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DHMH Daily News Clippings
Sunday, January 11, 2009


Maryland / Regional
County may reopen enrollment in medical services plan for limited-income residents (Baltimore Sun)
Salmonella hits Maryland (Baltimore Examiner)
Budget Cuts Are Focus for Md., Va. (Washington Post)
National / International
Director of Disease Control Centers Resigns (New York Times)
Education could slow teen births (Carroll County Times Editorial)
Parallel crises in health care, higher education (Baltimore Sun Commentary)
We All Want Longer, Healthier Lives. But It's Going to Cost Us. (Washington Post Commentary)
The Dying of the Light (Washington Post Commentary)
County may reopen enrollment in medical services plan for limited-income residents
By Larry Carson
Baltimore Sun
Sunday, January 11, 2009
Crafting a new way to extend medical services to uninsured residents has proved tricky for county health officials.
The health staff was initially overwhelmed in October, when 1,100 people came to the East Columbia library during nine sessions to enroll in Healthy Howard Inc. All but 66 turned out to be eligible for four existing insurance plans for limited-income people.
Now county health officer Dr. Peter Beilenson has come up with a new plan to reopen enrollment while trying to counter criticism from County Council member Greg Fox, a Fulton Republican. Fox argues that too few have been enrolled in the program to justify the county's $500,000 contribution. Healthy Howard offers a full range of health care for legal county residents without insurance for at least six months for as little as $50 a month.
Over the next few months, Beilenson wants to enroll more people in Healthy Howard, while placing applicants eligible for other, existing programs on a waiting list.
"We are not going to be targeting all comers for the next several months," he said.
Beilenson, who will present his revised strategy to the County Council tomorrow, said that his staff is seeking people like part-time community college instructors and students, state and county contractual employees, small-business workers without benefits, residents in subsidized housing, and the parents of children enrolled in a federally funded insurance program for limited-income people.
"We want to make sure we get our enrollment numbers up," Beilenson said, in the hope that public support for the program doesn't wane.
The original goal was to enroll up to 2,200 people in either Healthy Howard or an existing program by October. That's about 10 percent of the estimated number of county residents without insurance. The program, however, is experimental and intended to be a source for research data to see whether the program could be duplicated elsewhere.
"I don't want to be concerned about people questioning using $500,000," Beilenson said. "Politically speaking, if we've got 1,500 [enrolled by year's end] it's defensible. If we're serving 300, there is a real question."
So far, Beilenson has strong support from County Executive Ken Ulman and other council members, including this year's chairwoman, Mary Kay Sigaty, a west Columbia Democrat.
"To me, I'm a bit bemused at this whole issue," Ulman said about Fox's criticisms. "We've been able to get over 1,000 people. That's a huge accomplishment. We always knew this would be a work in progress."
Sigaty said she, too, supports the initiative.
"It is what we should be doing," she said, calling the October enrollment "a pretty good start."
Fox argues that not enough research was done before the program's launch. He has questioned the use of county funds, and ridiculed the questions the program's health coaches would ask participants to promote healthier lifestyles.
"Is his goal to get most people insured or get people in his signature program?" Fox asked.
If so many people are eligible for existing programs, that should have been the county's focus, he said.
"This has been in the press since October," he said. "People should have been banging down the doors."
Asking people if they take walks or are following suggestions about changing eating habits is silly, he suggested.
"I think it's a joke if you're going to track how people do these things," Fox said, though he would not say that the program should be ended or county funds withdrawn.
Beilenson found Fox's criticism groundless.
"We did a tremendous amount of research," he said.
Beilenson said that 299 people the county enrolled in a Kaiser Permanente insurance program also would have qualified by income for Healthy Howard. Full insurance is better, though, Beilenson said. Healthy Howard is not insurance and is only available inside the county.
The effort for the next few months will target people with incomes of roughly $20,000 to $30,000 for one person, or $40,000 to $63,600 for a family of four, Beilenson said. People interested in enrolling can go to the program's Web site, www.healthyhowardplan.org/apply, where they can fill out a brief screening form.
A program worker will call each applicant within two weeks, Beilenson said.
He speculated that many who need health care still may not have read or heard about Howard's unusual program. Ulman agreed with that.
"It's hard to reach out to people," he said.
Joanne Stato, a Baltimore resident who formerly taught English part time at Howard Community College, said she and other adjunct professors had no benefits.
"I prayed for a health benefit program like this while I still worked there," she said, adding that she later found a job with benefits in Baltimore.
Copyright © 2009, The Baltimore Sun

Salmonella hits Maryland
By Sara Michael
Baltimore Examiner
Sunday, January 11, 2009
At least seven people in Maryland have been sickened by a strain of salmonella sweeping the country.
So far, 388 people in 42 states have become infected by Salmonella typhimurium, according to the Centers for Disease Control and Prevention.
People started getting sick between Sept. 3 and Dec. 29, and most of the illnesses started after Oct. 1, the CDC said. Eighteen percent of the people have been hospitalized.
Seven cases with the same DNA fingerprint of this strain have been identified in Maryland, and of those, two were hospitalized, according to Dr. David Blythe, state epidemiologist at the Department of Health and Mental Hygiene.
"As we continue to look for Maryland cases, that number may change," he said in a statement, adding that an average of 800 to 1,000 salmonella cases are reported in Maryland each year -- 40,000 nationwide.
CDC officials are working with local public health officials to identify the contaminated product.
Salmonella can cause fever, diarrhea and abdominal cramps, according to the CDC. A small number of people with salmonella develop joint pain, irritation of the eyes and painful urination, a condition called Reiter's syndrome, which can last for months or years, and lead to chronic arthritis.
This latest outbreak comes months after Salmonella saintpaul sickened 1,442 people -- 39 in Maryland. That outbreak, which ended in August, was linked to jalape?o and serrano peppers from Mexico.

Budget Cuts Are Focus for Md., Va.
Legislators Meet This Week Facing Major Shortfalls
By John Wagner and Anita Kumar
Washington Post
Sunday, January 11, 2009; C01
Maryland and Virginia lawmakers will return to work Wednesday with thousands of bills to consider and one bleak reality hanging over their heads: If anything costs money, forget it.
With both states facing their worst financial crunches in decades, legislators are hunkering down for sessions that will be dominated by deep spending cuts and searches for creative ways to ease the pain -- and that will feature virtually no discussion of initiatives that come with a price tag.
"You're going to be hard-pressed to go forward with anything new," said Maryland Sen. Edward J. Kasemeyer (D-Baltimore County), vice chairman of the Budget and Taxation Committee, which has signed off in recent years on expanded funding for subsidized health insurance and cleanup of the Chesapeake Bay. "The question will be what kind of things we put off and don't do."
In Maryland, the General Assembly will start its annual 90-day session facing a budget shortfall of almost $1.9 billion for the fiscal year that starts in July. In Virginia, lawmaker will return for a 45-day session largely focused on cutting $2.9 billion from the two-year budget that took effect in July.
In both states, the magnitude of the shortfalls is prompting talk of measures that would have seemed foreign in recent years, as lawmakers look for ways to keep cuts to essential services, including education, health care and public safety, from getting any deeper than necessary.
Maryland lawmakers are considering freeing up money from their annual capital budget -- typically reserved for construction of schools, prisons and other projects -- to cover state operating expenses. Some legislators want to hand off teacher pensions and other expenses to counties. And there is serious talk about withdrawing money from the state's "rainy-day" reserve fund, a step state leaders have been reluctant to take for fear of alarming bond-rating agencies.
Virginia will also be weighing a proposal to make the largest withdrawal ever from its rainy-day fund, along with controversial plans by Gov. Timothy M. Kaine (D) to offer early release to some prisoners doing time for nonviolent offenses and to double the cigarette tax. Maryland lawmakers, who passed multiple tax increases in 2007, have all but ruled out more hikes to help close budget shortfalls this year.
Virginia Del. Terry G. Kilgore (R-Scott) said House leaders have instructed all 100 delegates to search for cuts and to look for ways to make government spending more efficient.
"Everyone needs to be concentrating on the budget this year," Kilgore said. "The budget transcends everything."
Other issues are expected to get an airing, of course.
In Maryland, Gov. Martin O'Malley (D) has signaled that he will push a package of anti-domestic violence laws, which would have no significant effect on the state's bottom line. O'Malley has also asked lawmakers to take another look at repealing the death penalty.
And legislative leaders say they will take up bills affecting state police surveillance policies, labor unions and land-use policies, among others. None of those would have an immediate financial impact.
"They're going to get attention, and some of them are going to get passed," said Maryland Senate President Thomas V. Mike Miller Jr. (D-Calvert).
In Virginia, legislators are expected to debate a variety of non-money issues, including a ban on text messaging while driving, the regulation of companies that offer vehicle title loans and a handful of hot-button issues that come up every year, including a smoking ban in restaurants and bars, which Maryland has in place.
Kaine will try to leave his imprint on the state by making energy and the environment the focus of his fourth and final year in office through his year-long "Renew Virginia" initiative, which aims to make the state a leader in conservation.
Robert Vaughn, staff director for the House Appropriations Committee, said some policy issues that might not appear to cost money could actually have financial impacts. Those include increasing penalties for crimes, which could cost money to house inmates, and protecting consumers, which could require additional staff members to enforce new laws.
"At the end of the day, dollars drive every program and policy," Vaughn said.
Given the magnitude of the shortfalls, some lawmakers doubt that anything but the budgets will generate much public attention.
"The budget is going to suck 99 percent of the oxygen out of the State House," said Maryland Sen. Brian E. Frosh (D-Montgomery), chairman of the Senate Judicial Proceedings Committee. He said his panel, which deals with legal issues, will probably have a lighter agenda than in recent years.
Virginia House Majority Leader H. Morgan Griffith (R-Salem) said his state's session might feel like a throwback to earlier short sessions. Virginia's shorter session, held every other year, had traditionally been used solely to tweak the state budget and approve emergency legislation. Over the years, the 45-day sessions have mushroomed to include consideration of thousands of bills.
"The serious economic situation is going to force us to focus," Griffith said.
Both states have taken measures to start coping with shortfalls that expanded rapidly amid the national economic downturn.
In an effort to balance its two-year, $77 billion budget, Virginia is starting to eliminate thousands of jobs, slash agencies' spending by 15 percent and trim $800 million from K-12 education and Medicaid, which helps cover medical needs for the indigent, elderly and disabled.
But legislators will have to consider some of Kaine's financial proposals, including the cigarette tax increase, early release plan and borrowing $490 million from the state's rainy-day fund.
Senate leaders support many of Kaine's proposals, but House leaders, including Speaker William J. Howell (R-Stafford), are opposed to some, including raising taxes.
In Maryland, lawmakers are not scheduled to get a budget proposal from O'Malley for the coming fiscal year until late this month. He is also grappling with a shortfall of about $400 million in the current year's $15 billion budget.
O'Malley has ordered furloughs for state workers and is considering scaling back a number of initiatives begun during his term, including a program that provides additional school funds for counties where the cost of education is more expensive. Montgomery and Prince George's are beneficiaries of the program.
O'Malley and other state leaders are also exploring ways to redirect money from other state funds to help close the shortfall in its primary operating budget, known as the general fund.
Last week, for example, O'Malley and Comptroller Peter Franchot (D) floated the idea of taking up to $367 million out of an obscure reserve fund that has been set aside to pay refunds owed on county income taxes. Franchot aides say the fund is not needed because refunds are paid out of current-year collections.
Leaders in both states, meanwhile, are watching anxiously to see what help Washington will provide in the form of a federal stimulus package. Additional Medicaid funding could help ease budget shortfalls in Maryland and Virginia.
"We're hopeful the Obama administration steps up," said Maryland House Speaker Michael E. Busch (D-Anne Arundel). "The state really doesn't have a whole lot of options if there's not help from the federal government."
© 2009 The Washington Post Company

Director of Disease Control Centers Resigns
Associated Press
New York Times
Sunday, January 11, 2009
ATLANTA (AP) — Dr. Julie L. Gerberding has resigned as director of the Centers for Disease Control and Prevention and will be replaced on an interim basis by a deputy as of Jan. 20, the day President-elect Barack Obama is inaugurated.
Her resignation was announced in an e-mail message to employees on Friday night.
Dr. Gerberding, the first woman to direct the agency, led the C.D.C. through a post-Sept. 11 world of bioterrorism fears and was considered an effective communicator with legislators and the public.
In a November e-mail message to staff members, Dr. Gerberding said she expected that she might leave the post after the Bush administration left office. But colleagues said she had quietly held out hope that she would be allowed to stay on.
A spokesman for the agency, Glen Nowak, said Dr. Gerberding was traveling in Africa on agency business and was not available for comment.
Mr. Nowak said in a prepared statement that the Bush administration, “as part of the transition process,” had requested resignation letters from “a number of senior-level officials, including Dr. Julie Gerberding. This week, the administration accepted Dr. Gerberding’s resignation, effective Jan. 20.”
The agency investigates disease outbreaks, researches the cause and prevalence of health problems, and promotes illness prevention efforts. In a 2007 Harris Poll, the C.D.C. was rated the government agency that does the best job.
Dr. Gerberding is also head of the sister agency to the C.D.C., the Agency for Toxic Substances and Disease Registry. The two have a combined budget of about $8.8 billion and more than 14,000 full-time, part-time and contract employees.
Dr. Gerberding receives a total compensation of $202,200.
Dr. Gerberding, 53, was named director in July 2002. She had been an infectious diseases specialist at the University of California, San Francisco, and joined the disease centers in 1998 to lead a patient safety initiative.
Copyright 2009 The New York Times Company

Education could slow teen births
Carroll County Times Editorial
Sunday, January 11, 2009
The more than 425,000 births to mothers ages 15 through 19 in the latest Centers for Disease Control and Prevention vital statistics report underscores the need for increased sex education and discussion in our schools and between family members at home.
The CDC last week released its final report on birth data from 2006. The final data confirms what the agency noted a year ago with preliminary numbers: the number of youngsters having children is on the rise for the first time in about 15 years.
According to the report, teen birth rates increased in 26 states. In Maryland, the rate increase from 31.8 per 1,000 births in 2005 to 33.6 per 1,000 births in 2006. The increase followed years of decline since 1991, when the number was 54.1.
Part of the increase likely is attributable to an overall increase in births across the board. According to the CDC, births increased 3 percent from 2005 to 2006, and most of the statistical groups saw increases. The 4,265,555 births was the largest number seen since 1961.
If there was any good news to glean from the report it is that births to the youngest age group, 10- to 14-year-olds, declined to 0.6 per 1,000. But the rate for 15- to 17-year olds, which has decreased 45 percent since 1991, rose 3 percent between 2005 and 2006. And births to 18- and 19-year-olds, which decreased 26 percent since 1991, rose 4 percent between 2005 and 2006.
Youngsters are bombarded with sex everywhere they turn every day. From television shows and movies to Madison Avenue ad campaigns that use sex to sell products, youngsters learn early on that sex and society are closely intertwined.
Add in high-profile teen pregnancies, such as the hype surrounding Jamie Lynn Spears and her pregnancy at age 16, and too often we are sending the wrong message to youngsters about the responsibilities that come with parenthood.
But talking to kids about sex is still too uncomfortable for some parents. And some don’t want schools to broach the subject either unless the conversation is limited to abstinence.
This line of thinking is difficult to understand given the successes that have been seen in other areas — such as drugs and drug abuse — where increased awareness and education has brought about positive results.
When one in 10 babies is born to a mother age 15 to 19, clearly there is a need to do more.
Copyright © 2009 Carroll County Times

Parallel crises in health care, higher education
By Patrick Callan and Andrew L. Yarrow
Baltimore Sun Commentary
Sunday, January 11, 2009
While America's deepening economic woes cast a pall over the nation, long-term U.S. fortunes are profoundly threatened by parallel crises of cost, quality, access, and equity in health care and higher education. Once-proud symbols of national greatness, these sectors no longer deliver world-class results, are increasingly inequitable, and elicit growing discontent from many Americans.
The U.S. health care bill is $2.3 trillion, 16 percent of gross domestic product - roughly double the percentage for Western Europe, Canada, Japan, and other rich countries. Spending is rising by 7 percent a year, with Medicare increasing by 13 percent in 2007. Escalating health-care costs are the leading cause of personal bankruptcy and are why America's $10.6 trillion national debt is projected to soar. Waste is a major culprit, manifested in such problems as vast overhead costs, overuse of medical services, insufficient competition and lack of information about cost-effective practices.
The United States also spends about 3 percent of GDP on higher education - again, roughly twice the percentage of virtually every other developed country. While health-care costs have risen 2.5 percentage points faster than economic growth, higher education costs have increased about 3.5 percentage points faster than GDP growth for the last several decades. Exploding higher education costs have caused real student loan debt to more than double in a decade.
Government support through Pell Grants and other student assistance has risen, but cost increases have outpaced public investment in financial aid. Reasons for this cost growth include the knowledge-based global economy and rising aspirations creating a seller's market for college; an "arms race" among colleges to have the fanciest facilities; and weak financial accountability and few incentives for controlling costs.
The problem would be bad enough if it were just a matter of cost. But it's not. Not long ago, the United States was arguably tops in both higher education and health care. No more. To make matters worse, a nation whose cherished ideals of equality were advanced immeasurably during the 20th century by the diffusion of high-quality health care and higher education now has become troublingly inequitable in both.
The World Health Organization reports that about three dozen other nations have better aggregate health-care outcomes than America, and the RAND Corporation finds that barely half the treatments Americans receive are considered "best practices." Similarly, the United States is no longer the world leader in college access, and is in the bottom half in Organization for Economic Cooperation and Development rankings in college completion rates and 10th in the proportion of its 25-to-35-year-old population that is college-educated.
Higher education increasingly reflects and reinforces inequities in American society. Large gaps in college access associated with race and income have not narrowed for decades. The wealthy can afford Ivy League tuitions, the upper middle class falls into debt to attend flagship state universities, the lower middle class also borrows heavily to enroll in regional state colleges and community colleges, and poor Americans simply lack college opportunity. What's more, the quality of much of higher education itself has declined, sliding behind both earlier U.S. standards and those of many other countries.
At the same time, nearly 50 million Americans lack health insurance, tens of millions have limited medical coverage, and millions more may lose coverage due to the current economic crisis. Access to good care varies tremendously by income. A sizable population faces the triple whammy of inadequate insurance coverage, poor health behaviors, and lower-quality health providers - compared to a decently covered middle class and a health-conscious elite with access to the world's best medicine. This has created a trifurcation of American health care equivalent to a beat-up Chevy, a new Toyota and a Rolls-Royce.
Few Americans are satisfied with their medical care. The once-friendly and admired image of a selfless corps of Marcus Welbys has given way to a more widespread belief that doctors, hospitals, and pharmaceutical companies are greedy, insensitive, incompetent and dishonest.
Likewise, three-fourths of Americans are worried about college costs and debt. Barely half think that students get a valuable return on higher education. Half believe that colleges "mainly care about the bottom line." And three-fifths think that talented students lack the opportunity to attend college; among African-Americans and Hispanics the proportions are even higher.
The danger to a prosperous, optimistic American future is enormous. Serious cost control, accountability for high-quality outcomes, and greater equity are desperately needed. Systemic overhaul of health care and higher education requires an outcry from the public and the business community, as well as political champions who understand that larger public subsidies without substantial reforms will not suffice; greater engagement by health-care and higher-education leaders; and public-policy intervention that recognizes the failure of market mechanisms to yield quality, affordability and access.
Higher education needs substantial rethinking about delivery and financing. Can online instruction be adapted and broadened to strengthen learning and reduce costs? Can colleges work collectively with high schools to identify readiness standards? Can transfer of credits among two- and four-year colleges become seamless, reducing costly and redundant course repetition? Can state finance and accountability systems increase college access and completion? Do four-year colleges need to look like swank corporate conference centers? And should scarce financial aid now used to compete for gifted - but less needy - students be refocused to qualified students strapped for resources?
How to control health-care costs is an even tougher nut to crack. Universal insurance - with government premium support, combined with some "managed competition" among insurance providers and greater cost-sharing - are important. Increased regulation of health-care providers and their costs, greater emphasis on public health and prevention, medical malpractice reform, some rationing of care, and use of information technology to disseminate best and most-cost-effective practices and maintain a national medical records database also could help.
Without such changes, even with additional public investments proposed by President-elect Barack Obama and others, America will be less and less likely to be healthy, wealthy or wise.
Andrew L. Yarrow, vice president and Washington director of Public Agenda, is author of the new book, "Forgive Us Our Debts: The Intergenerational Dangers of Fiscal Irresponsibility" and teaches U.S. history at American University. His e-mail is ayarrow@publicagenda.org. Patrick M. Callan is president of the National Center for Public Policy and Higher Education.
Copyright © 2009, The Baltimore Sun

We All Want Longer, Healthier Lives. But It's Going to Cost Us.
By David Brown
Washington Post Commentary
Sunday, January 11, 2009; B01
Over the next few months, this country will engage in the first serious national discussion on health care in 15 years. Most of the talk will be about ways to make medical insurance available to all U.S. citizens. There will be a fair amount, too, about the need to make the hodgepodge "system" of American health care safer, better and more efficient. What we're unlikely to hear, though, is something like this:
Arresting the growth of health care spending in the United States is impossible. The policies and programs we're suggesting will either accelerate the upward trend or slow it temporarily, but they won't stop it. Health care costs will go up year by year until you die, and probably until your children die, too.
This difficult truth, which has emerged over the past half-century, is leading the United States and the rest of the industrialized world into a new era of humankind.
We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish. Whether we can somehow avoid the collision is perhaps the most important domestic issue of this century. From now on, health care costs will be up there with globalization, terrorism and climate change as a force shaping our world.
For most of recorded history, food production was the chief goal of human labor. In the United States, that time is long gone. We spend a little less than 10 percent of our income on food, down from 25 percent in 1930. We spend twice as much -- 21 percent -- on shelter. But health care -- that's where we really get our wallets out.
Last year, 16 percent of the nation's gross domestic product went for health care, about $7,600 per person. In terms of human effort, health care is the new food. By 2016, when it reaches 20 percent of GDP, it will be the new shelter. If it grows at its present rate through the first three-quarters of this century, it will consume 38 percent of GDP by 2075. It will then be the new food and shelter.
This isn't a mistake. If it were, we might have a chance of stopping it. It's success -- the way things are supposed to be, and the way we want them to be.
"At the end of the day, when it comes to controlling health care costs, the enemy is us," said Drew Altman, head of the Henry J. Kaiser Family Foundation. "Americans want the latest and best in health care technology, and we want it down the street, and we want it now."
Medicine lies at the intersection of two profound forces. One is the desire to survive, which motivates all living things. The other is the ability to make things, which distinguishes humans from other animals.
Crowding that intersection are thousands of opportunities for avoiding or curing an illness, feeling better, living longer and being happier than our grandparents ever could have imagined. These opportunities take the form of implantable defibrillators, replacement knees, periodic colonoscopies, weight-loss surgery, life-long antidepressants, anti-retroviral medicines, breast tumor gene scans, biologically targeted chemotherapy, heart-lung transplants and prenatal tests for dozens of dread diseases.
These are just a few of the fruits of our desire to survive and our capacity to create -- and there's lots, lots more right around the corner.
All these things, of course, haven't come for free. Health care spending has grown faster than the economy, by an average of 2 to 3 percent a year, at least since the end of World War II. In the first five years of this decade, it averaged 6.9 percent a year.
Medicare, the federal government's insurance program for the elderly and disabled, provides an especially dramatic snapshot of health care's growing claim on our wealth and labor. In 1970, Medicare was 0.7 percent of GDP -- 70 cents of every $100 the country produced. By 2005, it was 2.7 percent. Last year, it was 3.2 percent, according to the Medicare trustees' annual report. In 2082, the program is projected to be 10.8 percent of GDP. Over the past half-century, total federal income tax receipts have averaged 11 percent of GDP per year. So unless something changes, in about 75 years, Medicare alone will cost as much as the sum of all our federal income taxes.
This kind of growth doesn't come just from jacked-up prices, a bureaucratic and inefficient delivery system or increasing numbers of sick and old people. Something else has to be going on to explain such steady, predictable, relentless growth.
That something is innovation. Various health economists have estimated that somewhere between 40 and more than 65 percent of the growth in per capita health care spending since 1940 can be attributed to advances in medical care. Each year, there's more that can be done and more that's judged worth doing.
And the effect has been profound. Consider heart disease, the leading cause of death in the United States. From 1980 to 2000, deaths from heart disease fell 40 percent. If the 1980 death rate from heart attacks had held in 2000, about 342,000 more Americans would have died in that year alone. A team of researchers recently calculated that 47 percent of those lives were saved by better medical care -- involving such developments as clot-dissolving drugs, coronary stents and medicines to prevent congestive heart failure. About 44 percent were saved because people had reduced their risk factors -- quit smoking, lowered their cholesterol and gotten their blood pressure under control, with many of those improvements also the effect of better drugs and medical care.
Two years ago, another group of researchers, led by Harvard economist David M. Cutler, looked at the money spent on health care from 1960 to 2000 and asked the crucial question: What did it get us? Their answer: Plenty -- but improvements are costing more all the time.
Their study found that over those 40 years, the life expectancy of people of all ages had increased. Not surprisingly, investments in the health of children were more cost-effective than investments in 60-year-olds. What's more interesting is that extending life cost more as the 20th century progressed, even taking inflation into account. In the 1970s, it took $46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s, it cost $145,000.
As we become healthier, it takes more effort to extend our lives than it did in a time when we were less healthy (and dying prematurely). Fifty years ago, American medicine picked the low-hanging fruit of life-extension as clean water, vaccines, antibiotics, insulin and other cheap innovations became available to everyone. Now, we're going after the higher and more expensive stuff.
Take implantable cardioverter-defibrillators, or ICDs. These "ambulances in the chest" shock hearts out of the fatal rhythms that are a major hazard for people who survive large heart attacks. Vice President Cheney has one wired into his heart.
Three years ago, a team of researchers calculated that putting an ICD into a heart-attack survivor added one to three years to the person's life expectancy. The cost? Between $30,000 and $70,000 for every year of life gained. In the world of "cost-effectiveness analysis," that's judged to be worth it, the convention being that a treatment that buys an extra year of life for $50,000 or less is "affordable."
Medicare estimates that about 500,000 Americans now qualify for an ICD on medical grounds. Undreamed of when our parents and grandparents were having heart attacks, these devices are keeping or will keep thousands alive. Sowho's going to give one up in the interest of slowing the growth of health care spending? Not I. And I suspect not you, either.
Of course, there are ways to save money.
Administrative costs consume 24 percent of health care spending, according to one often-quoted estimate. Establishing a more unified health care system could probably cut that in half. There is also tremendous regional variation in medical care in the United States, so bringing everybody into line will reduce costs.
Then there's prevention, a favorite money-saving ace in the hole. The trouble is that prevention also costs money. A study that got front-page coverage nationwide in the week after the election not only demonstrates that but also shows how much we value small improvements in health. A group of researchers in Boston found that if you prescribe cholesterol-lowering drugs to people whose cholesterol levels are normal but who have evidence of mild body-wide inflammation, you can reduce their chances of developing cardiovascular disease by about half. "It's a breakthrough study," effused the head of cardiology at the Cleveland Clinic. "These are findings that are really going to impact the practice of cardiology in this country," said the head of the National Heart, Lung and Blood Institute at the National Institutes of Health.
What few stories pointed out was how little bang you actually get for this prevention buck. You have to treat 95 people for two years to prevent one "event" -- death, heart attack, stroke. At a cost of up to $1,200 a year for the drug, Crestor, that's a big investment to make year after year to help a few people. Given the response to the study, however, I suspect it's an investment we'll soon start making routinely.
Furthermore, there's little evidence that preventing disease reduces health care costs over the long run, although it obviously extends lives and prevents misery.
So what's likely to happen?
Over the short term, many experts say, there will be the sort of adjustments that humans make whenever necessities -- food, heat, shelter -- become scarce. We'll pay more for health care. We'll give up small things in favor of it. We'll cut corners. We'll complain. And then we'll find other corners to cut and reluctantly pay still more. Of course, the "we" may not include all of us; some Americans pay little or nothing for their health care. But as a society, we'll all pay more.
In the longer term, however, not just the United States but the entire industrialized world is facing a conundrum resembling a famous one of 200 years ago. In 1798, an English parson named Thomas Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society." He laid out a chilling scenario in which population growth outstrips food production and produces a cycle of famine, catastrophic population decline, recovery, famine and catastrophic decline, over and over.
This was the so-called Malthusian Spectre. It was a hugely influential -- and horribly frightening -- idea. It kept members of Parliament awake at night. But it never came to pass because of two as-yet-undiscovered truths that Malthus never imagined.
The first was that scientific agriculture would eventually double, triple and quintuple crop yields. The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.
We will need something like the revolution of scientific agriculture and the demographic transition to rescue us from the Malthusian Spectre of health care spending.
What it might be -- ah, that's what nobody knows.
David Brown is a medical doctor and a health and science reporter for The Washington Post.
© 2009 The Washington Post Company

The Dying of the Light
The Drawn-Out Indignities of The American Way of Death
By Craig Bowron
Washington Post Commentary
Sunday, January 11, 2009; B01
It's January, and with the holidays behind us, here in Minnesota the deep psychosis of winter settles in. The cold has a sharper edge; the darkness of night seems more penetrating and brittle. We'll take the ornaments off the tree but leave the lights on and keep watering it until it gives up its photosynthetic ghost. The green must be cherished until life returns in earnest in the spring.
I'm a physician in a large hospital in Minneapolis, where I help care for patients struggling through the winter of their lives. We've got a lively spring unit, an obstetrical ward where fresh-faced tulips are popping up at all hours, but that's not my specialty. As a hospitalist, I see adult patients of all ages and complexities, most of whom make good recoveries and return to life as they knew it. But taking care of the threadworn elderly, those facing an eternal winter with no green in sight, is definitely the most difficult thing I do.
That's because never before in history has it been so hard to fulfill our final earthly task: dying. It used to be that people were "visited" by death. With nothing to fight it, we simply accepted it and grieved. Today, thanks to myriad medications and interventions that have been created to improve our health and prolong our lives, dying has become a difficult and often excruciatingly slow process.
Take one of my patients. She started dialysis six months ago at the tender age of 85, and the diabetic vascular problems that put her kidneys in the tank persist. One leg has been amputated above the knee, and several toes on her remaining foot have succumbed to gangrene. Robbed of blood, they appear dry, black and tenuously connected, like an ash dangling off a cigarette.
This patient was brought in for a decreased level of consciousness and low blood pressure, but she has been having periods of nausea, and her appetite seems to have died with her kidneys. The initial workup revealed little, perhaps a low-grade bladder infection, but treating it and her low blood pressure doesn't seem to make much of a difference. She is withdrawn; food goes into her mouth, but she won't chew and swallow unless her children instruct her to. She intermittently refuses pills. There's a language barrier, but her children are there to interpret for her. Translation: She feels exhausted and weak, and she feels that way most of the time.
This woman is suffering from what we call "the dwindles," characterized by advancing age and illness. Although dialysis is a miraculous technology -- she'd be dead without it -- it exacts a heavy toll from someone her age or with her medical problems. Three days a week are spent in dialysis, and the other four are spent recovering. It is extending her life, but she's miserable.
Her family has designated her "full code," meaning that if her heart stopped or she were to cease breathing, we would do CPR to revive her, even though there would be a very slim chance of success -- and even though it would be God's or the universe's way of giving her an easy way out.
Another patient is in even worse shape. He's 91 and still a very big man. When I enter his room to examine him, he seems like a giant oak felled into a hospital bed, stiff and rigid, with swollen arthritic joints. A stroke four months earlier paralyzed his right side and left him bed-bound and nearly helpless, with pressure sores on his heels. He is mildly demented, and the pain pills aren't helping. He was brought to the ER because he was thought to be having another stroke, though these new symptoms quickly resolved.
Talking with this patient, I recognize his face and the Cajun accent; I'm certain that I took care of him sometime in the past, but he is not the man he was then. Staring at his 230 pounds stretching the length of the bed, I wonder how difficult it must be to care for him. To transfer him to a toilet or a chair requires the use of a Hoyer lift, a gigantic sling that's wrapped around the patient and attached to a mobile mini-crane. Fully suspended, he looks like a massive baby being delivered by a giant stork. The contortions and gymnastics of getting him slung up and moved must drive him wild with arthritic pain.
Though I reviewed the patient's chart before going into his room, I can't recall seeing what nursing facility he had come from. So I ask the nurse. She tells me, unbelievably, that he has come from his home, where his son cares for him. Later in the day I place a call to this Clark Kent, this Superman in disguise.
The son answers with soft echoes of his father's Louisiana brogue, and I ask him how in the world he manages to take care of his dad. He replies that for one, it's all he does, a full-time job, and moreover, his experiences in Vietnam numbed him to some of the intimacies of caring for another human being. "Once you've shoved some guy's guts back into his stomach, you know, you can get used to the rest of it," he says.
He tells me that his father is wearing out and that it's hard to watch. The arthritis has become quite painful, and sometimes his dad just weeps. Some nights he needs a couple of Vicodin to be able to sleep through the pain. The old man is also spending a lot more time thinking about his wife, who passed away before him. His son thinks he may be ready to die.
Nothing in my medical training qualifies me to judge what kind of life is satisfying or worth living. Many would say that if we were to become paralyzed in an accident, just let us die. But many quadriplegics, once they've gone through an initial period of adjustment, find their lives very satisfying. Patients can and do make enormous efforts and fight precipitous odds to get back to life as they knew it, or even just to go on living. But the difference for many elderly is that what's waiting for them at the end of this illness is just another illness, and another struggle.
Another patient of mine has 86 years behind her and was brought to our hospital from a nursing home in the wee hours of the morning. Her diabetes has become very brittle and difficult to control; the day before, paramedics were called because her blood sugar had dipped so low that she was becoming unresponsive. She also has dementia, and a couple of months ago, she fell and broke a hip. Although it was repaired and she completed rehabilitation, she has wound up essentially bedridden. Strictly speaking, losing your mind won't kill you: It's the falling, the choking, the weakness, the bed sores.
This patient was brought in because the nursing home staff thought that she might have aspirated some food or secretions and developed pneumonia. She thinks it's 1982 and is, as we say, "pleasantly confused." She denies any and all symptoms, and her breathing looks comfortable. A review of her chart shows no fever and a normal white blood cell count. Her chest X-ray shows perhaps a subtle pneumonia but also a compression fracture of one of her vertebrae, which has gone from being 50 percent to 90 percent collapsed. Her dementia has mercifully spared her a lot of pain from the fracture, but it also keeps her from recognizing members of her extended family. Sometimes she doesn't recognize her own son, who drove to the hospital to be with her at this early hour.
He and I discuss what brought her in, and then we talk about her code status, which he confirms is Do Not Resuscitate. "She wasn't supposed to be brought to the hospital in the first place," the son tells me, and puzzled, I ask him to say that again. She was never supposed to be hospitalized: Whatever troubles arrived, the plan was to deal with them in the nursing home. His mother had made that decision herself, several years prior to this hospitalization, before the dementia really set in.
Later that day, I meet with the son and a few other close family members. They want to continue the medications that would bring their mother comfort and discontinue all the rest. They aren't looking to end her life, but they aren't looking to prolong it, either. They can see that she is moving away from them in both body and mind, and they are ready to let her go.
To be clear: Everyone dies. There are no life-saving medications, only life-prolonging ones. To say that anyone chooses to die is, in most situations, a misstatement of the facts. But medical advances have created at least the facade of choice. It appears as if death has made a counter-offer and that the responsibility is now ours.
In today's world, an elderly person or their family must "choose," for example, between dialysis and death, or a feeding tube and death. Those can be very simple choices when you're 40 and critically ill; they can be agonizing when you're 80 and the bad days outnumber the good days two to one.
It's not hard to identify one of these difficult cases in the hospital. Among the patient-care team -- nurses, physicians, nursing assistants, physical and occupational therapists, etc. -- there is often a palpable sense of "What in the world are we doing to this patient?" That's "to" and not "for." We all stagger under the weight of feeling complicit in a patient's torture, but often it's the nurses who bear most of that burden, physically and emotionally. As a nurse on a dialysis floor told me, "They'll tell us things that they won't tell the family or their physician. They'll say, 'I don't want to have any more dialysis. I'm tired of it,' but they won't admit that to anyone else."
This sense of complicity is what makes taking care of these kinds of patients the toughest thing I do. A fellow physician told me, "I feel like I am participating in something immoral." Another asked, "Whatever happened to that 'do no harm' business?"
If we can be honest and admit that we have no choice about dying, then the only thing we do have a say in are the circumstances. Like many nursing home patients, Dorothy was on the cholesterol-lowering medication Lipitor. Why? So that she wouldn't die of a heart attack or a stroke. But don't we all die of something?
Everyone wants to grow old and die in his or her sleep, but the truth is that most of us will die in pieces. Most will be nibbled to death by piranhas, and the piranhas of senescence are wearing some very dull dentures. It can be a torturously slow process, with an undeniable end, and our instinct shouldn't be to prolong it. If you were to walk by a Tilt-A-Whirl loaded with elderly riders and notice that all of them were dizzy to the point of vomiting, wouldn't your instinct be to turn the ride off? Or at the very least slow it down? Mercy calls for it.
This isn't about euthanasia. It's not about spiraling health care costs. It's about the gift of life -- and death. It is about living life and death with dignity, and letting go.
In the past, the facade of immortality was claimed by Egyptian kings, egomaniacal monarchs and run-of-the mill psychopaths. But democracy and modern medical advances have made the illusion accessible to everyone. We have to rid ourselves of this distinctly Western notion before our nation's obesity epidemic and the surge of aging baby boomers combine to form a tsunami of infirmity that may well topple our hospital system and wash it out to sea.
At some point in life, the only thing worse than dying is being kept alive.
Craig Bowron is a hospital-based internist and a writer in St. Paul, Minn.
© 2009 The Washington Post Company