DHMH Daily News Clippings

Sunday, January 11, 2004
News Clipping Archives
Official offers Crownsville details (Annapolis Capital)
Seeking health care for all (Baltimore Sun)
Amid Mad-Cow Fear, Worries in Md. Death (Washington Post)
Doctors reach a crisis point (Baltimore Sun)
Ehrlich Scores High Marks in Poll (Washington Post)
Top concerns are schools, state budget (Baltimore Sun)
All eyes are on slots as Assembly convenes (Baltimore Sun)
Assessing Risks of Mad Cow (Washington Post)
Medicare Portrayal Tailored by Parties (Washington Post)
Focus on 'Prevention' Divides Cancer Experts (New York Times)
The challenge, again (Baltimore Sun Editorial)
General Assembly session will revolve around fiscal issues (Annapolis Capital Editorial)
Choosing state's doomsday budget scenario (Baltimore Sun Commentary)
In Annapolis, A War of Absolutes (Washington Post Commentary)
No more free ride (Baltimore Sun Commentary)
Afflicted By Comfort (Washington Post Commentary)
Two Holes in the Medicare Drug Law (New York Times Commentary)
Thimerosal (Annapolis Capital Letter to the Editor)

Official offers Crownsville details
By Pamela Wood, Staff Writer
Annapolis Capital
Sunday, January 11, 2004
If the state closes Crownsville Hospital Center, several nonprofit groups on hospital grounds will get a reprieve from homelessness, at least for a little while.
Nelson J. Sabatini, state secretary of health and mental hygiene, told Anne Arundel County lawmakers Friday that as long as the state owns the property, the budget will include $90,000 a year for bare-bones maintenance of the facility, allowing the county food bank and several treatment centers to remain open.
"We have no intention whatsoever in displacing anyone," Mr. Sabatini said.
The General Assembly will have to decide through the budget process this year whether to close the psychiatric hospital to save $6 million a year. The assembly's annual session starts Wednesday.
In addition to 200 patients and 500 employees, several nonprofit groups are based on hospital grounds in exchange for minimal rent. They include the Anne Arundel County Food & Resource Bank, the Second Genesis treatment program, Hope House treatment program and a private school for troubled teens.
Other groups, like the Chrysalis House treatment center, a nursing home and a church are linked into the hospital's utility system.
"The intention is we will maintain it and we won't displace any tenants," Mr. Sabatini said.
But eventually, the Department of Health and Mental Hygiene will give up the land if the General Assembly endorses the closure. It will take about six months to move patients to other state hospitals, and then the Department of General Services can offer the land to other government agencies.
County Executive Janet S. Owens has her eye on the nearly 1,200 acre property, but said she hasn't decided yet whether it would be in the county's best interest to take over the land. About 500 undeveloped acres were supposed to be put in an environmental preservation program, but that has been put on hold.
After the meeting, Alvin Collins, Ms. Owens' chief of staff, said he's worried the county might be stuck with big bills to modernize or demolish the buildings scattered on the Crownsville campus.
Mr. Sabatini also outlined how the county would benefit from $5 million of the savings that will be earmarked each year for "community mental health services."
Frances Phillips, county health officer, will head up a committee with health officials from nearby counties to recommend how the money could best be spent. But she already has some ideas, including starting up a round-the-clock walk-in psychiatric center and adding beds at existing facilities.
She said the goal would be to treat more psychiatric patients near their homes instead of having them committed to the state hospitals.
"If we really focus on the community, we can do better," she said.
Published January 11, 2004, The Capital, Annapolis, Md.
Copyright � 2004 The Capital, Annapolis, Md.

Seeking health care for all
By M. William Salganik
Baltimore Sun Staff
Sunday, January 11, 2004
Norma Winchester, a part-time waitress at the Hilton hotel in Pikesville, had health insurance until August. Then her hours were cut back, and she no longer qualified for coverage from her employer.
Winchester, who lives in Randallstown, checked out individual policies, making several phone calls and using the Internet, but "they were all more than $100 a month - not something I could afford." Making up for her lost hours at the hotel, she takes child-care jobs through an agency, generally one or two days a week, but that work doesn't provide insurance, either.
2004 could be a decisive year for people like Norma Winchester - the roughly 690,000 Marylanders who don't have health insurance.
A group called Maryland Citizens' Health Initiative, chaired by Baltimore health chief Dr. Peter L. Beilenson, has been working for several years to develop and build support for a "health care for all" plan. More than 1,000 church, labor, community and business groups have endorsed the effort.
The group's plan was introduced in the legislature last year, but failed to develop much traction. However, since then, key political leaders have been talking about expanding coverage as rising health care costs and slow job growth have increased the problems of the uninsured.
The health initiative group says this is the year to pass a comprehensive plan. It is expected to begin a stepped-up public campaign tomorrow to build support.
Most of the uninsured in the state are adults - 540,000 of them. Over the past few years, the state has extended free or subsidized insurance to low- and moderate-income children, including Winchester's 10-year-old daughter.
And most of the uninsured, like Winchester, work or live with someone who works. Only 4 percent of the uninsured adults in Maryland live in a family with no working adult, according to a study released recently by the Maryland Health Care Commission.
The proposal by the Maryland Citizens' Health Initiative group seeks to expand free coverage for low-income adults, subsidize coverage for those with moderate incomes and require higher-income individuals to purchase coverage. It would be financed in theory by an increase in tobacco taxes and a payroll tax aimed at employers who do not offer health coverage to their workers.
Lawmakers, however, will also consider two other plans with less ambitious sweep, at least in the short term, but with more certain political backing.
Nelson J. Sabatini, Maryland's health secretary, says the Ehrlich administration agrees with the goal of universal health coverage.
However, Sabatini says, the administration will concentrate on incremental reforms this year, while looking to close the state's deficit. In the future, he says, the administration will support a package of tax credits and tax penalties to encourage individuals without health insurance to buy coverage.
John Adams Hurson, the Montgomery County Democrat who chairs the House Health and Government Operations Committee, argues that the state can't currently afford to buy or subsidize insurance for all who need it. Rather, he's looking to shore up "safety net" programs, such as clinics that treat the uninsured.
While the uninsured can get primary treatment at clinics, a study last year in Baltimore by the Open Society Institute - the public interest and charitable group founded by billionaire George Soros - determined that the uninsured often have trouble getting access to specialized care and related services such as lab tests and prescriptions.
Norma Winchester says that if the state were to offer free or subsidized coverage, "I'd love to try it."
Copyright � 2004, The Baltimore Sun

Amid Mad-Cow Fear, Worries in Md. Death
Lack of Autopsies Hampers Research
By Elizabeth Williamson
Washington Post Staff Writer
Sunday, January 11, 2004; Page C03
Early last February, Carolyn Lamb, a 64-year-old office administrator at a Bethesda school, phoned her husband. She had a headache and felt dizzy, she told Charles Lamb. Could he come and drive her home?
It was job stress, the Silver Spring couple reasoned. Then the headaches worsened, and Lamb began getting lost in her own home. Within two months, Carolyn Lamb was dead, believed to be the victim of a brain-wasting illness known as Creutzfeldt-Jakob disease that affects one in a million people.
Her age and symptoms, doctors say, pointed to a strain that is related to -- but not caused by -- eating beef from animals with bovine spongiform encephalopathy, or mad-cow disease. No brain biopsy or autopsy was performed, which would have confirmed the diagnosis. Even after the cause of his wife's death was recorded with the Maryland Health Department, Charles Lamb said: "Nobody contacted me. I was surprised."
Since the nation's first known case of mad cow disease was reported -- in a Holstein in Washington state -- Carolyn Lamb's death has newly worried her colleagues and friends. They wonder: Did Lamb die from the beef-related illness after all? The odds against it are overwhelming, but the case points to the difficulty in tracking an illness that until two weeks ago worried few in this country.
"We need to look more closely at [patients] with atypical neurological disease" by performing more diagnostic tests and autopsies, said Richard Johnson, a physician who teaches neurology, microbiology and neuroscience at Johns Hopkins University School of Medicine and its Bloomberg School of Public Health. "That's a hard thing to get done. . . . But for public health, we ought to be doing it."
Lamb was an energetic woman who owned a meeting and planning business in Olney during the 1980s and was active in the town's Chamber of Commerce. After she and her husband moved to Silver Spring three years ago, she joined the office staff at the Harbor School, a private elementary school in Bethesda.
Lamb's headaches in February, her husband recalled, were soon followed by other symptoms. In mid-February, when the region was coping with a blizzard that stranded many people in their homes, Charles Lamb struggled to help his wife. "She was so disoriented and confused, she'd get lost walking around the dining room," he said.
Soon after, Carolyn Lamb went to Johns Hopkins, where doctors diagnosed sporadic Creutzfeldt-Jakob disease. Like variant Creutzfeldt-Jakob, the strain of the illness linked to mad cow, the sporadic form is a fatal illness characterized by an abnormal protein, called a prion, that attacks and builds up in brain tissue.
The cause of sporadic Creutzfeldt-Jakob is unknown. It strikes suddenly, usually in people older than 40, and kills within weeks or months. The mad cow-related variant tends to affect people still in their twenties, has a years-long incubation period and takes longer to progress.
There has been only one case of variant Creutzfeldt-Jakob found in the United States -- that of a Florida woman who grew up in the United Kingdom, where a mad-cow epidemic has caused 143 cases of the disease in humans since being identified in 1996. By comparison, sporadic Creutzfeldt-Jakob has afflicted 586 people in the United States since 1997.
Lamb had never traveled outside the United States. The diagnosis was based on her age, symptoms, the disease's speed and test results, her husband said. But to be sure, doctors would have needed to test tissue from Lamb's brain, a difficult surgery that her husband felt had little point. "They said all we could do was to keep her comfortable, that it was just a matter of time," he said.
Carolyn Lamb died March 25. Charles Lamb did not want an autopsy, partly because the disease can spread to people who have contact with victims' nervous-system tissue. He said he was afraid that the disease would spread to people in laboratories and the funeral home that handled his wife's body. He said, however, that if he had known an autopsy could have helped further research into prion diseases, "I probably would have said yes."
Prion disease researchers say their efforts to track and discover new strains of the disease are hampered by a dramatic decline in the number of autopsies in the United States. Nationwide, autopsies are conducted in five percent of non-crime-related deaths, compared with 35 percent in the 1960s, according to the prion disease committee at the Institute of Medicine of the National Academies, which advises the federal government on public health issues.
The congressionally chartered institute said that examining brain tissue is the only sure way to pinpoint a prion disease. Yet "at least half of the estimated total number of deaths caused by [prion diseases] in the U.S. are not autopsied and confirmed by laboratory examination," a new report by the committee noted.
Even at a research mecca such as Johns Hopkins, only about eight percent of patients who die are autopsied, said Johnson, who serves on the committee. One reason: Most health insurance plans won't pay for them.
"You're not going to know what you miss without autopsies," Johnson said. "I'm concerned that there are other diseases like this out there."
In March, a Harbor School newsletter announced Lamb's sudden death. Adding to the shock and confusion was the rumor that Lamb had died of mad cow-related illness, said Suzanne Clarke, a former Harbor School teacher.
"Everybody thought that's what it was," she said. When the Holstein in Washington state was found to have mad-cow disease, Clarke said she grew more worried. "To kill someone that quickly . . . we should know what this is," she said. "If someone tried to connect some dots, they would be able to understand it better.
"It would seem to be the logical thing to do."
Staff researcher Bobbye Pratt contributed to this report.
� 2004 The Washington Post Company

Doctors reach a crisis point
Urgency: Physicians are leaving the field because of what they see as a malpractice insurance nightmare. The most extreme example of the situation is with OB/GYNs.
By James M. Kramon
Special To The Baltimore Sun
Sunday, January 11, 2004
THIS MONTH - Jan. 21 - more than 1,500 Maryland physicians are set to close their offices, put on white coats and travel to Annapolis to impress state legislators with the urgency of medical liability tort reform.
Although the emphasis of the physicians' arguments will concern economic aspects of medical liability, the presentations are expected to address a broad range of concerns.
Dr. Sharon M. Pusin, president of the Baltimore County Medical Association, makes the urgency clear: "[Legislators] must be made aware that to do nothing is not a viable option."
The medical liability insurance crisis has reached a point where it is chasing physicians out of medicine.
The most extreme aspect of the situation concerns obstetricians/gynecologists. The practice of obstetrics, preparation for and delivery of newborn babies, is a malpractice nightmare. Not only does that practice pose the potential for profound damage to a person that may last his or her life, but the statute of limitations for instituting such a lawsuit against a physician (normally three years) does not even begin to run until a child reaches the age of majority, which is 18 in Maryland.
In other words, a physician who delivers a baby is potentially liable for a lawsuit - justified or unjustified - for 21 years from the time of delivery. Almost nowhere in the law, short of heinous criminal offenses for acts resulting in death, does a statute of limitations exist nearly this long.
The result of this situation is not surprising. Numerous OB/GYNs have, in recent years, left the practice of medicine well before normal retirement age. Others have expressly limited their practices to exclude obstetrics. It is commonplace for contracts between OB/GYNs and hospitals to exclude matters related to the delivery of babies. Parts of Maryland have been without physicians practicing obstetrics for substantial periods of time and the future looks worse: Only one graduate of the Class of 2003 at the two Baltimore medical schools chose OB/GYN as a specialty.
The legal profession bears a heavy part of the responsibility for what is occurring. Lawyers, encouraged by the Supreme Court's approval of attorney advertising, have, in recent years, had a field day with tort liability. Since physicians have insurance and deep enough pockets to be interesting targets, it is difficult for some lawyers to take their eyes off them.
The absurdity of a lawsuit against a fast-food restaurant by a customer who spills hot coffee on himself or against a phone booth manufacturer because a car jumped a curb and ran through a phone booth injuring its occupant is obvious. But the absurdity of many medical malpractice lawsuits is harder to see.
In five years as general counsel for a Baltimore area hospital that had 185 physicians admitting patients, I saw dozens of malpractice lawsuits. Probably more than half of them had no reasonable foundation, perhaps a third were arguable (although I would not have been comfortable instituting many of these), and a relatively small number were slam-dunk errors.
Some attorneys who institute large numbers of medical malpractice cases seem to follow the notion that if you throw a lot of mud against a wall, some of it will stick.
Unfortunately - and for this I place the blame squarely on the legal profession - there is little downside for an attorney who files an unjustified medical malpractice lawsuit. Although recovery of defendants' costs is a theoretical possibility (as distinguished from the English system where such costs are routinely recovered), courts in this country almost never award them. Other than the nominal requirement that a physician certify there is liability - easily obtained - there is no limitation to filing such lawsuits other than the good faith of attorneys.
The threat of malpractice suits does not affect only careless physicians. The specter of medical malpractice, particularly the knowledge that a physician who has done nothing negligently can be sued at any time, utterly warps the practice of medicine and erodes physician-patient relationships.
First, medical malpractice premiums, particularly in high-risk specialties, are enormous. In recent years, such premiums have approached and occasionally exceeded six-figure amounts. In addition, since such insurance is now all but exclusively sold on what is known as a "claims made" basis, there is an expensive insurance fee for what is known as a "tail" due at the conclusion of a physician's practice. The economics of medical malpractice insurance are untenable for many physicians, but they are not the worst result.
A medical malpractice lawsuit, win or lose, is for many physicians the worst experience of their lives. Every lawyer who has represented physicians in such cases has had clients quit medicine, including some who have been found to have no liability. Months and, not infrequently, years of obsession with a lawsuit, dozens of phone calls and visits to one's lawyer, reviews of charts and other documents, depositions, discussions with colleagues, constant reminders of the lawsuit in other contexts, second-guessing, days of lost work time, and sometimes a full-blown trial, are too much for many to endure.
Because physicians work in this environment every day, the practice of "defensive medicine" has become commonplace. Any physician will tell you that defensive medicine is lousy medicine, but the medical malpractice situation leaves no choice.
Numerous physicians have told me that they spend upward of 50 percent, and in some cases as much as 90 percent, of their time engaged in defensive-medicine activities. A neurologist told me recently that more than half of the tests he prescribes for patients would not be prescribed if he were not preoccupied with liability concerns.
The economic cost of such measures is extraordinary, and the disruption of physician-patient relationships is immeasurable. When a physician is forced to look at a patient as a source of potential liability, he cannot easily look at that patient as someone he wishes to help in every possible way even if, as is often the case, risks must be taken.
Some years ago it was thought that mandatory health claims arbitration was the answer to this problem. But it was not. In most instances, a more complicated legal system does little to discourage malpractice cases.
Medical liability tort reform must do two things. It must reduce potential liability in ways that will not preclude a deserving claimant from achieving reasonable success in a reasonable amount of time.
This can be done by shortening the statute of limitations in situations like that of OB/GYNs, capping damages so that they are reasonable and within the limits of insurance coverage, and curtailing attorneys' fees so there is not an enormous windfall incentive - one large enough in fact to pay for primetime television advertisements - to bringing lawsuits.
In addition, something must be done to eliminate the shooting-fish-in-a-barrel aspect of medical malpractice litigation. An attorney who brings an unjustified malpractice suit against a physician, like anyone who recklessly undertakes any form of action that portends harm to someone else, should be answerable for doing that. The legal system is capable of distinguishing arguable and inarguable cases. There is all the difference in the world between a fairly arguable case - even if not successful - and an outright stickup.
James M. Kramon is a lawyer and a writer.
Copyright � 2004, The Baltimore Sun

Ehrlich Scores High Marks in Poll
Residents Applaud Fiscal Curbs but Worry About Schools
By Craig Whitlock and Claudia Deane
Washington Post Staff Writers
Sunday, January 11, 2004; Page A01
Robert L. Ehrlich Jr., Maryland's first Republican governor in a generation, has earned remarkably strong plaudits after his first year in office from residents impressed as much by his personality as by his policies, according to the latest Washington Post poll.
Marylanders gave Ehrlich especially high marks for such character traits as honesty and also said they liked his efforts to restrain government spending and promote economic growth. The statewide telephone poll of 1,000 residents also found that almost six in 10 people favored his signature policy proposal: legalizing slot-machine gambling at racetracks.
At the same time, those surveyed were hard-pressed to identify any major accomplishments by the governor, who watched most of his legislative agenda go down to defeat last year in a General Assembly controlled by Democrats.
Yet "he's what political scientists call an 'attractive candidate,' " said Donald F. Norris, a professor of public policy at the University of Maryland Baltimore County. "He just has one of those personalities that people like. People may disagree with his policies, but he still seems like the kind of guy who they can like."
With the assembly scheduled to convene Wednesday, more people listed education as the biggest problem facing Maryland: Fifty-five percent of those surveyed said they wanted Ehrlich and the legislature to make it their highest priority.
A similar percentage said they would be willing to accept tax increases, if necessary, to deliver the state from its chronic budget problems and to pay for a landmark $1.3 billion school-funding plan that a several legislators have said is unaffordable.
In the same vein, the poll, conducted last week, found that Marylanders are overwhelmingly opposed to spending cuts in education and other programs in order to solve the state's financial ills, something Ehrlich has threatened to do if the assembly again rejects slot machines.
"We cannot afford to cut any funds that go to schools," said Jacqueline Rousseau, 49, a federal employee from Silver Spring who calls herself an independent. "That's just not an option that's on the table, in my opinion. If we have to pay more in taxes, none of us wants to do that, but it may be one of the only options we have."
Already, there are deep divisions among Maryland lawmakers over whether legalized gambling, higher taxes or spending cuts are the best way to close the $700 million budget gap in next year's budget and solve the state's long-term financial problems.
Unlike their counterparts in Virginia, who return to Richmond this week to debate a detailed plan for restructuring the state's tax code, Maryland lawmakers have no clear road map for the three-month session. Democrats say it remains to be seen whether Ehrlich can capitalize on his personal popularity to win legislative support for his agenda.
Although a majority of residents surveyed credited Ehrlich with improving the quality of schools in the state, education was a weak point for the governor compared with almost every other major issue. Relatively few people said they wanted lawmakers to focus their energy on building roads or bringing slot machines to Maryland, two of Ehrlich's most visible policies.
Unlike people nationwide, Marylanders generally view their state's economy as strong, with 63 percent classifying it as "excellent" or "good." In comparison, a nationwide poll conducted by The Post and ABC News in late December found that 42 percent gave the U.S. economy the same ratings.
Maryland's optimism on the economy may help explain President Bush's strong showing in last week's poll: a 55 percent job approval rating, which compared favorably to the 40 percent of the state's vote he received in the 2000 presidential election.
Overall, Maryland residents are far more upbeat about conditions than they were prior to Ehrlich taking office, with 57 percent saying the state is headed in the right direction, compared with 42 percent in an October 2002 Post poll of likely voters.
Ehrlich narrowly defeated Lt. Gov. Kathleen Kennedy Townsend (D) with 52 percent of the vote to become the first Republican elected governor of Maryland since Spiro T. Agnew in 1966. Since then, his popularity has increased in a liberal-leaning state where registered Democrats outnumber Republicans 2 to 1.
With 62 percent of Marylanders approving of the job he has done, Ehrlich is held in much higher esteem than his Democratic predecessor, Parris N. Glendening.
In early 1995, as Glendening finished his first year battered by a pension scandal and a fight over building stadiums, polls put his approval rating in the mid-30s. That figure rose above 50 percent before his 1998 reelection but plunged to 37 percent in the final months of his tenure, Post polls showed.
While Ehrlich predictably polled strongest among Republicans, 63 percent of self-described independents and 50 percent of Democrats said he was doing a good job. The governor even received a 54 percent approval rating from black residents -- a bloc that voted heavily for Townsend even though Ehrlich's running mate, Michael S. Steele, was African American.
In the poll, his support was weakest in the economically struggling city of Baltimore, a traditional Democratic stronghold. It was highest in a swath of central Maryland, including the increasingly affluent suburbs of Anne Arundel, Frederick, Howard and Baltimore counties, among others. Residents in Prince George's and Montgomery mirrored the state figure of 62 percent.
Ehrlich appears to be cashing in on his charisma. Though he is a lawyer with an Ivy League education, the governor stresses his roots as the son of a car salesman from a blue-collar Baltimore suburb. He is a frequent guest on radio talk shows, in which he presents himself as an average guy named Bob predisposed to get along with anyone.
"I don't always agree with what he says, but he seems to me to be sincere," said Olga Fosler, 66, a registered Democrat and clerical worker from Baltimore who voted for Ehrlich in 2002. "He's not a razzle-dazzle speaker. He says, 'This is the problem' or 'This is the circumstance,' and it seems to me that what he says is the truth."
"They seem very human," Fosler added in describing the governor and his wife, Kendel. "I can relate to them in that regard."
A significant number of people who don't like the job Ehrlich is doing said they can't help liking him personally. Among those who disapprove of his performance, three in 10 still have a "favorable" view of him.
Ehrlich also outshines the two Democrats who are considered his chief rivals for a second term: Baltimore Mayor Martin O'Malley and Montgomery County Executive Douglas M. Duncan, neither of whom could match his name recognition or favorability ratings.
Although the GOP has high hopes for building on Ehrlich's historic win in 2002, the survey suggests that Republicans have little chance of knocking off incumbent Sen. Barbara A. Mikulski in November.
Of those surveyed, 65 percent said Mikulski deserved to be reelected. Her leading competitor, state Sen. Edward J. Pipkin (R-Queen Anne's), is a virtual unknown, with 87 percent reporting that they didn't know enough about him to have an impression of him.
In a telephone interview, Ehrlich attributed his high ratings to his persistence in trying to fulfill his campaign promises. Among them: pledges to resist tax increases, push for slots and build a long-planned highway between Montgomery and Prince George's.
"We've kept our word," he said. "In Maryland politics and national politics in this era, you get extraordinary credit for keeping your word. Most importantly, people understand I am following through on what I said and that words do count. There's a consistency there."
Ehrlich remains popular despite last year's legislative session, when the assembly bottled up most of his policy proposals. The House of Delegates killed his slots bill, the Senate refused to confirm his candidate for environmental secretary and neither chamber agreed to his legislation toughening penalties for gun crimes.
Leading Democrats have lately been criticizing Ehrlich as a do-nothing, feel-good governor.
Indeed, with one year under Ehrlich's belt as chief executive, the poll found that 49 percent of people couldn't name a single major accomplishment by the governor.
Duncan, who has tangled with Ehrlich on slots and other issues, said the governor is popular primarily because he's still a novelty.
Voters "wanted a change in the last election, and that's what they got," Duncan said. "The challenge Ehrlich is going to have is showing people what he stands for. Other than gambling and building the intercounty connector, there's nothing really there."
Indeed, when it comes down to whom the public wants running the government, Ehrlich doesn't have an advantage over the state's Democratic leadership.
When asked whom they trusted more to cope with the state's problems, those surveyed sided with Democrats in the legislature over Ehrlich by 44 to 41 percent. The poll's overall results have a margin of sampling error of plus or minus 3 percentage points.
Alan Gann, 64, an electrical engineer from Chevy Chase, said he voted for Ehrlich in part because Maryland had been controlled by the Democrats for too long.
"He's a fresh face," said Gann, a registered Democrat. "I think the trouble with being in a state where you have one party dominating state politics is that you don't get enough fresh air in the process. So he certainly brings that."
Although Gann said he was willing to cut the governor "a little slack" while he is learning the ropes, he added that he was reserving judgment on Ehrlich. "I don't think he's been in long enough to say with certainty that he's done a good job, or a bad job."
Director of Polling Richard Morin contributed to this report. Complete poll results can be found at www.washingtonpost.com/metro.
� 2004 The Washington Post Company

Top concerns are schools, state budget
Two-thirds of respondents would pay higher sales tax to improve education; Half conditionally support slots; Ehrlich remains adamant in opposing new taxes
By Stephanie Desmon
Baltimore Sun Staff
Sunday, January 11, 2004
More than two-thirds of Maryland voters say they would be willing to pay an additional penny sales tax for improving schools, despite the staunch anti-tax stance being taken by Gov. Robert L. Ehrlich Jr., a new poll for The Sun released today shows.
To close the state's projected $736 million budget gap - an ever-higher priority for those surveyed - a majority of voters oppose just putting programs on the chopping block.
Instead, more than one-third say it should be accomplished only by raising taxes; 20 percent say tax increases and program cutbacks must be done in tandem to get the job done.
Half of Marylanders still support bringing slot machines to the state - Ehrlich's biggest legislative priority, and failure a year ago - but more than seven in 10 want them confined to specific locations such as racetracks or rural areas.
Even if slot machines are approved, voters overwhelmingly said, they don't want millions of the dollars raised to prop up the horse racing industry.
The Maryland Poll, conducted for the newspaper and Sunspot.net by Bethesda-based Potomac Inc., depicts some of the complex choices facing the General Assembly as it convenes Wednesday for its annual 90-day legislative session.
"I just don't think people would be opposed to another one-cent tax," said Frances Snyder, a retired Baltimore County bookkeeper. "I hate to see programs cut, especially education and cleaning up the bay."
Budget issues, which have emerged as a top concern after barely showing up on voters' radar just two years ago, remain the second-leading concern of state residents, running close behind worries about the quality of public schools.
Taken together, nearly half of likely voters feel these are the biggest problems facing the state, the ones people most want the governor and the legislature to take up in the next three months.
Other issues such as crime, the economy and the environment trail far behind in the single digits.
The poll of 1,200 likely voters was conducted by telephone Jan. 2 though Monday. It has a margin of error of plus or minus 2.8 percentage points.
"The overwhelming message from voters is that education and the budget are dominant concerns, and everything else is pale in comparison," said Keith Haller, president of the polling firm. "Of all the possible ways to increase revenue at a time of a budget crisis, the sales tax is unquestionably the most politically palatable."
'Willing to sacrifice'
Ehrlich "has put his position in the sand," Haller added. "He's basically saying no taxes whatever. You don't want to come across as incorrigible, as insensitive when people are willing to sacrifice to deal with the budget crisis to make sure education and other critical concerns are at least taken care of."
But the governor isn't budging from his opposition to the sales tax, a position which he hasn't wavered from since his days on the campaign trail.
"That's the first number I've ever seen that would be that lopsided that would favor a sales tax increase. It's the most regressive major tax we have," Ehrlich said last week. "It's not going to happen, is the bottom line."
C. Timothy Tarr, a 51-year-old Gaithersburg engineer, is a Republican who voted for Ehrlich in 2002. He is not typically a proponent of higher taxes, but he does want to see quality public schools in Maryland. He would like to see the state's $1.3 billion landmark public schools reform initiative, known as the Thornton Plan, put in place, a plan that some elected officials have warned is in jeopardy without new dollars.
The Republican governor wants to pay for it, in part, with slot machines and has warned that the plan will have to be slashed without additional gambling revenue. Democratic House Speaker Michael E. Busch said a one-penny sales tax dedicated to the plan is a preferable source.
Many voters agree with Busch, according to the poll, and he said he is not surprised at the results now that people have had a year to see "what's at stake and have seen the alternatives."
The concept even has a majority of support among Ehrlich's base: 52 percent of Republicans surveyed support the penny tax, as do 56 percent of those who say they plan to vote for Ehrlich if he runs for re-election in 2006.
Tarr, a supporter of slot machines and casinos in Maryland, said he still thinks the sales tax might be the solution to the financial crunch facing schools.
"At the end of the day, if there's no other way to do it, that's what we have to do," Tarr said. "What are we if we're not an educated people? We can't go through life selling each other hamburgers."
Marylanders, on average, each pay $873 in sales, alcohol, cigarette and other levies, according to the state Department of Legislative Services. That's 40th in the country. The U.S. average is $1,099 per person. The state's 5-cent sales tax is a penny lower than most of its neighbors'.
William Cartwright, who works for Constellation Energy at the Calvert Cliffs nuclear power plant, said in lean times, government should cut back from "steak to hamburger," not go out and raise taxes.
In his business, he has "found all sorts of interesting ways to save money and be more efficient. I think there are tons of way to do that in government," the 50-year-old Solomons man said. "When a corporation has a bad year, everyone has to tighten up their belts a little bit. I don't see the same out of government. We've built in a lot of extras."
Ehrlich 'stubborn'
Snyder, the 76-year-old retiree, said she doesn't understand the hard-line stance Ehrlich is taking against raising taxes, especially in the face of the shortfall. "He's being really stubborn," she said.
Parkville resident Charles Hutton, a 36-year-old health care information analyst, worries about budget cuts that could go too deep if some taxes aren't increased.
"In cutting programs, it's costing a lot of jobs," he said. "In order for the economy to get well, you need to have consumers. I'd rather have a multitude of people pay taxes than see 10,000 people lose their jobs."
Paul E. Shurick, a spokesman for Ehrlich, said polling he has done shows a different result, that people prefer program cuts over tax increases.
"We have seen other recent polls that provide a very different answer to that question, and the governor hears every day from members of the public who overwhelmingly ask the governor to oppose raising taxes," he said.
Maryland is still a fairly progressive state, the poll shows. Nearly six in 10 voters said they favor protecting the environment, even if it costs some jobs, over bolstering the economy, even if it hurts the environment. And many Republican voters, who are conservative on fiscal and tax issues, feel that way about the environment.
More than half of voters said they support the death penalty, though less than half would extend it to people convicted of crimes committed when they were minors - a question prompted by the recent trial of Washington-area sniper Lee Boyd Malvo, 17 at the time of the crimes, who was tried in Virginia because Maryland doesn't execute minors. A jury recommended life in prison.
On the question of civil unions for gay and lesbian couples, 50 percent of voters said they oppose them and 40 percent favor them.
One year into his term, meanwhile, Ehrlich's job approval remains quite high. A year ago, 56 percent of voters predicted in the Sun's poll that the former congressman would do a "good job," while 21 percent said they thought he would do a "poor job."
Even with Glendening
This year, he still enjoys a 56 percent job approval rating, with 28 percent disapproving.
His approval numbers equal the highest that voters gave his predecessor, Parris N. Glendening, over the last four years of his term in office.
But looking beneath the surface, voters are not as supportive of the governor when asked how he is doing more specifically. Asked how he is handling the budget shortfall, for example, 50 percent have a negative opinion of Ehrlich. When asked how he is "changing the tone in Annapolis," one of his campaign promises, only 36 percent of voters have a positive view of how he is doing - 20 points lower than his overall job approval.
"Ehrlich has gotten through his first contentious year as governor with his personal popularity intact," Haller said. "On the flip side, if he doesn't effectively address the state budget or if his dealings with Annapolis come asunder, there will be danger signs for his popularity going forward."
Looking ahead to 2006 - an eternity in political time - a hypothetical gubernatorial match between Ehrlich and potential Democratic challenger Baltimore Mayor Martin O'Malley is a statistical dead heat.
It's a tossup in the Baltimore region, with city voters behind O'Malley in a big way and Baltimore County narrowly going for the homegrown Ehrlich. The Washington region would go to O'Malley, the poll suggests. Montgomery County Executive Douglas M. Duncan, who has also talked about a run for governor, is 10 points behind Ehrlich at this point if they were to go head-to-head.
Garrison Still, a 48-year-old electronics engineer from Bel Air, voted for Ehrlich in the last election and would probably do so again. "He's very smooth," Still said. "I can see some things he's doing right."
Sun staff writers Johnathon E. Briggs and David Nitkin contributed to this article.
Copyright � 2004, The Baltimore Sun

All eyes are on slots as Assembly convenes
Clashing interests imperil hopes for gambling bill
By David Nitkin
Baltimore Sun Staff
Sunday, January 11, 2004
Tavern owners want a chunk of the action. So does the state fair in Timonium. Casino interests are sniffing around.
With the legalization of slot machines an unsolved riddle in Maryland, the debate over expanded gambling has devolved into a battle royal among special interests since the General Assembly last considered the issue.
As lawmakers ready for a return to Annapolis this week, eyes remain fixed on House Speaker Michael E. Busch, the leading critic of slots, who some believe might be surreptitiously scuttling Gov. Robert L. Ehrlich Jr.'s top priority by allowing competing forces to gnaw it to death.
Slots will once again be a dominant issue in the capital as 47 senators and 141 delegates convene Wednesday for the start of Maryland's 418th General Assembly session. Lawmakers are hungry for a long-term financial solution for the state's expensive commitments to public schools, health and other programs that have created projected budget deficits for the foreseeable future.
But there's little sign that such a solution will come easily, if at all.
Ehrlich must, by law, submit a balanced budget by Jan. 21 that closes a $736 million gap between projected revenues and expenses. The $22 billion spending plan will cut heavily into some state programs, with no new money from sales or income tax increases - or from slots, which could take 18 months or longer to start delivering proceeds to state coffers.
Future years of a school funding program known as the Thornton Plan aren't possible without gambling, Ehrlich says, infusing the debate with tension.
He has ruled out sales or income tax increases.
As a first-year speaker, Busch single-handedly killed the governor's signature slots-at-racetracks initiative last year, becoming a champion of gambling opponents and a goat to others horrified that a delegate from Annapolis could derail plans of a popular governor.
Over the summer, a House committee studied gambling, as Busch publicly considered alternatives that he said would not unjustly enrich track owners and would offer the best return for the state. That amounted to an invitation for businesses that could benefit - from taverns to resorts that could house the electronic gambling devices - and they have responded enthusiastically.
Opponents think the wider interest could sink the slots bill that the governor says he intends to submit. Gambling forces will find it difficult to forge a successful plan this year, said anti-slots lobbyist W. Minor Carter, because of "greater fragmentation" among various interests.
"The casinos, the bar people - everybody's got their own proposal," Carter said.
Some Annapolis observers wonder whether the complications are the deliberate creation of a speaker who wants to kill the bill again.
"I get all kinds of mixed messages from the House," said Democratic Sen. Patrick J. Hogan of Montgomery County, vice chairman of the Budget and Taxation Committee. "If it's by design, I don't understand what the endgame is."
Busch said he does not intend to use his full influence to defeat the proposal this year. He prefers a sales tax increase to pay for public schools and considers slots an unreliable income stream that preys on those least able to afford it.
"My mission is to bring some kind of conclusion to this issue," Busch said. "It's clouded things for too long. I am not going to advocate for a bill, but I am to going to let each legislator vote their conscience."
Ehrlich says he is able to compromise if Busch will. "If he wants to do a deal, we can do it in an hour," Ehrlich said.
Public divided
According to a poll conducted for The Sun, state voters are divided on where slots should be. Thirty-nine percent favor confining them to racetracks, while 32 percent support specially built facilities away from urban areas, and 16 percent like tourist destinations such as the Inner Harbor.
"If a negotiation is ultimately successful, it will be a combination of every option there," Ehrlich said.
Voices representing those options and others are clamoring to be heard.
In Prince George's County, influential U.S. Rep. Albert R. Wynn is asking lawmakers to band together to fight for community interests. He is advocating casinos at the National Harbor project along the Potomac or at similar locations.
"My point is that a major hotel complex with a concert hall and high-end restaurants is much better than just throwing slots in a pre-fab barn somewhere," Wynn said. "It doesn't create permanent jobs."
Fearing their business will be cannibalized, bar owners have drafted their own plan. They want 5,000 slot machines at larger facilities and 5,000 divided among taverns that already have Keno.
Such an expansion of gambling is repugnant to some, but Joseph A. Schwartz III, the lobbyist for the Maryland State Licensed Beverage Association, calls it practical and fair. "I want my client to come out a winner," he said. "I either want my plan, or no plan."
Some fault Ehrlich for allowing confusion to reign. Critics say the governor has not been willing to dig into the details of the debate. He wasted the summer months in campaign mode, they say, traveling the state.
"If it didn't pass on the last day of the session, we should have worked on it the day after that, and the day after that, and the day after that," said Senate President Thomas V. Mike Miller, a slots supporter who has pledged to pass Ehrlich's plan as his chamber did a year ago. "To solve the crisis, people need to work around the clock. And that hasn't taken place this summer."
Ehrlich played down the need to work on slots, saying he has been waiting for Busch to yield.
Miller's credibility on the slots debate has been clouded by an FBI preliminary inquiry into $225,000 in donations received by a national political organization that he oversees from a group headed by Pimlico and Laurel track owner Joseph A. De Francis, a potential beneficiary of slots profits.
As last year, Maryland politics suffers from heightened partisanship. A Republican governor and a Democratic-controlled legislature have yet to figure out how to get along.
The mood will be set early, when the Assembly attempts an override of gubernatorial vetoes, which hasn't happened since 1989. Those votes will set a bitterly partisan tone that could endure for 90 days.
But much is expected of lawmakers. The second year of a four-year term is widely considered the most productive: Newcomers have worked out their jitters, but the next election is still three years off. "Traditionally, the closer you get to an election, the harder it is in this environment to do any major things that involve tax changes," said William S. Ratchford II, former head of the state Department of Fiscal Services.
It might be hard to tell, but slots won't be the only issue in Annapolis this year. Lawmakers face important decisions in a variety of other areas.
After campaigning on a promise to end traffic gridlock, Ehrlich has identified a $300 million yearly unmet need in transportation funding but has not developed a plan to close it.
More than a month ago, a high-level commission headed by former Transportation Secretary William K. Hellmann set the goal of raising $300 million a year to replenish the depleted Transportation Trust Fund. But the panel punted on the issue of how to raise the money, instead presenting Ehrlich with a "menu" of options including increases in the gasoline tax and vehicle registration fees.
So far, the governor has yet to announce a decision on what mix of revenue-raisers - if any - he will propose. Some leading transportation advocates are getting anxious.
"A package will emerge, and the administration will play a major role," Ehrlich said.
A year after the Senate rejected Ehrlich's original nominee to head the Department of the Environment - dealing the Republican administration its first major defeat - the governor will bring forward acting Secretary Kendl P. Philbrick.
Philbrick has spent the past 10 months wooing both environmental activists and Democratic lawmakers. Despite some lingering skepticism about his mostly corporate background, he appears to have captured enough support to win confirmation.
Philbrick will be helping the administration pass a $30 surcharge on the bills of municipal water users to raise tens of millions of dollars to upgrade sewage treatment plants and cut harmful nutrient pollution into the Chesapeake Bay.
The administration is also pushing for changes to existing programs aimed at reducing nutrient runoff from agriculture and encouraging cleanup and redevelopment of polluted industrial sites called brownfields.
Social, justice issues
In the aftermath of a Massachusetts Supreme Court ruling, lawmakers will consider the legalization of gay marriage or civil unions in Maryland.
Abortion critics are pressing for more stringent restrictions on abortion clinics, which they say should be subject to the same licensing requirements as other outpatient surgery facilities.
A bill sparked in part by the 2002 starvation and beating death of 15-year-old Ciara Jobes by her court-appointed guardian would revise the law terminating parental rights in cases of abuse and neglect.
Other measures will seek to ban the sale and possession of assault weapons and alter the death penalty in Maryland by eliminating local differences in sentencing.
Sun staff writers Greg Garland, Michael Dresser, Howard Libit and Kimberly A.C. Wilson contributed to this article.
Copyright � 2004, The Baltimore Sun

Assessing Risks of Mad Cow
Other Animals Likely Infected, Scientists Say
By Shankar Vedantam
Washington Post Staff Writer
Sunday, January 11, 2004; Page A09
In 1990, when the federal government designed a surveillance system to detect mad cow disease, scientists said the tests would find one case of the disease if there were 45 infected cattle in the country.
Nineteen days ago, for the first time in this country, one case of mad cow disease, or bovine spongiform encephalopathy (BSE), was spotted.
"Given that the United States has an adult cattle population of approximately 45 million, if we did have BSE in this country at the one-in-a-million level, we could assume that we would have 45 infected animals," says a Department of Agriculture Web site describing the surveillance program. But no one knows if that is actually the case.
Still, the discovery of an infected Holstein cow in Washington state points inexorably to the possibility that there are undetected cases in the U.S. herd, which would have major political, economic and public health consequences.
Determining the exact number of infected animals will be difficult, perhaps impossible. Unlike countries that test all slaughtered animals, the United States tests a tiny fraction of the 45 million animals thought to be at risk -- 20,526 tests were conducted last year -- leaving experts with more questions than answers.
"Up until the Wednesday before Christmas, we have not in this country felt that getting those answers warranted the costs," said Barrett Slenning, an associate professor in dairy production medicine at North Carolina State University. "My guess is that is going to change quite quickly."
Epidemiologists and statisticians say the infected Holstein raises a flag that could indicate there are two, 10 or even 90 infected animals in the United States.
The Holstein might also be the only infected animal, but that would mean the tests -- which sample fewer than one in 2,000 adult cattle -- spotted the only needle in a very large haystack.
"This is a surveillance testing system," said W. Ron DeHaven, USDA deputy administrator and chief veterinary officer, in a recent briefing. "It is not intended to determine whether every animal that goes to slaughter has the disease."
Different assumptions built into the surveillance program lead to different answers as to how many animals might be currently infected, statisticians say.
For example, the 20,526 tests conducted last year focused on visibly sick or "downer" animals -- cattle too sick or old to walk. The surveillance program assumes that if there were 45 infected animals, all would be among this population.
If that is wrong and tested animals have the same risk of BSE as the rest of the 45 million adult cattle, finding a single case could imply that 90 animals in all have mad cow disease in the United States, said Joshua Cohen, a senior researcher at the Harvard Center for Risk Analysis, whose analysis of mad cow disease government officials have repeatedly cited.
Even if most of the risk for mad cow disease is confined to downers -- which were banned from the food supply Dec. 30 -- then it "seems likely that there is at least one other animal with clinical BSE in the U.S," said Cohen, an expert in applied mathematics and statistics.
If the number of cattle at risk is even smaller -- say, only those downer cattle imported from Canada before a 1997 safety ban on infected feed was instituted -- then the number of infected animals in the United States "may be very small indeed" said Cohen, explaining how different assumptions lead to different answers. The 61/2-year-old infected Holstein was imported from a farm in Alberta, the province where a Canadian beef cow was discovered to have mad cow disease last May.
"In order to extrapolate how many animals might have disease, you would need to make assumptions what their risk would be," Cohen said.
If the untested animals had one-quarter the risk of the tested animals, "maybe the total number of infected animals is 10 to 12," Cohen said. "This animal is probably not the only one -- you wouldn't want to bet on it being the only one."
Government officials insist the nation's food supply is safe, because tissues known to transmit the infection are kept out of the food supply. And they believe that mad cow disease in the country is extremely rare. But scientists agree that there are too many assumptions in the surveillance system to draw concrete answers.
No one knows, for example, how many downer cattle entered the food supply in past years; estimates hover around 200,000, meaning that only one in 10 was tested. That is because, in 1990, when no one knew whether mad cow disease was in the country, it was considered a waste of resources to test more.
If the 45 hypothetical cases were evenly distributed among the 45 million adult cattle, finding one case would have required 3 million annual tests, said Victoria Bridges, a veterinary medical officer and epidemiologist with the USDA in Fort Collins, Colo. So officials narrowed their search to visibly sick and downer cattle.
That made the job easier.
"If you had 45 infected animals and all 45 are in that at-risk population, how many samples do you have to take to find the disease?" Bridges said.
The answer was about 12,500 tests. In recent years, USDA officials have conducted more than that -- last year, it was 20,526. The larger number increases the likelihood that disease will be spotted even if it occurs only at a low rate but falls far short of a system that can actually count cases.
The infected Holstein is a cautionary tale about the risks inherent in the assumptions: If some animals with early stages of mad cow disease appear healthy, they could escape detection.
Although government officials said the infected Holstein was a downer, Tom Ellestad, a manager at Vern's Moses Lake Meats, where the cow was slaughtered Dec. 9, said he remembered the animal standing, even walking. But even if government records showing the Holstein was a downer are accurate, officials insist the animal showed no clinical signs of disease.
Showing how difficult it is to visually identify mad cow disease, veterinary officials confirmed after the Holstein was slaughtered that there was damage in its pelvic canal -- consistent with a birthing injury it had suffered. While tissues from the Holstein's brain were tested for mad cow disease, officials assumed the animal was a downer because of the birthing injury and saw no reasons to keep the meat out of the food supply.
Two weeks later, however, after the meat was shipped to several states and Guam, the results came back positive for BSE, and officials ordered a recall "out of an abundance of caution." By then, an unknown quantity had been consumed.
DeHaven said the surveillance system worked perfectly to answer the question for which it was designed -- whether mad cow disease exists in the country.
But a new tool will be required to find out how many animals are infected.
"Every statistical procedure is a special kind of screwdriver," said N.C. State's Slenning. "It is designed to answer one particular question. If you use it to drive nails, you can get something done, but it won't do a very good job of it."
� 2004 The Washington Post Company

Medicare Portrayal Tailored by Parties
In Election Year, Seniors' Support Is Key
By Amy Goldstein
Washington Post Staff Writer
Sunday, January 11, 2004; Page A06
Now that Congress has enacted a Medicare prescription drug bill, Republicans and Democrats -- and their allies -- are pursuing aggressive campaigns to mold public opinion about whether the new law will help or hurt people who rely on the program.
A month after President Bush triumphantly signed the Medicare legislation, top administration health officials are planning an advertising blitz and speaking tours to promote the law during the election year. House Republicans have produced marketing materials that lawmakers are handing out to their constituents.
Foes of the Medicare changes have mobilized with equal vigor. Democratic House members convened five dozen town hall meetings around the country last month to spread their objections to the law; their Senate counterparts are scheduling dates when they plan to present particularly loud criticism. Families USA, which opposed the legislation, is producing a film, to be narrated by Walter Cronkite, that will be part of a Medicare road show the consumer health lobby plans for the spring.
In yesterday's Democratic weekly radio address, Wisconsin Gov. Jim Doyle said, "Instead of using Medicare's enormous bargaining power to get the best discounts for our seniors, American taxpayers and seniors will be forced to foot the bill for greater drug company profits."
Such intense advocacy is commonplace when important bills are pending in Congress. But lawmakers, scholars and policy analysts said they could not recall any modern precedent for public relations efforts of this scale after a major social policy has become law.
Those efforts attest to the stakes that both parties attach to Medicare for the 2004 election, as they vie to own an issue that is of vital importance to senior voters, a crucial voting bloc. The parties' eagerness is heightened by polls showing that public opinion is divided over the issue -- and remains malleable.
In another sense, the bitter aftermath is a perpetuation of the partisan passage of the law. Medicare has long been identified as a Democratic issue. But this time, it was the GOP that championed an unparalleled expansion of a vast entitlement program, while most Democrats -- frozen out of any role in shaping the bill's final form -- opposed it.
"There's a whole lot of political cross-dressing here," said Robert D. Reischauer, president of the Urban Institute, a Washington-based nonpartisan research organization. "It appears that the Republicans have stolen the Democrats' bacon."
"It is very different when each party is trying to take a victory lap than when you have one party throwing a lot of mud on the victors as they run around the track," said Norman Ornstein, congressional scholar at the American Enterprise Institute.
Approved by Congress in late November, the Medicare law will produce the largest expansion in the history of the program, which provides health insurance to about 40 million seniors and disabled Americans. Starting in 2006, the government will subsidize drug coverage for any Medicare patient who wants it. The law also contains steps intended to expand the role of private health plans in caring for senior citizens. During the bill's long, heated debate, the parties were polarized over whether the private-sector orientation is a good idea and whether the government will give older Americans enough help in paying for medicine.
Proponents and critics of the law seek to portray their plans as neutral efforts to educate Medicare patients and health care professionals about the way the 678-page law will change the program. But it is clear that the public education is laced with ideology and politics.
Ron Pollack, Families USA's executive director, said its film with Cronkite -- which his group wants to distribute to nearly every senior center in the country -- and its impending road show are "not intended to be a diatribe. . . . We are going to . . . explain to people what is in the legislation and how it will affect them." Still, Pollack said, "We have little doubt how people react to this stuff. . . . It will create a groundswell of people saying, 'This needs to be changed.' "
Doyle, for example, noted in the radio speech that the legislation does "nothing for those under 65, who aren't eligible for Medicare but often face exorbitant drug costs."
On the other side of the issue, Bill Pierce, spokesman for Health and Human Services Secretary Tommy G. Thompson, said the agency is organizing "a robust campaign . . . the goal being to cut through the rhetoric with what we view as straight facts and straight answers." HHS is beginning by mailing a letter and brochure about the law to every Medicare recipient this month, and officials want to place articles on newspaper editorial pages.
The speaking tour by Thompson and other senior HHS administrators will include several joint appearances with Republicans in Congress. And a recent White House news release, announcing a routine step by the Treasury Department toward creating Health Savings Accounts -- a controversial provision, favored by conservatives, that will allow Americans to set aside money for medical expenses in tax-free accounts -- began with the headline: "HSA's are good news for all Americans."
The House Republican Conference plans weekly polling to measure the impact of the themes its members use to describe the law -- "to see what our strongest message points are, where we need help," said a conference spokesman, Greg Crist.
Rep. Phil Gingrey (R-Ga.), a House freshman who is an obstetrician-gynecologist, is holding town hall meetings on Medicare in all 17 counties in his district before Congress reconvenes Jan. 20. "I can't let this get on the back burner," he said. His talking points are largely those the GOP made during the congressional debate. Gingrey said he tells constituents the law "is a godsend" for lower-income people on Medicare who will get the largest drug subsidies and that the government will not force patients to switch doctors or buy drug coverage. He also tells them that changes to the program will help prevent it from running out of money.
Rep. Shelley Moore Capito (R-W.Va.), who has attended community forums and made a public radio appearance during the past few weeks, said she encounters frequent resistance and misconceptions. One elderly woman erroneously believed that premiums for the drug coverage would automatically be subtracted from her husband's Social Security check. "A lot of it, unfortunately, is dispelling the rhetoric that's been put out on the negative side," Capito said.
Some Democrats acknowledge that they are actively sowing discontent. "Trying to influence public opinion is certainly part of our aim," said Rep. Benjamin L. Cardin (D-Md.), who has held meetings on Medicare in his suburban Baltimore district in recent weeks. Cardin is planning to introduce legislation later this month to change some of the law's most disputed features. .
Cardin and other Democrats want to fuel the kind of anger that erupted among older Americans during the late 1980s after Congress added "catastrophic" coverage to Medicare. That outcry prompted lawmakers to take the extraordinary step of repealing the law the following year. "We want the same type of public opinion to jell that brought about congressional action," he said. Cardin predicted that Democrats' best opportunity to change the law will come in 2005, after the presidential election but before the drug benefits are to take effect.
Senate Minority Leader Thomas A. Daschle (D-S.D.) plans to gauge -- and try to shape -- public reaction at nine town hall meetings throughout his state Sunday through Tuesday.
Senate Democrats have begun to coordinate with several liberal researchers who are writing papers critiquing the law, and with advocacy groups. Former representative Barbara B. Kennelly (D-Conn.), who is president of the National Committee to Preserve Social Security and Medicare, said her staff has held strategy sessions with aides to Sen. Edward M. Kennedy (Mass.), the Democrats' harshest critic of the final bill. Kennelly is appearing across the country at town hall meetings with congressional Democrats, and the organization is convening its own "caucuses" in Iowa in the two weeks before the nation's first presidential contest there to try to prime older voters there to complain about the law.
The MoveOn.org Voter Fund is spending $1.2 million on television advertising in four presidential battleground states, saying Bush pulled "the rug out from under Medicare." The Alliance for Retired Americans, a 3 million-member group with ties to organized labor, is organizing grass-roots campaigns, starting in four key states with large older populations. "It is our intention to make this a major issue in the 2004 presidential campaign," said Edward F. Coyle, the alliance's executive director.
Part of the rationale behind all this is evidence that public opinion about the Medicare law is malleable -- and mixed. A Washington Post/ABC News survey in mid-December found that one in five respondents had not made up their minds. Of those expressing an opinion, those who disapproved outnumbered those who approved, 42 percent to 37 percent.
Another poll, by the National Annenberg Election Survey, found even clearer signs that opinion is up for grabs. When asked whether they supported the law, about three in five respondents said they did -- at first. But after supporters were read criticisms of the law, most of that support switched to uncertainty. Conversely, some -- but not as many -- of the those who said they opposed the law changed their minds after pollsters confronted them with arguments for it.
"The party that wins the battle to define what was enabled will garner substantial political benefits," said Thomas E. Mann, a senior fellow at the Brookings Institution. "Democrats may begin with an advantage. That means the White House will redouble its efforts at salesmanship."
� 2004 The Washington Post Company

Focus on 'Prevention' Divides Cancer Experts
By Gina Kolata
New York Times
Sunday, January 11, 2004
The 2,000 people, the worried well, who come each year to Memorial Sloan-Kettering's cancer prevention center will learn that many cancers can, in fact, be prevented, and that it is up to them to have the appropriate medical tests and to live right.
For their $2,000 fee, most of which is paid by health insurance, they may be steered to smoking cessation sessions, or watch a cooking demonstration and hear a talk by a nutritionist. They will learn the early signs and symptoms of cancer and they almost certainly will have a cancer screening test.
"There is a lot that can be done to prevent cancer and detect it early," said Dr. Moshe Shike, the center's director. "We could probably cut cancer mortality by 50 percent."
Stopping smoking can prevent many forms of cancer, and changes in diet and weight loss also may have a marked effect. And while screening may find only cancer that is already present, it can save lives by catching it early.
Cancer prevention has become a buzzword these days, with some medical centers, like M. D. Anderson Cancer Center in Houston, planning entire buildings just for prevention. Its center will open in about a year, big as eight and a half football fields.
But even cancer experts who are participating in the new prevention efforts are divided on what really can be done to prevent cancer, other than stopping smoking. Looking at the same data on prevention, some experts say that for now most efforts involve research that may or may not lead to clinical advances.
That is a problem emblematic of the fiercely competitive world of cancer medicine, doctors say. Medical centers need to attract patients and federal research money. And that means they need to be on the cutting edge of the field. The National Institutes of Health requires medical centers that are designated comprehensive cancer centers, and eligible for its grants and contracts, to have a prevention component. The institute devoted $500 million, or 12 percent of its budget, to cancer prevention and control.
But, some ask, how can an honest message be communicated to the public about what can be done?
"I am concerned," said Dr. Donald Berry, a statistician at M. D. Anderson. "Most of what this is about is research. I think we're really early on in the cancer prevention area. Knowing what to do, knowing what the risk factors are and knowing when to intervene and how to intervene � we're not there yet."
He and others worry that many people greatly exaggerate their cancer risk and have inflated expectations of what science can do to protect them.
"We created the fear that everything is carcinogenic," said Dr. Michael Gallo, associate director for cancer prevention and control at the Cancer Institute at the Robert Wood Johnson Medical School. At the same time, he added, medical researchers "have convinced people that there is a magic bullet for everything." The result, he said, "is self-defeating."
At M. D. Anderson, for example, more than 80 percent of the cancer prevention center's budget is for research, which can range from basic laboratory work to epidemiology to clinical trials testing ideas of how to prevent cancer, said the center's director, Dr. Bernard Levin. Most people who come looking for ways to protect themselves against cancer are steered to the center's smoking cessation programs if they are smokers: a third of cancer patients there have smoking-related cancers. They are also offered screening tests.
Such strategies are hardly revolutionary, Dr. Gallo said. "It's what we've been doing for years. But it's sexy to be called the center for cancer prevention."
Dr. Otis Brawley, associate director for cancer control at the Winship Cancer Center at Emory University, shared Dr. Gallo's view. "To be politically correct as a cancer center you have to be interested in prevention," he said. The government expects it and so do patients, he added. "It is like a lot of things in medicine where we have implied success where actually there is very little."
Not everyone would agree. At Memorial Sloan-Kettering in New York, which offers diet and nutrition counseling and even cooking classes, cancer screening, genetic counseling and, of course, smoking cessation programs, the feeling is that there are great opportunities.
"There is a lot that can be done to prevent cancer and detect it early," said Dr. Shike, director of the cancer prevention and wellness program at Memorial Sloan-Kettering. "My feeling is that the general public and the medical profession don't take advantage of all the things we can do."
That depends on how you view the evidence and on what you mean by prevention, said Dr. Barnett Kramer, director of the office of disease prevention at the National Cancer Institute.
One potential source of confusion, he said, is that cancer prevention centers include screening. But screening, with a few exceptions like colon cancer and cervical screening that find and remove precancerous growths, looks for cancer that is already present. That may or may not save lives, Dr. Kramer said, depending on whether the treatment is effective and whether the cancer would have been deadly if it had been left alone, undetected.
Not all cancers will spread and kill, and sometimes the outcome is the same whether a cancer is found earlier or later. But with screening, doctors treat any tumors they find because they cannot tell which are worrisome and which are not.
In the end, screening, far from preventing cancer, actually leads to more cancer patients, Dr. Kramer noted, by finding both those whose cancers would have been deadly and those whose cancers would never have been a problem because they would have remained small and never spread, or would even have disappeared.
"People often talk about mammograms to prevent breast cancer when what it's done is to increase, not decrease, the incidence of breast cancer," Dr. Kramer said.
Many people decide to take their chances with screening, reasoning that they would rather be treated for a cancer that would not have killed them than to miss being treated for a cancer that could be lethal. But it is not easy to know if screening helps or harms over all, Dr. Kramer said, adding that it requires large controlled trials. Such studies, he noted, have not yet been completed for some popular tests, like the P.S.A. test for prostate cancer and spiral CT tests for lung cancer.
As for genetic screening to see who is susceptible to cancer, that is still in its infancy, Dr. Berry said. There are a couple of genes that predispose to breast cancer and a couple that predispose to colorectal cancer. "Not much is known beyond that," he said. And other than taking tamoxifen to prevent breast cancer or having one's breasts, ovaries or colon removed to prevent cancers in those organs, what does someone do who is genetically susceptible? Another research question, Dr. Berry said.
When it comes to other prevention strategies, like diet, Dr. Kramer said, "it gets a lot trickier." He urges caution in jumping to conclusions that specific foods, or diets, or even weight loss will be protective. Researchers often find associations between diets and cancer risk, but that does not mean that a particular diet or food caused or prevented cancer, he said. The history of research in this area has been sobering.
For example, study after study found that people whose diets were high in beta carotene had a lower incidence of lung cancer. But in studies in which smokers and former smokers took beta carotene supplements, it turned out that the vitamin actually increased lung cancer risk and lung cancer deaths. Studies found associations between high-fiber diets and reduced incidence of colon cancer. But a large study that randomly assigned some subjects to high-fiber diets found no reduction in cancer or in polyps, the growths that can precede cancer.
At Memorial Sloan-Kettering, Dr. Shike said, patients are taught how to eat healthy diets and even go over their diets food by food with a nutritionist and a computer program, but are not told that diets are a panacea. "We are not saying you can prevent cancer with a healthy diet, but we say a healthy diet and a healthy weight are part of a healthy lifestyle, which can help lower your risk."
Dr. Berry has a different view of cancer prevention centers. For now, while research continues, perhaps their greatest value to healthy people is not so much in giving them ways to prevent cancer but in showing them that their fears of getting cancer may be exaggerated and that if they do develop cancer, it usually is not because they did something wrong.
"The person in the street greatly exaggerates their risk of cancer," Dr. Berry said. One thing a cancer prevention center can do, he said, is let people know their real risk and the real effect of measures that many think will give them cancer, or protect them from it.
"We can be letting them know that changing their lifestyle may change their risks, but not by much," Dr. Berry said. "We can be letting them know that while hormone therapy may increase the risk of breast cancer, it does not increase it much."
Copyright 2004 The New York Times Company

The challenge, again
Baltimore Sun Editorial
Sunday, January 11, 2004
MEMBERS OF THE Maryland General Assembly departed Annapolis last spring like errant 9-year-olds, their most pressing homework left incomplete. As the state's political leaders gather again this Wednesday for the start of another 90-day session, they have a chance to atone, to mend old wounds, confront tough issues, end partisan bickering and find common ground.
So why does that seem so unlikely?
Alas, Gov. Robert L. Ehrlich Jr. and House Speaker Michael E. Busch remain in a depressingly familiar strait - the same deadlock over slot machines and the state's $1.8 billion budget deficit that they were stuck in last April. Mr. Busch doesn't want to expand gambling, but he might budge if the governor agrees to raise taxes. Mr. Ehrlich likes slot machines, but he won't go near a broad increase in taxes, particularly Mr. Busch's favorite budget-balancer - a penny more on the sales tax.
The clash looms as the spinning black hole of Annapolis. No issue of fiscal consequence can move through the legislature unless this conflict is resolved. And as if this crisis doesn't seem dire enough, be reminded: At stake in the non-debate is the state's ambitious schools initiative - the five-year, $1.3 billion Thornton Commission plan to boost public education statewide.
Some legislators grumble that Thornton is the deficit, and there is some truth to that. When approved by lawmakers in 2002, the plan lacked financing. It still does. Mr. Ehrlich has once again tied Thornton to slots. His message: If slots aren't acceptable, then Thornton gets scaled back after this year. Others in Annapolis, fearful of the looming budgetary train wreck, have even suggested recently that Thornton be deferred, stretched out or delayed no matter what happens to slots. Neither approach is particularly responsible.
In Annapolis, it is said that the first two years of any new administration are its most important. Now is the only chance for a newly elected governor to be bold. His political clout is at its height and voters at their most forgiving (since the next election is two years away). Last year was a painful lesson. This year may be the state's best hope.
With so much at stake, voters should rightly expect that Mr. Ehrlich, Mr. Busch and Senate President Thomas V. Mike Miller would have locked themselves in a room by now, vowing not to emerge until they've found a way out of this mess. Maybe even the beginnings of a compromise. But that has not happened yet. By all accounts, the state's most powerful leaders are barely on speaking terms. How depressing. How irresponsible. How ... familiar.
Yet even in this gloom, there is a flicker of hope. The Thornton funds haven't been cut - yet. The administration believes its most pressing problem - next year's $700 million chunk of the deficit - can be bridged through budget cuts and modest new sources of revenue (with neither a major tax hike nor money from slots as part of that plan). That's not a long-term solution, of course. But there also are signs that Mr. Ehrlich will be better prepared for this session than last. His agenda is more ambitious, his State House team a bit more experienced, the economic outlook less bleak.
That's a start. What we need now is for both sides to demonstrate a willingness to compromise. Mr. Ehrlich needs to stop being absolute about slots and taxes. Democrats need to hold their wagging tongues, offer new approaches (rejecting the advice of party hacks who'd rather they sandbag the governor), and then find a solution that they, and the governor, can endorse.
Experience tells us that the State House pot will have to boil a while before that could happen. Everyone will get steamed and the rhetoric will fly. But ultimately, the politicians should be graded not on what gets said but on what gets accomplished: The coming 90 days are the best indicator yet of who deserves favor - or a quick dismissal in 2006.
Copyright � 2004, The Baltimore Sun

General Assembly session will revolve around fiscal issues
Annapolis Capital Editorial
Sunday, January 11, 2004
LAST WEEK in Annapolis, as we reported, there was some interesting discussion of the state's continuing fiscal crunch, and some bold - if sometimes impractical - proposals for easing it.
The trouble is, the forum at St. John's College, co-sponsored by the Calvert Institute and Maryland Business for Responsive Government, wasn't a gathering of elected officials. In fact, none of the state's 188 legislators showed up at the symposium, held two blocks from the State House.
The legislators will be here this week to start their own 90-day symposium, and it will be vastly entertaining. There will be maneuvering and egos and games of beat-the-deadline and who's-up-and-who's-down. There will be cameo appearances by all sorts of issues, relevant and irrelevant.
But at the bottom of it all will be the basic dilemma discussed, if not resolved, at the symposium:
Even with the economy accelerating, the state is still in a fiscal hole of about $700 million. It is also committed to a huge increase in educational funding - the Thornton plan. Gov. Robert Ehrlich is committed to not raising sales or income taxes (although it seems to be a different matter with other taxes and fees).
The governor thinks he can fill much of the gap by legalizing slot machines, although so far he hasn't come up with a convincing plan for doing so. Indeed he spent much of last year saying he wouldn't even try, before changing his mind last month. The speaker of the House and other state political leaders remain opposed to slots.
In short, something has to give. What will it be?
Of course, we don't know what will happen. But we do sense an impending political disaster. Mr. Ehrlich, a bright and dynamic politician with the chance to permanently change Maryland's unhealthy tilt toward one-party government, remains convinced that slot machines are the state's path to solvency.
Quite apart from the social damage involved - sufficient reason to reject slots - what sense does it make to tie school spending, of all crucial priorities, to something as mercurial and unsteady as gambling revenue? What sort of legacy is that for a fiscal conservative? With time ticking away on Mr. Ehrlich's chances to reach a bipartisan consensus with the General Assembly - the closer he gets to the next election, the harder it will be - does he really want to expend effort and credibility on this?
By the way, we're not endorsing the notions discussed at last week's symposium. We're not as convinced as some of the participants that the state has run out of fat to cut and has no alternative to higher taxes. Some of the ideas - a tollbooth at the Wilson Bridge, anyone? - were hilariously impractical. But will the governor and the General Assembly do better? That, you might say, is the $700 million question.
Published January 11, 2004, The Capital, Annapolis, Md.
Copyright � 2004 The Capital, Annapolis, Md.

Choosing state's doomsday budget scenario
By C. Fraser Smith
Baltimore Sun Commentary
Sunday, January 11, 2004
THREE OF the state's most experienced and highly regarded students of government finance offered their views on how to deal with Maryland's deficit during a sparsely attended forum last week at St. John's College in Annapolis. For the most part, they left politics out of their equations.
Call it fiscal tennis without a net, but it was a scintillating exchange nonetheless.
Two days later, on the campus of the General Assembly, the net was up -- way up.
James C. "Chip" DiPaula Jr., Gov. Robert L. Ehrlich Jr.'s estimable budget secretary, said increased education funding hinges on passing a slot machine gambling bill. There will be no other sufficiently large revenue source, he said -- no sales or income tax increase. It was not a new warning.
Immediately, House Speaker Michael E. Busch declared again that gambling is the wrong way to pay for a public service as fundamental as education. The people and their representatives should assume that responsibility -- not slough it off on gamblers. He suggested a penny increase in the sales tax. Nothing new there, either.
Thus did the speaker and the governor redraw lines that have divided them over the last year or so. Neither man doubts the resolve of the other by now. But change is not unimaginable as the 2004 legislative session begins Wednesday. What worries many in Annapolis these days is also not new: The opposing sides don't talk much with each other. What you have is a kind of rolling stalemate in which two of the government's power centers haven't found a way to negotiate.
Senate President Thomas V. Mike Miller Jr., a Democrat, has sided with the governor in this debate, judging apparently that Mr. Ehrlich is right politically: people don't want to pay more taxes. Mr. Miller also is on the side of those Democrats who believe slots, even when operating at full bore, won't produce enough money to pay down the deficit and maintain other state services. In that event, the Republican governor would be driving Maryland into the ditch. Democrats could ride in to save the day with a tax increase that would hardly be felt. It's a dreary scenario.
Is there a politically feasible alternative? Maybe not in this new day of partisan, campaign promise-driven politics. But maybe reason will prevail.
Mr. Busch signals he's ready to relent on slots -- but only if compromise includes the governor's agreement to sign a tax bill. His apparent thinking: If you simply grant the gambling venture, you lose leverage for a tax increase. Better to stand firm, deny the slots revenue and let government go into the ditch in time for people to see the results before they vote for governor in 2006. You can have your doomsday now or you can have it later.
So, you ask, what role might wise advice and the public interest play in such an atmosphere?
At St. John's College, a starting point was quickly identified by the experts: William S. Ratchford II, former fiscal adviser to the Assembly; Robert R. Neall, former county executive and former state senator; and Nancy K. Kopp, state treasurer, were joined by George W. Liebmann of the Calvert Institute for Policy Research and James T. Brady, a businessman, Ehrlich administration adviser and former secretary of economic development.
Their thought? Maryland's tax structure is outdated, unfair and inefficient at a time when maximum efficiency is needed. An update would produce more revenue. The mere mention of the "T-word," even if followed by the word study, sends tremors through the political strategist's soul. This conclusion is not new, either. But politics always get in the way.
Are you studying the system so you can reduce taxes? Well, of course not. But you might be trying to align the tax structure with the economy as we know it. Fiscal leaders have been saying for some time that a service economy demands taxes on services: from those provided by lawn services to those you're supposed to get from lawyers and car repair shops. Yes, each of these groups will squeal. Retail merchants don't want an increase in the sales tax. People with lots of money don't want even a temporary surcharge on the income tax.
Oh dear. What to do. Pass slots and pray? Raise the sales tax? Increase fees because the fee word doesn't begin with T? Watch it all heading for the ditch? None or all or some of the above?
Look carefully at the options, select one and then sell it like political leaders ought to do.
C. Fraser Smith is news director for WYPR-FM. His column appears Sundays.
Copyright � 2004, The Baltimore Sun

In Annapolis, A War of Absolutes
By Tim Maloney
Washington Post Commentary
Sunday, January 11, 2004; Page B08
Maryland's chronic budget problems continue, but the state's finances are no longer a victim of the economy. Instead, the budget is being held hostage by political absolutists on both the spending and tax side who seem incapable of compromise.
The result? Maryland's key economic indicators appear stronger than those of most states, but its budget deficit continues to be larger than those of most states too.
Maryland's unemployment rate is the seventh-lowest in the nation, and the state also ranks seventh in job growth. Its housing market is the fifth-strongest in the nation, and Marylanders' personal income is far above the national average. The state's economic indicators grow stronger every day.
But a strong economy doesn't necessarily translate into a strong budget. Just a year ago, 31 states faced budget gaps totaling $17.5 billion. Most of these states have eliminated their deficits, but not Maryland. Today, Maryland is one of fewer than a dozen states still reporting significant budget gaps, with a deficit standing at $715 million.
What gives?
The Maryland deficit is a political condition, not an economic one. Anyone doubting this proposition need only recall April 4, 2002, the date that the Maryland General Assembly finalized the final phase of a $600 million income tax cut while enacting the six-year, $1.3 billion Thornton education funding commitment. Neither action was affordable. Neither was responsible. Reverse the two decisions, and Maryland's $715 million deficit turns into a $250 million surplus.
Of course, no one expects the income tax cut to be reversed or Thornton to be repealed. But Maryland needs to significantly modify both its education spending and its tax policies it if wants to preserve its triple-A bond rating and attain fiscal recovery.
But this requires compromise, the enemy of the absolutism reigning in Annapolis.
On the spending side, the absolutists demand funding Thornton's full cost of $1.3 billion. This number was developed on the basis of a consultant's complex report that cited the figure as the price of "educational adequacy" throughout the state, with an additional $80 million beyond the consultant's recommendations thrown in to pacify Montgomery County.
The thirst for additional dollars for education from kindergarten through 12th grade is unquenchable. In these circles, the Thornton spending recommendations have achieved an infallibility usually reserved for papal pronouncements. Responsible efforts to impose fiscal integrity on Thornton's massive cash call are usually met with a one-word threat: litigation.
Fortunately, this is a hollow threat. The notion that the state's educational finance system is unconstitutional unless the legislature appropriates an additional $1.3 billion is ludicrous. The Maryland Court of Appeals rejected a more ambitious challenge 20 years ago, and education aid today is larger by $2.2 billion annually.
Of course, missing from this debate is accountability. Few are asking what improvements occurred as a result of the $2.2 billion increase in educational spending. Last week it was announced that 60 percent of the state's high school seniors failed the English I competency exams. A promised administration task force to study school performance has not yet materialized.
At the other end of the philosophical spectrum are the "no-tax" absolutists. These legislators oppose raising state tax rates by even a penny, regardless of Maryland's fiscal condition. This translates into great 30-second TV ads, but it is terrible public policy.
Tax policy, like a budget, is dynamic. Throughout history, the legislature has modified the tax structure to meet the demands of the economy. When the retail economy emerged, it adopted a sales tax. When expressways and subways were needed, transportation taxes were levied.
But today the absolutists want the state's tax structure to be carved in stone. This means, for instance, that, without new revenue, the state's transportation program will become functionally insolvent in two years. And the state's capacity to benefit from technology growth will be limited by its '50s-style sales tax structure.
Many legislators have a healthy fear of both the no-tax absolutists and the Thornton absolutists. Some try to satisfy both by supporting Thornton and opposing new taxes to pay for it. This has created political gridlock.
Paralysis, though, has a way of making its own policy. For instance, by insisting on funding Thornton without new taxes, the state is essentially financing K-12 education by cutting higher education; 18 percent tuition increases at state colleges and universities are to make up for the more than $100 million in cuts. This represents a large transfer of support from higher education to primary and secondary schools.
On the transportation side, Maryland is facing a $300 million annual funding gap, and yet it borrowed $300 million from the transportation trust fund to pay general-fund operating expenses. By doing nothing, Maryland has sacrificed its highway program -- now ranked 47th in the nation -- to general fund spending and rising mass transit costs.
The same dynamic is at work in health care, with Medicaid costs rising $212 million this year and eroding the state's capacity to provide other critical preventive health care programs.
It is these dynamics, not deliberate decisions by the state's elected leaders, that will drive the budget. Despite its economic recovery, Maryland will not have a budget recovery without political leadership.
Compromise requires courage and hard work. By comparison, absolutism is easy. Whether Maryland has leaders who will stand up to absolutism and demonstrate leadership remains to be seen.
The writer is a lawyer and former Democratic member of the Maryland General Assembly. His e-mail address is tmaloney@jglaw.com.
� 2004 The Washington Post Company

No more free ride
By James K. Glassman
Baltimore Sun Commentary
Sunday, January 11, 2004
POLITICIANS CONTINUE their misguided -- and dangerous -- attempts to circumvent federal law in order to bring large quantities of prescription drugs into the United States from Canada.
In the latest episode, Illinois Gov. Rod R. Blagojevich asked U.S. authorities Dec. 22 to waive current laws and designate his state for the nation's first "federally approved drug importation program."
But Mr. Blagojevich, along with other advocates of reimportation in Congress and the states, is being disastrously short-sighted as well as economically obtuse. The most likely effects of reimportation would be fewer high-quality drugs for Canadian citizens, more risk of counterfeit or contaminated drugs for Americans and reduced incentives for pharmaceutical companies to spend billions of dollars a year to find new medicines.
In other words, if the reimporters are successful, their efforts will lead to more illness and more deaths.
Mr. Blagojevich and his allies have the problem exactly backward. Instead of focusing on re-importation, they should be pushing Canada and other countries to liberate their health care systems -- to end subsidies and restrictions and open their markets.
Canadians spend less on drugs for two reasons: First, they are poorer than U.S. citizens, so demand is lower, and second -- and more important -- their government imposes price controls on drugs and, through its monopoly health care system, restricts and delays the availability of new medicines.
Canada is not alone. Similar government monopolies, with power over price-setting and availability, prevail in Europe, Australia and elsewhere. Almost certainly, these countries are violating World Trade Organization rules by erecting barriers to the free flow of U.S. exports at market prices and by blackmailing the companies into offering them drugs at lower prices in order to avoid losing patent rights. That's bad enough, but now American politicians such as Mr. Blagojevich want to import this destructive system to the United States.
If, with the proper safety precautions, pharmaceuticals flowed freely across borders, as they should, then prices to consumers in countries with similar levels of income -- and, thus, demand -- would be nearly the same, just as a digital camera costs roughly the same in Toronto, Rome and Chicago.
U.S. policy-makers should focus attention not on the fact that Americans pay more for drugs, but on the fact that Canadians pay less because they are freeloading on Americans. U.S. consumers provide the funds necessary for pharmaceutical firms -- nearly all of them now U.S.-based -- to make the investment in research to develop new drugs. But the rest of the world benefits from those drugs.
This is the outrage, and it is reassuring that rather than playing demagogues, as has Mr. Blagojevich, top U.S. officials are speaking out responsibly and forcefully.
For example, House Speaker Dennis Hastert stated Dec. 11: "It is wrong that our friends in Canada use threats to steal the patents of American drug companies in order to negotiate lower prices, and their price control regime is unfair to American consumers. Americans shouldn't be forced to subsidize health care for the rest of the world. By getting fairer pricing in Canada, American consumers will get fairer prices for their prescription drugs."
Mr. Hastert's strong statement reflects action taken by the House and Senate in their conference agreement on the Medicare bill last year. The pact calls for a study by the Commerce Department that will identify "countries that use price controls or other such practices with respect to the pharmaceutical trade" and then estimates the "additional price to U.S. consumers because of such price controls" and the impact of "fair pricing, innovation, generic competition and research and development."
The agreement also directs the U.S. trade representative and other officials to analyze whether trade negotiations "present an opportunity to address these price controls" and other restrictive practices. This study, due in mid-year, will shine a spotlight on the real problem: nationalized health systems, directed by overweening bureaucrats with no interest in the process of developing life-saving drugs.
Republican Rep. Philip M. Crane of Illinois, who chairs the Ways and Means Trade Subcommittee, as well as all the top Republicans on that panel, signed a letter in November encouraging Trade Representative Robert B. Zoellick to "address Australian price controls as part of the U.S.-Australia free trade agreement."
The Australian government's Pharmaceutical Benefits Scheme covers 96 percent of all drugs. It thus has the power of what economists call a "monopsony" -- in effect, a single purchaser of a product. The PBS regularly delays or denies access to U.S. pharmaceuticals and sets unreasonably low prices.
This is how Australians, like Canadians and many Europeans, act as free riders. They get the benefits of pharmaceutical innovations while Americans pay for the research. This must end -- but it won't happen through reimportation.
It can happen, however, through tough trade negotiations. We need to force other countries to live up to their treaty obligations and stop subsidizing and restricting the flow of pharmaceuticals and controlling their prices. When that happens, a true free market will prevail worldwide, and Americans will be beneficiaries.
James K. Glassman is a fellow at the American Enterprise Institute.
Copyright � 2004, The Baltimore Sun

Afflicted By Comfort
By George F. Will
Washington Post Commentary
Sunday, January 11, 2004; Page B07
"What good is happiness? It can't buy money." -- Henny Youngman
Social hypochondria is the national disease of the most successful nation. By most indexes, life has improved beyond the dreams of even very recent generations. Yet many Americans, impervious to abundant data and personal experiences, insist that progress is a chimera.
Gregg Easterbrook's impressive new book, "The Progress Paradox: How Life Gets Better While People Feel Worse," explains this perversity. Easterbrook, a Washington journalist and fellow of the Brookings Institution, assaults readers with good news.
American life expectancy has dramatically increased in a century, from 47 to 77 years. Our great-great-grandparents all knew someone who died of some disease we never fear; as recently as 1952, polio killed 3,300 Americans. Our largest public health problems arise from unlimited supplies of affordable food.
The typical American has twice the purchasing power his mother or father had in 1960. A third of America's families own at least three cars. In 2001 Americans spent $25 billion -- more than North Korea's GDP -- on recreational watercraft.
Factor out immigration -- a huge benefit to the immigrants -- and statistical evidence of widening income inequality disappears. The statistic that household incomes are only moderately higher than 25 years ago is misleading: Households today average fewer people, so real dollar incomes in middle-class households are about 50 percent higher today. Since 1970 the number of cars has increased 68 percent and the number of miles driven has increased even more, yet smog has declined by a third and traffic fatalities have declined from 52,627 to 42,815 last year. In 2003 we spent much wealth on things unavailable in 1953 -- a cleaner environment, reduced mortality through new medical marvels ($5.2 billion a year just for artificial knees, which did not exist a generation ago), the ability to fly anywhere or talk to anyone anywhere. The incidence of heart disease, stroke and cancer, when adjusted for population growth, is declining.
The rate of child poverty is down in a decade. America soon will be the first society in which a majority of adults are college graduates.
And so it goes. But Easterbrook says that such is today's "discontinuity between prosperity and happiness," the "surge of national good news" scares people, vexes the news media and does not even nudge up measurements of happiness. Easterbrook's explanations include:
� "The tyranny of the small picture." The preference for bad news produces a focus on smaller remaining problems after larger ones are ameliorated. Ersatz bad news serves the fundraising of "gloom interest groups." It also inflates the self-importance of elites, who lose status when society is functioning well. Media elites, especially, have a stake in "headline-amplified anxiety."
� "Evolution has conditioned us to believe the worst." In Darwinian natural selection, pessimism, wariness, suspicion and discontent may be survival traits. Perhaps our relaxed and cheerful progenitors were eaten by saber-toothed tigers. Only the anxiety-prone gene pool prospered.
� "Catalogue-induced anxiety" and "the revenge of the plastic" both cause material abundance to increase unhappiness. The more we can order and charge, the more we are aware of what we do not possess. The "modern tyranny of choice" causes consumers perpetual restlessness and regret.
� The "latest model syndrome" abets the "tyranny of the unnecessary," which leads to the "10-hammer syndrome." We have piled up mountains of marginally improved stuff, in the chaos of which we cannot find any of our nine hammers, so we buy a 10th, and the pile grows higher. Thus does the victor belong to the spoils.
� The cultivation -- even celebration -- of victimhood by intellectuals, tort lawyers, politicians and the media is both cause and effect of today's culture of complaint.
Easterbrook, while arguing that happiness should be let off its leash, is far from complacent. He is scandalized by corporate corruption and poverty in the midst of so much abundance. And he has many commonsensical thoughts on how to redress the imbalance many people feel between their abundance of material things and the scarcity of meaning that they feel in their lives. The gist of his advice is that we should pull up our socks, spiritually, and make meaning by doing good while living well.
His book arrives as the nation enters an election year, when the opposition, like all parties out of power, will try to sow despondency by pointing to lead linings on all silver clouds. His timely warning is that Americans are becoming colorblind, if only to the color silver.
� 2004 The Washington Post Company

Two Holes in the Medicare Drug Law
By Fred Brock
New York Times Commentary
Sunday, January 11, 2004
THERE are a couple of questions that few people seem to be asking about the limited Medicare prescription drug law that goes into effect in 2006:
What impact will it have on pharmaceutical companies' programs that offer free drugs to low-income people, including those on Medicare?
Why does the law prohibit beneficiaries from buying private insurance to cover the considerable gaps in coverage?
The drug companies themselves are struggling with the first question, as is their trade group in Washington, the Pharmaceutical Research and Manufacturers of America. But one thing is clear: if the companies do not change their requirements by 2006, thousands of older low-income Americans will lose access to free or nearly free drugs. That's because participants in the programs generally must not have any drug coverage or access to it. Of course, they will have access to drug coverage in 2006 - although with coverage gaps that could cost thousands of dollars a year.
The free-drug programs are crucial for many recipients. The income limits are not that strict: in some cases, people earning up to $50,000 a year can qualify. The drugs are commonly dispensed through doctors or via discount cards; patients usually have to requalify regularly and apply separately to each company that makes the drugs they need.
Nancy Pekarek, a spokeswoman for GlaxoSmithKline, said her company had made no decisions yet about its free-drug program. "We have to see what this new Medicare bill is really saying and how it will play out, or be amended," she said.
She said one possible option was for GlaxoSmithKline to change its requirements and allow free drugs to be offered to low-income people when they encounter gaps in the new benefit. One gap is the so-called doughnut hole, under which coverage stops after a person spends $2,250 in a given year, and does not pick up again until drug expenses reach $5,100. That means an outlay of $2,850, not to mention premiums, deductible and co-payments.
"We've had this program in place for a long time, recognizing there are people who fall between the cracks in the system and need some assistance," Ms. Pekarek added. "My guess is there will still be people falling between the cracks after 2006."
Rick Luftglass, director of United States philanthropy at Pfizer, said changes in Pfizer's program were "up in the air and hard to answer at this point."
Pfizer provided free or nearly free drugs through various programs to 1.7 million patients of all ages in 2002. To get free Pfizer drugs through a doctor, a patient must have an income of less than $16,000, or $24,000 for a couple. Pfizer also offers a discount card for low-income Medicare patients that gives them a 30-day prescription of a Pfizer drug for $15. The new Medicare law includes a discount card, to be available this spring, for discounts of 10 to 25 percent. What this will mean for the Pfizer card is unclear. "We have made no decisions," said Mariann Caprino, a spokeswoman for Pfizer.
Robert M. Hayes, president of the Medicare Rights Center, a nonprofit group based in New York that helps people handle Medicare and Medicare H.M.O. problems, said he was concerned that "the drug companies may decide to end their discount cards because of the Medicare discount card."
MOST of the drug companies explain their free drug programs on their Web sites. In addition, the Pharmaceutical Research and Manufacturers of America Web site (www.phrma.org), provides information on all the programs offered by its members.
The prohibition against buying private insurance, meanwhile, will hit middle-income people the hardest. "Many people will be forced to put out their own money, even if they want to buy insurance," Mr. Hayes said.
A report accompanying the final Medicare bill when it was passed last year said the insurance prohibition was to keep beneficiaries from becoming "insensitive to costs." Well, if your mother needs a prescription, her "sensitivity" is not going to lessen her need, but the cost may lessen her ability to buy it. And why shouldn't she be allowed to buy private insurance to help if she wants to? By that logic, should we prohibit auto insurance to make people sensitive to high repair costs?
Some administration and Congressional officials argue that older Americans would consume less health care if they had to pay more for it, so the government would save money. Maybe, but what are the health consequences?
Deane Beebe, a spokeswoman for the Medicare Rights Center, said: "The whole concept is based on the idea that people will use too much medication if they have coverage. We're really troubled by that."
Mr. Hayes added, "There is something very unrealistic about politicians who think that people will rush off to take prescription medication they don't need."
The law, however, allows states to cover the gaps and deductibles for low-income people as long as no federal money is used.
"So the policy argument is that you want people to actually spend money to enjoy a benefit, but the bill is inconsistent in allowing states but not insurance companies to step in," Mr. Hayes said. "But this will vary widely from state to state. It's a crazy quilt."
He added: "This insurance prohibition will hit a broad swath of the middle class. It will hurt more people than it will help."
Mr. Hayes said he believed that the prohibition might be eliminated before 2006, partly because of pressure from insurance companies that want to sell the coverage.
"A lot of people who voted for this bill," he said, "had no clue about this provision."
Fred Brock is an editor at The Times. His column on the approach and arrival of retirement appears the second Sunday of each month. E-mail: fbrock@nytimes.com.
Copyright 2004 The New York Times Company

Annapolis Capital Letter to the Editor
Sunday, January 11, 2004
My son has been having chelation therapy for over two years after being diagnosed with five learning disabilities. He has already released over 1,400 micrograms of various heavy metals, including mercury.
I attended a "Defeat Autism Now" spring conference and heard Dr. Stephanie Cave speak on thimerosal poisoning and safe vaccinations. Presently, the medical community has been treating only the end result of a catastrophic toxic insult at the beginning of the physical and neurological development of children. These children are suffering from serious physical health conditions.
I attempted to contact the governor's office; Sen. Barbara Mikulski, D-Md.; area health departments; the Environmental Protection Agency and the Food and Drug Administration.
Only the FDA replied. When asked what was being done to address this problem, it stated that there was no proof that the traces of heavy metals came from thimerosal. I replied, "It's not traces, it's thousands!"
Introducing a toxin at the beginning of life convinces the body that a toxin is a nutrient. Consequently, the body absorbs environmental toxins as well.
The medical community should do the appropriate testing to diagnose the devastating health conditions that exist in these children. Currently, Maryland has the third-highest rate of autism in our country.
The first vaccine with thimerosal came out in the 1930s. I believe Dr. Leo Kanner, who documented this disorder in the 1940s, was really diagnosing three rare, but different, disorders that can have similar symptoms.
For a list of vaccines containing thimerosal, go to www.autism-mercury.com. Look for the latest report, soon to be released by Tulane and Wake Forest universities, based on Dr. Andrew Wakefield's research, on www.icdrc.org
Published January 11, 2004, The Capital, Annapolis, Md.
Copyright � 2004 The Capital, Annapolis, Md.