La. – 13-year-old Austin Irvine was helping his father unload scaffolding
from the top of a pickup truck when he took a fall that easily could have
ended his young life.
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nearby, his father saw his son plunge headfirst several feet onto the ground
Austin got up and seemed
fine, but out of an abundance of caution, his father took him to Chabert Hospital
in Houma just
to be safe.
doctors saw caused them to act swiftly. They recognized
had a skull fracture and his brain was swelling.
Austin doesn’t remember
remember going to the truck, going to hospital and getting into the
wheelchair and going down the hall, and that's about it," he said.
Austin had what is known as
an epidural hematoma. It is the brain injury that made headlines earlier this
year when actress Natasha Richardson died after a seemingly innocent fall on
a ski trip.
Irvine was rushed by
ambulance to New Orleans
to the trauma center at the LSU interim hospital. Doctors said they knew they
didn’t have much time.
kid was going to herniate,” said Dr. Edward Halton. “That means he would have died.”
Austin underwent emergency
surgery as doctors relieved pressure from his brain
and were able to save his life. In fact, Austin’s recovery went very quickly. After
a couple of tough days in the ICU, he returned to school just two weeks
he came back on the first day,” said Michelle Lapeyrouse
of Montegut Middle. “I think he checked out the first day, but he basically
came back and was in full swing.”
scar on Austin’s
head is still visible, but he has quickly returned to his normal life.
felt really good because I knew they (his family) would take care of me and
be by my side.”
father realizes that quick action saved his son and he that hesitation might
have proven fatal.
I had brought him home and just let him sleep, he would not have woke up.”
Colleges, hospitals withhold raises
state agencies have received permission from the state Civil Service to
withhold or reduce employee pay raises for the coming fiscal year to avoid
possible layoffs because of budget cuts.
colleges and hospitals in the LSU System plan to scrap the 4 percent annual
pay raise employees traditionally receive on their anniversary dates. Pay
increases for academic or professional employees also are being suspended
under LSU’s plan.
decision affects 25,700 employees, including those on LSU’s main campus in Baton Rouge and its Earl K. Long Medical
Center on Airline Highway.
the nearly 3,000 employees of Louisiana’s public safety services agencies are
scheduled to receive a 2 percent pay increase — half of the normal amount —
as part of its layoff avoidance plan, according the plans submitted by those
moves impact both rank-and-file classified Civil Service workers and
unclassified employees who serve at the pleasure of the administration,
according to top agency officials.
agencies have received the state Department of Civil Service permission to
alter normal merit pay rules in order to avoid employee layoffs, Civil
Service Director Shannon Templet said Monday. Templet said the state’s employment agency is expecting
at least 14 additional requests and there could be more in the coming weeks.
are waiting to see exactly what their budgets are going to be,” said Templet.
Legislature is debating a $28.7 billion proposed state spending plan for the
fiscal year that begins July 1 that has deep cuts in higher education and
health care. The state has $1.3 billion less in state revenues to spend in
the coming fiscal year.
state Civil Service Commission last week deferred action on a Civil Service
staff proposal to withhold “merit” pay raises for the 60,000 rank-and-file
classified state employees under its jurisdiction.
idea was advanced as a way to reduce layoffs across state government because
of cuts required to balance a state budget drafted absent $1.3 billion in
said the commission should leave it to state agencies to decide whether they
had the funds to cover the raises. Non-payment of merit pay raises, employee
furloughs and reduced work hours are options for which agencies can seek
Civil Service approval to avoid layoffs.
and public safety are taking advantage of the layoff avoidance option of
withholding or reducing pay raises. The step does not require commission
approval. It can be OK’d administratively.
Bobby Jindal’s budget did not include extra money
to cover the pay increases. Agencies would have to cut in other areas to
generate the dollars necessary just like past administration’s budgets.
System President John Lombardi informed all system colleges and hospitals
that no merit increases would be awarded in the upcoming fiscal year “as a
result of pending budget reductions.”
to system officials, the freeze on pay increases would save $5.3 million in
the upcoming fiscal year on Civil Service employees alone and another $5.3
million in the budget year after that. That’s because of the carry-over
effect from year to year caused by the pay increase on employee anniversary
dollar amount was available Monday on non-Civil Service employees in academic and
other arenas considered unclassified jobs.
had proposed 1,900 employee layoffs statewide.
a message distributed across the Baton
Rouge campus, LSU Chancellor Mike Martin said LSU
main campus will not award pay increases “to classified, professional, or
academic employees, regardless of the source of funds, next fiscal year.”
would be 5,710 employees — 1,436 faculty; 2,910 academic and 1,364 classified
Monday, State Police Col. Mike Edmonson said the public safety layoff
avoidance measure will prevent an extra $1.2 million in cuts that would have
been required to come up with the money to fund the raises.
didn’t want to have to lay off anybody,” said Edmonson.
Houma Courier | 06.08.09
HOUMA — At 29, Kandie Foret has to deal with limitations
others her age will likely never confront.
has to avoid microwave ovens.
has to keep her cell phone away from the right side of her body.
rarely drives, and when she does, she’s never alone.
Foret suffered a major heart attack in
November, a scare that left her with a cardioverter
defibrillator, a wallet-size device implanted in her chest that monitors
abnormal heart rhythms. It delivers high-energy electric shocks designed to
restore the heart’s regular rhythm, a method similar to those used by
emergency-room doctors via a set of defibrillator paddles. You’ve probably
seen TV doctors use the paddles on prone actors after yelling “clear.”
life-saving device is one typically used on patients
decades older than Foret.
I cry and ask God, ‘Why? Why is this happening to me?’ ” Foret,
of Chauvin, said. “It scares me a lot.”
she was 1, her parents learned she had an enlarged heart, the result of a
murmur, or uneven heartbeat.
fixed that problem.
was fine,” Foret said. “I was able to work and live
of that changed late last year when Foret suffered
the heart attack.
drove myself to the hospital because I didn’t know what was going on,” she
said, describing the rapid, irregular beating in her chest that sent her in
search of medical help.
at Houma’s Leonard J. Chabert Medical Center told Foret
she has congestive heart failure, a condition in which the heart can’t pump
enough blood to the body’s other organs. The heart works, just not as
efficiently as it should.
they told me that, I just started crying, I thought it was the end of my
life,” Foret said. “I mean, it’s not your liver,
not your lungs — that’s your heart. That’s what’s keeping you alive.”
suspect her heart problems were inherited. Foret’s
father, Henry Francis, was 36 when a heart attack killed him.
Foret’s heart, doctors told her, is working
at 35 percent of its capacity. The implanted device helps her maintain a
regular heartbeat, and a monitor alerts her doctors of any irregularities
Foret, a former fast-food-restaurant
employee, said life has been difficult since her surgery.
Foret said she had to leave her restaurant
job because she can’t work around microwaves. Close proximity to ringing
phones cause a strange sensation in her chest. And overexerting herself could
cause her to faint.
that happens, friends and family know they must not touch her because the
shock from the device in her chest could harm them.
they do touch me and the shock is strong enough, it can stop their heart,” Foret said. “I feel like the boy in the bubble
Foret said the effect of her health woes on
her children — she and husband Elrick have a
13-year-old son and a 10-year-old daughter — are among her biggest worries.
my kids see an ambulance, they call me to see if I’m OK,” Foret
said. “My daughter will tell me, ‘Mama, you ain’t
going to die today.’ ”
Foret said she’s publicly sharing her
struggles in the hopes that it will remind others to be thankful for their
people to go and get their hearts checked out,” Foret
said. “I think all the time, what did I do to make this happen?”
the end, though, the condition is one that has strengthened her resolve to
enjoy her remaining days.
can’t let yourself go down like that,” Foret said.
“You’ve got to fight.”
ROUGE -- Gov. Bobby Jindal said Monday that he has "serious
concerns" about the Senate-approved $28.7 billion budget bill that
proposes to patch holes in health care and higher education spending by
delaying a scheduled tax break and tapping the state's rainy-day fund.
Senate's version of House Bill 1, the operating budget for the fiscal year
that starts July 1, "doesn't so much relieve the budget pressure as much
as it moves it forward, maybe a year," Jindal said in a meeting with
approved the bill last week with $284 million in "contingencies" --
meaning the money won't be available unless other legislation is approved.
The contingencies include $118 million for public colleges and universities
tied to the passage of a bill to delay an income-tax cut, while some
restorations for health care and arts programs are dependent on money from
the Budget Stabilization Fund, or rainy-day fund.
Senate's move came three weeks after the House passed its version of the
bill, which would have eliminated 3,500 state jobs and included deeper cuts
to many programs. The House is expected to reject the Senate's amendments
this week, which means the differences between the two chambers would be
resolved in a conference committee.
has said he would veto the income-tax bill -- Senate Bill 335 by Sen. Lydia
Jackson, D-Shreveport -- though it's unlikely the measure would get that far.
Fifty-five of the 105 members of the House have signed a letter opposing the
bill, which cleared the Senate last week. House Speaker Jim Tucker,
R-Algiers, has refused to assign the bill to a House committee for a hearing,
saying that it's unconstitutional.
governor said he supports some use of the rainy-day fund, but he objects to
the Senate's approach. Senators have advocated taking one-third of the money
from the fund -- $258 million -- and using one-third of that amount in next
year's budget. The remaining two-thirds would be placed in a fund and used to
mitigate shortfalls in the following two fiscal years.
Jindal said he wants the full rainy-day money to be available in future
years, when the state's budget problems are expected to be more severe as
federal economic stimulus dollars dry up and the state's contributions to the
Medicaid program will increase. The governor has said he would support taking
$50 million from the rainy-day fund and replacing it with money from a
proposed tax-amnesty program.
predicted the House-Senate negotiations on the bill by Rep. Jim Fannin, D-Jonesboro, will last
until the final hours of the session, which adjourns June 25.
always seems to get done toward the end, and I suspect we're going to see
that again," Jindal said.
in both chambers had set a goal of sending the budget to Jindal with time to
spare in the session, so that lawmakers would still be meeting when the
governor issues his line-item vetoes. The state Constitution gives governors
10 days to veto a bill when lawmakers are in session and 20 days to issue
vetoes after adjournment.
year, Jindal issued 258 line-item vetoes, many times the amount issued in
said he doesn't expect the conferees to finish their work quickly.
Center wins quality award
Earl K. Long Medical Center
has received the Silver Level 2008 Louisiana Hospital Quality Award from the
Louisiana Health Care Review.
LHCR is the Medicare quality improvement organization for Louisiana.
K. Long is one of 18 hospitals in Louisiana
to receive the award, which recognizes the Baton Rouge hospital for improving the
quality of health care given to its patients.
established the awards to recognize Louisiana
hospitals that successfully implement quality initiatives to improve patient
care in the hospital setting, specifically in the areas of acute myocardial
infarction (heart attack), heart failure, pneumonia and surgical care.
federal Centers for Medicare and Medicaid Services have designated these
clinical topics as national health-care priorities.
ROUGE -- A House committee voted 8-7 Monday for a state tobacco tax increase
in a stunning reversal to the panel's earlier position and a rebuke to Gov.
Bobby Jindal, who has opposed the legislation.
conservative, anti-tax chief of the House Ways and Means Committee, Rep.
Hunter Greene, R-Baton Rouge, took the chairman's privilege and chose not to
vote, giving proponents of House Bill 889 by Rep. Karen Carter Peterson,
D-New Orleans, the one-vote edge needed to get the measure to the House
bill's next obstacle is to win a two-thirds majority in the House.
measure calls for a 50-cent-per-pack tax increase on cigarettes and an
increase in taxes on other tobacco products. The new revenue, estimated to be
about $92 million the first year, would go to a number of health-care
programs in Louisiana.
current rate is 36 cents per pack. The federal cigarette tax increased April
1 from 39 cents to about $1.01 per pack.
legislation's journey has been filled with intrigue this session. The Ways
and Means Committee wasted no time killing Peterson's first version of the
bill, for a $1-per-pack increase, on the second day of the session with an
cut the tax proposal by half and brought it May 12 to the committee, which
could not gather enough panel members to form a quorum. Two of those members
had decamped to the governor's offices, where they remained long enough for
the committee to cancel its meeting without hearing the bill.
lawmakers were Reps. Steve Carter, R-Baton Rouge, and Frank Hoffman, R-West
Monroe. Carter had had voted for the $1-per-pack bill and Hoffman had voted
against it. On Monday they both voted in favor of the 50-cent increase.
changing to a yes vote was Rep. Mike Danahay, D-Sulphur, who sponsored amendments to ensure the tax revenue would flow to programs for prevention of cancer
Taylor Barras, D-New Iberia, was against the bill but was absent Monday. Rep.
Mickey Guillory, D-Eunice, voted no last time but has since moved off the
committee. Rep. Cedric Richmond, D-New Orleans, who favored the tobacco tax,
also was absent.
could have killed the bill with a tie, but chose instead not to vote.
Speaker Jim Tucker, R-Algiers, said the bill has a very steep hill to climb in
the House with the 70-vote requirement needed to pass it. With the governor
pledging to veto the bill, Tucker questioned why anyone would want to be on
record backing a tax increase that never went into law.
Senate is seen as less resistant to the proposal.
brought seven House members from both parties to testify for the bill Monday.
not enamored with that industry whatsoever," said Hollis Downs,
R-Ruston, whose father died from emphysema. "I would support taxing them
out of existence, if I could."
to the bill included tobacco companies and trade associations for product
sellers, who argued that it would put a severe tax on an already decreasing
number of tobacco users who make up about 22 percent of the population. The
targeted programs would become reliant on the revenue to expand, they said.
not wise to fund a recurring expense with a diminishing source of
revenue," said David Tatman for the Louisiana
Association of Wholesalers.
$1.41-per-pack tax on cigarettes in Texas
helps draw customers from that state into Louisiana, which would lose much of that
business with a higher tax of its own, opponents said.
ROUGE -- State Treasurer John Kennedy called Monday for state government to
eliminate 15,000 jobs in the next three years, saying the downsizing is
needed to bring state spending in line with other states at a time when Louisiana's
post-hurricane economic boom has ended.
reductions should be part of "a serious discussion about what the
priorities of this state are," Kennedy said.
said the cuts "should be made strategically, with a lot of
thought," and could be handled mainly through attrition, or not
replacing workers who leave their jobs. As an example of the type of
downsizing necessary, he cited a recent consultants' report that found the Interim LSU
in New Orleans
is overstaffed and could shed 355 jobs.
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also said the state needs to do a better job of managing its far-flung
property assets and collecting on overdue accounts, citing $1.7 billion owed
to the state that is more than six months overdue.
are not uncollectables; these are receivables that
can be collected," Kennedy told the Press Club of Baton Rouge.
rhetoric into reality on state employment could prove difficult, as the
Legislature has been reluctant to cut deeply into state workers. The House
version of next year's budget bill, for example, calls for eliminating 3,500
state jobs, but that number was reduced by the Senate and now the budget
would strike about 1,200 jobs, many of them unfilled.
calling for a top-to-bottom review of state spending, Kennedy said it should
not be accompanied by a similar examination of the state's tax system, which
many critics regard as regressive because of its low property taxes and
historic reliance on sales taxes.
discussion of taxes, if it should come at all, should come last,"
House committee narrowly agreed Monday to advance legislation that would
boost cigarette taxes by 50 cents a pack.
Bobby Jindal is opposed to the increase, which now faces the hurdle of a
two-thirds vote of the full House.
opposed to tax increases,” the governor reiterated Monday.
Bill 889, the tobacco tax legislation, struggled to emerge from the House
Committee on Ways and Means.
bill initially proposed raising cigarette taxes by $1 a pack. It died in
bill’s sponsor, House Speaker Pro Tem Karen Peterson, then cut the tax in
half and refiled the measure. However, two
committee members bolted to the Governor’s Office the first time the revamped
proposal came up for a vote. The departure of state Reps. Steve Carter and
Frank Hoffmann prevented the committee from achieving the quorum necessary to
vote on HB889.
R-West Monroe, and Carter, R-Baton Rouge, voted for the bill Monday. They
were the only Republicans at the meeting to buck the governor by voting for
the legislation. The committee’s chairman, state Rep. Hunter Greene, R-Baton
Rouge, did not cast a vote. The panel voted 8-7 in favor of advancing the
pay 36 cents in state tax on a pack of cigarettes. Peterson’s proposal would
increase the tax to 86 cents a pack. Taxes on cigars and smokeless tobacco
would also increase.
number of Republican lawmakers spoke in support of the legislation.
Rep. Hollis Downs, R-Ruston, told the committee he is in favor of taxing
tobacco products out of existence.
it comes to this issue, I’m probably not particularly rational,” Downs said. “Tobacco killed my father.”
committee heard from other people with similar stories.
D-New Orleans, said a tobacco tax is a proven way to cut health-care costs
and generate sustainable revenue.
opportunity to move Louisiana
forward is now before us,” she said.
Rep. Joe Harrison, R-Napoleonville, said he knows from working in the health
insurance industry that smokers increase the rates for nonsmokers.
going to pay a higher rate because your fellow employee decided to smoke,” he
Rep. Thomas Carmody, R-Shreveport, said it goes
against his grain to raise taxes.
he said, there needs to be a discussion of how much smoking contributes to
the state’s health-care costs.
state is facing a $1.3 billion drop in revenue for the fiscal year that
starts July 1. To address the shortfall, Jindal proposed heavy cuts to health
care and higher education. The Legislature is trying to reduce those cuts.
50-cent tax increase is expected to generate about $100 million a year.
of the money would be used to pay health-care providers who treat Medicaid
patients. The rest of the money would largely be committed to cancer research
and prevention programs. The Pennington
Center would get a
share of the proceeds.
Rep. Joel Robideaux, No Party-Lafayette, asked if
Peterson had information on smokers’ income levels.
said the increase would place an unfair burden on the poor because it is a
flat tax rather than a progressive tax.
said he answered his own question.
Rep. Harold Ritchie, D-Franklinton, said the only ones who win by the bill’s
defeat are lobbyists and tobacco companies.
urged the committee members to vote what was in their hearts and their heads.
FOR increasing the tobacco tax (8): Burrell, Ritchie, Baldone,
Honey, Carter, Danahay, Hoffmann and G. Jackson.
AGAINST increasing the tobacco tax (7): Robideaux,
Jane Smith, Richard, Henry, Nowlin, Templet and Perry.
LAFAYETTE — Proposed state
budget cuts to health care and education could lead to the loss of 525 jobs
in Lafayette Parish, according to the University
of Louisiana at Lafayette, area hospitals and Acadian
President Joe Savoie, Acadian Ambulance CEO Richard Zuschlag
and the presidents of area hospitals held a news conference Monday to urge
the state House of Representatives to restore at least 75 percent of the
Zuschlag said 53 jobs at Acadian Ambulance
could be on the line if the full cuts go through.
said even restoring 75 percent of the proposed cuts would leave a substantial
would be difficult and hard, but we could manage that,” Zuschlag
Lady of Lourdes Regional Medical Center, Lafayette General Medical Center,
Women’s and Children’s Hospital, and smaller hospitals in the area reported a
combined loss of 450 jobs should the full cuts be implemented.
state budget cuts affect the private hospitals and ambulance service because
those businesses depend on reimbursement from government health programs.
example, the administration’s budget cuts Medicaid ambulance rates by 7.16
percent, which would translate into a loss of nearly $2 million for Acadian
Ambulance, according to information from the company.
said that, if the full cuts are implemented, an estimated 22 jobs at ULL that
will become vacant in the near future will not be filled.
cuts could result in furloughs, he said.
of whether 75 percent of the proposed cuts are restored, Savoie said, the
university is looking to reduce course offerings, to reduce the number of
adjunct professors, to implement a hiring freeze and other measures.
said higher education is facing what amounts to a 25 percent reduction when
considering the midyear budget cuts this fiscal year, the proposed cuts and
the expenses the state once covered but is now passing on to universities.
too much to take on,” he said. “This is much more than an equitable share of
Economic Development Authority President Gregg Gothreaux
said the proposed cuts could shake the foundation for a local economy that
has remained stable amid the national recession.
strength of the local health-care industry and the university is particularly
critical during an uncertain time for the oil sector, a central part of Lafayette’s economy, he
this is a one, two, three punch that we can’t sustain,” Gothreaux
Bobby Jindal said Monday he expects more “big changes” to the state’s budget
for the next fiscal year before the legislative session ends June 25.
state House and Senate are at odds over how much “rainy day” money to spend
and whether to implement an income tax cut delay to reduce higher education
cuts during lean economic times.
compared the budget tinkering, which is expected to end up in a legislative
compromise committee, to his children waiting until the last minute to
complete their homework.
always seems to get done towards the end,” Jindal said, “and I suspect we’re
going to see that again.”
were planning to approve the budget — House Bill 1 — early, to allow time to
override any of the governor’s line-item vetoes of lawmakers’ pet projects
without having to call a special session.
Senate wants to reduce proposed cuts to higher education and health care by
tapping the state’s “rainy day fund” and by delaying an income tax break.
“rainy day fund” was set up to create a cache of money to use during a budget
income tax delay would freeze the amount of federal excess itemized
deductions state income tax filers can deduct at current levels through 2011.
Instead of being able to claim 100 percent, tax filers would only be able to
claim 65 percent.
tax delay could reduce $118 million of the proposed $219 million in budget
cuts to higher education. The proposed cuts represent 15 percent of state
funding for colleges or $7.7 million of the total budgets for colleges, as
Jindal pointed out.
again said he is adamantly opposed to both ideas.
just exacerbates a budget that’s going to be facing even bigger challenges,”
called the Senate’s significant changes to the budget “a normal part of the
don’t think there are a whole lot of people expecting the House to concur
(with the changes),” Jindal said.
did express support for most of the House measures to reduce cuts to higher
education, adding that, “We do support efforts to mitigate the reductions.”
House proposed taking $50 million from a tax amnesty program for higher
education as well as other ways to reduce the cuts. Jindal said he would
support giving $50 million in “rainy day” dollars to colleges so long as the
amnesty dollars replenish the “rainy day fund.”
also said he wants more of a long-term plan from higher education officials,
because the state’s expenses are expected to continue to increase as federal
stimulus dollars run out and the federal match on Medicaid funding decreases.
Commissioner of Higher Education Sally Clausen said she wants to work with
House Speaker Jim Tucker on his plans to develop a commission to study making
higher education more efficient and possibly downsized.
goal would be to present recommendations before next year’s legislative
think he’s absolutely right,” Clausen said of Jindal’s
requests for greater planning.
tough questions must be asked, Clausen said.
may choose to close a particular institution,” she said. “What about athletics?
Should that be eliminated?”
Treasurer says La. must try to slice 15,000 state jobs
Louisiana should aim to trim
15,000 state government jobs over the next three years to help cope with
budget problems, State Treasurer John Kennedy said Monday.
said the reduction could be accomplished through attrition and trim the state work force by about 14 percent from 104,000
employees to 89,000.
do believe it can be done,” Kennedy said. “We see it done every day in America.
is not easy,” Kennedy added. “It is not done without pain. But it can be
treasurer made his comments to the Press Club of Baton Rouge.
offered the suggestion during a speech that focused on state budget problems.
revenue dropped by $1.3 billion for the financial year that begins July 1. Even-bleaker
financial forecasts are predicted for the next two years.
said the state’s current operating budget is nearly $30 billion, including
$4.6 billion for salaries.
said that, if the state gradually eliminated 15,000 jobs, it would save
between $600 million and $1 billion per year.
have got to get control of this budget,” he said.
said the state work force has an annual attrition rate of 15 to 22 percent,
depending on whether classified or unclassified jobs are involved.
said agency reorganizations and early retirements are among ways the work
force could be reduced.
mentioned Commissioner of Administration Angèle
Davis as one possibility to tackle the job.
about that, Davis’
office issued a statement that said previous and proposed actions could mean
the elimination of 3,411 full-time state jobs, which has saved $222 million
since Gov. Bobby Jindal took office.
said the state’s nearly $30 billion operating budget today is up from $11.9
billion in 1996 and $18.7 billion in 2005, in part because of hurricane
Louisiana has about 4.2
said Missouri has a $21.4 billion operating
budget with a population of 5.6 million; Tennessee
has a $24.8 billion budget with a population of 6.1 million; and Kentucky’s is $22.3 billion with roughly the same
population as Louisiana.
Bobby Jindal said Monday that the differences between the Louisiana House and
Senate over next year's budget are wide enough that he doesn't expect lawmakers
to finish work early on the spending plan.
want to deliver the 2009-10 budget bill to Jindal's
desk earlier than is typical so they would be in session and able to vote on
overriding any of the governor's line-item vetoes of their favored projects,
without having to call a special session.
the timeline is tight and the gap between the two versions of the budget is
large. Jindal said he expects negotiations to go into the final days of the
session that must end by June 25.
compare this process to my children doing homework. I don't care how long the
session is, I don't care how much time we have, it always seems to get done
towards the end, and I suspect we're going to see that again," Jindal
May, the House approved a $27.9 billion budget for the new year that begins
July 1 that contained deeper cuts to public colleges, health programs and
government jobs than the $28.7 billion budget approved by the Senate last
House is expected to reject the Senate changes to the budget bill and send it
to a legislative compromise committee to grapple over a final version of the
bill that will finance state government operations next year.
disagreements center on financing plans the Senate used to balance its
version of the budget with fewer cuts: Delay of a scheduled tax cut for
taxpayers who itemize to generate $118 million for higher education and use
of $86 million from the state's "rainy day" fund to offset some
cuts to health care, agriculture and the tourism department. Some of the
money also would be used to draw down additional federal matching dollars to
fill budget gaps.
and many House members oppose the financing plans contained in the
Senate-backed budget. A majority of House members already have signed a
statement pledging to reject the tax cut delay, and the rainy day fund
legislation is stalled in a House committee.
said he would veto the tax cut delay bill by Sen. Lydia Jackson,
D-Shreveport, if it reaches his desk, and he said Monday he has serious
concerns about the way the Senate used the rainy day fund money.
glitch with the fund requires it to be refilled if lawmakers use money from
it. Though senators are working on a plan to delay the refilling requirement,
Jindal said a delay of only a year would worsen the state's budget problems
in upcoming years.
doesn't actually relieve those budget pressures as much as it just shifts
them forward at best maybe a year," the governor said at a wide-ranging
press conference with reporters.
lawmakers can't hash out a compromise quickly, they won't make the deadline
to get the budget to Jindal's desk to force his
line-item vetoes to be done while they're in session.
Louisiana's governor has 10
days to veto a bill or strip individual items from the budget after a bill is
delivered to him — if the Legislature is in session. Otherwise, the governor
has 20 days. So, lawmakers have a week to work out their differences on the
budget to make that in-session deadline.
stripped out millions of dollars in legislators' pet projects from the budget
last year after they had left the Capitol, angering many who wanted to try to
override those vetoes. But an effort to call a special session failed.
leaders said this year they wanted to get the budget to Jindal's
the Internet: House Bill 1 can be found at www.legis.state.la.us
Opelousas Daily World [Gannett] | 06.09.09
ROUGE - While complimenting legislators on their work on the proposed state
budget Gov. Bobby Jindal frowned Monday on steps the Senate used to increase
funding for higher education and health care.
differences between the House and Senate versions of House Bill 1 are major.
To ease the cuts on state colleges and universities and health programs, the
Senate plan calls for passage of legislation delaying the implementation of
increased state income tax deductions and dipping into the Budget
Stabilization Fund, often called the "Rainy Day Fund."
of the House Jim Tucker, R-Terrytown, put the
brakes on the deductions delay, Senate Bill 335 by state Sen. Lydia Jackson,
D-Shreveport, by refusing to refer it to a committee for a hearing. Tucker
said it violated a constitutional provision requiring all revenue-raising
measures to start in the House.
the scheduled tax cut for the 24 percent of taxpayers who itemize would
generate $118 million for higher education. The Senate plan also uses $86
million in "rainy day" money to offset some cuts to health care,
agriculture and tourism.
Jackson said that since the
Senate overwhelmingly approved her proposal, "we hope we can get the
House to come along."
governor said he doesn't expect a budget compromise to be worked out any time
soon - but knows they'll have to come up with something by the time they are
set to leave June 25.
compare it to my children doing their homework," he said. They know
there's a deadline and "it all seems to get done by the end."
said the House made major changes in the budget he proposed, the Senate made
major changes to the House version and "I suggest you'll see big changes
again by the time it gets to us."
dispute is "a normal part of the budget process," he said,
acknowledging "last year it was unusual that the House concurred"
with Senate changes.
two major concerns with the Senate plan, he said, are its dependence on
funding from Senate Bill 335 and the rainy day fund.
Senate version extracts from the fund the allowed 33 percent - about $256
million - but splits the money in thirds to be used in each of the next three
state still has to pay those dollars back, almost immediately," Jindal
are pushing legislation that would delay pay-back one year but the governor
said that is only delaying the inevitable.
said the administration is working with legislative leaders to put together a
compromise and "we've had good conversations with leaders in both
said he will "support efforts to mitigate the cuts" to higher
education and health care but "it's absolutely critical for higher
education to present a plan" for dealing with less money in future
and universities can't be "everything to everybody," he said. Louisiana has more
four-year universities per capita than other states "and some are close
to each other," so consolidation of programs and elimination of
duplicative programs should be part of the plan.
governor hasn't commented on the fact that lawmakers have added about $25
million in local projects to the bill.
Letter: Charity Hospital
in New Orleans
is forging ahead with plans to build a $1.2 billion new hospital and
biomedical complex in New Orleans,
a bit afield from the existing medical center on Tulane Avenue. This project would take
away about 70 acres of midcity neighborhood and
contribute to the demise of the downtown area.
only hang-up at this point appears to be about $345 million from FEMA the
state believes it is owed, but that FEMA doesn’t seem inclined to fork over.
Perhaps FEMA now has a plan to come up with the money. The front page story
in the June 2 Advocate reports FEMA’s plans to transfer, donate or sell
118,000 travel trailers or mobile homes. If they get just under $3,000 for
each unit, they’d have enough money to pay for LSU’s proposed new
the other hand, if the state would consider the proposal to build a new,
modern hospital inside the beautiful, sturdy shell of old Charity Hospital
(It has been shown it could be done.), we wouldn’t need those funds from
FEMA. Health care could be returned to the city more quickly, both money and
a neighborhood could be saved and the same coveted biomedical complex could
grow up, just in a slightly different location.
could save the funds from the sale of the trailers for another rainy, windy
to Bill Feig, Advocate staff photographer, for the
front page aerial photograph, June 2. The massive display of FEMA trailers
gives one the impression that hurricane season is here again. Thanks for the
should FEMA decide to sell the 118,000 trailers at $3,000 apiece, they would
have enough money to pay the shortfall expected by Louisiana for Katrina’s
damage to Charity Hospital, which would enable the state and LSU to begin
medical recovery for New Orleans.
— President Obama recently summoned aides to the Oval Office to discuss a
magazine article investigating why the border town of McAllen, Tex., was the
country’s most expensive place for health care. The article became required
reading in the White House, with Mr. Obama even citing it at a meeting last
week with two dozen Democratic senators.
came into the meeting with that article having affected his thinking
dramatically,” said Senator Ron Wyden, Democrat of Oregon. “He, in effect,
took that article and put it in front of a big group of senators and said,
‘This is what we’ve got to fix.’ ”
part of the larger effort to overhaul health care, lawmakers are trying to
address the problem that intrigues Mr. Obama so much — the huge geographic
variations in Medicare spending per beneficiary. Two decades of research
suggests that the higher spending does not produce better results for
patients but may be evidence of inefficiency.
of Congress are seriously considering proposals to rein in the growth of health
spending by taking tens of billions of dollars of Medicare money away from
doctors and hospitals in high-cost areas and using it to help cover the
uninsured or treat patients in lower-cost regions.
proposals have alarmed lawmakers from higher-cost states like Florida, Massachusetts,
New Jersey and New York. But they have won tentative
support among some lawmakers from Iowa, Minnesota, Montana, North Dakota, Oregon
who say their states have long been shortchanged by Medicare.
according to the Dartmouth Atlas of Health Care, Medicare spent an average of
$8,304 per beneficiary in 2006. Among states, New York
was tops, at $9,564, and Hawaii
was lowest, at $5,311.
at Dartmouth Medical School
have also found wide variations within states and among cities. Medicare
spent $16,351 per beneficiary in Miami in
2006, almost twice the average of $8,331 in San Francisco, they said.
Senate Finance Committee recently suggested that one way to pay for health
care overhaul would be to reduce geographic variations by cutting or capping
Medicare payments in “areas where per-beneficiary spending is above a certain
threshold, compared with the national average.”
proposal would spare health care providers in low-spending, efficient areas
from across-the-board cuts in Medicare payments.
committee chairman, Senator Max Baucus, Democrat of Montana, and the panel’s
senior Republican, Senator Charles E. Grassley of Iowa, are from lower-spending states.
the proposals are not just pork-barrel politics. They are based on the
research by Dartmouth
experts who have documented wide geographic variations in health spending.
The research has become phenomenally influential on Capitol Hill since it was
popularized by Peter R. Orszag, as director of the
Congressional Budget Office and then as President Obama’s budget director.
said Mr. Obama had been intrigued by regional variations in health spending
since before his inauguration. The topic came up at a meeting with Mr. Orszag in Chicago
late last year.
magazine article, by Dr. Atul Gawande
in the June 1 issue of The New Yorker, said a major cause of the high costs
was “overuse of medical care.”
Elliott S. Fisher, one of the Dartmouth researchers, diagnosed the problem
this way: “Medicare beneficiaries in higher spending regions are hospitalized
more frequently, are referred to specialists more often and have a much
smaller proportion of their visits to primary care physicians.”
his blog last month, Mr. Orszag wrote, “The
higher-cost areas and hospitals don’t generate better outcomes than the
other researchers and politicians are not so sure. They say it would be a
mistake to cut or cap Medicare payments without knowing why spending in some
places far exceeds the national average.
is too much uncertainty about the Dartmouth
study to use it as a basis for public policy,” said Senator John Kerry,
Democrat of Massachusetts. “Researchers can’t explain why some areas of the
country spend more on health care than others. There are many reasons
spending could vary: higher costs of living, sicker people or more teaching
are concentrated centers of medical innovation where cutting-edge treatments
are tested and some of the nation’s finest doctors are trained,” Mr. Kerry
added. “This work might cost a little more, but it benefits the entire
H. Otto, an aide to Senator Bill Nelson, Democrat of Florida, said he was
“adamantly opposed” to the proposed cuts in higher-spending areas because the
cuts did not distinguish between necessary and unnecessary care.
Orszag says health spending could be reduced by as
much as 30 percent, or $700 billion a year, without compromising the quality
of care, if more doctors and hospitals practiced like those in low-cost
areas. The supply of hospitals, medical specialists and high-tech equipment
“appears to generate its own demand,” Mr. Orszag
Democrat from a low-spending state said critics were trying to “blow holes in
Michael L. Langberg, senior vice president of Cedars-Sinai Medical
Center in Los Angeles, is among the critics.
statement that Medicare costs can be cut by 30 percent has been repeated so
many times that it has come to be viewed as a proven fact by some,” Dr. Langberg said in a recent letter to the Senate Finance
Committee. “It is not a fact. It is a gross oversimplification of an untested
Langberg endorsed the goal of covering the
uninsured, but said, “We do not believe that rushing to make large cuts in
Medicare payments to hospitals is the right way to fund that coverage.” The Dartmouth team has cited
Cedars-Sinai as having very high Medicare spending per beneficiary.
by Dr. Robert A. Berenson and Jack Hadley of the Urban Institute suggests
that much of the geographic variation in health spending can be explained by
differences in “individual characteristics, especially patients’ underlying
health status and a range of socio-economic factors, including income.”
patients may benefit from higher spending,” said Mr. Hadley, who is also a
professor at George Mason University
“They could be adversely affected if they live in geographic areas where
payments are cut.”
Berenson, who was a Medicare official in the Clinton
administration, said, “There remains too much uncertainty about the Dartmouth findings to
ground public policy on them.”
Gay Stolberg contributed reporting.
decades of warnings about the inevitability of another pandemic of influenza,
it is astonishing that health officials have failed to make clear to the
public, even to many colleagues, what they mean by the word pandemic.
of people have used the term to describe widespread epidemics of influenza,
cholera and other diseases. But as the new H1N1 swine influenza virus spreads
from continent to continent, it is clear that a useful definition is far more
complicated and elusive than officials had thought.
what is at stake is far more than an exercise in semantics. A clear
understanding of the term is central to the World Health Organization’s
six-level staging system for declaring a pandemic, which in turn informs
countries when to set their control efforts in motion.
and medical journals offer little guidance. Their definitions can be too
vague or too narrow, contradictory and clouded by jargon.
is a lot of misinformation in the medical literature, and it is really quite
hard to figure out what is and what is not a pandemic,” said Dr. David M. Morens, an epidemiologist at the National Institute of
Allergy and Infectious Diseases who has been studying the history of
word implies the rapid spread of an infectious disease to many countries in
different regions, hitting each with more or less the same severity. But in
fact, severity varies — not all people are infected at the same time, and not
every country need be affected.
there can be many other factors, including the numbers and percentages of
people falling ill and dying; a population’s vulnerability to the disease,
based on previous rates of infection; and the quality of health care
facilities and disease monitoring systems.
least is that scientists do not know precisely how pandemics arise, what
fuels them, why they vary in their lethality, why some occur in waves and why
officials have long preached that with influenza, the only sure bet is to
expect the unexpected. The new swine influenza virus, which appeared suddenly
after years of warning about a potential pandemic of avian influenza, upset
the W.H.O.’s assumptions that most people have the
same understanding of the word pandemic.
years, the organization’s Web site defined an influenza pandemic as causing
“enormous numbers of deaths and illness.” But the agency recently pulled the
definition, apologizing for causing confusion and anxiety.
of the biggest problems in public health is communicating risk assessment.
United States and W.H.O. officials
say their preparedness plans are intended for governments, not people in the
street. Officials bristle at criticism that their messages and plans have led
the public to equate the word pandemic with the Spanish influenza of 1918-19,
the worst recorded pandemic in history, killing 20 million to 100 million
preparing for the worst, officials have considered milder pandemics, said Dr.
Nancy J. Cox, chief of the influenza division at the Centers for Disease
Control and Prevention in Atlanta.
Dr. William Schaffner, the chairman of preventive
medicine at Vanderbilt
University, said that
“we, the public health community, deserve to be chided” about the confusion.
ought to be able to do a better job in communicating in an understandable
way,” he said in an interview.
like to assert that theirs is an exact discipline. But like the terms
“evidence -based medicine” and “peer review,” pandemic turns out to be
another example of imprecise vocabulary that doctors use every day, assuming
everyone understands their meaning.
textbooks and reference works use pandemic in discussing certain diseases,
but rarely define the word.
example, the definition section of the Control of Communicable Diseases
Manual, a standard reference work, includes “endemic” (said of a disease that
is usually present in an area or a population group) and “epidemic” (more
cases of an illness than would normally be expected) but not “pandemic.”
disease manual’s editor, Dr. David L. Heymann, a
retired assistant director-general of the W.H.O., said the term had not
caused confusion in the past, but assured me in an interview that “pandemic
will be defined in the next edition.”
the indexes of most major medical textbooks do not list pandemic. One is Harrison’s Principles of Internal Medicine, of which
Dr. Anthony S. Fauci, who directs the National
Institute of Allergy and Infectious Diseases, is a main editor.
a mistake, and I’m surprised it’s not there because it should have been,” Dr.
Fauci said in an interview.
agencies do not have official lists of pandemics. Textbooks cite many recent
and old ones, including these:
Many experts have called H.I.V. a pandemic. Others disagree, saying the virus
is pandemic only in Africa.
Since 1817, most experts agree, the world has had seven pandemics of this
bacterial illness, which causes severe diarrhea and dehydration. ¶Acute
hemorrhagic conjunctivitis. Beginning in 1969, an enterovirus
has caused tens of millions of cases of a highly contagious, acute, painful,
but rarely blinding, form of hemorrhagic eye inflammation.
Since World War II, this mosquito-borne viral disease has spread widely in
Asia and Latin America.
A pandemic of the bacterial disease raced through Europe and Asia after Columbus’s return from America
and during mass movements of armies in Europe.
pandemics have been classically limited to infectious diseases, the term has
spread to noninfectious, chronic ones. For example, many health officials now
speak of pandemics of obesity and heart disease.
about past pandemics is necessarily incomplete; historical accounts cannot
make up for the absence of modern disease monitoring and laboratory tests.
14 pandemics of influenza have been described since the 16th century, with
the first indisputable one occurring in 1889.
1580, an influenza pandemic swept through Asia into Europe within six weeks,
and at least 10 percent of Rome’s 81,000
residents died in the first week, said Dr. Michael T. Osterholm,
director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Some Spanish cities were
almost totally depopulated.
Morens, of the infectious diseases institute, said
his studies of influenza pandemics left a confusing track record and “are
rewiring our brains about thinking about influenza.”
medical literature will tell you there were three pandemics in the 1830s,” he
said — “one from 1830 to 1832, a second in 1833 to 1834 and a third in 1836
to 1837. But I am beginning to think they were all one pandemic.”
Morens said he was puzzled as to why no influenza
pandemics were recorded for nearly 150 years after the one in 1580, although
there were some severe localized epidemics.
period of pandemic stability makes us wonder whether a pandemic comes at any
time by chance,” he said, “or whether something about epidemic situations
prevents pandemics,” or at least delays them.
W.H.O.’s staging system has long been part of its
plan for an influenza pandemic. Deep concern about a potential pandemic of
the H5N1 avian influenza virus led the organization to convene a large
meeting of experts in 2005. Among other things, the experts recommended
simplifying the staging system.
number of doctors ask why health agencies do not declare seasonal influenza a
pandemic when it spreads around the world.
Dr. Osterholm, the Minnesota expert, said that “you can’t use
the terminology for just worldwide transmission, because if you did that, you
would say every seasonal flu year is a pandemic.”
me,” he continued, “a pandemic is basically a new or novel agent emerging
with worldwide transmission.”
Keiji Fukuda, an influenza expert who is an
assistant director-general at the W.H.O., said in an interview that “as
difficult as things are right now,” the problem of defining a pandemic and
communicating risk “would be magnitudes worse and more confusing” if the
agency had not dealt with AIDS, SARS and avian influenza.
experiences prompted new international health regulations and pandemic plans,
and allowed critical scientific information to be disseminated quickly, he
process was “painful, sure,” he said. “But you can’t really do anything like
this without having some amount of pain.”
DONALD G. McNEIL Jr.
swine flu virus is rapidly making its way around the world, but it has been
relatively mild so far, causing only 139 confirmed deaths. Could it mutate
into something more lethal?
looking at its genetic structure say there is no obvious pressure for it to
do so — no reason for this virus to “want,” in the Darwinian sense, to kill
more of its hosts.
is already doing a near-perfect job of keeping itself alive by invading human
noses and inducing humans to cough it from one to another, said Dr. W. Ian Lipkin, director of the Center for Infection and
Immunology at Columbia University’s Mailman School of Public Health.
really aggressive flu that quickly kills its host” — like SARS and H5N1 avian
flu — “gives itself a problem,” Dr. Lipkin said.
flu viruses are highly mutable, and anything could happen in the next two
years, the time a new strain normally takes to circle the globe. After all,
Spanish influenza began as a mild strain, then
turned horrifically virulent, killing 20 million to 100 million people in
Dr. Peter Palese, head of microbiology at Mount
Sinai Medical School and part of the team that rebuilt that virus in 2005
from fragments found in old lung tissue, said that strain was a “once-a-millennium
or once-every-10-millennia event — things like it don’t happen very often.”
is it clear, he added, that viruses really “want” a particular outcome.
me, that’s too much anthropomorphic thinking,” Dr. Palese
said. “Look, I believe in Darwin.
Yes, the fittest virus survives. But it’s not clear what the ultimate
selection parameter is.”
mutation that confers lethality, he explained, may confer another advantage
scientists have not pinned down.
new virus has been described as “a real mutt” by Walter R. Dowdle, the former chief of virology for the Centers for
Disease Control and Prevention, because of its unique mix of Eurasian and
American swine, human and bird genes.
chromosomes are quite simple — eight short strands of RNA that issue the
genetic code for a grand total of 11 proteins. They break apart in a jumble
inside cells they infect, and then they reassemble, picking up random bits of
other flus, which makes
the results unpredictable.
current swine flu strain lacks several genes believed to increase lethality,
including those that code for two proteins known as PB1-F2 and NS-1, and one
that codes for a tongue-twister called the polybasic hemagglutinin
appears to weaken the protective membrane of the energy-producing
mitochondria in an infected cell, ultimately killing the cell. Specifically,
it attacks dendritic cells, the sentinels of the
immune system. Its lethality could be accidental — a protein good at killing
sentries might just go on killing other cells once inside the fort.
pandemic flus, including those of the Spanish, Hong Kong and Asian flus, make PB1-F2. So does
the H5N1 bird flu. The current swine strain does not.
NS-1 protein also maims the immune response by blocking interferon, an
antiviral protein made by cells.
lethal bird flus also have the unusual cleavage
site, which allows the hemagglutinin spike on the
virus’s shell to split and inject its genetic instructions into different kinds
of cells, like those in the lungs and the gut.
an addition to the novel H1N1 would be very dangerous. But because it has
been found only in avian flus, it is unlikely to
become a component of a human flu, Dr. Palese said.
Even the 1918 virus, which was avian in origin, lacked it.
much more likely change, scientists have said, is that the H1N1 swine flu
will become resistant to the antiviral drug Tamiflu.
A gene for Tamiflu resistance is now almost
universal in seasonal H1N1 flus.
that happens, the world’s Tamiflu stockpiles will
be all but worthless, and doctors may have to switch to Relenza,
which is a powder used with an inhaler, which makes it more expensive and
harder to take.
on the mutation, older antiviral drugs like rimantidine
may be useful, but so much resistance to them developed in seasonal flu that
they were largely abandoned a few years ago.
Palese was asked about another notion concerning
likely mutations. There has been outrage at Egypt’s decision to kill all the
pigs belonging to its Coptic Christian minority. It has been depicted as
misguided and motivated by religious bigotry, because the “swine flu” is
really now a human flu.
is also in an especially dangerous situation. The new swine flu reached it
just last week. The H5N1 avian flu has circulated in its backyard chickens
since 2006, defying all eradication efforts. In the last year, dozens of H5N1
cases have been confirmed in toddlers, almost all of whom have survived —
which led some experts to speculate that those are cases of a less lethal
version of H5N1 that is better adapted to humans.
that case, might it be wise to get rid of the country’s relatively small pig
population, since pigs are “mixing vessels” that can catch both human and
agree with the premise, if you really could eliminate an animal reservoir,”
Dr. Palese said. “But the virus is out of pigs now
— and it’s more important that those poor people have something to eat.”
SHERYL GAY STOLBERG
— After months of insisting he would leave the details to Congress, President
Obama has concluded that he must exert greater control over the health care
debate and is preparing an intense push for legislation that will include
speeches, town-hall-style meetings and much deeper engagement with lawmakers,
senior White House officials say.
of the failures of former President Bill Clinton, whose intricate proposal
for universal care collapsed on Capitol Hill 15 years ago, Mr. Obama until
now had charted a different course, setting forth broad principles and
concentrating on bringing disparate factions — doctors, insurers, hospitals,
pharmaceutical companies, labor unions — to the negotiating table.
Mr. Obama has grown concerned that he is losing the debate over certain
policy prescriptions he favors, like a government-run insurance plan to
compete with the private sector, said one Democrat familiar with his
thinking. With Congress beginning a burst of work on the measure, top
advisers say, the president is determined to make certain the final bill
bears his stamp.
as happened with the recovery act, it will become President Obama’s plan,”
the White House budget director, Peter R. Orszag,
said in an interview. “I think you will see that evolution occurring over the
next few weeks. We will be weighing in more definitively, and you will see
him out there.”
Saturday, while Mr. Obama was traveling in Europe,
he used his weekly radio and Internet address to make the case that “the
status quo is broken” and to set forth his ambitious goals.
speaking, he wants to extend coverage to the 45 million uninsured while
lowering costs, improving quality and preserving consumer choice. His budget
includes what he called a “historic down payment” of $634 billion over 10
years, accomplished mostly by slowing Medicare growth and limiting tax breaks
for those with high incomes.
must attack the root causes of skyrocketing health costs,” Mr. Obama said,
pointing to the Mayo Clinic in Minnesota and other institutions as among
those that offer high-quality care at low cost. “We should learn from their
successes and promote the best practices, not the most expensive ones. That’s
how we’ll achieve reform that fixes what doesn’t work and builds on what
radio address was the start of a public relations campaign coinciding with a
50-state grass-roots effort that Organizing for America, the president’s
political group, began Saturday to promote a health care overhaul. His hope
is to provide what his chief of staff, Rahm
Emanuel, called “air cover” for lawmakers to adopt his priorities. It is a
gamble by the White House that Mr. Obama can translate his approval ratings
into legislative action.
Mr. Emanuel said, “the president’s adoption of something makes it easier to
vote for, because he’s — let’s be honest — popular, and the public trusts
as Mr. Obama wades into the details of the legislative debate — a process
that began last week when he released a letter staking out certain specific
policy positions for the first time — he will face increasingly difficult
choices and risks.
say he will not dictate the fine print. “It was never his intent to come to
Congress with stone tablets,“ said his senior
adviser, David Axelrod. But he will increasingly make his preferences known.
he embraces a tax on employee benefits, an idea he attacked when he was
running for president, he may infuriate labor and the middle class. If he
insists on a big-government plan in the image of Medicare, he could lose any
hope of Republican support and ignite an insurance industry backlash. If he
does not come up with credible ways to pay for his plan, which by some
estimates could cost more than $1 trillion over 10 years, moderate Democrats could
Republicans are already angry over the emphasis Mr. Obama placed on the
public plan in last week’s letter. Senator Mitch McConnell, the Republican
leader, said Friday that “the key to a bipartisan bill is not to have a government
plan in the bill.”
Obama is well aware of these risks, advisers say. “This is what he is now
very focused on,“ Mr. Orszag
said. “What are the key things that are nonnegotiable? He is asking those
sorts of questions: What are the drop-dead things that we need to have in
order to have some hope of addressing long-term cost growth?”
Charles E. Grassley of Iowa, the senior Republican on the Finance Committee,
recalled how Mr. Obama made a personal pledge of bipartisanship when he and
Senator Max Baucus of Montana, the committee’s Democratic chairman, joined
the president for a private lunch at the White House last month.
said, ‘Yeah, it’s a problem,’ ” Mr. Grassley said of the public plan, “and he
said something along the lines of, ‘If I get 85 percent of what I want with a
bipartisan vote, or 100 percent with 51 votes, all Democrat, I’d rather have
it be bipartisan.’ ”
Friday, Mr. Grassley said he viewed the letter as “a political document, not
a policy document,” intended to shore up Democratic support while letting Mr.
Obama remain flexible.
Ron Wyden, an Oregon Democrat who is a longtime proponent of revamping health
care, said Mr. Obama seemed to be wrestling with how far he could push
president is very much aware that to bring about enduring change — health
care reform that lasts, gets implemented, wins the support of the American
people and does not get repealed in a couple of years — you need bipartisan
support,” said Mr. Wyden, who was among two dozen Senate Democrats who met
with Mr. Obama about health care last week. “So he’s grappling with, how do
you do that?”
Obama began taking steps to make his case early in his administration. He
convened a “fiscal summit” where health care was a major topic, followed by a
“health summit.” Not long ago, he invited industry leaders to the White
House, where they pledged to cut $2 trillion in health care costs over the
next decade. But he has been restrained in his dealings with Congress.
has, however, shown himself willing to exercise his presidential muscle when
he thinks it is necessary. In April, Senator Kent Conrad of North Dakota, the Budget Committee
chairman, balked at the idea of having the Senate consider health legislation
under the fast-track process known as reconciliation, which could avoid a
Republican filibuster. At a private meeting, Mr. Obama pressed him on it.
“ ‘I want to keep it on the table as an
option,’ ” Mr. Conrad recalled the president saying. Not long after that, Mr.
Emanuel, the White House chief of staff, visited Mr. Conrad on Capitol Hill.
Mr. Conrad was not convinced, but decided not to stand in the way. “The
Budget Committee chairman does not top the president of the United States,” he said.
forward, Mr. Emanuel said, lawmakers could expect “quiet one-on-one
discussions” with the president.
Republicans like Mr. Grassley say that after promising to leave the
legislative process to Congress, Mr. Obama must be cautious about his words,
and about the appearance of meddling.
doing good by staying out of it as much as he is,”
Mr. Grassley said. “He’d better use kid gloves at the start.”
guidelines for the care of youth athletes who sustain concussions are causing
controversy among brain-injury experts, reigniting the debate over whether
strict rules regarding concussions can actually leave athletes at greater
risk for injury.
international panel of neurologists, updating their recommendations on
concussion care in the May issue of The British Journal of Sports Medicine,
said that any athlete 18 or younger who was believed to have sustained a
concussion during a game or practice should never be allowed to return to the
playing field the same day. The group had previously said that such athletes
could return if cleared by a doctor or certified athletic trainer, but now
contend that such determinations are too difficult and dangerous for same-day
return to be considered safe.
doctors, many of whom work the sidelines of high school athletic events, said
they feared the effects of such strictness. They predicted that athletes
would respond by hiding their injuries from coaches and trainers even more
than they are already known to do, leaving them at risk for a second and more
panel’s recommendation to remove all players suspected of concussion has no
direct influence on rules governing United States youth sports, which
are generally made at the state and local levels. But it does spotlight how
some attempts to improve concussion-related safety can instead compromise it,
a paradox encountered at levels as high as the N.F.L.
many bad decisions are made when trying to assess whether a player is
symptomatic or not,” said Dr. Robert Cantu, an author of the guidelines who
is also a director of the Neurological Sports Injury Center at Brigham &
Women’s Hospital in Boston. “We know that an unacceptable number of kids are
being sent back while symptomatic, and sometimes with devastating effects.
The majority believe that the bullet should be bitten, and not let a kid go
back into the same contest.”
Dr. Bob Sallis, a past president of the American College
of Sports Medicine and a longtime sideline doctor in Southern
California, said he saw the recommendation as a step backward.
kids will be hurt seriously because of this, either by players not admitting
they might have gotten a concussion or coaches encouraging them not to be up
front about their symptoms, whether subtly or overtly,” Sallis
how the guidelines could have any influence on league rules throughout the
country — in Iowa, for example — Sallis said: “It does put the people in Iowa in scrutiny. When a kid gets hurt,
they’ll get sued and be told, why didn’t you follow those guidelines?”
school athletes in nine primary sports sustained an estimated 137,000
concussions in the 2007-8 school year, according to
a study conducted by the Center for Injury Research and Policy at Nationwide
Children’s Hospital in Columbus,
Ohio. Football had the most,
with more than 70,000, followed by girls soccer
(24,000), boys soccer (17,000) and girls basketball (7,000). These were only
reported concussions; more were almost certainly sustained but went
unrecognized or ignored.
postconcussion symptoms can be delayed for hours or
even days, like difficulty sleeping or concentrating,” Cantu said. “It’s a
clinical decision that’s difficult or sometimes damn near impossible to be
made on the sideline, and we aren’t doing a very good job at it. Athletes,
even when assessed by qualified people, seem to be returning to contests
prematurely or when symptomatic — an unacceptable number of cases.”
panel also emphasized the importance of not just physical rest for players
found to have a concussion, but cognitive rest as well. It said that
teenagers should be kept from activities ranging from schoolwork to video
games and text messaging while recovering from a concussion.
is the No. 1 management issue in our clinic — how do we manage the cognitive
activity that stresses that brain’s abnormal metabolism?” said Gerry Gioia, the chief of pediatric neuropsychology at
Children’s National Medical Center in Washington. “Studying for an algebra
exam, reading a lengthy text, sitting in a classroom for an hour and a half
trying to keep notes and keep up — it extends recovery, it feels miserable to
the kid, and it’s misunderstood by the school and public.”
Dr. José Batlle met his 93-year-old patient in her
small Bronx apartment, she didn’t have much
furniture beyond a small TV, a sofa and a wheelchair. What she did have in
abundance were pills — 15 types from a variety of
doctors, including a pulmonologist, a cardiologist and a gerontologist. He
discovered that some medicines had expired, others were unnecessary and some
were dangerous if taken together.
with his patient and her son, Dr. Batlle cut the
number of her medicines to four. He also gave the family his personal cellphone number.
coming to see him, the woman had endured several emergency-room visits and
hospital stays. With Dr. Batlle, she was able to
avoid all of that.
a doctor on his cell? No waiting for an appointment? It’s the type of service
that Dr. Batlle tries to offer to all of his 1,500
patients. “I prefer to keep them healthy than treat them when they are sick,”
efforts of Dr. Batlle and other primary care
physicians may get a boost at the federal level. The Obama administration is
considering ways to persuade medical students to pursue careers in primary care
by raising their pay, and is channeling them to work in underserved rural
areas. And the White House has already set aside $2 billion for community
health centers through the economic stimulus package.
more far-reaching health care reform remains an uncertainty, and in the
interim a small but growing number of doctors are trying to take matters into
their own hands.
stepping off the big-clinic treadmill, where doctors are sometimes asked to
see a different patient every 15 minutes, Dr. Batlle
has joined the vanguard of physicians trying to redefine health care. These
doctors spend more time with patients, emphasize prevention and education to
keep them healthy and can handle many medical problems without referrals to
many cases, this kind of care can reduce a patient’s medical bills. That’s
more crucial than ever: according to a study published online by the American
Journal of Medicine, 60 percent of all bankruptcies in the United States in 2007 were driven
by health care costs.
numbers are hard to come by, but doctors involved in this movement, called
“patient centered” practices, say its popularity is growing.
travel to a lot of medical conferences, and I’m meeting more and more doctors
embarking on this path,” said Dr. L. Gordon Moore, who runs
IdealMedicalPractices.org, a program to help small practices become more
innovative and efficient. The Web site IdealMedicalHome.org has about 800
doctors who post and trade ideas, while more than 700 physicians have adopted
methods from HowsYourHealth.org. Many of these doctors see fewer patients per
day than they did before.
make personalized care possible in an era when compensation is often tied to
the number of patients they see, doctors use technology to streamline
processes and reduce administrative costs. Dr. Batlle,
for example, uses online appointment scheduling and manages his medical
records electronically. He prescribes medications from his computer and
offers virtual visits by phone and e-mail.
cost Dr. Batlle about $25,000 to buy the technology
to make all of this possible, but he estimates that he saves close to
$100,000 a year in salaries and billing costs. And he has made enough money
to begin renovations on a new office in Washington
Heights in Manhattan.
model seems to be working, according to a 2008 study by Dr. John H. Wasson at
Dartmouth Medical School.
His research showed that patients in patient-centered practices were more
likely to say they were informed about how to manage chronic diseases and got
the care they needed, compared with those in a national sample of medical
practices. They also were less likely to say they had to wait for an
the goal is to deliver patient care when and how they want and need it, this
is the way to go,” Dr. Wasson said.
course, even doctors in this movement acknowledge that it is not a panacea
for the country’s health care problems. Privacy advocates warn that
electronic patient records can be breached, and computer glitches can make
patient records inaccessible for hours. Big clinics can be better for people
who have several health problems and need easy access to a variety of
specialists. Moreover, some doctors may not want to leave a big clinic
because they feel they lack the technical or business skills they need — or
because a salaried job there may be more stable in this economy.
while the patient-centered movement is growing, the nation may not be able to
afford to have all its primary care doctors reduce the number of patients
they see. Across the country, primary care physicians are in short supply, in
part because average salaries for family practitioners are the lowest of any
medical specialty. According to a 2008 survey of physician salaries by the American
Medical Group Association, their average annual salary is $201,555, versus
$356,166 for a general surgeon and $614,536 for a neurological surgeon.
school loans can be so high, you need to be a specialist to pay them back,”
Dr. Batlle said. “But our country doesn’t need yet
another sleep apnea specialist.”
SACKS, a primary care doctor in Seattle,
says she began thinking differently about her work on the day she realized
she was beginning each appointment with the words, “Sorry I’m late.”
to see as many as 25 patients a day at a large clinic, she lacked the time
for thorough examinations and discussions. Because of this, she said, primary
care doctors are often forced to order tests and send patients to
I have helped some people without specialists and tests? Absolutely,” said
Dr. Sacks. “Would it have saved the patient and the insurance company both
money? Absolutely. Is the system set up for the best care and cost
efficiency? Absolutely not.”
Sacks said she worried that seeing so many patients would lead to errors.
Last year, she moved to a clinic that focuses on longer patient appointments,
30 to 60 minutes. This translates to 10 to 12 patients a day. Patients also
communicate directly with her by phone or e-mail.
those longer appointments, Dr. Sacks can perform basic lab tests and simple
procedures, so patients see fewer specialists.
probably head off a handful of emergency-room visits and hospital stays every
month because patients can see me as soon as they have a problem, and I can
be thorough rather than rushed,” she said.
patient who avoided the emergency room was Todd Martin, a store manager in Seattle who went to Dr. Sacks’s clinic on a Saturday.
couldn’t stop coughing and was having trouble breathing,” Mr. Martin said.
“They were able to see me and give me a chest X-ray.”
Martin said he spent $40 for the resulting prescription but the rest was
covered by a monthly fee he pays Dr. Sacks. “A weekend visit to the E.R.
would have easily cost $1,000,” he said.
Sacks charges patients a direct monthly fee of $54 to $129 based on age, and
she doesn’t take insurance. Her office calls its philosophy “direct practice”
because it’s a direct contract between doctor and patient. But she advises
patients to obtain insurance plans to cover large, unexpected health costs
like those to treat cancer or a heart attack.
say it’s like having a car and paying for your own oil changes and tuneups, but getting insurance in case you need a big
repair,” she said.
Garrison Bliss, who in 2007 founded the group where Dr. Sacks works, has
offered direct-practice services since 1997. He says patients can save 15 to
40 percent of their medical costs by using this model, based on his
examination of insurance rates and his belief that good primary care can fill
most of a patient’s needs.
plans that cover every little thing can be very expensive, Dr. Bliss said. He
said that a patient who paid an annual fee at his clinic and took out a
higher-deductible insurance plan would usually come out ahead, even if the
patient’s health needs meant that he or she had to pay the entire deductible.
Bliss’s office operates with just two administrative employees for seven
doctors. He estimates that if he took insurance, one or two administrative
workers would be needed per doctor.
administration costs can take a big bite out of a practice’s revenue. A
recent Weill Cornell Medical
College study found
that a third of the money received by primary care physicians pays for
interactions between a doctor’s practice and patients’ health plans.
Rogers Caroselli, a retired assistant principal who
is a patient of Dr. Sacks, dreaded going to her former clinic. “The waiting
room was always noisy and crowded,” she said. In the examining room, she felt
that she should “get in and out and not waste the doctor’s time with
questions,” she said.
contrast, she said, she appreciates the friendly calm of Dr. Sacks’s new surroundings and the personal attention.
“Everyone should have this kind of patient care,” she said.
Sacks said the financial mechanics of the direct-practice model match her
medical goals. When she was compensated based on insurance, she was paid
every time she saw a patient. Now, if she can use education and prevention to
reduce office visits, she and her patients benefit, she said.
more time to sit with each patient has made me a better doctor,” she said. “I
had a disabled patient that I saw for 13 years. Until she came to my new
clinic, I never had the time to learn the details of her accident and the
resulting complications. I was always treating whatever the immediate concern
has helped many doctors reduce costs. Dr. Batlle
says he has been building his arsenal of technology solutions one by one,
with “lots of trial and error,” for eight years.
he saw a 52-year-old patient with hypertension. As he examined the patient,
noting blood pressure and other vital signs, he entered the information into
his laptop computer to add to the patient’s electronic medical record. He
also typed in the codes for billing and insurance.
patient wondered if he was due for a prescription refill, so Dr. Batlle checked his computer again, found that he was, and
hit a button to send the refill request to the pharmacy. As the patient left,
Dr. Batlle hit the keyboard to send the bill
electronically to the insurance company.
even go to the Web to schedule his follow-up appointment,” Dr. Batlle said. “I don’t pay a receptionist to sit and
Batlle says other doctors could outfit an office
for less than the $25,000 he spent on technology.
doctors think they need to hire two receptionists, a billing person and two
nurses to run a primary care office,” he said. “But they can learn about
these technologies from other doctors, and the software salespeople do some
physicians hire consultants to find and install the right equipment. Doctors
who want to switch to electronic health records may also receive financial
support from the government through the stimulus package.
using new technology and streamlining processes, small primary care practices
can reduce their costs to half of what a typical practice pays, from about 60
percent of income down to 30 percent, Dr. Wasson said. He said that doctors
who focus on reducing their costs can see fewer patients without sacrificing
income. Dr. Sacks said she and her colleagues didn’t have to take a pay cut
when they moved to Dr. Bliss’s practice.
Congress and the Obama administration begin to focus more closely on health
care, some primary care doctors are weighing in. Dr. Bliss, for instance, has
been to Washington
twice in the last month to share his ideas with legislators. He knows he’s in
a debate with powerful voices, especially insurance companies and hospitals.
So he and other doctors are encouraging patients to speak up as well.
need to bring the patients to the barricades with us,” Dr. Batlle says.