This post was written by Maggie Mahar and Niko Karvounis

2007 marked the first time in 50 years that less than 20% of Americans smoked.  This is the good news. The bad news is that, just as the battle against smoking has entered what may be its most critical, final phase, support for that battle has waned among policymakers—even though the problem is far from solved.

Tobacco use, especially cigarette smoking, continues to be the leading cause of preventable diseases in the United States. It is blamed for 435,000 premature deaths in this country each year, and it adds more than $75 billion to annual spending on health care, according to the federal Centers for Diseases Control and Prevention.

Consider the raw numbers: in 2007, an estimated 19.8% (43.4 million) of US adults were still smoking cigarettes; of these, 77.8% (33.8 million) smoked every day, and 22.2% (9.6 million) smoked some days.  That’s a lot of smoke.

Break down the demographics and you find stark patterns. Smokers are likely to have less education than other Americans: CDC research has found that adults who have a GED diploma (44.0%) and those with 9–11 years of education (33.3%) are most likely to use tobacco.  Americans with an undergraduate or graduate degree are least likely (11.4% and 6.2%, respectively). Poorer people also are more likely to smoke: 33% of U.S. adults living below the poverty level are smokers while only 23.5% of those living above that level still light up.

Given how expensive cigarettes are these days, these are striking statistics. Why do low-income people smoke? Medical research shows that being poor is extremely stressful. You have less control over your life and must cope with much more uncertainty: Will you be able to pay your rent? What will you do if you lose your job? Are your children safe walking home from school?  As anyone who has ever been addicted to tobacco knows, being anxious makes you reach for a cigarette.

Military veterans under the care of the Department of Veterans Affairs (VA) health care system are also more likely to smoke than other Americans. Indeed, a 2004 report titled “VA in the Vanguard: Building on Success in Smoking Cessation” points out that “the prevalence of smoking is approximately 43 percent higher” among these veterans than in the general population.  “Many Americans who may have never smoked prior to their military service began smoking while in the service,” the report observes.  In the past, “ ‘Smoke ‘em if you‘ve got ‘em’ was a common command, and in many cases was even encouraged as it was thought to help keep soldiers alert and awake—or to help them cope with the tedium of waiting while on watch and the stress of combat.”

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Today, the Kaiser Network reported that on Friday, the Medicare Payment Advisory Commission (MedPac) approved a set of recommendations that would revise the current Medicare payment system, which was implemented in 1983, for hospice care providers serving terminally ill patients.  CQ HealthBeat reports that these recommendations will be included in a report to be issued in March to Congress and to take effect in 2013. (Thanks to Brad F. for calling my attention to this piece of news.)

Apparently, MedPAC has been concerned that for-profit businesses have been driving growth in Medicare spending by targeting hospice patients who need relatively long periods of care. The new payment system intends to remove incentives for long hospice stays.

So MedPac is recommending that Medicare change its payment system to include relatively higher payments per day at the beginning of the episode, and relatively lower payments per day as the length of the episode increases. 

Call me cynical, but do you suppose that would give for-profit hospices and incentive to toss patients out and send them home if they linger on too long? Alternatively, the hospice might encourage them to “let go”…

The whole idea of “for-profit hospices” strikes me as a truly terrible idea—right up there with “for-profit prisons” (which have not worked out well). 

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Like so many other federal agencies, the National Institutes of Health (NIH) has struggled under the Bush Administration, and today, it needs to be revitalized. Not long ago, I wrote about what we can expect for the FDA when president-elect Obama comes to office; now I’d like to turn the NIH. But to understand the agency’s future, one needs to recognize its recent past.

The Bush Years: Starving the Beast

From 1998 to 2003, the NIH enjoyed a golden age. Over that span, the agency’s budget doubled to $ $27 billion, an increase that Harvard University president Drew Faust has called a "transformative force for biomedical research.” But since 2003, NIH funding has remained essentially flat and, when adjusted for inflation, it has actually declined.

This has caused concern within the medical research community While 10 percent of the agency’s budget funds in-house research, a whopping 85 percent supports biological and medical research at universities and medical centers. When the NIH has less money, it has less money to give—and more researchers on the cusp of biomedical breakthroughs miss out on the funding they need.

Last year, the Group of Concerned Universities and Research Institutions (GCURI)—an association of seven top-tier universities including Harvard, Duke, Johns Hopkins, and Brown—issued a report arguing that reduced funding for NIH means “slowing the pace of medical advances, risking the future health of Americans, discouraging [the country’s] best and brightest researchers, and threatening America's global leadership in biomedical research.”

Indeed, as the NIH budget has shrunk, researchers have had a harder time securing grants: according to GCURI’s report, the agency funded 32 percent of proposed research projects in 1999, but only 24 percent in 2007. Researchers who are awarded NIH grants also have to jump through more hoops than they did in the past. In 1999, 29 percent of grant proposals were approved upon first submission; in 2007, only 12 percent of projects were given the same first-time approval.  These days, 88 percent of researchers who end up with NIH funding do so after applying multiple times. According to GCURI “this trend represents a clog in the system that is causing researchers to abandon promising work, downsize labs, and spend more time searching for other financial support. Meanwhile,” the report continues, “Americans wait longer for cures.”

There’s no reason to think that the quality of grant proposals between 1999 and 2007 has dropped precipitously enough to warrant a stingier NIH. Good scientists are being left high and dry. The agency’s primary research grant—the so-called R01 grant—is generally regarded as the “gold standard” in science: when the government grants an R01 to a project, that research is officially legitimated as important, ground-breaking work. In fact, GCURI claims that “a scientist is not considered established and independent until he or she is awarded an R01, which…enable[s] scientists to hire staff and buy [the] equipment and materials necessary to conduct experiments.” Or, as Dr. Denis Guttridge, Associate Professor at The Ohio State University, puts it: “assistant professors cannot get going in their careers until they get their first R01.” Thus allowing federal grant money for medical research to shrink puts our country at risk of “los[ing] a generation of committed scientists” and the medical breakthroughs that they can provide.

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According to the American Bar Association’s Commission on Legal Problems of the Elderly, the notion that everyone should have a living will is a “myth.”  

In theory, a living will gives healthcare providers a window on the patient’s wishes regarding end-of-life care, telling caregivers whether he wishes to be resuscitated, intubated, or artificially hydrated.

In practice, doctors who deal with the dying say that such wills rarely capture the complex realities of being critically ill. An article published today in American Medical News quotes Angela Fagerlin, an associate professor of internal medicine at the University of Michigan Medical School and co-author of a study of living wills published in the Archives of Internal Medicine: “There are so many contingencies in medical scenarios that you can’t put them all down in a living will. You’re putting a lot of undue pressure on surrogates to correctly interpret advance directives.”

Even the patient who makes out a will may not know what he wants. After illness and hospitalization, three in 10 patients adjust their views, desiring more or less aggressive care than they previously thought they wanted.  “If patients’ own preferences are so unstable, then how reliable are their advance directives as a guide to what they would have wanted?” AMNews asks.

“People have a hard time anticipating the care settings in which they’ll face decisions in the future,” says G. Caleb Alexander, assistant professor of medicine at the University of Chicago Pritzker School of Medicine. “You can quote Yogi Berra: ‘It’s tough to make predictions, especially about the future'.”

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By now you’ve probably heard the calls for speedy action on health care reform during the Obama Administration’s first hundred days. Some prominent observers even say that the President-elect should get the ball rolling during “his first days in office” The possibility of imminent health care reform is certainly exciting, but a word of caution: just because some of us might be ready for health care reform doesn’t mean that the media is ready to cover it properly. And that could have important implications for how reform plays out.

Right now, health care reform is an abstract goal that everyone wants. Excitement and anticipation are high. But as the substantive process of health care reform gets underway, two things will happen: first, ideas will be crafted into policies—concrete plans of action and complex administrative measures—and second, politicians will become involved in the reform process. Policy can get pretty complicated; so the public will rely on the media to help it navigate the ins and outs of the issue. Once politics begins to shape policy discussions—that is, once politicians enter the picture—it’s all the more important to keep the focus on policy, because it’s at this point that policies have a real chance of being implemented. Americans should know their options.

Style Over Substance

Unfortunately, reporters aren’t health care policy experts. In fact, they rarely ever talk about the issue. In a December report, the Kaiser Family Foundation found that, out of 3,513 health news stories in newspapers, on TV and radio, and online between January 2007 and June 2008, health care policy comprised less than one percent of news stories and just 27.4 percent of health-focused stories. Instead of talking about issues like coverage, prescription drug care, costs, or public programs, the media prefers to report on specific diseases and conditions (cancer, diabetes, obesity and heart disease) and potential epidemics (contaminated food and water, vaccines, binge drinking). Together, these two topics comprised 72.6 percent of health coverage.

This is less than ideal. When Congress begins to talk about health reform in earnest, the important news that will affect all of us will be about policy and institutional changes. The media needs to be good at covering this stuff—yet as the Kaiser report shows, news casters, reporters, and editors have very little experience (or interest) in discussing such issues. Worse, history shows that when health care reform efforts are actually underway, the media ignores policy in favor of more sensational stories.

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Wishful thinking leads many well-meaning reformers to imagine that we can accomplish universal coverage in a single stroke. Writing in the December 31 edition of the New Republic,  political scientist Jacob Hacker suggests that by declaring “healthcare for all” we can achieve universal coverage and , simultaneously,  kick-start the economy.  How do we do it?  Easy—just spend as much money as possible as quickly as possible.

“In fact,” Hacker writes, “we have a magic bullet.”

This sentence stopped me. To my mind, the word “fact” just doesn’t belong in the same sentence with the phrase “magic bullet,” certainly not when we are talking about something as complicated as national healthcare.

Nevertheless, Hacker, who is an intelligent, highly-respected healthcare reformer , is dead serious. Just spread the money around, he says, and everyone will be happy—particularly the lobbyists who might otherwise object to any attempts to cut spending and eliminate some of the waste in our bloated system.

 “Buy off the opposition,” Hacker advises.  “Britain's health minister was once asked how he had gotten doctors on board for the National Health Service. His reply:  ‘I stuffed their mouths with gold.’ Money may not change everything, but it does make it easier to win friends, or at least divide and placate them. . . .”
The problem with the Clinton healthcare plan Hacker explains is that “it didn't include enough handouts to appease interest groups.” 

Still, I cannot help but wonder: Does “stuffing their mouths with gold” mean “stuffing health care legislation with pork”?  Is that really the most prudent way to design an affordable, sustainable, and effective health care system?   

But according to Hacker, Americans don’t want to hear about affordable; nor are they interested in eliminating waste.  “Most don't believe our nation spends too much on health care; they believe they spend too much.” In other words Americans are distressed that their own bills are so high.  The fact that Medicare spending is sky-rocketing, and that eventually we all will have to pay the piper, is, apparently, beyond the grasp of the average citizen.  The notion that unnecessary, often unproven and usually over-priced drugs, devices, tests and operations can be hazardous to our health is just too hard to understand.

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Earlier this month newspapers reported that Columbo—that is, actor Peter Falk—has Alzheimer’s Disease. Usually, when news breaks that a celebrity is suffering from a serious medical condition, there’s a flurry of coverage discussing the nature of the disease. Hopefully, the pattern will hold in Falk’s sad case—because Alzheimer’s is both a terrifying disease and a greater public health issue than most of us realize.   

Indeed, the incidence of Alzheimer’s Disease (AD), is rising. According to the Centers for Disease Control and Prevention, in 2006 Alzheimer’s disease was the sixth-leading cause of death in the U.S., killing 72,914 people. Another startling number: Alzheimer’s as a cause of death has skyrocketed in recent years, increasing by 33 percent between 2000 and 2004.

So What Is It?

A progressive brain disorder, AD literally shrinks the brain, eroding individuals’ memory, language, and their ability to coordinate basic motor skills like swallowing, walking, and bladder control. These deficiencies can lead to other serious problems: an inability to swallow can cause food to be inhaled, which can lead to pneumonia; not walking can lead to painful bedsores prone to infection; and incontinence can also lead to infections.

In other words, Alzheimer’s is a frightening disease that gradually can take over the mind and body.  Unfortunately, there is no known cure, and currently no medical tests that allow us to diagnose the disease with 100 percent certainty—doctors need to cut open the brain in order to tell for sure that it’s afflicted with AD.

Further, no one knows for sure what causes Alzheimer’s, though researchers do have some understanding about what happens to the brain during the disease. The culprits are two abnormal structures called plaques and tangles, which together kill nerve cells in the brain. Plaques build up between nerve cells and deposit proteins that impede normal neurological functions; tangles are knots of protein that build up in brain cells and collapse the structures needed to transport vital nutrients across the brain.  

Doctors aren’t entirely sure what causes the growth of plaques and tangles. Genes might play a role, but researchers don’t know just how—or how much—they matter. That’s due in part to the fact that Alzheimer’s, when it’s genetic, is not caused by a single gene, but rather mutations on multiple chromosomes. Sadly, this information is not as useful as it may seem: according to the National Institute of Aging (NIA), less than 10 percent of AD patients have “familial Alzheimer’s”, i.e. a genetically inherited form of the disease. Onset of familial AD is early, before the age of 65.  The other 90+ percent of Alzheimer cases are late-onset (after 65), and according to the NIA, this form of the disease “has no known cause and shows no obvious inheritance pattern.” Researchers have a hunch that genes play some sort of role in late-onset AD, but “only one risk factor gene has been identified so far” and it’s not enough to account for the entire disease.

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Imagine appointments with your primary care doctor that last 30 minutes—or longer. What if you could e-mail her when you need a prescription refill? If you have a two-minute question, she encourages you to call; she or a nurse practitioner will come to the phone. If they’re busy, they’ll return your call within a few hours.

A recent story in the Seattle Post-Intelligencer offers hope for primary care by focusing on an innovative program at Group Health Cooperative, a nonprofit health care system headquartered in the state of Washington. Under the new program, patients see their doctors less often, but when they do, it is a meaningful encounter.  And in between appointments, doctors are paid to communicate with patients in other ways.

A multi-specialty integrated health care system, Group Health, like Kaiser Permanente, provides both healthcare and insurance. Group Health’s doctors work on salary, so there are no financial incentives to “do more.” And because Group Health is both the insurer and the caregiver, the payer and the health care provider are not adversaries: they are on the same team. 

By creating its own small revolution in primary care, GroupHealth is demonstrating that private sector insurers can be part of the solution to our healthcare crisis.  In this case, the key is paying doctors for the time they spend e-mailing patients, returning phone calls, and doing research on their behalf. Because doctors are on salary, they are paid for everything they do—not just for the number of patients they manage to “see” in a given day.

In a two-year experiment, Group Health is encouraging doctors to spend more time in face-to face appointments with patients.  Given the finite number of hours on a physicians’ calendar, this means seeing patients less frequently. But doctors also keep in touch with patients by phone and e-mail.

As a result, a doctor like Dr. Patricia Boika can spend a half hour, or more, with the patient she sees.  Before she became part of this program, “The practice had become a dismal treadmill, with too many patients and not enough time, double-bookings and harried visits, and paperwork lugged home every night,” Boika, who has been a family doctor for 28 years, told the Post-Intelligencer.

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This is from the Wall Street Journal’s Washington Wire:

“Ezekiel J. Emanuel, a prominent bioethicist at the National Institutes of Health–and the brother of incoming White House Chief of Staff Rahm Emanuel–will serve as a senior counselor at the White House Office of Management and Budget on health policy, two Democratic officials said Thursday. 

“Zeke Emanuel will work closely with Department of Health and Human Services secretary-nominee Tom Daschle to formulate a national health insurance program and to try to curb the swelling cost of health insurance without adversely impacting health care.

“Two Emanuels in the White House might sound like a voluble combination, given Rahm Emanuel’s penchant for yelling, but his brother is known for being suave and soft-spoken”

As regular readers may remember, I’ve written about the plan for universal coverage that Zeke Emanuel outlines in his book Healthcare,Guaranteed in two posts: The first post begins:

“Imagine a proposal for health care reform that guarantees free, high quality health care for all Americans.

"No premiums. No deductibles. Under this plan, the government insists that all insurers offer the same comprehensive benefits to everyone including: office and home visits, hospitalization, preventive screening tests, prescription drugs, some dental care, inpatient and outpatient mental health care and physical and occupational therapy.

“These benefits are more generous than Medicare’s and more comprehensive than what 85 percent of all employers offer their employees. (Individuals who want to purchase coverage for additional services like concierge medicine, experimental drugs for serious conditions, complementary medicines or more mental health benefits could do so.)

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