonhormonal) might be the most effective for them.

Menopausal women who are about to or have already stopped menstruating may also experience hot flashes, sweating, insomnia, mood swings, fatigue, depression and vaginal dryness, among others. Although the tool does not encourage women to pursue one avenue of treatment over another, it prompts women to consider a range of options to alleviate menopausal symptoms, including hormone therapy.

Hormone replacement therapy, or HRT, a once widely used treatment option for menopause symptoms, came under fire in 2002 after a government-commissioned study, the Women's Health Initiative, found that hormone therapy could increase the risk of blood clots, stroke, breast cancer and heart attacks. But in the past few years, while some studies have continued to find that hormone therapy increases the likelihood of a host of health risks in patients, other trials have pointed to the effectiveness of hormones in treating menopause symptoms in women in their 50s.

For more perspective, we turn now to Dr. Cynthia Stuenkel, an endocrinologist specializing in menopause at the University of California, San Diego, and a member of the Endocrine Society who contributed to the creation of the new tool. The questions and responses were lightly edited for length.

One of the most confusing pieces of information for women's health in the last couple of years has been hormone replacement therapy. What were women doing to treat menopause before 2002, and what happened that year?

Stuenkel: Before 2002, doctors and health care professionals not only used hormone therapy to treat women's menopause symptoms, they also believed hormones would provide women with a way to prevent heart disease, osteoporosis, bone fractures, and possibly cognitive decline and dementia. In 2002, the Women's Health Initiative sponsored a study, which did not seek to say whether hormones would help women feel better, since we already knew that. The point of the study was to ask whether these hormones were going to be effective at prevention in women in their 50s, 60s and 70s because our current guidelines at the time suggested that we should be offering hormones to all these women, and the results showed that the risks of hormone therapy exceeded the benefits.

The risks were things like heart attacks, stroke, blood clots and breast cancer. And because of these findings, there was a dramatic decrease in the number of hormone therapy prescriptions written. At the time, I think a lot of women and health care professionals that take care of women just said, "This seems too negative, too threatening, and too scary."

Did a lot of women stop taking hormone therapy in 2002? Did they resort to other treatments, or did they stop seeking them?

Stuenkel: There was definitely a drop in therapy. Folks who chart prescriptions detected as much as a 60 to 70 percent reduction in the number of prescriptions for hormone therapy. However, some women looked to other therapies that had been once prescribed to women who should not have been on hormone therapy. Some of these are antidepressants or agents for nerve pain like Gabapentin, which are not as effective as hormone therapy but can certainly offer some relief of hot flashes, for example.

What has been going on in hormone therapy research since then?

Stuenkel: Over the last 10 years, we've had added follow-up with those participants of the original Women's Health Initiative from 2002, and we have had to further analyze the 2002 findings and to take a close look at different age groups and at different outcomes. Our current thinking is that for healthy women in their 50s -- women who have not had breast cancer or a history of blood clots -- and have been experiencing the symptoms of menopause for less than 10 years, hormone therapy can be very effective for symptom relief and overall is quite safe.

Why were the outcomes between the 2002 study and the recent study so different?

Stuenkel: I think it was looking at the absolute numbers that made the difference. The Women's Health Initiative said there's an increase in risk of stroke, and that was scary. However, when we analyzed the numbers, we realized that for a woman in her 50s, the risk of stroke is about 2 per 10,000 women per year taking hormones. There are a number of women that say, "I'm not taking any risk; that is absolutely too high for me."

We also looked at the scary question of breast cancer, and we also teased out the numbers and looked at what the risks were. We looked at women in their 50s and tried to see if 3 in 1,000 women will develop breast cancer in a year, how many more will develop it if they take hormone therapy? We realized that the number for combined hormone therapy would mean one more woman would develop breast cancer in a year, so 4 in 1,000. The question is whether a woman can live with that number. For some women, that number is way too high. But again, it has to be an individual decision, and I think women need to be made aware of this so that it is an informed decision and not a decision by indecision.

What spurred the Endocrine Society to create this tool?

Stuenkel: The Endocrine Society decided to create this Menopause Map, an interactive online tool, because of an April poll that the Endocrine Society put together that reported that 7 out of 10 symptomatic menopausal women weren't getting anything in the way of treatment. What I thought was even a little bit more disturbing was that 2 out of 3 women said that they hadn't discussed treatment options with their doctors.

Why is it significant that 72 percent of women aren't getting treatment? What does it mean for women and women's health?

Stuenkel: It depends on how they're feeling with their hot flashes. Some women are not particularly bothered. Some women sail through, and although they can be annoying, the hot flashes don't get in their way. And then other women are more debilitated and suffer from sleep disruption and irritability, and they find that their effectiveness in their daily activities can be compromised. So I think that for those women, therapy can be very beneficial.

You mentioned earlier that 2 out of 3 women haven't talked to their doctors about this. Why aren't women talking to their doctors about these symptoms?

Stuenkel: I'm not sure I know the answer to that question, but I can hypothesize that they might feel like hormones aren't safe for them and that there is not much to be discussed. A lot of women seem reluctant to initiate these kinds of conversations. So this is our goal with the Menopause Map. We wanted to give women a tool they can put their answers into and print out. We've included a list of questions for women to discuss with their doctors about their symptoms and their options for therapy.

Do you think some of the reason why women aren't talking to their doctors about this is because of the confusion out there regarding the treatment of menopause?

Stuenkel: There's certainly confusion as to what to believe. A study might come out today and another might come out tomorrow and contradict the previous study. I think women are wondering what the truth is. I think another reason why women might not be reaching out to their doctors about this is a matter of competing priorities. At midlife, women start developing more health issues like blood pressure, blood sugar or other gynecologic issues that might arise. In the short period of time that can be allotted for some health appointments, it just might not seem that important to them, so they might not bring it up.

What is the goal of this online quiz?

Stuenkel: The goal was to help women be aware of their symptoms, be aware of their risks, personal preferences. (It's also) to introduce them to the menu of options women have available to them if they want them. Our goal was to have something we can give women -- something they can print out, take with them and hopefully be a way to stimulate, encourage, empower this conversation with their doctor or health care professional so that women are having these conversations and making educated decisions. Our main idea is to hopefully get the conversation about menopause back on the map.

How exactly does it work?

Stuenkel: The interactive quiz on hormone.org gives women options depending on their lifestyles and characteristics. Depending on the answers a woman gives, the website might tell her that she's doing great and might suggest that she exercise or stop smoking. The website might tell another woman, depending on her answers, that she should have something checked out by a health care professional before she can go forward and consider any treatments. Another woman might see a number of different choices to treat her symptoms. I think laying it out in a menu format can be helpful. The website includes options for women who might exhibit very few menopause symptoms, women who have a history of breast cancer, cardiovascular risk, or blood clots. It covers some of the real-life situations that women find themselves in.

What advice would you give to women in menopause or about to enter menopause?

Stuenkel: I think the most important thing is for women to be in touch with their own body symptoms and what is happening to them. No. 2, they should be aware of their other health priorities at the time and how those may factor in. And No. 3 would be to know their options. I think having a choice is much better than not being fully informed. I would like to see women more armed at making decisions about what makes the most sense for them at midlife. I think it is also important for women to understand that it is worth it to try different therapies for a short period of time to see what works for them. I know new information is continuously coming forth, and that is why it is essential for women to start these conversations with their doctors.

Baby's Tumor Means Surgery Before Birth

Fri, 18 May 2012 12:02:00 EDT

Editor's Note: As the nation marks National Women's Health Week, PBS NewsHour will share the stories of three women -- and their doctors -- who refused to allow a cancer diagnosis interfere with a successful pregnancy. These are their stories of hope, perseverance and, ultimately, success.

Once a week, 2-1/2-year-old Cami Santee practices her walking in her grandfather's Bentleyville, Pa., carpet store, where there's lots of room for the tiny medical walker she needs for support.

Before Cami was born, a huge tumor began growing from her lower body and injured her hips and internal organs. To save her life, doctors had to operate on Cami en utero, half her body still inside a special incision in her mother Tami Dobrinski's womb.

Talking about it usually makes Dobrinski cry, but she says it's not because it makes her sad.

"It's OK. It's a happy story," she said. "I never thought she wouldn't be here."

Cami's tumor, called a sacrococcygeal teratoma, is just one example of an uncommon category of tumors and cancerous growths that can occur in unborn children -- a teratoma like hers occurs in only one in 35,000 infants. According to Cami's surgeon, Dr. Timothy Crombleholme, doctors don't fully understand what causes teratomas like hers to spontaneously form on fetuses. However, it may have something to do with their location.

"We think that many of these tumors derive from stem cells," said Crombleholme. Fetuses have a concentration of stem cells on their hindquarters called Hensen's Node, which on a very small percentage of fetuses can evolve into a tumor like Cami's.

"But we don't know why they occur in only some babies, or why some grow more than others," said Crombleholme, who is now surgeon-in-chief of the Children's Hospital Colorado and Director of both the Colorado Fetal Care Center and the Colorado Institute for Maternal and Fetal Health.

Once a fetus develops a tumor, it can grow very rapidly -- something else that doctors don't fully understand. "It's very likely that there's something about the fetal milieu that supports these tumors," said Crombleholme.

Dobrinski and Cami's father Chad Santee found out about the tumor shortly after her first ultrasound. "We had the ultrasound. I got to listen to the baby's heartbeat, and we left. And like an hour later they called and said we needed to go to the hospital right away," said Dobrinski. Because of the large size of Cami's teratoma, Dobrinski's Pittsburgh doctors immediately advised her to terminate the pregnancy.

The doctors were concerned because Cami's tumor was highly vascular, meaning that a great deal of the baby's blood was passing through the tumor. According to Dr. Bill Polzin, co-director of the Fetal Care Center of Cincinnati, such tumors are very delicate.

"By the end of gestation, the tumor is like wet tissue paper: You can blow on it and it will rupture," Polzin said.

If Cami's tumor ruptured under the stress of birth, it would put the baby in extreme danger. According to Crombleholme, a seven-month-old fetus might have a total blood supply equal to about a cup and a half of liquid. "If a person loses 20 percent of their blood supply, they can go into shock," said Crombleholme.

"Two tablespoons of blood loss is a significant danger to these babies," Polzin said. "They can exsanguinate [bleed out] in under two minutes."

However, despite the urging of the doctors, Dobrinski said that she never thought about terminating the pregnancy. "Even though they said that, I just never had a terrible feeling," she said. "We felt that if she was going to be here, she would make it," Santee said.

Frustrated with their local doctors, Dobrinski, Santee and their families started researching treatments for Cami's condition. Eventually the couple connected with the Fetal Care Center of Cincinnati, where they met Crombleholme.

Crombleholme said that hospitals that don't specialize in fetal care are not always familiar with all the possible treatments for rare conditions like Cami's. His solution -- one that is commonly used for large, highly vascular teratomas -- was to remove the tumor while she was still in the womb. According to Polzin, operations such as this are only done when the situation is dire because of the danger to both child and mother.

Dobrinski faced the dangers of general anesthesia, infection and possible internal bleeding during the surgery, along with a more unique complication called mirror syndrome, which occurs when a fetus goes into heart failure during surgery. For reasons that doctors don't fully understand, this can cause the mother's body to respond by also going into heart failure, a potentially fatal situation.

Though Crombleholme warned Dobrinski of the dangers, she said that she never thought of not going through with the surgery. "It just wasn't in my head not to do it," Dobrinski said. "I didn't think of it like that."

When Cami was still two months away from full term, Crombleholme performed a procedure called ex utero intrapartum treatment, or EXIT. With Dobrinski heavily sedated, Crombleholme reached through a small hole cut into her uterus and pulled Cami's legs, lower body and the dangling tumor out of the womb. He left Cami's upper body inside the womb with the umbilical cord attached to help keep the infant alive. He then delicately cut away the tumor. Once the operation was finished, he completed Cami's delivery without any complications.

"I love that guy," Dobrinski said of Crombleholme.

Though the tumor removal was a success, it left its mark on Cami. Hip dysplasia keeps her from walking normally, and because of the way the tumor affected the growth of her kidneys and bladder, she needs a catheter every three hours. However, Cami's father said there's no sign of developmental delays and that he's confident that Cami will walk one day, though she may need leg braces to do so. "She's a genius in my mind," said Santee.

Dobrinski said that during a recent physical therapy session, Cami's therapist took his hands off her leg braces. Cami stood for 46 seconds before she noticed no one was holding her up and fell down.

"That's a new record," Dobrinski said.

Photos courtesy of Tami Dobrinski. Sacrococcygeal teratoma illustration by artist Holly R. Fischer. Image courtesy of the University of Michigan's C.S. Mott Children's Hospital.

Chemotherapy During Pregnancy: Yes, It's Possible

Thu, 17 May 2012 15:00:00 EDT

No sushi. No caffeine. No alcohol. No Ibuprofen.

Minnie Narth could recite everything she'd heard she wasn't supposed to have while pregnant.

But as she entered her third trimester, her body was in desperate need of something she would never have predicted: chemotherapy.

Narth had just learned she had cancer. Stage-4 diffuse large B-cell lymphoma, to be precise, and her doctors informed her that thousands of women carry their children to term each year while receiving intensive chemotherapy treatment.

As many as one in 1,000 women are being diagnosed with malignant cancer during pregnancy each year, according to Dr. Natali Aziz at Lucile Packard Children's Hospital at Stanford University. One in 6,000 develop lymphoma alone.

Those numbers are on the rise as women continue having children later in life. But so too are the treatment options.

When Aziz broke the cancer news to Narth and her husband Paul, she advised them -- with a high level of confidence -- that continuing the pregnancy would be possible.

"Just 10 to 20 years ago, that would have been much more difficult," Aziz said. "And though it's more common these days, the end result is always amazing amidst a very frightening diagnosis. Minnie was able to celebrate one of the most amazing joys of her life -- the birth of her son."

Read more about the Narths' story in the slide show above.

When Cancer & Pregnancy Collide

Thu, 17 May 2012 14:48:00 EDT

No sushi. No caffeine. No alcohol. No Ibuprofin. Minnie Narth could recite everything she'd heard she wasn't supposed to have while pregnant. But as she entered her third trimester, her body was in desperate need of something she would never have predicted: Chemotherapy. This is her story.

Cancer and Infertility: Dodging the 'Double Blow'

Wed, 16 May 2012 14:41:00 EDT

Editor's Note: As the nation marks National Women's Health Week, the PBS NewsHour will share the stories of three women -- and their doctors -- who refused to allow a cancer diagnosis to interfere with a successful pregnancy. These are their stories of hope, perseverance and, ultimately, success.

It's the kind of pain Gina Danford had spent decades dreading -- a cramping, twisting pain in her core that could mean almost anything. Earlier in her life, it had been the first sign of cancer.

Now she prayed for it. Cramping might mean she was finally pregnant despite the odds -- that the embryo had implanted successfully. This was her third attempt at in vitro fertilization, and it would probably be her last.

"I thought that having cancer was the hard part," Danford said. "I wasn't prepared for the emotional ups and downs of fertility treatment."

For decades, two statistics had dominated Danford's life. Close to 120,000 women under the age of 50 are diagnosed with cancer each year. Danford became one of them at age 19. But it wasn't until her third tumor, at age 30, that she joined a much more exclusive number.

Only 10 percent of women facing cancer treatment take steps to preserve their fertility, according to Dr. Mitchell Rosen, Danford's reproductive endocrinologist and the director of the UCSF Reproductive Laboratories and Fertility Preservation Program.

Gina Danford's story ends well -- with a little girl who's playful and stubborn and looks a lot like her. But it very easily could have gone the other way. If not for Rosen and his colleagues, Danford says she might have been part of the 90 percent of women who fail to do anything about their fertility until it's too late.

The "Whole Shebang"

The tumor was the size of a small basketball -- far larger than the size necessary to turn a 19-year-old's life of "college classes, papers, and midterms to a world of oncologists, diagnostic tests, and an impending surgery." It was also enough to destroy her long-term hopes for a husband and a baby and a dog -- "the whole shebang."

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Danford spent the next 10 years "healthy and happy." Then the abdominal pain began, gradually growing so intense she couldn't get out of bed or stand up straight.

Tests confirmed a second mass -- this one situated near her left ovary. It would require immediate surgery.

"I didn't even consider fertility preservation prior to the surgery. I just wanted the pain to stop," she said.

Nationwide, those emotions are one of the primary barriers to fertility treatment. Rosen refers to it as the "double blow."

"Infertility's bad enough and cancer's bad enough, but both of them together is quite significant," he said.

Make that a triple blow. Between the consultations, clinical services, procedures necessary to retrieve eggs, produce embryos and freeze them, the costs can range anywhere from $8,000 to $24,000. And most insurance plans don't cover a penny of it.

Research developments over the past several decades have made it possible for fertility clinics "to take care of almost anybody," Rosen said. "So the issue now becomes more of access and cost."

Roadblocks

To find out just how significant the barrier is today, Rosen and his colleagues surveyed 1,041 randomly selected women from the California Cancer Registry between 1993 and 2007. Each was between the ages of 18 and 40 and all suffered from one of five different types of cancer: leukemia, Hodgkin's disease, Non-Hodgkin Lymphoma, breast cancer, and gastrointestinal cancer.

A total of 918 of the women underwent treatment that could impact fertility, and 61 were told that their ability to conceive in the future might be compromised. But only 1 to 10 percent of them took steps to ensure they could become pregnant in the future, with the rate varying based upon the year of treatment.

In a recent focus group, Rosen asked a collection of women why so many of them hesitated.

"After the fact, all of these women were wishing they had taken more steps to preserve their fertility, but it didn't even register in their mind when they were preparing for cancer treatment," he said. "The oncologist might have mentioned it -- it just wasn't in their purview to think about the possibility of what it was going to be like as a survivor."

Danford can vouch for that feeling. She remembers sitting in Rosen's fertility clinic in 2006, "completely shell-shocked" after learning she was facing the possibility of cancer for a third time.

The thought of dying nearly blacked out all hopes of being a mother.

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Access

In his consultation with Danford, Dr. Rosen laid out the basics: Not every woman with cancer needs to go through fertility preservation, but freezing eggs or freezing embryos is a good option for many. He showed her charts and percentages, and described when the treatment works and when it doesn't.

All signs pointed toward the likelihood that this would be Danford's last chance. Her upcoming surgery would require the removal of her remaining ovary, and a complete hysterectomy "was a distinct possibility."

"I could barely get my head around facing cancer again -- let alone facing infertility and menopause at 30," she said.

So she went for it. Danford and her husband borrowed money from family and put the rest on credit cards.

Having decided upon egg retrieval and embryo cryopreservation, the entire process took about four weeks, fitting like a puzzle piece inside her surgery preparation period.

The typical time span between a cancer diagnosis and treatment is about 50 days. And because Danford's oncology doctor referred her straight to the fertility clinic -- and the two departments coordinated care in the weeks after -- there was no delay in her surgery. Egg retrieval took place on a Friday and Danford was in the operating room for her surgery on Monday.

"If that kind of coordination between oncologists and reproductive endocrinologists occurred for every patient, there would never be a delay, there would never be a second thought about whether preserving fertility would jeopardize the health of the patient," Rosen said. "Cost would still be an issue, but we would be one step closer to getting everybody access."

Danford may have been among the lucky few, but she wasn't prepared for the difficulty of fertility treatment.

"I thought, I'm alive and healthy and this is the easy part, and it's absolutely not," she said. "It takes a huge emotional toll." There were more needles, sonograms and blood tests. Lots of waiting. Two failed attempts.

Then one day Rosen's assistant called and asked Gina to come down to the clinic. And there it was: "a tiny fetus on the fuzzy sonogram screen."

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Nine weeks passed before Danford sat down to write a letter. It was addressed to other women who find themselves "shell-shocked" in Dr. Rosen's office, wondering if the future is even worth considering.

"Your experience will undoubtedly leave scars," she wrote, "physical, mental and/or emotional. It took me years to come to peace with the jagged nine-inch scar on my abdomen. What I finally realized is that my scars, visible and invisible, represent who I am. Those scars saved my life."

They made her a survivor, she wrote. And in a roundabout way, they brought her Samantha.

Read Danford's letter, along with those shared by two of Rosen's other patients, below. If you have questions for Danford or Rosen, leave them in the comments section below or send them to onlinehealth@newshour.org. We'll post their answers in the days ahead.

Gina Danford Fertility Letter

Dr. Lynette Leighton Fertility Treatment Letter

Jennifer Ebrahimi Fertility Treatment Letter

U.S. Launches National Strategy to Combat Alzheimer's Disease

Tue, 15 May 2012 18:30:00 EDT

Listen to the Audio

As rates of Alzheimer's Disease continue to jump in the U.S., HHS Secretary Kathleen Sebelius announced Tuesday the first Congressionally mandated plan to help prevent and treat the disease. Margaret Warner discusses the details with NIH Director Dr. Francis Collins and Eric Hall, CEO of Alzheimer's Foundation of America.

JUDY WOODRUFF: Next, a new plan for tackling the ever-growing burden of Alzheimer's disease and targeting specific drugs to fight it. Margaret Warner has our story.

MARGARET WARNER: The numbers are daunting. More than five million Americans now suffer from Alzheimer's disease and related dementias. And barring a breakthrough, the figure could triple by 2050.

That prospect prompted the first-ever national Alzheimer's plan mandated by Congress and formally announced today. The secretary of health and human services, Kathleen Sebelius, set a deadline of 2025 to find effective ways to prevent and treat the disease.

SECRETARY OF HEALTH AND HUMAN SERVICES KATHLEEN SEBELIUS: So a short time ago, the fight against Alzheimer's lacked a national focus and a consistent, coordinated partnership with the nation's Alzheimer's community. Today, we have made the first historic investment of funds and a 15-year commitment to prevention and treatment.

MARGARET WARNER: The bulk of the new money, $50 million already approved this year and $100 million in 2013, will go for research. So far, there's no cure. The research focus will be on testing the most promising new therapies, including an insulin nasal spray and a drug to prevent the buildup of a protein associated with Alzheimer's.

The plan also includes a new Alzheimers.gov Web site offering struggling families information on available federal and community resources.

MAN: My wife's Alzheimer's, diagnosed it very early because we had had the experience of my mother. And I knew from behavior, not forgetting, as much as just general behavior, that there was something seriously wrong with her.

MARGARET WARNER: And it provides training for health care providers in identifying and managing the disease.

And for more on all this, we turn to two people involved with the new Alzheimer's plan. Dr. Francis Collins is director of the National Institutes of Health, which is funding key trials, including two announced today. And Eric Hall is president and CEO of the Alzheimer's Foundation of America, which offered input in designing the plan.

Welcome, gentlemen.

Dr. Collins, welcome to you.

There are elements here that we have heard a lot about before, research, education, outreach. What is new and different in this plan?

DR. FRANCIS COLLINS, director, National Institutes of Health: Well, first of all, let me say I think there is a new sense of excitement in the scientific community about the potential for making real strides in understanding what causes this disease and how to intervene just in the last two or three years in research coming from genomics, coming from an understanding of stem cells, coming from the able to identify new potential drug targets.

The field is energized. And so it is the right time, both given the enormous public health significance and the significance to individuals and families, and the scientific opportunity, to ratchet up our efforts here to really move in the direction of identifying potential prevention methods and treatments.

And, today, we are announcing two large clinical trials aimed at those goals that we're quite excited about.

MARGARET WARNER: And I want to get back to those trials.

First, let me ask you, Eric Hall, working with families, caregivers, what's new here to you? How is this going to make a difference. . .

ERIC HALL, president and CEO, Alzheimer's Foundation of America: Well, I think the fact that we have a plan is, in and of itself, really important for families coast to coast.

They now understand that people are recognizing the plight that they are living day in and day out. The other part of the plan -- we focus a lot on research, but there's also a very strong clinical care component to this plan. And there's also long-term support services as part of this plan, the education piece along the Web site, other activities that we will be engaged in.

All of that is really critical, because in the absence of a cure or prevention, care really does become the priority.

MARGARET WARNER: So, Dr. Collins, back to you.

Let's -- tell us about these two studies, first the one testing this insulin nasal inhalant. Now, why that? What is the link? What do researchers see between insulin and Alzheimer's?

DR. FRANCIS COLLINS: Well, insulin is a growth factor. And, apparently, it has the capability of stabilizing neurons, brain cells. We have learned about that indirectly from basic science efforts.

And not long ago, in a smaller pilot study, the idea of actually administering insulin by a nasal spray, which gets into the brain, was tested in individuals who were early in the onset of what appeared to be Alzheimer's disease. And there were indications of benefit.

It was a relatively small study. We're excited about the results, but we need to test this now in a much larger group. And that's what this new study that's being announced to will do, spending $8 million to study 240 individuals to see what happens.

MARGARET WARNER: Now, the other one is actually aimed at prevention. And can you simply explain that? It's to test a certain drug with a particular extended family in Colombia.

DR. FRANCIS COLLINS: So why are we going to Colombia in South America?

Well, because in that particular country, there is a very large extended family that has an early onset form of Alzheimer's disease caused by a single glitch in the DNA. And those individuals, if they have inherited that, are very, very high likelihood of getting this disease in their 40s.

That means that they are already at very high risk and very willing to participate in research that might prevent the disease even before any symptoms have appeared. So about 300 individuals in that family will be given the chance to receive a new therapy, a monoclonal antibody that aims to clear out this protein called amyloid which deposits in the brain and see whether that can in fact reduce the likelihood of going on to full-blown disease.

And we're going to follow this very carefully with a variety of measures, using brain imaging, measurements of proteins in the blood and the spinal fluid. We're going to learn a lot about what kinds of indicators will help us in the future to say whether a treatment is working or not.

MARGARET WARNER: Eric Hall, how big of a hunger is there out there for this kind of -- something effective to prevent it?

ERIC HALL: Well, I think Dr. Collins just said it.

We're really in a position where we need to learn more. And so the Alzheimer's Foundation of America really applauds this administration for making such incredible strides and not simply talking the talk, but also now putting resources behind it.

MARGARET WARNER: But, I mean, in terms of prevention, as I understand it, this is the first test that will ever -- trial that will ever be done on people who haven't shown any symptoms yet.

ERIC HALL: Sure.

MARGARET WARNER: Isn't that one of the greatest fear of families, that by the time they see the symptoms, it's really too late so far?

ERIC HALL: Right.

And, so, yes, look, we are dealing with a disease that has terrified our country and terrifies the world. And so the possibility that perhaps we will learn something out of here that will form a preventative measure for Alzheimer's disease would be miraculous, incredible, and truly probably the answer to everyone's deepest fears.

And so in order to get there, though, we need to be engaged. And we need to step in and at least this administration has really taken those steps to do just that. And so I would say, you know, for families at home, they're probably ecstatic that they're being recognized, that their care for their loved one and that Alzheimer's in their family is being recognized.

They're ecstatic about all the support that is coming, but also, too, as caregivers, they have their own fear that they too may end up with this disease.

MARGARET WARNER: And, Dr. Collins, finally, back to you.

Looking at the big picture here, you said there's a lot of new optimism. But is it fair to say that still there is currently no known effective either -- a drug to either prevent or retard or cure this disease?

DR. FRANCIS COLLINS: Despite a great deal of work over many decades, we do not at the present time have a convincing way to prevent the disease. We have some drugs that can actually improve the symptoms in individuals who have developed early signs of Alzheimer's, but nothing that actually delays the progression in a significant way or treats or prevents the disease.

So we have a big charge ahead of us to achieve those outcomes, and especially to do so by 2025. But I'm optimistic that, with this Alzheimer's plan, with the way in which these communities have come together, with the administration's commitment to an additional 130 million dollars for research this year and next, that we are going to have a real opportunity here to make a difference.

And our country needs this. And all those people who are waiting for something to happen need this, and their families do. But I think, today, we have had more hope than we have had in a long time.

MARGARET WARNER: Well, Dr. Francis Collins and Eric Hall, thank you both very much.

ERIC HALL: Thanks, Margaret.

DR. FRANCIS COLLINS: Thank you.

JUDY WOODRUFF: And a reminder: A new PBS website launched today designed for Americans over 50. It's called Next Avenue, and taps trusted sources for information about work, health, finances, leisure and caregiving. Explore NextAvenue.org by following a link on our home page.

Many Businesses Offer Health Benefits To Same-Sex Couples Ahead Of Laws

Mon, 14 May 2012 16:15:00 EDT

Photo by Jin Lee/Bloomberg via Getty Images

President Obama's pronouncement last week in favor of same-sex marriage has no legal effect on employers' decisions on whether to offer benefits to workers' domestic partners, but some advocates believe it could reinforce a decade-long trend toward coverage.

Last year, 52 percent of all employers offered domestic partner health benefits, with the percentage varying widely by region and industry, according to a nationally representative sample of about 3,000 employers surveyed by benefit consultant Mercer. That's up from 31 percent in 2010.

The biggest factors driving that change are employers' views on whether such benefits help them attract and retain desirable workers.

"Employers started doing this because they felt they needed to be competitive in the labor market, just like with other benefits," said Paul Fronstin of Employee Benefit Research Institute, a think tank in Washington D.C. "I don't see that changing."

The Village Voice newspaper in New York is credited with being the first private employer to offer workers domestic partner benefits in 1982. In 1995, Vermont became the first to offer coverage to state workers.

"There's been a steady growth for a long time," said Joan Smyth, a partner at Mercer. In the early days, some employers worried that adding coverage for domestic partners could make their costs skyrocket by attracting people with higher-than-average health risks, she said, but "that did not happen."

The District of Columbia and almost half of states currently offer benefits to domestic partners or same-sex spouses of state workers, according to the advocacy group Human Rights Campaign.

Same-sex partners of federal workers are not eligible for coverage under the Federal Employees Health Benefits Program (FEHB) because the Defense of Marriage Act, passed in 1996 and signed into law by President Bill Clinton, defines marriage as a legal union between a man and woman, according to the FEHB website. That law is being challenged and may well end up before the Supreme Court. The Obama administration has said it will not defend the statute.

In the Mercer survey, coverage of same-sex partners was most common in the West, with 79 percent of large employers offering such benefits. It was least common in the South, at 28 percent. Big differences were also noted within industries. Among manufacturing firms, for example, the coverage rate ranged from a high of 96 percent for pharmaceutical companies to 18 percent for machinery and heavy equipment makers.

Public-sector jobs had a lower rate of coverage, averaging 26 percent across state, county and municipal workers, the Mercer survey found.

Although Smyth at Mercer doesn't think the president's pronouncement will sway employers, Human Rights Campaign state legislative director Sarah Warbelow has a different take.

"Hearing the president supports this as well makes this even easier for corporations to get on board," said Warbelow, adding that 58 percent of Fortune 500 companies currently offer domestic partner benefits. Some of those companies limit those benefits to same-sex couples, while others include domestic partners of opposite sexes.

The climate remains volatile, particularly for state and municipal employees. What, for example, will happen in states like North Carolina that passed a ban on same-sex marriage and have municipalities that offer domestic partner benefits to government workers?

With last week's vote in North Carolina, there are at least 31 states that bar gay marriage.

In North Carolina, attorneys for cities such as Carrboro and Chapel Hill are still evaluating whether they can continue to offer domestic partner benefits, according to reports from the area's local NBC television affiliate.

"We have employees asking us, 'What's going to happen?' These are people who otherwise wouldn't have health care, children who wouldn't have health care," Chapel Hill Mayor Mark Kleinschmidt told NBC-17 in Raleigh, N.C.

Court decisions in other states with similar laws have split on whether domestic partnership benefits can be retained for state or municipal workers, Warbelow said.

Meanwhile, private-sector employers must contend with a confusing array of state laws governing the types of unions residents may enter.

Eight states and the District of Columbia have passed laws to allow same-sex couples to marry, for example, while an additional nine allow civil unions or domestic partnerships, which offer many, if not all of the same legal protections as marriage.

Although many employer health programs are exempt from state law because they are self-insured, some employers buy coverage from insurers that are subject to state rules.

Employers who buy coverage from insurers in those states must follow that state's law, even if the employees live another state, Smyth said.

A separate Mercer report out last week gave an example set in Virginia:

Ellen and Sue live in Virginia, which doesn't permit same-sex marriage. Ellen works in Washington, D.C., and is covered by a group health insurance policy issued in D.C., which must cover same- and opposite-sex spouses equally. Ellen and Sue marry in D.C., even though they live in Virginia. Ellen may add Sue to her health coverage because they are lawfully married and covered by a D.C. policy.

Employers are "focused on this right now and are watching" the changing political landscape to make sure they are in compliance with the rules, Smyth said. "They need to be really careful that they know the laws."

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

A Drug to Prevent HIV's Spread: Truvada's Promises and Problems

Fri, 11 May 2012 18:20:00 EDT

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The Food and Drug Administration gave the go-ahead Thursday to a drug combination called Truvada that is aimed at preventing the spread of HIV. Until now, it had only approved drugs for treating the disease. Ray Suarez discusses the details with Dr. Anthony Fauci of the National Institute of Allergies and Infectious Diseases.

JEFFREY BROWN: And we turn to the new use of a medicine to prevent the spread of HIV. Yesterday, an expert panel of the Food and Drug Administration gave the go-ahead to a drug combination for that very purpose. Until now, the agency has only approved drugs for treating the disease.

Ray Suarez picks up the story.

RAY SUAREZ: Antiviral medications have long been used to treat AIDS and extend millions of lives. The drug combination known as Truvada has been shown in some trials to reduce the risk of infection when used daily. It would be approved for use in healthy adults before they contract HIV.

But there are big questions, too. Daily adherence was a problem in some trials, and the medication is expensive. There are more than 50,000 new HIV infections in the U.S. each year. Globally, there are more than two-and-a-half million new AIDS cases annually.

Dr. Anthony Fauci is the director of the National Institute of Allergies and Infectious Diseases, which funded some of the trials.

And, Dr. Fauci, doctors have given patients Truvada in a so-called off-label way for years to lower their risk of infection. Why is it an important step for the FDA to say, yes, it's okay to use it as preventive medicine?

DR. ANTHONY FAUCI, National Institute of Allergy and Infectious Diseases: Well, first of all, because it would add to the armamentarium of proven prevention modalities.

Prevention for HIV is really a comprehensive, multifaceted group of prevention modalities that's kind of a tool kit. This one can be potentially very effective. So if it's approved and added to the recognized prevention modalities, it would be an important advance in making available for certain people a very effective way to prevent HIV infection.

RAY SUAREZ: You say for certain people. I guess Truvada is not going to be recommended for every sexually active person. Who is considered high-risk enough to use this medical approach?

DR. ANTHONY FAUCI: Well, there are at least two groups and probably a third group.

The groups that are being looked at is first men who have sex with men, and people who are in what is called discordant couple relationships, where one person is HIV infected and the other person is not. And then there are other high-risk groups of people who under special circumstances have very few other options to prevent HIV infection, except to do this.

But the two major groups are men who have sex with men and discordant HIV-infected couples.

RAY SUAREZ: There has been some interesting reaction from across the board, some welcoming this decision, some pretty worried about its future.

One anti-AIDS activist in the L.A. area said, oh, great, all men need is another excuse not to use condoms. They're afraid that if they get a partner on Truvada, preventative measures won't be taken to protect that partner any longer.

DR. ANTHONY FAUCI: Well, certainly that's a possibility.

But the clinical trials did not really indicate that that is the case. This is not meant to be a substitute for other proven prevention modalities, but to be a complement and an addition to others. And we did not see that kind of aversion for regular standard risk behavior during the period of the clinical trials.

Obviously, when this is made available to a larger number of people, we will have to keep an eye on that. But, hopefully, that won't be the case.

RAY SUAREZ: The FDA is barred from considering costs when assessing new medicines. But this pretty expensive, isn't it?

DR. ANTHONY FAUCI: Yes, it is.

If you look at a person taking Truvada for an entire year, the price range is somewhere between $12,000 and $14,000 a year. It's not an inexpensive drug. It is a combination of two drugs. It has been used for years for the treatment of people who are actually infected with HIV. So it is a drug with which we have a considerable amount of experience. But you are right. It is considerably costly.

RAY SUAREZ: But when do the cost/benefit analysis, is it cheaper to keep somebody from contracting HIV or perhaps developing AIDS than it is to give them this new therapy? I mean, how do you balance those two out?

DR. ANTHONY FAUCI: Absolutely. Absolutely.

If this drug, which it hopefully will be and looks like it could be quite effective in certain groups in preventing HIV infection, the cost savings would clearly be in the benefit of the -- if you balance cost with benefit, the benefit clearly outweighs the cost.

RAY SUAREZ: Can you skip a day on this drug? There are many drugs that really don't lose their effectiveness if you cut the dose or skip a day. Is this Truvada one of those, or is it really dangerous when you do that?

DR. ANTHONY FAUCI: Well, we know for sure, Ray, that adherence to the regimen of every day clearly makes it much more likely that you will prevent infection.

I don't think you could say, if you skip one day, it's over, because, remember, you're not treating an infection that's already there. You're trying to protect against infection that you would get. But if you really want the optimal effect, then clearly you should be taking it every day.

RAY SUAREZ: I ask because I think, in some of the clinical trials, they found that, in the lower adherence groups, the effectiveness went way, way down.

DR. ANTHONY FAUCI: Absolutely. But, you know, you're talking about either a day or somebody who really is relatively careless about taking it.

There is no doubt, if you look at the effectiveness of the drug, when you look at all comers in the study, particularly the study with men who have sex with men, it was 44 percent effective. But if you really asked very clearly, did you really take your medicine every day, the effectiveness actually went up to over 70 percent.

And if you actually did blood levels to absolutely prove that someone was taking the medicine essentially every day, the effectiveness of the prevention modality went up to 90 percent.

So it really does work if you use it. And that's why adherence to taking the drug is going to be a very important part of its effectiveness as it is used by more and more people.

RAY SUAREZ: In some parts of the world, what you call discordant couples, couples with different HIV status, are a big part of the infected population, because most transmission is heterosexual.

But it's also a very expensive drug. Can we eventually -- and has it worked that way in the past with these drugs? Can we expect the price to come down in a way that will really bring help to those mixed-status couples in some of the poorer places in the world?

DR. ANTHONY FAUCI: Well, I hope so, Ray.

And, certainly, if you compare in low- and middle-income countries the price for a standard regimen of antiretroviral drugs for HIV, for people who are already infected, the prices of those drugs are considerably lower than the prices that we would pay in the developed world, in rich countries.

So we would hope that when you are dealing with low- and middle-income countries, such as in sub-Saharan Africa, that the prices will be lower.

RAY SUAREZ: Dr. Anthony Fauci, thanks for joining us.

DR. ANTHONY FAUCI: Good to be here.

FDA Urges Caution Over Long-Term Use of Bone-Density-Building Drugs

Thu, 10 May 2012 18:38:00 EDT

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Millions of women grapple with whether to take bone-density-building drugs to treat or prevent osteoporosis, but the FDA this week warned that long-term use of bisphosphonates can lead to rare fractures and side effects. Margaret Warner and Maine Medical Center's Dr. Clifford Rosen discuss the risks outlined by the FDA.

JUDY WOODRUFF: Next, new cautions are raised over drugs to help your bones.

Margaret Warner has our story.

MARGARET WARNER: Millions of women as they age grapple with whether to take bone-density-building drugs to treat or prevent osteoporosis. This week, the Food and Drug Administration in an article in "The New England Journal of Medicine" urged caution about long-term use of so-called bisphosphonates, like Fosamax, Boniva, and Actonel. Long-term use has been linked to rare fractures and side-effects.

Osteoporosis afflicts some eight million women and two million men in the U.S., and another 34 million have reduced bone mass that raises their risk for the disease. The FDA analysis, drawing on two earlier industry-funded studies, found many of these women derive little or no benefit from the drugs after three to five years.

For more, we turn to Dr. Clifford Rosen, director of clinical research at Maine Medical Center's Research Institute, and a professor at Tufts University Medical School. He co-wrote the article accompanying the FDA study.

And, Dr. Rosen, thanks for being with us. There's been. . .

DR. CLIFFORD ROSEN, Maine Medical Center Research Institute: Thank you for having me, Margaret.

MARGARET WARNER: There's been an ongoing debate about these drugs.

What new -- what is new here in this analysis that the FDA has just provided?

DR. CLIFFORD ROSEN: Well, I think what they did is, they asked the question, are these drugs continually being beneficial if they're administered over a long period of time?

We know that the drugs work over three to five years. And the question they were asking is, are they still effective if you continue to take them? There's really been no statement or no data on what -- how long individuals should take these drugs.

And with some side effects being reported with increasing frequency, still rare, but there are some side effects, the FDA decided to go back and look very carefully at all the trials that were conducted that looked at long-term treatment, that is, more than three to five years.

MARGARET WARNER: And who is taking these drugs and how widely is it -- are they prescribed?

DR. CLIFFORD ROSEN: So -- right.

So, that's been the problem. We -- when these drugs came out -- they're great drugs. They reduce fracture risks. They protect individuals against osteoporosis. We initially thought that we should give them for a lifetime, and nobody was really clear, should there be a stop time? Should there be -- should they come off and then go back on?

And as people started taking them for up to 15 years now, since the first drug was approved, there were these occurrences of side effects. And I think every one of us got concerned and asked, what is the optimal duration of treatment? And I think this is where the investigation began.

MARGARET WARNER: And when you say side effects, what are you talking about, the serious ones?

DR. CLIFFORD ROSEN: So, interestingly enough, there were very rare side effects where the jaw -- there was problem with the jaw with infection.

But, then, over the last five years, there have been reports of fractures actually occurring in women who have been taking long-term therapy with these drugs, which we call the bisphosphonates. And it was this, I think, that alarmed both regulators and investigators and clinicians to go back and look at the long-term studies.

MARGARET WARNER: Explain, if you would, how these drugs work when they're -- when they're working right in the early going.

DR. CLIFFORD ROSEN: Right.

So they're very effective in the early going. And what they do is, they block the body's ability to dissolve the bone. Every 10 years, we get a new skeleton. It's surprising and we don't notice it, but we get a new skeleton. And part of that process is the repair process.

First, the bone is digested, and then it's repaired. If the digestion is too great, then there's bone loss. And what these drugs do, where they're very effective, it's stopping this bone -- what we call bone reabsorption, or dissolution of bone.

So they build bone density by keeping the bone that you already have and actually enhancing it. So the theory is great. And they actually work for the first three to five years.

MARGARET WARNER: So if they do increase the density of your bones, what is it about them that then would make after five years, you're actually at -- at least some people are at greater risk for a serious fracture?

DR. CLIFFORD ROSEN: Right.

So we don't think that there's a greater risk of fracture, but we don't think there's any additional benefit. So for reasons we really don't understand, we know that the density will continue to increase, but when you look at rate of fractures, that begins to plateau.

So the protection, which was 50 percent to 70 percent reduction in fractures that we saw in the first three to five years, then gradually disappears, even though the bone density is going up. So that means there's probably other factors going on.

So what the FDA found was that, if you continue the drugs beyond five years, there's no additional benefit. Now, we don't know the true risk of these rare side effects. And that's one of the issues that has to be resolved.

But the fact that there's no continued benefit made them come out with these findings and review all the data that was available.

MARGARET WARNER: So what's the takeaway message for women who may have -- who have been told they either have osteoporosis or they're in that broader category -- I think it's called osteopenia -- where they have some bone density loss?

DR. CLIFFORD ROSEN: Right. Right.

MARGARET WARNER: What should they do?

DR. CLIFFORD ROSEN: So I think the bottom-line message is, if you have very low bone density and/or you have had a fracture of your spine and your bone density is very low, you are still at very high risk of fracture.

Those individuals -- and we tried to point that out in our article -- those individuals should be maintained on the current drugs we have. But if your bone density has gotten a lot better, or if you're in that osteopenic range, we found -- and the FDA did as well -- that continuing therapy is not necessarily needed, because the drugs stay in the system for a fair amount of time, and there's no additional protection.

MARGARET WARNER: Well, Dr. Clifford Rosen, thank you so much.

Key Psychiatric Doctor Rejects Name Change for PTSD

Thu, 10 May 2012 16:15:00 EDT

PHILADELPHIA | A key leader in the psychiatric community has rejected the idea of altering the name of a traumatic condition affecting an estimated tens of thousands of U.S. combat veterans -- a move that effectively blocks growing efforts by a small group of psychiatrists and military brass concerned about reducing patient stigma.

Dr. Matthew Friedman, who is chairing the committee that is updating the trauma section of the dictionary of mental illness, said changing the name of the condition could have "unintended negative consequences" because "it would confuse the issue and set up diagnostic distinctions for which there is no scientific evidence." The dictionary, known as the Diagnostic and Statistical Manual of Mental Disorders, is considered the bible by the psychiatric association.

Last year, then-Army Vice Chief of Staff Peter Chiarelli asked the American Psychiatric Association to modify the name of Post-Traumatic Stress Disorder. The four star general says calling the condition a "disorder" perpetuates a bias against the mental health illness and is a barrier to veterans getting the care they need.

More recently, two leading trauma psychiatrists similarly asked the Association, which is updating its dictionary of mental health illness, to change the word "disorder" to "injury," calling the condition PTSI instead.

But at Monday's psychiatric association annual conference, Friedman said the net effect of such a modification would be to tinker with a psychiatric diagnosis rather than help patients. "To change to PTSI without anything else would accomplish nothing positive," Friedman said.

But Chiarelli, who is now retired and spoke on the same panel as Friedman at the conference, assailed the leading psychiatric professional organization's refusal to make a one-word change in nomenclature. "I believe language means something -- and it means something if your desire is to help and to treat everyone," he said. "To allow a word like disorder -- which may be no barrier to you whatsoever -- to get in the way of the help they need, I find this just absolutely unconscionable."

Friedman argued that the focus should not be on altering condition names but instead should be placed on how the U.S. military handles traumatized troops. He said it was "unfortunate" the Pentagon refuses to entitle soldiers with PTSD for the Purple Heart.

"I realize it's a complicated and contentious issue," he said. "But I think it would have gone much further in reducing stigma than changing the name of PTSD to PTSI."

Friedman suggested that a better approach would be for the U.S. military to follow the Canadian military's route to helping soldiers with wartime psychological trauma.

"The Canadians have demonstrated some exciting and successful approaches to helping military personnel acknowledge their PTSD, to reducing stigma for seeking help," he said.

The Canadian military has sponsored peer counseling centers for veterans and embarked on an education campaign to raise awareness about mental health wounds, Friedman stressed. The military also has coined the term "Operational Stress Injury," which refers to "persistent psychological difficulty resulting from military service ... such as anxiety, depression and post-traumatic stress disorder."

The Canadian military also makes soldiers with Operational Stress Injuries eligible for the Sacrifice Medal -- the equivalent of the U.S. Purple Heart.

Speaking at the APA event, retired Canadian Lt. Gen. Romeo Dallaire said "it would be a great mistake" if the medical establishment were to alter its lingo just to suit the military.

Now a Canadian senator, Dallaire commanded United Nations forces in Rwanda in 1994. There, he bore witness to genocide and was later diagnosed with PTSD.

Medically discharged in 2000, Dallaire said the Canadian military's decision around that time to call a mental health "disorder" an "injury" helped soldiers accept their condition. However, he said, it was unnecessary for psychiatrists to make a comparable change.

Following the APA panel discussion, Dallaire told the NewsHour that it was important that the military use its own jargon and "not fiddle with somebody else's in order to achieve the aim we are looking for."

But Chiarelli told the NewsHour that Canada's approach of creating its own language to be used solely among troops was "a wrong half-measure" that "doesn't go far enough."

If Army doctors adopted the Canadian term, OSI, Chiarelli maintained, it would be confusing for the troops once they separate from the military. "If we bring all our [Army] doctors on board and tell them to call it an Operational Stress Injury," then what happens when a soldier goes into civilian life where the health professionals will call it something else? "What are you going to do with this dual naming of a disease? Well, wait a second, I left the Army and it was Operational Stress Injury, but now I'm a veteran and it's Post-Traumatic Stress Disorder?"

By contrast, Friedman said, the Canadian approach is "brilliant" and is "proof that stigma can be addressed successfully without changing the name of the diagnostic label. So we can have it both ways. Keep the PTSD diagnostic term and have it regarded as an injury."

Chiarelli said, though, that one reason why the Canadian military invented its own term "is because the APA won't change the name." Canada's mental health community, he said, has accepted the medical language that the American Psychiatric Association dictates.

Dr. John Oldham, the APA president, has moved recently to bridge the two communities. However, his proposal to maintain the PTSD moniker for civilian cases -- such as following a rape or other trauma -- but create a subcategory for combat-related "injuries" appeared this week to have fallen by the wayside.

Will Obesity Reverse Rise in U.S. Life Expectancy?

Tue, 08 May 2012 18:18:00 EDT

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Public health experts have long warned of a growing obesity epidemic in America. This week, the Institute of Medicine and others launched a major campaign in hopes of curbing the problem. Ray Suarez and Dr. Francis Collins of the National Institutes of Health discuss the personal and public consequences of obesity.

GWEN IFILL: Public health experts have long warned of a growing obesity epidemic in America.

This week, government officials and others have launched a major campaign, warning those long-feared consequences are at hand. In a 474-page report, the Institute of Medicine called for systemic policy changes, from overhauling farm policies and the way food is marketed, to building more walkable neighborhoods, to ensuring children get at least 60 minutes of physical activity a day.

Our Health Unit has an in-depth look tonight, beginning with a Ray Suarez report on the rising toll.

RAY SUAREZ: Americans are fat and continue to get fatter. Today, two out of three adults in this country are overweight or obese.

ROSS HAMMOND, Brookings Institution: In 1960, the average height for a man was 5'8'', and the average weight was 165 pounds. Today, the average height for a man has gone up one inch to 5'9'',and the average weight has gone up 25 pounds to 190 pounds.

RAY SUAREZ: One of the most striking things about this change is that most people are aware of it, understand what causes it, yet nothing seems to stop it.

MRC GREENWOOD, president, University of Hawaii System: In spite of the fact that people get lots of information, it hasn't changed their behavior in the ways that we have been trying to change it. So I guess it tells you that more information doesn't necessarily mean better behavior.

RAY SUAREZ: New research from universities, think tanks and the federal government has tried to put a dollar cost on tens of millions of pounds of excess weight, in getting heavier and heavier passengers from place to place on public transportation and burning millions of excess gallons of gasoline in private cars, and jet fuel in the air, in lost productivity and increased absenteeism at work, and the tremendous impact obesity has on medical costs year after year.

The annual price tag for all of it? One estimate puts it at $190 billion a year.

TEVI TROY, Hudson Institute: The numbers are just enormous. And given our long-term budget situation, I think it's important to address this issue as soon as possible.

Tevi Troy is a health care economist and former deputy secretary of health and human services.

TEVI TROY: Well, let's look at a 12-year-old kid who is around today. And between ages 10 and -- 12 and 22, so over a 10-year window, he is not going to change that much in terms of the cost he has on society. But if you look at a 25-year window, the costs that might be imposed could be potentially huge in terms of earlier hospitalizations, less productivity at work, less ability to pursue and achieve his dreams.

RAY SUAREZ: Take a look at this animation from the Centers for Disease Control. It tracks the increasing incidence of obesity in America state by state from 1985 on, ending at today, with a large swathe of the country centered on the Southeast and Midwest in red, meaning more than 30 percent of adults are obese.

Ross Hammond has been studying the economic impact of obesity for the Brookings Institution.

ROSS HAMMOND, Brookings Institution: Part of the difficulty with something like obesity is that it's the accumulation of action over a long period of time that leads to obesity. If you eat a cheeseburger today, you won't necessarily have a heart attack today. But over many, many, many days of eating unhealthily and gaining a lot of weight, you might. And because of that time angle, it becomes harder to think about in your daily routine what the long-term consequences are. That's harder for people.

RAY SUAREZ: Just how hard is apparent to Dr. Frederick Finelli, who, in 33 years practicing medicine, has seen a change in his hospital's patients. He's now the medical director of the operating rooms at MedStar Washington Hospital Center.

DR. FREDERICK FINELLI, MedStar Washington Hospital Center: Oh, my God, it's been pretty dramatic.

RAY SUAREZ: How so?

DR. FREDERICK FINELLI: It used to be, years ago, we wouldn't have patients over 300, 400 pounds very often. Now we're seeing them daily. And it's become an operational problem at times.

RAY SUAREZ: Dr. Finelli's specialty is bariatric surgery, limiting the size of the stomachs of severely overweight people. The scales in his office are specially built to handle patients hundreds of pounds overweight, as are the exam tables, even the surgical instruments, now supersized to reach through larger bellies in order to operate.

One particular cost driver of excess weight is diabetes. According to the CDC, someone with diabetes costs an average $6,600 more per year to care for than someone without diabetes, and, collectively, diabetes costs about $150 billion a year.

DR. FREDERICK FINELLI: When someone gets diabetes, it increases their risk for all kinds of other problems, heart disease, kidney disease, eye disease, also makes them more prone to infection, more prone to arthritis.

So, as we get -- patients become obese and then get diabetes, it's really important to try to get the weight off them, because you can completely reverse that -- the disease processes by getting the weight off the patients. And it's. . .

RAY SUAREZ: Just through weight loss, you can become an ex-diabetic?

DR. FREDERICK FINELLI: Yes. For type two diabetes, just by weight loss, you can become an ex-diabetic.

RAY SUAREZ: But millions of us continue to gain weight, forcing hospitals to invest in new equipment, like the ambulance driven by Richard Biondi specially designed to handle patients up to 1,200 pounds.

RICHARD BIONDI, MedStar Transportation EMT: The size of the vehicle is tremendous. It's the size of a rescue squad for many fire departments. Everything else here is custom. Have this entire 10-foot-long ramp system. There's a winch system in the front. Stretcher is specially designed to accommodate patients that size. And then just the overall size inside the ambulance accommodates them as well.

RAY SUAREZ: The winch alone usually, used in trucks, is $8,000. The stretcher designed to hold patients over 1,000 pounds is $9,000. The ambulance alone costs $180,000.

Biondi says the super-obese are often confined to bed by their weight and wait until the last minute to call for help. Helping such a patient from an apartment can take three full ambulance crews. When he looks at the downstream costs of obesity to Medicare and Medicaid, Tevi Troy says the added costs could break the bank.

TEVI TROY: Absolutely, it's a large and looming issue and it's something that really threatens to cause huge problems for our budget situation. Our budget situation, however, is already quite perilous and quite difficult. Medicare is facing over a $35 billion annual budget deficit. That's more than the total budget deficit of Greece.

RAY SUAREZ: The terrible costs, physically and financially, of America's growing obesity problem hasn't been enough to get us to stop gaining weight.

Doctors say one thing that's holding us back might be the notion -- mistaken -- that we have to lose all the weight we have gained since we were teenagers. But if you just lose 7 percent to 10 percent of your body weight, start small, the tendency toward hypertension, heart disease and diabetes drops precipitously.

How do you get people to change their habits? That's the. . .

MRC GREENWOOD: Well, you know, the thing that's so interesting about it is that I had these when I was a kid.

RAY SUAREZ: MRC Greenwood is the vice chair of a huge and comprehensive report on the measures under way to fight back, accelerating progress in obesity prevention, solving the weight of the nation from the Institute of Medicine, incremental steps, like using dinner plates with measuring markers to control portion size, a modest daily exercise program, bringing P.E. back to the school day. They work.

MRC GREENWOOD: It can't just be that, you know, researchers or scientists say, this would be a good thing to do. Your mayors have to believe it. The families whose children are in school have to believe it. Teachers have to believe it.

It has to be -- it has to be more widespread than an individual doctor telling a particular family how to handle an obese child or telling you or me that we should take off 20 or 30 pounds.

RAY SUAREZ: The report is part of a series of initiatives to educate the public launched by the Institute of Medicine, the National Institutes of Health, and the Centers for Disease Control. And HBO will air a four-part documentary next week. It features dozens of top experts exploring the causes and solutions for obesity in the U.S.

WOMAN: I don't want to be fat for the rest of my life. I have got diabetes.

MAN: Sleep apnea.

WOMAN: High blood pressure.

MAN: I get dizzy when I get up.

WOMAN: Everything's hurting now.

RAY SUAREZ: New numbers out this week from Duke University predict that one in nine Americans will be more than 100 pounds overweight by 2030. Unless individuals and institutions begin pushing back on current trends, the cost of what we devour will eventually devour us.

We get more on the personal health consequences of obesity and the call for changing the larger environment that contributes to the epidemic, one problem, an ever-growing BMI, or body mass index.

We turn Dr. Francis Collins, director of the National Institutes of Health. The NIH is one of the leading partners in this week's efforts.

And, Dr. Collins, a lot of our conversation in this area goes to the super-obese. A lot of the statistics that are most troubling come from those people who have gained a huge amount of weight. But aren't there real health dangers that come from gaining a small amount of weight over a long amount of time?

DR. FRANCIS COLLINS, Director, National Institutes of Health: Well, there are significant health consequences even for those who are not in what you would call the severely obese category.

That would be somebody with a BMI over 40. But if your BMI is even over 25 -- and that's easy to do if you're just eating maybe an extra couple hundred calories a day over what you would need to maintain a normal weight -- that can actually put stress on a number of systems.

Importantly, it really stresses your system as far as how to handle sugar. And that results in over the course of time difficulties in producing enough insulin to keep your sugar in the normal range. And lots of people who are not really obese in a major way already have pre-diabetes.

That is, if you test their glucose tolerance, it's already abnormal -- 79 million people in the U.S. have pre-diabetes. Most of them don't know it. Most of them have a chance of going on to full-blown diabetes in five years that's as high as 40 percent or 50 percent. And that doesn't require you to be massively obese.

Other things happen also as you begin to gain weight. Obviously, it puts a stress on your joints. Interestingly, it also increases your risk of cancer, which many people have not really recognized until recently. We don't understand all the mechanisms for that, but it's a very serious concern.

RAY SUAREZ: One interesting finding that's emerged in all this new research is that kids are eating hundreds of calories per day more than they did a generation ago. Are we seeing diseases that we used to see in older people in ever-younger children?

DR. FRANCIS COLLINS: I think our greatest concern when you look at this public health crisis that is surrounding us is what's happening with kids.

Fully a third of kids are now overweight or obese. And about 17 percent of them are obese. And we know from studies that NIH has done over many years, including this Bogalusa Heart Study in Louisiana, that an obese child has a 77 percent chance of becoming an obese adult. And that means these kids are already on a pathway towards a lot of trouble.

And there are kids now getting what we used to call adult-onset diabetes, so called type two diabetes, at the age as young as 10, 11 or 12. We never would have seen that in past years. And those kids, it turns out, are very hard to treat, as was recently shown in a study that was just published a week or so ago.

And they, if not successfully treated, may find themselves in real trouble with heart disease, with diabetes, with kidney failure as young as age 30. We are therefore facing for the first time the chance that the current generation may have a shorter lifespan than their parents or their grandparents because of this obesity epidemic.

RAY SUAREZ: But, for years, we've been telling people that this is the case, that they have to change the way they're living. And just telling them so hasn't been enough, apparently.

The IOM report has a much broader set of suggestions for how to reengineer the way Americans eat, the way they live, the way they get through the day. Talk us through some of that.

DR. FRANCIS COLLINS: Well, clearly, the sort of moralistic finger-shaking at people is not the way to get the results that we hope our nation can achieve.

And we have spent too much time doing that, sort of considering that somehow if people just took initiative to watch their diet and exercise, everything would be fine. It's going to have to be much more than that. And the Institute of Medicine report outlines that. It's going to take, sure, the efforts of individuals. We all are going to have to take some additional responsibility for our part, but that's not sufficient.

It is going to take families working together. It is going to take your own social network. It's interesting. Your friends can make you fat. It's pretty clear that the way in which individuals interact with each other influences things like body weight.

I guess your friends can also make you thin. Think about that. And I think a very important role will be for local governance, for mayors and other community leaders to work on providing the kind of environment that makes it easier for individuals to find ways to exercise safely. Schools are a critical part of this.

And the IOM recommends that physical education should now be 60 minutes a day for children, which it has not been for a long time in many schools. And then, on top of that, industry has a role to play. We're barraged by advertisements for foods that are high in calories and otherwise may be low in nutritive value, and we need to systematically think about how we are surrounded by those kinds of options.

We need a place where the healthy choice is actually the easy choice, where the healthy choice is not a matter of self-deprivation; it's actually the desirable choice. And right now, the way things look, that's not how it is.

RAY SUAREZ: Dr. Collins, thanks for joining us.

DR. FRANCIS COLLINS: Nice to be with you, Ray.

RAY SUAREZ: Online, watch my interview with John Hoffman, producer of a new HBO documentary, "The Weight of the Nation," and find some stunning statistics about overweight Americans on our infographic called "Obesity by the Numbers." And check out our interactive map of obesity rates across the United States.

Obesity in America: By the Numbers

Tue, 08 May 2012 17:31:00 EDT

Collectively, the numbers spell out a familiar story. American adults are expanding by the year, along with their children and health care costs. Depressing? Yes. Easy to tune out? Even more so.

In isolation, the statistics are a little more difficult to ignore. And this month, a consortium of the nation's top health organizations are driving them home through a CDC conference, an IOM report and an HBO documentary series, "The Weight of the Nation."

Here's your cheat sheet to some of the most startling stats.

Too specific? If bigger-picture ideas speak to you more, click the map below to watch a tidal wave of weight gain sweep across the nation between 1995 and 2010.

On Tuesday's PBS NewsHour, Ray Suarez examines the economic impact of the obesity epidemic. Online, he speaks with John Hoffman, the producer of the HBO series, "Weight of the Nation."

Infographic by Joey Chou. Interactive map by Justin Myers.

'Weight of the Nation': U.S. Obesity Crisis Tackled in HBO Special

Tue, 08 May 2012 15:54:00 EDT

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They're the new minority in the United States: "healthy" waistlines. With a third of the nation's adults weighing in as overweight and another third registering as "obese," America's collective eating disorder has relegated those with a healthy body mass index to the fringes.

That's why officials from the Centers for Disease Control, the National Institutes of Health, and Institute of Medicine -- to name a few -- joined up with HBO recently to produce a four-part documentary series outlining the scope of the problem, some common myths and the costs of inaction. "The Weight of the Nation," slated to begin airing later this month, shares its name with a CDC conference taking place in Washington this week and a report released by the IOM on Tuesday.

The documentary series' producer, John Hoffman, stopped by the PBS NewsHour studio recently to talk with Ray Suarez about the multi-faceted project. Watch the video above and visit the HBO website for additional information on how to catch the full series.

And, of course, there's more to come on the PBS NewsHour. On Tuesday's broadcast, we'll have a full report on the epidemic's financial costs and a discussion with NIH director Dr. Francis Collins.

Full Transcript

Ray Suarez: Welcome back, I'm Ray Suarez. I'm here with John Hoffman, who is the producer of the new HBO series ... And, really, we'll talk about it, but it's more than that, the Weight of the Nation. John, welcome.

John Hoffman: Thank you.

Suarez: How did you embark on this enormous topic, enormous project and assemble this impressive list of partners?

Hoffman: Well, starting with the addiction project in 2007, which we did with the NIH, HBO has really tried to create a platform for public health, using its invitation into 30 million homes, but then all cable and satellite households when we open the signal, and when we put all this material online for anybody with access to a computer to watch. We've realized that we can use our platform every few years to really engage in public health. And not just public education but public health. Where, when we partner with the Institutes of Medicine, the NIH, the CDC, it really sends a message to the nation that we've gathered the most important voices on the topic to shape a dialogue that the country has to have about a health issue.

Suarez: Well, this is quite literally an existential crisis. This is going to drive health care costs, going to drive life expectancy. [We're] looking at the first generation of children that will likely be less healthy than their parents and grandparents, in many cases. You've made a big commitment, but how do you engage in storytelling around something that's got so many moving parts, is such a challenging story to tell, but also wants to deliver a health message?

Hoffman: Well, it's our belief, and I think the material shows this, that people did not recognize that the slow weight gain that was happening for themselves, for their families, and really seeing in the communities around them, that this was having health consequences. And what's happening, when you have too much weight around the middle, the changes in blood pressure, the changes in blood sugar, in cholesterol, these are silent processes. You don't feel any of those effects. So, I think for far too long, people had a rather benign view of this weight gain that was happening. And, it's now catching up. Now we have those generations of people who, in their 40s, 50s, 60s, are having heart attacks and strokes, and we're undoing these monumental gains in public health that we've made.

Especially in heart disease. It's still the No. 1 killer but these ... We've had just these miraculous changes in the public health around smoking cessation and because of statins. But we could undo all that with this weight gain.

Suarez: Just today, a report came out from Duke University that said one out of every nine adults will be at least 100 pounds overweight by 2030. And a lot of our visual cues, a lot of what we think about when we talk about the overweight, are those people -- the super-overweight. But a very touching moment in the film comes when one of the people you profile reflects on the fact that they're merely overweight. Not super- obese, but still in trouble. Let's take a look.

["Weight of the Nation" excerpt]

Suarez: Of course, the man that we see there is confined to a wheelchair because of his amputation. It's really had a tremendous impact on their lives.

Hoffman: Yes, this is what diabetes is going to do to the nation. It's one out of three children born in the year 2000 will develop diabetes in his or her lifetime. One out of two if that child is African-American or Latino. It's not just developing diabetes. If that child develops the diabetes before the age of 10, his or her lifetime will be cut by 19 years, and the life will be an unhealthy one. It will be a painful one. It will have kidney failure or amputations, heart attack or stroke. So, diabetes is an awful disease, but because we are able to manage it to a great extent, I think that people are not reacting with the sense of alarm as if they were given a cancer diagnosis. But any doctor will tell you, the same sort of alarms should be happening, if you are at risk for diabetes as if you are at risk for cancer.

Suarez: I was interviewing one of the people who was one of the lead authors behind the Institute of Medicine study and she said, "You know, a lot of people compare this to quitting cigarettes, but it's very different. Because once you stop smoking you're not constantly surrounded by cigarettes. You don't have to smoke for any reason. But you do have to eat. And you're surrounded by food. Decisions around eating, around changing your life, are just very different from making other lifestyle changes. Did you find that to be true when you went around the country?

Hoffman: Oh absolutely. And you have to also factor in that the foods that are at arms-reach. The foods that are so affordable, are the high fat, high sugared foods that are activating the pleasure centers of our brain in the same way that drugs do. It's the dopamine system. It's the pleasure-reward system of the brain. And so we've refined these food products to be as potent as we can for that reward. So you're going to ask people to not experience pleasure? You're going to ask them to turn away from these foods that give those momentary bursts of dopamine, that light up the pleasure centers of our brain? So that makes the challenge all that much more difficult if we have to really re-imagine the food environment that we should all be living in.

Suarez: The shape of Americans has changed drastically, just in the last 30 years. Now that you're steeped in this topic, did you come away optimistic that we can stop, as Mike Huckabee says, "digging our graves with a knife and fork?"

Hoffman: I'm optimistic because the other public health experts who have studied trends in public health in this country have optimism. Because they see that with smoking, with seat belt use, we have really changed cultural norms, and that it is possible. They find hope in those examples, but I am pessimistic at the same time about the willingness and the ability of the food industrial complex and the agricultural industrial complex to make the transformations that really have to occur if we're going to succeed. The profits that they're making from the unhealthiest foods are so enormous. We have an expert in the fourth show who says, "if every American were to reduce his or her intake by 100 calories a day, that would cost the food industry between $30 and $40 billion." What sector of the economy is going to willfully reduce the size of their industry by $30 to $40 billion?

Suarez: Yet at the same time, obesity is costing us some $200 billion a year.

Hoffman: I actually think the employers are where the leverage point might come. Because the health care costs are bankrupting not only the country, but they are seriously compromising the competitiveness of too many of the employers in this country. And so, we profile a small construction company. Well, it's a large construction company, it's the largest one in Arkansas, Naybolds Construction. One thousand employees -- almost all of them men. Over half of them overweight or obese. And they used a carrot approach. Not the stick, they used the carrot to incentivize their employees to do better on their weight, their smoking, their cholesterol, their blood pressure and their blood sugar. Three hundred dollars if they reduced in all those categories. Last year, they saved $600,000 in health care costs.

If they avoid one heart attack or one stroke in that company, they will drastically reduce their health care costs as a company. That's an incentive. So there are models of the employer saying to the employee, 'We're not going to punish you for your weight, we're going to reward you for improvements. And those kinds of cultural norms I think could be the leverage points this country needs, which will enable this country to really make progress.

Suarez: One striking visual moment -- you got a chance to look inside as doctors compared the hearts of two people, young people, and we saw what the heart of a man who is severely obese really looks like. Let's watch ...

["Weight of the Nation" excerpt]

Suarez: That's medicine you have to use sparingly, when you're doing this kind of documentary, right? I mean, you can't keep hitting people over the head with that kind of thing, but it is important.

Hoffman: I genuinely think we don't know enough about how our bodies work. And so, we at HBO have an ability to not have to resort to euphemisms, both visually and with our words, to explain very hard subjects. So, we're able to show what the body looks like through these autopsies, when it has lived with obesity. The man that we just saw, 51 years old. That's not old. But at 500 pounds ... what kind of heart you have to have to pump blood throughout a 500-pound body. We are not designed ... There is no precedent in the history of mankind for this kind of weight. And so our biology just does not have an ability to adapt to this kind of inexorable weight gain. So, what we are able to show through the generosity of these doctors is the serious consequences. I mean, in that scene, you go on and you see the aortas of people with heart disease and it's a very disturbing sight. And it is unsettling and it is purposely unsettling because we need to know how our bodies are reacting inside to this weight gain. It's not a silent process. We just don't hear it.

Suarez: The HBO documentary series is called "The Weight of the Nation." It's available to people who are not HBO subscribers. Go to the website for more information. It's also available in Spanish. It's also got an accompanying book and all kinds of information and graphs. John Hoffman is the producer. Thanks a lot.

Camerawork by Victoria Fleischer and Jason Kane.

High-Deductible Health Plans: Your Questions Answered

Thu, 03 May 2012 10:49:00 EDT

If the very sound of a "high-deductible health insurance plan" makes your head spin, you're not alone.

Last week on the PBS NewsHour, health correspondent Betty Ann Bowser explored the growing popularity of these insurance options with high out-of-pocket costs and low premiums, and the questions flooded our inboxes.

Here to answer 10 of them is Phil Lebherz, the founder and chairman of LISI, an agency that provides support for health insurance brokers throughout California. Responding to those same questions from the consumer-protection side are Marc Steinberg and Cheryl Fish-Parcham -- the deputy directors of the left-leaning patient advocacy group Families USA. Steinberg specializes in Medicare and Fish-Parcham in private markets.

Before we get started, a recap. Be sure to check out our "Top 10 Things to Know about High Deductible Plans" and watch the full broadcast report here:

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Question 1:

Viewer: No one can predict that next month they will not be diagnosed with breast cancer or MS or fall down the stairs and tear the ligaments in their knee. How is a secretary or file clerk making $27,600 (median earnings in the U.S.) supposed to come up with the deductibles? Or the typical median household with its income of $50,000, if that family has a child with hemophilia?

Phil Lebherz: Depending on the household size and income, they may qualify for a public program. In some states, a family of four can make up to $46,000 to $92,000 and still qualify to have their kids on a State Children's Health Insurance Plan (SCHIP). To search all available public programs, take the Eligibility Quiz at www.CoverageForAll.org. It's a five-step questionnaire that will give you a personalized list of your health coverage options. There is also access to affordable critical illness plans available online. These are individual policies that protect against illnesses such as cancer, stroke, heart attack, etc. These are customizable, affordable, and recommended to families with a history of critical illness.

Cheryl Fish-Parcham: That (cost issue described by the viewer) is exactly the problem we see with high-deductible plans. A "high-deductible plan" is one in which you must spend $1,200 or more for health care before your plan begins covering most expenses. Under the Affordable Care Act, if you purchased a high-deducible plan after March 2010, it must offer free preventive care even before you meet the deductible. However, you still have to pay for everything else until your deductible is reached. For a family plan, a high deductible is $2,400 or more. People who purchase high-deductible plans are permitted to deposit money in a tax-free health savings account to use for their out-of-pocket medical expenses, but many people cannot actually afford to put health savings aside.

For now, if your employer is considering establishing a high-deductible plan, you can advocate that your employer contribute as much as possible to employees' health savings accounts to help people pay for care until they reach the deductible. Unfortunately, too many people have high-deductible accounts but no savings and no help from their employers to meet deductibles. In 2014, the Affordable Care Act will help people who purchase coverage through a marketplace called an "exchange" by providing financial assistance with premiums and cost-sharing. For example, people with low and moderate incomes will not have to pay as much in copayments, co-insurance, and/or deductibles as other people. Decisions are still being made about exactly how this will work, so it is good for you to share your concerns about deductibles with your elected officials.

Question 2:

Viewer: I pay $800 a month with a $5,000 deductible at 50 years old for just myself with Blue Shield of California because I had cancer back in 2008, but I'm healthy now. Other than the yellow pages, where can I get good information about the top five competing insurance companies that I should compare Blue Shield of California against?

Lebherz: Talk with a broker/agent and they will be able to compare all plans and insurance carriers for you in your area. You can find a broker/agent by going to www.NAHU.org or to conduct the research yourself online at www.eHealthInsurance.com. To learn more background on insurance carriers in your state, you may want to contact the California Department of Insurance.

Fish-Parcham: A great government website is www.healthcare.gov. It has comprehensive information about health coverage. If you click on "Find Insurance Options" and answer a few questions about yourself, you will get to a page that lists insurance options in your state. You can sort plans according to different features -- for example, you can sort for the most popular plans (those with the highest enrollment in your state) or for the plans with the lowest deductibles. After you sort, you can look at a quick summary of each plan that interests you to learn more about what it covers and what deductibles and other costs you will face.

You can also call a consumer assistance program for help understanding your options. In California, the Department of Insurance, the Department of Managed Health Care, or the Health Consumer Alliance can all help answer your questions.

In 2014, the Affordable Care Act will further improve your access to health insurance. Plans will not be able to charge you higher premiums or deny you coverage based on your health status, and they will be limited in how much they can increase premiums based on age. Further, an insurance exchange will be operating in every state, where you will be able to get information on both private and public coverage and apply for assistance with premiums and cost-sharing.

Question 3:

Viewer: Though not unhealthy, I have some health issues and am now developing age-related health problems, i.e. prostate problems, arthritis and possibly high blood pressure. Am I a good candidate for this type of policy? If someone is unemployed or would be unable to pay the deductible anyway, should they just choose to be uninsured?

Lebherz: It's best not to cancel your plan until you are accepted by a new plan/insurance carrier. For most states, the individual market is underwritten, which means they will need to review your health history, evaluate the risk and determine if they are going to accept or decline your application for coverage. If you are able to switch, this may be a good option for you, especially if you select a high-deductible plan that is HSA-compatible, where you can save money to cover your deductible. The money in this account will roll over every year and will not be lost.

Fish-Parcham: It is better to have insurance than to be uninsured, especially if you have health problems that could require substantial care in the future. However, if you purchase a high-deductible plan and can't actually afford to pay for care until you reach the deductible, you could continue to have trouble getting providers to see you and you could still face medical debt. Ideally, it would be better to purchase a lower-deductible plan. However, we recognize that not everyone can afford that. A high-deductible plan would still offer you some protection against the greatest expenses if you were hospitalized, for example, or if you can find providers that are willing to take what you can pay them until you reach your plan's deductible. Sometimes charities will help you with the cost of health care if the amount you need is finite and they know that insurance will eventually pay your other costs.

Under the Affordable Care Act, many middle-class Americans and those who face prolonged unemployment will have more options for help with health plan costs in 2014. They may qualify for assistance paying their premiums or for lower cost-sharing, including lower deductibles, if they purchase coverage in a regulated marketplace called the "exchange." People with low incomes may also qualify for Medicaid in 2014, even if they do not have dependent children. (Currently, Medicaid is open to only children, their parents, the elderly, and people with permanent disabilities in most states, but you can check with your state Medicaid agency to learn more about current eligibility requirements in your state and if there are any other public programs available.)

Question 4:

Viewer: For those over 65 and on Medicare with no current health problems, how does having a high-deductible insurance policy as a Medigap policy compare to signing up with an HMO or PPO where there are copayments and/or co-insurance for usage? Is there a quality control issue that would have an influence on deciding to stay with high-deductible plan or go with an Advantage program?

Lebherz: When you become eligible and enroll in Medicare, you will find that there are defined copays and deductibles. A Medicare Supplement or Advantage plan fits into the Medicare deductibles and copays like a puzzle piece, whereas a traditional high deductible plan outside of Medicare isn't designed to cover these Medicare deductibles and copays. Thus, if you are eligible for Medicare, it is often less expensive and better coverage to sign up with a Medicare supplement or Advantage program.

Marc Steinberg: This question seems to really be about the different ways for people with Medicare to fill the gaps in the basic Medicare benefit. Private Medigap policies supplement traditional Medicare and cover most or all out-of-pocket costs. Private Medicare HMOs or PPOs (called "Medicare Advantage" plans) are an alternative form of coverage. They are provided by private insurance companies that contract with Medicare. Their plans must provide coverage that is at least on average equivalent to basic Medicare. Most Medicare Advantage plans charge fixed copays for services like doctors' visits and have lower deductibles than traditional Medicare, and some provide coverage that is not available in traditional Medicare. But these plans usually limit which doctors and hospitals you can use.

Whether someone is better off with traditional Medicare plus a private Medigap plan on one hand, or a Medicare Advantage plan on the other, really depends on that person's situation. Traditional Medicare allows people to see any doctor in the country who accepts Medicare. Medicare Advantage plans usually have limited provider networks and limited coverage when traveling away from home. Private Medigap premiums are often high, but they usually provide very stable protection against out-of-pocket costs as long as the beneficiary holds the policy. Medicare Advantage plans can change the terms of their coverage every year, and may have higher cost-sharing than traditional Medicare for specific services like home health care. Also, if you decide to drop your Medigap plan to join a Medicare Advantage plan, you may not be able to get that Medigap plan back in the future. So weigh your options carefully. The official Medicare website, www.medicare.gov, provides information about the traditional Medicare benefit and every Medicare Advantage plan by geographic region. It also includes ratings of the quality of Medicare Advantage plans so that beneficiaries can select a plan on more than just its cost. You can also call 1-800-MEDICARE and ask for a referral to your local State Health Insurance Assistance Program (SHIP) for free individualized counseling.

Question 5:

Viewer: Is there a list in existence of how I can use my HSA, and is the $3,100 the total that can be contributed yearly, or the most an account can have?

Lebherz: Yes, check your summary plan document from your insurance carrier (you would have received this document when you signed up). General rules on how you can use your HSA can be found here (always up to date). An HSA has an annual contribution limit of $3,100 for individual and $6,250 for a plan that has two or more enrolled. You cannot exceed this amount in any given year, however, you can continue to contribute annually. As of now, there is no maximum account balance determined. You can continue to contribute annually so long as you are enrolled in an HSA plan.

Fish-Parcham: The Internal Revenue Service (IRS) puts out guidance about the amount of health savings account (HSA) contributions that are tax deductible. In 2012, individuals with single coverage in a high-deductible plan can make annual contributions to their health savings account of up to $3,100, and individuals with family coverage in a high-deductible plan can make annual contributions of up to $6,250. See this IRS publication for some exceptions: http://www.irs.gov/pub/irs-pdf/p969.pdf. This same publication, along with IRS Publication 502: http://www.irs.gov/publications/p502/index.html, explain what are "qualified medical expenses" for which you can use your HSA. For example, they explain that you can use an HSA to pay for prescription drugs and insulin that you purchased after your HSA was established -- but if you do so, you cannot claim a tax deduction for these same expenses. Publication 502 provides a detailed listing of qualified medical expenses.

Question 6:

Viewer: I am on a low-deductible plan and when I renew each year, I get a message about being grandfathered in; about how if I opt for a higher deductible plan, I will no longer have the option of changing back to a low-deductible plan; that things may change depending on how laws change and play out. I am paying very high premiums and I'd like to switch to a higher deductible plan but don't know if I dare risk it. What sorts of things should I know about all this and how do I decide what to do? I'm 60 years old, unemployed/living off retirement funds, with a few health issues but nothing serious ... yet.

Lebherz: Compare the premium savings with the cost of a critical illness plan or accident plan. Perhaps if you can save enough money to purchase each of these, it would be advantageous to switch to a higher-deductible plan. Be sure that your Rx is still covered under any plan selected.

Fish-Parcham: Plans that you purchased before 2010 and that you have renewed without changes do not have to comply with certain requirements of the Affordable Care Act. For example, they do not have to adhere to new requirements to cover preventive services without cost-sharing, offer you access to OB/GYNs without a referral, limit charges for out-of-network emergency services, or provide improved rights for you to appeal a health plan's decision. Additionally, grandfathered plans may not cover all of the same benefits that newer plans are required to cover in 2014. The protections that new plans must offer are generally helpful to consumers.

However, before you give up a low-deductible plan, you should think carefully about whether you will be able to afford medical expenses before you reach the deductible in a high-deductible plan. Are you a person who is able to set aside money in a health savings account? If you spend the money in that account for medical expenses this year, will you be able to save again in the future? Keep in mind that many plans require you to satisfy an even higher deductible if you go out-of-network for care, which is sometimes unavoidable. Would you have enough resources for this as well? Be sure to look carefully at what the plan covers and at the costs that will be left to you.

Question 7:

Viewer: I've read that many personal bankruptcies involve a medical event, even when the person has some kind of health insurance. Are there numbers on how high-deductible plans are represented in those figures?

Lebherz: Must not be real "health insurance" if it caused someone to go medically bankrupt -- typical plans cover up to $5 million. If someone goes out of network, the doctor can charge whatever they want to and the insurance company will only reimburse up to what is Usual and Customary. The difference in costs can be quite high. Be sure to stay in-network.

Fish-Parcham: This report, from 2005, shows that people with high-deductible plans are much more likely to face medical debt than other insured people and also often go without medical care due to the cost: http://www.commonwealthfund.org/Publications/Fund-Reports/2005/Apr/How-High-Is-Too-High--Implications-of-High-Deductible-Health-Plans.aspx. A number of studies about medical bankruptcy, including this one, mention that medical debtors include the under-insured (people with health insurance that nonetheless must spend substantial portions of their income for medical care due to their coverage being insufficient): http://www.amjmed.com/article/S0002-9343%2809%2900404-5/fulltext.

Question 8:

Viewer: Typically, insurance companies negotiate a lower billing amount before payment. Under high-deductible plans, do individuals pay the 'list price' -- or non-negotiated rate -- making the plans more expensive?

Lebherz: You will still receive the negotiated rate as you are still within contract as long as you stay in-network. The amount you pay is higher than non HD-plans because you are responsible for 100 percent instead of having a co-insurance that shares cost, but either way, you still get the negotiated rate.

Fish-Parcham: People in high-deductible plans would still pay the negotiated rate for covered in-network services while they are satisfying their deductible. Like other people, they would pay list price for benefits that are not covered by their plan and could be charged list price for going to a provider or a facility that is not in their network.

Question 9:

Viewer: The other side of the high deductible coin is that when you meet your deductible, as I have this year in January ... man ... I am on a shopping spree! My experience has shown me that my provider is a predator and when I get the upper-hand, if only for 11 months, I am going to run the table and spend as much of their money as I can. The system is so poisonous to any vestige of actual mutual respect and cooperation towards what should be the goal, better health.

Editor: Panelists, how common is this "shopping spree" approach after a consumer hits their deductible?

Lebherz: Not sure how common ... but the "Shopping Spree" idea is a strategy if you have met your deductible and the insurance carrier covers 100 percent beyond the deducible. To prevent this from happening, some high-deductible plans also have co-insurance after the deductible, for example 80/20 up to $10,000 would mean you are responsible for 20 percent after the deducible and the insurance carrier will pay 80 percent up to 10,000 and then 100 percent beyond that threshold.

Fish-Parcham: Most plans still charge copayments or co-insurance for services after a person meets a deductible. These out-of-pocket costs can add up quickly for people who need a lot of medical services because they have a serious or chronic condition. It is unlikely that a person would want to spend even more out-of-pocket if health care isn't necessary. For many busy working people, simply finding time to get to the doctor for an annual check-up can be challenging. And few people think that a trip to the doctors or medical treatment is fun! But in the rare case where someone is driven to seek out excess care and finds a doctor who is willing to provide unnecessary medical treatment, health plans may identify the problem and generally will not pay for care unless they find the services "medically necessary." This would deter "shopping sprees," which would typically end up costing the patient a lot of money, even after a deductible is met.

Question 10:

Viewer: I have a question that applies to insurance coverage in general, though I have historically had high-deductible plans. I have worked as a temporary employee for the federal government for the past six years. Since I am hired under a temp status, I am required to move states every five to six months to obtain semi-consistent employment. I am currently unable to obtain/retain insurance coverage because I have no permanent address or residency for that matter. The high-deductible plans I have looked into all require you to identify your state of residency, which -- if incorrectly listed -- seems to me would be an easy way of denying coverage. For the past two years, I have searched unsuccessfully to find a policy which is not based off of your residency. Are you aware of high deductible, year-round, coverage for migrant workers, regardless of which state they work in?

Lebherz: The reason they ask is because price is based on ZIP code. However, if you move ZIP codes, cities, or even states, the insurance coverage will maintain, especially if it is a PPO through a carrier that has a nationwide network. Your company will not cancel your coverage because you moved, but they can re-rate the coverage based on a new ZIP code. If you can qualify, an option is to call your company to find out costs of the plan in the ZIP code you are moving to and compare it to another plan in the same area. If it is less and you can qualify, then switch. However, don't cancel coverage until the new coverage is in place.

Fish-Parcham: This is a tricky situation, but there are experts who can help. You might want to talk with some of the large health insurance companies with national provider networks, your current state insurance department, or a licensed insurance agent or broker to learn more about what exactly qualifies as permanent residency for the purposes of health plans and what your options are for finding continuous coverage.

Editor's note: Some questions have been slightly modified for clarity.

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Health Reform on the Brink: Mixed Feelings in Maine

Wed, 02 May 2012 14:49:00 EDT

Editor's Note: This story is part of a series profiling the views of ordinary Americans and their experiences -- good, bad or indifferent -- with the health care reform law. To capture the essence of the opinions expressed, the stories are told from the perspectives of the interviewees. They do not reflect the views of the PBS NewsHour.

As Jeff Aronson sees it, few things encapsulate the American health care dilemma as well as a car crash on the island of Vinalhaven, Maine.

Not the shattering glass and twisting metal of impact, but the aftermath -- the ambulance ride, the hospital stay, and, eventually, the stacks of bills from both. Emergency medical technicians like Jeff hear the same worries too often when they arrive at a scene of distress: "I can't afford the bill for an ambulance ride."

Vinalhaven's emergencies -- not just its auto accidents but its heart attacks, accidental burns, and broken limbs -- may take a little longer to treat than elsewhere in the nation. It is, after all, an island community an hour-and-a-half ferry ride from the mainland. But for the most part, the lobster fishermen and small business owners who fill this town struggle with the same rising costs and public health woes as the rest of the nation.

Jeff has seen his friends and neighbors forgo needed procedures because they simply couldn't afford them. He's experienced the strain when the island's volunteer ambulance service is "strapped by inadequate reimbursements." And he's grown close with both the low-income workers of the state and the high-end vacationers who travel there during the summer -- and both groups worry about the future of their health care.

It's fairly clear to Jeff that some type of health care reform is necessary. But, he said, "the Affordable Care law doesn't do anything for these issues." It may expand access to 32 million more Americans, but the law itself is a far cry from "real health care reform," largely because it's a law built on the idea that three concepts -- personal responsibility for health, the health care system, and the health insurance industry -- are virtually interchangeable, he said.

But they're not the same -- at least not the way Jeff sees it. He would like to see a much larger cultural debate, in which some pretty basic questions are raised and answered collectively: What's the role of health insurance at all? Is it to protect us in the case of catastrophes, so you don't have to declare bankruptcy to get your appendix out? Is it there so that you don't avoid potentially useful check-ups because you can't afford them or don't want to spend the money? Or is it to provide us with a way of funding a relatively healthier nation?

But that's getting ahead of the story. To understand Jeff Aronson's ideas about health care reform, it's helpful to know a bit more about Jeff Aronson.

Catastrophic

The hospital was "fairly barren by American-hospital standards," Jeff said. No big gift shop, no fancy lobby, "but everything was very clean."

Jeff had traveled to this hospital in Frejus, France, immediately after he heard the news -- his girlfriend had been in a serious auto accident. At the time, Jeff was working in Nice, helping to run an exchange program for the University of Vermont. And after several visits to the country, he had grown quite close with a French woman and her four-year-old child.

And now here she was, lying in a hospital bed. "And the one thing I remember asking her was, 'What will your employer do if you can't get back to work? Surely as a single mother, this concerns you.'"

She looked confused by his concern. Under French laws, she said, her employer couldn't dock her pay because of a medical situation. All of her costs from the accident were covered, "to the point where she had no stress about what was going to happen. She didn't face financial ruin over it."

It raised "a different kind of idea about where health care factored in your life," Jeff said. He began thinking more about his own generous benefits package through the University of Vermont, and wondered what would happen if he were in a crash back home.

Crashing

Jeff's own accidents were a little less dramatic. He broke a leg sliding into second base during an intramural softball game (but "the run scored," he said). And he was in so many skiing crashes that he began dislocating his shoulder. "I was falling because I was trying to do more than I should have," he said.

It eventually got to the point where his shoulder would fall out when he was simply trying to put on a seat belt.

With his university sponsored health insurance plan, Jeff could afford physical therapy to improve range of motion on his shoulder. But it may have come a little too easily.

When his physical therapist discovered that he had been lax on his home exercises, she told him a story. It involved a much older patient who was going through the same thing around the same time -- a Vermont farmer who "significantly dislocated his shoulder" when he fell from a hayloft. The difference was that this older gentleman was working hard at his exercises, and he would be back to normal in no time.

"Now as someone who ran every day, that got my competitive juices up, and I got pretty mad at myself," he said. "But I also got pretty puzzled at the whole situation -- why I was getting employer health care as a worker at the state-supported University of Vermont, while this farmer was probably doing it off his own dime to get back to work."

It not only made Jeff question the fairness of the employer-based insurance model, it made him re-examine his own views on the very concepts of health, health care, and health insurance. The farmer took full responsibility for his personal "health" -- a virtue strengthened by the fact that he needed it to remain a productive member of society. He most likely relied on the diagnosis and treatment of the medical establishment (i.e., the health care system) only when he absolutely needed it. And -- as Jeff imagined this man -- his "health insurance," if he had any at all, was simply a means of paying the unexpected medical bills. It wasn't a blank check to be lazy or reckless about personal health, and it certainly wasn't an excuse to rely on the "health care system" to do the heavy lifting of treatment and recovery.

Jeff admits his physical therapist could have been making the whole thing up to motivate him to try harder. She probably didn't intend for the story to be an epiphany about the American health care system. But it worked on both counts.

A New Course

In the early 1990s, Jeff left the shelter of traditional employment in search of a more "public setting." He found it the right mix in a set of freelance jobs in Vinalhaven, Maine -- employment that collectively brings in "far less income than I once earned" and no health insurance.

He now edits a national magazine for Land Rover enthusiasts and leads library reading discussion programs. He's also an EMS volunteer, a caretaker, carpenter and landscape worker for summer home owners. In recent years he's been a sea urchin tender and dock worker. Collectively, they keep him happy and fit.

"When I went out on my own, I realized that I needed to make sure I stayed healthy because I couldn't afford not to be," he said.

If the Supreme Court leaves the health care reform law intact, Jeff would be "forced" to either purchase health insurance or pay a fine starting in 2014, he said. And for someone who "earns below average wages, it's unlikely that any health care plan contemplated by this law will be truly affordable," he said.

So does Jeff think that's wrong, or somehow illegal? "No. It's not a violation of a constitutional right," he said. "There are plenty of things that governments -- at all levels -- tell us we have to do. And we accept them or repeal those laws."

But the law also doesn't do much to reward people like Jeff for their efforts to remain in good health, he said. It doesn't provide parents with the peace of mind he saw from the universal coverage in France. It doesn't encourage the responsible living that comes naturally to a self-employed farmer in Vermont. It doesn't even provide much relief to a fisherman off the coast of Maine when he's worried about an ambulance ride.

"And it's all because this law tiptoes around that central issue of what we mean by 'health' and 'health care' -- and what we would like to do, as a society, to provide and maintain both," he said. "Since we haven't done that -- since much of this debate avoids the point entirely -- I don't think it's going to work as well as its proponents hope. But I also don't think this is the constitutional catastrophe that its wildest opponents say it is, either."

Do you agree with Jeff Aronson? Or are your views of the health care reform law closer to supporter Lisa Hill or opponent Ron Castle? In the weeks ahead on the PBS NewsHour's Health Page, we will continue sharing the stories of ordinary Americans who love, hate, and feel indifferent about the Affordable Care Act. As the Supreme Court decides the fate of the law, we want to hear your verdict. Share your opinions here.

Photos, as shown from top: Lobster boats surround the island of Vinalhaven, Maine; photo by Melanie Stetson Freeman/The Christian Science Monitor via Getty Images. Jeff Aronson talks with a friend; photo courtesy of Jeff Aronson. Stock skiing photo by Alain Grosclaude/Agence Zoom/Getty Images. Lobster fisherman Brennan Dyer unloads traps in Vinalhaven; photo by Melanie Stetson Freeman/The Christian Science Monitor via Getty Images.

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Newborns Addicted to Painkillers: Study Finds Troubling Spike in Cases

Tue, 01 May 2012 18:30:00 EDT

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On average, one baby is born in the United States each hour addicted to opiates -- a class of drugs ranging from heroin to prescription painkillers, according to a new study in the Journal of the American Medical Association. Ray Suarez discusses the findings with lead author Dr. Stephen Patrick of the University of Michigan.

GWEN IFILL: Now, a new study highlights a troubling spike in babies born addicted to painkillers.

Ray Suarez has the story.

RAY SUAREZ: On average, every hour, a baby is born in the U.S. addicted to opiates, a class of drugs that ranges from heroin to prescription pain killers like Vicodin.

A new study published this week in The Journal of the American Medical Association looked at the growing number of mothers taking painkillers and the babies born hooked on drugs.

The lead author of the study is Dr. Stephen Patrick, who practices neonatal-perinatal medicine at the University of Michigan. And he joins me now.

Dr. Patrick, welcome.

What did you study to conclude that the number of babies with drugs in their system hadn't just increased over the last decade, but nearly tripled?

DR. STEPHEN W. PATRICK, University of Michigan: Well, we looked at neonatal abstinence syndrome, which is a drug withdrawal syndrome that newborns experience after they're born.

It usually happens after newborns have been exposed to opiates during the pregnancy. So over the last decade, from 2000 to 2009, we found that the rate of babies diagnosed with drug withdrawal grew by three-fold. In 2009, we noted that more than 13,000 babies were born with drug withdrawal or about one baby born per hour.

RAY SUAREZ: What drugs are we talking about here? Are they drugs we already knew Americans were taking a lot more?

DR. STEPHEN W. PATRICK: Well, the other part of our study, we looked at mothers using opiates at the time of the delivery. And that increased five-fold over the last decade.

One thing that we were not able to do was to tell the exact type of opiates. But opiates are a broad class. so it includes everything from heroin to opiate pain relievers like Vicodin and even methadone.

RAY SUAREZ: Are these illicitly acquired drugs, prescription drugs?

DR. STEPHEN W. PATRICK: Now, unfortunately, from our study, we were not able to determine -- determine that. That was a limitation of our study.

What we do know, looking at data that's been reported by the Centers for Disease Control, we know that over the last decade, prescription opiates have quadrupled in sales. And deaths attributes to prescription opiates have also quadrupled. So we think that this might be one explanation for the rapid increase that we see.

RAY SUAREZ: If we already knew there was a problem with these drugs, was it inevitable they were going to turn up in the bloodstreams of babies?

DR. STEPHEN W. PATRICK: You know, I don't know if I would say that.

I would say that the increases -- I think this study shows that multiple people are affected. And I hope that this study gets attention to think about ways that we can prevent this. I think that this should get the attention of federal and state government policy-makers to think about ways that we can control our opiates maybe in a more optimal way.

Often in our health system, we react to problems. And I think that this study calls for a public health approach. Many states are already doing things to limit abuses of opiates, such as registries of prescriptions that are written, so that we can tell if someone is doctor-shopping, or going from one doctor to another, to get the same opiate prescription.

It's things like these and strategies to limit opiate exposure that will prevent this problem way before it becomes an issue, especially in our newborns.

RAY SUAREZ: Many states have moved to a more punitive, more criminal justice-based response to women who take drugs during or after pregnancy. Is that part of the answer?

DR. STEPHEN W. PATRICK: I think blame is not always helpful.

What I think would be most helpful is again thinking about this from a public health perspective, preventing this before it even becomes an issue. And I think that does come from -- from a public health standpoint, limiting opiates before they're even used. And I think that we can do this through robust public health programs to think about the way we prescribe and think about the -- think about statewide programs that can limit abuses and diversion of these drugs to things that are illegal uses.

RAY SUAREZ: What are the consequences for newborns who have been exposed to drugs during their mother's pregnancy?

DR. STEPHEN W. PATRICK: The newborns who experience drug withdrawal often are more irritable. They're inconsolable. They sometimes have breathing problems. They oftentimes have difficulty feeding and loose stools.

And, rarely, they can have seizures. We also know that they're more likely to be born low-birth weight.

RAY SUAREZ: Your study found significant increases in the cost of caring for those children. What's driving those increases?

DR. STEPHEN W. PATRICK: Well, we found that from 2000 to 2009, the costs -- or the average hospital bill, actually, for these newborns across the entire United States increased from $190 million to $720 million.

We think that this increase is probably driven by the average length of hospital stay. So these babies on average had a length of stay of around 16 days, compared to all other U.S. hospital births of three days, as well as the rapid increase in the just -- the sheer number of these babies.

RAY SUAREZ: What's the long-term prognosis for these babies? Do we even know?

DR. STEPHEN W. PATRICK: That's a great question.

So, you know, the data is still -- is still out there. I think this study, I hope, will gain attention to this issue and get more research dollars to study this. We know that over the last couple of decades, that there have been some studies that have followed babies that have been exposed to opiates and found that there are developmental delays.

But there are also studies that show that there are no issues. So what we really need are big, robust studies to follow these babies as they grow into school-age and to adulthood to really get an idea of what the consequences are beyond the time of birth. We don't know what the consequences of some of these opiates are. We don't always know the exact consequences of some of the medicines that we use to treat these babies either.

RAY SUAREZ: We know many American women get little or no prenatal care. Should the prenatal care that women taking drugs are getting include more advice, more screening, more diversion to lower the number of babies born with drugs in their system?

DR. STEPHEN W. PATRICK: You know, prenatal care is a good thing.

And I think anything that allows women to, you know, spend more time with their obstetrician and get good counseling will improve care. So, certainly, from my perspective, as someone who takes care of babies after they're born, you know knowing some of these issues before the babies are born helps me identify and treat these babies most appropriately.

RAY SUAREZ: Dr. Patrick, thanks for joining us.

DR. STEPHEN W. PATRICK: Thank you very much.

ER Visits After Drinking May Not Be Covered

Mon, 30 Apr 2012 16:30:00 EDT

Photo courtesy of Flickr user daveybot

Up to half of the people who are treated at hospital emergency departments and trauma centers are under the influence of alcohol, experts say. That may be a sobering statistic, yet a recent study found that emergency departments can capitalize on this "teachable moment" to discourage problem drinking in the future.

But laws in more than half the states permit insurers to deny payment for medical services related to alcohol or drug use, and that can derail hospitals' best intentions, experts say. Faced with the prospect of not getting paid for care, some emergency department personnel may sidestep the problem by simply not testing patients' blood or urine for alcohol.

In the study, published online in the Annals of Emergency Medicine in March, nearly 600 emergency department patients who were identified as hazardous or harmful drinkers (defined for men as drinking more than 14 drinks per week or more than four on any single occasion, and for women as more than seven weekly drinks or three on any one occasion) took part in a seven-minute interview. During the interview, an emergency department staff member discussed the link between a patient's injuries and alcohol, as well as guidelines for low-risk drinking, and encouraged the patient to discuss what was stopping him from drinking less and to set a drinking goal.

Compared with those who received standard care, patients who took part in the sessions reduced their average number of weekly drinks significantly as well as their episodes of binge drinking and drinking and driving over the next 12 months.

"In the emergency department on a weekend, all the cases may be drug or alcohol related, and yet we don't do" screening and intervention, says Gail D'Onofrio, the study's lead author who is chair of emergency medicine at Yale University School of Medicine. "Our goal is to normalize this in the emergency department."

Although some of the nearly 4,000 emergency departments screen patients for drug or alcohol use, it's not required. Level 1 and 2 trauma centers, however, which are typically equipped to handle emergency patients suffering from serious injuries sustained, for example, in major car accidents, must screen for problem drinkers. Level 1 trauma centers must also be able to provide counseling.

Such screening and counseling can be effective, says Larry Gentilello, a trauma surgeon who has published studies on injury prevention and substance abuse.

"Most of the people who are injured don't need to go into treatment," he says. "They aren't alcoholics or alcohol dependent. That's why one counseling session can help them by talking about the risks of drinking."

The extent to which so-called alcohol-exclusion laws deter emergency medical personnel from screening and counseling patients for alcohol or drugs is unknown.

The laws have a long history. Since 1947, more than 40 states have passed measures allowing health plans to refuse to pay for care if the patient's injuries occurred while he was under the influence of alcohol or, in some states, drugs, say experts. As people came to understand alcohol addiction and the possibility of treatment, however, it became clear that the laws were counterproductive. In 2001, the National Association of Insurance Commissioners recommended against them.

Since then, at least 15 states have repealed or amended their laws and now prohibit exclusions of coverage for drinking or drugs, according to data from the National Institute on Alcohol Abuse and Alcoholism. Maryland and the District of Columbia are among them; Virginia's law remains in place.

Regardless of state law, self-insured companies that pay their employees' health care costs directly can refuse to cover employees for alcohol-related claims.

The laws have ensnared both problem and occasional drinkers.

Gentilello describes the case of a Seattle woman who was celebrating her 25th wedding anniversary and had a few glasses of champagne at dinner with her family. It was a rainy night and she was dressed up and wearing high heels. As she and her husband tried to hail a cab, she tripped on a curb, fell and broke her ankle. In the emergency department, her chart noted that she had a few drinks. Her insurer refused to pay. Washington subsequently adopted a prohibition on alcohol-related claims exclusions in 2004.

It's unclear how frequently insurers continue to apply such laws to avoid paying claims. Susan Pisano, a spokeswoman for America's Health Insurance Plans, a trade organization, says the group doesn't know what member practice is. Cynthia Michener, a spokeswoman for Aetna, says that "to our knowledge" the company doesn't apply such exclusions. Other insurers, including UnitedHealthcare and Humana, didn't provide information about their practices.

But a professor who has written about such laws says there are indications that health plans continue to use them to deny payment.

"There are tons of these cases," says Sara Rosenbaum, a professor of health law and policy at George Washington University's School of Public Health and Health Services. "The only evidence we have suggests that these cases go on."

"There's no reason to think that insurers, eager to hold down costs, wouldn't continue" to deny payment based on such exclusions, she adds.

Combat Paper: Veterans Battle War's Demons With Paper-Making

Mon, 30 Apr 2012 16:10:00 EDT

The statistic is stark, heartbreaking and unacceptable. According to the Department of Veterans Affairs, 18 veterans commit suicide every day -- about one every 80 minutes. Many suffer from post-traumatic stress disorder, which plagues their thoughts, invades every aspect of their lives and disables some to the point where death is preferable to living through the nightmare. It was once called shell shock and thought to be a byproduct of cowardice. It is now understood to be a natural reaction to astonishing stress, to seeing things that no one ought to ever see.

"There's a lot of things that I've seen, a lot of things that veterans see during war in a combat zone that are honestly some of the ugliest things you would ever see, that you could ever even imagine -- inhumane actions that are done by a veteran themselves that just make them feel like monsters," said Marine Corps veteran David Keefe. "The only people who are going to understand are veterans themselves. They feel like a community, so they can integrate into society."

Keefe is the director of the Combat Paper Project at the Printmaking Center of New Jersey. Combat Paper started in 2007 by Drew Cameron, an Iraq War veteran and artist, and Drew Matott, a paper-maker, to reckon with Cameron's service. They cut the uniform off Cameron's body, made pulp and turned the pulp into paper.

During the past five years, Combat Paper has helped many veterans make sense of their experiences in a constructive, safe and artistic environment. Now, Combat Paper has its first permanent East Coast home at the Printmaking Center of New Jersey, about 45 minutes west of New York City. Another project is underway on the West Coast.

Deconstruction and Transformation

At first blush, cutting up a military uniform may seem like an unsettling concept. Could this be seen as disrespect toward the uniform? In no uncertain terms, Keefe said no. "They are taking that uniform and transforming it into something better so they can live a healthier life. I find no disrespect in that," Keefe said.

Keefe outlined a four-stage process, a full-spectrum experience where the physical and emotional remnants of service are made one.

A veteran first cuts up his or her uniform. This represents the deconstruction of past military experiences. The paper-making in the second stage marks the reclamation phase. The veteran is making something new -- paper -- out of something that is old -- a uniform and all experiences good or bad associated with it. In the third stage, the paper is used to create art and marks the communication phase. This is where the veteran can tell their stories through art and poetry. The paper provides the platform, the larger community of veterans provides the confidence and support to undergo this transformation.

Battling the 'Grim Reaper'

I'd heard about the Combat Paper Project from Kyle Conley, a former Marine and combat comrade of Keefe's who I've known for more than 30 years. After Sept. 11, Conley volunteered for the Marine Reserves. In early 2003, Conley was in that first wave of troops who raced in across the deserts of Iraq. He later served with Keefe in Iraq's Anbar Province and patrolled the Euphrates River during 2006-2007, a harrowing era of a barely contained civil war.

Conley had told me of those days on the river, of close-quarter combat where insurgents lurked 15 feet away. He spoke of a creeping, episodic sensation that he'd seen and felt things there -- awful things -- that echo at home. He wrote me in mid-March to tell me about Combat Paper, and soon after, I sat in an empty, suburban New Jersey art studio on the first Sunday in April as the soft strains of bluegrass pickin' drifted through the room.

The first veteran to arrive was Sarah Mess, who served in Somalia at a field hospital in 1993. She also was pressed into combat duty. You can see in her face and eyes a strain still present nearly 20 years after that "humanitarian mission" in the Horn of Africa. It should also be known for the war it was, Mess said.

"I never fed one (expletive) kid," she said with a rueful, sardonic tone. "We were sent there not even having a clue or being briefed that we were going into combat." Mess said the "grim reaper" -- as she called PTSD -- rears its ugly head when triggered by certain circumstances. She comes to the Combat Paper Project in part to quell that feeling of dread.

Shredding Uniforms, Sharing Stories

Veterans of four American conflicts -- Vietnam, Somalia, Afghanistan and Iraq -- ranging in age from the mid-20s to late 60s eventually trickled in. There were occasional tears but surprisingly more broad smiles and cheer. The veterans gathered around the cutting table, shredding uniforms and letting the stories flow. An unburdening that is itself a catharsis many have sought and, before now, not found.

Walter Zimmerman, a Vietnam-era Air Force veteran, never saw combat -- he was at a computer work station in Iceland -- but he came to honor a friend's son who was horribly disfigured in Afghanistan.

"He was driving a truck along with six or seven other people, and they hit a roadside bomb," Zimmerman said. "Two people were instantly killed, and my friend's son was so badly burned that they were sure that he was dead -- but he wasn't. The only skin that was left on his body was underneath his helmet."

Zimmerman sat with his friend as she cared for her son at a San Antonio military hospital. "I was thinking ... that this is one room, you know, one room -- one person in one room in a hospital. You multiply that -- you just multiply that," he said.

Zimmerman said the Combat Paper Project offers him and -- more importantly -- younger veterans the chance to unburden themselves of the suffering they have witnessed and endured.

Nearby, Vietnam veteran Walt Nygard worked with Iraq veteran and early Combat Paper acolyte Eli Wright on a linoleum block print Nygard made of a soldier walking toward the horizon. It's entitled "Pacem in Terris" -- Peace on Earth.

On this morning in New Jersey, there is some.

Photos by Morgan Till.

Tune in to Monday's NewsHour broadcast for more on the Combat Paper Project. You can get a sneak peek of the report here:

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Making Your Own 'Combat Paper': A Step-by-Step Tutorial Veterans Changing the Arts: Share Your Story

Veterans Changing the Arts: Share Your Story

Mon, 30 Apr 2012 15:23:00 EDT

"Breaking Rank" by Drew Matott, 2007, Combat Paper Project

After years of war in Iraq and Afghanistan, art therapy programs for veterans to sprout up, including the Combat Paper Project, which will be featured on Monday's PBS NewsHour. (We'll have a link to the segment Monday evening.)

The increase in the number of professional artists with military experience and therapy programs related to military service has been so pronounced that a new collaboration called Arts, Military and Healing states that veterans are changing the arts in America. The collaboration is a week-long event in May that will bring artists, art institutions and art therapists together with service members and veterans.

Brian "BR" McDonald, an Army veteran, performer, founder of the Veteran Artist Program and one of the leaders of the initiative, thinks that the veteran experience adds an "amazing and palpable" energy into the arts and arts therapy worlds that wasn't there before.

"When you combine the focus of a military veteran with the creativity of an artist, it is an amazing hybrid for change," McDonald said. "When you consider that less than one percent of Americans have served, that's a perspective that most artists don't have."

The Smithsonian Institution's Jane Milosch, who directs the Provenance Research Initiative in the Office of the Under Secretary for History, Art and Culture, and is an adviser for the initiative, agreed.

"This is something that is unique in time," Milosh said. "There is a lot of vapid contemporary art driven by the art market today, so it's refreshing to see this type of transformation art that's emotional and is full of risk-taking."

The transformational power of creating and exhibiting art from veterans hasn't been lost on the U.S. government either, Martha Haeseler, art therapist and director of the Giant Steps Program at the VA Connecticut Healthcare System, said. Haesler has seen an increase in interest in art therapy in her career that spans over three decades. Just last month, the Army asked art therapists to train workers at several bases in the U.S. on simple arts therapy exercises they could do with soldiers there, Haeseler said.

"Art therapy engages all parts of the brain and taps into the sensory images that may not come out through talk therapy," Haeseler said. "So many veterans say 'When I'm making art I don't hear voices, I don't feel pain.' The art allows them to experience life more fully. Also, there is the product which other people and the community can see to better understand, if the person wants to share it."

"Art therapy has always helped people focus on their strengths," Haeseler later added via email. "And art-making becomes a great strength that helps people find meaning in their lives.

McDonald, Milosch and Haeseler had many examples of veterans who have entered the professional art world or who have been affected by art therapy. We want to give you the opportunity to share your story. If you have artwork or insight to share, submit it in the form below.

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More: - Combat Paper: Veterans Battle War's Demons With Paper-Making

- Making Your Own 'Combat Paper': A Step-by-Step Tutorial

High-Deductible Plans a 'Quiet Revolution in Health Insurance'

Fri, 27 Apr 2012 18:25:00 EDT

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As health costs rise, insurance plans characterized by lower premiums and higher out-of-pocket costs are on the rise in American workplaces. Health correspondent Betty Ann Bowser reports on the growing trend toward high-deductible health plans, and concerns that they may encourage delays in receiving needed medical care.

JEFFREY BROWN: Next, a growing change in the way Americans are buying and receiving health insurance.

NewsHour health correspondent Betty Ann Bowser reports.

BETTY ANN BOWSER: Dennis Adams is what the insurance industry calls a young invincible.

DENNIS ADAMS, professional dancer: I figured nothing would happen to me. When I was 26 or 25, when I got the plan originally, I had never had surgery, I had never broken a bone, I had never been in an ambulance, I had never been to the hospital.

BETTY ANN BOWSER: So when the non-profit Oberlin Dance Company of San Francisco offered a new type of health insurance three years ago, the 27-year-old professional dancer didn't think twice. He signed up right away.

It was a high-deductible insurance plan that traded lower monthly premiums for higher out-of-pocket costs to employees. In this case, Adams would have to pay $2,500 up front before his health insurance would kick in, if he needed it.

Then, the unthinkable.

DENNIS ADAMS: I got hurt.

BETTY ANN BOWSER: During a performance like this, Adams tore his ACL. When he need an MRI to determine how bad the damage was, the provider demanded the $1,600 test be paid for up front.

Adams was stunned, but, even worse, he didn't have the money. Of the growing number of companies that are going to high-deductible plans, about 23 percent of them offer employees some type of rainy-day option, usually called a health savings account, or HSA. And even though the dance company is a non-profit with a tight bottom line, it puts $100 a month in each employee's account.

The 30 people on the plan can also contribute to it tax-free, and the money rolls over year after year and from job to job. In the end, workers comp paid for Adams' treatment because the injury happened on the job. But for the young dancer, it was a teachable moment. He went back to a traditional plan with higher monthly premiums.

Dr. Drew Altman, president and CEO of the Kaiser Family Foundation in Palo Alto, calls this a reshaping of the insurance market.

DR. DREW ALTMAN, President and CEO, Kaiser Family Foundation: Well you know, I think we've been so focused on health reform in Washington, what we have missed is there is a quiet revolution happening in health insurance out in the country.

BETTY ANN BOWSER: According to Kaiser, last year, 31 percent of workers covered by their employers offered this type of insurance, with a deductible of at least $1,000. Enrollment has tripled, up from 10 percent, in five years.

DR. DREW ALTMAN: They don't have a lot of weapons to throw at their rising health care costs any longer, so they have really no choice but to go in this direction, especially the smaller employers, who are getting hit especially hard by rising health care costs.

So, we're seeing this quiet revolution in what health insurance really is. It's changing in the country and it has big implications for people.

PHIL LEBHERZ, founder and chairman, LISI: The logic is that, if you have a higher deductible, as a consumer, you're going to pay more attention to the marketplace and how much people are charging you for their services.

BETTY ANN BOWSER: Phil Lebherz is the founder and chairman of LISI, an agency that provides support for health insurance brokers throughout California. About a third of his employees are on these types of plans. And, Lebherz says, their rise in their popularity comes down to economics.

PHIL LEBHERZ: This move to high-deductibles is really, at the bottom line, an economic market adjustment to lowering the cost of the actual health insurance premium, putting some risk, or some emphasis, from a consumer standpoint, and some interest in people's trying to stay healthy, so that it protects them and protects the company at the same time.

What we're seeing is a change in the financing of health care, not an erosion of the coverage. The coverage is still there. In fact, there's more coverage than ever.

BETTY ANN BOWSER: That's why, in 2009, the dance company's finance manager, Charlene Folcomer, recommended they start offering a high-deductible plan with lower premiums.

About a third of the company's 100 full-time employees opted in.

CHARLENE FOLCOMER, finance manager, Oberlin Dance Company: So, it's made a huge savings for us. The employees that are on it stay with it because they're getting used to it. They have to do what it takes to keep their health care costs down now.

BETTY ANN BOWSER: But a new study found people on these types of plans sometimes put off medical care, more often than those in traditional low-deductible plans.

The study's lead author is Dr. Alison Galbraith, a pediatrician at Harvard Medical School.

DR. ALISON GALBRAITH, Harvard Medical School: What we found was that, in families in high-deductible plans, there was a much higher prevalence of delayed or foregone care due to cost, compared to people in the non-deductible plans. And an interesting thing was, it was -- there was the suggestion that actually it wasn't necessarily the chronically ill family members who were delaying care.

BETTY ANN BOWSER: But, Galbraith added, these plans can work well for some people.

DR. ALISON GALBRAITH: Ideally, the best person in a high-deductible plan, well, it's a healthy person who doesn't need a lot of care. And for those types of people, they're great plans. So that's why some families will want to buy them, because it may be the only affordable option for them.

BETTY ANN BOWSER: Lauryn Menard, an administrator for the dance company, is one of those ideal candidates for this type of insurance, and she's happy with it.

LAURYN MENARD, Oberlin Dance Company: I feel like I'm getting good coverage for me. I'm young, I'm healthy, I'm savvy. I know, you know, what my costs are going to be per month. I know those costs. I know what my expected medical costs are, so -- so, I -- and I feel like, if something were really worrying me, I could totally go to a doctor.

BETTY ANN BOWSER: But even Menard admits she now sometimes puts off going to the doctor to save money.

LAURYN MENARD: I do get headaches about once a month, and they can get really bad. And I still haven't gone to see a doctor about it. And I don't know. I haven't made plans to yet. It's like, I'm kind of trying to cheat the system a little bit, because it's like, if I don't go and it's not really serious, then I'm saving money.

BETTY ANN BOWSER: With this so-called quiet revolution already well under way for thousands of Americans, Altman is pushing the industry and the country to take stock.

DR. DREW ALTMAN: We really need to have a national discussion about whether this is a good thing or this is a bad thing. Or it may mean -- I think what it really means is, this is okay for some people if you are pretty healthy. But we have to worry about what these very high deductibles, $2,000, $3,000, $4,000, $5,000 deductibles, is that really even insurance coverage?

BETTY ANN BOWSER: The number of Americans enrolling in high-deductible plans is expected to rise as long as the cost of health premiums also continue to climb.

JEFFREY BROWN: Online, you can find our list of the top 10 things you need to know about high-deductible insurance plans. Plus, you can submit your questions via Facebook or Twitter or on our website, and we'll post answers from experts next week.

Top 10 Things to Know About High-Deductible Health Plans

Fri, 27 Apr 2012 13:19:00 EDT

High-deductible health care plans are no longer a novelty -- they are becoming mainstream. According to the industry trade group America's Health Insurance Plans, the number of people with this kind of coverage reached more than 11.4 million in January 2011 -- up from 10 million in January 2010.

A survey from the Kaiser Family Foundation found that about half of all workers in "small" businesses (up to 199 workers) who have health insurance have these plans.

On Friday's PBS NewsHour, health correspondent Betty Ann Bowser explored this "quiet revolution" in the health insurance industry. Watch the full report here.

But first, here is a brief guide to this type of health insurance:

These plans are generally defined as insurance policies with lower premiums and a hefty deductible -- the amount you have to pay before the insurer picks up any of the cost. Federal rules require these plans to have deductibles of at least $1,200 for an individual and $2,400 for family coverage for 2012.

Another term for these is "consumer-directed health plans."

Because of the health law, even high-deductible plans are now required to cover, usually for free, basic preventive services such as vaccinations and wellness exams.

Consumers and employers like the cost control that comes with the plans -- largely because the premiums are lower than standard insurance premiums by an average of $1,000 to $2,000 per year.

Even with the high deductible, patients' out-of-pocket costs are capped at $6,050 for an individual and $12,100 for a family. Out-of-pocket costs generally include the deductible, the patient's share of the cost of seeing a doctor, prescription medicines and hospital costs.

Health savings accounts (HSAs) sometimes accompany high-deductible plans. These accounts allow beneficiaries to contribute, tax-free, up to $3,100 for an individual and $6,250 for a family.

The money in an HSA belongs to the consumer. Funds left over at the end of the year are rolled over to the next year. If an employee changes jobs, the HSA stays with that individual. Some employers make tax-free contributions to their employees' HSAs.

Health policy experts say the popularity of high-deductible plans is the byproduct of the steep rise in health costs. A RAND Corporation study notes that high-deductible plans, especially those associated with HSAs, "create a strong financial incentive for the employee to manage health care costs carefully, because the account balance is owned by the employee." Deborah Chollet, a senior fellow at Mathematica Policy Research Center in Washington says that consumers "tend to be young, healthy males who (generally) avoid the health care system and only go to the doctor when necessary."

The plans are problematic for low-income individuals, especially those with chronic conditions such as diabetes. Paul Fronstin of the Employee Benefit Research Institute says HSAs and high-deductible plans have a "straitjacket design" in which consumers are responsible for paying the full dollar amount of their medical expenses until they meet their deductible. People with health problems can have the toughest time meeting the deductible, because their illnesses can keep them from working.

The IRS determines what medical expenses qualify toward the deductible. Recently, the IRS dropped over-the-counter medications from its list.

Do you have specific questions about the benefits and drawbacks of high-deductible health insurance plans? Submit them in the comments sections, by email at onlinehealth@newshour.org, or on Twitter @jasokane. We'll have financial experts from the insurance and consumer-protection worlds answer those questions next week on our Health Page.

Workers Putting 'More Skin' in the Health Care Game

Fri, 27 Apr 2012 13:18:00 EDT

The name pretty much says it all: high-deductible health insurance plans.

Higher deductibles, cheaper premiums.

But if you think the surprises end there, brace yourself for one more: Proportionally, these plans are growing faster than any other type in the United States. In 2006, only 10 percent of workers with employer-based insurance were enrolled in a high-deductible plan. Today, it's closer to 31 percent, according to the Kaiser Family Foundation.

It's a "quiet revolution," said Dr. Drew Altman, president of the foundation. "It's a big change in what health insurance is, which has been happening under the radar screen in our country without a lot of scrutiny, attention or debate."

On the PBS NewsHour on Friday, health correspondent Betty Ann Bowser will explore what's behind the "revolution," how it's impacting the health of employees and why some analysts say it may help bring down health care costs across the system if patients have "more skin in the game."

But first, some visuals. Click each graphic to see a larger version.

Deductibles of $1,000 or More

Accounting for 50 percent of the employee insurance plans at small businesses, high-deductible plans are almost "commonplace" these days, said Matthew Rae, a senior policy analyst for KFF and one of the authors of the foundation's 2011 Employer Health Benefits Survey.

Why the sudden spike in all of these plans? In a nutshell: "The cost of premiums has just really gone up," Rae said. "Employers have been trying to find ways for them to lower premiums. And offering a high deductible is one of those ways."

In 2001, the average insurance premium for a family of four would have been $7,000. Today, it's about $15,000. The average premium for a high-deductible plan is about $13,000.

Deductibles of $2,000 or More

In 2006, just 3 percent of workers in employer-sponsored health plans had a deductible of more than $2,000. Now it's 12 percent.

Can't wrap your head around a deductible that high? Some employees actually prefer it, Rae said.

"Many times, if a worker has a choice, they go with the high-deductible plan just because they want to have a smaller premium contribution," he said. "If you're healthy and you don't plan on using a lot of medical care and you're just hoping to avoid a catastrophe situation, then that plan would make a lot of sense for an individual worker."

Savings Options

Since the early 2000s, employers are increasingly coupling high-deductible health plans (HDHP) with health "savings" accounts that help workers to partially -- or sometimes completely -- match the deductible.

Known as Health Reimbursement Arrangements (HRAs) or Health Savings Accounts (HSAs), both of these options allow for the tax-free deposit and withdrawal of cash for qualifying medical expenses.

In an HRA, the company finances and controls the account, often allowing remaining funds to roll over from year to year. But when an employee leaves the company, the money usually returns to the firm.

HSAs, on the other hand, allow both workers and employers to deposit money tax free. Employees also get to keep the account after they leave their job, allowing for easy transfer between companies.

On average, U.S. firms that contribute to HRAs chip in $861 for individual coverage and $1,539 for family coverage. For HSAs, the average is $611 for individual coverage and $1,069 for families.

Forecast: More of the Same?

Among large firms with employer-sponsored health benefits, 41 percent now offer at least one high-deductible health plan with one of the two savings options (HDHP/SO).

While the total percentage isn't quite as large for small companies, it's still a significant shift, Rae said.

"For small firms -- especially very small firms -- many are likely to only sponsor one plan type," he said. "For more and more of them, that one plan type is a high-deductible health plan with a savings option."

And Rae doesn't see those numbers changing any time soon.

"With the costs of premiums continuing to increase, there's no reason to think that we're not going to see that kind of increase over the next couple of years," he said.

Follow @jasokane

What Rare Mad Cow Case Means for U.S. Consumers

Thu, 26 Apr 2012 17:27:00 EDT

Photo by Peter Cade via Getty Images

For the first time in six years, a case of mad cow disease surfaced in the U.S. this week. But there's no need to fear the beef aisle.

Why not? The California dairy cow infected with the disease never threatened the food supply, according to a USDA official.

"The carcass of the animal is being held under State authority at a rendering facility in California and will be destroyed," John Clifford, the chief veterinary officer at the USDA, said in a statement. "It was never presented for slaughter for human consumption, so at no time presented a risk to the food supply or human health."

The Center for Science in the Public Interest, a consumer group, agreed that the case shouldn't raise alarm. "A case of a single cow with Bovine Spongiform Encephalopathy is not a reason for significant concern on the part of consumers, and there is no reason to believe the beef or milk supply is unsafe," Sarah Klein, the organization's food safety attorney, said in a statement.

But at the same time, Klein said the United States is lagging behind many developing-world countries when it comes to tracking animals. Botswana, for example, uses microchips to track its animals up and down the supply chain.

"If American cattlemen suffer economic losses at the news of this discovery of BSE, they should blame only themselves and other opponents of a mandatory animal identification system," she said.

The animal in question this time around was found to be infected through a Department of Agriculture surveillance program, which annually tests some 40,000 cows for the disease, according to the Associated Press.

Formally known as Bovine Spongiform Encephalopathy (BSE), the disease is fatal in cattle, and humans who eat contaminated beef can be affected.

In the United States, there have only been four confirmed cases of mad cow disease, including this one.

Linda Detwiler, a Clinical Professor at the College of Veterinary Medicine at Mississippi State University, answers our questions about the causes, prevention and future of the mad cow disease below.

How is mad cow disease contracted and spread?

Detwiler: Bovine Spongiform Encephalopathy (BSE), also called mad cow disease, has been found to have several different types, known as Classical and Atypical BSE. The classical form, which is responsible for the majority of cases worldwide, usually spreads by an infected cow being slaughtered, rendered, processed into meat and bone meal and fed back to cattle. It does not spread from cow to cow by contact or from the environment. Thus, around the world, there have been many feed bans put in place, in the United States, Canada, Europe, etc. These measure are responsible for the large decline in cases.

In regard to the atypical cases, these were just reported in 2004. There is still research to get a better understanding of these diseases. The most recent case reported by the USDA is an atypical case. We do not know the origin of this disease or how it spreads (if it does) in nature. The origin may be sporadic (meaning it just occurs), genetic, or it may be a modification of classical BSE. It will take time for science and epidemiology to figure this out.

Should the public be concerned about this new mad cow finding?

Detwiler: I think all of us as consumers should maintain an awareness about BSE so that we can make informed choices. Currently, there are many safeguards in place to protect consumers as well as our national herd. I continue to stress that we must be vigilant in looking for ways to improve the system.

When mad cow first popped up, what types of precautions were taken?

Detwiler: BSE was actually first recorded in 1986 in the United Kingdom and rose to the epidemic proportions that peaked in '92 and '93. The UK put a ruminant-to-ruminant feed ban in place in 1988 ("ruminant" refers to the type of mammal that includes cows, sheep and goats). Even though they put the regulation in place in 1988, there was exposure to their cattle prior to the ban. That is, when a cow was to eat contaminated feed, you wouldn't see the disease for usually 3 to 8 years or so, due to the long incubation.

The UK then took precautions to protect the human food supply by removing tissues (from the animals) most likely to be high risk, such as brain and spinal cord.

What types of restrictions does the U.S. have? 

Detwiler: In the late 1980s, the USDA restricted imports from the United Kingdom and other countries in Europe that had BSE and this proved to be very important. In 1997, the FDA prohibited the feeding of most mammalian protein to ruminants through a feed ban. In 2004, high-risk tissues (like brain and spinal cord) were removed from the food supply for humans to protect public health.

This is the first case since 2006 and the fourth ever found in the U.S. How significant is that?

Detwiler: I don't know if I can say that there is a significance to the individual case other than that it's good to know that our the surveillance system picked it up. It established that our diagnostic laboratories can diagnose the various types of BSE. The fact that it's an atypical case will hopefully provide us with some more information to study because we know so little about this disease.

Does it make a difference that it was a dairy cow as opposed to a cow sent to slaughter?

Detwiler: By having the animal sent to a rendering plant (and the carcass held) versus being sent to slaughter prevents any exposure to the food or feed chains. Our safeguards, as previously mentioned, are in place to reduce the risk that animals incubating the disease are presented for slaughter or are rendered.

Could milk pass along mad cow disease?

Detwiler: There has been a considerable amount of research done with classical BSE and there's been no evidence of infectivity in the milk. Currently, research is in the early stages of understanding which tissues are infectious in cases of atypical BSE.

Do you have any recommendations going forward?

Detwiler: We do know that in both classical BSE and atypical BSE there is infectivity in certain tissues, hence it is important to not become complacent and to abide by our current regulations. It is also extremely important for the U.S. to monitor ongoing research and epidemiological evidence and modify policies if needed.

Millions Expected To Receive Insurance Rebates Totaling $1.3 Billion

Thu, 26 Apr 2012 10:48:00 EDT

Millions of consumers and small businesses will receive an estimated $1.3 billion in rebates from their health plans this summer under a provision of the health care law that effectively limits what insurers can charge for administration and profits, a new study projects.

About one third of people who bought their own insurance last year will get rebates averaging $127, according to an analysis of state data by the nonpartisan Kaiser Family Foundation.

"This alone is not going to make health insurance affordable for large numbers of people, but it is getting excess administrative cost out of the system," says Larry Levitt, a study author.

The percentage of consumers and businesses in line for rebates varies widely by state. In Texas, for example, 92 percent of consumers who purchased individual policies are expected to get rebates because insurers spent too little of their premium dollars on medical care. But in Vermont, Rhode Island, Iowa and Hawaii, insurers are likely to owe less than 1 percent of consumers who bought policies on the individual market.

Under the federal law, insurers must spend at least 80 percent of premium revenues on medical costs or quality improvements; the remainder can go toward administrative costs, sales commissions and profits. If companies set premiums too high, rebates in the form of checks or discounts off future premiums are due consumers and businesses by Aug. 1.

The requirement, aimed at holding insurers more accountable and slowing premium increases, went into effect last year and applies to all health plans, except those offered by self-insured employers. Insurers had criticized the rule as being too strict, while sales agents feared insurers would reduce their commissions.

The figures are based on the latest estimates insurers provided state regulators, so the actual rebate amounts may differ, according to the report's authors. The total dollar projection is similar to one released Wednesday by a Goldman Sachs analyst, but slightly lower than one made previously by the government, which had said rebates could be worth up to $1.4 billion.

Nationally, an estimated 3.4 million people who bought their own coverage are projected to receive rebates this year from 215 insurance plans, according to the study. The biggest dollar amounts are expected to go to consumers in Alaska, where per person rebates are expected to average $305, Maryland, $294, Pennsylvania, $243 and Idaho, $241. Insurers hit the spending targets for policies sold directly to consumers in several states, including Hawaii, Maine and the District of Columbia, so no rebates are expected for individual consumers there.

More than a dozen states sought to relax the standard for insurance sold directly to consumers, saying it would cause insurers to withdraw from their markets. The Obama administration granted seven such requests, choosing to phase in the requirement between now and 2014 in Georgia, Iowa, Kentucky, Maine, Nevada, New Hampshire and North Carolina.

Rebates averaging $76 per enrollee are projected to go to more than one quarter of small businesses nationally, covering an estimated 4.9 million people. When averaged by state, the biggest per-enrollee rebates will go to businesses in Alaska at $517 and Alabama, at $203 and Oregon, $172. No rebates will go to small businesses in eight states, where insurers met their spending targets, including Hawaii, Minnesota and North Dakota.

For the most part, insurers who offer coverage to large employers met the targets. Still, 19 percent of large employers, covering 7.5 million people, are likely to get rebates averaging $72 per member. Employers must use some or all of the rebate for the benefit of workers.

America's Health Insurance Plans, the industry trade group, said the spending rule could have unintended consequences, potentially causing some insurers to withdraw from certain markets and that it does not address the biggest reason for rising premiums -- underlying health care costs.

"Moreover, the taxes, benefit mandates and other regulations in the health care reform law will cause premium increases that far exceed the value of any prospective rebates," the group said in a written statement.

Ana Gupte, a senior health industry analyst at Sanford Bernstein, says insurers in some markets lowered premiums to avoid paying rebates, but others risked having to pay a rebate because they didn't want to underprice their policies. Some insurers may have miscalculated -- and thus owe a refund -- because of lower-than-expected utilization of health care kept their medical costs below projections, she says.

Looking ahead, Gupte expects to see fewer rebates in future years "because utilization (of medical care) will go back up, so the spread between pricing and cost will get narrower."

Still, Alexandria-Va.-based health industry consultant Robert Laszewski says the projected rebates are so small as to count mainly as a "rounding error" that most consumers won't even notice.

"If it saved you $200 on a $10,000 premium, does it feel like your insurance is more affordable?" asked Laszewski, a former insurance industry executive. He said some sales agents who saw insurers reduce their commissions as a result of the law have also begun charging clients a fee for helping them choose a policy.

But consumer advocate Timothy Jost, a professor at Washington and Lee University University School of Law, says the goal was never to deliver large refunds.

"The purpose isn't to generate rebates, but to force insurers to align their premiums more closely with their (medical) claims costs," says Jost. "Each year, premium costs have gone up more than medical costs, so what the rule does is force insurers to be more efficient and, if they charge too much, to give some back."

Aging Population, Costs Worsen Medicare's Long-term Prognosis

Mon, 23 Apr 2012 17:31:00 EDT

Photo by John Moore/Getty Images

On the PBS NewsHour Monday night, Ray Suarez will examine the grim reports released Monday by the trustees of Social Security and Medicare. Joining him to discuss the outlook for the Social Security program will be Nancy Altman of Social Security Works and David John of Heritage Foundation. For more on the Medicare report, read the full analysis from our partners at Kaiser Health News below.

Trustees of the Medicare program today forecast increased financial troubles as a result of an aging population and rising health care costs, increasing the visibility of an issue that is already proving divisive in the 2012 presidential and Congressional campaigns.

"Both programs took a turn for the worse this year," trustee Charles Blahous III, a senior research fellow at George Mason University in Virginia, said of Medicare and Social Security.

Overall, the outlook for the Medicare program which covers nearly 50 million elderly and disabled people was only slightly worse than findings from last year. Once again, trustees forecast that Medicare's hospital fund would begin to run out of money beginning in 2024, but many experts place little importance on the trustees' projection since the program's insolvency has been forecast from as little as two years away to as many as 28 years since 1970.

Today's report emphasized that Medicare costs in both the short term and long term would rise higher than previously reported, but that these costs would be offset by 2 percent cuts to the program agreed to in last year's deficit reduction agreement, unless Congress passes an alternative cost-cutting plan.

"The reported long-term financial outlook has grown worse," said Robert Reischauer, a trustee and former Congressional Budget Office director, who recently stepped down as head of the Urban Institute.

This year, trustees said, the hospital fund will pay out $38 billion more in benefits than it collects in taxes and premiums from seniors and the disabled.

The trustees stressed the need to look beyond the exhaustion date for Medicare to the toll health care costs are already taking. "A more immediate issue is the growing burden that the programs will place on the federal budget well before exhaustion of the trust funds," the report said.

AARP Executive Vice President Nancy LeaMond said the report "underscore[s] the need for an open, national conversation focused on strengthening retirement security for today's seniors and future generations."

In a politically charged campaign season, both sides attempted to use the report to their advantage.

Treasury Secretary Tim Geithner, who is the program's managing trustee, said the 2010 health care law had strengthened Medicare by beginning to rein in costs.

"One of the most important things we can do right now to preserve Medicare is to implement the Affordable Care Act fully and effectively." Geithner said. "Still, more needs to be done."

Hours before the release of the report, the Obama administration issued its own analysis, saying the health law would save over $200 billion in Medicare spending through 2016 and that beneficiaries in the traditional, government-run program would save nearly $60 billion through lower payments.

Those savings would come from ending extra payments to private health plans in Medicare, cracking down on fraud and "changing provider payment policies to reflect improvements in productivity," according to the report from the Centers for Medicare and Medicaid Services.

Tom Saving, professor of economics at Texas A&M University and a former trustee, and John Goodman, president of the National Center for Policy Analysis, a conservative think tank, painted a far less rosy scenario. The trustees must base their projections on current law, they said, but it is unrealistic to think that Congress will allow reductions to providers to stand in the long term, or that changes to reimbursements based on better performance and coordination of care will help much with costs.

"The financial picture will be worse than the trustees say," said Saving. The health care law reduces Medicare payments to hospitals and other medical providers. "For how many years can that happen before the pressure mounts to rescind them? These reimbursements are not sustainable, so eventually Congress will raise them," he said.

Moreover, the trustees based their findings on demonstration projects in the law, and Goodman says there is no solid evidence that they will save money. "All this about pay-for-performance and coordinated care and integrated care, none of it is working," said Goodman. "They are trying all this out, and there's no reason to believe there will be large savings here."

Medicare's Chief Actuary Richard S. Foster also said he was skeptical that some projected savings, from provider cuts to improved productivity, would materialize.

The program's two trustees who represent the public's interest urged Washington lawmakers to address Medicare's financial challenges soon to maximize options and allow ample time to phase in changes. "Earlier action will also help elected officials minimize adverse impacts on vulnerable populations, including lower-income workers and people already dependent on program benefits," said Reischauer and Blahous in a joint written statement.

Health Reform on the Brink: Nervous in New Mexico

Mon, 23 Apr 2012 14:09:00 EDT

They came unexpectedly and one after the other -- two massive heart attacks, the first in a hay field, the second in a hospital bed. Ron Castle was only 12 years old when he watched his father die.

It surprised Ron just as much as the rest of Frederick, Md. Dairy farmers usually didn't go like that, especially not so young, at age 37.

The Castle family farm was sold a short time thereafter, and Ron went to work part-time at another dairy farm to help support his mother and two younger siblings.

It was the start of 54 years of hard work and the first of many moments of chaos -- a year of gunfire in Vietnam, a failed marriage, and three decades' worth of drinking to forget -- that helped shape his current view of the world.

Now retired from 33 years of military service and 15 years of teaching, Ron is concerned America has lost some of that perseverance and work ethic. He sees too many "intelligent and capable people out there who have learned how to work the system." Government expansion is partially to blame for that, he says. "And it's not the answer to our problems."

That's primarily why Ron opposes the health care reform law. He worries the Medicaid expansion, in particular, will lead to more laziness, less productivity and an erosion of Medicare -- "a system I need now and one I paid into my entire life" -- to help fund the whole thing.

"Already, I see rampant abuse and the full law hasn't even gone into effect yet," he said. "We need to get back to the values I learned when I was a child. Everyone needs to contribute, and then everyone can benefit."

"We Wanted to Work"

Morning came early in Frederick, Md. From six years old and up, Ron's job started at 5:30 a.m, feeding calves and hogs before the sun rose. He learned how to drive the family pick-up truck at the age of eight to help out with some of the bigger errands.

"And I wasn't an anomaly -- that's the way we all were. Everybody I knew grew up that way," he said. "It was just expected, and we wanted to work."

Something else that bound most of the community was a complete lack of health insurance. "I don't know of anybody that had it," Ron said. When someone got sick, they simply went to the doctor and paid the bill, out-of-pocket.

After his father passed away, Ron's farm skills landed him a job at a neighboring farm for $10 per week. A few years later, he received "a major promotion" to $15 per week, and a few years after that came graduation, the military and war in southeast Asia.

Devastation

A total of 250 men flew to Vietnam with Ron in December of 1967. Twelve months later, 95 of them flew back.

In the Third Brigade, Fourth Infantry Division, "you were killing or being killed," Ron said. "That's basically it. We took a lot of direct fire." In the blurred memories of gunfire that remain, he thinks most often of the Tet Offensive, when "they had a direct hit on our tent," Ron said. For a week -- day in, day out -- he and his buddies took several rounds of mortar rocket fire and a constant barrage of small arms fire. He still can't forget the blood.

When Ron returned home, he tried to forget the memories by focusing on all the trappings of domestic life in Mt. Airy, Md. -- marriage, a home, two children. And when that didn't work, he attempted to dull them with alcohol -- round after round of it until, he said, the years started blurring together and he stopped caring about the kind of a man he wanted to be.

"I just stayed drunk," he said. "My daughters, who just turned 40 and 36, haven't spoken to me in 30 years because of the way I acted when they were young."

There was no diagnosis of Post-Traumatic Stress in those years, and Ron didn't have any health insurance. So the Castle family remained uncovered, both physically and emotionally.

Recovery

The marriage officially fell apart in the late 1970s, and Ron moved to Parsons, W.Va., to open an electronics store. And it's there that he found two things that would transform his life: the woman who would become his second wife and -- once again -- the military.

His brother was a member of the local National Guard unit, and he urged Ron to rejoin. "He recognized I had a lot of issues, but that I still had a love of the military way of life," he said. After several months of persuasion, Ron caved.

It was a medical unit, "just like MASH on TV," he said. "And seven of us were Vietnam veterans and so we were like our own therapists," he said. "And after about 10 or 12 years working together, we got ourselves straightened out."

The Golden Years?

Thirty three years, seven months and four days. All told, that's how long Ron Castle served in the military.

He followed it up with master's degrees in education and educational technology and concluded his career in the classroom -- 15 years of instruction at the elementary, middle- and high school levels. Today, he's comfortably retired in a small town in New Mexico, where he was deployed during Operation Desert Storm and decided to stay for the warm weather.

For several years now, Ron has received a combined total of $1,600 from his Social Security and military pension checks. Since he turned 65 last year, he has paid $100 per month for Medicare benefits, and since his 60th birthday, he's also qualified for Tricare, the health care program for uniformed services members. For the PTSD and hearing loss he developed while serving in Vietnam, he receives treatment from the U.S. Department of Veterans Affairs -- treatment he admits would have been available to him earlier if he would have overcome the stigma of seeking help.

Though Ron didn't feel he needed health insurance for much of his life, he now wants it to be handy for the high cholesterol and heart trouble that runs in his family.

He considers all of these programs "deserved" and none of them an "entitlement."

"I've been paying into them for most of my life and now it's my turn to enjoy them," he said.

From Ron's perspective, health care reform means less, not more. He worries that the scope of the law will force politicians to dramatically drive up Medicare premiums in the years ahead.

While the Obama Administration says that reform will help and not hurt seniors -- by offering millions of them free wellness check-ups, lower out-of-pocket costs and an eventual end to the doughnut hole -- Ron believes that federal funds should be going toward ensuring that seniors "actually receive the benefits they were promised," he said. "There shouldn't be a question."

Instead, he said, many millions will be spent on a Medicaid expansion to bring 16 million more low-income Americans into the system. And Ron worries that some of it will be "wasted" on people like the man he knew who had children to multiple women and "didn't pay a cent for them -- he just let the government pick up the tab for their health care," he said. Or some of his former high school students who told him they planned to stay single and have children out of wedlock so they could receive "free health care."

Ron knows from personal experience that people make mistakes and sometimes need help. But his own addiction and recovery convinced him that transforming that help into self-reliance is the best answer to life's problems.

"We've got something really way out of whack here when intelligent people -- people with jobs and nothing wrong with them -- have figured out the system and know the best way to take advantage of it," he said. "We need to get back to the idea of hard work and contribution. It's fine for benefits to be spread around, but everyone should be contributing something."

While he supports some of the ideas behind health care reform -- help for those facing catastrophic conditions or those dealing with legitimately dire circumstances, for instance -- the logic behind the law itself doesn't entirely make sense to him. For example, if 32 million Americans are going to be added to the ranks of the insured, "where are all the extra doctors going to come from?"

"My doctor won't be able to pay as much attention. For those who have paid and served, there will be cost increases across the board and decreased levels of care for everyone," he said.

How can he be so sure? One of his grandfather's sayings works well in this situation, he says.

"Figures don't lie, but liars can figure,'" he said. "The numbers here just don't add up."

Do you agree with Ron Castle? Or more with health care reform supporter Lisa Hill? In the weeks ahead on the PBS NewsHour's Health Page, we'll share the stories of ordinary Americans who love, hate, and feel indifferent about the Affordable Care Act. As the Supreme Court decides the fate of the law, we want to hear your verdict. Share your opinions here.

Photos courtesy of Ron Castle. From top, the Castle family farm in the 1950s; Castle at his high school graduation; in the military; and after retirement.

VA Adds 1,600 Workers to Fix Backlog, but 'Always More We Can Do'

Thu, 19 Apr 2012 18:09:00 EDT

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Responding to a backlog of mental health cases and a blistering federal appeals court ruling, Veteran Affairs Secretary Eric Shinseki said Thursday that the agency will hire 1,600 more professionals -- including psychiatrists, psychologists and social workers. Jeffrey Brown and the VA's Sonja Batten discuss the new hires' goals.

JEFFREY BROWN: And to a response from the Veterans Administration to a growing backlog of mental health cases from current and past wars.

Today, Veterans Affairs Secretary Eric Shinseki said the agency will add 1,600 professionals, including psychiatrists, psychologists and social workers, and another 300 clerical workers to speed up processing of claims.

A federal appeals court issued a blistering ruling last year demanding the VA offer better mental health care for veterans. Next week, Senate committee hearings on the issue are scheduled, as is the release of a report from the VA's inspector general.

To discuss all this, we're joined by Sonja Batten, a senior mental health official at the VA.

And welcome to you.

SONJA BATTEN, Veterans Administration: Thank you.

JEFFREY BROWN: The criticism you have faced is that the VA has up to now been underprepared and not responsive enough, given the sheer numbers. Is that fair?

SONJA BATTEN: In VA, we take the issue of access to mental health care very seriously.

And we've been instituting a number of measures to make sure that we're identifying where there may be gaps in care. And so we want to make sure that as we do our site visits to every VA medical center around the country, we identify where there may be gaps, problems with staffing.

And that's why Secretary Shinseki today announced and we're so delighted that we're going to be adding 1,600 new clinicians so that we can provide the care that we need.

JEFFREY BROWN: Well, may be gaps. It sounds like critics see gaps. The judge -- I mentioned this case. That was a very strong report. He said, "The VA's unchecked incompetence has gone on long enough. No more veterans should be compelled to agonize or perish while the government fails to perform its obligation," tough language.

So what is the problem?

SONJA BATTEN: In VA, we're very proud of the advancements that we have made in our clinical care.

In the past seven years, we have added 7,000 new mental health professionals. We have provided training and we have instituted the Veterans Crisis Line. So we feel that we have made great progress, but there's a lot more to do, and we acknowledge that there's more that we need to do in order to meet our own aspirational standards.

JEFFREY BROWN: Has the more to do been a shortage of personnel, or using the right personnel, or the personnel you have not able to do what is necessary given the needs?

SONJA BATTEN: The primary issue that we've identified at this point is having enough personnel, which is exactly why we have announced today that we will be hiring new people.

JEFFREY BROWN: And what will happen now with these new hires? How specifically will they be used?

SONJA BATTEN: So the money will go out to VA medical centers around the country beginning immediately.

We'll start recruiting immediately and we will be able to hire psychologists, psychiatrists, social workers, mental health nurses. And one of the things we're very excited about is actually that we've just finished the qualification standards for two new sets of mental health professionals that have previously been untapped resources.

JEFFREY BROWN: Meaning what?

SONJA BATTEN: Those are marriage and family therapists and licensed professional counselors. So we've been recruiting for psychiatrists, psychologists, social workers and nurses, but now we'll also be able to expand to those other counselors as well.

JEFFREY BROWN: You mean a specific need. Is this a question of identifying specific problems and trying to address it with professionals that have those specific abilities?

SONJA BATTEN: Yeah, exactly. So each facility will be identifying -- if they have gaps, if there's a facility that doesn't have enough of one type of professional or they want to expand the services they have for couples and families, a facility like that might begin to hire more marriage and family therapists.

JEFFREY BROWN: I gather one issue here has been the problem of finding and hiring qualified people, especially in rural areas. How do you address that?

SONJA BATTEN: You know, one of the things that we think is important is, for example, today being able to come on your show and we really are looking forward to recruitment.

These positions will begin to be posted immediately. All of our positions are posted on USAjobs.gov. And we hope that if there are committed professionals out there today even watching this show, they will start to look for those positions.

JEFFREY BROWN: And where does the funding for this come from, at a time of obviously limited resources?

SONJA BATTEN: VA has actually identified that we have sufficient funding in this fiscal year's budget to be able to finance these positions and we are going to start looking at what we have for fiscal year '13 and identifying if we have enough to support that. But we are committed to keeping these positions full.

JEFFREY BROWN: How serious a problem is this? I mean, the suicides, the depression it's something we've looked at many times on this program. It's not new. And it seems to continue and now you're addressing it with this.

But how serious is it and why hasn't it been addressed up to now?

SONJA BATTEN: Well, I think what we know is that since the beginning of warfare, if you go back to the Trojan War, we have reports of these very same issues. So these are not new problems and we have been addressing them.

We have more mental health professionals than we've ever had before. We have more well-trained mental health professionals than ever before. We have 24/7 crisis line that veterans can contact. We've added a chat feature and a texting feature so that veterans can contact us anonymously if they prefer.

We feel like we have made significant advances, but there's always more that we can do.

JEFFREY BROWN: Is this the idea that these 1,600 is enough, do you think, or this going to be reassessed and possibly more will be needed?

SONJA BATTEN: Yes, we're going to continue reassessing this. We're not going to stop at this 1,600. We are doing site visits to every VA across the country. We're looking at our administrative data. We're talking to veterans at every VA that we go to and getting their input.

And if it turns out that a few months from now or six month from now, we feel like we need more, we'll ask for more.

JEFFREY BROWN: You're continuing to take heat from -- I mentioned Senate hearings next week, an Inspector General report that may have some more detail. Is that causing some of these changes, leading to some of the changes or rethinking of how you do it?

SONJA BATTEN: We appreciate the attention from the Senate, from the I.G.

We share with them the commitment to making sure that what the veterans need they are receiving. But this is actually a process that we began months ago. We started with surveys of our own mental health professionals then in -- last summer. And we began site visits in December to go out to every VA facility. And this is the next step after looking at those interim data. So this is something we've had in process for months.

JEFFREY BROWN: All right, Sonja Batten of the Veterans Administration, thank you very much.

SONJA BATTEN: Thank you.

Just Ask: What Health Benefits Do the Supreme Court Justices Receive?

Thu, 19 Apr 2012 13:09:00 EDT

The Supreme Court Building. Photo by Tim Sloan/AFP/Getty Images.

Rob Rabie has some health care advice for the Supreme Court, straight from St. Johns, Ariz.

"Perhaps the justices would better appreciate the problem if they were to forego their health insurance plans for a year or so and just pay the medical bills out of pocket like many Americans," he said. "I am sure they could all afford it, but I suspect sticker shock would be rampant."

The idea that nine justices with access to "generous" health care insurance will be deciding the fate of the entire health reform law makes Rabie nervous. His concern was shared by several others who wrote to the NewsHour in the aftermath of the Supreme Court hearings last month, most with two underlying questions:

What kind of health insurance does the government offer Supreme Court justices? And how might that play into their decision over whether to strike down the health care reform law?

The answer to the first is simple: The plans are pretty generous, but certainly not to the extent that many expect.

All federal employees can access health care insurance through the Federal Employees Health Benefits Program. That includes Supreme Court justices, members of the Senate, congressional aides and the janitorial staff in the Department of Health and Human Services.

The Supreme Court declined to provide specifics on the health plans of the individual justices or how many of them even participate in the Federal Employees Health Benefits Program. Some federal employees elect to receive their coverage elsewhere -- through a spouse's plan, for instance.

Regardless, they have the same options as everyone else in the federal government -- no more, no less. By far, the biggest advantage of being a member of the club is its not-so-exclusive size. About 8 million federal employees, retirees and their family members are enrolled.

The large, diversified pool is ideal for private insurance companies -- businesses built around the concept of trying to spread risk among the young, old, sick and healthy. So a wide number of them participate, increasing competition, upping the government's bargaining power and maximizing the chances that its employees will get a good deal.

The federal program offers 206 health plan choices, according to the Office of Personnel Management. "It's unusual, even for a large employer, to offer so much choice," Gary Burtless, a labor economist at the Brookings Institution, said.

Even more unusual are the perks of the plans themselves. Several include a national network of physicians. All are available without a waiting period. And unlike many private-employer plans, they're not allowed to deny coverage or charge higher premium rates based upon an employee's pre-existing conditions (if the health care reform law goes forward, the practice will be banned for all U.S. plans starting in 2014). Perhaps the biggest perk: Federal employees also have the option of keeping their coverage after retirement.

Aside from those major advantages, the plans available to federal employees aren't "more or less generous" than those offered by other large U.S. employers, Burtless said.

"They're typical. Civil servants in the United States are not getting a Cadillac insurance plan while they're at work," he said, referring to the rare, extremely generous plans that offer very low deductibles and benefits so rich they cover even the most expensive procedures.

In fact, several studies conducted in recent years show premiums, deductibles and employer contributions running more or less neck-in-neck between the federal options and other large-group insurance plans. If federal employees pay less at the doctor's office than the national average, for example, they often shell out more for premiums. And contributions from the federal government -- 70 percent of total premiums -- might cost taxpayers about $43 billion per year, but the percentage is comparable to the national average of about 72 percent.

Now for the second question: How does all of that intersect with the Supreme Court hearings on health reform?

Well, that's anyone's guess.

According to a recent Washington Post poll, just 40 percent of Americans think the justices will rule based primarily "on the basis of the law." If they do so, the federal government's employee health care program won't be a factor. But 50 percent of the nation -- including people like Rabie -- believe the justices' "partisan political views" will interfere. And if that's the case, it opens the door for nearly anything to play a role.

Again, it's unclear whether the justices even participate in the Federal Employees Health Benefits Program. If none of them do, all of this information is a moot point.

But that's unlikely, according to Donald Devine, a former director of the Office of Personnel Management. "I would assume most of them do choose it," he said. "It's a generous program even if it has some controls on it."

Still, even while Devine says the program "may look good compared to the plans of many Americans," he also cautioned against drawing direct connections between the federal health insurance program and an eventual ruling on the health care law.

After all, he said, federal judges have access to the same health care options as the Supreme Court, "and they've come down on both sides of this thing all across the country."

After Heart Attack, Turning Scar Tissue Back Into Beating Heart Cells

Wed, 18 Apr 2012 18:37:00 EDT

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A study published Wednesday in the journal Nature revealed that scientists have managed to convert damaged tissue into functioning heart muscle by inducing mild heart attacks on lab mice then coaxing their hearts into rebuilding themselves. In collaboration with KQED's QUEST program, correspondent Spencer Michels reports.

GWEN IFILL: Next, a development that could be good news for millions of heart attack victims. Scientists announced they have managed to convert damaged tissue into functioning heart muscle.

The research appeared today in the science journal Nature.

NewsHour correspondent Spencer Michels has our story, produced in collaboration with KQED San Francisco's QUEST program.

And a note: Some of the pictures of the medical procedures are graphic.

SPENCER MICHELS: In hospitals all over the country, doctors try to keep alive the more than five million Americans with damaged hearts, a result of heart attacks. Damage means their hearts can no longer beat at full capacity.

When the heart muscle cells are deprived of oxygen during an attack, scar tissue forms in the heart, tissue that doesn't beat like other heart cells do. Now, in what they consider a dramatic development, scientists at the Gladstone Institutes in San Francisco have figured out a way to transform scar-forming cardiac cells into beating heart muscle in mice, and hope they can replicate the feat in humans.

Deepak Srivastava directs cardiovascular and stem cell research at Gladstone, an independent biomedical research institution. He led the team that published results in Nature and explained the challenge and what he called the breakthrough.

DR. DEEPAK SRIVASTAVA, Gladstone Institutes: From the moment an embryo is three weeks old until the day an organism dies, the heart never takes a break.

The heart cell is unique in that it incorporates some features of brain cells, and some features of muscle cells all together. It's actually an amazing thing to see cells in a dish that just without any stimulus just start contracting. And it's that property that allows the cells in unison to generate force and pump blood through the body.

SPENCER MICHELS: Though doctors can save most patients' lives after a heart attack, they can't always preserve all of their heart function.

DR. DEEPAK SRIVASTAVA: An individual may have trouble walking up a flight of stairs. They may have to stop several times trying to walk across the street to get to work.

There are a variety of approaches we use right now to help people who are left with damaged hearts. But none of them actually get to the root of the problem, which is replacing that damaged heart muscle. And that's where our focus has been at Gladstone.

And you have enough for how many mice today?

WOMAN: So I have enough for like three mice.

SPENCER MICHELS: Researchers here have discovered a way to coax mouse hearts into rebuilding themselves. In their experiments, they first give lab mice a mild heart attack.

DR. DEEPAK SRIVASTAVA: We do a more limited type of heart attack that doesn't result in too many symptoms in the mice and doesn't cause death. So we first anesthetize the mice, so they don't feel any of the pain.

It's almost out.

There are billions of muscle cells in the heart that are important for the squeeze of the heart. But there's an equal number of cells that are really there to support the muscle cells, and sort of form the architecture of the organ.

The support cells are the ones that actually make the scar after a heart attack, and the breakthrough we have made is that we have found a way to genetically engineer these cells to make new muscle, instead of scar.

SPENCER MICHELS: First, the researcher mimics a heart attack by cutting off blood to parts of the heart. Then, she injects three genes that will transform the scar cells into beating heart muscle cells.

DR. DEEPAK SRIVASTAVA: Three months after the injury, what we find is quite remarkable. Using ultrasounds on these animals, what we see is that the heart's function is greatly restored.

The ultrasound provides us an image of the walls of the heart and the valves in the heart, and shows how it squeezes and relaxes with each heartbeat. It's very close to normal in the amount of blood it's able to pump out to the rest of the body. There's still some scar. We can see that, but embedded within the scar tissue is new muscle.

SPENCER MICHELS: This new research has impressed Yerem Yeghiazarians, director of the Translational Cardiac Stem Cell Program at the University of California, San Francisco, though he had some questions.

DR. YEREM YEGHIAZARIANS, University of California, San Francisco: So what we need to know is if we can do the same thing using non-retroviral techniques with small molecules, if we can replicate the experiments in larger animal models and eventually do this safely in humans, because if we can do that, that could potentially revolutionize the way we treat our patients with weakened hearts either after a heart attack or other causes for cardiac failure.

It is the first time that anybody has described this as a novel way of treating damaged hearts, because up to this point, there are no medications and no devices that replace a scar in the heart with beating functional heart muscle cells.

SPENCER MICHELS: Srivastava admits there is a long road ahead before the procedure can save human lives.

DR. DEEPAK SRIVASTAVA: We have to make sure that it's scalable to the size of a human heart where, where instead of thousands of cells that we might need to regenerate in the mouse, we may need millions in the human heart.

The second thing that we have to do is to make sure that this will be a safe approach. And for that, we will likely use a larger animal model that's closer to human, such as a pig. And then the final thing that we really have to work out is, what is the best way to deliver the reprogramming genes into the cells of the heart.

SPENCER MICHELS: Srivastava estimates it will be six or seven years before treatments might be available for humans.

GWEN IFILL: On our website, we have more reporting on the science behind the genetic technique researchers are using to repair hearts. That's in a blog post from our colleagues at KQED QUEST on the NewsHour home page.

Buckle Up: Deadly Accidents More Likely on Tax Day

Tue, 17 Apr 2012 10:23:00 EDT

Getty illustration by Steven Taylor.

Death and taxes. The two certainties in life, as Benjamin Franklin once said.

But new research suggests another link between the two: Americans are about six percent more likely to be in a fatal car crash on Tax Day compared to the week before or after, according to a letter published in the Journal of the American Medical Association.

That equates to an average of 13 more deaths nationwide, said Dr. Donald Redelmeier, a professor of medicine at the University of Toronto who took an interest in the phenomenon after working as an emergency room physician. He and medical student Christopher Yarnell perused the National Highway Traffic Safety Administration's crash data from 1980 to 2009 and determined that the increase is comparable to the spike in wrecks seen on Super Bowl Sunday.

But there are some key differences between the two days, Redelmeier said. Primarily alcohol.

The increased risk on Super Bowl Sunday jumps by about 30 to 40 percent in the three to four hours after the game, with alcohol playing a major role in those crashes.

The same doesn't hold true for Tax Day. In fact, the statistically significant 6 percent increase in crash-related fatalities holds throughout the entire day, whether it is morning, noon, or night. If alcohol was a contributing factor, Redelmeier said, the risk would probably spike in the evening hours when consumption is more frequent.

So why the jump? While the study didn't analyze the specific cause of the accidents, Redelmeier believes higher stress and the distractions that come with it are to blame.

"Driver error contributes to a majority of [vehicle crash] events, and stress is often speculated as a factor of human error," said Redelmeier. "That's what makes Tax Day special. It lets us study large, widespread stress on a single day, on a repeated basis to test how short stress can contribute to driver behavior."

In particular, for the 20 percent of Americans who do not do their taxes early, the stress of filling out and filing tax forms at the last minute can lead to anxiety, sleep deprivation, a decreased tolerance for hassles, and other factors that contribute to vehicle accidents. And even if you file in advance, you aren't necessarily immune to the phenomenon, Redelmeier said. The increased risk applies to everyone on the road -- no matter when they file or whether they are drivers, passengers, or pedestrians.

However, the risk increase was only observed in adults younger than 65 -- presumably because many individuals over the age of 65 no longer have to do taxes, Redelmeier said.

The authors do not believe the higher rate of accidents is due to increased driving on Tax Day. That's because the risk was more accentuated in the last two decades even though electronic filing has become more common. If anything, the ability to electronically file may actually lead to more filing procrastination and cause even more stress, Redelmeier said.

Given the increased risk, Redelmeier recommends being extra-vigilant of safety practices, such as wearing seat belts and driving under the speed limit.

"In our world, there is no way to avoid stress, but there are lots of ways of making stressful situations worse," Redelmeier said. "We just want people to be a little more mindful of the distracting abilities of stress in a single day."

It's good advice to keep in mind this election year. Redelmeier also said crash rates jump on the day Americans head to the polls to vote for president.