Mary Ellen Schneider

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago.

These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States. For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health and mental health issues.

Dr. Warren A. Jones, the first African American president of the American Academy of Family Physicians, agreed further action is needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313). The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-325).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. That group has been working to expand the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal is to have as much diversity among physicians as in the general population, where African Americans make up about 12% of the U.S. population, Dr. Davis said. “Obviously, we have a long way to go,” he said.

'Talk is cheap,' and the AMA should back it up by supporting research into minority health issues. DR. BELL

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago.

These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States. For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health and mental health issues.

Dr. Warren A. Jones, the first African American president of the American Academy of Family Physicians, agreed further action is needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313). The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-325).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. That group has been working to expand the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal is to have as much diversity among physicians as in the general population, where African Americans make up about 12% of the U.S. population, Dr. Davis said. “Obviously, we have a long way to go,” he said.

'Talk is cheap,' and the AMA should back it up by supporting research into minority health issues. DR. BELL

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago.

These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States. For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health and mental health issues.

Dr. Warren A. Jones, the first African American president of the American Academy of Family Physicians, agreed further action is needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313). The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-325).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. That group has been working to expand the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal is to have as much diversity among physicians as in the general population, where African Americans make up about 12% of the U.S. population, Dr. Davis said. “Obviously, we have a long way to go,” he said.

'Talk is cheap,' and the AMA should back it up by supporting research into minority health issues. DR. BELL

With Sen. Barack Obama (D-Ill.) set to become the Democrat's presidential nominee, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program.

Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but still needed financial assistance to purchase health insurance.

Sen. Obama also would guarantee that no American could be turned down for insurance because of illness or a preexisting condition. However, he wouldn't require all Americans to purchase coverage, mandating coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. To target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage widespread adoption of EHRs. The idea is that the investment would reap savings through increased efficiencies since paper records are more costly to store and process than are electronic ones, according to the Obama campaign. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

“I want to wake up and know that every single American has health care when they need it, that every senior has prescription drugs they can afford, and that no parents are going to bed at night worrying about how they'll afford medicine for a sick child,” Sen. Obama said in June during a health care town hall meeting in Bristol, Va.

If elected, Sen. Obama has pledged to implement his health care proposal by the end of his first term as president.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market.

“That is not a level playing field,” said Ms. Turner, an adviser to the presidential campaign of Sen. John McCain (R-Ariz.). Sen. Obama's approach is a “backdoor” to getting everyone on a government-funded health plan, she said.

Ms. Turner also criticized Sen. Obama's plan to have the federal government take on a portion of the costs of catastrophic health costs in employer-sponsored health plans. This would require the government to be heavily involved in auditing health care expenditures, she said.

Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is its potential to destabilize the existing employer-based coverage system, he said. While in the long-term it might be a good idea to move away from that system, it should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute.

However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Sen. Barack Obama estimates that, if implemented, his plan would save the average family about $2,500/year.

With Sen. Barack Obama (D-Ill.) set to become the Democrat's presidential nominee, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program.

Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but still needed financial assistance to purchase health insurance.

Sen. Obama also would guarantee that no American could be turned down for insurance because of illness or a preexisting condition. However, he wouldn't require all Americans to purchase coverage, mandating coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. To target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage widespread adoption of EHRs. The idea is that the investment would reap savings through increased efficiencies since paper records are more costly to store and process than are electronic ones, according to the Obama campaign. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

“I want to wake up and know that every single American has health care when they need it, that every senior has prescription drugs they can afford, and that no parents are going to bed at night worrying about how they'll afford medicine for a sick child,” Sen. Obama said in June during a health care town hall meeting in Bristol, Va.

If elected, Sen. Obama has pledged to implement his health care proposal by the end of his first term as president.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market.

“That is not a level playing field,” said Ms. Turner, an adviser to the presidential campaign of Sen. John McCain (R-Ariz.). Sen. Obama's approach is a “backdoor” to getting everyone on a government-funded health plan, she said.

Ms. Turner also criticized Sen. Obama's plan to have the federal government take on a portion of the costs of catastrophic health costs in employer-sponsored health plans. This would require the government to be heavily involved in auditing health care expenditures, she said.

Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is its potential to destabilize the existing employer-based coverage system, he said. While in the long-term it might be a good idea to move away from that system, it should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute.

However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Sen. Barack Obama estimates that, if implemented, his plan would save the average family about $2,500/year.

With Sen. Barack Obama (D-Ill.) set to become the Democrat's presidential nominee, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program.

Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but still needed financial assistance to purchase health insurance.

Sen. Obama also would guarantee that no American could be turned down for insurance because of illness or a preexisting condition. However, he wouldn't require all Americans to purchase coverage, mandating coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. To target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage widespread adoption of EHRs. The idea is that the investment would reap savings through increased efficiencies since paper records are more costly to store and process than are electronic ones, according to the Obama campaign. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

“I want to wake up and know that every single American has health care when they need it, that every senior has prescription drugs they can afford, and that no parents are going to bed at night worrying about how they'll afford medicine for a sick child,” Sen. Obama said in June during a health care town hall meeting in Bristol, Va.

If elected, Sen. Obama has pledged to implement his health care proposal by the end of his first term as president.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market.

“That is not a level playing field,” said Ms. Turner, an adviser to the presidential campaign of Sen. John McCain (R-Ariz.). Sen. Obama's approach is a “backdoor” to getting everyone on a government-funded health plan, she said.

Ms. Turner also criticized Sen. Obama's plan to have the federal government take on a portion of the costs of catastrophic health costs in employer-sponsored health plans. This would require the government to be heavily involved in auditing health care expenditures, she said.

Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide additional funding through taxes or to have some method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is its potential to destabilize the existing employer-based coverage system, he said. While in the long-term it might be a good idea to move away from that system, it should be a gradual process, he said.

Dr. Lewin also praised the Obama plan for starting with coverage for children. However, after the mandate for universal coverage of children, the plan's details are murky, he said. For example, Sen. Obama's plan commits to improving quality and efficiency in the system but doesn't define how it would be done, he said.

Sen. Obama also has been vague about subsidies, requirements on businesses, and the interaction of the public and private plans, said Len Nichols, director of the health policy program at the New America Foundation, a nonpartisan public policy institute.

However, that murkiness may be appropriate since members of Congress will be the ones to refine the details of any health care reforms, he said. “He clearly intends to engage and work with Congress and stakeholders.”

And Sen. Obama's plan is likely to get a warm reception in Congress next year, Mr. Nichols predicted. The debate over SCHIP has started the conversation about the need for universal coverage and at the same time a majority of Americans are worried about the affordability of health insurance, he said. “There's a different environment,” Mr. Nichols said.

Sen. Barack Obama estimates that, if implemented, his plan would save the average family about $2,500/year.

Washington's summer wrangling paid off for physicians as Congress successfully overrode President Bush's veto of legislation to stop a 10.6% cut to Medicare physician payments.

The legislation (H.R. 6331), which originally passed both the House and Senate by veto-proof margins in early July, extends the 0.5% Medicare pay increase in place for the first half of 2008 through the end of the year and gives physicians a 1.1% raise for next year.

The bill relies on cuts to the Medicare Advantage program to fund the pay update, authorizes increased bonus payments under the Physician Quality Reporting Initiative (PQRI), and delays implementation of the Competitive Acquisition Program for durable medical equipment.

H.R. 6331 (the Medicare Improvements for Patients and Providers Act) passed the House by an overwhelming margin in late June, but failed to get enough votes in the Senate for cloture, which would have closed debate and allowed for an up-or-down vote. Following the July 4th recess and a week of intense lobbying by physician and patient groups, the Senate reconsidered the bill on July 9. At that time, a number of Republican senators changed their votes to help pass the bill.

The Democrats also racked up an extra vote when Sen. Edward M. Kennedy (D-Mass.) returned to the Senate for the first time since having surgery for a brain tumor in order to help pass the bill. In the final tally, the bill passed 69-30. Days later, President Bush vetoed the bill, but the House and Senate acted quickly to override the veto.

The American College of Rheumatology praised Congress for its passage of the H.R. 6331. Without that legislation, physicians would be facing a cumulative 16% cut by January, which most rheumatologists would be unable to absorb, said Dr. Sharad Lakhanpal, chairman of the government affairs committee of the American College of Rheumatology. Some rheumatologists already are limiting the number of new Medicare patients they see, and problems accessing rheumatologists would have gotten worse if the cut had been fully implemented, he said.

While the 1.1% payment increase for 2009 is welcome, he said, many physicians are frustrated that they have had their pay frozen for the last years. During that same time they have had to absorb increasedcosts in rent, salaries, equipment, and insurance. “We are actually behind,” said Dr. Lakhanpal, a rheumatologist in Dallas.

ACR officials are hopeful that the 18-month payment fix will give Congress time to work out a permanent solution.

The American Medical Association applauded the “courage” of senators who switched their votes to support the bill, but also is seeking a long-term solution, said Dr. J. James Rohack, AMA president-elect. The baby boomers will begin to enroll in Medicare around the time the fix expires.

Physicians groups have long objected to the Sustainable Growth Rate formula used to calculate physician payments under Medicare. The formula links physician pay to the gross domestic product and critics say it does not take into account the actual costs of medical practice.

A permanent fix should take into consideration the effort required to care for a patient, in the same way that hospitals receive higher payments for caring for sicker patients, he said. While physicians applaud the efforts of lawmakers to secure a 1.1% increase in payment for 2009, this comes as hospitals are projected to receive a 3% increase in payments from Medicare in 2009.

Congress finances the pay increases for physicians in part through controversial cuts to Medicare Advantage plans. Officials at America's Health Insurance Plans, which represents the health insurance industry, estimated that the bill will cut nearly $14 billion from the Medicare Advantage plans over the next 5 years. The inclusion of these cuts in the bill slowed its passage in the Senate and caused President Bush to veto the legislation.

In addition to the physician pay provisions, the legislation also includes increased patient benefits, most notably a phase-out of higher copayments for psychiatric services under Medicare. It also authorizes coverage by Medicare of new preventive services recommended by the U.S. Preventive Services Task Force.

The bill also encourages physicians and other providers to use electronic prescribing by providing incentives to those who e-prescribe and imposing penalties on those who do not. The bill calls for providing a bonus of 2% to physicians who use e-prescribing in 2009 and 2010, a bonus of 1% in 2011 and 2012, and a bonus of 0.5% in 2013. Physicians who don't use e-prescribing will be paid 1% less starting in 2012 with that amount increasing to 2% by 2014.

The bill allows the Health and Human Services secretary to exempt physicians on a case-by-case basis if complying with e-prescribing would be a “significant hardship,” such as a physician practicing in a rural area without sufficient Internet access.

The bill would delay the first round of Medicare's competitive acquisition program until 2009. Critics of the program, which began July 1, have said that it makes it too difficult for vulnerable seniors to get supplies, including diabetes testing supplies. The bill also establishes an ombudsman for the program, who would be responsible for responding to complaints and inquiries from suppliers and individuals.

Just days before the passage of H.R. 6331, officials at the Centers for Medicare and Medicaid Services released the 2009 Medicare Physician Fee Schedule proposed rule including new measures for the PQRI, new requirements for physicians offering diagnostic testing services, and plans to reevaluate services and supplies potentially valued incorrectly. For PQRI, the agency is recommending 56 new measures for 2009, bringing the total number to 175.

Officials at the Centers for Medicare and Medicaid Services also are proposing new “measures groups” to allow physicians report on subsets of measures related to a condition. New measures groups for 2009 include coronary artery disease, coronary artery bypass surgery, HIV/AIDS, rheumatoid arthritis, care during surgery, and back pain.

What Happens to My Claims Now?

Now that H.R. 6331 is law, Medicare contractors are working to make sure physicians are paid at the correct rate.

However, it may take up to 10 business days for some contractors to begin paying claims at the higher (0.5%) rate, according to CMS. Once the local contractors start paying claims at the increased rate, they will go back and reprocess any claims paid at the lower amount.

Most claims will be automatically reprocessed, but a few providers may need to contact their local contractor for direction on getting their claims adjusted. For example, physicians who have submitted charges that are lower than the Medicare fee schedule amount will need to contact their local contractor, CMS said. In addition, nonparticipating physicians who submitted unassigned claims at the reduced nonparticipation amount will need to request an adjustment from the carrier.

There may be some variation in how different contractors handle this process, said Brett Baker, director of the regulatory affairs at the American College of Physicians, with some paying claims at the new amount immediately and others taking slightly longer to retool their systems. But for the most part, physicians won't need to take any additional steps to ensure they receive their full payments, he said.

Washington's summer wrangling paid off for physicians as Congress successfully overrode President Bush's veto of legislation to stop a 10.6% cut to Medicare physician payments.

The legislation (H.R. 6331), which originally passed both the House and Senate by veto-proof margins in early July, extends the 0.5% Medicare pay increase in place for the first half of 2008 through the end of the year and gives physicians a 1.1% raise for next year.

The bill relies on cuts to the Medicare Advantage program to fund the pay update, authorizes increased bonus payments under the Physician Quality Reporting Initiative (PQRI), and delays implementation of the Competitive Acquisition Program for durable medical equipment.

H.R. 6331 (the Medicare Improvements for Patients and Providers Act) passed the House by an overwhelming margin in late June, but failed to get enough votes in the Senate for cloture, which would have closed debate and allowed for an up-or-down vote. Following the July 4th recess and a week of intense lobbying by physician and patient groups, the Senate reconsidered the bill on July 9. At that time, a number of Republican senators changed their votes to help pass the bill.

The Democrats also racked up an extra vote when Sen. Edward M. Kennedy (D-Mass.) returned to the Senate for the first time since having surgery for a brain tumor in order to help pass the bill. In the final tally, the bill passed 69-30. Days later, President Bush vetoed the bill, but the House and Senate acted quickly to override the veto.

The American College of Rheumatology praised Congress for its passage of the H.R. 6331. Without that legislation, physicians would be facing a cumulative 16% cut by January, which most rheumatologists would be unable to absorb, said Dr. Sharad Lakhanpal, chairman of the government affairs committee of the American College of Rheumatology. Some rheumatologists already are limiting the number of new Medicare patients they see, and problems accessing rheumatologists would have gotten worse if the cut had been fully implemented, he said.

While the 1.1% payment increase for 2009 is welcome, he said, many physicians are frustrated that they have had their pay frozen for the last years. During that same time they have had to absorb increasedcosts in rent, salaries, equipment, and insurance. “We are actually behind,” said Dr. Lakhanpal, a rheumatologist in Dallas.

ACR officials are hopeful that the 18-month payment fix will give Congress time to work out a permanent solution.

The American Medical Association applauded the “courage” of senators who switched their votes to support the bill, but also is seeking a long-term solution, said Dr. J. James Rohack, AMA president-elect. The baby boomers will begin to enroll in Medicare around the time the fix expires.

Physicians groups have long objected to the Sustainable Growth Rate formula used to calculate physician payments under Medicare. The formula links physician pay to the gross domestic product and critics say it does not take into account the actual costs of medical practice.

A permanent fix should take into consideration the effort required to care for a patient, in the same way that hospitals receive higher payments for caring for sicker patients, he said. While physicians applaud the efforts of lawmakers to secure a 1.1% increase in payment for 2009, this comes as hospitals are projected to receive a 3% increase in payments from Medicare in 2009.

Congress finances the pay increases for physicians in part through controversial cuts to Medicare Advantage plans. Officials at America's Health Insurance Plans, which represents the health insurance industry, estimated that the bill will cut nearly $14 billion from the Medicare Advantage plans over the next 5 years. The inclusion of these cuts in the bill slowed its passage in the Senate and caused President Bush to veto the legislation.

In addition to the physician pay provisions, the legislation also includes increased patient benefits, most notably a phase-out of higher copayments for psychiatric services under Medicare. It also authorizes coverage by Medicare of new preventive services recommended by the U.S. Preventive Services Task Force.

The bill also encourages physicians and other providers to use electronic prescribing by providing incentives to those who e-prescribe and imposing penalties on those who do not. The bill calls for providing a bonus of 2% to physicians who use e-prescribing in 2009 and 2010, a bonus of 1% in 2011 and 2012, and a bonus of 0.5% in 2013. Physicians who don't use e-prescribing will be paid 1% less starting in 2012 with that amount increasing to 2% by 2014.

The bill allows the Health and Human Services secretary to exempt physicians on a case-by-case basis if complying with e-prescribing would be a “significant hardship,” such as a physician practicing in a rural area without sufficient Internet access.

The bill would delay the first round of Medicare's competitive acquisition program until 2009. Critics of the program, which began July 1, have said that it makes it too difficult for vulnerable seniors to get supplies, including diabetes testing supplies. The bill also establishes an ombudsman for the program, who would be responsible for responding to complaints and inquiries from suppliers and individuals.

Just days before the passage of H.R. 6331, officials at the Centers for Medicare and Medicaid Services released the 2009 Medicare Physician Fee Schedule proposed rule including new measures for the PQRI, new requirements for physicians offering diagnostic testing services, and plans to reevaluate services and supplies potentially valued incorrectly. For PQRI, the agency is recommending 56 new measures for 2009, bringing the total number to 175.

Officials at the Centers for Medicare and Medicaid Services also are proposing new “measures groups” to allow physicians report on subsets of measures related to a condition. New measures groups for 2009 include coronary artery disease, coronary artery bypass surgery, HIV/AIDS, rheumatoid arthritis, care during surgery, and back pain.

What Happens to My Claims Now?

Now that H.R. 6331 is law, Medicare contractors are working to make sure physicians are paid at the correct rate.

However, it may take up to 10 business days for some contractors to begin paying claims at the higher (0.5%) rate, according to CMS. Once the local contractors start paying claims at the increased rate, they will go back and reprocess any claims paid at the lower amount.

Most claims will be automatically reprocessed, but a few providers may need to contact their local contractor for direction on getting their claims adjusted. For example, physicians who have submitted charges that are lower than the Medicare fee schedule amount will need to contact their local contractor, CMS said. In addition, nonparticipating physicians who submitted unassigned claims at the reduced nonparticipation amount will need to request an adjustment from the carrier.

There may be some variation in how different contractors handle this process, said Brett Baker, director of the regulatory affairs at the American College of Physicians, with some paying claims at the new amount immediately and others taking slightly longer to retool their systems. But for the most part, physicians won't need to take any additional steps to ensure they receive their full payments, he said.

Washington's summer wrangling paid off for physicians as Congress successfully overrode President Bush's veto of legislation to stop a 10.6% cut to Medicare physician payments.

The legislation (H.R. 6331), which originally passed both the House and Senate by veto-proof margins in early July, extends the 0.5% Medicare pay increase in place for the first half of 2008 through the end of the year and gives physicians a 1.1% raise for next year.

The bill relies on cuts to the Medicare Advantage program to fund the pay update, authorizes increased bonus payments under the Physician Quality Reporting Initiative (PQRI), and delays implementation of the Competitive Acquisition Program for durable medical equipment.

H.R. 6331 (the Medicare Improvements for Patients and Providers Act) passed the House by an overwhelming margin in late June, but failed to get enough votes in the Senate for cloture, which would have closed debate and allowed for an up-or-down vote. Following the July 4th recess and a week of intense lobbying by physician and patient groups, the Senate reconsidered the bill on July 9. At that time, a number of Republican senators changed their votes to help pass the bill.

The Democrats also racked up an extra vote when Sen. Edward M. Kennedy (D-Mass.) returned to the Senate for the first time since having surgery for a brain tumor in order to help pass the bill. In the final tally, the bill passed 69-30. Days later, President Bush vetoed the bill, but the House and Senate acted quickly to override the veto.

The American College of Rheumatology praised Congress for its passage of the H.R. 6331. Without that legislation, physicians would be facing a cumulative 16% cut by January, which most rheumatologists would be unable to absorb, said Dr. Sharad Lakhanpal, chairman of the government affairs committee of the American College of Rheumatology. Some rheumatologists already are limiting the number of new Medicare patients they see, and problems accessing rheumatologists would have gotten worse if the cut had been fully implemented, he said.

While the 1.1% payment increase for 2009 is welcome, he said, many physicians are frustrated that they have had their pay frozen for the last years. During that same time they have had to absorb increasedcosts in rent, salaries, equipment, and insurance. “We are actually behind,” said Dr. Lakhanpal, a rheumatologist in Dallas.

ACR officials are hopeful that the 18-month payment fix will give Congress time to work out a permanent solution.

The American Medical Association applauded the “courage” of senators who switched their votes to support the bill, but also is seeking a long-term solution, said Dr. J. James Rohack, AMA president-elect. The baby boomers will begin to enroll in Medicare around the time the fix expires.

Physicians groups have long objected to the Sustainable Growth Rate formula used to calculate physician payments under Medicare. The formula links physician pay to the gross domestic product and critics say it does not take into account the actual costs of medical practice.

A permanent fix should take into consideration the effort required to care for a patient, in the same way that hospitals receive higher payments for caring for sicker patients, he said. While physicians applaud the efforts of lawmakers to secure a 1.1% increase in payment for 2009, this comes as hospitals are projected to receive a 3% increase in payments from Medicare in 2009.

Congress finances the pay increases for physicians in part through controversial cuts to Medicare Advantage plans. Officials at America's Health Insurance Plans, which represents the health insurance industry, estimated that the bill will cut nearly $14 billion from the Medicare Advantage plans over the next 5 years. The inclusion of these cuts in the bill slowed its passage in the Senate and caused President Bush to veto the legislation.

In addition to the physician pay provisions, the legislation also includes increased patient benefits, most notably a phase-out of higher copayments for psychiatric services under Medicare. It also authorizes coverage by Medicare of new preventive services recommended by the U.S. Preventive Services Task Force.

The bill also encourages physicians and other providers to use electronic prescribing by providing incentives to those who e-prescribe and imposing penalties on those who do not. The bill calls for providing a bonus of 2% to physicians who use e-prescribing in 2009 and 2010, a bonus of 1% in 2011 and 2012, and a bonus of 0.5% in 2013. Physicians who don't use e-prescribing will be paid 1% less starting in 2012 with that amount increasing to 2% by 2014.

The bill allows the Health and Human Services secretary to exempt physicians on a case-by-case basis if complying with e-prescribing would be a “significant hardship,” such as a physician practicing in a rural area without sufficient Internet access.

The bill would delay the first round of Medicare's competitive acquisition program until 2009. Critics of the program, which began July 1, have said that it makes it too difficult for vulnerable seniors to get supplies, including diabetes testing supplies. The bill also establishes an ombudsman for the program, who would be responsible for responding to complaints and inquiries from suppliers and individuals.

Just days before the passage of H.R. 6331, officials at the Centers for Medicare and Medicaid Services released the 2009 Medicare Physician Fee Schedule proposed rule including new measures for the PQRI, new requirements for physicians offering diagnostic testing services, and plans to reevaluate services and supplies potentially valued incorrectly. For PQRI, the agency is recommending 56 new measures for 2009, bringing the total number to 175.

Officials at the Centers for Medicare and Medicaid Services also are proposing new “measures groups” to allow physicians report on subsets of measures related to a condition. New measures groups for 2009 include coronary artery disease, coronary artery bypass surgery, HIV/AIDS, rheumatoid arthritis, care during surgery, and back pain.

What Happens to My Claims Now?

Now that H.R. 6331 is law, Medicare contractors are working to make sure physicians are paid at the correct rate.

However, it may take up to 10 business days for some contractors to begin paying claims at the higher (0.5%) rate, according to CMS. Once the local contractors start paying claims at the increased rate, they will go back and reprocess any claims paid at the lower amount.

Most claims will be automatically reprocessed, but a few providers may need to contact their local contractor for direction on getting their claims adjusted. For example, physicians who have submitted charges that are lower than the Medicare fee schedule amount will need to contact their local contractor, CMS said. In addition, nonparticipating physicians who submitted unassigned claims at the reduced nonparticipation amount will need to request an adjustment from the carrier.

There may be some variation in how different contractors handle this process, said Brett Baker, director of the regulatory affairs at the American College of Physicians, with some paying claims at the new amount immediately and others taking slightly longer to retool their systems. But for the most part, physicians won't need to take any additional steps to ensure they receive their full payments, he said.

With Sen. Barack Obama (D-Ill.) set to become the Democratic Party's presidential nominee this month, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program. Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but still needed financial assistance to purchase health insurance.

Sen. Obama also would guarantee that no American could be turned down for health insurance because of illness or a preexisting condition. However, his proposal stops short of requiring all Americans to purchase coverage. Instead, the plan mandates coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. For example, he would target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers. Under his plan, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage adoption of EHRs. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market. “That is not a level playing field,” said Ms. Turner, who also is an adviser to the presidential campaign of Sen. John McCain (R-Ariz.).

Sen. Obama's approach is really a “backdoor” to getting everyone on a government-funded health plan, she said. Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide more funding through taxes or to have a method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Relies on Tax Changes, Cost Control, June 2008, p. 25, or www.ecardiologynews.com

Dr. Lewin also praised the Obama plan for starting with coverage for children. But after the mandate for universal coverage of children, the plan's details are somewhat murky, he said.

Sen. Barack Obama says his plan would save the average family $2,500 a year.

With Sen. Barack Obama (D-Ill.) set to become the Democratic Party's presidential nominee this month, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program. Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but still needed financial assistance to purchase health insurance.

Sen. Obama also would guarantee that no American could be turned down for health insurance because of illness or a preexisting condition. However, his proposal stops short of requiring all Americans to purchase coverage. Instead, the plan mandates coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. For example, he would target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers. Under his plan, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage adoption of EHRs. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market. “That is not a level playing field,” said Ms. Turner, who also is an adviser to the presidential campaign of Sen. John McCain (R-Ariz.).

Sen. Obama's approach is really a “backdoor” to getting everyone on a government-funded health plan, she said. Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide more funding through taxes or to have a method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Relies on Tax Changes, Cost Control, June 2008, p. 25, or www.ecardiologynews.com

Dr. Lewin also praised the Obama plan for starting with coverage for children. But after the mandate for universal coverage of children, the plan's details are somewhat murky, he said.

Sen. Barack Obama says his plan would save the average family $2,500 a year.

With Sen. Barack Obama (D-Ill.) set to become the Democratic Party's presidential nominee this month, health care experts are once again scrutinizing his plans to reform the health care system.

The centerpiece of Sen. Obama's plan is a public-private system that would allow people to remain in their employer-sponsored health plans while offering the uninsured the chance to purchase either a private or government-sponsored plan.

For the government-sponsored plan, the proposal uses as a model the Federal Employees Health Benefits Program—the system available to federal employees and members of Congress. For individuals and families who want to purchase insurance on the private market, Sen. Obama is proposing to create a National Health Insurance Exchange through which they could enroll in either the new government-sponsored plan or purchase a private plan.

All plans offered through the exchange would be required to offer at least the same coverage as the government-sponsored plan and adhere to the same standards for quality and efficiency.

Employers also would have a role to play under the Obama plan. Those employers that do not offer or contribute to employee health coverage would be required to pay a percentage of their payroll toward the cost of the government health plan. There would be an exemption for some small employers under the proposal.

The Obama proposal also calls for expanding eligibility for Medicaid and the State Children's Health Insurance Program. Under the proposal, the government would offer subsidies to individuals who do not qualify for Medicaid or SCHIP but still needed financial assistance to purchase health insurance.

Sen. Obama also would guarantee that no American could be turned down for health insurance because of illness or a preexisting condition. However, his proposal stops short of requiring all Americans to purchase coverage. Instead, the plan mandates coverage for children only.

The other half of Sen. Obama's plan is aimed at reducing premiums and decreasing overall health system costs. For example, he would target the catastrophic health expenses that account for a significant portion of the costs incurred by private payers. Under his plan, the federal government would reimburse employer-sponsored health plans for a portion of the cost of catastrophic health events above a certain threshold. In exchange, the plans would have to use the savings to reduce the cost of premiums.

Cost control also is addressed in the Obama plan, with electronic health records playing a big role. The candidate proposes to spend $10 billion a year for the next 5 years in an effort to encourage adoption of EHRs. The plan also seeks to control costs through greater regulation of insurance companies and by allowing the federal government to negotiate drug prices.

The Obama campaign estimates that, if implemented, the reforms they are proposing would save the average family about $2,500 a year in medical expenses.

But the plan continues to face critics on the left and the right. Grace-Marie Turner, president of the Galen Institute, an organization that favors free-market approaches to health care, said she is concerned that the government-sponsored program would be underpriced and crowd out the private insurance options the same way that Medicare has crowded out private insurance in the over-65 market. “That is not a level playing field,” said Ms. Turner, who also is an adviser to the presidential campaign of Sen. John McCain (R-Ariz.).

Sen. Obama's approach is really a “backdoor” to getting everyone on a government-funded health plan, she said. Sen. Obama's plan also faced criticism from the left. Dr. Don McCanne, a senior health policy fellow with Physicians for a National Health Program, said the plan “falls far, far, short.” Dr. McCanne said he objects to the plan because it continues to use the private health insurance industry as part of the structure. His organization favors the elimination of private plans and the creation of a single public program for health care.

The concern with providing a government-sponsored plan in competition with private plans is that it would be subjected to adverse selection and the premiums would become unaffordable, Dr. McCanne said. The only way around that would be to provide more funding through taxes or to have a method of risk pool transfer, in which the private plans with healthier beneficiaries would shift funds to pay for the higher risk individuals, he said.

But Dr. Jack Lewin, CEO of the American College of Cardiology, said that maintaining the private system is politically smart. One of the drawbacks of Sen. McCain's plan is that it has the potential to destabilize the existing employer-based coverage system, he said. (See “McCain Plan Relies on Tax Changes, Cost Control, June 2008, p. 25, or www.ecardiologynews.com

Dr. Lewin also praised the Obama plan for starting with coverage for children. But after the mandate for universal coverage of children, the plan's details are somewhat murky, he said.

Sen. Barack Obama says his plan would save the average family $2,500 a year.

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago. These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States. For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health and mental health issues.

Dr. Warren A. Jones, who was the first African American president of the American Academy of Family Physicians, agreed that further action will be needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change in the mind-set of the AMA leadership.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313).

The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-5).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. That group has been working to expand the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal is to have as much diversity among physicians as in the general population, where African Americans make up about 12% of the U.S. population, Dr. Davis said. “Obviously, we have a long way to go,” he said.

The AMA should go beyond the apology for racial discrimination by backing it with meaningful action. DR. BELL

The AMA's apology is a signal of change in the mind-set of the organization's leadership. Dr. Jones

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago. These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States. For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health and mental health issues.

Dr. Warren A. Jones, who was the first African American president of the American Academy of Family Physicians, agreed that further action will be needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change in the mind-set of the AMA leadership.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313).

The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-5).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. That group has been working to expand the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal is to have as much diversity among physicians as in the general population, where African Americans make up about 12% of the U.S. population, Dr. Davis said. “Obviously, we have a long way to go,” he said.

The AMA should go beyond the apology for racial discrimination by backing it with meaningful action. DR. BELL

The AMA's apology is a signal of change in the mind-set of the organization's leadership. Dr. Jones

African American physicians are looking for action to back up the words of apology recently tendered by the American Medical Association for more than a century of racial inequity and bias.

In accepting the AMA's apology, the National Medical Association (NMA), which represents minority physicians, urged the AMA leadership to work with them on three initiatives: recruiting more African American physicians, reducing health disparities among minorities, and requiring medical schools and licensing boards to make cultural competency mandatory for medical students, residents, and practicing physicians.

“We really want to use this apology as a springboard,” said Dr. Nedra H. Joyner, chair of the NMA board of trustees and an otolaryngologist in Chicago. These changes will be critical to reversing racial health disparities that have led to poorer health outcomes in African Americans, she said.

“Talk is cheap,” said Dr. Carl Bell, professor of public health and psychiatry at the University of Illinois at Chicago.

Dr. Bell said that while he is hopeful that the AMA will take some meaningful action to reduce health disparities, he is unimpressed by the apology alone. Instead, he would like the AMA take a stand on issues that would advance minority health in the United States. For example, he said that he wants to see the AMA push for single-payer national health insurance, be stronger in challenging the pharmaceutical industry, do a better job of promoting public health, and support research into minority health and mental health issues.

Dr. Warren A. Jones, who was the first African American president of the American Academy of Family Physicians, agreed that further action will be needed but called the AMA's apology “appropriate” and “timely.” This is not an apology of convenience, he said, but a signal of a change in the mind-set of the AMA leadership.

The AMA now has an opportunity to ensure that cultural competency becomes a tool in the medical armamentarium in the same way as the stethoscope or the scalpel, he said. “Now is the time for the AMA to put its resources where its mouth is,” said Dr. Jones, executive director of the Mississippi Institute for Improvement of Geographic Minority Health.

The AMA offered the apology in July to coincide with the release of a historic paper in its flagship journal that examined race relations in organized medicine (JAMA 2008;300:306-313).

The paper, which chronicles the origins of the racial divide in AMA history, was prepared by an independent panel of experts convened by the AMA in 2005. The panel reviewed archives of the AMA, the NMA, and newspapers from the time to provide a history from the founding of the AMA through the civil rights movement.

The paper notes a number of instances where the AMA leadership fostered racial segregation and bias. For example, in 1874 the AMA began restricting delegations to the organization's national convention to state and local medical societies. This move effectively excluded most African American physicians because many medical societies, especially those in the South, openly refused membership to them. Later, in the 1960s, the AMA rejected the idea of excluding medical societies with discriminatory practices.

During the civil rights era, the AMA was seen as obstructing the civil rights agenda, the paper noted. In 1961, the AMA refused to defend eight African American physicians who were arrested after asking to be served at a medical society luncheon in Atlanta.

In its review, the independent panel applauded AMA for its willingness to explore its history. But the researchers also noted that the legacy of inequality continues to negatively affect African American physicians and patients. For example, in 2006 African Americans made up 2.2% of physicians and medical students, less than in 1910 when 2.5% were African American.

In a commentary to accompany the history, Dr. Ronald M. Davis, immediate past president of the AMA, acknowledged the “stain left by a legacy of discrimination” and outlined what AMA is doing to eliminate prejudice within the organization and improve the health of minority patients (JAMA 2008;300:323-5).

Dr. Davis said that the AMA leadership felt it was important to offer the apology because it demonstrates the “current moral orientation of the organization” and lays down a marker to compare current and future actions.

Within the organization, AMA has in place a number of policies that explicitly prohibit discrimination in membership and support funding for “pipeline” programs to engage minority individuals to enter medical school. In addition, in 2004, the AMA joined the NMA and the National Hispanic Medical Association to form the Commission to End Health Care Disparities. That group has been working to expand the “Doctors Back to School” program, which brings minority physicians into schools to encourage students to consider careers in medicine.

The ultimate goal is to have as much diversity among physicians as in the general population, where African Americans make up about 12% of the U.S. population, Dr. Davis said. “Obviously, we have a long way to go,” he said.

The AMA should go beyond the apology for racial discrimination by backing it with meaningful action. DR. BELL

The AMA's apology is a signal of change in the mind-set of the organization's leadership. Dr. Jones

Washington's summertime wrangling paid off for physicians as Congress successfully overrode President Bush's veto of legislation to stop a 10.6% cut to Medicare physician payments.

The legislation (H.R. 6331), which passed the House and Senate by veto-proof margins in July, extends the 0.5% Medicare pay increase in place for the first half of 2008 through the end of the year and gives physicians a 1.1% raise for next year.

H.R. 6331 also encourages physicians to use electronic prescribing by providing incentives to those who e-prescribe and imposing penalties on those who do not.

The bill, which also authorizes increased bonus payments under the Physician Quality Reporting Initiative and delays implementation of the Competitive Acquisition Program for durable medical equipment until 2009, relies on controversial cuts to the Medicare Advantage program to fund the pay update. Officials at America's Health Insurance Plans, which represents the health insurance industry, estimated that the bill will cut nearly $14 billion from the Medicare Advantage plans over the next 5 years.

The American Academy of Family Physicians praised the passage of the legislation and called on Congress to end the yearly cycle of 11th-hour congressional negotiations over physician payments.

“Congress must make good use of the time afforded them by H.R. 6331,” Dr. James King, AAFP president, said in a statement. “They must pass Medicare reform that discards the destabilizing and flawed sustainable growth formula and in its place implements the Medicare Economic Index as the basis for physician payment calculations.”

The Sustainable Growth Rate formula links physician payments to the gross domestic product and critics say it does not take into account the actual costs of medical practice.

Washington's summertime wrangling paid off for physicians as Congress successfully overrode President Bush's veto of legislation to stop a 10.6% cut to Medicare physician payments.

The legislation (H.R. 6331), which passed the House and Senate by veto-proof margins in July, extends the 0.5% Medicare pay increase in place for the first half of 2008 through the end of the year and gives physicians a 1.1% raise for next year.

H.R. 6331 also encourages physicians to use electronic prescribing by providing incentives to those who e-prescribe and imposing penalties on those who do not.

The bill, which also authorizes increased bonus payments under the Physician Quality Reporting Initiative and delays implementation of the Competitive Acquisition Program for durable medical equipment until 2009, relies on controversial cuts to the Medicare Advantage program to fund the pay update. Officials at America's Health Insurance Plans, which represents the health insurance industry, estimated that the bill will cut nearly $14 billion from the Medicare Advantage plans over the next 5 years.

The American Academy of Family Physicians praised the passage of the legislation and called on Congress to end the yearly cycle of 11th-hour congressional negotiations over physician payments.

“Congress must make good use of the time afforded them by H.R. 6331,” Dr. James King, AAFP president, said in a statement. “They must pass Medicare reform that discards the destabilizing and flawed sustainable growth formula and in its place implements the Medicare Economic Index as the basis for physician payment calculations.”

The Sustainable Growth Rate formula links physician payments to the gross domestic product and critics say it does not take into account the actual costs of medical practice.

Washington's summertime wrangling paid off for physicians as Congress successfully overrode President Bush's veto of legislation to stop a 10.6% cut to Medicare physician payments.

The legislation (H.R. 6331), which passed the House and Senate by veto-proof margins in July, extends the 0.5% Medicare pay increase in place for the first half of 2008 through the end of the year and gives physicians a 1.1% raise for next year.

H.R. 6331 also encourages physicians to use electronic prescribing by providing incentives to those who e-prescribe and imposing penalties on those who do not.

The bill, which also authorizes increased bonus payments under the Physician Quality Reporting Initiative and delays implementation of the Competitive Acquisition Program for durable medical equipment until 2009, relies on controversial cuts to the Medicare Advantage program to fund the pay update. Officials at America's Health Insurance Plans, which represents the health insurance industry, estimated that the bill will cut nearly $14 billion from the Medicare Advantage plans over the next 5 years.

The American Academy of Family Physicians praised the passage of the legislation and called on Congress to end the yearly cycle of 11th-hour congressional negotiations over physician payments.

“Congress must make good use of the time afforded them by H.R. 6331,” Dr. James King, AAFP president, said in a statement. “They must pass Medicare reform that discards the destabilizing and flawed sustainable growth formula and in its place implements the Medicare Economic Index as the basis for physician payment calculations.”

The Sustainable Growth Rate formula links physician payments to the gross domestic product and critics say it does not take into account the actual costs of medical practice.

NEW YORK — HIV infection may not be a significant risk even among adolescent populations with a high prevalence of other sexually transmitted infections, according to a study of adolescents at a juvenile detention center in Houston.

Although chlamydia and gonorrhea were relatively common among this group of incarcerated teens—28% among girls and 9% among boys—the prevalence of HIV was low among those tested, with only two cases among boys and no cases among girls.

Researchers at the University of Texas evaluated 6,805 sexually active boys and 1,425 sexually active girls who were incarcerated at the Harris County Juvenile Detention Center in 2006 and 2007. The mean age of the population was 15 years old (range 13-16 years) and all identified themselves as heterosexual, Dr. William Risser said at a joint conference sponsored by the American Sexually Transmitted Diseases Association and the British Association for Sexual Health and HIV.

All of the detainees received a physical examination and health history, and a first-catch urine screening for chlamydia and gonorrhea. They also received an HIV and rapid plasma reagin (RPR) test for syphilis if they had suspicious symptoms, had not been tested for more than 1 year, had another sexually transmitted infection, had sold sex, or requested testing.

Among the 6,805 boys evaluated, 78% were sexually active in the month before admission to the facility, 69% had used a condom at last intercourse, and 29% reported that they had a new partner in the previous month. Nearly 8% of the boys tested positive for chlamydia, 0.68% tested positive for gonorrhea, and 1% tested positive for both organisms. Of the 2,524 boys who were tested for HIV, only 2 tested positive (0.08%). Of those who tested positive for HIV, their only admitted risk behavior was heterosexual intercourse, said Dr. Risser, director of the division of adolescent medicine at the university in Houston.

Among the 1,425 girls evaluated in the study, the rates of chlamydia and gonorrhea were higher, but there were no cases of HIV. About 74% reported that they were sexually active in the month before they were admitted to the facility, 49% said they had used a condom at last intercourse, 19% had a new partner in the previous month, and 9% said they had traded sex for drugs or money.

Overall, 17% of the girls tested positive for chlamydia, 5% tested positive for gonorrhea, and 6% were positive for both organisms. Of the 807 who underwent HIV testing, no one tested positive.

One of the factors in the low rates of HIV infection might have been the small amount of high-risk drug use. Other studies on the same population show that almost none used drugs other than marijuana. “I really believe that's true because culturally these kids don't use IV drugs,” Dr. Risser said.

NEW YORK — HIV infection may not be a significant risk even among adolescent populations with a high prevalence of other sexually transmitted infections, according to a study of adolescents at a juvenile detention center in Houston.

Although chlamydia and gonorrhea were relatively common among this group of incarcerated teens—28% among girls and 9% among boys—the prevalence of HIV was low among those tested, with only two cases among boys and no cases among girls.

Researchers at the University of Texas evaluated 6,805 sexually active boys and 1,425 sexually active girls who were incarcerated at the Harris County Juvenile Detention Center in 2006 and 2007. The mean age of the population was 15 years old (range 13-16 years) and all identified themselves as heterosexual, Dr. William Risser said at a joint conference sponsored by the American Sexually Transmitted Diseases Association and the British Association for Sexual Health and HIV.

All of the detainees received a physical examination and health history, and a first-catch urine screening for chlamydia and gonorrhea. They also received an HIV and rapid plasma reagin (RPR) test for syphilis if they had suspicious symptoms, had not been tested for more than 1 year, had another sexually transmitted infection, had sold sex, or requested testing.

Among the 6,805 boys evaluated, 78% were sexually active in the month before admission to the facility, 69% had used a condom at last intercourse, and 29% reported that they had a new partner in the previous month. Nearly 8% of the boys tested positive for chlamydia, 0.68% tested positive for gonorrhea, and 1% tested positive for both organisms. Of the 2,524 boys who were tested for HIV, only 2 tested positive (0.08%). Of those who tested positive for HIV, their only admitted risk behavior was heterosexual intercourse, said Dr. Risser, director of the division of adolescent medicine at the university in Houston.

Among the 1,425 girls evaluated in the study, the rates of chlamydia and gonorrhea were higher, but there were no cases of HIV. About 74% reported that they were sexually active in the month before they were admitted to the facility, 49% said they had used a condom at last intercourse, 19% had a new partner in the previous month, and 9% said they had traded sex for drugs or money.

Overall, 17% of the girls tested positive for chlamydia, 5% tested positive for gonorrhea, and 6% were positive for both organisms. Of the 807 who underwent HIV testing, no one tested positive.

One of the factors in the low rates of HIV infection might have been the small amount of high-risk drug use. Other studies on the same population show that almost none used drugs other than marijuana. “I really believe that's true because culturally these kids don't use IV drugs,” Dr. Risser said.

NEW YORK — HIV infection may not be a significant risk even among adolescent populations with a high prevalence of other sexually transmitted infections, according to a study of adolescents at a juvenile detention center in Houston.

Although chlamydia and gonorrhea were relatively common among this group of incarcerated teens—28% among girls and 9% among boys—the prevalence of HIV was low among those tested, with only two cases among boys and no cases among girls.

Researchers at the University of Texas evaluated 6,805 sexually active boys and 1,425 sexually active girls who were incarcerated at the Harris County Juvenile Detention Center in 2006 and 2007. The mean age of the population was 15 years old (range 13-16 years) and all identified themselves as heterosexual, Dr. William Risser said at a joint conference sponsored by the American Sexually Transmitted Diseases Association and the British Association for Sexual Health and HIV.

All of the detainees received a physical examination and health history, and a first-catch urine screening for chlamydia and gonorrhea. They also received an HIV and rapid plasma reagin (RPR) test for syphilis if they had suspicious symptoms, had not been tested for more than 1 year, had another sexually transmitted infection, had sold sex, or requested testing.

Among the 6,805 boys evaluated, 78% were sexually active in the month before admission to the facility, 69% had used a condom at last intercourse, and 29% reported that they had a new partner in the previous month. Nearly 8% of the boys tested positive for chlamydia, 0.68% tested positive for gonorrhea, and 1% tested positive for both organisms. Of the 2,524 boys who were tested for HIV, only 2 tested positive (0.08%). Of those who tested positive for HIV, their only admitted risk behavior was heterosexual intercourse, said Dr. Risser, director of the division of adolescent medicine at the university in Houston.

Among the 1,425 girls evaluated in the study, the rates of chlamydia and gonorrhea were higher, but there were no cases of HIV. About 74% reported that they were sexually active in the month before they were admitted to the facility, 49% said they had used a condom at last intercourse, 19% had a new partner in the previous month, and 9% said they had traded sex for drugs or money.

Overall, 17% of the girls tested positive for chlamydia, 5% tested positive for gonorrhea, and 6% were positive for both organisms. Of the 807 who underwent HIV testing, no one tested positive.

One of the factors in the low rates of HIV infection might have been the small amount of high-risk drug use. Other studies on the same population show that almost none used drugs other than marijuana. “I really believe that's true because culturally these kids don't use IV drugs,” Dr. Risser said.

One in five Americans postponed or skipped needed medical care last year because of cost, insurance problems, or difficulty getting an appointment, according to a report from the Center for Studying Health System Change.

Researchers, who compared nationwide survey data from the years 2003 and 2007, found that the number of Americans that reported problems with access to health care increased dramatically during the intervening period. In 2007, more than 23 million individuals (8%) said that they went without needed medical care, compared with 13.5 million (5.2%) in 2003.

There were even more problems with delaying care. In 2007, 36 million (12.3%) reported that they delayed seeking care, compared with about 23.5 million (8.4%) in 2003. The most recent figures come from the 2007 Health Tracking Household Survey, a nationally representative sample of about 18,000 individuals. The earlier data are drawn from a similar survey of about 47,000 individuals.

“The change is not only large, but it is widespread,” Peter J. Cunningham, Ph.D., the study's lead author and a senior fellow at the Center for Studying Health System Change, said at a press conference.

Specifically, the researchers found that access problems were increasingly affecting people with and without insurance. In 2007, about 20% of uninsured people and 11% of insured people reported delaying care. In addition, 17.5% of uninsured people and 6.3% of insured people reported unmet medical needs.

But while more uninsured people reported access problems, the rate of increase for unmet medical needs between 2003 and 2007 was higher among people who had insurance. Of the additional 9.5 million people who reported unmet needs between 2003 and 2007, 6.7 million had health insurance, Mr. Cunningham said.

The researchers also found greater unmet medical needs among individuals with fair or poor health and among children from families with lower incomes. For example, unmet medical needs increased from 11.9% in 2003 to 17% in 2007 for people who were in fair or poor health.

The gap in access to care between low- and higher-income children grew wider in 2007 after having been virtually eliminated in 2003 following expansions of the Medicaid and State Children's Health Insurance Programs. In 2003, 2.2% of children below 200% of poverty experienced unmet medical needs, the same percentage as those children whose family incomes were at 200% of poverty or higher. However, in 2007, 5.4% of children below 200% of poverty had unmet medical needs, compared with 2.9% of children at 200% of poverty or higher.

One in five Americans postponed or skipped needed medical care last year because of cost, insurance problems, or difficulty getting an appointment, according to a report from the Center for Studying Health System Change.

Researchers, who compared nationwide survey data from the years 2003 and 2007, found that the number of Americans that reported problems with access to health care increased dramatically during the intervening period. In 2007, more than 23 million individuals (8%) said that they went without needed medical care, compared with 13.5 million (5.2%) in 2003.

There were even more problems with delaying care. In 2007, 36 million (12.3%) reported that they delayed seeking care, compared with about 23.5 million (8.4%) in 2003. The most recent figures come from the 2007 Health Tracking Household Survey, a nationally representative sample of about 18,000 individuals. The earlier data are drawn from a similar survey of about 47,000 individuals.

“The change is not only large, but it is widespread,” Peter J. Cunningham, Ph.D., the study's lead author and a senior fellow at the Center for Studying Health System Change, said at a press conference.

Specifically, the researchers found that access problems were increasingly affecting people with and without insurance. In 2007, about 20% of uninsured people and 11% of insured people reported delaying care. In addition, 17.5% of uninsured people and 6.3% of insured people reported unmet medical needs.

But while more uninsured people reported access problems, the rate of increase for unmet medical needs between 2003 and 2007 was higher among people who had insurance. Of the additional 9.5 million people who reported unmet needs between 2003 and 2007, 6.7 million had health insurance, Mr. Cunningham said.

The researchers also found greater unmet medical needs among individuals with fair or poor health and among children from families with lower incomes. For example, unmet medical needs increased from 11.9% in 2003 to 17% in 2007 for people who were in fair or poor health.

The gap in access to care between low- and higher-income children grew wider in 2007 after having been virtually eliminated in 2003 following expansions of the Medicaid and State Children's Health Insurance Programs. In 2003, 2.2% of children below 200% of poverty experienced unmet medical needs, the same percentage as those children whose family incomes were at 200% of poverty or higher. However, in 2007, 5.4% of children below 200% of poverty had unmet medical needs, compared with 2.9% of children at 200% of poverty or higher.

One in five Americans postponed or skipped needed medical care last year because of cost, insurance problems, or difficulty getting an appointment, according to a report from the Center for Studying Health System Change.

Researchers, who compared nationwide survey data from the years 2003 and 2007, found that the number of Americans that reported problems with access to health care increased dramatically during the intervening period. In 2007, more than 23 million individuals (8%) said that they went without needed medical care, compared with 13.5 million (5.2%) in 2003.

There were even more problems with delaying care. In 2007, 36 million (12.3%) reported that they delayed seeking care, compared with about 23.5 million (8.4%) in 2003. The most recent figures come from the 2007 Health Tracking Household Survey, a nationally representative sample of about 18,000 individuals. The earlier data are drawn from a similar survey of about 47,000 individuals.

“The change is not only large, but it is widespread,” Peter J. Cunningham, Ph.D., the study's lead author and a senior fellow at the Center for Studying Health System Change, said at a press conference.

Specifically, the researchers found that access problems were increasingly affecting people with and without insurance. In 2007, about 20% of uninsured people and 11% of insured people reported delaying care. In addition, 17.5% of uninsured people and 6.3% of insured people reported unmet medical needs.

But while more uninsured people reported access problems, the rate of increase for unmet medical needs between 2003 and 2007 was higher among people who had insurance. Of the additional 9.5 million people who reported unmet needs between 2003 and 2007, 6.7 million had health insurance, Mr. Cunningham said.

The researchers also found greater unmet medical needs among individuals with fair or poor health and among children from families with lower incomes. For example, unmet medical needs increased from 11.9% in 2003 to 17% in 2007 for people who were in fair or poor health.

The gap in access to care between low- and higher-income children grew wider in 2007 after having been virtually eliminated in 2003 following expansions of the Medicaid and State Children's Health Insurance Programs. In 2003, 2.2% of children below 200% of poverty experienced unmet medical needs, the same percentage as those children whose family incomes were at 200% of poverty or higher. However, in 2007, 5.4% of children below 200% of poverty had unmet medical needs, compared with 2.9% of children at 200% of poverty or higher.

Reproductive rights advocates are mobilizing against an effort by the Bush administration to redefine abortion in a way that could limit access to family planning services.

Last month, officials at the Department of Health and Human Services circulated a draft proposal aimed at beefing up protections for physicians and other health care providers who object to performing procedures such as abortion and sterilization. As part of this effort, the draft contains a new definition of abortion: the prescription or administration of a drug or procedure that “results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”

Reproductive rights advocates say this broad definition would classify some oral contraception, IUDs, and emergency contraception as methods of abortion.

If adopted as a federal regulation, the new definition of abortion could limit access to federally funded family planning services, according to the Association of Reproductive Health Professionals, which is calling on physicians and other providers to express objections to HHS.

The proposal would “radically redefine pregnancy,” said Mary Jane Gallagher, president and CEO of the National Family Planning and Reproductive Health Association. The definition is contrary to definitions used by medical societies and blurs the line between what is abortion and what is contraception, she said. With such a broad definition, health professionals could refuse to provide contraceptives under the heading of objecting to abortion, she said.

The effects could be “devastating” especially in small towns and rural areas where women have few choices of where to access contraceptives, said Dr. Philip Darney, chair of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. Because of the broad wording of the proposal, anyone with an objection to any type of contraception could take this as a license to refuse to provide this care, he said. “It's really bad news for access to contraception,” Dr. Darney said.

In a letter to HHS, Sen. Hillary Clinton (D-N.Y.) and Sen. Patty Murray (D-Wash.) asked agency officials to reconsider the regulations.

“These draft regulations could disrupt state laws securing women's access to birth control. They could jeopardize federal programs like Medicaid and Title X that provide family planning services to millions of women. They could even undermine state laws that ensure survivors of sexual assault and rape receive emergency contraception in hospital emergency rooms,” the senators wrote.

In a statement, HHS said it is exploring a number of options to enforce antidiscrimination laws. “Over the past 3 decades, Congress has passed several antidiscrimination laws to protect institutional and individual health care providers participating in federal programs. HHS has an obligation to enforce these laws,” the statement said.

The draft proposal also would require recipients of HHS funding to certify in writing that they will not discriminate against a provider for refusing to perform abortion or sterilization procedures and will not require involvement in procedures that the provider considers morally objectionable. Written certification is necessary to ensure that health professionals are aware of federal “conscience” laws, according to the HHS draft document.

Reproductive rights advocates are mobilizing against an effort by the Bush administration to redefine abortion in a way that could limit access to family planning services.

Last month, officials at the Department of Health and Human Services circulated a draft proposal aimed at beefing up protections for physicians and other health care providers who object to performing procedures such as abortion and sterilization. As part of this effort, the draft contains a new definition of abortion: the prescription or administration of a drug or procedure that “results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”

Reproductive rights advocates say this broad definition would classify some oral contraception, IUDs, and emergency contraception as methods of abortion.

If adopted as a federal regulation, the new definition of abortion could limit access to federally funded family planning services, according to the Association of Reproductive Health Professionals, which is calling on physicians and other providers to express objections to HHS.

The proposal would “radically redefine pregnancy,” said Mary Jane Gallagher, president and CEO of the National Family Planning and Reproductive Health Association. The definition is contrary to definitions used by medical societies and blurs the line between what is abortion and what is contraception, she said. With such a broad definition, health professionals could refuse to provide contraceptives under the heading of objecting to abortion, she said.

The effects could be “devastating” especially in small towns and rural areas where women have few choices of where to access contraceptives, said Dr. Philip Darney, chair of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. Because of the broad wording of the proposal, anyone with an objection to any type of contraception could take this as a license to refuse to provide this care, he said. “It's really bad news for access to contraception,” Dr. Darney said.

In a letter to HHS, Sen. Hillary Clinton (D-N.Y.) and Sen. Patty Murray (D-Wash.) asked agency officials to reconsider the regulations.

“These draft regulations could disrupt state laws securing women's access to birth control. They could jeopardize federal programs like Medicaid and Title X that provide family planning services to millions of women. They could even undermine state laws that ensure survivors of sexual assault and rape receive emergency contraception in hospital emergency rooms,” the senators wrote.

In a statement, HHS said it is exploring a number of options to enforce antidiscrimination laws. “Over the past 3 decades, Congress has passed several antidiscrimination laws to protect institutional and individual health care providers participating in federal programs. HHS has an obligation to enforce these laws,” the statement said.

The draft proposal also would require recipients of HHS funding to certify in writing that they will not discriminate against a provider for refusing to perform abortion or sterilization procedures and will not require involvement in procedures that the provider considers morally objectionable. Written certification is necessary to ensure that health professionals are aware of federal “conscience” laws, according to the HHS draft document.

Reproductive rights advocates are mobilizing against an effort by the Bush administration to redefine abortion in a way that could limit access to family planning services.

Last month, officials at the Department of Health and Human Services circulated a draft proposal aimed at beefing up protections for physicians and other health care providers who object to performing procedures such as abortion and sterilization. As part of this effort, the draft contains a new definition of abortion: the prescription or administration of a drug or procedure that “results in the termination of the life of a human being in utero between conception and natural birth, whether before or after implantation.”

Reproductive rights advocates say this broad definition would classify some oral contraception, IUDs, and emergency contraception as methods of abortion.

If adopted as a federal regulation, the new definition of abortion could limit access to federally funded family planning services, according to the Association of Reproductive Health Professionals, which is calling on physicians and other providers to express objections to HHS.

The proposal would “radically redefine pregnancy,” said Mary Jane Gallagher, president and CEO of the National Family Planning and Reproductive Health Association. The definition is contrary to definitions used by medical societies and blurs the line between what is abortion and what is contraception, she said. With such a broad definition, health professionals could refuse to provide contraceptives under the heading of objecting to abortion, she said.

The effects could be “devastating” especially in small towns and rural areas where women have few choices of where to access contraceptives, said Dr. Philip Darney, chair of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. Because of the broad wording of the proposal, anyone with an objection to any type of contraception could take this as a license to refuse to provide this care, he said. “It's really bad news for access to contraception,” Dr. Darney said.

In a letter to HHS, Sen. Hillary Clinton (D-N.Y.) and Sen. Patty Murray (D-Wash.) asked agency officials to reconsider the regulations.

“These draft regulations could disrupt state laws securing women's access to birth control. They could jeopardize federal programs like Medicaid and Title X that provide family planning services to millions of women. They could even undermine state laws that ensure survivors of sexual assault and rape receive emergency contraception in hospital emergency rooms,” the senators wrote.

In a statement, HHS said it is exploring a number of options to enforce antidiscrimination laws. “Over the past 3 decades, Congress has passed several antidiscrimination laws to protect institutional and individual health care providers participating in federal programs. HHS has an obligation to enforce these laws,” the statement said.

The draft proposal also would require recipients of HHS funding to certify in writing that they will not discriminate against a provider for refusing to perform abortion or sterilization procedures and will not require involvement in procedures that the provider considers morally objectionable. Written certification is necessary to ensure that health professionals are aware of federal “conscience” laws, according to the HHS draft document.

CHICAGO — Short-term treatment with high-dose celecoxib reduced expression levels for a biomarker associated with precancerous lung lesions in a chemoprevention study of about 200 current and former smokers, according to data presented at the annual meeting of the American Society of Clinical Oncology.

The randomized, double-blind prospective study found a significant reduction in Ki-67 expression, as well as reduced levels of cyclooxygenase-2 (COX-2) in patients who received 400 mg twice daily of celecoxib (Celebrex) for 3 months.

“We cannot sit here and say that taking celecoxib is going to prevent lung cancer. That needs further, larger-scale studies,” Dr. Edward S. Kim, the lead author and a medical oncologist at the University of Texas M.D. Anderson Cancer Center, Houston, cautioned at a press briefing at the ASCO annual meeting.

Between November 2001 and September 2006, the researchers enrolled 212 current and former smokers with at least a 20 pack-year smoking history. Most patients did not have a prior cancer, but those who did had been disease free for 6 months. The median age of the study participants was 53 years. The study was funded by a grant from the National Cancer Institute, part of the National Institutes of Health.

Study participants were randomized into four treatment arms: 3 months of placebo, then 3 months of celecoxib; 3 months of celecoxib, then 3 months of placebo; 6 months of celecoxib; or 6 months of placebo. Celecoxib was administered at 200 mg twice daily, and then increased to 400 mg twice daily.

In addition, patients underwent three consecutive bronchoscopies: at study enrollment, at 3 months, and at 6 months. Predetermined biopsies were also performed at the same time.

The primary end point of the study was change in the Ki-67 marker (a nuclear protein that appears to be related to cell proliferation) from baseline to 3 months. Over a 3-month period, high-dose celecoxib, when compared with placebo, did reduce the expression levels of Ki-67 for patients who received 400 mg of celecoxib twice daily. The effect was not seen in the 200-mg dose. The study was designed to detect a 1.2% difference in Ki-67 between celecoxib and placebo with a two-sided 5% level of significance.

In addition, the researchers looked at two other biomarkers: COX-2 and NF-kappaB. The COX-2 levels showed a significant decrease with celecoxib treatment at 400 mg, and decreases were close to significant with the 200-mg dose. Levels of NF-kappaB were significantly lowered with the 400-mg dose of celecoxib for former smokers only.

The study does show the safety and tolerability of celecoxib, Dr. Kim said. Three study participants experienced one grade 3 toxicity, but the researchers observed no cardiac toxicities. The study also showed that it was safe for patients to undergo consecutive bronchoscopies, he said.

When the researchers first decided to study celecoxib, prior to the 2001 launch of the study, cardiac safety concerns had yet to be raised about COX-2 inhibitors, Dr. Kim said. In December 2004, officials at the M.D. Anderson Cancer Center voluntarily suspended the trial at the request of the National Cancer Institute and Pfizer Inc., which markets Celebrex.

The study reopened in May 2005 after officials at the Food and Drug Administration recommended that Celebrex continue to be evaluated for cancer treatment and prevention.

“We cannot … say that taking celecoxib is going to prevent lung cancer.” That needs more studies, said Dr. Edward S. Kim. ©ASCO/Scott Morgan

CHICAGO — Short-term treatment with high-dose celecoxib reduced expression levels for a biomarker associated with precancerous lung lesions in a chemoprevention study of about 200 current and former smokers, according to data presented at the annual meeting of the American Society of Clinical Oncology.

The randomized, double-blind prospective study found a significant reduction in Ki-67 expression, as well as reduced levels of cyclooxygenase-2 (COX-2) in patients who received 400 mg twice daily of celecoxib (Celebrex) for 3 months.

“We cannot sit here and say that taking celecoxib is going to prevent lung cancer. That needs further, larger-scale studies,” Dr. Edward S. Kim, the lead author and a medical oncologist at the University of Texas M.D. Anderson Cancer Center, Houston, cautioned at a press briefing at the ASCO annual meeting.

Between November 2001 and September 2006, the researchers enrolled 212 current and former smokers with at least a 20 pack-year smoking history. Most patients did not have a prior cancer, but those who did had been disease free for 6 months. The median age of the study participants was 53 years. The study was funded by a grant from the National Cancer Institute, part of the National Institutes of Health.

Study participants were randomized into four treatment arms: 3 months of placebo, then 3 months of celecoxib; 3 months of celecoxib, then 3 months of placebo; 6 months of celecoxib; or 6 months of placebo. Celecoxib was administered at 200 mg twice daily, and then increased to 400 mg twice daily.

In addition, patients underwent three consecutive bronchoscopies: at study enrollment, at 3 months, and at 6 months. Predetermined biopsies were also performed at the same time.

The primary end point of the study was change in the Ki-67 marker (a nuclear protein that appears to be related to cell proliferation) from baseline to 3 months. Over a 3-month period, high-dose celecoxib, when compared with placebo, did reduce the expression levels of Ki-67 for patients who received 400 mg of celecoxib twice daily. The effect was not seen in the 200-mg dose. The study was designed to detect a 1.2% difference in Ki-67 between celecoxib and placebo with a two-sided 5% level of significance.

In addition, the researchers looked at two other biomarkers: COX-2 and NF-kappaB. The COX-2 levels showed a significant decrease with celecoxib treatment at 400 mg, and decreases were close to significant with the 200-mg dose. Levels of NF-kappaB were significantly lowered with the 400-mg dose of celecoxib for former smokers only.

The study does show the safety and tolerability of celecoxib, Dr. Kim said. Three study participants experienced one grade 3 toxicity, but the researchers observed no cardiac toxicities. The study also showed that it was safe for patients to undergo consecutive bronchoscopies, he said.

When the researchers first decided to study celecoxib, prior to the 2001 launch of the study, cardiac safety concerns had yet to be raised about COX-2 inhibitors, Dr. Kim said. In December 2004, officials at the M.D. Anderson Cancer Center voluntarily suspended the trial at the request of the National Cancer Institute and Pfizer Inc., which markets Celebrex.

The study reopened in May 2005 after officials at the Food and Drug Administration recommended that Celebrex continue to be evaluated for cancer treatment and prevention.

“We cannot … say that taking celecoxib is going to prevent lung cancer.” That needs more studies, said Dr. Edward S. Kim. ©ASCO/Scott Morgan

CHICAGO — Short-term treatment with high-dose celecoxib reduced expression levels for a biomarker associated with precancerous lung lesions in a chemoprevention study of about 200 current and former smokers, according to data presented at the annual meeting of the American Society of Clinical Oncology.

The randomized, double-blind prospective study found a significant reduction in Ki-67 expression, as well as reduced levels of cyclooxygenase-2 (COX-2) in patients who received 400 mg twice daily of celecoxib (Celebrex) for 3 months.

“We cannot sit here and say that taking celecoxib is going to prevent lung cancer. That needs further, larger-scale studies,” Dr. Edward S. Kim, the lead author and a medical oncologist at the University of Texas M.D. Anderson Cancer Center, Houston, cautioned at a press briefing at the ASCO annual meeting.

Between November 2001 and September 2006, the researchers enrolled 212 current and former smokers with at least a 20 pack-year smoking history. Most patients did not have a prior cancer, but those who did had been disease free for 6 months. The median age of the study participants was 53 years. The study was funded by a grant from the National Cancer Institute, part of the National Institutes of Health.

Study participants were randomized into four treatment arms: 3 months of placebo, then 3 months of celecoxib; 3 months of celecoxib, then 3 months of placebo; 6 months of celecoxib; or 6 months of placebo. Celecoxib was administered at 200 mg twice daily, and then increased to 400 mg twice daily.

In addition, patients underwent three consecutive bronchoscopies: at study enrollment, at 3 months, and at 6 months. Predetermined biopsies were also performed at the same time.

The primary end point of the study was change in the Ki-67 marker (a nuclear protein that appears to be related to cell proliferation) from baseline to 3 months. Over a 3-month period, high-dose celecoxib, when compared with placebo, did reduce the expression levels of Ki-67 for patients who received 400 mg of celecoxib twice daily. The effect was not seen in the 200-mg dose. The study was designed to detect a 1.2% difference in Ki-67 between celecoxib and placebo with a two-sided 5% level of significance.

In addition, the researchers looked at two other biomarkers: COX-2 and NF-kappaB. The COX-2 levels showed a significant decrease with celecoxib treatment at 400 mg, and decreases were close to significant with the 200-mg dose. Levels of NF-kappaB were significantly lowered with the 400-mg dose of celecoxib for former smokers only.

The study does show the safety and tolerability of celecoxib, Dr. Kim said. Three study participants experienced one grade 3 toxicity, but the researchers observed no cardiac toxicities. The study also showed that it was safe for patients to undergo consecutive bronchoscopies, he said.

When the researchers first decided to study celecoxib, prior to the 2001 launch of the study, cardiac safety concerns had yet to be raised about COX-2 inhibitors, Dr. Kim said. In December 2004, officials at the M.D. Anderson Cancer Center voluntarily suspended the trial at the request of the National Cancer Institute and Pfizer Inc., which markets Celebrex.

The study reopened in May 2005 after officials at the Food and Drug Administration recommended that Celebrex continue to be evaluated for cancer treatment and prevention.

“We cannot … say that taking celecoxib is going to prevent lung cancer.” That needs more studies, said Dr. Edward S. Kim. ©ASCO/Scott Morgan