Starting Points: health care

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Jan 21, 2010

Scientist David Ho: The Man Who Could Beat AIDS

Dr. David Ho was sitting in the audience during an AIDS meeting in 2007 when the presenter flashed a cartoon onscreen to make a point. Along with his colleagues, Ho chuckled at the image of a blindfolded baseball player swinging mightily at an incoming pitch. But as amused as the scientists were, they were sobered too; they knew that the player in the cartoon was them. A swing and a miss, the image was saying, one of many in the long battle against AIDS.

Ho certainly got the message. For nearly a quarter of a century, he and other AIDS scientists had been whiffing repeatedly, failing to make contact as HIV stymied them again and again. Powerful drugs to foil HIV could do only so much. To corral the epidemic and truly prevent HIV, only a vaccine would do. The problem was that no vaccine strategy had ever succeeded in blocking the virus from infecting new hosts, and that wasn't likely to change in the near future. "It struck a special chord with me," says Ho of the baseball image. "I think it accurately pictured our chance of success. We all felt that frustration." (See the top 10 medical breakthroughs of 2009.)

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Since that meeting, much has changed, but the fundamental problem of developing an effective AIDS vaccine remains. On the positive side, in 2009, scientists announced that they had developed the first vaccine to show any effect against HIV infection — although that effect is, by all measures, modest. The vaccine's ability to reduce the risk of new HIV infection 31% is nowhere near the 70% to 90% that public-health experts normally view as a minimum threshold for an infectious-disease vaccine. Even further behind in development, but still promising, are two new antibodies identified by a group of researchers working at a number of labs that, at least in a dish, seem to neutralize the virus and thwart attempts to infect healthy cells.

The excitement over those advances, however, has been tempered by the still raw memories of a humbling retreat in 2007, after a highly anticipated shot against the virus was deemed a failure. While nobody expected spectacular results, neither did anyone expect such a stunning defeat, and the scientific community is still struggling to recover from it. "We are still a long ways away from having an effective HIV vaccine that physicians can reach into the cabinet and pull out in a vial and inject into a person," says Dr. Bruce Walker, an HIV expert at Harvard Medical School. (See the top 10 scientific discoveries of 2009.)

That may be true, but Ho, who has been working to develop an HIV vaccine of his own, now believes that a traditional shot, one that relies on snippets of a virus to both awaken and prod the immune system to churn out antibodies, may not be the best way to fight HIV. Rather than expecting the body to do all the work of first recognizing then mounting an attack against the virus, why not just present the body with a ready-made arsenal of antibodies that can home in on HIV? It's the immunological equivalent of a frozen dinner; the already cooked antibodies eliminate all the hard work of prepping and priming the immune system to do battle.

It's a bold strategy and one that has never been tried before in the AIDS field, but Ho is willing to stake his reputation and that of his nearly 20-year-old facility, the Aaron Diamond AIDS Research Center (ADARC) in New York City, on his hunch. So is the Bill & Melinda Gates Foundation, which has steered nearly $7 million his way to pursue the theory. Ho has redirected more than half of his lab to the project, and the results so far have reignited his passion for discovery; he's now back at the lab bench overseeing experiments.

Ho can't help breaking into a grin whenever he discusses the new project, and smiles haven't come easily to him of late. In the 1990s, he and ADARC established themselves as leaders in the AIDS field by pioneering the early use of the antiretroviral (ARV) cocktails that have reduced the death rate from AIDS (for which Ho was named TIME's Person of the Year in 1996). But in recent years, the center has suffered a series of setbacks, including a scientific paper that required a partial retraction, and the departure of key scientists. These challenges have some in the field wondering whether ADARC — and its golden-boy director — are on the verge of the next big breakthrough in AIDS or are wandering down yet another detour in the long and maddening fight against the disease.

First Responder
Whatever successes Ho does or doesn't have ahead of him, he long ago earned his credentials in the AIDS field. As a physician at the University of California, Los Angeles, in the early 1980s, he began keeping a diary of patients who were rushed to the emergency room with a mysterious amalgam of symptoms such as pneumonia, cancer and, most important, a devastating drop in immune function. After a few months, he noticed a pattern: most of the patients were gay men. Intrigued, he became nearly obsessive about chronicling the growing wave of cases. Within two years, Ho and the rest of the world would know that they were seeing the first cases of AIDS.

See pictures of Africa's AIDS crisis.

See what the selection meant to past Persons of the Year.

Ho's preoccupation with HIV only grew as the virus continued to baffle scientists. Expecting the unexpected was the best way to confront HIV, he soon learned, and he quickly amassed an impressive array of scientific firsts in the field. As director of ADARC, which was founded in 1991 and was one of the first research centers dedicated solely to the study of AIDS, he led a team that pioneered the "hit 'em early and hit 'em hard" approach to drug therapy, now the core of the ARV-cocktail treatment that is keeping millions of HIV-positive patients alive. His lab showed how HIV therapies would be most effective in the days and weeks immediately after HIV infected a new host. That understanding came from their breakthrough finding that rather than sitting latent for years after infection, as many experts believed at the time, HIV was actively challenging the immune system from Day One. Soon after that revelation, ADARC scientists were the first to add to existing data on how HIV worked by identifying a second, key receptor that the virus uses to invade cells.

Vaccines in Vain
But while AIDS scientists began making inroads in developing drug therapies, designing a vaccine was proving nearly impossible. Despite all that they have learned about HIV, experts are still missing one essential ingredient: to this day, they do not know exactly what cells or immune responses could protect the body from HIV infection. Could an antibody that binds to and neutralizes the virus do the trick? Are T cells, specially formulated to recognize portions of HIV's surface proteins, the solution? Or, as many experts now suspect, is some elusive combination of those factors the key to outwitting HIV? (See TIME's photo-essay "Access to Life.")

Without an answer, developing vaccines is a very halting process. "The virus is a moving target," says Dr. Gary Nabel, director of the Vaccine Research Center at the National Institutes of Health (NIH). "It is constantly changing its genetic makeup through mutations. It's also a moving target because the proteins of the virus surface are actually moving themselves — they are conformationally flexible. The net result is that the immune system never gets a really good look at them."

It didn't take long before these futile efforts began to wear on the researchers in the field, not least of all those at ADARC, where Ho's group was attempting to develop its own vaccine — with little success. The center — which had earned such laurels for its ARV triumph — began to suffer a scientific slump and lack of direction, according to those who left in the early 2000s. Some blame Ho's management style, which, they say, changed in the aftermath of media attention that came with his recognition as Person of the Year. They describe a highly competitive atmosphere in which members scrambled to claim key projects and kept certain studies under wraps out of fear that colleagues would poach their ideas. Frustrated, several high-level faculty members, none of whom agreed to be quoted by name, decamped. (Watch TIME's video "New Hope for Kids with AIDS.")

"ADARC was a great experience," says one, who now heads an immunology lab at a major university. "Those were really great times, and you don't experience them often in an academic career. The structure put in place for the first few years was magnificent and very collegial. But unfortunately the happy ending didn't go forth."

The malaise at the lab, which Ho attributes to personality conflicts among the faculty, began to infect the quality of the science. In 2002, Ho generated headlines when he thought he had found the X factor made by immune cells that protected some people from developing AIDS. It turned out, however, that his conclusion was premature. Other cells had contaminated his results, and he was forced to issue a "retraction of an interpretation" of the paper describing the study. "It was an embarrassing moment for us, but we fixed it ourselves," says Ho. "It was certainly a low point in our history here."

ADARC had plenty of company. Vaccine efforts were progressing elsewhere in the AIDS community, but unevenly. Testing for one candidate, made by Merck, began in 2004 with much fanfare and ended three years later with disappointing results: not only had the vaccine not offered protection against HIV infection, but it actually seemed to increase the risk for some people. Because of the Merck results, the NIH, which had a similar vaccine in the works, put off plans for its own study.

"The year to two years after the disclosure of those results had to be among the most bleak of times for AIDS-vaccine scientists," says Nabel. "We questioned just about everything we were doing."

The Clouds Part
But by early 2007, Ho had already glimpsed the possibility of an answer. In Houston the biotech firm Tanox had developed a compound that it thought might interest him. Ho knew Tanox well. He is a friend of one of the company's co-founders and is a member of its scientific-advisory board, so if the scientists there thought they were onto something, he suspected it was worth a look.

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He flew to Houston, where he was given a briefing on a new agent called ibalizumab, an antibody that appeared able to block HIV's entry into healthy cells. In the 200 or so HIV-positive patients tested in the early trial, the compound was effective, but Tanox was worried about resistance. No matter how promising ARV drugs were, HIV inevitably found a way to evade them. So while the agent seemed to reduce the burden of virus in the blood up to 90% in patients with full-blown AIDS, no one knew how long the viral standoff would last. The company's leaders wanted Ho's opinion on whether the agent was worth developing further.

Looking at the numbers, Ho saw more than just another member of the growing arsenal of ARV cocktails. Each of the ARVs focuses on thwarting just one of several different steps in HIV's infection process. Ibalizumab works at the critical juncture where the virus meets a healthy CD4 cell — a critical component of the immune system — essentially interposing itself between the two and preventing infection. If ibalizumab was so good at tamping down HIV in AIDS patients who were already infected, then maybe it could be tweaked to prevent AIDS in the first place. In other words, maybe it could become a vaccine — just a whole different kind of vaccine that bypassed the traditional, and frustrating, process of figuring out what the immune system needs to fight HIV. (See pictures of the Red Cross.)

Ho didn't even wait to leave the meeting before phoning his lab with instructions to investigate the literature on ibalizumab. "He was so excited about it," says Yaoxing Huang, who received the call and is now one of the two researchers Ho has diverted to investigating the compound. Barely three years later, that initial enthusiasm has only grown, spreading throughout the labs that occupy two floors at ADARC's Lower East Side facility.

What the ADARC scientists are struggling to achieve is a thorough understanding of how ibalizumab operates and how they can control those machinations. The CD4 cell is a bit like an immunological sentinel, endowed with the ability to recognize snippets of various pathogens, from common influenza to HIV, and mark them for destruction by other cells. Once attached to a CD4, HIV begins an intricate series of steps to gain entry into the cell. Ibalizumab is able to disrupt this intricate molecular choreography by binding to the CD4 and serving as an immunological snare. With the antibody stuck to the CD4 receptor, the virus is physically unable to complete the necessary contortions it must perform to slide into the cell and take over its genetic machinery to pump out more virus.

That's the beautifully elegant scenario that attracted Ho to the antibody, but the problem is that tying up CD4 this way may not be such a good idea. Taking so many of the body's essential defense cells out of commission means the patient may be left vulnerable to any number of other infectious agents — exactly the immunocompromised position that AIDS patients are trying to avoid. That was the fear that Ho's lab members expressed when he broached the idea.

"My initial reaction was, Are you crazy?" recalls Sandy Vasan, a researcher at ADARC who, along with Ho and Huang, is now heading the ibalizumab studies. A clinician who sees patients, Vasan says, "It's really scary to want to put an antibody on CD4. You need CD4." (See "The Year in Health 2009: From A to Z.")

But Ho believes ibalizumab is more agile than that. CD4, it turns out, is like a marina with several docks; HIV berths in one, and ibalizumab in another, leaving the cell free to fight other pathogens. "If CD4's binding site to HIV is with its nose, then this antibody is binding to the back of CD4's neck," Ho says. That means the cell's ability to function as a pathogen troller is not impaired by being coupled to ibalizumab. "There is a solid scientific rationale for what they are attempting to do," says Harvard's Walker.

The lab is now working with monkeys to test whether ibalizumab can head off infection not just with the notoriously weaker lab strains of HIV but also but with naturally circulating strains as well. The idea is to hit the antibody with the most potent HIV around, so if the strategy doesn't work, Ho can shut down the project, before it gets too far along.

Ho is hoping it won't come to that. He is not under any illusion that a successful antibody-based treatment will have the sweeping effect of the polio or measles or smallpox vaccines — essentially wiping out the diseases in treated populations. Instead, an ibalizumab-based therapy will be just one of many weapons against HIV, albeit a very powerful one. "At our first meeting on this, I said I have a strategy that I feel will work," Ho recalls. "It was truly my gut feeling."

It takes more than instinct to make good science, of course, and Ho is keenly aware of that. But like a talented batter, he's hoping that a combination of intuition and technical skill will guide him to make contact. A solid hit would be nice — but Ho is still trying for a home run.

Hospitals: Radical Cost Surgery

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A hospital that slashes costs—and delivers high-quality care as it innovates? Yes, it exists

By Catherine Arnst

Walk into most hospitals, and you'll see patients scattered about the halls on gurneys or wheelchairs. They're waiting to be moved from intensive care to a standard ward, or to an X-ray room, or to physical therapy. Each journey adds to the patient's discomfort and increases the risk of infections and other complications. Tally up a single patient's migrations over 24 hours, and they may consume as much as half a day of staff time.

Walk into Providence Regional Medical Center, in Everett, Wash., and you will see a hospital trying something different: It brings the equipment to the patient. In 2003, Providence opened one of the few "single stay" wards in the nation. After heart surgery, cardiac patients remain in one room throughout their recovery; only the gear and staff are in motion. As the patient's condition stabilizes, the beeping machines of intensive care are removed and physical therapy equipment is added. Testing gear is wheeled to the patient, not the other way around. Patient satisfaction with the "single stay" ward has soared, and the average length of a hospital stay has dropped by a day or more.

This is just one of many changes—some radical, many quite small—that have enabled Providence Regional to join a special subset of American hospitals: those that do not lose money on Medicare patients.

Almost 60% of U.S. hospitals report losing 20 cents on the dollar for every elderly patient that comes through their doors. They make up the difference by charging the under-65s a far higher fee. But Providence breaks even on the elderly, even though Medicare pays about $1,000 less per enrollee in the hospital's region than the national average. The hospital accomplishes this feat while winning a doctor's satchel full of national awards for top-notch care, placing it among the elite 5% of all U.S. hospitals.

High quality at a low price. Every other industry strives for that combination, but a hospital that does both is all too rare. Providence and its cost-efficient brethren demonstrate that quality care can be delivered at an affordable price, provided hospitals can be persuaded to rethink decades-old practices.

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The crazy world of hospital economics does not offer a lot of incentives to change. Both Medicare and private insurers reimburse on a piecework basis—known as fee-for-service—that encourages hospitals to treat more, prescribe more, and test more. Economists refer to this arrangement as a "value-blind" payment system since no premium is paid for quality.

Consequently, hospitals have no financial motivation to invest in productivity-enhancing computer technology, management experts, or efficiency research—and by and large, they don't. Columbia University economist Frank Lichtenberg calculates that productivity growth for the hospital industry has increased at less than half the rate of the general economy.

There are no proposals in either the House or Senate reform bill to scrap the fee-for-service system. As a result, the Congressional Budget Office expects the legislation to do little to halt the medical inflation that has pushed health-care spending to 16.2% of the gross domestic product. Because hospitals are among the largest employers in many congressional districts, their political clout protects them from reforms that would cause any real financial pain.

But even under a value-blind system, there are ways to "bend the cost curve," an oft-stated goal of President Barack Obama. The nonprofit Institute for Healthcare Improvement last year identified 70 regions around the country, out of a total of 306, where high-quality care is delivered at a reasonable cost. One of those regions is Everett, home of Providence Regional.

Providence is the only hospital in this coastal city of 98,000 people located 20 miles north of Seattle. It is the third-largest hospital in Washington, with two campuses serving 25,000 overnight patients a year, and operates the second-busiest emergency room in the state. It's building a $500 million, 368-bed tower, due to open next year, that will double its capacity.

What sets Providence apart from its peers is not size or location but its ability to operate within a Medicare-designated budget. The majority of U.S. hospitals have the market power to demand higher reimbursements from private insurers to make up for what they see as insufficient payments by Medicare. Because of a wave of consolidation in the 1990s, when more than 900 hospitals merged (including the two medical centers that created Providence Regional), some 90% of the U.S. population that lives in metropolitan areas is now served by just one or two hospital networks. "Hospitals simply don't need to be efficient," says Dr. Robert A. Berenson, a leading health-care economist and member of MedPAC, an independent agency that advises Congress on Medicare. "They are able to get payment differentials from the private sector of 30% to 35% over what Medicare pays." In some markets, it's 50% to 100%, he says.

Providence doesn't have enough private payers to engage in such fee-shifting. Forty percent of its annual revenues come from Medicare, and an additional 13% from Medicaid. Commercial insurers account for only 39%. Dependence on Medicare has forced it to focus on taking costs out of its operation rather than maximizing revenues.

To get those savings, the hospital tries to standardize best practices whenever possible. "There is a tremendous variation in medical delivery that is not quality driven," complains Dr. James Brevig, director of cardiac surgery at Providence. Doctors and nurses are often reluctant to analyze and change their methods because it would mean revamping long-accepted treatments or routines. As a result, says Brevig, "there are no standards in hospitals. Why is that? It's crazy. No other industry is like this."

Providence took a different path after picketing by workers nine years ago reflected a shattered morale. A new administration decided to attack the internal staff divisions and foster collaboration among doctors, nurses, and administrators. Everyone is encouraged to contribute ideas on driving down costs and improving patient outcomes. "I'm eligible for retirement, and under the prior leadership I would have left," says pediatric nurse Kathy Elder, a 34-year veteran of Providence. "They were very hierarchical, very closed. There was a lack of trust all around."

The current CEO, 48-year-old David T. Brooks, a fast-talking Detroit native, took over two years ago. He says the administration is open to suggestions from any and all staffers. "We have scorecards for everything around here, which measure both quality and efficiency. If all we had were great clinical outcomes but costs kept rising, that just wouldn't be good enough."

The staff embraced the challenge to innovate. The nursing team came up with the idea of checking on patients every two hours without waiting for a call button, to see if they need help walking to the bathroom or moving about their rooms. Ten percent of fatal falls by the elderly in the U.S. occur in hospitals. This one change at Providence reduced falls by 25%, according to chief nursing officer Kim Williams. "We believe we'll see more improvement over the next six months."

CONTROVERSIAL PRACTITIONERS

One of the bigger changes at Providence, implemented in 2003, is to place the day-to-day care of almost all its inpatients in the hands of hospitalists, a new type of doctor that has emerged in the last decade. Unlike primary care physicians, who usually visit their patients only early in the morning or late at night, hospitalists are available around the clock, checking that medications are administered properly, chart orders followed, and infection risks minimized. About 37% of Medicare inpatients are attended by hospitalists nationwide, and several studies have associated their use with better outcomes. Providence has also published data showing that infections, lengths of stay, and surgical complications have dropped since starting its own program.

But hospitalists are still controversial in many communities, because primary care physicians are wary of giving up control of their patients, along with their share of inpatient fees. Dr. Joanne C. Roberts, one of the first hospitalists at Providence, has not seen this conflict in Everett, possibly because most of the hospitalists and primary care doctors are associates at one large medical practice, Everett Clinic. That's not true everywhere, she says. "In another community where I worked, independent doctors were pretty hostile. Everyone was trying to grab part of the money. That just doesn't happen here."

The lack of hostility could be because Washington attracts people who appreciate the region's quality of life. The ocean on one side of Everett and the Cascade Mountains on the other are their own kind of bonus. "It helps that most doctors don't move to the Seattle area just to get rich," says Dr. William M. Wisbeck, a radiation oncologist at Providence.

It also helps that Providence has no competition nearby. "We don't have to engage in a medical arms race," says Dr. Lawrence M. Schecter, chief medical officer. Instead, a 20-member Value Analysis Committee consisting of doctors, nurses, and administrators scrutinizes every proposal for a major equipment purchase to determine if it is warranted in terms of patient need, rather than to keep up with the competition or to increase billings.

Providence's savings efforts don't stop at the hospital doors. It offers financial training courses to the 800 independent doctors affiliated with the hospital in an effort to get them thinking about cost efficiencies. That's no easy task, however, since savings don't necessarily flow into their pockets. Cutting back on unnecessary services may be better for the bill payer, but it lowers the income of doctors and hospitals.

Thus there is no national rush to imitate Providence's strategies. The Centers for Medicaid & Medicare Services, which administers Medicare, tries to encourage fiscal restraint through its reimbursement rates, but hospitals consistently argue that these rates are too low. MedPAC estimates seem to support this position—it calculates that hospital Medicare margins were -7.2% in 2009. But overall operating margins are far more robust. Thanks to income from private insurers, the nation's 5,000 nonprofit hospitals had a median operating margin of 8.4% in the second quarter of 2009, according to a Thomson Reuters (TRI) analysis. Health insurers, by comparison, had a median margin of less than 4%.

Brooks says Providence's 2009 operating margins were 6%, despite its heavy dependence on Medicare. Reaching that level is a challenge. As the only major hospital in a fast-growing county, Providence must provide every kind of medical service. Thus its lucrative cardiology unit and high-tech cancer centers are offset by an obstetrics ward that delivers 4,000 babies a year. The hospital loses money on almost every one of those births. Providence also has to absorb some $16 million in unpaid bills each year, more than any other Washington hospital except a public facility in Seattle.

Charity care fulfills a moral mission at Providence that sometimes trumps economics. The hospital is owned by the Sisters of Providence, a Canadian order of Catholic nuns founded in 1843 to minister to the poor. "Everything we do has to uphold our core values," says Brooks. "Our mission doesn't end with our business goals."

DOING PENANCE

But business goals and social mandates do sometimes align. To make life easier for dying patients, Providence opened a hospice in 2003 that offers palliative treatments. Patients tend to express relief when offered the option of hospice over hospital care, says Dr. Roberts, the hospitalist who helped start the program. She recalls one day last fall when the palliative care staff was asked to consult on two patients who, between them, had been admitted 35 times to the hospital within 12 months. "As a result of calm discussions with patients and families regarding their goals for their own care and future, both were referred to hospice," she says. Roberts estimates that Medicare saves an average of $3,120 on patients who choose hospice over drastic interventions.

Providence also seeks to soften contentious encounters among doctors and patients by doing penance for errors. The hospital set up an independent panel to investigate medical mistakes, disclose its findings to the patient, and voluntarily offer a financial award if warranted. As a result, Providence has only two malpractice suits pending, compared with an average of 12 to 14 at other hospitals of similar size.

When Providence can't find standard medical practices, it innovates. That was the case with blood transfusions. Cardiac and orthopedic surgeons realized a few years ago that there was no widely accepted data on the optimal amount of blood to give patients during surgery, despite the $240 cost per bag. Dr. Brevig started looking around and found several studies that correlated greater transfusion volumes with longer patient stays and higher infection rates.

He was particularly surprised that transfusion rates varied greatly from hospital to hospital, regardless of the patient's status. "The variations were related to the culture of the hospital, not the decisions of the doctor," he says. Brevig set out to create a low-transfusion culture at Providence. He got surgeons to slow down because speedy operations cause more blood loss. Settings were changed on heart bypass machines to save blood, and the hospital hired a blood conservation coordinator. In a study of 2,531 operations at Providence, Brevig reported that the incidence of transfusions was reduced to just 18% in 2007, from 43% in 2003, while the average patient stay was reduced by half a day. The changes have saved Providence an estimated $4.5 million.

Brevig has been proselytizing for his plasma practices at medical meetings, but to little avail. Only some 200 U.S. hospitals have a blood conservation program. Since patients are billed the cost of the plasma, doctors aren't motivated to change their habits.

There is also the fear that cutbacks on services will lead to accusations of rationing. Dr. Donald Berwick, president of the Institute for Healthcare Improvement and a longtime campaigner for better, safer hospitals, says this attitude must be revamped. In a recent speech he called on hospitals to reduce costs by 10% over the next three years without harming care. In almost every case, he noted, fewer interventions and adherence to standards lead to better medical outcomes. "Doctors and patients alike need to realize that the best health care is the very least health care that we need," he said. "The best hospital bed is empty, not full."

Jan 10, 2010

In Britain or France, my aging mother would have gotten better health care

Image by seiuhealthcare775nw via Flickr

By Sara Mansfield Taber
Sunday, January 10, 2010; B01

In the final months before her death in May, my mother kept her shoes on all day, even when napping. She had to -- at her assisted-living facility in Mitchellville, Md., three certified nursing assistants looked after 39 residents. My mom couldn't depend on one of them to have the time to put her shoes on when she needed to get out of bed. Only in the mornings and evenings, when one of her private aides was with her for about 30 minutes, did she have personalized care.

Disabled by heart disease, two hip replacements and depression, my mother was often groggy when I visited. She needed me to take her hand and pull her up so she could grab the bed rail and maneuver into a sitting position. Though she brightened when I told her stories about her grandchildren over lunch in the facility's dining room, her joy vanished as soon as we returned to her unit. A blank look on her face, she would lay back on her bed, prone and helpless.

Like many American women of my generation, I struggled to figure out how to best care for my aging mother. As the end neared, I compared notes with my friends Fiona and Juliette. Fiona lives in Canada, but her mother lives in their native England, while Juliette lives with her mother in their family home in France. How could we establish safe and comfortable environments for our ailing mothers? How could we find high-quality medical care within reach of their incomes, and our own? And how could we preserve their mental health and sense of well-being while limiting our stress?

My mother's plight made my stress considerable. Each month, Lois Taber paid $4,069 to reside in her assisted-living community, $1,400 for private aides and an average of $140 for medications. Just before she died at age 82, she liquidated assets from her 401(k) to pay for a $5,800 hearing aid. At $169.50 per ride, the retirement home's fee for transporting her to medical appointments was prohibitive. Other than Medicare, my mom had no government-subsidized elder-care services. Already, the lack of affordable in-home support had forced my parents to leave their beloved house in Chevy Chase, Md., to receive the basic care they needed.

Overseas, things are different -- that is, better. In England, which has a national health system similar in structure to our Veterans Affairs system, Fiona's mum, Pat Reid, suffers from disabling arthritis and diabetes, and cannot move without great pain. But a government-supplied home health aide visits Pat at breakfast, lunch and dinner every day. This costs the family 120 pounds a week (approximately $785 per month), a little more than half of what my mom paid for private aides. Lower-income patients receive this service free. The National Health Service provides general practitioners, nursing care, ambulance services, diabetic clinic visits, medications and hospitalizations for no charge. Doctors and nurses make home visits.

In addition, Pat's son Simon, who has no work at the moment and lives in his mother's converted garage, receives 50 pounds a week (about $325 per month) from the government to help him look after her. With this government support, Pat is able to stay in the home where she lived with her husband for more than 35 years. The cost of her care is well within her monthly income of 2,000 pounds.

In France, Juliette's maman, Madeleine Fournot, has Alzheimer's disease. She receives assistance via a national health reimbursement system similar to Medicare as well as through a special program for the elderly and disabled called l'Allocation Personalisée à l'Autonomie ("Personal Autonomy Allocation"). Since the government refunds 560 of every 1,200 euros Juliette spends on her mother's medical expenses, she is able to hire a caregiver who looks after her mother around the clock 3 1/2 days per week. This allows Madeleine to stay in her suburban Paris home, where her family has lived for three generations, and provides Juliette a regular respite from elder care.

Madeleine receives one free doctor's visit per month, and the doctor makes house calls when needed. Four days a week, a physical therapist visits her, charging a one euro co-pay per visit -- less than the cost of a cup of coffee on the Champs-Élysées. Because Madeleine is on blood thinners, a hematology technician comes each week to check her blood levels. If she is in bed when he arrives, she can stay snug under her covers while he takes the sample. All medications related to Madeleine's Alzheimer's are free, as is transportation to her neurologist in Paris. Her doctor simply fills out a form stating that she cannot stand without assistance, and she is reimbursed for the 30-minute taxi ride into the city.

Other services available to Madeleine include daily medication-administration house calls by a trained nurse, daily meal service (a three-course lunch and soup for dinner) and a specially designed activity program for Alzheimer's patients. The total monthly cost of Madeleine's care is 1,500 Euros, or $2,205.

I am struck by all that Fiona's mum and Juliette's maman can take for granted. They enjoy access to services far beyond free and full medical and prescription drug coverage. In England, my mother's $5,800 hearing aid would have been free. While Mum and Maman get house calls from their doctors and cash compensation for family members who care for them, I often had to take time off from work -- an expensive proposition for a self-employed psychologist and writer -- to help Mom. Taking her back and forth to her medical appointments ate up entire days and, with her disabilities, she could barely get in and out of my car. This was hard work, not quality time with an aging parent.

Mom, Mum and Maman were not very different people. All three married civil servants, led middle-class lives and retired on government pensions. Pat and her husband, a BBC editor and translator who escaped five Italian prison camps during World War II, sought to create a peaceful life for their children. After her husband died, Pat took a job on the local council for village planning. Madeleine spent most of her middle years in Afghanistan, where her husband was posted with the United Nations. My mother worked in orphanages and schools in Asia, Europe and the United States as she followed my father, a CIA officer, across three continents. All three women eventually became widows and developed significant medical problems. Illness and enfeeblement limited their lives, and they came to require help with their daily activities.

There, the similarity ends. As seniors, each woman's quality of life was shaped by her government's health-care policies. The services offered to older people in Britain and France seem, to this American observer, straightforward, logical and humane. These countries provide the basic help their elders need to remain in their homes and in their communities, close to family and friends. It upsets me to think how much more peacefully my mother's life might have ended had she had the support available to older people in Britain and France. Why should Mum and Maman be able to grow old at home, but not Mom?

Many Americans protest that Europeans pay high taxes for medical care. It is true that people in other countries pay more in taxes, but, between out-of-pocket expenses and private health insurance premiums, many Americans spend much of their tax savings staying alive. Of course, high-quality health care costs money. Treating Mom like Mum and Maman is expensive. But Pat and Madeleine both have much lower living and medical expenses than my mother had, and, unlike Americans, they never had to pay for health insurance in their prime.

If our taxes were somewhat higher but we received dependable services that enabled us to spend less out of pocket on doctors' visits, medications and nursing care -- services that helped us remain independent, at home, and that relieved our families of financial and emotional burdens -- wouldn't peace of mind outweigh the additional cost?

My mother, a physical therapist and teacher with a blow of cumulus hair, was a hard-working person whose motto was: "If, at the end of the day, I can say I've helped someone's life to be better, then I've had a good day." It would have been nice if, at the end of her days, she could have taken her shoes off.

Sara Mansfield Taber, a psychologist and writer, is the author of "Bread of Three Rivers: The Story of a French Loaf."

Dec 29, 2009

Rasmussen Poll - Election 2012: Nebraska Senate

{{w|Ben Nelson}}, U.S. Senator from Nebraska.

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The good news for Senator Ben Nelson is that he doesn’t have to face Nebraska voters until 2012.
If Governor Dave Heineman challenges Nelson for the Senate job, a new Rasmussen Reports telephone survey shows the Republican would get 61% of the vote while Nelson would get just 30%. Nelson was reelected to a second Senate term in 2006 with 64% of the vote.
Nelson's health care vote is clearly dragging his numbers down. Just 17% of Nebraska voters approve of the deal their senator made on Medicaid in exchange for his vote in support of the plan. Overall, 64% oppose the health care legislation, including 53% who are Strongly Opposed. In Nebraska, opposition is even stronger than it is nationally.
Fifty-six percent (56%) of voters in the state believe that passage of the legislation will hurt the quality of care, and 62% say it will raise costs.
The House and Senate have passed different versions of the health care legislation and now will try to agree on a plan to pass early in 2010. Because every Democratic vote is required to pass the legislation in the Senate, Nelson’s vote is essential. If Nelson votes to block final passage of the health care plan, he would still trail Heineman but would be in a much more competitive situation.

Official photo of Governor Dave Heineman (R-NE).

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When survey respondents were asked how they would vote if Nelson blocks health care reform, 47% still pick Heneman while 37% would vote to keep the incumbent in office. Twenty percent (20%) of those who initially said they’d vote for Heineman say they’d switch to supporting Nelson. Another six percent (6%) of Heineman supporters say they’re not sure what they’d do if Nelson stops the health care plan from becoming law.
If Nelson votes to block health care reform, 10% of all voters would prefer a third-party option. Most of those who would prefer a third choice initially said they would vote for Nelson.
Overall, 40% of Nebraska voters have a favorable opinion of Nelson while 55% have an unfavorable view. Those figures include 12% with a Very Favorable opinion while 34% hold a Very Unfavorable view.
Twenty-six percent (26%) say Nelson has done a good or excellent job in the health care debate. Forty-seven percent (47%) give him poor marks.
Forty-two percent (42%) say their senator has been too supportive of President Obama’s agenda while 13% say he’s not been supportive enough. Thirty percent (30%) say he’s got the balance about right.
Nelson is also one of the key players in the discussion about how abortion should be handled in the health care plan. Sixty-five percent (65%) of Nebraska voters say that coverage of abortion should be prohibited in any plan that receives government subsidies. Only six percent (6%) want coverage mandated, while 22% want no requirements either way.
Obama earned 42% of the Nebraska vote in 2008, and 38% continue to approve of his job performance. Sixty-one percent (61%) of Nebraska voters disapprove of how the president is performing.

Dec 28, 2009

The not-so-sweet side of closing 'doughnut hole'

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By Amy Goldstein
Washington Post Staff Writer
Monday, December 28, 2009; A03

Six years after Congress added a prescription drug benefit to Medicare, Democrats in the House and Senate are poised to make a central change that they and most older Americans have wanted all along: getting rid of a quirk that forces millions of elderly patients with especially high expenses for medicine to pay for much of it on their own.

The closing of an unusual gap in Medicare drug coverage -- a gap that Republicans had, when they controlled Capitol Hill and the White House, insisted was needed for the government to be able to afford the program -- would "forever end this indefensible injustice for American's seniors," Senate Majority Leader Harry M. Reid (D-Nev.) said in announcing that the Senate would join the House in supporting the change.

But details of the change underscore that, for patients and the federal budget alike, the implications of the sprawling health-care bills pushed through by congressional Democrats are more nuanced than lawmakers' talking points.

The Democrats and President Obama have been clear that the "doughnut hole," as the gap is known, would disappear gradually over the next 10 years. They have not mentioned that Medicare patients would, according to House figures, face a slightly larger hole in coverage during two of the next three years than they do today.

Proponents say the government can afford to eliminate the gap because the pharmaceutical industry would pay for the phaseout. But less than half of the $80 billion that drugmakers agreed to provide, under a health-care reform agreement over the summer with Senate Democrats and the White House, would be used to help fill the gap, according to Senate Democratic aides. Moreover, there are no budget forecasts far enough into the future to show how much the expanded drug benefit would cost the government once the gap is fully closed.

Image by stacyjclinton via Flickr

Despite such uncertainties, the prospect of filling the hole in drug coverage responds to a strong desire among older Americans -- a significant constituency that tends to be wary of changes to the health-care system. The 2003 law that added the drug benefit to Medicare was the largest expansion since the creation of the federal health insurance system for the elderly four decades ago. The new coverage became available in 2006. As of last year, about 32 million people, nearly three-fourths of everyone on Medicare, had it.

Nancy LeaMond, executive vice president for social impact at AARP, the lobby for people age 50 and over, said that although the benefits have proven popular, "you really can't have a meeting with a chapter, you can't have a town hall" without complaints surfacing about the doughnut hole. "It's a major pocketbook issue."

Pat Liberti, a retired nurse in Salem, Mass., who has heart disease and diabetes and has had five small strokes, takes 16 prescription drugs. She is 59, six years younger than the typical age to join Medicare, and is eligible because her health problems have classified her as disabled. She's entered the doughnut hole each year, this year in May. At that point, her Blue Cross/Blue Shield plan stopped paying 75 percent of her medicine's price. Since then, she has spent $2,206 on drugs.

"You know, I did everything right. I worked. I saved. I own my own home. I have an IRA," Liberti said. She had hoped to save the long-term disability checks she gets from her former job for her old age. Instead, she spends them on medicine.

How many people are in similar circumstances is unclear. The Kaiser Family Foundation, a health policy organization on whose figures House Democrats relied, estimated that, in 2007, one-quarter of the Medicare patients with drug coverage fell into the gap. Less publicized figures by the Centers for Medicare and Medicaid Services, the agency responsible for the program, show that about half that many fell into it. Kaiser and the agency disagree on how often people who reach the gap stop taking some of their medicine.

However many people have been affected, closing the doughnut hole has been a rallying cry among the elderly. During the second week in December alone, LeaMond said, AARP members placed 240,000 calls to 29 Senate offices, asking them to follow the House in eliminating the gap.

Under the health-care bill the House passed in November, people who reach the doughnut hole would be $500 better off next year than they would otherwise. But the impact over the next few years would be subtler than it appears at first for two reasons: The gap -- without any change -- is scheduled to expand each year, and the bill would fill it gradually. As a result, patients would face a larger coverage hole in 2011 and 2012 than this year, according to Ways and Means Committee data. After that, it would shrink more rapidly and disappear in 2019.

The just-passed Senate measure would narrow the gap halfway. Even before the bill was approved, Reid and the chairman of the two Senate committees that handle health-care issues said they would, as part of negotiations to resolve differences between the two bills, accept the House's goal of closing the hole completely.

Congressional budget analysts have not said how much that would cost. Instead, they predicted a savings of $43 billion over the next decade -- based on the combined effect of filling the hole and two steps the pharmaceutical industry has said it would take in part under the deal earlier this year with the White House and the Senate. As one of those steps, drug manufacturers would repay the government the difference between the prices the companies charge for medicine for low-income patients in Medicare and the prices they used to charge in Medicaid, before the drug benefit existed. As the other step, the House bill requires the manufacturers to give a 50 percent discount for brand-name drugs that patients buy once they enter the doughnut hole -- and to give the government the equivalent of that money after the hole closes.

Budget analysts say the discounts for brand-name drugs would end up costing the government money; fewer people would switch to cheaper generic medicine, in turn causing more people to reach the gap's far side, beyond which almost all remaining drug expenses are covered.

Without a Congressional Budget Office prediction, the only estimate of the cost of filling the gap comes from the Medicare program's chief actuary, Richard S. Foster, who told House Republicans it would be $31 billion over the next decade. No one has analyzed how expensive the expanded drug benefits would become after that, although health-care options prepared a year ago by the CBO provided a clue: It said that, if the gap were eliminated right away, it would cost $134 billion over 10 years.

Democrats predict that, in the end, pharmaceutical companies will provide enough money to cover the expense. Republicans are skeptical. "They are shielding the true cost by phasing it in," said Sage Eastman, spokesman for Rep. Dave Camp (Mich.), ranking Republican on the Ways and Means Committee.

Meanwhile, no one knows how much the pharmaceutical industry could end up benefiting by an expansion in coverage that could drive up spending on brand-name drugs. Said one health policy expert who favors closing the gap: "It's not very transparent."

Dec 26, 2009

American Indians Hit Hard By Swine Flu

December 25, 2009 from APR

Although H1N1 has proven less deadly than originally anticipated, it has taken a serious toll on American Indians.

According to a recent report released by the Centers for Disease Control and Prevention, the mortality rate from the virus is four times higher among American Indians and Alaska Natives than any other racial or ethnic group.

Phil Stago and his family were hit particularly hard by the virus.

Nationwide Reports Of Flu-Like Illness

Map: Nationwide Reports Of Flu-Like Illness

They live in a tiny house in the tiny town of Winslow, Ariz., just outside the vast Navajo Nation. On a recent morning, his 2-year-old watched cartoons and snuggled with her dad. The baby rocked in a swing.

The mellow day was quite a switch from the drama the household experienced in September, when Stago says swine flu wiped out his family for a whole month.

Stago's son got it first — itchy throat, fever and aches. Then 2-year-old Alicia picked up the virus. She’s feeling much better now, but when her newborn sister, Gabriela, caught swine flu, things got scary.

Stago took her to an Indian Health Service hospital nearby when her fever hit 100 degrees.

"They secluded us from her, and they put her in a little tent of oxygen," Stago says. "[We] had to wear the whole full isolation gowns and gloves and mask. That was pretty scary."

Indigenous People More Vulnerable

When patients require more intensive care than Gabriela did, they're sent to Flagstaff Medical Center, about an hour west of Winslow.

One day during the peak of the second wave of the swine flu virus, the intensive care unit was almost full of American Indians on respiratory ventilators.

The scene reflects a statewide trend. In Arizona, of the more than 1,500 people who have been hospitalized for swine flu, 13 percent have been American Indian. Yet American Indians make up only 5 percent of Arizonans.

Aboriginal Australians and First Nations groups in Canada have reported similar disproportionate findings.

There are plenty of theories as to why indigenous people are more at risk. John Redd, an epidemiologist for the Indian Health Service, says that crowding and poor housing, both risk factors for influenza, are more present in indigenous populations around the world.

In addition to poverty, Redd also points out that American Indians are prone to diabetes and asthma. When you combine swine flu with these pre-existing conditions, the outcomes are worse.

Access to health care is also an issue. There are a dozen Indian health care centers scattered throughout the Navajo Nation, but the reservation is the size of West Virginia.

Cindy Galloway, who works at a family health center that serves American Indians in the Flagstaff area, believes there are other factors contributing to the higher mortality rates.

"They are more stoic people. They don't complain, frankly," Galloway says.

She says it's typical for American Indian patients to wait until their symptoms become severe before they seek treatment.

"People will tolerate feeling bad longer and thinking it's going to go away," Galloway says. "When finally after four or five days they can't even take a deep breath, then they realize that this could be more serious."

Indian Health Service officials say many people have been exposed to swine flu or have been vaccinated now, so there's hope that the next possible wave of the virus, which could come as early as January, won’t be as severe.

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Dec 22, 2009

Nurses Say Senate Bill Entrenches Chokehold of Insurance Giants

Image by seiuhealthcare775nw via Flickr

by John Nichols

Want to know what's wrong -- really wrong -- with the health-care "reform" bill being pushed through the Senate by Majority Leader Harry Reid?

Ask a nurse.

"It is tragic to see the promise from Washington this year for genuine, comprehensive reform ground down to a seriously flawed bill that could actually exacerbate the health-care crisis and financial insecurity for American families, and that cedes far too much additional power to the tyranny of a callous insurance industry," says National Nurses Union co-president Karen Higgins, RN.

"Sadly," adds Higgins, "we have ended up with legislation that fails to meet the test of true health-care reform, guaranteeing high quality, cost effective care for all Americans, and instead are further locking into place a system that entrenches the choke-hold of the profit-making insurance giants on our health. If this bill passes, the industry will become more powerful and could be beyond the reach of reform for generations."

The 150,000-member NNU, the largest union and professional organization of registered nurses in the U.S., condemned Reid's bill -- which is expected to gain Senate approval this week -- as a deeply flawed measure that grants too much power to the nation's largest private and for-profit insurers.

Specifically, the union that takes in the powerful California Nurses Association, cited 10 fundamental flaws in the Senate bill:

1. The individual mandate forcing all those without coverage to buy private insurance, with insufficient cost controls on skyrocketing premiums and other insurance costs.
2. No challenge to insurance company monopolies, especially in the top 94 metropolitan areas where one or two companies dominate, severely limiting choice and competition.

3. An affordability mirage. Congressional Budget Office estimates say a family of four with a household income of $54,000 would be expected to pay 17 percent of their income, $9,000, on healthcare exposing too many families to grave financial risk.

4. The excise tax on comprehensive insurance plans which will encourage employers to reduce benefits, shift more costs to employees, promote proliferation of high-deductible plans, and lead to more self-rationing of care and medical bankruptcies, especially as more plans are subject to the tax every year due to the lack of adequate price controls. A Towers-Perrin survey in September found 30 percent of employers said they would reduce employment if their health costs go up, 86 percent said they'd pass the higher costs to their employees.

5. Major loopholes in the insurance reforms that promise bans on exclusion for pre-existing conditions, and no cancellations for sickness. The loopholes include:

· Provisions permitting insurers and companies to more than double charges to employees who fail "wellness" programs because they have diabetes, high blood pressure, high cholesterol readings, or other medical conditions.

· Insurers are permitted to sell policies "across state lines", exempting patient protections passed in other states. Insurers will thus set up in the least regulated states in a race to the bottom threatening public protections won by consumers in various states.

· Insurers can charge four times more based on age plus more for certain conditions, and continue to use marketing techniques to cherry-pick healthier, less costly enrollees.

· Insurers may continue to rescind policies for "fraud or intentional misrepresentation" – the main pretext insurance companies now use to cancel coverage.

6. Minimal oversight on insurance denials of care; a report by the California Nurses Association/NNOC in September found that six of California's largest insurers have rejected more than one-fifth of all claims since 2002.

7. Inadequate limits on drug prices, especially after Senate rejection of an amendment, to protect a White House deal with pharmaceutical giants, allowing pharmacies and wholesalers to import lower-cost drugs.

8. New burdens for our public safety net. With a shortage of primary care physicians and a continuing fiscal crisis at the state and local level, public hospitals and clinics will be a dumping ground for those the private system doesn't want.

9. Reduced reproductive rights for women.

10. No single standard of care. Our multi-tiered system remains with access to care still determined by ability to pay. Nothing changes in basic structure of the system; healthcare remains a privilege, not a right.

In fairness to Reid and his fellow Senate Democrats, most of the flaws in their bill are also present in the House bill. And that's the really depressing part.

While members of the Obama administration and key senators claim that the legislation should be enacted because it seeks to expand coverage, places new regulations on insurers and might be improved in the House-Senate conference committee, NNU co-president Deborah Burger, RN, offers a more realistic diagnosis:

"Those wishful statements ignore the reality that much of the expanded coverage is based on forced purchase of private insurance without effective controls on industry pricing practices or real competition and gaping loopholes in the insurance reforms."

Dec 21, 2009

The Virtual Visit May Expand Access to Doctors

By CLAIRE CAIN MILLER

SAN FRANCISCO — Americans could soon be able to see a doctor without getting out of bed, in a modern-day version of the house call that takes place over the Web.

Image by leoncillo sabino via Flickr

OptumHealth, a division of UnitedHealth Group, the nation’s largest health insurer, plans to offer NowClinic, a service that connects patients and doctors using video chat, nationwide next year. It is introducing it state by state, starting with Texas, but not without resistance from state medical associations.

OptumHealth believes NowClinic will improve health care by ameliorating some of the stresses on the system today, like wasted time dealing with appointments and insurance claims, a shortage of primary care physicians and limited access to care for many patients.

But some doctors worry that the quality of care that patients receive will suffer if physicians neglect one of the most basic elements of health care: a physical exam.

“This is a pale imitation of a doctor visit,” said David Himmelstein, a primary care doctor and associate professor at Harvard Medical School. “It’s basically saying, ‘We’re going to give up any pretense of examining the patient and most of the nonverbal clues that doctors use.’ ”

Others, including Rashid Bashshur, director of telemedicine at the University of Michigan Health System, say online medicine is a less expensive way of providing routine care.

Image by Ben Dodson via Flickr

“The argument that you need the ‘laying on of hands’ to practice medicine is an old and tired argument that simply has no credibility,” he said. “There are two constants in medicine: change and resistance to change.”

Christopher Crow, a family physician in Plano, Tex., who used the system during its test period, said, “NowClinic gives you the ability to have that gut feel if something is wrong, in tone or facial expression or body language, that you have when you walk in the door with a patient.”

Many patients who do not have primary care physicians nearby use the emergency room for routine problems. Wait times for patients needing immediate attention have increased 40 percent, in part because of overcrowding, according to a study by Harvard Medical School and Cambridge Health Alliance.

In Texas, 180 counties do not have enough physicians, 70 percent of patients cannot obtain a same-day visit with their primary care doctor, and 79 percent of emergency room visits are for routine problems, according to OptumHealth.

“We are, through this technology, replenishing the pool of physicians and making them available to patients,” said Roy Schoenberg, chief executive of American Well, which created the system that OptumHealth is using.

For $45, anyone in Texas can use NowClinic, whether or not they are insured, by visiting NowClinic.com. Doctors hold 10-minute appointments and can file prescriptions, except for controlled substances. Eventually they will be able to view patients’ medical histories if they are available.

The introduction of NowClinic will be the first time that online care has been available nationwide, regardless of insurance coverage.

American Well’s service is also available to patients in Hawaii and Minnesota, through Blue Cross Blue Shield, and to some members of the military seeking mental health care, through TriWest Healthcare Alliance.

Some hospitals and technology companies provide similar services on a smaller scale, including Cisco, the networking equipment maker, which uses its videoconferencing technology to remotely connect employees with doctors. It is working with UnitedHealth Group to offer the service more broadly.

The service has encountered resistance in states where it is already available. Texas law requires that before doctors consult with patients or prescribe medicine online or over the phone, they form a relationship through means like a physical examination.

The Texas Medical Board, which regulates doctors in the state, is evaluating its telemedicine policies in light of new technologies. But Mari Robinson, executive director of the board, said that an online or telephone exam was inadequate if doctors and patients had not met in person and was “not allowed under our rules.”

After American Well’s service began in Hawaii last year, lawmakers passed legislation that allowed doctors and patients to establish a relationship online, though the Hawaii Medical Association opposed the bill.

“From our perspective, we still are a little bit concerned that a relationship can be established online with no prior relationship,” said April Troutman Donahue, the association’s executive director.

American Well and OptumHealth predict that health care professionals will adapt. “This is new technology, so you have a lot of code written that doesn’t take these medical technologies into account,” said Rob Webb, chief executive of OptumHealth Care Solutions.

Many patients seem ready to embrace the new technology. In a recent study, a Harvard research team at Beth Israel Deaconess Medical Center found that patients were comfortable with computers playing a central role in their health care and expected that the Web would substitute for face-to-face doctor visits for routine health problems.

Passing health reform could be a nightmare for Obama

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By Robert Samuelson
Monday, December 21, 2009; A19

Barack Obama's quest for historic health-care legislation has turned into a parody of leadership. We usually associate presidential leadership with the pursuit of goals that, though initially unpopular, serve America's long-term interests. Obama has reversed this. He's championing increasingly unpopular legislation that threatens the country's long-term interests. "This isn't about me," he likes to say, "I have great health insurance." But of course, it is about him: about the legacy he covets as the president who achieved "universal" health insurance. He'll be disappointed.

Even if Congress passes legislation -- a good bet -- the finished product will fall far short of Obama's extravagant promises. It will not cover everyone. It will not control costs. It will worsen the budget outlook. It will lead to higher taxes. It will disrupt how, or whether, companies provide insurance for their workers. As the real-life (as opposed to rhetorical) consequences unfold, they will rebut Obama's claim that he has "solved" the health-care problem. His reputation will suffer.

It already has. Despite Obama's eloquence and command of the airwaves, public suspicions are rising. In April, 57 percent of Americans approved of his "handling of health care" and 29 percent disapproved, reports the Post-ABC News poll; in the latest survey, 44 percent approved and 53 percent disapproved. About half worried that their care would deteriorate and that health costs would rise.

These fears are well-grounded. The various health-care proposals represent atrocious legislation. To be sure, they would provide insurance to 30 million or more Americans by 2019. People would enjoy more security. But even these gains must be qualified. Some of the newly insured will get healthier, but how many and by how much is unclear. The uninsured now receive 50 to 70 percent as much care as the insured. The administration argues that today's system has massive waste. If so, greater participation in the waste by the newly insured may not make them much better off.

The remaining uninsured may also exceed estimates. Under the Senate bill, they would total 24 million in 2019, reckons Richard Foster, chief actuary of the Centers for Medicare & Medicaid Services. But a wild card is immigration. From 1999 to 2008, about 60 percent of the increase in the uninsured occurred among Hispanics. That was related to immigrants and their children (many American-born). Most illegal immigrants aren't covered by Obama's proposal. If we don't curb immigration of the poor and unskilled -- people who can't afford insurance -- Obama's program will be less effective and more expensive than estimated. Hardly anyone mentions immigrants' impact, because it seems insensitive.

Meanwhile, the health-care proposals would impose substantial costs. Remember: The country already faces huge increases in federal spending and taxes or deficits because an aging population will receive more Social Security and Medicare. Projections the Congressional Budget Office made in 2007 suggested that federal spending might rise almost 50 percent by 2030 as a share of the economy (gross domestic product). Since that estimate, the recession and massive deficits have further bloated the national debt.

Obama's plan might add almost an additional $1 trillion in spending over a decade -- and more later. Even if this is fully covered, as Obama contends, by higher taxes and cuts in Medicare reimbursements, this revenue could have been used to cut the existing deficits. But the odds are that the new spending isn't fully covered, because Congress might reverse some Medicare reductions before they take effect. Projected savings seem "unrealistic," says Foster. Similarly, the legislation creates a voluntary long-term care insurance program that's supposedly paid by private premiums. Foster suspects it's "unsustainable," suggesting a need for big federal subsidies.

Obama's overhaul would also change how private firms insure workers. Perhaps 18 million workers could lose coverage and 16 million gain it, as companies adapt to new regulations and subsidies, estimates the Lewin Group, a consulting firm. Private insurers argue that premiums in the individual and small-group markets, where many workers would end up, might rise an extra 25 to 50 percent over a decade. The administration and the CBO disagree. The dispute underlines the bills' immense uncertainties. As for cost control, even generous estimates have health spending growing faster than the economy. Changing that is the first imperative of sensible policy.

So Obama's plan amounts to this: partial coverage of the uninsured; modest improvements (possibly) in their health; sizable budgetary costs worsening a bleak outlook; significant, unpredictable changes in insurance markets; weak spending control. This is a bad bargain. Health benefits are overstated, long-term economic costs understated. The country would be the worse for this legislation's passage. What it's become is an exercise in political symbolism: Obama's self-indulgent crusade to seize the liberal holy grail of "universal coverage." What it's not is leadership.